05. AKT: Infection/Blood/MSK Flashcards
(101 cards)
1
Q
How long is a patient infectious for with measles?
A
Atleast 5 days after the onset of rash
2
Q
How does measles present?
A
Prodrome:
- Fever, malaise, loss of appetite, followed by conjunctivitis, cough, coryza (blocked or runny nose)
- Koplik spots (blue-white spots on the inside of the mouth, opposite the molars) occur before the rash
Exanthem:
- Flat, red spots appear on 4-5th day
- Non-itchy rash that begins on the face and behind the ears, then spreads over the entire trunk and extremeties (palms and soles rarely involved)
- Onset of rash usually coincides with a high fever atleast 40C
3
Q
Clinical definition of measles?
A
BOTH:
1. Generalised descending maculo-papular rash (persisting for 3 or more days)
2. Fever atleast 38C at the time of rash onset
AND atleast one of:
- Cough
- Coryza
- Conjunctivitus
- Koplik spots
4
Q
Differentials for maculopapular rash?
A
- Measles
- Rubella
- Human Parvovirus B19
- Enterovirus
- HIV
- Adenovirus
- Arbovirus
- Roseola infantum
- Scarlet fever
- Drug reaction
- Kawasaki disease
5
Q
What actions are needed if there is suspected measles?
A
- Urgent call to Public Health
- Lab testing: nose or throat swab for measles PCR AND urine PCR for measles (if within 3 weeks of rash)
- Measles IgM and IgG
- Isolate case immediately
6
Q
Who are high risk groups when considering Group A strep infection?
A
- ATSI
- Maori and Pacific Islander people
- Personal history of rheumatic fever or rheumatic heart disease
- Family history of rheumatic fever or rheumatic heart disease
7
Q
Red flags when assessing a sore throat?
A
- Unwell/toxic appearance
- Respiratory distress
- Stridor
- Trismus
- Drooling
- “Hot potato” voice (muffled voice associated with pharyngeal/peritonsillar pathology - sounding like they have a hot potato in their mouth)
- Torticollis - neck muscle spasm causing head turning
- Neck stiffness/fullness
8
Q
What investigations would you order if there was a patient with sore throat + hepatosplenomegaly?
A
FBC, monospot +/- EBV serology
9
Q
Most common causes of fever in travellers?
A
- Malaria
- Dengue fever
- Mononucleosis
- Rickettsial infection
- Typhoid
- Paratyphoid fever (enteric fever)
10
Q
Characteristic features of malaria?
A
- Fever
- Malaise
- Nausea
- Vomiting
- Abdominal pain
- Diarrhoea
- Myalgia
- Anaemia
11
Q
What should be done if there is clinical suspicion for malaria but the first diagnostic evaluation is negative?
A
Follow up testing should be performed each day for two more days.
Malaria is still possible even if an initial malaria smear is negative.
12
Q
Features of dengue virus infection on history, exam and lab findings?
A
Symptoms:
- Headache
- Retro-orbital pain
- Marked myalgia and arthralgia
- Transient macular rash
Exam:
- Haemorrhagic features: petechiae, ecchymoses, vaginal or gastrointestinal bleeding
- Conjunctival injection
- Pharyngeal erythema
Lab findings:
- Leukopenia
- Thrombocytopenia
- Elevated aminotransferases
13
Q
What is the primary purpose of malarial chemoprophylaxis?
A
Minimise the risk of dying from malaria when travelling to or residing in high-risk malaria areas
14
Q
How long should malaria still be considered as a differential for cause of fever in a returned traveller?
A
Up to at least one year after visiting a malaria-risk area, regardless of whether chemoprophylaxis was taken
15
Q
What can hand, foot and mouth disease look like?
A
- Small, oval white blisters on the palms, soles of the feet, as well as in the mouth
- A red skin rash with a brown scale on it
16
Q
What is the most common cause of hand, foot and mouth disease?
A
Coxsackie virus
17
Q
When is tetanus immunoglobulin indicated?
A
Children with a tetanus-prone wound (dirty or major wound) AND any of the following:
1. who are unimmunised
2. have had incomplete primary tetanus immunisation
3. uncertain tetanus immunisation history
18
Q
How long should a postpartum woman wait after packed red blood cell transfusion if she also needs MMR booster?
A
6 months post PRBC to receive the MMR booster
19
Q
Why should a woman wait after blood transfusion to get the MMR booster?
A
The PRBC may reduce the immune response to the MMR booster
20
Q
What two tests are available for diagnosis of latent tuberculosis? Can they distinguish between latent and active TB?
A
- Mantoux test - tuberculin skin test
- Interferon-gamma release assay (IGRA)
No, they cannot distinguish between latent or active infection. They tend to remain positive indefinitely after infection or disease
21
Q
Symptoms of active tuberculosis?
A
Especially if symptoms present for >3 weeks:
- Fever
- Cough
- Weight loss
- Lymphadenopathy
22
Q
- What treatment for latent tuberculosis can be started in general practice if <35 years with normal liver function tests?
- What are its side effects?
A
- Isoniazid 10mg/kg, up to 300mg, daily PO. Co-prescription of vitamin B6 (pyridoxine) is generally offered
- GI upset, acne, hepatotoxicity, peripheral neuropathy
23
Q
Ross River virus symptoms and signs?
A
- Joint pain
- Tiredness
- Fever
- Myalgia
- Rash
- Headache
- Joint swelling
- Depression
Most common manifestation is acute onset of joint pains +/- rash (maculopapular), fever, lethargy and myalgia
24
Q
How is Ross River virus diagnosed?
A
- Diagnosis is confirmed by serology
- A blood sample should be collected within 7 days of symptom onset for IgM and IgG and another sample 10-14 days later tested in parallel by the same laboratory for IgG to confirm seroconversion. Diagnosis is confirmed by a 4 fold increase in IgG
25
Standard recommended management of bites and clenched-first injuries?
Thorough cleaning, irrigation, debridement, elevation and immobilisation
26
What factors indicate high risk of of wound infection in bite and clenched-first injuries, and therefore require presumptive antibiotic therapy?
- Presentation to medical care is delayed by 8 hours or more
- Puncture wound that cannot be debrided adequately
- Wound is on hands, feet or face
- Wound involves deeper tissues (e.g. bones, joints, tendons)
- Wound involves an open fracture
- Patient is immunocompromised
- Cat bite
27
When is air travel restricted in pregnancy?
- Domestic (more than 4 hours): after 36 weeks
- International: 32 weeks
28
What birth year range do you need to check for a completed 2 dose course of MMR vaccine?
Born between 1966 and 1994 (may not have received the complete 2 doses). Before this, measles was prevalent and would confer natural immunity.
29
What is the most common cause of erysipelas?
Streptococcus pyogenes (group A strep)
30
In cellulitis, what suggests strep pyogenes rather than staph aureus as the likely causative organism and what is first line treatment?
- Features: nonpurulent, recurrent or spontaneous, rapidly spreading
- Treatment: phenoxymethylpenicillin 500mg Q6hourly PO for 5 days
31
In cellulitis, what suggests staph aereus rather than strep pyogenes as the likely causative organism and what is first line treatment?
- Features: purulent, penetrating trauma, associated ulcer
- Treatment: Flucloxacillin 500mg Q6hourly PO for 5 days
32
Risk factors for superficial vein thrombosis?
- Intravenous cannulation
- Pregnancy
- Active cancer
- Varicose veins
Note: causes of venous stasis and venous trauma
33
What is a low risk superficial vein thrombosis?
- Caused by intravenous cannulation
- Located more than 3cm from the deep venous system
- Is shorter than 5cm
34
What is an intermediate risk superficial vein thrombosis?
- More than 3cm from deep venous system
- Is longer than 5cm
35
What is a high risk superficial vein thrombosis?
- Extends to within 3cm from the deep venous system
- Propagates despite anticoagulant therapy given for an intermediate risk superficial vein thrombosis
36
Management of low risk superficial vein thrombosis?
Symptomatic care with topical or oral NSAID therapy for 7 to 14 days
37
Management of intermediate risk superficial vein thrombosis?
Enoxaparin 40 to 80mg subcut daily for 45 days
38
Management of high risk superficial vein thrombosis?
Anticoagulant therapy for 3 months (similar to VTE treatment)
39
First line investigations for thrombocytopenia?
- FBC and peripheral blood film
- Fibrinogen, D-dimer, clotting factors
- Haemolysis screen: FBC and peripheral blood film, reticulocyte count, direct and indirect antibody test (Coombs), lactate dehydrogenase, haptoglobin, urinary haemosiderin, haemoglobin
- Vitamin B12 and folic acid levels
- Liver function tests
- HIV and hepatitis serology
- Stool for occult blood
- Renal function (deranged in thrombotic thrombocytopenic purpura/haemolytic uraemic syndrome)
- Platelet indices (size and volume): limited value
40
What level of thrombocytopenia may spontaneous bleeding occur?
- Platelet count < 20.
- Requires urgent referral to haematologist. If age >60, then urgent referral at platelet <30 is appropriate (risk of spontaneous bleeding increases with age)
41
What level of thrombocytopenia may traumatic bleeding occur?
Platelet count 20-50
42
What is the management of thrombocytopenia (<150) without red flags?
Close observation (i.e. repeat in 6 weeks and if unchanged, repeat in several months)
43
Red flags for thrombocytopenia?
Evidence of haemolysis with the presence of neurological findings and renal dysfunction
- Thrombotic thrombocytopenic purpura
- Haemolytic uraemic syndrome
Age >60 years and dysplastic features on peripheral film:
- Myelodysplastic syndrome
- Leukaemia
Platelet count <100 with active bleeding
44
Management options for supratherapeutic INRs?
- Withhold warfarin with careful monitoring (resume therapy at lower dose when INR approaches therapeutic range; if only minimally above therapeutic range up to 10%, dose reduction is generally not necessary)
- Vitamin K
- Prothrombinex (completely reverses INR within 15 minutes but need to also give Vitamin K due to short half lives of clotting factors)
- Fresh frozen plasma
45
Clinical features of Hodgkin lymphoma?
- Painless (rubbery) lymphadenopathy, especially cervical lymph nodes
- Constitutional symptoms (e.g. malaise, weakness, weight loss)
- Fever and drenching night sweats - undulant (Pel-Ebstein) fever
- Pruritus
- Alcohol-induced pain in any enlarged lymph nodes
- Possible enlarged spleen and liver
46
DxT: malaise + fever/night sweats + pruritus?
Hodgkin lymphoma
47
Examples of procedures with minimal bleeding risk?
- Minor dental extractions
- Skin excisions of less than 1cm
- Cataract procedures
48
Examples of procedures with low to moderate bleeding risk (procedures with a possibility of major bleeding but an overall lower incidence)?
- Laparoscopic cholecystectomy
49
Examples of procedures with high bleeding risk (procedures with a higher incidence of major bleeding)?
- Invasive procedures (e.g. bowel resection, major orthopaedic surgery)
- Involve highly vascularised organs (e.g. kidney, liver, spleen)
- Procedures with a low incidence of bleeding but for which a minor bleed can cause significant morbidity or mortality (e.g. intracranial, spinal or cardiac surgery)
50
Patient-related factors that increase bleeding risk?
- A history of bleeding (particularly if this occurred with a similar procedure)
- A recent supratherapeutic INR while on warfarin
- High alcohol intake
- Factors included in risk indices e.g. HAS-BLED score (hypertension, abnormal kidney or liver function, prior stroke, history of bleeding, labile INR, age, or other drug or alcohol)
51
Factors that increase risk of periprocedural thromboembolic event?
- History of ischaemic stroke, transient ischaemic attack or VTE
- Existing AF, left ventricular thrombosis, a mechanical heart valve or mitral stenosis
- Factors included in risk indices such as CHADS-vasc score
- Certain types of surgery (e.g. coronary artery bypass graft, carotid endarterectomy)
52
Causes of neutropenia?
- Duffy-null associated neutrophil count: inherited in African descent (benign, normal variant)
- Familial neutropenia
- Congenital neutropenia: premature graying of the hair, abnormalities of fingernails or skeleton
- Infection: viral (hepatitis, HIV, EBV), bacterial, parasitic, rickettsial infections
- Medications: cytotoxic or immunosuppressive therapy - usually associated with thrombocytopenia and/or anaemia
- Nutritional - deficiencies in vitamin B12, folate, copper
- Haematologic malignancies: lymphoproliferative disorders, myelodysplastic syndromes or other
- Rheumatologic disorders: e.g. RA, SLE
- Autoimmune neutropenia: primary or secondary
- Aplastic anaemia: neutropenia may be initial or predominant manifestation but typically this occurs as a pancytopenia
53
Relevant history for unexplained neutropenia?
- Active or prior infection or inflammatory process? (e.g. trauma, rheumatologic disorders)
- Episodic aphthous ulcers and/or infections (e.g. a periodicity of two or three weeks may suggest cyclic neutropenia)
- Previously diagnosed haematologic malignancy
- Gastrointestinal disorders (e.g. IBD, bariatric surgery): may impair absorption of vitamin B12, folate, copper)
- Liver disease: e.g. infections, rheumatologic conditions, haematologic malignancies
- Infections: hepatitis, HIV, EBV, intestinal parasites
- Medications: immunosuppressants or cytotoxic drugs
- Diet: veganism (vitamin B12 deficiency), excessive alcohol (folate deficiency)
54
Initial investigations for unexplained neutropenia?
- Peripheral blood smear: neutrophil morphology
- Vitamin B12, folate and copper levels
- LFTs, screening for viral hepatitis and HIV
- Coags, d-dimer, LDH, EUC: for febrile or haemodynamically unstable patients for sepsis and/or DIC
- ESR, CRP
55
Worrying clincial findings that should be excluded in patients with polycythaemia?
Hypoxia, carbon monoxide poisoning or other potentially life-threatening causes
Clinical conditions that may be due to increased blood viscosity:
- Transient visual disturbance, stroke, confusion
- Myocardial infarction, peripheral arterial occlusion
- Venous thromboembolism
56
Investigations for persistent, unexplained polycythaemia?
- Pulse oximetry
- LFTs
- EUC, CMP
- Glucose
- Serum erythropoietin level
- Urinalysis
57
Intense, burning pain and/or redness of the extremeties - what is it?
Erythromelalgia - can be caused by polycythaemia
58
Causes of secondary polycythaemia?
- Dehydration
- Hypoxia
- Cardiopulmonary process
59
When to suspect polycythaemia vera?
Key:
- Increased red blood cell mass or increased Hb/haematocrit AND
- Arterial oxygen sats > 92%
Other additional evidence to suggest polycythaemia vera:
- Splenomegaly
- Thrombocytosis and/or leukocytosis
- Thrombotic complications
- Erythromyelalgia or aquagenic pruritus
- Microvascular symptoms (e.g. headaches, paraesthesias)
60
Pathognomonic microvascular thrombotic complications in polycythaemia vera and essential thrombocytopenia?
- Erythromelalgia, erythema, pallor or cyanosis in the presence of palpable pulses
- Acral paraesthesias (burning feet, burning hands)
61
Clinical features of cervical spondylosis?
- Dull, aching suboccipital neck pain
- Improves with gentle activity and warmth (e.g. warm showers)
- Deteriorates with heavy activity (e.g. working under car, painting ceiling)
- Usually unilateral pain
- May wake patient at night +/- paraesthesia in arms
- Restricted tender movements, especially rotation/lateral flexion
62
Differential diagnoses of hip pain in young adults - intra-articular causes?
Bones:
- Femoroacetabular impingement
- Osteoarthritis
- Avascular necrosis
- Developmental dysplasia of the hip
- Fractures
- Perthe's disease
- Septic arthritis
Soft tissue:
- Labral tear
- Chondral defect
- Ligamentum teres injury
63
Differential diagnoses of hip pain in young adults - entra-articular causes?
Muscles:
- Abductor muscle injuries
- Gluteus muscle tears
Nerves:
- Sciatica
- Obturator nerve irritation
- Lateral Femoral Cutaneous Nerve irritation
- Piriformis syndrome
Tendons:
- Snapping hip (ITB or iliopsoas)
- Bursa
- Trochanteric bursitis
Ligaments:
- Inguinal ligament strain
- Joint capsule
Referred pain:
- Lumbar spine
- Knee
- Non-musculoskeletal pathology
64
What is femoroacetabular impingement?
Subtle deformities in hip shape that cause impingement between the femoral neck and anterior rim of the acetabulum during the normal range of functional hip movement.
Symptoms particularly occur in flexion adduction and internal rotation.
Hip shape deformities are classified into three times:
- Cam type: asphericity of the femoral head; widening of the femoral neck (more common in men)
- Pincer type: over coverage of the anterosuperior acetabular wall; a deep socket (more common in women)
- Mixed type
65
Management of femoroacetabular impingement?
Targetted physiotherapy for range of movement and incremental exercise rehabilitation
66
Radiological features of ankylosing spondylitis on xray?
- Fusion of both sacroiliac joints
- Dagger spine appearance (calcification of interspinous and supraspinous ligaments from enthesitis)
- Bamboo spine appearance (ankylosis through marginal syndesmophytes) [advanced AS]
- Calcification of the intervertebral discs
67
Characteristics of ankylosing spondylitis?
- Gradual onset before the age of 40 years
- A duration of symptoms of longer than 3 months
- Prolonged morning stiffness and night pain
- Improvement with physical activity or exercise, and failure to improve with rest
- Response to NSAIDs
Note: sacroilitis manifests as stiffness and pain in the buttock, soemtimes radiating into the thigh. Alternating buttock pain is characteristic
68
What is the most common extra-articular feature of ankylosing spondylitis
Acute anterior uveitis
69
Extra-axial features of ankylosing spondylitis?
- Asymmetric oligoarthritis (
70
What is Legg-Calve-Perthes disease?
1. Blood supply to part of the femoral head is disturbed, causing loss of bone cells
2. Softening and collapse of the affected bone
3. Re-establishment of the blood supply, repair and remodeling of the femoral head
71
Clinical presentation of Perthes disease?
- Typically occurs between ages 4 to 10 years
- Variable pain with activity including thigh, groin or knee pain
- Exam: loss of hip motion, especially internal rotation and abduction in flexion
72
Red flags to look for when a child presents with a limp?
- Acute onset severe localised joint pain
- Concern for inflicted injury
- Persistent limp > 7 days
- Nocturnal symptoms
- Suspicious for malignancy
- Systemic symptoms e.g. fever, weight loss
- Petechiae or purpura
73
Diagnostic features of somatic symptom disorder?
Core features:
- One or more current somatic symptoms that are long-standing and cause distress or psychosocial impairment
- Excessive thoughts, worrying or behaviours (time and energy) related to the somatic symptoms or to health concerns
Other features:
- Dominate interpersonal relationships, psychosocial and physical functioning decline
- Somatic symptoms that are common include pain, nonspecific symptoms (e.g. fatigue), gastrointestinal symptoms, cardiopulmonary symptoms, neurologic symptoms and reproductive organ symptoms
74
Management of somatic symptom disorder?
- Improve coping with physical symptoms
- Improve occupational and interpersonal functioning
- Regular outpatient visits (Q4-8weekly) that are not contingent upon active symptoms
- Acknowledge and legitimize the somatic symptoms
- Goal of treatment as functional improvement including activation and exercise
- Limit diagnostic testing and referrals
- Reassue patients that grave medical diseases have been excluded
- Explain that the body can generate symptoms in the absence of disease, that psychological and social issues (e.g. stress and conflict) can affect the body
- Assess and treat patients for comorbid psychiatric disorders
75
Clinical features of cervical radiculopathy - root C5:
- Location of pain?
- Location of numbness?
- Location of weakness?
- Reflexes affected?
Pain:
- Neck
- Shoulder
- Scapula
Numbness:
- Lateral arm (in distribution of axillary nerve)
Weakness:
- Shoulder abduction
- External rotation
- Elbow flexion
- Forearm supination
Reflexes affected:
- Biceps
- Brachioradialis
76
Clinical features of cervical radiculopathy - root C6:
- Location of pain?
- Location of numbness?
- Location of weakness?
- Reflexes affected?
Pain:
- Neck
- Shoulder
- Scapula
- Lateral arm
- Lateral forearm
- Lateral hand
Numbness:
- Lateral forearm
- Thumb
- Index finger
Weakness:
- Shoulder abduction
- External rotation
- Elbow flexion
- Forearm supination
- Forearm pronation
Reflexes affected:
- Biceps
- Brachioradialis
77
Clinical features of cervical radiculopathy - root C7:
- Location of pain?
- Location of numbness?
- Location of weakness?
- Reflexes affected?
Pain:
- Neck
- Shoulder
- Middle finger
- Hand
Numbness:
- Index finger
- Middle finger
- Palm
Weakness:
- Elbow extension
- Wrist extension (radial)
- Forearm pronation
- Wrist flexion
Reflexes affected:
- Triceps
78
Clinical features of cervical radiculopathy - root C8:
- Location of pain?
- Location of numbness?
- Location of weakness?
- Reflexes affected?
Pain:
- Neck
- Shoulder
- Forearm
- Fourth and fifth digits
- Medial hand
Numbness:
- Medial forearm
- Medial hand
- Fourth and fifth digits
Weakness:
- Finger extension
- Wrist extension (ulnar)
- Distal finger flexion, extension, abduction and adduction
- Distal thumb flexion
Reflexes affected:
- None
79
Clinical features of cervical radiculopathy - root T1:
- Location of pain?
- Location of numbness?
- Location of weakness?
- Reflexes affected?
Pain:
- Neck
- Medial arm
- Medial forearm
Numbness:
- Anterior arm
- Medial forearm
Weakness:
- Thumb abduction
- Distal thumb flexion
- Finger abduction and adduction
Reflexes affected:
- None
80
Management of cervical radiculopathy that is low risk for neoplastic, infectious or inflammatory causes and has no or mild motor deficits?
Conservative management with one or more of the following:
- Non-narcotic oral analgesia e.g. NSAIDs: NSAIDs have evidence; paracetamol has limited evidence but is safe; trial of TCA can be considered if pain is not adequately relieved with other measures and is persisting beyond 2 to 3 weeks and if sleep is interrupted
- Short course of oral corticosteroids (if severe pain): prednisone 30mg daily for 5-10 days, then taper the dose over 1 to 3 weeks then stop
- Manage expectations that pharmacological management is aimed at reducing, rather than abolishing pain
- Avoidance of provocative activities
- Short-term neck immobilisation (cervical collar and/or pillow)
- Physical therapy (delay start until pain tolerable)
Reassess at 6 to 8 weeks
81
Characteristics of polymyalgia rheumatica?
- Bilateral aching and stiffness of the shoulders and hip-girdle area
- Morning stiffness is the hallmark of the disease
- Stiffness tends to improve after a hot shower, and with activity
- Age older than 50 years
- Elevated ESR and/or CRP
82
Management of greater trochanteric pain syndrome?
- Exercises to improve the tensile strength of the gluteus medius and minimus tendons
- Advise patient to avoid compression of the gluteal tendons over the greater trochanter (e.g. avoid leg-crossing, hip-hanging and side-lying in bed)
- Local corticosteorid injection for more severe symptoms (night pain, impaired physical function, inability to lie on side)
83
What is greater trochanteric pain syndrome usually due to?
Gluteus medius or minimus tendinopathy, with variable involvement of the regional bursae
84
Risk factors for greater trochanteric pain syndrome?
- Female
- Obesity
- Low back pain
- Scoliosis
- Leg length discrepancy
- Hip and knee arthritis
- Plantar fasciitis
85
Key examination finding of greater trochanteric pain syndrome?
Tenderness to palpation over the greater trochanter
86
Describe fibromyalgia
Chronic widespread non-inflammatory musculoskeletal pain accompanied by a variety of typical symptoms including fatigue, sleep disturbance and cognitive clouding.
Pain in fibromyalgia is typically widespread and may be experienced in both soft tissues and joints
87
Clinical presentation of fibromyalgia?
Hallmark: chronic widespread musculoskeletal pain
Other symptoms:
- Cognitive clouding (fibrofog)
- Fatigue
- Impaired concentration
- Sleep dysfunction
- Depression
- Gastrointestinal and urogenital dysfunction and discomfort (irritable bowel and irritable bladder)
88
Physical exam findings for fibromyalgia?
No specific physical examination findings.
Suggestive:
- Soft tissue tenderness to pressure is typically diffuse
- Some anatomical locations (e.g. lateral epicondylesm trapezius muscles, anserine bursae) are tender in most patients
- Allodynia: pain induced by inflation of a sphygmomanometer cuff is a useful screening tool
89
Management of fibromyalgia?
- Regular graded aerobic exercise (over several months): reduce pain and fatigue, improve QoL
- Graded by the duration of time spent exercising rather than the pain experienced (to reduce the risk of unhelpful cycles of overexertion followed by inactivity)
- Cognitve behavioural therapy
- Attention to good sleep practices
- Reassurance that the condition is not damaging to joints or soft tissues ---- explain is it like an alarm system that has become oversensitive and is generating its alarm under conditions that offer no threat to the tissues
- Low dose TCA: amitriptyline 10mg in the early evening PO (dose adjustments should not be made more frequently than monthly)
- Paracetamol/NSAIDs only moderately helpful
90
Signs, symptoms or risk factors for spinal infection (e.g. epidural abscess or osteomyelitis)?
- Objective fever
- Current immunosuppression, haemodialysis
- Current or recent bacteraemia, injection drug use, endocarditis, invasive epidural/spinal procedure
91
Fever + Back pain (especially if tender) + Neurologic deficit/radiculopathy?
Spinal epidural abscess
92
Gold standard imaging to assess for spinal epidural abscess?
MRI with contrast (gadolinium)
93
In symptomatic lumbar disc herniation, can the herniated portion of the disc regress over time?
Yes
94
Signs and symptoms of nerve root involvement at L3:
- Reduced muscle power?
- Reduced sensation?
- Reduced or absent reflex?
Reduced muscle power:
- Knee extension
Reduced sensation:
- Anterior and lateral aspects of thigh
Reduced or absent reflex: knee jerk
95
Signs and symptoms of nerve root involvement at L4:
- Reduced muscle power?
- Reduced sensation?
- Reduced or absent reflex?
Reduced muscle power:
- Knee extension
Reduced sensation:
- Anterior and lateral aspects of thigh
Reduced or absent reflex: knee jerk
96
Signs and symptoms of nerve root involvement at L5:
- Reduced muscle power?
- Reduced sensation?
- Reduced or absent reflex?
Reduced muscle power:
- Dorsiflexion of big toe
- Dorsiflexion of ankle
Reduced sensation:
- Particularly dorsum of foot
Reduced or absent reflex: ankle jerk
97
Signs and symptoms of nerve root involvement at S1:
- Reduced muscle power?
- Reduced sensation?
- Reduced or absent reflex?
Reduced muscle power:
- Plantar flexion of ankle
Reduced sensation:
- Particularly lateral aspect of foot
- Sole of foot
Reduced or absent reflex: ankle jerk
98
Signs and symptoms of cauda equina?
- Progressive bilateral foot or leg weakness
- Altered bladder and/or bowel function (e.g. urinary retention, faecal incontinence)
99
Management of symptomatic lumbar disc herniation?
- Conservative management in first 6 to 8 weeks
- Activity modification to avoid provoking pain
- Epidural corticosteroid injection (short term relief)
- Oral corticosteroids for 15 days may improve physical function but has little effect on pain
Surgical consult is indicated for all patients with:
- Severe or progressive neurological deficits
- Severe persisting leg pain at 6 to 8 weeks despite conservative management
100
Patient education points for acute nonspecific low back pain?
- Explanation of pain and why imaging is not required - most back pain is caused by simple strain of the back
- Advice to stay active
- Encouragement to continue to work or to return to work as soon as possible
- Reassurance that recovery is likely to be quick even though pain may be severe
- Addressing fear-avoidance behaviour
101
