Flashcards in Diagnosis and Investigations Deck (50):
Questions to ask re swollen and painful hands?
When did your symptoms start and have they built up gradually?
Do they vary throughout the day?
When are at they at their worst and how do they respond to activity and time of day?
Do your joints ever feel stiff, for example in the morning?
Any constitutional symptoms i.e. fever, night sweats or weight loss?
Any skin rashes, change in bowel habit or dry or watery eyes?
Do joint problems run in your family?
Types of Inflammatory Arthritis
How does IA present?
<30 mins morning stiffness
Improves with exercise and as the day goes on
If multisystem or constitutional sx, expect CTD
If other symptoms such as bowel habit or eye involvement consider Seronegative
How does RA present?
As with IA but expect strong family hx
Symmetrical small joint polyarthritis
What is non inflammatory arthritis?
How does OA present?
No morning stiffness, or morning stiffness lasting <30 mins
Worse with exercise and better with rest
How does Septic Arthritis present?
Associated fever and infective sx
Acute hx over hours or days
Pt feels generally unwell
What are the types of crystal arthritis?
How can you differentiate between gout and pseudogout?
Gout: Negatively bifringent needles
Pseudogout: Positively bifringent rhomboids
Gout more likely in pattern - MTP - Ankle - Knee
Pseudogout more likely in larger joint and in patient with underlying OA
What are the risk factors for gout?
Taking thiazide diuretics
Consume large amount of alcohol
Diet high in purines i.e. meat, oily fish, marmite
How does crystal arthritis present?
acutely painful and unable to weight bear on affected joint
What is Sjogren's Syndrome?
Goes often alongside CTD/RA
Dry eyes and mouth
What is reactive arthritis?
Presents after an infection such as food poisoning or STI
Affects younger patients
What do you do if you suspect someone has RA?
Provide simple analgesia for pain relief
Refer urgently to Rheumatology
What investigations would you do in someone who has RA?
Baseline FBC, LFT, U&E
ESR/CRP - markers of inflammation
TFT - if abnormal can present with joint pain
Rheumatoid Factor and anti-CCP - suggest RA
ANA - suggest CTD
X-Rays of hands and feet - may see RA changes
What would you see on an X-Ray of a patient with RA?
Soft tissue swelling
Loss of joint space
How do you diagnose RA?
Using the American College of Rheumatologist guidelines
Which areas are looked at in the diagnosis of RA?
Number of joints involved - at least 1 must be a small joint
Serology - RF or anti-CCP
Acute phase reactants - CRP or ESR
Duration of symptoms >6 weeks
How do we monitor disease activity in RA?
Disease Activity Score - DAS
Calculated after looking at number of tender joints, number of swollen joints, global assessment of disease activity from 0-100, and ESR/CRP measurement.
When would you use USS in a patient with joint swelling?
If there is clinical suspicion about whether or not swelling is present. USS can identify synovitis and joint effusion as well as bone erosions very sensitively.
How common are extra-articular manifestations of RA?
40% of patients with RA have extra-articular manifestations i.e. dry mouth, lung problems, heart problems, vasculitis, Felty's syndrome, eye problems
What is Felty's Syndrome?
What eye problems do people with RA suffer from?
Differentials for a single hot, swollen joint?
What investigations would you do in someone presenting with a hot swollen joint?
FBC and CRP - infection
U&E - any renal disease
LFT - alcohol damage
Blood cultures - sepsis
Joint aspirate and send for culture, microscopy and gram stain
Basic observations - systemically well or unwell
X Ray joint - look for classical changes
What are the differences on microscopy between gout and pseudogout?
Gout - negatively biferingent needles of monosodium urate
Pseudogout - positively biferingent rhomboids of calcium pyrophosphate
What are differentials for an acute exacerbation of knee pain?
Mechanical disruption I.e. ligaments, meniscus, bursa
Rapidly progressive OA
What are the risk factors for OA?
BMI - the main modifiable risk factor
Previous joint injury
Intense sporting activity
Muscle strength around the joint
Deformities or malalignment
What are the causes of secondary OA?
Joint injury or surgery
IA or Septic Arthritis
Red flags for hip pain in a child?
Constitutional symptoms - ALL
Fever, systemically unwell, hot swollen joint - Septic Arthritis
Changeable history, unusual history regarding mechanism of injury - Non accidental Injury
High fever, non weight bearing - Osteomyelitis
What areas would you want to examine in a child presenting with hip pain?
Perform a hip exam - may be pain on internal rotation
Abdomen including testicles and hernial orifices
Differential Diagnoses for hip pain in a child?
Non accidental Injury
Non MSK causes i.e. testicular torsion
Red flags for back pain
Age <20 or >50
Night or rest pain
Trauma or fracture possibility
Bladder/bowel incontinence or retention
Fever, night sweats, weight loss, anorexia
Weakness or numbness in the legs
History of Ca
What are the most common causes of sciatica pain by age?
<50 - disc prolapse
>50 - spinal stenosis
What investigations should you do in someone presenting with multisystem disease?
Observations and examinations
Urine dipstick - send it for casts if abnormal
FBC, U&E, LFT, CRP, TFT
RF, anti-CCP, ANA, ANCA
X-ray of any areas which appear abnormal
What does a positive p-ANCA indicate?
What does a positive c-ANCA indicate?
What is the diagnostic criteria for EGPA?
Multi-system involvement (>2 organs affected)
What would a CXR show in vasculitis?
GPA - cavities in the lung
What is the most common type of glomerulonephritis associated with vasculitis?
Cresenteric Glomerulonephritis - can present with nephrotic or nephritic syndrome clinically
What are the features of nephrotic syndrome?
Proteinuria, hypoalbuminaemia and oedema
What are the features of nephritic syndrome?
Haematuria, proteinuria, hypertension, oedema, oliguria, uraemia
What is the pattern of inflammatory markers seen in SLE?
What is the significance of extra nuclear antibodies in pregnancy?
Some, such as Ro and La are able to cross the placenta and cause neonatal lupus
May be associated with antiphospholipid syndrome
Which antibodies are associated with SLE?
What is the diagnostic criteria for Fibromyalgia?
Sx (pain) last >3 months
On both sides of the body and above and below the waist
Along the axial spine
Difficulty sleeping and poor concentration/memory
Differentials for Fibromyalgia?
Lymphoma or infection
What investigations should you do if you are suspecting fibromyalgia?
History and exam including trigger points
Widespread pain index score
B12 and Iron studies
What are the extra-articular manifestations of Ankylosing Spondylitis?
AV node block
Apical pulmonary fibrosis