MSK Hx's Flashcards by Csaba Sali

What are the components of HPC for back pain?

O’SOCRATES
- open q, site, onset, character, radiation, associated features, timing, exac/releiving factors & severity
Associated symptoms
- Cord compression
  - waterworks/bowel/weakness/strange sensations down legs/buttocks
  - in men: difficulty gaining erections?
- inflammatory
  - stiff back in the morning & if yes how long lasting?
- constitutional
  - any sig weight loss over the past few months? Appetite? fever/ill? mood?
- ICE
  - what do you think is wrong? whats your biggest concern?

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What conditions should be asked about specifically in back pain Hx for PMH and FH?

PMH
- osteoporosis, arthritis, TB and previous cancer
FH
- ankylosing spondylitis and osteoporosis

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What are the red flag symptoms in back pain Hx?

red flag symptoms = indicative of serious pathology
TUNA FISH
trauma, unexplained weight loss, neurologic symptoms, age >50, fever, IVDU, Steroid Use, History of cancer (prostate, renal, breast, lung)
- cord compression and cauda equina are medical emergencies that should be sought after in the Hx

progressively worsening pain not relieved by rest
age of onset under 20 or over 50 yrs
urinary/foecal incontinence, leg weakness, saddle anaethesia
hx of cancer; weight loss; fever
sever trauma or minor trauma in presence of known osteoporosis

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What are the yellow flag symptoms to watch for in back pain Hx?

yellow-flag symptoms are prognostic of long term disability:
- negative attitude that their back pain is severely disabling
- belief that activity is harmful to recovery
- belief that passive treatment will be beneficial
- depression and social withdrawal
- financial difficulties

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What are the DDx for back pain?

mechanical lower back pain (inc lumbar spondylosis)
prolapsed intervertebral disc
malignancy
cauda equina syndrome
osteoprootic crush fracture
seronagative spondyloarthropathy (HLA-B27-associated conditions)
infection
spinal canal stenosis
non-spinal causes of back pain

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What investigations should be done for back pain hx?

Bedside
back examination and lower limb neuro exam
bloods
bloods- FBC, LTS, U&Es, CRP and ESR
Imaging
If TB suspected: CXR and quantiferon-TB Gold (blood test to recognise TB)
MRI (not needed if Hx suggests uncomp mech back pain)
if cord compression or cauda equina suspected = Urgent MRI/CT scan
If crush fracture suspected = x ray and subs DEXTA scan if a crush fracture is suspected

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What is the management for back pain hx?

Simple back pain inc prolapsed intervertebral disc
- advise to stay active and avoid prolonged bed rest
- physio regular analgesia and consider ST muscle relaxants
serious pathology or red flag sx:
- cord compression = dexamethasone and urgent surgery; radiotherapy in malignancy
cauda equina syndrome
- urgent surgery
ankylosing spondylitis
- NSAIDs
Osteoporosis
- bisphosphonates, vit D and calcium supplements

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What are the S/Sx of mechanical lower-back pain in a back pain Hx?

Usually is a localised pain that worsens with movement and changes in posture
there maybe a hx of trauma/heavy lifting OR it could be spontaneous
there will frequently be a Hx of previous similar episodes over a number of years
no features of systemic illness nor neurological symptoms

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What are the S/Sx of prolapsed intervertebral disc?

Sudden, severe lower back pain often brought on by heavy lifting
nerve-root involvement [most commonly sciatic nerve] classically causes a shooting pain down the leg that extends below the knee with paraesthesia in a dermatomal pattern

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What are the S/Sx of a malignacy in a back pain hx?

Unwell systemically e.g. weight loss and symptoms from primary malignancy
usually of gradual onset with constant pain not relieved by rest
PMHx of malignancy with tendency to metastatise to bone e.g. multiple myeloma, prostatic or breast carcinoma

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What is are symptoms of cauda equina syndrome in a back pain Hx?

Urinary and faecal incontinence
sensory numbness of buttocks and backs of thighs & weakness of the legs [saddle anaesthesia]
the most common causes of cauda equina (things putting pressure on the spinal cord) are malignancy and infection

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What are the S/Sx of osteoporotic crush fracture in a back pain Hx?

Risk factors for osteoporosis
- increasing age
- female sex
- corticosteroid therapy
- premature menopause (<40 years), smoking and malabsorption
sudden localised back pain afer minimal trauma (even a sneeze)[e.g. ask what was happening immediately before the incident/pain]

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What are the S/Sx of seronegative spondyloarthropathy (HLA-B27-associated conditions)? [in joint pain and back pain hx]

ankylosing spondylitis
psoratic arthritis
enteropathic arthritis (from IBD)
reactive arthritis (infection in GU/GI tract)

typically a young male of caucasian origin,

typically asymmetrical oligoarthritis affecting large joints, the spine is frequently involved with sacroiliitis most commonly and enthesitis

Ank spond: 20-40y/o male, blurring of sacroiliac joints, pain, forward bend stiffness, progressive, electric type sciatic pain

morning back stiffness lasting > 1 hour which improves & the pain also with exercise

reduced range of movement of spine with characteristic question mark posture in the late stages

So particularly consider in a Hx of psoriasis/bowel disorders/recent infection

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what are the S/Sx of infection in a back pain Hx?

severe back pain in a systemically unwell patient with fever and night sweats
past history of TB may suggest Potts disease

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What are the S/Sx of spinal canal stenosis?

associated with degenerative changes, so more common in an elderly population
pain brought on by exercise and relieved by rest
patient usually feels more comfortable in a slightly stooped forward position

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what are the non spinal causes of back pain and their S/Sx?

Dissecting aortic aneurysm
- suddent-onset severe ‘tearing’ back pain typically felt between the shoulder blades
Fibromyalgia
- more generalised aches and pains including arthralgia and myalgia
pancreatitis, endometriosis and renal calculi are also rare causes of back pain

What should be asked in HPC of joint pain?

O’SOCRATES
Open q, site, onset, character, radiation, associated features, timing, exac/relieving factors, severity
Associated features = stiffness
- have you noticed any stiffness in your joings when you wake up in the morning? how long does that last for?
Swelling
- swelling/redness/heat in your joints?
extra articular features
- infections,
- rashes,
- enteropathy (diarrhoea),
- uveitis/iritis (peinful or red eyes),
- spondyloarthropathy (back pain/morning back stiffness),
- CTD (mouth ulcers/dry eyes or mouth/painfully cold hands that change colour)

What should specifically be asked about in PMH, DH and FH of joint pain?

PMH
- psoriasis, IBD, STIs, conjunctivitis and uveitis
DH
- specifically thiazides can precipitate gout
FH
- arthritis and clarify what type

What are the DDx for joint pain?

inflammatory [ind by exercise, swelling and heat improving stiffness]
- rheumatoid arthritis
- seronegative spondyloarthropathy (HLA-B27-associated conditions)
- SLE
  - NB: many arthritides are associated with systemic symptoms - extra articular features may provide useful clues as to the underlying pathology
  - also chronic or not e.g. >6w ~RA etc but acute swollen ~different DDx
Non inflammatory
- osteoarthritis
- gout
- fibromyalgia
- spetic arthritis
  - (beware of the acutely hot, swollen joint for ?Sep arth)

What are the investigations for joint pain hx?

Bedside
- examine joints in question and screen other joints; look for evidence of extra articular features e.g. rash, nail changes, gouty tophi, lung fibrosis
Bloods
FBC, U&Es, LFTs, CRP and ESR
- Autoimmune screen if suspecting RA or connective tissue disorder
- blood cultures if suspecting septic arthritis
- if gout suspected –> serum urate
- Acute setting: joint aspiration and synovial fluid analysis for septic arthritis and gout
Investigations
- CXR if possibility of interstitial lung disease

What is the management of joint pain?

physio –> in chronic condition
osteoarthritis = exercise, weight loss, regular analgesia and monitoring
RA - early DMARDS e.g. methotrexate; anti-TNF therapy if conventional DMARDs fail
Gout - treat acute attack with NSAIDs, after acute episode resolution, review precipitating factors and consider allopurinol for long-term prevention
Seronegative spondyloarthropathy
- nsaids, dmards in peripheral arthritis and anti TNF therapy
Lupus
- hydroxychloroquine for mild symptomsl steroids and DMARDs for joint disease; high dose steroids and potent immunosuppressants for end organ disease
Fibromyalgia
- patient education; amitryptyline currently first line medication
septic arthritis
- broad spectrum IV antibiotics

What are the S/Sx of rheumatoid arthritis?

symmetrical polyarthritis that typically causes synovitis in small joints-
- particularly hands and feet although large joints can also be affectee
morning stiffness lasting >1hr
- along with pain that improves with exercise

What are the S/Sx of systemic lupus erythematosus?

Arthrialgia and/or symmetrical small-joint polyarthritis (non-erosive)
typical pt pic: non-caucatian females w/age of early adulthood (20s)
common features include oral ulcers, Raynauds phenomenon, dry eyes and/or mouth, photosensitivity, malar rash, discoid rash, fever and general malaise

What are the S/Sx of osteoarthritis in joint pain Hx?

pain in older patients
- that is worse with exercise and
- at least partially relieved by rest
symmetrical oligo- or polyarthritis
- that most frequently affects hips, knees and hands
Hx of previous injury to the joint and/or obesity (especially for knee OA)

What are the S/Sx of gout in joint pain Hx?

* Triad: joint pain, oedema and erythema * that develops acutely - classically over night * usually it is a large joint monoarthritis affecting the first metatarsophalangeal joint but it can affect any joint and can be polyarticular * Hx of excessive alcohol and red meat consumptions, HTN, renal failure, diuretics and being male!

What are the S/Sx of fibromyalgia in joint pain hx?

* myalgia that can be reproduced over specific trigger points without joint involvement * patient may complain of swelling despite objectively no swelling being present * associated with depression and IBS

What are the S/Sx of septic arthritis in joint pain hx?

* an acutely hot, very painful and swollen joint in an unwell patient with fever * maybe a hx of immunosupression * trauma * unilateral swollen joint with local tenderness and preceding history of injury

What does S2,3,4 do?

S234 keeps 3 p's off the floor pee, poo and penis (without these = Erectyle dysfunction, getting and maintaining)

What is the management of cauda equina?

Cauda equina leads to urinary retention (overflow incontinence) so urinary catherter and pain relief while they get ready for surgery ask if they feel catheter when its in feel anal tone?

What position and where does a slipped disc normally happen?

* Posterio-lateral * L5 so L4/5 most likely prolapse place --\>sciatica

Where do osteoporotic fractures normally occur?

T12

where does the spinal cord terminate?

in adults: L1-2 in babies: L3 then spinal cord continues as corda equina

What is schobers test?

Schober’s test – tests the range of motion in the lumbar spine **10 above PSIS and 5 below --\> 20cm leaning forward** 1. Identify position of the posterior superior iliac spine (PSIS) – “dimples of Venus” 2. Mark the skin in the midline 5cm below PSIS 3. Mark the skin in the midline 10cm above PSIS 4. Ask the patient to touch their toes – full lumbar flexion 5. Measure the distance between the two lines (started at 15cm) Normally the distance between the two marks should increase to \>20cm. Reduced range of motion can indicate conditions such as ankylosing spondylitis

What does the CRAB acronym mean in myeloma?

* C - hyperCalcaemia * R - renal failure * A- anaemia * B - bone pain (esp Back) Ask these as screening q's!

What is spondyloLYSIS vs spondyloLISTHESIS, SpondyLITIS and spondyLOSIS?

LOSIS- degeneration of the intervertebral discs. LYSIS- breakdown LISTHESIS- prolapse disc and wedge fracture LITIS- inflamamtion