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13.04.08 Rheumatology diagnoses

Mechanical injury
  • Characteristics
    • Clear precipitating injury
    • Worse on movement/better with rest
  • Management
    • Short-term
      • NSAIDs
        • Strong e.g. Indomethacin
      • Compound analgesics
      • Neuropathic painkillers (gabapentin etc)
    • Long-term
      • Core strength/stability: Esp. paraspinals, abdominals, gluteals


Ankylosing spondylitis

  • Presentation
    • Slow onset
    • Worse in the morning
    • Better when moving
  • Investigations
    • Bloods
      • ESR, CRP, Plasma viscosity
      • Anaemia of chronic disease
      • Thrombocytosis
      • Raised alk phos
      • Raised ferritin
      • Low albumin
    • MRI
      • Bone marrow oedema on T2: Lumbar spine/sacroiliac joints
  • Management
    • Strong anti-inflammatories
    • Anti-TNF drugs
    • Low impact, non-weight bearing activities
      • Swim, cycle, cross-train


Gout

  • Risk factors
    • CKD, thiazides, HTN
  • 2 stages
    • Acute attacks
    • Chronic arthritis (stiff hands)
  • Management
    • Titrate uric acid to 300 uM with allopurinol
      • Tophi should dissolve
    • Uricase analogues (pegloticas, rasburicase)


de Quervain's tenosynovitis

  • Presentation
    • New mother - frequent lifting
    • Pain, tenderness, and swelling over the thumb side of the wrist
    • Difficulty gripping
  • Aetiology
    • Tenosynovitis of extensor pollicis brevis and abductor pollicis longus tendons
  • Finkelstein's test
    • Grasp the thumb and sharply ulnar deviate the hand
    • If sharp pain occurs along the distal radius, DeQuervain's tenosynovitis is likely
  • Management
    • Hydrocortisone injection
    • Topical or oral anti-inflammatory (But poor tendon penetration)
    • Splint


Tennis elbow

  • Diagnosis
    • Clinical +/- USS
    • Enthicitis
  • Management
    • Steroid injection (max. once every 3 months)
    • Oral/topical analgesia
    • Behaviour/technique modification 


Proximal myopathy

  • Aetiology
    • Endocrine
      • Hypo/hyper -thyroid
      • Cushing's
      • Addison's
    • Inflammatory
      • PMR
    • Genetic
      • Muscular dystrophy (may not present until adulthood)
    • Metabolic
      • Low vitamin D
      • Alcohol


Pathological fracture

  • Primaries
    • Breast
    • Bung
    • Byroid
    • Brostate
    • Bidney
    • + Steroids (Osteoporosis)
  • Investigations
    • MRI of vertebral body
      • Tumour will be obvious, Osteoporosis looks normal


Rheumatoid arthritis

  • Presentation
    • Slow onset
    • Worse in the morning
    • Symmetrical
    • Small joints
  • Differentials
    • Psoriatic arthritis
      • NB has many different mimicking patterns:  Ank Spond, OA..
    • Lupus
    • Sjögrens
  • Investigations
    • Standard chronic inflammatory screen
    • RF
    • Anti-CCP
      • Can precede symptoms by many years
      • Very specific


Temporal arteritis

  • Presentation
    • Subacute/acute onset
    • >55 years old
  • Signs
    • Inflammation limited to head + neck
    • Beading of temporal artery (may be palpable)
  • Management
    • Steroids
      • High-dose for GCA (60 mg) / Low-dose for PMR
    • Vitamin D
    • Bone protection


Lupus

  • Typical presentation
    • Jamaican
    • Hair falling out
    • Dry mouth
    • Mouth ulcers
    • Facial rash and scars
    • Serositis
      • Pleura, Pericardium, Peritoneum
    • Fatigue
    • Renal disease
    • Raynaud's


Raynauds

  • Classical/True Raynauds:
    • White initially
      • Spasm of arterioles + venules
    • Dusky blue later
      • Venules relax first
      • Back-flow of deoxygenated blood => Blue colour
    • Very red later
      • Reactive hyperaemia
    • Affects just the digits
      • Palms spared
      • Thumb sometimes spared
  • Raynauds phenomenon
    • Stand-alone
    • Starts in teens
    • Mild
    • Need a big trigger
  • Raynauds disease
    • Raynauds in the context of a disease
      • Scleroderma
      • Lupus
      • Sjögrens
      • Myositides
    • Starts later
    • More serious
    • Requires only a small trigger
    • Always ANA positive


Notes
  • RA and gouty nodules are clinically indistinguishable
    • Except gouty nodules may appear yellow if very superficial
  • Be careful of NSAIDs!
    • Asthma/COPD, Kidneys, GI
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