DVT Gradual onset, painful (improved with legs raised) Red, swollen, hot, tender leg Compartment syndrome Recent trauma or surgery POP Severe pain on passive movement Increased compartment pressure Joint Trauma, pain on movement, unable to bear load Tender over joint, joint eff usion, pain on movement (active = passive) Abnormal X-ray (eg arthritic changes); abnormal synovial fl uid Muscle Trauma, pain on movement Tender swelling on muscle/tendon insertion, pain on movement (active >passive) Normal X-rays, may have a iCK Bone Trauma, pain on movement and at rest Bony tenderness with swelling and reduced range of movement Abnormal X-ray Cause of limb pain covered elsewhere b p424 b p356 b p412 b p448 b p450 b p441 b p452 b p411 \200\223419 b p413 b p434 Ulcers Back pain/sciatica Cellulitis Chronic limb pain DVT Swelling Joint pain Rashes Necrotising fasciitis Trauma 3Acute limb ischaemia This is an emergency; ischaemia is irreversible after 6h. Worrying si gns dsensation; purple, non-blanching mottling. Causes emboli, thrombosis, dissecting aneur ysm, trauma. Risk factors arterial graft, peripheral vascular disease, previous thrombo- em boli, AF, prosthetic heart valves, recent MI, dehydration, malignancy. Symptoms unilateral painful, tingling, weak limb, worse on raising limb. Signs absent pulses, slow cap refi ll (compare with opposite limb), cold and pale (can be red if limb below heart), reduced power and sensation. Investigations a hand-held Doppler probe will show a reduced or absent puls e; angiography may demonstrate an obstruction. Treatment this needs urgent surgery \200 \223 call a senior surgeon who will consider embolectomy, intra-arterial thrombolysis, bypa ss or amputation. Give 15l/ min O2 and analgesia (eg morphine); IV access with IV fl uids i f dehydrated; may require heparinisation (b p406) pre- or post-op. Complications amputation , gangrene, iK+, renal failure, sepsis. OHFP.indb 446 OHFP.indb 446 30/05/2014 16:18 30/05/2014 16:18 447 ACUTE LIMB PAIN 3Gas (wet) gangrene This is an emergency; Clostridium infection causing necrosis and sepsis . Symptoms unwell with painful extremities or wound. Signs pyrexia, shock, tender brown/bla ck area with blistering and oedema, muscle necrosis, crepitus (from gas in tissue). Risk fa ctors ischaemia, DM, malignancy, surgery/trauma. Investigations blds FBC, U+E, LFT, CRP, CK , blood cultures, clotting; ABG acidosis; Gram stain of pus or necrotic tissue; X-ray may s how gas (dark patches in soft tissues). Treatment call a senior surgeon who will consider u rgent debridement. Give 15l/min O2, fl uids and broad-spectrum antibiotics (eg benzylpenici llin 2.4g/4h IV, clindamycin 600mg/6h IV, and metronidazole 500mg/8h IV). Complications amp utation, sepsis, death. Dry gangrene Ischaemic muscle necrosis without infection. Signs wel l-defi ned, painless, shriveled brown/black area. Treatment debridement or amputation may h elp prevent infection; alternatively conservative management awaiting autoamputation. Compl ications wet gangrene. 3Compartment syndrome This is an emergency; call a senior surgeon if suspected. Symptoms excessive pain following an injury or fracture, distal tingling, numbn ess or weakness. Signs pain at rest, worse on passive stretching of a muscle, reduced sensa tion (loss of two point discrimination), redness, swelling, slow cap refi ll; absent pulse and pallor are late signs. Risk factors long bone fractures and plaster casts, signifi cant injury, crush injury, vascular injury, anticoagulants, burns. Investigations clinical diag nosis; blds FBC, U+E, CK, clotting; it is possible to measure compartment pressure by inser ting a manometer through the skin (eg Wick catheter), pressures >30mmHg indicate need for u rgent fasciotomy, although some surgeons advocate avoiding intervention if compartment pres sure is 20mmHg of diastolic pressure. Treatment 15l/min O2; elevate limb (lie the patient fl at); ensure adequate analgesia; IV fl uids if dehydrated (monitor urine output); remove plaster cast if present; discuss with surgeons regarding urgent fasciotomy. Complications rhabdomyolysis, iK+, neurological damage, amputation. Osteomyelitis Risk factors DM, immuno compromise, open fractures, prostheses. Symptoms fever, bone pain, malaise (or fever withou t focus). Signs bony tenderness, warm, red, swollen. Investigations blds iWCC, iESR, iCRP, blood cultures; imaging X-ray (insensitive since there are rarely changes in the fi rst 10d ), USS (may show periosteal lifting), MRI (gold standard); bone biopsy where indicated. Cul ture try to obtain a sample for microbiology prior to starting antibiotics (by swabs, USS-g uided aspiration or bone biopsy in theater). Treatment high-dose antibiotics (discuss with microbiology) for at least 6wk; often requires central access; surgical drainage of abscess if present. Complications septic arthritis, fracture, amputation, seeding to other sites. _OHFP.indb 447 _OHFP.indb 447 30/05/2014 16:18 30/05/2014 16:18 448 CHAPTER 15 Emergency department Chronic limb pain Peripheral arterial disease (PAD) Chronic limb ischaemia causes intermittent claudication/c ritical ischaemia. \200 Intermittent claudication cramp in calf, thigh or buttock on walk ing a fi xed distance, worse uphill, relieved by stopping or rest Critical ischaemia pain in limb at night, relieved by hanging legs out of bed; arterial ulcers, dry gangrene. Signs early cool, hairless, pulseless limbs; late pain and pallor on elevation. Investigati ons blds FBC, U+E, lipids, ESR; ECG; ABPI (ankle brachial pressure index, see box); imaging CT or Doppler arteriography. Treatment address vascular risk factors (exercise, stop smoki ng, treat DM, iBP and icholesterol); aspirin 75mg/24h PO, avoid B-blockers; refer to vascul ar team for consideration of angioplasty or bypass graft. g Complications acute ischaemia, gangrene, rest pain, ulcers. , g , p , p Ankle brachial pressure index (ABPI) With the patient lying fl at, a Doppler probe is used to record the systolic BP (ie lowest pressure at which the pulse is occluded) in each arm ( cuff around upper arm, probe over brachial artery) and twice in each leg (cuff around calf, probe over posterior tibial and dorsalis pedis). The result is expressed as a ratio of the highest ankle pressure for each leg, to the highest brachial pressure. Example: left ankle posterior tibial pressure of 126, dorsalis pedis pressure of 124, brach ial pressures of 138 and 142; ABPI = 126/142 = 0.89 0.8 \200\2231.3 Moderate PVD Normal 0.5 \200\2230.8 Severe PVD <0.5 Calcifi cation >1.3 Lumbar spinal stenosis Symptoms cramp in thigh or leg on walking, worse on walking downhill or standing, associated back pain. See Table 15.5. Signs pain on straight leg raise/back e xtension, often no neuro symptoms. Investigations lumbar spine X-ray and MRI spine. Treatme nt exercise, NSAIDs, steroid injections, spinal decompression. Complications cord compressi on, cauda equina syndrome (b p357). Table 15.5 Nerve entrapment syndromes Symptom Syndrome Aching of wrist and forearm, tinglin g of Carpal tunnel syndrome (median) thumb, index, middle, ring fi nger Tingling of ring and little fi ngers, forearm Weak extension of fi ngers and thumb Ulnar entrapment (wrist or elbow) Radial tunnel syndrome or posterior interosseous syndrome Meralgia paraesthetica Common peroneal compression Tingling lateral thigh Weak dorsifl exion of foot Chronic limb pain covered elsewhere b p454 b p355 b p424 b p455 Gout b p357 Sciatica/radiculopathy Analgesia in chronic pain b p86 Osteoarthritis Peripheral neuropathy Limb ulcers OHFP.indb 448 OHFP.indb 448 30/05/2014 16:18 30/05/2014 16:18 449 LIMB SWELLING Limb swellingg Worrying features weight loss, night sweats, pain, hard irregular lump, vomi ting, SOB and chest pain. Think about causes depend upon site (Table 15.6). Table 15.6 Clinical assessment of limb swelling Pitting Bilateral: congestive cardiac failure, nephrotic syndrome, renal failure, dalbumin, early l ymphoedema, venous insuffi ciency, trauma, SVC/IVC obstruction (arms/legs) Unilateral: cell ulitis1, deep vein thrombosis, early lymphoedema, venous insuffi ciency, trauma Non-pitting Bilateral: chronic congestive cardiac failure, lymphoedema, chronic venous insu ffi ciency, trauma, compartment syndrome Unilateral: lymphoedema, chronic venous insuffi ci ency, trauma, compartment syndrome 1 The diagnosis of bilateral cellulitis is a rare one, and more usually represents a misdia gnosis (eg elderly with CCF, venous insuffi ciency and venous stasis eczema). Ask about swelling location, onset, duration, redness, warmth, pain (severity, radiation), associated rash, history of trauma, insect bites/stings; systemic symptoms nausea and vomit ing, pyrexia, sweating, weight loss; PMH recent operations, fractures or immobility, cancer ( radiotherapy), DM, IBD, IHD, polycythaemia, thrombocytosis, thyroid disease; DH COCP/HR T, steroids, amlodipine, drug allergies; SH recent long distance travel, alcohol, smoking. Obs temp, HR, BP, RR, sats, urine output, blood glucose. Look for swollen limb: site, size, shape, color, tenderness and tempera- ture of swelling, evidence of trauma, skin breaks be tween toes (for leg cel- lulitis), nail condition, tortuous veins; systemic evidence of mal ignancy (eg cachexia, abdominal/rectal mass, clubbing, lymphadenopathy); evidence of chroni c liver disease (b p313, eg ascites, jaundice, spider naevi); surgical scars (eg previous m astectomy/axillary clearance), evidence of cardiac failure (b p282, bibasilar creps, wheeze ); in 5: gravid uterus, consider PV tenderness, palpable masses. Investigations target acco rding to likely causes (see following sections). Lymphoedema (OHGP3 b p1039) Accumulation o f interstitial fl uid due to abnormal lymphatic drainage; may be congenital, or secondary t o surgery, radiotherapy, malignancy or fi lariasis. Symptoms limb swelling, reduced mobilit y, recurrent infections. Signs acute lymphoedema may be pitting, but as it becomes more chr onic the tissues become woody and pitting is less likely. Chronic oedema from congestive ca rdiac failure can also become woody and non-pitting. Risk factors female sex, malignancy, b reast cancer surgery (especially axillary node clearance), radiotherapy, family history, ob esity. Treatment medical elevation of the limb, compression bandages, massage of the limb i n a proximal direction (to aid fl uid return), exercise, weight loss, antibiotics if 2 \232 skin infection present; no evidence for use of diuretics; surgical excisional techniques a vailable, but radical. Complications cellulitis, ulcers, psychological problems, pain. _OHFP.indb 449 _OHFP.indb 449 30/05/2014 16:18 30/05/2014 16:18 450 CHAPTER 15 Emergency department Deep vein thrombosis1,2 (OHCM9 b p580) Symptoms unilateral swelling and/or pain. Signs warm , red, tender, swollen limb (eg leg >3cm compared to other calf measured 10cm below tibial tuberosity), pitting oedema. Risk factors age >60yr, obesity, recent surgery/immobility/lon g distance travel, estrogen (pregnancy, HRT, OCP), PMH or FH PE/DVT, malignancy, thrombophi lia, medical comorbidity (eg CCF, IBD, active infl ammation). Investigations blds FBC, U+E, D-dimer (see box). Assess the DVT prob- ability (risk score Table 15.7 D-dimer) to deter mine the need for further investigation with Doppler ultrasonography.3 If suspected PE (b p 278), perform ECG and consider ABG. Treatment Commence parenteral anticoagulation (eg enoxa parin 1.5mg/ kg/24h SC) if USS +ve or delayed >4h. If confi rmed DVT, start oral anticoagul ation (b p407). g) Complications PE, post-thrombotic syndrome (chronic pain and swelling). y , p ( p p Pre-test probability in DVT Symptoms and signs of DVT are non-specifi c; likewise, the much over-ordered D-dimer blood test is a non-specifi c marker of thrombosis. The application o f clinical scoring systems, which combine established risk factors with reliable clinical f i ndings, allow the identifi cation of low-risk patients, in whom a negative D-dimer has a robust negative predictive value. In higher risk patients, Doppler ultrasonog- raphy is jus tifi ed, regardless of the D-dimer assay result. The Wells score has proven to be clinicall y reliable and is widely used in modifi ed 2 level form.4 The following measures score 1 point each if present: \200 Active cancer (treatment ongoing or in past Pitting oedema \200 Tenderness along veins \200 Whole leg swollen \200 >3cm calf swel ling (cf other calf ). 6mth, or palliative) Leg paralyzed or in plaster \200 Recent bed rest >3d or major surgery within 12wk \200 Previous documented DVT \200 Visible collateral superfi cial veins (non-varicose) Subtrac t 2 points if there is another diagnosis that is as or more likely (eg cellulitis). Table 1 5.7 The 2 level DVT Wells score Score Risk of DVT Unlikely (5.5%) \211 1 Likely (28%) \211 2 Management5 D-dimer test, if +ve USS, if \200\223ve unlikely to be DVT Arrange USS; LMWH i f delay in USS >4h Where risk score \211 2 but USS -ve, perform D-dimer test: if +ve, repeat USS in 6 \200 \2238d. 4 Wells, P.S. et al. NEJM 2003 349:1227 (available free at (cid:27)NEJM.org); a goo d overview of the use of clinical scoring alongside further tests is Scarvelis, D. et al. C MAJ 2006 175:1087 available free at (cid:27)www.ncbi.nlm.nih.gov/sites/ppmc/articles/PMC160 9160 5 Most hospitals will also have their own guidelines which you should consult, particularly regarding logistics of arranging USS through ambulatory pathways. Venous insuffi ciency Symptoms bursting/throbbing leg pain, relieved by elevating legs, wor se on standing; previous DVT or thrombophlebitis. Signs pain d by lifting legs, red discolo uration, swelling, varicose veins. Investigations Duplex ultrasound, D-dimer if DVT suspect ed. Treatment compression bandages (if ABPI >0.8), varicose vein surgery. Complications var icose veins, thrombophlebitis, ulcers, cellulitis. 1 See also thromboprophylaxis, b p406; N ICE guidelines at (cid:27)guidance.nice.org.uk/CG92 2 NICE DVT/PE guidelines at (cid:27)gui dance.nice.org.uk/CG144 3 Most radiology departments will only scan the leg veins above the knee, since below knee DVTs carry a much lower risk of PE; there is a low risk (1 \200\223 2%) of clot extension into more proximal veins \200\224for this reason, in those with a hig h pre-test probability, a positive D-dimer and a negative Doppler USS, consider repeat Dopp ler USS at 1 \200\2232wk. OHFP.indb 450 OHFP.indb 450 30/05/2014 16:18 30/05/2014 16:18 451 LIMB SWELLING Post-cannula swelling Tissuing is where an IV cannula has not been inserted correctly and i s sited only partially in the vein or outside the vein altogether, meaning that fl uid or d rugs cannot be infused/injected. Treatment remove cannula and re-site if required, elevate the aff ected limb and give simple analgesia for pain. If no improvement consider possibili ty of infection of cannula site (b p412); assess swelling for collection \200\223 if in do ubt request USS \200\223 if present, start IV ABx (eg co-amoxiclav 1.2g/8h IV) and discuss drainage with surgeons. Baker \200\231s cyst Symptoms pain and swelling behind the knee, may radiate to calf; simil ar to symptoms of DVT, common in osteoarthritis. Signs fl uctuant swelling in the popliteal fossa; can also have calf swelling. Investigations distinguishable from DVT by USS. Treatm ent conservative (NSAIDs, ice packs). Angioedema Episodic subcutaneous and submucosal oedema, 2 \232 to ivascular permeability oc curring in hereditary, idiopathic, drug-induced and antigen-driven forms. Symptoms colicky abdominal pain, shortness of breath (laryngeal oedema), dysphagia, watery diarrhea, pruritu s (in antigen-driven cases). Signs well demarcated swelling (eg hands/feet/face), dyspnoea stridor (if largyngeal/tongue swelling leads to airway compromise), urticaria. Investigat ions diagnosis made clinically; blds itryptase (from mast cell degranulation) if reaction w as anaphylactic, dcomplement levels help confi rm diagnosis (see Anaphylaxis b p470). Tre atment assess airway \200\223 if any concerns 3request immediate senior help since IM adre naline (0.5ml (0.5mg) 1:1000 adrenaline STAT) and urgent intubation may be required; nebuli sed salbutamol (5mg NEB STAT) or nebulised adrenaline (5ml (5mg) of 1:1000 adrenaline) may also help; give antihistamines (eg chlorphenamine 10mg IV STAT) and steroids (eg hydrocorti sone 200mg IV STAT). Identify and stop any likely precipitant (eg new ACEi) and avoid in fu ture; request C1 esterase inhibitor assays and consider referral to an immunologist if seve re/fre- quent episodes and precipitating cause not clear (androgens, tranexamic acid and FF P are all used to prevent attacks in hereditary angioedema). Limb swelling covered elsewhere b p412 b p373 b p376 b p316 b p470 Cellulitis Compartment syndrome b p447 Nephrotic syndrome Heart failure Pre-eclampsia SVC o bstruction Renal failure b p282 b p504 b p283 Cirrhosis Anaphylaxis _OHFP.indb 451 _OHFP.indb 451 30/05/2014 16:18 30/05/2014 16:18 452 CHAPTER 15 Emergency department J Joint pain Worrying features fever, weight loss, severe pain, rashes. p Think about emergency septic arthritis; polyarthritis rheumatoid, osteoarthritis, ankylosin g spondylitis, psoriatic arthritis, connective tissue disease (eg SLE), reactive arthropath y, rheumatic fever, polymyalgia rheu- matica, IBD; monoarthritis septic arthritis, trauma, crystal arthropathy (gout, pseudo-gout), monoarthritic presentation of polyarticular diseas e, leukemia, endocarditis, sickle-cell, hemophilia. Ask about description of pain site, rel ieving/exacerbating actions, duration, other joint involvement; in \202 ammatory symptoms morning stiff ness, pain that improves with exercise but not rest, alternating buttock pain , nocturnal pain during 2nd half of night only; systemic fever, night sweats, weight loss, nausea, rashes, altered bowel habit, mouth ulcers, dysuria, visual disturbance, dry eyes or mouth, trauma; PMH joint pain, gout, hemophilia, sickle-cell, trauma, IBD, heart problems; DH steroids, anticoagulants, thiazide diuretics; FH joint disease, IBD; SH occupation, mob ility, help at home, change in lifestyle due to symptoms. Obs temp, HR, BP. Look for see b p146 \200\223152 for specifi c joint examinations; always check the joint above and below; look resting position/deformity, swelling, rashes, erythema; feel warmth, tenderness, nodul es; move reduced range of move- ment (passive and active), crepitus; systemic fi nger clubb ing, psoriasis (check nails and scalp), enthesitis (tenderness at tendon insertions eg Achi lles), muscle tenderness, back fl exion, sacroiliitis (pain on pelvic squeeze), gait, ulcer s, lymphadenopathy, hepatomegaly, splenomegaly. Investigations blds FBC, U+E, CK, CRP, ESR, RhF, ANA; also consider: sickle-cell, urate, anti-dsDNA, complement titres, antiphospholip id anti- bodies; urine dipstick send for casts; imaging X-ray aff ected joints; joint asp iration (M,C+S, crystals). Classi \201 cation of rheumatological disease Systemic rheumatic disease Infl ammatory dis eases aff ecting joints, with multiple extra-articular manifestations; autoantibodies aid c lassifi cation but role in pathogenesis unclear. Examples include rheumatoid arthritis, SLE , myositis, scleroderma, mixed connective tissue disease. Spondylarthropathies (seronegativ e arthopathies) Group of chronic disorders with infl ammation of the sacroiliac joint (sacr oiliitis), vertebrae (spondylitis). All are associated with HLA-B27; serum rheumatoid facto r is usually negative (hence \200\230seronegative \200\231). Includes ankylosing spondylit is, psoriatic arthritis, reactive arthritis and enteropathic arthopathies. Vasculitis Infl ammatory destruction of blood vessels; may be 2 \232 to other infl ammatory or infectious c onditions; 1 \232 forms include giant-cell arteritis, Churg \200\223Strauss syndrome, Beh et \200\231s disease, polyarteritis nodosa, Wegener \200\231s granulomatosis. Crystalline a rthropathy Crystal deposition in joints seen in gout and pseudogout; usually mono/oligoarti cular. Infectious arthritis Joint infection, seen in septic arthritis; often occurs in alre ady damaged joint. Also seen in disseminated gonococcal infection. OHFP.indb 452 OHFP.indb 452 30/05/2014 16:18 30/05/2014 16:18 453 JOINT PAIN Table 15.8 Common causes of joint pain History Examination Investigations iESR, +ve RhF, erosive changes Rheumatoid arthritis Infl amed, swollen joints, early deformity Non-infl amed, dROM Symmetrical; typically hands and wrists; malaise Osteoarthritis Chronic onset; Normal blds; joint space narrowing, osteophytes iWCC/CRP/ ESR, +ve culture Urate crystals o n joint aspirate typically in hands, hips and knees Fever, single joint, rapid onset Acute onset, severe sin gle joint pain Gradual onset, single joint pain Elderly, symmetrical shoulder/pelvic pain B ack pain, stiff ness, young male Lower limb pain, dysuria, eye pain Septic arthritis Tender, swollen, hot, red, unable to move Red, tender, swollen, tophi Red, tender, swollen CPP crystals on Gout Pseudo-gout joint aspirate iiESR, iALP Polymyalgia rheumatica Ankylosing spondylitis Reactive arthritis Muscle tenderness, pain on movement dBack fl exion and chest expansion Infl amed joints, co njunctivitis, keratoderma blennorrhagica iESR, \200\223ve RhF, HLA-B27 +ve iESR, \200\223ve RhF, X-ray normal; throat/genital swab s for eg chlamydia iESR, \200\223ve RhF, erosive changes Psoriatic arthritis SLE Psoriasis, variable joint involvement Psoriasis, nail changes, dactylitis Malar rash, ulcers ANA, dsDNA +ve, dHb, dWCC, iESR/CRP iESR/CRP, ASOT +ve Fever, malaise, weight loss, rash, lethargy Sore throat, migratory joint pain, rash, fever Migratory arthritis, abdo pain, diarrhea, PR bleeding Weight loss, bruising, weakness Dacty litis in children, septic arthritis all ages Sudden onset, single joint in children Murmur, chorea, nodules Rheumatic fever Abdo tenderness, erythema nodosum Distinctive colonoscopy IBD iiWCC, dHb Leukemia Petechiae, bruises, lymphadenopathy Swollen, hot, tender monoarthritis Sickle-cell positive, dHb Sickle-cell iAPTT, dfactor VIII or IX Haemarthrosis, tender, swollen Hemophilia Causes of joint pain covered elsewhere b p434 b p447 b p397 b p396 b p309 b p405 Trauma Leukemia Osteomyelitis Sickle cell IBD Hemophilia _OHFP.indb 453 _OHFP.indb 453 30/05/2014 16:18 30/05/2014 16:18 454 CHAPTER 15 Emergency department Rheumatoid arthritis1 Chronic infl ammatory disease causing symmetrical peripheral arthriti s and systemic manifestations; associated with considerable morbidity and mortality. Common joints PIP, MCP and MTP joints, wrist, elbow, knee, ankle. Risk factors female sex (but wo rse prognosis in males), family history. Symptoms morning stiff ness, malaise, fatigue, mil d fever, weight loss. Signs swelling, redness, hand deformity (Swan neck or Boutonni re de formi- ties and ulnar deviation of fi ngers; Z-deformity of thumb), nodules (elbows). Inves tigations blds dHb, normal MCV, iESR, Rh factor +ve (80%), ANA +ve (30%); X-ray erosions, c ysts, osteopenia, narrow joint space, deformity. Treatment analgesia, NSAIDs, exercise, phy siotherapy, corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs) eg sulfasalazi ne, methotrexate, azathioprine, ciclosporin should be started at diagnosis ideally in combi nation, biological therapies (anti-TNFA eg infl iximab), surgery (reconstructive, synovecto my, joint replacement, fusion). Flare ups analgesia, splinting, corticosteroids (oral or in tra-articular). Complications joint destruction, septic arthritis, antiphospholipid syndrom e. Systemic manifestations MI, pericardial or pleural eff usions, pulmonary fi brosis, Sj gren syndrome (dry eyes and mouth), episcleritis, nerve entrapment (b p448), vasculitis, Fe lty syndrome (splenomegaly + neutropenia). American College of Rheumatology diagnostic classi \201 cation \211 4 of the following fo r \211 6wk supports a diagnosis of rheumatoid arthritis \200 Morning stiff ness >1h \200 Symmetric arthritis \200 Rheumatoid nodules \200 +ve rheumatoid factor Arthritis of \211 3 left or right PIP, MCP, wrist, elbow, knee, ankle, and MTP joints \200 Arthritis of \211 1 of PIP, MCP, wrist joints \200 Typical radiographic changes Osteoarthritis2 Common joints knees, hips, spine, DIP and PIP joints. Risk factors age, fem ale sex, previous trauma, obesity. Symptoms pain worse with activity, stiff ness on resting . Signs initially none; eff usion, deformity, reduced range of movement. Investigations bld s normal; X-ray loss of joint space, subchondral scle- rosis, bone cysts and osteophyte for mation. Treatment exercise (especially strengthening of muscles near aff ected joints), wei ght loss, walking aids, analgesia (b p86, eg paracetamol, NSAIDs (topical before PO), COX-2 inhibitors), steroid/local anesthetic joint injections; joint replacement if refractory to medical therapy. Complications disability, immobility, chronic pain, joint destruction. Po lymyalgia rheumatica Symmetrical myalgia aff ecting muscles of neck, shoulder, hips or thig hs. Risk factors >50yr, female sex, giant-cell (temporal) arteritis. Symptoms bilateral mor ning pain and stiff ness in proximal muscles lasting >1h, weight loss, fatigue, malaise, de pression, mild fever. Signs muscle tenderness, normal power; drange of movement (from pain) . Investigations blds iiESR (typically >50mm/h), iCRP, iALT, iALP, dHb, normal MCV, normal CK; temporal artery biopsy if suspect giant cell arte- ritis (b p361). Treatment prednisolo ne 20mg/24h PO, gradually reduced (over months). 1 NICE guidance available at (cid:27)guida nce.nice.org.uk/CG79 2 NICE guidance available at (cid:27)guidance.nice.org.uk/CG59 OHFP.indb 454 OHFP.indb 454 30/05/2014 16:18 30/05/2014 16:18 455 JOINT PAIN 3Septic arthritis Common joints single knee or hip. Risk factors joint disease, prosthetic joint, immunosuppression, iage, DM, trauma. Symptoms acute onset painful joint, swelling, f ever. Signs swollen, hot, tender, red, painful joint, often held slightly fl exed, drange o f movement. Investigations blds iWCC, CRP and ESR, +ve blood culture; joint aspira- tion iW CC, organisms on Gram stain, +ve culture; X-ray as baseline. Organisms staphylococci, Strep tococcus pyogenes; Gram \200\223ve bacilli or fungi in elderly or debilitated; TB. Treatme nt analgesia, urgent orthopedic referral, high-dose IV antibiotics for \211 6wk (eg co-amo xiclav 1.2g/8h IV) after diagnostic joint aspiration; may need repeated aspiration/surgical washout. Complications joint destruction, 2 \232 osteoarthritis, septicaemia. Gout (urate crystal arthropathy) Common joints monoarticular in 90%: eg great toe MTP, ankle, knee. Ris k factors iage, male sex, thiazide diuretics, red meat, alcohol. Symptoms acute onset painf ul joint, fever; drange of movement. Signs swollen, hot, tender, red, painful joint; chro nic tophi (white/yellow or skin colored nodules of urate) over Achilles, elbow, knee or ear . Investigations exclude septic arthritis; blds iWCC/ESR/CRP; joint aspiration \200\223ve birefringent needle-shaped crystals; X-ray normal. Treatment acute attack rest, high fl uid intake, reduce thiazide diuretics, alcohol and red meat, NSAIDs (eg diclofenac 50mg/8h PO) or ster- oids (eg prednisolone 40mg/24h PO for 3d, then tapered over 3wk); avoid colchicin e (causes diarrhea); recurrent attacks allopurinol (100mg/24h PO) reduces urate levels; do not start during acute attacks. Pseudo-gout (calcium pyrophosphate crystal arthropathy) Com mon joints mono/oligoarticular: knee, wrist, hips. Risk factors age, family history, trauma , haemochromatosis. Symptoms and signs are similar to gout, though less intense. Investigat ions exclude septic arthritis; blds iWCC/ESR/CRP; joint aspira- tion weak +ve birefringent rhomboid-shaped crystals; X-ray calcifi cation. Treatment rest; NSAIDs (eg diclofenac 50mg/ 8h PO); intra-articular or oral steroids (eg prednisolone 40mg/24h PO for 3d, then tapered over 3 weeks); no eff ective prophylactic treatment. Ankylosing spondylitis Common joints s acroiliac, spine. Risk factors male sex, HLA-B27. Symptoms back pain worst at night, mornin g stiff ness >1h, heel pain. Signs fi xed spinal kyphosis, restricted chest expansion, heel tenderness (enthesitis), pain on loading sacroiliac joints; uveitis. Investigations blds i WCC/ESR/CRP, \210\222ve RhF, HLA-B27 (92%); X-ray spinal and sacroiliac erosions, squared vertebrae, syndesmophytes (ossi- fi ed edges of vertebral disks), fusion of spine (bamboo s pine). Treatment exercise; NSAIDs, sulfasalazine, biological therapies (anti-TNFA eg infl i ximab); spinal surgery. Complications spinal fusion, aortic regurgitation, pulmonary fi bro sis, restricted ventilation. _OHFP.indb 455 _OHFP.indb 455 30/05/2014 16:18 30/05/2014 16:18 456 CHAPTER 15 Emergency department Reactive arthritis1 Arthritis developing 2 \200\2234wk after genitourinary or gastrointesti nal infection. Common joints asymmetrical aff ects large joints eg knee, ankle, hips. Organ isms triggers include Chlamydia, Campylobacter, Shigella and Salmonella. Risk factors HLA-B 27. Symptoms recent diarrhea or genitourinary infection; regardless of trigger, initial sym ptoms are often dysuria and urethral discharge; acute asymmetrical oligoarthritis with mala ise, fatigue fever; heel pain, gritty eyes. Signs bilateral conjunctivitis, swollen joint s, tender tendon insertion points (enthesitis), genital ulceration, nail thickening; vesicl es, pustules or plaques on genitals, palms or soles of feet (keratoderma blennorrhagica). I nvestigations blds iWCC/ESR/CRP, \200\223ve RhF and \200\223ve ANA; X-ray ini- tially nor mal; consider stool/throat/genital swabs for causative organism. Treatment NSAIDs, rest, in tra-articular or oral steroids; sulfasalazine or methotrexate if severe; 1% chloramphenicol ointment/6h for eyes; doxycycline 100mg PO/12h for 3mth if caused by Chlamydia. Complicati ons recurrent/chronic arthritis, ankylosing spondylitis (5%). Enteropathic arthopathies These rheumatological diseases are seen in the context of bowel i nfl am- mation, such as IBD, or after a gastrointestinal infection. All share an asso- ciat ion with HLA-B27 and highlight a fascinating but poorly understood gut \200\223joint immuno logical axis. Sacroiliitis, spondylitis, and asymmetrical hip or knee infl ammation are acc ompanied by enthesitis (infl ammation of points of insertion of tendons/ligaments into bone ). Treatment of any underlying condition improves the arthritis. Psoriatic arthritis (see also b p417) Common joints fi ve distinct patterns of disease: \200 Asymmetrical oligoarthritis (often fi ngers/toes + fl exor tendons) \200 Symmetrica l polyarthritis (may resemble rheumatoid but involves DIP) \200 Spondylitis sacroiliiti s (may resemble ankylosing spondylitis) \200 Asymmetric DIP arthropathy with nail changes \200 Arthritis mutilans (widespread destruction of joints of hands). Risk factors psoria sis (joint symptoms may present fi rst), family history. Symptoms vary with pattern; skin c hanges (of any form of psoriasis). Signs nail ridging, pitting and lifting (onycholysis); p soriasis (check scalp, perineum, umbilicus); enthesitis, dactylitis (swollen fi ngers). Inv estigations blds iWCC/ESR/CRP, \200\223ve RhF and ANA; X-ray mild erosive changes especial ly in hands; osteopenia less extensive than rheumatoid. Treatment rest, splinting; treat sk in lesions (b p417); NSAIDs, intra- articular or oral steroids, methotrexate, ciclosporin; biological therapies (anti-TNFA eg infl iximab); reconstructive surgery. Complications join t destruction, immobility, antiphospholipid syndrome. 1 The term \200\230Reiter \200\231s syndrome \200\231 is to be avoided, in light of the in volvement of Hans Reiter (1881 \200\2231969) in the Nazi party, eugenics and research in concentration camps. OHFP.indb 456 OHFP.indb 456 30/05/2014 16:18 30/05/2014 16:18 457 JOINT PAIN Systemic lupus erythematosus (SLE) Chronic, relapsing-remitting, multi-organ infl ammatory disease; joint pain represents one of the commonest initial presentations of SLE. Common jo ints symmetrical or asymmetrical; PIP, MCP, wrists, knees. Risk factors 5 (90%); African or South East Asian ethnicity. Symptoms systemic malaise, fever, weight loss musculoskeletal joint or muscle pain skin photosensitive malar or discoid rash, oral ulcers renal oedema, h aematuria neurological seizures, psychosis lung pleuritic chest pain, dyspnoea cardiac exer tional chest pain or pain on sitting forwards (per- icarditis) GI abdo pain, diarrhea hemat ological pallor, frequent infections, recurrent miscarriage. Signs arthritis (swelling, ten der), malar/discoid rash, oral ulcers, altered mental state, pericardial or pleuritic rubs, peritonitis. Investigations blds dHb/WCC/plts, dC4 C3, iESR, ANA +ve (95%, but non specif i c), dsDNA +ve (70%, highly specifi c, refl ects disease activity), anti-Sm +ve (40%, most specifi c), U+E; urine blood, protein, casts; X-ray non-erosive arthritis, pleural eff usi ons; echo valve vegetations, pericardial eff usion. Treatment NSAIDs, hydroxychloroquine oral steroids (for fl ares) in mild disease; methotrexate, azathioprine, mycophenolate in more severe disease; limited evidence for biological therapies (eg belimumab, rituximab). C omplications IHD, stroke, antiphospholipid syndrome (10%). Drug induced certain drugs can c ause a lupus-like syndrome that resolves promptly upon drug withdrawal; these include isoni azid, methyldopa, hydralazine and diltiazem. American College of Rheumatology diagnostic classi \201 cation The presence of \211 4 of the following supports a diagnosis of SLE: \200 Arthralgia \200 Renal disease \200 AN A +ve \200 Serositis (pleuritic or Photosensitivity \200 Oral ulcers \200 Immunological tests (eg anti-dsDNA, anti-Sm) Neuropsychiatric symptoms (seizures, pericardial) Hematological abnormalities psychosis) \200 Malar rash \200 Discoid rash (dHb/WCC/plts) Can be remembered by the mnemonic \200\230A RASH POINts MD \200\231. Antiphospholipid syndrome (APS) Antibodies to membrane phospholipids (formerly confusingly referred to as \200\230lupus anticoagulant \200\231) are found in severe infl ammatory dis eases as well as in normal individuals. APS is the association of antiphospholipid antibodi es with arterial or venous thromboembolism, or recurrent or late-term miscarriage. Rheumati c fever This migratory polyarthritis occurring 2 \200\2236wk after a streptococcal infectio n was previously a common cause of childhood mortality and structural heart disease, but is now rare in the developed world. Diagnosis requires 2 major or 1 major and 2 minor \200 \230Jones \200\231 criteria: \200 Major Carditis (new murmur, valve lesions, CCF); migrat ory large joint polyarthritis; Aschoff bodies (fi rm, painless nodules on wrist, elbow or k nee); erythema marginatum (pink rings on trunk or limbs); Sydenham \200\231s chorea (face o r arms) Minor Prolonged PR interval (if carditis not counted); arthralgia (if polyarthritis not counted); iWCC/CRP/ESR; fever, previous rheumatic fever. Treatment penicillin, NSAIDs steroids (see Children \200\231s BNF). _OHFP.indb 457 _OHFP.indb 457 30/05/2014 16:18 30/05/2014 16:18 458 CHAPTER 15 Emergency department Neck lumps Worrying features >45yr, weight loss, night sweats, hard irregular lump. Think about serious malignancy (primary, metastases, lymphoma); common many of the lumps on b p420; see Table 15.9 for lumps found only in the neck. Table 15.9 Location and causes of neck lumps Location Causes Midline Anterior triangle Lymph node, thyroid mass, salivary gland mass, branchial Goiter, thyroid isthmus mass, dermoid cyst, thyroglossal cyst cyst, carotid artery aneurysm Posterior triangle Lymph node, cervical rib, pharyngeal pouch Ask about location, onset, duration, change with time, pain, other lumps, trauma, bites, in fections, skin changes, systemic symptoms (eg weight loss, vomiting, fever), sore throat, c ough, hoarse voice; PMH previous lumps, cancer, radiotherapy, thyroid problems; SH foreign travel, smoking, alcohol intake; FH thyroid disease, cancer. Look for assess as for other l umps (b p420) along with the following: movement on swallowing, movement on tongue protrusi on, dentition, mouth ulcers, lumps inside the mouth, lumps in the tongue, appearance of the tonsils (?asymmetry), ear examination, facial nerve palsies. Investigation blds consider FBC, U+E, LFT, TFT, CRP, ESR; imaging CXR, USS, CT/MRI; biopsy fi ne needle aspiration (FNA) especially for thyroid or salivary gland lumps, USS-guided bi opsy, excision biopsy. Management a neck lump should always be taken seriously and referred to ENT unless it is cl early a reactive lymph node. Preauricular Postauricular Parotid Occipital Submandibular (submaxillary) Anterior triangle Retropharyngeal (tonsillar) Submental Anterior cervical Posterior cervical Posterior triangle Supraclavicular nodes (a) Fig. 15.3 (a) Lymph nodes of the head and neck. (b) Anatomical tr iangles of the neck. Sternocleidomastoid (b) OHFP.indb 458 OHFP.indb 458 30/05/2014 16:18 30/05/2014 16:18 459 NECK LUMPS Thyroid lump/goiter Symptoms and signs midline or anterior triangle mass, moves with swallowing but not with pr otruding tongue, may be hypo/eu/hyperthyroid. Management send TFT, arrange USS and refer to ENT for fi ne needle aspiration; increasing r isk of malignancy with increasing age. Salivary gland lump Causes stone, gland infl ammation (eg mumps), malignancy. Symptoms and signs lump in sublingual, submandibular, or parotid gland. Management refer discrete lumps to ENT for fi ne needle aspiration; increasing risk of mali gnancy with increasing age; suspect mumps if diff use uni- or bilateral parotid enlargement with fever (supportive management). Thyroglossal cyst Embryological remnant from the descent of the thyroid gland. Symptoms and signs young patient (<40yr) with single lump by the hyoid which moves with swa llowing and protruding tongue, may be infl amed. Management confi rm presence of functioning thyroid gland, since may be the only thyroid ti ssue; refer to ENT for removal (Sistrunk procedure). Dermoid cyst A benign, cystic teratoma which may contain fat or hair. Symptoms and signs single subcutaneous lump, found in the midline of the neck or next to th e eye in young patients (<20yr). Management refer to ENT for complete removal, can recur. Branchial cyst Incomplete closure of an embryological branchial arch, resulting in a cyst. Symptoms and signs slowly enlarging smooth mass, typically presenting in 2nd or 3rd decade; most arise from 2nd branchial arch, appearing at the anterior border of sternocleidomastoi d; may be tender, or enlarge after URTI. Management refer to ENT for surgical excision, may recur. Pharyngeal pouch (Zenker diverticulum) Symptoms and signs elderly patient with upper oesoph ageal dysphagia; regurgitation of undigested food; halitosis; mass rarely palpable. Management confi rmed by contrast swallow, treated by surgical myotomy. Cervical rib Congenital abnormality, with an extra rib arising from C7. Symptoms and signs hard mass in posterior triangle; usually unilateral; may have Raynaud \200\231s, distal muscle weakness or pain. Adson \200\231s sign is loss of radial pulse on elevation of arm on aff ected side. Management may require physiotherapy or excision if causing problems. _OHFP.indb 459 _OHFP.indb 459 30/05/2014 16:18 30/05/2014 16:18 460 CHAPTER 15 Emergency department