42 year old woman. Admitted unwell.
Ileostomy output increased in last 48 hrs.
Almost 3 litres on day prior to admission.
Afebrile.
Clinically moderately volume depleted. BP 110/62.
managing to drink but anxious
she is unable to keep up due to nausea.
- What are the goals of IV fluid therapy
- What are you replacing
- What else should you consider
- Resuscitation and replacement
- volume, Ileostomy secretions alkali (high in sodium and potassium)
- Nausea strong stimulus to ADH
– Ileostomy output may fall rapidly.
– Oral intake may vary
– Patient may be able to calculate fluid balance
- Nausea strong stimulus to ADH
Jane is a 24 year old lady. She consulted her GP because of pain in her fingers and knees. She described fatigue and morning stiffness,unable to continue her work as a waitress.
She has also developed a butterfly rash onher face.
- What further questions would you like to ask in the history that might help in reaching a diagnosis?
- What is the diagnosis?
- What initial investigations would you like to do and why?
1. Further questions to ask • Which joints affected? • Any swelling of the joints? • Length of morning stiffness? • Distribution of the rash? Any mouth ulcers? • Any hair loss? • Any Raynaud’s symptoms? • Any systemic associated features? (fever, weight loss, fatigue) • Any recent new drugs?
- Diagnosis: SLE
3. Initial investigations: FBC Inflammatory markers Liver Function Tests U&E
Rheumatological blood tests: ANA (Anti Nuclear Antibodies) Double stranded DNA ENAs (Extractable Nuclear Antigens): – Ro (linked to skin manifestations) – La – Sm – RNP – Jo-1 Complements: – C3 – C4
Jerry is a 46 year old male labourer. He presented to his GP with a 2 month history of a blocked nose and nose bleeds. He has also been feeling a little short of breath. A urine dipstick has shown 3+ blood and 1+ protein
- What further questions would you like to ask?
- What further investigations would you do?
- What is the likely diagnosis?
- History:
– Any systemic features: Fever, weight loss, night sweats
– Resp: Cough, haemoptysis, chest pain, SOBOE
– ENT: any change in nose shape, Any hoarseness or stridor, Any ear infections or deafness
- CNS: Any numbness in arms or legs, Any symptoms of cranial nerves lesions
– Skin: Any rash, ulcers
– Joints: Any joint pain, swelling of joints, morning stiffness
2. Blood tests: – Haematology: FBC, PV – Biochemistry: U and Es, LFTs, CRP – Immunology: ANCA Urine dipstick Radiology: – CXR – CT sinuses
- Wegner’s granulomatosis (affects small & medium vessels)
A 60 year old lady has a 3 month history of difficulty getting out of a chair. There is marked early morning stiffness but no
weakness. It came on fairly suddenly over a period of a few days. Bilateral hip flexion is grade 3-4 due to discomfort, and she also has discomfort on attempting to put her hands behind her head. The remainder of the clinical examination is unremarkable
Na 135, K 3.7, urea 6.7, creatinine 137, Hb 12.3, WCC 7.4, plt 346, ESR 68, CRP 32
- Interpret the blood results
- What is the most likely diagnosis?
- What is the main treatment?
- Give 4 side effects of long term use of this drug
- Raised creatinine (but consider age), raised ESR (normocytic normochromic anaemia), raised CRP
- Polymyalgia Rheumatica (age >60, female, constitutional symptoms (fever, fatigue, anorexia, weight loss), sudden onset, musc strength normal - differentiate from polymyelocytis)
3. Steroids (should show prompt, dramatic response) 15mg od (am) then wean down in response to inflammatory markers for ~2yrs
- Side effects from long-term steroid use e.g. Hyperglycaemia, immune suppression, Cushing’s syndrome, peptic ulcer, pancreatitis, osteoporosis (give Bisphosphonates, Ca, Vit D), mood/psychosos
A 65 year old white man presented to his GP with headache, malaise and morning stiffness of the shoulders.
His CRP was 40 mg/dl and his temporal arteries were tender and dilated.
- What is the diagnosis
- What is the characteristic biopsy finding
- What would be your management plan in the short & long term
- Giant cell arteritis/Temporal Arteritis
- Giant cells (but can have skip lesions so may not show on biopsy) - take 1cm biopsy from temporal artery
- Short term: immediate commencement prednisolone 40mg od (60mg if visual loss) whilst awaiting diagnosis confirmation (risk blindness if untreated)
Long term: continue on steroids for ~2years, gradually tapering dose (as for PMR) + Ca, Vit D, bisphosphonates, PPI, methotrexate, azathioprine
Sandra is a 30 year old lady.
She complains of cold fingers which is worse in cold weather. Her symptoms are intermittent.
She is otherwise fit and well.
- What is her most likely diagnosis & What further history would you ask?
- What is your non-pharmacological & pharmacological management?
- Raynaud’s
Onset (usually present as teenager)
History/symptoms of other CT diseases e.g. Arthralgia
- Non-pharm: stop smoking, hand warmers/socks, in severe cases: surgery (sympathectomy for lower limbs)
Pharm: oral vasodilators (nifedipine, amplodipine, diltiazem), parenteral vasodilators (prostacyclin)
Manoj is a 28 year old pharmacist. He has noticed the skin on his hands and feet has become very tight. In addition his hands and feet have been changing colour in the cold
weather for the last year
1. What further history would be helpful?
2. What would you look for on clinical examination?
3. What investigations might help?
4. What is the most likely diagnosis?
- Where are skin changes? (Distal/proximal)
Any finger tip ulcers?
GI symptoms: reflux oesophagitis, constipation, malabsorption (weight loss)
Pulmonary symptoms: dry cough, SOB
2. Hands: Raynaud's, abnormal nailfold capillaries, calcinosis (Ca deposits on skin), sclerodactyly/puffiness, finger tip ulcers, digital pits/gangrene Face: microstomia, telangestasia Heart: murmurs Lungs: crackles (ILD) Feet: sclerodactyly
- Immunology: ANA, Topoisomerase I antibodies, Anticentromere antibodies, ANCA, ENA
Radiology: CXR, CT, Echo
Pulmonary function
BP - Systemic sclerosis
Judith is a 45 year old secretary. Shecomplains of a scratchy sensation in her eyes for the last year. She has also had
a dry mouth and arthralgia.
- What questions would you like to ask?
- What investigations would you do?
- What is the most likely diagnosis?
- What are other associated clinical features?
- Medical Hx (esp those causing dry eyes), weight loss (increased risk lmphoma), sexual history (Bechet’s STDs), features of underlying CT disease (rashes, allergies)
- Bloods: ANA, ENA (Ro, La), raised ESR/anaemia, RF, anti-mitochondrial antibody
CXR (check for bilateral hilar lymphadenopathy), Schirmer’s test (dry eyes), measurement of salivary flow - Sjogren’s syndrome
- Increased risk lymphome, arthralgia, Raynaud’s, non-erosive arthritis
Harish is a 60 year old man who complained of muscle weakness and fatigue for the last 3 months. He also complained of increasing tiredness and noticed difficulty in walking
upstairs.
On examination there is tenderness in the
deltoids, weakness in the upper arm muscles and he was unable to rise from the sitting position without using his arms to push himself
out of the chair.
- What is the likely cause of his symptoms?
- What further investigations would you do?
- Polymyositis (proximal musc involvement, weakness)
2. Bloods; CK, CRP, FBC, ANA, ENA MRI - proximal musc EMG nerve conduction Musc biopsy CXR: paraneoplastic syndrome (dermatomyositis, screen before methotrexate)
A 68 year old woman with RA attends her GP surgery with a sudden onset of well-localised pain in the thoracic area which came on suddenly after lifting her shopping 3 days before. She has no neurological symptoms.
PMH=Graves disease
DH=methotrexate and prednisolone
Examination shows localized bony tenderness
- What key questions would you ask her
- What key investigations would you carry out
- What treatment is needed
- Think osteoporosis/fracture: Age, ethnicity, diet (Ca, Vit D). Weight loss, exercise (lack weight bearing?), fatigue, alcohol/smoking, GI disturbance (IBD, malabsorption), corticosteroid use history, repro history (late onset menarchy/early onset menopause), anto-convulsants, libido/impotence, chronic disease/cancer, hyperparathyroidism, family Hx
- DXA scan (bone density, monitoring), CXR, Bloods (incl FBC, ESR or PV, U&E, LFT, Ca PO4, TFT, LH/FSH (menopause), Serum Ig’s, Bence Jones protein)
- Lifestyle: exercise, alcohol, smoking, falls assessment
Drugs: Bisphosphonates (e.g. Etidronate), prevent resporption (HRT, SERM - Raloxifene), Stimulate formation (PTH - teriparatide, Forseto), dual action (strontium ranelate)
Dear rheumatologist
Please see the above 68 year old South Asian lady who has had pain in her thighs and back for 3 years. She has no past medical history. She is intolerant of NSAIDs and co-codamol has not helped.
She has a raised alkaline phosphatase (321 IU/L), but her FBC is normal.
- What is the differential diagnosis? What is the most likely diagnosis?
- key questions that you would ask her?
- key blood tests are most needed?
- Metabolic disorder with raised alk phos
Mechanical back pain + alk phos not bony (e.g. From liver)
(Inflammatory back pain (Ank Spond with alk phos secondary))
(Metastatic cancer)
(Multiple myeloma)
Osteomalacia
- Diet (Vit D/Ca deficiency), signs of malabsorption, drug Hx (esp anticonvulsants), renal impairment, hepatic imapirment (alcohol)
- Plasma:
Low/normal Ca (may be some secondary increase as PTH compensates)
Low/normal PO4
Increased Alk Phos
High PTH
Low 25-hydroxy-vitamin D (except Vit D resistance)
Renal failure: low calciferol
A 53 year old man is seen in A&E complaining that his right ankle has been swollen for 2 days. This came on within hours and he has had previous attacks in the other ankle. He takes antihypertensives. On examination he is overweight and the right ankle is red, swollen and very tender.
- What is the differential diagnosis? What is most likely?
- What further history should be taken?
- What might you find on examination?
- What investigations are needed?
- What treatment would you give?
- Gout (most likely), septic arthritis, inflammatory arthritis
- Any recent infections, medications (esp immunosuppressants), IV drug use, family Hx, diet (red meat etc), alcohol
- Tophi (gout), increased temperature over affected joint
- MC&S & polarised microscopy of joint aspirate, blood cultures, CRP (septic arthritis & gout), U&E, LFT, FBC (neuropenia in sepsis & gout)
5.Acute: High dose NSAID or coxib (Colchicine if contraindicated), Corticosteroids, Rest & elevate affected joint, Ice pack, bed cage
Prophylaxis: Allopurinol/Febuxostat,
Prevention: Weight loss, Avoid prolonged fasts, Reduce alcohol, Avoid purine-rich meat, Avoid aspirin
A 28 year-old lady attends her GP surgery due to pain and swelling in her hands and feet.
What questions should you ask
Polyarticular:
• Is this acute, subacute, or chronic
• Was onset sudden or insidious
• Is it progressive
• Is this regional or generalised
• Is it symmetrical or asymmetrical
• Is it peripheral or axial
• Is there inflammation
– Morning stiffness >1 hour, relief with NSAIDs or steroids
• Is this a mechanical problem
– Worse after activity, only certain movements may induce pain,
crunching/locking
• Is there evidence of systemic involvement
• Are there associated extra-articular features
• Is there functional loss and disability
• Is there a relevant family history
A 28 year old lady comes to her GP with pain & swelling in her hands & feet. She gives the following history: • came on 3 months ago, gradual onset • hands & feet ache all the time • knees ache too • knuckles are swollen • worse in mornings • struggling to work
- What is the differential diagnosis?
- What findings would you expect on examination?
- A symmetrical, chronic, polyarthicular inflammatory joint disease: RA, psoriatic arthritis, SLE, vasculitis
- Signs of inflammation: joint held in ‘loose pack’ position, soft tissue swelling, warmth, ‘stress pain’ (at extremes of ROM), joint line tenderness
A 57 year-old lady presents to her GP with neck pain, hand and arm pain, and aching thighs. She is also very fatigued.
- What are the differential diagnoses?
- What would you ask in the history?
Widespread pain:
1. Fibromyalgia, polymyalgia rheumatica, metabolic disease (hypothyroid, hyperparathyroid, hypercalcaemia, cushings), inflammatory arthritis, myositis (e.g. From statins), malignancy
2. Any swelling or objective features of inflammation • Effect of exercise • Associated systemic features • What medication • What is the psycho-social back ground • Are there tender points • Is there fatigue and unrefreshed sleep • What have previous investigations shown
26 year old clerk who saw her GP with a 3 month history of right knee pain and swelling.GP prescribed diclofenac which helped her somewhat.
Now also presenting with a 3 week history of swelling and pain of the right 2nd toe and heel.
GP checked FBC, CRP and RF (all normal).
On examination: Right Achilles & right 2nd toe swollen and
painful. Scaling salmon pink patches of skin behind the ears and on both elbows.
1. What is the most likely Diagnosis?
2. What investigations would you carry out?
- Psoriatic arthritis
(Not RA: no involvement of hands, not symmetrical)
2. Blood tests: U and Es and LFTs Hand and feet X-rays Ultrasound or MRI of Achilles Other investigations – Knee aspiration (?chronic infection) – Consider dermatology opinion if not convinced is psoriatic arthritis
Dear Dr,
Please could you advise me about this 25 year old man. He gives a 1 year history of back pain. It is worst in the mornings and he has profound stiffness for 2 hours every morning when he first
wakes up. There are no problems with any other joints. His symptoms have gradually got worse over the last 6 months. He has no PMH. He was seen in eye casualty a few months ago but I don’t have any
details of this. His brother has longstanding back pain and has been off work for a number of years.
- Questions to ask in history?
- What would you expect to see on examination?
- What investigations would you do?
- What is the most likely diagnosis?
- Is your back pain eased by exercise?
Has your brother got ankylosing spondylitis?
What was the eye problem you had?
2. Loss of lumbar lordosis Globally reduced spinal ROM Positive sacroiliac stress test Any evidence of peripheral joint synovitis Reduced chest expansion (
A 21 year old man recently went to Thailand. He had diarrhoea for 5 days when he got home. A week later his right knee swelled up.
- What investigations would you carry out?
- What is the most likely diagnosis?
- What is your management plan?
1. Bloods – FBC, U and Es and LFTs – Inflammatory markers Other investigations – Aspirate knee and send for urgent M,C and S and crystals – Stool culture + serology – Urethral swabs + PCR of EMU (chlamydia)
- Reactive arthritis
- NSAIDS
Antibiotics if microbe isolated (to reduce spread of infection)
If knee aspirate growth negative consider steroid injection
If still synovitis after 6 months consider DMARDS
26M normally fit and well
◻ 2 week history of bloody diarrhoea
⬜ Frequency difficult to assess
⬜ GP gave Codeine, Loperamide & Diorylate
◻ No one else unwell
◻ Feeling generally tired & lethargic
◻ GP carried out following investigations:
CRP 296, Hb 14.4, WBC 12.2, Platelets 526
AXR – proximal constipation
Flexi Sig – severe inflammation rectum & distal sigmoid (did not progress further)
- Interpret the blood results
- What is the most likely diagnosis
- Outline a management plan
- CRP severely raised (normal
A 40 year old lady
Referred by GP to GI clinic with: abdo pain, diarrhoea & constipation, faecal calprotectin 80 (raised)
From case history: Been going on Number of years tried Mebeverine (didn't help) No blood bowels open 1-4 times per day (not at night); sometimes loose operation for 3rd miscarriage Suffers from Hypertension (medicated: Amlodipine) Family history: Auntie suffered prolapse
What is the most likely Diagnosis?
What Investigations would you carry out to confirm?
IBS:
Loose motions during the day only
No malena/rectal bleeding
although faecal calprotectin raised, is not significantly high to suggest IBD
Flexi Sig / biopsy
