Transcript Slide 1

Celina Goes
6/10/10
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Rheumatoid arthritis
Asthma
Depression
ADHD
Biliary Colic
Endometriosis
ACR RA Criteria 1987
Morning joint stiffness lasting> 1hr/day
• Arthritis in 3 or more joints simultaneously
• Arthritis in wrist, MC or PIP joints
• Symmetrical arthritis
(Each of above present for 6/52)
• Rheumatoid nodules
• Positive serum RF
• Typical of xray changes in hand/wrist
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However ACR criteria defined for research and not diagnosis.
Much more useful for indicating prognosis
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NICE recommends clinical diagnosis more important than
meeting all the ACR criteria
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If clinical history and examination are suggestive of RA early
referral is needed to treat a persistent synovitis quickly and
prevent permanent joint damage
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Do not wait for symptoms to be present for 6 weeks before
referral
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Waiting for blood results should not delay referral
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Plain X-ray is not sensitive in detecting early RA changes and
normal x-ray should not prevent referral
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If persistent synovitis involving small joints of
hands or feet, more than one joint affected or
symptoms were present >=3 months before
presentation: Refer urgently for specialist
opinion, even if normal inflammatory markers or
rheumatoid factor negative
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30-40% patients with RA have negative RF
throughout the disease
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RF is abnormal in 5% of the normal population
and up to 25% in the elderly
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Diagnosis based on recognition of characteristic
pattern of symptoms and signs and absence of
alternative explanation
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Careful history is key
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Spirometry preferred initial test
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Normal spirometry when not symptomatic does not
r/o asthma
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Repeat measurements more informative than single
assessment
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>1 of: wheeze/ SOB/ chest tightness /cough,
especially if:
– Worse at night/early morning
– In response to allergen, exercise or cold air
– After taking aspirin/beta blockers
Hx atopy
FH asthma/atopy
Widespread wheeze on ausculation
Otherwise low FEV1/ PEF
Otherwise unexplained eosinophilia
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Prominent dizziness/light headndenss/ tingling
Chronic productive cough in absence of
wheeze/SOB
Repeated normal chest examination when
symptomatic
Voice disturbance
Symptoms with colds only
>20 pack yrs smoking hx
Cardiac disease
Normal PEF/spirometry when symptomatic
DSM-IV Criteria for Major Depressive episode:
A 5 or more of the following symptoms present during the same
2-week period and representing change from previous
functioning
At least one of the symptoms is either 1) depressed mood or 2)
loss of interest or pleasure
1) Depressed mood most of the day, nearly every day
2) Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day
3) Significant weight loss or weight gain (change > 5% in a
month), or decrease or increase in appetite nearly every day
4) Insomnia or hypersomnia nearly every day
5) Psychomotor agitation or retardation nearly every day
(observable by others)
6) Fatigue or loss of energy nearly every day
7) Feelings of worthlessness or excessive or inappropriate guilt
nearly every day (not merely self-reproach or guilt about
being sick)
8) Diminished ability to think/concentrate, or indecisiveness,
nearly every day
9) Recurrent thoughts of death/suicidal ideation/ attempt
B The symptoms do not meet criteria for a Mixed
Episode
C Symptoms cause clinically significant distress or
impairment in social, occupational, or other
important areas of functioning
D Symptoms are not due directly due to drug
abuse/medication or a general medical condition
(e.g.hypothyroidism)
E Symptoms are not better accounted for by
Bereavement
Based on DMS-IV
 < 5 symptoms: Subthreshold depressive symptoms
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Mild depression: Few, if any, symptoms in excess
of 5 and only minor functional impairment
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Moderate depression: Symptoms or functional
impairment are between ‘mild’ and ‘severe’
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Severe depression: Most symptoms, and marked
interfere with functioning
Can occur with or without psychotic symptoms
PHQ-9 scoring
 1-4
Minimal depression
 5-9
Mild depression
 10-14
Moderate depression
 15-19
Moderately severe depression
 20-27
Severe depression
NICE Guidelines on diagnosis
 Made by specialist
 Based on a full clinical, psychosocial and mental state
assessment with full developmental and psychiatric history,
and observer reports
 Should meet the criteria in DSM-IV or ICD-10 (hyperkinetic
disorder) and
 Be associated with at least moderate psychological, social
and/or educational or occupational impairment, and
 Be pervasive, occurring in at least two settings
 Do not diagnose ADHD based on rating scales or
observational data alone (however may be useful)
 Should be considered in all age groups
 Take into account children or young people’s views when
determining the clinical significance of impairment
ICD-10 criteria:
Inattention
• At least 6 of the following for at least six months:
1) often fails to give close attention to details/careless errors
in school work
2) often fails to sustain attention in tasks/play activities
3) often appears not to listen
4) often fails to follow through on instructions /finish school
work, or chores
5) is often impaired in organising tasks and activities
6) often avoids/strongly dislikes tasks that require sustained
mental effort
7) often loses things necessary for certain tasks and activities
8) often easily distracted by external stimuli
9) is often forgetful in the course of daily activities
Hyperactivity
• At least 3 of the following for at least six months:
1) often fidgets with hands or feet/ squirms on seat
2) leaves seat in classroom or in other situations
3) often runs about or climbs excessively inappropriately
4) often unduly noisy in playing or has difficulty in engaging
quietly
5) exhibits a persistent pattern of excessive motor activity
that is not substantially modified by social context or
demands
Impulsivity
• At least 1 of the following for at least six months:
1) often blurts out answers before questions completed
2) often fails to wait in lines or await turns in games
3) often interrupts/ intrudes on others
4) often talks excessively without appropriate response to
social constraints
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Onset no later than age of 7 years
Pervasiveness
• Criteria should be met for more than a single situation
(e.g. present both at home and at school, or at both
school and in clinic)
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Symptoms cause clinically significant distress or
impairment in social, academic, or occupational
functioning
The disorder does not meet the criteria for another
disorder e.g.pervasive developmental disorders, manic
episode, or anxiety disorders
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Sub-threshold conditions also recognised:
◦ attention deficit only
◦ activity disorder only
◦ home-specific/ classroom-specific disorder (Only
meet criteria for one situation)
◦ many children with sub-threshold disorders fit with
other syndromes e.g. Oppositional Defiant
Disorder
Clinical features:
Pain:
• Classically right upper quadrant but also epigastric
and left sided pain (Infrequently (7%) retrosternal)
• Tends to recur at the same sites
• May radiate around costal margin into the back ,be
referred to scapula region or less commonly to left
arm
• Often difficulty describing nature of the pain: vague
aching/cramping discomfort and generally not sharp
• Constant rather than colicky
• Much inter individual variability in describing pain
• Can be severe (patient may curl up / changing
position frequently in order to be more comfortable)
Clinical features:
• Usually begins abruptly and subsides gradually (reaches
maximum intensity within 60 minutes in 2/3 pts)
• Lasts from a few minutes to several hours (30mins -6hrs)
• Often occurring postprandially
• Can occur at night, waking pt
• May be associated nausea and often a bout of vomiting
signifies the end of an attack
• No fever , significant hypotension but may have mild
tachycardia
• Often local tenderness due to gallbladder distension
• Jaundice, stigmata chronic liver disease, rebound, guarding,
absent bowel sounds, or a palpable mass support an alternate
diagnosis
Clinical features:
• Morphine can increase the pain in some people
• NSAIDs and nitrates help relieve pain
• If attack >24 hours suggests acute cholecystitis
• Uncomplicated biliary colic leaves no persisting symptoms
following the acute attack
• Frequency of attacks very variable (from almost continuous to
many years apart)
 May have associated intolerance of fatty foods, dyspepsia,
and flatulence
ROME II diagnostic criteria:
 used to evaluate the patient considered to have gallbladder
dysmotility with acalculous disease
– Episodes of severe steady pain in epigastrium/RUQ
– All of the following:
• Episodes last 30 minutes or more, with pain-free intervals
• Symptoms on 1 or more occasions in previous 12
months
• Pain interrupts daily activities or requires consultation
• No evidence of structural abnormalities to explain the
symptoms
• There is abnormal gallbladder functioning with regard to
emptying
Clinical features:
Symptoms may be absent or may include:
• Secondary dysmenorrhoea
• Deep dyspareunia
• Vaginal spotting
• Menorrhagia (adenomyosis)
• Bowel symptoms e.g. cyclical pain passing motions, rectal
bleeding, constipation
• Bladder involvement (cyclical haematuria-rare)
• Pelvic pain - variable in severity and location
• Chronic fatigue
• Infertility (30-40% of couples are infertile if the female has
endometriosis)
• But pregnancy rates are the same with and without treatment
if there is minimal disease
Clinical features:
Signs may be absent or may include:
• Tender nodules along the uterosacral ligaments, or in the
pouch of Douglas
• Fixed, retroverted uterus and tender, fixed adnexia
• Enlarged ovaries
• Visible lesions in the vagina or on the cervix
• blood filled, chocolate cysts may be seen on laparoscopy
Pathology:
 most commonly - endometriotric deposits are multiple small
(<1cm) raised blue-black nodules
 other 'atypical/subtle' lesions commonly seen include red
petechial,haemorrhagic flame-like lesions and serous/clear
vesicles
 Endometrioma (chocolate cyst)
 deep infiltrating nodules may penetrate or adhere to other
structures (eg. bowel, bladder, ureters, vagina)
 extensive pelvic damage due to fibrosis and adhesions may
occur in chronic disease
Investigations:
 Laparoscopic visualisation gold standard investigation (unless
visible lesions seen in the posterior vaginal fornix)
 Histological confirmation of at least one lesion is considered
ideal
• TV USS:
• Helpful in assessing endometriotic ovarian cysts
• May be useful in assessing deep infiltrating disease
involving POD
• Little value in assessing the presence of adhesions and mild
peritoneal deposits
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Other investigations dictated by symptoms:
• Endoanal USS
• Cystoscopy
Treatment:
 When pelvic pain associated with endometriosis, treatment is
indicated even if there is only mild disease at laparoscopy
Medical options
 Analgesia e.g. NSAID'S
 Hormonal treatments (prolonged period of treatment ,at least
6 mths)
◦ Medroxyprogesterone acetate (10 mg TDS for 90 days)
◦ COCP (cyclically/continuously for 3/12 )
◦ Danazol (testosterone derivative, given for 6-9mths)
◦ Gestrinone (similar actions and side effects to danazol)
◦ GnRH analogues (very expensive )
◦ IUS
Beneficial treatments: COCP or medroxyprogesterone
 Treatments where trade-off between benefits and harms :
danazol, gestrinone, and GnRH analogues
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Medical therapy does not seem to improve fertility
Surgical options :
 Laparoscopic - small lesions can be treated via laser;
adhesions may be divided, uterine nerve ablation (likely to be
a beneficial)
 Laparoscopic cystectomy for ovarian endometriomata
 Hysterectomy and BSO
Limited data available suggests that surgery can improve a
woman's chances of conceiving
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NICE Guidelines CG79 Rheumatoid arthritis: April 2009
BTS/SIGN Guidelines on Management of Asthma :2008
(Revised 2009)
NICE Guidelines CG90 Depression in adults: October 2009
Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition
NICE Guidelines CG72 Attention deficit hyperactivity disorder
(ADHD): September 2008
GP notebook