Celina Goes6/10/10

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

• However ACR criteria defined for research and not diagnosis. Much more useful for indicating prognosis

• NICE recommends clinical diagnosis more important than meeting all the ACR criteria

• If clinical history and examination are suggestive of RA early referral is needed to treat a persistent synovitis quickly and prevent permanent joint damage

• Do not wait for symptoms to be present for 6 weeks before referral

• Waiting for blood results should not delay referral

• Plain X-ray is not sensitive in detecting early RA changes and normal x-ray should not prevent referral

• 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

• 30-40% patients with RA have negative RF throughout the disease

• RF is abnormal in 5% of the normal population and up to 25% in the elderly

• Diagnosis based on recognition of characteristic pattern of symptoms and signs and absence of alternative explanation

• Careful history is key

• Spirometry preferred initial test

• Normal spirometry when not symptomatic does not r/o asthma

• Repeat measurements more informative than single assessment

• >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

• 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

Mild depression: Few, if any, symptoms in excess of 5 and only minor functional impairment

Moderate depression: Symptoms or functional impairment are between ‘mild’ and ‘severe’

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 activities3) often appears not to listen 4) often fails to follow through on instructions /finish school

work, or chores5) is often impaired in organising tasks and activities6) often avoids/strongly dislikes tasks that require sustained

mental effort7) often loses things necessary for certain tasks and

activities8) often easily distracted by external stimuli9) 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

• 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)

• 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

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• 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 laparoscopyMedical 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

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

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