NBE CME programme for DNB consultants - National Board Of ...

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NBE CME programme for DNB consultantsInvestigations - Complete Haemogram; L.F.T. ; Detailed Opthalmic examination; ASLO titres; Workup for SLE; Thyroid function tests if autoimmune thyroidities is suspected; Serum copper andceruloplasmin levels. ; L.P. ; CT Scan Brain; MRI S can of Brain; EEG if required; Estimation of druglevels( if required) ; ECHOTreatment – Parkinsonism - Symptomatic, supportive and palliative; Physical therapy and psychotherapy;Requirement of lifelong medications; Treatment programme to be personalized; Medicaltreatment for compensated phase and decompensated phase.; Medications under evaluation;Role of surgeryTreatment of other Movement Disorderso-Drug treatment of Tremors; treatment of Dystonia; Roleof surgery; Use of botulinum toxinRheumatological DiseasesThe diagnosis and assessment of articular disease are based on the clinical processes of historytakingand examination. Blood tests and radiological investigations are often useful, and may beessential, but they cannot replace careful history- taking and examination of the patient. Unnecessaryinvestigations are expensive , may cause anxiety to patients, and if taken out of clinical context, leadto over-diagnosisand over-treatment. The initial history and examination may lead immediately tothe diagnosis of a specific disorder, such as rheumatoid arthritis, or may indicate a pathologicalprocess such as vas ulitisor synovitis, or may suggest that the condition is self-limiting or nonpathological.Appropriate assessing the patient and the results of the investigations, the physicianshould be able to offer the patient an explanation of his symptoms in terms the patients canunderstand and formulate with the patient a plan for treatment.History - The patient should be asked first about the nature of the main problem and it’s impact ontheir daily life. Factor’s such as the patient’s age, sex, race and employment are often relevant.The mode of the onset of the symptoms and any precipitating factors such as trauma should beasked about. The development of symptoms, their evolution over time, and pattern of remissionand relapse are also important. The effect of previous therapies, the patient’s compliance withthem and any adverse reaction are important in planning future treatment.Pain - Pain is a cardinal symptom of rheumatic disease and should be enquired about in detail.Site - It is important, and sometimes surprisingly difficult, to establish whether the pain arises froma joint, muscle, bone or other tissue, in general, pain arising in a joint is worse when the joint ismoved, whereas pain arising elsewhere will not be affected by joint movement. Associatedsymptoms such as joint swelling suggesting inflammatory joint disease or paraesthesiae andweakness, suggesting a neurological cause for the pain, may also help. It is helpful to askpatients to demonstrate on their own bodies the site where pain is felt.Quality or character - Pain is notoriously difficult to describe in words, but some features are veryuseful. Pain, which is worse at night, disturbs sleep and is unrelenting and unaffected by position,is strongly suggestive of serious disease such as malignancy and requires urgent investigation.The pain of malignancy is usually less acutely severe than the pain of an acute inflammatorycondition such as gout. The severe shooting pain of nerve root entrapment, which travels down alimb or around the trunk, is often characteristic enough to be diagnostically useful. Relieving andexacerbating factors- Joint pain due to mechanical problems without inflammation is typicallyworsened by movement and rapidly relived by rest. Inflamed joints are often painful at rest andsomewhat better after a few minutes of use. Patients with active inflammatory joint disease areoften troubled by severe night pain and stiffness.Stiffness and restriction of movement - Stiffness is highly subjective and variable sensation oftightness and resistance to movement. Patients may equate stiffness with fatigue, pain, weakness,loss of range of movement or swelling. Most patients with joint pain experience an initial, shotlivedsensation of stiffness after immobility. This needs to be differentiated from the severe stiffnessexperienced with patients with inflamed joints when they begin to move after sleep or rest. This124
NBE CME programme for DNB consultantsstiffness typically “ wears off”after minutes or hours, and patient can often quantify this time quiteaccurately. The duration of “early morning stiffness” on first arising after the night’s sleep may beused to assess the changing severity of inflammatory disease. A duration of more than 30 minutesof morning stiffness remains one of the American Rheumatism Association criteria for rheumatoidarthritis.Swelling - Patients may notice swelling, but it is unwise to assume that what the patient is describingis synovial swelling or joint infection unless the description is very clear, or there is evidence ofsynovitis or effusion on examination. Stiffness , paraesthesiae from nerve entrapment,malallignment, discolouration or pain itself may lead the patient to a perception of swelling whichis not confirmed by examination. If swelling or deformity is present, it is necessary to determinewhether it is due to fluid, soft-tissue or bone.Family History - The family history may be useful; a history of similar problems in other familymembers may give a clue to HLA B27- related arthropathies, psoriatic arthritis, gout or someautoimmune rheumatic diseases.Systemic symptoms - Symptoms of systemic illness such as fever, weight loss and malaise maybe due to active inflammatory joint disease, but should also alert the doctor to the possibility of anunderlying infection, malignancy or tuberculosis, may be relevant. Non- articular symptomsassociated with joint disease such as ankylosing spondylitis should be specifically asked for ;patients will seldom associate a history of a painful red eye; skin rash or urethral discharge withtheir painful swollen knee. Tact, and appropriate explanation, are needed when enquiring aboutsexually transmitted diseaseand genital symptoms, but failure to ask the relevant questions mayresult in misdiagnosis.Essential points in the history - * Pain -Onset; site and radiation; referred pain character effect ofmovement and rest night pain and unremitting pain * Stiffness morning- duration—, Immobilitystiffness and gelling, Swelling and deformity, Disability and handicap, Systemic illness, extraarticularfeatures, sleep and depression, Social and family history.Patients should be asked specifically about sleep disturbance depression, which are commonlyfeatures of chronic painful conditions. Fatigue is a characteristic symptoms of autoimmune diseasesuch as reheumatoid arthritis and systemic lupus erythematosus.Examination of the locomotor systemSwelling - Swelling around a joint may be cause by fluid, as in an intra-articular effusion or effusioninto an inflamed bursa, by soft tissues such as synovium or extra-articular fat pads, or by bonyenlargement as in the osteoarthritis. Subluxation, as the metacarpophalangeal joint, may also givean impression of swelling. Intra-articular fluid produces a swelling defined by the margins of thejoint capsule. The synovial lining layer is normally too thin to be palapable but the thickenedinflamed synovium in chronic synovitis such as rheumatoid arthritis may have a “boggy” consistencyand be easily felt. Effusion without synovial thickening, where the joint line can be clearly felt , isusually due to trauma or osteoarthritis. Fluid can often be shifted from one area of the joint toanother by compressing one side of the swollen joint.Tenderness, redness and warmth - Inflammed joints are tender along the joint line. Paplation mayalso localize tenderness to the sites of attachment of tendons or ligaments, bursae, muscles or fatpads. Inflammed joints are usually warmer than the surrounding tissues. Redness over the joint isa sign of intense inflammation, usually due to gout, pseudogout or infection.Limitation of movement, deformity and instability - Limitation of a movement is a common symptomof joint disease. Older people have less mobile joints than the young, women are generally moreflexible than men and joint mobilityis greater in some races than others. It is important to developa feeling for the normal for a particular race, age and sex so that generalized hypermobility, as wellas restriction of movement at specific joints may be detected. Limitation of movement of a joint maybe due to swelling, soft-tissue contracture, tendon rupture, muscle weakness, joint subluxation or125
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