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\author{bee.f (bee.f)}
\pdfinfo{
  /Title (5002-case-9.pdf)
  /Creator (Cheatography)
  /Author (bee.f (bee.f))
  /Subject (5002 Case 9 Cheat Sheet)
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        \hspace*{-6pt}\includegraphics[width=5.8cm]{/web/www.cheatography.com/public/images/cheatography_logo.pdf}}
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\begin{tabulary}{11cm}{L}
    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{5002 Case 9 Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{bee.f (bee.f)} via \textcolor{DarkBackground}{\uline{cheatography.com/180201/cs/38541/}}}
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  \mymulticolumn{2}{p{5.377cm}}{\bf\textcolor{white}{Cheatographer}}  \\
  \vspace{-2pt}bee.f (bee.f) \\
  \uline{cheatography.com/bee-f} \\
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  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Published 23rd February, 2024.\\
   Updated 14th May, 2023.\\
   Page {\thepage} of \pageref{LastPage}.
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  Measure your website readability!\\
  www.readability-score.com
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\begin{document}
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\begin{tabularx}{17.67cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Case}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{- 64 y.o. male\{\{nl\}\}- Upper neck \& suboccipitals\{\{nl\}\}- Onset 8 yrs ago for no apparent reason\{\{nl\}\}- Episodic \& fluctuates in severity\{\{nl\}\}- Overall getting worse \& more persistent} \tn 
% Row Count 4 (+ 4)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{-6/10 at worse\{\{nl\}\}- "Sore" \& "deep pressure" w/ stiffness\{\{nl\}\}- Worse in the morning \& gets bit easier w/ movement / activity after approx. 1hr} \tn 
% Row Count 7 (+ 3)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{{\bf{AF:}} Inactivity\{\{nl\}\}{\bf{RF:}} NSAIDs partially improve the pain (paracetamol doesn't help)} \tn 
% Row Count 9 (+ 2)
% Row 3
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\mymulticolumn{1}{x{17.67cm}}{{\bf{Extras}}\{\{nl\}\}- Kidney stones\{\{nl\}\}- Currently awaiting hospital investigation for a chronic cough \& recurrent bronchitis\{\{nl\}\}- Ibuprofen for current complaint\{\{nl\}\}- Atorvastatin 20mg/day (preventative)\{\{nl\}\}- Sometimes wakes due to pain when it's worst\{\{nl\}\}- Early in the morning (around 4-5am)\{\{nl\}\}- Mother: hypertension from 40 y.o., died from a stroke at 72 y.o.\{\{nl\}\}- Father: died from MI at 65 y.o.\{\{nl\}\}- Brother: hypertension @ 55 y.o.; survived MI @ 60 y.o.\{\{nl\}\}- Imaging revealed RA in hands but no complains of Sx} \tn 
% Row Count 20 (+ 11)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
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\begin{tabularx}{17.67cm}{X}
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\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Physical Examination Findings}}  \tn
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\mymulticolumn{1}{x{17.67cm}}{{\bf{BMI:}} 26.8\{\{nl\}\}- {\bf{Pulse:}} 80\{\{nl\}\}- {\bf{BP:}} R - 140/78; L - 138/80} \tn 
% Row Count 2 (+ 2)
% Row 1
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\mymulticolumn{1}{x{17.67cm}}{{\bf{Posture / stance}}\{\{nl\}\}- Upper crossed w/ anterior head carriage} \tn 
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\mymulticolumn{1}{x{17.67cm}}{{\bf{Reflexes}}\{\{nl\}\}- DTRs UL \& LL all 3+ bilaterally\{\{nl\}\}- Flexor plantar response} \tn 
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\mymulticolumn{1}{x{17.67cm}}{{\bf{ROM}}\{\{nl\}\}- {\bf{AROM Cx:}} all mildly restricted \& painful @ end range\{\{nl\}\}- {\bf{Gentle PROM:}} w/ no overpressure as AROM} \tn 
% Row Count 9 (+ 3)
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\mymulticolumn{1}{x{17.67cm}}{{\bf{TTP}}\{\{nl\}\}- {\bf{Upper Cx:}} U traps, suboccipital \& scalenes TTP w/ no referral B} \tn 
% Row Count 11 (+ 2)
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\mymulticolumn{1}{x{17.67cm}}{{\bf{Supine Cx motion palpation:}} little less stiff than seated\{\{nl\}\}- {\bf{Palpation:}} mid - lower Tx spine stiff but no pain\{\{nl\}\}- {\bf{Mild oedema R ankle:}} non pitting, no pain; no other obvious abnormality observed in extremities} \tn 
% Row Count 16 (+ 5)
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\mymulticolumn{1}{x{17.67cm}}{{\bf{Clinical tests}}\{\{nl\}\}- {\bf{Cx specialists:}} no provocation\{\{nl\}\}- {\bf{Wall angel test:}} failed} \tn 
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\begin{tabularx}{17.67cm}{X}
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\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Discussion}}  \tn
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\mymulticolumn{1}{x{17.67cm}}{{\bf{Working diagnosis}}\{\{nl\}\}- Rheumatoid arthritis (RA)\{\{nl\}\}→ Most probable cause of inflammatory neck pain in pts' of this age (\& also due to it being most common inflammatory arthropathy i.e. prior probability)\{\{nl\}\}- Links w/ non-pitting swelling at the ankle \& the respiratory Sx} \tn 
% Row Count 6 (+ 6)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{{\bf{Why is this an unusual case?}}\{\{nl\}\}- Presents w/ neck Sx \& denied any Sx in the hands \& feet\{\{nl\}\}- Typically involvement of the spine occurs yrs after the onset of Sx in the {\bf{distal extremities}}} \tn 
% Row Count 10 (+ 4)
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\mymulticolumn{1}{x{17.67cm}}{{\bf{Differentials to be considered}}\{\{nl\}\}- Lung cancer for the respiratory symptoms: based on being a past heavy smoker} \tn 
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\mymulticolumn{1}{x{17.67cm}}{{\bf{Oedema}}\{\{nl\}\}- {\bf{Pitting:}} cardiovascular\{\{nl\}\}- {\bf{Non-pitting:}} joint inflammation or infection} \tn 
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\begin{tabularx}{17.67cm}{X}
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\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Learning outcomes}}  \tn
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\mymulticolumn{1}{x{17.67cm}}{{\bf{Rheumatoid arthritis}}\{\{nl\}\}- Chronic systemic inflammatory disease\{\{nl\}\}- Pt w/ RA have an {\bf{increased}} risk of developing {\bf{heart disease}}\{\{nl\}\}- Usually affects {\bf{distal}} extremities, {\bf{bilaterally}} \& {\bf{symmetrically}}\{\{nl\}\}- Associated w/ increased risk of CVD disease, osteoporosis, anaemia \& infection\{\{nl\}\}- Peak onset {\bf{30-50}} y.o.\{\{nl\}\}- Associated w/ {\bf{anaemia}}\{\{nl\}\}⏺ {\bf{{\emph{Presentations:}}}}\{\{nl\}\}- {\bf{Symmetrical synovitis}} of small joints of {\bf{distal}} extremities\{\{nl\}\}- Pain, swelling, heat \& stiffness in affected joints\{\{nl\}\}- Pain worse at {\bf{rest/inactivity}}\{\{nl\}\}- {\bf{Swelling}} around affected joint\{\{nl\}\}- Early {\bf{morning stiffness}}, lasting {\bf{1+}}\{\{nl\}\}- Bumps/{\bf{nodules}} under skin (rheumatoid nodules)\{\{nl\}\}⏺ {\bf{{\emph{Diagnosis:}}}}\{\{nl\}\}- No set tests in primary care\{\{nl\}\}- {\bf{Blood tests}} \& x-ray to confirm: C-reactive protein, rheumatoid factor, ESR\{\{nl\}\}- Inability to make a {\bf{fist/flex}} fingers\{\{nl\}\}- Other inflammatory presentations\{\{nl\}\}- Family Hx of RA\{\{nl\}\} {\bf{DON'T LET INVESTIGATIONS DELAY REFERRAL FOR SUSPECTED RA}}\{\{nl\}\}⏺ {\bf{{\emph{Management:}}}}\{\{nl\}\}- NSAIDs until rheumatological appt.\{\{nl\}\}- During flare ups: rest\{\{nl\}\}- During emission: exercise\{\{nl\}\}- Low-impact activities in remission periods\{\{nl\}\}- Referral to GP\{\{nl\}\}- Exercises for enhancing joint flexibility, muscle strength \& managuingother functional impairments} \tn 
% Row Count 28 (+ 28)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{{\bf{How to identify inflammatory arthropathy, how to refer \& what the further investigations \& management would be?}}\{\{nl\}\}⏺ {\bf{{\emph{Identifying:}}}}\{\{nl\}\}- Medical Hx \& physical exam\{\{nl\}\}- Key features: joint pain, swelling \& stiffness; distal extremity joint affected; usually bilateral \& symmetrical; worse in morning (improves throughout day); fatigue, malaise, other {\bf{systemic}} symptoms; family Hx of inflammatory arthritis\{\{nl\}\}⏺ {\bf{{\emph{How to refer?}}}}\{\{nl\}\}- {\bf{Urgent}} referral\{\{nl\}\}- Written letter to GP for further referral to rheumatologist for investigations\{\{nl\}\}⏺ {\bf{{\emph{Further investigations:}}}}\{\{nl\}\}- Blood tests: rheumatoid factor - C-reactive protein\{\{nl\}\}- X-ray\{\{nl\}\}⏺ {\bf{{\emph{Management:}}}}\{\{nl\}\}- NSAIDs\{\{nl\}\}- Glucocorticoids\{\{nl\}\}- Encourage regular exercise in remission periods, rest w/ flare ups\{\{nl\}\}- Exercises fro enhancing joint flexibility, muscle strength \& managing other functional impairmens} \tn 
% Row Count 47 (+ 19)
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\begin{tabularx}{17.67cm}{X}
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\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Learning outcomes (cont)}}  \tn
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\mymulticolumn{1}{x{17.67cm}}{{\bf{Modify physical examinations according to risk}}\{\{nl\}\}- {\bf{Avoid Cx manipulation:}} RA can damage transverse ligament in Cx\{\{nl\}\}- {\bf{Gentle joint mobility}} testing\{\{nl\}\}- {\bf{Postural analysis:}} address misalignment or bracing posture (take breaks as needed or adjust position to suit pt)\{\{nl\}\}- {\bf{Neurological testing}} (e.g. sensory/reflex): may be difficult to perform, modify/remove altogether if not clinically relevant to pt\{\{nl\}\}- Adjust {\bf{duration \& intensity}} of treatment to suit pt} \tn 
% Row Count 10 (+ 10)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{{\bf{Identify risk factors for cardiovascular disease}}\{\{nl\}\}- Rheumatoid arthritis (RA)\{\{nl\}\}- Increasing age: especially after 55 (F) \& 45 (M)\{\{nl\}\}- Gender: males at higher risk\{\{nl\}\}- Family Hx: of heart attacks, strokes, angina\{\{nl\}\}- Hypertension\{\{nl\}\}- Cholesterol levels: Hugh LDL, low HDL\{\{nl\}\}- Smoking\{\{nl\}\}- Diabetes: due to damage to blood vessels \& increased inflammation in body\{\{nl\}\}- Obesity/sedentary lifestyle: contribute to high BP, cholesterol, diabetes\{\{nl\}\}- Stress: increase BP \& contribute to inflammation} \tn 
% Row Count 21 (+ 11)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
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