CLINICAL CARE OF THE MUSCULOSKELETAL SYSTEM Flashcards
What issue? how would you treat?
Major cause of chest pain in the ambulatory setting
(1) Reported ranges of 10-50% of patients
(2) Chest pain is said to “reproducible”
(3) Able to exacerbate pain with palpation on physical exam
(4) Causes of this syndrome poorly studied and documented
(5) Likely secondary to viral illness and other causes of inflammation
(6) Other rheumatic diseases such as fibromyalgia a common cause of chest wall pain
Costochondritis
Most cases improve course of few weeks:
(1) NSAIDS
(2) Home stretching program
(3) Activity modification
Osteoarthritis affects an estimated 30 million people in the US:
(1) Knee joint accounts for approximately ___% of cases
(2) Also affects:
-a) Hand
-(b) Spine
-(c) Hip
80%
Risk factors are numerous and include:
(1) Age: More common in ____ population
(2) In general population age over __ y/o
(3) Gender: Greater risk in _____
(4) 1.7 times as likely as ____
(5) Family history
(6) ____ injuries
(7) Chronic inflammation
(8) Obesity
(9) Occupation
(10) Heavy workload
1) older
2) 50
3) females
4) males
6) Joint
What dx/Tx
Symptoms
(1) Pain that is exacerbated with use, alleviated with rest
(2) Pain is aching, deep in later stages
(3) Sharp pain in beginning stages
Physical Exam
(1) Visual = Bony swelling possible
(2) Palpation = Joint line tenderness, crepitus
(3) ROM = Limited
(4) Muscle Test = Unremarkable
(5) Neurovascular = Unremarkable
(6) Special Test = Depends on affected joint
Osteoarthritis
Treatment
(1) Control pain
(a) NSAIDS
(b) Tylenol
(2) Stop insult to cartilage
(3) Rehabilitation
What is considered to Stop insult to cartilage when treating osteoarthritis
(a) Activity/lifestyle modification
(b) Weight reduction
(c) Loss of 10% body weight associated with 50% reduction in pain over 18 months
Common examples of Inflammatory arthroses are
-rheumatoid arthritis
-reactive arthritis
-psoriatic arthritis
-ankylosing spondylitis
What Dx/Tx
(1) Unknown etiology
-(a) Autoimmune disorder
-(b) Mostly small joints and bilateral: hands, finger, wrists, feet, ankle
-(c) Insidious onset, distal joints first (DIPJ of hands are spared)
-(d) Extra-articular manifestations (pulm, CV, eyes)
Symptoms
-(a) 4 of 7 ACR criteria:
-(b) Morning stiffness (1 hour for 6 weeks)
-(c) Arthritis (>/= 3 joints for 6 weeks)
-(d) Swelling of hand joints (6 weeks)
-(e) Symmetrical joint swelling (6 weeks)
-(f) Rheumatoid nodules
-(g) Positive RF factor
-(h) Erosions or osteopenia in hand XR
-(i) May have myelopathy with C1-C2 involvement
Physical Exam
(a) Visual
-1) Nodules (elbow mostly)
-2) Swelling/hypertrophy (esp PIP early sign)
-3) Swan neck deformity
-4) Lateral drift of toes
(b) Palpation = Boggy sensation
(c) ROM = Diminished and painful
(d) Muscle Test = Reduced grip strength
(e) Neurovascular = Numbness and tingling in the affected nerve
(f) Special Test = None
Rheumatoid Arthritis
Treatment
(a) MEDAVICE with GMO or refer to Internal Medicine
(b) Typical medications used:
1) NSAID/Tylenol
2) DMARD (Disease-Modifying Anti- Rheumatic Drug)
a) -Ab, , etanercept, methotrexate, hydroxychloroquine, cyclosporine
(c) Physical Therapy/Surgery
Diagnostic Tests for suspected Rheumatoid arthritis
Laboratory studies
1) Rheumatoid Factor (RF)
2) Antibody to cyclic citrullinated peptide (Anti-CCP)
3) C-reactive Protein (CRP)
4) Erythrocyte Sedimentation Rate (ESR)
Plain Films
Clinical Manifestations
(a) Acute onset of joint pain 1-4 weeks after infection
(b) Peripheral arthritis in Knees, Small joints of hands/wrists
(c) Enthesitis - Achilles tendon commonly involved
–1) Inflammation of insertion sites of ligaments, tendons, fascia
(d) Dactylitis (“sausage digits”)
(e) Lower back pain
(f) Extra articular manifestations:
–1) Nail changes
–2) Conjunctivitis, anterior uveitis
–3) Oral lesions
Reactive Arthritis
Treatment
(a) Treat infection if active
(b) Symptoms self-limited, May last up to 6 months
(c) NSAIDS for pain
(d) Severe cases
-1) Refer to specialist
-2) DMARDS/steroids considered
What is Enthesitis
Inflammation of insertion sites of ligaments, tendons, fascia
what is Dactylitis
Sausage digits
Reactive Arthritis
In a patient with active infection consider testing
1) Joint effusion: _____
2) Active diarrhea: ______
3) GU symptoms: ________
- Arthrocentesis
- Stool cultures
- UA and STD panel
What Dx/ Tx
Associated with a derm issue
Clinical Manifestations
(a) Pain and stiffness in affected joints
–1) Stiffness sometimes alleviated by physical activity
(b) Asymmetric distribution of joint pain
–1) SI joint, large joints (such as knee), small joints (such as DIP)
(c) Majority have skin lesions prior to pain
–1) Pain may precede lesions
(d) Soft tissue inflammation: Enthesitis, dactylitis, tenosynovitis
(e) Nail lesions
(f) Ocular involvement
Psoriatic Arthritis
Do not attempt to manage
1) Refer to rheumatology and dermatology
2) Treat symptoms in the interim
3) NSAIDs
4) DMARDs to be considered by specialist
What issue?
(a) Common inflammatory skin disease
(b) Most common manifestation: well demarcated erythematous plaques with silver scale
psoriasis
True/False
Diagnosis for Psoriatic Arthritis made in patient who has both psoriasis and classic arthritis pattern
true
