FINAL - MSK & Pain Flashcards
What is gout?
Derangement in metabolism resulting in hyperuricemia, urate crystal deposits in tissues (tophi) and synovium (microtophi).
What is the most common type of inflammatory arthritis?
Gout
Is gout more common in M or F?
Male (5.2 % of males, 2.4% females)
What age group of men is gout most common in
30 -60
T/F Women have increased suscepitbility to gout after menopause
True
What are some non modifiable risk factors for gout?
Genetic mutations, male gender, and advanced age
Presence of medical conditions like renal failure, metabolic syndrome, DM (though I would argue how well you are managing these diseases is modifiable/ within your influence)
What are some modifiable risk factors for gout?
Diet -alcohol, purine rich foods such as meats and seafoods, fructose/sugar sweetened foods
What are some medications that are known to precipitate gout
Drugs are FACT
-Furosemide
-Aspirin, alcohol
-Cyclosporin
-Thiazide diuretics
Briefly describe the patho of gout.
-Uric acid can be obtained from the diet or made endogenously by xanthine oxidase
-An excess of uric acid results in hyperuricemia
-Uric acid can deposit in the skin/subcutaneous tissues (tophi), synovium (microtophi), and kidney, where they can crystalize to form monosodium urate crystals
-Intense inflammatory reaction is triggered in response to crystals
Differentiate primary and secondary gout.
Primary: high levels of uric acid from either increased production or decreased excretion
Secondary: Hyperuricemia from primary disease processes such as HTN, renal failure, kidney disorders, etc.
True or false: In acute gout, the maximal severity of the flare is reached in 12-24 hours
True
When will an acute gout attack subside?
Subsides spontaneously in 5-10 days
What is chronic/ tophaceous gout
Inadequately treated gout results in urate crystal deposits in joins that cause deformity and disability of joint
What joint is most commonly affected in gout?
First metatarsal phalangeal joint (base of great toe)
What other joint is commonly affected in gout?
The knee
T/F, 80% of initial gout flares involve a single joint
True
Most often the great toe or the knee
T/F, onset of most gout flares occur at night
True
What is the classic presentation of acute gout?
-Severe pain
-Erythema
-Joint swelling
-May have limited joint mobility
-Onset most commonly at night
-Great toe
What are tophi?
Urate deposits found on cartilage, tendons, bursae, soft tissues, and synovial membranes.
Where are common sites for tophi formation?
First MTP, ear helix, olecranon bursae, tendon insertions (common in Achilles tendon
T/F Tophi are exquisitely tender
False- Tophi typically are not painful or tender, but can be accompanied by chronic inflammation and destructive changes to surrounding tissue.
Name 2 renal complications of gout.
Gouty nephropathy
Uric acid nephrolithiasis
What is the single most important differential to assess in gout?
Septic arthritis
What are other important differentials in gout?
Pseudogout (CPP arthritis)
Bursitis
Cellulitis
Hyperparathyroidism
Trauma
Diagnosis of gout?
Joint aspiration!
From Up To Date:
In patients with a suspected gout flare in whom the diagnosis has not been previously established or in whom the cause of acute arthritis is uncertain should undergo arthrocentesis; testing of the synovial or bursal fluid should include cell counts and differential white count, Gram stain and culture, and examination for crystals under polarizing light microscopy,
“But that’s not how my preceptor diagnoses gout”… Is there another way to diagnose gout?
In primary care, if unable to do aspiration/ synovial fluid analysis, can apply clinical criteria (IF no signs of infection, i.e., red/ hot/ swollen/ painful joint with fever or evidence of extraarticular infection).
From Up To Date
Use of a clinical diagnostic rule — A clinical diagnostic approach (“rule”), which can be used to estimate the likelihood of gout, has been shown to improve the accuracy of diagnosis of a gout flare made in primary care practice without joint fluid analysis (algorithm 1) [81]. The model uses seven variables (which were assigned weighted scores) that can be ascertained in primary care to distinguish three levels of risk for gout. It uses the following variables and scoring values:
●Male sex (2 points)
●Previous patient-reported arthritis flare (2 points)
●Onset within one day (0.5 points)
●Joint redness (1 point)
●First metatarsal phalangeal joint involvement (2.5 points)
●Hypertension or at least one cardiovascular disease (1.5 points)
●Serum urate level greater than 5.88 mg/dL (3.5 points)
Based upon the total score, patients can be identified as having low (≤4 points), intermediate (>4 to <8 points), or high (≥8 points) probability of gout
T/F Serum urate will be elevated in a gout flare
Not always- most accurate time for assessment is at least 2 weeks after a flare
What are characteristic XR findings of tophi?
Soft tissue swelling, bone/joints - punched-out lesions, erosion with “over-hanging” edge
T/F Initiation of gout treatment should be initiated only after 24 hours into an acute flare.
False- early treatment of a gout flare leads to more rapid and complete resolution of the flare.
T/F Septic arthritis should be excluded before using glucocorticoids
True
T/F Urate lowering medications should be stopped during a gout flare
False
During a gout flare, urate-lowering medication (i.e., allopurinol, probenicid) should be continued, without interruption. There is no benefit to temporary discontinuation of these medications. Moreover, subsequent reintroduction of urate-lowering therapies may precipitate another flare.
What is the first line treatment of an acute gout flare?
- Latest evidence suggests that if possible, intrarticular glucocorticoid injection is best (esp if first or infrequent episodes). This avoids complications of systemic therapy.
- If practitioner cannot do this in a timely manner/ IA glucocorticoids are not available, systemic (NSAIDs), colchicine, or glucocorticoids are alternatives. Patient factors, prior experience, and availability should guide the choice of therapy.
Can you treat with NSAIDs and colchicine at the same time?
Great question- if anyone knows the answer please tell me.
From my reading it seems to be just one or another?
Lexicomp says no interactions between the two drugs indicating it is safe. However, they both have adverse GI effects and are CI in renal impairment.
Up To Date has a great treatment algorithm for gout and says to choose ONE of the options (oral glucocorticoids, NSAIDs, colchicine)
How much colchicine would you give?
- Colchicine 1.2 mg at the first signs of attack, then 0.6mg 1 hour later and 0.6 mg BID on subsequent days until the attack has resolved
Describe conservative management of chronic gout.
o Avoid foods with high purine content (visceral meats, sardines, shellfish, beans, peas)
o Avoid drugs with hyperuricemic effects (pyrazinamide, ethambutol, thiazide, alcohol)
o Additional management of lifestyle factors: limiting alcohol intake, high fructose corn syrup, weight loss (if overweight)
Describe when medication is indicated for chronic gout.
> 2 attacks/year, bone erosions/arthritis, high risk of severe gout
What kind of medication is used for chronic gout?
o Antihyperuricemic drugs – decrease uric acid production by inhibiting xanthine oxidase. Start low and titrate up.
What medication is first line for medical management of chronic gout?
Allopurinol
What is an important consideration when starting a patient on urate lowering therapy
Acute falls in urate levels can precipitate a gout attack.
Either start low and titrate up or use low doses of colchicine/ NSAID to prevent
Order these opioids from most to least potent
Tramadol, hydromorphone, codeine, morphine, hydrocodone, fentanyl, oxycodone
Fentanyl > hydromorphone > morphine > hydrocodone >oxycodone > codeine/ tramadol
T/F When starting opioids for chronic pain, clinicians should prescribe extended release/ long acting opioids (instead of immediate release) in order to better manage the patients pain/ avoid break throughs in pain.
False. Clinicians should prescribe IR opioids instead of ER when starting opioid therapy. Risk of OD with ER (patient keeps taking expecting instant effect) is what Sarah explained in class.
At what number of morphine miligram equivalents (MME) day should a clinician be mindful of reassessing evidence of individual benefits?
When increasing dosage to 50+ MME/ day
Clinicians should avoiding increasing dosage to ______MME/ day or carefully justify their decision to titrate doses above this level.
90
T/F When opioids are prescribed for acute pain, the prescriber should prescribe 1.25x the quantity needed for the expected duration of pain.
False. Prescribe no greater than quantity needed.
How many days of opioids are typically needed for acute pain?
3; more than 7 days will rarely be needed
When a clinician prescribes opioids for chronic pain, when should they reassess the patient?
Sarah’s ppt: within 1-4 weeks of starting opioid therapy/ escalating dosage. Reassess harms/ benefits q3 months or more frequently.
What factors increase risk for opioid OD?
Hx of OD
Hx SUD
MME/ day 50+
Concurrent BZD use
When prescribing/ renewing a prescription for opioids, what should the clinician do every encounter?
Check pharmanet/ prescription drug monitoring program to determine whether the patient is receiving opioid dosages or dangerous combos that put them at higher risk for OD.
(Among other things, but this is something Sarah emphasized in exam review)
T/F When prescribing opioids for chronic pain, clinicians should use urine drug testing before therapy and annually
True per Sarah’s ppt.
Why is it important to calculate total daily dosage of opioids?
-ID patients who may benefit from closer monitoring, reduction/ tapering of opioids, naloxone, or other measures to reduce risk of OD
How do we calculate the total daily dose of opioid?
1) Determine the daily amount of each opioid the patient takes.
2) Convert each to MMEs (multiply the dose for each opioid by its conversion factor- found in a table)
3) Add them together.
T/F You can use the calculated dose of MMEs to determine dosage for converting one opioid to another
False. The new opioid should be lower to avoid unintentional OD caused by incomplete cross tolerance and individual pharmacokinetic differences.
When considering opioid therapy for chronic pain, providers should take the following steps:
Assess risks to patient safety by conducting a physical examination, mental health screening, prescription drug monitoring program (PDMP) check, and urine drug tests
Set goals for improvements in pain and function with the patient
Check that non-opioid therapies are tried and optimized
Discuss risks and benefits with the patient
Establish criteria for stopping or discontinuing opioid therapy
You have a patient on hydromorphone 2 mg BID. How many MME per day?
Conversion factor for hydromorphone: 5
1) Calculate daily dosage of HM (2mg BID= 4mg)
2) Multiply total dosage of HM by conversion factor (4mgx 5)
Answer: 20MME
You have a patient on Codeine 30mg QID. How much is the MME per day?
Conversion factor for codeine: 0.15
1) Calculate daily dose of codeine (30mg x QID= 120mg)
2) Multiply by conversion factor: 120mg x 0.15
Answer= 18 MME daily
You have a patient on Codeine 30mg BID. How much is the MME per day?
1) Total daily dosage of codeine: 30mg x BID= 60 mg
2) Conversion factor: 0.15
9MME
T/F The relation between dosage and overdose risk is different for buprenorphine. The MME thresholds of 50 and 90 MME do not apply, and there isn’t a calculation to identify equivalency.
True
Why is dosing methadone complicated?
Long and unpredictable t1/2
QTc prolongation
Potential for cardiac arrythmia
Name some medical conditions that can pose a life threatening risk with opioid use.
Sleep-disordered breathing such as sleep apnea
Pregnancy
Renal or hepatic insufficiency
Age >= 65
Certain mental health conditions
Substance use disorder
Previous nonfatal overdose
Reasonable tapering regiment for opioids?
Individualized. Reduction of 10% per week/ month
Which three bones compose the shoulder girdle?
Clavicle, scapula and proximal humerus
When assessing the shoulder (and doing other MSK assessments), what are the three steps in the assessment?
Look, feel, move
When doing the inspection for MSK assessments, what are you looking for? There is an acronym for it..
SEADS
Swelling
Erythema
Atrophy
Deformity
Skin changes/scars/symmetry
When doing the palpation for MSK assessments, what are for feeling for? There is an acronym for that too!
TESTCAPS+
Tenderness
Effusion
Swelling
Temperature
Crepitus
Atrophy
Pulses
Sensation
+DTR
Susan is reporting a gradual onset of anterior and deep shoulder pain. On exam you find decrease in both active and passive motion of the shoulder. What might the source of this shoulder pain be?
Osteoarthritis
What are some risk factors you might expect to uncover in the history of a patient with shoulder osteoarthritis?
Older age
Trauma
Previous shoulder injuries
Which shoulder condition is associated with the connective tissue of the shoulder becoming inflamed and stiff?
Adhesive Capsulitis (frozen shoulder)
What is the time course of adhesive capsulitis?
9 months of disabling pain and increasing stiffness
Followed by up to 12 months of progressive ROM limitation to passive and active ROM to the point where the should can barely move. Pain is less pronounced in this stage
Finally the recovery phase occurs in which patients regain their mobility, can take up to 2 years!!!
Risk factors for adhesive capsulitis
Diabetes
Immobilizing disability (stoke, injury requiring a sling)
What are some shoulder injuries that may occur with trauma to the joint/limb?
Acromioclavicular dislocation
Glenohumeral dislocation
Clavicle fractures
Proximal humerus fractures
The Grinch undertakes a lot of overhead work preparing his sleigh and undecorating everyone’s trees. What shoulder injury might he experience if he sustains these movements over time?
His symptoms would include anterolateral shoulder pain worsening with overhead movement and pain with external rotation
Degenerative rotator cuff injury - tendinopathy/impingement of supraspinatus tendon is the most common degenerative rotator cuff injury
What are some special tests for assessing the Grinch for rotator cuff impingement?
Empty can test
Full can test
Neers test
Hawkins Kennedy test
lots of others
In addition to rotator cuff impingement/tendinopathy, the rotator cuff can also tear. What is a special test for this?
Drop arm test
Findings with a torn rotator cuff
Pain and weakness with testing (whereas the impingement would mostly just show pain)
Most common is age > 40
What are some non-MSK sources of shoulder pain to keep in mind?
Referred from thoracic or abdo source
Cervical nerve root impingement - sharp pain radiating from neck into the posterior shoulder or arm
Splenic injury can present as shoulder pain in MVAs
Myocardial ischemia - especially if associated with diaphoresis or dyspnea
What physical exam findings would suggest a non-shoulder cause of pain?
Normal MSK assessment
UTD has a 4 step frame work to evaluate shoulder complaints
Step 1 - Determine if traumatic or atraumatic. Plain x-rays may be needed if traumatic
Step 2 - Determine if intrinsic (shoulder related) or extrinsic (from something else) - Extrinsic pain may be difficult to localize and vague or sharp with radiation if neurologic
Step 3 - Glenohumeral or extra-glenohumeral. For extra-glenohumeral source, patient often able to localize pain and passive ROM of glenohumeral joint should be normal. Extra glenohumeral disorders could include biceps tendinopathy and AC osteoarthritis.
Step 4 - Differentiate glenohumeral pathology if extra-glenohumeral ruled out. Use history and assessment to differentiate rotator cuff tendinopathy, rotator cuff tear, adhesive capsulitis, osteoarthritis.
For the hand and wrist, as with other MSK injuries, a good first question to ask is whether there was any trauma. What are the two common wrist fractures?
Colles fracture and Smith fracture
What do you remember about Colle’s fracture?
Complete fracture of the distal radius bone with posterior displacement of the radius. Ulnar styloid ma also be fractured.
From FOOSH
Associated with “Dinner fork appearance”
What do you remember about Smith’s fracture?
Fracture of the distal end of the radius from a fall on the back of the flexed hand
Results in volar displacement of the fractured fragment
