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Therapeutics 2 > Modul 7. MSK > Flashcards

Modul 7. MSK Flashcards

1
Q

please define acute, subacute, and recurrent lower back pain

A
  1. Acute 0-30 days
  2. Subacute 4-12 weeks
  3. Recurrent occurring up to 6 months after onset

For recurrentbackpainor persistentbackpainof 3–6 months, reassessment is advised and should include reevaluation for yellow flags

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2
Q

What is sciatica?

A

pain that starts in the back and is referred below the level of the knee

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3
Q

true or false?

For uncomplicatedlowbackpain(acute, subacute or chronic) or for chronic radiculopathy with no red flags, diagnostic imaging is not recommended.​

A

true dont order imaging unless they have redflags

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4
Q

list the red flags of lower back pain

A

N- neurological (cauda equina symptoms, motor/sensory loss, neurological deficits)

I - Infection (fever, IV drug use, immunocompromised)

F- fracture (history of trauma, osteoporosis risk)

T- Trauma hx of cancer, unexplained weight loss, significant night pain, severe fatigue

I- Inflammation, chronic low back pain more than three months, age above 45, morning stiffness greater than 30 minutes, improves with exercise, disproportinate night pain

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5
Q

What are some yellow flags to lower back pain?

A
  • work absence
  • self report of extreme pain and constant pain in multiple areas
  • patients who believe they will never return to work
  • psychiatric distress
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6
Q

if a patient presents with acute lower back pain, you ruled out red flags, what is the first line treatment?

A

first line:

nonpharm, advise to stay active avoid bedrest, resume activity as tolerated, tylenol/advil till tolerated

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7
Q

If a patient has lower back pain (no red flags), you already provided first line treatment which is nonpharm management and they have not improved what is your second line option

HOW long do you wait till you reassess>

A

second line

consider a trial of oral or topical NSAID, muscle relaxant, tylenol with codeine or tramadol

you will wait 4 weeks to reassess

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8
Q

it has been 4 weeks since you prescribed your patient a muscle relaxant for their lower back pain, and they are still in pain, what do you do nexT?

A

Subacute pain is 4weeks-12 weeks

you need to re-evaluate for red flag symptoms, consider diagnostic imaging
screen for yellow flags
consider pharmacologic options not yet tried (topical nsaid, tylenol with codeine etc)
Consider physiotherapy

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9
Q

if a patient has back pain that is unresolved past 3-6 months what would you do for treatment?

A

back pain beyond 3 months is considered chronic back pain, treatment is non pharm

  • multidisciplinary rehabilitation
  • CBTherapy
  • relaxation therapy
    -coping skills
  • workplace modification
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10
Q

please list some non-pharm treatments for acute lower backpain

A
  • physical activity as tolerated
  • physiotherapy
  • chiropracter
  • psychological interventions (CBT)
  • acupuncture
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11
Q

please list some chronic lowerback pain non pharm options?

A
  • physical activity (the goal is not weight loss)
  • physiotherapy exercises
  • yoga
  • nordic walking
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12
Q

what dose of Tylenol would you prescribe for acute uncomplicated lower back pain?

A

500mg q4

it has a better saftey profile over advil

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13
Q

why would you chose celecoxib over an NSAID for acute lower back pain?

A

it has less GI side effects

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14
Q

if opiods are used for lower back pain, what duration would you give

A

less than 3 days is preferred

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15
Q

if a patient has a spastic component to their lower back pain what medication can you prescribe?

A

direct acting muscle relaxants:

baclofen
benzodiazepines
cyclobenxaprine
tizanidine

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16
Q

If a patient has epilepsy and is taking high doses of tylenol what do we need to be worried about?

A

hepatotoxicity

Antiepileptic drugs with chronic high use of tylenol can cause liver damage

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17
Q

What drug interactions should we be worried about regarding advil and other medications?

A

Advil may decrease the efficacy of antihypertensive medications:

beta-bloackers, diuretics, ACEIs

NSAIDS inhibit renal excretion of methotrexate

and SSRI increased risk for bleeds

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18
Q

What natural health products could be used topically for chronic or acute lower back pain?

A

acute- comrey root extract

chronic- topical cayenne

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19
Q

For acute lower back pain, what timeline should you use to follow up with the patient?

A

if the pain is severe follow up in 24 hours

if the pain is moderate re-evaluate in 7-10 days

Regardless for all, see client in 2-4 weeks

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20
Q

when would you consult a neurologist for a patient with lower back pain?

A

when a patient has redflag symptoms like:

Cauda equina syndrome
Herniated disc
widespread neurological involvement
significant trauma
carcinoma

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21
Q

for lower back pain when would you consider consulting a rheumatologis?

A

clients who notes significant morning stiffness with gradual onset prior to age 40 years, with continuing spinal movements in all directions and involving some peripheral joint joints, iritis, skin rashes indicating inflammatory disorders such as ankylosing spondylitis and related disorders.

22
Q

When would you use opioids for back pain?

A

VERY RARLEY, often in the subacute-chronic phase and ONLY after you have completely optimized all other treatment options

you will reevaluate after 3days and you will deprescribe if the paitent still has pain at 3-6 months with no improvement

23
Q

if a patient was taking a non prescription muscle relaxant like chlorzoxanone, orphenadrine, or methocarbamol what would you tell them?

A

nonprescription muscle relaxants such as chlorzoxazone, methocarbamol or orphenadrine have little direct muscle-relaxing properties or evidence to support their use.​[55]

Muscle relaxants are associated with an increased risk of adverse effects, such as dizziness, drowsiness and sedation, which outweigh their benefit

24
Q

what controlled substances CANT a NP prescribe?

A

opium
Coca leaves (cocaine)
anabolic steroids EXCEPT testosterone

25
Q

can any NP prescribe controlled substances?

A

no, only NPs who have completed college approves substance education in Ontario can prescribe

26
Q

what are the risk factors for osetoarthritis?

A

greater than 65
advancing age
join injury

27
Q

what type of imaging would you order for osteoarthritis?

A

an xray or ultrasound

MRI has low sensitivity, only use MRI if there is soft tissue injury

28
Q

in what instances is it appropriate to prescribe cannabis?

A

in general advise against it unless:

neuropathic pain, palliative and
end-of-life pain, chemotherapy-induced nausea and vomiting, and spasticity due to multiple sclerosis or spinal cord
injury

29
Q

what are your first line non pharm treatments for osteoarthritis?

A
  • strength exercise
  • weight loss if obese
  • mobility aids
  • physiotherapy
    -heat/cold compress
  • patient education
30
Q

After providing nonpharm therapy for osteoarthritis, and pt still has symptoms what are your next steps?

A

first trial tylenol 4g/max per day

if that is not helping then add topical agents like diclofenac (NSAID) or capsaicin

31
Q

what GI risk factors would determine if a patient with osteoarthritis is low, medium, or high risk ?

A

low risk = NO risk factors
moderate= 1-2 risk factors
high= more than 2

32
Q

Please list some risk factors that would be evaluated for a patient with osteoarthritis who needs to start an NSAID

A

the number of these risk factors below, is what places a pt at low,med, or high risk

  • age above 65
  • diabetes
  • HTN
  • rheumatoid arthritis
  • alcohol liver disease
  • upper GI bleed
  • h pylori
  • kidney disease
  • dehydration
33
Q

if your patient has no GI risk factors what medications can you start them on for ostearthritis (after you trialed non pharm, tylenol, and topicals)

A

low dose nonselective NSAID

34
Q

if your patient has moderate (1-2) GI risk factors what medications can you start them on for osteoporosis (after you trialed non pharm, tylenol, and topicals)

A

low dose celoxib (100mg/day)

or

nonselective low dose nsaid with gastroprotection (misoprostol 200mcg QID,omeprazole 20-40mg/day)

35
Q

if your patient has high (3 or more) GI risk factors what medications can you start them on for osteoarthritis (after you trialed non pharm, tylenol, and topicals)

A

alternative therapies like duloxetine (SNRI) for pt with depression + widespread neuropathic pain

or an opioid Trazadone

OR low dose celoxib with gastroprotection (misoprostol 200mcg QID, omeprazo

36
Q

For your patient with osteoarthritis after you have trialed nonpharm,tylenol,topicals, low dose nsaid/celecoxib

What is your next step?

A

high dose NSAId or high dose celecoxib (200mg/day) with GI protection

37
Q

your patient with osteoarthritis

youve tried everything up to high dose nsaid/high dose celecoxib

what is your last resort?

A

surgery

38
Q

when would you consider intra-aricular coticosteroid injections?

A

in patients where NSAIDs are contraindicated or those who are poor candidates for surgery

the steroids only provide temporary relief 4-6 weeks

should not be used more than 3-4 times per year.

39
Q

What natural health products are available for osteoarthritis, and are they recommended?

A

glucosamine and chondriotin are available, and it has a good safety profile but its not recommended for osteoarthritis

If they want to use it they can, chondroitin is best for hand osteoarthritis and glucosamine sulfate is the best option over glucosamine hydrochloride

40
Q

What do you know about topical Devils claw and Glucosamine

A

Devils claw has been demonstrated to reduce acute/chronic lower back pain, but not a lot of research for long-term affect

may reduce pain in acute and chronic lower back pain.​[60] For devil’s claw, standardized daily doses of 50–100 mg of the active ingredient harpagoside improved pain compared with placebo

Those who are interested in taking these supplements can be advised that glucosamine sulfate may be superior to glucosamine hydrochloride, and that the best available evidence is for the use of chondroitin sulfate for hand OA.​

[14] Both glucosamine and chondroitin have good safety profiles.

41
Q

how would you interpret the opiod risk assessment tool?

A

A score of 3 or lower indicates low risk for future opioid abuse, a score of 4 to 7
indicates moderate risk for opioid abuse, and a score of 8 or higher indicates a high risk for opioid abuse

42
Q

True or false NSAIDs may cause asthma attack.

A

true

43
Q

what investigations would you order for a patient with suspected rheumatoid arthritis

A

Anti-CCP,​[a] CBC, CRP, ESR, RF, liver panel

44
Q

what is the first line treatment for Rheumatoid Arthritis?

A

Methotrexate, weekly dose of up to 25mg po/SQ

45
Q

What are the common side effects of methotrexate and what medication can you take to reduce these side effects?

A

Side effects: apothous ulcers, GI, liver dysfunction

Taking 5mg folic acid weekly reduces these side effects

46
Q

please list the conventional synthetic disease modifying antirheumatic drugs (csDMARD)

A
  1. methotrexate
  2. Sulfasalazine
  3. Hydroxychloroquine (antimalaria drug), long term use associated with retinal (eye) toxicity eye check q6-12 months
  4. Leflunomide, causes severe diarrhea and liver injury
47
Q

if a patient fails trialing monotherapy for rheumatoid arthritis, what is the next best option?

A

this means failure to acheive remission/low disease activity by 3 months

the next best option is triple therapy

methotrexate, hydroxychloroquine and sulfasalazine

48
Q

please list some nonpharm tx for gout

A
  • low calorie diet (more effective than low purine)
  • drink wine instead of beer
    -consume 2L of water per day
    -avoid pop and sugar drinks
  • during an attack rest, elevate limb, apply ice avoid
49
Q

what are the first line treatment options during an acute gout attack (first 24 hours)

A

colchicine
nsaids
coticosteroids

avoid starting/stopping/changing dose of allopurinol during a flare as it may prolong the flare

50
Q

what medication do you use for maitanece for gout? and when would you consider starting this medication?

A

Allopurinol is the maitanece medication for gout, you would only start a patient on this medication if:

  • more than or equal to 2 attacks a year
    -sUA above 800
  • chemotherapy
    -urolithiasis
  • stage 2 chronic kidney disease
51
Q

what are the side effects (including serious) of cholicine?

A

side effects include: nausea,diarrhea, serious neutropenia, liver and rhabdomyolysis

Therapeutics 2 (12 decks)

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