MSK Flashcards

Question

Management of fibro in pregnancy

Answer 1

#1 nonpharm (pain control, stress management, energy conservation) if nonpharm insufficient -tylenol -NSAID (only first trimester) SSRI/SNRI = increase risk of NAS Amitryptilline= relatively safe ish dont use gabapinoids or tramadol

Answer 2

typically only effective for mild cases, moderate-severe need pharm alternatives -engage in mental alertness activities (cards, puzzles) to reduce symptoms in boredom -abstain from alcohol, caffeine, nicotine -take hot baths -stretch and exercise moderately. -yoga might help, massage might help -discontinue meds that contribute antidepressant- mirtazapine antiemetics- metoclopramide antiepileptics- topiramate antihistamines- diphenhydramine antipsychotics- seroquel, zydis, clozapine -minimize aggravating factors such as sleep deprivation -if RLS and varicose veins; consider sclerotherapy to improve RLS

Answer 3

Start lowest dose and should be administered 1-2 hours prior to bed ** should check iron (most are iron deficient Intermittent RLS (<2/week) : ~intermittent use of: **first line** 1. Levodopa prep -increased risk of rebound **others** 2. benzodiazipines -not improve core symptoms but improves sleep 3. low potency opioids (only if refractory to other treatments) -strong sedative effect may be responsible for effectiveness -low potency like codeine are best options

Answer 4

**FIRST LINE** (esp if symptoms severe, excessive wt, comorbid depression, cognitive impairment or increase risk of falling) **-> Dopamine agonist** -Pramipexole -Ropinirole (bromocriptine, rotigotine/ also but others have better a.e profile) SE= nausea, sedation, lightheadness ** increased risk of developing high risk behaviors like pathological gambling, hypersexuality // need to taper **SECOND LINE** (consider first if severe sleep disturbances. comorbid insomnia, anxiety, painful RLS, hx of compulsive behaviors or anxiety) **-> gaba deriviatives** -gabapentin -pregabalin

Answer 5

** often happens in pregnancy/ educate pt about self limiting nature of symptoms in pregnancy ** nonpharm is maintay #1 for both pregnancy and breastfeeding must r/o iron deficiency

Answer 6

Steps: 1. consider combining agents from different drug classes (dopamine agonist, Gaba deriviatives, benzo, low or high potency opioids) 2. if continues to be refractory and resistant to treatment -> high potency opioids (oxycodone or methadone)

Answer 7

Nonpharm is mainstay #1 -reassure pt benign nature of cramps -most can be relieved with acute static stretching -hot pack or hot bath can help relieve cramps -icing can be used (no study on effectiveness)

Answer 8

no med clearly beneficial magnesium has mixed results small benefit with dilitazem, vitamin B complex

Answer 9

stretching despite inconsistent results, magnesium for 2-4 weeks is a safe treatment option to decrease cramps

Answer 10

HENT eye injury -> blurred vision, loss of vision, mod to severe eye discomfort head injury -> confusion, amnesia, headache, LOC after injury, n/v nosebleed -> >20 min ruptured tympanic membrane -> earche, hearing loss, slight bleeding, dischrage from ear

Answer 11

stretching proper conditioning and training warm up cooling down ~wearing adequate protection if sports require it

Answer 12

for soft tissue injury - RICE REST ~first 24-48 hours of injury ICE- Cold is preferred 20-30 min at regular intervals t/o waking hours Compression -first 24 hours ELEVATE - above level of heart to reduce swelling After first 48 hours -> heat is preferred (once swelling is subsided, acts like analgesia to decrease joint stiffness) 20-30 min q2-4 hours prn

Answer 13

oral analgesia (tylenol/ NSAID) topical analgesia (value limited, use only <4/day -methyl salicylate (A535) -menthol -capsacin Arnica Montana (to reduce bruising) (limited evidence) Topical NSAID -diclofenac 1.5% (OA) -Diclofenac 1.16% or 2.32% (acute pain caused by injury) Corticosteroid injections (tendinitis) -3/year d/t risk of atrophy, tendon rupture

Answer 14

after 14 days if no improvement refer to appropriate providers

Answer 15

-assess pain quickly, calmly and with empathy -provide reassurance and encourage pt to verbalize their pain -initiate immediate measures to decrease pain (immobilize fracture, apply dressings to burn, employ cold or heat or other techniques until pharm takes effect) -do not wait till full assessment is made to start pharm therapy

Answer 16

FIRST LINE for mild-moderate (Numerical score <7) non-opioid analgesics -COX-2 (celecoxib) -ASA (avoid in kids <18) -Tylenol #1 -ibuprofen (can combine with misoprostol 200 mcq QID for gastroprotection) -naproxen *if pain persists consider adding oral opioids Opioids -use lowest recommended dose a) Meperidine -> do not use if pain >3 hours, CI in those who received MAOI <14 days ago b) codeine -> not recommended for kids <12, not recommended alone c) morphine -> better alternative than codeine d) hydromorphone -> alternate to morphine/ lower dose than morphine e) oxycodone -> high abuse potential f) tramadol -> acts through opioids and nonopioids mechanism/ less abuse potential ** active CYP2D6 metabolite, if patient are ultra rapid metabolizers they are at risk of resp depression/ do not use first line.

Answer 17

GI ulcers Bleeding perforations renal failure can precipitate asthma in asa sensitive patients increase risk of MI avoid in: -pt with peptic ulcer disease -renal failure -HF -ischemic heart failure

Answer 18

mild -> tylenol severe -> opioids (all stages) - if needing it, later stage is better. will need to watch for NAS and resp depression in newborn

Answer 19

mild -> tylenol nsaids can be used tho too for most immediate release opioid, drug is transferred to ebm -> should be aware of opioid toxicity such as constipation, oversedation, drowsiness, sedation, breathing difficulties -> should avoid codeine* ***

Answer 20

parenteral is best if that severe./ faster onset of action #1 morphine IV or ketorolac

Answer 21

possible fracture (major trauma) possible cancer (wt loss?) cauda equina syndrome (bladder dysfunction, paresthesia, weakness) infection (chills, fever) inflammatory condition (morning stiffness >30 min, improves with exercise? etc. )

Answer 22

This is mainstay #1 4Ps + C -Physio -physical activity -psychological interventions (conflicting evidence) -patient education -chiropractor Nonspecific low back pain -provide education regarding treatment options, cause of disease and maintain usual acitivity -reassurance/ will improve with time regardless of tx -stay active and only avoid activities that may worsen pain -physiotherapy -physical activity as tolerated * -Physiotherapy * -massage therapy (only for acute/ subacute // not beneficial for chronic) -acupuncture (helpful for chronic pain at end of treatment) -chiropractor -motor control exercises. which includes exercises aimed at restoring coordination, strength, control may improve pain/function with subacute and chronic but not acute symptoms chronic low back pain: -exercise programs as effective as other conservative tx such as massage, chiro, physio etc -yoga, tai chi -heat may relieve in short term -CBT, operant therapy, progressive relxation, may result in lower post treatment pain intensity -mindfulness based stress reduction ma provide greater improvement in pain symptoms and function compared to usual treatment **combined excersies + behavioral therapy is superior** -surgery only with persistent, disabling symptoms from common degenerative spinal changes

Answer 23

pharm therapy only if nonpharm fails nonspecific low back pain #1 NSAIDS > tylenol (tylenol not useful) if CI to this can try muscle relaxant (baclofen, benzo, cyclobenzaprine, tizanide) -avoid in >65, increased risk for falls LAST RESORT -> opioids -if not responding to anything and nonpharm and pharm have been optimized

Answer 24

DC WW CT CR devils claw white willow cayenne topical confrey root extract topical

Answer 25

HTN and NSAIDS -> measure BP within 1 week of starting nsaid why? NSAIDs may decrease anti-hypertensive effects, measure BP at baseline, 1-2 weeks after and adjust dosing of anti-hypertensive or nsaid as tolerated renal dysfunction and signs of fluid retention and nsaids -> can monitor SCr at baseline and repeat at 1 week periodically in all >65 year **hold NSAID if pt cannot eat or drink**

Answer 26

1. repositioning (avoid bony prominence) 2. support surfaces (active mattress > standard mattress) 3. pressure relieving devices (soft pillows, foam edges, medical sheeskin shown to decrease risk of PI) **donut cushion not recommended** 4. consideration for medical devices (avoid positioning above drains, medical devices)

Answer 27

-keep skin clean, adequately hydrated -use nonalkaline soaps and cleansers -prompt cleanup after incontinence -use barrier product

Answer 28

assess for malnutrition and optimize nutrition

Answer 29

RD -> optimal nutrition chiropodist, OT, PT -> ensure proper pressure redistribution pharmacist -> review meds and assist with smoking cessation pt/family -> ensure adherence to recommended interventions

Answer 30

nutrition -> vit C, zinc and protein supplements may improve wound healing (evidence limited) smoking cessation -> encourage cessation meds affecting wound healing -> anticoagulants, antiplatelets, immunosuppressants, cytotoxic agents, corticosteroids pain management -> specific plan psychosocial management -> minimize impact of QOL and wound care to accomodate activities financial considerations -> consult SW if financial difficulties getting services (ex. meds, dressings that are not covered under insurance)

Answer 31

healable - no known factors to prevent wound from healing. Goal= complete healing nonhealable -> pt does not have physical capacity to heal (PVD that cannot be surgical corrected, end of life, cancer). Goal: minimize pain/ prevent infection maintenance -> healable wounds that cannot be healed d/t systemic related concerns that prevent optimal care (lack of access to pressure devices). Goal = reduce pain/ prevent infection

Answer 32

wound cleansing - NS wound debridement - (not recommended for dry, stable eschar) wound dressing - for uncomplicated wounds; change q3-7 days

Answer 33

clinical picture and culture results (you want to culture the fluid) -do not rely on erythema, edema or warmth

Answer 34

not healing as expected wound becomes painful increased amount of exudate development of foul odor

Answer 35

Topical -> in combination with systemic antibiotics (use for 2 weeks prior to assessing effectiveness) ex. gentian violet/ methylene blue medical grade honey iodine polmexamethylene biguanide silver systemic -> if systemic infection is suspected and adjust therapy based on C+S

Answer 36

PMR = bilateral aching and stiffness in neck, pectoral, pelvic girdles and thighs -acute onset -morning stiffness lasting hours -symptoms worsen at night, movement during sleep causes discomfort -systemic symptoms (fever, malaise, anorexia, wt loss, fatigue) Diagnosis- decrease ROM to neck/shoulder d/t pain rather than stiffness -severe swelling with pitting edema over dorsum of both hands and feet -large and small synovitis present in unusual location giant cell arteritis -chronic vasculitis of large medium sized arterities -headache, jaw claudication and visual loss are characteristic presentations *** -systemic symptoms in 50% diagnosis -diminished or absent temporal artery, scalp tenderness diagnosis- temporal artery biopsy is gold standard IF NO SYMPTOMS SUGGESTIVE OF GCA - TREAT FOR POLYMYALGIA RHEUMATICA

Answer 37

prompt diagnosis and initiation of treatment is critical for the prevention of vision loss in pt with GCA -treatment should not be delayed for biopsy (can still test positive 4 weeks after) #1 Systemic corticosteroids **Prednisone 40-60 mg/day** Duration: 1-2 years (50% will experience exacerbation) some may require 5-10 years or indefinite Please note: once vision loss occurs/ steroids will not reverse it **+** Antiplatelet **ASA 81-100mg/day** -continue for 4-6 weeks untl clinical lab indication of systemic inflammation have normalized and risk of vision loss has ablated -can use PPI or misoprostol during prednisone and ASA to reduce GI tox ALTERNATIVE: Methotrexate - if unable to wean below 7.5 mg or if frequent relapses Resistant cases -> refer to Rheumatologist

Answer 38

#1 systemic corticosteroid Prednisone 10-20 mg/day (LOWER than GCA) Duration: 1-2 years of therapy -some require 5-10 years or indefinite ** substantial or complete symptom resolution of symptoms occurs within days after prednisone admin -> if symptoms fail to improve after 1 week -> reconsider diagnosis ** Second line: IM methylprednisolone (if high risk of corticosteroid tox) Alternative: methotrexate -if unable to wean below 7.5 mg of prednisone daily -consider in pt with frequent relapses

Answer 39

BG BP vision changes (check for cataracts - check vision yearly) wt gain BMD (Q1-3 years sooner if high risk of #) Ensure regular clinical assessments to look for recurrence of the original symptoms while concurrently checking CBC, ESR and CRP during the prednisone taper. An isolated rise in ESR or CRP is usually not sufficient justification to increase the dose of corticosteroids. If a disease flare occurs, increase the dose of prednisone to the lowest level that was previously effective in controlling the disease. Maintain at that level for 1 month, then taper as before.

Answer 40

6 S Sick- increase susceptibility to infection Sad- mood swings Sex- decrease libido Salt - weight gain, HTN Sugar - glucose intolerance Swelling Acne, glucose intolerance, weight gain, mood swings and agitation, cataracts, myopathy, hypertension, osteoporosis, aseptic necrosis of large joints, adrenal suppression, increased susceptibility to infection.

Answer 41

use lowest dose needed to control symptoms increase risk of fractures with prednisone use ** -> Biphosphonates prevent bone loss associated with corticosteroid and should be prescribed in pt commencing high dose corticosteroid therapy ->encourage nonpharm: wt bearing, smoking cessation, limited alcohol intake to 1-2 drinks/day, calcium 1200 mg/day, vit d 800-2000 units

Answer 42

morning stiffness >30 min symmetrical joint swelling to hands and feet

Answer 43

if suspected RA - refer to rheumatologist ideally within 6 weeks of onset of symptoms -pt education, emotional and psychological support and physical neuromotor performance -**energy conservation, appropriate levels of activity** (cardio/strength/ flexbility) (balance and rest and exercise to maintain joint motion) -**smoking cessation** -**applying heat/cold tx** -**osteroporosis prevention** -**psychosocial interventions** -periodically evaluate for splints, foot orthoses and proper footwear -**dietary omega 3 have small benefit**

Answer 44

diagnosis should be confirmed by rheumatologist who will start disease modifying drugs. #1 Methotrexate 15-25 mg/ week -improvement may be seen in 6-8 weeks Second line (if intolerant to methrotrexate) Sulfasalazine or Leflunamide -> this is no longer recommended/ can cause death or hydroxychloroquine -> need regular eye exam Q6-12 months ->refer to opthalmologist

Answer 45

Methotrexate + sulfasalazine or hydroxychloroquine FURTHER ESCALATE MTX +HCQ + SSZ (triple therapy) MTX+ biologic **** (usually what happens)

Answer 46

hold mtx and biologics until resolution of infection/ completion of antimicrobial therapy hold biologics prior to surgery

Answer 47

prior- ensure up to date vaccines during - cannot have live vaccines should have: pneumococcal and influenza inactive recombinant herpes zoster vaccine (live - do it before) HPV vaccine, recommended hep b to high risk patients

Answer 48

short term prednisone NSAIDS topical NSAIDS (diclofenac)

Answer 49

BioLoGiCs B- blood pressure L- lipids G-glucose C-CVS risk may increase CVS risk ( if lipids increase, use statin)

Answer 50

corticosteroid- low dose ok .. not teratogenic methotrexate- may cause NTD, folic acid 5 mg/day should be taken if treated 3 months prior. Should really be stopped prior to conception hydroxy- not much data sulfasalazine - folic acid supplement of 5 mg/day should be taken, monitor for jaundice for baby. May cause infertility in men biologics- could have implications, breastfeeding: all except biologics ok

Answer 51

COMPLETE CI -need drug eliminating protocol (very extensive)

Answer 52

stiffness after inactivity, mornings limited ROM pain with activity

Answer 53

pt education on self management strength training aerobic exercise tai chi wt loss (decrease load on joints) joint protection (braces, splints) supportive footwear use ambulation aid social support (improves pain and psychological status acupuncture heat/cold massage transcutaneous electrical nerve stimulus ->refer to physio or occupational therapy

Answer 54

#1 Tylenol (for pain) 1g QID x1-2 weeks, following this the lowest effective dose should be tried. Adjunct: #1 Diclofenac Topical -> if suboptimal pain with tylenol -can take up to 2 weeks for max effect Capsaicin topical TID QID x 7 days -can take up to 4 weeks for max effect Second line: NSAIDS ->add gastroprotection if moderate risk of GI events celecoxib -> can exacerbate pre-existing renal disease. Baseline and periodic monitoring of SCr and lytes is recommended in high risk pt. THIRD LINE -opioids -in combo with tylenol or NSAIDS (who do not respond to other analgesics -codeine products is reasonable -tramadol FOURTH LINE duloxetine -could be used as monotherapy or in combination with tylenol or NSAID

Answer 55

>65 alcoholic liver disease H. Pylori infection PUD RA Upper GI bleed 1-2 = moderate -> gastroprotection >3 = high - > use alternative or gastroprotection

Answer 56

METHO not very drug related M-mouth ulcers E- end of blood cell (cytopenias, anemia, leukopenia) T-tiredness H-hepatotoxic O-pneumOnitis N-nephrotoxic V-vomiting and nausea D-diarrhea, dizziness m R-rash, pruritus ** do not use in liver or renal disease, or in lung disease** Mouth ulcers Of Infections GI perforatio Nephrotoxic Hepatotoxic Cytopenias Skin necrotizing vascular is **so cool having no good infections or mouth ulcers**

Answer 57

CBC , liver panel , Scr Q2-4 weeks for first 3 months then Q3 months Chest xray at baseline

Answer 58

Folic acid 1-5 mg -helps decrease a/e Usually you take it on non methotrexate days (x6 days) because dosing is 25mg po once weekly