MSK

Question 1

Low Back Pain

Answer 1

DDx
Org(Vasculo)]
AAA – older, HTN, “ripping pain”, syncope, pulsatile abdominal mass, POCUS >5cm

Org(Nephros)]
Nephrolithiasis – renal colic (obstruction of urinary tract) causing increased peristalsis of urreter and renal capsular distention leading to visceral pain, intermittent pain that waxes and wanes with writhing and inability to sit still, N, V, unilateral flank pain radiating to groin, CVA tenderness,

Infla]

• *OA** – age
• *Anklyosing spondylitis** – young, HLA-B27 positive, pain/stiffness from cervical to lumbar worse in the morning and with inactivity
• *Psoriatic spondylitis** – psoriasis

Oncos]

• *Mets** – prior history of cancer, constitutional symptoms, midline tenderness (over specific vertebrae)
• *MM** – CRAB (Hypercalcemia, renal failure (bence jones proteins), anemia, bony lytic lesions

Infect]
OM, Discitis (endocarditis), Psoas abscess – IV drugs, indwelling catheter, fever, new onset back pain, bacteremia, immune compromise (DM, HIV), midline tenderness, neurological deficits
Spinal Epidural Abscess (SEA) – SEA triad – fever, mindline tenderness, neurological deficits
UTI (Cystitis) – dysuria, frequency, urgency, suprapubic pain, low back pain
Pyelonephritis – flank or abdominal pain, CVA tenderness, fever, N, V
Herpes zoster – rash

Struct]
Cauda Equina/cord compression – bilateral sciatica, lower extremity weakness, urinary retention, bowel incontinence, loss of anal tone, sacral anesthesia
Note: Cauda equina is L2 and below resulting in LMN lesion. Conus medullaris is L2 and above resulting in UMN lesion.
Herniated disk (radiculopathy)/spondylolithesis/ligamental strain – clear casual event, degenerative changes
Fracture (vertebral, compression) – age, osteoporosis, osteopenia, trauma, steriods

HPI]
AAA – syncope, lightheaded, diaphoresis, “ripping pain”
Anklyosing/Psioratic Spondylitis – young, worse with inactivity (morning), psoriasis
Mets, MM – fevers, night sweats, weight loss
OM (discitis), Psoas abscess – fevers, IV drugs, midline tenderness
SEA – fever, midline tenderness, neurological deficit, IV drugs
Cauda equina – bilateral sciatica, urinary retention, bowel incontinence, saddle anesthesia

PMHx]
Cancer (Mets, MM)
Osteoporesis (fracture)
DM, HIV, Immunocompromised (OM, SEA, Psoas abscess)
Renal failure (MM)

Meds]
Anti-coagulants
Steriods (compression fracture)

SHx]
IV drug use (OM, SEA, Psoas abscess)

• *O/E] TC (AAA), HypoTN (AAA) , Fever (Infect, Oncos)**
• *Neuros** – gait, strength, tone (anal if necessary), reflexes, sensation, 95% of disc herniations occur at the L4/L5, L5/S1
• *L4** - sqauat and rise, knee jerk reflex - extension of quadriceps; sensory loss to anterior leg, first toe, medial malleolus; pain to anterior medial thigh
• *L5** - heel walking - dorsiflexion of great toe and foot; sensory loss to dorsal foot, middle 3 toes; pain to lateral thigh and leg
• *S1** - toe walking, ankle jerk reflex - plantar flexion of great toe and foot, sensory loss to lateral foot, pinky toe, and heel; pain to posterior thigh and leg, lateral foot
• *S2,S3,S4** - anal tone, saddle anesthesia
• *Strait leg exam** – pain produced in raised leg, crossed strait-leg test produces pain in unraised leg
• *Cardios** – new murmur (endocarditis)
• *Vasculo** – symmetric pulses – femoral, popliteal, dorsalis (AAA)
• *Abdos** – pulsatile abdominal mass (AAA) , abdominal distention
• *MSK** - midline tenderness (SEA, OM, malignancy, fracture)

POCUS – AAA>5cm, hydronephrosis

INVESTIGATIO]
L(H)/Infect] ESR (90-98% sensitive) (OM, SEA), CRP
L(O)/Haim | Meta | Infect] Urine dip (Hemoglobin | Protein | Leukocytes & Nitrates) (UTI, pyelonephritis)
Note: Psuedomonas (gram - ), Enterococci (gram + cocci in pairs) , and Staph. sparophyticus (gram + ) do NOT reduce nitrates
L(I)/Haim] Blood C&S (OM, SEA, urosepsis)
L(I)/Meta] beta HCG
L(I)/Ou] Urine C&S (UTI, pyelonephritis)

I]
XR Spine (Mets, MM, fracture, spondylolithesis)
KUB (nephrolithiasis, radioopaque - calcium, struvite – ammonium, magnesium, phosphate, cystine)
Note: KUB has limited utility as some stones such as uric acid are radiolucent
CT with contrast (OM, SEA) without contrast (nephrolithiasis, fracture, spondylolisthesis, cord compression)
MRI with contrast (OM, SEA, mets, MM) without contrast (fracture, spondylolithesis)
U/S PVR >100mL (cord compression), U/S kidney (hydronephrosis, stones)

RECIPERE]
NP/C] PIV and Fluids (AAA, nephrolithiasis), type and cross (AAA)
NP/Mon] cardiac, BP, SpO2 (Trauma)

P/Poin]
Acetaminophen 650-1000mg q6h PRN
Ibuprofen 400-600 mg q6h PRN
Diazepam 5-10mg q8h PRN (muscle relaxant)
Toradol 30mg IM/IV (IV for nephrolithiasis)
Tramadol 50mg q12h PRN titrated up to 400mg/day
Percocet 1-2 tabs PO q4-6h PRN (short course)
P/N,V]
{Zofran} 4mg IV
{Gravol} 50mg IV/PO
P/Org(Vasculo)]
Nifedipine 10mg PO TID x4weeks (CCB for nephrolithiasis )
Tamsulosin 0.4mg PO OD x4weeks (alpha1 blocker for nephrolithiasis)
P/Infla, Struct]
Dexamethasone 10mg IV (cord compression)
P/Infect]
Pip-Tazo 3.375g IV (broad spectrum)
Vancomycin 1g IV

Consult]
Neurosurg (cord compression, OM, SEA)
Gensurg (AAA)
Urology (Nephrolithiasis, stone>10mm)

Question 2

Approach to Ortho

Answer 2

HPI]
Mechanism of Injury

O/E]
Point tenderness

I] OLD ACID
Open vs Closed

Location
Epiphysis
Physis
Metaphysis
Diaphysis

Degree – Complete vs Incomplete
Complete
Incomplete
Salter-Harris

Articular involvement
Intraarticular vs non-intraarticular

• *Comminuted/pattern**
• *Normal – Transverse – Oblique – Spiral – Comminuted – Avulsion – Impacted – Fissure – Greenstick**

Intrinsic Bone Quality
Osteoporosis, Osteopenia

Displacement – body in anatomical position, distal in relation to proximal – Angulation, Rotation
Distraction vs Impaction
Displacement (translation) – lateral (0-100%), with and without shortening
Angulation – Medial (varus) vs Lateral (valgus), Dorsal vs Palmer (Volar), Radial vs Ulner
Rotation – Internal vs External