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3rd year - Family Medicine > MSK > Flashcards

MSK Flashcards

1
Q

What are the 3 most common pathogens of septic arthritis?

A
  1. Staphylococcus aureus
  2. Streptococcus penumonia
  3. Gonococcal infection

Gram negative bacteria usually in immune compromised host with GI infection

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2
Q

Gonnococcal septic arthritis presentation

A

Can present in 2 ways

  1. Triad
    a) Tenosynovitis
    b) Painless vesiculopustular dermatitis
    c) Polyarthralgia with prurulent arthritis
  2. Prurulent arthritis without skin lesions
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3
Q

Empiric antibiotic treatment for septic arthritis with culture pending and no results on gram stain

A
  1. Vancomycin 15-20 mg/kg IV q 8-12h
  2. For suspected gonococcal infection Ceftriaxone 1 g IM/IV once daily x 14 days + Azithromycin 1 g PO 1 dose

If immunocompromised, traumatic, IV drug use - add 3rd generation cephalosporin

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4
Q

Antibiotics based on gram stain for gram positive cocci and gram negative bacilli

A

Gram positive cocci - vancomycin

Gram negative bacilli - 3rd generation cephalosporin (ceftriaxone, ceftazidime, cefotaxime)

Add Gentamycin if pseudomonas is suspected

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5
Q

Gout cystals

A

Monosodium urate crystals

Negative yellow birifringement needle crystals

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6
Q

Psuedogout crystals

A

Calcium pyrophosphate dihydrate crystals

Positive blue crystals

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7
Q

Management of gout

A

Treatment of acute gout

First line - NSAIDs
Second line - Colchicine if within 3 days of acute flare
Third line - Glucocorticoid injection if 1-2 joints, Systemic glucocorticoid for >2 joints

Prophylaxis

First line - Lifestyle modification
Second line - Urate lowering therapy if 3+ attacks/year, radiographic evidence, tophi, renal implications
1. Allopurinol
2. Febuxostat or Probenecid
Start urate lowering therapy with Colchicine or Indomethacin to prevent risk of acute gout flare for the first <6 months

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8
Q

Management of Pseudogout

A

Treatment of acute gout
First line - rest and immobilization
Medications are the same as gout

Prophylaxis if 3+ attacks per year
First line - Chronic colchicine
Second line - Chronic NSAIDs

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9
Q

Rheumatoid arthritis diagnostic criteria

A
  1. Inflammatory arthritis including 3+ joints
  2. Positive RF or CCP
  3. Elevated ESR or CRP
  4. Duration of symptoms >6 weeks
  5. Other arthritis excluded including spondyloarthropathies, SLE, gout, pseudogout
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10
Q

Rheumatoid arthritis management

A

1st line - DMARD (+ NSAID or Glucocorticoid until symptoms under control)
Mild - Sulfasalazine or Hydroxychloroquine
Moderate to severe - methotrexate

2nd line - biologics

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11
Q

What are extra articular manifestations that can be seen in rheumatoid arthritis

A

Sjogren ‘s syndrome

Subcutaneous rheumatoid nodules

Tenosynovitis of hands and feet

Normocytic anemia

Keratoconjunctivitis sicca, episcleritis, scleritis

Interstitial lung disease

Pericarditis

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12
Q

Side effects of NSAIDs

A

Peptic ulcer and GI bleeding

Hypertension

Renal failure (contraindicated in patients with renal failure or CHF)

Anaphylaxis (contraindicated in asthmatic patients)

Induce labour

Reye’s syndrome

Urate accumulation

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13
Q

Side effects of celecoxibs

A

Hypertension

Renal failure (contraindicated in patients with renal failure or CHF)

Cardiovascular events (stroke, MI)

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14
Q

Side effects of methotrexate

A

Nausea, abdo pain, fatigue

Hepatotoxicity

Pneumonitis

Teratogen

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15
Q

Side effects of azathioprine

A

N/v/d, fatigue, rash

Acute pancreatitis

Increased risk of blood cancer

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16
Q

Side effects of hydroxychloroquine

A

Nausea, abdo pain

Diarrhea

Blood disorder

Hearing loss

Hepatotoxicity

Muscle weakness/paralysis

Retinopathy **

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17
Q

Side effects sulfasalazine

A

Infertility

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18
Q

Contraindication to biologics

A

Positive TB test

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19
Q

Examples of xanthine oxidase inhibitors

A

Allopurinal

Febuxostat

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20
Q

Examples of uricosuric agents

A

Probenecid

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21
Q

MOA of xanthine oxidase inhibitors

A

Inhibit xanthine oxidase which is required in the metabolism of purines to produce uric acid

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22
Q

MOA uricosuric agents

A

Increase renal excretion of uric acid

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23
Q

Contraindication of uricosuric agents

A

Renal failure

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24
Q

Xanthine oxidase inhibitor side effects

A

Nausea, diarrhea
Hepatitis
Hypersensitivity (fever, rash, eosinophilia, Stevens-Johnsons)
Aplastic anemia

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25
Q

Colchicine contraindications

A

Liver failure

Renal failure

Heart disease

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26
Q

MOA colchicine

A

Stops microtubule polymerization -> stops mitosis -> stops proliferation of inflammatory cells

Inhibits neutrophil motility and activity

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27
Q

Colchicine side effects

A

GI upset

Neutropenia

Bone marrow suppression

Poisoning at high doses

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28
Q

Why do you mix glucocorticoid for injection with local anesthetic

A

Decreases the risk of soft tissue atrophy and tendon rupture

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29
Q

Absolute contraindications to joint injection, soft tissue injection or joint aspiration

A

Local cellulitis

Septic arthritis

Bacteremia

Acute fracture

Joint prosthesis

History of allergy to injection

Intra-tendinous injection or injection into an area with tendinopathy is contraindicated due to risk of tendon atrophy and weakening

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30
Q

Relative contraindications to joint injection, soft tissue injection or joint aspiraation

A

Patients with no response after trial of 1-2 joint injections will not likely respond with subsequent injections

Coagulopathy or anticoagulant therapy

Surrounding joint osteoporosis

Anatomically inaccessible joint

Uncontrolled diabetes

31
Q

Maximum number of glucocorticoid injections

A

Max 4 injections per year per patient

32
Q

Back pain red flags

A

Fracture - history of osteoporosis, history of trauma, history of long term systemic steroid use

Infection - skin opening, history of recent infection, immunocompromised, constitutional symptoms, IV drug use

Malignancy - history of malignancy, constitutional symptoms

Radiculopathy - unrelenting pain at rest and at night

Neurological - weakness, numbness, tingling, cauda equina

Intraabdo/GI/GU - referred pain, dysuria, AAA history

33
Q

Indications for lumbar xray in low back pain (and ESR if risk of malignancy, infection, inflammation)

A

Risk factors for cancer (history, suspicion, >50 years, unexplained weight loss)

Risk factors for ankylosing spondylitis (morning stiffness, buttock pain, night pain)

Risk factor for vertebral compression fracture (osteoporosis, glucocorticoid use, trauma, >65 year old man, >75 year old woman)

Signs and symptoms of radiculopathy without bowel or bladder implications

Failing 4-6 weeks of therapy

34
Q

Indications for MRI in low back pain

A

risk factor for spinal infection: fever, IV drug use, recent infection

cauda equina syndrome

severe or progressive neurologic deficit

failed 4-6 weeks of therapy with nerve impingement (in L4-S1 distribution, positive straight leg raise), spinal stenosis (radiating leg pain, older age)

MRI may be considered in patients with lower back pain >12 weeks

35
Q

Indication for referral to neurosurgeon or orthopedic surgeon

A

cauda equina syndrome

spinal cord compression: acute neurologic deficits in patient with cancer and risk of spinal metastases

progressive or severe neurologic deficit

36
Q

Indication for referral to neurologist or physiatrist

A

Motor deficit persisting after 4-6 weeks of therapy

Persistent sciatica, sensory deficit or reflex loss after 4-6 weeks of therapy in patients with positive straight leg raise

37
Q

Differential diagnosis of chronic low back pain

A
  1. Non specific or idiopathic (sprain or strain) 70%
  2. Mechanical 27%
    Degenerative - spondylosis (aka DDD), degenerative disease of facet joints, spinal stenosis
    Disk disruption
    Fracture - spondololysis, spondololisthesis, osteoporotic
    Congenital disease
  3. Non mechanical
    Malignancy, infectious, inflammatory, osteochondrosis, Paget
  4. Visceral disease
38
Q

What is osteochondrosis

A

Interruption to blood supply to epiphysis causing necrosis and later regrowth

39
Q

Pharmacological management of low back pain

A
  1. Tylenol
  2. NSAIDs
  3. Tramadol and opioids
  4. TCA, gabapentin
  5. Last line - muscle relaxant
40
Q

Indications for epidural injection or surgical referral for low back pain

A

severe functional disability

radiculopathy

refractory pain to non-pharmacological and pharmacological management

41
Q

Indication for surgery in low back pain

A

anatomic abnormality identified is consistent with

distribution of pain unremitting pain lasting >1 year despite multiple non-surgical treatment

42
Q

Features of psoriatic arthritis that differentiate it from rheumatoid arthritis

A
  1. Asymmetric involvement of joints
  2. Involvement of DIP
  3. Involvement of all joints in one digit
  4. Dactylitis (inflammation of whole digit including joints and tendons)
  5. Enthesitis (inflammation of tendon and ligament insertions) such as lateral epicondylitis (tennis elbow) and plantar fasciitis
  6. Spondylitis
43
Q

What monitoring has to be performed with methotrexate use

A

Frequent CBCs due to the risk of bone marrow suppression

Frequent liver enzyme panels due to the risk of hepatitis

44
Q

Severe potential adverse effect of ace inhibitor

A

Angioedema

45
Q

Management of mild eczema

A

Remission therapy -
Corticosteroid (Desonide, hydrocort, betamethasone) BID x 2-4 weeks in conjunction with emollients

Maintenance
Corticosteroid daily x 2 days during the weekend for up to 16 weeks

46
Q

Management of moderate eczema

A

Remission
1st line - Fluocinolone, Triamcinolone, betamethasone same regimen as mild BID x 2-4 weeks in conjunction with emollients
2nd line - topical calcineurin inhibitors BID (Tacrolimus, pimecrolimus)

Maintenance
Desonide, hydrocort, betamethasone daily x 2 days during the weekend x 16 weeks

47
Q

Management of severe eczema

A

1st line - phototherapy UVB x 3/week

2nd line - cyclosporine 3-5 mg/kg PO per day in 2 divided doses x 6 weeks for remission and then lowered to minimum effective dose for maintenance up to 1 year

3rd line - DMARD (methotrexate, imuran, cellcept)

48
Q

What is viral exanthem 1, cause, presentation and infectious period?

A

Measles (Rubeola)

Cause: Paramyxovirus

Presentation:
Maculopapular erythematous rash following several days following fever
Kopik’s spots (specific for measles)
Fever, cough, coryza, conjunctivitis

Infectious: 3 days before and after rash

49
Q

What is viral exanthem 2, cause, presentation?

A

Scarlet fever

Cause: Group A beta hemolytic streptococcus

Presentation: 
maculopapular sandpaper erythematous rash 
Strep throat 
Strawberry tongue 
Fever
50
Q

What is viral exanthem 3, cause, presentation?

A

Rubella (German Measles)

Cause: Togavirus

Presentation: Macular erythematous rash x 3 days with viral symptoms

51
Q

What is viral exanthem 4?

A

Filatov-Duke’s disease - historical term not used and does not refer to anything

52
Q

What is viral exanthem 5, cause, presentation?

A

Erythema infectiosum (Fifth Disease)

Cause: Parvovirus B19

Presentation: maculopapular erythematous rash usually in cheeks (slapped cheeks) which will then progress to erythematous reticular “lacy” rash to rest of body

53
Q

What is viral exanthem 6, cause, presentation?

A

Roseola infantum (exanthem subitum)

Cause: human herpes virus 6

Presentation: high fever, followed by exanthem when child is just about to recover

54
Q

Hallmark morphology of varicella zoster virus

A

Simultaneous occurence of all stages of disease including vesicle, pustule and crusts

55
Q

Pityriasis rosea presentation

A

Primary herald rash - pink salmon patch with scale and clear centre

Secondary exanthem - generalized pink macules and patches with scale in Christmas tree distribution

56
Q

RNA enterovirus coxsackie A causes which condition, morphology?

A

Hand, foot and mouth disease

Painful vesicles around mouth and on extremities, which can blister

Whole infection lasts 7-10 days

57
Q

Presentation of dermatofibroma

A

Commonly on arms and legs

Firm hard nodules which can vary in colour

Dimple forms if skin surrounding is squeezed

58
Q

Indications for wound care

A

2nd or 3rd intention wound healing

Chronic non-healing wounds

59
Q

Androgenetic alopecia presentation

A

Men - M shaped pattern hair thinning (on temples and brow)

Women - thinning in central and frontal scalp with hyperandrogenism signs (PCOS, menstrual abnormalities, hirsutism)

60
Q

Androgenetic alopecia management

A

Men
1st line - 5% Minoxidil +/- Finasteride
2nd line - surgery, hair piece

Women
1st line - Minoxidil 2%
2nd line - Spironolactone or cyproterone acetate if no improvement after 1 year of minoxidil
3rd line - hair transplant
Treat hyperandrogenism with hormone replacement or oral contraceptives

61
Q

Alopecia areata pathophysiology

A

Autoimmune reaction

62
Q

Alopecia areata treatment

A

Mild to moderate <50% scalp involved
1st line - Intralesional corticosteroid injection +/- Minoxidil +/- topical steroids

2nd line - PUVA or corticosteroid

Last line - hair transplant

Severe
1st line - topical immunotherapy (PUVA, topical or systemic corticosteroid)
Minoxidil topical +/0 high potency topical steroids

Hair transplant

63
Q

Tinea capitis diagnosis

A

Wood’s lamp fluoresces or slide/culture

64
Q

Tinea capitis treatment

A

Oral antifungal

65
Q

Circatricial alopecia pathophysiology

A

Repetitive trauma/disorder causes irreversible destruction of hair follicle

66
Q

Circatricial alopecia treatment

A

Intra-lesional steroids or antimalarial agents

67
Q

How long does it take to replace a fingernail or toenail

A

Finger - 6 months

Toe - 1-1.5 years

68
Q

Potential causes of longitudinal melanonychia

A
  1. Normal variant in black persons
  2. Subungual melanoma - presents with sudden change in appearance, involves single nail, width >3 mm, extends onto cuticle or nail fold
69
Q

Onychomycosis cause

A

Fungal or yeast infection of nail

70
Q

Onychomycosis diagnosis

A

KOH testing of scraping or nail culture or biopsy

71
Q

Onychomycosis treatment

A

Systemic oral antifungal x 1 year (Terbinafine, itraconazole, fluconazole)

72
Q

Paronychia cause

A

Bacterial infection (commonly staph aureus, strep pyogenies or pseudomonas if green)

73
Q

Paronychia management

A

Cephalexin

Ketoconazole if fungal infection suspected

Topical neomycin for pseudomonal superinfection

74
Q

Subungual hematoma management

A

drilling hole through nail with hot metal wire or co2 laser to relieve pressure

3rd year - Family Medicine (9 decks)

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