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MSK Flashcards

1
Q

List red flags for MSK disease

A

Bone pain: Pain all the time - at rest, activity and at night - cancer, infection, fracture
Inflammatory pain
Osteroarthritis
Neuralgic pain - nerve root compression - pain and paraesthesia in dermatomal distribution
Referred - unaffected by local movement

Hx of cancer
Weight loss
Fever
Recent serious illness/ infection (bone infection, eg discitis)
Bladder/ bowel dysfunction 
Saddle paraesthesia 
Any new neuro symptoms- foot drop etc
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2
Q

explain how you would distinguish between inflammatory vs degenerative disease

A 
Inflammatory: 
Pain in joint better with use/ moving
Stiff - new 30 mins or longer in AM 
Swelling (often - this is fluid in joint or joint thickening)
Hot and red joint 
Young patient
Family hx of autoimmune disease 
Distribution - eg RA hands and feet 
Responds to NSAIDs

Degenerative:
Osteoarthritis - stiffness less than 30 mins in morning
Swelling - boney
Distribution - single joint, base of thumb - common for osteoarthritis

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3
Q

Commonly used DMARDs*

Why? When? What to look out for?

A

Methotrexate:
Interactions - trimethoprim, septrin
Complications - pneumonitis (ARDS) - baseline chest xr
Monitoring - FBC (can get pancytopaenia), LFT (hepatotoxic), U&E (renally excreted, so need to monitor kidney function, only nephrotoxic at egrf <20). Every 3 months.
Unusual circumstances, eg pregnancy - teratogenic - used for medical abortions, need counselling not to get pregnant - dont do standard pregnancy test

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4
Q

give some examples of systemic complications of rheumatoid arthritis

A

Fibrosis - interstitial lung disease - can be hidden bc patient isnt as mobile so dont notice change in lung function
Cardiomegaly - pericardial effusion
Pleural effusion - protein rich exudative effusion
Pitting odema - nephrotic syndrome
Vasculitis - digital vascuilitis

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5
Q

give some examples of systemic complications of rheumatoid arthritis

A

Fibrosis - interstitial lung disease - can be hidden bc patient isnt as mobile so dont notice change in lung function
Cardiomegaly - pericardial effusion
Pleural effusion - protein rich exudative effusion
Pitting odema - nephrotic syndrome
Vasculitis - digital vascuilitis (more common in smokers - RF positive arthritis)
abdominal pain - at risk of gastric ulcers bc of immunosuppresant drugs - can present more sub-acutely than normal ulcers

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6
Q

What is the most common sign of methotrexate toxicity in blood results

A

Pancytopaenia

Albumin ? also important

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7
Q

How frequently are bloods monitored for methtrexate

A

Every 3 months

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8
Q

What is the biggest risk for patient pregnant on methotrexate

A

Miscarriage
Must stop methotrexate for 3 months before pregnancy
Cant use in breastmilk either

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9
Q

What is used instead in pregnancy

A

sulfasalazine

hydroxychloroquine

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10
Q

Interactions for methotrexate

A

Trimethoprim
Septrin
NEVER EVENTS - BONE MARROW FAILURE

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11
Q

What should you NEVER prescribe with methotrexate

A

Trimethoprim

Septrin

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12
Q

What must you prescribe with methotrexate

A

Folate

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13
Q

List some anti TNF drugs used for RA

A

Infliximab, adalimumab

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14
Q

If an immune suppressed placement comes into hospital ill what should you do

A

Take them off immunosupressant

Stop drug for duration of antibiotics and 2 weeks afterwards

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15
Q

how should a patient acutely unwell on steroids be managed

A

sick day rules - double the dose

if cant tolerate orally - need IV

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16
Q

list some common drugs to consider for low mg

A

PPIs
Frurosemide
Chemotherapy

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17
Q

What is the level for severe hypo mg

A

<1.9

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18
Q

how long does it take to normalise mg2+ with oral replacement

A

6-8 weeks

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19
Q

when should you check mg2+ after stopping replacement and why

A

1 week as can get rebound hypo mg

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20
Q

what should you always check on a patient with hypo mg2+

A

ecg

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21
Q

what axis/ gland is involved in calcium homeostasis

A

Parathyroid

Low plasma calcium = raised PTH

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22
Q

What is the action of PTH

A

RAISES PLASMA CALCIUM
promotes osteoclasts = release of calcium and phosphate from bones
promotes resorption of calcium from renal tubules
promotes excretion of phosphate from renal tubules (low phosphate)
promotes vit d synthesis and excretion from kidneys to gut for increased calcium absorption

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23
Q

in a patient with raised calcium what PAIRED test must you do, and why

A

calcium and PHT
PHT very reactive, if dont do paired with calcium the result is meaningless, can only interpret if know what calcium was at time of pth

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24
Q

what are the symptoms of hypercalcaemia

A

grones, moans, bones, stones

polyuria (osmotic diuresis?), polydipsia, dehydration

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25
what would be your assessment of a patient with hypercalcaemia
ECG, fluid status (dehydrated?) Rehydrate - 0.9% saline 4-6 litres/24hrs Consider IV bisphosphonate - discuss this with senior - pamidronate 30-90mg Consider secondary treatments - steroids, calcimimetics, denosumab
26
what level of adjusted raised calcium is severe
>3.4
27
what level of adjusted low calcium is severe
<1.9
28
at what (raised) plasma calcium level would someone become symptomatic
>3
29
describe what raises in calcium are linked to symptoms
2. 6-3.0 - asymptomatic 3. 0-3.4 - may be tolerated if chronic, otherwise symptoms 3. 4 - severe
30
what are the serious (life threatening) complications of hypercalcaemia
short QT (high calcium means when ca channels open, intracellular ca concentration is reached sonner and channels close = shorter plateau stage of depolarisation) arrhythmia HTN Death
31
what are the ecg changes for hyper and hypo calcaemia
Hyper - short QT | Hypo - long QT
32
what are the symptoms of hypocalcaemia
``` muscle excitability (as depolarisation isnt stable) - twitching nerves (numbness/ paraesthesiae) Cognitive dysfunction Seizures Stridor (laryngeal weakness) Long QTc/ arrhythmias/ death ```
33
symptoms of hypercalcaemia
Cognitive dysfunction (moans) Nausea/ vomiting/ constipation (groanes - abdo pain) Abdominal pain Nephrolithiasis/-calcinosis (stones) Polyuria Short QTc/ arrhythmias/ hypertension/death Asymptomatic
34
what are the key blood tests do you need to request for hypercalcaemia
PTH - high/ normal = primary hyperparathyroid normal/ low = malignancy (or other rarer causes) Phosphate - can tell you if parathyroid as will drop Albumin - can tell you about dehydration or malignancy raised - dehydration low - more likely to be malignancy
35
what are the most common causes for hypercalcaemia
Primary hyperparathyroid | Malignancy
36
What additional investigations could you do for hypercalcaemia after initial bloods
24 hour urine calcium bone density x-rays ? malignancy work up electrophoresis
37
what is the most common cause of hypercalcaemia with a raised PTH
Primary hyperparathyroid (90%) of time
38
what is the most common cause of hypercalcaemia with a low PTH
Malignancy (90%) of the time
39
what are the key blood tests to request for hypocalcaemia
Mg - low mg can cause low PTH Vit D - starts affecting calcium when vit d is <0.5 - usually causes a mild calcium deficiency PTH
40
what are the causes of hypo mg
``` gut losses low intake (alcoholics) malabsorption renal failure drugs oral mg rehydration ```
41
how long does it take to correct low mg with sachets
6-8 weeks - must test mg 1 week after as can get rebound low mg
42
what are the action limits for low vit d
< 25 nmol/L – high dose supplementation 25-50 nmol/L – if bone health an issue standard dose supplementation 50-125 nmol/L – no action required
43
what is the management of severe hypocalcaemia
ECG - admit to hospital IV calcium gluconate 10mls 10% Arrythmias or digoxin- need continuous monitoring Different guidance for renal failure - alfacalcidol
44
common causes for hypocalcaemia
``` poor intake (mild) vit D deficiency (mild) CKD Low mg Malabsorption Diabetes drugs - ppi, furosemide, chemo ```
45
what is the management of hypo mg
``` Severe = Mg <0.4 mmol/L IV Mg Symptoms of hypomagnesaemia Significant hypokalaemia or hypocalcaemia Digoxin therapy ```
46
what are the symptoms of low mg
same as low calcium | muscle twitches/ cramps
47
what should you consider when giving oral mg relpacement
that it can cause rebound hypo mg | need to do mg repeat in 1 week
48
what is the normal mg range
1.7-2.2
49
what is the main thing you need to exclude with hypercalcaemia
malignancy
50
what is the function of rank ligand
stimulates bone resorption via activating clasts
51
what is the function of osteoprogenerator (OPG)
inhibits rank ligand - therefor inhibits bone resorption
52
what makes up the bone matrix
Organic - mainly collagen scaffold (structural support) | Inorganic - hydroxyapatite - calcium and phosphate (mineral that provides strength)
53
what are typical osteoperotic fractures
(colles) wrist, femur, vertebral
54
how common are osteroperotic fractures in men and women over 50
1/2 of women | 1/5 of men
55
by how much does osteoperotic medication reduce this risk
by half
56
what is the morbidity associated with osteoperosis fractures
20% die within first year after fracture
57
what are common causes of osteoperotic fractures
can be fall | vertebral fracture - sitting down too quickly, changing the bed
58
explain the bone remodelling cycle, how does this link to osteoperosis
injury/ physical activity (any changes to pressure on bones) will stimulate bone remodelling bone remodelling is clast activation - resorption - and the blasts - deposition. So you have new bone. When bone turnover is going too fast - eg after menopause - greatly increases fracture risk Medications aim to slow down clast activity and restore balance between clasts and blasts
59
how do osteoperotic medications work
Inhibit osteo clasts to rebalance normal bone remodelling
60
who is at risk of osteopersosis
``` Post menopausal Inflammatory disease (including IBD) Endocrine - early menopause conditions, hyperthyroid, cushings syndrome Immobility- problems with bone loading Malabsorption - coaeliac Low BMI Family history - has your parent fractured a hip Alcohol excess Vitamin D deficiency ```
61
what medications can cause osteoperosis
Steroids - downregulate (inhibit) whole calcium homeostasis axis Any meds that lower oestrogen eg GnRH analogues Depo Aromatase inhibitors (used in breast cancer)
62
how is fracture risk assessed
QRisk or FRAX | Bone densitometry - DEXA, vertebral fracture assessment
63
what is a T-score from DEXA scan
DS score of bone density for gender matched young adult - so essentially looking at how much bone have you lost since you were an adult with peak bone mineral density -1 - within normal (normal bone loss) -2.5 - osteoperosis in between osteopenia
64
what is vertebral fracture assessment
use dexa - low dose xray to get image of spine Look for fractures vertebral fractures indicate very high risk for future fractures Only around 30% of vertebral fractures are diagnosed at the time - so many people could have these and be at high risk of future fractures and not know
65
what is first line investigation for osteoperosis
DEXA scan | Vertebral fracture assessment
66
What are second line investigations of osteoperosis - why are they done
``` Bloods - to look at secondary causes that need treatment. Think: Endocrine, inflammatory, malabsorption, reproductive, malignancy Calcium, phosphate, ALP (tells you about bone turn over) PTH - primary hyperparathyroid TSH - hyperthyroid vit D ESR and FBC Coeliac antibodies Sex hormnes Serum and urine electrophoresis ```
67
what is the management of osteoperosis
1.Treat secondary causes 2.Lifestyle causes - alcohol, exercise, adequate calcium and vit D, smoking 3.medicines - decided by metabolic done disease team first line - BISPHOSPHONATES- alendronic acid - reduce fractures by 50%. Can have oral (PO, weekly) or IV - 3 monthly, or yearly 2nd lines - HRT, denosumab
68
what is recommended calcium intake and vit D
800 mg of calcium a day (2-3 portions of diary a day)
69
what are the actions of anti-osteoperotic medications
1. Anti resorbative (decrease osteoclast activity) Alendronic acid, HRT, denosumab 2. Anabolic (drive osteoblast activity) Teriparatide
70
side effects of bisphosphonates
oesophagitis - need to give v specific dosing IV can cause flu like symptoms AF - not that common - usually not a problem in stable well controlled AF Osteonecrosis of the jaw - rare but serious - usually occurs when had dental procedure and bone has taken a while to remodel/ heal because of bisphosphonate - usually been on meds long time with this Atypical femoral fractures - to do with reducing bone resorption and makes bone stiff so fractures in unusual way - if someone on bisphosphonates been on for long time have hip pain - get xray as could be atypical fracture
71
when is pneumonitis most likely to start with methotrextae
first 6 months
72
if methotrexate does cause pulmonary fibrosis what would be this clinical picture
chronic clinical picture - not acute
73
can you be on methotrexate and biologic
yes, but only try to use 1 DMARD with biologic not mutiple
74
what is DAS-28, and what is it used for
activity score to grade patients with inflammatory disease
75
what bloods should you do first line for gca
crp and esr | bc esr can have false negative so want crp as well as less prone to false positives
76
what should you give stat from gca
pred 60 mg
77
red flags for septic discitis
Point pain | diffuse pain more likely to be myeloma
78
in a patient with AKI and on methotrexate - what should you do
Stop methotrexate | Stop ACE and diuretics
79
when would you re-start methotrexate in someone who had it stopped for AKI
depends on renal function - may need to dose adjust depending on kidney function (if patient been on abx and normal kidney function - can wait 2 weeks)
80
how long should you wait after abx to re start dmards
2 weeks
81
when could you use trimethoprim in a patient who has previously been on a dmard
at least 6-8 weeks - minimum
82
differences in PMR and RA
PMR - older patients >50 years sero negative PMR - acute ish presentation (weeks)
83
what are the instructions for taking a bisphosphonate and why
First thing in the morning Empty stomach (bc poor absorption - 5%) Big glass of water (prevent sticking in oesophagus) Dont eat/ drink for 3 mins (bc of poor absorption) Dont lie down (prevent reflux/ oesophagitis)
84
what should you always check when you see a patient who is taking bisphosphonates
that they are taking correctly in the morning
85
how does denosumab work
monoclonal ab to RANKL | Blocks the action of RANKL activating osteoclasts
86
what are contraindications to HRT for osteoperosis
PMHx breast cancer CVD risk factors VTE risk factors if over 60 - hrt less beneficial
87
what is teriparatide
PTH analogue
88
what should you do a junior dr to prevent osteoperosis
Think about and know Risk factors for osteoperosis If see vertebral fracture on a report and not been followed up - refer for DEXA scan If DEXA scan actions not been followed up - do this Make sure they are taking their bisphosphonates correctly
89
what is pagets disease and what are symptoms
Disease of clast hyperactivity - increase in bone remodelling but disorganised - leads to deformity and pain Triad of symptoms - pain, fracture deformity
90
what investigations should you do for pagets
1. XRay 2. biochemistry ALP - if active disease will be raised (ALP raised when lots of bone remodelling happening) Ca/ phophate - usually normal. Ca not high because local disease, not systemic metabolic disease 3. can do isotope scan with IV bisphosphonate to see where disease is
91
what is the management of pagets
Depends if they are symptomatic Only treat with bisphosphonates if symptomatic Be aware that pagets disease radiologically is common, but symptomatically uncommon
92
what age group usually presents with pagets
>40/50s
93
what drug group can cause hypercalcaemia
thiazides
94
what is a t score in DEXA
SD
95
what does inflammatory disease put you at risk of osteoperosis
because inflammation drives osteoclast activity
96
what age should patient be to be put on bisphosphonate regardless of bone mineral density
over 65 and on steroids
97
does a dexa of -2.5 always mean osteoperosis diagnosis
No - low bone density also seen in osteomalacia
98
what is the differential diagnosis for a dexa result of -2.5
Osteomalacia
99
what are the blood results for osteomalacia
Low calcium High PTH High ALP (bc of PTH driven bone turnover) Low urine calcium
100
what does a raised ALP tell you
high bone turnover
101
other non dairy sources of calcium
calcium supplement
102
when are z scores used in DEXA
under 25 z score looks at BMD for matched age group t score looks at BMD in comparison to gender matched young adult
103
osteomalacia management
High dose vit D (cholecalciferol) plus calcium Have to give both Long term Adcal-D3
104
what is active vit d, when is this given | what is normal vit D, when is this given
calcitriol - CKD | cholecalciferol - normal vit D (pre kidney activation) - give this to anyone who doesnt have kidney disease
105
what medications should you consider stopping in severe hypercalcaemia
any calcium supplements and diuretics | discuss with snrs about when to restart

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