MSK Flashcards
List the risk factors for gout
- Elevated body mass index
- Hypertension
- Diuretic use
- Coffee consumption
- Alcohol intake
- Sweetened beverage consumption
- Meat/seafood consumption
- Dairy product consumption
- Vitamin C intake
List the Diagnostic Criteria for Gout
- one of the following
Presence of urate crystals in the joint fluid
Presence of tophus proven to contain urate crystals by chemical means or polarized light microscopy
Presence of 6 or more of the following - Asymmetric swelling within joint on radiograph
- attack of monoarticular arthritis
- culture of joint fluid negative for microorganisms
- development of maximal inflammation within one day
- hyperuricemia
- joint redness
- more than one attack of acute arthritis
- pain or redness in first metatarsophalangeal joint
- subcortical cyst without erosion on radiography
- suspected tophus
- unilateral attack involve first metatarsophalangeal joint
- unilateral attack involving tarsal joint
Discuss the management of gout
- begin treatment within 24 hours of symptom onset to achieve rapid and complete resolution of symptoms Medical Management for Mild-Moderate - NSAID monotherapy - Colchicine monotherapy - Corticosteroid monotherapy Medical Management Severe - Colchicine and NSAIDs - Colchicine and oral corticosteroids - Intra-articular steroids and all other modalities
Discuss the dosing of NSAIDs, colchicine and corticosteroids for gout treatment
NSAIDs
- Naproxen 500mg BID
- Indomethacin 50mg TID
- side effects: GI upset, worsen renal function
- contraindicated in patients with PUD, CKD, Heart failure or on anticoagulants
Colchicine
- 1.2mg intially then 0.6mg one hour later then 0.6-1.2mg OD
- side effects: GI, renal and hepatic risk
- contraindicated: clarithromycin
Corticosteroids
- Oral prednisone: 40mg for 4 days -> 20mg for 4 days -> 10mg for 4 days
- side effects: rebound flare when tapering
- contraindicated when already using NSAIDs and colchicine
Discuss the prevention of gout
Dietary Modifications
- reduce high fructose corn syrup
- reduce beef, lamb, pork, shellfish
- reduce alcohol
- increase vegetable and low fat dairy products
Pharmacologic
- First line: Allopurinol (Xanthine oxidase inhibitor)
- Second line: Probenecid (increase urinary uric acid so possible kidney stone risk)
- in addition use NSAID, colchicine and low-dose steroid (required when starting during flare)
Duration
- no ongoing symptoms continue for 3-6 months following flare
- ongoing symptoms continue indefinetly
Discuss the definition and diagnostic criteria for fibromyalgia
- Chronic, widespread, multisite MSK pain with characteristic tender points associated with fatigue and sleep disturbance
Diagnostic Criteria - WPI >=7 and SSS >=5 OR WPI >=5 and SSS >=9
- symptoms present at same level for 3 months
- patient does not have any other disorder
Discuss the Widespread Pain Index
Number of Areas in Which Patient Had Pain Over Last Week
- shoulder L/R
- Upper arm L/R
- Lower arm L/R
- Hip L/R
- Upper leg L/R
- Lower Leg L/R
- Jaw L/R
- chest
- abdomen
- upper back
- lower back
- neck
Discuss the Symptom Severity Score
0=none, 1=mild, 2=moderate,3=severe
- Severity of fatigue
- waking unrefreshed
- cognitive symptoms over the last week
- extent of somatic symptoms (IBS, cramps, dry mouth, fever)
Discuss the management for fibromyalgia
Bio - Duloxetine and Pregabalin - cannabinoids Psycho - CBT - coping skills - stress reduction - education Social - exercise - physical therapy for posture, stretching, strength
Discuss the red flags for back pain
- NIFTI Neurological - diffuse motor/sensory loss - progressive neurological deficits - cauda equina syndrome (urinary retention, fecal incontinence, saddle paresthesia) - require MRI Infection - fever - IV Drug use (epidural abscess) - immunosuppression - Xray and MRI Fracture - trauma - osteoporosis - fragility fracture - Xray and CT Scan Tumour - History of cancer - unexplained weight loss - significant and unexpected night pain - severe fatigue - Xray and MRI Inflammation - Chronic low back pain >3 months - age <45 - morning stiffness >30 minutes - improves with exercise - disproportionate night pain - Rheumatology consultation
List the nerve roots associated with each exam
L3-L4 - patellar reflex - quadriceps power - femoral nerve stretch L4-L5 - heel walking - ankle dorsiflexion L5 - trendelenburg test - great toe extension S1 - toe walking - great toe flexion - gluteus maximus power S2-S4 - saddle anesthesia
Discuss the management for disc pain (flexion), facet pain (extension), compressed nerve (leg pain) and spinal stenosis
Disc - Tylenol and NSAIDs - repeated prone lying passive extension - short frequent walking and avoid sitting Facet - Tylenol and NSAID - sitting in chair, bend forward and stretch in flexion. Using trunk and knees to push trunk upright - encourage sitting or standing on stool Compressed nerve - possible Opioids or Anticonvulsants - Z lie - change positions frequently Spinal Stenosis - Tylenol and NSAIDs - rest in seated or other flexed position - use support with walking or standing - frequent breaks
Discuss the risks, presentation and investigations for osteoarthritis
Risks - older age - gender (<50 M>F, >50 F>M) - trauma - obesity - endocrine disorder Presentation - asymmetric joint pain - worsens with activity - relieved by rest - morning stiffness (<30 min) - joint swelling - Bouchard's nodes (PIP) - Heberden's nodes (DIP) Xray Findings - joint space narrowing - subchondral sclerosis - subchondral cysts - osteophytes
Discuss the management of osteoarthritis
Mild Arthritis - regular exercise - weight loss - physical therapy - bracing or splinting - Acetaminophen first and then move to OTC NSAID then prescription NSAID Moderate - Glucosamine injection - Corticosteroid injection - Hyaluronic acid injection Severe - joint replacement
Discuss factors for initial bone mineral density testing
Age <50 - fragility fracture - high risk medication use - hypogonadism - malabsorption syndromes - chronic inflammatory conditions - primary hyperparathyroidism Age 50-64 - fragility fracture after 40 - prolonged glucocorticoid use - parental hip fracture - vertebral fracture or osteopenia on xray - high alcohol intake or current smoking - low body weight (<60kg) or major weight loss (>10% from age 25) Age >65 - all men and women
