MSK Flashcards
MSK history important points
- Joint/soft tissue? x-rays
- Acute/ Chronic >6wks ?
is it - sudden, cause (infection/trauma), treatments its responded too?
chronic - exacerbations w remission - inflammatory or not?
- Inflammatory RA (prolonged early-morning stiffness, pain at rest, joint swelling)
- non - inflammatory OA (Pain>localised stiffness, activity exacerbates) - symptoms
- SQUITARS, numbness tingling usually involves nerves
- mechanical symptoms - locking, joint giving way
- occupational triggers - repetitive movements, posture. lifting - pattern of affected joints
- number - (1 - septic arthritis , few - psoriatic arthritis , polyarticular many - RA )
- symmetrical RA /asymmetrical psoriatic
- OA affects weightbearing joints - Impact on pt’s life
- ICE
- functional issues, openended q - ask to describe
typical day, dominant hand
- psychosocial impact - PMH, FH, Other systems involved?
fatigue and depression common
other conditions could contraindicate drug treatment
psoriasis, gout, cancer
MSK screening assessment ?
Gait - symmetry, smoothness, turn quickly? obs pics in notes
Arms - behind head, straighten, supination, fist, grip, finger to thumb, squeeze finger for tenderness, observe palms for bulk/abnormalities
Legs - internal rotation w hip in flexion, patellar tap, sweep/bulge test, inspect feet and squeeze MTPJ for tenderness
Spine - inspect, tilt head side-side, touch toes
3 q:
- pain, swelling, stiffness in muscles/joints/back
- dress yourself w out difficulty
- stairs “ “ “
MSK emergency conditions
Cauda equina MSCC - metastatic spinal cord compression Spinal infection septic arthritis 1/2dary cancers insufficiency fractures major spinal related neuro deficit CSM - cervical spondylotic myelopathy Acute inflammatory arthritis/suspected rheumo conditions
early signs score of MSCC
Referred back pain - multisegmental/band-like
Escalating pain - poorly responsive to medication
Different character/site to previous symptoms
Funny feelings - odd sensations/heavy legs
Lying flat - increases back pain
Agonising pain - anguish/despair
Gait disturbance - unsteady, stairs
Sleep v disturbed - pain worse at night,
Red Flag symptoms
systemically unwell
escalating pain + progressively worsening symptoms - unresponsiveness to conservative management
night pain - as escalating pain/lying flat
hot, swollen, painful, multi-directional restricted movement joint - septic
sudden onset
incontinence in bowel/bladder, sciatica, saddle numbness
rash, Raynaud’s, mouth ulcers, dry eyes/mouth,
myalgia symmetrical pattern, early morning stiffness >30mins, raised ESR/CRP
new onset headache, >50, raised CRP
OA - prevention
- healthy weight/control blood sugar
- regular exercise - joint strength, avoid straining exercise
- good posture - avoid same position too long
OA - self-care
- balanced diet and lose weight overweight
- keeping positive mindset
- thermotherapy - hot/cold ice packs
- braces/splints/supportive footwear
OA - conservative M
- pharmacological order: paracetamol, add topical NSAIDs, oral NSAIDS/cox-2 inhibitors to sub topical (PPI) or opioids, steroid injections consider as adjunct
- structured exercise plan w physiotherapist: aerobic
and strengthening for affected joint
OA - surgical M
order offered
- Arthroplasty - joint replacement - hip/knee - last <20 yrs
- Arthrodesis - joint fusing
- Osteotomy - add/remove parts of bone in/around joint - knee to realign weightbearing points –> reduce stress
OA diagnosis
> =45 yrs
activity related joint pain
NO early morning stiffness or lasts <30 mins
RA - diagnosis - including who to refer for investigations
persistent synovitis - no known cause
small joints - hand/feet affected
>1 joint
>=3mths between onset of symptoms and seeking medical advice
RA - investigations - to confirm diagnosis in suspected RA pts and then after diagnosis
- blood test - Rheumatoid factor
- b. anti - CCP antibodies - if - ve RF - do asap after diagnosis if not done before
- X-ray - hand/feet in all pts - look for erosions
after
3. HAQ - to measure functional ability
RA - management
aims
pharmacological
target - remission/low disease activity, target remission if complete cant be met
conventionalDMARDS
1. monotherapy - oral methotrexate - asap within 3mths of onset of symptoms
2. Consider short-term bridging treatment w glucocorticoids when starting new cDMARDs - (improve symptoms while waiting for new DMARD to take effect)
until target met:
3. increase dose as tolerated
4. step-up strategy - other DMARDS in combo - leflunomide, sulfasalazine, hydroxychloroquine
RA - management - symptomatic treatment
NSAIDS/cox II selective inhibitors if control of pain/stiffness inadequate
- lowest effective dose
- PPI
- not first line if pt needs aspirin
RA - management - rehabilitative
physio - reg exercise, joint flexibility, muscle strength
occupational therapy - daily activity difficulties improve
hand exercise programmes/podiatrist - depends which affected
diet - no strong evidence - but Mediterranean