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MSK disorders Flashcards

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Family Nurse Practitioner (FNP) flashcards
1
Q

Bursitis treatment

A

Prepatellar bursitis → US guided aspiration

Others → eliminate offending activity, apply ice for 15 minutes x4/day, elevate, take NSAIDs

  • If does not work after 4-8 weeks, intrabursal corticosteroid injection

Septic bursitis → antibiotics while waiting for culture results

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2
Q

Tendinitis treatment

A
  • Limit or discontinue contributing activity
  • Apply ice
  • NSAIDs
  • Splinting for hands/wrist/achilles
  • For biceps tendonitis, limit overhead movement and intrabursal corticosteroid injections to prevent bursitis
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3
Q

Tendonosis (chronic state of tendonitis) treatment

A
  • PT
  • Extracorporeal shock wave therapy (ESWT)
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4
Q

Lateral vs medial epicondylitis

A

Lateral → tennis elbow

Medial → golfer’s elbow

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5
Q

Tennis elbow (lateral epicondylitis) clinical presentation

A
  • Can be due to other repetitive activities that are not tennis
  • Pain increases with resisted wrist extension (especially when lifting object in front of patient) and elbow extension
  • Tender to palpation
    • Without warmth or redness
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6
Q

Golfer’s elbow (medial epicondylitis) clinical presentation

A
  • Associated with racquet sports, bowling, archery, weight lifting
  • Local tenderness and pain
  • Wrist and forearm weakness
  • Pain aggravated by wrist flexion and pronation
  • Decreased grip strength
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7
Q

Epicondylitis treatment

A
  • Rest, applying ice, avoidance of precipitating activity
  • Topical or oral NSAIDs and/or corticosteroids for short term relief
  • PT
  • Counterforce bracing
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8
Q

Gout risk factors

A
  • Obesity
  • DM
  • Family history
  • Medications → thiazides, niacin, ASA, cyclosporine
  • Chronic alcohol use
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9
Q

Gout clinical presentation

A
  • Sudden pain
  • Most commonly affect MCP joint of great toe
    • Unable to walk, move joint, tolerate weight of bed sheet on affected joint
  • Red and enlarged
  • Chronic gout → tophi
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10
Q

Gout diagnostic testing

A
  • First episode → uric acid level
  • Diagnostic → joint aspiration
  • X-ray

After acute flare subsides → 24 hour urine collection for uric acid

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11
Q

Gout treatment

A

Inflammation prevention/management

  • Loading dose of NSAID followed by lower doses
  • Short course of systemic corticosteroid (replaced colchicine)

Reduction of uric acid

  • Complete at least 6 months of anti inflammatory therapy first
  • Xanthine oxidase inhibitors → allopurinol or febuxostat
  • Probenecid

Chronic gout refectory to other meds → pegloticase (krystexxa)

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12
Q

Gout diagnostic testing

A

Serum uric acid should be maintained below 6 mg/dL

  • Levels monitored at 6 month intervals
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13
Q

Dietary modifications to prevent gout

A

Avoid high purine foods

  • Seafood (scallops, mussels)
  • Organ and game meat
  • Beans
  • Spinach
  • Asparagus
  • Oatmeal
  • Baker’s and brewer’s yeast
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14
Q

Osteoarthritis clinical presentation

A
  • Insidious/gradual onset
  • Joint pain relieved with rest
  • Joint stiffness worse at rest but resolves with <15 minutes of activity
  • Reduced ROM
  • Discomfort increases as day progresses
  • Heberden’s nodes on DIP joints of hands
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15
Q

Osteoarthritis treatment

A
  • Weight loss with minimal weight bearing (water based activities)
  • Application of heat before activity and ice after activity
  • Acetaminophen (if using NSAIDs for long term, also add PPI)
    • Duloxetine (cymbalta) as alternative for chronic MSK pain
  • Topical analgesics
  • Intra articular corticosteroid joint injection
  • Knee or hip joint replacement
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16
Q

Rheumatoid arthritis clinical presentation

A
  • Initial presentation → acute polyarticular inflammation
  • Slowly progressive malaise, weight loss, stiffness
  • Morning stiffness (lasts about 1 hour)
  • Symmetric
  • Involves at least three joint groups
    • Smaller joints (hands, toes, etc.)
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17
Q

Rheumatoid arthritis diagnostic testing

A
  • Labs: ANA, ESR, CRP, ACPA, RF
  • X-rays at early stages of disease can determine progression
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18
Q

Rheumatoid arthritis treatment and management

A
  • Referral to rheumatology
  • Anti inflammatory → NSAIDs, cox-2 inhibitors (celecoxib), corticosteroids
  • Analgesic → NSAIDs, cox-2 inhibitors, acetaminophen, opioids, topicals
  • DMARDs (methotrexate)
    • Monitored every 3-6 months
    • Non biologic and biologic DMARD (TNF inhibitor) indicated for moderate to high disease
  • PT, water exercises
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19
Q

SLE clinical presentation

A
  • Malar rash (covering cheeks and nasal bridge, spares nasolabial folds)
  • Fever without identifiable cause
  • Unexplained fatigue
  • Headaches
  • Involuntary weight loss
  • Joint pain, stiffness, swelling
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20
Q

SLE diagnostic testing

A
  • Labs: anemia, elevates ESR, proteinuria, positive ANA
  • Chest x-ray → inflammation in lungs
  • Echocardiogram → changes in heart
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21
Q

SLE treatment and management

A
  • Pregnancy should be delayed until SLE under control for at least 6 months
  • NSAIDs
  • Hydroxychloroquine for long term treatment
  • Systemic corticosteroids for inflammation
  • Immune suppressants for those who do not respond to initial therapy
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22
Q

What is sjogren syndrome?

A

Autoimmune disease that occurs in conjunction with another chronic inflammatory condition (RA or SLE)

  • Affects the eyes, mouth, parotid gland, lungs, kidneys, skin, nervous system
  • Symptoms: oral and ocular secretions, underlying disease with RA and SLE, dry eyes (xerophthalmia), dry mouth (xerostomia), bilateral parotid swelling
  • Diagnosis: salivary gland biopsy, schirmer’s test
23
Q

Sjogren syndrome treatment and management

A
  • NSAIDs or medications that suppress immune system
    • Methotrexate, hydroxychloroquine
  • Eye lubricants
  • Sips of water, artificial saliva, sugar free mouth drops
  • Routine dental care and fluoride treatment
24
Q

Meniscal tear clinical presentation

A

Can be due to injury or degenerative changes

  • Knee locking
  • Popping sound or “gives out”
25
Q

Diagnostic tests and maneuvers for meniscal tears

A
  • McMurray test → palpable popping of joint
  • Apley grinding test
  • Squatting for kneeling impossible for large tears
  • MRI if symptoms do not resolve within 2-4 weeks
26
Q

Carpal tunnel syndrome clinical presentation

A
  • Burning, aching, tingling pain radiating to forearm along median nerve
    • Can radiate to shoulder, neck, chest
  • Worse at night (acroparesthesia): waking up at night with numbness and burning pain in fingers
  • Positive Tinel and Phalen test
  • Muscle weakness later on
27
Q

Carpal tunnel syndrome diagnostic testing

A
  • EMG
  • Nerve conduction studies
  • MRI and high resolution US to rule out other causes of wrist pain
28
Q

Carpal tunnel syndrome treatment and management

A
  • Limit activity that cause CTS
  • Elevate affected extremity
  • Nighttime use of solar splints
  • NSAIDs and acetaminophen
  • Corticosteroid injections at 6 week intervals
  • PT
  • Surgery
29
Q

What is sarcoidosis?

A

Inflammatory condition that results in production of noncaseating granulomas in various sites of the body

  • Predominantly in the lungs, lymph nodes, eyes, skin
  • Likely due to exaggerated immune response to unidentified antigen
30
Q

Sarcoidosis clinical presentation

A
  • Derm → rash, lesions, color change, nodule formation under skin
  • Ocular → blurred vision, eye pain, severe redness, sensitivity to light
  • Resp → DOE, cough, chest pain
  • Systemic → fever, fatigue, anorexia, arthralgia
31
Q

Sarcoidosis diagnostic testing

A
  • Serological markers: serum amyloid A, soluble interleukin-2 receptor, ACE, glycoprotein KL-6
  • Hypercalcemia
  • Hypercalciuria
  • Chest x-ray → lung damage, enlarged lymph nodes
  • CT → alveolitis, fibrosis
  • Biopsy to check for noncaseating granulomas
32
Q

Sarcoidosis treatment and management

A

Often self limiting

  • NSAIDs for arthralgia
  • Corticosteroids
  • Hydroxychloroquine and immune suppressing medications used to treat RA
33
Q

What is cauda equina syndrome?

A

When associated with lumbar radiculopathy, will have:

  • Rectal or perineal pain
  • Disturbance in bowel and bladder function (neurologic deficits in Les)
  • Medical emergency
34
Q

Lower back pain conservative management

A
  • Cold packs for 20 minutes 3-4 times/day
  • Heat application before gentle stretching exercises
  • NSAIDs or acetaminophen
  • Muscle relaxants for short periods of time
  • Anticonvulsants (gabapentin) for neuropathic pain
35
Q

What is reactive arthritis?

A

Acute non purulent arthritis complicating an infection elsewhere in the body

  • Occurs after exposure to certain GI and GU infections
  • Develops about 2-4 weeks after infection
36
Q

Reactive arthritis clinical presentation

A
  • Acute onset malaise, fatigue, fever
  • Unilateral LE arthritis (especially knees)
  • Lower back pain
37
Q

Reactive arthritis diagnostic testing

A
  • Bacterial urethral or urine testing
  • Stool cultures
  • Elevated ESR
38
Q

Reactive arthritis treatment and management

A
  • Symptomatic and supportive care
  • NSAIDs or systemic corticosteroids
    • Can consider corticosteroid injections
  • DMARDs for chronic states
  • If associated with urethritis, doxycycline x7 days or single dose azithromycin
39
Q

Osteoporosis treatment and management

A
  • Calcium and vitamin D supplementation
  • Bisphosphonates
    • Taken in the AM with full glass of water, wait 30 minutes before food or drinks, remain upright for at least one hour
  • Selective estrogen receptor modulators (SERMs)
    • Raloxifene, calcitonin, estrogen
  • Bone forming medications (teriparatide)
    • For women with low bone density or prior fracture
40
Q

Are drug holidays necessary when considering treatment with bisphosphonates?

A

Yes - bisphosphonates provide a degree of anti fracture reduction when treatment is discontinued; recommend a drug holiday after 5-10 years of therapy

  • If low risk for fracture, consider stopping after 5 years and remain off treatment until bone mineral density is stable
  • If high risk, can be treated for 10 years and have drug holiday of no more than 1-2 years with consideration of a non bisphosphonate treatment
41
Q

Grade I ligamentous sprain (pathology and presentation, intervention)

A

Pathology: slight stretching or microscopic tear

Presentation: no instability

Intervention:

  • RICE
  • Immobilizer
  • Limit weight bearing
  • Analgesia
  • Length of disability usually limited to a few days
42
Q

Grade II ligamentous sprain (pathology and presentation, intervention)

A

Pathology: partial ligamentous tear

Presentation: moderate joint instability, moderate swelling, mild to moderate ecchymosis

Intervention:

  • RICE
  • Immobilizer
  • Limit weight bearing
  • Analgesia
  • Length of disability usually several weeks to a few months
  • Ortho referral
43
Q

Grade III ligamentous sprain (pathology and presentation, intervention)

A

Pathology: complete ligamentous tear

Presentation: complete ankle instability, significant swelling, moderate to severe ecchymosis

Intervention:

  • RICE
  • Immobilizer
  • Limit weight bearing
  • Analgesia
  • Length of disability may be many months
44
Q

Ottawa Ankle Rules criteria

  • Is imaging necessary for an ankle sprain?
A

Only if the patient experiences malleolar pain and any of the following:

  • Bone tenderness at posterior edge or tip of lateral malleolus
  • Bone tenderness at posterior edge or tip of medial malleolus
  • Inability to bear weight immediately after injury and in ED
45
Q

What is fibromyalgia?

A

Chronic pain syndrome diagnosed by widespread presence of body pain

  • Sometimes begins after physical trauma, surgery, infection, or significant psychological stress
46
Q

Fibromyalgia clinical presentation

A
  • Burning, aching, sore pain
  • Point tenderness
  • Lasted for at least 3 months
  • Persistent fatigue, non refreshing sleep
  • Tension headaches
  • TMJ
  • IBS
  • Anxiety and/or depression
47
Q

Is diagnostic testing required for fibromyalgia?

A

No imaging or labs are diagnostic but can be used to rule out other causes

  • Labs: CBC w/ diff, metabolic panel, UA
    • TSH, vitamin D, vitamin b12 for fatigue and muscle pain
    • IDA normal
48
Q

Fibromyalgia conservative management

A
  • Physical activity → flexibility exercises, progressive stretching, low impact activities (aquatics)
  • Stress management
  • Maintain healthy lifestyle
    • Eat healthy foods
    • Limite caffeine
    • Get sufficient sleep
49
Q

Fibromyalgia pharmacotherapy

A
  • Acetaminophen and NSAIDs for pain
  • Trazadone for sleep
  • Antidepressants
    • TCAs
    • SNRIs (duloxetine)
  • Anti epileptics (gabapentin, pregabalin)
50
Q

Causes of vitamin D deficiency

A
  • Sun avoidance and use of sun protection
  • Increased skin pigmentation
  • Inadequate dietary and vitamin D supplemental intake
    • Breastmilk only without vitamin D supplementation
  • Malabsorptive syndromes (gastric bypass, hepatic and renal disease)
  • Obesity
  • Medications (phenytoin, phenobarbital)
51
Q

Vitamin D deficiency clinical presentation

A

Often mistaken for fibromyalgia

  • Muscle weakness and muscles aches
  • Osteomalacia → pain to palpation
  • Dull, aching pain
  • Difficulty arising from a chair or walking
  • Pseudofractures
52
Q

Vitamin D deficiency diagnostic testing

A
  • Serum 25-hydroxyvitamin D
    • Increased PTH levels with vitamin D levels of at least 20
    • Normal vitamin D range is 20-100
53
Q

Vitamin D deficiency treatment and management

A
  • Vitamin D intake recommendations
    • Infants (400 IU/day)
    • Ages 1-70 years, pregnant and lactating women (600 IU/day)
    • Older than 70 years (800 IU)
  • Vitamin D3 supplementation
    • 50,000 IU PO once/week for at least 8 weeks
54
Q

Foods high in vitamin D

A
  • Fortified milk, OJ, infant formulas, yogurts, breakfast cereals
  • Salmon
  • Tuna
  • Mackerel
  • Cod liver oil
  • Shitake mushrooms
  • Egg yolk

FNP boards (20 decks)

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