MSK - Final Flashcards
Two main factors that predispose elderly ppl to foot problems
PAD and neuropathy
What does Romberg test for?
Proprioception
Cerebellar exam (8)
Scanning speech
Nystagmus
Finger to nose & finger to finger test
Rapid alternating movements
Rebound phenomenon (of Stewart & Holmes)
Heel to shin test
Hypotonia
Gait (Acute Cerebellar Ataxia)
All of the following are signs and symptoms of:
paresthesia
sensory impairment of pain/temperature
motor weakness
decreased or lost achilles/patellar reflexes
decreased vibration sense
loss of proprioception
anihydrosis
diabetic neuropathy
Loss of the plantar metatarsal fat pad can be a sign of what?
PVD
WHO definition of OP
T score 50 years
WHO definition of osteopenia
T score -1.0 to -2.5
Self reported height loss of > ___ cm is associated with OP
3cm
Common exam findings for OP include height loss of > _____, rib-pelvis distance < _____ and inability to touch _______ to ______ when standing with heels to the wall
Common exam findings for OP include height loss of > 4 cm , rib-pelvis distance < 2 fingerbreadths and inability to touch occiput to wall when standing with heels to the wall
BMD screening is recommended for women at what ages and with what risk factors?
> 65 years OR postmenopausal < 65 years with RF ie. low body weight, prior #, use of high risk medications (corticosteroids) or conditions associated with bone loss (RA)
BMD screening is recommended for MEN at what ages and with what risk factors?
> 70 years or < 70 years with RF
T/F FRAX can be used with or without BMD results
True
T/F
Duration and dose of corticosteroid use and smoking use are included in FRAX score
False
Ongoing monitoring for OP
Yearly height measurement –> Vertebral imaging if > 2cm loss in height
BMD testing every 1-3 years after initiating therapy (controversial)
Treatment compliance and SE
Duration of oral biphosphonates
Duration of IV biphosphonates
Oral - up to 5 years
IV - up to 3 years
What medication for OP should not be discontinued for a drug holiday and is associated with rapid decline in bone density in first year after discontinuation?
Denosumab
T/F Older adults with inflammatory arthritis are more likely to die from CV condition than the MSK condition
True
When do PMR patients experience relief after starting oral steroid therapy?
2-4 weeks
If prednisone doses exceed 7.5mg/d for >/= 3 months with PMR what therapy is indicated?
OP prevention with biphosphonates
Two complications of steroid therapy for GCA
OP and pneumocystis pneumonia
All of the following are risk factors for OP EXCEPT: (multiple)
A) parental hip #
B) use of glucocorticoids dose >7.5mg daily for 3+ months
C) Alcohol intake > 3 per day
D) Kyphosis
E) Chronic back pain
F) Previous smoker
G) Major weight loss (10% below body weight at age 25)
D
E
F - only current smokers
What screener should be used for general patient population (50-64 years) to determine BMD testing? What results would warrant BMD testing?
Osteoporosis self-assessment tool
OST < 10 indicating moderate risk –> BMD
OST >/= 10 is low risk and requires reassessment with screener in 5 years
What BW is indicated to rule out secondary causes of OP?
Calcium, corrected for albumin
CBC
Creatinine
Alk Phos
TSH
Serum protein electrophoresis (for pts with vertebral #)
DO NOT ORDER 25-hydroxyvitamin D unless specific indication
Non-pharm OP Mgmt
- smoking cessation
- Vitamin D 1000 IU/d (MORE IS NOT BETTER)
- Calcium 1200mg/day from all sources
- Exercise
- Fall prevention
SE of IV biphosphonate
Self-limiting flu like illness
SE of oral biphosphonates
Esophagitis
ONJ
AFF
Max duration of biphosphonate use
10 years
What is the best next step if patient has known diagnosis of OP and has CKD?
Refer to specialist
True/false
Bisphosphonates are not recommended in patients with EGFR less than 30 due to lack of clinical experience.
True
What time on the TUG test indicates increased risk of frailty?
> 10 seconds
Bone resorption
OsteoCLASTS breakdown bone
Bone formation
OsteoBLASTS form new bone
PTH and effect on bone
Responds to low levels of serum calcium and increases bone resorption or breakdown by osteoclasts to increase serum ca
Calcitonin
Produced by thyroid gland in response to high serum calcium, increasing bone formation and decreasing bone resorption (countering effects of PTH)
Vitamin D effect
Promotes Ca+ absorption in gut, increasing serum calcium, decreasing bone resporption and increase building of bone
Findings on diagnostics for osteporosis
Fewer trabeculae (spongy bone) and thinning of cortical bone (outside)
Factors that decrease bone mass
Low estrogen (menopause)
low calcium
Substance use - EtOH, smoking
Meds - glucocorticoids (decrease Ca+ absorption from gut), thyroid hormone and heparin,
Physical inactivity
Conditions: DM, etc.
Most common type of fractures in OP
Femoral fracture
Vertebral fractures
Treatment options (pharm) for OP
HCTZ
Denosumab - inhibits ostoclasts
Biphosphonates
etc.
White people are at higher risk for osteoporosis. T/F?
True
Daily alcohol consumption >______ and caffeine intake > ____ increase the risk of osteoporosis
Daily alcohol consumption >3 units and caffeine intake >4 cup/day
Corticosteroids (>/= _______ of prednisone >/= _______ mg per day) increases the risk of osteoporosis
Corticosteroids (>/= 3 months of prednisone >/= 7.5 mg per day)
Fill in the blanks: all of the following are risk factors for osteoporosis
Prospective height loss > ____cm
Historical height loss >______ cm
Rib-pelvis distance ≤ _____fingers
Occiput-wall distance > ______ cm
Prospective height loss > 2 cm
Historical height loss > 6 cm
Rib-pelvis distance ≤ 2 fingers
Occiput-wall distance > 5 cm
Most men under 70 and women under age 65 probably DO/DO NOT need DXA scan?
DO NOT
Younger women and men ages _____ to _____ should consider the test if they have risk factors for serious bone loss. Risk factors include:
Breaking a bone in a minor accident.
Having rheumatoid arthritis.
Having a parent who broke a hip.
Smoking.
Drinking heavily.
Having a low body weight.
Using corticosteroid drugs for three months or more.
Having a disorders associated with osteoporosis.
50 to 69
Frax score < 10 when is the follow up expected
in 3-5 years
Frax score Mod 10-20% interventions
lifestyle + consider pharm, LAT x-ray r/o vertebral #, BMD in 1-3 years
High OP risk > 20% OR prior fragility fracture of hip/spine OR > 1 fragility fracture interventions
→ lifestyle + pharm + falls prevention education
True/False
Order BMD for:
o Chronic back pain (aiming to rule out vertebral fractures)
o Kyphosis (best investigated using lateral thoracic spine X-rays to rule out anterior
compression fractures)
o Menopause, in the absence of risk factors
False
BW to consider for OP
** When thinking calcium think kidneys, albumin and thyroid **
o Calcium, corrected for albumin
o Complete blood count
o Creatinine
o Alkaline phosphatase
o Thyroid-stimulating hormone
o Serum protein electrophoresis (for patients with vertebral fractures)
S&S of MDS
C alcium increased
R enal dysfunction
A nemia
B one pain
Bence jones proteins + in urine electrophoresis
True/False
For oral bisphosphonates re-assess risk and need for continued therapy after five years. Consider extending therapy to a maximum 10 years of therapy in patients at high fracture risk (e.g., previous fragility
fracture or risk >20%).
True
True/False
Refer to specialist if OP and CKD < 30
True
T/F
In the absence of RF, do not screen all people > 50 for osteoporosis self assessment
False, do that!
All of the following are concerning side effects of what medication class?
jaw/ear pain
swelling of joints/hands/ankles/feet
increased or severe bone/joint/muscle pain
new or unusual hip/thigh/groin pain
black/tarry stools
vomit that looks like coffee grounds
Biphosphonates
When to order x ray for back pain?
Presence of red flags or persistence of symptoms > 6 weeks despite treatment
What nerve root is being tested with the following:
Heel walking
L4-5
What nerve root is being tested with the following: Toe walking
S1
What nerve root is being tested with the following: Patellar reflex
L3-4
What nerve root is being tested with the following: Great toe extension
L5
What nerve root is being tested with the following: Great toe flexion
S1
What nerve root is being tested with the following: Saddle sensation testing
S2, 3, 4
Continuous back dominant pain that is relieved by extension
Disc pain
Intermitted back dominant pain that is relieved by flexion
Facet joint pain
Constant leg dominant pain
Compressed nerve
Intermittent leg dominant pain relieved with forward flexion
Spinal stenosis
What age and comorbidity is most commonly associated with spinal stenosis?
OA and > 60 years
True/False
Weakness in legs is a sign of spinal stenosis
True
T/F
ASA will help with claudication associated with spinal stenosis
False
All of the following are possible signs of what condition:
Weakness to L5 (great toe extension) and S1 (great toe flexion)
Wide-based gait and/or + Romberg (90% specificity)
+/- absent ankle(43%) and knee (18%) DTR
SLR may be +
Spinal stenosis
When walking, the patient will hold his or her arm to one side and drags his or her affected leg in a semicircle (circumduction)
hemiplegic gait
Gait where he or she will be stooped with the head and neck forward, with flexion at the knees. The whole upper extremity is also in flexion with the fingers usually extended. The patient walks with slow little steps known at marche a petits pas (walk of little steps).
Parkinsonian Gait
(Festinating Gait, Propulsive Gait)
this gait is described as clumsy, staggering movements with a wide-based gait. While standing still, the patient’s body may swagger back and forth and from side to side, known as titubation. Patients will not be able to walk from heel to toe or in a straight line.
Ataxic Gait
(Cerebellar)
If you have weakness on one side, this will lead to a drop in the pelvis on the contralateral side of the pelvis while walking
Myopathic Gait (Waddling Gait)/Trendeleburg sign
Seen in patients with foot drop (weakness of foot dorsiflexion), the cause of this gait is due to an attempt to lift the leg high enough during walking so that the foot does not drag on the floor.
Neuropathic Gait
(Steppage Gait, Equine Gait)
Quad muscle weakness is associated with RA. T/F?
False, it is associated with OA
Which type of RA has a bimodal distribution in 30’s and 70’s
RA
T/F? Inflammatory arthritis pain improves with exercise
True
What are the 3 most frequent joints affected by RA
PIP, MCP and wrist
T/F?
RF can be elevated in sjogrens, lupus, sarcoidosis and hep B?
True
What does this indicate:
X-ray - joint space narrowing, osteophytes, subchondral sclerosis, cystic changes
OA
What does this indicate: X-ray - loss of articular space, multiple erosions, juxta articular osteopenia and ulnar deviation
RA
All of the following are SE of what medicaiton for RA?
- Myelosuppression
- Hepatotoxicity/hepatic fibrosis/cirrhosis
- Pulmonary fibrosis/infiltrates
- Oral lesions (daily folic acid to prevent)
- Nausea
- Alopecia
Methotrexate
What medication for RA requires Ophthalmic exam Q6-12 months?
Hydroxychloroquine due to retinal deposits
Negative RF is found in psoriatic arthritis. T/F?
True
Out of pocket expense: Anti-CCP testing
through primary care currently costs the
patient $75 in BC.
T/F?
True
What BW may indicate a + diagnosis of SLE?
ANA
two causes of PMR
Genetic or environmental (Parvovirus or adenovirus)
T/F
A normal CRP is an effective “rule out” test for GCA?
False
headache, jaw claudication and visual symptoms are a sign of what and what is the most appropriate treatment
GCA
Low dose prednisone oral STAT prednisone 40-60 mg OD and EMERGENTLY send for biopsy
What concurrent treatment is recommended for PMR patients?
Osteoporosis treatment with biphosphonates
Treatment of PMR
Initiate Prednisone 15-20 mg PO once daily (expect improvement in 1 week). Taper over 1 year (1mg taper Q4 weeks).
Normal flexion of the knee is which of the following?
> 110 degrees
> 90 degrees
> 130 degrees
> 130 degrees
All four parts of the quadriceps muscle insert into the tibial tuberosity where the quadriceps tendon becomes the __________ ligament.
patellar
What is the name of the deformity that has the following features:
Hyperextension of the MTP and DIP joints with DIP flexion of toes 2, 3, 4, and 5
Associated with hallux valgus
Pain associated with wearing foot wear
Often associated with helomas (corns)
Hammer toes
The Deltoid muscle is supplied by the C5-6 root and which of the following nerves?
Radial nerve
Musculocutaneous
Axillary nerve
Axillary nerve
Which nerve runs superficially and laterally around the knee and is at risk of injury from surgery or trauma (ie. fracture of fibula, with a resultant footdrop? Common _________ nerve.
The common peroneal nerve runs along lateral surface of the knees and divides into the superficial peroneal nerve and the deep peroneal nerves. The most common site of compression is at the lateral knee, where the common peroneal nerve is compressed between fascial structures and the fibula.
The superficial peroneal nerve innervates the peroneus longus and brevis muscles & the skin over the antero-lateral aspect of the leg along with the greater part of the dorsum of the foot (with the exception of the first web space, which is innervated by the deep peroneal nerve). Symptoms of peroneal nerve injury include:
Sensory dysfunction: : Decreased sensation, numbness, or tingling on the dorsum of the foot or the lateral aspect of the upper or lower leg.
Motor dysfunction: Drop foot, “slapping gait”, weakness of ankles and feet Compression of the peroneal nerve branches is most common in patients with neuropathy (e.g. DM), a knee injury, and knee surgery.
Which of the following muscles make up the quadriceps femoris?
Rectus femoris, vastus lateralis, vastus medialis & gracilis
Rectus femoris, vastus lateralis, vastus medialis, & vastus intermedius.
Vastus lateralis, vastus medialis, sartorius
Rectus femoris, vastus lateralis, vastus, medialis, & iliopsoas
Rectus femoris, vastus lateralis, vastus medialis, & vastus intermedius.
Which of the following are bones of the hand & wrist?
Atlas & Axis
Cuboid & Cuneiform
Trapezium & Trapezoid
Hamate & Talus
Trapezium & Trapezoid
T/F?
Uric acid stones do not show on plain radiographs as they are radiolucent. Ultrasound or Non-contrast CT scans are required for detection.
True
Toxic effects of colchicine are increased if given to patients on which of the following medications?
Clarithromycin
All Answers are Correct
Ciclosporin
Rosuvastatin
Verapamil
All Answers are Correct
RA is more common in women 3:1 and is often seen in people with other autoimmune diseases. New onset can occur at any age, but peak age of onset is________ to _____ years
20-40 years
Drugs that are implicated in development of secondary gout include all of the following EXCEPT:
Ascorbic Acid
Levodopa
Tacrolimus
Hydrochlorothiazide
Low Dose Aspirin
Ascorbic Acid
