MSK/RHEUM

Question 1

If flexion of the back or sitting relieves back pain the cause is likely what?

Answer 1

Spinal stenosis

Question 2

Where do most lumbar discs rupture? Cervical?

Answer 2

Lumbar = L5 or S1

Cervical = C6 or C7

Question 3

How do we treat herniated disc?

Answer 3

Exercise and PT – NOT bedrest

Question 4

If you see a crescent sign or flattening on a hip xray – what does this indicate? What was the person most likely taking?

Answer 4

AVN

Most likely taking prednisone

Question 5

If you see bumps on the DIP joints of the hands – what is it?

Answer 5

Heberden’s nodes (caused by OA)

Question 6

If you see bumps on the PIP joints of the hand – what is it?

Answer 6

Bouchard nodes (caused by OA)

Question 7

If a pt has rapid onset of pain, warmth, tenderness, and redness in a joint with decreased ROM – what should you think of?

Answer 7

Infectious arthritis

Question 8

If a pt has a T score of less than 2.5 what do they have?

Answer 8

Osteoporosis

Question 9

If a pt has a T score between 1-2.5 what do they have?

Answer 9

Osteopenia

Question 10

When do we start DEXA scan?

Answer 10

After age of 65; then every 2 years

Question 11

How do we treat osteoporosis?

Answer 11

Bisphosphonates

Question 12

What should we remember about bisphosphonates?

Answer 12

Must be taken fasting, with 8oz of water, must remain upright x30minutes

Only take for 5 years, then a “drug holiday”

Question 13

If a pt has symmetric joint pain for longer than 6 weeks and morning stiffness that doesn’t seem to go away – what might they have?

Answer 13

Rheumatoid arthritis

Question 14

Does rheumatoid arthritis involve the DIP joints or spare them?

Answer 14

Spares them

Question 15

How do we diagnose rheumatoid arthritis?

Answer 15

Rheumatoid factor and positive anti-ccp

Elevated ESR/CRP

Question 16

How do we treat rheumatoid arthritis?

Answer 16

DMARDS – methotrexate

Question 17

What if a pt fails the DMARDS?What if a pt fails the DMARDS?

Answer 17

Go to triple therapy (hydroxychloroquine, methotrexate, and sulfasalazine)
Or a biologic TNF inhibitor

Question 18

What do all pts need before given a biologic?

Answer 18

screened for TB

Question 19

How do we treat flares of RA?

Answer 19

NSAIDs or steroids

Question 20

How do we treat a pregnant female with RA?

Answer 20

Hydroxychloroquine or sulfasalazine

Question 21

How do we treat an acute gout attack?

Answer 21

NSAIDs or colchicine (third line is steroids)

Question 22

What classifies as chronic gout? How do we tx?

Answer 22

More than 2 attacks/year

Lifestyle modifications and Allopurinol

Question 23

Can you start allopurinol during an acute attack?

Answer 23

NO

Question 24

What medications can cause a gout flare?

Answer 24

Thiazides and ASA

Question 25

If a pt has an acute flare of gout, you aspirate and needle shaped crystals are seen – what’s the cause?  What about rhomboid shaped crystals?

Answer 25

``` Gout = needle shaped crystals; problem with uric acid Pseudogout = rhomboid shaped; problem with calcium pyrophosphate ```

Question 26

What would xrays show in pseudogout?

Answer 26

Cartilage calcification

Question 27

If a pt has generalized aching, pain, fatigue, stiffness – what dx do you think of?

Answer 27

Fibromyalgia

Question 28

How do we treat fibromyalgia?

Answer 28

Exercise, heat, stress management, CBT

Question 29

What dz is more common in African americans and presents with a malar rash, arthritis, and a renal disorder?

Answer 29

SLE

Question 30

What does a pt need clinically to be diagnosed with SLE?

Answer 30

4 of 11 clinical features               Malar rash, discoid rash, photosensitive, oral/nasal ulcerations, arthritis in 2 or more joints, Serositis, renal disorder, neurologic disorder, hematologic disorders, immunologic disorder, and a positive ANA

Question 31

What labs must be done in order to dx SLE?

Answer 31

ANA, DS DNA that shows anti-smith antibodies

Question 32

How do we treat SLE?

Answer 32

NSAIDs and steroids (acute)  Hydroxychloroquine

Question 33

If a pt is noted to have skin thickening in the fingers and hands with digital ulcers as well – dx?

Answer 33

Scleroderma

Question 34

What is scleroderma?

Answer 34

Autoimmune dz of unknown origin – causes fibrosis of the skin/organs AKA CREST syndrome               Calcinosis, raynauds, esophageal dysmotility, sclerodactyl, and telangiectasia

Question 35

How do we dx Scleroderma?

Answer 35

``` ANA, anticentromere antibodies               PFT’s should also be done (for interstitial lung dz)               Biopsy of skin confirms ```

Question 36

How do we treat scleroderma?

Answer 36

``` Tx organs involved               ACE for kidneys               Raynauds with CCB’s               GI dysmotility with PPI ```

Question 37

If an older woman presents with intense morning stiffness in her shoulders and pelvis – what do you think of?

Answer 37

Polymyalgia rheumatica

Question 38

How do we diagnose polymyalgia rheumatica?

Answer 38

Elevated ESR/CRP               ANA and RF factor negative

Question 39

How do we treat polymyalgia rheumatica?           

Answer 39

Low dose corticosteroids

Question 40

What is often closely associated polymyalgia rheumatica?

Answer 40

Giante cell arteritis

Question 41

If a pt has post-infectious arthritis, urethritis, and conjunctivitis – what do you think of?

Answer 41

Reactive arthritis

Question 42

What is the cause of reactive arthritis, what is it associated with?

Answer 42

After GI or GU infection, MC bacteria (chlamydia, salmonella, shigella)               Associated with HLA-B27

Question 43

How do we treat reactive arthritis?

Answer 43

Arthrocentesis will be negative               Tx with NSAIDs

Question 44

If an xray shows a “sunburst” pattern – dx?

Answer 44

Osteosarcoma (young 20-30’s)

Question 45

What orthopedic tumor would not show up on an xray, why?

Answer 45

Chondrosarcoma (tumor of cartilage)

Question 46

If an xray shows a “moth eaten” pattern or a “onion peel” pattern – dx?

Answer 46

Ewing sarcoma

Question 47

How is a bone tumor definitively diagnosed?

Answer 47

Biopsy

Question 48

What are some lifestyle and vitamin recommendations we should make for those at risk of osteoporosis?

Answer 48

1200mg of calcium once over the age of 50               800IU of vit D3               Don’t smoke               Weight bearing exercise and balance training

Question 49

What types of fractures often indicate a bone mineralization problem?

Answer 49

Vertebral, hip, and wrist fractures

Question 50

What meds raise our concern for bone loss?

Answer 50

Antipsychotics, steroids, litihium, PPI’s, SSRI’s