Musculoskeletal Flashcards
In the pharmacological management of osteoarthritis of the knee or hand, if regular paracetamol is insufficient, what would be the second line option, before considering oral NSAIDs?
Topical NSAID gel
What medications are NOT recommended in the pharmacological management of OA?
Intra-articular injections of Hyaluronic acid or any of its derivatives
Glucosamine or Chondroitin sulphate
The name of the scoring system used to monitor the effects of treatment in Rheumatoid Arthritis
DAS28: Disease Activity Score, marked out of 28 points
In terms of Rheumatoid Arthritis, what class of drug is Methotrexate?
Disease Modifying Anti-Rheumatic Drug (DMARD)
How often is Methotrexate taken and what other supplement is taken on an alternative day of the week when taking Methotrexate?
Methotrexate taken ONCE WEEKLY with the addition of folic acid on an alternative day of the week.
In acute management of gout, what is the FIRST line pharmacological treatment?
NSAIDs
In acute management of gout, what is the SECOND line pharmacological treatment if the first line is not tolerated or contraindicated?
Colchicine (Pronounced: kowl·chuh·seen).
Anti-inflammatory response to urate crystals, mechanism unknown
The three medications that increase Methotrexate toxicity - bonus points for explaining how!
- NSAIDs
- Penicillin’s
(Both reduce the renal clearance of Methotrexate) - Trimethoprim - Another folate antagonist; increased the risk of haematological abnormalities if combined.
(8) Common side effects of Methotrexate…
Nausea, Vomiting, Diarrhoea, Skin rash, Sun sensitivity, Mouth ulcers, Sore gums and/or Throat.
The most commonly used urate-lowering medication in the chronic management of gout which inhibits uric acid production…
Allopurinol
Second line uric acid lowering drug used in the chronic management of gout that increases the amount of uric acid secreted in the urine…
Sul-fin-pyra-zone
In what (7) circumstances/pathologies would the chronic management of gout be initiated? (i.e. starting medications to reduce uric acid/urate)
- Recurrent attacks of gout twice or more per year
- Presence of tophi (uric acid crystals in joints)
- Chronic gout arthritis
- Joint damage
- Uric acid stones
- Young age
- CKD
(3) Complications of Methotrexate
Hepatotoxicity, Bone Marrow suppression, Lung fibrosis
Name the sections of the spine, including the natural curvature of each section
Cervical (Lordosis); Thoracic (Kyphosis); Lumbar (Lordosis); Sacral (Kyphosis)
How many vertebra in each section of the spine?
Cervical = 7 Thoracic = 12 Lumbar = 5 Sacrum = 5 Fused Coccyx = 4 Fused
The two ‘types’ of skeleton in the human body and their functions
Appendicular = Bones of the upper and lower limbs. Functions = Locomotion
Axial = Skull, Vertebral column and thoracic cage. Function = Protection and muscle attachment
The two bone types
Cortical and Trabecular bone
Describe the bone growth and breakdown cycle
RANK-L secreted by osteoblasts to stimulate osteoblasts to begin breaking down bone.
Osteoclast secrete H+ ions, lowering the pH and cytoplasmic lysosomes digest the matrix.
TGF-B inhibits RANK-L secretion by osteoblasts, bone building is initiated by recruiting pre-osteoblasts.
Approximately how long does the bone BREAK DOWN cycle take?
~3 Weeks
Approximately how long does the bone BUILDING cycle take?
~3 Months
(5) Clinical indicators of muscle disease
Atrophy/Hypertrophy Muscle Weakness Abnormal Contraction Loss of Contractile Ability PAIN!
Main type of muscular dystrophy, briefly describe the pathophysiology
Duchenne Muscular Dystrophy.
Gene mutation in dystrophin protein which causes muscles to become fragile/weak, easily damaged and atrophy.
Dystrophin is part of a protein complex that work together to strengthen muscle fibers and protect them from injury.
The three main types of muscular atrophy
Disuse; Neurogenic; Denervation
briefly describe the pathophysiology of myasthenia gravis
Autoimmune disorder that involves the failure of transmission of nerve impulses to the muscle fibres.
Caused by antibodies against the acetylcholine receptor which is essential for effective synaptic transmission.
It is characterised by persistent weakness and easy fatigability that tends to get worse as the day progresses.
Some of the common causes of muscle spasm include:
Overuse and/or overstrain of certain group of muscles
Injury or trauma
Neural overstimulation
Congenital disorders/genetic conditions (ALS, muscular dystrophies, MG)
Electrolyte imbalance (lactic acid; Hypokalemia; Hypocalemia)
(8) Signs and symptoms of musculoskeletal disorders
Decreased range of motion, Decreased grip strength, loss of function, pain, tingling, numbness, deformity, muscle fatigue
3 Aspects of Joint Examination Techniques
Look: Rest position of joints noted. Skeletal deformity? Swelling or wasting? Scaring?
Feel: Warmth? Tenderness? Joint effusion? Synovial thickening? Bony enlargement?
Move: Assessing function and range of motion – Active or Passive Flexion/Extension?
(6) Predisposing factors to chronic lower back pain
Degenerative disc disease, Previous injury, Postural Abnormalities, Obesity, Lack of exercise, Systemic Disease
Investigations for a suspected prolapsed disc
History; MRI; ESR/CRP; Myeloma screen, PSA
Treatments of prolapsed disc
Conservative: Heat and massage, Avoiding activities that worsens pain, Keep active, Physiotherapy.
Medical: Pain relief (Ibuprofen/naproxen first line)
Surgical: prosthetic intervertebral disc replacement
How long should it for for symptoms to resolve after a disc prolapse/herniation?
Generally symptoms should ideally resolve within 6 weeks
List the steps of the WHO Pain Ladder
If pain occurs, there should be prompt oral administration of drugs in the following order:
- Non-opioids (aspirin and paracetamol); then, as necessary,
- Mild opioids (codeine)
- Strong opioids such as morphine, until the patient is free of pain.
With regards to the WHO Pain Ladder, what are ‘adjuvants’?
Adjuvantsmay help pain in other ways like anti-depressants or anti-epileptics or can be anything that reduces pain, so could include antibiotics to treat a painful infection or non-pharmacologicalapproaches such as cooling a burn or splinting a fracture
What is the mechanism of action of opioids?
Opioids mimic naturally occurring pain-killing peptides
They are agonists – binding presynaptic and post synaptic nerves/receptors and cause the same response as endogenous pain killing peptides would, e.g. endorphins.
Causes a decrease in neurotransmitter release
Describe the prescribing considerations of opioids
Avoid prescribing opioids for chronic pain as they’re ineffective or may actually worsen it!
Need to use lowest effective dose for the shortest possible time.
Stop using them if they’re not helping
Structural scaffolding and organ protection are two functions of the skeletal system. Name two more functions.
Calcium storage, Haematopoiesis, Movement
