Musculoskeletal

Question 1

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?

Answer 1

Topical NSAID gel

Question 2

What medications are NOT recommended in the pharmacological management of OA?

Answer 2

Intra-articular injections of Hyaluronic acid or any of its derivatives

Glucosamine or Chondroitin sulphate

Question 3

The name of the scoring system used to monitor the effects of treatment in Rheumatoid Arthritis

Answer 3

DAS28: Disease Activity Score, marked out of 28 points

Question 4

In terms of Rheumatoid Arthritis, what class of drug is Methotrexate?

Answer 4

Disease Modifying Anti-Rheumatic Drug (DMARD)

Question 5

How often is Methotrexate taken and what other supplement is taken on an alternative day of the week when taking Methotrexate?

Answer 5

Methotrexate taken ONCE WEEKLY with the addition of folic acid on an alternative day of the week.

Question 6

In acute management of gout, what is the FIRST line pharmacological treatment?

Answer 6

NSAIDs

Question 7

In acute management of gout, what is the SECOND line pharmacological treatment if the first line is not tolerated or contraindicated?

Answer 7

Colchicine (Pronounced: kowl·chuh·seen).

Anti-inflammatory response to urate crystals, mechanism unknown

Question 8

The three medications that increase Methotrexate toxicity - bonus points for explaining how!

Answer 8

1. NSAIDs
2. Penicillin’s
   (Both reduce the renal clearance of Methotrexate)
3. Trimethoprim - Another folate antagonist; increased the risk of haematological abnormalities if combined.

Question 9

(8) Common side effects of Methotrexate…

Answer 9

Nausea, Vomiting, Diarrhoea, Skin rash, Sun sensitivity, Mouth ulcers, Sore gums and/or Throat.

Question 10

The most commonly used urate-lowering medication in the chronic management of gout which inhibits uric acid production…

Answer 10

Allopurinol

Question 11

Second line uric acid lowering drug used in the chronic management of gout that increases the amount of uric acid secreted in the urine…

Answer 11

Sul-fin-pyra-zone

Question 12

In what (7) circumstances/pathologies would the chronic management of gout be initiated? (i.e. starting medications to reduce uric acid/urate)

Answer 12

1. Recurrent attacks of gout twice or more per year
2. Presence of tophi (uric acid crystals in joints)
3. Chronic gout arthritis
4. Joint damage
5. Uric acid stones
6. Young age
7. CKD

Question 13

(3) Complications of Methotrexate

Answer 13

Hepatotoxicity, Bone Marrow suppression, Lung fibrosis

Question 14

Name the sections of the spine, including the natural curvature of each section

Answer 14

Cervical (Lordosis); Thoracic (Kyphosis); Lumbar (Lordosis); Sacral (Kyphosis)

Question 15

How many vertebra in each section of the spine?

Answer 15

Cervical = 7
Thoracic = 12
Lumbar = 5
Sacrum = 5 Fused
Coccyx = 4 Fused

Question 16

The two ‘types’ of skeleton in the human body and their functions

Answer 16

Appendicular = Bones of the upper and lower limbs. Functions = Locomotion

Axial = Skull, Vertebral column and thoracic cage. Function = Protection and muscle attachment

Question 17

The two bone types

Answer 17

Cortical and Trabecular bone

Question 18

Describe the bone growth and breakdown cycle

Answer 18

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.

Question 19

Approximately how long does the bone BREAK DOWN cycle take?

Answer 19

~3 Weeks

Question 20

Approximately how long does the bone BUILDING cycle take?

Answer 20

~3 Months

Question 21

(5) Clinical indicators of muscle disease

Answer 21

Atrophy/Hypertrophy
Muscle Weakness
Abnormal Contraction
Loss of Contractile Ability
PAIN!

Question 22

Main type of muscular dystrophy, briefly describe the pathophysiology

Answer 22

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.

Question 23

The three main types of muscular atrophy

Answer 23

Disuse; Neurogenic; Denervation

Question 24

briefly describe the pathophysiology of myasthenia gravis

Answer 24

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.

Question 25

Some of the common causes of muscle spasm include:

Answer 25

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)

Question 26

(8) Signs and symptoms of musculoskeletal disorders

Answer 26

Decreased range of motion, Decreased grip strength, loss of function, pain, tingling, numbness, deformity, muscle fatigue

Question 27

3 Aspects of Joint Examination Techniques

Answer 27

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?

Question 28

(6) Predisposing factors to chronic lower back pain

Answer 28

Degenerative disc disease, Previous injury, Postural Abnormalities, Obesity, Lack of exercise, Systemic Disease

Question 29

Investigations for a suspected prolapsed disc

Answer 29

History; MRI; ESR/CRP; Myeloma screen, PSA

Question 30

Treatments of prolapsed disc

Answer 30

Conservative: Heat and massage, Avoiding activities that worsens pain, Keep active, Physiotherapy.

Medical: Pain relief (Ibuprofen/naproxen first line)

Surgical: prosthetic intervertebral disc replacement

Question 31

How long should it for for symptoms to resolve after a disc prolapse/herniation?

Answer 31

Generally symptoms should ideally resolve within 6 weeks

Question 32

List the steps of the WHO Pain Ladder

Answer 32

If pain occurs, there should be prompt oral administration of drugs in the following order:

1. Non-opioids (aspirin and paracetamol); then, as necessary,
2. Mild opioids (codeine)
3. Strong opioids such as morphine, until the patient is free of pain.

Question 33

With regards to the WHO Pain Ladder, what are ‘adjuvants’?

Answer 33

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

Question 34

What is the mechanism of action of opioids?

Answer 34

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

Question 35

Describe the prescribing considerations of opioids

Answer 35

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

Question 36

Structural scaffolding and organ protection are two functions of the skeletal system. Name two more functions.

Answer 36

Calcium storage, Haematopoiesis, Movement