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3rd year - Family Medicine > MSK > Flashcards

MSK Flashcards

(74 cards)

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1
Q

What are the 3 most common pathogens of septic arthritis?

A
  1. Staphylococcus aureus
  2. Streptococcus penumonia
  3. Gonococcal infection

Gram negative bacteria usually in immune compromised host with GI infection

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2
Q

Gonnococcal septic arthritis presentation

A

Can present in 2 ways

  1. Triad
    a) Tenosynovitis
    b) Painless vesiculopustular dermatitis
    c) Polyarthralgia with prurulent arthritis
  2. Prurulent arthritis without skin lesions
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3
Q

Empiric antibiotic treatment for septic arthritis with culture pending and no results on gram stain

A
  1. Vancomycin 15-20 mg/kg IV q 8-12h
  2. For suspected gonococcal infection Ceftriaxone 1 g IM/IV once daily x 14 days + Azithromycin 1 g PO 1 dose

If immunocompromised, traumatic, IV drug use - add 3rd generation cephalosporin

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4
Q

Antibiotics based on gram stain for gram positive cocci and gram negative bacilli

A

Gram positive cocci - vancomycin

Gram negative bacilli - 3rd generation cephalosporin (ceftriaxone, ceftazidime, cefotaxime)

Add Gentamycin if pseudomonas is suspected

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5
Q

Gout cystals

A

Monosodium urate crystals

Negative yellow birifringement needle crystals

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6
Q

Psuedogout crystals

A

Calcium pyrophosphate dihydrate crystals

Positive blue crystals

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7
Q

Management of gout

A

Treatment of acute gout

First line - NSAIDs
Second line - Colchicine if within 3 days of acute flare
Third line - Glucocorticoid injection if 1-2 joints, Systemic glucocorticoid for >2 joints

Prophylaxis

First line - Lifestyle modification
Second line - Urate lowering therapy if 3+ attacks/year, radiographic evidence, tophi, renal implications
1. Allopurinol
2. Febuxostat or Probenecid
Start urate lowering therapy with Colchicine or Indomethacin to prevent risk of acute gout flare for the first <6 months

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8
Q

Management of Pseudogout

A

Treatment of acute gout
First line - rest and immobilization
Medications are the same as gout

Prophylaxis if 3+ attacks per year
First line - Chronic colchicine
Second line - Chronic NSAIDs

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9
Q

Rheumatoid arthritis diagnostic criteria

A
  1. Inflammatory arthritis including 3+ joints
  2. Positive RF or CCP
  3. Elevated ESR or CRP
  4. Duration of symptoms >6 weeks
  5. Other arthritis excluded including spondyloarthropathies, SLE, gout, pseudogout
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10
Q

Rheumatoid arthritis management

A

1st line - DMARD (+ NSAID or Glucocorticoid until symptoms under control)
Mild - Sulfasalazine or Hydroxychloroquine
Moderate to severe - methotrexate

2nd line - biologics

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11
Q

What are extra articular manifestations that can be seen in rheumatoid arthritis

A

Sjogren ‘s syndrome

Subcutaneous rheumatoid nodules

Tenosynovitis of hands and feet

Normocytic anemia

Keratoconjunctivitis sicca, episcleritis, scleritis

Interstitial lung disease

Pericarditis

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12
Q

Side effects of NSAIDs

A

Peptic ulcer and GI bleeding

Hypertension

Renal failure (contraindicated in patients with renal failure or CHF)

Anaphylaxis (contraindicated in asthmatic patients)

Induce labour

Reye’s syndrome

Urate accumulation

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13
Q

Side effects of celecoxibs

A

Hypertension

Renal failure (contraindicated in patients with renal failure or CHF)

Cardiovascular events (stroke, MI)

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14
Q

Side effects of methotrexate

A

Nausea, abdo pain, fatigue

Hepatotoxicity

Pneumonitis

Teratogen

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15
Q

Side effects of azathioprine

A

N/v/d, fatigue, rash

Acute pancreatitis

Increased risk of blood cancer

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16
Q

Side effects of hydroxychloroquine

A

Nausea, abdo pain

Diarrhea

Blood disorder

Hearing loss

Hepatotoxicity

Muscle weakness/paralysis

Retinopathy **

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17
Q

Side effects sulfasalazine

A

Infertility

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18
Q

Contraindication to biologics

A

Positive TB test

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19
Q

Examples of xanthine oxidase inhibitors

A

Allopurinal

Febuxostat

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20
Q

Examples of uricosuric agents

A

Probenecid

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21
Q

MOA of xanthine oxidase inhibitors

A

Inhibit xanthine oxidase which is required in the metabolism of purines to produce uric acid

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22
Q

MOA uricosuric agents

A

Increase renal excretion of uric acid

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23
Q

Contraindication of uricosuric agents

A

Renal failure

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24
Q

Xanthine oxidase inhibitor side effects

A

Nausea, diarrhea
Hepatitis
Hypersensitivity (fever, rash, eosinophilia, Stevens-Johnsons)
Aplastic anemia

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25
Colchicine contraindications
Liver failure Renal failure Heart disease
26
MOA colchicine
Stops microtubule polymerization -> stops mitosis -> stops proliferation of inflammatory cells Inhibits neutrophil motility and activity
27
Colchicine side effects
GI upset Neutropenia Bone marrow suppression Poisoning at high doses
28
Why do you mix glucocorticoid for injection with local anesthetic
Decreases the risk of soft tissue atrophy and tendon rupture
29
Absolute contraindications to joint injection, soft tissue injection or joint aspiration
Local cellulitis Septic arthritis Bacteremia Acute fracture Joint prosthesis History of allergy to injection Intra-tendinous injection or injection into an area with tendinopathy is contraindicated due to risk of tendon atrophy and weakening
30
Relative contraindications to joint injection, soft tissue injection or joint aspiraation
Patients with no response after trial of 1-2 joint injections will not likely respond with subsequent injections Coagulopathy or anticoagulant therapy Surrounding joint osteoporosis Anatomically inaccessible joint Uncontrolled diabetes
31
Maximum number of glucocorticoid injections
Max 4 injections per year per patient
32
Back pain red flags
Fracture - history of osteoporosis, history of trauma, history of long term systemic steroid use Infection - skin opening, history of recent infection, immunocompromised, constitutional symptoms, IV drug use Malignancy - history of malignancy, constitutional symptoms Radiculopathy - unrelenting pain at rest and at night Neurological - weakness, numbness, tingling, cauda equina Intraabdo/GI/GU - referred pain, dysuria, AAA history
33
Indications for lumbar xray in low back pain (and ESR if risk of malignancy, infection, inflammation)
Risk factors for cancer (history, suspicion, >50 years, unexplained weight loss) Risk factors for ankylosing spondylitis (morning stiffness, buttock pain, night pain) Risk factor for vertebral compression fracture (osteoporosis, glucocorticoid use, trauma, >65 year old man, >75 year old woman) Signs and symptoms of radiculopathy without bowel or bladder implications Failing 4-6 weeks of therapy
34
Indications for MRI in low back pain
risk factor for spinal infection: fever, IV drug use, recent infection cauda equina syndrome severe or progressive neurologic deficit failed 4-6 weeks of therapy with nerve impingement (in L4-S1 distribution, positive straight leg raise), spinal stenosis (radiating leg pain, older age) MRI may be considered in patients with lower back pain >12 weeks
35
Indication for referral to neurosurgeon or orthopedic surgeon
cauda equina syndrome spinal cord compression: acute neurologic deficits in patient with cancer and risk of spinal metastases progressive or severe neurologic deficit
36
Indication for referral to neurologist or physiatrist
Motor deficit persisting after 4-6 weeks of therapy Persistent sciatica, sensory deficit or reflex loss after 4-6 weeks of therapy in patients with positive straight leg raise
37
Differential diagnosis of chronic low back pain
1. Non specific or idiopathic (sprain or strain) 70% 2. Mechanical 27% Degenerative - spondylosis (aka DDD), degenerative disease of facet joints, spinal stenosis Disk disruption Fracture - spondololysis, spondololisthesis, osteoporotic Congenital disease 3. Non mechanical Malignancy, infectious, inflammatory, osteochondrosis, Paget 4. Visceral disease
38
What is osteochondrosis
Interruption to blood supply to epiphysis causing necrosis and later regrowth
39
Pharmacological management of low back pain
1. Tylenol 2. NSAIDs 3. Tramadol and opioids 4. TCA, gabapentin 5. Last line - muscle relaxant
40
Indications for epidural injection or surgical referral for low back pain
severe functional disability radiculopathy refractory pain to non-pharmacological and pharmacological management
41
Indication for surgery in low back pain
anatomic abnormality identified is consistent with distribution of pain unremitting pain lasting >1 year despite multiple non-surgical treatment
42
Features of psoriatic arthritis that differentiate it from rheumatoid arthritis
1. Asymmetric involvement of joints 2. Involvement of DIP 3. Involvement of all joints in one digit 4. Dactylitis (inflammation of whole digit including joints and tendons) 5. Enthesitis (inflammation of tendon and ligament insertions) such as lateral epicondylitis (tennis elbow) and plantar fasciitis 6. Spondylitis
43
What monitoring has to be performed with methotrexate use
Frequent CBCs due to the risk of bone marrow suppression Frequent liver enzyme panels due to the risk of hepatitis
44
Severe potential adverse effect of ace inhibitor
Angioedema
45
Management of mild eczema
Remission therapy - Corticosteroid (Desonide, hydrocort, betamethasone) BID x 2-4 weeks in conjunction with emollients Maintenance Corticosteroid daily x 2 days during the weekend for up to 16 weeks
46
Management of moderate eczema
Remission 1st line - Fluocinolone, Triamcinolone, betamethasone same regimen as mild BID x 2-4 weeks in conjunction with emollients 2nd line - topical calcineurin inhibitors BID (Tacrolimus, pimecrolimus) Maintenance Desonide, hydrocort, betamethasone daily x 2 days during the weekend x 16 weeks
47
Management of severe eczema
1st line - phototherapy UVB x 3/week 2nd line - cyclosporine 3-5 mg/kg PO per day in 2 divided doses x 6 weeks for remission and then lowered to minimum effective dose for maintenance up to 1 year 3rd line - DMARD (methotrexate, imuran, cellcept)
48
What is viral exanthem 1, cause, presentation and infectious period?
Measles (Rubeola) Cause: Paramyxovirus Presentation: Maculopapular erythematous rash following several days following fever Kopik's spots (specific for measles) Fever, cough, coryza, conjunctivitis Infectious: 3 days before and after rash
49
What is viral exanthem 2, cause, presentation?
Scarlet fever Cause: Group A beta hemolytic streptococcus ``` Presentation: maculopapular sandpaper erythematous rash Strep throat Strawberry tongue Fever ```
50
What is viral exanthem 3, cause, presentation?
Rubella (German Measles) Cause: Togavirus Presentation: Macular erythematous rash x 3 days with viral symptoms
51
What is viral exanthem 4?
Filatov-Duke's disease - historical term not used and does not refer to anything
52
What is viral exanthem 5, cause, presentation?
Erythema infectiosum (Fifth Disease) Cause: Parvovirus B19 Presentation: maculopapular erythematous rash usually in cheeks (slapped cheeks) which will then progress to erythematous reticular "lacy" rash to rest of body
53
What is viral exanthem 6, cause, presentation?
Roseola infantum (exanthem subitum) Cause: human herpes virus 6 Presentation: high fever, followed by exanthem when child is just about to recover
54
Hallmark morphology of varicella zoster virus
Simultaneous occurence of all stages of disease including vesicle, pustule and crusts
55
Pityriasis rosea presentation
Primary herald rash - pink salmon patch with scale and clear centre Secondary exanthem - generalized pink macules and patches with scale in Christmas tree distribution
56
RNA enterovirus coxsackie A causes which condition, morphology?
Hand, foot and mouth disease Painful vesicles around mouth and on extremities, which can blister Whole infection lasts 7-10 days
57
Presentation of dermatofibroma
Commonly on arms and legs Firm hard nodules which can vary in colour Dimple forms if skin surrounding is squeezed
58
Indications for wound care
2nd or 3rd intention wound healing Chronic non-healing wounds
59
Androgenetic alopecia presentation
Men - M shaped pattern hair thinning (on temples and brow) | Women - thinning in central and frontal scalp with hyperandrogenism signs (PCOS, menstrual abnormalities, hirsutism)
60
Androgenetic alopecia management
Men 1st line - 5% Minoxidil +/- Finasteride 2nd line - surgery, hair piece Women 1st line - Minoxidil 2% 2nd line - Spironolactone or cyproterone acetate if no improvement after 1 year of minoxidil 3rd line - hair transplant Treat hyperandrogenism with hormone replacement or oral contraceptives
61
Alopecia areata pathophysiology
Autoimmune reaction
62
Alopecia areata treatment
Mild to moderate <50% scalp involved 1st line - Intralesional corticosteroid injection +/- Minoxidil +/- topical steroids 2nd line - PUVA or corticosteroid Last line - hair transplant Severe 1st line - topical immunotherapy (PUVA, topical or systemic corticosteroid) Minoxidil topical +/0 high potency topical steroids Hair transplant
63
Tinea capitis diagnosis
Wood's lamp fluoresces or slide/culture
64
Tinea capitis treatment
Oral antifungal
65
Circatricial alopecia pathophysiology
Repetitive trauma/disorder causes irreversible destruction of hair follicle
66
Circatricial alopecia treatment
Intra-lesional steroids or antimalarial agents
67
How long does it take to replace a fingernail or toenail
Finger - 6 months | Toe - 1-1.5 years
68
Potential causes of longitudinal melanonychia
1. Normal variant in black persons 2. Subungual melanoma - presents with sudden change in appearance, involves single nail, width >3 mm, extends onto cuticle or nail fold
69
Onychomycosis cause
Fungal or yeast infection of nail
70
Onychomycosis diagnosis
KOH testing of scraping or nail culture or biopsy
71
Onychomycosis treatment
Systemic oral antifungal x 1 year (Terbinafine, itraconazole, fluconazole)
72
Paronychia cause
Bacterial infection (commonly staph aureus, strep pyogenies or pseudomonas if green)
73
Paronychia management
Cephalexin Ketoconazole if fungal infection suspected Topical neomycin for pseudomonal superinfection
74
Subungual hematoma management
drilling hole through nail with hot metal wire or co2 laser to relieve pressure

3rd year - Family Medicine (9 decks)

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