- smoking cessation - Vitamin D 1000 IU/d (MORE IS NOT BETTER) - Calcium 1200mg/day from all sources - Exercise - Fall prevention

MSK - Final Flashcards by Brittany Morrison

Two main factors that predispose elderly ppl to foot problems

PAD and neuropathy

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What does Romberg test for?

Proprioception

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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)

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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

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Loss of the plantar metatarsal fat pad can be a sign of what?

PVD

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WHO definition of OP

T score 50 years

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WHO definition of osteopenia

T score -1.0 to -2.5

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Self reported height loss of > ___ cm is associated with OP

3cm

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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

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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)

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BMD screening is recommended for MEN at what ages and with what risk factors?

> 70 years or < 70 years with RF

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T/F FRAX can be used with or without BMD results

True

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T/F
Duration and dose of corticosteroid use and smoking use are included in FRAX score

False

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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

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Duration of oral biphosphonates
Duration of IV biphosphonates

Oral - up to 5 years
IV - up to 3 years

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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

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T/F Older adults with inflammatory arthritis are more likely to die from CV condition than the MSK condition

True

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When do PMR patients experience relief after starting oral steroid therapy?

2-4 weeks

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If prednisone doses exceed 7.5mg/d for >/= 3 months with PMR what therapy is indicated?

OP prevention with biphosphonates

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Two complications of steroid therapy for GCA

OP and pneumocystis pneumonia

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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

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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

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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

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Non-pharm OP Mgmt

smoking cessation
Vitamin D 1000 IU/d (MORE IS NOT BETTER)
Calcium 1200mg/day from all sources
Exercise
Fall prevention

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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

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

What nerve root is being tested with the following: Great toe flexion

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

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

What does this indicate: X-ray - loss of articular space, multiple erosions, juxta articular osteopenia and ulnar deviation

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

MSK - Final Flashcards

(103 cards)