4. MSK/Rheumatology

4. MSK/Rheumatology
Knowledge Premium

4. MSK/Rheumatology

By Andrew Harris
On

Read week

4

Current Week

Hi Everyone!

How are your muscles and joints feeling today? Take a moment now to stand up and roll your ankles, roll your wrists, roll your shoulders and stretch your neck. If you haven’t seen them already, check out Bob and Brad on Youtube. They are a physiotherapy duo who provide excellent information about stretching and back health. I particularly find this video excellent – https://bit.ly/2GM0lnX. Your body is just as important as your mind – take the time throughout the day to nourish it with stretching and movement.

This article is about musculoskeletal medicine and rheumatology.

Most people with obvious fractures bypass the GP practice and head straight for the emergency department. It is generally the GP’s responsibility to provide repeat x-ray forms at 4-6 weeks post-fracture and to coordinate with the fracture clinic for ongoing care. There are times when, especially in particularly stoic patients, that the GP may have to investigate and/or manage finger fractures (“punched a wall on the weekend, Doc”), rib fractures (“slipped in the bath!”) or stress fractures (“I want to run again, please!”). Either way, it’s important to have a good understanding of fracture management and who to call for further advice.

Rheumatological issues are often a mystery. Their presentations come with a cluster of symptoms such as joint aches, rash, fatigue and/or sicca symptoms. It’s important to know the investigations for these conditions – particularly ESR, rheumatoid factor, anti-CCP and ANA which are a good starting point if you are ever unsure. Borderline elevated ANA can be a confounding finding on investigation, and shouldn’t distract. Therapeutic guidelines are an excellent resource for understanding rheumatology.

One of my more complicated patients over the last couple of years is a female patient with Sjogren’s disease. She has typical sicca symptoms with chronic dry eyes and dry mouth. She has developed renal tubular acidosis and subsequent hypokalaemia. The treatment for the hypokaelamia, potassium citrate, causes the production of renal stones and consequently biliary colic. She has been treated also with prednisolone which has given her a cushingoid appearance. The last I have heard, the rheumatologists have given her a diagnosis of systemic lupus erythematosis. It goes to show that even to rheumatologists, these conditions are not simple.

Be kind to yourself, and give your body a good stretch regularly throughout the day!

Dr Andrew Harris

Director of Amadeus Education.

Did you know?

According to BEACH data, 14.1% of all encounters in General Practice were specifically related to the musculoskeletal system. Consider this as you are preparing for your exams. (Source: General practice activity in Australia: 2015-16. https://bit.ly/2c4d8Em)

Presenting complaints:

These are the common presenting complaints that should be covered for this topic:

Important conditions:

These are the common conditions that should be reviewed for this topic:

Topics

Important reading

Arthritis – including osteoarthritis, rheumatoid arthritis, viral arthritis.

Fracture management – including stress fractures, clavicle, scaphoid, NOF

Gout

SLE

  • Systemic lupus erythematosus: When to consider and management options. AFP, October 2013. (https://bit.ly/2Sgt99v)

Scleroderma

Polymyalgia rheumatica

Scoliosis

Fibromyalgia

  • Fibromyalgia: Should we be testing and treating for vitamin D deficiency? AFP, September 2011. (https://bit.ly/2E14a4C)

Injuries – including knee, shoulder, spine, hands

Seronegative arthropathies – including ankylosing spondylitis, psoriatic arthritis, reactive arthritis, Reiter’s syndrome, juvenile idiopathic arthritis

Bone tumours

Tendon disorders

Paediatric orthopaedics

Osteomyelitis

Sjogren’s

Medication doses:

These are the medications and doses that should be learned for the exam:

Condition

Medication

Pain

  • Paracetamol 1g orally QID PRN
  • Ibuprofen 400mg orally TDS PRN
  • Oxycodone 5mg orally PRN

Polymyalgia rheumatica

  • Prednisolone 15mg orally daily for 4 weeks, then reduce by 2.5mg every 4 weeks to 10mg daily, then reduced by 1mg every 4-8 weeks to stop.

Gout

  • Acute (options):
    • Ibuprofen 400mg orally TDS for 3-5 days
    • Prednisolone 25mg orally daily for 3-5 days
    • Colchicine 1mg initially, then 500mcg 1 hour later
  • Prevention:
    • Allopurinol 50mg orally daily for 4 weeks then increase to achieve target of <0.36 (or <0.3 if tophi present)

Rheumatoid arthritis

  • Methotrexate 5-10mg (up to 20mg) orally or subcutaneous weekly.
  • Folate 5mg weekly (not on day of methotrexate)

Checks:

Here are the list of recommended Checks that would be useful in your study for GP exams (accessed via subscription from http://gplearning.racgp.org.au):

  • Sports medicine, September 2016
  • Bones/Joints, August 2015
  • Sports medicine, October 2013

Focus on clinical skills:

Here is a brief focus on some OSCE preparation materials related to this topic:

Focus on medicolegal:

Here is a brief focus on the medicolegal issues covered in Australian Family Physician:

Copyright © 2021 Andrew Harris

Leave a Reply