1. Grandma’s aching knees and snapping fingers
LeeChuy, Katherine
Lee, Sidney Abert
Lerma, Daniel Joseph
Legaspi, Roberto Jose
Li, Henry Winston
Li, Kingbherly
Lichauco, Rafael
Lim, Imee Loren
Lim, Jason Morven
Lim, John Harold
Lim, Mary
Lim, Phoebe Ruth
Lim, Syndel Raina
Lipana, Kirk Andrew
Liu, Johanna
Llamas, Camilla Alay

2. Pain and stiffness of thumb and middle finger of R hand
79 y/o F
Chief Complaint
Chronic knee pain
Pain and stiffness of thumb and middle finger of R hand

3. History of Present Illness
Years
Painful knees, more pronounced on walking
Recently
Limited kitchen and cooking chores
Pain and stiffness of thumb and middle finger of R hand
Prescribed NSAID, temporary relief

4. Past Medical History Hypertension Osteoporosis
Controlled on daily amlodipine
Hypertension
2 yearly infusion of zoledronic acid
Osteoporosis
Zoledronic acid belongs to a class of drugs known as bisphosphonates. It works by reducing the amount of calcium released from your bones into your blood.

5. Physical Examination Normal vital signs; BMI 28
Musculoskeletal Exam
Crepitus on both knees without effusion
1st and 3rd fingers of R hand would snap on flexion and required assistance due to pain on attempted extension

6. Physical Examination Stooped posture Bilateral genu varum deformity
Non-tender bony nodes on PIP and DIP

7. Salient Features 79 y/o female
Years of painful knees, pronounced when walking
Crepitus on both knees without effusion
Bilateral genu varum
Pain and stiffness of thumb and middle finger of R hand
would snap on flexion and require assistance on extension
Non-tender bony nodules on PIP and DIP
Diagnosed with osteoporosis, received 2 yearly infusion of zoledronic acid
Stooped posture
Hypertension controlled on daily amlodipine

8. Musculoskeletal signs and symptoms in the Patient
Painful knees, more pronounced on walking; Non-tender bony nodules on PIP and DIP; Crepitus on both knees without effusion; bilateral genu varum
Pain and stiffness of thumb and middle finger of R hand; would snap on flexion and require assistance on extension
Stooped posture; previous diagnosis of osteoporosis with prescribed medication

9. Musculoskeletal conditions in the Patient
Osteoarthritis
Painful knees, more pronounced on walking; Non-tender bony nodules on PIP and DIP; Crepitus on both knees without effusion; bilateral genu varum
“Trigger Finger/ Digit”
Pain and stiffness of thumb and middle finger of R hand; would snap on flexion and require assistance on extension
Osteoporosis
Stooped posture

10. Osteoarthritis Patient Osteoarthritis 79 years old female
leading cause of disability in the elderly
BMI = 28
Obesity
Painful knees; Crepitus on both knees without effusion
affected joints include the cervical and lumbosacral spine, hip, knee.
Painful knee on walking
Joint pain from OA is activity-related
Non-tender bony nodules on PIP and DIP
Presence of Heberden’s nodes in DIP and Bouchard’s nodes in PIP

11. Management for OA Non-pharmacologic Management
(1) avoiding activities that overload the joint, as evidenced by their causing pain
(2) improving the strength and conditioning of muscles that bridge the joint, so as to optimize their function
(3) unloading the joint, either by redistributing load within the joint with a brace or a splint or by unloading the joint during weight bearing with a cane or a crutch.

12. Management for OA Exercise lessens pain and improves physical function
consist of aerobic and/or resistance training (strengthens muscles across the joints)

13. Management for OA Correction of Malalignment (Genu Varus/Valgus)
Leg brace
Surgery

14. Management for OA

15. “Trigger-finger/digit”
Patient
Trigger-finger
Pain and stiffness of thumb and middle finger of R hand
would snap on flexion and require assistance on extension
common disorder of later adulthood characterized by catching, snapping or locking of the involved finger flexor tendon, associated with dysfunction and pain

16. Management for “Trigger-finger/digit”
Local steroid injection
Cortisone, prednisolone, dexamethasone, and triamcinolone.
A mixture of steroid, 1% lidocaine, and 0.5% bupivacaine is used, in a ratio of 2:1:1, respectively
After injection, the patient is encouraged to move the digit.
A follow-up appointment is made for 3-4 weeks after the treatment

17. Management for “Trigger-finger/digit”
Splinting
For those patients who decline injection
MCP joint is splinted in approximately 15° of flexion.

18. Osteoporosis Patient Osteoporosis 79 y/o Advanced age Female
Female sex
Estrogen deficiency
Low calcium intake
Alcohol and cigarette consumption

19. Management for Osteoporosis
To maintain bone health:
Make sure there is enough calcium in your diet
Get adequate vitamin D intake, which is important for calcium absorption and to maintain muscle strength
Get regular exercise, especially weight-bearing exercise.
(1000 mg per day of calcium for adults under the age of 50 and 1200 mg per day for those ages 50 and older, which are the current recommended guidelines from the National Osteoporosis Foundation).
( IU per day for adults younger than age 50, 800 to 1000 IU per day for those age 50 and older, which are the current recommended guidelines from the National Osteoporosis Foundation). Doses may need to be adjusted according to blood levels of vitamin D.

20. Management for Osteoporosis
Bisphophonates
alendronate, residronate, etidronate
Patient was given zoledronic acid
Calcitonin
Calcitonin works by directly inhibiting osteoclast activity via the calcitonin receptor.
Calcitonin directly induces inhibition of osteoclastic bone resorption by affecting actin cytoskeleton which is needed for the osteoclastic activity.

21. Management for Osteoporosis
Selective Estrogen Receptor Modulators (SERMs)
are a class of medications that act on the estrogen receptors throughout the body in a selective manner
Raloxifene (60 mg/d) - act on the bone by slowing bone resorption by the osteoclasts

22. What is the mechanism of action of NSAIDs?

23. NSAIDs
Most NSAIDs act as nonselective inhibitors of the enzyme cyclooxygenase(COX), inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes.
COX catalyzes the formation of prostaglandins and thromboxane from arachidonic acid
Prostaglandins act as messenger molecules in the process of inflammation.

24. MOA of NSAIDS

25. Selective and Non-Selective NSAID
Stomach
Kidney
Platelets
Endotheliumcc
Macrophages
Leukocytes
Fibroblasts
Endothelium

26. Bisphosphonate preparations
Philippine Brands
Primary indication
Dose
Route
Alendronate
Fosamax
Osteoporosis
10 mg/day; 70mg/week
Oral
Risedronate
Actonel
5 mg/day; 35 mg/week
Ibandronate
Bondronat, Bonviva
2.5 mg/day; 150mg/month
Pamidronate
Aredia
Bone Metastasis
90mg/3 weeks IV
Zoledronate
Aclasta, Zometa
4mg/3 weeks
Incadronate
Bisphonal
Bone metastasis
10mg/2weeks
Clodronate
Bonefos
Pagets / Bone metastasis
md/day
300mg/day

27. Thank You!