• key findings
• investigations
• treatment
• differential diagnosis
• contraindications/important cautions
• ICU management (when relevant)
• OPD prescription examples (adult, typical pattern)

30 Important Bone and Muscle Diseases (15 Bone + 15 Muscle)

Educational reference format only. Real prescriptions must be individualized.

1) Osteoporosis

• Findings: Fragility fractures (hip, vertebra, wrist), height loss, kyphosis.
• Investigations: DEXA T-score ≤ -2.5; Ca, PO4, ALP, Vit D, PTH; FRAX.
• Treatment: Calcium + vitamin D, bisphosphonates (alendronate/zoledronic acid), denosumab/teriparatide in selected cases.
• DDx: Osteomalacia, metastatic bone disease, multiple myeloma.
• Contraindications/cautions: Oral bisphosphonates in severe esophageal disease, low eGFR (drug-specific).
• ICU: Usually fracture-related complications (immobility, PE, post-op care).
• OPD Rx (example): Tab Alendronate 70 mg weekly + Tab Calcium carbonate 500 mg OD + Tab Cholecalciferol.

2) Osteomalacia (adult) / Rickets (child)

• Findings: Bone pain, proximal weakness, waddling gait; rickets: bow legs, rachitic rosary.
• Investigations: Low Vit D, low/normal Ca, low PO4, high ALP, PTH rise; X-ray Looser zones.
• Treatment: Vitamin D replacement + calcium; treat cause (CKD, malabsorption).
• DDx: Osteoporosis, hyperparathyroidism, renal osteodystrophy.
• Contraindications: Avoid excessive vitamin D/calcium (hypercalcemia risk).
• ICU: Severe hypocalcemia, seizures, arrhythmias.
• OPD Rx: Cholecalciferol (e.g., 60,000 IU weekly x 6–8 weeks), calcium supplementation.

3) Paget Disease of Bone

• Findings: Bone pain, deformity, hearing loss, increased skull size.
• Investigations: Isolated high ALP; X-ray: mixed lytic/sclerotic lesions; bone scan.
• Treatment: Zoledronic acid (first-line), analgesia.
• DDx: Bone metastasis, osteomalacia, hyperparathyroidism.
• Contraindications: Bisphosphonate caution in renal impairment/hypocalcemia.
• ICU: Rare; high-output failure or severe complications.
• OPD Rx: Zoledronic acid IV (specialist setting), calcium/vit D support.

4) Osteomyelitis

• Findings: Local pain, fever, swelling, sinus (chronic).
• Investigations: CBC, ESR/CRP, blood culture, MRI, bone biopsy (definitive).
• Treatment: IV then targeted antibiotics; surgical debridement when needed.
• DDx: Septic arthritis, bone tumor, cellulitis.
• Contraindications: Avoid blind prolonged antibiotics without culture.
• ICU: Sepsis/shock management.
• OPD Rx: Culture-guided oral step-down (e.g., linezolid/fluoroquinolone depending organism and site protocol).

5) Septic Arthritis

• Findings: Hot swollen painful joint, fever, inability to bear weight.
• Investigations: Urgent joint aspiration (WBC, Gram, culture, crystals), blood cultures, CRP.
• Treatment: Emergency drainage + IV antibiotics.
• DDx: Gout, pseudogout, reactive arthritis.
• Contraindications: Do not delay aspiration/antibiotics in suspected sepsis.
• ICU: Sepsis protocol if unstable.
• OPD Rx: Follow-up culture-tailored oral therapy after stabilization.

6) Avascular Necrosis (Femoral head common)

• Findings: Groin pain, limited ROM, limp.
• Investigations: MRI early best; X-ray late collapse.
• Treatment: Offloading early, bisphosphonate (selected), core decompression; arthroplasty late.
• DDx: OA hip, stress fracture, referred spine pain.
• Contraindications: Continued steroids/alcohol worsen progression.
• ICU: Post-op complications only.
• OPD Rx: Analgesia + protected weight-bearing; ortho referral.

7) Osteoarthritis

• Findings: Mechanical pain, brief morning stiffness, crepitus.
• Investigations: Clinical + X-ray joint space narrowing/osteophytes.
• Treatment: Weight reduction, exercise, topical NSAID, oral NSAID PRN, intra-articular steroid selected, joint replacement advanced.
• DDx: RA, gout, septic arthritis.
• Contraindications: Long-term NSAID risks (GI/renal/CV).
• ICU: Rare (NSAID bleed/renal failure complications).
• OPD Rx: Topical diclofenac + paracetamol ± short NSAID + physiotherapy.

8) Rheumatoid Arthritis

• Findings: Symmetrical small-joint inflammatory arthritis, morning stiffness >1 hr.
• Investigations: RF, anti-CCP, ESR/CRP, CBC/LFT/RFT baseline.
• Treatment: Early DMARDs (methotrexate ± hydroxychloroquine/sulfasalazine), steroids bridge, biologics if refractory.
• DDx: SLE, viral arthritis, psoriatic arthritis.
• Contraindications: Methotrexate in pregnancy/liver disease.
• ICU: Severe infection from immunosuppression, vasculitic complications.
• OPD Rx: Methotrexate weekly + folic acid + NSAID PRN (after screening).

9) Gout

• Findings: Acute monoarthritis (1st MTP classic), tophi in chronic disease.
• Investigations: Synovial urate crystals (needle-shaped negative birefringent), serum urate.
• Treatment: Acute: NSAID/colchicine/steroid; chronic ULT (allopurinol/febuxostat) after flare control.
• DDx: Septic arthritis, pseudogout.
• Contraindications: Start urate-lowering without prophylaxis can trigger flare.
• ICU: Polyarticular severe pain with comorbidity, sepsis exclusion.
• OPD Rx: Colchicine low dose acute; allopurinol titrated for recurrent disease.

10) Pseudogout (CPPD)

• Findings: Acute arthritis (often knee), elderly.
• Investigations: Rhomboid weakly positive birefringent crystals; chondrocalcinosis on X-ray.
• Treatment: NSAID, colchicine, intra-articular steroid.
• DDx: Gout, septic arthritis, OA flare.
• Contraindications: NSAID caution in elderly CKD/HF.
• ICU: Rare.
• OPD Rx: Colchicine prophylaxis in recurrent CPPD.

11) Ewing Sarcoma

• Findings: Bone pain/swelling, fever, diaphyseal lesion in youth.
• Investigations: X-ray onion-skin periosteal reaction, MRI, biopsy, staging CT/PET.
• Treatment: Multi-agent chemotherapy + surgery/radiotherapy.
• DDx: Osteomyelitis, osteosarcoma.
• Contraindications: Delay in biopsy/staging before definitive treatment.
• ICU: Neutropenic sepsis, chemo complications.
• OPD Rx: Oncology protocol based.

12) Osteosarcoma

• Findings: Progressive pain/swelling near knee, adolescent growth phase.
• Investigations: X-ray sunburst/Codman triangle, MRI, biopsy.
• Treatment: Neoadjuvant chemo + limb-salvage surgery/amputation.
• DDx: Ewing, osteomyelitis.
• Contraindications: Unplanned surgery before oncologic planning.
• ICU: Post-op/chemo complications.
• OPD Rx: Oncology protocol.

13) Giant Cell Tumor of Bone

• Findings: Epiphyseal pain/swelling, pathologic fracture.
• Investigations: X-ray lytic “soap-bubble” lesion, MRI, biopsy.
• Treatment: Curettage + local adjuvant; denosumab selected.
• DDx: Aneurysmal bone cyst, chondroblastoma.
• Contraindications: Inadequate excision risks recurrence.
• ICU: Rare.
• OPD Rx: Pain control + ortho-oncology follow-up.

14) Multiple Myeloma (bone disease dominant presentation)

• Findings: Bone pain, anemia, renal dysfunction, fractures.
• Investigations: SPEP/UPEP, free light chains, marrow biopsy, skeletal imaging.
• Treatment: Regimen-based therapy + bisphosphonate + supportive care.
• DDx: Metastatic carcinoma, MGUS.
• Contraindications: NSAIDs worsen renal injury.
• ICU: AKI, hypercalcemia crisis, sepsis.
• OPD Rx: Hematology-guided protocol + bone protection.

15) Vertebral Compression Fracture

• Findings: Sudden back pain after minor trauma, kyphosis.
• Investigations: Spine X-ray/MRI if neuro deficit/red flags.
• Treatment: Analgesia, brace, osteoporosis treatment, vertebroplasty selected.
• DDx: Metastasis, infection, disc disease.
• Contraindications: Missed cord compression red flags.
• ICU: Neuro compromise, severe pain with respiratory compromise.
• OPD Rx: Analgesia + anti-osteoporotic therapy.

16) Polymyositis

• Findings: Symmetrical proximal weakness, elevated CK.
• Investigations: CK, aldolase, EMG, myositis panel, MRI, muscle biopsy.
• Treatment: High-dose steroids then steroid-sparing agents (azathioprine, methotrexate).
• DDx: Dermatomyositis, statin myopathy, hypothyroid myopathy.
• Contraindications: Missed malignancy screen, infection before immunosuppression.
• ICU: Respiratory muscle weakness, aspiration, severe dysphagia.
• OPD Rx: Prednisolone + calcium/vit D + steroid-sparing agent as indicated.

17) Dermatomyositis

• Findings: Proximal weakness + heliotrope rash/Gottron papules.
• Investigations: As above + malignancy screening.
• Treatment: Steroids, immunosuppressants, IVIG in refractory disease.
• DDx: SLE, drug rash + myopathy.
• Contraindications: Delay in cancer workup.
• ICU: Interstitial lung disease flare, respiratory failure.
• OPD Rx: Immunosuppressive regimen + photoprotection + rehab.

18) Inclusion Body Myositis

• Findings: Distal + quadriceps weakness, older adults, slow progression.
• Investigations: CK mild-moderate rise, biopsy with rimmed vacuoles.
• Treatment: Mostly supportive; poor steroid response.
• DDx: Polymyositis, motor neuron disease.
• Contraindications: Prolonged ineffective immunosuppression.
• ICU: Dysphagia aspiration complications.
• OPD Rx: Physiotherapy, fall prevention, swallow care.

19) Duchenne Muscular Dystrophy

• Findings: Childhood proximal weakness, Gowers sign, calf pseudohypertrophy.
• Investigations: Very high CK, genetic dystrophin mutation.
• Treatment: Steroids, cardiopulmonary support, physiotherapy, mutation-specific therapy.
• DDx: Becker dystrophy, spinal muscular atrophy.
• Contraindications: Missed cardiomyopathy surveillance.
• ICU: Respiratory failure, cardiomyopathy decompensation.
• OPD Rx: Deflazacort/prednisone protocol + ACE inhibitor when indicated.

20) Becker Muscular Dystrophy

• Findings: Similar to Duchenne but later onset/milder.
• Investigations: Genetic testing, CK raised.
• Treatment: Rehab, cardiac surveillance/treatment.
• DDx: Limb-girdle dystrophy.
• Contraindications: Ignoring cardiac involvement.
• ICU: Advanced cardiopulmonary failure.
• OPD Rx: Symptomatic + cardioprotective regimen.

21) Limb-Girdle Muscular Dystrophy

• Findings: Proximal limb weakness, variable genetics.
• Investigations: CK, genetic panel, muscle biopsy selected.
• Treatment: Supportive rehab, cardiopulmonary monitoring.
• DDx: Inflammatory myopathy, endocrine myopathy.
• Contraindications: Overlooking respiratory decline.
• ICU: Ventilatory failure in advanced stages.
• OPD Rx: Physiotherapy + assistive support.

22) Myasthenia Gravis

• Findings: Fatigable weakness, ptosis/diplopia, bulbar symptoms.
• Investigations: AChR/MuSK antibodies, repetitive stimulation, chest imaging for thymoma.
• Treatment: Pyridostigmine, steroids/immunosuppressants, thymectomy selected.
• DDx: Lambert-Eaton, botulism, motor neuron disease.
• Contraindications: Drugs worsening MG (aminoglycosides, magnesium, some beta blockers).
• ICU: Myasthenic crisis: airway, ventilatory support, IVIG/plasmapheresis.
• OPD Rx: Pyridostigmine scheduled + immunotherapy plan.

23) Lambert-Eaton Myasthenic Syndrome

• Findings: Proximal weakness improves with use, autonomic symptoms.
• Investigations: VGCC antibodies, electrophysiology, malignancy screen (SCLC).
• Treatment: Treat tumor, amifampridine, immunotherapy.
• DDx: MG, peripheral neuropathy.
• Contraindications: Missed underlying malignancy.
• ICU: Respiratory involvement rare but possible.
• OPD Rx: Specialist-directed symptomatic therapy.

24) Rhabdomyolysis

• Findings: Muscle pain/weakness, dark urine.
• Investigations: Very high CK, urine heme positive with few RBC, K+, creatinine.
• Treatment: Aggressive IV fluids, treat cause, manage hyperkalemia.
• DDx: Myositis, trauma-related crush syndrome.
• Contraindications: Delayed fluid resuscitation.
• ICU: AKI, hyperkalemia, arrhythmia.
• OPD Rx: Mild cases follow-up hydration and serial CK/renal labs.

25) Pyomyositis

• Findings: Fever + focal muscle pain/swelling; abscess phase later.
• Investigations: CBC/CRP, ultrasound/MRI, aspirate culture.
• Treatment: Anti-staphylococcal antibiotics ± drainage.
• DDx: DVT, cellulitis, septic arthritis.
• Contraindications: Missed abscess needing drainage.
• ICU: Sepsis management if severe.
• OPD Rx: Culture-tailored oral completion after IV phase.

26) Compartment Syndrome

• Findings: Severe pain out of proportion, pain on passive stretch, tense compartment.
• Investigations: Clinical; compartment pressure if uncertain.
• Treatment: Emergency fasciotomy.
• DDx: DVT, nerve injury, cellulitis.
• Contraindications: Delayed surgery causes necrosis.
• ICU: Post-op monitoring, rhabdomyolysis/AKI support.
• OPD Rx: Not an OPD-managed acute condition.

27) Fibromyalgia

• Findings: Widespread pain, fatigue, sleep/cognitive symptoms.
• Investigations: Clinical diagnosis; limited labs to exclude mimics.
• Treatment: Exercise, CBT, sleep optimization, duloxetine/pregabalin/amitriptyline.
• DDx: Hypothyroidism, inflammatory rheumatic disease, depression.
• Contraindications: Chronic opioid therapy generally avoided.
• ICU: Not typical.
• OPD Rx: Duloxetine or pregabalin + graded activity plan.

28) Statin-Associated Myopathy

• Findings: Myalgia ± CK rise after statin initiation/increase.
• Investigations: CK, TSH, Vit D, renal/liver profile.
• Treatment: Hold/change statin, lower dose/intermittent strategy, non-statin therapy when needed.
• DDx: Polymyositis, hypothyroid myopathy.
• Contraindications: Rechallenge at high dose in severe previous reaction.
• ICU: If rhabdomyolysis develops.
• OPD Rx: Switch to low-dose rosuvastatin/alternate regimen + monitor CK as indicated.

29) Hypothyroid Myopathy

• Findings: Proximal weakness, cramps, delayed reflex relaxation.
• Investigations: High TSH, low free T4, CK elevated.
• Treatment: Levothyroxine replacement.
• DDx: Polymyositis, drug myopathy.
• Contraindications: Rapid over-replacement in ischemic heart disease.
• ICU: Myxedema severe cases.
• OPD Rx: Levothyroxine titrated by TSH every 6–8 weeks.

30) Steroid-Induced Myopathy

• Findings: Gradual painless proximal weakness with chronic glucocorticoid use.
• Investigations: Usually normal/near-normal CK; clinical diagnosis.
• Treatment: Reduce steroid dose if possible, switch steroid-sparing plan, resistance training.
• DDx: Active inflammatory myositis, ICU-acquired weakness.
• Contraindications: Abrupt steroid stop (adrenal crisis risk).
• ICU: Ventilated patients may worsen with critical illness myopathy.
• OPD Rx: Taper plan + physiotherapy + alternate immunomodulator if needed.

Quick ICU Red Flags (across these diseases)

• Respiratory muscle weakness (MG crisis, severe myositis, advanced dystrophy)
• Sepsis/shock (osteomyelitis, septic arthritis, pyomyositis)
• AKI/hyperkalemia (rhabdomyolysis)
• Hypercalcemic crisis/pathologic fractures (myeloma/metastatic bone disease)
• Post-op instability (major orthopedic oncology/trauma surgery)

OPD Safety Checklist

• Baseline CBC/LFT/RFT before DMARDs/immunosuppressants
• Bone protection for long-term steroids
• Renal/GI/CV risk before NSAIDs
• Vaccination + infection screening in immunosuppressed patients
• Fall-risk and fracture prevention in elderly bone disease

1. One-page rapid revision table, or
2. Detailed DOCX handbook with separate sections for each disease and adult/pediatric dosing notes.