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CS Handbook MSK

Here are the key steps to examine the knee: 1. Observe the patient walk and inspect the knee while standing and supine 2. Palpate for temperature, tenderness, effusion 3. Assess active and passive range of motion, noting crepitus 4. Perform special tests for ligaments (drawer, Lachman's) and meniscus (McMurray's) 5. Document findings and formulate differential diagnoses Be thorough but efficient in your approach. Ask questions as needed and obtain consent.

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0% found this document useful (0 votes)
53 views43 pages

CS Handbook MSK

Here are the key steps to examine the knee: 1. Observe the patient walk and inspect the knee while standing and supine 2. Palpate for temperature, tenderness, effusion 3. Assess active and passive range of motion, noting crepitus 4. Perform special tests for ligaments (drawer, Lachman's) and meniscus (McMurray's) 5. Document findings and formulate differential diagnoses Be thorough but efficient in your approach. Ask questions as needed and obtain consent.

Uploaded by

Naomi Halm
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 43

Clinical Skills II

Instructional Book

Musculoskeletal System

Clinical Skills Center


Faculty of Medicine
Pelita Harapan University
Karawaci – Tangerang
Semester III
2017

1
The history taking section was adapted from INTRODUCTION TO CLINICAL
MEDICINE 4, MELBOURNE MEDICAL SCHOOL, THE UNIVERSITY OF
MELBOURNE; with permission from University of Melbourne

2
Tutorial 1

Knee & Hip


During the next five weeks, the focus will be on aspects of the medical interview and
physical examination that relate to the musculoskeletal system.

Knee pain
The knee is the hinge joint between the femur and the tibia. It is secured internally by two
cruciate ligaments and externally by adjacent collateral ligaments, tendons and muscles. It is
the most complex articulation in the body and has the greatest susceptibility to injury.

Knee pain is a very common problem. There are many causes, ranging from injury to the
ligaments or menisci to loss of cartilage from osteoarthritis or inflammation due to conditions
such as rheumatoid or psoriatic arthritis. Inflammation of the surrounding tendons and bursae
can also cause knee pain. The knee is also a site of referred pain from the hip or back.

When interviewing a patient who presents with knee pain, one of the most important cardinal
features to elicit is the exact site of the pain. Anterior knee pain suggests osteoarthritis or a
problem with the patella, whereas lateral or medial pain may be due to ligament sprain or a
meniscal tear. Posterior knee pain can be due to a range of conditions such as hamstring
strain, bursitis, Baker’s cyst or deep vein thrombosis. In the case of arthritic conditions, the
knee may be only one of a number of affected joints, so it is important to ask about other sites
of joint pain.

After establishing the site of the knee pain, find out about the other cardinal features. Ask
about the quality of the pain and its severity. It is important to determine the time course of
the pain. Acute onset of knee pain occurs with trauma or other problems such as haemorrhage
into the joint. A slow onset of pain is more consistent with arthritis, bursitis or tendonitis.

Find out about any precipitating factors, such as trauma. In the case of an injury, establish the
exact mechanism by which it occurred. Ask about the position of the knee at the time the
injury was sustained and also about the direction of the force of the injury. Find out about
exacerbating factors such as certain movements and relieving factors such as rest or use of
analgesics.

Common associated features to ask about are swelling or abnormal noises such as clicking or,
in the case of an acute injury, a popping sound. Establish if there is any loss of function
associated with the pain such as weakness, limping and difficulty walking. In the case of
chronic knee pain, ask how it is impacting on the patient’s life. There are other associated
features that are important to ask about in the case of knee pain but you will learn more about
these later in the course.

3
Case Study 4.07

Kirstie Jamieson, a 33-year old engineer, has


injured her right knee playing netball. She is being
interviewed by Jane Lee, a second year medical
student.

Watch the interview between Ms Jamieson and Jane


Lee, and write down the cardinal features of Ms
Jamieson’s presenting problem. Draw- ing upon
your knowledge of the anatomy of the knee joint,
discuss the mechanism of her injury and identify the
most likely structure to have been injured.

Practice with role-plays


In pairs, use role-plays to practise interviewing a patient about knee pain. Give each
other feedback using the Medical Interview Assessment forms.

4
Medical Interview Assessment Form
Opening segment of interview Yes No

Greets the patient


Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement

Exploration of the presenting problem Yes No N/A

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features

Communication Skills Done Well Adequate Needs


improvement
Demonstrates active listening skills
Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions

Interview Management Done well Adequate Needs


Improvement
Is systematic with questioning
Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

5
Knee Examination

You will learn how to interview a patient who presents with knee pain and to perform an
examination of the knee. A sound knowledge of the anatomy of the knee joint is important
for both of these skills.

Knee complaints are very common presentations to A&E, general practice as well as
orthopaedic clinics. Some hospitals even have special “knee” clinics. Common presenting
complaints are pain in the knee, the knee locking or giving way. Common conditions that
cause these symptoms include arthritis, ligament and/or cartilage injuries.

The knee examination, along with all other joint examinations, is commonly tested on in
OSCE. You should ensure you are able to perform this confidently. The examination of all
joints follows the general pattern of “look, feel, move” as well as occasionally special tests, in
which this station has many.

Subject steps

1. Start by washing your hands and introduce yourself to the patient. Clarify the patient’s
identity and explain what you would like to examine, gain their consent. Ensure both
knees are appropriately exposed, in this case the patient will probably be wearing shorts.

2. To begin, ask the patient to walk for you. Observe any limp or obvious deformities such
as scars or muscle wasting. Check if the patient has a varus (bow-legged) or valgus
(knock-knees) deformity. Also observe from behind to see if there are any obvious
popliteal swellings such as a Baker’s cyst.

Ask the patient to walk (from http://www.osceskills.com)

3. Next ask the patient to lie on the bed to allow a further general inspection. Look for
symmetry, redness, muscle wasting, scars, rashes, or fixed flexion deformities.

General observation (from http://www.osceskills.com)

6
4. Now palpate the knee joint, start by assessing the temperature using the back of your
hands and comparing with the surrounding areas.

Assess joint temperature (from http://www.osceskills.com)

5. Palpate the border of the patella for any tenderness, behind the knee for any swellings,
along all of the joint lines for tenderness and at the point of insertion of the patellar
tendon.
Finally, tap the patella to see if there is any effusion deep to the patella.

Palpate the border of the patella Palpate the joint lines


(from http://www.osceskills.com) (from http://www.osceskills.com)

Palpate the point of insertion Tap the patella


(from http://www.osceskills.com) (from http://www.osceskills.com)

6. The main movements which should be examined both actively and passively are:
 flexion
 extension
A full range of movements should be demonstrated and you should feel for any crepitus.

7
Knee flexion movement Knee extension movement
(from http://www.osceskills.com) (from http://www.osceskills.com)

7. Now perform the specialist tests which assess the cruciate ligaments.
Anterior drawer test: Flex the knee to 90 degrees and sit on the patient’s foot. Pull
forward on the tibia just distal to the knee. There should be no movement. If there is
however, it suggests anterior cruciate ligament damage. Another test for ACL damage is
Lachman’s test.
Posterior drawer test: With the knee in the same position, observe from the side for any
posterior lag of the joint, this suggests posterior cruciate ligament damage.

Draw test Posterior lag test


(from http://www.osceskills.com) (from http://www.osceskills.com)

8. Now perform the specialist tests which assess the collateral ligaments. Do this by holding
the leg with the knee flexed to 15 degrees and place lateral and medial stress on the knee.
Any excessive movement suggests collateral ligament damage.

Lateral stress Medial stress


(from http://www.osceskills.com) (from http://www.osceskills.com)

9. Perform McMurrays test to assess for meniscal damage. Hold the knee up and fully
flexed, with one hand over the knee joint itself and the other on the sole of that
foot. Stress the knee joint by medially and laterally moving the foot. Pain or a click is a
positive test, confirming meniscal damage.

10. Allow the patient to dress and thank them. Wash your hands and report your findings.
8
Hip Examination
Hip complaints in adults are often related to pain e.g. arthritis or bursitis, however in children
can occur in a well child e.g. “irritable hip” or in more serious conditions e.g. Perthes disease
or slipped upper femoral epiphysis. Hip pain can also be referred pain from another joint,
most commonly knee and spine.

The hip examination, along with all other joint examinations, is commonly tested on in
OSCEs. You should ensure you are able to perform this confidently.
The examination of all joints follows the general pattern of “look, feel, move” and
occasionally some special tests.

Subject steps
1. Start by washing your hands and introduce yourself to the patient. Clarify the patient’s
identity and explain what you would like to examine, gain their consent.
Ensure the joints you wish to examine are appropriately exposed, in this case the patient
will probably be wearing shorts, although in reality they should be exposed from the
waist down. Therefore you should offer a chaperone.

Introduce yourself to the patient Wash your hands


(from http://www.osceskills.com) (from http://www.osceskills.com)

2. A hip examination should begin with asking the patient to walk for you. This allows you
to assess muscle bulk around the hip joint, ensure that you check both hips from behind,
the side and in front. Compare both hips for any asymmetry. Check the gait for: an
antalgic gait, limp or a Trendelenburg gait, and waddling due to proximal muscle wasting.

3. Whilst the patient is still standing, perform the Trendelenburg test. Ask the patient to
alternately stand on one leg. Stand behind the patient and feel the pelvis. It should remain
level or rise slightly. If the pelvis drops markedly on the side of the raised leg, then it
suggests abductor muscle weakness in the leg the patient is standing on.

The Trendelenburg test (from http://www.osceskills.com)

9
4. Now ask the patient to lie flat on the bed. Begin with a general observation of the hip and
legs. Check muscle bulk and symmetry as well as any obvious abnormalities such as
scars. Now check both the apparent and true length of the leg. True leg length
discrepancy is found by measuring from the anterior superior iliac spine to the medial
malleolus. Apparent leg length discrepancy is measured from the xiphisternum or
umbilicus to the medial malleolus.

True length leg measurement Apparent leg length measurement


(from http://www.osceskills.com) (from http://www.osceskills.com)

5. As the hip joint lies deeply there is little to palpate. However as always you should assess
the temperature of the joint compared to surrounding tissue and palpate the greater
trochanter as any tenderness here could suggest trochanteric bursitis.

Palpate the Greater Trochanter (from http://www.osceskills.com)

6. Movements to be assessed at the hip are:


 flexion
 extension
 internal rotation
 external rotation
Flexion is performed by flexing the knee to 90 degrees and passively flexing the hip by
pushing the knee towards the chest.
Extension is performed by placing your hand under the patient’s ankle and asking them to
push your hand into the bed.
Internal and external rotation are also performed with the knee flexed and by inverting the
knee for internal rotation and everting it for external rotation.

10
Hip flexion Hip extension
(from http://www.osceskills.com) (from http://www.osceskills.com)

Hip internal rotation Hip external rotation


(from http://www.osceskills.com) (from http://www.osceskills.com)

7. The final specialised test to be performed is Thomas’ test. Place your hand under the
patient’s lumbar spine to stop any lumbar movements and fully flex one of the hips.
Observe the other hip; if it lifts off the couch then it suggests a fixed flexion deformity of
that hip.

Thomas' test Place your hand under the patients lumbar spine
(from http://www.osceskills.com) (from http://www.osceskills.com)

8. Allow the patient to dress and thank them. Wash your hands and report your findings to
the examiner

11
Tutorial 2

Shoulder & Elbow

This tutorial focuses on the shoulder joint. You will learn how to interview a patient who
presents with shoulder pain and to perform an examination of the shoulder. A sound
knowledge of the anatomy of the shoulder joint is important for both of these skills.

Shoulder pain
The shoulder is a complex anatomical structure that connects the arms to the rest of the
skeleton. It consists of three bones (the clavicle, the scapula and the humerus) and a number
of articular surfaces (glenohumeral, acromoclavicular, sternoclavicular and scapulothoracic).
The glenohumeral joint, the main joint of the shoulder, has a ball and socket articulation. This
joint allows the shoulder to rotate in a circular fashion, making it the easiest in the body to
move. The bones of the shoulder are held together by a group of associated muscles (called
the rotator cuff muscles), as well as ligaments and tendons.

Shoulder pain is a common problem in our community. It can arise from within the shoulder
(intrinsic pain) due to pathology in the joints, bursae, muscles or tendons. Shoulder pain can
also arise from outside the shoulder (extrinsic or referred pain) from structures such as the
cervical spine or the heart.

When interviewing a patient about shoulder pain, one of the key tasks is to establish whether
it is exacerbated by movement. This helps to distinguish intrinsic from extrinsic causes for the
pain. It is important to check for extrinsic causes of shoulder pain, as some of these, such as
ischaemic heart disease, are potentially life-threatening. When you have acquired more
clinical experience, you will be able to ask questions targeted at finding out the likely causes
of extrinsic shoulder pain.

If you have established that the patient has intrinsic shoulder pain, enquire about the specific
movements that produce the pain as this may help to establish the diagnosis. Find out about
the other cardinal features, including whether there were any precipitating factors, such as
trauma, and whether any other joints are affected. In the case of chronic shoulder pain, also
find out about how it is impacting on the patient’s life.

12
Case Study 4.08

Warren Humphries, a 53-year old accountant,


has presented with right-sided shoulder pain.
He is being interviewed by Jane Lee, a second
year medical student.

Watch the interview between Mr Humphries and


Jane Lee. Write down the cardinal features of
Mr Humphries’s presenting problem. Discuss
what you think the cause of his shoulder pain
might be and explain your reasoning.

Practice with role-plays

In pairs, use role-plays to practise interviewing a patient about shoulder pain. Give each other
feedback using the Medical Interview Assessment forms.

13
Medical Interview Assessment Form
Opening segment of interview Yes No

Greets the patient


Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement

Exploration of the presenting problem Yes No N/A

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features

Communication Skills Done Well Adequate Needs


improvement
Demonstrates active listening skills
Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions

Interview Management Done well Adequate Needs


Improvement
Is systematic with questioning
Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

14
Shoulder Examination
The shoulder exam is an examination that can be administered as part of the physical exam
and is used to identify potential pathology involving the shoulder.

Subject steps
1. Begin by washing your hands. Explain the procedure to the patient and gain informed
consent to continue.

2. Begin with observation of the patient.

Observe the shoulder from the front Observe the shoulder from the side
(from http://www.osceskills.com) (from http://www.osceskills.com)

Observe the back of the shoulder


(from http://www.osceskills.com)

3. With the patient still stood, you perform two quick and easy function tests. This involves
the patient placing their hands behind their head and behind their back. This checks that
they can perform everyday tasks.

Hands behind the head Hands behind the back


(from http://www.osceskills.com) (from http://www.osceskills.com)

4. Feel over the joint and its surrounding areas for the temperature of the joint. A raised
temperature may suggest inflammation or infection in the joint. Systematically feel along
both sides of the bony shoulder girdle. Start at the sternoclavicular joint, work along the
15
clavicle to the acromioclavicular joint, feel the acromion, and then around the spine of the
scapula. Feel the anterior and posterior joint lines of the glenohumeral joint and finally
the muscles around the joint for any tenderness.

Feel joint temperature Sternoclavicular joint


(from http://www.osceskills.com) (from http://www.osceskills.com)

Acromioclavicular joint Spine of the scapula


(from http://www.osceskills.com) (from http://www.osceskills.com)

Glenohumeral joint
(from http://www.osceskills.com)

5. The movements of the joint should start being performed actively. Ask the patient to
bring their arm forward (flexion), bend their arm at the elbow and push backwards
(extension). Bring their arm out to the side and up above their head (abduction). Flex the
elbow and tuck it into the side and move the hand outwards (external rotation). And
finally see how far they can place their hand up their back (internal rotation).

16
Shoulder flexion movement Shoulder extension movement
(from http://www.osceskills.com) (from http://www.osceskills.com)

Shoulder abduction movement Shoulder external rotation movement


(from http://www.osceskills.com) (from http://www.osceskills.com)

Shoulder internal rotation movement


(from http://www.osceskills.com)

6. Once all of these movements have been performed actively, you should perform them
passively and feel for any crepitus whilst moving the joints

7. There are three special tests which can be performed on the shoulder. These are:
1. the impingement test,
2. the apprehension test
3. and the scarf test.

The impingement test is performed by placing the shoulder out at 90 degrees with the arm
hanging down, press back on the arm and check for any pain.

The apprehension test is similar but the arm is facing upwards and push back on the arm; the
patient may be apprehensive about the movement as the joint feels unstable.

The scarf test is performed with the elbow flexed to 90 degrees, placing the patient’s hand on
their opposite shoulder and pushing back. Again look for any discomfort.

17
Shoulder impingement test Shoulder apprehension test
(from http://www.osceskills.com) (from http://www.osceskills.com)

Shoulder scarf test


(from http://www.osceskills.com)

8. An extension to this station may be to assess each rotator muscle individually.

9. On completion, thank the patient for their time and wash your hands.

Elbow Examination
The elbow exam is a simple examination that can be administered as part of the physical
exam to help guide healthcare providers diagnosis and management of acute elbow fractures.
The elbow examination is performed when an elbow fracture, most commonly caused by
trauma, is suspected as the source of pain and dysfunction.

Subject steps
1. Begin by washing your hands. Explain the procedure to the patient and gain informed
consent to continue.

2. Begin with observation of the patient. Inspect the front to check the carrying angle, from
the side to check for a fixed flexion deformity, and from behind and on the inside to
check for scars, swellings, rashes, rheumatoid nodules and psoriatic plaques.

18
Inspect the front Inspect the side
(from http://www.osceskills.com) (from http://www.osceskills.com)

Inspect behind and on the inside


(from http://www.osceskills.com)

3. Feel the elbow, assessing the joint temperature relative to the rest of the arm. Palpate the
olecranon process as well as the lateral and medial epicondyles for tenderness.

Assess the joint temperature Palpate the olecranon process


(from http://www.osceskills.com) (from http://www.osceskills.com)

4. The movements at the elbow joint are all fairly easy to describe and assess. These are
flexion, extension, pronation and supination. Once these have been assessed actively they
should be checked passively checking for crepitus.

19
Flexion joint movement Extension joint movement
(from http://www.osceskills.com) (from http://www.osceskills.com)

Pronation joint movement Supination joint movement


(from http://www.osceskills.com) (from http://www.osceskills.com)

5. Finally you should check for tennis elbow and golfer’s elbow.

Tennis elbow localises pain over the lateral epicondyle, particularly on active extension of the
wrist with the elbow bent. Golfer’s elbow pain localises over the medial epicondyle and is
made worse by flexing the wrist. Check each of these individually to eliminate them.

Check for tennis elbow Check for golfers elbow


(from http://www.osceskills.com) (from http://www.osceskills.com)

6. On completion, thank the patient for their time and wash your hands.

20
Tutorial 3
Hand & Wrist

Arthritis
Medical history and current medical condition are important factors that help us diagnose
and/or evaluate rheumatoid arthritis. To assess patient’s medical history, we may ask:
 How long symptoms have been present and whether there has been any pattern to
them.
 Whether there is a family history of arthritis.
 Whether there are any other general symptoms (fatigue, weight loss, fever).
 Whether there has been any recent or past injury to the affected joints.
 How symptoms have affected your daily activities of living, driving, and working.
During the physical examination, we may look at, feel, and move each joint and evaluate it
for:
 Swelling, warmth, and tenderness.
 Presence of fluid on the joint.
 Range of motion.
 Joints that are affected.
 The presence of bumps (rheumatoid nodules) over pressure points in the body.
During the examination, we may also do a routine evaluation of the lungs, heart, liver, and
kidneys.

Results
Important findings in the physical examination include the:
 Pattern of symptoms in the affected joints.
 Presence of swelling or tenderness in the joints.
Rheumatoid arthritis often causes painful, swollen, "hot" joints and often affects the same
joints on both sides of the body. Your health professional will note the location of affected
joints, as well as other symptoms, to determine whether your condition meets the criteria for
a diagnosis of rheumatoid arthritis.

21
Medical Interview Assessment Form
Opening segment of interview Yes No

Greets the patient


Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement

Exploration of the presenting problem Yes No N/A

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features

Communication Skills Done Well Adequate Needs


improvement
Demonstrates active listening skills
Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions

Interview Management Done well Adequate Needs


Improvement
Is systematic with questioning
Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

22
Hand & Wrist Examination

The hands are quite difficult to examine as there are a number of signs which can be detected
from them. Try and remember each of these and also some of the causes behind the signs.

1. As always, wash your hands, explain the procedure to the patient and gain informed
consent.

2. Firstly place the patient’s hands on a pillow in between you and them, ensuring the
patient is comfortable.

Inspection preparation (from http://www.osceskills.com)

3. Have a look at the hands. In particular look for swellings, deformities, muscle wasting,
scars – particularly carpal tunnel release scars, skin changes, rashes, nail pitting or
onycholysis, nailfold vasculitis, palmar erythema. If there are joint swellings note which
joints are involved and whether the changes are symmetrical or not.

Inspect the hands (from http://www.osceskills.com)

4. You need to feel the hands. This should look as smooth as possible so try and develop
your own technique. A good one is to start proximally and work towards the fingers. So,
start by feeling the radial pulses and the wrist joints with the two thumbs on the extensor
surface and the index fingers on the flexor surface. Then feel the muscle bulk in the
thenar and hypothenar eminences. In the palms, feel for any tendon thickening and assess
the sensation over the relevant areas supplied by the radial, ulnar and median nerves. As

23
with all other joints, you should assess the temperature over the joint areas and compare
these with the temperature of the forearm. Next you should squeeze over the row of
metacarpophalangeal joints whilst watching the patient’s face for any discomfort. You
should then move onto any MCP joints which are noticeably swollen. Palpate these
bimanually with your two thumbs on the dorsum and two index fingers on the palm.
Move onto the interphalangeal joints and again palpate any which are swollen. This
palpation is done with one of the thumbs on the top and the other on one of the sides. The
index fingers go on the vacant sides of the joint.

Feel for temperature Carpals inspection


(from http://www.osceskills.com) (from http://www.osceskills.com)

Thenar inspection MCP inspection


(from http://www.osceskills.com) (from http://www.osceskills.com)

IP inspection (from http://www.osceskills.com)

5. At this point you should also look at the underside of the elbows to check for any
psoriatic plaques as these could suggect the presence of psoriatic arthritis and for any
rheumatoid nodules.
24
Check for psoriatic plaques (from http://www.osceskills.com)

6. The movements which should be assessed are wrist flexion and extension, finger
extension and flexion as well as abduction. You should also test thumb abduction and
opposition.

Wrist flexion examination Wrist extension examination


(from http://www.osceskills.com) (from http://www.osceskills.com)

Finger flexion examination Finger extension examination


(from http://www.osceskills.com) (from http://www.osceskills.com)

25
Finger abduction examination 1 Finger abduction examination 2
(from http://www.osceskills.com) (from http://www.osceskills.com)

Finger opposition examination (from http://www.osceskills.com)

7. One special test which you may like to employ is Phalen’s test. Forced flexion of the
wrist, either against the other hand or by the examiner for 60 seconds will recreate the
symptoms of carpal tunnel syndrome. Froment’s test may also be performed to check
Ulnar nerve function by asking the patient to hold a piece of paper between their thumb
and index finger (hence checking adductor pollicis). In a patient with Ulnar nerve palsy
the interphalangeal joint of the thumb will flex to compensate.

Phalen's test (from http://www.osceskills.com)

8. Finally you should perform a functional assessment of the patient. This involves forming
a power grip around your middle and index fingers, a pincer grip against your index
finger and asking your patient to pick up a small object such as a coin.

26
Power grip assessment Pincer grip assessment
(from http://www.osceskills.com) (from http://www.osceskills.com)

Pick-up assessment (from http://www.osceskills.com)

9. Thank the patient and wash your hands again.

27
Tutorial 4

Spine
This tutorial focuses on the lumbar spine. You will learn how to interview a patient who
presents with low back pain and to perform an examination of the lumbar spine. An
understanding of the anatomy of the lumbo-sacral spine, including spinal canal, inter-
vertebral discs, facet joints and outlet foramen, will help you to understand the potential
causes of low back pain. The tutorial will highlight the importance of identifying the features
of low back pain that indicate the potential for a serious underlying cause.

Low back pain


The spine provides structure and support for the body. It enables upright posture and plays an
important role in protecting the spinal cord. It is also flexible enough to allow movement,
such as bending. The low back usually refers to the lumbar region of the spine, as well as the
sacrum. The lumbar region of the spine is composed of the lumbar vertebrae (L1 to L5),
which are separated by discs, which act like shock absorbers. The lumbar vertebrae are linked
by facet joints and are held together by ligaments. A series of tendons connect the vertebrae
to the surrounding musculature. The sacrum is made up of five fused vertebrae below the
lumbar region. It is positioned between the two iliac bones and linked with them by the sacro-
iliac joints.

Pain in the lower back is an extremely common problem. Up to 70% of adults have low back
pain at some time1. For most patients, the underlying cause is benign and the course of the
problem is self-limiting. Most benign causes of back pain are due to degenerative or
mechanical problems relating to the lumbo-sacral spine, often produced by too much strain,
such as from lifting or carrying heavy objects. The most common presentation is with non-
specific low back pain, usually confined to the lumbo-sacral region. It is made worse by
activity and usually improves with rest. Degenerative back pain can be associated with
radicular pain, due to nerve root irritation. This typically affects the L5 or S1 nerve roots and
is often referred to as “sciatica”. Low back pain can also be due to stenosis of the spine. This
type of pain starts in the lower back and radiates down the buttocks and into the back of the
legs on both sides. It is usually made worse by walking and is relieved by bending forward.
Although degenerative back pain is usually benign, it can often be quite severe and cause
significant distress for the patient.

For a small percentage of patients, the cause of their back pain will be a serious problem,
such as malignancy, compression fracture secondary to osteoporosis, infection or an
inflammatory disorder. In some cases, the pain will be referred from a visceral structure, such
as a kidney.

When interviewing a patient who has back pain, it is important to differentiate common and
benign causes of back pain from rarer, serious causes that require specific and often urgent
treatment. Serious causes include compression of the spinal cord, regardless of the aetiology,
and conditions such as malignancy or infection. There are some key features of low back pain
that are more commonly associated with serious underlying diseases than benign conditions.
These are often called “red flags”, as they can alert you to the serious causes.

28
Red flags for back pain
 Age > 50 years
 History or suspicion of cancer
 Intravenous drug use
 Symptoms of or risk factors for systemic disease (eg fevers and sweats, unexplained
weight loss, use of glucocorticoids)
 Sciatica or neurological deficit
 Pain not relieved by rest (eg pain at night)
 Pain over one month’s duration unresponsive to routine therapies

Case Study 4.09

Miss Marjorie Wilson, a 66-year old retired teach-


er, has presented with a problem of back pain. She
is being interviewed by Dr Ramin Shayan.

Watch the interview between Miss Wilson and


Dr Shayan. Write down the cardinal features of
Ms Wilson’s presenting problem. Identify the red
flags that might indicate that she has a serious
cause for her back pain.

Also review Case Study 1.15. This represents a


different cause of back pain. Identify red flags that
might suggest a serious cause for Miss Wilson’s
back pain.

Practice with role-plays


In pairs, use role-plays to practise interviewing a patient about back pain. Give each other
feedback us- ing the Medical interview assessment forms.

29
Medical Interview Assessment Form
Opening segment of interview Yes No

Greets the patient


Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement

Exploration of the presenting problem Yes No N/A

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features

Communication Skills Done Well Adequate Needs


improvement
Demonstrates active listening skills
Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions

Interview Management Done well Adequate Needs


Improvement
Is systematic with questioning
Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

30
Spine Examination

Back pain is one of the most common presentations to general practice and A&E departments
worldwide, it is therefore one you should know well. Common causes of back pain include
arthritis, prolapsed disc and muscular injuries, occasionally it can be the underlying cause of
other conditions such as sciatica.

The spine examination, along with all other joint examinations, is commonly tested on in
OSCEs. You should ensure you are able to perform this confidently.
The examination of all joints follows the general pattern of “look, feel, move” as well as
occasionally special tests.

Subject steps
1. Start by washing your hands and introduce yourself to the patient. Clarify the patient’s
identity and explain what you would like to examine, gain their consent. Ensure the joint
in which you wish to examine is appropriately exposed, in this case the patient should be
exposed from the waist up. You should therefore offer a chaperone.

2. The patient should be standing. Start by examining the patient from behind, looking for
any obvious abnormalities such as scars. Also note the muscle bulk and any wasting. Note
the symmetry of each side and look for any scoliosis. Now look from the side to check for
the normal curvatures of the spine. This is cervical lordosis, thoracic kyphosis and lumbar
lordosis.

Examine patient from behind Examine patient from the side


(from http://www.osceskills.com) (from http://www.osceskills.com)

3. Now feel the areas around the spine. Feel along the entire length of the spine, palpating
each spinous process and checking with the patient for any tenderness. Now palpate the
sacroiliac joints and finally the paraspinal muscles. As it is difficult to observe the
patient’s face for signs of discomfort, you should regularly ask them if what you are
doing is painful.

31
Feel areas around the spine (from http://www.osceskills.com)

4. Movements of the spine are all performed actively. The first movements which are
examined are lumbar flexion, extension and lateral flexion. Flexion and extension are
checked by asking the patient to try and touch their toes (flexion) and then lean
backwards (extension). These movements may be assessed quantitatively by placing the
index and middle fingers 5 centimeters apart and noting how close and far apart they
move on the movements. Lateral flexion is examined by asking the patient to run their
hand down the outside of their leg.

Lumbar flexion movement Lumbar extension movement


(from http://www.osceskills.com) (from http://www.osceskills.com)

Lumbar lateral flexion movement


(from http://www.osceskills.com)

5. Cervical spine movements which are assessed are lateral flexion, rotation, flexion and
extension. There are some easy commands for checking these. Lateral flexion: place your
ear on your shoulder; rotation: look over your shoulder; flexion: put your chin on your
chest; and extension: put your head back to look at the ceiling.

32
Cervical flexion movement Cervical rotation movement
(from http://www.osceskills.com) (from http://www.osceskills.com)

Cervical flexion forward movement Cervical extension backward movement


(from http://www.osceskills.com) (from http://www.osceskills.com)

6. The last movement to assess is thoracic rotation. For this the patient should be sat on the
edge of the bed to fix the pelvis then ask the patient to turn to each side.

Thoracic rotation left Thoracic rotation right


(from http://www.osceskills.com) (from http://www.osceskills.com)

7. Now ask the patient to lie flat on the bed. Perform a straight leg raise which assesses for
nerve entrapment such as sciatica.

Straight leg raise (from http://www.osceskills.com)

8. Allow the patient to dress and thank them. Wash your hands and report your findings to
the examiner

33
9. An extension to this station could be to perform an Upper Limb Neurological
Examination or Lower Limb Neurological Examination if your findings suggest nerve
entrapment from the cervical or lumbar spine.

34
Tutorial 5

Ankle & Foot

Osteomyelitis
Osteomyelitis is an inflammation or swelling of bone tissue that is usually the result of an
infection. Osteomyelitis, or bone infection, may occur for many different reasons and can
affect children or adults. Some of the causes of osteomyelitis include the following:
 Osteomyelitis may occur as a result of a bacterial bloodstream infection, sometimes
called bacteremia, or sepsis, that spreads to the bone. This type is most common in
infants and children and usually affects their long bones such as the femur (thighbone)
or humerus (upper arm bone). When osteomyelitis affects adults, it often involves the
vertebral bones along the spinal column. The source of the blood infection is usually
Staphylococcus aureus, although it may be caused by a different type of bacteria or
fungal organism.
 Osteomyelitis can also occur from a nearby infection due to a traumatic injury,
frequent medication injections, a surgical procedure, or use of a prosthetic device. In
addition, individuals with diabetes who develop foot ulcers are more susceptible. In
any of these situations, the organism has a direct portal of entry into the affected bone.
 Individuals with weakened immune systems are more likely to develop osteomyelitis.
This includes individuals with sickle cell disease, human immunodeficiency virus
(HIV), or individuals receiving immunosuppressive medications such as
chemotherapy or steroids.

Osteomyelitis can have a sudden onset, a slow and mild onset, or may be a chronic problem,
depending on the source of the infection.

Osteomyelitis can affect all populations from infants and children to the elderly. It is more
common in infants, children, and older adults. The incidence in males is greater than females.
Populations at increased risk include individuals with weakened immune systems.

Symptoms of osteomyelitis vary, depending on the cause and if it is a rapid or slow onset of
infection. The following are the most common symptoms of osteomyelitis. However, each
individual may experience symptoms differently. Symptoms may include:
 fever (the fever may be high when osteomyelitis occurs as the result of a blood
infection)
 pain and tenderness in the affected area
 irritability
 feeling ill
 swelling of the affected area
 redness in the affected area
 warmth in the affected area
 difficulty moving joints near affected area
 difficulty bearing weight or walking
 a new limp
 a stiff back (with vertebral involvement)

In addition to a complete medical history and physical examination, diagnostic procedures for
osteomyelitis may include the following:
35
 blood tests, including the following:
o complete blood count (CBC) - a measurement of size, number, and maturity
of the different blood cells in a specific volume of blood; to check for a blood
infection.
o erythrocyte sedimentation rate (ESR) - a measurement of how quickly red
blood cells fall to the bottom of a test tube. When swelling and inflammation
are present, the blood's proteins clump together and become heavier than
normal. Thus, when measured, they fall and settle faster at the bottom of the
test tube. Generally, the faster the blood cells fall, the more severe the
inflammation.
o C-reactive protein (CRP) - a blood test to help detect the presence of
inflammation or an infection.
 needle aspiration or bone biopsy - a small needle is inserted into the abnormal area
in almost any part of the body, guided by imaging techniques, to obtain a tissue
biopsy. This type of biopsy can provide a diagnosis without surgical intervention.
 x-ray - a diagnostic test which uses invisible electromagnetic energy beams to
produce images of internal tissues, bones, and organs onto film.
 radionuclide bone scans - pictures or x-rays taken of the bone after a dye has been
injected that is absorbed by bone tissue. These are used to detect tumors and bone
abnormalities.
 computed tomography scan (Also called CT or CAT scan.) - a diagnostic imaging
procedure that uses a combination of x-rays and computer technology to produce
cross-sectional images (often called slices), both horizontally and vertically, of the
body. A CT scan shows detailed images of any part of the body, including the bones,
muscles, fat, and organs. CT scans are more detailed than general x-rays.
 magnetic resonance imaging (MRI) - a diagnostic procedure that uses a
combination of large magnets, radiofrequencies, and a computer to produce detailed
images of organs and structures within the body.
 ultrasound - a diagnostic technique which uses high-frequency sound waves and a
computer to create images of blood vessels, tissues, and organs. Ultrasounds are used
to view internal organs as they function, and to assess blood flow through various
vessels.

Treatment for osteomyelitis:


Specific treatment for osteomyelitis will be determined by your physician based on:
 your age, overall health, and medical history
 extent of the condition
 your tolerance for specific medications, procedures, and therapies
 expectation for the course of the condition
 your opinion or preference

The goal for treatment of osteomyelitis is to cure the infection and minimize any long-term
complications. Treatment may include:
 medications
Administration of intravenous (IV) antibiotics, which may require hospitalization or
may be given on an outpatient schedule, may be necessary. Intravenous or oral
antibiotic treatment for osteomyelitis may be very extensive, lasting for many weeks.
 monitoring of successive x-rays and blood tests
 pain management

36
 bed rest or restricted movement of the affected area
 surgery
In some cases, surgical intervention may be necessary to drain infectious fluid, or to
remove damaged tissue and bone.

Long-term considerations for osteomyelitis:


Osteomyelitis requires long-term care to prevent further complications, including care to
prevent the following:
 fractures of the affected bone
 stunted growth in children (if the infection has involved the growth plate)
 gangrene infection in the affected area

37
Medical Interview Assessment Form
Opening segment of interview Yes No

Greets the patient


Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement

Exploration of the presenting problem Yes No N/A

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features

Communication Skills Done Well Adequate Needs


improvement
Demonstrates active listening skills
Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions

Interview Management Done well Adequate Needs


Improvement
Is systematic with questioning
Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

38
Ankle & Foot Examination
1. This examination starts with observing the joint.
o Watch the patient walk, observing for a normal heel strike, toe-off gait.
o Look at the alignment of the toes for any valgus or varus deformities.
o Examine the foot arches, checking for pes cavus (high arches) or pes planus (flat
feet).
o Whilst the patient is stood, feel the Achilles tendon for any thickening or swelling.
o Finally you inspect the patient’s shoes, note any uneven wear on either sole and
the presence of any insoles.

Observing the ankle joint (from http://www.osceskills.com)

2. Ask the patient to lie on the bed, and perform a general inspection.
Check the symmetry, nails, skin, toe alignment, toe clawing, joint swelling and plantar
and dorsal calluses.

Make a general inspection of the patient. (from http://www.osceskills.com)

3. Feel each foot for temperature, comparing it to the temperature of the rest of the leg.
Feel for distal pulses, squeeze over the metatarsophalangeal joints observing the patient’s
face. Also palpate over the midfoot, ankle and subtalar joint lines for any tenderness.

39
Checking the patient's ankle temperature Checking the patient's mid-foot temperature
(from http://www.osceskills.com) (from http://www.osceskills.com)

Squeezing over the metatarsophalangeal joints Palpating over the patient's mid-foot
(from http://www.osceskills.com) (from http://www.osceskills.com)

Palpating over the patient's ankle


(from http://www.osceskills.com)

4. Assess all active movements of the foot. These movements are:


o inversion,
o eversion,
o dorsiflexion
o and plantarflexion, of the great toe as well as of the ankle.
Movements should be tested passively.

Inversion movement 1 Inversion movement 2


(from http://www.osceskills.com) (from http://www.osceskills.com)

40
Eversion movement back Eversion movement forward
(from http://www.osceskills.com) (from http://www.osceskills.com)

Toe dorsiflexion Toe plantarflexion


(from http://www.osceskills.com) (from http://www.osceskills.com)

5. Finally examine the midtarsal joints by fixing the ankle with one foot and inverting and
everting the forefoot with the other.

Passive inversion Passive eversion


(from http://www.osceskills.com) (from http://www.osceskills.com)

41
REFERENCES

1. INTRODUCTION TO CLINICAL MEDICINE 4, MELBOURNE MEDICAL


SCHOOL,THE UNIVERSITY OF MELBOURNE, Melbourne.
2. http://www.osceskills.com

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