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2MBChB Musculoskeletal > Clinical Skills > Flashcards

Clinical Skills Flashcards

1
Q

What findings should you look for in an examination of a local swelling?

A

Site.

Size.

Definition - well- or ill-defined.

Consistency - cystic, solid, soft, hard.

Surface - smooth, regular.

Mobility or fixity - to skin or deep tissues.

Temperature - abscess.

Transilluminable - fluid-filled.

Overlying skin changes.

Local lymphadenopathy.

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2
Q

What is the relevance of testing haemoglobin in rheumatology?

A

May be low in most inflammatory conditions - may be an indicator of disease activity.

May get iron deficiency anaemia with NSAIDs.

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3
Q

What is the relevance of testing MCV in rheumatology?

A

May be high in patients on sulfasalazine, methotrexate, or azathioprine - this is of no significance if the Hb is stable and B12, folate and TFTs are normal.

Low in iron deficiency.

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4
Q

What is the relevance of testing neutrophil in rheumatology?

A

May be low in connective tissue diseases (especially SLE and Sjogren’s syndrome).

Neutropenia can be an adverse effect of most DMARDs.

Occasionally can be raised in inflammatory arthritis.

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5
Q

What is the relevance of testing lymphocyte count in rheumatology?

A

May be low in connective tissue disease (especially SLE and Sjogren’s syndrome) - indicator of disease activity.

Reduced by immunosuppressants.

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6
Q

What is the relevance of testing platelet count in rheumatology?

A

May be low in connective tissue diseases (especially SLE, Sjogren’s syndrome and antiphospholipid syndrome).

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7
Q

What is the relevance of testing plasma viscosity in rheumatology?

A

High in inflammatory conditions - indicator of disease activity.

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8
Q

What is the relevance of testing renal markers in rheumatology?

A

Methotrexate is excreted renally, therefore, risk of toxicity if there is renal impairment.

Connective tissue disease may cause renal impairment.

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9
Q

What is the relevance of testing liver function in rheumatology?

A

DMARDs, allopurinol and NSAIDs may cause hepatitis.

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10
Q

What is the relevance of testing corrected calcium in rheumatology?

A

Hyperparathyroidism may cause pseudogout/calcium pyrophosphate arthropathy (CPPD).

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11
Q

What is the relevance of testing ferritin in rheumatology?

A

Low in iron deficiency, high in anaemia of chronic disease - even in presences of iron deficiency can be artificially high in inflammatory disease as it also acts as an acute phase reactant.

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12
Q

What is the relevance of testing creatine kinase in rheumatology?

A

Raised in myositis - indicator of disease activity; may also be raised in muscle trauma and strenuous exercise.

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13
Q

What is the relevance of testing uric acid in rheumatology?

A

Raised in gout - normal in about 30% of cases of acute gout; may get asymptomatic hyperuricaemia.

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14
Q

What is the relevance of testing urine protein/creatinine ratio in rheumatology?

A

May get glomerulonephritis as part of connective tissue disease/vasculitis.

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15
Q

What is the relevance of synovial fluid microscopy and culture in rheumatology?

A

If suspected septic arthritis or crystal arthritis.

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16
Q

What is the relevance of testing rheumatoid factor in rheumatology?

A

70% sensitive (only 50% in early arthritis), 85% specific for rheumatoid arthritis.

Extra-articular manifestations of RA very unlikely, if RF is negative.

Worse prognosis in sero-positive patients.

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17
Q

What are the extractable nuclear antigens (ENA)?

A

Anti-RNP.

Anti-centromere antibody.

Anti-Scl-70.

Anti-Ro; anti-La.

Anti-Jo-1.

Anti-SM.

Anti-cardiolipin (ACLA) antibodies.

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18
Q

What is the relevance of testing anti-CCP antibody in rheumatology?

A

70% sensitive.

~98% specific for RA.

Worse prognosis in sero-positive patients.

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19
Q

What is the relevance of testing anti-nuclear antibody in rheumatology?

A

98% sensitive for SLE (hence negative test is very useful to rule out SLE) but very non-specific e.g. 13% adults are positive at a titre of 1/80.

Positive in a wide range of connective tissue diseases including RA.

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20
Q

What is the relevance of testing anti-dsDNA antibody in rheumatology?

A

95% specific for SLE, positive in about 30% - may fluctuate with disease activity and can be used to monitor disease activity.

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21
Q

What is the relevance of testing anti-RNP antibody in rheumatology?

A

Usually positive in mixed connective tissue disease and may be positive in SLE.

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22
Q

What is the relevance of testing anti-centromere antibody in rheumatology?

A

Usually positive in limited systemic sclerosis.

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23
Q

What is the relevance of testing anti-Scl-70 antibody in rheumatology?

A

May be positive in diffuse systemic sclerosis.

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24
Q

What is the relevance of testing anti-Ro and anti-La antibody in rheumatology?

A

Usually positive in diffuse systemic sclerosis.

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25
Q

What is the relevance of testing anti-Jo-1 antibody in rheumatology?

A

May be present in inflammatory myositis.

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26
Q

What is the relevance of testing anti-Sm antibody in rheumatology?

A

Very specific for lupus but in UK population only positive in ~3%.

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27
Q

What is the relevance of testing c-ANCA/anti-PR3 in rheumatology?

A

Very sensitive and specific for granulomatosis with polyangiitis (Wegener’s granulomatosis).

May fluctuate with disease activity and can be used to monitor disease activity.

28
Q

What is the relevance of testing anti-cardiolipin antibodies in rheumatology?

A

Positive in anti-phospholipid syndrome.

If present increased risk of thrombosis or pregnancy loss.

29
Q

What is the relevance of testing p-anca/anti-MPO in rheumatology?

A

Less specific than ANCA/anti-PR3.

Associated with microscopic polyangiitis and Churg Strauss syndrome.

May fluctuate with disease activity and can be used to monitor disease activity.

30
Q

What is the relevance of testing C3/C4 in rheumatology?

A

Low in immune complex vasculitis especially lupus nephritis.

May fluctuate with disease activity (low in active lupus) and can be used to monitor disease activity.

31
Q

In an examination of the spine, what are you looking for?

A

From behind: Posture of the head, neck and shoulders. Thoraco-lumbar scoliosis (standing, bending forward).

From the side: Cervical lordosis, thoracic kyphosis (+/- gibus), lumbar lordosis.

32
Q

In an examination of the spine, what are you feeling for?

A

Supraclavicular: feel for cervical ribs or enlarged lymph nodes.

Mid-line: spinous processes (cervical to lumbar vertebrae).

Para-spinal muscles (muscle bulk and note any spasm).

Iliac crest heights (asymmetry or excessive pelvic tilt).

Sacroiliac joints.

Chest expansion.

33
Q

In an examination of the spine, what are you moving?

A

Cervical spine: flexion/extension rotation (left/right) lateral flexion (left/right).

Lumbar spine: flexion,extension.lateral flexion (left/right).

34
Q

In an examination of the spine, what special tests can you do and what does it test?

A

Schober’s test - to assess lumbar flexion.​

35
Q

What is Schober’s test?

A

Marks made at approximately at the level of L5 (fifth lumbar vertebra).

Two points are marked: 5 cm below and 10 cm above this point (for a total of 15 cm distance).

Patient is asked to touch his/her toes while keeping the knees straight.

If the distance of the two points does not increase by at least 5 cm (with the total distance greater than 20 cm), then this is a sign of restriction in the lumbar flexion.

36
Q

In an examination of the spine, what are you looking for?

A

Patient standing: limb alignment, quadricep/hamstring muscle mass, popliteal fossae.

Gait: pace, symmetry, gross gait abnormalities, walking aids.

Patient lying on couch: local inspection of the knee for erythema or skin changes, bruising, scars, hair changes, swelling (generalised or joint effusion).

37
Q

In an examination of the spine, what are you feeling for?

A

Temperature.

Tibial tuberosity.

Patella tendon.

Medial and lateral joint line.

Medial and lateral collateral ligaments.

Popliteal fossa.

38
Q

In an examination of the spine, what are you moving?

A

Flexion (active and passive).

Extension (passive +/- heel height testing for locked knee).

39
Q

In an examination of the spine, what special tests can you do?

A

Straight leg raise.

Effusion tests.

Patella tests.

Steinman’s test.

Collateral ligament testing.

Cruciate ligament testing.

40
Q

Why would you perform a straight leg raise in a knee examination?

A

To confirm the extensor mechanism is intact.

41
Q

Why would you perform effusion tests in a knee examination?

A

Medical gutter sweep test - it will be positive with a small effusion

Patella tap - it will be positive with a large effusion.

42
Q

Why would you perform patella tests in a knee examination?

A

Patella apprehension tests test for patella instability).

Patella grind test tests for patella-femoral osteoarthritis.

43
Q

Why would you perform a Steinman’s test in a knee examination?

A

It’s a meniscal provocation test to test for a meniscal tear.

44
Q

Why would you perform collateral ligament testing in a knee examination?

A

Stressing of medial (valgus) and stressing of lateral (varus) ligaments to test for ruptures.

45
Q

Why would you perform cruciate ligament testing in a knee examination?

A

Posterior drawer test (PCL) and Lachman’s test (ACL) will test if there is a rupture of the cruciates.

46
Q

Which professions come under allied health professionals?

A

Arts Therapies.

Podiatry.

Dietetics.

Occupational Therapy.

Orthoptics.

Prosthetics.

Orthotics.

Paramedics.

Physiotherapy.

Speech & Language Therapy.

Radiography (Diagnostic & Therapeutic).

47
Q

On examination of the hip, what is the best viewing point to inspect the hamstring muscle bulk?

A

Posteriorly.

48
Q

On examination of the hip, what is the best viewing point to inspect the gluteal muscle mass?

A

Posteriorly.

49
Q

On examination of the hip, what is the best viewing point to inspect the quadricep muscle bulk?

A

Anteriorly.

50
Q

By performing a Trendelenburg’s test, the strength of which muscles are being assessed?

A

Abductor muscles.

51
Q

With the patient lying on the couch what are you inspecting for on/around the hip?

A

Bruising.

Scars (traumatic or from surgery).

Skin changes - such as erythema, eczema or psoriasis.

52
Q

What are the two descriptors typical of limb attitude in an extracapsular neck of femur fracture?

A

External rotation.

Limb shortening.

53
Q

During a hip examination, how is apparent limb length measured?

A

Measuring from the xiphisternum to the tip of the medial malleolus.

54
Q

During a hip examination, how is true limb length measured?

A

Measuring from the anterior superior iliac spine (ASIS) to the tip of the medial malleolus.

55
Q

What would tenderness in the mid-point of the groin suggest?

A

Hip arthritis or fracture.

56
Q

What would tenderness in the greater trochanter suggest?

A

Trochanteric bursitis.

57
Q

Which movements of the hip joint are assessed in a hip examination?

A

Flexion.

Internal rotation.

External rotation.

Abduction.

Adduction.

58
Q

What finding does a positive Thomas’ test indicate?

A

A fixed flexion deformity (loss of hip extension).

59
Q

Which movements are assessed in the shoulder examination?

A

Internal rotation.

External rotation.

Abduction.

Flexion.

60
Q

How many movements can the shoulder do?

A

6.

61
Q

What does a painful arc suggest?

A

Suggests a rotator cuff tendon impingement.

62
Q

What symptom or sign would indicate a positive Jobe’s test?

A

Pain.

63
Q

What does Jobe’s test assess?

A

Suggests there is a tear of the supraspinatus.

64
Q

What does a positive sulcus sign suggest?

A

Significant shoulder instability.

65
Q

What symptom would a patient exhibit to indicate a positive apprehension test?

A

Apprehension.

2MBChB Musculoskeletal (17 decks)

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