Clinincal History and Examination - General Considerations Flashcards
General considerartions
History
A diagnosis can often be made from a good history and inspection of joints. At the outset it is worthwhile asking the patient the following questions:
- Do you have any pain or stiffness in your muscles, joints or back?
- Can you dress yourself without difficulty?
- Can you walk up and down stairs without difficulty?
If all three replies are negative, the patient is unlikely to have a significant musculoskeletal problem.
General considerartions
History
Common questions to be elicited in the history and their relevance
Red flags’ in non-traumatic disorders
Clinical ‘red flag’ features suggesting serious pathology
Red flags’ in non-traumatic disorders
Malignancy
Malignant tumours of bone and soft tissues are aggressive and, therefore, grow rapidly. Features indicative of malignant potential include lesions that are:
- rapidly growing
- more than 5 cm in size
- painful
- deep to deep fascia.
These lesions should be viewed as a potential malignant tumour until proven otherwise. Even one or two of these features should provoke early investigation. A delay of weeks will compromise treatment options and survival.
Red flag symptoms in non-traumatic disorders
Infection
Features of bone and joint infection are those of local inflammation. This can be masked in the immunosuppressed, and infection should be part of the differential diagnosis in a patient with a musculoskeletal swelling who is unwell, on immunosuppressive therapy or suffering from an immunodeficiency disorder. In non-immunosuppressed children, clinical features predictive of osteomyelitis or septic arthritis include:
- inability to weight-bear
- temperature >38°C
- leukocyte count >12 000×109 per litre
- erythrocyte sedimentation rate (ESR) >40 mm/h
- raised C-reactive protein (CRP) level
Red flag symptoms in non-traumatic disorders
Spinal disorders
Additional features identified by the Royal College of General Practitioners are:
- presentation under age 20 or over age 55 years
- non-mechanical pain
- thoracic pain
- past history of carcinoma, steroids, human immunodeficiency virus
- widespread neurological symptoms
- structural deformity.
- Signs of an ‘upper motor neurone’ lesion indicating central cord compression include hypertonic weakness and rigidity, brisk reflexes and sustained clonus
- Causes include spinal infection (pyogenic or tuberculosis), tumour, cervical vertebral subluxation secondary to trauma or rheumatoid arthritis, or a cervical or thoracic central disc prolapse
- Symptoms of sphincter and gait disturbance with saddle anaesthesia are highly suggestive of cauda equina syndrome, requiring an urgent magnetic resonance imaging scan for confirmation of central disc prolapse and appropriate urgent spinal decompression.
Red flag symptoms in non-traumatic disorders
Giant Cell Arteritis
- When this form of vasculitis affects the temporal artery it is known as ‘temporal arteritis’ and can occasionally produce ciliary artery occlusion, leading to blindness.
- Symptoms of polymyalgia rheumatica should prompt questions about temporal pain and blurred vision, and examination for temporal tenderness.
- If these features are present then steroids should be commenced and an immediate rheumatological referral made to include temporal artery biopsy.
Red flag symptoms in non-traumatic disorders
Slipped upper femoral epiphysis
- A mild form of this condition of late childhood and adolescence is important to identify early for the prevention of complete slip and a uniformly poor outcome
- The typical description is of an older boy with an externally rotated leg and unable to bear weight on the affected side being supported by two parents.
- In an adolescent, a radiograph in the antero-posterior and (especially) lateral planes might reveal a slip of the proximal femoral epiphysis
- Even in those able to walk, persistent limp or pain for longer than a week should be investigated promptly to avoid a progressive ‘acute on chronic’ slip
