Joint Examination and History Flashcards
How do you take a joint History
History of presenting compliant
- What have you come to see us with today?
- Do you have any other symptoms?
- How are you feeling at the moment
- How long has it gone on for
- Has this happened before and when did it start
- was the start of this pain associated with a specific event
- What does it (pain) feel like
- Do it start suddenly or a gradual onset
- Where speficially is the pain and does it spread
- What is the character of the pain
– does anything make it better or worse
- What treatments has this responded to
- can you rate the pain on a scale of 0-10
- How are you generally – are you fit and well
Then go into more specific questions about symptoms:
- what is the impact on your day to day activities such as getting out of bed, washing, dressing
- how does it affect your mood
- how does it affect what you do for a living
- what would you like to be able to do but currently are unable to do
Ideas Concerns Expectations
- Do you have any idea of what might be going on
- Is there anything that is worrying you specifically
- What were you hoping id be able to do for you today
Past Medical history - Do you have any medical conditions - Have you seen anyone for this before Specific questions - Have you had contact with those that are unwell recently -
Drug history and allergies
- What prescribed medication do you take
- What over the counter medication do you take
- Have you taken any illicit substances?
- Do you have any allergies?
Social history
- What do you do for a living
- Do you smoke – how long have you smoked, how many cigarettes do you smoke a day
- Do you drink
- Where do you currently live
- Do you have a support network that helps you
- Do you require any assistane in day to day life
- How much exercise do you do – how often and what type
Family History
- Has your family had any significant illness
- Are they well and still alive
Systematic review
Now just before we finish I just have some quick general questions to ask
- Have you had a fever
- Any weight changes
- Do you fill fatigued
- Have you had a cough?
- Do you get any stomach pain or nausea and vomiting
- Are you going to the toilet as usually?
- Have you had a headache, any visual changes, or motor and sensory disturbances
- Any chest wall pain, or trauma
- Do you have any rashes or other skin problems
Before I examine you is there anything else that you would like to add or think that I have missed
How long does a musculoskeletal symptom have to go on for before it is described as chronic
lasting more than 6 weeks is described as chronic
What are the main symptoms of musculoskeletal conditions s
- pain
- stiffness
- joint swelling
what are inflammatory joint conditions associated with
- conditions such as rheumatoid arthritis are associated with early morning stiffness that eases with activity
what are non inflammatory joint conditions associates with
- non inflammatory joint conditions such as osteoarthritis are associated with pain more than stiffness and the symptoms are exacerbated by activity
where is pain from the acromioclavicualr joint and the genohumeral joint felt
Acromioclavicular joint = tis pain is usually felt in that joint
glenohumeral joint = pain form the glenohumeral joint or rotator cuff is usually felt in the upper arm
where can pain in the knee be felt
- can sometimes be felt in the knee
- or sometimes in the hip and ankle
What does pain due to compression of nerves feel like
- feels like a numbness and a tingling sensation associated with it
what does serve bone pain feel like and is suggestive of
- suggestive of underlying malignancy
- often unremitting and persists throughout the night which disturbs the patients sleep
the duration of morning stiffness is a rough guide to…
the duration of morning stiffness is a rough guide to the activity of the inflammation
can inflammatory diseases cause pain
- with inflammatory diseases such as rheumatoid arthritis where joint destruction occurs over a prolonged period of time the inflammatory component may become less active and give way to a secondary mechanical pain as a result of the damage
- can be difficult to distinguish between pain and stiffness
what is a good indiction of inflammatory disease process
- history of joint swelling
when does swelling of the knee happen
- less suggestive of inflammatory disease and can occur with trauma and in OA
what are differential diagnosis of swelling and inflammatory process
- can have swelling of DIP and PIP but this can be a sign of osteoarthritis
- swelling in the knee more commonly occurs in trauma and OA
- ankle swelling is common due to oedema than to swelling of the joint
when is an inflammatory disease less likely
- pain at end of day/ after use
- morning stiffness for less than 30 minutes
- no systemic symptoms
- chronic symptoms
When is an inflammatory disease more likely
- pain worse after rest
- morning stiffness for greater than 30 minutes
- systemic symptoms present
- actue/subacute onset
What are the common patterns of joint involvement
- Monoarticular - one joint (septic arthritis)
- pauciarticular - only a few joints affected (psoriatic arthritis)
- polyarticular - many joints affected (rheumatoid arthritis)
- axial - spine predominantly affected (ankylosing spondylitis)
- symmetrical (rheumatoid) or asymmetrical( osteoarthritis)
- large (osteoarthritis - more likely to be weight bearing joints) or small joints
What investigations can you use to classify musculoskeletal presentations
- imaging of bone and joints
- blood tests
- synovial fluid analysis
What can a plain X ray be useful for
- rheumatoid arthritis
- osteoarthritis
- gout
- can be useful as they can provide a historical record and show the changes one time
what are DEXA scans used for
osteoporosis
what is the ESR used for
- inflammatory marker - indicates what has been happening over the last few days
What markers in blood tests do you look for
- ESR - inflammation
- C- reactive protein - inflammation
- serum uric acid - for gout
- autoantibodies - such as rheumatoid factor and Anti CCP
Describe how to examine the knee
WIPER
- wash hands
- introduce yourself
- permissions and pain
- expose the patient
- reposition the patient lying down at a 45 degree angle
look for the end of bed
- symmetry
- loss of normal leg alignment - varus and vagus
- left up the heel and make sure both of them fully extend
- look at quadriceps muscle bulk and any swelling that you see in the knee itself
- look over the rest of the lower limb for scars, and rashes such as psoriasis
Palpate the knee
- assess for temperature using the back of your hand - above the joint line and below the joint line
- then feel around the patella - around the superior and inferior border
- feel round the back of the knee for popliteal swellings and cyst
patella tap
- make sure no fluid within the knee joint itself
- put the hand above the knee in the superior patella bursa and squeeze downwards
- with either the thumb or two or three of my fingers push down of the patella and see if it bounces back up
- if it is positive patella tap - you would have the sensation of the patella hitting the femoral condyle
- needs just the right amount of fluid - too much or too little you won’t get the sensation
- can look for a bulge of fluid on the inside aspect of the knee - milk up the fluid and go round the knee to see a bulge of fluid
bring the knee up to 90 degrees
- feel the knee at 90 degrees - opens up the joint line
- can feel into the joint line round the medial and lateral collateral ligament
- also feel around the back fo the knee and make sure there is no tenderness there
movement
- get them to bend there knee all the way up and straighten all the way down
- put a hand on the top of the patella and feel for crepitus
anterior draw test
- knee flexed to 90 degrees - view the knee from the side
- put he fingers into the hamstring and the hand on the tibial condyle and use the elbow to brace the lower leg and pull gently towards you
- watch the patients face for any sign of pain
- if a positive test you can feel the knee moving forward
- this is to check the ACL
- do the same for posterior put push towards the patient - checks for PCL
collateral ligament
- bring the knee 15 degrees to unlock the knee
- hold the knee and Lowe leg
- use the left hand to push on the lateral collateral ligament which stresses the medial collateral ligament
- then do the opposite for the lateral collateral ligament
- shouldn’t feel any movement
get them off the couch
- inspect them in stance
function
- get them to walk
- look for a limp, normal extension and flexion
Describe how to do a hip examination
WIPER
- wash hands
- introduce yourself
- permissions and pain
- expose the patient
- reposition the patient lying down at a 45 degree angle
- patient lying as flat as possible
- look from the end of bed for things such as asymmetry, one leg shorter than the other, externally or internally rotated
Measuring the leg
- palpate over the Anterior iliac crest and measure to the medial malleolus of the ankle
- if there is a difference in the measurements can be due to a real leg length discrepancy
- or a fixed flexion deformity
feel of the hip
- need to expose the patient and have a good look at the outside of the hip
- palpate down over the greater troncatner for any tenderness s
- feel in the joint line itself
movement
- full flexion of the hip
- bend the knee all the way up
- do internal rotation and external rotation while the hip is flexed
Thomas’ test
- put hand under back
- as you lift the right leg the lumbar spine is pushing down into the hand and the lumbar lordosis has been removed
- forces the pelvis to tilt - if there is a fixed flexion deformity will lift the left leg of the couch
- if it is positive - the left leg raises of the couch
trendelenburgs test
- alternative standing on one leg alone
- in a negative test the pelvis remains level
- in a positive test it goes downwards on the contralateral side
function
- assess the patient walking
- waddling gait - proximal muscle weakness or hip problem
