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Phase 2B Examination Findings > MSK > Flashcards

MSK Flashcards

1
Q

MSK ‘site’ question examples?

A

Pattern of involvement, which joints, small/ large, one/ more, speed of onset, bilateral, symmetrical/ asymmetrical

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2
Q

‘Onset’ questions?

A

When did it start, acute/ chronic, constant since onset, episodic- frequency, regularity and duration of episodes

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3
Q

‘Character’?

A

Ache, sharp, throbbing

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4
Q

‘Radiation’?

A

Neck–> upper limb, lower back pain to buttocks/ lower limb, hip pain to knee

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5
Q

Associated symptoms?

A

Stiffness/ swelling, crepitus, erythema/ increased local temp, fatigue/ malaise/ depression, systemic temp, rashes/ skin conditions, nodules, fever, abdo pain, weight loss- vasculitis, CND, IBD, dry mouth and gritty eyes

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6
Q

Timing questions?

A

Feel like on rising/ at end of the day/ how do you sleep

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7
Q

Exacerbatin factors?

A

Exercise in mechanical/ degenerative; rest in inflammatory

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8
Q

Alleviating factors?

A

NSAIDs, exercise/ rest

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9
Q

Severity?

A

Very- acute gout +/ sepsis, less= RA/OA, any movements painful? Function limited by pain

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10
Q

Completing the MSK HPC Qs?

A

Anything similar previous? Tests, Ix, Tx- response? Previous meds- SEs, why was it changed?, history of trauma? Recent infective episodes- dental/ pharyngeal? Diabetes–> infection? Psoriasis, IBD/ coeliac? TB? AI conditions? RFs for gout?

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11
Q

Drug, social and family Hx?

A

Drug- current med for presenting condition, other meds, over the counter meds- do they work?
Social- occupation, hobbies, home circumstances, ADLs, smoking, alcohol consumption
Family- RA/OA, psoriasis, gout, UC, Crohn’s, CND/ other AI disease

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12
Q

Intro for a GALS exam?

A

Wash hands, intro, confirm patient ID, explain, consent and expose arms: “screen for any joint problems, general inspection, watch you walk, do some head, arms and legs movement, need to remove top, trousers, socks and shoes, chaperone, any pain?”

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13
Q

Screening Qs for GALS exam?

A

Any pain/ stiffness in muscles, joints/ back, able to completely dress and undress yourself without any difficulty? Able to climb up and down stairs without difficulty?

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14
Q

What do you inspect for from the front in GALS?

A

Posture- asymmetry/ scoliosis
Body habitus- obesity can be ass w/ joint path like OA in knees
Skin rashes
Shoulders- bulk, asymmetry
Elbows- joint contractures can result in inability to extend elbow at rest
Leg length and alignment- valgus/ varus deformity
Quadriceps- bulk+ symmetry
Knees- swelling and erythema= inflammatory/ joint sepsis, valgus/ varus deformity, asymmetry from joint effusion, any hyperextension of knee joints
Ankles- swelling and erythema
Feet- mid/ forefoot deformity(flat feet), asymmetry- bunion

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15
Q

From the side in GALS?

A

Cervical spine- hyperlordosis(slipped vertebra)
Thoracic spine- kyphosis(normal= 20-40) Lumbar spine- lordosis(loss= sacroiliac disease)
Knee joints- degree of flexion(hyperextension= hypermobility)

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16
Q

From back in GALS?

A

Shoulder muscles
Spinal alignment
Iliac crest alignment
Gluteal muscle bulk- reduced mobility
Popliteal swellings- Baker’s cyst, popliteal aneurysms
Hind-foot abnormalities- thickening of achilles tendon= tendonitis

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17
Q

Inspect for in gait in GALS?

A 
Walk to end of room, turn around and come bacl
Gait cycle- heel strike, toe-off+ coordination
Antalgic (painful) gait
Normal arm swing
Pelvic tilt
Able to turn quickly 
Normal foot arches/ absent 
Painful/ painless walking
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18
Q

Inspect for what in spine of GALS?

A

Flexion of lumbar spine- put fingers on two adjacent lumbar vertebrae, ask patient to bend forward to touch their toes, observe fingers moving apart and together
Put hands on floor= joint hypermobility

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19
Q

Question to assess shoulders in GALS?

A

Can you place hands behind your head and push your elbows back as far as you can- abduction and external rotation and elbow flexion

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20
Q

Question for wrists and hands in GALS? Inspect for what and assess what?

A

Hands out in front with palms down
Shoulder flexion, elbow extension, wrist extension and extension of small joints of fingers
Asymmetry, swelling and deformity
Nails- pitting (psoriasis)

Turn hands over
Wrist and elbow supination
Muscle bulk of palms

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21
Q

Feel for what in wrists/ hands in GALS?

A

Lateral squeeze of MTC joints- non-verbal signs discomfort (active inflammatory arthropathy)

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22
Q

Questions, assess for what in ‘moving’ wrists/hands in GALS?

A

Can you make a fist- flexion of small joints and hand function (swelling/ deformities)
Can you squeeze my fingers- grip strength(swelling/ nerve pathology)
Can you touch each finger to your thumb?- precision grip, coordination and manual dexterity(inflammation/ contractures)

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23
Q

How position patient for legs in GALS? Question for hips and knees, assess for what?

A

Lying down
Bring foot to bum and straighten again whilst I hold your knee- one at time, feel for crepitus over patella, ROM and symmetry

Passive internal rotation- flex knee and hip to 90 degrees, use ankle to move leg(first to be lost in hip pathology)

Patellar tap- slide left hand down thigh, press down on patella with right hand fingertips

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24
Q

Inspect feet in GALS for what? Do what?

A

Swelling, deformity, callosities

Lateral squeeze of MTT joints- tenderness= inflammatory arthropathy

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25
Q

Presenting a GALS exam?

A 
Performed x on x a x y/o patient 
General inspection, comfortable at rest 
Normal appearance in gait, arms, legs and spine 
Full ROM in all modalities tested 
Consistent with normal exam

Further= regional exam of MSK system

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26
Q

Starting a hip exam?

A

Wash hands, intro, confirm patient, explain, consent and expose: “General inspection, feeling and moving your joints and perform a few special test, chaperone, any pain?”

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27
Q

In hip exam, what to inspect from the front? From side? From behind?

A

Pelvic tilt, joint deformities(fixed flexion,) wasting of quadricep muscles

Exaggerated lumbar lordosis- fixed flexion deformity

Wasting of gluteal muscles, scoliosis of the spine- can be primary or secondary to pelvic tilt

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28
Q

How to assess gait in hip exam and what to assess? Ask patient to do what?

A

From various angles
Footwear
Speed/ smoothness/ turning(waddling- hip pain/ proximal muscle weakness, antalgic- pain on weight-baring, stance phase abnormally shortened relative to swing phase

Lay down on exam cough

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29
Q

Assess what two things when patient laid down in hip exam?

A

Apparent leg length- xiphisternum to medial malleolus(influenced by pelvic tilt)
True leg length- from ASIS to medial malleolus, if discrepancy- in tibia or femur–> bend knees to right angle and heels flat, inspect from side, hand across both tibial tuberosities, femoral= hand dip down towards shortened side, both suprapatellar regions, tibial= dip down towards shortened side

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30
Q

Ask what in ‘feel’ of hip exam?

A

Any pain/ tenderness in hips, temp using dorsum of hand in upper thigh and greater trochanter
Palpate greater trochanter or trochanteric bursitis

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31
Q

3 hip movements for active ROM?

A

Abduction- keep legs straight and move them outwards(normal= 45 degrees)
Adduction- move inwards(normal= 30 degrees)
Flexion- bring knees towards chest (normal= 120 degrees)

32
Q

3 hip movements for passive ROM?

A

Flexion- stabilising ASIS
Abduction- stabilise contralateral iliac crest and use other hand to abduct hip until feel tilt (normal= 45 degrees)
Adduction- stabilise contralateral iliac crest and use other hand to adduct hip across midline as far as possible (normal ROM= 30 degrees)

Internal and external rotation in extension
Internal= flex hip and knee to 90 degrees and rotate foot laterally(normal= 40 degrees)
External= flex hip and knee, rotate foot medially(normal= 45 degrees)

33
Q

2 special tests for hip exam?

A

Thomas’ test- hand under lumbar spine, passively flex unaffected leg, hand should detect lumbar lordosis flattened, contralateral leg should be flat on bed
Repeat on other hip joint (raises off= loss of extension, fixed flexion deformity)

Trendelenburg’s sign- hands on iliac crests on either side, stand on one leg for 30 seconds, observe hands up/down,(normal= side with foot off ground should rise, +ve= pelvis falls on side with foot off ground= weak hip abductors on contralateral side)

34
Q

Presenting hip exam?

A 
General inspection= comfortable at rest 
No abnormalities on inspection 
Normal gait 
Palpation= no tenderness
Full ROM in all modalities tested 
Special tests= -ve 
Consistent with normal hip exam

Further= lumbar spine, ipsilateral knee joint, full neurological and vascular exam of patient’s lower limb

35
Q

Starting a spine exam?

A

Wash hands, introduce, confirm patient ID, explain, consent and expose: “General inspection, feel, some movements and some special tests, remove top, chaperone, any pain?”

36
Q

What to look for from bedside, front, side and behind for spine exam?

A

Aids/ adaptations; walking stick/ wheelchair

Posture of head and neck
Symmetry of shoulders

Cervical hyperlordosis(spondylolisthesis, spondylosis)
Thoracic hyperkyphosis>45 degrees= vertebral fracture 
Lumbar hyperlordosis- obesity/ tight lower back muscles

Scars
Wasting of paraspinal/ back muscles; chronic immobility
Scoliosis
Cafe-au-lait spots; neurofibromatosis
Sacral dimple/ naevus/ hairy patch; spina bifida

37
Q

Assessing gait in spine exam?

A

Normal heel-strike/ toe off gait, normal height, smooth and symmetrical, obvious abnormalities
Place supine on couch with hips and knee extended and inspect

38
Q

What would you feel in spine exam?

A

Spinal processes, sacroiliac joints and paraspinal muscles

Thyroid, supraclavicular fossae and cervical lymph nodes for masses- cervical rib, lymph glands, tumours

39
Q

Testing flexion in cervical spine? Extension? Lateral flexion? Rotation? What if reduced ROM on active movements?

A

Touch chin to chest
Schober’s test- posterior superior iliac spine, 5cm below and 10cm above, touch toes, normally= increases by >5cm(reduced=AS)
Look up to ceiling- 50 degrees
Ear to shoulder- restricted= cervical spondylosis
Turn head left to right, restricted= cervical spondylosis

Perform passively with one hand on neck for crepitus and other on top of head for movement

40
Q

Testing flexion in lumbar spine, spine exam? Extension? Lateral flexion?

A

Touch toes with legs straight- normal= <7cm from ground

Lean backwards as far as possible- thoracic= 25 and lumbar= 35 degrees (restricted in prolapsed IV disc)

Stand straight, hands by sides, feet 30cm apart
Measure distance tips to floor
“Slide hand down as far as you can”- difference= should be 10cm

41
Q

What movement for thorax in spine exam?

A

Rotation(45 degrees)- arms crossed, sat, turn side to side

42
Q

Last step of spine exam?

A

Percuss- bend forward and lightly percuss spine from root of neck of sacrum(infection, fractures and neoplasia)

43
Q

Special tests for spine exam?

A

Straight leg raise/ sciatic stretch test(disc prolapse)- place supine on bed, hold ankle and raise leg while knee straight(+ve= buttock pain, indicates sciatica, back pain= central disc prolapse), lower leg until pain gone and dorsiflex foot to increase tension

Bowstring test- flex hip, if pain, flex knee slightly and apply pressure to pop fossa(radiating pain= nerve root irritation)

Femoral nerve stretch- position prone, flex knee and extend hip, plantarflex foot(+ve= anterior thigh pain)

Suspected AS= chest expansion at 4th IC space(normal= 3-5cm), can be reduced in AS

44
Q

Presenting spine exam?

A 
General inspection= comfortable at rest 
No abnormalities on inspection 
Normal gait 
Palpation= no tenderness 
Full ROM in all modalities 
Special tests= -ve 
Consistent with normal exam

Further= full neuro and vasc exam of upper and lower limbs, hip and shoulder joints, peripheral pulses and lower back pain= abdo exam and rectal exam

45
Q

Intro to a knee exam?

A

Wash hands, confirm patient ID, explain, consent and remove patient’s trousers, shoes and socks: “General inspection, feeling and moving your joints and then perform a few special tests, chaperone, any pain”

46
Q

Look for around bedside, anteriorly, from side and behind in knee exam?

A

Mobility aids/ adaptations
Scars, swelling, asymmetry, valgus/ varus knee, quadriceps wasting
Knee hyperextension, flexion deformity
Scars, asymmetry, popliteal swellings

47
Q

Gait in knee exam?

A

Normal heel strike/ toe off gait, normal height?- high-stepping gait in foot drop, smooth and symmetrical, obvious abnormalities, position supine with hips and knee extended and inspect

48
Q

Feel for what in knee exam?

A

Temperature- mid-thigh, patella and upper tibia- normally feels cooler than surrounding
Palpate knee and surrounding structures when extended-
quadriceps tendon; tenderness in tendonitis, patella; medial and lateral patella facets whilst stabilising one side of the patella and palpate with fingertip of other
Patellar tap
Palpate when flexed to 90 degrees- patella tendon, tibial tuberosity, joint line, head of fibula, medial and lateral collateral ligaments, popliteal fossa

49
Q

Active movements in knee exam?

A

Flexion- move heel to bottom(normal= 135 degrees), extension- now straighten(normal= 0 degrees)

50
Q

Passive movements in knee exam?

A

Flexion and extension whilst feeling for crepitus

Hyperextension; elevate both by heels, <10 degrees= normal

51
Q

Anterior draw test in knee exam?

A

Knee flexed to 90 degrees and foot flat on bed, stabilise leg with forearm across, position fingers behind knee, thumb on tibial tuberosity, forward pull
positive= significant movement, anterior cruciate ligament damage

52
Q

Posterior sag test?

A

Flex knee to 90 degrees and foot flat, inspect from side, posterior sag of upper tibia with ‘step’ visible below the patella= posterior cruciate ligament damage

53
Q

Lateral CL test?

A

Flex knee to 20 degrees, grasp heel with one hand and exert pressure against medial knee with other
LCL damaged= hand detect lateral aspect of joint opening up

54
Q

Medial collateral ligament test?

A

Flex knee to 20 degrees, exert pressure against lateral knee with other, grasp heel with one hand
MCL damage= feel medial aspect opening up

55
Q

McMurray’s test?

A

Flex hip to 90 degrees and maximally flex knee, externally rotate knee and maintaining, move knee gradually from fully flexed position to fully extended
Repeat using internal rotation

56
Q

Presenting a knee exam?

A

“Today I performed a knee examination on [name] a [age] year old
[gender].”
o On general inspection, [name] appeared comfortable at rest.
o No abnormalities were detected on inspection.
o There was normal gait.
o On palpation, there was no tenderness.
o Full range of movement in all modalities tested.
o Special tests were negative.

o To conclude, this is consistent with [diagnosis/a normal knee
examination]”.

o “To complete my examination, I’d like to examine the patients ipsilateral hip
and ankle and perform a full neurological and vascular examination of the
patient’s lower limb”.

57
Q

Intro for shoulder exam?

A

Wash hands, introduce, confirm patient, explain, consent and expose: “general inspection, feel, some movements and some special tests, chaperone, pain?”

58
Q

Look for what around bedside, anteriorly, laterally, posteriorly in shoulder exam?

A

Aids/ adaptations
Scars, asymmetry- scoliosis, arthritis, trauma, bony prominence, swelling, muscle wasting
Scars
Scars, asymmetry/ deformity- winged scapula(hands against wall- long thoracic nerve injury, scoliosis), paravertebral muscles- swelling/wasting, in supra/ infraspinatus fossa

59
Q

Feel what in shoulder exam?

A

Temperature

SC joint, clavicle, AC joint, GH joint, coracoid process, head of humerus, greater tuberosity of humerus, spine of scapula

Muscle bulk of- deltoid, supraspinatus, infraspinatus, trapezius

60
Q

Screening examination in shoulder exam?

A

Put hands behind head and push elbows back- external rotation and abduction, behind back and push back(internal rotation, abduction)- difficulty, limitation/ pain

61
Q

Active movements of shoulder exam?

A

External rotation- flex to 90 degrees, tuck into side and rotate outwards- lost in frozen shoulder
Internal- above but inwards
Flexion and extension- raise arms in front and behind them
Ab/ adduction- to side palm downwards and lower(normal= 180 degrees), across each other for adduction, observe front and behind for symmetrical scapula
Assess glenohumeral and scapulothoracic movement
(Rotator cuff pathology often pain from 60-120 degrees, may be alleviated by repeating with palm facing upwards, only at end may be ACJ arthritis)

62
Q

Passive movements in shoulder exam? Function Qs?

A

External/ internal rotation, flexion/ extension, abduction/ adduction
Feel for crepitus
Dress themselves without difficulty, wash their own hair?

63
Q

Motions of rotator cuff muscles?

A

Supraspinatus= resisted abduction first 15 degrees, deltoid= up to 90 degrees, trapezius/ serratus anterior= scapular rotation for abduction> 90 degrees
Infraspinatus, teres minor= resisted active external rotation
Subscap= resisted internal rotation

64
Q

Special tests for shoulder exam?

A

“Lift-off test”- place dorsum behind lower back, apply light resistance to hand, ask to move hand off back (loss of power= subscapularis pathology)

“Scarf test”- put arm across chest to opposite shoulder- any pain/ tenderness over ACJ?

65
Q

Presenting a shoulder exam?

A

Further tests= examine cervical spine, elbow joints and full neurological and vascular exam of patient’s upper limbs

66
Q

Look for what local and global issues in nails of hand exam?

A

Local= pitting/ nail ridges- psoriasis, onycholysis- psoriasis/ fungal infection/ hyperthyroidism, hypertrophic- post-traumatic/ PVD

Global= splinter haemorrhages, clubbing

67
Q

Look for what on dorsum of hands?

A

Skin- colour(Raynaud’s,) changes(sclerodactyly, ulceration due to neuropathies,) psoriasis, scars, muscle wasting, deformity

68
Q

Deformities on dorsum of hand?

A

Focal swelling- dactylitis(psoriatic arthritis, arthropathies ass w/ AS/IBD,) nodular, swan neck+ Boutonniere, ulnar deviation, clawing, wrist swelling

69
Q

Look for what on palms?

A

Skin, scars, muscle wasting- thenar and hypothenar, Dupuytren’s, elbow- nodules/ psoriatic plaques

70
Q

Feel for what 4 things in hand exam?

A

Temperature- both sides, over redness areas

Joints- 4 fingers for joints, 2 hands for palm, joints from wrist to metacarpals by sliding thumb distally, lateral squeeze of MCPJs, anatomical snuffbox

Neuro- C6-8 dermatomes, median, ulnar and radial nerve distributions

Vascular- ulnar, radial pulses, Allen’s test

71
Q

What movements in hand exam?

A

Fingers= flexion/ extension(full fist and straighten,) abduction/ adduction- spread fingers apart and bring back together

Thumb- flexion/ extension(to side and back together,) abduction/ adduction- point to ceiling, opposition- thumb to little finger

Wrist- dorsiflexion; prayers sign keeping elbows straight
Palmar flexion; reverse and keep elbows straight

72
Q

Function tests in hand exam?

A

Grip strength:
Lateral pinch grip- hold key/ pen
Power grip- clench pen and pull out
Precision grip- can you undo and do up buttons

73
Q

Tests for median nerve(Carpal tunnel syndrome)?

A

Sensation- light touch
Motor- thumb palmar abduction against resistance

Tinel’s test- tap strongly(+ve= pain/ tingling over area)
Phalen’s test= reverse prayer sign for one minute

Compression test- direct pressure over carpal tunnel can reproduce symptoms

74
Q

Ulnar nerve tests?

A

Sensation- light touch
Motor- cross index and middle fingers, grip paper between thumb and index finger without flexing thumb IP joint
Finger abduction against resistance

75
Q

Radial nerve tests?

A

Sensation- light touch in radial nerve distribution, motor= wrist and finger dorsiflexion against resistance

76
Q

Presenting a hand exam?

A

“Today I performed a shoulder examination on [name] a [age] year old
[gender].”
o On general inspection, [name] appeared comfortable at rest.
o No abnormalities were detected on inspection.
o On palpation, there was no tenderness.
o Full range of movement in all modalities tested.
o Sensation was intact.
o Special tests were negative.
o To conclude, this is consistent with [diagnosis/a normal hand
examination]”.
FURTHER= observe elbow joint if pain/ restricted movement at wrist joint and perform full neurological and vascular examination of patient’s upper limbs

Phase 2B Examination Findings (8 decks)

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