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Phase 2B medicine > MSK history and examination > Flashcards

MSK history and examination Flashcards

1
Q

What do you need to ask about the site of pain?

A

What is the pattern of joints involved?

  • Which joints?
  • Small or large?
  • Single/multiple?
  • Bilateral?
  • Symmetrical/asymmetrical?
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2
Q

What are some associated symptoms of MSK pain?

A 
Stiffness and/or swelling
Crepitus
Erythema
Increased local temperature
Fatigue
Malaise
Depression
Systemic temperature
Rashes/skin conditions
Nodules
Abdominal pain
Weight loss
Systemic symptoms
Dry mouth and gritty eyes
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3
Q

What do you need to ask about timing?

A

Relationship to time of day?

  • How do they feel in the morning/evening?
  • How do you sleep?
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4
Q

What do exacerbating factors have to do with the type of condition?

A

Exercise - mechanical/degenerative conditions

Rest - inflammatory conditions

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5
Q

What do you ask in a MSK PMH?

A 
Anything similar previously?
Tests/diagnoses/treatments? Did they work? S/E?
Hx of trauma?
Recent infective episodes?
Diabetes?
Psoriasis? IBD? Coeliac disease?
TB?
Autoimmune conditions?
Risk factors for gout?
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6
Q

What do you ask in a drug Hx?

A

Current medications for presenting condition
Other current medications
OTC? Do they work?

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7
Q

What should you ask in a social Hx?

A 
Occupation - does it affect their employment?
Sports and hobbies?
Home circumstances
AODL
Smoking
Alcohol
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8
Q

What should you ask in a FHx?

A

FHx of RA, OA, psoriasis, gout, UC, Crohn’s, connective tissue disease or any other autoimmune diseases?

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9
Q

What are the initial questions to ask in a GALS examination?

A

Do you have any pain or stiffness in your muscles, joints or back?
Are you able to completely dress or undress yourself without difficulty?
Are you able to climb up and down stairs without any difficulty?

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10
Q

What are the main steps in a GALS examination?

A 
Inspection
Gait
Arms
Legs
Spine
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11
Q

What do you look for in the inspection and how do you do it? GALS

A

Look from front - abnormalities in shoulders, elbows, wrists, hands, chest, hips, knees, thighs and feet
Look from side - presence of normal spine curvatures, hip and knee flexion deformities or knee hyperextension
Look from back - abnormalities in shoulders, spine, and paraspinal muscles, level of iliac crests, gluteal regions, popliteal fossae, calves, achilles tendons nad hind feet

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12
Q

What do you look for in their gait and how do you do it? GALS

A

Ask patient to walk a few steps, turn and walk back
Comment on arm swing, pelvic tilt, stride length, ability to turn quickly and any painful gait on walking
Ask whether walking is painful/painless

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13
Q

What do you assess in the spine? GALS

A

Assess flexion of lumbar spine

Assess lateral flexion of neck

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14
Q

What should you observe in the arms? GALS

A

Shoulders

Wrists and hands

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15
Q

What movements do you need to do when assessing the shoulders? GALS

A

Ask patient to put their hands behind their head and push their elbows back
Observe abnormalities in ROM of shoulder abduction and external rotation and elbow flexion

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16
Q

What do you need to do when assessing the hands and wrists? GALS

A

Look
Feel
Move

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17
Q

What should you look for in the wrists and hands? GALS

A

Hands out in front of them palms down
Ask them to turn hands over palms up
Observe any joint swelling, deformity, loss of contours, muscle wasting, skin/nail changes and nodules in wrists and hands
Observe ability to supinate and pronate at elbow
Observe ability to fully straighten elbow

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18
Q

What do you feel for in the hands? GALS

A

Assess tenderness by performing lateral squeeze of MCPs

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19
Q

What do you look for when you move the hands? GALS

A

Check ability to make a full fist covering the nails
Ask patient to squeeze fingers to assess grip strength
Ask patient to bring each finger to meet the thumb

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20
Q

What do you look at in the legs? GALS

A

Hips and knees

Feet

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21
Q

What do you look for in the hips? GALS

A

Ask the patient to fully flex and extend their knee placing hand over knee to assess for crepitus
Bend knee and hip to 90 degrees
Hold knee and use ankle to move leg assessing external and internal rotation of the hip
Patellar tap test/bulge test

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22
Q

What do you look for in the feet? GALS

A

Inspect soles for swelling, deformity or callosities

Squeeze across MTP joints checking for tenderness

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23
Q

What are the steps in a joint examination?

A

Look
Feel
Move
Special tests

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24
Q

What do you look for in a hip examination and how do you do it?

A

With patient standing
- Inspect from front for pelvic tilt, joint deformities, wasting of quadriceps
- Inspect from side for exaggerated lumbar lordosis
- Inspect from behind for wasting of gluteal muscles and scoliosis
- Look at stance
With patient supine
- Inspect for scars in groin, anterior and lateral thighs
- Roll patient onto side to inspect gluteal region
Assess symmetry - leg length discrepancy?

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25
How do you measure leg length?
Apparent leg length - from xiphisternum to medial malleolus True leg length - from ASIS to medial malleolus If true leg length discrepancy then assess whether originates in tibia/femur Position patient with knees bent up to right angle and heels flat on bed Inspect from side Place hand on both tibial tuberosities - if femoral shortening then hand will dip down towards shortened side Place hand on suprapatellar regions, if tibial shortening then hand will dip down towards shortened side
26
What do you feel for in a hip examination?
Ask patient if they have tenderness in hip Assess temperature in upper thigh and greater trochanter Palpate greater trochanter for trochateric bursitis
27
How do you move the joint in a hip examination?
Check active ROM in flexion, abduction and adduction | Check passive ROM in the same + internal and external rotation
28
What is the normal active ROM in hip flexion?
115-125
29
What is the normal active ROM in hip abduction?
40-50
30
What is the normal active ROM in hip adduction?
15-25
31
What is the normal passive ROM for internal rotation in extension?
30-40
32
What is the normal passive ROM for external rotation in flexion?
25-50
33
What is the normal passive ROM for internal rotation in flexion?
25-40
34
What special tests do you do in a hip examination?
Thomas' test Assess gait Trendelenburg's test
35
What is Thomas' test?
Assessing for fixed flexion deformity of contralateral hip Place hand under patients lumbar spine to check for fill correction of lumbar lordosis then observe contralateral hip as flex hip fully If fixed flexion deformity then raise leg off bed
36
What is Trendelenburg's test?
Ask patient to stand on one leg to assess the abductor muscle strength of that hip In a negative (normal) test, pelvis remains level or rises on contralateral side as contracts abductors In positive test, pelvis will dip on contralateral side
37
How should you complete a hip examination?
Examine patients lumbar spine and ipsilateral knee joint | Perform a neurological and vascular examination of lower limb
38
What do you look for in a knee examination and how do you do this?
``` With patient standing inspect from front, side and back for... - Valgus deformity - Varus deformity - Genu recurvatum - Flexion deformity - Swellings in popliteal fossa - Comment on patients stance With patient supine with hips and knees extended inspect for... - Symmetry - Valgus and varus deformities - Rashes - Scars - Swelling - Muscle wasting - Displacement of patella - Fixed-flexion deformity ```
39
What do you feel for in a knee examination?
Assess temperature Palpate around borders of patella for tenderness at full extension and 90 flexion Palpate behind the knee for popliteal swellings or cysts Assess for effusion by either - bulge test or patellar tap
40
What is the bulge test?
Sweep hand firmly up medial fossa, over suprapatellar pouch and down lateral fossa Medial fossa may refill producing a bulge of fluid
41
What is the patellar tap test?
Compress suprapatellar pouch to empty it | Press down on patellar
42
How do you move the joint in a knee examination?
Actively flex and extend knee Passively flex and extend knee Palpate for crepitus
43
What special tests do you do in a knee examination?
``` Posterior sag test Anterior draw test Lateral collateral ligament test Medial collateral ligament test Gait ```
44
How do you do a posterior sag test?
Position patient with knee flexed to 90 and foot flat on bed Inspect from side Posterior sag of upper tibia with step visible below patellar suggestive of PCL damage
45
How do you do an anterior draw test?
Position patient with knee flexed to 90 and foot flat on bed Stabilise leg using forearm With fingers of both hands behind knee and patients hamstrings relaxed, place thumbs over tibial tuberosity and apply a forward pull Significant movement indicates positive draw test and suggests ACL damage
46
How do you do a lateral collateral ligament test?
Flex knee to 20 Grasp patients heel with one hand whilst exerting pressure against inside of knee with other hand Varus stress applied causes lateral gaping in laterally unstable knee Small amount of lateral joint gaping is physiological and is asymmetry of gaping that constitutes abnormal finding
47
How do you do a medial collateral ligament test?
Flex knee to 20 Grasp patients heel with one hand whilst exerting pressure against outside of knee with other hand Valgus stress applied causes medial gaping in medially unstable knee Small amount o medial lateral joint gaping is physiological and is asymmetry of gaping that constitutes abnormal finding
48
How should you complete a knee examination?
Examine ipsilateral hip and ankle | Assess neurological and vascular status of limb
49
How do you inspect the spine in a spinal examination?
Inspect from front, side and behind | Inspect skin, cervical spine and thoracolumbar spine
50
What do you look for in the skin in a spinal examination?
``` Cafe-au-lait spots (neurofibromatosis) Sacral dimples Naevus Hairy patch suggestive of spina bifida Scarring suggestive of previous thoractomy or spinal surgery ```
51
What do you look for in the cervical spine in a spinal examination?
Deformity - cervical spondylosis, acute torticollis Abnormal head posture Asymmetry of the clavicles, scapulae and shoulders
52
What do you look for in the thoracolumbar spine in a spinal examination?
Kyphosis or scoliosis
53
What do you feel for in a spinal examination and how do you do it?
Palpate cervical spine posteriorly in midline, laterally and anteriorly Palpate supraclavicular fossae for any masses Palpate thoracolumbar spine and sacrum for tenderness Palpate paraspinal muscles Palpate for tenderness over sacroiliac joints
54
How do you assess the active ROM in the cervical spine?
Flexion Extension Lateral flexion Lateral rotation
55
What is the normal active ROM for flexion of the cervical spine?
80 - chin able to touch sternoclavicular joint
56
What is the normal active ROM for extension of cervical spine?
50
57
What is the normal active ROM for lateral flexion of the cervical spine?
45 from midline
58
What is the normal active ROM for lateral rotation of the cervical spine?
80 to each side
59
How do you assess the ROM of the thoracolumbar spine?
Flexion Extension Lateral flexion Rotation
60
How do you assess flexion of the thoracolumbar spine?
Combination of thoracic, lumbar and hip movements Composite movement recorded as distance between patient's fingers and ground Modified Schober's test
61
How do you do the modified Shoeber's test?
15cm length of lumbar spine with patient erect Measure 10cm above and 5cm below PSIS Instruct patient to flex spine maximally Remeasure distance between marks Normally increases distance by at least 5cm
62
How do you assess extension of the thoracolumbar spine and what is normal?
Arch back Thoracic 25 Lumbar 35
63
How do you assess lateral flexion of the thoracolumbar spine?
Stand erect with hands at sides and feet 30cm apart Measure distance from finger tips to floor Flex maximally and remeasure distance from finger tips to floor Normally > 10cm
64
How do you assess rotation of the thoracolumbar spine?
Seated Fold arms across chest and twist round to each side Mostly thoracic - 40 Lumbar contribution < 5
65
How do you percuss the spine in a spinal exam?
Bend forwards slightly and percuss spine from root of neck to sacrum Significant percussion tenderness is feature of infection, fractures and neoplasia
66
What special tests should you do in a spinal exam?
Gait Full neurological examination of upper and lower limbs Abdominal examination if lower back pain Peripheral pulses Shoulder joints if neck pain Lower back pain examine hips If suspected prolapsed intervertebral disc - bowstring test/femoral stretch test Test for ankylosing spondylitis if suspected
67
How do you test for a suspected prolapsed intervertebral disc?
Straight leg raise - lie flat on couch and passively flex thigh with leg extended - if complains of back or leg pain test is positive Lower leg gradually until pain disappears then dorsiflex foot which should increase tension in nerve roots aggravating pain
68
What is Bowstring test?
Straight leg raise If patient experiences pain, flex knee slightly and apply firm pressure with thumb in popliteal fossa to stretch tibial nerve radiating pain and paresthesiae suggest nerve root irritation
69
What is the femoral stretch test?
With patient prone and anterior thigh fixed to couch, flex each knee in turn Causes pain in skin overlying anterior compartment of thigh by stretching the femoral nerve roots in L2-4 Pain produced normally aggravated by extension of the hip
70
How do you test for suspected ankylosing spondylitis?
Assess chest expansion at level of 4th intercostal space | Normal 3-5cm
71
How do you examine a patient in a shoulder examination?
Standing | From the front, side and back
72
What should you inspect for from the front in a shoulder examination?
``` Symmetry Posture Swelling Deformity Bony prominence Muscle wasting Scars Skin changes ```
73
What should you inspect for from the back in a shoulder examination?
Muscle bulk Abnormalities in the scapula Scars/skin changes
74
What should you palpate in a shoulder examination?
Assess temperature Palpate from the front, work from medial to lateral - look for joint tenderness, swelling and crepitus Palpate muscle bulk of deltoid, supraspinatus, infraspinatus, trapezius
75
What is the screening examination for ROM in a shoulder examination?
Ask patient to put hands behind head and push elbows back as far as they can (external rotation and abduction) Ask the patient to put their hands behind their back (internal rotation and abduction)
76
How do you assess the active ROM in a shoulder examination?
External rotation - flex elbow to 90 and tuck into patients side, turn arm outwards Internal rotation Flexion and extension Abduction (checking painful arc)
77
How do you assess passive ROM in a shoulder examination?
``` Internal and external rotation Flexion Extension Abduction Palpate shoulder for creptius ```
78
What questions should you ask the patient in shoulder examination?
Can they dress themselves without difficulty? | Can they wash their own hair?
79
What special tests should you do in a shoulder examination?
Test rotator cuff | Acromioclavicular joint pathology
80
How do you test the rotator cuff?
Resisted active abduction (supraspinatus) Resisted active external rotation (infraspinatus and teres minor) Resisted active internal rotation (subscapularis)
81
How do you test for acromioclavicular joint pathology?
Place arm into forced adduction (scarf test)
82
How should you complete a shoulder examination?
Examine cervical spine and elbow | Assess neurological and vascular status of limb
83
What should you inspect in a hand exam?
Hands - nails, palm and dorsum | Elbow
84
What should you look for in the nails in a hand exam?
``` Pitting and/or nail reidges Onycholysis Onychogryphosis Splinter haemorrahes Clubbing ```
85
What should you look for on the palm and dorsum of the hand in a hand exam?
Skin - colour, changes, psoriasis Scars Muscle wasting Deformities
86
What deformities might you see in the hands?
``` Dactylitis Bouchards/Herbeden's nodes Swan neck and Boutonniere deformities Squaring of the hand Windswept deformity Clawing Wrist swelling Dupuytren's contracture ```
87
What should you look for on the elbow in a hand exam?
Rheumatoid nodules | Psoriatic plaques
88
What should you palpate for in a hand exam?
Temperature Tenderness, swelling or bony deformities Squeeze test of MCPJs Palpate along dorsal and volar aspect of metacarpals and phalanges Palpate radial and ulnar aspects of phalanges Check sensation in dermatomes and peripheral nerve (median, ulnar and radial distribution) Check ulnar and radial pulses Allen's test
89
How do you test range of motion in a hand exam?
Fingers - flexion/extension, abduction/adduction Thumb - flexion/extension, palmar abduction, adduction and opposition Wrist - dorsiflexion and palmar flexion, radial and ulnar deviation with elbows by side
90
How do you test function in a hand exam?
Assess grip strength - power grip, lateral pinch grip and precision
91
What special tests do you do in a hand exam?
Carpal tunnel tests (median nerve tests) Ulnar nerve tests Radial nerve tests
92
How do you test the median nerve?
Sensory - test light touch in median nerve distribution Motor - test palmar abduction against resistance Provocation - Tinel's, Phalen's and compression test
93
How do you perform Tinel's test?
Tap over median nerve as it goes through the carpal tunnel | Reproduction of pain, numbness or tingling in the cutaneous distribution of the medial nerve is a positive test
94
How do you perform Phalen's test?
Hold both wrists in palmar flexion for one minute | Reproduction of pain, numbness or tingling in the cutaneous distribution of the median nerve is a positive test
95
How do you perform a compression test?
Direct pressure of carpal tunnel
96
How do you test ulnar nerve sensation and motor function?
Sensory - test sensation in ulnar nerve distribution Motor - ask patient to cross index and middle fingers Grip a piece of paper between thumb and index finger without flexing thumb IP joint Abduct fingers against resistance
97
How do you test radial nerve sensation and motor function?
Sensation - test sensation in the anatomical snuff box | Motor - test wrist and finger dorsiflexion against resistance
98
How should you complete a hand exam?
Examine ipsilateral elbow if abnormal exam

Phase 2B medicine (16 decks)

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