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MSK screening
Knee exam
Shoulder Exam
Hand exam
Spinal Exam of a young man
Hx from an elderly man with 1 month of low back pain
Hx from a patient with recent onset (<6 months) of polyarthralgia
Hx from a patient with suspected RA
1. Assess gait.
2. Describe knee alignment.
3. Assess quadriceps bulk and symmetry.
4. Test for effusion.
5. Test for tenderness.
6. Localise tenderness to an anatomical structure. Score ‘correct’ if no tenderness
is present.
7. Assess range of flexion and extension.
8. Assess collateral ligaments.
9. Assess anterior cruciate ligaments.
10. Assess posterior cruciate ligaments.
Shoulder Examination
1. Inspect both shoulders.
2. Palpate for tenderness over appropriate areas.
3. Assess range of adduction and abduction.
4. Assess range of flexion and extension.
5. Assess range of internal and external rotation.
6. Assess range of passive movements.
7. Performs test for rotator cuff impingement.
8. Performs test for anterior instability.
Hand Examination
1. Observe hands - obtain good exposure.
2. Check for hand asymmetry/ deformities.
3. Note finger nails and skin for rashes.
4. Ask patient about tender areas in hands.
5. Gently palpate wrist and finger joints for swelling and tenderness.
6. Determine if joint swelling is soft or hard.
7. Test wrist and finger movements actively and passively.
8. Examine hand function (e.g. turning key/ undoing buttons).
1. With adequate exposure of the subject, describe the standing posture using the
descriptors: lordosis, kyphosis and scoliosis.
2. Assess the range of spinal movement, including: • Lumbar: flexion
Thoracolumbar: rotation and lateral flexion
Cervical: lateral flexion, flexion, extension and rotation
3. Assess spinal tenderness and differentiate from widespread tenderness not
restricted to the spine.
4. Show an understanding of the difference between hip flexion and lumbar flexion
when assessing ability to bend forward.
5. Assess hip joint movement.
6. Assess sacroiliac joint irritability.
1. Onset of symptoms.
2. Distribution of joints involved.
3. Features of inflammation: swelling, pain, heat.
4. Early morning stiffness.
5. Systemic features: fatigue, weight loss, fever.
6. Extra-articular features: rash, eyes, mucosal ulceration, respiratory, etc.
7. Medications or other treatments used, and effectiveness.
8. Functional assessment (effect of activities of daily living).
9. Family history of arthritis (attempt to clarify what type).
1. Try to obtain a detailed history of the onset of joint symptoms. You should
establish which joints are effective and how sudden was the onset.
2. How long have the symptoms been present? In rheumatoid arthritis, at least 6
weeks is required for the diagnosis.
3. Morning joint stiffness typically exceeds 60 minutes in active rheumatoid
arthritis.
4. Ask about presence of joint swelling (soft tissue) as well as joint pain.
5. Rheumatoid arthritis is a systemic disease, so it is important to check for
evidence of extra- articular involvement. These include the development of
rheumatoid nodules over traumatised surfaces (olecranon, calcaneal tuberosity,
matacarpo-phalangeal joints) and sicca symptoms (reduced tear and saliva
production).
6. In general, patients with rheumatoid arthritis have some relief of symptoms
with non-steroidal anti-inflammatory drugs.
1. Identify the patient and date of the Arterial Blood Gas (ABG)
2. Identify the Fraction of Inspired Oxygen (FiO2)
3. Determine if the pH is normal (7.35-7.45); low (<7.35) indicating acidosis; or
high (>7.45) indicating alkalosis
4. Determine if the PaCO2 is normal (35-45 mmHg); low (<35) indicating hypocapnia;
or high (>45) indicating hypercapnia
5. Determine whether the PaCO2 is appropriate, or inappropriate for the pH
6. Determine if the PaO2 is low (<80 mmHg.) indicating hypoxaemia
7. Identification of Type I or Type II respiratory failure
8. Calculate the Alveolar-arterial (A-a) gradient
1. As with all investigations: Check the name of the patient and the date on
which the investigation was performed
2. Patients may or may not be receiving supplemental oxygen therapy at the time
they have arterial blood gas (ABG) analysis performed. It is important to know
this, as an increased fraction of inspired oxygen (FiO2) will influence the
interpretation of ABG results. (Note: FiO2 for room air is 0.21)
3. ABG pH is a measure of the blood’s acid/base status. Normal pH is 7.35 -
7.45. A value of less than 7.35 is considered acidic, while a value above 7.45 is
alkaline.
4. The partial pressure of Carbon Dioxide (PaCO2) directly influences the
acid/base balance of blood. A PaCO2 of less than 35 mmHg is low (hypocapnia), while
a value above 45 mmHg is high (hypercapnia). An elevated PaCO2 is the hallmark of
Type II respiratory failure.
5. As pH and PaCO2 are intricately related, it is important to make an
assessment of whether the PaCO2 is in keeping with the observed pH. For example, if
the pH is low (acidotic), a low PaCO2 suggests that the patient is trying to blow
CO2 off in an attempt to increase the blood pH. This would be an appropriate
response to acidosis, and suggests that the primary problem is a metabolic cause
(so called "metabolic acidosis”). Alternatively, in the setting of a low pH
(acidosis), a high PaCO2 is an inappropriate response, and likely to be the cause
of the acidosis (so called "respiratory acidosis”).
6. An assessment of the partial pressure of oxygen (PaO2) is necessary. This is
affected by the partial pressure of inspired oxygen. A patient who has a PaO2 of
less than 80 mmHg has arterial hypoxaemia. This is the hallmark of Type I
respiratory failure.
7. Effective gas exchange is characterised by the relationship between oxygen
and carbon dioxide. An imbalance in this relationship indicates an abnormality of
gas exchange. This information can be obtained by calculating the Alveolar-arterial
(A-a) oxygen gradient. This value can be calculated for a patient breathing room
air at sea level by the using the following equation:
A-a gradient =150- pO2 - (1.25*pCO2)
While the A-a gradient normally increases with age, a value of greater than
20 is considered to be abnormal, and suggests either ventilation/perfusion mismatch
or impaired gas diffusion. It is a valuable tool to help differentiate hypoxaemia
caused by primary lung diseases from things such as respiratory depression and
hypoventilation due to neurological disease or drug over dosage.
Chest exam
1. You should position the patient so that you have good access and they are
comfortable. You should note if they appear breathless, are using accessory muscles
of respiration to breathe or are notably obese or cachectic.
2. The respiratory and pulse rates give you a useful guide to physiological
stress. Increased respiratory rates at rest reflect severe compromise of the
system.
3. Cyanosis reflects deoxygenated haemoglobin. Peripheral cyanosis may reflect
slow peripheral circulation with increased oxygen extraction or poor central
oxygenation. Cyanosis of the tongue and oral mucosa reflects poor gas exchange.
Clubbing is an increase in tissue at the nail base so that the angle is lost.
4. The trachea will deviate to the side of a collapsed lung. It can be palpated
with a finger in the sternal notch. Dilated neck veins may be seen with obstruction
of the vena cava by tumour or in right sided heart failure.
5. Palpable lymph nodes in the supra clavicular fossae may represent spread of
lung malignancy to regional nodes.
6. Signs of previous chest surgery should alert you to items not covered in your
history. Thoracotomy scars on the back follow the line of the ribs and can be
surprisingly difficult to see.
7. Hyper expansion of the chest is often associated with chronic airways
disease. Reduced expansion is seen in people with fibrotic lung disease.
8. Chest percussion if is performed by laying your non-dominant hand on the
chest and striking the middle finger with your dominant index finger. It is most
useful for revealing effusions (fluid in the pleural space) and should be performed
from side to side looking for a marked distance difference in the level at which
the note becomes dull.
9. Auscultation can reveal a variety of changes. You should ask the patient to
breathe through there their open mouth and compare the sounds from side to side.
Asymmetry is likely to reflect pathology. The upper lobes are best heard
anteriorly. Some pathologies (pulmonary fibrosis and tuberculosis) favour the upper
lobes.
10. A cough will tell you whether the patient is producing sputum, has normal
vocal cord innervation or has wheeze. Leave it until last in case it sets off a
chain of coughing.
11. The sputum cup will reveal evidence of infection (green or yellow copious
sputum) or bleeding (TB or malignancy). The temperature chart provides information
about infection.
CXR interpretation
1. You need to know that the X-ray is of the correct person and how it relates
to the current illness. Check the labelling and the date of the X-ray.
2. Technical issues can alter your interpretation of an X-ray. The X-ray should
be straight on rather than oblique. This can be checked by looking at the
relationship of the clavicular heads to the lateral borders of the vertebra behind
them. You should also know whether the X-ray has been shot Posterior to Anterior
(usual) or Anterior to Posterior (X-ray in bed) as the latter produces a larger
heart shadow. The depth of inspiration alters the appearance of an X-ray; the
anterior sixth rib should be at the level of the diaphragm. Poor inspiratory effort
leads to difficulty interpreting shadows in the lung fields.
3. Air filled structures will appear dark (air is radiolucent) while fluid
filled structures (heart and great vessels) will appear light.
4. The hilar of the lungs are formed by the pulmonary arteries and the main
bronchi.
5. The major anatomic structures down the left border of the mediastinal are the
aortic arch, the pulmonary artery and the left ventricle. The major structures
forming the right border of the heart are the left atrium then the right atrium.
The right ventricle is in front of the left and contributes to the inferior border
of the heart.
6. The cardio cardio-thoracic ratio is calculated by comparing the maximum
transverse diameter of the heart to the transverse diameter of the lung fields
measured at the costophrenic angles. An increase implies enlargement of the heart.
7. The right lung is divided into three lobes which are arranged in order down
the thorax (upper, middle and lower). The left lung has an upper and a lower lobe.
The lingula of the left upper lobe overlies the heart and is best seen on the
lateral film.
8. The right and left hemi- diaphragms lie above the liver and stomach
respectively. The gastric bubble (gas in the stomach) usually identifies the
latter. The costophrenic angles should be sharp and loss of this angle implies that
there is fluid in the pleural space.