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Year 3 PHA332 Clinical Skills W17

MSK Examination Hand/Wrist Examination  

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Wash hands Introduction: Hi my names Aqsa, I’m one of the 3rd year pharmacy students and today I’ll be conducting an assessment that will involve me asking questions or performing an examination on your presenting complaint Consent: Would that be okay? It may involve me touching you at some points. Name and Age: Can I start by taking your name and age? Nice to meet you.

Presenting Complaint: How can I help you there today? 

I’ve been feeling some pain/discomfort in my hand/wrist

(Ensure patient area is exposed to see above and below joint – if not ask if to remove clothing) LOOK Get patient to put hands in front of you:  Swelling - So just comparing left to right looking for any signs  Inflammation – looking for  Deformities – looking for any deformities in the wrist or hand  Differences in size – also looking for any size differences but both seen to be symmetrical  Bruising and wounds – looking for these signs but don’t seem to be present FEEL Temperature:  Just having a feel down just above the wrist working my way down to have a feel of the temperature – if it was high sign of infection, if low sign of poor perfusion Palpate: (keep hands in front) and have a feel of the wrist and hand and we’d always compare left to right to make a comparison between the two Palpate (just one hand but mention would always do both and make comparison):  So just having a feel down from above the wrist joint, down the wrist there – specifically the radius ulcer and just checking for any areas of TENDERNESS or GENERAL tenderness the patient is reporting while having a feel  Also just having a feel down the hands – having a feel down all the metacarpals (fingers) all the way to the end, individually and just seeing if the patient reports any pain while I palpate those.

MOVE (Perform like Simon Says)

Year 3 PHA332 Clinical Skills W17

Now I’m gonna move the hand and the wrist and perform certain movements – I’m going to be doing this actively and passively then consider any resistance or function tests that I’d like to do Get patient to keep elbows towards waist (no use of other joints e.g. elbow while performing movements): ACTIVE WRIST:  Flexion (Inferior) – Just get you to put your wrists up and then bring them back to the neutral position  Flexion (Superior) – Just get you to push your wrists down and back to neutral  Radial Deviation – Just get you to bring your wrists in and that is RD and back to neutral  Ulnar Deviation – Then UD and move the wrists on the outsides ACTVE HAND  Flexion (Fist) – Just get you to make a fist with your hand  Extension – then relax and extend fingers out  Abduction (Spread fingers) – Then just get you to spread your fingers out  Thumb opposition – Then just get you to touch your thumb on each finger what we call TO So now moving onto passive part and always comparing left to right (just use one side). So I’m just going to hold above the wrist so we have a fixed point PASSIVE WRIST:  Flexion (Inferior) – So just extending the wrist down going upwards  Flexion (Superior) – and the same going downwards and then back to neutral  Radial Deviation – Just doing RD making sure elbows tucked in and using wrist  Ulnar Deviation – and UD PASSIVE HAND:  Flexion (Fist) – So just making a fist with the patient’s hand  Extension – then relax that open FUNCTION So now going to be considering all of those things with regards to resistance so again just wrap hand around wrist – use other hand RESISTANCE WRIST:  Flexion (Inferior) – so just get you to push up against my hand  Flexion Superior – and just push down on my hand  Radial Deviation – then just want you to bring your hand in against mine – this is RD  Ulnar Deviation – then on the opposite side against mine – this is UD RESISTANCE HAND (BOTH HANDS):  Abduction (Spread fingers) – and just checking resistance and if patient can do that  Grip – Just ask you to grip my fingers with both hands to check the grip function Conclusion – And that completes the wrist and hand examination. Do you have any questions? Thank you for your time.

Year 3 PHA332 Clinical Skills W17

Elbow Examination  

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Wash hands Introduction: Hi my names Aqsa, I’m one of the 3rd year pharmacy students and today I’ll be conducting an assessment that will involve me asking questions or performing an examination on your presenting complaint Consent: Would that be okay? It may involve me touching you at some points. Name and Age: Can I start by taking your name and age? Nice to meet you.

Presenting Complaint: How can I help you there today? 

I’ve been feeling some pain/discomfort in my elbow

(Ensure patient area is exposed to see above and below joint – if not ask if to remove clothing) LOOK So when looking at the elbows – comparing left to right (might get the patient to stand up to have a look) So just having a look for any:     

Swelling Inflammation Deformities – around the joint Differences in size – with regards to symmetry Bruising and wounds

FEEL Temperature:  So just comparing left to right checking temperature – above and below the joint so just below the shoulder checking the inside and outside around the joint. Temperature seems to be normal so no sign of injury or infection Palpate (just one elbow):  So palpating along the joint line and just feeling around the radius and ulnar head (big bone at elbow and on sides) and specifically feeling for any bony tenderness across those and a general feel around the joint for tenderness – making notes of any bony tenderness as opposed to general tenderness  Would always palpate both joints comparing left to right MOVE (Perform like Simon Says) So we’re going to do some movements of the elbow joint - I’m going to be doing this actively and passively then consider any resistance or function tests that I’d like to do ACTIVE ELBOW (Get patient to stand up and tuck elbows into waist)  Flexion (Hand to shoulder) – so just get you to put your hand up to your shoulder  Extension (Straighten) – then relax your hands down to the neutral position  Hyperextension – then hyperextend the elbows ensuring arm is still  Pronation (Palms down) – (position: elbows tucked in – arms in front) – just get you to put your hands down and just rotating through the elbow and this is called pronation

Year 3 PHA332 Clinical Skills W17

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Supination (Palms up) – just bring your palms up and that is supination

So now moving onto passive part and always comparing left to right (just use one side) and just going to hold above the elbow joint to restrict movement of other joints PASSIVE ELBOW  Flexion (Hand to shoulder) – just putting hand to shoulder  Extension (Straighten) – then extending back to neutral position  Hyperextension – then trying to hyperextend the elbow  Pronation (Palms down) – so just rotating that joint (hold at wrist) and that’s pronation  Supination (Palms up) – and again rotating in other direction and that’s supination FUNCTION  So now considering resistance – going to compare left to right RESISTANCE ELBOW (Hold above elbow joint and make sure elbow into waist):  Flexion (Hand to shoulder) – so just push up against my hand and relax  Extension (straighten) – and just push down on my hand WEIGHT BEARING ELBOW:  Bearing Weight – so want to make sure that the joint is able to bear weight so I’m just going to grab an object and ask the patient to pick the object up, ensuring they are able to bear weight using their elbow joint Conclusion: That conducts the elbow examination. Do you have any questions? Thank you for your time.

Shoulder Examination 

Wash hands

Year 3 PHA332 Clinical Skills W17

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Introduction: Hi my names Aqsa, I’m one of the 3rd year pharmacy students and today I’ll be conducting an assessment that will involve me asking questions or performing an examination on your presenting complaint Consent: Would that be okay? It may involve me touching you at some points. Name and Age: Can I start by taking your name and age? Nice to meet you.

Presenting Complaint: How can I help you there today? 

I’ve been feeling some pain/discomfort in my shoulder

(Ensure patient area is exposed to see above and below joint – if not ask if to remove clothing) LOOK So when looking at the shoulders – just comparing left to right (have patient standing up – face them) So just having a look for any:     

Swelling Inflammation Deformities Differences in size – with regards to symmetry Bruising and wounds

Also just get the patient to move the side so looking at the shoulder from a lateral view and then move to the back to look at the shoulder from a posterior view so can get full view of shoulder and can see any: swelling, inflammation, deformities, differences in size and any bruising and wounding, again comparing left to right FEEL Temperature:  So just having a quick feel around the shoulder joint and just feeling temperature (front sides and back) – if it was high it might be a sign of trauma and infection, but the patient seems to be normal Palpate (palpate one side and mention would do both and compare left to right):  So when palpating the joint just having a feel for general tenderness and just having a quick feel around the structure (scapula, clavicle and shoulder joint), so just having a feel around the shoulder joint itself all the way round and checking to see if the patient reports any general tenderness while I’m having a feel or any bony tenderness when I’m palpating.

MOVE (Perform like Simon Says) So we’re going to do some movements of the elbow joint - I’m going to be doing this actively and passively then consider any resistance or function tests that I’d like to do

Year 3 PHA332 Clinical Skills W17

ACTIVE SHOULDER:  Flexion (Anterior) – so bringing arms from neutral position, anterior so all the way up to the top as far as you can and then relax down to neutral position  Extension (Posterior) – then just to put your arms back so that’s your posterior flexion – note patient got good range of movement (ROM) and isn’t complaining of any pain  Abduction (Lateral) – going to do one side at a time so lifting arm and taking it away from the body on the side, all the way up and then all the way back down and same on other side  Adduction (Medial) – going to do one side a time and going towards to patients’ body. So put your arm slightly in front and move across the body towards the midline and relax and then same on other side  External rotation (elbow tucked in and rotate laterally) – so just making sure patients’ elbows are tucked in and just to make a fist and then bring arms out and away from the body – that’s external rotation and then back to neutral position  Internal rotation (Hands up back) – then just to get the patient to put one hand behind their back with back of palm touching around the sacrel area – that’s internal rotation and relax down and repeat the same with the other arm So we’ve performed those movements actively and now we’re going to perform them passively. So for the purpose of the OSCE we would always compare left to right and perform on both sides PASSIVE SHOULDER (Perform on one side – stand beside patient and place one hand on shoulder joint):  Flexion (Anterior) – so from the neutral position, just lifting the arm up to get anterior flexion and then back to neutral position  Flexion (Posterior) – so just moving the arm back to get posterior flexion – seems to have good ROM  Abduction (Lateral) – so just moving the arm laterally away from the body and just all the way up  Adduction (Medial) – and then just bring it down to the front of the body and across the body and then relax back  External rotation (elbow tucked in and rotate laterally) – so just bring the arm out and making sure the elbow is tucked in and moving arm away from body  Internal rotation (Hand up back) – and then internal rotation so moving the patients hand to the sacrel area and then relax down

FUNCTION So considering resistance we’re gonna be doing all the same movements but considering resistance as best as we can RESISTANCE SHOULDER:

Year 3 PHA332 Clinical Skills W17

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Flexion (Anterior) – so if you could just push up against by hands from the neutral position Extension (Posterior) – and just putting my hands on the back of the lower arm and just if you could push back Abduction (Lateral) – so could you just push sideways against my hands Adduction (Medial) – so just doing one at a time just bring arm forward and try push across body and then the same on the other side External rotation (Elbow tucked in and rotate laterally) – so if you could just tuck your elbows in and make a fist and push against my hands on the outside Internal rotation (Hand up back) – so just one a time so just place your hand at your back and push against my hand and then just the same on the other side

WEIGHT BEARING SHOULDER:  Bearing weight – need to make sure patient can weight bear and load the joint. Just asking the patient to lift an object up and see if they can weight bare. Wanting to see if they can pick the object up just using their shoulder – not with the help of elbow or wrist and the patient seems to be okay doing that Conclusion: That conducts the shoulder examination. Do you have any questions? Thank you for your time.

Year 3 PHA332 Clinical Skills W17

Knee Examination  

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Wash hands Introduction: Hi my names Aqsa, I’m one of the 3rd year pharmacy students and today I’ll be conducting an assessment that will involve me asking questions or performing an examination on your presenting complaint Consent: Would that be okay? It may involve me touching you at some points. Name and Age: Can I start by taking your name and age? Nice to meet you.

Presenting Complaint: How can I help you there today? 

I’ve been feeling some pain/discomfort in my knee

(Ensure patient area is exposed to see above and below joint – if not ask if to remove clothing) LOOK So just starting by comparing left to right, looking for any:     

Swelling Inflammation Deformities – so just looking above and below the joint Differences in sizes – with regards to symmetry, seems normal Bruising and wounds

FEEL So just gonna have a general feel of the joint and then specific points around the joint Temperature:  So just having a quick feel above and below the knee, checking for any changes in temperature – seems to be okay Palpate:  So just specifically having a feel of the patella in the centre and all the way around the patella and just noticing if the patient reports any pain on palpation. Now I’m just gonna raise the knee slightly and have a feel from the left side across the collateral ligament and the left side at the medial collateral ligament (outer side then inner side). Also just having a feel around the joint line at the meniscus of the knee and noticing if the patient reports any discomfort or pain when palpating. Also just having a quick feel of the tibia and fibula, particularly the head (outside of knee). Mainly looking for any specific bone tenderness or general tenderness around the knee MOVE So we’re going to do some movements of the knee joint - going to be doing this actively and passively then consider any resistance or function tests that I’d like to do ACTIVE KNEE:  Flexion (Bent) – (dependent on lying on bed or at side of bed) – just get you to lift your knee up towards your chest then just relax  Exentison (Straight) – back to neutral position and extend. Both seem to be normal

PASSIVE KNEE:

Year 3 PHA332 Clinical Skills W17

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Flexion (Bent) – so just doing it passively (hold one hand above ankle and other pushing knee) Extension (Straight) – bringing it back down and just extending

FUNCTION So considering resistance we’re gonna be doing all the same movements but considering resistance as best as we can RESISTANCE KNEE:  Flexion (Bent) – so just lift your knee up and pull leg back and pull against my hand (hold hand at back of ankle)  Extension (Straight) – (keep same position and hold hand on front of ankle) – and just push forward and relax STRESS TESTS:  Anterior/Posterior lag test (cruciate/ligaments) – this is where we stress the two ligaments, the one at the front and the back of the knee, so just get the patient to bend their knee up to 90 degrees. Just gonna sit slightly on the foot so the foot doesn’t move when we cause the stress and just having a feel around the knee joint and around the menisci line and going to draw the knee forward and push it back and noticing if the patient reports and pain. Doesn’t seem to be any extra movements there or crepitus there and so that’s how you check the anterior and posterior cruciate ligaments 

Lateral/Medial stress test (Collateral ligaments) – So we’re gonna stress the lateral and medical collateral ligaments of the knee. I’m going to create an anchor point above the knee and relax hand just above the ankle. First going to stress the medial collateral on the inside. So going to firmly grip the ankle and pull the lower leg towards me and can feel the stress on the medial aspect and patient doesn’t seem to be reporting any pain. Then just going to do the same on the other side and stress the lateral collateral ligament on the outside – noticing if the patient reports any pain and if there is increased movement.

OTTAWA RULES Introduction: So the knee joints follow a specific guideline which we have to follow called the OTTAWA rules. The things to consider are:     

>55 – considering age, if over 55 the patient needs an xray Patient needs to be able to bend/flex the knee at 90 degrees – (get patient to do this), if they were unable to do this, they would need an xray Patella – so just isolating the patella and having a feel around it, just palpating it to look specifically for any bony tenderness and seeing if the patient reports any pain Fibula head (lift leg up) – feeling around the bone and feeling for any bony tenderness and seeing if the patient reports any pain and now to relax 4-5 Steps – explain if the patient isn’t able to walk 4-5 steps and bear weight they would need an xray

Year 3 PHA332 Clinical Skills W17

Year 3 PHA332 Clinical Skills W17

ANKLE/FOOT EXAMINATION  

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Wash hands Introduction: Hi my names Aqsa, I’m one of the 3rd year pharmacy students and today I’ll be conducting an assessment that will involve me asking questions or performing an examination on your presenting complaint Consent: Would that be okay? It may involve me touching you at some points. Name and Age: Can I start by taking your name and age? Nice to meet you.

Presenting Complaint: How can I help you there today? 

I’ve been feeling some pain/discomfort in my ankle/foot

(Ensure patient area is exposed to see above and below joint – if not ask if to remove clothing) LOOK So just starting by comparing left to right of both lower legs, ankles and feet and looking for any signs of:     

Swelling Inflammation Deformities (ankle/metatarsals) Differences in size – with regards to symmetry Bruising or wounds

FEEL Temperature:  Just checking below the knees, all the way down, inside and on the outside and ankles and tops of feet – temperature seems to okay and has a normal colour so that would be okay Palpate: Always comparing left to right (just do one):  Just having a general feel first, around the ankle bone and the foot and a feel across it and seeing if they patient reports any pain when feeling for general tenderness. So for more specific structures...