VTE risk

Venous thromboembolism is a significant cause of potentially avoidable deaths in surgical patients. It’s important to spot who is at greater risk of clot formation long in advance to help prevent this happening.

Mrs Thrombus is an obese 61 year old lady having surgery for her cancer, currently in a bed on ITU.

  • Active cancer/cancer treatment
  • >60 years of age
  • obesity
  • critical care admission

She is wearing a red jumper with the letter C on it, because she is known to have a protein C deficiency thrombophilia, and she’s downing glass after glass of water because she feels terribly thirsty.

  • known thrombophilia
  • dehydration

Mrs Thrombus has in front of her a mountain of pills for her various ailments, including HRT and an oral contraceptive pill as well.

  • significant medical comorbities
  • HRT
  • contraceptive pill

She downs all her pills and gets up to go to the toilet, when you notice her legs are covered in varicose veins. When you ask her about them, she says they are very sore and run in her family.

  • varicose veins with phlebitis
  • family history 

Back Pain red flags

A really effective way of taking a history is to ensure you’ve covered all the red flag symptoms. As a junior doctor you’re not expected to know the minutiae of how to treat every condition, but you most certainly are expected to be able to spot an emergency, or potentially very serious condition. Learning red flags, and ensuring you’ve ruled them out in the history is a great way to reassure yourself, your consultant and your patient that it’s not likely to be a serious problem. Back pain is one of those symptoms that is incredibly common, and 99% of the time is not due to a serious underlying pathology, but when it is, you absolutely need to spot it.

So here’s a story to remember the red flags of back pain!

Mr back pain is normally a fairly spritely young man. One day he wakes up drenched in sweat with this splitting pain in his lower back. It’s sending shooting pain down both of his legs and when he tries to climb out of bed he realises his muscles aren’t working and he slumps to the ground in a heap.

  • New pain at young age
  • Nocturnal pain
  • Night sweats
  • Bilateral symptoms
  • Neurological symptoms

He lies in the foetal position for a while, contemplating his predicament, and finally summons up enough strength to climb to his feet. He realises that he hasn’t been to the loo yet and he is bursting for a pee, so he begins to shuffle, very stiffly, towards the bathroom. However before he manages to reach the toilet he sneezes and urinates all over the floor.

  • Pain does not reside when in foetal position
  • Urinary incontinence
  • Morning stiffness

It’s puzzling as to why his back hurts.  He hasn’t bashed it recently and doesn’t do any sport that would strain his back. He has had a cold with a fever for the last few days but it hadn’t been that bad, certainly not the worst he’d ever had. He had been diagnosed several years ago with acute myeloid leukaemia but had since made a very good recovery.

  • No history of trauma
  • Recent illness/immunosuppression
  • History of malignancy

He stands on the scales and is happy that he’s lost weight without even trying, even though his belly seems to have gotten bigger, but the pain in his back hasn’t got any better. After a while his calves start to hurt so he decides to go back to bed.

  • Weight loss (unintentional)
  • Abdominal mass
  • Unremitting pain
  • Claudication symptoms

Back Pain red Flags

– Acute pain in over 55 or <30

– Neurological signs

– Claudication symptoms

– Limb ischaemia

– Constant pain/progressive pain

– Abdominal mass

– Nocturnal pain

– No relief from foetal position

– Alternating or bilateral pain

– Fever, malaise

– Weight loss

– Recent or current infection

– Immunosuppression

– Non mechanical history

Ankylosing Spondylitis

I find it really hard to remember the features of the individual rheumatic conditions because there is so much overlap, so I started making stories for each to try and get it straight in my head. Today’s is Ankylosing Spondylitis, one of the several seronegative spondyloarthropathies that is not massively common (1/100 000) but still important as it has a huge impact on the person’s life, and you might be able to do something about it!

The Story


You are a GP in your surgery, and you call for your next patient to come in. Three caucasian males all come limping in and very slowly sit down with a grown on the bed. One of them is 27, the next is his dad, and the third his grandad.

  • 3:1 male:female ratio
  • Caucasians more affected (higher HLA B27 prevalence)
  • Enthesitis (inflammation of tendinous insertions, particularly in the lower limbs)
  • Inflammatory back pain with reduced flexion of the lumbar spine
  • Family history
  • Usually between 20-30 years of age

You take ask them what it is that’s brought them in today.

The first man pipes up, “Well doc, I’ve just been feeling really tired, and this pain in my back has been getting worse and worse on both sides

  • Gradual onset
  • Bilateral sacroiliitis
  • Fatigue is common early sign (often before any physical symptoms)

You examine him and the first thing you notice is he has one very red eye, as does his father, and grandfather. You ask him when his eye became red, and he said it was when they were cooking sausages on the barbecue and some of the fat spat up into his eye. The father and grandfather nod bashfully.

  • Anterior uveitis
  • Iritis – typically unilateral
  • Sausage fingers – dactylitis

You then continue your exam and notice he’s got a mangled left leg, which you ask about:

Well doc, I was on my motorbike with my girlfriend Amy, and the engine started coughing and spluttering. Then a valve blew and we crashed, she died and I snapped my achilles and fractured my leg! I lost loads of blood and I’ve been having temperatures ever since – but I’ve lost some weight so that’s good I guess…”

  • Main causes of mortality in Ankylosing Spondylitis
    • Amy – Renal amyloidosis 
    • Coughing – Respiratory disease (upper lobe bilateral fibrosis)
    • Valve – Cardiovascular (particularly valve disease)
    • Fractures
  • Achilles – enthesitis particularly affecting insertion of Achilles tendon and plantar fascia (also intercostals)
  • Extra-articular features:
    • Anaemia
    • low grade fever
    • weight loss

How to examine the hands

OSCEs are interesting beasts. They’re designed to measure one’s clinical prowess, although end up being a very artificial process that requires specific attention to learn, rather than just clinical experience. As a result, examinations in particular end up becoming a rehearsed routine that can be rattled off under intense pressure, without much actual thought as to what one is looking for in the first place. What I’ve tried to do here is write the ‘script’ but also give an idea of what to be thinking along the way, to help answer examiner questions and also to help be an actual doctor (which I’m hoping is the ultimate goal). Of course everyone will have their own style, and this is simply my own, but hopefully it might provide a useful framework. In particular I find it much easier to demonstrate movements rather than trying to describe them, and it helps build rapport between you and the patient if they’re playing a game of copying you #psychologywin.

The Dance

Introduction

*Student enters cubicle, washes hands and smiles*

“Good morning, my name is Will Sloper, I’m one of the fourth year medical students, I’ve been asked to do a quick examination of your hands, would that be alright?”

*Patient says yes*

“Thank you, may I ask your name? And how old are you if you don’t mind me asking”

(please could I ask you to roll up your sleeves?/remove your jumper?/put the cat down?)

“Before I begin, are you in any pain at the moment?”

*Patient says no/a little/yes my hand hurts*

“Great/Okay well I’ll be quick and do my best not to cause you any (more) pain. Is there anywhere that’s really sore to touch?”

*patient points at specific point*

“Alright, I’ll avoid that finger/bruise/bleeding open fracture as much as I can”

*Student offers cushion to patient. Patient places hands palms down on cushion on lap or table*

LOOK

“Firstly I’ll have a look at your wrists…”

*Student looks intently at wrists*

“…your hands…”

*ditto*

“…your fingers, and nails.”

*Student dwells on nails slightly to ensure examiner knows they have been thoroughly inspected*

“Lovely, please could you turn your hands over?”

*smiles*

*Patient turns hands over, while student watches patient’s face*

“Was there any pain while turning your hands over?”

*no*

“I’ll have a quick look at your palms…”

*Student looks intently at palms*

“…and wrists…”

*again*



FEEL

Now if it’s alright I’ll feel your wrists and palms”

*Student feels pulses, then the thenar and hypothenar eminences and then the palm*

“Lovely, thank you, can you please close your eyes for a moment and say ‘yes’ if you can feel me touch your hand?”

*Student lightly touches both eminences and index and little finger tips*

*yes, yes, yes, yes…*


“Does this make your fingers tingle?”

*Student lightly taps skin over carpal tunnel*

*no*

“Great, put your palms down again please and I’ll do the same on the back”

*Patient turns hands over, student watches face again*

“Close your eyes again and say yes if you can feel this”

*Student lightly touches first dorsal interosseous*

*yes*

“Thank you”

*Student places backs of hands on forearm for 2 seconds, wrist, then over the mcp joints*

“Let me know if this is at all tender” (if patient has identified tender area, address the fact that you do have to touch it, but will be as careful as possible)

*Student lightly squeezes the mcp joints while watching the patient’s face*


“I’ll now have a quick feel of each joint in turn”

*Student bimanually palpates each joint in turn, comparing each group with the other hand, and watching the patient’s face the whole time*

“Thank you, I’ll just do the same on your wrists”

*Student bimanually palpates wrists, guess what, while watching the patient’s face*

“Lovely, now I will just feel your forearms”

*Student runs hand up ulnar aspect of forearm while holding wrist with other hand*

MOVE

“Right, we’re almost there!” *smiles*

“Lastly I need you to do some movements for me if that’s alright, could I ask you to straighten your fingers as much as you can”

*Student then passively extends patient’s fingers gently, while watching the patient’s face*

“Thank you, next can you make a fist for me?”

*Student passively flexes patient’s fingers gently, again… FACE*

“Now could you do this?” *Student extends own wrists and places them together in prayer position in friendly and personable style*

*Patient copies student, #facialsurveillance*

“And now this?” *Student flexes own wrists and places together in equally nonthreatening manner*

*Patient copies student, #facialsurveillance*

Squeeze my fingers as hard as you can?”

“Finally could you spread your fingers as far as you can, and then do this?…”

*Student opposes thumb to each finger in turn, and patient does the same*

“…and could you pick this up for me with your index finger and thumb?”

*Student produces coin/magic bean/small rodent*


Conclusion


“Well thank you very much, I’ve finished my examination, do you have any questions for me?”

*Patient says no*


“Thanks again”

*Student smiles, washes hands and turns to examiner*



Presentation

“I performed an examination of the hands and wrists on Mrs Phalange who reported tenderness in her left wrist and upon inspection, noted the presence of a longitudinal scar/slight bruise on the dorsum of the right hand. The rest of the examination was normal, with sensation of the median, ulnar and radial nerves intact and good movement and function of all joints”

(Obviously this bit is going to vary hugely – practice making up a bunch of different presentations and you might find that in the exam, you can adapt one you’ve already made to fit your current patient)

“To complete my examination, I would like to:

  • take a full history
  • do a regional musculoskeletal exam of the elbow
  • do a neurological and peripheral vascular exam of the upper limbs

Why do the exam?

The main purpose of the hand exam is to elicit whether the patient has any:

  • pain
  • stiffness
  • reduction of function
  • evidence of previous disease/surgery

And as with all musculoskeletal examinations, it’s a good idea to follow a structure of:

  • look
  • listen
  • feel
  • move

And always, always, always…

  • ask about pain
  • compare the two sides

The things to look out for in the hand exam are as follows:

  • Looking
    • swelling
    • muscle wasting
    • deformity
    • skin changes
      • bruising
      • thinning
      • rashes
    • scars
    • nail changes
      • onycholysis
      • pitting
      • vasculitis of nail folds
  • Feeling
    • pulses
      • vascular impairment?
    • muscle wasting
      • may suggest nervous injury or carpal tunnel syndrome
    • tendon thickening
    • sensation
      • carpal tunnel, peripheral neuropathy
    • temperature
      • inflammation is hot
      • Raynaud’s is cold
    • nodules
      • Heberden’s nodes in osteoarthritis
      • gouty tophi
      • rheumatoid nodules
    • squeezing
      • tenderness is early sign of inflammation
    • joint palpation
      • warm, rubbery swollen joints are suggestive of active synovitis
    • Tinel’s test
      • special test for carpal tunnel syndrome
    • Phalen’s test
      • same idea
  • Moving
    • failure of movement could be:
      • muscular
      • neurological
      • tendinous
      • articular
    • Passive extension may help determine which
    • Picking up a coin/small rodent gives an idea of function

How to examine the shoulder

This post is an outline of the examination of the shoulder that is required for the rheumatology and orthopaedics part of the medical school course. Different sites and schools include different things so I’ve tried to make this one as comprehensive as possible by compiling my favourite things from a few sources, and hope it’s of some use.

OSCEs are interesting beasts. They’re designed to measure one’s clinical prowess, although end up being a very artificial process that requires specific attention to learn, rather than just clinical experience. As a result, examinations in particular end up becoming a rehearsed routine that can be rattled off under intense pressure, without much actual thought as to what one is looking for in the first place. What I’ve tried to do here is write the ‘script’ but also give an idea of what to be thinking along the way, to help answer examiner questions and also to help be an actual doctor (which I’m hoping is the ultimate goal). Of course everyone will have their own style, and this is simply my own, but hopefully it might provide a useful framework for you to base your own technique upon.

I like to talk to the patient, as this is what I do in a clinical setting, especially as patients sometimes ask what I’m testing. This also looks better than trying to narrate what you’re doing to the examiner. I also find it much easier to demonstrate movements rather than trying to describe them, and it helps build rapport between you and the patient if they’re playing a game of copying you #psychologywin.

The Dance

BEFORE ENTERING – what age is the patient, are they male or female, what’s their occupation, are they right or left handed, what side is the problem on?

Introduction

*Student enters cubicle, washes hands and smiles*

“Good morning, my name is Will Sloper, I’m one of the fourth year medical students, I’ve been asked to do a quick examination of your shoulder, would that be alright?”

*Patient says yes*

“Thank you, may I ask your name? And how old are you if you don’t mind me asking”

(exposure – please could I ask you to remove your shirt?/put the cat down?)

*Student washes hands and asks patient to stand*

“Before I begin, are you in any pain at the moment?”

*Patient says no/a little/yes my shoulder hurts*

“Great/Okay well I’ll be quick and do my best not to cause you any (more) pain. Is there anywhere that’s really sore to touch?”

*patient points at specific point*

“Alright, I’ll avoid that finger/bruise/bleeding open fracture as much as I can”

“Are you right or left handed?”

*Patient responds (unless they don’t have any hands in which case poor choice of question)*

LOOK


“Do you have anything with you such as a sling or any medications?”

*Student looks around – trying not to appear suspicious of patients*

“Firstly I’ll have a look from the front…”

*Student looks intently at sternum, clavicle and then shoulders*

“…the sides…”

*it may be easier to ask the patient to rotate, rather than try to climb around them*

“…and the back.”

*Student stares blindly at shoulder blades contemplating exactly what it is they’re doing with their life*

“Lovely, please could you turn to face me again?”

*smiles*

FEEL

Now if it’s alright I’ll have a quick feel of your shoulders”

*Student feels temperature with back of hands.

“Ok, now please let me know if any of these parts are tender, I don’t want to cause you any pain.”

*Student palpates touches both sternoclavicular joints, clavicles, acromioclavicular joints, coracoid processes, greater tuberosities, joint lines, deltoid bulk and insertions, acromion processes, scapular spines, supraspinatus, infraspinatus, borders of the scapulae, and paraspinal muscles*


Now I’ll have a quick feel for the tendons in your shoulder”

*Student passively flexes patient’s arm and feels along biceps for the tendons. Then extends the shoulder (pushes elbow back) to tilt the head of humerus forward, and palpate for the supraspinatus tendon*

“Thank you, have you noticed any tingling or numbness around your shoulder?”

*no/yes/just on the tip of the shoulder/where this knife has been inserted*

“Could you please close your eyes and say yes if you can feel me touch your shoulder?”

*Student lightly touches regimental patch and skin over trapezius*

*yes*

“Thank you”

*smiles – customer service-style, not Willem Dafoe*


MOVE

“Now I’d like to test some movements if that’s alright”

*Patient nods*

“Please could you copy what I do with both hands?”

*Student puts both hands behind head, then behind back*

*Patient copies*

*While patient’s hands are behind back, student places hands on patient’s*

“Now push my hands away” (subscapularis power)

*Patient pushes hands away. Student hovers one hand in front of patient in case they push themselves forwards*


Great, now if you copy me, and I’ll help you at the end of each movement”

*Student then abducts arms above head, patient copies, meanwhile student places hand on patient’s scapula to assess rotation*

*adducts them across the chest*

*flexes forward to 170 degrees*

*extends to 40 degrees*

*Patient copies, and student adds passive movement at the end of each one*

“Any discomfort?”

*Patient says ‘no/yes/screams’*



“Thank you, now hold your hands out like you’re holding a dinner tray

*Student externally and internally rotates arms and patient copies*

*Student applies passive force at the end of each. At the point of maximum external rotation, ask patient to hold their hands there, and let go – see if arm drifts back to centre (Lag sign)*



Specific muscle tests

(Subscapularis has already been tested earlier with hands behind the back, to make it more convenient for the patient)


“Now could you do the same, but push against me?”

*Patient externally rotates against resistance*


And now place your arms by your sides

*Student holds patient’s arms by their sides*

“Push out against me?”

“Thank you, now could you do this?”

*Student holds arms flexed to 90 degrees and slightly abducted so that supraspinatus is aligned with the humerus, with thumbs towards the ceiling*

*Patient copies*

“Now resist me”

*Student pushes down*

And now the same with thumbs down?”

*Same again*


“Thank you”

Impingement tests


“I’m now going to lift your arm up, please hold it there”

*Student passively abducts patient’s arm to maximum abduction and lets go*

“Now could you slowly lower it down to your side, and let me know whether there is any pain”


Now let me take your arm, and let it go all floppy, letting me take all the weight”

*Student flexes shoulder to 90 degrees, elbow to 90 degrees, and then internally rotates the shoulder*

Any pain?”

*no*

*Student repeats motion at varying degrees of abduction, watching patient’s face each time”


Ok, thank you, let your arm go loose again”

*Student stabilises scapula with one hand, and uses the other to internally rotate the patient’s arm and passively flexes it*

Any pain?”

*Patient says ‘no’*


“Finally, please could you do this for me?”

*Student places own hand on contralateral shoulder, with elbow moving across midline*

*Patient copies*

Are you able to get the elbow all the way across?”

*Student looks, showing that she is checking whether elbow has crossed midline*


“And just to finish off, I’ll take your arm, let it go nice and loose, and let me know if this is uncomfortable”

*Student takes patient’s arm, moves it into the ‘POLICE – HANDS UP!’ position (correct anatomical name) and gently externally rotates*

“Does that feel wobbly or unstable?”

*Patient says ‘no’/shoulder dislocates*

Conclusion


“Well thank you very much, I’ve finished my examination, do you have any questions for me?”

*Patient says no*


“Thanks again”

*Student smiles, washes hands and turns to examiner*



Presentation

“I performed an examination of the shoulder on Mrs Bananas who reported tenderness in her….. and upon inspection, noted the presence of a longitudinal scar/slight bruise over the clavicle. The rest of the examination was normal, with good movement and function of all muscles”

(Obviously this bit is going to vary hugely – practice making up a bunch of different presentations and you might find that in the exam, you can adapt one you’ve already made to fit your current patient)

“To complete my examination, I would like to:

  • take a full history
  • do a regional musculoskeletal exam of the elbow and spine
  • do a neurological and peripheral vascular exam of the upper limbs

If asked what management you would do, you can’t really go wrong with:

In accordance with local trust guidelines, this condition can be managed:

  • Conservatively
    • physiotherapy
    • modification of daily activities
  • Medically
    • nsaids
    • steroid injections
  • Surgically
    • manipulation under anaesthesia (adhesive capusilitis)
    • surgical stabilisation (dislocation)
    • arthroscopy (impingement)

I would also want to ensure I am aware of the patient’s desires and concerns, what activities they would like to be able to do, and what their outlook on the issue is like.

Why do the exam?

The main purpose of the shoulder exam is to elicit whether the patient has any:

  • pain/impingement
  • stiffness
  • reduction of function
  • evidence of previous disease/surgery

And as with all musculoskeletal examinations, it’s a good idea to follow a structure of:

  • look
  • listen
  • feel
  • move
  • special tests

And always, always, always…

  • ask about pain
  • compare the two sides
  • watch the patient’s face during movement

The things to look out for in the shoulder exam are as follows:

  • Looking
    • swelling
    • muscle wasting
    • deformity
      • internally rotated at rest suggests posterior dislocation of the shoulder
    • skin changes
      • bruising
      • thinning
      • rashes
    • scars
    • Winging of scapular
      • long thoracic nerve
  • Feeling
    • Temperature
      • inflammation
    • muscle wasting
      • may suggest nervous injury
    • sensation
      • axillary nerve lesion
    • joint palpation
      • warm, rubbery swollen joints are suggestive of active synovitis
    • Bony deformity
      • previous fracture
    • Tendons
      • feel for tendon rupture/sensitivity
  • Moving
    • failure of movement could be:
      • muscular
      • neurological
      • tendinous
      • articular
    • Passive movement:
      • feel for crepitus
      • tells you if problem is muscular or intra-articular
    • Pain on movement suggests impingement or inflammation
    • Muscles to test:
      • Deltoid
        • abduct beyond 15 degrees
      • Rotator cuff
        • subscapularis
          • lift off test
        • supraspinatus
          • empty can test
          • abduction first 15 degrees
        • infraspinatus
          • external rotation
          • Lag sign 
        • teres minor
          • external rotation
          • Lag sign
      • Teres Major
        • internal rotation
  • Special tests
    • Subscapularis
      • lift off test
    • Supraspinatus
      • empty can – impingement if pain
      • Neer’s test
      • Hawkin’s test
      • Scarf test
    • Instability
      • Crank apprehension test

Common pathologies to watch out for:

  • Adhesive capsulitis
    • ‘frozen shoulder
      • loss of external rotation
      • loss of abduction
      • pain on active movement
      • reduced active and passive range of movement
  • Impingement
    • Pain on impingement tests
    • may have reduced abduction
    • Painful arc 60-120 degrees
  • Rotator cuff injury
    • pain on external rotation
    • supraspinatus tests show weakness/pain
    • subscapularis tests may also
  • Instability
    • repeated previous dislocation
    • apprehension test
    • may have deformity
  • Osteoarthritis
    • pain on movement
    • reduced range of movement