Ultimate Finals List - Locomotor

Locomotor

• Gals and knee - nice, patient looked like he wanted to sleep. Pain in all his joints, lots of OA. Also had Pagets. I thought his legs looked Bowed, but didn’t mention it, had to have the examiner point it out later! Note, if you think something say it! He had big lumpy thing below his knee.. not sure if that’s an osteosarcoma. Questions on tests for Pagets, eg bloods what would be high and low and who and how and why to treat. Straightforward. // GALS on a patient who was actually half asleep. I forgot all my gals questions and half the examination but this doesn't seem to matter too much (!). I examined the knee after doing GALS because the man had a scar on his knee. The examiner then asked why the man had a scar on his knee. It was a knee replacement scar so I said so. He then asked why this patient might have had a knee replacement. I said osteoarthritis or rheumatoid. He then asked me if this patient had rheumatoid, I said no. He then asked what investigations I would do. After all the bloods etc etc, I got to bone scan and he asked apart from rheumatoid and osteoarthritis ...what else could show on a bone scan. I finally saw the light and said Paget’s. He also asked me look at the patient's legs again and pointed out (I quote) "there is subtle bowing of the tibia." He then asked me about blood tests for Pagets, I said alk phos, he asked what I would see. I said it was raised, and he asked me about calcium and phosphate which I said would both be normal. He then asked about the treatment of Pagets, I said bisphosphonates, although most patients are usually symptomatic. He nodded and said "yeess" so I think I made up for missing the diagnosis! He then made me answer questions about osteoarthritis and rheumatoid arthritis, about the investigations, and the treatment and the WHO analgesic ladder.

• Knee exam on med student pretending to have a gait disorder. Just examined and told to explain actions. I even had to do the Mcmurray test // Knee exam – football injury. Was medial collateral ligament. // examination - anterior cruciate ligament tear

• Please perform the GALS and the examine this lady’s hands. UNIlateral MCP subluxation, Z thumb, flexion deformity of the MCPs, Boutonniere’s – the works except the unilateral bit. Examiner didn’t know why either but rheumatoid was the answer. // GALS screen - rheumatoid hands and feet, DDx and Ix // details of DMARD side effects // asked about how long I thought the patient had had the condition, asked differentials and which other joint would be improtant to examine, then had to examine it, I picked the neck // Musculoskeletal- Do GALS and then examine hip of a young man with RA. He had one leg shorter than the other. // locomotor- I performed GALS. The patient said he had pain in his arms and could not dress himself. On inspection there was obvious subluxation at wrists and ulnar deviation at MCPs. I went on to perform Rheum hand exam. I gave the differentials of RA, Psoriatic arthropathy, SLE (had pt been young and female). Once I had presented the examiner asked me about the reasons for patient having leg and foot bandages. I didn’t have a clue but I said 'pt may have had operation to fix deformity caused by rheumatoid arthritis', or patient may have ulcers due to systemic effect of connective tissue disease. Not sure what examiner was getting at. // GALS + hands - RA - asked what else I would examine and I said "feet" and he made me do a foot exam!! // rheumatoid hands. good station but they hid a medic alert bracelet under the patients watch so only saw it if looking very closely

• Locomotor exam- "GALS of just the arm" plus hand exam. She had osteoarthritic changes- Heberden's nodes (forgot to call them this), Bouchard's nodes (forgot to call them this), no rheumatoid nodules, no vasculitic lesions, marked DIP involvement.

• GALS in a lady who could not lie on the bed due to pain, so slightly pointless. she had had a knee replacement, and the examiner just asked questions on that. // Mention would complete examination by examining neurovascular status of legs and examine joint above and below (hip and feet).

• GALS – Patient with scleroderma. She had a waddling gait and sclerodactyly. Scleroderma seems to be a common thing in exams. Might want to imprint that to students, so they dun get caught out (which i am sure a lot did) // MSK - scleroderma - only signs were painful joints and raynauds phenomenon - had to do GALS then examine the hands // GALS and MSS - did a GALS screen on a lady who had very limited signs! I thought she had limited internal rotation of her hips, so presented my GALS screen and said 'I would further like to formally examine this lady's hips'...to which the examiner suggested I examined her hands...oops! On examination her hands were near normal, with some slight redness and thickening of her skin from her PIPJ's distally. I was almost ready to present her a normal case (and was slightly panicking now!) but with 1 min to spare the examiner said 'if you want to ask her a few questions go ahead' - so I asked the lady if she had any pain or stiffness at any time of day, she replied 'not time of day, but time of year...Finally! I then asked the questions you suggested on your course 'do you notice they change colour at all? (yes..they did!) and she had some difficulty in swallowing too!) She had scleroderma (although really didn't have the typical facial features I've seen before! - then presented her case, discussed a little re scleroderma what investigations I would like etc etc.

• Locomotor - hip examination. right sided restricted movement due to pain, DDx, ?OA secondary to trauma, RA vs OA

• GALS screen, ank spond and psoriatic arthritis I think. // MSK - ank spond - did GALS then stood there looking at the woman for ages That station was run by a fairly.. shall i say..notorious rheum consultant. She wouldn’t let me talk to her till 7 mins was up (which is fair enough). The instructions were that this young man had a problem with his neck and I was to do a GALS screen and anything else necessary to make an assessment. So I did the GALS screen - he basically had severely limited ROM in the cervical, lumbar and thoracic spine and stiffness on internal and external rotation of the hips, otherwise all normal. Having done full inspection, palpation and movement of the spine i couldnt think of anything else to do. There was a box of neuro 'toys' - vibration, orange sticks, etc so i tested his sensation in broad terms and the power, but i was done within about 4 and half minutes. so i just waited. The questions were 'so tell me what you found' and she shook her head all the way through it, which was a little off putting. Then she said what was my main differential - so i said ank spond. and she asked for any other possibilities.. and I couldn’t think of anything else. so I said lupus (hahah) which is the answer to everything along with HIV, TB and idiopathic. then the bell went. // Asked me to present, asked differential, then extra articular manifestations of ank spond and lastly, the available treatment

• Orthopaedics - examine back and hip in 6 mins. Ank Spond, Hip Replacement (scar), OA of other hip.

• Knee examination - osteoarthritis // Knee examination (he then asked me to examine the neurovasculature of the foot) // GALS I had to a gals screen and then I focussed examination depending on what I found, this lady had a very bad knee, every time I touched her she would yelp. I did the best I could, the examiner was quite sympathetic, even when the time to examine was up, she gave me an extra minute to complete my examination, I presented, and said I thought she had osteoarthritis, she asked what else could she have, I wasn’t too sure what she was getting at, I said an atypical presentation of rheumatoid or septic arthritis although I would expected more redness, I think that’s what she wanted me to say, she then said considering what u found in her back what is the most likely diagnosis, I then realised I hadn’t tested flexion of the back in my gals screen but obviously thought I had, just goes to show, if you act confident they wont even realise that you've missed anything out! it was OA of back and knee

• A hip examination. The patient had undergone arthrodesis of the right hip and the left hip had severe osteoarthritis and almost no range of movement. He had scars EVERYWHERE from previous orthopeadic surgery. I don't know about the history of this patient but he had deep sinuses in his lower spine which looked like some kind of neural tube defect. V confusing. I’d never seen anything like it and it really distracted me. I’m sure they just wanted us to mention it and then focus on the hip but it was difficult not getting distracted. // He couldn't flex hip past 20 degrees so i was unable to test int and ext rotation in flexion so instead did it in extension. Quest- management of OA (worth having a spiel for that one i think- my friends and I prepared OA pretty well as it seems to come up most of the time).

• Musculoskeletal – I think I was just asked to examine the patient's joints so I did the GALS screen. The only abnormalities I found were bony swellings over the PIPs and DIPs and that the patient had had some knee pain in the past when I asked the 3 questions. When I reported this to the examiner and said that this would be consistent with a diagnosis of OA he said "What about his spine?" I had found forward flexion of the patient's spine to be normal during the GALS screen but the one movement I had forgotten to test in the GALS screen was lateral flexion of the spine! I remembered when the examiner prompted me, tested this and sure enough it was markedly reduced. The examiner then asked me to look at the patient's hands which were erythematous. He asked me what this could be and led me towards saying Raynaud's. I had trouble putting this all together but then the time was up.

• Patient had congenital kyphoscoliosis // Klingon syndrome or something similar?!!

• GALS - this was ridiculous. You were asked only to perform a gals screen. We all offered to examine another joint to help with the diagnosis, but the examiner wouldn't let us, so instead we all finished the station in 2 minutes and twiddled our thumbs for 5 minutes not knowing what to do until the examiner starting asking questions. None of us have any idea what was wrong with this patient. I am pretty sure she had scelrodactyly because when I offered this to the examiner, she seemed to think I was on the right tracks, but then she kept asking me what sclerodactlyly was called, even though I'd already told her. I said I thought it was scleroderma and she asked me for another diagnosis seeing as that was so rare.

• MSK: knee exam....again which was nice...massive swollen left knee on an elderly lady in pain! wasn’t sure but he told me its a tense effusion....then he waned to make sure that we know what to do when we see a swollen single joint!!! so septic arthritis 1st differential and aspirate with broad spectrum antibiotic n he was happy with that answer... then he said how to investigate: FBC, ESR., CRP (inflammatory markers) // Musc skeletal: Examination of a hot red swollen knee, too painful to do special tests asked about differentials, what is important to rule out, what I think it could be...I said pre patella bursa, Then asked about Ix

• do gals then examine the spine. patient had scoliosis had to give a differential and why I didn’t think this was ank spond.

... and for fun...

• GALS screen - my examiner knocked over the cubicle walls and spent about 5 mins rebuilding them! I just carried on blissfully, afterwards the examiner apologised and said that I had passed, which was nice!