Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

the muscle is good. Eso today station is gonna be on the M s K station. Also want to say is today's my last lecture that I'm gonna be delivering by itself in terms of this activity here. In case I forget to say at the end, I just want to say it's been an absolute pleasure to teach you guys off the past. Osteo bi teaching experience has been a lot of fun and setting up this platform and giving so many teaching sessions and hope you guys are going to enjoy this last one that I'm delivering myself. Oh, shall be around to help with the other sessions. Yeah, case you guys leave. Uh, so today's session is on the M S K station. So again, it's general rheumatology. Basically will cover a lot of during presentations. Okay, we'll cover the osteopath. Oh, just to the hot, swollen joints cover sort of approach to general crime joint pain presentations, osteoarthritis, rheumatoid on. Going to cover in good detail. The hand examination. Okay, so the first half of the session will be born sort of, uh, history, taking clinical aspects off. Um, sk on the second half will go through the, um, examination in a lot of detail on Make sure everyone is very confidence in the pathology is that we're looking for in a hand exam because generally the hand examination is one of the most notoriously poorly performed examinations by students. Okay, people just don't understand the hand exam as well as they understand. The cardiovascular respiratory are Donaldson. Vision's okay, they don't practice it as much. So I'm going to try and make sure everyone is very, very confident in understanding the clinical significance off the on examination. So gonna start off with our first station. So we're in the emergency department. Okay, So this is a a cute station that we've lost to see Mr Well, but the a 48 year old male who presents with acute joint pain on we've been taking concise history. So So this is a acutely hot, swollen joint station. Okay, so hopefully you guys already have some differential is growing in your head. So before we start going into the actual sort of talked about the different conditions, let's first your quick swap diagnosis exercise on acutely hot, swollen joint differentials. So if this one a 77 year old female presents with a hot, swollen knee. She has a fever and restricted range of motion. She has a past medical history off diabetes and rheumatoid arthritis. What do you think? Yeah. So something off, Right. His goods. Okay, um, so with the acutely hot swollen joints, Okay, this is the most important differential to do. Lots in the anybody in the emergency setting. You know, it always for the acute helps with joint. It's setting off writers until you've adequately proven it's not. So why is this most likely static joints? So we got acutely hot, swollen knee. Septic arthritis most commonly will affect the neat Okay, because it has, um because in the S very apple amounts of blood supply onda, uh, associative features for a septic going fever, restrictive range of motion classic for septic arthritis. And this patient as he he It's more septic arthritis, a world eighties. The risk factor for for general infections okay, including joints, because being, you know, suppression on Glumetza and arthritis. So this patient has history of rheumatoid. So that's pretty existing joint damage. Okay. And that's another risk factor for septic arthritis. Okay, Next, 1 54 year old man presents with a two day history of severe pain and swelling off his left. Left her He drinks six beers daily. He recently was also diagnosed with heart failure. That would be, I think, gots good. Um, is this acute? Got chronic guts. Que guts? Okay, so, uh, remember, you all see, it's more important. It's important to just qualify acute. That's a cute guts. Okay, I'm glad I did, but you'll see it can if I did. This is like an acute gout attack. And so you have a man. We take out steadily more common in men. And why do you think this has got what sticky features of gaps here? Yes, but the toe again, gout's classically will affect the first metatarsal. Phalangeals joints get the big toe. Um, anything else? What? What's the associative features? What's the other stuff? House. I remember. Yeah, alcohol. Alcohol's there. Very people. Rumor got out. Okay, so this patient dropped drink is a very significant alcohol drinker. Acute onset. Okay. God is very acute. Onset. Okay, All happened within a couple of days, okay? And well, so what's the relevance of the What's the relevance will be heart failure. Okay. Diuretic skipped against the diuretics for heart failure. And so the patients I've started diarrhetics for heart failure. That's another trigger forgets. Okay. Um, good. So that's got okay. Can you tell me why does guts affect the big toe? Mainly combat any other of the other joints. What's special about the big toe? Do you? Why does God effects the big toe? Me? Yeah. Okay, So you think about the why the Victoza, the most distal one of the most distal joints in the body. Okay, so the actual temperature is a lot colder combat relative to the rest of the body, so it's more likely for Got it for crystals to become pacific, dated in the big toe. That's why the big toes. Most common location for gout attacks. Okay, um, be a, uh, that's got okay. Remember, it's one of the crystal crystal induced arthritis. Got this characterized by specific crystals, and we'll talk about the specific time to the crystals they drawn. Next one is 35 year old mind with frequent and painful urination. Hey, as frequent and painful urination, Yes. I had progressive right knee swelling, sexually active with two female partners and has bilateral conjunctivitis is uh huh. Want us think about this. Yeah. Reactive. Arthritis get okay. What What is the What's the saying for reactive arthritis? What's the trial? Reactive Arthritis. Yeah, I can see he on. Can't climb a tree. Okay, so this patient has speech is off. Is vision has history off? Basically a str. Okay. Like a, um, a comedian or gonorrhea infection. Ongoing active arthritis. Classically, it's a react. It's a reaction to an infection. Okay, so this patient has arthritis. That's a right knee swelling as a reaction to the infection. Okay, so this actually extracted two female partners. Painful urination. That's the history of the sexually transmitted infection. And also bilateral conducted by just Can't see. Okay, So another feature of reactive arthritis last one and stop swollen joint presentation. So you're a woman with a swollen, painful right knee. Abbvie is your hemochromotosis X rays performed and showed chondrocalcinosis. Yeah, I think, but, uh, this woman okay, did I got to get Okay? So what about this? Is that it's not that common. Okay, you know, it's pseudo gout, okay? But it's not actually not common, but eso won. So the key thing with pseudo gout is that it's affecting the bigger joints. Uh huh. Like under That's it. Right. But yeah, was so super got. Typically affects the bigger joints. Okay, typically, the knees and the shoulders on the key radiological feature for pseudo gout is chondrocalcinosis. Okay. And calcification of the cartilage and history of hemochromatosis is it's one of those associating because you're supposed to take outpatients. Okay, get those get those are sort of keep differential. We're gonna be talking about for acutely hot, swollen joints so quickly in terms of some basic history taking for MSG. Okay, so joint pain presentations, because important. But it's obviously as you can imagine is our Socrates. Okay, so I'm sure you guys know what all these are pretty speeches up, and I just listed out what? How to specifically us the Socrates on. But, um, all these sort of relevance specific questions. Okay, this is generally the most important bet with us. My drunk pain. And when you present the history back to the Examiner, okay. When you present this represented complain, you just work through the Socrates that you elicited from the patient's. Okay, So this you're presenting your weight is pretty easy for joint pain presentations on We'll we'll go through specific history beaches as we go on. Okay. Things like morning stiffness associated peaches. Okay. How they're relevant for this specific conditions. Um, it is a past medical history. Okay, general things asked previous history of MSG, a disease rheumatological disease, history of psoriasis. Okay, we'll talk about psoriatic arthritis. And when we talk about examination diabetes, we talked about respected for septic joints. It's your peptic ulcer is why Why would that be relevant? If someone has a history of empting ulcer disease, it's the inside. So Okay, so it's it's relevant thing to elicit. Okay? Because if someone's his your peptic ulcer disease but joint pain presentations, you want to be considering different analgesia. Culkin's okay, Someone has a history of have to go to disease. You be very cautious about giving things like insects. History of infections. So we said, worried about septic joints okay on, but it's important to elicit if they've had any previous surgery on the joints. Okay. And if they have any operations plan for a particular joints, okay. Very relevant to any joint pain systems review of a case of ruling out important stuff. Relevance. Okay, Things like fever. Very, very crucial. History off, um, travel. Unprotected sex. Thinking about, um, the active arthritis. Okay, uh, skin rash, low back pain. Uveitis. What? What's the relevance of us getting bloods? Well, the list, uh, skin rush, low back pain. Uveitis. What's the relevance? Yeah. So you guys got I'm closing spondylitis that story out Scalp, right. So some certain differentials are certain conditions that affect that, But the back, Okay, the seronegative spondyloarthropathies they can have extra article and manifestations like skin rash. You guys this Okay, So just again, systems reviewed, be able to recognize and just think about these different days. The really important thing to ask about with joint pain is all these different functional questions. Okay, as you imagine, someone has joint pain. What other joint? It is the function you need to assess the level of functional impairment because of that joint damage. Okay. You know, I smile. If you have problems with your joints, you're gonna have a lot off issues, but function off. You know, we'll talk about handing it down later on. You can imagine if you're not able to lift anything up. It's a problem with Instagram. It's a lot of functional impoundments. Okay, so I've just described a lot of different questions to ask about the function impairment. Okay, so make sure you're able to elicit the level of function impairment because of the joint pain. Okay, so remember when you whenever you want, um, think about functional and family need to know What is that? A sign function okay. Before before they develop joint pain. And what is that function now? Okay, So you need to sort of clarify the progression off the functional impairments because of the joint pain and then other stuff. Just general stuff. Trust about in history, Like smoking housing to take this number of stairs important, functional, functional questions. Well, cool. So that's a basic, uh, rheumatological history. Okay, Joint pain history on. Now we're gonna talk about those specific differentials which we talked about the stuff from the spot diagnosis. So it's a lot of joint effusions. The way I like to think about classifying the cause is of different joints. Infusions is inflammatory effusions, noninflammatory effusions, septic joint infusion and, um, bleeding. Okay, So hemarthrosis like it's beating into the going. So in terms of the specific cause, there's there's a whole bunch of inflammatory causes. Okay, Gout, pseudogout. So after after, I just reactive arthritis. Rheumatoid. These are all inflammatory conditions. Okay. No inflammatory stuff like osteoarthritis. Okay, remember, osteoarthritis, You know, says itis. Okay, It's not predominantly and flammatory condition like rheumatoid. Okay, It's primarily key. Feature osteoarthritis. Is degeneration of the joints okay into the septic effusions? Um, you can take this two major causes upset that confusion. Okay, terms of the cost of organisms Staphylococcus aureus is that is the most common one, and I see you're going to hear is common in young people. Okay, on in terms, of course, of beating. So there's different causes of bleeding into the joints. Okay, You can have eye Tradjenta causes, you know, from the aspiration trauma, Big one. And if someone has an underlying bleeding plotting disorder and also cause bleeding into the joints So those are majors that that that's how we classify enjoyed infusion. Okay, on this is very relevant. So okay, cause it's good to classify this way because if you classify it this way, when you interpret the and results of a joint aspiration. Okay, It's a lot easier to interpret it if you if you understand, the cause is of joint pain based on this classification. Okay, well, we'll come on, Tonto. Aspiration later on. But just remember, this is how, uh, this is the best way to classify the cause is of an infusion. Okay, so now we're gonna talk about specific differentials, and my first sort of question to you guys is Can you guys tell me one of the closes off gout, if you can examine it, cost you just straight out. What are the causes off? Got any eyes? Give me some causes. Increased production of uric acid gets okay. So hypouricemia? Yeah. A good way to pacify is to divide it into causes off, increase uric acid production and causes off. Reduced your casted excretion again. Remember, got is access levels of uric acid in the blood. Uh, excessive puree, puberty's and the diet goods. Renal dysfunction. Yet? So I've got a new mike here to help. Remember? So then you're Monica Here. Is that terrific dilating against H delay. So you can remember it so each for how's your senior? Okay, So situations that caused my levels of uric acid can be here at your editorials. Well, D for diabetics. Okay, so I I diuretic, like diabetics. They're common triggers guts for FMLA. Okay, So alcohol. Very again. Very common trigger for guts, al. For leukemia. Okay, so humans logical on dignities situations of increased cell turnover can cause excess levels off your cast it in the blood other than leukemia. Can you think of any other humans? A logical presentation which leads to access your casted in the blood. Yes. Yeah, she realizes syndrome. Good. Okay. So, um, situations off, uh, where tumor cells get busted up. That leak a lot of your casting into the blood and guts A four v know impairments. Okay, so this is the most common cause of belts. Okay. The definite by far patient to have quite kidney disease. Not able to excrete your gas. It probably That's very common course of gout. On Why? For a leash. My hand syndrome. Okay, this is ah is getting a very rare a metabolic condition. Ah, okay. For for the for the elite medical students out there. Can you guys tell me which enzyme is deficient in leash? And I haven't syndrome. Yeah, I know. As being oxidants, get eso the specific separate type. It's, uh those are being, um Ghani, uh, hospital. Roberts, I'll transfer. Is that something like that against, like, HD PRTs? Okay, but that's again, that's more sort of finals. Little knowledge. Okay, but yeah, these are the sort of, uh, closes off guts. Okay, Again, remember, the most common one is a real independence. Okay, So in terms of the actual differentiating feature, So I made we talk about some of the major differentials, but can you give me some classic features that's going to help? Differentiates are causes of gaps in terms of a history. What would you What sort of features would you want to pick up from? A history that's going to point towards a certain differential involved? Joint again? That's very important. Okay, Which joint is what is what involved? What else? What else? It would be useful to pick up from a history that's going to, let's say, point multiple. World's a septic joint. Systemic upset, good fever, diabetes, But my history grange of motion. Okay, first time very, very good. Okay. Is this the first time they're presenting with an acutely hot, swollen joints get very, very relevant. Cool. I say I've taken this table from my rheumatology for final session. Okay, these this the main sort of summarize version off the key features to pick up from the history. Okay, that's in terms of guts, generally into the history with it. We're thinking about men. We think about acute presentations. It might have a history of binge drinking. Okay, so remember alcohol, big culprit, renal stones. So they might have a history of renal stones because, uh, issue of high levels uric acid can cause renal stones. Okay, well, good question. What? What do you like? Acid? Renal stones. Looked like on the next refill. What is it? What is it? You're a gas if we don't start like on an X ray. Yeah, doesn't. It? Doesn't show up. Okay, it's a trip. It's a trick question. Okay. You can't see. You can't really see renal stones on a on an extra. You can't see you like acid. Renal stones on extract from. Okay, the radio loosens s So that's why you need to do the CT, baby. Teo, accurately Pick up your gas and little stones. Um, so just be aware of that. And tofu, I so ah, go through it. So if I When we talked about the examination, but again took my teacher off chronically elevated uric acid levels, uh, lastly would go to see Big, so that spect it. Okay, pseudogout, it's unlikely you'll be asked to take a history of someone pseudogout. Okay, It's not There's not that much they can ask you about with regards. Okay? Typically, it's history of human rheumator assists hyperparathyroidism or so I typically affects the bigger joints. Okay. Like the knees and the risks of shoulder. We talked about septic joints. Okay. Very, very acute presentation. Typically accept it. Joints, five, fever, existing joint damage. Okay. Or if they have a lot of joint replacement instead of smoking a prosthesis on. Typically, it's a single hot joints. Okay, you don't get multiple joints getting set to get the same time we can. Typically, it's a single hot joint on drastically. Instantly he because he has Ah, a big, uh, blood supply. Okay, cool s So that's our sort of keep differentials for acutely hot, swollen joints. Okay, so when you're presenting the history, remember, this is the sort of structure for presenting a history and osteo Uh, it comes off how to do it when you present you a history of presenting complaints. Okay. Remember, easiest way to do it is to literally just present, but he Socrates, that you've done for the for the patient. Okay, so literally just go through all the Socrates that you've elicited a relevant negatives on. So remember, with the acute hospital, enjoy. The big thing you're worried about is a septic septic drinks. Okay, Septic arthritis. So the key relevant negatives that you want to clarify to the Examiner is anything that's going to point towards septic joints. Okay, so you want to demonstrate to the Examiner that you're being very safe and that you see accurately assessed a patient to unlikely have a septic joint? Okay, So rather than negatives, would be things like the patient doesn't have a history of fever, has no history off immunosuppression on diabetes has no restrictive range of motion, has no systemic upsets. Okay, Those would be relevant negatives to mention um, rather fascinating history. We've talked about all these around since history previous history to pick up, go through the ice of the patients are cases. So remember this. You want to mention the fact functional impairments because of the joint pain. If you've listed it properly and that goes 100 with the ice is well, I go to the top differential and why? Okay, so it's acute gout. Talk about what the risk factor for God was on, Dex. Plane it and go through your other differential. So whenever you're doing an acute, hot, swollen joint history, your differentials always has to include septic arthritis. Okay, even if you don't think the patient has a septic joint, septic arthritis always has to be in your differential diagnosis. You always have to be thinking about it and showing that to the example. Okay, so we've gone through ah, sort of history for acute, hot, swollen joints on. Now we're gonna move onto investigations. So remember, with investigations we divided into bedside investigations, blood tests on imaging and special tests. So he has to be some investigations. That would be relevance to do for any acutely hot, swollen, tender joints. Okay. Yeah, Temperature. Okay, So basically observational, including temperature joint aspiration. Good. Okay. Definitely say you do in office, and he says and extracted joint fluid. Yes. Ah, COPD. It's on the market is urinalysis. Yeah, you It's you. You can mention it. Uh, full blood counts. You're eight. So if you think the most likely diagnosis of guts, then you could mention your it's okay, but first time about any What joints. Okay, so let's go through it. So in terms of, uh, the investigation, this, uh, it isn't acute presentation. Okay, so on. But remember again, the emergency thing we're worried about is septic arthritis. So always a B c. The assessment. Sepsis six. Okay, even if this is it doesn't seem like a, uh that, uh, that they don't seem very unwell. Okay, because we're thinking about acutely septic joints. Just mentioned you do a three assessment sepsis, six tg focused MSG examination. Okay, So what examined the joint that that's affected and the joints apartment below? Uh, okay, So let's go through all these blood tests again. Justify why we're doing that. Uh, so called back. And what is a full blood count going to tell us in a spot? Swelling doing Why? Is it a little bit useful? Yeah, White cells. Okay, good. That's a good estimate of thing or detective that raised white cells. Uh, another thing that you might seem a bit, uh, as out there's, you know, think about gout. If they have a little article malignancies, they might have, uh, deranged for blood counts. Okay, So that my bunch of lows, because about, um, LFTs. What would an lft be useful? Never function test. Okay. Yeah. Was liver function gonna be specifically What? What would be a s t two l t ratio be useful for And yeah, keep it. Sort of joint. Yeah. So they have a history of alcohol. Okay. Again, gout's, uh, alcohol is a very common trigger for got. Okay, So left is mature history of alcohol use. Also, if they have deranged allergies, you're going to be careful about giving on Sutent on TV. Also exposed Texas. Um, he's what? What are you And you and he's gonna be useful. Why is it relevant to get there, you know, function good. Okay. So remember, chronic kidney disease. Very relevance, generally for acute presentation, but especially for guts, because I can kidney disease leading cause of guts because of reduced exclusion off your gusted crp. Yes, uh, plotting screen. Why is a clotting too useful. This is interesting. Why? Why would that clotting screen be relevant to do? Yeah, it's a quite a lot of these one. Okay, so check if they have, uh, bleeding in the joints is any other reason. If you think more practically in the emergency department, why is it relevance to get a patient's floating profile? If I think he acutely in the emergency departments, what's if someone has an iron A off 10? What is not gonna make you be? Careful. Loss doing Yes. Surgery is one. Okay. The other thing about the media thing you're gonna want to arrange in the emergency department is the aspiration. Okay, So if someone has a deranged I and, uh, okay, the I was super high. You're gonna realistically avoid doing the aspiration, okay? Because you don't wanna cause excessive bleeding into the joint. So again, just think practically as well as the sort of medical stuff as well. VBG and blood cultures, you know, part of the sets a six. Okay, uh, joint aspiration. So this is the have to mention you would do an aspiration. Okay, do the office of pieces. And when you say that you want to say that you'll send off be joint fluid for ground staining white cell count cultures and also for your eyes like microscopy. Okay. To look for specific type two culture, airport of crystals. And also mention you can do X rays off the joints effected. Okay on. We'll go through the specific investigation, finance, But those are your investigations for any hot tender joints. Okay, if you can mention all of these and justify them, okay, you look really impressive. So it's under the specific differential, So Okay, there's some extra stuff you can add on. Okay? So for static joints, you have to mention you get urgent or pulls up eating review okay, Because they need to assess if the patient needs to be taken for surgery if they need. If they could do the aspiration as well on you also want to look for sources off infection. So you say you do ST I screen stool cultures, urinalysis and urine cultures as well, and also for septic joints on. You can also could say you consider doing an MRI scan. Why would you do it tomorrow? I prosthetic arthritis. What would you be worried about to do an MRI scan for a septic joint for complication. Would you be worried about osteomyelitis? Good. Okay, so if you think if we weren't about osteomyelitis, you say, get the, uh I'm all right and just got so additional stuff you can I don't know. It's a glucose and lipid profile cause cardiovascular respect, this uric acid levels. This is interesting because the uric acid levels is not useful acutely for guts. Okay, so the the F in a shin is that in acute guts? You're gassy. Levels can be normal, okay. Or even low. Because the crystals, the uric acid, gets precipitated in the joints, so the actual blood uric acid levels can be normal. So it's not actually actually useful to do your acid test? Acutely forgot. Generally, the advice is to measure it a couple of weeks later, after the acute presentation on an additional imaging modality. Forgot is the jewel energy CT scan. So if you're not able to aspiration, you can do in a CT of the joint effective. Okay. Just remember, aspiration is is can be complex procedure, okay, Especially for guts, which is affecting your tiny joint in the big toe. Okay, Can be a difficult procedure to do. So sometimes the CT scan will be preferred after super guy that you can mention a blood test spoon profile in studies. So for, um, I have a parathyroid is, um and for hemochromatosis. Okay. Again, pseudo gout is unlikely to show up in your house keys, but this is stuff. Teo this just stuff to you. Tell the Examiner. Okay, so, joint aspirate interpretation. This is, uh this is a bit of data interpretation that might show up in Austin. So remember this thought we divided are closes off a effusion into these separates divisions? Okay, we divided into function Infusions. No, no. From the infusions. Septic infusions on bleeding effusions again here, the different causes again. I'm gonna go through all of this. Okay? The most important bit of interpretation here is interpreting the white some trans. Okay, you can You can learn about all the other features as well. But the most important thing that you have to remember is the numbers for the white cell count for joint aspirate fluid interpretation. So generally, the rule of thumb is that if someone's white cell count is less than 2000, it's unlikely that they have an inflammatory infusion or a separate confusion. Okay, so 2000 is like the number where you're not worried about any kind of information or infection If someone has a white cell count off greater than 50,000 cells for millimeter Cute. That's highly concerning for septic fusion. Okay, so again, 50,000 is, in general rule be used for septic confusion. It's, uh, anywhere between 2000 and 5000, we'd be thinking about inflammatory infusion. Okay, so some of these causes, Um, but that's the general sort of numbers to think about. Okay, so between 2000 and 7. 5000 is within your inflammatory infusions. Greater than 50,000 would think about, uh, sent it effusions. Okay, on the other major thing to think about. It's crystals, okay. And we'll talk about it. So if you see crystals that could indicate guts or suit adults, Okay, so we're going to go through a little bit more data interpretation. Okay, That can definitely show up in your ski. So the situation here is that we're saying that the joint fluid has been analyzed under plain polreis lights on Let's say this is the first image that the Examiner shows to you. What do you think about this image here? So this is this is a cross cream itch off fluid, as I've been analyzed under being food for rice lights. Do you think about this bit of data? Yeah. So you guys got it. So this is super got. Okay, so this is the key description here is that there's so these are different types of crystals. Okay. All these different objects. You see how these are types of crystals. So the way to describe it is rhomboid tripped. Okay, you can see these rhomboid shaped crystals here. Okay, So you can also call it polygonal shapes. Okay, so he's a wrong boy. Cheap on a Z. Guys are saying positively by referencing Bristol's. Okay, So with pseudo gout, you get positively by your friends or crystals under playing polarized lights. So that's the description here for this image. Likewise. So we have another image off a bit of some fluid under thing polarized lights. Okay. And again, we have some crystals here. Now, what do you think about this image? What's different about this image? Come back to this image What's the difference about between these crystals? Yeah, needles fit. Okay, so these crystals are needle shape there. Okay? Whereas they're rhomboid shape here. Okay, so this is suggestive of guts against the needle shape crystals on. The key thing with gout is that the crystals are needle shape and then negatively by refrigerants. Okay, so, again, shooting out the crystals are weekly positively by refrigerants underplaying polarized lights. Whereas we've got their strongly negatively by refrigerants. Okay. Make sure you are able to appreciate the difference. Actually, how do you tell if it's positive in a kid you can't still? Okay, The the only difference here in the image is is that the shape of the needles? Okay, you can't really from these images. I wouldn't be able to tell which ones are positively by a French or negatively. Okay. Uh, what does virus friend you mean by a friend consisted? Basically, it's it's complicated visits. Okay? You don't need to understand what by a friend. That's means it's to do with the alignment's off the crystals on the plane for rice lights. Okay. So you don't you don't need to worry about understanding the physics off by refrigerants. I just remember the which ones are positively by a frigid and which ones are negatively boyfriend. Okay, I got some X rays to show you before we finish this sort of, uh, station. Uh, what do you think about this X ray here? So it just don't do a joint fluid, interpretative way gone through playing with painful rice lights. Findings? What do you think about this, X ray? This is actually of the big toe to remember. And you lost e always firefight. Patient details on wall type of, actually film. This is okay on. Like someone said, this is guts. Okay, so this is we're talking about X ray, which has features off gout's, um, so one of the features s So this patient has different features of guts. Okay, so these are the key key features of guts. Okay. The major one thing about is the erosions. Okay, so you can see these erosions next to the joint. Yeah, and they described as rock bites erosions, so it looks like a rat's bit in a bit of the joint outs. Okay, Sclerotic overhanging lesion. So you can see these bits of sclerosis next to these erosions So those store are cirrhotic overhanging lesions, a soft tissue swelling so you can see all the soft tissue swelling around the joints here. Okay, um, keep you took out again. Interosseous vision. So you can also get erosions inside the actual bone, which miles to show up on the X ray. But the key features I want you guys to also think about is that the patient, the extra here is preserved joint space and preserve bone density. Okay, so if you actually look at the joint space here and got the joint space is not obliterates, okay, this is normal. Okay? There's not reduced joint space. If there was, if there was reduced joint space, what would you be thinking about? Well, can cause produced doing space between the joints? Yeah. Also, arthritis or rheumatoid arthritis? Okay, both osteoarthritis, rheumatoid can reduce the joint space. Okay, but there's no the joint space is not affected here. Okay, So that's important feature to pick up on. And also the bone densities is normal years. Well, okay, so there's no, there's no sort of osteoporosis or osteopenia Kenya backing joints, Um, a lot other than things back up on. So That's a X ray off a patient with guts. So we're gonna move on to talk about treatment for gout. I can, Yes. Tell me some indications for your age. Lowering therapy and guts. When do you start your rate lowering? They're being up. So when do you stop it? Things like allopurinol for patients with guts. Two more attacks in the air gets again any of any of any anything else? Uh, two weeks after acute attack. And that's historically, they say it started two weeks after the acute attack. Okay, but generally in clinical practice, it's It's not that commonly done these days. Okay, But historically, they say it should be started a couple of weeks after the type I have someone has got to to fight gets. But that's another major indication. So I found it really good. You like to remember these Okay, is that the new Monica is your So it's only a history of renal stones. Okay, so if they're so basically any history of chronically elevated uric acid levels, that's an indication to start your lowering therapy. So they have a history of, you know, stones because of your gusted teeth of to fight. Okay. History of erosions over over two attacks per year. I guess, as you guys said off a renal disease against if they have a history of chronic kidney disease and the for the elderly patients, Okay. So generally, for elderly patients, it's advised to start allopurinol types of your it lowering therapy. So summarize the management forgot here. Okay, So in terms of the conservative medical and surgical aspect, sough story, not city will be monitoring for guts. Okay, I'm not gonna go through this in detail, okay? You guys kind of a reader of it. Keep things is that it is a medical management for you want to manage symptoms with allergies here, like and said your coaches seeing you can try steroids as well. If it's if these if this stuff is not effective. We talked about indications for allopurinol again. If albuterol is not affected, there's more expensive drugs. Like about the future is that that's available. Onda. Here's the sort of general aspects of conservative management as well. Okay, so we talked about gout in a bit of detail there. Okay, now we're gonna quickly talk about the other major difference off acutely swollen joints. So I've got another image for you guys. So we have joint fluid that's been analyzed with a ground state and microscopy. What do you think about this? Bit of data? So exam this showed you in another microscopic image of joint fluids. Uh, what do you think? So you guys are jumping straight in to say the answer. Okay, Staphylococcus aureus. First thing, and you're also is about describing the data. Okay, before you give me the overall diagnosis. So I think I said this is, like, the stuff like August or is Okay, so but first describing it. We want to say this. We see caca. Okay, So circular shaped bacteria on during clusters. Okay, so there there's groups off and coke. I in contrast this. Okay. And that's classic for staphylococcus. Okay, that's the description of stuff. A copy, okay. And cock, I shape bacteria that's occurring. Clusters around the fluid as the classic appearance off stuff Caucus aureus on the organism on it's also a gram negative organism as well. It's not office or yes. Okay, so remember, if you think this is kind of based interpretation, I will be Elkem up. Okay? Because we're thinking about swollen joints again. The most common cause offsetting arthritis is Staphylococcus aureus. Okay, so just be mindful of the different types of dated that can show up. Similarly, let's say so. We covered stuff, a caucus or es. Okay? And I've got another image, if you guys a similar kind of thing we're going about. What do you think about this image? First described the image for me before you made the diagnosis. Yeah. Ground positive diplococcus. Okay. Yeah. Oh, sorry. Sorry. Staphylococcus is a gram. Positive, but sorry. I said that. Connected gonorrhea get okay, Ground positive difficulty gets s. Oh, this is nice. Syria Gonorrhea. Okay, um so the key description is we have diplococcus okay? And that's classic for Neisseria species. Okay, so Neisseria they show up as diplococcus. Okay, so two bits of caca I stuck together. That's the description. My seriously cheese and the context off acutely hot, swollen, tender joints. Everything about my Syria gonorrhea as the cause of the I'm tender one. Okay, so they're going to You're going to be a gram. Negative. Difficult. Yeah. Sorry. I said get Neisseria grandpas. It's not It's a sulfa caucuses. Gram Positive. My serious. Grand. Negative. Okay. Sorry if I, uh, if I confused it. Um, Neisseria is, like around next species. So it was a septic arthritis management's. I'm not going to go through this again. I'll let you guys read threat. But the key thing to mention the first sentence to mention in your osteo is a B c. The assessment and sepsis. It's okay, because it's a acutely septic presentation on down. I'm not going to go to do this. I'm just talked through the different aspects of management of septic arthritis. Okay, just how you can formulate a management plan for your skin is you guys have a reading of this in your own time, but general days investigations, Okay? We talked to the investigations on your object. That would be okay. How you initiate antibiotic therapy on, but when you when you need to consider surgical intervention as well. Okay, that's the kind of thing. Do you want to get out in your presentation? Off the manager. But okay, that was the first station. Okay, so we pretty much covered the acutely hospital and tender joint presentation. Uh, now we're going to quickly go over other bits of joint pain presentations on down, we'll take a break. So we've been on since he misses norcraft, a 44 year old woman with pain in multiple joints. We're gonna dio we're only gonna cover to differentials. Yeah, Yeah, I'm sure you guys can tell me which differentials. You probably already know which differentials we're going to discuss. But let's do a quick spot diagnosis. So we know the the key differences. So a six year old women who presents because off pain in the fingers and knees, the stiffness lasts for about 10 minutes in the morning. Pain is west of the evening. D I p m p I d joints on both of active. What do you think? Yeah, this is osteoarthritis. Okay, so why osteoarthritis? So Friday's chronic joint pain for presentation Key thing is, the osteoarthritis is a non inflammatory cause off drinking. Okay, so this patient has a morning stiffness that last less than 30 minutes. Okay, that's the key history for any no inflammatory joint pain presentation. Okay, History of mornings. Lack of his your morning stiffness. Pain worse in the evening. Okay. Classic for non inflammatory poses off drinking like osteoarthritis on both the IV, NPR. The joints are affected again. Classical osteoarthritis. Okay. And in terms of the next one. So for your older presents with worsening joint pain in the hands and wrists ain't is in both hands and wrists are predominantly in the morning. And when she also has significant stiffness, run out. MCP and Prp joints are affected. What do you think about this condition? All right. Okay, good. So this is, uh, rheumatoid arthritis. Okay, so these these are two major things differentials. You need your understanding detail. So why rheumatoid? So remember, rheumatoid arthritis is an inflammatory cause off during pain. Okay. Rheumatoid is very inflammatory. Uh, this patient has significant pain. Okay, but the key thing with inflammatory arthritis is that patients have significant morning stiffness. Okay, this patient has morning stiffness greater than 30 minutes. Okay, So significant Morning stiffness. The pain is bilateral. Well, okay, we would do it. Is it causes symmetrical off ritis Penis worse in the morning. Okay. Classic for inflammatory arthritis on the distribution is classic for rheumatoid is well, okay. MCP joints almost always be affected as well as the CRP joints in. So again, we're just gonna emphasize some of those concepts that I just talked about. So when we think about drawing pain presentations, we divide it into inflammatory pathologies on day non inflammatory pathologies. Okay, So can you give me some key features in the history that helps us differentiate between inflammatory arthritis on down inflammatory arthritis? One of the key features on a history that you tried to extract That's gonna help you differentiate between the two. Yeah, the time of morning stiffness. Okay, so it's something significant. Morning stiffness. That's that's inflammatory. Arthritis fever gets a case of generally systemic features on predominant in inflammatory. Um, the joints of the distribution of joints effected activity is a big one. Okay. Does activity make the joint pain worst Okay, or does it improve on activity? Um, good. So those are all the different things, so I've listed them here. Um, so these are the key differences, Romans. Country is worse with, um, breast. Okay, but it improves with activity. Okay, I've talked to a rheumatoid arthritis patients who who say they have to wake up on our earlier in the morning. Okay, because the morning stiffness is so predominant that they need to just loosen up all their joints. Okay. Run their fingers on the underwater in just a loose and then joints. Okay. So, inflammatory arthritis. It's worse in the morning and worsens with the mobility. Okay. Gets better with activity and generally opposite stuff for non advantage, because is like osteoarthritis. Okay, so we'll talk about both East and both rheumatoid and osteoarthritis in a bit of detail. But I got a quick question for you guys. Can you just tell me one of the extra intestinal manifestations off rheumatoid arthritis? Every screenwriters party fibrosis. So there's extra test or a, um, and say, um, extra articular manifestations off rheumatoid. Sorry as the thing You have IBD stuff, but just let's just say extra articular manifestations. Epistle writers, calorie nodules get, uh, he what? Which one is the most common? What's the most common extra articular manifestation? Off limits. No deals. Good. Okay. Rooms are not. Those are the most common. Okay, so I listed them here. Okay, again, this is taken from from my, uh, rheumatology for final session. Okay, I really recommend you guys watch my rheumatol you for finals stature, which I gave a couple of months ago. Okay, but this is taken from that. So these are all the different systems. So the problem is rheumatoid is that it's a multi system disease generally, Okay, they can it involved into a multi system disease. So this is important because the key goal of treatment and rheumatoid is too. Get remission. Is the initiate remission as quickly as possible? Because rheumatoid, it's it becomes a multi system disease. And if it becomes multi if it becomes a multi system disease, patients get a worse prognosis. Okay, that's why you when you start treatment from rheumatoid patients, you start treatment very aggressively generally. Okay, um, goods. So instead of the key differences between osteoarthritis and rheumatoid, a list of them in this table. Okay, So you guys can ever read about it. It is just general things. General differences between no involuntary writers and inflammatory arthritis. Okay, um, a good thing, Remember, in rheumatoid, remember, the D I P joints are classically spread of rheumatoid. Okay, that's a very important thing to remember and relevance to when we talk about the examination as well. Okay, so we come in the, uh, chemical different presentation. Differences. Let's talk about the investigations now. So can you give me some investigations for both these conditions? What investigations? What do you do for your arthritis and rheumatoid arthritis? Uh, useful X ray is good. Anti CCP, uh, 80. And I fell X rays for osteoarthritis. Good rheumatoid factor. Yeah, I guess that's that. Well, I'm separated out for both conditions or osteoarthritis for both of the easy one. Mentioned you do a focused, um, SK examination. Okay. For whatever joint is affected, you you tell you to examine that joint on it comes with a blood test. Um, so, generally, also fried. Just you don't need to do blood tested diagnosed. I'll start Friday. It's okay, but the blood test can be useful for different stuff. Okay, So Focalin counts on crp es are on is generally just an investigation to rule stuff out to get to rule out into inflammatory causes of us off arthritis. Okay, human knees lft. So I get the union Altes, so it's may need to think about if it's appropriate to give certain types of analgesia. Okay, So things like, um and said's all RC small. Okay, So if someone has significant kidney disease to be careful giving and sets for the also practice. It's known as very elevated allergies. You be careful with giving paracetamol. Okay. Imaging a special test for osteoarthritis. So X ray films of 80 and life of useful osteoarthritis. And also MRI scan, which is being increasingly performed for osteoarthritis. Okay, but those investigations away and the Bruins, right. So it's seven of things in terms of the reasoning, So I hope that can think about in white cell counts. I also remember anemia is common in in rheumatoid arthritis for a couple bunch of different reasons. And crp sa, because off information. Okay, rheumatoid factor and the CCP are the key antibodies for rheumatoid. Okay, uh, I talk about a list up in a lot more detail in my final session. Okay, but factor is very sensitive, okay, but lacks specificity. And he's He is very specific for rheumatoid arthritis again. Just say you do the same X rays and all right. Okay, so we're gonna talk through the investigations and one detail. So can you tell me what does this extra a show here describe the changes for me so I see a lot of loss again. The loss of what? So There's lots of joint space gets. Yeah, pick up anything else. Some condos says there are that This patient has all the features of osteoarthritis. There's a condo. This also your bites of gun doses get a A. So this is a Remember when you present the extra cost. Always start with patient details. Always start with what this x ray is. Okay. So you mentioned this electric film off. You ever on this is review off the left hip joint. Okay, so in terms of the radiological features off osteoarthritis, and so the pneumonic is loss. Okay, so loss of joint space. So you can see. Remember, with that gout X ray, there was the joint space was preserved. Okay, but here the joint space is completely in a litter ated. Okay, You can't see any visible joint space here. Okay, That's the hallmark off osteoarthritis. Uh, also, your fights is well, so you can see some marginal osteo fights here. Some pond roll on, sis. Okay, So CDs control cysts bearing on the joint here on some chondral sclerosis. Okay, so you see there sclerotic and sheer. So these are your radiological features off osteoarthritis on. We talk about rheumatoid arthritis now. So what do you think about one of the sort of changes on this X ray suggests about rheumatoid? Yes, it is. Oh, Deviation gets against a lot of these fingers before we'll we'll talk to on a deviation in the examination. But these fingers are gonna deviated. Okay? The testicle and these are all not needed. A 24 to 20. Good. That's very good. Good. So this hyperflexion at the at the ideas and extension did the eyepiece. Okay, we'll talk about between years in a bit more detail later on, uh and you know, stuff like station. What's the What's the whole month feature off rheumatoid arthritis on an X ray? What's the most important feature that we tried? Almost Europe in almost all patients erosions get okay. They're very particular erosions. Erosions is the whole mark feature of rheumatoid. Okay, so you see all these erosions on the joints here down the MTV joints. That's the hallmark features of rheumatoid. Okay, So in terms of the radiological features of rheumatoid, the pneumonic is less so l for most of joint space, like a TV don't base is lost in all these joints here. He for erosions. You see, all these periarticular oceans happening here is well s for soft tissue swelling. So you see, talk to she's rolling around the joints as well. And, um, esports off for soft bones osteopenia. I guess it's a darkening of the bones around the joints here as well. And there's other things deformity. So there's only deviation here as well. On those are all the sort of features to be thinking about with rheumatoid. Okay, so in terms, so we come in the investigation, so we'll quickly cover the management. So, osteoarthritis, there's not much you need to talk about. Okay? It's general things. You need to mention the MBT approach. Definitely. Okay, physiotherapist gp ot therapy. Because both osteoarthritis and rheumatoid arthritis that both conditions which significantly affect the function of patients. Okay, so you really need to talk about the how you're gonna How you gonna help it? How you gonna help patients manage that function? Amendments? Uh, there's a medical management algesia generally okay. And said sports, it's more in traffic. Less steroids on last line. Cynical in the basement. If conservative medical management bills and for rheumatoid general stuff as medical management all the management stuff. You guys will cover it in the final session. But his general things symptom control and said steroids demarte. So these are the really important drugs to be thinking about with rheumatoid. So these drugs, like methotrexate's oxalate, seen very important drugs to have control the course of disease and rheumatoid. And remember that commenced. Really? Because you really want it prevents the progression of rheumatoid to becoming a multi system disease s. So you start the march early, and you often combine them us together as well. Um, it was a conservative management I mentioned here and show patients have an up to date vaccination status. Can anyone explain that? Why do I say patience? He to ensure that vaccination status is up to date. Yeah. So something so immune. Suppression. Good. So if you're gonna stop biologic agents for rheumatoid which are, you know, suppress it, you want to ensure that they're vaccination. Status is up to date before you start them. Because if you start, if you make them immuno suppressed, uh, then they're not gonna be able to get certain vaccines that a live attenuated vaccine so control that the vaccination status is up to date and it doesn't margarine up. Talk through some of the different aspects of monitoring there as well. Okay. And if it could be even examine, ask you one of the effects off adverse effects of the meds in rheumatoid arthritis. I've included this table, which I've taken from my rheumatoid for final session as well. So you can have a read off the different demons, which I used in rheumatoid arthritis as well. Okay, so we've come a day sort of history aspects. We're gonna take a five minute break, and then we'll talk to the hand examination. Well, most the feedback, uh, in the chart, I guess you need to leave early. Um, then you stop. Go. So we're gonna talk through, so we're gonna talk to the hand examination, So I forgot to edit this light. Okay. We'll say Yeah, we're doing a hand examination. Okay, So in the DPC eating before we go into the details of the hand exam, okay? Room and exam is one of the most poorly performed examinations. Okay, well, yeah, I'm going to try to talk through the sort of pathologies first again. Then we'll talk through systematic If I help too. System, I have to do the examination on. So let's see that Quick spot diagnosis access. So we have a 40 year old woman with happened. I resumed, develops numbness and tingling in the right thumb and index and middle fingers. She's a type A cyst on his right 100 on examination, there is wasting off the non muscles but no sensory loss in that area. What do you think? Yeah, right hand examination is really interesting. I hopefully you guys will find the all this stuff, right? Cool. Too little, But a couple times in a row, it gets okay, Onda. So why couple total one of the features off Couple tunnel syndrome here? The median nerve problems. So yes. So keep things. We will talk about all the median nerve stuff drawn. Okay, but couple times characterized by compression of the median nerve. Okay. On day she gets symptoms because of it. There's a median nerve distribution for century symptoms is the right thumb index finger and middle finger. Since patient has are seizures and the median nerve distribution okay on wasting off the the muscles of patients are chronic compression off the needle if, okay, they can get wasting off the thenar muscles. And decision has risk factors a couple times. Okay, hypothyroidism is in the differential. A couple of pounds syndrome, and we talked about this in the end of colonization. But hypothyroidism is one of the causes. Will talk about all the different causes later on. Um, and also, this patient is a type of cyst. Okay, So very common cause of carpal tunnel. Okay, people, people said it was set at the computer all day a bit like me. Just make sure you guys constantly giving I'm not typing, but a couple tunnels being a type. It is one of the causes, and she's right handed. Why is it relevant that she's right handed? Why is that particularly relevant? That dominant time is it is the right time. Use more. Yeah, it's generally this is important thing in the hundreds on. Okay. To clarify which hand is the dominant time. Okay, so they have symptoms in the right time again. Right handed, because that should already think this is probably symptoms because of overuse in that injury. Okay, in the context, off couple sound syndrome. Um, so that's the sort of reaches. Why's that know? Century loss in the muscles. So this patient has sensory symptoms in the right thumb. Index media, middle fingers. Okay, There's most of deficit from median. Nerve compression goes as wasting in the penile muscles, but there's no sensory loss in the penile eminence. Why is that? Why is that? Yeah, So this is important. Okay, Well, come on. This in a little later. Um, but the palm a cutaneous branch of the median nerve which supplies the thenar muscles. Okay. The century area of the denial minutes. That's that. Branches earlier than the carpal tunnel. Okay, so in someone who has a cure, couple down syndrome. So compression at the level of the couple tunnel, the palm. A cutaneous brunch is bad. Okay, so you don't you don't get century. You don't lose sensation in the area off the palm of the 39 minutes. Okay, go next. 1 70 year old man presents with pain in his left hand On examination, he has swollen d I piece on Does crepitus during finger extension I was using Yeah, you're right. It's kit. Okay, so this is not too much information again. Eventually the elderly man pain in the D I P joints. Okay, the I'd be commonly involved in osteoarthritis. What would swollen this? The eyepiece be called in Austria in the context of osteoarthritis. What type of notes might be showing up? Yeah, habitants nose gets. Okay, we'll go through the different notes, but also arthritis on crap. This is another key feature for osteoarthritis goods. Next, 1 25/1 fell off a horse and landed with a hand landed with the hands on examination to severe tenderness in the jungle. Snuffbox, what do you think? Schedule a fractured goods. Okay, so the station, as the room of the classic history for skin foot fractures, is patients who fall on the outstretched hands. Okay, Foucher on this patient has a history, and the key pill goes and nation finding or skateboard factor is tenderness in the anatomical snuffbox. Okay, we'll talk about anatomical snuffbox on that to me in a bit. Next 1 19 year old man has visually struggles to write on examination. There is poor grip, strength and sensory deficit in the medial aspect of the positive stuff. This hand. Yes. I'll go. Okay. Cubital tunnel isn't which which nerve is damaged first before you come in the course. Yeah, only lives. Okay, so this is like an alternative palsy presentation. Okay? But as you guys said this in terms of the cause of the illness, dialysis is probably off cubital tunnel syndrome again. Eso Why all the new palsy? Okay, so this patient has speech is off. Um, I only live palsy, so the sensory deficit is in the distribution of the ordinary. Okay, medial aspect of the partnerships of the hand is is theophylline distribution. Okay, so there's a sensation loss in the left on disk or grip strength. So those motor deficits in the intrinsic muscles on but also suggested by difficulty writing on elbow pain here. So that's one of the causes. Only live palsy. It is if it gets in trapped at the level of the elbow. Okay. In the cubital. So no. And that's known as a cubital tunnel syndrome. Okay, that's one of the equals is off on the nerve palsy. Okay, there's a whole bunch of other causes. A swell. Okay, My common one is things like cubital tunnel syndrome. Um, as someone said that people are leaning on the elbows that can often lead in track. The news or, you know, surgical operations as well are people doing surgery that that can compress the elevator at the elbow joints. There there's some common cause is off a live palsy or otherwise call it I'll live can be damaged at the level of the wrist is well okay, but it's not that common. Okay, if you get damage of the other thing about the risk, you can also get hypo the in. Our research thing was, well, next one a drunk students fell asleep on his chair over nights after a heavy nights when you wake. When he woke up, he was unable to bend his right wrist backwards. There's decreased sensation in his posterior forearm. Yeah, really? Lift was he gets again, as some of you are saying, it's a Saturday nights palsy. So why were you lives palsy here? So now this patient, The key. The easiest way to pick up these lesions in examples to look at the sensory deficit. Okay, decrease sensation and post your forearms are posterior aspect. Sensation is supplied with the radio live on the the key that most of deaths it happens in a radio. Live palsy is a risk drop. Okay, because remember your radio. Nearly supplying your expenses of Yeah, be really imposing. You get weakness in this extension. So this patient, this patient unable to do extend the risk of the compound. The risk? Quite risk backwards that's causing. That's the wrist drop. Okay, on Daz. So we said something. The night palsy. So that describes the drunk students fell with the hand so they passed out in their hands like this, eh? So, with the regular palsy, you could get compression of the level of the Xeloda on after the Saturday night palsy because it's commonly occurring. And drug people who eat that anything like that. Excellent. On examination of patients, finger is fixed in a black spot on without stain. A pop sound is hurt on extension. Uh, what do you think? Uh huh. True, Nothing against the cases trigger finger. So, uh, what having your trigger finger is? You're getting thickening off a set of poorly. Okay, this police, which is which were all the tendons which go to the fingers posterior. So you that's getting thick and on, like the classic history for trigger finger is patients. Fingers get fixed in a flexed position. Okay, so they often have to pull the finger up to get it in back into the normal position. Oh, that used to be difficult force to try and get back into a normal position or just fix completely. But if they're able to extend the fingers, they classically the is pop sound. Okay, catches okay. That's sort of history they described for a trigger finger. Um, SATs trigger finger. Next one. Last one today for your old professional, Gaylor develops pain in the radios. Silent. She has been caring for her newborn baby. Uh, what do you think? Yeah, yeah, Deco veins. Tina. Sinusitis. So why do you go on maintenance? Invited. So the key thing with the equipment inside of itises you're getting information off the tendons which are forming the lateral border of your anatomical stuff parts. Okay, so they are extensive. Close his brother standing and your doctor posters. Brevis tendons. Okay. On da Elsie. Because of that, you're getting pain at the level of the radio style. It Okay, that's a classic history for be quitting. 19 a synovitis. Keep this like this. Well, you have the seventies. You getting pain with some abduction and function. Okay, so it's a common hit. Risk history is patient to our professional games. Okay? We're constantly flexing abducting the thumb on also newly pregnant mothers who have recently had newborn babies because of the way they carry the baby. So I'm not going to send, like, I carried a lot of babies in my life, but the way they carry their babies, it puts a lot of, um, pressure on those particular attendants again because they ducked and black September lot. Okay, so that's why that's a common history teaches for equal Beatty. No synovitis. And I saw it was positive. Finkelstein's that's that's It's just a special test that you can use for evaluating deeper vein, Tina side like this. Cool. I just wanted to quickly cover some front different types of fractures. Okay. In the form of pictures. What you think about this wrist X ray? No, but I think I'm look at all the couple bones there. Yes. So this is a skin doctor. Okay, so you see the skateboard one here. Okay, So there's a horizontal skip, skip fracture. You can see the proximal segment and the distal segments off the scale for gun that's escaped for your fracture. Well, you think about this time here. It's not quite it's not. It's This isn't a swan neck again. This is that. It's it is safe. Dissipation has history problem? A moderate finger. Get it. Okay, so my fingers and see patients d I'd be doing is hyper flexed. Okay, so the abuse I perplexed. Okay, so this is basically that you're getting an avulsion from fracture of the extensive digitorum tendon. Okay, at the end of it. And so you're getting hyperflexion at the VIP joints? That's not finger next one. Uh, what do you think about this time here? If I say this division's who is, uh, I get what do you say? Don't have a look at the MCP joints. So certainly the 4th and 5th metacarpals soft tissue boxes factor. Good. There's a box of good against. A little bit trickier. Okay. The boxes practice a patient to punished, you know, like a war. Something again. Fasting and boxes. They get displacement of the 4th and 5th four or fifth metacarpal. So casings any MTP joints is this is completely displaced. The medical close here. Okay, So this patient needs agent fixation. Uh, next one. So I got extra another x ray again. I'm sure it with a cartoon images. Well, what's that? Was his x ray showing here on. Not on. It's it's a yet. It's a collie structure. Okay, so the police fracture. So you see these fracture? It's a daily for infinity. So patient to land outstretched hands you get displacing off the distal radius. Okay, you get those all relation off the discoloration radius because of falling on all straight transthoracic described as the dental. Forgive a deformity. Okay. Uh, last one, uh, tricky out again. Again. We think I'm just going to a different types of fractures. I could jump in the fingers. What do you think? Okay, what is from problem? Yeah. Avulsion fracture. Could you guys know what this type of avulsion fracture schools? It's a game. Steeples the thumb because there's basically is a lesion off the ulnar collateral ligaments. Okay, um, off the, um Okay. So, classically, basically to fallen from skiing at the numbers extended and abducted in your vision, off the collateral ligaments. I guess that's what he circles are like here. So is it just different types of practice? I just want to quickly go through, okay, Just for your own understanding. But let's just go through the heart examination, Okay? So hang on. Examination is it's a very involved examination. Okay. The 100 wrist examination, It's a bit tricky on that. It's a very hard to do systematically on, but, uh, I'm gonna try and take you guys through the key things. The introduction is generally the same thing. Okay, but the key things you want to remember to do is to give a pillow to the patient. Okay? You're doing the examination over a pillow. Okay, I'm going to demonstrate stuff. So you're gonna give a patient. Oh, and also, when you're you're introducing yourself, you also want to ask what the dominant hand is on. Remember we talked about it. Why is it why it's relevant to ask where China's dominance, okay? Because it's it can be suggestive of what the pathology is. I'm just a trip on in terms of the structure for the hand examination. It's a bit different for the structure of general orthopedic examination. There's, you know, look, feel, move special tests. Okay, but for behind examination, there's a couple of extra exercise, so there's luck feel. Then there's move. Then there's a functional assessment. Okay. You want to say it's function and you assess the urological assessment? Okay. You need to do a basic neurological assessment of the hand with the when you do a heart examination, and then you do your special tests. Okay? So I'm gonna we're gonna go to look in the form of difference on physical finding, so it's a bit different with today. I'm going to show you a whole bunch of pictures, and I want you guys to tell me what the overall diagnosis is. So can you have a lot of these pictures together and tell me what the patient's diagnosis is? Yes. Rheumatoid arthritis. Okay, so I'm going to show you a little bit different hands. Okay? You guys are gonna be overloaded with hand images today, but these are these are all features off rheumatoid arthritis. Okay, so if we go through each one quickly because of this picture, had these two pictures here showing rheumatoid nodules. Okay. Eso promise that bony prominences over the joints? Uh, here we have swelling of the joints. Okay. Remember, rheumatoid classically effects MCP joints and prp joints actually have swelling of the joints here. We have all my deviation, because what was MCP swelling? So you can see all my deviation of the fingers. And remember, we would typically affects MCP joints. Okay, so you can see the swelling of the MCP joints. Okay. Difficult. Normally, when you look at, you're not those. You just see a normal pillow. Valley Hill, Bali hill. Okay, but you could just see pills. Okay, so it's MCP swelling. Uh, what is this? The phone here. But sister from the tension on the bottom left? Yeah. They say Just say, between you and deformity, I guess Ah. Hyperflexion at the joints on hyperextension at the d I P drinks. Okay. Wanted different teas. You see, a rheumatoid on this one is a small neck. Informative. Okay, so it's a bit different. Okay, so it's basically the opposite because you're getting hyper extension of the peace hyperflexion at the diabetes. This one has multiple deformities. Okay. So you can see on a deviation here. You can see it between 80 to 40. See, uh, you see the 20 deformity here as well, but the key thing I want to show you again. He has disease 40. Okay, so this hyper reflection of the joints. Okay, last one. What do you think about this image here? What is this image going here? Surgery. Yeah, NCP joint replacement gets. So these are drugs or basement's got so starting from someone who's had that MCP joints replaced. Because, remember, the rheumatoid is the MCP joints, which are almost always affected. Okay, so, patients, this vision has has scars for MCP joint replacement surgery. Okay, Next couple of pictures were Let's put these pictures together and let you guys let me know where you just think the overall diagnosis. Yeah, I think. Yeah. This is osteoarthritis. Okay, so we're looking at signs of osteoarthritis. Step. Okay, so is ventricle. Yeah. So here we have some pushups notes. Okay, So who shows? Knows about the pee I pee joints. Here. We have a habitants note. Okay, so I think the the I'll be joined on. Do you mostly have a complication off degenerative joints this mucoid sister on. So we have Bouchard's nodes, habitants notes on often, people often started to remember which one of the effects that the idea which one affects diabetes s so I used the way I used to remember is to think off, uh, use the hasty and so Okay, so remember, with three d i p. Joints if the diabetes bones are affected, that's a heavens, No. If the PFC joints are affected, that's a bushels note. Okay, The way I like to remember is think about each me pencil. So H b as the h for him. Habitants affects the the eyepiece. Be for Bouchard's effects. The approximate Okay, hair, the hair. We have, um, swearing off the thumb. Okay, so you see the the number, the actual angle is square. That basically, um And here is just a picture of the topical NSAID. Okay, on went to a commonly used for on hand osteoarthritis. Okay, cool. Next one. What do you think about these pictures together and tell me what you think My own on elbow for the I'll have my own hand for these for diagnosis. Yes. Yeah. Sorry. I think. All right. That's good. Okay. And I have, uh, trips writes. This is well, the back. But yet so they were looking for signs off. Sorry, I think. Arthritis. Yeah, on. So if you go through each one and so here we have a pretty standard. A psoriatic plaque. Okay. So scaly lesion. I mean, classically, it'll affect the acceptance of services like the back of the elbow. Okay, but in fact, a bunch of other services. Hey, we have some nail pitting. Okay. Classic nail finding for psoriatic arthritis. Uh, here we have, um, another plastic needle finding for psoriatic arthritis is a nickel, isis. So detachment off the nail from the nail bed here. Here we have is symmetric it to see that this is Dr Lighter. So information off the digits. So it's known a sausage like visits. Okay, Good, because it looks like a sausage, but the entire finger is inflamed here. Uh, what do you think about this? Extra? Yeah, but you think about this extra here. Yes, it's all right. So this is psoriatic mutual hands. Okay, so there's a destructive story of scar property. But the one thing I wanted teo point out is these pencil and cop deformities. Okay. Classic X ray. Change your psoriatic arthritis is these penciling cup deformities. So those are some signs of osteoarthritis next one. Let's put these images together and tell me what you guys think. What's he doing? Overall Diagnosis it. Scleroderma? Yes, it's systemic sclerosis. Okay, so this patient has speech is off the so called crests in drum. So this patient is very non phenomenon skin tightening here. Okay, So it's Claritin. Actually, it's no No. So their skin gets very skin gets cool because it becomes very tight on there's also some ulceration because of this conflict. Me Here. Okay, so it's been off and on on sclerodactyly here. We have a car stenosis. Okay, So calcium deposits over the digits again on here. We have some telangiectasia. Okay, so remember that with the with limited systemic sclerosis, you get the so called press syndrome off. Carcino says, you know, phenomenon esophageal dysmotility, which haven't shown here. Scared, actually. And telangiectasia. Okay. Yeah. Next one. What do you think about these images here? Yeah, Got it again. This you want to look for signs of guts again? The's two images of both images of got a toe. Okay, Someone's asking about two a viral er so this patient has to file the bony sepsis. So this is accumulation of uric acid levels. Accumulation of your gas it over the skin. And also, this image is just in image of synovitis of the elbow on so little signs off cats. Next one. This is a civic trickier. What do you think about this one? I This is tricky. Yeah, you gotta think a lot of broadly about this one. Yeah, someone's got dramatic. My eyes tightest. Okay, so look for signs of the matter myositis. So what can you tell me? What is this? I'm showing you what? This time. It already here? Yeah, I got to stop your get against. These have gotten populace. Classic Sign of the matter, my scientist. One of the inflammatory myopathies. These are another feature of the matter. My sides of these mechanics chance that this will dry skin of the digits. These numbers mechanic son's steroid dependent. What's the relevance off this bridge? Steroid based on that Absolutely crazy. Yes, sir. Get this is steroid idea. They say it's relevant. I just put a relevant for dermatomyositis because steroids are the mainstay of management for the matter. Myositis. Okay, so patient will have to be wearing it as a precaution for being on long term steroids on here. We have some tall stating. Okay, what's the relevance of prostate in? What's the rounds of smoking? And you're not on my side tests? Yes, a paraneoplastic syndrome. So it's often a complication of lung cancer. The case off small cell lung cancer, as that's why I've been created. Toss stating and couple more on. We'll look through the steps. Okay? Yeah, Yeah, a couple times syndrome. Okay, So look for signs of couple times that you don't. So we go through each one. So this patient has a couple of different features. Okay, Couple of that you probably would never seen before. So this is a couple time release, Scott. Okay. The city for carpal tunnel syndrome. Then we have, ah, female wasting. Okay, because off, um, compression of meat. Enough. This is a risk splint. Okay, So one of the major stick mainstays of management for a couple of times to do is to I give them a wrist splint to wear at night. I hear it's a just a mobility devices I don't would be useful to include. Okay, So this is a patient, a couple of dollars syndrome there. They'll have a lot of it. Might have a lot of function impairment. Okay, So you wanna give them a bility age that will reduce the amount of reduce the need to use the median nerve a lot. So Okay, so this is a jar jar opener. Okay, this is just a a shoo, shoo older. Just something to help them with their shoes. And this is just a cattle tipper. Okay? To avoid them having to for the cattle with their and use that. Aggravate that median, It's injury. Okay. Ah, coming home. What do you think? I'll just go through this. So this here we're just looking for signs of any crime traditions. Okay, we've already gone through this last week with the endocrine station. So here we have spayed hands for acromegaly. Okay, We have thin skin for Cushing's syndrome. Here we have our our pouchy for graves disease. And here we have some think about people smart for diabetes. Diabetes? I have a good this one. This is that hopefully stuff you're being familiar with? Yeah. Gets liberties. Okay, So look for signs off chronic liver disease. Okay, We've I've gone through this in great detail during a gastroenterology stations here we have, uh, Taameri, FEMA Do we have do portraits construction? Okay, this is on leukonychia ago of the nail, but that is a kind of a line of the nail if we have some bruising. Okay, So remember, coagulopathy is a key feature of off kind of liver disease on do Here we have ah, clubbing. Gets to remember to check for coming in your inspection of this. Well, cool. So, in terms of the course of clubbing, Okay, I thought I quickly some, right. So doing my cardiovascular station, respiratory station and gastrin controls your station. We covered the relevant courses of hoping for that specialty. Okay, but have summarized all of them in this slide here. Okay. And remember, we used in your mom. See, see, See, for cardiovascular causes of trouble. We use the amount of a B c d. To remember the cause is off. Yeah, Espiritu cause a problem. We used a new monitor milk to remember. The, um, gastrointestinal goes to public. Okay, so remember, he's all these sort of major cause of clubbing. Okay? And remember to classify it by the system. Okay, so we have basically gone through our general inspection. Okay, but your ski you will be very stressed. Okay, So if you want to remember the five things you just tell the exam in quickly. I use I use this new monocle seeds against the seeds within a set of a s O s for swellings be for eczema A for atrophy, the for deformities and s for Scott's. Okay, so on your skin when you're just having a look at the hands, Okay. You just call the Examiner. I'm looking for any evidence off swelling's erythema. Any evidence off? You know, atrophy, any deformities, that many scarring. Okay. And so if you don't want to mention all those other ones that you just you can just on tell the examine You looking for these specific ones? So you'd only look at spect the examination again. I've listed all of them, which we just went through. Let's we wanted the next. That too. It's feel so we did our look. Now we're gonna move on to feel so in terms of feel, we want to check the temperature. Okay, Both feet, Palmer. And also aspects of the hand you check temperature. We can use the backs of the back of your hands to check the temperature. You also want to palpate you the radio posters together. Okay, so, um, just save time and do it together, Okay? Rather than one by one. Okay, check. Check the rate rhythm volume and check for any value or radio delay. Anyone helping the muscle bulk off the pharmacy. If it's okay, so palpates the muscle bulk. And also palpates be, um, pump for any thinking. Okay, for, you know, for depression is contracture There have promised sickening here. So again, you helping the muscle boat? Because, uh, what is this dementia in here? But do you think this image is showing here? What's their problem in the right time here? Yeah. So the steam always say Okay, so you palpate the muscle bulk. Okay, Because you were looking for anything are wasting. Okay. Oh, high protein are wasting. And you also puppets the palm for any thinking. Okay, basically looking for features on dupixent contracture. Okay, um, so then we're gonna move on to palpate in the couple bones. I got a quick question. I'm going to really test your anatomy here. Can you guys tell me? Is one of the different couple bombs in your wrist. Uh, give me some ways. He used to remember the different couple boats. So I've got I've included this diagram here. So here we have the only different trouble, Bones. Okay. Make sure you know your carpal bone, and that's me effectively. Okay. When you're palpating, your couple bones, you need to know which one's which. I mean, clearly this diagram for reference. But the way I like to remember it is the use of your Monica some gloves, propositions that they can't handle. Okay, I think that's the best one first. So for the proximal row off couple boats, you have your state for lunate. Try country, um, and form. Okay, so going from a radio, too. On the side, fast the bottoms and in our distal row again going from radio on the side. We have our trapezium trapezoid, capitate and Hamid's. Okay. Remember your couple balls? Okay. On if a someone asked you to label an x ray, this is these are the bones on the extra foam. Okay, again, I've just included it for reference, but make sure you know your couple bone and ask me so the key thing to know. Reason to know your couple born at me because you want to know where your palpating against. Do you want a palpate? Both the anatomical snuffbox and the copper bunts. Remember, with palpating the Antarctic of stuff bucks for because if there's pain in the answer but snuffbox and suggested off a skateboard fracture. So I play the video. So here, patient feeling these that's careful. But the answer of stuff box a disappoints there palpating the new neighbor. Um, so she's about 18 units here. She's palpating the right atrium. Okay, then if the move on So she's palpating the house phone boat. Okay, So that bony prominence at the almost Tyler, that's surprising form. So if the pricing form, then she's moving on to the, uh, okay, hum, it's okay. So your bone just sits above your bicycle on. Since he's not getting the comic that, um then she's not palpate in the upstate bone, which is just lateral to your Hamid's. Then just populating the top is order and the trapezium bones. Okay, So again, make sure you need to do know your couple bone accident on That's the so you probably all the different bones to elicit anything. So I got a quick question for you guys. Can you guys tell me one of the borders and contents off the anatomical stuff box? So, in terms of the goddess on the two different borders, we have a radio border, and all are on the medial gotta, because sometimes our video border, we have the extensive posters, breath standing, and we have ah, doctor poses longest standing. Okay, on those are Teo tendon on the radio side on the on the side of the anatomical snuffbox. We have extensive policies longer standing, okay. And, um, the actual contents of what's inside the answer of a softball starts passing through. We have our radio artery as a bean and a branch off the radio lives. Okay, so they that's your antifungal stuff box. And actually, Okay, So remember, on your radio a border, you have to tenders. Okay. If you get if you get, like, your thumb again, you public based off your some Okay? You should be able to properly feel that there's two separate 10 pills which are forming your aunt Uncle stuff box. Okay, so we did a populated the couple bones on. We calculated the on from soft marks that we want to do an MCP squeeze. Okay. And this is the technique for doing and see peace Peace of squeeze across the MCP joints and see if they have any pain there. And then this is a This is going to big part of the examination. Okay, doing you're buying manual operation off the joints. Okay, so the hand examination you need to cooperate every single joints in the hand. Okay? On the technique for doing it is to use the fourth finger technique. Okay, so use your thumbs to palpate the joints and the two fingers under leave to support the joints. Okay, so you're by money palpating every single joint. And remember when your palpating look at the patient's base to see if you see to see if it's tender. Okay. So you by by money, palpate all the MCP joints, all the joints, all the IV joints on the supply and your joints off the thumb as well. Okay, don't forget that. And a quick tip. Okay. When you're asleep, palpating the bones. Okay, uh, possibly move the joints as well. Okay. So when you're doing a bimanual patient. You can see here. The position is moving the the finger at the same time. Okay, so your palpating the joints and your power passively moving the joints at the same time. Okay. And the reason I say this, Okay, this is a quick tip or getting for doing an Aussie is because when you do, when you come into the move part of the examination, you need test boast each test, both active movements and passive movements. So if you possibly move the point at this point, okay, While you're doing deep by manual probation, you're saving yourself a lot of time, Okay? You don't need to possibly move the joint again when you actually come on to the move aspect. Because you already 50 tested passive movements. Okay, cool. So that's our feel aspect. Okay, so we've, uh we palpated stuff on the farmer aspect of the hands, and we probably stopped on the dorsal aspect of the hands. Okay. Remember, also just quickly around your hands up, up to the elbows to see if they have any rheumatoid nodules or any plaques or any to five on the elbows. So that's the feel aspect. Let's go on to the move aspect of the examination. So we're we're doing the move aspect of the examination with testing both active movements on passive movements. Okay, so we're testing movements at the wrist testing finger movement and testing some movements. Okay, It's a gentle the risk movements. Um, I go to each video. So here the the the exam is testing wrist extension on respect shin. Okay, It's a risk extension. Flexion. Okay. Other ways you could do it is to get them to make a good prayer sign or on some forest extension, and but their door sauce services together discussed risk election. Okay, But whether we do it, your testing this extension reflection okay, on a refill of the actual normal degrees of movement. Okay, So normally should about 80 degrees of infection and 70 degrees off extension. Hey, we have, um, wrist radio radiation on rest on a deviation. Okay. And so you're testing both video and all ideation at the restaurants. Then you want to test the supper nation and pronation. Okay, So a little bit. So your testing supper nation is a This is operation, and then your testing pronation off be at the level of the restaurants on. Finally, you're testing circumducting. Okay, so just get the move. The, um, risk in a circular motion. Okay, so that's circumducting in. Okay, So keeping when you're testing wrist movements is you're supporting the forearm at the same time. Okay, because remember, if you think about it, if you just ask the patient to do radio deviation, okay? They're going to just end up moving their entire arm, okay? Or engaging the biceps muscle. Okay, But you don't want to Do you wanna make the, um, straits and, uh, hold that for, um Okay, so your only moving the restaurants. Okay, Uh, in terms of the finger movements, so there's two different movements. Okay? It's getting to make a fist and then get them to straighten the fingers up against your testing risks, finger flexion, and then finger extension. Okay, So when you're making infested your testing the infection off all the NCP I pee and the joints. Okay. When you test extension, you're testing finger extension and against gravity. Okay. Remember you You have to test fingers extension against gravity to properly assess active movements of the fingers on. Did you should. Typically, you're able to get about 30 degrees off extension on, and we're testing finger a deduction. Okay, so a deduction and finger a deduction. Okay, So, a reduction away from the midline A deductions once a midline and it turns off some movements. So a couple of different movements of the thumb we need to do so there's some flexion, some extension. Okay. So remember, with some movements, if you're moving your thumb towards the palm, a surface, that selection away from the pharmacy surface, that's extension. Okay, The testing thumb addiction on some a deduction. Okay, So if you're moving your thumb to war, different attempts, that's a deduction. Okay. Adduction away from the fingertips. That's a deduction. Okay. On last week, the other thumb movement you need to test is opposition. Okay, So touch each of your thumb to or your fingertips get to test opposition. So again, you need to test active and passive movements. Okay, So just ostentation to these, do these movements, and then just quickly possibly test them as well on you can also offer to test extrinsic tendon function's. Okay. Um, so I'll play the video. And so and this is you only often to do this. So here we're testing the function off the diaper flexion because they were testing the flex a digital and profundis tendon function. Okay. Suppose the FDP is involved in the i p function? It were testing the flexion, not being prp joints. Okay, so that's testing the backs of digitorum superficialis muscle. Okay, so remember, Profundis is mainly involved in the, uh, infection superficialis is involved in. Um okay, I'll be function okay on here. They're testing the fax extent and posters. Longest function. Okay, so the testing, the tongue a flexion and extension at the PDR it's okay again. You don't need to do this. Okay? This is yours. Just something you're also to do to the exam. So we've done our move aspects of the examination. Okay, so we've done We've lost a patient to do a bunch of different active movements and possibly wants on, but we also offer to test the individual function of certain, um, tendons. Okay, this should be tendons. Then we're going to move on to a functional up a couple of functional assessments. Okay. The first functional assessment is to test the pincer grips function, so the way to do this is the dust. A patient to make a pencil grip, okay between the thumb and the index finger, and then try and break the pencil with your own cancer. Okay, so that's testing Pensacola function. But can you guys tell me which nerve is also being tested at the same time? So when you're doing pincer grips, if someone is know able to make a proper pincer What? Which nerve is being tested here? A median is good. Which specific branch of the media nets? Yeah. Yeah. So it's the anterior interosseous sniff get. It's the anti PD injustice stuff. Okay, this is clinically relevant. So if someone who has anterior interosseous syndromes a lesion off the anterior interosseous. No, this is not able to make a proper pincer, okay? Because they can't flex there into financial joint of the thumb or flax, the interval and your joints off the index finger. Okay, so you can see that the both of these joints on flex properly so they can't make a proper pincer. Okay, so if you ask them to make an okay sign, they can't make a proper okay. Sign, okay. And then you want test palabra. Okay, so your finger are sent to grip that. Book your fingers tightly as possible. Okay. Uh, remember, pencil grip is very important. Functional assessment because a lot of you need you need a good pincer grasp to do a lot of daily to us again. Paragraph is what is very important for a lot of everyday daily activities. Uh, we tested pop pincer grips, tested power grip, and then you want to test the fine motor function, okay. And so you want to ask you on a clarify which one is the dominant hand again? They ask them to do some kind off fine motor function activity. Okay, so this is kind of where you need to think about outside the box. Okay. Think about what is, um what is where you need to what is available in the station to actually test. Okay, so you actually need to look around the station, have a look at what different objects are available. Okay. Are you able to get them to pick up a coin or pick up a pen? Are you able to actually get them to write a sentence? Okay. Oh, are you under a ship button. Okay, if you're a guy, maybe maybe avoid asking a woman to under their shirts ago. But general things, Teo, do it. These just different things to do to test fine motor function. Okay, cool. So he tested function. Okay, so we tested integrate. We tested pollen grip, and we tested the fine motor function. Okay, Now we want to do a quick, basic neurological examination off the hands, okay? And this is why we're testing the median nerve. I only live and the radio minutes. Okay. So remember, with each of these nerves does a sensory components and they and in motor components, okay, with the so these are the different distribution. So with the median nerve, you test it on the index finger. Okay, uh, with the owner of your testing it on the middle finger on with the radial nerve testing sensation on the first dose or webspace. Okay, because this is these are the different sensory distributions off each of these notes on these the clinical places you test them. Okay, Now we're gonna talk about being motor deficits associated with each of these medics. So can you tell me what this picture is? showing you in terms of if you think about a lesion of one of these notes once this. Yeah. So this is a wrist drop. Okay, so we think about a radial nerve palsy. So if someone has a radial nerve, palsy classically don't get weakness, and wrist extensions of their risk will be dropped. Uh, what you guys think? Here. What, is this a maturing? Yeah. Yeah. So this is a core hunt. Okay, so this is remember, this is at rest. Okay, so they have a program at rest again. That's very important. Okay, So arrest have a clue on so that, um, forefingers are bent at the MCP joints and so they're not able to extend therefore, the big fingers basically on that's classic for a whole new 40 last one. Here. Uh, what do you think about this before, my dear? Yeah, this has been a punt. Okay, so a pound. So basically, um, it's seen in the media live palsy. So because you're not able, Teo, about your thumb, probably this unopposed action off addiction on your thumb against your family is addicted, eh? So that's why I arrest that you get this a time Okay, It's over. The median nerve palsy. We get unopposed. Action off the back before is this muscle. So you get this a pound appearance? Forget it on. I have colored certain letters here, Okay? Because it makes a nice new monitor known as a doctor. Doctor, you. Ah. Okay, So the new market is Dr Cuma. Okay, so BRCA drop for radio. See you. So your hand on the left Posey on M s o median nerve palsy for an 8 lb. Okay. Okay, so that's just a deficit. So, in terms of how you actually test the motor function, So with radial nerve palsy, remember, we have any risk drop of those deaths it So we want to test risk extensions. Where you do it is to get them to make a fist on Mick on. Do you remember your testing against resistance of history? You're asking them to try and push against your risk against resistance. Okay, that's testing the radio live motor function on. But I've got this video wrist drop. There's a gay, which I'll tell you. This is another video of risk dropped. You see, a soon as the examiner releases pressure, the risk is is dropping again because it's weakness. An extension on have included some stuff on radio move palsy, which you guys can have a read about. Then we want to move on to median nerve motor testing. So we remembered, Um So the way you testing median of motor function is your testing some abduction against resistance. Okay. Remember where the median nerves palsy? We had weakness and some abduction, which led to some addiction, because your testing some abduction against resistance for a median nerve palsy. That's how you just need to live on. I've included some stuff on median nerve palsy here, but you guys could read about it. Actually, we run out of time to talk about this stuff in detail on in terms off the element of motor function testing. Um, so remember the other night we had, um, weakness with we get weakness with abduction again and a finger abduction adduction on. So you're testing here Also do tests to have doctor fingers and your testing finger abduction on election. Okay, so it doesn't think abduction many You testing at the index finger on the little finger? Um, the key tip here is that when you actually testing the power against resistance? So you can see here. When they examine was testing the finger abduction, they were testing, like for like, Okay, So they using that index finger, Teo, push against the patient's index finger on the little finger to test against the patients with a bigger Okay, So that's how you test being motor function. You get so again, So they do not like for like, Okay, So you don't You don't just use your entire hand to check to see if that resisting it, okay? You just use the same finger to test resistance on. Also, you can check a test for another way you can offer to test on the nerve function is by using Rowlands test. Okay, So from a sign is another way of testing the onus. So here, the way you get it is to ask them to pull a piece of paper between the thumb on do index finger. So this is what a patient was. It was pulling it normally, but this is a patient of us. An older nerve lesion. Gaston was the difference between these stupid kiss. Why is this an all innovation? Why is this normal? What's different here? Yeah. So the thumb this black step. Okay, so you're getting the patient to pull the whole long to the piece of paper, okay? And normally, the patient doesn't need to, um flax that thumb, okay? Normally, because that from his other tips to hold on to that piece of paper on, they don't need to fax it. Um, okay, but if someone has an all the new lesion, they can have weakness and adopting the thumb. Okay, so they need to compensate for that weakness by flexing that thumb to go along to the piece of paper. Okay, so if someone is flat in that thumb to hold onto piece of paper, that's an all in their vision. Okay, so that's from. And scientists, if you actually have a piece of paper available, it's I'd recommend just testing it on. Yeah, this is just a quick slide on on the lift 40 Which you guys gonna read about. So that's our neurological assessments. Okay, so we tested sensation and we tested different motor movements. Okay, Finally, we're doing Tuesday front specialties. Okay. Um, so the do special test? That's another sign. And Phalen's test okay for carpal tunnel syndrome. So you found a little bit the final moments of today's session just talking about carpal tunnel syndrome. So it turns off the carpal tunnel. Not to me. Um, examine might ask you one of the boundaries and structures that passed. It'd be a couple of little. And so I ask you this. Remember, there's nine tendons and wonder which faster The carpal tunnel. Okay, so there's nine different tendons, or there's four tendons from fax. These storms superficialis four tendons from vaccine jittering profundis on one tendon from the facts of policies longest. Okay. And you have one lives. Okay. You're really didn't. Okay, so those are your contents of the carpal tunnel on. Can you guys tell me one of the 100 muscles which are innovated by the median this loaf get okay, So I used to do more like two loaves to remember. Okay, This is relevant to carpal tunnel where you're getting problems with media live function, so the muscles are long. Rickles, you're You're too lateral longer. Girls. Oh, opponents polycysts a for abductor posters, breaths and fo fax. It posted premise. Okay. And this is relevant because these are all of your feet are muscles. Okay, so these are your muscles in the back, Obama. So because you can get weakness in these muscles, patients can get seen our muscle wasting. Okay. Finally, in terms of the causes of couple summers syndrome, I take it, And you Mark, which was used in by one of our friends, Doctor Anthony, with, um, So the new market is the pyramid. So these just some general courses. A couple, some of syndrome, a chicken. Used to answer any questions about it. Uh, and then we cover this other stops. So if we if I asked you guys again, why is that? No loss of sensation over the FENA Eminence and couple down syndrome. What? Why? Why did we say there was no loss of sensation? Why did we say there was no loss of sensation in the united minutes? Yeah, the pollen containers branch of the median nerve. It branches earlier. Okay, So I quickly, if I like this with a couple of Bagram. So again, this is the sensory distribution of the hand. So we have a median nerve distribution here, all in the distribution here, but in the Thenar Eminence, here. Okay. This area in particular is innervated by the Tom. A continuous bunch of the medium nerves. Okay, but remember the public achiness brunch it branches earlier than the couples? Um okay, so here we have our couple tunnel again. You see, our pharmacy tennis branch of the median nerve is branching earlier than the carpal tunnel. Okay, so that's why in couple times syndrome you get, you don't get lost of sensation in the peanut, eminence, because the problem continues. French is not effective enough your couple times. And so, in terms of the actual special test, we do for a couple time A syndrome. Okay, there's two tests. This pain. It's tests where you get the patient to hyperflexed both hands together. I put the door, steps this together, okay? And then you for the examiner to wait for a minute Again. The idea is you're trying to provoke parasthesia is and the median lobe distribution okay, in your actual osteo, you're not gonna actually wait for a minute, okay? Just gonna offer to do it offered to wait for a minute and then to know stuff is where your cussing over the median nerves and see if that elicit any parasthesia. Okay, cool. So, in terms of the chemo management, that's a couple tunnel syndrome with the Examiner ask you, you could use the pneumonic wrist. Okay, So the Monica's wrist, which is relevant for carpal tunnel. So if you go through each one, So w for Westlands at night. So Okay, so we're responds. Offer rest. I I for inject store. It's okay. So start injections for couple. Several syndrome. As for surgical decompression, Okay, So patients are very severe symptoms of capital. They might be candidates for a surgical decompression and t four diarrhetics. Okay, so diarrhetics have been shown to have some improvement in Kabul tunnel syndrome symptoms on, but that's just a useful in your mind to remember. Okay, so that's our specialties. Okay, so we did two nose test and Phalen's test. Both tests full a couple sound syndrome, and then that's it. Okay, so we find that patients remember for the hand examination, you know, exposing the patient completely. Okay? You you only need the patient exposed after the sort of upper upper aspect of the young. You don't actually need to get them to be fully exposed. So you just kind of patients on, but yeah, that's your hand examination. Okay? We've gone through it pretty systematically there. Um, So it doesn't present in your hand examination. Have a good a couple of sentences, which you can include and how you present the normal 100 risk examination. Yeah, that's it. Thank you, guys. Hope you guys find it useful up. Sorry that it was dragging on a bit, Uh, on examination is very details, but thank you guys for sticking with me.