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Advanced Musculoskeletal
Physiotherapy Selfdirected Learning
Modules:
Post Arthroplasty Review
(PAR) Clinic
2014
Module 6: Pathology
Prepared by Alfred Health on behalf of the Victorian Department of Health 2014
1
Module 6: Pathology
Contents
Module 6: Pathology ............................................................................................ 2
6.1: Haematology .............................................................................................. 3
6.2 Biochemistry ................................................................................................ 5
6.3: Assessment of Pathology ..................................................................... 7
6.4: Pathology to aid Differential Diagnosis ......................................... 9
6.5: Case Studies ............................................................................................. 11
Case Study 1 .................................................................................................. 11
Case Study 2 .................................................................................................. 12
Case Study 3 .................................................................................................. 13
Case Study 4 .................................................................................................. 14
Case Study 5 .................................................................................................. 15
Case Study 6 .................................................................................................. 16
Case Study 7 .................................................................................................. 17
Case Study 8 .................................................................................................. 18
Case Study 9 .................................................................................................. 19
**Please note case studies are example from patients presenting to the
Emergency Department. Examples of patients presenting to Screening / ED
Soft tissue review clinics will be provided soon.
Module 6 Pathology
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6.1: Haematology
LEARNING OBJECTIVES:
1. To understand common abbreviations and definitions used in haematology
2. To understand the basic function of red blood cells, white blood cells and coagulation
3. To understand the following problems associated with each of these areas:
a. Anaemia
b. Infection/neoplasia
c. Thrombosis/haemorrhage
4. To understand the indications for haematology tests in common musculoskeletal
presentations
5. To understand simple haematology results
a. Full blood count
b. ESR and CRP
6. To be familiar with the reliable online sites with information about pathology
7. Identify the risks and consent procedures associated with use of pathology tests
*All pathology tests to be requested by medical staff and physiotherapists should
ensure any tests ordered for patients in their care are followed up by the medical
staff who made the request
KNOWLEDGE:
 Provide definitions, abbreviations and normal ranges where relevant of the following
terms and tests: (use different online sites below to familiarize yourself with the
different resources)
o Hemoglobin (Hb)
o Haematocrit (Hct)
o Red Blood Cell Count (RBCC)
o Red Blood Cell Indices
o Erythrocyte Sedimentation Rate (ESR)
o White Blood Cell Count
o The WBCC differential
o Neutrophils
o Lymphocytes
o Monocytes
o Eosinophils
o Basophils
o Blasts/atypical cells
o Platelets
o Fibrinogen
o Prothrombin time (PT)
o Partial Thromboplastin time (PTT)
o International normalized ratio (INR)
o Blood culture
 What is the function of:3
o The red blood cell
o The white blood cell
o Coagulation and fibrinolysis
Module 6.1 Haematology
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o Thrombosis and haemorrhage
 What is anaemia and how may it be classified?3
 What effect does the following have on white blood cells:3
o Inflammation
o Leucopenia
o Leukocytosis
o Leukemia
o Lymphoma
o Myeloma
 What would a normal D-dimer indicate?3
 What assessment findings of a patient presenting with a musculoskeletal condition
would indicate the need for a:4
o Full Blood Count
o Coagulation tests
o ESR
o D-Dimer
 What abnormal pathology findings would warrant immediate escalation for a
medical review?
 What are the risks associated with pathology tests and what information should be
obtained during the history taking and communicated to the medical team to
minimize these risks?
 going medical management
RECOMMENDED RESOURCES
1. American association for clinical chemistry (2013) Lab Tests Online Australasia
www.labtestsonline.org.au
2. Blann, A (2008) Routine Blood Results Explained. A Guide for Nurses and Allied
Health Professionals. 2nd Edition. M&K Update Ltd. Chapters 1,2,3,5.
3. Robbins, S. L. & Cotran, R. S. (2005). Pathologic basis of disease. Elsevier Saunders,
Philadelphia.
4. The Royal College of Pathologists Australasia (2009) RCPA Manual
http://rcpamanual.edu.au
5.The Royal College of Pathologists of Australasia (RCPA)
www.rcpa.edu.au
6.The Royal College of Pathologists of Australasia (2013) ePathway
http://epathway.rcpa.edu.au
7.The Royal College of Pathologists Australasia (2011) Pathology professionals
www.pathology.med.pro
Module 6.1 Haematology
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6.2 Biochemistry
LEARNING OBJECTIVES:
1.
2.
3.
4.
5.
To understand common abbreviations and definitions used in biochemistry
To demonstrate a basic understanding of tests for renal function
To demonstrate a basic understanding of tests for liver function
To demonstrate a basic understanding of plasma proteins
To demonstrate a basic understanding of tests associated with Diabetes
mellitus – blood glucose and oral glucose tolerance test.
KNOWLEDGE:
 Provide definitions, abbreviations and normal ranges where relevant of the
following terms and tests: (use different online sites below to familiarize
yourself with the different resources)
o Urea
o Creatinine
o Glomerular filtration rate
o Sodium
o Potassium
o Hypernatraemia
o Hyponatraemia
o Hyperkalaemia
o Hypokalaemia
o Urate/Uric acid
o Acute renal failure (ARF)
o Chronic renal failure (GRF)
o Liver function tests – Alkaine phosphate, bilirubin, gamma GT, ALT and AST
o Acute liver disease
o Chronic liver disease
o Total proteins
o Albumin
o C-reactive protein
o Calcium
o Hypercalcaemia (>2.6 mmol/L)
o Hypocalcaemia (<2.2 mmol/L)
o Phosphate
 What are the functions of the kidney?3
 What are the functions of the liver?3
 What are the functions of the plasma proteins?3
 For a patient presenting with musculoskeletal like symptoms, describe the
indication and interpretation of:
o Urinalysis1, 4,
o Joint aspiration (to be conducted by medical team)2, 6-10
RECOMMENDED RESOURCES
1. American association for clinical chemistry (2013) Lab Tests Online Urinalysis
Module 6.2 Biochemistry
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http://labtestsonline.org/understanding/analytes/urinalysis/tab/glance
2. American association for clinical chemistry (2012) Lab Tests Online Synovial Fluid
Analysis
http://labtestsonline.org/understanding/analytes/synovial
3. Blann, A (2008) Routine Blood Results Explained. A Guide for Nurses and Allied
Health Professionals. 2nd Edition. M&K Update Ltd. Chapters 1,2,3,5.
4. National Kidney Foundation (2002) What you need to know about urinalysis. New
York.
http://www.kidney.org/atoz/pdf/urinalysis.pdf
5. The Royal College of Pathologists Australasia (2009) RCPA Manual
http://rcpamanual.edu.au
Up to date
6. Goldenberg, D & Sexton, D (2013) Septic arthritis in adults
http://www.uptodate.com/contents/evaluation-of-the-adult-withmonoarticular-pain?source=see_link
7. Helfgott, S (2013) Evaluation of the adult with monoarticular pain
http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticularpain?
source=see_link
8. Nigrovic, P (2012) Hemarthrosis
http://www.uptodate.com/contents/hemarthrosis?source=search_result&search=
haemarthrosis&selectedTitle=1%7E53
9. Roberts, W (2012) Joint aspiration or injection in adults: Technique and indications
http://www.uptodate.com/contents/evaluation-of-the-adult-with-monoarticularpain?source=see_link
10. Russell, A & Sholter, D (2012) Synovial fluid analysis and the diagnosis of septic
arthritis http://www.uptodate.com/contents/evaluation-of-the-adult-withmonoarticular-pain?source=see_link
Module 6.2 Biochemistry
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6.3: Assessment of Pathology
LEARNING OBJECTIVES:
1. To understand the key principles of history taking in relation to pathology in the
management of musculoskeletal conditions
2. To understand the red flag escalators identified in assessment that need to be
communicated to the medical team and indicate that pathology is required
KNOWLEDGE:
 What is the significance of a patient presenting with a musculoskeletal condition
reporting the following history of:1-5
o Gastric ulcers o Renal and/or liver failure
o IVDU
o Multiple medications
o Recent surgery
o Heart condition
o Lung/kidney/heart transplant
o Rheumatological conditions eg SLE, RA
o Recent DVT
o Use of anti-coagulation medications such as warfarin
o Diabetes
o An open wound with purulent discharge
o History of cancer
o High alcohol intake
o Lethargy, fevers, chills or sweats
o Human bite
o Persistent unrelenting non mechanical night pain
o Hep C +ve or HIV +ve
o Recurrent UTI (presenting with back pain)
 When and what laboratory tests would be indicated in the patients described
above?1-5
 What features of your clinical examination may indicate the need for laboratory
tests and the involvement of the medical team?
RECOMMENDED RESOURCES
1. The Royal College of Pathologists Australasia (2009) RCPA Manual
http://rcpamanual.edu.au
Up to date
2. Aronson, M & Gold, M (2013) Alcohol abuse and dependence: Epidemiology, clinical
manifestations and diagnosis
http://www.uptodate.com/contents/alcohol-abuse-and-dependence-epidemiologyclinical-manifestations-and-diagnosis?source=related_link
3. Saitz, R (2012) Screening for unhealthy use of alcohol and other drugs
Module 6.3 Assessment for Pathology
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http://www.uptodate.com/contents/screening-for-unhealthy-use-of-alcohol-andother-drugs?source=see_link
4. Zehnder, J (2013) Clinical use of coagulation tests
http://www.uptodate.com/contents/clinical-use-of-coagulationtests?source=search_result&search=Clinical+use+of+coagulation+tests&selectedTitle=
1%7E150
5. Kraut, E (2012) Easy bruising
http://www.uptodate.com/contents/easybruising?source=search_result&search=easy+bruising&selectedTitle=2%7E150
American association for clinical chemistry (2013) Lab Tests Online Australasia
www.labtestsonline.org.au
The Royal College of Pathologists of Australasia (RCPA)
www.rcpa.edu.au
The Royal College of Pathologists of Australasia (2013) ePathway
http://epathway.rcpa.edu.au
The Royal College of Pathologists Australasia (2011) Pathology professionals
www.pathology.med.pro
George, T ( 2012) Automated hematology instrumentation
http://www.uptodate.com/contents/automated-hematologyinstrumentation?source=see_link
Module 6.3 Assessment for Pathology
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6.4: Pathology to aid Differential Diagnosis
LEARNING OBJECTIVES:
1. To understand how pathology tests can aid in confirming or refuting if the
diagnosis is a musculoskeletal or non-musculoskeletal condition
2. To understand when and what pathology tests can be used in assessment of a
patient presenting with a musculoskeletal condition who have other medical
conditions
3. To understand how the results of pathology tests may impact on management
options such as medication use
KNOWLEDGE:
1. If the following diagnoses or conditions associated with a musculoskeletal
presentation are suspected, what basic laboratory tests maybe indicated and
requested by the medical team?
(use the online resource The Royal College of Pathologists of Australasia Manual –
Clinical Problems)
 Arthritis
o Polyarticular arthritis
o Rheumatoid
o Virus associated arthritis
o SLE
o Osteoarthritis
o Septic Arthritis
 Bone fracture –pathological
 Multiple myeloma
 Sarcoma
 Osteoporosis
 Gout, Pseudogout, Chondrocalcinous and CPPD
 Osteomyelitis
 Abdominal/flank pain
 Alcoholism
 Analgesic abuse
 Cellulitis
 Bleeding disorder – excessive bleeding in relation to musculoskeletal injury
 Cirrhosis
 Cystitis
 Haematuria
 Myocardial infarction
 Renal failure – acute and chronic
 Wound infection
 Use of warfarin (anti-coagulant monitoring)
2. Review the resource The Royal College of Pathologists of Australasia Manual Clinical
decision making tools for 1) Arthritis and 2) Bone pain in adults
Module 6.4 Pathology to aid differential diagnosis
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3. What significance would abnormal pathology tests have on the use of the following
analgesics:2
 Paracetamol
 NSAID’s
 Opioids
 Aspirin
RECOMMENDED RESOURCES
1. Australian Medicines Handbook (No date)
https://shop.amh.net.au/
2. MIMS Online Australia (No date) MIMS
https://www.mimsonline.com.au/Search/Search.aspx
3. The Royal College of Pathologists Australasia (2009) RCPA Manual
http://rcpamanual.edu.au
4. Therapeutic guidelines limited (2011) Therapeutic guidelines
www.tg.org.au
Module 6.4 Pathology to aid differential diagnosis
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6.5: Case Studies
Case Study 1
Clinical Details
35 year old male presents with knee pain. Reports increasing knee pain since knock to
knee 1/52 ago. 7/10 pain at rest.
Phx 2/52 post sinus infection – taking cephalexin
Previous bursitis of knee
O/E red hot swollen knee
Able to ambulate on flexed knee
AROM 0-120 degrees
Laboratory Results
Interpretation (identify any findings that warrant escalation for immediate
medical review)
Blood results indicate:
Differential diagnosis is:
Management is:
Module 6.5 Pathology Case Studies
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Case Study 2
Clinical Details
24 year old male presents with L thigh pain post contact with player whilst playing rugby
1/7 ago. Increasing swelling, pain and decreased knee ROM today. No other symptoms.
PHx – nil, medications: x2 paracetamol and x2 ibuprofen
O/E: Neurovascular intact, able to PBW with crutches
visible swelling to left quads, tenderness over mid quads muscle belly.
AROM knee 0-40.
Laboratory Results
Interpretation (identify any findings that warrant escalation for immediate
medical review)
Blood results indicate:
Differential diagnosis is :
Management is:
Module 6.5: Pathology Case Studies
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Case Study 3
Clinical Details
65 year old male presents with severe LBP after waking up with it four days prior. Nil
injury. 8/10 pain at rest and activity, nil neurology
Normal vital signs
PHx arthritis and hernia otherwise well, no B&B, no weight loss, no fevers sweats, non
smoker
Meds panadol osteo, endone, vit D, glucosamine
X-ray – L4/5 spondylolisthesis
Laboratory Results
Why were bloods taken in this scenario?
Interpretation (identify any findings that warrant escalation for immediate
medical review)
Blood results indicate:
Management is:
Module 6.5: Pathology Case Studies
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Case Study 4
Clinical Details
45 year old male present post a fall down stairs 1/12 ago. Painful R great toe at the time.
Over last 1/52 increasing R great toe pain 9/10.
Phx Gout R great toe 1 year ago
Non smoker, drinks 4 units alcohol per day
nil medications or medical history
O/E vital signs normal
Swollen R great toe, tenderness over MTP joint, decreased ROM
X-ray NAD
Laboratory Results: FBC/ uric acid
Interpretation (identify any findings that warrant escalation for immediate
medical review)
Blood results indicate:
Differential diagnosis is:
Management is:
Module 6.5: Pathology Case Studies
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Case Study 5
Clinical Details
59 year old lady presents with L groin/buttock and leg pain after a long walk a few days
prior. Pain 8/10 with activity, 5/10 at rest, nil neurology.
PHx: HT, L THR 12/12 ago
O/E +ve Trendelenberg gait
Restricted hip ROM in all directions due to pain
Lumbar spine Ax NAD
Normal vital signs
X-ray NAD
Laboratory Results
Interpretation (identify any findings that warrant escalation for immediate
medical review)
Blood results indicate:
Differential diagnosis is :
Management is:
Module 6.5: Pathology Case Studies
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Case Study 6
Clinical Details
67 year old lady presents with bruised swollen hand following a knock to it 10/7 ago.
Now getting worse with a dull ache 8/10 pain with activity.
Phx 2 valve replacement – Warfarin
Bilateral THR
2 minor strokes 10 years ago
Meds- warfarin, lanoxin, coversyl, vit D, panadol, atenolol
O/E neurovascular intact.
Mild swelling and warmth over dorsum of hand
Bruising extending from hand to PIP joints
Reduced ROM – unable to make a full fist due to pain
X-ray – undisplaced # base of 5th MC
Laboratory Results
Interpretation (identify any findings that warrant escalation for immediate
medical review)
Blood results indicate:
Differential diagnosis :
Management:
Module 6.5: Pathology Case Studies
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Case Study 7
Clinical Details
49 year old presents with painful stiff elbow – woke up with it, nil trauma.
8/10 pain, nil other symptoms/cuts/wounds.
Phx #elbow 30 years ago – but not problems since injury
Overweight
Meds: panado osteo, Zyprexin, Coversyl, Temazepan,sulindoc
O/E
Well looking, vital signs – normal, afebrile
Swollen, warm to touch, reddened elbow – extending proximal forearm,
Skin intact, neurovascular intact
Elbow ROM 30-100 degree flexion arc
Laboratory Results
Interpretation (identify any findings that warrant escalation for immediate
medical review)
Blood results indicate:
Differential diagnosis is :
Management:
Module 6.5: Pathology Case Studies
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Case Study 8
Clinical Details
29 year old female presents 1/7 after insidious onset of R calf pain, nil trauma. Worse
with walking . Took 2hr flight 5/7 ago.
Phx endometriosis
Non smoker and social alcohol
Meds:OCP
O/E nil swelling or redness of leg or ankle/foot, pain mid muscle belly med gastrocs.
Pain on Df, unable to push off during gait
Vital signs – normal, O2 sats 96% RA
US: occlusive thrombosis x2 in vessels distal to knee crease
Laboratory Results
Interpretation (identify any findings that warrant escalation for immediate
medical review)
Blood results indicate:
Differential diagnosis is :
Management is:
Module 6.5: Pathology Case Studies
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Case Study 9
Clinical Details
50 year old male presents with left medial elbow pain – currently receiving weekly
Injection therapy at gym? 3/7 days ago had injection into deltoid and now presents with
sore and stiff shoulder. Anterior shoulder pain 8/10. Feels hot and cold. Had plain film
xray done 1/7 ago – NAD.
GHx HT, smoker 1 packet a day
O/E Neurovascular intact, vital signs normal limits
Swollen L shoulder
Decreased shoulder ROM in all directions due to pain- Painful supination and flexion
US shoulder – biceps tendonopathy
Laboratory Results
Interpretation (identify any findings that warrant escalation for immediate
medical review)
Blood results indicate:
Differential diagnosis is :
Management is :
Module 6.5: Pathology Case Studies
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Module 6.5: Pathology Case Studies
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