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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 2 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 3 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 4 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 5 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 6 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 7 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 8 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 9 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 10 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 11 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 12 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 13 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 14 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 15 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 16 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 17 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 18 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 19 Module 6.5: Pathology Case Studies 20