Advanced Musculoskeletal Physiotherapy Self-

directed Learning Modules:

Emergency Department 2014

Module 6: Pathology

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Prepared by Alfred Health on behalf of the Victorian Department of Health 2014

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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

Module 6 Pathology 3

6.1: Haematology

LEARNING OBJECTIVES:

1. To understand common abbreviations and definitions used in haematology2. To understand the basic function of red blood cells, white blood cells and coagulation3. To understand the following problems associated with each of these areas:

a. Anaemiab. Infection/neoplasiac. Thrombosis/haemorrhage

4. To understand the indications for haematology tests in common musculoskeletal presentations

5. To understand simple haematology results a. Full blood countb. 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 Indiceso Erythrocyte Sedimentation Rate (ESR)o White Blood Cell Counto The WBCC differentialo Neutrophils o Lymphocyteso Monocyteso Eosinophilso Basophilso Blasts/atypical cellso Plateletso Fibrinogeno 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 cello The white blood cell

Module 6.1 Haematology 4

o Coagulation and fibrinolysiso 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 Inflammationo Leucopeniao Leukocytosiso Leukemiao Lymphomao 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 managementRECOMMENDED 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 professionalswww.pathology.med.pro

Module 6.1 Haematology 5

6.2 Biochemistry

LEARNING OBJECTIVES:

1. To understand common abbreviations and definitions used in biochemistry2. To demonstrate a basic understanding of tests for renal function3. To demonstrate a basic understanding of tests for liver function4. To demonstrate a basic understanding of plasma proteins5. 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 Creatinineo Glomerular filtration rateo Sodiumo Potassiumo Hypernatraemiao Hyponatraemiao Hyperkalaemiao Hypokalaemiao Urate/Uric acido Acute renal failure (ARF)o Chronic renal failure (GRF)o Liver function tests – Alkaine phosphate, bilirubin, gamma GT, ALT and ASTo Acute liver disease o Chronic liver diseaseo Total proteinso Albumino C-reactive proteino Calciumo 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

Module 6.2 Biochemistry 6

1. American association for clinical chemistry (2013) Lab Tests Online Urinalysis 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-with- monoarticular-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-monoarticular-pain? 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-monoarticular-pain?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-with-monoarticular-pain?source=see_link

Module 6.2 Biochemistry 7

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 date2. Aronson, M & Gold, M (2013) Alcohol abuse and dependence: Epidemiology, clinical manifestations and diagnosishttp://www.uptodate.com/contents/alcohol-abuse-and-dependence-epidemiology-clinical-manifestations-and-diagnosis?source=related_link

Module 6.3 Assessment for Pathology 8

3. Saitz, R (2012) Screening for unhealthy use of alcohol and other drugs http://www.uptodate.com/contents/screening-for-unhealthy-use-of-alcohol-and-other-drugs?source=see_link

4. Zehnder, J (2013) Clinical use of coagulation testshttp://www.uptodate.com/contents/clinical-use-of-coagulation-tests?source=search_result&search=Clinical+use+of+coagulation+tests&selectedTitle=1%7E150

5. Kraut, E (2012) Easy bruisinghttp://www.uptodate.com/contents/easy-bruising?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 professionalswww.pathology.med.pro

George, T ( 2012) Automated hematology instrumentationhttp://www.uptodate.com/contents/automated-hematology-instrumentation?source=see_link

Module 6.3 Assessment for Pathology 9

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)

Arthritiso Polyarticular arthritiso Rheumatoido Virus associated arthritiso SLEo Osteoarthritiso 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

3. What significance would abnormal pathology tests have on the use of the following Module 6.4 Pathology to aid differential diagnosis 10

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 guidelineswww.tg.org.au

Module 6.4 Pathology to aid differential diagnosis 11

6.5: Case StudiesCase Study 1

Clinical Details35 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 kneeO/E red hot swollen kneeAble to ambulate on flexed kneeAROM 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 12

Case Study 2

Clinical Details24 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 ibuprofenO/E: Neurovascular intact, able to PBW with crutchesvisible 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 13

Case Study 3

Clinical Details65 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 neurologyNormal vital signsPHx arthritis and hernia otherwise well, no B&B, no weight loss, no fevers sweats, non smokerMeds panadol osteo, endone, vit D, glucosamineX-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 14

Case Study 4

Clinical Details45 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 agoNon smoker, drinks 4 units alcohol per daynil medications or medical history

O/E vital signs normalSwollen R great toe, tenderness over MTP joint, decreased ROMX-ray NADLaboratory 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 15

Case Study 5

Clinical Details59 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 gaitRestricted hip ROM in all directions due to painLumbar spine Ax NADNormal vital signsX-ray NADLaboratory 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 16

Case Study 6

Clinical Details67 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 – WarfarinBilateral THR2 minor strokes 10 years agoMeds- warfarin, lanoxin, coversyl, vit D, panadol, atenololO/E neurovascular intact.Mild swelling and warmth over dorsum of handBruising extending from hand to PIP jointsReduced ROM – unable to make a full fist due to painX-ray – undisplaced # base of 5th MCLaboratory Results

Interpretation (identify any findings that warrant escalation for immediate medical review)

Blood results indicate:

Differential diagnosis :

Management:

Module 6.5: Pathology Case Studies 17

Case Study 7

Clinical Details49 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 injuryOverweightMeds: panado osteo, Zyprexin, Coversyl, Temazepan,sulindoc

O/EWell looking, vital signs – normal, afebrileSwollen, warm to touch, reddened elbow – extending proximal forearm,Skin intact, neurovascular intactElbow ROM 30-100 degree flexion arcLaboratory 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 18

Case Study 8

Clinical Details29 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 endometriosisNon smoker and social alcoholMeds: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 gaitVital signs – normal, O2 sats 96% RAUS: 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 19

Case Study 9

Clinical Details50 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 dayO/E Neurovascular intact, vital signs normal limitsSwollen L shoulderDecreased shoulder ROM in all directions due to pain- Painful supination and flexionUS shoulder – biceps tendonopathyLaboratory 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 20

Module 6.5: Pathology Case Studies 21