Clinical Skill Assessment Task

Internal Medicine – Rheumatological System

Content: Rheumatological System Examination / Arthritis

Skill: Physical Examination

Candidate’s task list

Your tasks are to:

 Perform a complete rheumatological examination on the patient’s hands

 Comment on the presence / absence of signs to rule in / out the possible
differentials as you proceed with the examination

Candidate’s brief scenario

You are an Intern working at the Rheumatology Clinic. Your Registrar has asked you
to perform a complete rheumatological physical examination on the hands of Jean
Wilson, a 70-year-old female retired seamstress, whose GP had made an appointment
for her to see the Rheumatology Clinic doctor because of the pain in her hands.

Examiner’s instructions

This CSAT station tests the candidate’s ability to perform a rheumatological system
examination. Essential skills and knowledge tested include:

1. Professional approach to patient

2. Physical examination
Marking Sheet

1. Approach / Attitude to patient

Did the candidate demonstrate an appropriate professional approach towards the

patient?

Surpasses Achieves Standard not

Standard Standard Achieved
Appropriate beginning (CE)
 Knocks before entering
 Introduces self by name
0.5 0.25 0
 Identifies role / position
 Correctly uses patient’s name and
makes eye contact with patient
Explains examination and obtains
0.5 0.25 0
verbal consent (CE)

TOTAL MARKS /1

2. Content / Knowledge

Did the candidate adequately perform a rheumatological examination?

Surpasses Achieves Standard not

Standard Standard Achieved
Washes hands using alcohol hand wash
0.25 0.25 0
provided (CE)
Checks that patient is comfortable and
ensures patient is correctly positioned
0.5 0.25 0
with hands resting on a pillow / flat
surface
Asks patient if she has any particularly
0.25 0.25 0
painful joints before starting
Observes patient from end of bed and
comments on:
 Obvious distress / pain / discomfort
 Wellbeing of patient
1 0.5 0
 General appearance (pale, blue,
plethoric, etc.)
 Gait aids
 Posture
Asks for vital signs 1 0.5 0
 Respiratory rate: 18/min, regular
 Heart rate: 90/min, regular
 BP: 130/90mmHg
 Temperature: 37.4°C
  O2 saturation: 99% on RA
Asks patient to show her elbows and
comments on presence / absence of:
 Rheumatoid nodules 1 0.5 0
 Psoriatic plaques
 Gouty tophi
Observes patient’s hands and comments
on:
 Acute arthritic changes (swelling,
erythema, etc.) 1 0.5 0
 Pattern of joints affected (CE)
 Wasting
 Scars
Observes patient’s hands and comments
on signs of rheumatoid arthritis
 Boutonnière (CE)
 Swan-neck (CE)
 Z-thumb (CE)
2 1 0
 MCP subluxation (CE)
 Ulnar deviation (CE)
 Vasculitic changes
 La main en lorgnette
 Palmar erythema
Observes patient’s hands and comments
on signs of psoriatic arthritis
 Dactylitis
 La main en lorgnette
 Rash / plaques 0.5 0.25 0
 Psoriatic nail changes
o Pitting
o Transverse ridging
o Onycholysis
Observes patient’s hands and comments
on signs of gouty arthritis 0.5 0.25 0
 Gouty tophi
Observes patient’s hands and comments
on signs of SLE
 Rash 0.5 0.25 0
 Jaccoud’s arthropathy
 Vasculitic changes
Observes patient’s hands and comments
on signs of osteoarthritis
0.5 0.25 0
 Heberden’s nodes (CE)
 Bouchard’s nodes (CE)
Correctly feels for: 1 0.5 0
 Joint bogginess
 Joint fluctuance
 Joint-line tenderness
  Stress tenderness
 Ulnar styloid tenderness
Assesses wrist movements
 Extension (prayer sign)
o Range of movement
o Wrist stress tenderness
1 0.5 0
o Reversibility of deformities
 Flexion (reverse prayer sign)
o Range of movement
o Phalen’s test
Assesses digital movements
 Make a fist
o Grip strength
o Range of movement of fingers
 Thumb movements 1 0.5 0
o Opposition
o Extension
o Abduction
o Adduction
Assesses median nerve function
 Phalen’s test
 Tinel’s test
 Sensory test 1 0.5 0
 Thumb movements
o Opposition
o Abduction
Assesses function
 Key grip
0.5 0.25 0
 Writing test
 Button-unbutton test
Suggests examination of other joints
and for extra-articular manifestations of 0.5 0.25 0
disease

TOTAL MARKS / 14
CSAT Station: Rheumatological Examination
Student Name Total marks Marks Remarks for performance beyond the scope of
possible obtained pre-defined, pre-marked criteria
Briefing document for role player

This station tests the candidate’s ability to perform a rheumatological system

examination.

Key attributes

You are Jean Wilson, a 70-year-old female retired seamstress, who has come to the
Rheumatology Clinic with a referral from your GP for pain in your hands.

Prompts

If asked about the pain, say:

The pain is the same everywhere in my hands, I couldn’t tell you exactly
where.