Teaching a screening musculoskeletal examination: a randomized, controlled trial of different instructional methods.

PURPOSE: To develop and test a program to teach a rapid screening musculoskeletal examination. METHOD: In 1995, 191 medical and physician assistant students were randomized to four intervention groups: written materials only (n = 47), written materials and videotape (n = 46), written materials and small-group sessions facilitated by fourth-year medical students (n = 55), and all three methods (n = 43). Assessments, in the form of a written test and standardized patient examinations, were conducted before the interventions (n = 40 randomly selected students), seven to ten days and again three months after the interventions (n = all 191 students), and 16 months after the interventions (n = 103 students). RESULTS: While the four intervention groups' written test scores were approximately equal, their scores on the standardized patient examination differed significantly. The students taught in small groups demonstrated significantly superior examination skills compared with the students taught with written material or videotape at seven to ten days and retained this relative superiority after three and 16 months (p < .0001). CONCLUSION: Small-group instruction with hands-on supervised practice is superior to more passive instructional methods for teaching musculoskeletal examination skills and can be successfully delivered by trained senior medical student facilitators with minimal direct expenditure of faculty time.

Polyarticular versus monoarticular gout: a prospective, comparative analysis of clinical features.

This investigation was undertaken to define prospectively the clinical characteristics of patients with crystal-documented gouty arthritis simultaneously involving multiple joints. Of 106 consecutive patients with gouty arthritis (GA), 42 (40%) had articular inflammation at 2 or more sites. Comparison of these 42 patients with GA with the 64 patients with GA who presented with monoarthritis yielded the following conclusions: 1) Polyarticular gout represents one end of a generally predictable spectrum of GA, reflecting chronicity associated with poor patients understanding, poor patient compliance, and suboptimal physician management. 2) Polyarticular patients with GA tend to develop attacks of more smoldering onset and increasing duration, while joint involvement tends to occur in an ascending but asymmetrical fashion, with upper extremity joints later added to repeatedly active lower extremity sites. 3) There may be a significant discrepancy between the site (or sites) of the GA patient's chief complaint and clinically involved joints on careful physical examination. 4) Recognition of polyarticular joint involvement increases the number of sites for potential joint and/or tophus aspiration, permitting greater ease of establishing a definitive diagnosis. 5) No single laboratory or synovial fluid value meaningfully distinguishes patients with polyarticular from those with monoarticular gout.

Laryngeal involvement in rheumatoid arthritis. A clinical, laryngoscopic, and computerized tomographic study.

Laryngeal involvement was evaluated in 45 patients with moderately severe rheumatoid arthritis (RA). RA duration and severity, prior laryngeal symptoms, and abnormalities detected by concurrent indirect laryngoscopy (IL) and computerized tomography (CT) were noted and correlated with changes of basilar interstitial fibrosis (BPF) found by chest radiograph. Thirty-two percent had abnormalities detected by IL, 54% had abnormalities by CT, and 36% had BPF on chest radiographs. Comparison of these groups revealed: only two symptoms (sore throat and difficulty during inspiration) were predictive of abnormalities detected by IL; no symptoms predicted abnormalities on percentage of RA patients even in the absence of symptoms; IL tends to detect mucosal and gross functional abnormalities while CT detects structural lesions; BPF shown on chest radiographs in RA patients does not appear to be correlated with cricoarytenoid arthritis as defined by IL and CT.