The first goal of your evaluation of musculoskeletal disorders is to characterize the patient’s complaint in terms of four key features. Is the joint problem: 1. Articular or extra-articular Articular disease typically involves swelling and tenderness of the entire joint, crepitus, instability, “locking,” or deformity, and limits both active and passive range of motion due to either stiffness or pain. Extra-articular disease typically involves “point or focal tenderness in regions adjacent to articular structures” and limits active range of motion. Extra-articular disease rarely causes swelling, instability, or joint deformity. 2. Acute (usually <6 weeks) or chronic (usually >12 weeks) Acute or Chronic. Acute joint pain typically lasts up to 6 weeks; chronic pain lasts >12 weeks. 3. Inflammatory or noninflammatory Ask about the four cardinal features of inflammation—swelling, warmth , and redness , in addition to pain. 4. Localized (monoarticular) or diffuse (polyarticular) Ask the patient which joints are painful.
Transcript
The first goal of your evaluation of musculoskeletal disorders is to char-acterize the patient’s complaint in terms of four key features. Is the joint problem:
1. Articular or extra-articular
Articular disease typically involves swelling and tenderness of the entire joint, crepitus, instability, “locking,” or deformity, and limits both active and passive range of motion due to either stiffness or pain. Extra-articular disease typically involves “point or focal ten-derness in regions adjacent to articular structures” and limits active range of motion. Extra-articular disease rarely causes swelling, in-stability, or joint deformity.
2. Acute (usually <6 weeks) or chronic (usually >12 weeks) Acute or Chronic. Acute joint pain typically lasts up to 6 weeks; chronic pain lasts >12 weeks.
3. Inflammatory or noninflammatory Ask about the four cardinal features of inflammation—swelling, warmth, and redness, in addition to pain.
4. Localized (monoarticular) or diffuse (polyarticular) Ask the patient which joints are painful.
Recall the 7 attributes of pain:
OPQRST, or Onset, Palliating/Provoking Factors, Quality, Radiation, Site,
and Timing
Pain in a single joint suggests injury, monoarticular arthritis, or extraarticular causes like tendinitis or bursitis. Lateral hip pain with focal tenderness over the greater trochanter is typical of trochanteric bursitis.
In rheumatic fever or gonococcal arthritis, there is a migratory pattern of spread; in RA, the pattern is additive and progressive with symmetric involvement. In-flammatory arthritides are more common in women.
Severe pain of rapid onset in a red swollen joint suggests acute septic arthritis or crystalline arthritis (gout; CPPD).6,7 In children, consider osteomyelitis in a bone contiguous to a joint.
Extra-articular pain occurs in inflammation of bursae (bursitis), tendons (ten-dinitis), or tendon sheaths (tenosynovitis) as well as in sprains from stretching or tearing of ligaments.
In articular joint pain there is decreased active and passive range or motion and morning stiffness or “gelling” (see page 633); in nonarticular joint pain, there is periarticular tenderness and only passive range of motion remains intact.
Inflammatory disorders have many causes5: infectious (Neisseria gonorrhoeae or Mycobacterium tuberculosis), crystal-induced (gout, pseudogout), immune-related (RA, systemic lupus erythematosus [SLE]), reactive (rheumatic fever, reactive arthritis), or idiopathic.
In noninflammatory disorders, consider trauma (rotator cuff tear), repetitive use (bursitis, tendinitis), degenerative changes (OA), or fibromyalgia.
Inflammation with fever and chills is seen in septic arthritis; also consider crys-talline arthritis.
Morning stiffness that gradually improves with activity is more com- mon in in-flammatory disorders like RA and PMR9–11; intermittent stiffness and gelling are seen in OA.12
Monoarticular arthritis can be traumatic, crystalline, or septic. Oligoarticular arthritis occurs in infection from gonorrhea or rheumatic fever, con- nective tis-sue disease, and OA. Polyarthritis may be viral or inflammatory from RA, SLE, or psoriasis.
nvolvement is usually symmetric in RA, SLE, and ankylosing spondylitis and asymmetric in psoriatic, reactive (Reiter), and IBD-associated arthritis.
Constitutional symptoms are com- mon in RA, SLE, PMR, and other inflamma-tory arthritides. High fever and chills suggest an infectious cause.
Leukemia can infiltrate the synovium; chemotherapy can also cause joint pain.
Some joint disorders have systemic manifestations in other organ sys-tems that provide important clues to diagnosis. Ask about any family his-tory of joint or muscle disorders. Watch for the symptoms, signs, and dis-orders below.
Joint Pain and Systemic Disorders
● Skin conditions
● Butterfly (malar) rash on the cheeks- Systemic lupus erythematosus
● Scaly plaques, especially on extensor surfaces, and pitted nails- Psoriatic arthritis
● Heliotrope rash on the upper eyelid - Dermatomyositis
● Papules, pustules, or vesicles with reddened bases on the distal extrem-ities- Gonococcal arthritis
● Expanding erythematous “target” or “bull’s eye” patch early in an ill-ness -Lyme disease (erythema chronicum migrans)
● Painful subcutaneous nodules especially in pretibial area -Sarcoidosis, Behçet disease (erythema nodosum)13,14
● Palpable purpura - Vasculitis
● Hives - Serum sickness, drug reaction
● Erosions or scaling on the penis and crusted scaling papules on the soles and palms- Reactive (Reiter) arthritis (with urethritis, uveitis)
● The maculopapular rash of rubella -Arthritis of rubella
● Mental status change, facial or other weakness, stiff neck -Lyme disease with central nervous system involvement
Body Regions:
Neck pain is also common. If the patient reports neck trauma, common in motor vehicle accidents, ask about neck tenderness and consider clinical decision rules that identify risk of cervical cord injury. The NEXUS criteria and the Canadian C-Spine Rule are highly sensitive and specific for establishing a low probability of cervical spine injury.15–17 Persistent pain after blunt trauma or a collision war-rants further evaluation. (The NEXUS criteria are normal alert- ness, no poste-rior midline cervical spine tenderness, no focal neurologic deficits, no evidence of intoxication, and no painful distracting injury).
Neck pain is usually self-limited, but it is important to ask about radiation into the arm or scapular area, arm weakness, numbness, or paresthesias. Elicit any of
the “red flag” symptoms listed below. Radicular pain signals spinal nerve com-pression and/or irritation, most commonly at C7 or C6. Unlike low back pain, the principal cause is foraminal impingement from degenerative joint changes (70% to 75%), rather than disc herniation (20% to 25%).
Begin by asking “Do you have any back pain?,”—at least 40% of adults have low back pain at least once during their lifetime, usually between the ages of 30 and 50 years, and low back pain is one of the most common reasons for office visits. There are numerous clinical guidelines, but most categorize low back pain into three groups: nonspecific (>90%), nerve root entrapment with radicu-lopathy or spinal stenosis (~5%), and pain from a specific underlying disease (1% to 2%).Note that the term “nonspecific low back pain” is preferred to “sprain” or “strain.” Using open-ended questions, get a clear and complete pic-ture of the problem, especially the location and radiation of the pain and any prior history of trauma. Nonspecific low back pain is usually from musculoliga-mentous injuries and age-related degenerative processes of the intervertebral discs and facet joints.
Approach:
Determine if the pain is on the midline, over the vertebrae, or off the midline.
For midline back pain, diagnoses include musculoligamentous injury; disc hernia-tion; vertebral collapse; spinal cord metastases; and, rarely, epidural abscess. For pain off the midline, assess for muscle strain, sacroiliitis, trochanteric bursi-tis, sciatica, and hip arthritis as well as for renal conditions like pyelonephritis or stones.
Is there radiation into the buttock or lower extremity? Is there any associated numbness or paresthesias?
Sciatica is radicular gluteal and poste- rior leg pain in the S1 distribution that in-creases with cough or Valsalva (see pp. 765–766 for related neurologic findings); 85% of cases are associated with a disc disorder, usually at L4–L5 or L5–S1.Leg pain that resolves with rest and/or lumbar forward flexion occurs in spinal steno-sis.
Importantly, is there any associated bladder or bowel dysfunction?
Consider cauda equina syndrome from an S2–S4 midline disc or tumor if there is bowel or bladder dysfunction (usually urinary retention with overflow inconti-nence), especially if there is saddle anesthesia or perineal numbness. Pursue im-mediate imaging and surgical evaluation.
Elicit any key warning signs or “red flags” for serious underlying systemic dis-ease.
In cases of low back pain plus another indicator, there is a pretest probability of serious systemic disease of ~10%.
Red Flags for Low Back Pain from Underlying Systemic Disease ● Age <20 years or >50 years
● History of cancer
● Unexplained weight loss, fever, or decline in general health
● Pain lasting more than 1 month or not responding to treatment
● Pain at night or present at rest
● History of intravenous drug use, addiction, or immunosuppres-sion
● Presence of active infection or human immunodeficiency virus (HIV) infection
● Long-term steroid therapy
● Saddle anesthesia, bladder or bowel incontinence
● Neurologic symptoms or progressive neurologic deficit
Assessing the Four Signs of Inflammation
● Swelling. Palpable swelling may involve: (1) the synovial membrane, which can feel boggy or doughy; (2) effusion from excess synovial fluid within the joint space; or (3) soft tissue structures, such as bursae, tendons, and tendon
sheaths.
● Warmth. Use the backs of your fingers to compare the involved joint with its unaffected contralateral joint, or with nearby tissues if both joints are involved.
● Redness. Redness of the overlying skin is the least common sign of in-flamma- tion near the joints and is usually seen in more superficial joints like fingers, toes, and knees.
● Pain or tenderness. Try to identify the specific anatomic structure that is ten-der.
NERVOUS SYSTEM:
Guiding Questions for Examination of the Nervous System
● Does the patient have neurologic disease?
● If so, what is the localization of the lesion or lesions? Are your findings sym- metric?
● What is the pathophysiology of abnormal findings?
● What is the preliminary differential diagnosis?
When you conduct the neurologic examination, it is wise to adopt a fixed rou- tine or examination sequence to minimize omission of one of its important com-ponents.
Central Nervous System
Brain and Spinal Cord
Peripheral Nervous System
Cranial Nerves, Peripheral Nerves
EXAMINATION OF CRANIAL NERVES I-XII"On Old Olympic Towering Tops A Finn And German Viewed Some
Hops"
Equipment Needed:Penlight
CottonballSnellen Card or Newsprint
Safety Pin or Paperclip2-3 Smells (peppermint, alcohol, coffee)
Ticking Watch or Small Clock
Cranial Nerves Assessment FormCranial Nerve Function Method Normal Find-
ingsClient’s Re-
sponsesI Olfactory Smell reception
and interpreta-tion
Ask client to close eyes and identify different mild aromas such alcohol, pow-der and vine-gar.
Client should be able to distin-guish different smells
II Optic Visual acuity and fields
Ask client to read newsprint and deter-mine objects about 20 ft. away
Client should be able to read newsprint and determine far objects
III Oculomotor Extraocular eye movements, lid elevation, papil-lary constrictions lens shape
Assess ocular movements and pupil re-action
Client should be able to exhibit normal EOM and normal reaction of pupils to light and accommo-dation
IV Trochlear Downward and inward eye movement
Ask client to move eye-balls obliquely
Client should be able to move eyeballs obliquely
V Trigeminal Sensation of face, scalp, cornea, and oral and nasal mu-cous mem-branes. Chewing movements of the jaw
Elicit blink reflex by lightly touch-ing lateral sclera; to test sensa-tion, wipe a wisp of cot-ton over client’s fore-head for light sensation and use al-ternating blunt and sharp ends of safety pin to test deep sensation
Assess skin sensation as of oph-thalmic branch above
Ask client to clench teeth
Client blinks whenever sclera is lightly touched; able to feel the wisp of cotton over the area touched; able to discrimi-nate blunt and sharp stimuli
Client is able to sense and dis-tinguish differ-ent stimuli
Client should be able to clench teeth
VI Abducens Lateral eye movement
Ask client to move eyeball laterally
Client should be able to move eyeballs later-ally
VII Facial Taste on anterior 2/3 of the tongueFacial move-ment, eye clo-sure, labial speech
Ask client to do different facial expres-sions such as smiling, frowning and raising of eyebrows; ask client to identify vari-ous tastes placed on the tip and sides of the mouth: sugar, salt and coffee
Client should be able to do differ-ent facial ex-pressions such as smiling, frowning and raising of eye-brows; able to identify different tastes such as sweet, salty and bitter taste
VIII Acoustic Hearing and bal-ance
Assess client’s abil-ity to hear loud and soft spoken words; do the watch tick test
Client should be able to hear loud and soft spoken words; able to hear ticking of watch on both ears
IX Glossopharyn-geal
Taste on poste-rior 1/3 of tongue, pharyn-geal gag reflex, sensation from the eardrum and ear canal.Swallowing and phonation mus-cles of the phar-ynx
Apply taste on posterior tongue for identification (sugar, salt and coffee); ask client to move tongue from side to side and up and down; ask client to swallow and elicit gag re-flex through sticking a clean tongue depressor into client’s mouth
Client should be able to identify different tastes such as sweet, salty and bitter taste; able to move tongue from side to side and up and down; able to swallow without difficulty, with (+) gag reflex
X Vagus Sensation from pharynx, viscera, carotid body and carotid sinus
Ask client to swallow; as-sess client’s speech for hoarseness
Client should be able to swallow without diffi-culty; has ab-sence of hoarse-ness in speech
XI Spinal acces-sory
Trapezius and sternocledomas-toid muscle movement
Ask client to shrug shoul-ders and turn head from side to side against resis-tance from nurse’s hands
Client should be able to shrug shoulders and turn head from side to side against resis-tance from nurse’s hands
XII Hypoglossal Tongue move-ment for speech, sound articula-tion and swallow-ing
Ask client to protrude tongue at midline, then move it side to side
Client should be able to protrude tongue at mid-line and move it side to side
Spinal Reflexes: The Muscle Stretch Response
To elicit a muscle stretch reflex, briskly tap the tendon of a partially stretched muscle. For the reflex to occur, all components of the reflex arc must be intact: sensory nerve fibers, spinal cord synapse, motor nerve fibers, neuromuscular junction, and muscle fibers. Tapping the tendon activates special sensory fibers in the partially stretched muscle, triggering a sensory impulse that travels to the spinal cord via a peripheral nerve. The stimulated sensory fiber synapses di-rectly with the anterior horn cell innervating the same muscle. When the im-pulse crosses the neuromuscular junction, the muscle suddenly contracts, com-pleting the reflex arc.
● Fainting and blacking out (near-syncope and syncope)
● Seizures
● Tremors or involuntary movements
Always look for unusual headache warning signs, such as sudden onset “like a thunderclap,” onset after age 50 years, and associated symptoms such as fever and stiff neck. Examine for focal neurologic signs.
Important Areas of Examination ● Mental status—see Chapter 5, Behavior and Mental Status
● CNs I through XII
● Motor system: muscle bulk, tone, and strength; coordination, gait, and stance
● Sensory system: pain and temperature, position and vibration, light touch, discriminative sensation
● Deep tendon, abdominal, and plantar reflexes
American Academy of Neurology: Guidelines for a Screening Neurologic Examination (continued)
Mental Status—level of alertness, appropriateness of responses, orientation to date and place
Sensory System—one modality at toes—can be light touch, pain/tempera- ture, or proprioception
Reflexes
● Deep tendon reflexes—biceps, patellar, Achilles
● Plantar responses - Babinski
Note: If there is reason to suspect neurologic disease based on the patient’s his- tory or the results of any components of the screening examination, a more com- plete neurologic examination is necessary. Source: Adapted from the American Academy of Neurology. Available at https://www.aan.com/ up-loadedFiles/4CME_and_Training/2Training/3Fellowship_Resources/5Core_Curricula/skilz.pdf. Ac-cessed July 23, 2015.
Scale for Grading Muscle Strength
Muscle strength is graded on a 0 to 5 scale:
0 —No muscular contraction detected1 —A barely detectable flicker or trace of contraction
2 —Active movement of the body part with gravity eliminated 3 —Active movement against gravity
4 —Active movement against gravity and some resistance5 —Active movement against full resistance without evident fatigue. This is normal muscle strength.
