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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. 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. Inflammatory 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 (tendinitis), 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 crystalline arthritis. Morning stiffness that gradually improves with activity is more com- mon in inflammatory 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 tissue 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 inflammatory 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 systems that provide important clues to diagnosis. Ask about any family history of joint or muscle disorders. Watch for the symptoms, signs, and disorders 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 extremities- Gonococcal arthritis● ?Expanding erythematous “target” or “bull’s eye” patch early in an illness -Lyme disease (erythema chronicum migrans) ● ?Painful subcutaneous nodules especially in pretibial area -Sarcoidosis, Beh?et 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 ● ?Nailfold capillary changes -Dermatomyositis, systemic sclerosis ● ?Clubbing of the fingernails (see p. 211) - Hypertrophic osteoarthropathy● ?Red, burning, and itchy eyes (conjunctivitis), eye pain and blurred vision (uveitis) -Reactive (Reiter) arthritis, Beh?et syndrome, ankylosing spondylitis● ?Scleritis - RA, IBD, vasculitis● ?Preceding sore throat -Acute rheumatic fever or gonococcal arthritis● ?Oral ulcerations - RA (usually painless); Beh?et disease● ?Pneumonitis; interstitial lung disease - RA; systemic sclerosis ● ?Diarrhea, abdominal pain, cramping -IBD, reactive arthritis from Salmonella, Shigella, Yersinia, Campylobacter; scleroderma● ?Urethritis -Reactive (Reiter) arthritis, gonococcal arthritis ● ?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 warrants further evaluation. (The NEXUS criteria are normal alert- ness, no posterior 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 compression 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 radiculopathy 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 picture of the problem, especially the location and radiation of the pain and any prior history of trauma. Nonspecific low back pain is usually from musculoligamentous 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 herniation; vertebral collapse; spinal cord metastases; and, rarely, epidural abscess. For pain off the midline, assess for muscle strain, sacroiliitis, trochanteric bursitis, 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 increases 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 stenosis. 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 incontinence), especially if there is saddle anesthesia or perineal numbness. Pursue immediate imaging and surgical evaluation.Elicit any key warning signs or “red flags” for serious underlying systemic disease.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 immunosuppression ● ?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 inflamma- 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 tender. 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 components. Central Nervous System Brain and Spinal CordPeripheral Nervous System Cranial Nerves, Peripheral NervesEXAMINATION OF CRANIAL NERVES I-XII"On Old Olympic Towering Tops A Finn And German Viewed Some Hops"Equipment Needed:PenlightCottonballSnellen Card or NewsprintSafety Pin or Paperclip2-3 Smells (peppermint, alcohol, coffee)Ticking Watch or Small ClockCranial Nerves Assessment FormCranial NerveFunctionMethodNormal FindingsClient’s ResponsesIOlfactorySmell reception and interpretationAsk client to close eyes and identify different mild aromas such alcohol, powder and vinegar.Client should be able to distinguish different smells IIOpticVisual acuity and fieldsAsk client to read newsprint and determine objects about 20 ft. awayClient should be able to read newsprint and determine far objectsIIIOculomotorExtraocular eye movements, lid elevation, papillary constrictions lens shapeAssess ocular movements and pupil reactionClient should be able to exhibit normal EOM and normal reaction of pupils to light and accommodationIVTrochlearDownward and inward eye movementAsk client to move eyeballs obliquelyClient should be able to move eyeballs obliquelyVTrigeminalSensation of face, scalp, cornea, and oral and nasal mucous membranes. Chewing movements of the jawElicit blink reflex by lightly touching lateral sclera; to test sensation, wipe a wisp of cotton over client’s forehead for light sensation and use alternating blunt and sharp ends of safety pin to test deep sensationAssess skin sensation as of ophthalmic branch aboveAsk client to clench teethClient blinks whenever sclera is lightly touched; able to feel the wisp of cotton over the area touched; able to discriminate blunt and sharp stimuliClient is able to sense and distinguish different stimuliClient should be able to clench teethVIAbducensLateral eye movementAsk client to move eyeball laterallyClient should be able to move eyeballs laterallyVIIFacialTaste on anterior 2/3 of the tongueFacial movement, eye closure, labial speechAsk client to do different facial expressions such as smiling, frowning and raising of eyebrows; ask client to identify various tastes placed on the tip and sides of the mouth: sugar, salt and coffeeClient should be able to do different facial expressions such as smiling, frowning and raising of eyebrows; able to identify different tastes such as sweet, salty and bitter tasteVIIIAcousticHearing and balanceAssess client’s ability to hear loud and soft spoken words; do the watch tick testClient should be able to hear loud and soft spoken words; able to hear ticking of watch on both earsIXGlossopharyngealTaste on posterior 1/3 of tongue, pharyngeal gag reflex, sensation from the eardrum and ear canal.Swallowing and phonation muscles of the pharynxApply 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 reflex 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 reflexXVagusSensation from pharynx, viscera, carotid body and carotid sinusAsk client to swallow; assess client’s speech for hoarsenessClient should be able to swallow without difficulty; has absence of hoarseness in speechXISpinal accessoryTrapezius and sternocledomastoid muscle movementAsk client to shrug shoulders and turn head from side to side against resistance from nurse’s handsClient should be able to shrug shoulders and turn head from side to side against resistance from nurse’s handsXIIHypoglossalTongue movement for speech, sound articulation and swallowingAsk client to protrude tongue at midline, then move it side to sideClient should be able to protrude tongue at midline and move it side to sideSpinal 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 directly with the anterior horn cell innervating the same muscle. When the impulse crosses the neuromuscular junction, the muscle suddenly contracts, completing the reflex arc. Muscle Stretch Reflexes Ankle reflex —Sacral 1 primarily Knee reflex —Lumbar 2, 3, 4Supinator (brachioradialis) reflex — Cervical 5, 6 Biceps reflex — Cervical 5, 6Triceps reflex — Cervical 6, 7Common or Concerning Symptoms ● ?Headache ● ?Dizziness or vertigo ● ?Weakness (generalized, proximal, or distal) ● ?Numbness, abnormal or absent sensation ● ?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 reflexesAmerican Academy of Neurology: Guidelines for a Screening Neurologic Examination (continued) Mental Status—level of alertness, appropriateness of responses, orientation to date and place Cranial Nerves ● ?Vision—visual fields, fundoscopic examination ● ?Pupillary light reflex ● ?Eye movements ● ?Hearing ● ?Facial strength—smile, eye closure Motor System ● ?Strength—shoulder abduction, elbow extension, wrist extension, finger abduction, hip flexion, knee flexion, ankle dorsiflexion ● ?Gait—casual, heel walk, toe walk, tandem walk ● ?Coordination—fine finger movements, finger-to-nose, heel-knee-shin Sensory System—one modality at toes—can be light touch, pain/tempera- ture, or proprioception Reflexes ● ?Deep tendon reflexes—biceps, patellar, Achilles ● ?Plantar responses - BabinskiNote: 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 uploadedFiles/4CME_and_Training/2Training/3Fellowship_Resources/5Core_Curricula/skilz.pdf. Accessed 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.

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