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MUSCULOSKELETAL EXAM 37M people have some form of arthritis-you will have lots of patients Rheumatology- needs more than just a few good physicians- needs a lot of physicians Value of the H&P- a truism…if you don’t know 90% of the time or better what the patient has by the end of the HPI..you are in trouble

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Things you must Do Is the pain worse on weight bearing? Is the worst pain and stiffness present upon arising? What drugs have you tried, what dose and what happened? Always do bilateral assessments of joints

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Make the patient focus!

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How not to write your history

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RECORDING THE EXAM In the real world-”BJM are normal”or “all joints:ROM intact” Can use either a table format or Stick diagram/template STL system is 0-4 with 4 being the worst possible and 0 is normal Worst is maximal swelling, severe tenderness and complete loss of motion Simply state whether fluid is present or not

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BONDING “Our hands are central to our psychology as they continually switch between executive, exploratory and expressive activity”

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UPPER BODY Nails

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UPPER BODY Nails Palms, Hands…….. Grip strength and “ knuckle sign” are very helpful.

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Depression

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More or less susceptible to myocardial infarction?

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Heberden’s Nodes

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Bouchard’s Nodes

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Clue to an infectious arthritis

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Palmar Erythema

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telangiectasia

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Double Jointed

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This Patient should stop what?

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What are the yellow nodules?

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What drug should this patient have been on?

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Synovitis

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Rheumatoid arthritis

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UPPER BODY Nails Palms, Hands…….. Grip strength and “ knuckle sign” are very helpful. Do a Tinel’s sign while you are there Arms- slide hand along ulna for nodules

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What is this?

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UPPER BODY Nails Palms, Hands…….. Grip strength and “ knuckle sign” are very helpful. Do a Tinel’s sign while you are there Arms- slide hand along ulna for nodules Elbow-synovial thickening at ulnar groove and epitroclear nodes are the “S4s” of the rheumatology consult! Olecranon bursal effusions are likely when elbow has full ROM

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UPPER BODY Cervical Spine and ……..don’t forget the TMJ! Shoulders

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Quick Assessment of Shoulder Function If the pt can abduct, elevate the arm above the head and touch the contralateral shoulder-then re-elevate and by reverse motion to touch the L-S spine..it is highly unlikely there is significant pathology present. Rotator Cuff assessment: by history there will be inability/pain on abducting arm >90o and by PX pain on internal /external rotation at 90o Pt may also have + beer can sign If there is abnormal and/or pain upon motion of the humerus in the A-P dimension, pathology is in the G-H joint

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A SLIGHTLY HIGHER YIELD THAN SPINAL PERCUSSION

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DOES THIS MAN HAVE HEART DISEASE?

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LOWER BODY Skin

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ERYTHEMA MIGRANS

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ERYTHEMA NODOSUM

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LOWER BODY Skin Feet- MTPs are sentinel joints for inflammatory arthritis Ankle

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Podagra

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Psoriasis

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LOWER BODY Knee flexion extension patello/femoral clicking don’t forget the anserine bursa

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WHAT IS THE ANSERINE BURSA? VERY COMMONLY MISSED SOURCE OF “KNEE” PAIN Worst at night and on stairs Obese DJD of knee common Know the muscles insertions that define it. Very easy to treat

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LOWER BODY Skin Feet Ankle Knee Hip internal/external ROM while knee flexed

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TERMS/SYNDROMES Arthralgia/arthritis Myalgia Baker’s cyst Ganglion cyst Medial and lateral epicondylitis Patello-femoral syndrome Hypermobility syndrome

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The End

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Recording the Exam S…L…T graded on a scale of 1-4 Writing that a joint has fluid and is warm and tender means a lot ROM..”normal vs abnormal” can suffice in most circumstances Stickpeople can be helpful

Теги Musculoskeletal exam

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