Topics

• History
• Screening and Health Promotion
• Pediatric Variations

NDNP 819: Advanced Health Assessment Across the Lifespan

Module: Musculoskeletal

History

History is the most important part for assessing musculoskeletal complaints. An injury mechanism can explain the pathology and symptoms of the problem. Determine if the injury is traumatic or atraumatic, acute or chronic, high (greater structural damage) or low velocity, or if movement aggravates or relieves pain associated with the injury

As always, use OLDCART to assess HPI, especially include timing of the problem (intermittent, constant, increasing, decreasing, time of day, with activity), characteristics of the pain (sharp, dull, achy, radiation), what makes it better (ice, elevation, etc.), worse, and associated symptoms (fatigue, weakness).

For joint problems, is there decreased range of motion, swelling, warmth, erythema, morning or activity related pain, stiffness, instability, loss of function, unilateral or bilateral, crepitus, related to deformity? Is it one joint or multiple joints? Multiple joints relate more to systemic illness.

For back/spine problems, it is important to ask about bladder and bowel incontinence, radiation to buttock or legs, midline versus paravertebral, sharp, aching, paresthesia, and night pain.

Patients should determine the exact location of symptoms which helps determine the anatomic area of pain. For example, when a patient point to his/her knee, it identifies the point of maximal tenderness, leading the APN to direct history questions appropriately.

Realize that symptoms and signs are often nonspecific. Patients may describe locking or catching (consider internal derangement), instability or giving way (consider ligament injury). Those symptoms may also be due to pain causing muscular inhibition

Constitutional symptoms of fever, weight loss, swelling with no injury, or system illness suggest medical conditions. History of insect bite?

PMH/FH: history of osteoarthritis, rheumatoid arthritis, septic arthritis, gout, fractures, strains, carpal tunnel syndrome, fibromyalgia, osteoporosis, psoriatic arthritis, plantar fasciitis, tendon problems, surgeries, depression, anxiety, eating disorders, chronic pain, cancer

Meds: statins (muscle pains), NSAIDs, acetaminophen, corticosteroids

HM: calcium, Vitamin D intake, exercise (over use), tobacco, ETOH, drug use

SH: occupation, symptoms related to job? Participation in sports

Depending on whether symptoms are localized or systemic dictates your ROS:

• Local: General, Skin, MS, Neuro (strength, numbness, tingling)
• Systemic would also include HEENT (dry eyes, scleritis, corneal ulcer—rheumatoid arthritis) CV, Resp, PV, Lymph

Physical Exam

Perform a detailed MS physical exam. Use this trauma guide to rule out serious injury:

SEADS with inspection (swelling, erythema, atrophy, deformity and (surgical) scars) -
Observe gait, ease of movement and grimacing

Plan to examine joint above and below the chief complaint. For example, a knee complaint requires hip and ankle exam. Palpate the bone/joint for warmth, crepitus, ROM, edema, muscle origin and insertion, defect, hematoma and taut bands. If ROM is problem or asymmetric, assess for passive ROM and for physical limitation.

Document musculoskeletal assessment based on what you examined:

Don’t forget a full neurological exam including mental status.