Health assessment musculoskeletal questions 2

Rheumatoid arthritis (RA)

- Onset is gradual with fatigue, morning stiffness, diffuse muscle ache, and weakness

- Synovial lining inflamed with deterioration of cartilage and erosion of surfaces (spurs)

- Ligaments and tendons around joints become fibrotic and shortened (contractures and joint subluxation)

- Joint involvement is bilateral

RA symptoms

- Symptoms are pain, edema, and stiffness of fingers, wrists, ankles, feet, and knees

- Systemic symptoms caused by autoimmune response include low-grade fever and fatigue

- As disease continues, ulnar deviation, swan-neck deformity, and boutonnière deformity may be observed (these are chronic)

Osteoarthritis

- Affects weight-bearing joints (vertebrae, hips, knees, and ankles); also, hands and fingers

- Affects joints with repetitive movement, those used in playing sports on a regular basis

- As cartilage wears away, bones move against each other (joint inflammation)

- Joint involvement may be unilateral or bilateral

Carpal tunnel tests

- Pahlen: sit down, elbows flexed and back of hands together facing down for one minute: positive ie numbness in palmar aspect

T- inel: sitting, elbow flexed, wrist up, tap on median nerve: positive is tingling and pain in hands or fingers

- Longer than one min can cause pain for either

- Sqeeze test: pain

Abnormalities

- Hand: thenar atrophy, ganglion tenosynovitis

- Foot: Gout, Hallux valgus, Corn, Hammer toe, Plantar wart

Knee tests

1. Bulge test: to detect small amounts of fluid - discern against soft tissue edema or joint diffusion/swelling

- Stroke medial side of knee upward with ball of hand 3-4 times

- Press on lateral knee and look forward bulge on medial side

2. Ballottement test: to detect large amounts of fluid

- With non-dominant hand squeeze about patella

- With other hand press patella against toward femur to assess for click or fluid wave

- Femur usually sits against patella without movement

- No crepitus and pain

3. McMurray's test: for torn meniscus

- Flex knee and hip of affected leg

- Press thumb and index finger on opposite sides of knee

- With other hand rotate lower leg laterally noting pain or clicking

4. Test ROM: Flexion and Hyperextension

Common Problems: Osteoporosis

- Loss of bone density because reabsorption outpaces formation

- Commonly in spine and hip

- Causes kyphosis and loss of height

- Occurs without signs or symptoms; clients may not know until they discover: a loss of height, have spontaneous fracture from brittle bones, or develop kyphosis

Fixed Osteoporosis risk factors

- Age, gender (female: ⅓ women over 90), and ethnicity

- Fam hx and Previous fx

- Menopause/hysterectomy

- Long term glucocorticoid therapy

- RA

- Hypogonadism in men

Modifiable Osteoporosis risk factors

- Alcohol intake and smoking (big one)

- Low BMI, poor nutrition, eating disorder

- Vitamin D deficiency and low calcium intake

- Sedentary lifestyle: exercise is most important (muscles pull on the bone to encourage strength and bone formation)

- Frequent falls and injury: hip forearm and spine common fractures

Bone problems

- fracture

- pain caused by muscle spasm is common

- Deformity or loss of function caused by tissue shortening around bone (cast - important to assess capillary refill and color) and localized edema

Genetic & Cultural Variations

- Many biologic variations of bones and muscles

- Lactose intolerance: 80% to 95% of Asians and Native Americans; 18% to 26% of northern Europeans

- Ethnic differences in lengths of radius and ulna

- Osteoporosis: related fractures: 51% Europeans and Americans, followed by Western Pacific and

Southeast Asia

- Difference in incidence of arthritis: non-Hispanic Whites (41.3 million), non-Hispanic Blacks (6.1 million), Hispanics (4.4 million), non-Hispanic Asians (1.5 million); 26% women, 19.1% men

Genetic Variations

- Osteoporosis: affects 200 million women worldwide: approximately 1/10 aged 60, 1/5 aged 70, 2/5 aged 80, 2/3 aged 90; one in three women and one in five men will have fractured bone

- Bone lose density with age, risk for bone fracture, especially wrists, hips, vertebrae.

- Joint-stiffening conditions may be misdiagnosed as arthritis, especially in older adult.

- Osteoporosis is more common as person ages because bone resorption increases, calcium absorption decreases, and production of osteoblasts decreases.

- Some positions during physical examination will be uncomfortable due to decreased flexibility.

Geriatric considerations

- Slower movements, reduced flexibility, decreased muscle strength due to age-related muscle fiber and joint degeneration, reduced elasticity of tendons, joint capsule calcification

- May have impaired sense of position in space, contributing to risk of falling

- Kyphosis is common.

- Do not insist the client touches toes when bending forward unless the client is comfortable with the movement.

- May have bow-legged appearance due to decreased muscle control

Scoliosis

- Stand behind patient and ask them to bend at the waist

- Look for lateral curve in spine or a hump in a vertebral muscle or thoracic rib

- One side higher than others

Anatomic Snuffbox

- Stand behind patient and ask them to bend at the waist

- Look for lateral curve in spine or a hump in a vertebral muscle or thoracic rib

- One side higher than others