Advanced Health Assessment

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Advanced Health Assessment

• Heather Hull, ARNP, PNP

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Musculoskeletal System
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Primary Functions

• Provides structure for soft tissues
• Protects vital organs
• Storage place for minerals
• Produces blood cells
• Provides stability mobility for physical
  activity

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Development of M-S System

• Fetal Cartilage calcifies becomes bone
• Childhood Bone increases in length via
  epiphyses
• Increase in diameter
• New bone tissue around bone shaft
• Ligaments stronger than bone until puberty

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Development of M-S System

• Bone growth completed about age 20
• Peak bone mass around age 35
• Aging results in Fibrosis of connective tissue
  with aging
• Increased collagen
• Decreased water content

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Aging

• Tendons become less elastic
• Decreased reaction time ROM
• Increased bone resorption
• Decreased bone density
• Deterioration of cartilage around joints

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Common M-S Problems

• Systemic
• RA, Lupus Polymyositis
• Local
• Lumbar strain
• Tennis elbow

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Facts

• 1 of 7 persons suffer from some type of M-S
  disorder
• Cost 60 billion annually
• Ranks second for reasons for visits to medical
  office

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Structure

• Bone
• Bursae
• Muscles
• Ligaments
• Tendons
• Cartilege
• Joints

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Anatomical References

• Medial ulnar tibial
• Lateral radial fibular
• Joint Motion Shoulder
• abduction - adduction
• flexion - extension
• internal external rotation

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History Questions

• Employment, Exercise,Weight, Nutrition, Cigarette
  use, Medications
• PMH Trauma to nerves or soft tissues,
  fractures, viral illness, chronic illness, breast
  implants
• FH Congenital deformities, scoliosis, back
  problems, arthritis

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Common Symptoms

• Pain
• Weakness
• Deformity
• Limitation of movement
• Stiffness
• Joint clicking

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Assessment

• Inspection
• Palpation
• Passive Active ROM
• Muscle Strength
• Integrated Function
• Gait
• Spine

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Joint Pain

• Inflammation Present
• Yes RA, SLE
• No Osteoarthritis
• Number of Joints Involved
• Monoarticular - Gout, Trauma, Septic Arthritis,
  Lyme Disease
• Polyarticular - RA, SLE

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Joint Pain Site of Involvement

• Distal phalangeal - Osteoarthritis
• Metacarpal phalangeal, wrists - RA, SLE
• First metatarsal phalangeal - Gout, Osteoarthritis

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Osteoarthritis

• Affects 1/4 or population
• Degeneration of articular cartilage
• Weightbearing distal finger joints
• Pain worsens with exercise
• Morning stiffness or immobility
• Heberdons nodes

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Rheumatoid Arthritis

• Chronic inflammatory condition
• Insidious onset over weeks to months
• Fatigue, malaise, morning stiffness
• Swelling of joints, polyarticular, PIP, MCP
  joints commonly affected, symmetrical movement
• ROM may be limited, tenderness of joints
• Lab RF, Low HH, ANA

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Low Back Pain

• Disables 5.4 million Americans
• Lifetime prevalence 60-90

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Risk Facators

• Repetative Lifting
• Exposure to vibration
• Cigarette Smoking
• Osteoporosis - Spinal Stenosis
• Obesity
• Lack of Exercise
• Increased Age

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Differential Diagnosis

• Acute lumbar-sacral sprain
• Postural backache
• Lumbar disk syndrome
• Osteoarthritis
• Irritable bowel syndrome

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Differential Diagnosis

• Urinary Disorders
• Gynecological disorders
• Ankylosing spondylitis
• Tumors

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Examination

• Inspection
• Palpation
• Passive Active ROM
• Flexion
• Extension
• Lateral
• Rotation

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Examination

• Heel - Toe Walking
• Deep tendon reflexes
• Motor strength
• Sensation
• Distracted SLR

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Examination

• In Supine position
• SLR
• Hip - ROM
• Sacroiliac joints
• Hip abduction

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Lumbar Disc Syndrome

• With repetative trauma progressive degeneration
  of nucleus pulposus leading to protrustion or
  complete extrusion of portion of disc contents
  into neural canal.
• 95 at 4 5 spaces
• Most common between 3rd 4th decades

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Clinical Features

• Low back pain
• Restriction of back motion
• Radicular pain
• Paresthesias
• Local tenderness

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Acute Lumbar-Sacral Strain

• Related to muscular, ligaments, or facial strain
  secondary to specific trauma or continuous
  mechanical stress
• Most common in age 20 - 40
• Obesity lack of exercise

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Clinical Features

• Low back pain
• Muscle spasm
• Local tenderness or swelling
• Neurologic exam negative

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Treatment

• Bedrest
• Ice - 24 hours
• Heat - dry or moist
• NSAIDS
• Low back exercises
• May need to add a muscle relaxant

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Cauda Equina

• Massive midline protrusion
• Medical emergency
• Presentation weakness to legs, urinary changes,
  impotence, loss of sphincter tone saddle
  anesthesia

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Knee

• Largest joint in body
• No intrinsic stability, depends on ligaments,
  muscles, menisci capsule for support

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Knee

• Medial collateral ligament
• Lateral collateral ligament
• Anterior cruciate ligament
• Posterior cruciate ligament
• Quadriceps
• Hamstrings
• Meniscus

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Knee Pain - History

• Position of leg at time of injury
• Popping?
• Slepping out of joint?
• Swelling?
• Stiffness?
• Loss of function?

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Examination

• Inspection
• Palpation
• ROM
• Stability Testing

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Examination

• Lachman
• Posterior drawer
• Valgus varus stress
• McMurry

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Examination

• Apley compression
• Compression
• Shrug
• Apprehension

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Injuries to Meniscus

• Normal rotation of tibia is forcibly prevented as
  knee is flexed or extended
• Simple twisting injury to knee can tear meniscus
• Medial meniscus injuries 10 X more common that
  lateral meniscus injuries

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Clinical Features

• Knee pain - well localized
• Swelling - gradual
• Locking of knee
• Popping or tearing

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Clinical Features

• Walking up down stairs difficult
• Joint effusion
• Limited ROM
• Positive McMurray
• Normal X-ray

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Treatment

• Rest
• Immobilization of knee
• Ice
• Elevation
• ROM - quadriceps strengthening exercises
• NSAIDS
• Possible surgery

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Lesions of Ligaments

• Forceful stress against knee - abduction
• Ability to bear weight is lost
• Immediate swelling
• Popping or tearing
• Positive Lachman or Posterior Drawer

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Treatment Grade I or II

• Protection
• Rest
• Ice
• Compression
• Elevation
• Support
• NSAIDS

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Treatment Grade III

• Orthopedic Consultation

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Anterior Knee Pain

• Seen in adolescents and young adults
• Athletes
• Irregular pattern of movement of patella
• Over-use type of syndrome

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Clinical Features

• Pain beneath or near patella
• Aggravated by walking up down stairs, squatting
  or prolonged sitting
• No pain during activity - pain follows activity
• Crepitus
• Swelling
• Positive compression, shrug and/or apprehension
  tests

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Treatment

• R
• I
• C
• E
• NSAIDS

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Osgood - Schlatter Disease

• Involves the growing tibial tuberosity
• Adolescents, 8 - 15 years
• Bilateral
• Males gt Females
• Self-limited

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Clinical Features

• Local pain swelling over tibial tuberosity
• Pain with stair walking, exercise, squatting on
  kneww
• Lateral x-ray may reveal variable degrees of
  separation fragmentation of tibial epiphysis

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Treatment

• Remove stress on tendon
• Abstinence from physical activity

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Carpal Tunnel Syndrome

• Compression of medial nerve of wrist
• Associated with
• Hypothyroidism
• Gouty Arthritis
• Decreased B6

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Clinical Features

• Numbness/Tingling of long index fingers
• Tinels Sign Phalens Sign