History & general exam

in MSK system

Dr. Zaid Jafar AlBachachy

2023
General history
• Similar to other medical histories in that you need to identify
Age
Chief complaint
History of present illness
Past medical & surgical history
General history
• Medications
NSAIDS
Steroids
Narcotics
• Other treatment for this injury
Injections
Bracing
Physiotherapy
Chiropractic care
• Allergies
Social history
• Occupation
• Working / retired
• Manual labor / Desk job
• Living situation
• Alone / spouse / other support
• Two-storey house / Apartment
• Ambulatory status
• How far can they walk
• Do they use a walker/cane
• Smoking/alcohol/drug use
Specifics to the HPI
Precipitating incidents
Trauma ( Macro-trauma )
Repetitive stress ( micro-trauma )
Is this a work-related injury?
Is there a lawsuit ongoing?
Specifics to the HPI
For MVAs
Driver/passenger
Belted/ non-belted
Location of impact and severity of crash ( required jaws of life, if
anyone, if anyone died in the crash, thrown from the car, etc)
Speed at impact
Position of the patient and the limb in question at impact
Specifics of the HPI
• For pain or presenting problem
1. Onset
2. Duration
3. Character
4. Course
5. Aggravating and relieving factors
6. Location
7. Radiation
8. Associated symptoms
Associated symptoms
• In addition to pain do they have ;
Clicking
Snapping
Catching
Locking
Sensation of giving way ( including prior falls or dislocations )
Swelling
Weakness
Stiffness
Generalized (Rh. Arthritis & Ankylosing spondylitis)
Localized to a particular joint
Aggravated & relieving factors of stiffness
How many joints involved
Is there locking of the joint ( mechanical block)
swelling
• Rapidly following trauma is hematoma or haemarthrosis
• Slowly is tissue inflammation or joint effusion
• If it is painful may due to inflammation
Temporality or timing
• Is it worse when they wake up in the morning?
• Does it gradually get worse over the course of the day?
• Does the pain wake up at night?
Red Flags
Pain at night or rest
Associated wt. loss and loss of appetite
Hx. Of cancer
Steroid use
Hx of trauma
Extreme age
Bowel or bladder symptoms
General consideration for examination
• When taking a history for an acute problem always inquire about the
MECHANISM OF INJURY, loss of Fxn., the onset of swelling (<24
hr.s), and initial treatment
• When taking a history for chronic problem always inquire about past
injuries, past treatments, effect on function, And current symptoms
General consideration for examination
• The MSK exam is all about anatomy

• Think of the underlying anatomy as you obtain the history and

examine the patient
General consideration for examination
The cardinal signs of musculoskeletal disease are:
Pain
Redness (erythema)
Swelling
Increased warmth
Deformity
Loss of function
General consideration for examination
• Always begin with inspection, palpation, and ROM., regardless of the
region you are examining (Look, Feel, Move)
• Specialized tests are often omitted unless a specific abnormality is
suspected
• A complete evaluation will include a focused neurological exam of the
affected area
Inspection
Look for scars, rashes, or other lesions like abrasions/open wounds.
Look for asymmetry, deformity, or atrophy
Always compare with the other side
Look for swelling
Look for erythema (redness)
Posture/position of the joint or limb
Percussion
• Typically, we don’t percuss things in orthopedics however the one
exception is nerves
• If tapping over a nerve causes pain or electric shock sensations, this is
called a Tinel’s sign
• Presents when nerves are compressed or irritated
• Also used to monitor nerve recovery after injury (in the form of an
“advancing’s Tinel’s sign)
Auscultation
• We don’t really listen to anything in orthopedic
palpation
Examine each major joint and muscle group in turn
Identify any areas of tenderness
Joint line
Tendinous insertions
Palpate for any crepitus
Identify any deformity
Always compare with the other side
palpation
Warm or cold including pulses
Fluctuation/ fluid collection
Compartments – soft or firm and painful
Sensation
ROM
Active ROM
Passive ROM
Active ROM
• Ask the patient to move each joint through a full ROM
• Note the degree and the type of any limitation (pain, weakness, etc)
• Note any increased ROM or instability
• Always compare with the other side
• Proceed to passive ROM if abnormalities found
Passive ROM
• Ask the pt. to relax and allow you to support the extremity to be
examined
• Gently move each joint through full ROM
• Note the degree and type (pain or mechanical) of any limitation
• If increased ROM is detected, perform special tests for instability as
appropriate
• Always compare with the other side
Vascular status
Pulses
• UL
Check the radial pulses on both sides
If the radial pulses is absent or weak, check the brachial pulses
• LL
Check the PT & DP pulses on both sides – if these pulses are absent or
weak, check the popliteal and femoral pulses
Vascular status
Capillary refill
• Press down firmly on the pt.’s finger or toenail so it blanches
• Release the pressure and observe how long it takes the nail bed to pink
up
• Capillary refill times greater than 2-3sec.s suggest peripheral vascular
disease, arterial blockage, heart failure, or shock
Thank you