Unit IV

Question 1

What is the leading primary dx of office visits in the US?

Answer 1

Musculoskeletal complaints

Question 2

Number of MSK d/o (with %)

Answer 2

93 million visits

10% of all ambulatory care visits

Question 3

Arthritis - Stats

Answer 3

affects 1 in 5 Americans

22% of the adult population

leading cause of disability

Question 4

Spinal d/o - Stats

Answer 4

4th highest dx group for office visits

LBP is one of the top 20 reasons for office visits

Question 5

Key factors in evaluation of MSK d/o

Answer 5

Articular vs. extra-articular

Acute (< 6wk) vs. chronic (>12 wk)

Inflammatory vs. Non-inflammatory

Localized (monoarticular) vs. diffuse (polyarticular)

Question 6

Structures of a Joint

Answer 6

Articular structures

Extra-articular structures

Question 7

Articular structures

Answer 7

Joint Capsule
Articular cartilage
synovium
synovial fluid
Intra-articular ligs
Juxta-articular bone

Question 8

Extra-articular Structures

Answer 8

Ligs
tendons
bursae
muscle
fascia
bone
nerve
overlying skin

Question 9

What causes is a major potential cause of joint pain?

Answer 9

age

Question 10

Types of joints

Answer 10

synovial
cartilaginous
fibrous

Question 11

synovial

Answer 11

Bones covered by articular cartilage

Synovial membrane lines the synovial cavity and secretes a small amount of viscous lubricating fluid

Fibrous joint capsule surrounds the synovial membrane

Freely movable

Example - elbow, shoulder

Question 12

Types of Synovial Joints

Answer 12

Spheroidal (ball & socket)

Hinge

Condylar

Question 13

Cartilaginous

Answer 13

Between pubic symphysis and vertebrae (slightly movable)

Fibrocartilaginous discs separate the bony surfaces

Example - vertebral bodies of the spine

Question 14

fibrous

Answer 14

Almost in direct contact

immovable

Example - sutures of the skull

Question 15

Spheroidal

Answer 15

Ball & socket

Convex surface in concave cavity

Motion - flexion, extension, abduction, adduction, rotation, curcumduction (allows a wide rotary movement)

Example - Shoulder, hip

Question 16

Hinge

Answer 16

Flat, planar, or slightly curved

Motion in one plane; flexion, extension; gliding motion on a single plane

Example - Interphalangeal joints of the hand & foot; elbows

Question 17

Condylar

Answer 17

Convex or concave (condyles)

Movement of two articulating surfaces not dissociable

Knee; TMJ

Question 18

Bursae

Answer 18

Roughly disc-shaped synovial sacs

Allow adjacent muscles or muscles and tendons to glide over each other during movement

Question 19

Bursae - Examples

Answer 19

prepatellar bursa

Hip bursa

subacromial bursa of the shoulder

Question 20

Common complaints

Answer 20

LBP

Neck Pain

Joint pain with associated constitutional symptoms & systemic manifestations from other organ systems

Question 21

Joint pain - onset

Answer 21

Is the pain acute or chronic?

Was there an injury?
Clarify and record the mechanism of injury - esp. if trauma

Question 22

Joint Pain - Location

Answer 22

Localized, diffuse or systemic

“point to the pain”

Does it involve joints or tissues?

Question 23

monoarticular

Answer 23

one joint

Question 24

polyarticular

Answer 24

diffuse or several joints

Question 25

nonarticular

Answer 25

involving muscles, bones & tissues around the joint

Question 26

joint pain - duration

Answer 26

``` When does the pain occur? How long have you had the pain? Acute or chronic Did it develop rapidly or insidiously? Has the pain progressed or fluctuated? ```

Question 27

Joint Pain - Direction

Answer 27

Does the pain radiate - down arm/legs? Numbness? Tingling?

Question 28

Joint Pain - Determine the severity of the pain

Answer 28

``` Pain right now? Pain at its worst Pain at its bets Pain with activity? Pain with Exercise? Pain with tx? What is it like over the course of the day? What is the the pain like in the morning? How is the pain as the day wears on? ```

Question 29

Joint Pain - What makes it worse

Answer 29

Rest Activity stairs hills

Question 30

Joint pain - What makes it better

Answer 30

``` Ice Heat Rest Activity Medication ```

Question 31

Joint pain - Timing

Answer 31

``` When does the pain occur? Morning? Getting in a car? Lifting weight? How long does it last? ```

Question 32

Joint pain - Quality

Answer 32

``` ADL? Change in activities? Do joints "lock-up" or "catch"? Occupation? Inflammatory or non-inflammatory ```

Question 33

Cardinal signs of inflammation

Answer 33

``` Swelling Warmth Redness Pain Pattern of stiffness Hx of arthritis ```

Question 34

Types of Arthritis

Answer 34

Rheumatoid arthritis Osteoarthritis Gouty Arthritis

Question 35

RA - definition

Answer 35

Chronic inflammation of synovial membranes with erosion of bones

Question 36

OA - Affected areas

Answer 36

``` knees hips DIP PIP Wrists - 1st CMC Joint Joints injured or dzed ```

Question 37

RA - Affected Joints

Answer 37

``` PIP MCP MTP Wrists knees elbows ankles ```

Question 38

Gouty Arthritis - affected joints

Answer 38

Acute - 1st MTP (base of big toe), Instep or dorsum of feet, ankles, knees & elbows Chronic - feet, ankles, wrists, fingers & elbows

Question 39

OA - Definition

Answer 39

Degeneration & progressive loss of cartilage

Question 40

Gouty - Definition

Answer 40

Reaction to accumulation or presence of sodium urate acute or chronic

Question 41

RA - symptoms

Answer 41

``` Symmetrically additive Insidious Chronic with remissions/exacerbation Frequent swelling Sub-Q nodules Tender Often warm Seldom red Stiffness prominent for an hour or more in AM or after inactivity Limits motion Weakness Fatigue Weight Loss Low fever ```

Question 42

OA - symptoms

Answer 42

``` One joint or additive Insidious Slowly progressive, Temporary exacerbation Small effusions, possible Bony hypertrophy Possibly tender Seldom warm Rarely red stiffness is frequent but brief (in AM) Limited motion ```

Question 43

Gouty - Acute Symptoms

Answer 43

``` Early attacks one joint Sudden, occasional isolated attacks lasting up to 2 weeks Swelling Very tender Hot & red No stiffness evidentP Limited motion Possible fever ```

Question 44

Gouty - Chronic Symptoms

Answer 44

``` Additive Gradual with repeated attacks Tophi in joints, bursa & sub-Q Warmth Tenderness Redness Stiffness Limited motion Possible fever Symptoms of Renal stones & failure ```

Question 45

Systemic Symptoms with Joint Pain

Answer 45

``` Fever Chills Rash anorexia weight loss weakness ```

Question 46

SLE

Answer 46

Butterfly rash on cheeks

Question 47

Psoriatic arthritis

Answer 47

Scaly rash Pitted nails

Question 48

Gonococcal Arthritis

Answer 48

Few papules Pustules or vesicles on reddened bases on distal extremities

Question 49

Lyme Dz

Answer 49

Expanding erythematous patch early in illness

Question 50

Serum sickness

Answer 50

Hives

Question 51

Drug reaction

Answer 51

Hives

Question 52

Reiter's syndrome

Answer 52

Erosions or scale on the penis and crusted scaling papules on the soles and palms

Question 53

hypertrophic osteoarthropathy

Answer 53

Clubbing of the fingernails

Question 54

Rubella

Answer 54

Maculopapular rash

Question 55

Conjuctivitis

Answer 55

Reiter's syndrome Behcet's syndrome

Question 56

Sore throat

Answer 56

Acute rheumatic fever Gonococcal arthritis

Question 57

Diarrhea Abdominal Pain Cramping

Answer 57

Arthritis with UC Regional enteritis Scleroderma

Question 58

Urethritis

Answer 58

Reiter's syndrome Gonococcal Arthritis

Question 59

Mental status changes Facial or other weakness Stiff neck

Answer 59

Lyme dz with CNS involvement

Question 60

Articular symptoms

Answer 60

``` pain possible swelling stiffness Limited AROM Limited PROM Deformity Locking ```

Question 61

Non-Articular

Answer 61

``` pain out of joint possible swelling possible stiffness Limited AROM No Limited PROM No Deformity No Locking ```

Question 62

Muscles

Answer 62

``` Pain Cramping Fever/Chills/Flu Weakness Atrophy ```

Question 63

LBP / Neck PAin

Answer 63

``` Is there a hx of trauma? Establish location (midline or off midline) Radiate to arms/legs? Numbness Tingling Bladder/bowel dysfunction? Weakness ```

Question 64

LBP Red Flags

Answer 64

``` >50 yo / <20 yo Hx of ca unexplained weightloss, fever, or decline in health Pain >1m & not responding to tx Pain at rest/night Hx of IV drug use/ addiction/ immunosuppression Active infection / HIV Long-term steroid use Saddle anesthesaia bladder/bowel incontinence Neuro symptoms Progressive neuro deficit ```

Question 65

Mechanical LBP - Patterns

Answer 65

``` Acute Often Recurrent Chronic Aching pain Possibly radiating posterior thigh aggravated by moving/lifting/twisting ```

Question 66

Mechanical LBP - Possible Physical Signs

Answer 66

``` local tenderness spasm pain with movement loss of lumbar lordosis no sensory or motor loss no reflex abnormality ```

Question 67

Radicular LBP - Patterns

Answer 67

``` Sciatic pain Radiates down one or both legs Below knee Dermatomal distribution Worsened by spinal movement ```

Question 68

Radicular LBP - Possible Physical Signs

Answer 68

``` Pain with straight leg raise Tenderness of sciatic N. Loss of sensation in dermatomal distribution Local weakness Atrophy Decreased/absent ankle jerk ```

Question 69

Spinal Stenosis - Patterns

Answer 69

Pseudocladication in back of legs, worsened with walking | Improving with flexing spine

Question 70

Spinal Steosis - Physical Signs

Answer 70

Posture may be flexed forward Motor weakness & hyporeflexia in LE

Question 71

Chronic Persistent Low Back Stiffness - physical signs

Answer 71

Loss of normal lumbar lordosis Muscle spasm Limitation or anterior & lateral flexion Flexion and immobility of spine

Question 72

Aching nocturnal back pain - physical signs

Answer 72

Variable Local bone tenderness

Question 73

Back pain referred from the pelvis or abdomen - patterns

Answer 73

Deep, aching pain Levels varies with source

Question 74

Back pain referred from the pelvis or abdomen - physical signs

Answer 74

Spinal movements not painful ROM not affected Look for signs of primary d/o