The Health History

Common or Concerning Symptoms

■ Monoarticular or polyarticular joint pain

■ Inflammatory or infectious joint pain

■ Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, weakness

■ Joint pain with symptoms from other organ systems

Joint pain is a common complaint of patients seeking health care. The health history is especially important in guiding you to the correct assessment.

You may wish to begin with "Any pains in your back?" since backache is the See Table 15-1, Low Back Pain, most common and widespread disorder of the musculoskeletal system. Using p. 522. your usual interviewing style, get a clear picture of the problem, especially its location. Establish whether the pain is on midline, in the area of the vertebrae, or off the midline. If the pain radiates into the legs, ask about any associated numbness, tingling, or weakness.

Neck pain is also common, especially after trauma. Approach it in the same manner. For both neck and back pain, be especially alert for symptoms such as weakness, loss of sensation, or loss of bladder or bowel function.

To pursue other musculoskeletal disorders, ask "Do you have any pains in your joints?" If yes, you will need to determine whether the pain is localized or widespread, acute or chronic, inflammatory or noninflammatory.

Joint pain may be localized, diffuse, or systemic. Ask the patient to point to the pain. If the joint pain is localized and involves only one joint, it is monoarticular. Pain originating in the small joints of the hands and feet is more sharply localized than that from the larger joints. Pain from the hip joint is especially deceptive. Although it is typically felt in the groin or buttock, it is sometimes felt in the anterior thigh or partly or solely in the knee.

More diffuse joint pain may be polyarticular, involving several joints. Ask whether the pain involves one joint or several joints. If polyarticular, what is the pattern of involvement . . . migrating from joint to joint or steadily spreading from one joint to multiple joint involvement? Is the involvement symmetric, affecting similar joints on both sides of the body?

Note that joint pain may also be nonarticular, involving bones, muscles, and tissues around the joint such as the tendons, bursae, or even overlying skin. Generalized "aches and pains" are called myalgias if in muscles and arthralgias if there is pain but no evidence of arthritis.

Assess the timing, quality, and severity of the joint symptoms. Timing is especially important. Did the pain or discomfort develop rapidly over the course of a few hours or insidiously over weeks or even months? Has the pain progressed slowly or fluctuated, with periods of improvement and worsening? How long has the pain lasted? What is it like over the course of a day? . . . In the morning? . . . As the day wears on?

If more rapid in onset, how did the pain arise? Was there an acute injury or overuse from repetitive motion of the same part of the body? If the pain comes from trauma, what was the mechanism of injury or the series of events that caused the joint pain? Further, what aggravates or relieves the pain? What are the effects of exercise, rest, and treatment?

Causes of midline back pain include musculoskeletal strain, vertebral collapse, disc herniation, or spinal cord metastases. Pain off the midline may arise from sacroiliitis, trochanteric bursitis, sciatica, or arthritis in the hips.

Motor or sensory deficits, loss of bladder or bowel function in spinal cord compression at S2-S4

Pain in one joint suggests trauma, monoarticular arthritis, possible tendinitis, or bursitis. Hip pain near the greater trochanter suggests trochanteric bursitis.

Migratory pattern of spread in rheumatic fever or gonococcal arthritis; progressive additive pattern with symmetric involvement typically in rheumatoid arthritis

Problems in tissues around joints include inflammation of bursae (bursitis), tendons (tendinitis), or tendon sheaths (tenosynovitis); also sprains from stretching or tearing of ligaments

Severe pain of rapid onset in a swollen joint in the absence of trauma seen in acute septic arthritis or gout. In children consider osteomyelitis in bone contiguous to a joint.

See Table 15-3, Patterns of Pain In and Around the Joints, pp. 524-525.

Try to determine if the problem is inflammatory or noninflammatory. Is there tenderness, warmth, or redness? These features are best assessed on examination, but patients can sometimes guide you to points of tenderness. Ask about systemic symptoms such as fever or chills.

Additional symptoms can help you decide if the pain is articular in origin, such as swelling, stiffness, or decreased range of motion. Localize any swelling as accurately as possible. If stiffness is present, it may be difficult to assess because people use the term differently. In the context of musculoskeletal problems, stiffness refers to a perceived tightness or resistance to movement, the opposite of feeling limber. It is often associated with discomfort or pain. If the patient does not report stiffness spontaneously, ask about it and try to calculate its duration. Find out when the patient gets up in the morning and when the joints feel the most limber. Healthy people experience stiffness and muscular soreness after unusually strenuous muscular exertion; such symptoms tend to peak around the second day after exertion.

To assess limitations of motion, ask about changes in level of activity because of problems with the involved joint. When relevant, inquire specifically about the patient's ability to walk, stand, lean over, sit, sit up, rise from a sitting position, climb, pinch, grasp, turn a page, open a door handle or jar, and care for bodily needs such as combing hair, brushing teeth, eating, dressing, and bathing.

Finally, some joint problems have systemic features such as fever, chills, rash, anorexia, weight loss, and weakness.

Other joint disorders may be linked to organ systems outside the musculoskeletal system. Symptoms elsewhere in the body can give important clues to these conditions. Be alert to such symptoms as:

■ Skin conditions

A butterfly rash on the cheeks

The scaly rash and pitted nails of psoriasis

A few papules, pustules, or vesicles on reddened bases, located on the distal extremities

An expanding erythematous patch early in an illness

Hives

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

Fever, chills, warmth, redness in septic arthritis; also consider gout or possible rheumatic fever

Pain, swelling, loss of active and passive motion, "locking," deformity in articular joint pain; loss of active but not passive motion, tenderness outside the joint, absence of deformity often in nonarticular pain

Stiffness and limited motion after inactivity, sometimes called gelling, in degenerative joint disease but usually lasts only a few minutes; stiffness lasting >30 minutes in rheumatoid arthritis and other inflammatory arthritides Stiffness also with fibromyalgia and polymyalgia rheumatica (PMR)

Generalized symptoms are common in rheumatoid arthritis, systemic lupus erythematosus (SLE), PMR, and other inflammatory arthritides. High fever and chills suggest an infectious cause.

Systemic lupus erythematosus Psoriatic arthritis Gonococcal arthritis

Lyme disease

Serum sickness, drug reaction

Reiter's syndrome, which also includes arthritis, urethritis, and ureitis

Arthritis of rubella

Hypertrophic osteoarthropathy

Reiter's syndrome, Behcet's syndrome

Acute rheumatic fever or gonococcal arthritis

Arthritis with ulcerative colitis, regional enteritis, scleroderma

Reiter's syndrome or possibly gonococcal arthritis

Lyme disease with central nervous system involvement

Important Topics for Health Promotion and Counseling

■ Balanced nutrition, exercise, appropriate weight

■ Lifting and the biomechanics of the back

■ Risk factor screening and prevention of falls

■ Counseling about prevention and treatment of osteoporosis

Maintaining the integrity of the musculoskeletal system brings many features of daily life into play—balanced nutrition, regular exercise, appropriate weight. As shown in this chapter, each joint has its specific vulnerabilities to trauma and wear. Care with lifting, avoidance of falls, household safety measures, and, for selected postmenopausal women, hormone replacement therapy help to protect and preserve well-functioning muscles and joints.

The habits of a healthy lifestyle convey direct benefit to the skeleton. Good nutrition supplies calcium needed for bone mineralization and bone density. Exercise appears to maintain and possibly increase bone mass, in addition to improving outlook and management of stress. Weight appropriate to height and body frame reduces excess mechanical wear on weight-bearing joints such as hips and knees. (For further discussion of these topics, see pp. 59-62.)

One of the most vulnerable parts of the skeleton is the low back, especially L5-S1, where the sacral vertebrae make a sharp posterior angle. More than 80% of the population experiences low back pain at least once in a lifetime. Usually symptoms are short lived, but there is a pattern of recurrence in 30%

The maculopapular rash of rubella Clubbing of the fingernails (see p. 110)

■ Red, burning, and itchy eyes (conjunctivitis)

■ Preceding sore throat

■ Diarrhea, abdominal pain, cramping

■ Symptoms of urethritis

■ Mental status change, facial or other weakness, stiff neck.

to 60% of individuals when onset is work related. Exercises to strengthen the low back, especially in flexion and extension, are often recommended (although studies have not consistently demonstrated a reduction in sick days from work). Alternatively, general fitness exercises appear equally effective. Education on lifting strategies, posture, and the biomechanics of injury is prudent for patients doing repetitive lifting such as nurses, heavy-machinery operators, and construction workers.

Among elderly persons in the United States, falls exact a heavy toil in morbidity and mortality. They are the leading cause of nonfatal injuries and account for a dramatic rise in death rates after age 65, increasing from ~5/100,000 in the general population to ~10/100,000 between the ages of 65 and 74 to ~147/100,000 after age 85.* Approximately 5% of falls result in fractures, usually of the wrist, hip, pelvis, or femur. Risk factors are both cognitive and physiological, including unstable gait, imbalanced posture, reduced strength, cognitive loss as in dementia, deficits in vision and proprioception, and osteoporosis. Poor lighting, stairs, chairs at awkward heights, slippery or irregular surfaces, and ill-fitting shoes are environmental dangers that can often be corrected. Clinicians should work with patients and families to help modify such risks whenever possible. Medications affecting balance, especially benzodiazepines, vasodilators, and diuretics, should be scrutinized. Home health assessments have proven useful in reducing environmental hazards, as have exercise programs to improve patient balance and strength.

Finally, it is important to counsel selected postmenopausal women about hormone replacement therapy and osteoporosis, defined as bone density >2.5 standard deviations below normal bone mass in young women.t Bone density reflects the interaction between bone mass (highest in the second decade), new bone formation, and bone resorption. A 10% drop in bone mineral density, equivalent to one standard deviation, is associated with a 20% increase in risk of fracture. Most fractures in patients over age 45 are attributable to post-menopausal osteoporosis. The decline in bone mass begins in the third decade and then accelerates in early menopause, especially in the trabecular bone of the vertebrae. At highest risk are women of Caucasian origin, slender build, or prior history of bilateral oophorectomy before menopause.

A number of agents inhibit bone resorption—calcium, vitamin D, calcitonin, bisphosphonates, and estrogen—but consensus on several clinical management decisions has yet to emerge. Criteria are unclear for identifying those women at menopause at greatest risk of bone loss and fractures one to two decades later. In addition, guidelines for tailoring dosage of medication to level of bone density have yet to be determined. Estrogen therapy appears to prevent vertebral trabecular bone resorption, and is most beneficial when started near menopause. Lifetime use is recommended because bone loss

*U.S. Preventive Services Task Force: "Counseling to Prevent Household and Recreational Injuries," In Guide to Clinical Preventive Services. Baltimore, Williams & Wilkins, pp. 659-685, 1996. tU.S. Preventive Services Task Force: In Guide to Clinical Preventive Services. Baltimore, Williams & Wilkins, pp. 509-516, 1996.

resumes once therapy is discontinued. Although hormone replacement protects against osteoporosis and possibly cardiovascular disease, use of estrogen must be weighed carefully in each patient against risk of breast cancer, endometrial cancer (risk is decreased by progesterone), and thrombosis. Cognitive, environmental, and other physiologic risk factors for falls and fractures should also be addressed.

Preview: Recording the Examination— The Musculoskeletal System

The examples below contain phrases appropriate for most write-ups. Unfamiliar terms are explained in the next section, Techniques of Examination. Note that use of the anatomic terms specific to the structure and function of individual joint problems makes your write-up of musculoskeletal findings more meaningful and informative.

"Good range of motion in all joints. No evidence of swelling or deformity."

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