History Taking for Musculoskeletal Disorders Flashcards
what are the main questions to ask when taking history to identity the cause of MSK disorders?
The aim of history taking is to identify the cause of the musculoskeletal (MSK) disorder
You ask the following question:
Which structures are involved?
Joints
Muscles
Supporting tissue e.g. tendon
Bone
Time course? (chronic or acute)
Are other organ systems involved?
Was there a precipitant to the development of symptoms e.g., preceding infection of trauma?
Cover Past medical history, treatment history, family history and social history
What is the impact of the problem on the patient?
What is the patients expectations in terms of management and outcome?
what are the 3 screening questions to identify if a patient has MSK problems?
- Do you have any pain/stiffness in your muscles, joints or backs?
- Can you dress yourself completely without any help?
- Focuses on fine motor function and the upper limb function - Can you walk up and down stairs without any difficulty?
- Focuses on the lower limb function and large joints e.g. knees and hips
- If patient answers no to all three questions it is unlikely, they have MSK problems.
How do MSK problems present?
(1 or more these symptoms)
- Pain
- Stiffness/swelling
- Loss of function
what are the 4 things to consider when looking at MSK pain?
Site – which joints are affected?
Distribution – symmetrical or asymmetrical?
Onset – timing (acute or chronic) and any precipitating factors
Nature of pain:
Quality of pain - throbbing pain, burning pain or electrical pain
Severity of pain (scale 0-10)
associated features
Any factors that relieve the pain
how would you determine the distribution of pain?
You would want to know how many joints are affected and if they are symmetrical to each other or symmetrical
1 joint = mono-articular problem
2-4 joints = oligo-articular
>4 = poly-articular
in image:
Left is symmetrical and poly-articular
Right is asymmetrical and oligoarticular
why would knowing which joints are affected be important?
Knowing what joints are affected is important in diagnosis as some joints are more likely to be effected by a certain conditions e.g:
E.g. Pain in the joint of the big toe is more likely to be cause by Gout than septic arthritis
Where pain at the kneecap is more likely to be cause by Septic arthritis than gout.
Symptoms of MSK problems e.g., Hot, red, tender, reduced movement can be mirrored by other MSK conditions so it is important to know which joints are affected
what does assessing onset, timing and precipitating factors help with?
Can help in identifying underling pathology
Fastest to slowest cause of joint problems are:
how does the nature of the pain tells us if the condition is Inflammatory or degenerative in origin?
name some specific pain types
Bone pain (due to malignancy in bone)
- Severe
- Localised to an area
- Disturbs sleep (keeps people up at night)
Peri-articular (pain originates in structures surrounding the joint (eg, tendons, ligaments, bursae, muscles)) e.g. tendonitis
- Diffuse
- Not well-localised (wide sweeping motion to show area of pain used)
- Around joint
what is radiation of pain?
This is when the pain starts in one place and travels to another (usually by travelling along the path of a nerve)
E.g. sciatica
Neck pain radiating to fingers
Hip pain radiating to knee
what are other things to think about when looking at MSK disorders?
Could the patient be describing muscle pain? (myalgia)
Instability of joint e.g., if knee locks or gives way (degenerative/trauma)
Pain gets worse against resistance e.g. picking up heavy stuff (tendinitis)
Weakness in joints and limbs (Is this due to pain or is the weakness independent of pain)
Neurological symptoms?
Neuropathic pain – shooting/electric shock/burning pain
Paraesthesia (tingling)
Numbness
what are specific questions for trauma?
When and how did incident occur?
What happened exactly?
How much force was involved?
Has the bone or joint been damaged before?
History of other trauma/fractures
Is their peripheral circulation intact?
Is the PNS and CNS intact?
From surgical aspect is patient fit for anaesthetic?
what associated features/systems would you review?
Many MSK conditions affect tissues outside the joint: extra-articular
E.g., skin rashes or lesions, hair (alopecia), mucosal membranes (ulcer on tongue), eyes (eye inflammation)
give examples of assessing deeper organ systems
Cardiovascular - Raynaud’s phenomenon?
Kidneys - Blood in urine
GIT - change in bowels?
Respiratory - shortness of breath or chest pain?
NS - tingling/numbness
what can past medical history tell us about MSK disorders?
this can aggravate or cause MSK problems
History of infections (precipitate symptoms)/ or travel?
Bowel symptoms? Skin disease (psoriasis)?
MSK problems can onset in childhood. Ask this
name some things that can be associated with arthritis
Undercooked chicken (associated with development of infection – food poisoning) causing inflammatory arthritis
Chlamdydia can cause reactive arthritis
Tics that live on deer can cause lime disease if bitten
what questions could you ask regarding social history?
Smoking/alcohol/other drugs?
Occupation and what this entails?
Home situation
Who they live with?
Who is dependent on them e.g. small child?
Adaptations in their home to help?
what questions could you ask regarding family history?
1st degree relatives with similar conditions?
Autoimmune diseases e.g. rheumatoid arthritis “hunt in packs”
Monogenic MSK conditions:
rare
inflammatory syndromes
have arthritis as a feature
Polygenic MSK problems:
majority of MSK condition
e.g., rheumatoid arthritis concordance
Monozygotic: 15%
Dizygotic: 4%
what could the impact of the problem be on patients?
Impact of problem
Limitation of activities they do?
Time off work?
Personal hygiene management? – dressing/washing themselves
Needing to use walking aids/other devices? E.g walking sticks or frames
Ask Psychological impact of MSK problem.
what info would treatment history provide you with?
What has been tried already e.g., prescriptions or OTC (painkillers)?
Non-medical treatments they are taking – physio therapy and acupuncture
If previous treatments have failed – why?
Inefficacy of drug
Adverse effects to drug
Non-compliance
MSK Could be related to the drugs patient is taking for other conditions?
E.g. statins cause myalgia
what are the 3 steps to take when classifying MSK disorders?
- Localised problems of joints/bones/periarticular structures (i.e. no or very little systemic involvement) e.g.
- Osteoarthritis
- Crystal arthritis (gout)
- Tendonitis or bursitis
- Bone tumours - Systemic conditions with prominent joint features – aetiology often unclear e.g.
- rheumatoid arthritis. - Non-rheumatological conditions which can affect the MSK system:
- Although symptoms are in MSK system the cause of symptoms are due to other disorders e.g.
- Bone pain due to Sickle cell disease
- Cancer metastasis to bone causing bone pain
- Vitamin D deficiency causing osteomalacia
what would this history suggest the patient has?
24-year-old with knees pain
Normally fit and well
Pretty active
Playing football, headed ball (scored a goal), landed “a bit funny”
Felt a “pop” in the knee
Suddenly very painful and difficult to move
Unable to walk, severe pain
Classic history for ACL rupture
what would this history suggest the patient has?
68-year-old
Retired shop assistant
2-year history of worsening pain in both knees
Pain killers help but don’t remove pain completely
Worse after a day of shopping
Struggles walking up and down stairs
Stiffens up after watching TV
Stiff in the morning for 10 minutes
Degenerative arthritis - OSTEOARTHRITIS
what would this history suggest the patient has?
25 year old
2 weeks of pain in left knee
Able to walk but painful, no injury
Knee swollen and stiff
Patient says it feels warm Stiff in the morning (until lunchtime)
Feeling generally unwell but managing to work
Had severe diarrhoea 4 weeks ago (? undercooked chicken kebab)
Reactive INFLAMMATORY ARTHRITIS
