L6 - STEP BY STEP GUIDE FOR MSK RECORD Flashcards
8 steps for good record
Patient info
Subjective exam
Objective exam
ICF
Health prognostic profile
PT diagnosis
Outcome measures
Treatment diary
Description of patient’s information part
- Name
- Surname
- Gender
- Age
- Profession
- Sport, hobbies (what activities & how often)
Steps of subjective exam
Present condition
Behavior of symptoms
HOPC
Prognostic profiling
Past medical history
Patient’s perspective
Index of suspicion
Development of diagnostic hypothesis
Parts & description of present condition
Reason for consultation
- Primary complaint: pain, stiffness, sense of sagging, heaviness, instability, weakness,
paresthesia, tingling, numbness & cramp
- Concomitant or associated complaints
Location of symptoms
- Allowing to consider among diagnostic hypothesis those pathologies / disorders referring
patient’s symptom to the indicated location
- Filling in body chart indicating:
o Location of main & secondary symptoms
o Severity
o Quality of symptoms
Severity: pain intensity
- Numerical Pain Rating Scale(NPRS): pain intensity from 0 to 10, where 0 = no pain & 10 =
maximum pain
- Visual Analog Scale(VAS): pain intensity on a 10 cm line with “no pain” & “worst possible pain”
at ends
Pain quality
- Examples of pain descriptors: deep, superficial, dull, sharp, shooting, electrical, pulsating,
burning….
- Is pain constant or intermittent?
- Constant pain could be a red flag
- Intermittent pain: mechanical, ON/OFF, movement or activity dependent pain
- Provides clues about structure / condition causing pain or symptoms
Description of behavior of symptoms
Aggravating factors
- What makes symptom worse?
- Need to stop activity?
- How long to get better? => Define SIN (severity)
Easing factors
- What do you do to feel better?
Description of HOPC
Onset
- Traumatic origin
o Knowing mechanism of onset allows to differentiate traumatic from no-atraumatic
pathologies
o In case of traumatic onset, knowing dynamic of trauma is helpful in developing diagnostic hypothesis & to screen for serious condition
- Sudden or gradual onset
o Investigate possible overload or influence of new activities
- Duration / start
o Knowing duration of pain / symptoms allows to know stage of pathology (recent, subacute or persistent) & to work out a prognosis
Symptoms progression & adopted strategies
- Change from onset
- Constant, improvement or worsened?
Knowing evolution of symptoms allows to hypothesize prognosis: if symptoms has improved compared to onset, condition probably in remission & will therefore have favorable prognosis compared to patient who report that symptom is stationary or worsened since its onset
- What have you done since onset?
Investigate strategies implemented by patient: rest, medication, other visits, imaging, previous treatment
24-hour behavior
- Variation during day
- More intense in morning, in afternoon or in evening
- Pain during night
- Pain prevents from sleeping
- Changing position wake you up? Can you go back to sleep?
Previous episodes
- Prior episode or first time
- What done in past to get better?
Investigating any previous episodes = useful profile prognosis & to investigate strategies implemented by patient, coping (+/-) as well as expectations about physiotherapy treatment
Description of prognostic profiling
- Relationship between listed symptoms
- Quality of sleep & average hours (=> persistent pain affects sleep)
- Beliefs (expectations, symptom causes, consequences)
- Lifestyle
- Smoking
- Alcohol
- Drugs
- Family situation (=> supportive or unsupportive family, unsupportive family = risk factor of persistent pain ➔ BLUE FLAG)
Description of past medical history
- Medical conditions or conditions of internist interest
o Investigate presence of risk factors that may increase incidence & prevalence of certain
MSK condition (CTS or Frozen shoulder with metabolic disorders: thyroid disease,
diabetes…)
o Investigate presence of clinical conditions that may influence patient’s prognosis
(depression, hypertension, obesity…)
o Investigate presence of clinical conditions that may be obstacle to certain treatment
strategies (cardiac patient…) - Family history
- Medications taken regularly or recently for management of problem (ex: long use of
corticosteroids => higher incidence of osteoporosis) - Specialist medical examination or advice from your general practitioner
- Imaging
- Major trauma
- Previous surgery
- Previous physiotherapy treatments
- Other MSK conditions
Description of patient’s perspective
Understand pain, easing pain, more strength, return training, …
Description of index of suspicion
- Serious condition
- Specific condition
- Non-specific condition + prognosis
- Red flags
o History of cancer, unjustified weight loss, fever, nausea, vomiting, night pain, smoking,
dizziness, saddle anesthesia, urinary retention, bilateral paresthesia, loss of strength…
- Risk factors
- Elements of emergency or urgency
Description of development of diagnostic hypothesis
- Dynamic & circular process starting from first contact with patient
- Structural or functional element considered in relation to symptoms
o Articular structures
o Myotendinous structures
o Neurological structures
o Pain mechanism - Make diagnostic hypotheses and define the supporting elements and considerations
Parts of objective exam
Plan objective exam
Structure objective exam
Description of plan of objective exam
- Choice of test to be administered must be consistent with diagnostic hypothesis
- Give priority to screening tests
- Determine test depending on patient’s SIN
- Planning
Description of structure of objective exam
Observation
- Patient’s movements & spontaneous gestures observed as soon as patient enters office: how
walk, undresses, how sits & how stand-up from chair
- Postural assessment in standing & sitting in frontal plane (anteriorly / posteriorly) & sagittal plane: observe any asymmetries, shifts, antalgic, attitudes
- Inspect: redness, cyanosis, wounds, scars, edema, moles, erythema, swelling
Functional demonstration / painful movement
- Ask to show painful or altered activity/ movement/ position
- Can be used as outcome measure
Active movement
- Assess movement, quality, quantity & pain
- May include combined movements, repetitive movements, maintained positions, addition of
overload, changes in speed
- Active movement reproduces familiar pain can be used as outcome measure
Passive movement
- Physiological (angular) movements:
o Regional movements
Segmental movements
Assess ROM, pain, end-feel, spasms
- Accessory movements
o Glide / slide
o Spin
o Compressions
o Tractions
Assess quantity & quality of movement, pain, end-feel, crepitus
Testing
- Palpation
o Tenderness of myofascial tissues
o Tissue texture & elasticity
o Sweating
o Temperature
o Muscle tone & trophism
o Oedema
- Provocative testing (report tests & results)
o Coded procedures for purpose of increasing or reducing probability of diagnostic
hypothesis
o Performed in isolation, process low diagnostic accuracy (cluster more informative)
o Current evidence challenges the clinical utility of most orthopedic tests
- Myotendinous testing
o Strength: dynamometer
o Endurance: assessment of ability to sustain activity over time
o Length: assessment of muscle extensibility
Monitor any familiar pain or deficits
- Neurodynamic testing
Heightened nerve mechanosensitive
o Upper limb neural test (ULNT 1, 2a, 2b, 3)
o Straight leg raises (SLR)
o Prone knee bent (PKB)
o Slump test
- Neurological examination
o Cranial nerves
o Upper motor neuron = Babinski test
o Somatosensation
o Muscle function
o Reflexes
Screening for neurological deficit (loss of function)
Part of ICF and description of each
Impairment
- Biological: imaging
- Functional/physiological: pain, stiffness, reduced ROM
- Psychological: measured prognostic factors
Activity limitations
- Difficulty in dressing
- Walking
- Doing housework
Participation restriction
- Restriction in jogging with friend
- Restriction in accompanying grandchildren to park
Environmental factors
- Living on second floor without lift (-) vs strong family support (+)
Personal factors
- Smoker
- Sedentary lifestyle
- Obese
- Hypertension
- Diabetic
