ANSWER
A Patient’s History of Musculoskeletal Disease
It is critical to take an accurate and comprehensive history of a patient’s musculoskeletal symptoms to make the correct diagnosis. This history must include a clear understanding of what the patient means by the symptoms described. The physician must obtain a detailed account of symptom onset, location, patterns of progression, and severity, as well as exacerbating and alleviating factors and associated symptoms. The relationship between symptoms and psychosocial stressors is critical and should be established. The impact of the symptoms on all aspects of the patient’s functioning must be assessed to guide therapy.
The effects of current or previous therapy on the course of the illness can aid in understanding current symptoms. An anti-inflammatory or glucocorticoid response may indicate an inflammatory origin. Such responses, however, are not limited to inflammatory rheumatic diseases and must be considered in the context of the entire history and physical examination. The physician must evaluate compliance with musculoskeletal disease therapies. Noncompliance with the recommended treatment must be distinguished from treatment failure as the cause of the patient’s failure to improve.
The patient provides verbal and nonverbal cues to the nature of the illness and how the patient has responded to it while the physician is taking the patient’s history. Patients with early rheumatoid arthritis should keep their hands flexed to reduce intra-articular pressure and pain. Some patients may appear overly concerned, while others may appear unconcerned about their symptoms. To begin effective treatment, the physician must appreciate the patient’s understanding of the illness and attitudes toward it.
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Pain
Pain is the most common symptom that brings a musculoskeletal disease patient to the doctor. Pain is a subjective hurting sensation or experience that can be described in various ways, often as actual or perceived physical damage. Pain is a complex sensation to define, qualify, and quantify. Emotional factors and previous experiences may influence the patient’s pain.
The nature of the pain is usually best defined early in the interview because it can help categorize the patient’s complaints. Aching in a joint indicates an arthritic condition, whereas “burning” or “numbness” in an extremity may indicate neuropathy. When the patient is otherwise able to function, descriptions of pain as “excruciating” or “intolerable” indicate that emotional or psychosocial factors contribute to or exacerbate the symptoms.
The physician must elicit the patient’s pain distribution and determine whether it corresponds to anatomic structures. Patients describe their pain locations in terms of body part names, but the terms are frequently used anatomically incorrectly. Patients frequently complain of “hip” pain when they mean “low back,” “buttock,” or “thigh” pain. The interviewer should try to clarify this complaint by asking the patient to point to the source of the pain with one finger. A localized pain in the distribution of a joint or joints most likely indicates an articular disorder. Pain can be localized to bursae, tendons, ligaments, or nerves, indicating a problem with these structures.
In contrast to superficial structures, deep structures frequently give rise to poorly localizing pain. Similarly, pain from small, peripheral joints is frequently more focal than from large, proximal joints like the shoulders and hips. Pain that is widespread, ill-defined, and does not follow anatomical distributions usually indicates a chronic pain syndrome, such as fibromyalgia or psychiatric disease.
The level of pain should be determined. A common approach is to ask the patient to rate their level of pain on a scale of 0 (no pain) to 10 (extreme pain) (very severe pain). Measuring pain on a visual analogue scale by having the patient mark the severity of pain over the previous week on a 100-mm line can help monitor disease activity in inflammatory arthritis. Validated instruments, such as the McGill Pain Questionnaire, employ similar scales.
The doctor must figure out what causes and relieves pain. Joint pain that occurs at rest but worsens with movement indicates an inflammatory process, whereas pain that occurs primarily with activity and is relieved by rest usually indicates a mechanical disorder, such as degenerative arthritis. The timing of pain symptoms during the day and night is also essential, as discussed in the following section.
QUESTION
You will perform a history of musculoskeletal problems on the client below. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided. Your subjective portion of the documentation should briefly describe your “client”. In terms of your objective findings, remember to only record what you have assessed. Do not make a diagnosis or state the cause of a finding. You are not coming to any conclusions within your documentation.
You will submit this documentation as a Word document to the dropbox provided.