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Advanced Health Assessment

Advanced Health Assessment. Heather Hull, ARNP, PNP. Musculoskeletal System. Primary Functions. Provides structure for soft tissues Protects vital organs Storage place for minerals Produces blood cells Provides stability & mobility for physical activity. Development of M-S System.

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Advanced Health Assessment

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  1. Advanced Health Assessment • Heather Hull, ARNP, PNP

  2. Musculoskeletal System

  3. Primary Functions • Provides structure for soft tissues • Protects vital organs • Storage place for minerals • Produces blood cells • Provides stability & mobility for physical activity

  4. Development of M-S System • Fetal: Cartilage calcifies & becomes bone • Childhood: Bone increases in length via epiphyses • Increase in diameter • New bone tissue around bone shaft • Ligaments stronger than bone until puberty

  5. Development of M-S System • Bone growth completed about age 20 • Peak bone mass around age 35 • Aging results in Fibrosis of connective tissue with aging: • Increased collagen • Decreased water content

  6. Aging • Tendons become less elastic • Decreased reaction time & ROM • Increased bone resorption • Decreased bone density • Deterioration of cartilage around joints

  7. Common M-S Problems • Systemic • RA, Lupus & Polymyositis • Local • Lumbar strain • Tennis elbow

  8. Facts • 1 of 7 persons suffer from some type of M-S disorder • Cost 60 billion annually • Ranks second for reasons for visits to medical office

  9. Structure • Bone • Bursae • Muscles • Ligaments • Tendons • Cartilege • Joints

  10. Anatomical References • Medial: ulnar & tibial • Lateral: radial & fibular • Joint Motion:Shoulder • abduction - adduction • flexion - extension • internal & external rotation

  11. History Questions • Employment, Exercise,Weight, Nutrition, Cigarette use, Medications • PMH: Trauma to nerves or soft tissues, fractures, viral illness, chronic illness, breast implants • FH: Congenital deformities, scoliosis, back problems, arthritis

  12. Common Symptoms • Pain • Weakness • Deformity • Limitation of movement • Stiffness • Joint clicking

  13. Assessment • Inspection • Palpation • Passive & Active ROM • Muscle Strength • Integrated Function • Gait • Spine

  14. Joint Pain • Inflammation Present: • Yes: RA, SLE • No: Osteoarthritis • Number of Joints Involved: • Monoarticular - Gout, Trauma, Septic Arthritis, Lyme Disease • Polyarticular - RA, SLE

  15. Joint Pain: Site of Involvement • Distal phalangeal - Osteoarthritis • Metacarpal phalangeal, wrists - RA, SLE • First metatarsal phalangeal - Gout, Osteoarthritis

  16. Osteoarthritis • Affects 1/4 or population • Degeneration of articular cartilage • Weightbearing & distal finger joints • Pain worsens with exercise • Morning stiffness or immobility • Heberdon’s nodes

  17. Rheumatoid Arthritis • Chronic inflammatory condition • Insidious onset over weeks to months • Fatigue, malaise, morning stiffness • Swelling of joints, polyarticular, PIP, MCP joints commonly affected, symmetrical movement • ROM may be limited, tenderness of joints • Lab: RF, Low H&H, ANA

  18. Low Back Pain • Disables 5.4 million Americans • Lifetime prevalence 60-90%

  19. Risk Facators • Repetative Lifting • Exposure to vibration • Cigarette Smoking • Osteoporosis - Spinal Stenosis • Obesity • Lack of Exercise • Increased Age

  20. Differential Diagnosis • Acute lumbar-sacral sprain • Postural backache • Lumbar disk syndrome • Osteoarthritis • Irritable bowel syndrome

  21. Differential Diagnosis • Urinary Disorders • Gynecological disorders • Ankylosing spondylitis • Tumors

  22. Examination • Inspection • Palpation • Passive & Active ROM • Flexion • Extension • Lateral • Rotation

  23. Examination • Heel - Toe Walking • Deep tendon reflexes • Motor strength • Sensation • Distracted SLR

  24. Examination • In Supine position • SLR • Hip - ROM • Sacroiliac joints • Hip abduction

  25. Lumbar Disc Syndrome • With repetative trauma: progressive degeneration of nucleus pulposus leading to protrustion or complete extrusion of portion of disc contents into neural canal. • 95% at 4 & 5 spaces • Most common between 3rd & 4th decades

  26. Clinical Features • Low back pain • Restriction of back motion • Radicular pain • Paresthesias • Local tenderness

  27. Acute Lumbar-Sacral Strain • Related to muscular, ligaments, or facial strain secondary to specific trauma or continuous mechanical stress • Most common in age 20 - 40 • Obesity & lack of exercise

  28. Clinical Features • Low back pain • Muscle spasm • Local tenderness or swelling • Neurologic exam negative

  29. Treatment • Bedrest • Ice - 24 hours • Heat - dry or moist • NSAIDS • Low back exercises • May need to add a muscle relaxant

  30. Cauda Equina • Massive midline protrusion • Medical emergency • Presentation: weakness to legs, urinary changes, impotence, loss of sphincter tone & saddle anesthesia

  31. Knee • Largest joint in body • No intrinsic stability, depends on ligaments, muscles, menisci & capsule for support

  32. Knee • Medial collateral ligament • Lateral collateral ligament • Anterior cruciate ligament • Posterior cruciate ligament • Quadriceps • Hamstrings • Meniscus

  33. Knee Pain - History • Position of leg at time of injury • Popping? • Slepping out of joint? • Swelling? • Stiffness? • Loss of function?

  34. Examination • Inspection • Palpation • ROM • Stability Testing

  35. Examination • Lachman • Posterior drawer • Valgus & varus stress • McMurry

  36. Examination • Apley compression • Compression • Shrug • Apprehension

  37. Injuries to Meniscus • Normal rotation of tibia is forcibly prevented as knee is flexed or extended • Simple twisting injury to knee can tear meniscus • Medial meniscus injuries 10 X more common that lateral meniscus injuries

  38. Clinical Features • Knee pain - well localized • Swelling - gradual • Locking of knee • Popping or tearing

  39. Clinical Features • Walking up & down stairs difficult • Joint effusion • Limited ROM • Positive McMurray • Normal X-ray

  40. Treatment • Rest • Immobilization of knee • Ice • Elevation • ROM - quadriceps strengthening exercises • NSAIDS • Possible surgery

  41. Lesions of Ligaments • Forceful stress against knee - abduction • Ability to bear weight is lost • Immediate swelling • Popping or tearing • Positive Lachman or Posterior Drawer

  42. Treatment: Grade I or II • Protection • Rest • Ice • Compression • Elevation • Support • NSAIDS

  43. Treatment: Grade III • Orthopedic Consultation

  44. Anterior Knee Pain • Seen in adolescents and young adults • Athletes • Irregular pattern of movement of patella • Over-use type of syndrome

  45. Clinical Features • Pain beneath or near patella • Aggravated by walking up & down stairs, squatting or prolonged sitting • No pain during activity - pain follows activity • Crepitus • Swelling • Positive compression, shrug and/or apprehension tests

  46. Treatment • R • I • C • E • NSAIDS

  47. Osgood - Schlatter Disease • Involves the growing tibial tuberosity • Adolescents, 8 - 15 years • Bilateral • Males > Females • Self-limited

  48. Clinical Features • Local pain & swelling over tibial tuberosity • Pain with stair walking, exercise, squatting on kneww • Lateral x-ray may reveal variable degrees of separation & fragmentation of tibial epiphysis

  49. Treatment • Remove stress on tendon • Abstinence from physical activity

  50. Carpal Tunnel Syndrome • Compression of medial nerve of wrist • Associated with • Hypothyroidism • Gouty Arthritis • Decreased B6

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