Physical Examination

Chapter 1 Physical Examination


The diagnosis of disorders of the musculoskeletal system begins with compiling a complete history and performing a physical examination. The history is of special significance because physical findings are often minimal. Its importance cannot be overemphasized. Most musculoskeletal conditions should be able to be diagnosed by history and physical examination alone. Referral for elaborate laboratory or radiographic testing is usually unnecessary in the analysis of most orthopedic conditions, at least in the early stages.



History



BIRTH HISTORY


The history of the pediatric patient should include several important points. It should first be determined whether fetal movements were experienced by the mother during pregnancy. Absence or weakness of these movements by the fourth or fifth month of gestation may indicate neuromuscular disease in the newborn. Any maternal diabetes, toxemia, drug ingestion, fetal distress, or prematurity is noted.


The type of delivery should also be determined. This is important because certain disorders, such as congenital hip dysplasia, are more common with breech delivery.


The condition of the child at birth and immediately after delivery should be ascertained. It should be noted if the hospital stay of the baby was unusually prolonged or if the care was intensive. The presence of any jaundice, cyanosis, or difficulty with the delivery that might predispose the infant to brain damage is also recorded.


The physical and mental development of the child is then determined, and any deviation from normal progress is noted (Table 1-1).


Table 1-1 Normal Milestones*
























Age (mo) Milestone
1–2 Holds up chin
6–8 Sits alone
8–10 Stands with support
10–12 Walks with support
14 Walks without support
24 Ascends stairs one foot at a time

* Note: There is frequently a wide variation in physical development, but if a child cannot walk unsupported by 18 months of age, a neuromuscular disorder should be suspected. A wide-based gait is often the first noticeable abnormality when neuromuscular disease is present in the child. In addition, the child should not have hand preference before 18 months of age.


For greatest accuracy, the ages of all children should be listed by years plus months.



FAMILY HISTORY


A review of the family history is important, not only for certain visible musculoskeletal problems, such as polydactyly, but also for those disorders that may not be so obvious, such as scoliosis, osteoporosis, neuromuscular disease, and tuberculosis. Other family members may even need to be interviewed or examined.



PAST HISTORY


The general health of the patient is recorded, as well as any recent weight loss or gain. The patient’s exact occupation should be determined and any relevant military history noted, especially if a disability rating resulted from time spent in the service. The disorder that prompted the rating is noted, and impairment ratings from other sources are also recorded. All chronic renal, metabolic, pulmonary, and previous orthopedic disorders should be assessed in view of the initial complaint. Any drug or alcohol use is recorded. The smoking history is especially important, because tobacco use may adversely affect multiple musculoskeletal conditions, including osteoporosis, fracture healing, and low back pain.


The menstrual history is noted, especially the date of onset, when assessing scoliosis and menopause (at which time, osteoporosis should always be discussed, even though the present illness may be unrelated).


Present medication use is recorded in addition to the use of all nonprescription drugs, vitamins and minerals, and herbal supplements.



PRESENT ILLNESS


The nature of the onset of symptoms, whether gradual or sudden, should be established. If an injury is involved, the exact nature, date, and place of the injury are recorded. This is frequently an important fact in determining injury liability. If the problem seems job-related, other information regarding the patient’s work history may be helpful as follows:


1 Whether the symptoms may have been caused by the work or simply developed while the patient was working;

2 If the patient is working or has missed any work as a result of the problem;

3 If the patient has ever been on light duty as a result of the disorder; and

4 If a report of the injury was filed at work.

The chief complaint should also be evaluated in relation to any previous similar symptoms or other musculoskeletal complaints. In addition, it should be noted whether the patient has had any other recent, seemingly unrelated illness or symptoms, such as fever or chills. The results of any previous treatment or tests should also be ascertained.


The exact location and nature of any pain should be determined. In addition, the following important facts are noted:


1 The relationship of the pain to normal daily activities;

2 Whether the pain is worse in the morning or late in the day;

3 Whether coughing, sneezing, or other similar activities aggravate the pain;

4 Whether the pain improves or worsens with rest; and

5 Whether the pain remains well localized or is referred or radicular in nature. If the pain is radicular, it should be determined whether the radiation follows any dermatome or peripheral nerve pattern. The effect of any home remedies on the pain should also be assessed.

Weakness and numbness may be extremely subjective. (Weakness is more often caused by pain than actual motor loss.) An attempt should be made to document these symptoms, however. The following information should be ascertained:


1 Whether the weakness is generalized or involves specific muscles or muscle groups;

2 Whether there is any loss of sphincter control; and

3 Whether the numbness follows a dermatome, peripheral nerve, or stocking/glove pattern.

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Jun 12, 2016 | Posted by in ORTHOPEDIC | Comments Off on Physical Examination

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