Reumatologia

PART

5

EVALUATION OF GENERALIZED AND LOCALIZED SYMPTOMS

35

History and Physical Examination of the Musculoskeletal System
John M. Davis iii • Kevin G. MoDer • Gene G. hunDer diseases, however, and must be considered in light of the entire history and physical examination. The physician must assess compliance with therapies for musculoskeletal diseases. Noncompliance with therecommended treatment must be differentiated from treatment failure as the explanation for the patient’s lack of improvement. While the physician is taking the patient’s history, the patient provides verbal and nonverbal clues to the nature of the illness and how the patient has responded to it. Patients with early rheumatoid arthritis may hold their hands in a flexed posture to minimize intra-articularpressure and pain. Patients with fibromyalgia or chronic pain syndromes often dramatize in describing their symptoms. Some patients may be overly concerned, whereas others may seem inappropriately indifferent to their symptoms. The physician must appreciate the patient’s understanding of the illness and attitudes toward it to begin effective treatment. PAIN

KEY POINTS
Taking a detailed andaccurate history is crucial for making the correct diagnosis for patients with musculoskeletal diseases. The cardinal symptoms of musculoskeletal disease are pain, stiffness, swelling, limitation of motion, weakness, and fatigue. Understanding the anatomy, the planes of motion, and particularly the configuration of the synovial lining is imperative for proper physical diagnosis of musculoskeletaldiseases. It is important to record qualitative and quantitative aspects of the joint examination to monitor disease activity in patients with inflammatory arthropathies. Early recognition of how patients’ psychosocial factors affect their musculoskeletal symptoms and musculoskeletal examination enhances clinical assessment.

HISTORY IN A PATIENT WITH MUSCULOSKELETAL DISEASE
Taking an accurate andcomprehensive history of a patient’s musculoskeletal symptoms is crucial for making the correct diagnosis. This history must include a precise understanding of what the patient means by the description of symptoms. The physician must obtain a detailed account of symptom onset, location, patterns of progression, severity, exacerbating and alleviating factors, and associated symptoms. Therelationship of the symptoms to psychosocial stressors is important and should be determined. 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 are helpful in understanding the current symptoms. Response to anti-inflammatory or glucocorticoid medications may suggest an inflammatoryetiology. Such responses are not specific to inflammatory rheumatic
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Pain is the most common symptom that brings a patient with musculoskeletal diseases to the physician. Pain is a subjective hurting sensation or experience described in various terms, often of actual orperceived physical damage. Pain is a complex sensation that is difficult to define, qualify, and measure. The patient’s pain may be modified by emotional factors and previous experiences. The character of the pain usually is best defined early in the interview because this can be helpful in categorizing the patient’s complaints. Aching in a joint area suggests an arthritic disorder, whereas “burning”or “numbness” in an extremity may indicate a neuropathy. Descriptions of pain as “excruciating” or “intolerable” when the patient is otherwise able to function provide a clue that emotional or psychosocial factors are contributing to or amplifying the symptoms. The physician must elicit the distribution of the patient’s pain and determine if this fits with anatomic structures. Patients describe...