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2-General Examination of nursing MSS.pptx

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This document provides guidance on performing a general examination of the musculoskeletal system. It outlines examination principles and specific techniques for assessing the skin, nails, soft tissues, and individual joints. Key steps include observing appearance, palpating for warmth, swelling or deformity, and assessing both active and passive range of motion. Common abnormal findings associated with various rheumatologic conditions are described. The overall examination sequence and areas to evaluate are also outlined.

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General Examination of the Musculoskeletal System Prepared by Dr. Ruqaya Al-Kathiry Head of the Medical Department in UST Medicine is learned at the bedside and not in the classroom Sir William Osler (1849-1919)
2-General Examination of nursing MSS.pptx
Dynamic tests are difficult to describe in pictures & text so ask an experienced clinician to check your technique. Practise examining as many joints as possible to become familiar with NL appearances & ranges of movement. General Principles: Ask Look Feel Move After taking the Hx observe, palpate & move. Always expose the joint above & below the one in question. Compare one limb with the opposite side. Examine the overall appearance for pallor, rash, skin tightening & hair changes. Look at the skin, SC tissues & bony outline of each area. Before palpating, ask the pt which area is painful or tender. Feel for warmth, swelling, stability & deformity. Assess if a deformity is reducible or fixed. Assess active before passive movement. Do not cause the pt additional pain. In suspected systemic dis, examine all joints and fully examine all systems. Use standard terminology to describe joint limb positions & movement. Always describe movements from the neutral position. Commonly used terms are: o Flexion: bending at a joint from the neutral position o Extension: straightening a joint back to the neutral position o Hyperextension: movement beyond the NL neutral position because of a torn lig. or underlying ligamentous laxity, e.g. Ehlers-Danlos $ PHYSICAL EXAMINATION
o Adduction: movement towards the midline of the body (finger adduction is movement towards the axis of the limb) o Abduction: movement away from the midline. Describe the position of a limb because of joint/bone deformity: o Valgus: the distal part deviates away from the midline o Varus: the distal part deviates towards the midline. Equipment: You need a: Tape measure Tendon hammer Goniometer (protractor for measuring the range of joint movement) Stethoscope Blocks for assessing leg length discrepancy General Examination: Skin, nail & soft tissue ABNL Findings: Skin & related struct. are the most common sites of ass. lesions. Psoriasis may be hidden (U, natal cleft, scalp). Nail changes: fine or coarse pits in nail, onycholysis, thickening and ridging. Rash of SLE is induced by UV light exposure.
Small, dark red vasculitic spots (due to capillary infarcts) occur in RA, SLE & PAN These indicate active dis. Common sites: nail folds, finger and toe tips & other pressure areas. Raynauds phenomenon: episodic ischaemia of the fingers ppt. by stimuli as cold, pain & stress. There is a typical progression of colour changes: blanching (white) followed by cyanosis (blue) & reactive hyperaemia (red) ass. dysaesthesia (altered sensation) & pain. It is common in healthy individuals but is a freq. in systemic sclerosis & SLE. Systemic sclerosis: thickened, tight skin produces a ch.ch. facial appearance. In the hands, flexion contractures, calcium deposits in the finger pulps & tissue ischaemia leading to ulceration. Telangiectasias of systemic sclerosis are purplish, blanch with pressure & are most common on the hands & face. Beaking of the nose & taut skin around the mouth Calcium deposits ulcerating through the skin Reactive arthritis has extra-art. features & is ass. with skin & nail changes similar to those of psoriasis, together with conjunctivitis, circinate balanitis (painless superficial ulcers on the prepuce & glans), urethritis & superficial mouth ulcers.
Nodules: S.C nodules in RA: most commonly occur on the extensor surface of the forearm. They are firm & non-tender, felt at sites of pressure or friction (sacrum or Achilles tendon). Multiple small nodules can occur in the hands & are part. ass. with MTX therapy. These are strongly ass. with a +ve RF & can occur at other sites (lungs). Bony nodules in OA: affect the hand & are smaller & harder than rheumatoid nodules. They occur on the lat. aspects of the interphalangeal (IP) joints. o DIP joints Heberdens nodes. o PIP joints Bouchards nodes. Gouty tophi: firm, white, irregular SC crystal collections (monosodium urate monohydrate). Common sites: olecranon bursa, helix of the ear & extensor aspects of the fingers, hands, knees & toes. The overlying skin may ulcerate, discharge crystals & become secondarily infected. Heberdens nodes Bouchards nodes Eyes: affected in many MSS conditions. Dry Eyes: Sj旦grens $, RA & other CTD. Blue Sclerae: certain types of osteogenesis imperfecta & scleromalacia of RA.
General Features of Systemic Involvement: Wt loss, Muscle loss, Fever & LAP
Examination Sequence: Perform Schirmers tear test to Dx keratoconjunctivitis sicca. Hook a small strip of notched blotting paper ~40 mm long over the lower eyelid while the pt looks upwards. The notch is ~5 mm from one end of the strip & is where the strip is bent over the eyelid. Ask the pt to close the eye. Wait for exactly 5mins, then remove the strip. Measure the distance that tears travel down the strip with a millimetre rule: >15mm = NL 515 mm = equivocal <5 mm = ABNL ABNL findings Conjunctivitis reactive arthritis. tear production with dry eyes (keratoconjunctivitis sicca) conjunctivitis & blepharitis (inflam. of the eyelids) Sj旦grens $ & as 2ary changes in RA & other CTD. Scleritis & episcleritis RA & psoriatic arthritis. Ant. uveitis (iritis) ~25% of pts with ankylosing spondylitis & reactive arthritis but is asymp. in juvenile idiopathic arthritis (JIA), so ophthalmological assessment is essential if JIA is suspected. The sclerae are blue in certain types of osteogenesis imperfecta & in the scleromalacia of long-standing RA.
Medicine is learned at the bedside and not in the classroom Sir William Osler (1849-1919) THANK YOU FOR YOUR ATTENDANCE

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2-General Examination of nursing MSS.pptx

  • 1. General Examination of the Musculoskeletal System Prepared by Dr. Ruqaya Al-Kathiry Head of the Medical Department in UST Medicine is learned at the bedside and not in the classroom Sir William Osler (1849-1919)
  • 3. Dynamic tests are difficult to describe in pictures & text so ask an experienced clinician to check your technique. Practise examining as many joints as possible to become familiar with NL appearances & ranges of movement. General Principles: Ask Look Feel Move After taking the Hx observe, palpate & move. Always expose the joint above & below the one in question. Compare one limb with the opposite side. Examine the overall appearance for pallor, rash, skin tightening & hair changes. Look at the skin, SC tissues & bony outline of each area. Before palpating, ask the pt which area is painful or tender. Feel for warmth, swelling, stability & deformity. Assess if a deformity is reducible or fixed. Assess active before passive movement. Do not cause the pt additional pain. In suspected systemic dis, examine all joints and fully examine all systems. Use standard terminology to describe joint limb positions & movement. Always describe movements from the neutral position. Commonly used terms are: o Flexion: bending at a joint from the neutral position o Extension: straightening a joint back to the neutral position o Hyperextension: movement beyond the NL neutral position because of a torn lig. or underlying ligamentous laxity, e.g. Ehlers-Danlos $ PHYSICAL EXAMINATION
  • 4. o Adduction: movement towards the midline of the body (finger adduction is movement towards the axis of the limb) o Abduction: movement away from the midline. Describe the position of a limb because of joint/bone deformity: o Valgus: the distal part deviates away from the midline o Varus: the distal part deviates towards the midline. Equipment: You need a: Tape measure Tendon hammer Goniometer (protractor for measuring the range of joint movement) Stethoscope Blocks for assessing leg length discrepancy General Examination: Skin, nail & soft tissue ABNL Findings: Skin & related struct. are the most common sites of ass. lesions. Psoriasis may be hidden (U, natal cleft, scalp). Nail changes: fine or coarse pits in nail, onycholysis, thickening and ridging. Rash of SLE is induced by UV light exposure.
  • 5. Small, dark red vasculitic spots (due to capillary infarcts) occur in RA, SLE & PAN These indicate active dis. Common sites: nail folds, finger and toe tips & other pressure areas. Raynauds phenomenon: episodic ischaemia of the fingers ppt. by stimuli as cold, pain & stress. There is a typical progression of colour changes: blanching (white) followed by cyanosis (blue) & reactive hyperaemia (red) ass. dysaesthesia (altered sensation) & pain. It is common in healthy individuals but is a freq. in systemic sclerosis & SLE. Systemic sclerosis: thickened, tight skin produces a ch.ch. facial appearance. In the hands, flexion contractures, calcium deposits in the finger pulps & tissue ischaemia leading to ulceration. Telangiectasias of systemic sclerosis are purplish, blanch with pressure & are most common on the hands & face. Beaking of the nose & taut skin around the mouth Calcium deposits ulcerating through the skin Reactive arthritis has extra-art. features & is ass. with skin & nail changes similar to those of psoriasis, together with conjunctivitis, circinate balanitis (painless superficial ulcers on the prepuce & glans), urethritis & superficial mouth ulcers.
  • 6. Nodules: S.C nodules in RA: most commonly occur on the extensor surface of the forearm. They are firm & non-tender, felt at sites of pressure or friction (sacrum or Achilles tendon). Multiple small nodules can occur in the hands & are part. ass. with MTX therapy. These are strongly ass. with a +ve RF & can occur at other sites (lungs). Bony nodules in OA: affect the hand & are smaller & harder than rheumatoid nodules. They occur on the lat. aspects of the interphalangeal (IP) joints. o DIP joints Heberdens nodes. o PIP joints Bouchards nodes. Gouty tophi: firm, white, irregular SC crystal collections (monosodium urate monohydrate). Common sites: olecranon bursa, helix of the ear & extensor aspects of the fingers, hands, knees & toes. The overlying skin may ulcerate, discharge crystals & become secondarily infected. Heberdens nodes Bouchards nodes Eyes: affected in many MSS conditions. Dry Eyes: Sj旦grens $, RA & other CTD. Blue Sclerae: certain types of osteogenesis imperfecta & scleromalacia of RA.
  • 7. General Features of Systemic Involvement: Wt loss, Muscle loss, Fever & LAP
  • 8. Examination Sequence: Perform Schirmers tear test to Dx keratoconjunctivitis sicca. Hook a small strip of notched blotting paper ~40 mm long over the lower eyelid while the pt looks upwards. The notch is ~5 mm from one end of the strip & is where the strip is bent over the eyelid. Ask the pt to close the eye. Wait for exactly 5mins, then remove the strip. Measure the distance that tears travel down the strip with a millimetre rule: >15mm = NL 515 mm = equivocal <5 mm = ABNL ABNL findings Conjunctivitis reactive arthritis. tear production with dry eyes (keratoconjunctivitis sicca) conjunctivitis & blepharitis (inflam. of the eyelids) Sj旦grens $ & as 2ary changes in RA & other CTD. Scleritis & episcleritis RA & psoriatic arthritis. Ant. uveitis (iritis) ~25% of pts with ankylosing spondylitis & reactive arthritis but is asymp. in juvenile idiopathic arthritis (JIA), so ophthalmological assessment is essential if JIA is suspected. The sclerae are blue in certain types of osteogenesis imperfecta & in the scleromalacia of long-standing RA.
  • 9. Medicine is learned at the bedside and not in the classroom Sir William Osler (1849-1919) THANK YOU FOR YOUR ATTENDANCE