Musculoskeletal Exam and Assessment PDF

10/13/24 MUSCULOSKELETAL EXAM AND ASSESSMENT Rachel McInerney FNP, PMHNP 1 EQUIPMENT SKIN-MARKING PENCIL Goniometer Tape measure Reflex hammer 2...

10/13/24 MUSCULOSKELETAL EXAM AND ASSESSMENT Rachel McInerney FNP, PMHNP 1 EQUIPMENT SKIN-MARKING PENCIL Goniometer Tape measure Reflex hammer 2 1  10/13/24 MUSCULOSKELETAL EXAMINATION BEGIN YOUR EXAMINATION OF THE MUSCULOSKELETAL SYSTEM BY OBSERVING GAIT AND POSTURE Note how the patient walks, sits, rises Expose the body surface under good lighting Examine each region for: ⚬ limb and trunk stability ⚬ muscular strength ⚬ joint range of motion. Look for asymmetry in the extremities. 3 INSPECTION OVERVIEW INSPECT THE ANTERIOR, POSTERIOR, AND LATERAL OF THE PATIENT’S POSTURE. Observe the patient’s ability to stand erect, symmetry of body, and alignment of extremities. Note any lordosis, kyphosis, or scoliosis. 4 2  10/13/24 SKIN AND SUBCUTANEOUS TISSUE INSPECT THE SKIN AND SUBCUTANEOUS TISSUES OVER THE ARTICULAR STRUCTURES. Look for discoloration, swelling, and masses. 5 EXTREMITY INSPECTION OBSERVE EXTREMITIES FOR SIZE, GROSS DEFORMITY, BONY ENLARGEMENT, ALIGNMENT, CONTOUR Expect bilateral symmetry in length, circumference, alignment, extremity position 6 3  10/13/24 MUSCLE INSPECTION INSPECT MUSCLES FOR GROSS HYPERTROPHY, ATROPHY, FASCICULATIONS, SPASMS Muscle size should approximate symmetry bilaterally Fasciculations can occur after motor neuron injury 7 PALPATION PALPATE ANY BONES, JOINTS, TENDONS, AND MUSCLES IF SYMPTOMATIC Palpate inflamed joints last Note heat, tenderness, swelling, crepitus, pain, resistance to movement pressure applied to bones or joints- No pain Muscle tone should be firm Crepitus (a grating sound) can be felt when bony surfaces rub together 8 4  10/13/24 ROM: ACTIVE AND PASSIVE EXAMINE BOTH ACTIVE AND PASSIVE RANGE OF MOTION FOR EACH MAJOR JOINT AND RELATED MUSCLE GROUPS Allow space for the patient to move each muscle group Instruct the patient to move each joint through its full range 9 MUSCLE TONE AND MOVEMENT During passive range of motion, assess muscle tone by feeling the resistance to passive stretch Passive range of motion often exceeds active range by 5 degrees Discrepancies in range of motion may indicate muscle weakness or joint disorder 10 5  10/13/24 USING A GONIOMETER WHEN THERE IS AN INCREASE OR LIMITATION IN RANGE OF MOTION, USE A GONIOMETER TO PRECISELY MEASURE THE ANGLE. START WITH THE JOINT IN A NEUTRAL POSITION AND FLEX AS FAR AS POSSIBLE. MEASURE THE ANGLES OF FLEXION AND EXTENSION. 11 MUSCLE STRENGTH OVERVIEW EVALUATING MUSCLE STRENGTH IS PART OF THE NEUROLOGIC EXAMINATION, OFTEN INTEGRATED WITH RANGE OF MOTION ASK THE PATIENT TO CONTRACT THE MUSCLE BY EXTENDING OR FLEXING THE JOINT, AND APPLY FORCE AGAINST THE CONTRACTION 12 6  10/13/24 TESTING MUSCLE RESISTANCE INSTRUCT THE PATIENT TO PUSH AGAINST YOUR HAND TO FEEL RESISTANCE Compare muscle strength bilaterally, expecting symmetric strength with full resistance to opposition 13 GRADING MUSCLE STRENGTH MUSCLE STRENGTH IS GRADED FROM NO VOLUNTARY CONTRACTION TO FULL STRENGTH. A grade of 3 or less indicates disability, requiring external support. Weakness may result from muscle disorders, pain, or fatigue. 14 7  10/13/24 HAND AND WRIST INSPECTION: CARPAL DISLOCATION, WRIST FRACTURES, SEPTIC ARTHRITIS Palpation: Radius, ulna, scaphoid, 5th metacarpal, carpal rows Range of Motion: Wrist extension (70-90°), flexion (70-80°), ulnar (25°), radial deviation 15 HAND AND WRIST Strength Testing: Median, ulnar, and radial nerve functions. Special Tests: Gamekeeper's thumb, Jersey finger, mallet finger, flexor/extensor tendon injuries. 16 8  10/13/24 INSPECTION OF ELBOWS INSPECT THE CONTOUR OF THE PATIENT’S ELBOWS IN BOTH FLEXED AND EXTENDED POSITIONS. SUBCUTANEOUS NODULES ON THE ULNAR SURFACE MAY INDICATE RHEUMATOID NODULES OR GOUTY TOPHI. 17 PALPATION OF ELBOWS PALPATE THE EXTENSOR SURFACE OF THE ULNA, THE OLECRANON PROCESS, AND THE MEDIAL AND LATERAL EPICONDYLES CHECK FOR TENDERNESS, SWELLING, OR THICKENING OF THE SYNOVIAL MEMBRANE. OLECRANON BURSITIS CAUSES SWELLING AND TENDERNESS 18 9  10/13/24 ELBOW RANGE OF MOTION ASK THE PATIENT TO FULLY EXTEND, BEND, AND ROTATE THE ELBOW. Expect 160 degrees of flexion, full extension, and 90 degrees each of pronation and supination. 19 ELBOW RANGE OF MOTION ASK THE PATIENT TO FULLY EXTEND, BEND, AND ROTATE THE ELBOW. Expect 160 degrees of flexion, full extension, and 90 degrees each of pronation and supination. 20 10  10/13/24 SHOULDER INSPECTION INSPECT THE CONTOUR OF THE SHOULDERS, THE SHOULDER GIRDLE, THE CLAVICLES, SCAPULAE, AND SURROUNDING MUSCULATURE Expect symmetry in size and contour of all shoulder structures Asymmetry or hollows may indicate a shoulder dislocation Observe for a winged scapula 21 SHOULDER PALPATION P A L P A T E T H E S T E R N O C L A V IC U L A R JO IN T , C L A V IC L E , A C R O M IO C L A V IC U L A R JO IN T , S C A P U L A , C O R A C O ID P R O C E S S , A N D G R E A T E R T U B E R C L E O F T H E H U M E R U S. R o ta te th e a rm a n d fo re a rm e x te rn a lly to lo c a te th e b ic e p s g ro o v e. P a lp a te th e m u sc le in se rtio n s o f th e su p ra sp in a tu s, in fra sp in a tu s, a n d te re s m in o r n e a r th e g re a te r tu b e ro sity o f th e h u m e ru s. N o te n d e rn e ss sh o u ld b e n o te d o v e r th e m u scle in se rtio n s. 22 11  10/13/24 SHOULDER ROM SHRUG THE SHOULDERS R a ise b o th a rm s fo rw a rd a n d stra ig h t u p o v e r th e h e a d : fo rw a rd fle x io n o f 18 0 d e g re e s. E x te n d a n d stre tc h b o th a rm s b e h in d th e b a c k : h y p e re x te n sio n o f 5 0 d e g re e s. L ift b o th a rm s la te ra lly a n d stra ig h t u p o v e r th e h e a d : sh o u ld e r a b d u c tio n o f 18 0 d e g re e s. S w in g e a c h a rm a c ro ss th e fro n t o f th e b o d y : a d d u c tio n o f 5 0 d e g re e s. P la c e b o th a rm s b e h in d th e h ip s, e lb o w s o u t: in te rn a l ro ta tio n o f 9 0 d e g re e s. Place both arms behind the head, elbows out: external rotation of 90 degrees. 23 TEMPOROMANDIBULAR JOINT L O C A T E T H E T M JS B Y P L A C IN G Y O U R F IN G E R T IP S J U S T A N T E R IO R T O T H E T R A G U S A llo w y o u r fin g e rtip s to slip in to th e jo in t sp a c e a s th e p a tie n t o p e n s th e ir m o u th p a lp a te th e jo in t sp a c e. A u d ib le o r p a lp a b le sn a p p in g o r c lic k in g is n o t u n u su a l. P a in , c re p itu s, lo c k in g , o r p o p p in g m a y in d ic a te te m p o ro m a n d ib u la r jo in t d y sfu n c tio n 24 12  10/13/24 ROM AND STRENGTH (TMJ) E X A M IN E T H E R A N G E O F M O T IO N : ⚬ O p e n a n d c lo se th e m o u th : E x p e c t a sp a c e o f 3 to 6 c m b e tw e e n th e u p p e r a n d lo w e r te e th ⚬ M o v e th e lo w e r ja w la te ra lly : T h e m a n d ib le sh o u ld m o v e 1 to 2 c m in e a c h d ire c tio n ⚬ P ro tru d e a n d re tra c t th e c h in : B o th m o v e m e n ts sh o u ld b e p o ssib le E v a lu a te th e stre n g th ⚬ b y a sk in g th e p a tie n t to c le n c h th e ir te e th ⚬ T h is m a n e u v e r a lso te sts c ra n ia l n e rv e V (th e trig e m in a l n e rv e ). 25 CERVICAL SPINE IN S P E C T T H E P A T IE N T ’S N E C K F R O M B O T H A N T E R IO R A N D P O S T E R IO R P O S IT IO N S , O B S E R V IN G F O R A L IG N M E N T C h e c k fo r sy m m e try o f th e sk in fo ld s a n d m u sc le s T h e c e rv ic a l sp in e sh o u ld h a v e a c o n c a v e c u rv e P a lp a te th e p o ste rio r n e c k , c e rv ic a l sp in e , a n d p a ra v e rte b ra l, tra p e z iu s, a n d ste rn o c le id o m a sto id m u sc le s T h e m u sc le s sh o u ld h a v e g o o d to n e , sy m m e try in siz e , a n d n o p a lp a b le te n d e rn e ss o r m u sc le sp a sm 26 13  10/13/24 ROM AND MUSCLE STRENGTH SPINE A S K T H E P A T IE N T T O : ⚬ B e n d th e h e a d fo rw a rd , c h in to c h e st: 4 5 ° fle x io n. ⚬ B e n d th e h e a d b a c k w a rd , c h in to w a rd th e c e ilin g : 4 5 ° e x te n sio n. ⚬ B e n d th e h e a d to e a c h sid e , e a r to sh o u ld e r: 4 0 ° la te ra l b e n d in g. ⚬ T u rn th e h e a d to e a c h sid e , c h in to sh o u ld e r: 7 0 ° ro ta tio n. E v a lu a te th e stre n g th o f th e ste rn o c le id o m a sto id a n d tra p e z iu s m u sc le s b y a p p ly in g o p p o sin g fo rc e D u rin g h e a d ro ta tio n , c ra n ia l n e rv e X I is te ste d. 27 THORACIC AND LUMBER SPINE K E Y L A N D M A R K S : S P IN A L P R O C E S S E S , S C A P U L A E , IL IA C C R E S T S , A N D PARAVERTEBRAL MUSCLES T h e th o ra c ic sp in e sh o u ld b e c o n v e x th e lu m b a r sp in e sh o u ld b e c o n c a v e T h e h e a d p o sitio n e d o v e r th e g lu te a l c le ft w ith stra ig h t v e rte b ra e , sy m m e tric sh o u ld e r, sc a p u la r, a n d ilia c c re st h e ig h ts K y p h o sis m a y b e o b se rv e d in a g in g a d u lts L o rd o sis is c o m m o n in o b e sity o r p re g n a n c y 28 14  10/13/24 SPINAL PALPATION AND FLEXION TEST W ith th e p a tie n t sta n d in g e re c t, p a lp a te th e sp in a l p ro c e sse s a n d p a ra v e rte b ra l m u sc le s T h e re sh o u ld b e n o m u sc le sp a sm o r sp in a l te n d e rn e ss P e rc u ss e a c h sp in a l p ro c e ss a n d p a ra v e rte b ra l m u sc le s fo r te n d e rn e ss b e n d fo rw a rd a n d to u c h th e ir to e s- In sp e c t fo r u n e x p e c te d c u rv a tu re la te ra l c u rv a tu re /rib h u m p m a y in d ic a te sc o lio sis M e a su re th e d e g re e o f ro ta tio n w ith a sc o lio m e te r O b se rv e fo r lu m b a r c u rv e re v e rsa l b a c k e x te n sio n 29 RANGE OF MOTION OF THE SPINE A S K th e p a tie n t to p e rfo rm th e fo llo w in g m o v e m e n ts: B e n d fo rw a rd a t th e w a ist: E x p e c t 7 5 to 9 0 ° fle x io n B e n d b a c k a t th e w a ist: E x p e c t 3 0 ° h y p e re x te n sio n B e n d to e a c h sid e : E x p e c t 3 5 ° la te ra l b e n d in g b ila te ra lly S w in g th e u p p e r tru n k in a c irc u la r m o tio n fro m fro n t to sid e to b a c k , w h ile sta b iliz in g th e p e lv is: E x p e c t 3 0 ° ro ta tio n fo rw a rd a n d b a c k w a rd. 30 15  10/13/24 HIPS INSPECTION IN S P E C T th e h ip s a n te rio rly a n d p o ste rio rly w h ile th e p a tie n t sta n d s U se th e m a jo r la n d m a rk s o f th e ilia c c re st a n d th e g re a te r tro c h a n te r o f th e fe m u r N O te a n y a sy m m e try in : ⚬ Ilia c c re st h e ig h ⚬ S ize o f th e b u tto c k s ⚬ N u m b e r a n d le v e l o f g lu te a l fo ld s 31 HIPS ROM- FLEXION AND HYPEREXTENSION A S K T H E P A T IE N T T O : R a ise th e le g w ith th e k n e e e x te n d e d (e x p e c t u p to 9 0 ° h ip fle x io n ). S w in g th e stra ig h te n e d le g b e h in d th e b o d y (e x p e c t u p to 3 0 ° o r le ss h y p e re x te n sio n ). S U P IN E : R a ise o n e k n e e to th e c h e st w h ile k e e p in g th e o th e r le g stra ig h t (e x p e c t u p to 12 0 ° h ip fle x io n ). 32 16  10/13/24 HIP ABDUCTION AND ADDUCTION A S K T H E P A T IE N T T O : ⚬ S w in g th e le g la te ra lly a n d m e d ia lly w ith th e k n e e stra ig h t ⚬ E x p e c t u p to 4 5 ° o f a b d u c tio n a n d u p to 3 0 ° o f a d d u c tio n 33 HIP ROTATION (INTERNAL AND EXTERNAL) A S K T H E P A T IE N T T O : F le x th e k n e e , k e e p in g th e fo o t o n th e ta b le , a n d ro ta te th e le g to w a rd th e o th e r le g (e x p e c t 4 0 ° in te rn a l ro ta tio n ). P la c e th e la te ra l fo o t o n th e k n e e o f th e o th e r le g a n d m o v e th e fle x e d k n e e to w a rd th e ta b le (e x p e c t 4 5 ° e x te rn a l ro ta tio n ). 34 17  10/13/24 TESTING HIP FLEXION STRENGTH T E S T H IP F L E X IO N S T R E N G T H B Y A P P L Y IN G R E S IS T A N C E W H IL E T H E P A T IE N T M A IN T A IN S F L E X IO N O F T H E H IP W IT H B O T H F L E X E D A N D E X T E N D E D K N E E S A lso e v a lu a te m u sc le stre n g th d u rin g a b d u c tio n a n d a d d u c tio n , a n d re sista n c e to u n c ro ssin g th e le g s w h ile se a te d 35 TESTING HIP FLEXION STRENGTH T E S T H IP F L E X IO N S T R E N G T H B Y A P P L Y IN G R E S IS T A N C E W H IL E T H E P A T IE N T M A IN T A IN S F L E X IO N O F T H E H IP W IT H B O T H F L E X E D A N D E X T E N D E D K N E E S A lso e v a lu a te m u sc le stre n g th d u rin g a b d u c tio n a n d a d d u c tio n , a n d re sista n c e to u n c ro ssin g th e le g s w h ile se a te d 36 18  10/13/24 KNEE INSPECTION IN S P E C T T H E K N E E S A N D T H E IR P O P L IT E A L S P A C E S IN B O T H F L E X E D A N D E X T E N D E D P O S IT IO N S N o te th e m a jo r la n d m a rk s: ⚬ T ib ia l tu b e ro sity ⚬ M e d ia l a n d la te ra l tib ia l c o n d y le s ⚬ M e d ia l a n d la te ra l e p ic o n d y le s o f th e fe m u r ⚬ A d d u c to r tu b e rc le o f th e fe m u r ⚬ P a te lla IN S P E C T T H E E X T E N D E D K N E E F O R N A T U R A L C O N C A V IT IE S O N T H E A N T E R IO R A S P E C T , E A C H S ID E , A N D A B O V E T H E P A T E L L A ⚬ L O S S O F T H E S E C O N C A V IT IE S M A Y S U G G E S T K N E E E F F U S IO N 37 LOWER LEG ALIGNMENT O B S E R V E T H E L O W E R L E G A L IG N M E N T. T H E A N G L E B E T W E E N th e fe m u r a n d tib ia sh o u ld b e le ss th a n 15 d e g re e s. ⚬ G e n u v a lg u m (k n o c k -k n e e s) ⚬ G e n u v a ru m (b o w le g s) ⚬ G e n u re c u rv a tu m (e x c e sS IV E H Y P E R E X T E N S IO N ) M A Y IN D IC A T E Q U A D R IC E P S WEAKNESS. 38 19  10/13/24 KNEE EFFUSION A N E F F U S IO N O F T H E K N E E F IL L S T H E S U P R A P A T E L L A R P O U C H A N D T H E C O N C A V IT Y B E L O W T H E P A T E L L A M E D IA L L Y T h e u su a l in d e n ta tio n a b o v e a n d o n th e m e d ia l sid e o f th e p a te lla b e c o m e s c o n v e x ra th e r th a n c o n c a v e 39 POPLITEAL SPACE AND KNEE JOINT PALPATION P A L P A T E T H E P O P L IT E A L S P A C E , N O T IN G A N Y S W E L L IN G O R T E N D E R N E S S F U L L N E S S p a lp a te th e tib io fe m o ra l jo in t s p a c e ⚬ P a te lla ⚬ S u p ra p a te lla r p o u c h ⚬ In fra p a te lla r fa t p a d T h e jo in t s h o u ld fe e l s m o o th a n d firm , w ith o u t te n d e rn e s s , s w e llin g , b o g g in e s s , n o d u le s , c re p itu s 40 20  10/13/24 KNEE RANGE OF MOTION AND STRENGTH ROM B E N D E A C H K N E E (E X P E C T 13 0 ° O F F L E X IO N ) S T R A IG H T E N T H E L E G A N D S T R E T C H IT (E X P E C T F U L L E X T E N S IO N A N D U P T O 15° O F H Y P E R E X T E N S IO N ) stre n g th p a tie n t m a in ta in s fle x io n a n d e x te n sio n a s y o u a p p ly o p p o sin g fo rc e T h is c a n b e a sse sse d w ith th e p a tie n t e ith e r sittin g o r sta n d in g 41 IN S P E C T T H E F E E T A N D A N K L E S W H IL E T H E P A T IE N T IS B E A R IN G W E IG H T (S T A N D IN G /W A L K IN G ) A N D W H IL E S IT T IN G ⚬ M E D IA L M A L L E O L U S ⚬ LATERAL MALLEOLUS ⚬ A C H IL L E S T E N D O N S M O O T H A N D R O U N D E D M A L L E O L A R P R O M IN E N C E S , P R O M IN e n t h e e ls, a n d m e ta ta rso p h a la n g e a l jo in ts C a llu se s a n d c o rn s m a y in d ic a te c h ro n ic p re ssu re o r irrita tio n C o m m o n a lig n m e n t v a ria tio n s: ⚬ P e s v a ru s (in -to e in g ) ⚬ P e s v a lg u s (o u t-to e in g ) W E IG h t-b e a rin g o n th e m id lin e o f th e fo o t: ⚬ p e s p la n u s (h ig h ) p e s c a v u s (c la w ) FEET AND ANKLES 42 21  10/13/24 T H E T O E S S H O U L D B E S T R A IG H T F O R W A R D , F L A T , A N D A L IG N E D U N E X P E C T E D D E V IA T IO N S IN C L U D E : ⚬ H A M M E R T O E : H Y P E R E X T E N S IO N O F T H E M E T A T A R S O P H A L A N G E A L J O IN T W IT H F L E X IO N O F T H E P R O X IM A L J O IN T ⚬ M A L L E T T O E : F L E X IO N D E F O R M IT Y A T T H E D IS T A L IN T E R P H A L A N G E A L J O In t ⚬ C la w to e : H y p e re x te n s io n o f th e m e ta ta rs o p h a la n g e a l jo in t w ith fle x io n o f b o th p ro x im a l a n d d is ta l jo in ts ⚬ H a llu x v a lg u s : L a te ra l d e v ia tio n o f th e g re a t to e , o fte n c a u s in g o v e rla p p in g w IT h th e s e c o n d to e. A b u rs a m a y fo rm , le a d in g to a p a in fu l b u n io n TOE DEFORMITIES 43 H E A T , R E D N E S S , S W E L L IN G , A N D T E N D E R N E S S A R E S IG N S O F A N IN F L A M E D JO IN T R H E U M A T O ID A R T H R IT IS GOUT S E P T IC JO In t F R a c tu re T e n d o n itis A n in fla m e d m e ta ta rso p h a la n g e a l jo in t o f th e g re a t to e m a y in d Ic a te g o u ty a rth ritis SIGNS OF AN INFLAMED JOINT 44 22  10/13/24 ROM P O IN T T H E F O O T T O W A R D T H E C E IL IN G ( 2 0 ° D O R S IF L E X IO N ). P O IN T T H E F O O T T O W A R D T H E F L O O R (4 5 ° P L A N T A R F L E X IO N ). T U R N T H E S O L E O F T H E F O O T T O W A R D A N D A W A Y F R O M T H E O T H E R F O O T (3 0 ° IN V E R S IO N , 2 0 ° E V E R S IO N ). R O T A T E T H E F O O T A W A Y A n d to w a rd th e o th e r fo o t (10 ° a b d u c tio n , 2 0 ° a d d u c tio n ). B E N D A n d stra ig h te n th e to e s (fle x io n a n d e x te n sio n ). STRENGTH a p p ly o p p o sin g fo rc e d u rIN G D O R S IF L E X IO N , P L a n ta r fle x io n , a b d u c tio n , a d d u c tio n , a n d fle x io n /e x te n sio n o f th e to e s. FOOT AND ANKLE RANGE OF MOTION AND STRENGTH 45 MSK CASES 46 23  10/13/24 SCENARIO: A 65-YEAR-OLD WOMAN COMES IN WITH CHRONIC KNEE PAIN THAT WORSENS WITH ACTIVITY AND IMPROVES WITH REST. SHE REPORTS STIFFNESS IN THE MORNING THAT LASTS ABOUT 15 MINUTES AND HAS NOTICED A DECREASED RANGE OF MOTION IN HER KNEES. THERE IS NO SWELLING, BUT SHE HAS DIFFICULTY CLIMBING STAIRS AND GETTING UP FROM A SEATED POSITION. CASE 1 47 CASE 2 SCENARIO: A 25-YEAR-OLD BASKETBALL PLAYER PRESENTS WITH RIGHT ANKLE PAIN AND SWELLING AFTER ROLLING HIS ANKLE WHILE LANDING FROM A JUMP. HE HEARD A "POP" AT THE TIME OF THE INJURY AND HAD IMMEDIATE SWELLING AND DIFFICULTY BEARING WEIGHT. ON EXAMINATION, THERE IS SWELLING AROUND THE LATERAL MALLEOLUS, AND THE PATIENT HAS DIFFICULTY WITH WEIGHT-BEARING. 48 24  10/13/24 SCENARIO: A 45-YEAR-OLD MAN PRESENTS WITH ACUTE LOW BACK PAIN AFTER LIFTING A HEAVY OBJECT AT WORK. THE PAIN RADIATES TO HIS RIGHT BUTTOCK BUT DOES NOT GO PAST THE KNEE. HE REPORTS NO NUMBNESS OR WEAKNESS BUT FEELS STIFFNESS IN HIS LOWER BACK. HIS PAIN IMPROVES WITH REST BUT WORSENS WITH BENDING OR LIFTING. CASE 3 49 S C E N A R IO : A 4 0 -Y E A R -O L D W O M A N W H O P L A Y S T E N N IS R E G U L A R L Y C O M P L A IN S O F G R A D U A L O N S E T P A IN IN H E R R IG H T E L B O W T H A T W O R S E N S W IT H G R IP P IN G O B J E C T S. S H E H A S D IF F IC U L T Y W IT H A C T IV IT IE S S U C H A S L IF T IN G , T W IS T IN G D O O R K N O B S , A N D H O L D IN G A T E N N IS R A C K E T. O N E X A M , T E N D E R N E S S IS N O T E D O V E R T H E L A T E R A L E P IC O N D Y L E O F H E R E L B O W. CASE 4 50 25  10/13/24 CASE 5 SCENARIO: A 55-YEAR-OLD MAN PRESENTS WITH PAIN AND SWELLING OVER HIS LEFT SHOULDER, WHICH WORSENS WITH OVERHEAD ACTIVITIES LIKE REACHING OR THROWING. HE REPORTS THAT THE PAIN HAS BEEN PRESENT FOR SEVERAL WEEKS AND IS WORSE AT NIGHT WHEN LYING ON THAT SIDE. ON EXAMINATION, THERE IS TENDERNESS OVER THE SUBACROMIAL AREA, AND RANGE OF MOTION IS LIMITED BY PAIN. 51 CASE 6 SCENARIO: A 50-YEAR-OLD MAN COMPLAINS OF SUDDEN, SEVERE PAIN IN HIS BIG TOE. HE WOKE UP IN THE MIDDLE OF THE NIGHT WITH REDNESS, SWELLING, AND INTENSE PAIN IN THE JOINT OF HIS RIGHT BIG TOE. HE HAS A HISTORY OF DRINKING ALCOHOL FREQUENTLY AND ADMITS TO EATING A DIET RICH IN RED MEAT AND SHELLFISH. HE’S HAD A FEW SIMILAR EPISODES IN THE PAST. 52 26  10/13/24 S C E N A R IO : A 3 5 -Y E A R -O L D A D M IN IS T R A T IV E A S S IS T A N T R E P O R T S N U M B N E S S A N D T IN G L IN G IN H E R R IG H T H A N D , E S P E C IA L L Y IN T H E T H U M B , IN D E X , A N D M ID D L E F IN G E R S. T H E S Y M P T O M S A R E W O R S E A T N IG H T A N D IM P R O V E W H E N S H E S H A K E S H E R H A N D. S H E A L S O M E N T IO N S D R O P P IN G O B JE C T S M O R E F R E Q U E N T L Y O V E R T H E P A S T F E W M O N T H S. CASE 7 53 CASE 8 SCENARIO: A 55-YEAR-OLD PAINTER COMES IN WITH SHOULDER PAIN THAT STARTED AFTER PAINTING A CEILING. HE COMPLAINS OF PAIN WHEN LIFTING HIS ARM OR REACHING OVERHEAD AND HAS DIFFICULTY SLEEPING ON THE AFFECTED SIDE. ON EXAMINATION, THERE IS TENDERNESS OVER THE ACROMION, AND THE PATIENT HAS DIFFICULTY WITH SHOULDER ABDUCTION. 54 27  10/13/24 CASE 9 S C E N A R IO : A 3 0 -Y E A R -O L D W O M A N P R E S E N T S W IT H J O IN T P A IN IN H E R H A N D S , W R IS T S , A N D F E E T T H A T H A S B E E N W O R S E N IN G O V E R S E V E R A L M O N T H S. S H E N O T IC E S M O R N IN G S T IF F N E S S L A S T IN G O V E R A N H O U R A N D D IF F IC U L T Y U S IN G H E R H A N D S F O R T A S K S L IK E G R IP P IN G O B J E C T S. O N E X A M , T H E R E IS S W E L L IN G A N D T E N D E R N E S S IN M U L T IP L E J O IN T S , IN C L U D IN G H E R W R IS T S A N D P R O X IM A L IN T E R P H A L A N G E A L (P IP ) J O IN T S. 55 CASE 10 SCENARIO: A 40-YEAR-OLD WOMAN WHO RECENTLY STARTED RUNNING PRESENTS WITH PAIN IN HER RIGHT HEEL. SHE DESCRIBES THE PAIN AS WORSE IN THE MORNING WHEN SHE FIRST STEPS OUT OF BED AND AFTER LONG PERIODS OF STANDING. THE PAIN IMPROVES WITH REST AND GENTLE STRETCHING BUT RETURNS WITH ACTIVITY. 56 28  10/13/24 ANSWERS.... Find them in a PDF document on Canvas THE END 57 29