Musculoskeletal Subjective Data Study Guide with Complete Solution

Musculoskeletal Subjective Data Study Guide with Complete Solution Subjective Data - 1. Joints 2. Knee Joint (if injured) 3. Muscles 4. Bones 5. Functional Assessment (ADLs) 6. Patient-centered care Most common problem that prompts people to see care? - -joint pain -loss of function Joints Questions - -any problems w/ joints? -any pain? -stiffness? -limited ROM? -swelling / redness / heat -*any tick bites?* (assess for risk of Lyme disease) -what makes it better or worse? Joints Questions: Quality - -what does it feel like? ex: aching, stiff, sharp, dull, shooting Joint Questions: Location & Severity - -which joint? -one or both sides? -how strong is the pain? Joints Questions: Onset & Timing - -when did it start? -what time of the day does the pain occur? -how long does it last? -how often does it occur? Joint Questions: Associated w/ Fever - joint pain 10-14 days after an untreated strep throat suggest rheumatic fever Rheumatoid Arthritis (RA) - -involves symmetric joints -exquisitely tended w/ acute inflammation -worse in the morning -movement decreases pain -pain occurs in AM and after rest periods Muscle Questions - -pain or cramping? if yes, which muscles? -weakness? if yes, where? -do muscle look smaller where the pain is? -does pain go away w/ rest? -how long have you had the pain? Myalgia - muscle pain usually felt as cramping or aching *often included w/ viral illness* Bone Questions - -any pain? back pain? -is pain affected by movement? -any deformity? -any accidents or trauma? -when did it start? -have you received treatment? -is ROM affected by pain? -any numbness or tingling? -any limping? Functional Assessment - screens the safety of independent living, the need for home care, and quality of life Functional Assessment Questions - do your joints/muscles/bones affect how you perform your ADLs? -Bathing -Toileting -Dressing -Grooming -Eating -Mobility -Communication Patient Centered Care - -any occupational hazards that could affect joints? -does work involve heavy lifting? -any repetitive motion or chronic stress on joints? -pain during exercise? -recent weight gain? -taking any meds for M.S. System? (aspirin, muscle relaxers) -taking any supplements? -do you smoke? Additional Questions: Infants & Children - -any trauma during birth? -did baby head come out first? -any need for forceps or resuscitation? -were milestones achieved about same time as siblings or age-mates?