Let’s get back to the nervous system
because one of the first things you do
when you start talking to a person
is make sure that they’re a good historian.
Make sure that you can trust
what they’re saying,
or if you’re not going to trust what they’re
saying, establish that early.
When I talk to patients in another language,
I often have trouble telling if
they’re confused or not
because it doesn’t feel the same when
it’s not in your native tongue.
If somebody’s oriented to time,
place and person
that’s the basics to start a conversation,
but if you say what time is it?
Or what day is it? Or what year
is it? They look at you funny
but there are ways of saying,
“What’s your name?”
Checking the name and make
sure that the armband
is the same name the person is giving you.
It is a quality control that matters.
Place—what brings you here? What
brings you to the hospital?
What part of the hospital? Have you
been to the hospital before?
Those are some basics.
tests whether or not they understand
the seriousness of their event,
the seriousness of their condition,
and whether they are capable
of making decisions.
In the emergency room, this is a lot
more important than in the office.
In the office, most people are oriented,
much more so than in the ER,
where you don’t have substance abuse
issues to deal with as much.
But it’s always important to establish
that the person understands they are sick,
and that if they have chest pain and
confusion, they can’t leave.
Or if they’re just scared,
it’s good to know that too.
The musculoskeletal system.
We tend to look at the muscles
and examine the joints,
but we need to examine both of
them in the same way
We need to look at how the
muscles are functioning.
Is there free motion?
Are they in Fryette’s rule #1
which is fluid motion sidebend
right, rotate left,
push the weight control and the weight
on as much of the vertebrae as possible
looking fluid, and assessing any limitations?
So can they do 90°, 90°, 45°, 45°, flex
to 90° and extend to 15°.
Do you have full functional motion?
Is there a single spot or region
that’s standing out,
that the person is protecting, or splinting
or guarding against the exam?
It’s a good thing to notice early on
and did this change
and is this pain or problem there
all the time or sometimes?
Does it develop as they’re doing something
for long periods of time?
Those are very helpful aspects to
the musculoskeletal exam.
The other thing that’s unique to
the musculoskeletal exam,
is that things tend to spread.
When somebody hurts themselves,
they can identify it easily.
They punch something, they hurt—
they can identify it.
A couple hours later it tends to spread
and they tend to have a harder
time saying exactly
where the pain is,
and they’ll expand the range of
what they’re complaining of,
and that’s when touching the area involved
noticing any tenderness, any warmth,
any tissue texture change, will help.
Another question is, when do you expose
the area and examine the skin?
And when do you need to see the skin?
And it’s hard that we can’t
give a consistent answer
because if someone’s wearing yoga pants,
it’s easy to examine them and get
a sense of what their motion is.
If they’re wearing jeans, it’s harder
and you may not be able to get a good sense
of what the tissue texture is,
if there is tenderness, if there
are areas of mushiness
or softness of the muscle,
because the cloth will matter.
So if there’s ever a question, it's important
to get someone undressed
and examine them that way.
Again, we try and standardize
how we assess muscles.
Most people in the office are going
to have a muscle strength of 5/5.
And that means they move
well against gravity
and they’re able to function,
lift weights, and move things around.
If you’re in the hospital, and somebody
is unable to move—
that you can’t even get a contraction,
might be central or might be
peripheral, but that’s a 0.
No muscle contraction is 0 muscle strength.
If they can contract, but they can’t move,
if you see them making an effort,
that’s a 1/5 muscle strength.
If they can move the limb but it
falls down quickly, that’s a 2.
They can lift it but they can’t sustain
the lift against gravity.
It’s a 3/5 muscle strength if they
can move against gravity.
It’s a 4/5, if you can push down
and it can resist you.
And it’s a 5/5 muscle strength
if they have full strength and can
move around comfortably.
We also assess deep tendon
reflexes to tell us
how their innervation is and what’s going on.
If they have no response, no
deep tendons—that’s a 0,
mild reflex is 1, normal reflex is 2,
hyperreflexia is 3,
and clonus is when you have the clapping
and the multiple muscle movements.
So there is an ARTT
to examining the musculoskeletal system
and assessing muscles.
You look for any asymmetry,
any difference between the left and
right side, top and bottom.
You look for range of motion abnormalities,
a long of motion and a loss of ability.
And you look for tenderness,
tissue texture changes or
Those are the ARTT that
you have to practice
to see whether the musculoskeletal
system is affected.
A lot of times, people will come
to osteopathic physicians
because they know we’ll focus on
the musculoskeletal system.
Others don’t think the musculoskeletal
is part of their routine physical exam
and they don’t bring it up to us
because they don’t see that as the problem,
that’s something they live with.
There is so much back pain out there.
There’s so much musculoskeletal difficulty
that it tends to get glossed
over as everyday life.
And when you start examining and
doing the physical exam,
every part gets inspected,
gets palpated or touched, gets percussed
to sense the thickness of what’s inside,
and auscultation where you can listen
and hear heart/lungs lung sounds,
that’s part of the full exam.
In the musculoskeletal exam again,
it’s a little bit more diffuse exam
and you may need to expand both
1 joint above and 1 joint below.
A lot of times people will focus on
their joints they use the most
and not the ones they just damaged.
So you don’t want to miss a broken elbow
because you’re examining the wrist.
So always examine 1 joint
above and 1 joint below.
Splinting or stopping motion is very common
and you need to look for that as well.