228 CH 24 & 25 Musculoskeletal & Neuro Assessment

Subjective: Do you experience difficulty swallowing?

Difficulty swallowing may relate to CVA; Parkinson disease; myasthenia gravis; Guillain-Barré syndrome; or dysfunction of cranial nerves IX (glossopharyngeal), X (vagus), or XII (hypoglossal).

Subjective: Have you noticed a decrease in your ability to smell or to taste?

A decrease in the ability to smell may be related to a dysfunction of cranial nerve I (olfactory) or a brain tumor. A decrease in the ability to taste may be related to dysfunction of cranial nerves VII (facial) or IX (glossopharyngeal).

Subjective: Describe your activities during a typical day. How much time do you spend in the sunlight?

A sedentary lifestyle increases the risk of osteoporosis. Prolonged immobility leads to muscle atrophy. Exposure to 20 minutes of sunlight per day promotes the production of vitamin D in the body. Vitamin D deficiency can cause osteomalacia and limit calcium absorption.

Subjective: Describe your typical 24-hour diet. Are you able to consume milk or milk-containing products? Do you take any calcium supplements?

Adequate protein in the diet promotes muscle tone and bone growth; vitamin C promotes healing of tissues and bones. A calcium deficiency increases the risk of osteoporosis. Vitamin D intake via sun exposure, dietary sources, and/or supplement is required to absorb calcium. A diet high in purine (e.g., meat, liver, sardines) and alcohol can trigger gouty arthritis.

Subjective: How did you view yourself before you had this musculoskeletal problem, and how do you view yourself now?

Body image disturbances and chronic low self-esteem may occur with a disabling or crippling problem.

Subjective: Describe any joint, muscle, or bone pain you have. Where is the pain? What does the pain feel like (stab, ache)? When did the pain start? When does it occur? How long does it last? Any stiffness, swelling, limitation of movement?

Bone pain is often dull, deep, and throbbing. Joint or muscle pain is described as aching, but has been differentiated between mechanical- and inflammatory-type pains. Sharp, knifelike pain occurs with most fractures and increases with motion of the affected body part. Osteoarthritis pain usually begins in one set of joints and on one side of the body, with a feeling of pain deep in the joint, improving with rest but worsening with rainy weather, perhaps a sensation of bones grating together, with stiffness early in the morning improving with movement. Rheumatoid arthritis pain and symptoms are varied; client may feel burning or throbbing on both sides of the body, which worsen after sitting for long periods, has inconsistent pattern of worse and less pain, and experiences a feeling of heat and soreness in joints. The client may also experience weak muscles, feeling tired or depressed, weight loss, decreased appetite, slightly elevated temperature, swollen glands, or significant stiffness in the morning that persists at least an hour. Fibromyalgia, a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood changes, or cognitive disorders, is hard to diagnose. Causes seem to be genetic or from triggers such as infections or physical or emotional trauma. Females, those with family history, or those having a rheumatic disease, are at risk. Diagnosis no longer includes specific pressure points for pain, but only the history of widespread pain for 3 months with no underlying cause for the pain. Although nonspecific, blood tests for complete blood count (CBC), sedimentation rate, and thyroid function are often performed.

Subjective: Describe your occupation.

Certain job-related activities increase the risk for development of musculoskeletal problems. For example, incorrect body mechanics, heavy lifting, or poor posture can contribute to back problems; consistent, repetitive wrist and hand movements can lead to the development of carpal tunnel syndrome (CTS).

Subjective: Have you noticed any change in your vision?

Changes in vision may occur with dysfunction of cranial nerve II (optic), increased intracranial pressure, or brain tumors. Damage to cranial nerves III (oculomotor), IV (trochlear), or VI (abducens) may cause double or blurred vision. Transient blind spots may be an early sign of a cerebrovascular accident (CVA).

Subjective: Describe any difficulty that you have chewing. Is it associated with tenderness or pain?

Clients with temporomandibular joint (TMJ) dysfunction may have difficulty chewing and may describe their jaws as "getting locked or stuck." Jaw tenderness, pain, or a clicking sound may also be present with TMJ

Subjective: Do you experience dizziness or lightheadedness or problems with balance or coordination? If so, how often? When does it occur? Does it occur with activity? Have you had any falls with the lightheadedness or dizziness? Do you have any clumsy movement(s)?

Dizziness or lightheadedness may be related to carotid artery disease, cerebellar abscess, Ménière disease, or inner ear infection. Imbalance and difficulty coordinating or controlling movements are seen in neurologic diseases involving the cerebellum, basal ganglia, extrapyramidal tracts, or the vestibular part of cranial nerve VIII (acoustic). Diminished cerebral blood flow and vestibular response may increase the risk of falls.

Subjective: Do you drink alcohol or caffeinated beverages? How much and how often?

Excessive consumption of alcohol or caffeine can increase the risk of osteoporosis.

Objective: Evaluate rotation. Ask the client to turn the head to the right and left

Expected: About 70 degrees of rotation is normal. Abnormal: Limited ROM is seen with neck injuries, osteoarthritis, spondylosis, or disk degeneration

Objective: Assess pupillary response to light (direct and indirect) and accommodation in both eyes

Expected: Bilateral illuminated pupils constrict simultaneously. Pupil opposite the one illuminated constricts simultaneously. Abnormal: Some abnormalities and their implications follow: Dilated pupil (6-7 mm): oculomotor nerve paralysis. Argyll Robertson pupils: CNS syphilis, meningitis, brain tumor, alcoholism. Constricted, fixed pupils: narcotics abuse or damage to the pons. Unilaterally dilated pupil unresponsive to light or accommodation: damage to cranial nerve III (oculomotor). Constricted pupil unresponsive to light or accommodation: lesions of the sympathetic nervous system.

Objective: Observe the cervical, thoracic, and lumbar curves from the side, then from behind. Have the client standing erect with the gown positioned to allow an adequate view of the spine. Observe for symmetry, noting differences in height of the shoulders, iliac crests, and buttock creases.

Expected: Cervical and lumbar spines are concave; thoracic spine is convex. Spine is straight (when observed from behind). Abnormal: A flattened lumbar curvature may be seen with a herniated lumbar disk or ankylosing spondylitis. Lateral curvature of the thoracic spine with an increase in the convexity on the curved side is seen in scoliosis. An exaggerated lumbar curve (lordosis) is often seen in pregnancy or obesity. Unequal heights of the hips suggest unequal leg lengths.

Objective: Assess for the risk of falling backward in the older client or the client with handicaps by performing the "nudge test." Stand behind the client and put your arms around the client while you gently nudge the sternum.

Expected: Client does not fall backward. Abnormal: Falling backward easily is seen with cervical spondylosis and Parkinson disease.

Objective: Ask the client to repeat the cervical ROM movements against resistance.

Expected: Client has full ROM against resistance. Strength 5/5. Abnormal: Decreased ROM against resistance is seen with joint or muscle disease.

Objective: Ask the client to read a newspaper or magazine paragraph to assess near vision.

Expected: Client reads print at 14 in. without difficulty. Abnormal: Client reads print by holding closer than 14 in. or holds print farther away as in presbyopia, which occurs with aging.

Objective: Check the client's ability to swallow by giving the client a drink of water. Also note the client's voice quality.

Expected: Client swallows without difficulty. No hoarseness noted. Abnormal: Dysphagia or hoarseness may indicate a lesion of cranial nerve IX (glossopharyngeal) or X (vagus) or other neurologic disorder.

Objective: Observe gait. Observe the client's gait as the client enters and walks around the room. Note: • Base of support • Weight-bearing stability • Foot position • Stride, length, and cadence of stride • Arm swing • Posture

Expected: Evenly distributed weight. Client able to stand on heels and toes. Toes point straight ahead. Equal on both sides. Posture erect, movements coordinated and rhythmic, arms swing in opposition, stride length appropriate. Abnormal: Uneven weight bearing is evident. Client cannot stand on heels or toes. Toes point in or out. Client limps, shuffles, propels forward, or has wide-based gait.

Objective: Test ROM. Explain to the client that you will be assessing ROM (consisting of flexion, extension, adduction, abduction, and motion against resistance). Ask client to stand with both arms straight down at the sides. Next, ask the client to move the arms forward (flexion), then backward with elbows straight

Expected: Extent of forward flexion should be 180 degrees; hyperextension, 50 degrees; adduction, 50 degrees; and abduction 180 degrees. Abnormal: Painful and limited abduction accompanied by muscle weakness and atrophy are seen with a rotator cuff tear. Client has sharp catches of pain when bringing hands overhead with rotator cuff tendinitis. Chronic pain and severe limitation of all shoulder motions are seen with calcified tendinitis.

Objective: Assess CN III (oculomotor), IV (trochlear), and VI (abducens). Inspect margins of the eyelids of each eye.

Expected: Eyelid covers about 2 mm of the iris. Abnormal: Ptosis (drooping of the eyelid) is seen with weak eye muscles such as in myasthenia gravis

Objective: Assess extraocular movements. If nystagmus is noted, determine the direction of the fast and slow phases of movement

Expected: Eyes move in a smooth, coordinated motion in all directions (the six cardinal fields). Abnormal: Some abnormal eye movements and possible causes follow: Nystagmus (rhythmic oscillation of the eyes): cerebellar disorders. Limited eye movement through the six cardinal fields of gaze: increased intracranial pressure. Paralytic strabismus: paralysis of the oculomotor, trochlear, or abducens nerves

Objective: Test ROM of the lumbar spine. Ask the client to bend forward and touch the toes. Observe for symmetry of the shoulders, scapula, and hips.

Expected: Flexion of 75-90 degrees, smooth movement, lumbar concavity flattens out, and the spinal processes are in alignment. Abnormal: Lateral curvature disappears in functional scoliosis; unilateral exaggerated thoracic convexity increases in structural scoliosis. Spinal processes are out of alignment.

Objective: Test ROM of the cervical spine. Test ROM of the cervical spine by asking the client to touch the chin to the chest (flexion) and to look up at the ceiling (hyperextension)

Expected: Flexion of the cervical spine is 45 degrees. Extension of the cervical spine is 45 degrees. Abnormal: Cervical strain is the most common cause of neck pain. It is characterized by impaired ROM and neck pain from abnormalities of the soft tissue (muscles, ligaments, and nerves) due to straining or injuring the neck. Causes of strains can include sleeping in the wrong position, carrying a heavy suitcase, or being in an automobile crash. Cervical disk degenerative disease and spinal cord tumors are associated with impaired ROM and pain that radiates to the back, shoulder, or arms. Neck pain with a loss of sensation in the legs may occur with cervical spinal cord compression.

Objective: Assess visual fields of each eye by confrontation.

Expected: Full visual fields Abnormal: Loss of visual fields may be seen in retinal damage or detachment, with lesions of the optic nerve, or with lesions of the parietal cortex

Objective: Test the gag reflex by touching the posterior pharynx with the tongue depressor.

Expected: Gag reflex intact. Some normal clients may have a reduced or absent gag reflex. Abnormal: An absent gag reflex may be seen with lesions of cranial nerve IX (glossopharyngeal) or X (vagus).

Objective: Test ROM. Ask the client to open the mouth and move the jaw laterally against resistance. Next, as the client clenches the teeth, feel for the contraction of the temporal and masseter muscles to test the integrity of cranial nerve V (trigeminal nerve).

Expected: Jaw has full ROM against resistance. Contraction palpated with no pain or spasms. Abnormal: Lack of full contraction with cranial nerve V lesion. Pain or spasms occur with myofascial pain syndrome.

Objective: Sit down behind the client, stabilize the client's pelvis with your hands, and ask the client to bend sideways (lateral bending), bend backward toward you (hyperextension), and twist the shoulders one way, then the other (rotation).

Expected: Lateral bending capacity of the thoracic and lumbar spines should be about 35 degrees, hyperextension about 30 degrees, and rotation about 30 degrees. Abnormal: Low back strain from injury to soft tissues is a common cause of impaired ROM and pain in the lumbar and thoracic regions. Other causes of impaired ROM in the lumbar and thoracic areas include osteoarthritis, ankylosing spondylitis, and congenital abnormalities that may affect the spinal vertebral spacing and mobility.

Objective: Measure leg length. If you suspect that the client has one leg longer than the other, measure them. Ask the client to lie down with legs extended. With a measuring tape, measure the distance between the anterior superior iliac spine and the medial malleolus, crossing the tape on the medial side of the knee

Expected: Measurements are equal or within 1 cm. If the legs still look unequal, assess the apparent leg length by measuring from a nonfixed point (the umbilicus) to a fixed point (medial malleolus) on each leg. Abnormal: Unequal leg lengths are associated with scoliosis. Equal true leg lengths but unequal apparent leg lengths are seen with abnormalities in the structure or position of the hips and pelvis.

Objective: Palpate the spinous processes and the paravertebral muscles on both sides of the spine for tenderness or pain.

Expected: Nontender spinous processes; well-developed, firm and smooth, nontender paravertebral muscles. No muscle spasm. Abnormal: Compression fractures and lumbosacral muscle strain can cause pain and tenderness of the spinal processes and paravertebral muscles.

Objective: Test lateral bending. Ask the client to touch each ear to the shoulder on that side

Expected: Normally the client can bend 40 degrees to the left side and 40 degrees to the right side. Abnormal: Limited ROM is seen with neck injuries, osteoarthritis, spondylosis, or disk degeneration.

Objective: Observe posture. Observe the client's posture while standing with the feet together, noting alignment of the head, trunk, pelvis, and extremities. Also observe client's posture while sitting.

Expected: Posture is erect and comfortable for age. Abnormal: Slumped shoulders may result from poor posture (especially while seated) or from depression. Abnormal curvatures of the spine include lordosis, scoliosis, or kyphosis

Objective: Inspect and palpate shoulders and arms. With the client standing or sitting, inspect anteriorly and posteriorly for symmetry, color, swelling, and masses. Palpate for tenderness, swelling, or heat. Anteriorly palpate the clavicle, acromioclavicular joint, subacromial area, and the biceps. Posteriorly palpate the glenohumeral joint, coracoid area, trapezius muscle, and the scapular area.

Expected: Shoulders are symmetrically round; no redness, swelling, deformity, or heat. Muscles are fully developed. Clavicles and scapulae are even and symmetric. The client reports no tenderness. Abnormal: Flat, hollow, or less-rounded shoulders are seen with dislocation. Muscle atrophy is seen with nerve or muscle damage or lack of use. Tenderness, swelling, and heat may be noted with shoulder strains, sprains, arthritis, bursitis, and degenerative joint disease (DJD).

Objective: Inspect and palpate the TMJ. Have the client sit; put your index and middle fingers just anterior to the external ear opening. Ask the client to open the mouth as widely as possible. (The tips of your fingers should drop into the joint spaces as the mouth opens.) • Move the jaw from side to side • Protrude (push out) and retract (pull in) jaw

Expected: Snapping and clicking may be felt and heard in the normal client. Mouth opens 1-2 in. (distance between upper and lower teeth). The client's mouth opens and closes smoothly. Jaw moves laterally 1-2 cm. Jaw protrudes and retracts easily. Abnormal: Decreased ROM, swelling, tenderness, or crepitus may be seen in arthritis. Decreased muscle strength with muscle and joint disease. Decreased ROM, and a clicking, popping, or grating sound may be noted with TMJ dysfunction.

Objective: Test motor function. Ask the client to clench the teeth while you palpate the temporal and masseter muscles for contraction

Expected: Temporal and masseter muscles contract bilaterally. Abnormal: Decreased contraction in one or both sides. Asymmetric strength in moving the jaw may be seen with lesion or injury of the fifth cranial nerve. Pain occurs with clenching of the teeth. Bilateral muscle weakness is seen with peripheral or central nervous system dysfunction. Unilateral muscle weakness may indicate a lesion of cranial nerve V (trigeminal).

Objective: With client sitting, inspect the sternoclavicular joint for location in midline, color, swelling, and masses. Then palpate for tenderness or pain

Expected: There is no visible bony overgrowth, swelling, or redness; joint is nontender. Abnormal: Swollen, red, or enlarged joint or tender, painful joint is seen with inflammation of the joint.

Objective: Test CN VII (facial). Test motor function. Ask the client to: Smile Frown and wrinkle forehead (Fig. 25-13A) Show teeth Puff out cheeks (Fig. 25-13B) Purse lips Raise eyebrows Close eyes tightly against resistance

Expected; Client smiles, frowns, wrinkles forehead, shows teeth, puffs out cheeks, purses lips, raises eyebrows, and closes eyes against resistance. Movements are symmetric. Abnormal: Inability to close eyes, wrinkle forehead, or raise eyebrows along with paralysis of the lower part of the face on the affected side is seen with Bell palsy (a peripheral injury to cranial nerve VII [facial]). Paralysis of the lower part of the face on the side opposite to that affected may be seen with a central lesion that affects the upper motor neurons, such as from stroke. If stroke is suspected, Act FAST! See Clinical Tip. Additional symptoms of stroke Sudden numbness or weakness of face, arm, or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance, or coordination Sudden severe headache with no known cause

Subjective: Do you experience any repetitive, involuntary trembling, quivering, shaking, or other movements? Describe.

Fasciculations (continuous, rapid twitching of resting muscles) may be seen in lower motor neuron disease. Tremors (involuntary contraction of opposing groups of muscles) are typical in degenerative neurologic disorders, such as Parkinson disease (3-6 per second while muscles are at rest or "pin rolling" between thumb and opposing finger), or in cerebellar disease and MS (variable rate, and especially with intentional movement). Tics (involuntary repetitive twitching movements) may be seen in Tourette syndrome, habit psychogenic tics, or tardive dyskinesias. Myoclonus (sudden jerks of arms or legs) may occur normally when falling asleep as a single jerk. However, severe jerking is often seen with grand mal seizures. Chorea (sudden rapid, jerky voluntary and involuntary movements of limbs, trunk, or face) is seen in Huntington disease and Sydenham chorea. Athetosis (twisting, writhing, slow, continuous movements) is seen in cerebral palsy.

Subjective: Have you ever been diagnosed with diabetes mellitus, sickle cell anemia, systemic lupus erythematosus (SLE), or osteoporosis?

Having diabetes mellitus, sickle cell anemia, or SLE places the client at risk for development of musculoskeletal problems such as osteoporosis and osteomyelitis. Type 1 diabetes increases risk of low bone density, and may increase fracture risk, but fractures may be related to poor vision and nerve damage, which are likely to produce falls. Although clients with type 2 diabetes often have increased body weight and thereby increased bone density, they, too, are likely to have an increased risk of fractures due to vision and nerve damage. Clients who are immobile or have a reduced intake of calcium and vitamin D are especially prone to develop osteoporosis

Subjective: Have you ever had any type of head injury with or without loss of consciousness (e.g., sports injury, auto accident, fall)? If so, describe any physical or mental changes that have occurred as a result. What type of treatment did you receive?

Head injuries, even if minor, can produce long-term neurologic deficits and affect the client's level of functioning.

Subjective: Do you have difficulty performing normal ADLs (bathing, dressing, grooming, eating)? Do you use assistive devices (e.g., walker, cane, braces) to promote your mobility and ADLs?

Impairment of the musculoskeletal system may impair the client's ability to perform normal ADLs. Correct use of assistive devices can promote safety and independence. Some clients may feel embarrassed and not use their prescribed or needed assistive device.

Subjective: Describe what happens before you have the seizure and where on your body the seizure starts. Does anything seem to initiate a seizure? Do you lose control of your bladder during the seizure? How often? How do you feel afterward? Do you take medications for the seizures? Do you wear medical identification to alert others that you have seizures? Do you take safety precautions regarding driving or operating dangerous machinery?

In some cases, an aura (an auditory, visual, or motor sensation) forewarns the client that a seizure is about to occur. Where the seizure starts and what occurs before and after can aid in determining the type of seizure (e.g., generalized seizure, formerly known as grand mal and affecting both hemispheres of the brain, or absence seizure, also known as petit mal) and its treatment. Clients with generalized seizures often experience bladder incontinence during the seizure. Antiepileptic medications (anticonvulsants) must be distributed at a therapeutic level in the blood to be effective.

Subjective: Do you have difficulty understanding when people are talking to you? Do you have difficulty making others understand you? Do you have difficulty forming words (dysarthria) or comprehending and expressing your thoughts (dysphasia)?

Injury to the cerebral cortex can impair the ability to speak or understand verbal language.

Subjective: Do you frequently lift heavy objects or perform repetitive motions?

Intervertebral disc injuries may result when heavy objects are lifted improperly. Peripheral nerve injuries can occur from repetitive movements.

Subjective: When were your last tetanus and polio immunizations?

Joint stiffening and other musculoskeletal symptoms may be a transient effect of the tetanus, whooping cough, diphtheria, or polio vaccines

Subjective: Have you lost bowel or bladder control or do you retain urine?

Loss of bowel control or urinary retention and bladder distention are seen with spinal cord injury or tumors.

Subjective: Do you experience any numbness or tingling? If yes, use COLDSPA to further assess: Character: Describe the sensations (e.g., Pins and needles? Burning? Sand running over skin?) Onset: When does this begin and when does it occur? Do you have numbness or tingling? Location: Where do you have this sensation? Duration: How long does this last? Is it continuous? Severity: Does it interfere with your ability to perform any activity? Pattern: Does anything relieve or make it worse (activities, rest)? Associated factors/how it affects the client: Does it occur with other symptoms?

Loss of sensation, tingling, or burning (paresthesia) may occur with damage to the brain, spinal cord, or peripheral nerves

Subjective: Has your neurologic problem changed the way you view yourself? Describe.

Low self-esteem and body image problems may lead to depression and changes in role functions.

Subjective: Do you experience headaches? Use COLDSPA to further explore: Character: Describe the character of the pain. Onset: When do they occur? Location: Point to the location on your head where you feel the headache. Duration: How long does it last? Severity: Does it interfere with your ADLs? Pattern: What relieves the headache? What makes it worse? Associated factors/how it affects the client: Do you have any other associated symptoms (nausea, vomiting, dizziness)?

Morning headaches that subside after arising may be an early sign of increased intracranial pressure such as with a brain tumor.

Subjective: Has your musculoskeletal problem added stress to your life? Describe.

Musculoskeletal problems often greatly affect ADLs and role performance, resulting in changed relationships and increased stress.

Subjective: How have your musculoskeletal problems interfered with your ability to interact or socialize with others? Have they interfered with your usual sexual activity?

Musculoskeletal problems, especially chronic ones, can disable and cripple the client, which may impair socialization and prevent the client from performing the same roles as in the past. Back problems, joint pain, or muscle stiffness may interfere with sexual activities.

Subjective: Has your neurologic problem added much stress to your life? Describe.

Neurologic problems can impair ability to fulfill role responsibilities, greatly increasing stress. Stress can increase existing neurologic symptoms.

Subjective: Can you perform your normal independent activities of daily living (IADLs)?

Neurologic symptoms and disorders often negatively affect the ability to perform IADLs.

Subjective: Do you smoke?

Nicotine, which is found in cigarettes, constricts the blood vessels, which decreases blood flow to the brain. Cigarette smoking is a risk factor for CVA

Subjective: Describe your usual daily 24-hour diet recall.

Peripheral neuropathy can result from a deficiency in niacin, folic acid, or vitamin B12.

Subjective: Describe your posture at work and at leisure. What type of shoes do you usually wear? Do you use any special footwear (i.e., orthotics)?

Poor posture, prolonged forward bending (as in sitting) or backward leaning (as in working overhead), or long-term carrying of heavy objects on the shoulders can result in back problems. Contracture of the Achilles tendon can occur with prolonged use of high-heeled shoes.

Subjective: Do you take any prescription or nonprescription medications? How much alcohol do you drink? Do you use recreational drugs such as marijuana, tranquilizers, barbiturates, or cocaine?

Prescription and nonprescription drugs can cause various neurologic symptoms such as tremors or dizziness, altered level of consciousness, decreased response times, and changes in mood and temperament.

Subjective: Have you ever had prolonged exposure to lead, insecticides, pollutants, or other chemicals?

Prolonged exposure to these substances can alter neurologic status.

Subjective: Do you experience any memory loss?

Recent memory (24-hour memory) is often impaired in amnesic disorders, Korsakoff syndrome, delirium, and dementia. Remote memory (past dates and historic accounts) may be impaired in cerebral cortex disorders.

Subjective: Describe any routine exercise that you do.

Regular exercise promotes flexibility, muscle tone, and strength, while weight-bearing exercises are the only exercises that can promote bone density. Regular exercise can also help to slow the usual musculoskeletal changes, progressive loss of total bone mass (osteopenia/osteoporosis), and degeneration of skeletal muscle fibers (sarcopenia) that occur with aging. Improper body positioning in contact sports results in injury to the bones, joints, or muscles.

Subjective: Have you experienced any ringing in your ears (tinnitus) or hearing loss?

Ringing in the ears and decreased ability to hear may occur with dysfunction of cranial nerve VIII (acoustic).

Subjective: Do you wear your seatbelt when riding in vehicles? Do you wear protective headgear when riding a bicycle or playing sports?

Seatbelts and protective headgear can prevent head injury

Subjective: Do you experience seizures (altered or loss of consciousness that occurs with involuntary muscle movements and sensory disturbances)?

Seizures occur with epilepsy, metabolic disorders, head injuries, and high fevers.

Subjective: Do you smoke tobacco? How much and how often?

Smoking increases the risk of osteoporosis

Subjective: What medications are you taking?

Some medications can affect musculoskeletal function. Diuretics, for example, can alter electrolyte levels, leading to muscle weakness. Steroids can deplete bone mass, thereby contributing to osteoporosis. Adverse reactions to HMG-CoA reductase inhibitors (statins) can include myopathy, which can cause muscle pain, soreness, tiredness, or weakness

Subjective: Have you ever had a bone density screening? When was your last one?

The U.S. Preventive Services Task Force recommends that postmenopausal women younger than age 65 get bone density scans if they have risk factors for osteoporosis, including a history of fractured bones, being White, smoking, alcohol abuse, or a slender frame. Bone density screening is recommended for all women at age 65. The USPSTF recommended against screening for men.

Subjective: Do you have a family history of rheumatoid arthritis, gout, or osteoporosis?

These conditions tend to be familial and can increase the client's risk for development of these diseases.

Subjective: Have you ever had meningitis, encephalitis, injury to the spinal cord, or a stroke? If so, describe any physical or mental changes that have occurred as a result. What type of treatment did you receive?

These disorders can affect the long-term physical and mental status of the client.

Subjective: Do you have a family history of high blood pressure, stroke, Alzheimer disease, dementia, epilepsy, brain cancer, or Huntington chorea?

These disorders may be genetic. Some tend to run in families.

Subjective: Describe any past problems or injuries you have had to your joints, muscles, or bones. What treatment was given? Do you have any aftereffects from the injury or problem?

This information provides baseline data for the physical examination. Past injuries may affect the client's current ROM and level of function in affected joints and extremities. A history of recurrent fractures may be seen with osteomalacia but should also raise the question of possible physical abuse.

Subjective: What activities do you engage in to promote the health of your muscles and bones (e.g., exercise, diet, weight reduction)?

This question provides the examiner with knowledge of how much the client understands and actively participates in activities to promote the health of the musculoskeletal system.

Subjective: Do you have muscle weakness? Do you have any loss of movements? If so, where?

Unilateral weakness or paralysis (loss of motor function from lesion[s] in the neurologic or muscular systems) may result from CVA, compression of the spinal cord, or nerve injury. Progressive weakness is a symptom of several nervous system diseases.

Subjective: Have you had any recent weight gain?

Weight gain can increase physical stress and strain on the musculoskeletal system.

Subjective: For middle-aged women: Have you started menopause? Are you taking estrogen or hormone replacement therapy?

Women who begin menarche late or begin menopause early are at greater risk for development of osteoporosis because of decreased estrogen levels, which tend to decrease the density of bone mass