Assessment

HISTORY. Establish a history of deep, aching joint pain or "grating" joint pain during motion. Determine if the pain intensifies after activity and diminishes after rest and which joints are causing discomfort. Ask if the patient is taking medication for pain and, if so, how much and how often. Ask if the patient feels stiff upon awakening. Determine the relationship of the patient's stiffness to activity or inactivity. Ask if the joints ache during weather changes. Establish a history of altered gait contractures and limited movement. Determine whether the patient has had a severe injury in the past or has worked at an occupation that may have put stress on the weight-bearing joints, such as construction work or ballet dancing. Ascertain whether a family history of OA exists.

PHYSICAL EXAMINATION. Observe the patient's standing posture and gait. Note any obvious curvature of the spine or shuffling gait, which are indicators of limited joint movement. Note if the patient uses a cane or walker. Determine the patient's ability to flex, hyperextend, and rotate the thoracic and lumbar spine. For a patient with lower back pain, place the patient in a supine position, raise the leg, and have the patient dorsiflex the foot. Intensified pain may indicate a herniated disk; if this occurs, defer the examination and report these findings to the physician. Otherwise, have the patient stand, stabilize the pelvis, and rotate the upper torso 30 degrees to the right and to the left. Support the patient if necessary, and ask her or him to bend over from the waist as far as is comfortable. Then ask the patient to bend backward from the waist. Ask the patient to stand up straight and bend to each side. Note the degree of movement the patient is capable of in each maneuver.

Determine the patient's ability to bend the hips. Do not perform this assessment if the patient has had a hip prosthesis. Ask the patient to stand and extend each leg backward with the knee held straight. Have the patient lie on the back and bring each knee up to the chest. Assess internal and external rotation by having the patient turn the bent knee inward and then outward. Have the patient straighten the leg and then adduct and abduct it. Again, note the degree of movement. Listen for crepitus, and observe for pain while the joint is moving.

If DJD is advanced, flexion and lateral deformities of the distal interphalangeal joints occur. Inspect any nodes for redness, swelling, and tenderness. Observe the patient's hands for deformities, nodules, erythema, swelling, and asymmetry of movement. Grasp the hands and feel for sponginess and warmth. Observe for muscle wasting of the fingers. Ask the patient to extend, dor-siflex, and flex the fingers. Assess for radial and ulnar deviation. Finally, have the patient adduct and abduct the fingers. Ask the patient about the degree of pain during each of these movements.

PSYCHOSOCIAL. If the patient has had the disease for some time, explore how it has affected his or her life and how well he or she is adapting to any lifestyle changes. Many elderly patients look forward to retirement and leisure and become depressed about the prospect of pain and limited movement. Trauma from occupational or accidental injuries leaves many individuals unable to work.

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