肌肉骨骼史

临床沟通技巧（其中的历史是一部分）是任何医疗保健从业人员获得的最重要技能之一 - 这只能通过常规练习来实现。临床检查结果支持的良好历史将使您诊断。在下面，我们更仔细地查看需要解决的关键问题。

如下所示的结构以图表表示关节炎两种主要类型中发生的变化。但是，重要的是要确定可能从关节引起疼痛但实际上是引用疼痛的情况，例如，患者描述了左肩的疼痛，实际上可能是从diaphragm的疼痛中引用疼痛，脖子，或者可能是缺血性心痛。如果检查显示关节没有异常，则将通过详尽的历史获得其他线索。例如，正常联合检查的普遍疼痛的常见原因是fibromyalgia。

滑膜关节及其周围结构的X射线和横截面图。

X-ray and diagrammatic representation of an index finger MCP joint affected by rheumatoid arthritis.

X射线和图形表示受骨关节炎影响的食指MCP关节。

您将需要听取患者的病史来找出答案：

• When did the symptoms start and how have they evolved? Was the onset sudden or gradual?
• Was the onset associated with a particular event – for example, trauma or infection?
• Which treatments has the condition responded to?

症状进化和应对治疗的方式可能是做出诊断的重要指南。痛风, for example, is characterised by acute attacks – these often start in the middle of the night, become excruciatingly painful within a few hours, and respond well tonon-steroidal anti-inflammatory drugs (NSAIDs)。

Musculoskeletal symptoms lasting more than six weeks are generally described as chronic. Chronic diseases may start insidiously and may have a variable course with remissions and exacerbations influenced by therapy and other factors. It may be helpful to represent the chronology of a condition graphically as shown below:

The main symptoms of musculoskeletal conditions are pain, stiffness and joint swelling.

评估这些症状和临床评估可以使炎症和非炎症状况之间进行分化。炎症关节条件，例如类风湿关节炎（RA）, are frequently associated with prolonged early morning stiffness that eases with activity – whilst non-inflammatory conditions, such as骨关节炎（OA）与疼痛相关，而不是僵硬，并且通常会因活动而加剧症状。

疼痛

As with all pain, it is important to record the site, character, radiation, and aggravating and relieving factors.

患者可以将疼痛精确地定位于受影响的关节，或者可能会感觉到它从关节甚至相邻关节辐射。例如，在肩膀上，通常在该关节中感受到巨麦克洛马关节的疼痛，而垂体颈关节或肩袖的疼痛通常在上臂中感觉到。膝盖可能会感觉到膝盖的疼痛，但有时会在臀部或脚踝中感觉到。例如，在神经的分布中，由于神经的刺激而引起的疼痛 - 例如在坐骨神经痛中。疼痛可能位于接近接近的结构上，例如，通常在肘关节的外部会感觉到网球肘部的疼痛。

The character of the pain is sometimes helpful. Is it sharp, deep, achy, burning or stabbing? Pain due to pressure on nerves often has a combination of numbness and tingling associated with it.

非炎症起源的疼痛与使用更直接相关 - 您做得越糟，会得到的疼痛 - 可能会因休息而缓解。疼痛有时会尖锐，刺伤或疼痛。

疼痛caused by inflammation is often present at rest as well as on use and tends to vary from day to day and from week to week in an unpredictable fashion. It flares up and then it settles down and can be associated with tenderness to the touch. Severe bone pain (suggestive of underlying malignancy) is often unremitting and persists through the night, disturbing the patient’s sleep.

刚性

通常，炎症性关节炎与长时间的早晨僵硬有关，这是普遍的，可能持续数小时。早晨刚度的持续时间是炎症活性的粗略指南。

非炎性关节炎，例如膝盖的骨关节炎，倾向于引起局部刚度，这可能是短暂的（少于30分钟），但坐着短时间后可能会复发。

随着炎症性疾病（例如类风湿关节炎）在长时间内发生关节破坏，炎症成分最终可能会变得较少活跃，并因损害而使次级机械疼痛取代。因此，有时患者很难区分疼痛和僵硬，因此您的问题需要具体。

关节肿胀

关节肿胀的病史，尤其是如果是间歇性的，通常是炎症过程的良好迹象。患者经常描述戒指变紧或在鹅卵石上行走的感觉。

但是有例外。例如，淋巴结骨关节炎会导致手指的近端（PIP）和远端的指间（dip）关节引起骨，硬质和非刺激性肿胀。膝盖的肿胀也不太暗示炎症性疾病，因为创伤和OA也可能发生。踝关节肿胀是一个普遍的抱怨，但这通常是由于水肿而不是关节肿胀。

联合参与的模式在定义关节炎的类型方面非常有帮助，因为不同的模式与不同的疾病有关。

共同参与的常见模式包括：

Monoarticular- 只有一个关节受影响（例如，化粪池关节炎）

pauciarticular(or oligoarticular) – only a few joints affected (e.g.银屑病关节炎)

Polyarticular- 受影响的许多关节（例如rheumatoid arthritis)

Axial- 脊柱主要受到影响（例如ankylosing spondylitis)

以及受影响关节的数量, it is useful to consider whether thelarge or small jointsare involved, and whether the pattern issymmetrical or asymmetrical。例如,类风湿性关节炎是一种polyarthritis (it affects lots of joints) that tends to be symmetrical (if it affects one joint, it will affect the same joint on the other side), and if it affects one of a group of joints it will often affect them all, for example, the metacarpophalangeal (MCP) joints.

但是请注意，这描述了已建立的疾病和早期RA可能会影响任何关节模式。

脊椎按钮症，例如银屑病关节炎，更可能是不对称的，并且可能与炎症症状有关，例如涉及脊柱的清晨僵硬。Osteoarthritis倾向于影响承重关节和移动最多的脊柱（腰椎和颈椎）的部分。

This table提供了一些常见的肌肉骨骼状况以及寻找的东西的典型特征的摘要。

了解疾病对患者的影响对于谈判合适的管理计划至关重要。

Ask open-ended questions about functional issues and difficulty with day-to-day activities. It may be easiest to get the patient to describe a typical day, from getting out of bed to washing, dressing, toileting etc. Potentially sensitive areas – such as hygiene or sexual activity, mood, depression and anxiety – should be approached with simple, direct, open questions. The impact of the disease on the patient’s employment will be crucial.

患者的需求和愿望是方程式的重要组成部分，将影响他们适应疾病的能力。询问一个人想做的事情，但目前无法做到的事情，可能会指出关键问题。他们的想法，关注和期望是什么？后来与患者进行平衡干预风险和利益的谈判将受到患者的优先事项的极大影响。

所有医疗保健从业人员都应了解功能损失，活动限制和参与限制之间的关系，如世界卫生组织的国际功能，残疾和健康分类所示（请参见下面的模型）。例如，无法完全弯曲手指（功能丧失）可能会导致困难，例如，固定按钮（活动）可能会对一般生活产生较小的影响（参与）。然而，同样的功能丧失可能会阻止钢琴家演奏（活动），对于专业音乐家而言，这可能会对他/她的生活方式（参与）产生重大影响。

A model of disability - the relationship between loss of function, limitation of activity and restriction of participation.基于世界卫生组织的国际功能，残疾和健康分类。残疾和功能是健康状况与背景因素（环境和个人因素）之间相互作用的结果。

Inflammatory arthritis often involves other systems including the skin, eyes, lungs and kidneys. In addition, patients with inflammatory disease often suffer from general symptoms such as malaise, weight loss, mild fevers and night sweats. Osteoarthritis, in contrast, is limited to the musculoskeletal system and is not associated with immune activation. Systemic symptoms would therefore not be expected.

Fatigue and depression may be common in any arthritis where there is functional loss or chronic pain. A comprehensive history must include the usual screening questions for all systems as well as specific enquiries relating to known complications of specific musculoskeletal disorders.

Arthritis may occur on a background of other illnesses and it is important to consider other ongoing health issues, particularly with an increasingly ageing population. A combination of two problems will be worse than either one alone, and the impact on the patient will therefore be greater. In addition, other conditions may be affected by the treatments prescribed for the arthritis – for example, the presence of liver disease may limit the use of disease-modifying drugs for inflammatory arthritis, because most of these drugs can upset the liver.