1: History and Physical Exam - Mahoney Flashcards
cc should contain…
age race sex occupation referred by
who needs to be asked about pregnancy?
women 12-50 yo
what ROS questions should be asked in regards to DM?
type duration last accucheck last Hgb A1C last time checked by family physician
gravida vs. para
of pregnancies
of births
THE CHADS
thyroid heart emphysema cancer hypertension asthma diabetes stroke
what info do you need about meds?
dosage amount frequency route length of time taking med last taken
CPMS clinic policy regarding foot exams
wash hands AND apply gloves prior to any exam or tx of feet
wash hands after visit completed
normal pulse
2/4
pulse with a thrill or bruit
4/4
can be associated with a wide pulse pressure (greater than 60 mmHg)
FACTS and wide pulse pressure
fevere aortic insufficiency complete heart block thyrotoxicosis systolic hypertension
pulses that should always be reported and for each limb separately
dorsalis pedis pulse and posterior tibial pulse
technique for CFT capillary fill time
apply firm digital pressure to the tip of a toe for 3 sec
after releasing your finger, the skin blanches white
a delay beyond 3 sec of return to normal skin color indicates decrease arterial flow into the capillary bed
avoid pressing over toenail to cause blanching due to frequency of thick nails which makes evaluation of the CFT difficult
any delay in CFT can be associated with either vasospasm or structural changes to the lg vessels supplying the microcirculation
non-pitting vs. pitting edema
pitting - prtn poor exudate
non-pitting - prtn rich exudate
method for checking edema
press firmly with your thumb for at least 5 sec over area of max swelling
pitting edema scale
1+ indentation 2 mm
2+ indentation 4 mm
3+ indentation 6 mm
4+ indentation 8 mm
how do you test for turgor and mobility?
lift a fold of skin and note the ease with which it is moved (mobilitiy) and the speed with which it returns into place (turgor)
flat, non-palpable less than .5 cm
macule
flat, non-palpable greater than .5 cm
patch
palpable, solid less than .5 cm
papule
palpable, solid .5-1 cm
nodule
palpable, solid greater than 1 cm
tumor
palpable, solid elevated surface formed by coalescence of papules greater than .5cm in size
plaque
clear, fluid filled less than .5 cm
vesicle
clear, fluid filled greater than .5 cm
bulla
cloudy, pus filled less than .5 cm
pustule
cloudy, pus filled greater than .5 cm
abscess
0A ulcer classification
no break in skin
no inf. or ischemia
IA ulcer classification
to subcutaneous
no infection or ischemia
IIA ulcer classification
to tendon
no infection or ischemia
IIIA ulcer classificiation
to bone
no inf. or ischemia
IB ulcer classification
to subcutaneous
infection
IIB ulcer classification
to tendon
infection
IIIB ulcer classification
to bone
infection
IC ulcer classification
to subcutaneous
ischemia
IIC ulcer classification
to tendon
ischemia
IIIC ulcer classification
to bone
ischemia
ID ulcer classification
to subcutaneous
ischemia and infection
IID ulcer classification
to tendon
infection and ischemia
IIID ulcer classification
to bone
infection and ischemia
normal hip ROM
45 internal and external rotation 45 abduction 20 adduction 120 flexion 0-15 hyperextension
normal knee ROM
130 flexion
15 hyperextension
normal ankle ROM
10 dorsiflextion (knee extended and flexed) 50 plantarflexion
STJ normal ROM
20 inversion
10 eversion
1st MPJ normal ROM
60 dorsiflexion
5-10 plantarflexion
1st ray normal ROM
10 mm total ROM
movement against gravity but not against added resistance
3/5
movement at joint, but not against gravity
2/5
b/c normal pod msk exam occurs in sitting position with feet elevated, active movement of the foot and ankle against resistance implies that the muscle strength rating is at least..
2/5
early loss of strength is usually seen in
extensor digitorum brevis
weakness is normal after 65 yo
more sever m. strength loss seen with
ankle dorsiflexion
most severe loss seen with ankle plantarflexion
mediate voluntary movement, particularly fine, discrete, conscious movement
corticospinal or pyramidal tract
problem could be CVA
helps to maintain m. tone and to control body movements, especially gross automatic movements such as walking
extrapyramidal tract
problem could be parkinsons
receives both sensory and motor input and coordinates muscular activity - maintains equilibrium and helps control posture
cerebellar system
problem could be seen as a loss of the sense of balance
after entry into the dorsal (posterior sensory) spinal cord, the sensory impulse proceeds along one of two courses:
posterior column
lateral spinothalamic tract
pt complains of burning, cramping
lateral spinothalamic tract
sharp and dull pain
temp
crude touch
lateral spinothalamic tract
composition of lateral spinothalmic tract
aka small tract
C and Adelta fibers
composition of large fiber tract
a alpha fibers
aka posterior column
position
vibration
fine touch
posterior column
patient complains of pins and needles or electric shock sensation
posterior column
SWM tests which tract?
lateral spinothalamic
describe how to use the SWM
using a 5.07 SWM apply pressure to 1st, 3rd,5th metatarsal heads and toes, the plantar arch, the plantar hell, beneath the 5th metabase and the dorsal midfoot
inability to detect the pressure in more than 3 areas suggests the potential for neurotrophic ulceration, especially in the diabetic
describe the sharp dull test
use th cotton tip and opposite end to test dull vs. sharp along at least 2 dif dermatomes
ask pt to close eyes then touch asking “which is sharper the first touch or the second touch or are they same?”
sensory tests for posterior column
vibration
position sense
2pt discrimination
describe the vibration test
use a 128 cyc/sec tuning fork over IPJ of hallux, ask pt to tell you when it stops vibrating
place tuning fork over DIPJ of your index finger - vibration should extinguish withing 10 SECONDS
if sensed found to be decreased, proceed more proximally over bony prominences until vibration felt and note area of normal pallesthesia
normal minimal distance at which the pt can discriminate one from two pts on the tip of great toe
5-6 mm
when is an absent achilles reflex normal?
after 80 yo
using reinforcement to facilitate observation of reflexes in LE
jendressic maneuver
document as “reflex with reinforcement”
knee: L2,3,4
ankle: S1,2
deep reflexes are dependent on 5 things. They are NOT dependent upon higher levels of motor function in brain and cord.
intact sensory n. functional synapse in spinal cord intact motor n. fiber NMJ competent m.
normal reflex grade
2/4
4/4 may be associated with clonus and indicates UMN disease
0/4 no response, LMN disease
reflex and dermatome patterns ***
hip - L23 knee - L34 ankle - L45 achilles- S12 back of knee - L5,S1 butt - L45
ankle reflex associated with which n. roots?
S1,2
normal babinski (superficial reflex)
flexing
fanning and dorsiflexion is abnormal and indicates UMN disease
how do you do the bedside babinski
remove pt socks in bed or after placing bedsheet under heel, pull it out from under heel and over toes
if pt can stand on tiptoes but not on heels =
peripheral neuropathy
stand on heels but not on tiptoes = spinal lesion
hop in place with each foot
intact motor system in legs
normal cerebellar function
good position sense
another word for diagnosis
impression
why might a child present with a limp?
Hip AVN
Kohler’s disease (AVN of navicular)
tarsal coalition
child abuse
what should you ask about fetal movements?
was the mother aware of fetal movements beginning in 4th mo of pregnancy?
APGAR *** =
appearance (skin color) pulse (heartbeat) grimace (response to touch or pin-prick) activity (muscle tone) respirations (breathing)
taken immediately and 5 min post birth
desirable score greater than 7
less than 5 - 20% chance breathing difficulty
no hand preference until the age of…
2
if before 2 could be neuromuscular prob
lift head
3 mo
control head position while sitting
6 mo
crawl
6 mo
pull self to stand
9 mo
walk
14 mo
ascend stairs with 2 hand support
18 mo
run forward
2 yr
pedal tricycle
3 yr
balance or hop on one foot
4 yr
heel-toe walk
5 yr (normal heel-toe gait)
skip one foot at a time
6 yr
