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Clinical Pod Med Exam 1 > 1 - Podiatric History and Physical > Flashcards

1 - Podiatric History and Physical Flashcards

1
Q

What is the single most important part of the podiatric exam?

A

History

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2
Q

Describe the podiatric history

A
  • Once completed, you should be able to have a working diagnosis even before your physical exam.
  • Your physical exam should complement your history.

Although the history is the most important, there will be NO questions on the exam on history - ONLY physical exam

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3
Q

What are the five things about diabetes that you NEED to document when seeing a diabetic?

A
  • Type
  • Duration
  • Last accucheck
  • Last Hgb A1C
  • Last time checked by family physician

These will help you get highest reimbursement from medicare

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4
Q

What is the policy for washing and gloving at CPMS?

A
  • Wash hands and apply gloves prior to any examination or treatment of the feet.
  • Wash hands after visit completed.

Even when you’re taking the history, I suggest you have on your gloves.

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5
Q

What is the first parts of the physical exam?

A

Vitals: BP, pulse, respirations, oral temperature

General appearance

CHART:
“His vital signs are within normal limits (WNL). He is grossly obese and disheveled. He has poor hygiene.”

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6
Q

Describe the scale of pulses

A

Pulses: Pulses are classified according to the following scheme:

0/4 - Absent
1/4 - Weakly palpated
2/4 - Normal
3/4 - Bounding
4/4 - Strongest, usually associated with thrill or bruit (“feel a thrill, hear a bruit”)
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7
Q

What can cause a bounding pulse?

A

Bounding pulses can be associated with a wide pulse pressure (> 60 mm Hg) and seen with (FACTS):

F = Fever
A = Aortic insufficiency
C = Complete heart block
T = Thyrotoxicosis
S = Systolic hypertension
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8
Q

Describe the dorsalis pedis pulse

A

Dorsalis pedis pulse and posterior tibial pulse should always be reported and for each limb separately

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9
Q

What other pulses do you check?

A

Also check peroneal, popliteal, and femoral pulses if indicated

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10
Q

What do you do if you are unsure on a pulse?

A

Make sure you are not feeling your own pulse. If unsure, can use a doppler to locate the pulse and then palpate it

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11
Q

Describe capillary fill time

A

Capillary Fill Time (CFT): Apply firm digital pressure to the tip of a toe for 3 seconds. After releasing your finger, the skin blanches white. A delay beyond 3 seconds of return to normal skin color indicates decrease arterial flow into the capillary bed.

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12
Q

Describe capillary fill time in thick/yellow nails

A

Avoid pressing over toenail to cause blanching due to frequency of thick nails which makes evaluation of the CFT difficult

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13
Q

Describe a delay in capillary fill time

A

Any delay in CFT can be associated with either vasospasm or structural changes to the large vessels supplying the microcirculation.

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14
Q

Describe edema

A

Edema: Ascertain if it is mild, moderate, or severe , if it is non-pitting (protein rich exudate) or pitting (protein poor exudate), and if it is bilateral and symmetrical

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15
Q

How do you check edema?

A

Press firmly with your thumb for at least 5 seconds over the area of maximum swelling. If an indentation remains for over 5 seconds, it is considered pitting edema.

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16
Q

Describe the scale of pitting edema

A

Pitting edema sometimes classified on a numerical scale:

1+: indentation 2mm
2+: indentation 4 mm
3+: indentation 6 mm
4+: indentation 8 mm

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17
Q

How do you evaluate the nutritional condition of the skin?

A

Note the nutritional condition of the skin:

  • Presence or absence of hair growth
  • Temperature
  • Color
  • Texture: Roughness, smoothness
  • Turgor: Lift a fold of skin and note the ease with which it is moved (mobility) and the speed with which it returns into place (turgor)
  • Appearance of toenails
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18
Q

Describe the aspects of the dermatology exam

A

Color: Brownness, cyanosis, redness, yellowness, pallor.
Vascularity: Evidence of bleeding or bruising.

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19
Q

What are primary lesions in the dermatology exam

A
  • Flat, not palpable
  • Palpable, solid
  • Clear, fluid filled
  • Cloudy, pus filled
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20
Q

Describe the types of flat, non-palpable primary lesion

A
  • Macule (less than 0.5 cm)
  • Patch (larger than 0.5 cm)

If a flat, non-palpable lesion is smaller than 1/2 cm, it is a macule, if it is larger, it is a patch

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21
Q

Describe the types of palpable, solid primary lesions

A
  • Papule (less than 0.5 cm)
  • Nodule (0.5 cm to 1 cm)
  • Tumor (larger than 1 cm)
  • Plaque (larger than 0.5 cm and formed by the coalescence of numerous papules
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22
Q

Describe the types of clear, fluid filled primary lesions

A
  • Vesicle (smaller than 0.5 cm)

- Bulla (larger than 0.5 cm)

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23
Q

Describe the types of cloudy, pus filled primary lesions

A
  • Pustule (smaller than 0.5 cm)

- Abscess (larger than 0.5 cm)

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24
Q

Secondary lesions

A
  • Erosion
  • Crust
  • Scale
  • Fissure
  • Ulcer
  • Lichenification
  • Atrophy
  • Excoriation
  • Scar
  • Keloid
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25
Q

What are the ulcer classification systems?

A
  • Wagner’s-vascular surgery
  • International Pressure Ulcer Advisory Panel (IPUAP)-wound care nursing
  • University of Texas San Antonio (UTSA)
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26
Q

Texas Classification

You will NEED to know this for the exam

A 
0 = no break in skin 
I = subcutaneous break in skin
II = break in skin to tendon 
III = break in skin to bone 
A = No infection or ischemia
B = Infection
C = Ischemia
D = Ischemia and infection
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27
Q

Question: A lesion that is smaller than 0.5 cm and is filled with pus is called a…

A

Pustule

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28
Q

Describe the evaluation of joint motion in the musculoskeletal exam

A

Joint motion

  • Hip
  • Knee
  • Ankle
  • STJ
  • 1st MPJ
  • 1st ray
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29
Q

Hip

A

45° internal & external rotation; 45° abduction, 20° adduction; 120° flexion, 0-15° hyperextension

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30
Q

Knee

A

130° flexion, 15° hyperextension

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31
Q

Ankle

A

10° dorsiflexion (knee extended and flexed), 50° plantarflexion

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32
Q

STJ

A

20° inversion, 10° eversion

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33
Q

1st MPJ

A

60° dorsiflexion, 5-10° plantarflexion

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34
Q

1st ray

A

10 mm total R.O.M.

35
Q

Describe the scale used to test muscle strength

A

Muscle strength: Based on a 0 to 5 scale; always test strength against your resistance.

  • 5/5: Normal strength
  • 4/5: Movement against resistance, but less than normal.
  • 3/5: Movement against gravity, but not against added resistance.
  • 2/5: Movement at the joint, but not against gravity.
  • 1/5: Visible muscle movement, but no movement at the joint.
  • 0/5: No muscle movement
36
Q

What is IMPORTANT to remember about testing muscle strength?

KNOW THIS

A

Because the normal podiatric musculoskeletal exam occurs in the sitting position with the feet elevated (gravity is eliminated), active movement of the foot and ankle against resistance implies that the muscle strength rating is at least 2/5

37
Q

Describe the common motor signs and patters of muscle strength loss

A
  • Early loss of strength will usually be seen in extensor digitorum brevis
  • More severe loss seen with ankle dorsiflexion*
  • Most severe loss seen with ankle plantarflexion*
  • Weakness normal after 65 y/o
38
Q

What are the deformities we see in the foot?

A

Deformities: bunions, hammertoes, enlarged joints, osteophytes

Painful areas to palpation.

39
Q

Describe the motor pathway we test in the neurological exam

A

Corticospinal or Pyramidal tract

  • Mediate voluntary movement, particularly fine, discrete, conscious movement
  • Problem: CVA
40
Q

Describe the extramyramidal tract in the neurological exam

A

The Extrapyramidal Tract:

  • Help to maintain muscle tone and to control body movements, especially gross automatic movements, such as walking
  • Problem: Parkinson’s Disease
41
Q

Describe the cerebellar system in the neurological exam

A

Cerebellar system

  • The cerebellum receives both sensory and motor input and coordinates muscular activity- maintains equilibrium and helps control posture
  • Problem: loss of sense of balance
42
Q

Describe testing sensation in the lower extremity

A

Sensation: initiated by stimulation of sensory receptors located in skin. After entry into the dorsal (posterior, sensory) spinal cord, the sensory impulse proceeds along one of two courses:

(1) posterior column
(2) lateral spinothalamic tract

43
Q

Describe the function effects of lesions of the lateral spinothalamic tract

A

Lateral spinothalamic tract (also known as small fiber tract due to composition of C and A-delta fibers)

  • Sharp and dull pain (nociceptive)
  • Temperature
  • Crude touch
  • Patient complains of “burning, cramping”
44
Q

Describe the function and effects of lesions of the posterior column

A

Posterior column (also known as large fiber tract due to composition of A-alpha fibers)

  • Position
  • Vibration
  • Fine touch
  • Patient complains of “pins and needles or electric shock sensation”
45
Q

Describe the role of the neurological exam

A

Neurological exam is sensitive for detecting peripheral nerve loss and dysfunction

46
Q

Describe how you determine the sensory level

A

Sensory Level:

Ask patients to draw a line of demarcation , below which sensations are abnormal and above which sensations are normal

47
Q

What are the sensory tests that can be done to evaluate the lateral spinothalamic tract?

A
  • SWM
  • Sharp/dull
  • Temperature
48
Q

Describe SWM testing

A

SWM: a measure of low threshold mechanoreception

  • Using a 5.07 Semmes-Weinstein monofilament, apply pressure to the 1st, 3rd, & 5th, metatarsal heads, the 1st, 3rd, & 5th toes, the plantar arch, the plantar heel, beneath the 5th metabase and the dorsal midfoot
  • The inability to detect the pressure in more than 3 areas suggests the potential for neurotrophic ulceration, especially in the diabetic
49
Q

Describe sharp/dull testing

A

Sharp stimuli
- Use the cotton tip and opposite end of a Q-tip to test dull vs. sharp along at least 2 different dermatomes

Recommended method by neurologists

  • Ask the patient to close his eyes. Break a Q-tip in half and use each end to touch the skin
  • Ask a three-part question: “Which is sharper, the first touch, the second touch, or are both the same?”
50
Q

Describe temperature testing

A

Temperature:

  • Omit if pain sensation is normal
  • Touch the skin with hot and cold water test tubes.
51
Q

What are the sensory tests that can be done to evaluate the posterior column?

A
  • Vibration
  • Position sense
  • 2-point discrimination
52
Q

Describe vibration testing

A
  • Use a 128 cycles/sec tuning fork over the IPJ of the hallux.
  • Ask the patient to tell you when it stops vibrating.
  • Place the tuning fork over the DIPJ of your index finger.
  • The vibration should extinguish within 10 seconds on your finger.
  • If it does not, patient has reduced vibratory sensation.
  • If vibration sense decreased, proceed more proximally over bony prominences until vibration felt and note the area of normal pallesthesia.
53
Q

Describe position sense testing

A
  • Passively move the great toe up and down only a few mms. and ask patient which direction you are moving the toe.
  • Grasp toe along sides of toe.
54
Q

Describe 2-point discrimination testing

A
  • Two-point discrimination is worthwhile when other types of sensation are intact
  • Using the sides of two pins, touch the tip of the great toe simultaneously.
  • Find the minimal distance at which the patient can discriminate one from two points (normally about 5 to 6 mm)
55
Q

What do tendon reflexes test?

A

SENSORY nerve function

Tendon reflexes are objective measures of sensory nerve function

Absent Achilles reflex after 80 y/o is normal

56
Q

Describe deep tendon reflexes

A

Often have to use reinforcement (Jendressic maneuver) to facilitate observation of reflexes in the lower extremity

57
Q

What are the nerve roots for the knee reflex?

A

L2, 3, 4

58
Q

What are the nerve roots for the ankle reflex?

A

S1, 2

59
Q

Describe Jendressic tendon testing

A
  • Jendressic: a technique involving isometric contraction of other muscles that may increase reflex activity. Ask the patient to lock his fingers and pull one hand against the other.
  • If deep reflex elicited after performing Jendressic maneuver, it is recorded as “reflex with reinforcement”.
60
Q

What are deep tendon reflexes dependent upon?

A

Deep reflex dependent upon (1) an intact sensory nerve, (2) a functional synapse in the spinal cord, (3) an intact motor nerve fiber, (4) a neuromuscular junction and (5) a competent muscle.

61
Q

How do you classify deep reflexes?

A

Deep reflex classified on a 0 to 4 scale

62
Q

Describe each step in the reflex scale

A
  • 4/4: very brisk, hyperactive, associated with clonus (rhythmic oscillations between flexion and extension) – indicates upper motor neuron disease.
  • 3/4: brisker than average and possibly, but not necessarily, indicative of disease.
  • 2/4: Average, normal
  • 1/4: Somewhat diminished
  • 0/4: No response (lower motor neuron disease, peripheral neuropathy).
63
Q

LOOK AT SLIDE 72

A

Know the nerve roots - I’m going to ask you a question on this

64
Q

Question: The ankle reflex is associated with which nerve roots?

A

S1-S2

65
Q

What is the superficial reflex or plantar response?

A

Superficial reflex or plantar response (L4, L5, S1, S2): Elicited by stroking the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball. Toes normally flex. If there is dorsiflexion of the great toe and fanning of the other toes, it indicates upper motor neuron disease (Babinski response).

66
Q

What is the “bedside Babinski”

A
  • “Bedside Babinski”: more reliable than standard Babinski at producing positive sign
  • Remove patient’s socks in bed or after placing bedsheet under heel, pull it out from under heel and over toes
67
Q

What is the rule of thumb for standing on toes/heels and lesion location?

A
  • If a patient is able to stand on tiptoes but not on the heels, suggests a peripheral neuropathy
  • If a patient is able to stand on heels, but not on tiptoes, suggests a spinal lesion
68
Q

What does asking the patient to hop in place help you evaluate?

A

Hop-in-place with each foot: Ability to do this indicates an intact motor system in the legs, normal cerebellar function and good position sense.

69
Q

Describe dermatomes

A

Dermatomes are the skin bands innervated by the sensory or posterior nerve roots. Although their levels are considerably more variable than most diagrams suggest, localizing sensory problems to a particular dermatome can also help localize a peripheral nerve lesion

70
Q

What is important to remember about dermatomes?

A

**Remember pattern for deep tendon reflexes to give a rough estimation of the dermatomes

71
Q

What do you include in the biomechanical exam?

A

Biomechanical exam: Always check gait and hip R.O.M. in addition to the usual measurements.

72
Q

What do you include in the radiographical exam?

A

Radiographical exam: Standard x-rays include AP, lateral, medial oblique, lateral oblique, axial sesamoid, and axial calcaneal of the foot and AP, mortisse view, lateral, and oblique of the ankle

73
Q

What labs are standard?

A

Labs: Standard labs include CBC, chem profile, urinalysis.

  • Includes C&S of wounds
  • Includes KOH and fungal culture
74
Q

Skipped over slides 81-100

A

Read through? Just a sample note and we are not being tested on notes

75
Q

Describe the podiatric physical exam of a pediatric patients

A

The pediatric history is geared towards an orthopedic physical examination

76
Q

What are common presenting complaints in pediatric patients?

A
  • Foot or limb deformity (in-toeing, pronation)
  • Weakness
  • **Limp (avascular necrosis of the hip (AVN), Kohler’s Disease (AVN of navicular), tarsal coalition, child abuse) **
  • Swelling or joint stiffness
  • Pain
  • Gait alteration (due to pain)
77
Q

Describe questions to ask on the prenatal history

A
  • Any disease during pregnancy, especially 1st trimester?
  • Any alcohol, tobacco, drug use during pregnancy?
  • Any accidents involving abdominal injury?
  • Was the mother aware of fetal movements beginning in the 4th month of pregnancy?
78
Q

Describe questions to ask on birth history

A
  • Was the child full-term? (birth weight between 6 to 9 lbs. and length between 19 and 21 inches preferred)
  • If premature, was the child placed in a special environment or in an incubator? (greater chance of musculoskeletal problems developing)
  • Was the birth vaginal or via C-section?
  • Did the child present head first (vertex position) or breech (buttocks presented first)? (greater chance of lower extremity problems, especially hip dislocation with or without metatarsus adductus)
79
Q

What is the APGAR score?

** TEST QUESTION **

A 
A: appearance
P: pulse
G: grimace
A: activity
R: respirations
80
Q

Describe the function of the APGAR score

A
  • Standardized scoring system for newborns taken immediately and 5 minutes after birth
  • A maximum of two points for each sign that is evaluated: skin color, muscle tone, breathing, heartbeat, and response to touch or pin-prick
  • Desirable score is > 7
  • Less than 5 has a 20% chance of breathing difficulties
81
Q

Describe the questions to ask for developmental history

A
  • Were there any respiratory problems noted at birth? Did the mother hear the infant cry immediately after birth?
  • Were there any unusual findings at birth such as jaundice, cyanosis, birth anomalies, infection?
  • Did the child leave the hospital with the parents?
  • Were there any feeding problems? Did the child suck right away and was it of sufficient strength?
  • Has the child been hospitalized for any reason?
  • Did the child ever have a convulsion?
  • Does the child use both hands equally? (usually there is no hand preference until the age of 2; a preference could signify a neuromuscular problem)
  • Does the child keep up in play with his peers?
82
Q

List the developmental landmarks you NEED to know

A
  • Lift head? - 3 months
  • Control head position while sitting? - 6 months
  • Crawl?- 6 months
  • Pulls self to stand? – 9 months
  • Walk? - 14 months
  • Ascends stairs with 2 hand support? – 18 months
  • Run forward? – 2 years
  • Pedal tricycle? – 3 years
  • Balance or hop on one foot? – 4 years
  • Heel-toe walk? – 5 years
  • Skip one foot at a time? – 6 years
83
Q

Question: A child develops a normal heel-toe gait at age…

A

5

Clinical Pod Med Exam 1 (17 decks)

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