ALL cards Flashcards
(170 cards)
1
Q
resources available outlining recommendations for preventative health care:
A
formal publications, websites, digital apps
US preventative Services Task force (USPSTF)
American college of physicians (ACP)
CDC
uptodate, clinicalkey, accessmed, pubmed, etc.
2
Q
Common grading criteria for preventative health recommendations in determining supportive evidence-based guidelines + clinical relevance
A
A: USPSTF recommends service; high certainty of net benefit
B: USPSTF recommends service; net benefit is moderate or moderate certainty that net benefit is moderate-substantial
C: USPSTF recommends selectively offering or providing service based on professional judgement and pt preferences; least moderate certainty benefit is small
D: USPSTF recommends against service (discourage use)
I: USPSTF concludes that current evidence is insufficient to asssess the balance of benefits and harms of service; lacking, of poor quality, or conflicting evidence`
3
Q
What is grade for colorectal cancer screening?
A
A for 50-75 y/o
C for 76-85 y/o
4
Q
Barriers relating to quality, access, and cost
A
Quality, access, and cost are issues that battle w/ eatchoter
if you wanna increase quality, youll have to decrease access and costs
if you wanna increase access, you’ll have to decrease cost and quality
5
Q
Barriers to patient compliance when considering preventative health recs:
A
- diverse populations
- resources (financial, access, community education, gov’t)
- patient buy-in
6
Q
significant preventative health guidelines standing out specific to children and adolescents
A
- vaccines/ vaccination schedules
- growth and develop’t
- safety
- illness prevention
- sexual health
- behavioral medicine
- suicide prevention
creating the guidelines via big data, public health research, and data analysis
7
Q
guidelines associated w/ global health preventative medicine
A
- Global health initiatives (significant funds from multiple countries; US = most); ex. Rwanda- global fund has helped expansion of commmunity health insurance coverage; 1/3 = for upgrading healthcare infrastructure
- global funds contribute to: reducing mortality among peronsell, reducing incidence of infectious dzs through preventative interventions, limiting hospitalization rates, dz targeted programs
8
Q
top cause of death in Kenya vs. US
A
Kenya: HIV/AIDS
US: heart dz; unintentional injuries is high for younger ages (25-44)
9
Q
Components of a complete history and physical
A
history
ROS
physical exam
documentation (SOAP)
10
Q
historical elements (besides the typical ones) that should be included in a complete history:
A
immunizations preventative health reproductive/sexual blood transfusions accidents childhood dzs cardiac risk advanced directives
11
Q
in a comprehensive physical exam, look at:
A
lymph nodes
hair, skin, nails
breasts
other typical ones (EENT, CV, vasc, etc.)
12
Q
Reasonable approach in obtaining history:
A
information gathering: health hx questionnaire (paper, electronic, web-based) and medical records
interview
physical exam
13
Q
Cardinal techniques for use in physical exam:
A
inspection–> palpation–> percussion–> auscultation
14
Q
equipment and other considerations necessary for comprehensive physical
A
medical equipment and room set up exam table set up comfy enverinment pt dressed/undressed timing patient positioning (standing, sitting, lying down) physician comfort + efficiency point of care documentation
15
Q
Appropriate physician behavior related to profession and respectful communication
A
- communication and rapport
- relaxed, not hurried
- smooth and seamless
- establish expectations both from pt and for patient
- non-judgmental
- safe environment
- comfort
- safety
16
Q
clinical reasoning and assessment towards making accurate decisions include:
A
Clinical reasoning: approach to content and context, data assimilation, intuitive determinations (clinical acumen + knowledge), and process identification (based on evidence, skill, experience)
use processes like pattern recognition, illness scripts, and science application
17
Q
generating a clinical hypothesis:
A
- identify abnormal findings
- localize findings anatomically
- cluster clinical findings
- search for probable cause of findings
- generate hypotheses about pts presentation
- cluster the clinical data
- test the hypotheses and establish working dx or dxs
STEPS:
- select most specific and critical findings to support your hypothesis
- match findings against conditions that can produce them
- eliminate diagnostic possibilites that fail explain findings
- weight competing possibilities and select most likely dx
- give special attention to potentially life-threatening conditions (**include the worst case scenario in your differential!!)
18
Q
methods ensuring quality patient data as result of comprehensive examination
A
make sure to have quality patient data! analyze mistakes and keep open mind
19
Q
general documentation tips for a complete h&p
A
synthesize as you go, clinical reasoning starts in the first of the encounter, develop meaning and impact to your findings, dx is supported by findings, be concise + succint, assessment (impressions, dont list sign or symptoms)
put as much info as you can
20
Q
what does the glasgow coma scale assess
A
level of consciousness
21
Q
what are you testing in the glasgow coma scale and what is the scale?
A
eye opening - 1: none, 2: to pain, 3: to speech, 4: spontaneous
motor response - 1. none, 2. extension (decerebrate rigidity), 3. Flexor response (decorticate rigidity), 4. withdrawal, 5. Localized pain, 6. Obeys commands
verbal response - 1. none, 2. incomprehensible, 3. inappropriate (no sustained sentences), 4. confused (disoriented), 5. oriented
total: 3-15
22
Q
what is the confusion assessment method (CAM)?
A
diagnostic algorithm for delirium
23
Q
what will prove a diagnosis of delirium by CAM?
A
requires presence of features 1 + 2 and either 3 or 4:
1) acute onset or fluctuating course
2) inattention
3) disorganized thinking
4) altered level of consciousness
24
Q
nuchal rigidity
A
pt unable to touch chin to chest either actively or passively
Dx: meningeal irritation
25
Tests to dx meningeal irritation
nuchal rigidity, brudzinski's test, kernig test
26
Brudzinski's test
pt lies supine, when head is elevated, the knees involuntary flexing knees + hips in an attempt to relieve pain caused by meningeal irritaiton
Dx: meningeal irritation
27
Kernig test
pt supine; hip and knee begin in flexed position;
when knee is extended--> pain in back (men. irritation)
when return to knee flexion--> relieves pain
Dx: meningeal irritation
28
Babinski response
stimulation of plantar aspect foot normally results --> plantarflexion
+babinski = dorsiflexion
Dx: cns lesion affecting corticospinal tract
29
pronator drift
pt extends arms, palms up, and closes eyes for 20-30 seconds
they than close eyes and try to maintain arm position
+= when one arm drifts downard
Tests: corticospinal tract lesions in contralateral hemisphere (UMN)
Dx: mild hemiparesis or CVA
30
finger-to-nose test
hold finger in one place so pt can touch it with one arm and finger outstretched; ask pt to raise arm overhead and lower it again to touch finger
after several repeats, ask pt to close both eyes and try more time
normal: perform maneuver w/ open and closed eyes
cerebellar dz: movements are clumsy or unsteady ; vary in speed
test: position sense and fxn of both labyrinth of inner ear and cerebellum
31
heel to shin (knee) test
have pt place one heel on opposite knee, then go up and down shin of big toe; repeat w/ pts eyes closed
observe for smoothness + accuracy; repeat on other side
Tests: coordination fo multiple systems (motor, basal ganglia, cortical association and cerebellar systems)
32
rapid alternating movements
normal: can alternate quickly
cerebellar dz: movements are slow, irregular, and clumsy (DYSDIADOCHOKINESIS)
33
DYSDIADOCHOKINESIS
slow, irregular, and clumsy hand movements
34
Romberg test
pt stands w/ feet together, arms extended, and palms face upwards; pt instructed to close their eyes
neg: pt can maintain balance (posterior columns)
+ sign (cerebellar dz): pt begins to sway or has to move feet to maintain balance; cerebellar- wide based asymmetric gait (cerebellar ataxia)
35
uncoordinated gait w/ reeling and instability is:
ataxic
36
levels of consciousness:
```
alert- normal
vigilant-hyperalert
lethargic- drowsy but easily aroused
obtunded- arousable but responds slowly and is somewhat confused
stupor - difficult to arouse
coma- unarousable
```
37
decorticate posture
flexor posture
upper arms tightly to sides of body
elbows, wrists, fingers- flexed
feet-plantar flexed
legs- extended and IR
fine tremors or intense stiffness may be present
38
decerebrate posture
extensor posture
```
arms fully extended
forearms pronated
wrists and fingers- flexed
jaw-clenched
neck-extended and back may be arched
feet-plantar flexed
```
39
steps of assessing pt w/ acute mental status changes
1. ABCs - make sure pt stable
2. full head to toe exam w/ special attention to neuro evaluation (DTR, sensation, CNS, fundoscopic)
3. additional maneuvers to reveal specific neuro deficits and pathology
40
Acute mental status change steps
cognitive assessment--> delirium or depression
delirium: review meds list(remove if harmful) and look at hx, vital signs, PE, lab testing, occult infection
look at nonpharmacologic approaches for delirium (reorientation strategies and schedule of activities, use of sitters, relaxation techniques, avoid physical restraints, maintain mobility, keep room quiet at night, allow uninterrupted sleep, eyeglass use, etc.)
41
biomechanical model for altered mental status
considerations: loss of muscle mass/ bone density, osteoarthritis
assess: gait, posture, ROM, UE/LE, feet for ulcers nail care, OSE
OMT: FPR, BLT, ST, MET, HVLA
42
neurological model for altered mental status
considerations: decr brain weight, memory, sleep, alterations in CNS NTs, gait
assess: muscle tone, motor strength, attention/orientation, gait, OA/AA (vagus n.), T10-2 (VSR bladder/bowel)
OMT: S/CS, paraspinal inhibition
43
resp, circulatory model for altered mental status
considerations: CV- calcification, stenossi, decr baro reflex + elasticity of vasculature; Resp- decr resp muscle strength
assess: VSs, resp effort, edema
OMT: rib raising, lymphatics, ST to C- and T-spine
44
metabolic, energetic, immune model for altered mental status
considerations: decr T cell fxn, gastric HCL pdtn, colonic motility, bladder capacity, calcium absorption
assess: skin for any signs of breakdown, abdomen for signs of constipation
OMT: lymphatics, mesenteric release, FPR, BLT, ST, MET
45
behavioral model for altered mental status
considerations: cognitive changes and decr mobility, memory and brain wt
assess: gait, muscle tone, motor strength, mental status exam
OMT: ST for anxiety/depression symptoms
46
Dementia vs. Delirium:
DEMENTIA: SLOW, progressive loss of mental capacity, leading to deterioration of cognitive abilities and behavior;
- strongest risk factor= AGE (advanced); other= environmental risks (head trauma, smoking, sendentary lifestyle, lwo mental activity, etc.)
- decline in cognition precedes decline in function
- can be complicated by neuropsychiatric symptoms
DELIRIUM: acute confusional state (develops over days-hours, persists days-months), REVERSIBLE; often misinterpreted
syxs- disturbance in attention (develops over short period of time and FLUCTUATES) and cognition
47
Battle's sign
bruising over mastoid process; caused by extravasation of blood along posterior auricular artery
sign of head trauma
48
what dysfunction has patients not respond to basic stimuli
coma
49
in depression, are pts usually oriented and able to follow command?
yes
50
exacerbation of agitation and cognitive issues seen during EVENING + NIGHT HOURS are seen in what pts
delirium and/or dementia
51
treatment for delirium
identify and treat cause, use supportive care (ABC + pt safety)
reorientation to time cues w/ lights off at night, window blides open in day
meds: haloperidol sometimes used for acute hyperactive delirium
52
what should you avoid in delirium
BENZOS except in alc withdrawal; paradoxical stimulating effect in elderly
53
when diagnosing dementia what should you rule out first?
depression
54
treatment for dementia
ensure safety with family/caretakers
mementadine = noncompetitive NMDA receptor antag
donepizil, rivastigimine, galantamine= cholinesterase inhibs
start low and go slow!!
55
discuss I WATCH DEATH pnemonic
~diff dx of delirium~
I: Infection - hiv, sepsis, pneumonia
W: Withdrawal - alc, barbs, sedative-hypnotics
A: Acute metabolic - acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure
T: Trauma- closed head injury, heat stroke, postop severe burns
C: CNS pathology- abscess, hemorrhage, hydroceph, subdural hematoma, infection, seizures, stroke, tumors, mets, vasculitis, encephalitis, meningitis, syphillis
H: Hypoxia- anemia, CO poisoning, hypotension, pulm or cardiac failure
D: Deficiencies - B12 (cobalamin), B9 (folate), B3 (niacin), B1 (thiamine)
E: Endocrinopathies- hyper/hypoadrenocricism, hyper/hypoglycemia, myxedema, hyperparathyroidism
A: Acute vascular - HTN encephalopathy, stroke, arrythmia, shock
T: Toxins or drugs - prescription drugs, illicit drugs, pesticides, solvents
H: Heavy metals - lead, manganese, mercury
56
MC types of dementia
AD: progresive, prominent mem loss, etc
Vascular dementia: asymmetric neuro exam; stroke risk factor
Dementia w/ Lewy body: parkinsonism, fluctuating cognition, well formed visual hallucinations, REM sleep behavior disorder in some
PD w/ dementia: PD precedes dementia at least by 1 yr
Frontotemporal dementia: disinhibition, social inappropro, apathy, language problems, all worse than memory; onset <65 before (younger ish)
57
Glasgow coma scale: high vs. low
scored bw 3-15
3: worst, 15: best
58
Richmond Agitation Sedation Scale (RASS) purpose and scale:
assessing pts level of agitation or sedation in mechanically ventilated patients to avoid under or over sedation
unarousable (-5) combative (+4)
Test:
1. observe if pt alert and calm--> restlessness or agitation?
2. pt not alert: in loud speaking voice state name and direct them to open eyes; -1==> -3 (depending eye opening and movement)
3. if pt no respond to voice, physically stimulate them by shaking shoulder and then rubbing sternum if no response; (-4= no movement to physical stimulation; -5= no response to voice or physical stimulation)
59
Confusion Assessment Method (CAM)
allows nonpsychiatric clinicians to detect delirium in high risk environments
can be administered within 10 mins
60
modification of CAM: bCAM
step 1: delirium triage screen (rule out screen = highly sensitive)
- altered level of consciousness (RASS); if DTS + --> confirm w/ bCAM OR no --> move on
- inattention (>1 error in spelling a word backwards)
- if both neg = no delirium
step 2: brief confusion assessment method (confirmation = highly specific)
- feature 1: altered mental status or fluctuating course; no = bCAM neg (no delirium) OR yes move on
- feature 2: inattention (name months backwards from dec to july); no = bCAM neg (no delirium) OR >1 errors move on
- feature 3: altered level of consciosness (RASS); yes = bCAM + (delirium present) OR no move on
- feature 4: disorganized thinking; any errors--> bCAM + (delirium present) OR no errors--> bCAM neg (no delirium)
61
Mini-COG
dementia screen
screening for cognitive impairment in older adults
3 components- 3 item recall test for memory + simply scored clock drawingi test
better sensitivity for MCI than MMSE; no diff in specificity; less affected by age + education levels than MMSE
62
MoCA (montreal cognitive assesment)
dementia screen
screening tool for dementia, (55-85 y/o)
scores 0-30; normal = 25+
tests ST memory, visuospatial abilities, attention, concentration, working memory, language and orientation
better at detecting MCI than MMSE
63
MMSE
dementia screen
widely used test of congitive fxn, among elderly, used to screen for dementia
scores 0-30; normal = 25+
not uncommon for someone w/ AD to have score decrease 2-4 pts/yr
tests cognitive fxn in orientation, attention, memory, language, and construction abilities
basically worst at detecting MSI
64
SLUMS
dementia screen
elderly
scores 0-30; normal = 25+ if less than high school education; 27+ if high school education
not as well studied as MMSE, though equivalent to MoCA for being better able than MMSE to detect MCI
65
body language and words that might provide clues for underlying psychosocial concern
being closed off, not making eye contact
talking about long explanations for reasonings to things going on in life, not talking at all or avoiding (apathy)
66
SIG E CAPS
S: Sleep change
I: Interests decreased
G: Guilt
E: Energy decreased
C: Concentration decreased
A: Appetite/ weight disturbance
P: Psychomotor changes
S: Suicide thoughts
67
what can you administer to evaluate depression and suicidal risk
PHQ-9
10 questions (talked mainly about..)
9) thought that you would be better off dead or hurting yourself
10) summary question- if checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other ppl
68
assessing suicidal risk
Current ideation, intent and plan: have you thought of killing yourself, do you have a PLAN to harm yourself, what is it?
Previous attempts: have you ever attempted b4?
Risks and protective factors: what would keep you from killing yourself
69
greatest risk of depression
suicide
70
risks for suicide
past suicide attempt + suicidal ideation
male gender
physician
71
protective factors for suicide
supportive relationships
religious/cultural beliefs against suicide
72
what would help you examine risk factors and protective factors of suicidality:
social history!!
| spirituality, support system, hobbies, exercise, caffeine, tobacco, recreational drugs, alcohol
73
how does the Audit-C work
3 item screening tool to identify unhealthy alcohol use including hazardous drinkers or active alcohol use disorder
- 5 choices/ question (0-4 points
- how often do u have a drink containing alc; how many standard drinks containing alc do you have on typical day; how often do u have 6+ drinks on one occasion
hazardous heavy drinking:
74
you have a pt you suspect has unhealthy alcohol use, what should you screen them with?
AUDIT-C
CAGE quetionairre
75
Audit-C hazardous (heavy) drinking scores
Men > or equal to 4
women > or equal to 3
76
CAGE questionnaire
C: Cut down- have u ever felt need to cut down on drinking
A: Annoyed - have ppl annoyed you by critizing your drinking
G: Guilty - have you ever felt bad/guilty about drinking
E: Eye-opener: have you ever had a drink first thing in morning to steady your nerves or to get rid of a hangover
Women: 7+/week
Men: 14+/week
+= score > or equal to 2
77
what are some commonly associated somatic complaints w/ underlying psychosocial issues
insomnia
fatigue
chronic pain
unexplained physical symptoms (frequent ED visits, vague abdominal pain)
recent life changes or stressors (bereavement, job loss, relocation, relationship)
comorbidities (ex. chronic dz)
78
when documenting a patient with psychosocial concerns, what should you make sure you do
be objective - avoid editorializing, avoid judgmental phrases, use concrete descriptions, gather evidence rather than jumping to conclusions
79
glycemic targets in management (normals)
premeal plasma glucose (mg/dL) = <100
postprandial plasma glucose = <140
AIC = 4-6%
80
recommendations for glucose monitoring in T2DM
check capillary glucose 1/day (fasting)
81
how to use a glucometer:
1. wash hands w/ soap and water. Allow to dry completely. OR If you use alcohol, be sure the
site is completely dry before sticking your finger.
2. Insert the lancet into the lancet device. Make sure the depth is set correctly (deep enough to
obtain a sample) and the device has been cocked and is ready to use.
3. Verify the test strips are within their expiration period. Expired test strips can result in
unreliable readings. Insert the strip into the monitor.
4. Stick the side of your finger (there are fewer nerve endings on the side, which may help
decrease the pain associated with the test).
5. Allow the blood to wick into the strip without touching the strip.
6. Apply pressure with a cotton ball or gauze at the site of the stick to stop the bleeding.
7. Record the reading with the date and time. Take glucose readings to each appointment with
your doctor.
8. Lancets should be disposed in a proper container, not put directly in the trash; can purchase hazard waste container from most drug stores; household generated sharps can be placed in regular trash in MO
82
how often should diabetics get a foot exam and should check their own feet?
foot exam: annualy
check feet: daily (identify open sores or risks for wounds)
83
recommendations for foot care/own foot exam in diabetic pts
- always wear shoes and make sure they fit properly (so they dont reduce BF or increase wound development risk)
- keep feet warm and dry; if feet sweat--> foot powder + change socks frequently
- nails trimmed neatly + straight (horiz); angled nails can cause ingrown nails (pain + infection risk)
- look at all skin areas and bw toes (look for scaling or break-down of skin (maceration= sign of fungal infection)
- monitor for calluses + corns or signs of thickening (indicate footware too tight maybe)
- feet should be WARM to touch ; cool toes - problem w/ circulation
- hair over joints of toes = sign of good circulation; when circulation compromised, pts will lose hair and skin and be shinier/fragile appearing
84
required components of diabetic foot exam
inspection (all surfaces)
pulses (dorsalis pedis or posterior tibial); if pulses not present, further assessment like more proximal pulses and anterior doppler of LE may be required
protective sensations (monofilament + vibration); make sure slight bend in monofilament
reflexes at ankle (achilles)
note: if cant feel more distal locations, continue moving more proximally until they voice sensation
85
basic components of a diabetic diet
no one size fits all diet for diabetics; can go to dietician/diabetic educator for detailed evaluation/teaching
physician: get diet hx of meals, snacks, beverages; identify high calorie snacks and sugary dranks as first intervention; discuss trading out calorie dense food for healthier choices
balance is key; wide variety of foods ; half plate w/ non-starchy veggies; eat regularly, dont go for long periods bw meals (large swings in blood sugar); include some protein and fiber w/ each meal; fiber helps you feel full longer
fresh foods> frozen > canned
if blood sugar <70--> have a starch + protein snack
86
signs of hypoglycemia
weakness, sweating and palpitations
87
other professionals in diabetic mgmt
podiatrist or wound care team- if wounds or complications; included in mgmt of pt
dietician or diabetic education- resource for detailed evaluation and dietary teaching
88
where do foot exam findings go in the SOAP Note
objective portion
89
where does record of home glucose readings go in the SOAP note
objective findings
90
where does discussion about self-care get documented in SOAP note
Plan
also include patient education materials, name of document and site it came from
91
olecranon fractures
humerus fractures
radial head and/or neck fractures
--all indications for what splint
posterior long arm splint
92
how do u put on posterior long arm splint
start at posterior proximal arm, down ulnar forearm, end at MCP joints
positioning: elbow flex 90, forearm in neutral position, with thumb up; wrist extended 10-20 degrees (holding can)
93
soft tissue injuries of hand and wrist
carpal bone fractures
2-5th metacarpal head fractures
-- all indications for what splint:
volar splint
94
how do u put on volar splint
start at metacarpal heads--> distal forearms
positioniing: forewarm in neutral position w/ thumb up; wrist extended 10-20 (holding a can)
95
distal radius and/or ulna fracture
--indication for what splint:
sugar tong splint
96
how do u put on sugar tong splint
start on dorsal metacarpal heads + end at volar MCP joints
positioning: elbow flex 90, forearm in neutral position, with thumb up; wrist extended 10-20 degrees (holding can)
97
complex and unstable forearm fractures
elbow fractures
--all indications for what splint:
double sugar tong splint
98
how do u put on double sugar tong splint
- forearm sugar tong splint first--> arm sugar tong splint (start at medial proximal humerus, wrap around elbow, end at lateral proximal humerus)
positioning: elbow flex 90, forearm in neutral position, with thumb up; wrist extended 10-20 degrees (holding can)
99
Injuries to scaphoid, lunate, thumb and first metacarpal
gamekeepers/skiers thumb
dequervians tenosynovitis
--all indications for what splint:
thumb spica splint
100
how to apply thumb spica splint
start at mid-distal phalanx of thumb--> end at mid-forearm
positioning:: forearm neutral, wrist extended 10-20 degrees (holding can), thumb ABDUCTED (holding wine glass)
101
5th digit fractures and/or soft tissue injuries
4th and 5th metacarpal fractures of neck, shaft, and/or base
--indications for what splint:
ulnar gutter splint
102
how do u put on ulnar gutter splint
start at ulnar side of mid-forearm, end at mid distal phalanx of 4th and 5th digits
positioning: forearm in neutral position, wrist extended 10-20 degrees (holding can), MCP flexed (50-70); 90 for boxers fracture; PIP and DIP flexed 5-10 degrees
103
phalanx fractures and/or dislocations
PIP or MCP dislocations
tendon injuries
--indications for which splint:
finger splint
104
how do u put on finger splint
typically use prefabricated splint or cut splinting material to proper size; can be placed on dorsal or volar side; extending from fingertip to mid-hand or distal forearm depending on jts requiring immobilization
positioning: MCP flexed 50, PIP and DIP flexed 15-20
tendon repair injuries--> splint in F or E as indicated
105
mallet finger injury splint placement + positioning (not LO)
splint only the DIP joint on dorsal side
positioning: dorsal splinting requires full extension (not hyperextension)
106
2nd +3rd digit fractures or ST injuries
2nd +3rd metacarpal fractures of neck, shaft, and/or base
--indications for what splint (not LO):
radial gutter
107
how do u put on radial gutter splint:
- start radial side of mid forearm--> end at mid distal phalanx of 2nd and 3rd digits
positioning: forearm in neutral; wrist extended 10-20 degrees (holding can), Thumb ABducted, MCP flexed 50-80 (90 for metacarpal neck fractures)
108
xray views for elbow
AP and lateral w/ elbow flexed
109
xray views for forearm
AP and lateral
110
xray views for wrist
AP, lateral, and oblique (helpful for curved/overlapping joints)
111
systemic approach to examining a pt presenting w/ an extremity complaint:
start w/ broad differential dx spectrum
all injuries must be completely exposed in order to visualize and assess for any bony deformity or ST damage
inspection--> palpation--> ROM (active + passive)--> test muscle strength bilaterally --> sensory testing for deramatomal distribution and possible nerve injury--> vascular assessment (pulses + cap refill) --> DTR of affected extremity bilaterally --> OSE
112
xray imaging of distal femur fracture
General:
- AP and lateral x-ray views
- CT angiogram if diminished pulses after reduction
Exam: Pain/swelling/deformity at distal thigh. Popliteal injury if significant
displacement
Management:
- Immobilization in posterior long-leg splint
- Non-weight bearing
Disposition: Discuss with orthopedic specialist while patient is in the ED. Almost always
requires surgical management
113
xray imaging of femoral shaft fracture
General:
- AP and lateral x-ray views (consider pelvis and knee x-rays d/t high incidence of
concurrent injuries)
- Fractures involving the shaft of the femur which begins 5 cm distal to the lesser
trochanter and end 6-8 cm proximal to the adductor tubercle
- Mechanism: most commonly MVC or penetrating trauma, also seen in falls in
the elderly and non-accidental trauma in children
Exam: tense/swollen/tender thigh, possible leg shortening
Management:
- Immediate reduction in orthopedic consultation if signs of neurovascular injury
- Immobilization in traction splint unless concurrent fracture/dislocation of the
ipsilateral hip, knee, or ankle
Disposition: Discuss with orthopedic specialist while patient is in the ED. Almost always
requires surgical management
114
xray imaging for hip dislocation
General:
- AP and lateral x-ray views. Consider CT for occult fractures
- Displacement of the femoral head from the acetabulum
- Simple: without associated proximal femur or acetabular fracture
- Complex: with associated proximal femur or acetabular fracture
Exam:
- Posterior: leg held in the AD-duction and internal rotation
- Anterior: leg held in the AB-duction and external rotation
Management:
- Reduction within 6 hours and immobilization in knee immobilizer
- Protected weight-bearing
Disposition: Discuss with orthopedic specialist while patient is in the ED or admit for ortho
consult
115
xray imaging for hip fracture
General:
- AP view of the hip/pelvis. Consider MRI for occult fractures (more sensitive
than CT for early detection of hip fractures)
- Any fracture of the proximal femur, within 5 cm of lesser trochanter
- Mechanism: fall or direct trauma
Exam: Pain with active/passive range of motion, leg may be shortened and
externally rotated
Management: Immobilization, non-weight bearing
Disposition: Discuss with orthopedic specialist while patient is in the ED or admit for ortho
consult
116
xray imaging for fibula fracture
General:
- AP and lateral views of the lower leg
- Mechanism: direct trauma over lateral aspect of leg
Exam: Pain worse with foot eversion
Management:
- Immobilization in posterior short legs splint (for comfort)
- weight-bearing as tolerated with crutches
Disposition: Discuss with orthopedic specialist while patient is in the ED or admit for ortho
consult
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Ottawa knee rules:
Decision-making tool to help determine need for radiographic evaluation; high
sensitivity yet low specificity for clinically significant knee fractures
Obtain imaging in patients with:
- Age > 55
- Isolated tenderness to palpation of patella
- Tenderness to palpation it fibular head
- Unable to flex knee to 90°
- Unable to bear weight both in ED and immediately after incident (limping
counts as weight-bearing)
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LE fractures use which xray views?
distal femur, femoral shaft fracture, hip dislocation, and fibula fracture --> AP and lateral
hip fracture--> only AP
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general treatment for LE fractures/dislocations?
immediate reduction (femoral shaft fx and hip dislocation-w/in6hrs)
immobilization in all
weight bearing only as tolerate with crutches in fibular fracture
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which LE fracture happens most commonly MVC or penetrating trauma and is also seen in elderly and non-accidental trauma in children
femoral shaft fractures
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a fall or direct trauma can lead to what LE fracture
hip fracture
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direct trauma over lateral aspect of leg leads to what fracture
fibula fracture
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what xray views do u use for ligament injuries of the knee?
AP and lateral views to evaluate for bony injury
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collateral ligaments and how they are damaged+ tests
MCL: valgus and ER stress to flexed knee
joint laxity w/out stress test
LCL: varus stress +/- IR
joint laxity w/varus stress test
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cruciate ligaments and how they're damaged + tests
ACL: valgus and ER to flexed knee, hyperextension stress
+ anterior drawer test and lachmans test
PCL: posterior stress to flexed knee
+ posterior drawar sign and sag sign
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exam findings for a meniscus injury
+ McMurrays, APleys compression/distraction test
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fracture vs. dislocation of patella
dislocation: from forceful contraction of quads w/ flexed and rotated knee or direct trauma to flexed knee
(pain worse w/ knee movement, deformity)
fracture: direct trauma to anterior knee
(hemarthrosis, palpable deformity, inability to straighten leg)
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pain worse w/ valgus/varus testing is seen with what fracture?
tibial plateau fx
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tibial platea fx mechanism
high or low energy force
valgus/varus force w/ axial loading
assoc injuries: poplitial artery injury, ligamentous injuries and meniscal tears (lateral>medial), compartment syndrome
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in knee injuries, what is the typical management?
immobilization in knee immobilizer if significant laxity
posterior long leg splint for patella and tibial plateau fracture
reduction of dislocation (if have- aka patella); weight bearing as tolerated
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Ottawa Ankle Rule
- < 15% of ankle injuries have a clinically significant fracture
- Ottawa ankle rule can be used to exclude fractures of the ankle and midfoot and
reduce x-ray utilization
- Sensitivity is 100% for the Ottawa Ankle Rule with moderate specificity
- Can be used in children > age 6
- Exclusions: pregnant women, intoxicated patients, head injuries
Ankle x-ray required if:
- Any pain along malleolar regions AND any of the following:
- Bony tenderness along the distal 6 cm of posterior edge of tibia
- Bony tenderness at the tip of medial malleolus
- Bony tenderness along distal 6 cm of posterior edge of fibula
- Bony tenderness at tip of lateral malleolus
- Inability to bear weight immediately or after 4-steps during evaluation
Foot x-ray required if:
- Any pain in the midfoot region AND any of the following:
- Bony tenderness at the base of the 5th metatarsal
- Bony tenderness at the navicular bone
- Inability to bear weight immediately or after 4-steps during evaluation
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which injuries use AP, lateral, and mortise views?
ankle!!
ankle dislocation, lateral malleolus + medial malleolus fxs, maisonneuve fx, pilon/tibial plafond fx
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examining the 4 types of ankle dislocation:
Anterior Ankle Dislocation—foot dorsiflexed and displaced interiorly.
Associated Injuries: fracture of the anterior portion of the distal tibia,
mechanical obstruction of dorsalis pedis artery
Lateral Ankle Dislocation—foot displaced laterally
Associated Injuries: malleolar (medial and/or lateral) and distal fibula fractures,
deltoid ligament injury
Posterior Ankle Dislocation—foot plantar flexed and displaced posteriorly
Associated Injuries: lateral malleolus fracture, disruption of the tibiofibular
syndesmosis
Superior Ankle Dislocation—shortened lower leg with obvious deformity
Associated Injuries: articular damage, thoracolumbar and/or calcaneal fractures
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management for ankle dislocations/fractures
reduction and immobilization in posterior short-leg w/ stirrup splint, non weight bearing
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exam findings for lateral and medial malleolus fracture
lateral: tenderness, swelling, ankle instability with inversion stress testing
medial: same but w/ eversion stress testing
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types of malleolar fractures:
- Bimalleolar: Unstable fracture of both lateral and medial malleoli
- Bimalleolar equivalent: lateral malleolus fracture with widened mortise
concerning for deltoid ligament injury
- Associated Injuries: deltoid and tibiofibular syndesmotic ligament injury
- Trimalleolar: unstable fracture of lateral, medial, and posterior malleoli
- Associated Injuries: deltoid ligament rupture, fibular neck fractures, injury to
the tibial nerve, posterior tibial artery, peroneal artery
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how would one get a maisonneuve fx? exam findings?
IR of leg and ER of talus w/ planted foot
exam: tenderness, swelling, over proximal fibula and medial ankle
assoc injuries= medial malleolus avulsion fx, ankle ligamen injuries
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how would one get a pilon/tibial plafond fx? presentation on exam?
from axial loading (jumping from ht and landing on feet); fracture pattern depends on foot position on impact; tibia is DRIVEN into talus bone):
pain worse w/ ankle mvmt, deformity
assoc injuries: high risk for compartment syndrome, thoracolumbar and/or calcaneal fxs, fibula fxs
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what is the gold standard for calcaneal body/extra-articular foot fractures?
CT (if concern for intra-articular extension)
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jumping/falling from significant height can cause:
calcaneal body/extra-articular foot fractures?
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calcaneal body/extra-articular foot fractures can show what on exam findings
heel hematoma (mondor sign)
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mgmt of calcaneal body/extra-articular foot fractures?
reduction and immobilization in posteiror shortleg w/ stirrup splint like other ankle but also with bulky heel padding; splint in plantar flexion if tuberosity elevation
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AP, lateral, and oblique views are used in:
FOOT FRACTURES!
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midfoot fracturs:
navicular, cuboid, 3-cuneiform
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the mc fractured bone in midfoot is
navicular (usually due to trauma or rotational forces)
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navicular fractures have worse pain w/
eversion or pushing off
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mgmt of foot fractures:
immobilization in posterior short-leg splint, nonweight bearing
toe fracture + dislocaiton = diff (use reduction w/ traction and manipulation for both:; toe dislocation= = immobilization w/ dynamic splinting (buddy taping), hard soled open toe, weight bearing as tolerated
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pain over dorsolateral (cuboid) or dorsal/dorsomedial (cuneiforms) midfoot worse w/ weight bearing is seen in
cuboid + cuneiform fx
direct trauma, axial load, forced inversion
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plantar ecchymosis, +pronation ABduction test, + tarsal metatarsal squeeze test, +piano key sign =
Lisfranc injury
disruption of tarsal metatarsal (lisfrance) joint complex; usually from rotationl and axial load on plantarflexed foot
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metatarsal fractures have pain worse w/___ and is typically from___
axial compression or weight bearing
typically from direct crush injury
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Jones fracture:
fracture of 5th metatarsal at meatphyseal-diaphyseal jxn involving medial face articulating w/ 4th meatarsal
pain worse w/ horizontal compression of metatarsal heads
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open vs closed fracture
open: fracture w/ direct communication to external environment
closed fracture: broken boke w/ no direct communication to external environement
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general managment in ED:
hemostasis (direct pressure to control bleeding); tourniquet above wound, distal
assessment
dressing (remove gross debris from wound, and put dressing on -sterile saline soaked)
stabilize (splint fracture for temp stabiliz to decrease pain)
antibiotics (tetanus prophylaxis + IV antibiotcis +/- aminoglycoside or piperacillin)
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Fracture types:
• Complete: a break all the way through the bone.
• Transverse: runs perpendicular to the long axis of the bone.
• Oblique: runs diagonally to the long axis of the bone.
• Spiral: corkscrew shaped fracture resulting from rotational/torsional force.
• Comminuted: > 2 fracture fragments.
• Incomplete (Pediatrics): the entire cortex is not broken.
• Bowing: bending of a long bone without returning to its original position.
• Torus/buckle: bulging of the cortex, typically at the metaphysis, resulting from
axial compression.
• Green stick: fracture of the cortex on just one side of the bone.
• Salter-Harris: fractures that involve the growth plate.
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Fracture locations:
Long bones: proximal, middle, distal.
Pediatric:
• Diaphysis: shaft
• Metaphysis: widened parts at ends of bones adjacent to physis.
• Physis: radiolucent growth plate between metaphysis and epiphysis.
• Epiphysis: secondary ossification center at the end of bones.
• Apophysis: secondary ossification center at sight of tendon or ligament
attachment.
Anatomical location (such as base, shaft, neck, or head of the metacarpals)
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Displacement:
Angulation/alignment describes the extent of angulation relative to the long axis of
the bone.
• Valgus: lateral angulation
• Varus: medial angulation
Apposition: describes the amount of contact between the ends of the fracture
fragments.
• Bayonet apposition: used to describe when fracture fragments are line
side-by-side.
Distraction: describes when fragments are pulled apart.
Impaction: describes when fragments are pushed together.
Translation: describes extent of movement perpendicular to long axis of the bone,
typically as a percentage of the bones width.
```
Rotation: describes extent of rotation of the distal fracture fragment relative to the
proximal portion (often clinically apparent).
```
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Concurrent injuries:
joint involvment and/or additl fractures or other signs of tissue trauma
evaluate at least one joint above and below, clinically +/- imaging
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What is Salter-Harris classification?
-Most widely used classification system to describe physeal fractures in children.
-Management includes adequate reduction of the fracture, splinting, non-weight
bearing, orthopedic consultation.
Type I - Involve transverse fracture through the growth plate (physis)
- Tenderness over the physis should be a presumed SH type-I
Type II - Fracture through physis and metaphysis.
Type III - Fracture through physis and epiphysis involving the articular surface.
Type IV - Fracture through metaphysis, physis, and epiphysis involving the articular surface.
Type V - Compression fracture of the growth plate (physis).
- Often missed or thought to be a Salter-Harris I
- Suspect if mechanism of injury involves a significant axial load.
- Often diagnosed retrospectively after arrest of growth has developed
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which fracture types often require surgical management as part of the Salter-Harris classification
• Type III-V often require surgical management.
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what is the MC type of Salter-harris fracture
type 2
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splinting material
8-10 layers for upper extremity ; 10-12 layers for LE (plaster)
or can use prefabricated fiberglass
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measuring out length x width of splinting material
length: measure our dry splint material on contarlateral extremity
width: slightly greater than diameter of limb
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procedure of applying splint:
1. Apply the stockinette to extend 2 inches beyond the splinting material; cut holes for
finger(s) as needed.
2. Apply several layers of padding over the airy to be splinted in between digits being
splinted;; add an extra 2 to 3 layers over bony prominences.
3. lightly moisten splinting material and fold the ends of stockinette over the splinting Material.
4. Apply the elastic bandaging.
5. While still wet, use palms to mold the splint to the desired shape.
6. Once hardened, check neurovascular status and motor function.
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posterior knee splint:
Indications:
- Patella fracture and or dislocation
- Patella or quadriceps tendon injury
- Soft tissue injuries of the knee
- Patients with legs too large for knee immobilizer
Procedure:
- Start just distal to gluteal fold, end approximately 6 cm above the
malleoli
Positioning:
- Knee flexed 15-20°
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posterior leg (short and long) splint:
INDICATIONS:
Short-Leg with stirrup: Calcaneus fractures; talus fractures; ankle fractures, dislocations and/or
sprains; metatarsal fractures; midfoot fractures; Achilles tendon injuries
Long-Leg: Knee dislocations; tibial plateau fractures; tibia fractures; distal femur fractures
PROCEDURE:
Short-Leg: With patient prone, start at plantar surface of metatarsal
heads (base of the toes) and end at the level of the fibular head (just
below the knee)
Stirrup: Place after short leg, start 3 to 4 cm below the level of the fibular
head, extend under the plantar surface of the foot, and at the starting
height on contralateral side of leg
Long-Leg: Start distal to the gluteal fold and end at base of the toes
POSITIONING:
Short-Leg: Ankle in neutral position (90° to leg)
- Achilles injuries: ankle plantar flexed 20-30°
- Have patient hang leg off table (while sitting up) and ankle will
naturally relax to this position
Long-Leg: Ankle in neutral position (90° to leg) with knee flexed 15-20°
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documentation of splint applications:
document physical findings before and after application
specifically document extremity perfusion (color, cap refill, pulses), and proper anatomic positioning of extremity after application
neurological assessment is presence or absence of sensation DISTAL to injury before and after application of splint
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where in soap note should u document splint stuff
record in OBJECTIVEEEEE portion (under msk or extremity portion)
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patient discharge after splinting and injury:
written form the pt can refer back to after instrxns given verbally; ask pt to repeat back what they understand about dx and home mgmt
instructions must clearly inform pt of potential complications (infection, scarring, swelling, numbness, pain, compartment syndrome, etc.)
document to whomoe u spoke with and specific date and time when pt required to follow up
provide analgesia as appropiate; limit amt of paint meds to get to follow up appt (no more than 3-7 days )
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recommendations for preventative health activities for a young26 y;o female needing a physical
cervical cancer screening (A), pap spear, using protection, no smoking, immunizations, HPV, tetanus booster
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recommendations for preventative health activities for a 72 y/o male
colorectal screening, smoking cessation, all immunizaitons = A
other: colonoscopy, biopsy of polyps, remove polyps
