Exam 6 Flashcards
Order of musculoskeletal exam
Inspection, palpation, evaluation of ROM, strength testing, special testing for joints
Which form of ROM should always be assessed first?
Active ROM before passive ROM
Normally passive ROM exceeds active ROM by how much?
5 degrees
Muscle strength grading scale: 0/5
No movement
Muscle strength grading scale: 1/5
Trace movement (palpable muscle contraction)
Muscle strength grading scale: 2/5
Full motion, but not against gravity
Muscle strength grading scale: 3/5
Full motion against gravity but not resistance
Muscle strength grading scale: 4/5
Full motion against gravity & some resistance, but weak
Muscle strength grading scale: 5/5
Full motion against gravity & resistance, normal
Painless weakness suggests
neurological problem
Weakness with pain suggests
weakness is muscular in origin
Normal knee flexion in degrees
130 degrees
Normal knee extension in degrees
full extension and up to 15 degree hyperextension
Normal knee internal rotation
20-30 degrees
Normal knee external rotation
30-40 degrees
Ballottement test
Assesses for large effusion or excess fluid in knee
Push patella against femur - should be no fluid-type movement
Bulge sign
Assesses for minor effusions of knee
Tap lateral side of patella
Should be no fluid-type movement
Positive bulge sign = fluid bulge returning to hollow area medial to patella
McMurray Test
Evaluates for torn meniscus in knee on posterior side
Popping/clicking or pain in joint may indicate tear
External rotation tests medial meniscus, Internal rotation tests lateral meniscus (whichever direction bottom of foot is facing)
Anterior drawer test
Evaluate anterior cruciate ligament (ACL)
Pull upper calf forward
Positive test when tibia slides forward (suggest tear in ACL)
Posterior drawer test
Evaluate for posterior cruciate ligament (PCL) tear
Sit on top of foot to stabilize, push upper calf backward
Positive test if abnormal posterior movement of tibia
Lachman test
Evaluates ACL
Hip extended, knee flexed 20 degrees
Pull forward on tibia, & back on femur to stress ligament
Positive test is abnormal when there is significant forward movement of tibia
Pivot Shift test
Evaluates ACL
Reproduce “giving away” symptom, involves internally rotating ankle & foot
Positive test if tibia does almost nothing from 0-30 degrees, but at 40-50 degrees suddenly knee subluxes posteriorly & feels like knee is giving away
Varus stress test
Abduction, bow legged
Evaluates instability of lateral collateral ligament
Apply force against ankle toward midline & internal rotation
Positive if pain or excessive laxity
Valgus stress test
Adduction, knock kneed
Evaluates medial collateral ligament
Apply force against ankle away from midline & external rotation
Positive if pain or excessive laxity
Apley compression & distraction tests
If pt complains of knee locking
Compression tests for torn medial or lateral meniscus
Distraction tests for ligamentous injury
Positive test if pain, locking, or clicking
Normal dorsiflexion in degrees
Greater than 10 degrees
Normal plantarflexion in degrees
45 degrees
Normal Inversion (plantar aspects face each other) in degrees
20 degrees
Normal eversion in degrees
10 degrees
Abduction of foot in degrees
10 degrees
Normal adduction of foot in degrees
20 degrees
Abduction
movement of limbs toward lateral plane or away from axial line of a limb
Adduction
movement of limbs toward medial plane of body or toward axial line of limb
Bursitis
inflammation of the bursa due to repetitive movement or pressure
Claw toe
hyperextension of the metatarsophalangeal joint with flexion of toe’s proximal and distal joints
Clubfoot
fixed congenital defect of ankle and foot
Dislocation
complete separation of contact between 2 bones in a joint
Eversion
outward turning, movement of the sole of foot outward at ankle
Hallux valgus
lateral deviation of great toe with overlapping of second toe
Inversion
inward turning, movement of sole of foot inward at ankle
Legg-Calve-Perthes disease
avascular necrosis of femoral head
Mallet toe
flexion deformity of distal interphalangeal joint of foot
Metatarsus adductus
most common deformity of foot, marked by the middle bones of the foot pointing in toward the body
Osgood-Schlatter disease
common overuse injury of adolescents, which causes painful swelling of the knee due to apophyseal traction of the anterior aspect of the tibial tubercle
Pes cavus
high arch on sole of foot
Pes planus
Flat foot, collapsed arch of foot
Abnormal results from palpation of lymph nodes
Palpable, shotty (multiple, small, BB like nodes), or tender nodes, or fixed nodes
Occipital lymph node
at base of skull
Posterior auricular lymph node
over mastoid process
Preauricular lymph node
in front of ear
Tonsillar lymph node
at angle of mandible
Submandibular lymph node
halfway between angle of mandible and the chin, inferior boarder of jaw line
Submental lymph node
midline behind tip of mandible (chin)
Anterior cervical lymph node
In front of the sternocleidomastoid
Posterior cervical lymph node
2 chains of posterior superficial cervical & posterior cervical spinal nerve chain located on anterior boarder of trapezius & deep to SCM
Supraclavicular lymph node
at angle formed by clavicle & SCM (also called Virchow nodes)
Axillary lymph node
Pectoral muscles anteriorly, back muscles, posteriorly, rib cage medially, upper arm laterally, & axilla at apex
Epitrochlear lymph node
proximal & posterior to medial condyle of humerus
Superior superficial inguinal (femoral) lymph node
Just over inguinal canal
Inferior superficial inguinal lymph node
Deeper in groin compared to superior superficial inguinal
Popliteal lymph node
in posterior fossa behind knee
Hard & discrete lymph node; rapid enlargement & no signs of inflammation - think:
malignancy
Slow enlargement of lymph node over weeks or months - think:
benign
Tender lymph node - think:
inflammatory
Pulsatile lymph node - think:
artery, nodes do not pulsate
Enlarge left sided supraclavicular node - think:
thoracic or abdominal malignancy
Pitting edema +1
Slight, no visible distortion, disappears rapidly
Pitting edema +2
Little deeper pit, no real detectible distortion, disappears in 10 to 15 seconds
Pitting edema +3
Noticeable deep pit, lasts more than a minute, noticeable dependent swelling or fullness
Pitting edema +4
Very deep pit, lasts 2 to 5 minutes, dependent gross distortion
Aneurysm
balloon like swelling of wall of artery, vein, or heart; generally result of congenital defect in wall or degenerative disease or infection; dissecting aneurysm is longitudinal splitting of arterial wall from hemorrhage
Ascites
abnormal intraperitoneal accumulation of serous fluid
Atherosclerosis
most common form of arteriosclerosis, deposits in walls of arteries
Brudzinski sign
flexion of hips when neck is flexed from supine position. occurs in patients with meningeal inflammation
Bruit
unexplained audible swishing sound or murmur over an artery or vascular organ
Cellulitis
inflammation of soft or connective tissue that causes a watery exudate to spread through the tissue spaces
Claudication
condition resulting from muscle ischemia due to decreased arterial blood flow to an area, characterized by intermittent pain and limping
Edema
Excessive accumulation of fluid in the cells, tissues, or serous cavities of the body
Fluctuant
wavelike motion felt when palpating a node
Kernig’s sign
sign of meningeal irritation evidenced by reflex contraction and pain in the hamstring muscles, when attempting to extend the leg after flexing the hip
Lymphadenopathy
enlargement of the lymph nodes, typically to greater than 1.5 cm. Increased size caused by activation & proliferation of lymphocytes & phagocytic WBC within node or by invasion of node by tumor
Lymphangitis
Inflammation of lymphatics that drain an area of infection which is often associated with tender erythematous streaks extending proximally from infected area
Lymphedema
swelling, particularly of subcutaneous tissues, caused by obstruction of lymphatic system & accumulation of interstitial fluid
Matted
used to describe a group of nodes that feel connected and appear to move as a single unit
Meningitis
inflammation of the membranes of the spinal cord or brain, usually but not always caused by an infectious illness
Nuchal rigidity
resistance to flexion of the neck, seen in individuals with meningitis
Pitting
form of edema which appears as an indentation or depression that will not rapidly return to its original appearance
Shotty nodes
small nontender nodes that feel like BBs under the skin
Thrombophlebitis
inflammation of the wall of a vein associated with thrombus formation
Thrombosis
formation or presence of blood clot within a blood vessel or within one of the cavities of the heart
Varicose vein
enlarged, dilated superficial vein
Most common in lower extremities & esophagus
Allen’s Test
Assess arterial supply to hand, test patency of ulnar artery prior to a radial artery puncture or insertion of radial artery catheter
Normal reperfusion within 3-5 sec
Abnormal if reperfusion doesn’t occur within 3-5 sec
Jugular venous a wave
rebound from right atrial systole
Jugular venous c wave
expansion of underlying carotid artery
Jugular venous v wave
filling of right atrium from systemic veins while tricuspid valve closes
Prominent a wae from
increased resistance to right atrial contraction (tricusipd stenosis)
Absent a waves
atrial fibrillation
Large v waves
tricuspid regurgitation & constrictive pericarditis
Homan’s test
Assess venous thrombosis
Normal = no pain when dorsiflex foot
Positive sign = calf pain, may indicate venous thrombosis (not always indicative)
Trendelenburg test
Venous incompetence & used to locate incompetent valves in saphenous & communicating veins
Normal = slow refill
Abnormal - incompetent valve is present in communicating veins when sudden refilling is noted before removal of pressure
Incompetent valve is in saphenous vein when sudden additional refilling takes place after removal of pressure
Bruit
harsh ausculatory sound, abnormal
Claudication
pain resulting from muscle ischemia presenting with a dull ache, muscle fatigue, & cramps
Embolism
obstruction of vessel by embolus
Hum
nonpathologic venous phenomenon commonly found in children
Orthopnea
discomfort in breathing that is brought on or aggravated by lying flat
Peripheral arterial disease
stenosis of blood supply to extremities by atherosclerotic plaques
Phlebitis
inflammation of vein
Preeclampsia
specific pregnancy syndrome associated with hypertension occurring after the 20th week of pregnancy and presence of proteinuria
Raynaud phenomenon
vascular disorder resulting in exaggerated spasms of arterioles in response to cold
Regurgitation
backflow of blood due to incompetent valves
Syncope
loss of consciousness and postural tone caused by diminished cerebral blood flow
Temporal arteritis
inflammatory disease of aortic arch
venous thrombosis
blood clot that forms within a vein
Normal shoulder flexion
180 degrees
Normal shoulder extension
50 degrees
Normal shoulder adduction
50 degrees
Normal shoulder abduction
180 degrees
Normal shoulder internal rotation
90 degrees
Hand behind back
Normal shoulder external rotation
90 degrees
Place hand on back of head with elbow out
Subscapular Muscle Strength
Subscapularis lift off test or Gerber’s test
Internally rotate hand behind back & push away from spine
Supraspinatus Muscle Strength
Empty Can or Jobe’s test
Clinician lifts pts arms 90 degrees in plane of scapula, arms internally rotated with thumb pointed down
Arm Drop Test
Evaluate large rotator cuff tear
Pt lifts arm 90 degrees, then slowly lowers arm to side
If have tear, arm will drop suddenly
Neer’s Test
Evaluate for shoulder rotator cuff impingement or tear
Clinician presses on scapula & raise pts arm in forward flexion while depressing scapula
Neer’s impingement sign if pt has pain
Yergason’s Test
Rotator cuff tear, inflammation of long head of biceps
Clinician flexes pts forarm 90 degrees at elbow & pronates pts wrist. Pt supinates against resistance
Positive test if have pain
Normal extension of elbow
180 degrees
Normal flexion of elbow
160 degrees
Normal supination of elbow
90 degrees
Normal pronation of elbow
90 degrees
Normal wrist flexion
90 degrees
Normal wrist extension
90 degrees
Normal wrist adduction
20 degrees
Normal wrist abduction
30 degrees
Flexor Digitorum Superficialis test
Integrity of flexor digitorum superficialis
Hold fingers in extension & as pt to flex one finger at a time to PIP joint
Snapping or grating is positive - trigger finger
Flexor Digitorum Profundus test
integrity of flexor digitorum profundus
Hold finger at MCP & PIP joints & have pt flex at DIP joint
Positive test = snapping or grating
Positive Snuffbox Tenderness on palpation
indicative of fracture of the scaphoid bone
Phalen’s Test
Assesses for median nerve compression
Hold both wrists together in a fully palmar-flexed position with dorsal surfaces together for 60 seconds
Positive test if numbness & paresthesia in median nerve distribution - carpal tunnel syndrome
Tineal’s sign
Assesses median nerve compression
Tap pts wrist where median nerve passes under flexor retinaculum & carpal ligament
Positive test if numbness or tingling radiating from wrist to hand in median nerve distribution within 60 seconds
Normal hip flexion
120 deg
Normal hip abduction
45 deg
Normal hip adduction
30 deg
Normal hip internal rotation
40 deg
Normal hip external rotation
45 deg
Thomas Test
Hip flexion contracture eval
Positive test if hip flexion contracture is present in the opposite (extended) leg, will flex at knee & lift off table
Trendelenburg Test
Weak hip abductors (gluteus medius & minimus)
Positive if iliac crest drops on side of lifted leg (when standing on one leg). Indicates hip abductor muscles on opposite, weight bearing side are weak
Straight Leg Raising (Laseque’s sign)
Assesses for lumbosacral radiculopathy caused by L4, L5, or S1 nerve root irritation, or lumbar disc herniation. Used if pt experiences pain that radiates down leg (sciatica)
Lift pts extended leg, flexing at hip, dorsiflex foot
Positive test if pain down ipsilateral leg (pain in hips & back are negative test)
Ankylosing spondylitis
hereditary chronic inflammatory disease, initially affecting lumbar spine & sacroiliac joints
Arthritis
inflammation of a joint, usually with pain, & frequently changes in structure
Arthropathy
any disease affecting joint
Arthrosis
joint affection caused by trophic degeneration
Carpal tunnel syndrome
pressure on median nerve at the point at which it goes through carpel tunnel of wrist
Crepitus
crinkly crackling, grating feeling or sound in joints, skin, or lungs
Dupuytren’s contracture
contracture of palmer fascia causing ring and little fingers to bend into palm so they can’t be extended
Fibromyalgia
painful nonarticular condition that leads to diffuse musculokeletal discomfort
Gibbus
sharp, angular deformity associated with collapsed vertebra due to osteoporosis
Goniometer
apparatus to measure joint movements and angles
Kyphosis
increased convex curvature of throacic spine
Lordosis
increased concave curature of lumbar spine
Osteoarthritis
deterioration of articular cartilage covering bone ends in synovial joints
Osteomyelitis
infection of bone
Osteoporosis
decrease in bone mass that occurs due to bone resorption that is more rapid than bone deposition
Polydactyly
hand or foot has more than 5 digits
Radial head subluxation (nursemaid’s elbow)
dislocation injury of elbow
Scoliosis
lateral curvature of spine
Simian
single crease extending across palm
Associated with Down syndrome
Syndactyly
congenital condition that results in fusion of digits of hand or foot
Tendonitis
Inflammation of tendon
Tenosynovitis
inflammation of sheath of tendon
Confusion
Pt is disoriented to person, place, or time but has normal consciousness
AVPU scale
Alert, Responsive to Verbal stimuli, Responsive to Painful stimuli, Unresponsive
Glasgow Coma Scale
Assess cerebral cortex & brainstem function Eye Opening (E): Spontaneous (4), To voice (3), To pain (2), None (1) Verbal Response (V): Normal (5), Disoriented (4), Inappropriate (3), Incomprehensible (2), None (1) Motor Response (M): Normal (6), Localizes to pain (5), Withdraws to pain (4), Flexes to pain (3), Extends to pain (2), None (1)
Highest & lowest possible scores on Glasgow Coma Scale
15 & 3
Cannot score below 3 (deepest coma)
Less than 12 not good, less than 10 is really bad
If the score gets worse it is bad
Mini-Cog test
Determines dementia
Have pt remember 3 unrelated words
Then have pt draw face of a clock from memory & put hands where you tell them
Then have pt repeat 3 words again - get 1 point for every correct word
1 or 2 points with normal clock is negative for dementia
Mini Mental Status Exam
standardized brief screening tool for delirium
If changes by more than 4 points over time it indicates significant change in cognition
Test CN I
Olfaction
Pt closes eyes
Ask to identify 2 different scents w/ eyes closed (one scent under each nostril, one at a time)
Abnormal if have difficulty discriminating scents (elderly, smoking, inflammation)
Anosmia (no smell) - lesion in olfactory tract
Test CN II
Optic
Test visual acuity & fields, & afferent limb of pupillary response (CN III required for efferent limb)
Snellen or Rosenbaum eye charts - visual acuity
Funduscopic exam
Confrontation test - evaluate peripheral visual fields
PERLA
Tests CN II & III together
Pupils Equal, React to Light and Accommodation
Evaluate pupils for equal size/shape
Shine light into each eye - both pupils should constrict
Accommodation - look at distant object, than close object, pupils should constrict when look at close object
EOM & eyelid drooping
Test CN III, IV, & VI together
EOM = extra-ocular movements
Pt follows your finger with their eyes - draw an X and + to get all directions; bring finger close to nose for convergence
Test CN III
Oculomotor PERLA (parasympathetics - pupil constriction & lens accommodation) EOM - all eye movement except lateral & inward rotation when looking down (intorsion)
Test CN IV
Trochlear
EOM - inward rotation when looking down (intorsion) - superior oblique muscle
Test CN V
Trigeminal
Motor to muscles of jaw - hands on side of face as pt clenches jaw
Sensory to face - pt closes eyes & identifies if there is sharp or dull touch on both sides of face (forehead, cheek, chin)
Test CN VI
Abducens
EOM - lateral eye movement (lateral rectus muscle)
Test CN VII
Facial
Motor to facial expression muscles - wrinkle forehead, squeeze eyes shut, puff cheeks, smile & show teeth, purse lips & blow out
Sensory to anterior 2/3 tongue & pharynx - taste
Parasympathetic secretion of saliva & tears
Test CN VIII
Vastibulocochlear (acoustic)
Whisper, Weber, & Rinne test - hearing
Romberg test - balance
Test CN IX & X
Glossopharyngeal & Vagus
Sensory (IX) & motor (X) to palate & pharynx
Observe normal speech & swallowing
Say “AH” while using tongue depressor - soft palate should rise symmetrically, uvula in midline
Gag reflex using tongue depressor to touch back of pharynx - palate rise symmetrically, uvula in midline
Taste in posterior 1/3 of tongue (IX)
Test CN XI
Spinal Accessory
Motor to SCM & Trapezius
Strength test - turning head & shoulder shrug
Test CN XII
Hypoglossal
Motor to muscles of tongue - protrude & lift/lower tongue
Tongue strength - push against side of cheek
Cerebellar rapid alternating movement tests
Finger-thumb test
Palm up/palm down test (test both hands separately)
Cerebellar accuracy of upper & lower extremity movement tests
Finger to nose test (pt touches your finger then their nose, eyes open)
Finger-nose-finger test (eyes closed, extend arms, alternately touch fingers to their nose)
Heel-to-shin test
Cerebellar balance tests
Romberg test (feet together, arms at side, eyes closed) Hop test (eyes open, hop on one foot, then other for 5 sec)
Cerebellar gait & stance tests
Pt walk without shoes
Tandem walk (heel-toe walking)
Walk on heels & toes
Pronator drift - tests contralateral lesion of corticospinal tract & position sense (stand for 20 to 30 sec with both arms straight forward, palms up, eyes closed; tap down on arms) - abnormal if hands drift into pronation
Grading for reflexes: 0
No response
Grading for reflexes: +1
Sluggish or diminished
Grading for reflexes: +2
Active or expected response (normal)
Grading for reflexes: +3
More brisk than expected, slightly hyperactive
Grading for reflexes: +4
Brisk, hyperactive, with intermittent or transient clonus
Normal reflex
+2
Active but not hyperactive or sluggish
Clonus test
Tests for upper motor neuron disease after finding hyperactive reflex
Pt supine, knee slightly flexed
Briskly dorsiflex foot
Positive if sustained clonus (rhythmic oscillating movement of foot)
Brudzinski’s sign
Positive for meningeal irritation, involuntary flexion of hips when neck is passively flexed
Affect
Person’s external expression of his/her inner emotional state
Afferent pupillary defect (Marcus-Gunn pupil)
continued pupillary dilation instead of constriction in eye with a pre-chiasmic optic pathway lesion in response to shining a light in the damaged eye after first shining it in the normal eye
Agraphia
Loss of ability to express oneself in writing due to a central lesion or muscular incoordination
Akathisia (acathisia)
Inability to sit down because the thought of doing so causes severe anxiety. Patient has a feeling of restlessness and an urgent need of movement and complains of a feeling of muscular quivering
Akinesia
complete or partial loss of muscle movement
Antalgic
a behavior used to limit pain
Aphasia
inability to express oneself properly through speech, or loss of verbal comprehension. It is considered to be complete or total when both sensory and motor areas are involved
Ataxia
Impaired ability to coordinate muscular movement usually associated with staggering gait and postural imbalance
Athetosis
slow, twisting, writhing movements, with larger amplitude than chorea, commonly involving hands
Bell palsy
acute paralysis or weakness of one side of the face that is temporary
Cerebral palsy
Large group of persisting, nonprogressive motor disorders appearing in young children and resulting from brain damage caused by birth trauma or intrauterine pathology
Chorea
dance-like, involuntary, rapid movements. Can be associated with Huntington disease, rheumatic fever, systemic lupus erythematosus, or other conditions
Clonus
rapidly alternating involuntary contraction and relaxation of skeletal muscle
Dementia
irrecoverable deteriorative mental state, common end result of many entities. Loss of memory and other intellecutal functions that is of sufficient severity to interfere with daily functioning
Diplopia
double vision caused by defective function of the extraocular muscles or a disorder of the nerves that innervate the muscles
Dysarthria
defective articulation secondary to a motor deficit involving lips, tongue, palate, or pharynx
Dysdiadochokinesia
inability to quickly substitute antagonistic motor impulses to produce antagonistic muscular movement
Inability to perform rapid alternating movements
Dysethesia
sensations (pricks of pins) or crawling
Dyskinesia
defect in voluntary movements
Dysphasia
impairment of speech resulting from brain lesion
Dysphonia
difficulty in speeking; hoarsness
Dystonia
impaired or disordered tonicity, muscle tone
Encephalitis
acute inflammation of brain & spinal cord
Fasciculations
localized, uncoordinated twitching of a single muscle group innervated by a single motor nerve filament; visible or palpable
Fluent aphasia (Wernicke’s or receptive aphasia)
fluent, effortless speech; words are malformed, may be totally incomprehensible. Can hear words but cannot relate them to previous experiences. Impairment of language comprehension including impaired repetition due to lesion of posterior left superior temporal gyrus
Graphesthesia
ability to recognize symbols, shapes, numbers, or letters traced into skin
Hemianopia
blindness for half of field of vision in one or both eyes (lesion posterior to optic chiasm)
Hemiballismus
jerking or twitching movements of one side of body (involuntary violent jerking o flimb)
Meningitis
inflammation of meninges
Multiple sclerosis
progressive autoimmune disorder causing degeneration of myelin sheath of brain’s white matter
Myelitis
inflammation of spinal cord or bone marrow
Myelomeningocele (spina bifida)
congenital defect of spine that allows spinal content to protrude
Myelopathy
any pathological condition of spinal cord
Myoclonus
twitching or clonic spasm of a muscle or group of muscles
Myopathy
any disease or abnormal condition of striated muscle
Non-fluent aphasia (Broca’s or expressive aphasia)
cannot express oneself in language; few words; laborious effort; primarily uses nouns and verbs. Fair to good word comprehension
Nuchal rigidity
stiff neck
Paresis
partial or incomplete paralysis
Paresthesia
unusual sensation like numbness, tingling, burning
Peripheral neuropathy
commonly seen in diabetes, decrease in both motor and sensory function in PNS
Sterognosis
ability to recognize form of solid objects by touch
Stroke
sudden disruption of blood flow to brain
Tremor
involuntary movement of a part or parts of body resulting from alternate contractions of opposite muscles
