exam II Flashcards
anterior triangle borders
superior- mandible
medial- midline of neck
lateral- sternocleiodomastoid
posterior triangle content
spinal accessory cervical plexus roots of brachial plexus phrenic nerve subclavian a transverse cervical a suprascapular a external jugular
posterior triangle borders
inferior- clavicle
posterior- trapezius
anterior- sternocleidomastoid
cervical lymph nodes
preauricular postauricular occipital deep cervical submandibular
thryroglossal duct cyst
during development thyroid tissue migrates from base of tongue through thyroglossal duct into neck
if duct does not close can form cyst
ROM neck
flex- 45
extend- 85
rotate- 90
side bend- 40
mm used in neck rotation
trap, scalenes, SCM, splenius, longissimus, semispinalis, and obliqus capitus
mm used in sidebending neck
trap, scalene, SCM, splenius, longissiums, semispinalis, obliqus, longus, and rectus capitis
spurling’s maneuver
cervical foramina compression test
side bend w/compression produces pain and neruo symptoms
maximum cervical compression test- add extension and rotation to the same side
distraction test
pull up on head and neck
used to alleviate radicular symptoms and support a diagnosis of radicuopathy
Roos Test
arms abducted to 90 and externally rotated
elbows flexed at 90
patient slowly opens and closes hands for 3 minutes
if there is weakness, numbness, or tingling test is positive or thoracic outlet syndrome
Adson’s test
palpate the radial pulse with the elbow and shoulder in extension
continue to palpate pulse while moving arm into abduction and external rotation and flex elbow
have patient turn head away
if pulse diminished positive for thoracic outlet syndrome
apley scratch test
upper arm- tests external rotation and abduction
lower arm- tests internal rotation and adduction
internal rotators of the shoulder
subscapularis
teres major
external rotators of the shoulder
teres minor
infrascapularis
mm strength scale
0- no contraction or movement
1- mm contracts, does not move
2- full active ROM when gravity eliminated
3- full active ROM against gravity
4- full active ROM against partial resistance
5- full active ROM overcome full resistance
test supraspinatus
patient abducts against resistance
test subscapularis
patient rotates forearm medially against resistance
test infraspinatus/teres minor
patient rotates forearm laterally against resistance
test thoracohumeral group
patient adducts forearm against resistance
test infraspinatus
patient flexed elbows to 90 and abducts against bilateral resistance
empty can test
tests supraspinatus
abduct arms to 90 and forward flex to 45, internally rotate to point thumb down. patient pushed up against resistance
lift off test
hand on lower back palm out
patient pushed against resistance
subscapularis test
cross over test
adduct arm across test to compress acromioclavicular joint and caused pain if there has been disruption of AC joint or arthritis
drop arm test
examiner abducts patients arm to 90and asks patient to slowly lower it
if arm drops indicative of rotator cuff problem, usually supraspinatus
apprehension test
arm abducted to 90 and externally rotated
push inferior on shoulder while extending arm
pain indicative or loose joint capsule or dislocation
O’briens test
flex arm to 90 and adduct across chest, internally rotate to point thumb down and push down on arm
pain is positive for labral tear, if thumb points up, no pain
speed test
flex straight arm to 90 with palm up
patient resists examiner pushing down, pain in bicipital groove positive or bicipital tendonitis
Hawkins impingement sign
examiner grasps elbow with one hand and distal forarm with other
passively externally rotates shoulder impinges subscapularis
passively internally rotates shoulder impinges supraspinatus, teres minor, and infraspinatus
subacromial bursa test
stabalize shoulder and extend humerus
pain indicates subacromial bursitis, could be rotator cuff problem
nursemaids elbow
radial head dislocation
lateral epicondylitis
extensor tendinitis
tennis elbow
generally chronic
pain in lateral elbow and dorsal forarem, worse with wrist extension, gripping, or lifting
medial epicondylitis
flexor tendinitis
golfers elbow
chronic
pain in medial elbow worse with flexion, gripping, or lifting
lateral epicondylitis test
palpate lateral epicondyle while resisting patient wrist extension, pain is positive test
medial epicondylitis test
palpate medial epicondyle while resisting patients wrist flexion, pain positive test
radiohumeral and ulnohumeral joint tests
position elbow where discomfort occurs, radially or ulnarly deviate the wrist to compress radial head or ulna, pain indicates problem
boutonniere deformity
knucle large and raised
bouchards nodes
at proximal IP joint, osteroarthritis, may not be symmetric
heberdens nodes
at distal IP joint, osteroarthritis, may not be symmetric
tinels sign
tap on median nerve at wrist -> pain indicative of compression, not specific to carpel tunnel
phalens manuver
point fingers down to bring wrists together, opposite of prayer, carpel tunnel
tenosynovitis
dequervain’s disease and others
rheumatoid arthritis
symmetric
psoriatic arthritis
involves DIP joints and inflammation of skin
colels fracture
distal radius fracture with distal fragment displaces dorsally
usually from falling on outstretched hand
boxers fracture
distal 5th metacarpal fracturewith volar angulation
duptrens contracture
inflammation, thickening, and contracture of palmar fascia, most commonly 4th and 5th digits
trigger finger
inflammation of flexor digitorum tendon sheath which becomes trapped under pulley just proximal to MCP joints during flexion so cannot extend
grind test
tests for carpo-metacarpal osteoarthritis
most commonly found at 1st carpo-meta joint
abduct thumb and grasp base of meta rotating, pain positive
finkelstein test
thumb inside fist and gently ulnar deviate wrist, pain positve for tenosynovistis of the extensor pollicis brevis brevis and abductor pollicis longus mm
aka dequervains disease
major contraindications to injections
known hypersensativity to the drug or its excipients (flu vaccine has eggs)
skin is inflamed, irritated, excoriated, or infected
patient is pregnant or breastfeeding (Botox, rubella, hormones, opiates)
stopper is latex and patient has latex allergy
ID
intradermal
administered at 10-15 degress
primarily for diagnositc purposes or applying local anesthetics
usually uses small syringes and small gauge needles, ex 1cc syringe with 27 gauge 1/2 in needle
creates wheal
usually done on arm or back
SQ
administered into subcutaneous layer at 45-90, 45 preferred
allows for slow sustained absorption of medications such as insulin, hormones, and opiates
uses a variety of syringe and needle sizes
1-3cc with a 23-25 gauge 1/2-5/8 needle
at abdomen, lateral and posterior arm, anterior thigh, and ventrolateral gluteal region, wherever there is a good layer of fat
IM
well perfused m at 90 degrees
rapid and systemic action of relatively large doses (1-2 cc)
includes vaccines
size varies greatly, usually a 3cc cyringe, 21-25 gauge and 1-1.5 inch needle
deltoids, gluteus medius, vastus lateralis, rectus femoris, gluteus maximus
absolute contraindications to joint injections
local cellulitis septic arthritis acute fracture bacteremia joint prosthesis achilles or patella tendiopathies hx of allergy or anaphylaxis to injectable pharmaceuticals more then 3 injections to same joint w/in year
relative contraindications to joint injections
minimal relief after 2 attempts underlying coagulopathies anticoagulation therapy evidence of surrounding joint osteoporosis anatomically inaccessible joints uncontrolled diabetes
lidocaine
anesthetic
vasodilator
quick onset, short duration (30-60min)
safe in fingers, nose, penis, toes, and earlobes
use in contaminated wounds
use if vascular disease is present or pt is immunocompromised
lidocaine w/epi
anesthetic causes vasoconstriction longer duration highly vascular areas to improve visualization use in clean wounds
bupivacaines
longer duration
for nn block
adverse leeffects of corticosteroids
accelerate normal aging related articular cartilage atrophy or periarticular calcification
may weaken tendons or ligaments
post-injection steroid flare
infection, bleeding
tendon rupture
facial flushing, skin atrophy, and or depigmentation
hypersensitivity rxn, transient paresis
reiters syndrome
uveitis, sacroilits, urethritis
tredelenburg test
evaluates gluteus medius- > hip drop
ober test
IT band
with patient on side flex knee to 90 and abduct leg at hip, if leg maintains abduction positive test
thomas test
flexion contractures of hip due to tight psoas
flex hip with patient supine so thigh touches abdomen, upon extending one hip should lie flat on table, positive if does not fully extend
patrick
aka fabere
supine put ankle over knee, apply pressure to bent knee, may elicit SI tenderness
buldge sign
minor effusion
balloon sign
large effusions
balloting
large effusion
prepatellar bursitis
anterior
dome swelling over patella associated with tenderness
from excessive kneeling
aka housemaids knee
tenonitis vs bursitis
tendonitis hurts with active, but not passive motion
bursitis, equal pain with active and passive motion
anserine bursitis
medial, tibial plateau
also from valgus knee defrmity and arthritis
hard to tell from pes anserine tendonitis
bakers cyst
posterior in popliteal fossa
leg extended check posterior/medial aspect of knee for swelling or fullness, sometimes tenderness as well
patellofemoral grind test
patient supine with knee extended
compress patella against femur
instruct patient to tighten quads
assess for roughness of motion, crepitus, or pain
chrondromalaicia/patellofemoral syndrome
usually hurts while going up stairs or rising from chair
apprehension test
test for dislocation of patella
attempt to dislocate patella laterally
watch for pain
anterior drawer sign
patient supine and flex knee and hip to 90
pull tibia forward to check for movement anteriorly
compare to opposite side
ACL tear
lachmans test
only for ACL
knee flexed 15, externally rotateda
grasp femur and tibia, move in opposite directions
forward movement of femur positive
posterior drawers sign
supine knee and hip flexed 90
push tibia posteriorly
PCL
mcmurray test
heal points towards direction of meniscus being tested
patient supine grasp heal and fully flex knee
hold knee joint with other hand palpating along joint line
rotate lower leg internally to engage lateral meniscus and extend leg, pop, click, or pain in knee positive
not specific
apleys compression
patient prone knee flexed to 90
stabalize thigh with one hand while leaning onto heal compressing medial and lateral menisci, rotate heal during compression noting pain
thessaly test
standing, rotatory motion on one leg
more specific for meniscal tear then mcmurray
medial collateral ligament
valgus stress test
abduction stress test
patient supine and flex knee
one hand against lateral knee the other around medial ankle, push medially against knee while laterally against ankle
lateral collateral ligament
varus stress test
adduction stress test
patient supine with slight knee flexion
hands against medial knee and lateral ankle
homans sign
evaluates for DVT
dorsiflex foot with leg extended at knee, pain posiitve test
thompson test
patient prone, leg bent to 90, squeeze calf and observe normal passive plantar flexion, best to determine achilles rupture w/in 48hours
talar tilt test
sitting with legs dangling off table
invert calcaneus
if talus gaps or rocks in ankle mortise the ATF and calcaneofibular ligs are torn and test is positive
pes planus
loss of longitudinal arch of foot
pseugogout
from calcium crystals
hammer toes
hyperextension of MTP joint and flexion of IP joint, usually in digit 2
ankle-brachial index
should be .9-1.3, less then that is indicative of loss of blood flow to LL below .4 is severe
virchow’s triad
stasis, hypercoaguability, endothelial injury
lymphangitis
get erythema usually tender localized bacterial infection acute onset pain and fever
benign lymphadenopathy
less then 1 cm tender may be firm, but not hard freely moveable discreet borders
malignant lyphadeopathy
greater then 1 cm not tender rock hard fixed to surrounding tissue difficult to palpate borders
grading edema
1- 2mm, resolves quickly
2-4mm resolves in less then 1 min
3- 6mm, last1-2 min
4-8mm lasts 2-5min
erythema nodosum
inflammation of skin of shins
gradual onset often associated with infection or immune reaction, not vascular disease
recurrent and b/l
no aggravating or alleviating factors
associated with fatigue, joint pain, fever
examination raised red inflammatory nodules
cellulitis
inflammation of skin and/or subcutaneous tissues
almost always bacterial infection, ususally strep or staph
acute onset
usually with pain, redness, and warmth
well demarcated area very tender
frequently accompanied by lymphadenopathy
S3
ventricular gallop
rapid ventricular filling
better heard with bell
S4
atrial gallop
marks atrial contraction
always pathologic
better heard will bell
murmur grading
1- very faint
2-quiet, but heard with stethoscope
3-moderately lous
4- loud w/palpable thrill
5-very loud with thrill, may be heard with stethoscope partially off chest
6-very loud with thrill, may be heard with stethoscope entirely off chest
carotid pulse
between S1 and S2
innocent murmurs
stills murmur
venous hum
stills murmur
mid-systolic, best left lower sternal border
musical quality
louder in supine position
innocent
venous hum
continuous humming, best heard right upper sternal border
flow of venous blood from head and neck into thorax
continuous while sitting
disappears with light pressure over jugular v
fremitus
strongest intrascapular right side
increased indicative of consollidation (pneumonia)
decreased/absent indicative of COPD, obstruction, pleural cavity, effusion, pneumothorax
flat
soft, high pitch, thigh
dull
medium volume, medium pitch, liver
resonance
loud, low pitch, lungs
hyperresonance
very loud, very low pitched, not normal
tympany
loud, high pitched, gastric bubble,
vesicular
over lung fields, soft, low pitched, inspir>expir
bronchovesicular
1/2nd ICS anterior and btwn scapula, intermediate volume and pitch
inspir=expir
bronchial
loud, high pitched, manubrium
expir>inspir
tracheal
very loud and high pitched over trachea
inspir=expir
Wheeze
relatively high pitched with hissing or shrill quality
continuous, musical, prolonged
suggests partial airway obstruction- secretions, inflammation, or foreign body
rhonchi
relatively low pitched with snoring quality
continuous, musical, prolonged
suggests partial airway obstruction- secretions, inflammation, or foreign body
stridor
wheeze only during inspiration
louder in neck then chest
indicates partial obstruction of larynz or trachea
crackles/rales
discontinuous, non-musical, brief
only inspiration
pleural rub
like crackles but in both inspiration and expiration
bronchophony
‘99’ muffles and indistinct normally, abnormal very loud and clear
egophony
‘ee’ sounds like ‘aa’
whispered pectoriloquy
abnormal can hear loud n clear
