Final Exam Cram Flashcards
What is the most sensitive indicator of joint disease?
ROM Testing
Describe Apprehension test
- Patient seated
- Dr beside patient abducting their shhulder to 90 and then push it into external rotation
- Positive is if they show apprehension
- Glenohumeral instability
Empty can test
- Flex shoulders 90 and abduct to 45, internally rotate arms so thumbs face down
- Push down on forearm ask patient to resist
- is if pain or weakness indicating supraspinatus pathology
Drop arm test
- Abduct arm to 90 slowly return it to neutral
- is if arm drops uncontrolled indicates supraspinatus pathology
Painful arc test
- Abduct arm from neutral
- is pain btw 60-120 indicating subacromial bursa impingement or rotator cuff
Neer Impingement
- Stabilize shoulder and pronate forearm, passively flex shoulder into full flexion
- is pain indicates subacromial bursa impingement or rotator cuff impingement
Hawkins test
- Flex shoulder to 90 and elbow to 90 (make a hawk wing)
- Passively internally roate shoulder
- pain for subacromail bursa impingement or rotator cuff impingement
Cross Arm test
- Passively adduct arm across patients chest and rest hand on their opposite shoulder
- Monitor posterior AC joint
- AC joint pain or increased TTA indicating AC pathology
Spencers Technique?
Elephantss Fart Constantly To Annoy All Intelligent Tigers
- Extension
- Flexion
- Compression w/ circumduction
- Traction Circumduction
- ABduction w/ ext rotation
- ADDuction
- Internal Rotation
- Traction with inferior glide
Patient is lateral recumbent with injured shoulder UP
Patient has tenderness and pain when raising arm above head, pain is more prevalent at night and pain over lateral deltoid. What could this be?
Rotator Cuff injury
What can cause Referred shoulder pain?
- MI
- Pulmonary issues such as embolism or apical lung tumor
- Abdominal issues uch as hepatobiliary disease or intraperitoneal blood
- Herpes Zoster
- Spinal cord lesion
- TOS
- Radiculopathy
When the scapula depresses what happens to hte AC and SC joint?
- AC: inferiorly glides
- SC: Superiorly glides
The GH flexes so the scapula ____ making the AC joint____ and SC joint ___.
- Protracts
- Anteriorly glides
- Posteriorly glides
If the SC joint is in an inferior glided position what is happening to the AC, shoulder and scapula?
- Abduction of shoulder
- Superior glide of AC joint
- Elevation of scapula
What happens to the SC joint with internal and external rotaion?
NOTHING trick question, only the AC joint does internal and external rotation
Patient presents with neck pain and denies any trauma to cause it. Her sx inculde pain, spasm, decreased ROM and a headache stemming from the occipital region. What could her problem be?
Myofascial neck pain such as whiplash or muscle strain
What is a SCIWORA?
- Spinal Cord Injury Without Radiographic Abnormality
- Rare and requires a high suspicion as the patient has normal CT, but continues to have neuro signs and symptoms
- It is more common in kids and elderly
- Must keep spine immobilized until Neurosurgeon consult and MRI
What are the three kinds of Torticollis?
- Congenital: from musclar fibrosis of SCM
- Adult: Acquired from SCM or Traps injury/inflammation, cervical muscle spasm or cervical nerve irritation
- Life threatening causes: Retropharyngeal abscess, C spine injury, CNS turmor or spinal epidural hematoma
What is the most common cause of acute and chronic neck pain in adults?
Cervical Spondylosis
Differnece between Myelopathy and Radiculopathy?
- Myelopathy is a defecit related to the spinal cord, has emergent symptoms requiring immediate MRI such as loss of bladder or bowel control, or patient complains weakness numbness bilaterally, clumsy hands, gait distrubances, sexual dysfunctions
- Radiculopathy is a “pinched nerve”, a neurologic deficit occuring at/near the root. Sharp radiating pain down arm, weakness or paresthesia can develop
- C5-6 are most commmon
What are the 11 redflags in patients with neck pain?
- Recent neck trauma
- Sx that suggest spinal cord injury such as loss bladder/bowel control
- Shock like paresthesia
- Fever chills
- Hx of IV drug
- Immunosuppression
- Chronic glucocorticoid use
- Unexplained weight loss
- Heachache shoulder hip pain or visual sx in older adults
- Anteior neck pain
- Hx of cancer
Describe the 3 specialty tests for suspected Radiculopathy?
- Neck compression: seated pt, dr behind place hands on top of head and press down, pain is positive
- Neck Distraction: seated pt, dr behind place one hand under chin other on occiput and pull upwards, positive is alleviation of pain
- Spurlings: essentially the compresion test only in three stages, first stage is neutral, second extend and compress, third extend SB to affected side and compress
- DO NOT continue if pain is reproduced
What are the special tests for TOS? Describe the short ones.
- Roos/EAST: abduct shoulders 90 flex elbows 90 externally rotate 90 and alternate making a fist 3 minutes
- Costoclavicular: seated with elbow exttended and hand supinated find radial pulse place hand on top of shoulder and extend the patients arm and apply downard pressure
- tests entrapment of neurovasucalture btw 1st rib and clavicle
- Wright’s Hyperabduction: seated elbow extended and hand supinated, dr beside find radial pulse, abduct arm above head with slight extension
- Testing for neurovasculature compression by pec minor
- Adsons
Describe Adsons and what is it for?
- TOS
- patient seated with elbow extended and hand supinated
- dr monitor radial pulse and abduct extetnd and externally rotate arm
- Ask patient to extend and rotate their head towards that arm and hold their breath
- pain indicates subclavian compressed btw 1st rib and clavicle
- Return to neutral and then ask patient to look away from that arm and hold their breath
- pain indicates compression of subclavian btw anteriro and middle scalenes
HVLA cervical contraindications
- RA
- Down syndrome
- Carotid disease
- Osteoperosis
- Anticoagulatnts
- Osseous or ligamentous disruptions
Mechanics of C2-C7?
Rotation and side benidng occur in same direction due to the uncinate process
Restriction on C4 extension and rotation to the right. Discovered C4 is rotated left restricted in extension, and likes left to right translation. What is the SD?
C4 F RL SL
Typical Cervical vertebrae SB and rotate in same direction
OA mechanics?
- Joint btw occpiut and C1
- Major motions are flexion and extension minor motions are SB and rotationi
- SB and rotation occur opposite due to shape of the joint
AA joint mechanics?
- C1 on C2
- ONLY rotation
What does it mean to say difficult translation from left to right?
Difficulty side bending left
When doing OMT on AA what is the most important thing to remember?
Fully Flex the neck isolating rotation to the atlas locking C2-7
How do you treat C2-7 F SR RR with MET?
- Patient supine dr at head of table
- cradle head with hands and extend neck to level of dysfxn
- Press laterally on the left articular pillar inducing sidebending towards and up to restriction
- Rotate occiput to and up to restriction until vertebra moves engaging the barrier in 3 planes
- 3-5 seconds gently have patient SB or rotate head away while dr counters the force
- Relax and repeat 3-5 times moving to new barrier
- Reassess TART
How are pulses, reflexes, and strength graded?
- P: 2/3
- R: 2/4
- S: 5/5
Subluxation of radial head?
- Aka Nursemains elbow
- Common in kids due to sudden pulling, falling, or arm twisting causing the annular ligament to slip out from radial head
- Presents wit harm close to body elbow slightly flexed OR arm fully extended with forearm pronated
Hyperpronation has best success rates
What is golfers elbow?
- Medial epicondylitis, due to overuse and inflammation of flexor tendons
- Pain on medial aspect of elbow and tenderness wit hpassive extension of wrist and resisted flexion
- Perform medial epicondylitis test having the patient extend their elbow pronate arm and ask them to flex their wrist against you
Tennis elbow?
- Lateral epicondylitis due to overuse / inflammation of the extensor tendons, excessive hyperextension
- Pain on lateral aspect of elbow tendertnes with resisted wrist extension
- Perform lateral epidondylitis test, extend elbow pronate arm ask pt to extend their wrist against you
Olecranon Bursitis? How do you distinguish btw bursitis with effusion and without effusion?
Miner’s elbow/Student’s elbow
- Inflammation of olecranon bursa caused by inflammatory arthritis, gout, trauma, hemorrhage or sepsis
- pain and swelling on olecranon bursa
- Distinguish btw bursitis vs effusion- if the patient can fully extend at the elbow WITHOUT severe pain its bursitis w/o effusion. If effusion is present pain with extension will occur due to increased pressure
Carpal Tunnel specialty tests
Tinnel- tap over median nerve get pins and needle sensation
Phalens- flex wrists so that dorsal aspect of hands touch
What is DeQuervain Tenosynovitis? Specialty test?
- Radial wrist pain at base of thumb especially with thumb movement
- Caused by recurrent inflammation of tendon and synovial sheath covering extensor pollicis brevis and abductor pollicis longus from recurrent movements
- Finikelsteins test make a fist enclose the thumb and adduct wrist
*
What is trigger finger?
- Pain, locking,clicking of MCP joint most common on ring finger in 50-60s
- Causes are idiopathic, risks include DM, RA, hyperthyroidism, amyloidosis, overuse
What is Dupuytren’s contracture
- Fibrosis of palmar fascia causing progressive stiffening of joint and inability to fully extend finger
- Idiopathic causes , thickening of palmer fascia due to fibroblastic proliferation and collagen deposition
- Presents with cord like structure and flesxed digit w/ palpable cord, more comon in white men
What causes a scaphoid fracture?
FOOSH
tenderness on anatomic snuff box is sensitive for this fracture
poor blood supply so nonunion is complication
Patient got in a fight and comes to office with pain in his fifth digit. Swelling, bruising and tenderness is presesnt . What is this?
Boxer’s fracture
Colles Fracture?
- Possibile “Dinner fork” deformity, but Xray can be normal
- Tenderness over fracture site on radial aspect of wrist
- Usually young patients due to sports injury or white women over 50 at risk for OA
- Caused by FOOSH
Most common fracture in upper extremity?
Colles
When the wrist is pronated what happens to the radial head?
Glides posteriorly
Posterior Pronation
what happens with wrist supination?
Radial head moves anteriorly
What is the mechanism for a posterior radial head SD?
Falling prone (forwards)
(Supinated SD would be falling supine, so backwards onto your hand)
Wrist abduction is also known as ___
Radial deviation
What is the direct barrier with a Posterior Radial head SD?
Wrist supination
Anterior radial head SD would be wrist pronation
Dysarthria?
Defective articulation of speech cacused by defect in motor control of speech apparatus
Describe Delirium?
Common in older adults during hospitilazation
Reversible!!
Describe depression
- Feeling down depressed hopeless, anhedonia
Describe Dementia
- Not Reversible!
- Must eliminate depression and delirium before diagnosing
- Medication can slow progression
What causes Pupillary dilation or asymmetry?
- Disruption of ciliary plexus specifically parasympathetic supply
- CN III lesion
Opthalmoplegia?
- Denervation of majoirty of EOM
- “Down and Out” gaze
- CN III Lesion
Hypertropia
Eye drifts medially
If the patient has an eye drifting upwards what muscle is weak
Superior oblique (CN IV)
Lesions of IV?
- Hypertropia
- Weakness of downward gaze
- Vertical diplopia
- head tiliting to opposite side of lesion
What is the most common isolated CN palsy, why, and how does it present?
- VI due to its long course, seen in patients with SAH, syphilis or trauma
- Results in Medial esotropia (convergent strabismus): inability to abduct the eye to to LR weakness
- Horizontal diplopia
Lesions to CN V?
- Decreased face sensation
- Loss corneal reflex
- weak mastication
- jaw deviates toward weak side
Efferent limb of the corneal reflex?
Facial
Difference between Bell’s palsy and suspranuclear facial palsy?
- Supranuclear spares teh upper face and associated with weakness on one side of body (hemiplegia).
- Bell’s is one entire side of the face affected
Specific lesions in CN IX
- loss gag reflex
- loss sensation in pharynx and posterior 1/3 of tongue
- slight dysphagia
Specific lesions in CN X
- Dysphonia
- Dysphagia
- Dyspnea
- Loss gag or cough reflex
When testing SCM the patient cannot turn their head against mild resistance to the left. Where is the lesion and what nerve?
- Right side CN XI
- Contracting the left SCM will normally result in head turing to the right and vise versa*
Cerebellar Ataxia
- staggering unsteady feet wide apart
Sensory ataxia
- Unsteady feet wide, feet thrown forward and slapped down heel first, pay close attention to ground when walking
Chalazion
- Usually nontender
- Blocked Meibomian gland
- In the lid
Hordeolum
- aka stye
- bacterial infection of meibomian gland
- tender and painful
- along lash line
Blepharitis?
- Inflammation at eyelid margin
- Sx: Red swollen itchy eyes, gritty burning, excessive tearing, blurred vision with improvement when blinking, flaking scaling eyelids
- Treat with warm compress, dilute baby shampoo, artifical tears and topical antibiotics
Dacrostenosis?
Dacro means tears-associate with lacrimal gland to get to nasolacrimal duct
- Stenosis of nasolacrimal duct that can be treated by milking the duct
- Some cases need opening with a probe
Dacrocystitis
- Infections of lacrimal duct
- Occurs in newborns and older adults
- Requries systemic abtibiotics
Describe Viral vs Bacterial Conjunctivitis
Viral:
- Bilateral gritty burning, clear discharge, eyes matted shut in the morning, HIGHLY CONTAGIOUS supportive tx
Bacterial:
- Unilateral, lots of purulent drainage all day, reaccumulates within minutes of cleaning, tx erythromycin ointment or trimethoprim-polymyxin B drops
How do you look at corneal abrasions?
- Flourescein stain and a blue light
- Herpes simplex Keratitis can also be seen and is leading cause of blindless in world
Arcus Senilis
White lipid deposition encircling the iris, common in those older than sixty, check cholesterol levels in those less than 40
Acute Angle glaucoma?
- Medical emergency due to suddden increase in intraocular pressure
- Acute severe pain wit hdecreased vision, pupil is dilated and fixed
- Opthalamologist referral needed
Describe the different colors seen in the sclera
- Blue associated with osteogensis imperfecta
- Yellow Icterus due to liver disease, neonatal, pancreatic cancer, or GB issues
- Brown or grey can be birth marks
Cover uncover test
- Stare straight and cover one eye and watch for uncovered eye to focus
- Movement in the uncovered eye means tropia is present!
- eye will move opposite direction of the tropia
- Esotropia means eye turned in
- Exotropia eye turned out
Cotton wool spots?
- White or greyish ovoid lesions with soft borders
- from extruded axoplasm from retinal ganglion cells due to microinfarcts of retinal nerve fiber
- Seen in Htn, DM , HIV
Drusen bodies
- Yellowish round spots edges can be hard or soft
- Haphazardly distributed but can concentrate btw optic disc and macula
- made of dead pigmented epithelial cells
- seen in normal aging and age related macular degeneration
Retinal detachment
- Painless vision loss
- initial warning signs of PVD are transient floaters and flashes of light
- Persistent sx of visison loss or black dots are concerning
- curtain over parts of visual field is ominous classic sign of detachment of retina
- refer to opthalmology
What headache lasts for minutes to days, is usually bilateral radiating from posterior to anterior and has a pressure that waxes and wanes?
Tension HA
What headache lasts 4-72 hours is usually unilateral in the temporal/frontal region and can have an aura, gradual onset and pulsatile feeling. Usually severe and patient is photophobic.
Migraine
What headache can be 15 min to 3 hrs, involves “ice pick” feeling, in the temporal or eye region, is unilateral, and has a quick onset with sharp and stabbing pain?
Cluster
What is SNOOP?
- Systemic symptoms such as fever weight loss
- Neuro symptoms
- Older onset (>50)
- Onset sudden (such as thunderclap)
- Papilledema, Precipitated by Valsalva, Positional provocation, Progression or change in HA hx
Danger signs that could be a space occupying mass, vascular lesion, infection or systemic problem
What signs along with a HA require emergency evaluations?
- Potential CO poisoning
- Thunderclap
- Suspected meningitis or encephalitis
- Orbital or periorbital symptoms
- global or focal neurologic deficit or papilledema
- acute or subacute neck pain with horner syndrome &/or neuro deficit
What are the three types of peripheral vertigos
- BPPVTransient symptoms of vertigo due to canalith movement in semicircular canals
- Meniere Disease spontaneous vertigo with unilateral hearing loss caused by increase endolymphatic pressure in inner ear
- Otosclerosis bony overgrowth of stapes resulting in spontaneous vertigo and conductive hearing loss
Neuro mediated reflexes for syncope?
- Carotid sinus syndrome: head rotation with pressure to carotid resulting in stimulation of carotid sinus pausing ventricles causing fainting
- Vasovagal: overcorrection to stimulus of SNS resulting in rebound over stimulation of PNS resulting in bradycardia and vasodilation
- Situational: occurs wehn standing coughin micturition triggers neural reflex resulting in transient bradycardia and vasodilation
How do things appear on a CT? (color)
- Dark is the least dense to bright is the most dense
- Air<csf></csf>
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Advantages and disadvantages to CT
Advantages:
- Fast good for trauma
- skull facial bone imaging
- quick for brain bleeds
Disadvantages:
- Cant detect ischemic strokes
- Lower resolutioin on soft tissue brain
Adv and disadv to MRI
Adv:
- Highest resolution
- good for soft tissue lesions
Disadv.:
- slow claustrophobic
- no metal
- sensitive to movement
- not good at bones
T1
- normal anatomy white matter appears white and gret matter appears grey
- Good for looking at soft tissue tumors
- easy to see disruption of BBB blood is bright
How does CSF and inflammation appear on T1
CSF is dark
Inflammation is bright
T2 characteristics and appearance of CSF and Inflammation
- opposite of t1
- White matter is dark
- Grey matter is light
- Good for seeing demylination but hard to see inflammation next to ventricles
- CSF appears bright
- Inflammation appears bright
T2 FLAIR
- Similar contrast to normal T2, but CSF appears dark in order to check for inflammation near the ventricles as on normal T2 CSF and inflammation look the same
- CSF is dark, white matter is dark grey, grey matter is light grey, inflammation is bright
Describe the fluoroscopy swallow study
- swallow radio-opaque barium slurry to be recorded by video used if patient has problems swallowing
What is a Myelography
- Dye injected below dura and imaged by fluoroscopy helps to visualize spaces between nerves and surrounding structures
- Uncommon and replaced by MRI CT but can be used for spinal stenosis or herniated discs masses in SC or spondylosis
EEG
diagnosing siezure activity
EMG
- Measure electric conduction in nerves and muscles
- diagnoses and maps out nerve injuries
Where is the AC1 mandible tenderpoint and how do you treat
- posterior surface of the ramus of mandible
- Maverick point! RA
Where is the AC1 TP how do you treat?
- On C1 TO midway btw ramus and SCM
- Push medially treat by SaRa
AC2-6 location and how do you treat?
- on the anterior aspect of transverse process of vertebrae
- push posterior medial
- treat supine F SaRa
AC7 location and treatment
- superior portion of medial end of clavicle
- F St Ra Maverick point!
AC8 location and treatment
- superior poriton of medial end of clavicle sternal head of SCM lateral portion of insertion at claicle
- Treat with F Sa Ra
How are almost all Anterior cervical tenderpoints treated and what are the two that are different
- F Sa Ra for AC1 TP (minus flexion), AC2-6, AC8
- AC1 mandible is Ra
- AC7 is F St Ra
How are almost all posterior tenderpoints treated?
- e-E Sa Ra PC1 and 2 occiput, PC2 Spinous process, PC4-8 spinous process
- PC3-7 lateral (e-E Sa-A Ra-A)
What are the two maverick pointss on the posterior cervical region?
- PC3 spinous process treate fSaRa
- PC1 inion F StRa
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