MIDTERM Flashcards
Draping patient - abdomen
Patient in supine position
Keep drape over, ask patient to reach under the drape pulling their gown up to thee level of the inferior breasts
This allows the patient to control the procedure
Now you are able to examine the abdomen by lowering the drape
Thomas test
Anterior/iliopsoas compartment.
- Pt supine and pulls knees to chest
- One leg is lowered to the table to test the flexibility of the hip flexors
+Test: inability to fully extend, or extended leg raises off table
Tests: hip flexors contraction
DDx of Lateral knee pain?
Lateral collateral L sprain
Lateral meniscus tear
IT band tendinitis
Ankle sprain
- Lateral ankle sprains are most common sprain, most are related to sports injury
- Lateral ankle sprain —> lateral ankle L (from anterior talofibular (AFT “always tear first) or calcaneofibular LOs) injury secondary to foot inversion and plantar flexion
- Medial ankle sprain —> medial ankle L (deltoid L complex) to forced eversion -
Syndesmotic sprain (high ankle sprain) —> dorsiflexion and/or eversion with external rotation and sprain the distal tibiofibular syndesmosis
Social history - FEDTACOS
Food
Exercise
Drugs
Tobacco
Alcohol
Caffeine
Occupation
Spirituality, sexual relationships, and safety
Tuning fork - air conduction
Lasts longer, hold fork external auditory meatus
HIP - complaint specific for knee complaint
- Traumatic or atraumatic
- Precipitating factors/events? Sports?
- Recreational or occupational activities?
- Able to bear weight?
- Knee locking, popping (ligament injury), or giving out?
What is ROS
Review of symptoms is an inventory of body systems obtained by asking a serious of questions to identify signs and/or symptoms the patient may be experiencing or has experienced
—General, skin, HEENT, neck, breast, respiratory, CVS, GI, GU, endocrine, neurologic, MSK, hematologic/immunologic, psychiatric
**Time savers: define a time frame that patients may have experienced theses symptoms**
General appearance
Check for alertness/consciousness
Ex: alert, somnolent, listless, lethargic, comatose, easy to arouse
**Can use Glasgow coma scale
—> Best response 15
—> Comatose 8 or less
—>Totally unresponsive 3**
Gait
Objective of observing the patient’s gait is to assess the impact of the pt’s hip condition o their overall mobility by observing the ability to perform simple movements
-Ask pt to walk in examination room (toe to heel walk)
Palpation - 1/4 techniques of examination
Performed with your hands, superficial and deep
What is the result of using a BP cuff that is too small?
BP will read high
Great toe Dermatome
L4-L5
Why do we obtain ROS?
- Identify co-existing medical conditions
- Build your case medically and legally
—> provide documentation of medical considerations that you can link to the medical assessment of your patient
- Provide accurate billing information
Elbow specialty test - Valgus stress test
- Arm slightly abducted and externally rotated
- Forearm supinator and flexed to approx. 30 degrees
- Sight medial directed valgus stress is applied to elbow joint
+Test: pain/tenderness, increased laxity
Tests: sprained medial (ulnar) collateral ligament
Normal RR
14-20 breaths per minute
Most common causes of shoulder pain - Chronic
Rotator cuff disorders
Adhesive capsulitis
Shoulder instability
Shoulder arthritis
Ophthalmoscope
To examine the:
—Fundus, retina, posterior chamber of eye
—The pupillary reflex (directs and consensual)
—Red reflex, which is the normal reflection of the retina
Morton’s neuroma
- Inflammation and thickening of tissue that surrounds the nerve between toes (most commonly between 3rd and 4th toes)
- Pt feels like they are walking on a marble
- Palpable in 3rd web space, replicate burning pain
- Can have radiation of pain and numbness of toes
Test: Mulder’s sign: clicking sensation upon palpation with one hand on the third web space and other hand compressing transverse arch together
FICA - spirituality and religion
F - faith and belief
I - importance
C - community
A - address in care or assessment & plan
Process for developed and working through a DDX
- Develop broad DDX -Based on CC, age, sex, race
- Narrow DDX - HPI, PMHx, PSHx, etc.
- Develop working DDX -Most common/likely diagnosis and IgE threats
- Pursue working DDX -Therapeutic interventions and diagnostic testing
- Assessment and plan (primary and secondary DX) -Tx, disposition, documentation
Ottawa Knee Rule
If one criteria is +, need imaging:
- Age >55 years
- Inability to bear weight for four steps (unable to transfer weight twice) immediately after injury or in the emergency setting
- Inability to flex knee to 90 degrees
- Tenderness over head of fibula or isolated to patella without other bony tenderness
Diaphragm of stethoscope
Larger circle
Used for higher frequency sounds such as breath and heart sounds
Reflex patellar
L4 nerve root
Patrick (Fabere) test
- Allows assessment of the hip and sacroiliac joint
- The examiner Flexes, ABducts, Externally Rotates, and Extend the affected leg so that the ankle of that leg is on top of the opposite knee
- Affected leg is then slowly lowered toward the table
+Test: affected leg remains above the opposite leg and may be indicative of hip disease, iliopsoas spasm, or sacroiliac disease
Internal rotation ROM of hip
30-40
Iliopsoas
Posterolateral calf/little toe dermatome
S1
Active listening skills
Smile
Eye contact
Posture
Mirroring
Minimize distraction
Inspection - 1/4 techniques of examination
Assess appearance of age, posture, mobility, asymmetry, color changes
Dx and Tx of plantar fasciitis
Dx: clinical
- TTP over the medial plantar calcaneal region;
Pain worsens with passive dorsiflexion
Tx: typically self-limited, rest, NSAIDs, stretching exercises, orthotics, glucocorticoid injections —>Roll stretch, place cold bottle of water/can of soda underneath foot
ROM - flexion of hip
With knee straight: 90
With knee flexed: 120-135
Iliopsoas M. —>Innervated by: Femoral N. (L2-4) and ventral rami of lumbar (L1-2)
CAGE questions - alcohol
Useful to screen for patients who drink more than one drink daily or who drink a lot on the weekends, can open door to conversation about getting help
C: Has anyone ever suggested you cut back?
A: Are you ever annoyed wen people talk about your drinking?
G: Do you ever feel guilty about your drinking?
E: Do you ever need a drink in the morning to steady your nerve (an eye opener)?
Lumbar radiculopathy
Particularly involving L4-L5
Causes lateral hip pain that extends over a much wider area
Radiating down the leg and into the foot with or without associated foot numbness
Sharp shooting pain
What info to gain for full HPI
- Past medical history
- Past surgical history
- Current medications —> Rx, OTC, supplements —> dose, timing, positive or negative
—>Reminder to ask about OCPs for females
- Allergies (medications, and reaction, environmental, food)
- Family history: mom, dad, siblings, kids
- Social history
ROM extension of hip
15-30
Gluteus Maximus M
—>innervated by inferior gluteal nerves (L5-S1,S2)
Dx and Tx of PAPS
-Clinical: medial knee pain, tenderness over proximal medial tibia, and absence of local swelling
Tx: weight loss, quadriceps-strengthening exercises, NSAIDs Glucocorticoid injection into bursa
Bone fractures in shoulder
Clavicle - most occur in kids and young adults
Proximal humerus - most commonly in the elderly
Scapular - associated with blunt trauma
OA - classic presentation
Gradual onset, potentially ASYMMETRIC joint pain and stiffness commonly in DIP, PP, 1st carpometacarpal, hip, knee Cervical, lumbar joints
Pain worse with activity but relieved with stress
Joint stiffness last <1 hour after waking up and improves with activity
Consensual pupillary light reflex
When light shines in one eye, contralateral (opposite side) pupil also constricts
DDx of Medial knee pain?
Medial collateral L sprain
Medial meniscal tear
Pes anserine bursitis
Medial plica syndrome
Phalen’s sign
- Place dorsal aspects of patient’s hands together and force into wrist flexion
- Hold for 60 seconds
+Test: any reproduction of sxs of paresthesia in the distribution of median N.
Tests: Carpal tunnel syndrome
Techniques of examination (in order)
Inspection, Auscultation, Percussion, and Palpation
Shoulder pain —> traumatic
Bone
-fractures and dislocations
Soft tissue
-myofascial, acromial clavicular, rotator cuff
Joint (intra-articular)
-cartilage (labrum), hemarthrosis, joint capsule
Elbow specialty test - Tinel test
-Tap between olecranon and medial epicondyle in ulnar groove
+Test: elicits tingling sensation down forearm
Tests: ulnar nerve entrapment
Finkelstein test
-Ask pt to make a fist encompassing their thumb and ulnar deviate the wrist
+Test: increased pain in first dorsal compartment
Tests: DeQuervain’s tenosynovitis
Squeeze test
- Wrap hands around leg proximal to the ankle, contacting distal tibia/fibula with both thenar eminences
- Squeeze for 2-3 seconds, then rapid release
+Test: Pain at syndesmosis
Tests: Syndesmosis pathology (high ankle sprain)
Hawkin’s test
Tests: rotator cuff or subacromial bursa impingement
- Flex shoulder and elbow to 90
- Passively rotate the humerus into internal rotation
- This opposes rotator cuff against coracoacromial ligament and acromion
+Test: pain
“Little league elbow”
-Group of problems related to stress of throwing in young athletes
—>pain over the medial epicondyle, initially after throwing (repetitive valgus distraction forces), progresses to persistent pain
—>most common elbow injury during childhood
—> as bone development matures, most common injury seen evolves (apophysitis —> avulsion —> ligamentous injury)
Rheumatoid arthritis - etiology
Etiology: autoimmune, inflammatory arthritis of unclear etiology
Thompson test
- Patient prone with foot off the table
- Squeeze the pt’s calf
- Observe for plantar flexion
+Test: Absence of plantar flexion
Tests: Achilles’ tendon rupture
Etiology of PFPS
Maybe overuse of knee vs patellar maltracking due to quadriceps weakness
-Large Q angle? (B/w ASIS and patella)
Olecranon bursitis
FLies superficial to posterior elbow joint
- Posterior elbow distention and discomfort due to overuse “student’s elbows” or “miners elbow” or athletic pain
- Region is often painless
ROM normal
Shoulder pain
3rd most common MSK complaint
The only joint in the human body where tendons (rotator cuff) pass between bones (acromion and humerus)
Dislocation of glenohumeral joint
50% of all major joint dislocation
-3 types
—>anterior dislocation: most common, accounting for 95-97%
—>posterior: 2-4%
—>inferior: luxatio erect, which means “to place upward”: 0.5%
Drop-arm test
Tests full thickness tear of supraspinatus
- Pt abducts arm to 90
- Then slowly drops arm
+Test: arm will drop or gentle tap on wrist will cause arm to drop
Adduction ROM of hip
20-30
Adductor longus/brevis/magnus, pectineus, gracilis Ms.
Adductor longus innervated by: Obturator nerve (L2-4)
Examination of the hip - sources of referred pain to the hip from?
- Lumbar spinal nerves (straight leg raise)
- Sacroiliac joint (palpation of the joint)
- Lateral femoral cutaneous nerve (sensation in the upper outer thigh)
- The lower abdominal vascular structures (low extremity pulses)
Labral loading
Central compartment of the hip
- Flex the pt’s knee and hip to 90
- Load into the femur towards the innominate
+Test: Pain
Tests: labral or cartilaginous pathology
Top causes of life threatening joint pain
Septic arthritis
Referred pain
- > Acute MI
- > Intraperitoneal hemorrhage
- > lung pathology
Bell of stethoscope
Smaller circle
Used for lower frequency sounds such as bruits
Otoscope grasp in adults and children >12 months
Pull up, out and back
Visualization with ophthalmoscope
Hold device in right hand and use right eye to examine patient’s right eye
—Perform bilaterally
Move light lateral (15 degrees out) to medial until over the iris then move toward the patient
Identify pupillary light reflex and red reflex
Giving out sensation of knee pain suggests?
Ligamentous rupture or patellar subluxation
Talar tilt test
- Grasp distal tibia/fibula with one hand and inferior calcaneus with the other
- Blocking motion of the calcaneus on the talus
- INVERT the talus to evaluate ROM
+Test: laxity, increased ROM, or pain
Tests: calcaneofibular L pathology/tear; also tests some ATF (lateral ankle sprain)
Tredelenburg gait
- Pt shifts the torso over the affected hip, thereby reducing the load on the hip and decreasing pain
- Suggests the presence of hip joint disease and/or weakness of the gluteus medius muscle
Joint exam
- Inspection
- Palpation
- Range of motion
- Specialty testing
- Always compare to opposite extremity
Skin exam - general examination
Color: pale, jaundice, cyanosis, reddened
Condition: dry, pigmented, diaphoretic, rash
Lesions: location, macular, popular, petechial
**Screen for melanoma with ABCDE**
**Exam hair and nails**
Osteoarthritis arthritis (OA) - risk factors
- Most common form of arthritis in adults
- Age >50, obesity, female, joint trauma, genetics
Specialty tests for rotator cuff
Painful arc - most sensitive and specific
Neer impingement
Hawkins
Yergason sign
Empty can
Drop arm test
Diagnostic: X-ray not helpful, US or MRI test of choice
Tx: rest, ice, NSAIDs and PT
LGBTQIA
Lesbian
Gay
Bisexual
Transgender
Queer or questioning
Intersex
Asexual or allied
A question you may use: In the past, have you had sexual relationships with men, women, or both? How about now?
Anterior cruciate ligament (ACL) injury
- Most commonly injured knee L
- Contact injury: 30%
- Non-contact injury: 70%; sudden deceleration with change in direction
- Sudden onset of severe knee pain with large effusion developing with 2 hours typically from hemarthrosis
- Pt can report “popping sensation” or knee instability (giving out)
- Can lead to osteoarthritis 10-20 years after the initial injury
Insertion of otoscope
-Approx 1/4 to 1/2 length of speculum (1-2 cm into ear)
—Identify canal, tympanic membrane, and reflected cone of light
Snellen eye chart
Example: 20/20 is normal and 20/40 means that the test subject sees at 20 feet what a normal person sees at 40 feet
Chart is held ~14 inches from eyes
**Test both eyes open, then covering one eye at a time
Forefoot adduction
20
RA - classic presentation
SYMMETRIC JOINT PAIN, joint swelling, joint stiffness of hands, wrists, feet, knees, and other joints
—> joint stiffness lasts >1 hour after waking up and improves throughout the day
CLINICAL PEARL: commonly involves joints: wrists, MCPs, PIPs
Ottawa Ankle Rule
Ankle/foot XRs should be obtained in patients with the following:
- TTP over medial malleolus or lateral malleolus or inability to bear weight immediately after injury
- Tenderness over base of 5th metatarsal or navicular instability to bear weight immediately after injury
Achilles tendonitis
- Inflammation at Achilles’ tendon
- Presents as sharp heel pain and stiffness at mid-Achilles tendon to insertion
- Pain with worse with strenuous exercising, better with walking
- Micro tears in tendon causes swelling and thickening
- Commonly associated with tight calf muscles, sudden change in activity, poorly fitting shoes, incorrect running technique
Joint pain —> traumatic —> extra-articular
Bone —> fractures, dislocations
Soft tissue —> ligaments, tendons, bursae, macula, fascia, nerve
Reflex biceps
C5 nerve root
**Thumb in between tendon and hammer - on patient’s AC fossa**
Exam findings - RA
Edema Synovitis
Ulnar deviation
Swan neck deformities
Boutonnière deformities
Rheumatoid nodules
Positive MCP squeeze test
Most common causes of shoulder pain - acute
Rotator cuff injuries
Fractures/dislocation
Acromioclavicular joint injuries
Myofascial
Anterior hip or Groningen pain
Suggests primary involvement of the hip joint itself
Gradual onset of pain in association with variable degrees of impaired movement is consistent with osteoarthritis
Tennis elbow test
-Pain with resisted wrist extension with elbow in full extension
+Test: pain/tenderness around lateral epicondyle
Tests: lateral epicondylitis
Dupuytren’s contracture
Caused by progressive fibrosis of palmar fascia which results in gradual joint stiffness and inability to fully extend the finger
Turf toe
- Inflammation and pain at base of 1st MTP
- Presents as pain and bruising at base of great toe
- Caused by hyperextension of great toe causing damage to the joint capsule
- Severe cases can damage sesamoids and flexor tendon
- Commonly associated with activities performed on hard surfaces
Cross arm test
Tests: AC joint pathology
-Physician passively adducts pt’s arm across their chest and rests pt’s hand on their opposite shoulder
+Test: pain in AC joint with end range adduction
Meniscal injuries
- Medial or lateral
- Acute: sudden change of direction in which the knee is twisted or rotated while the corresponding foot is planted
- Chronic: often from degenerative changes seen in older patients
- Slow onset knee pain with swelling or effusion over the next 24 hours
- > degree of pain related to severity of meniscal tear
- If untreated, pts may report “locking” or “catching” of knee during extension
Empty can test
Tests rotator cuff pathology (specifically supraspinatus)
- Flex pt’s shoulders to 90 while horizontally abducting to 45
- then internally rotate both arms so thumbs are pointing down
- Press down on forearm while pt resists
+Test: pain or weakness
Iliotibial band syndrome (ITBS)
- Second most common cause of knee pain from overuse after PFPS; commonly seen in runners or cyclists
- Slow onset, diffuse, lateral knee pain and/or leg pain; intermittent, sharp or burning pain that can progress to constant/deep
Scour test
Central compartment of hip. “Omega”
- Flex and externally rotate pt’s hip
- Load into the socket and articular through annular ROM
+Test: Pain
Tests: labral or articular cartilage pathology
Eversion test (ankle/foot)
- Grasp distal tibia/fibula with one and hand plantar surface of the mid-foot with the other
- Evert the foot to evaluate ROM
+Test: Laxity, increased ROM, or pain
Tests: Deltoid ligament pathology (medial ankle sprain)
Plantar fasciitis
- One of the most commons cases of foot pain in adults
- Most likely biomechanical overuse causing microtears in the plantar fascia resulting in degeneration of fibrous tissue or acute inflammation
- Sharp, stabbing, medial, plantar heel pain
Golfer’s elbow test
-Pain with resisted flexion with elbow in full extension
+Test: pain/tenderness around medial epicondyle
Tests: medial epicondylitis
Rotator cuff injury
SITS (supraspinatus, infraspinatus, teres minor, subscapularis)
-supraspinatus - most often injuries
**Painful arc test**
Sx: shoulder pain (over lateral deltoid) more prevalent with overload activity and at night; weakness
Can have impingement syndrome, tendon injury (acute), or tendinopathy
Trigger finger
Caused by disparity in size of flexor tendon to surrounding retinacular pulley system system/sheath, impairing gliding of flexor tendon
Classic presentation: painless to painful snapping, catching, or locking of fingers during flexion
Apprehension - FABER (1/3)
Central compartment of the hip.
- Pt’s hip is flexed, abducted, and externally rotated
- Physician induces further external rotation by applying a posterior force at the knee (figure four)
+Test: anterior subluxation of hip or apprehension/pain
Tests: labral pathology - or impingement
Homan’s sign
- Pt laying or sweating with knee extending
- Dorsiflexion the pt’s foot; can apply lateral compression to calf
+Test: Pain with dorsiflexion
Tests: Thrombophlebitis or acute deep vein thrombosis (DVT)
*Can also observe accompanying signs of edema, erythema, and warmth of lower leg —> would need to order a Venous Doppler to rule out clot*
Apprehension test
Tests for glenohumeral instability
- Pt seated or supine
- Shoulder abducted to 90 and elbow flexed at 90
- Stabilize shoulder with one hand
- Force arm into external rotation
+Test: patient apprehensive of repeated dislocation
Patrick’s (FABER) 2/3
Lateral compartment of the hip.
- Pt’s hip is flexed, abducted, and externally rotated (figure 4)
- Physician braces contralateral ASIS
- Pt externally rotates/abducts a/g resistance
+Test: pain or weakness
Tests: gluteus medius pathology
Acromioclavicular joint injuries
Usually occurs from direct trauma to the superior or lateral aspect of the shoulder (acromion) with the arm adducted
Spectrum of injuries: AC sprain/ligament rupture, sprain/rupture of CC ligaments
PE: tenderness over AC joint
Anterior-posterior radiographs including both AC joints or US
Inspection for pelvic obliquity
- Screening maneuver for leg length discrepancy
- Pt asked to stand with feet together
- Hands are places on top of the iliac crease and the level of the pelvis is estimated
- Asymmetry of the iliac crests is seen with leg length discrepancy, pelvis fracture, scoliosis, and unilateral paraspinal muscle spasms
Labral distraction
Central component of the hip
-Distract pt’s femur away from innominate
+Test: improvement of pain
Indicated: labral or cartilaginous pathology
Tinel’s sign of wrist
- Tap over the transverse carpal ligament/flexor retinaculum with either the tip of the finger or reflex hammer
- Pt’s wrist is held in extension
+Test: parasthesia/numbness/tingling//pain radiating to thumb, index, and middle finger
Tests: Carpal tunnel syndrome
Ober’s test
Lateral compartment of the hip.
+Test: restricted ROM
Indication: tight IT band
Painful Arc Test **
Test for subacromial impingement and rotator cuff tendon injury
*A positive test is shoulder pain from 60-120 of abduction*
Valgus deformity
Distal part of limb directed away from midline
“Knock knees”
Popliteal cyst (Baker’s cyst)
- Posterior aspect of knee
- Comes from bursa
- Commonly associated with OA, RA, or meniscal tears
- Most are asymptomatic and incidental detected on imaging
Dx: Foucher’s sign: cysts softens or disappears with knee flexion to 45 degrees
Tx: asymptomatic- no tx;
symptomatic —> treat underlying joint disorder when present
Diabetic neuropathy
- Complication of DM causing gradual loss of nerve fibers
- Loss of vibratory sensation along with impaired pain, light touch, and temperature sensations
- Test pressure sensation suing a monofilament test (plantar aspect), vibration using a tuning fork, and superficial pain using a pinprick
- Complete exam includes: examining pulses, checking for skin lesions (sores, ulcers, open wounds, etc.)
Varus deformity
Distal part of limb directed toward midline
“Bowlegs”
Ganglion cyst
- Common soft tissue finding of wrist/hand
- Seen typically in 2nd-4th decades of life
- Etiology unclear
Class presentation: potentially painful, smooth, firm to rubbery cystic lesion that can be seen in wrist, hand, feet, etc.
*typically seen on dorsal wrist but can on palmar*
Clinical Dx —> 50% spontaneously resolve
Scaphoid fracture
- Most commonly fractures carpal bone
- Blood supply to bone is poor and can result in avascular necrosis
- Pain in anatomical snuff box
- 20% of initial XRs will be normal
—>if suspicion is high for fx, place patient in thumb spica cast, repeat wrist XR in 7-14 days
Never impingement
Tests subacromial bursa or rotator cuff impingement
- Stabilize pt’s shoulder
- With forearm pronates, passively flex shoulder to fuller flexed position
+Test: pain
Expressing empathy - NURSE
N - name
U - understand
R - respect
S - support
E - explore
Nursemaid elbow
- Radial head instability
- Annular ligament tear and/or radial head subluxation from annular ligament
- Trauma from extending a child’s arm
- Pain with palpation of radial head with anterior displacement of radial head and restriction to posterior glide
Anterior drawer test - ankle/foot
- Grasp posterior calcaneus with one and hand distal tibia/fibula with the other hand
- Monitor anterior talus
- Provide anterior force on calcaneus with stabilizing the distal tibia/fibula
- Normal springing of calcaneus back to neutral should occur
+Test: pain, no springing, excessive motion/laxity
Test: ATF ligament pathology/tear - lateral ankle sprain
