PD3 Flashcards
flexion
bending motion that decreases angle between 2 body parts
ABduction
motion that pulls a structure or part AWAY from midline
extension
bending motion that increases the angle between 2 body parts
ADduction
motion that brings a structure or part to/ACCROSS midline
hyperextension
added movement (extension) beyond the normal limit
internal rotation
rotation TOWARDS the axis of body
rotation
rotating, turning action of body part from another, internal or external
external rotation
rotation AWAY from axis of body
lateral bending
re spine: standing tall and tilting side to side w torso
re neck: ear to shoulder (not rotation, just tilting)
inversion
rotation inward, medially (most common method of sprained ankle.. sole of foot tilted IN)
supination
rotation that is turned outwards - laterally - holding a bowl of soUP
eversion
rotation outwards, laterally, sole of foot is tilted OUT
pronation
rotation that is turned inwards - toward medial line
plantar flexion
toes pointed away from shin
radial deviation
hands in neutral (flat) position and turned in towards thumb
ulnar deviation
hands in neutral (flat) and turned out towards pinky
dorsiflexion
toes brought up towards shin
grading system used to classify muscle strength
0-5, 5/5 is normal
supplies needed for exam of musculoskeletal system
skin marking pen
goniometer
tape measure
reflex hammer
myopathy
any congenital or acquired muscle disease, marked clinically by focal or diffuse musc weakness
neuropathy
any nerve disease or injury that affects a single nerve
polyneuropathy
any disease that affects multiple peripheral nerves
sprain
trauma to ligaments
strain
trauma to muscles & tendons from violent contraction or excessive/forcible stretch
dislocation
displacement of a bone from its normal position in a joint
subluxation
a partial or incomplete dislocation
additional body systems to evaluate during musculoskeletal exam
skin/soft tissues
surrounding joints
neurologic
shoulder joint
most potentially unstable of all major joints.
complex of 4 joints
4 joints that make up the shoulder
acromioclavicular
glenohumoral
thoraco-scapular
sternoclavicular
elbow joint
serves as link between powerful movements of shoulder and fine motor control of hand
wrist
required for most ADLs. injuries here can affect gross and fine motor movements
hands & fingers
required for most ADLs. injuries can greatly affect cross and fine motor movements
shoulder ROM
flexion: 90
extension: 45
ABduction: 180
ADduction: 45
Internal rotation: 55
external rotation: 40-45
Elbow ROM
flexion: 135
extension: 0- -5
pronation: 90
supination: 90
wrist ROM
flexion:80
extension: 70
radial deviation: 20
ulnar deviation: 30
fingers ROM
flexion: 90
etension: 35-45
opposition (thumb): touch tip of thumb to each fingertip
ABduction: 20
ADduction: 0
Sequence of exam techniques for upper extrem
- history
- inspection
- palpation
- functional assessment (ROM, musc strength)
- neuro
scapular winging
w/ abduction of arm, an outward prominence of the scapula indicates injury to the nerve of the anterior serratus muscle
drop arm test
w/ pt standing or sitting, a fully abducted shoulder is slowly lowered to the side. if there are rotator cuff tears (esp in supraspinatus muscle), the arm will fall uncontrollably to the side from 90 degrees
Yergason test
used to determine the stability of the long head of biceps tendon in the bicipital groove. have pt flex elbow, hold the flexed elbow w/ one hand while holding the pts wrist w/ other hand, internally rotate the arm and pull down on elbow at the same time. if biceps tendon is unstable in the groove, it will pop out and cause pain
apprehension test
for chronic shoulder dislocation. abduct and externally rotate pts arm to a position where it would easily dislocate. if the shoulder is ready to dislocate, the pt will have a look of apprehension or pain
tennis elbow test (lateral epicondylitis)
to reproduce pain of tennis elbow, stabilize pts forearm while they make a fist and they extend their wrist. apply pressure w/ your other hand to the dorsum of fist to force pts hand into flexion, which will cause pain at the lateral epicondyle
Tinnel sign - elbow
to elicit tenderness over a neuroma w/in a nerve. tap the area in the ulnar groove between the olecranon and the medial epicondyle. if neuroma is present, will cause tingling sensation down forearm.
Tinnel sign - wrist
tap pts wrist where the median nerve passes under the flexor retinaculum. if a tingling sensation radiates from the wrist into the hand, this is positive and indicative of carpal tunnel syndrome
allen test
to determine whether radial & ulnar arteries are supplying adequate amount of blood to hands. Have patient open/close hand into fist several times, then with the hand in a fist, occlude both radial and ulnar arteries. Patient then opens hand (which should appear pale), release ONE of the arteries while still occluding the other. The hand should flush immediately, if it doesn’t, this is an indication of a problem with that artery. Repeat testing the opposite artery and then the opposite hand as well.
Finkelstein test
to test for DeQuervain’s disease, where inflammation of the synovial lining of tunnel 1 in wrist narrows the tunnel opening and results in pain when the tendons move. Have patient make a fist with thumb tucked inside the other fingers. Stabilize their forearm with one hand, and use the other to deviate their wrist to the ulnar side. If sharp pain is felt in the area of tunnel 1, indicates stenosing tenosynovitis (DeQuervain’s disease).
Phalen test
to test for carpal tunnel syndrome, have patient flex wrists to maximum degree and hold for at least 1 minute. If tingling of fingers occurs, positive test.
DTR of upper extremity
Biceps (C5)
Brachioradialis (C6)
Triceps (C7)
Dermatomes of upper extremity
C5,6, 7 : lateral parts of upper limb
C8: medial upper limb
C6: thumb (ant&post)
C7: middle & index finger&mid hand (ant/post)
C8: ring& pinky fingers, medial hand (anatomical position)
primary sensory functions of upper extremities
superficial touch&pain
vibration
temp&deep pressure
proprioception
cortical sensory (cerebral) functions of upper extremity
stereognosis 2-point discrimination extinction phenomenon graphesthesia point location
cubitus valgus
deviation in carrying angle >5 in men, >10-15 in women; forearm bending laterally
cubitus varus
deviation in carrying angle <10-15 in women; forearm bending medially
olecranon bursitis
pain&stiffness surrounding elbow joint, limited motion caused by swelling/pain – inflamed bursa tissue
rheumatoid nodules
subcutaneous nodules along pressure points of the ulnar surface
dupuytren contracture
involuntary curling of hand digits, generally ring & pinky finger, w/ impaired extension
swan-neck deformity
hyperextension of PIP &DIPs are flexed
Boutonniere deformity
POP of finger is markedly flexed, DIP is hyperextended
mallet finger
DIP hyperflexed
Heberden nodes
discrete but palpable bony nodules found on dorsal and lateral surfaces of DIPs, suggests osteoarthritis
ganglion cyst
cystic, pea sized swelling filled w jelly-like substance on dorsal and lateral surfaces of DIPs, not fixed to connective tissue, not tender to palpation
carpal tunnel syndrome
numbness, burning, tingling in hands, often at night. weakness of thumb, flattening of thenar eminence. from compression of the median nerve
carrying angle of elbow
the amount of lateral bending of the forearm from 0 degrees.
men: 5
women: 10-15
sequence of exam for lower extrem
inspect palpate ROM strength neuro
DTR of lower extrem
patellar (L4, L2, L3)
achilles (S1, S2)
Thompson or Simmonds test
for achilles tendon rupture: have pt lie prone on table and squeeze calf. should see plantar flexion. if there is rupture, this flexion will be diminished or absent.
patellar ballottement
for fluid accumulation between the joints (effusion): extend pts knee, push patella into the trochlear groove & quickly release. if there is a large amount of fluid, knee will rebound
anterior drawer sign
for ACL tear: w/ pt laying supine, flex leg, stabilize the foot and hold the calf and pull towards you. if there is an ACL tear, the leg will go further than expected
Posterior drawer sign
for PCL tear: w/ pt lying supine, flex the leg, stabilize the foot, hold the calf w/ both hands and push the leg back
true/apparent leg length
to test for asymmetry: true length (measure from anterior superior iliac crest to malleolus); apparent length (measure from umbilicus to medial malleolus. compare the measurements bilat
homan sign
for DVT: passively dorsiflex ptsfoot to elicit pain in calf
Ortolani/Barlow test
for hip dislocation or subluxation in infants.
barlow maneuver: use a small amount of force. test 1 hip at a time. w/ infant supine, flex hip and knee to 90. adduct thigh and gently push downwards on femur. a positive sign is indicated when you hear a clunk or sensation is felt as the femoral head dislocates from acetabulum.
ortolani maneuver: w/ infant in same position as in barlow test, slowly abduct thigh while maintaining pressure. listen for femur to move back into acetabulum.
patellar bulge sign
for excess fluid in knee: w/ knee extended, mild the medial and lateral aspects of knee upward. observe for a bulge of fluid to return to the space.
apprehension test of knee
for patellar dislocation & subluxation: pt supine on table w legs relaxed, press agains the medial side of patella w thumb, watch pts face. if patella begins to move or dislocate, the pts face will show distress
mcmurray test
medial meniscus tear: have pt lie supine on table, w legs extended in neutral position. w/ one hand, grab the heel and flex the leg. place the other hand at the knee joint and begin to rotate the leg internally and externally. feel for any tenderness, palpable or audible “clicking” may indicate a tear.
apley distraction test
for ligamentous injury: have pt lie prone w leg flexed to 90. stabilize the back of thigh. apply traction to the leg while rotating the tibia internally and externally. this reduces tension on the menisci and puts pressure on the ligaments. if there is a tear the pt will experience pain.
apley grinding test
have pt lie prone w leg flexed to 90. stabilize the back of the thigh. lean hard on the heel to compress the medal and lateral menisci between the femur and tibia. rotate the tibia internally and externally. if this elicits pain there is probably a meniscus tear.
patellofemoral grinding test
for rough articulating surfaces of patella and trochelar groove of femur. pats w/ this often complain of pain when climbing stairs or getting up from a chair. pt lies supine w legs relaxed in neutral position. push the patella distally into the trochelar groove, then have pt flex their quads. palpate and offer resistance to the patella as it moves under your fingers. if there is roughness of the articulating surfaces you will feel crepitus. it should normally be smooth.
varus/valgus stress
for collateral ligaments damage:
valgus stress- to test the MCL, apply stress by pushing on the lateral aspect of the knee w leg extended.
varus stress - to test the LCL strength, apply pressure on the medial aspect of the knee w leg extended.
genu varum
outward bowing of legs
hammer toe
bending of 2nd-5th toes (contracture)
genu valgum
knees angle in and touch one another
pes planus
flat feet
genu recurvatum
knee bends backwards
hallux valgus
big toe points toward 2nd toe
claw toe
toe contracted at PIP &DIP joints
pes cavus
high arch of foot
morton’s neuroma
irritation and fibrosis of the nerve running between 3rd &4th toes or 4th and 5th toes, most commonly
neck ROM
flexion: chin to chest
extension: should be able to look at ceiling
rotation: chin should be almost in line w/ shoulder
lateral bending: 45 degrees
back ROM
flexion:75
extension: 30
lateral bending: 35
rotation: 30
Hip ROM
flexion: 120
extension: 30
ABduction: 45
ADduction: 30
external rotation: 45
internal rotation: 40
sequence of exam for spinal column
- inspect C, T, L, S spine
- palpate vertebral column
- assess ROM
- blunt percuss over spinal column
distraction test
to assess for C spine pain and determine nerve impingement, place one hand under chin and other under occiput. lift upwards gently. if there is C nerve compression, this test should relive the pain.
valsalva test
have pt hold their breath and bear down. if pain occurs, have pt describe location. this tests for space-occupying lesion (herniated disc or tumor) by increasing intrathecal pressure.e pain may radiate to dermatome corresponding w/ neurologic level of C spine pathology.
adson test
determines if there i compression of the subclavian artery. find the pts radial pulse and begin to abduct, extend, and externally rotate the arm. have pt take a deep breath and turn their head toward the arm being tested. if there is compression of the cubclav artery, you will feel a marked diminution or absence of the radial pulse.
compression test
press down on the top of pts head while sitting or supine, if there is an increase in pain, note distribution & dermatome. test will reproduce pain referred to the upper extremity from the C spine to help locate neurologic level of a prob
straight leg raising test
test to look for discogenic disease that may be compressing/affecting the sciatic nerve. pt is supine and you passively lit the leg (keep straight) upwards. the foot is then dorsiflexed and if there is pain, it is likely sciatic.
hoover test
place hands under pts heels during active straight leg raise test. as the pt (lying supine) tries to lift one leg up, the opposite heel should be pressing down. used to determine pts effort
normal gait phase
- stance phase - foot is on ground (heel strike, foot flat, mid stance, push off)
- swing phase - foot is off ground (acceleration, mid swing, deceleration)
spastic hemiparesis gait
· The affected leg is stiff and extended with plantar flexion of the foot
· Movement of the foot results from pelvic tilting upward on the involved side
· The foot is dragged, often scraping the toe, or is circled stiffly outward and forward (circumduction)
· The affected arm remain fixed and abducted and does not swing
· Examples – cerebral palsy
spastic diplegia gait
· Patient uses short steps, dragging the ball of the foot across the floor
· Legs are extended and the thighs tend to cross forward on each other at each step due to injury to the pyramidal system
steppage/drop foot gait
· Hip and knee are elevated excessively high to lift the plantar flexed foot off the ground
· The foot is brought down to the floor with a slap
· Patient is unable to walk on heels
· Muscle weakness of tibialis anterior
cerebral ataxia
Patient’s feet are wide based
· Staggering and lurching from side to side is often accompanied by swaying of the trunk
sensory ataxia
Patient’s gait is wide-based
· Feet are thrown forward and outward, bringing them down first on heels, then on toes
· Patient watches the ground to guide his/her steps
· Positive Romberg sign is present
dystonia gait
· Jerky, dancing movements appear nondirectional
ataxia
Uncontrolled falling occurs
abductor lurch gait
· Weakened gluteus medius muscle forces the patient to lurch toward the involved side to place the center of gravity over the hips
extensor lurch gait
Gluteus maximus muscle is weakened and patient must thrust his thorax posteriorly to maintain hip extension (an extensor or gluteus maximus lurch)
flat foot gait
· Patients with muscle weakness of the gastrocnemius-soleus group (S1-S2) may have a flat foot gait with no forceful toe off
back knee gait
· Patients with quadriceps weakness may walk with a back knee gait to lock their knees into extension
antalgic gait
Patient limits the time of weight bearing on the affected leg to limit pain
5 major areas tested by mini mental status exam
orientation registration attention/calculation recall language
equipment/supplies needed for neuro exam
eye chart cotton swab tongue depressor tuning fork paper clip monofilament line key coin vials of aromatic scent pen light opthalmascope sterile needles reflex hammer
scoring DTR
0- no response 1+ sluggish or diminished 2+ active or expected 3+brisk, more than expected 4+hyperactive
superficial reflexed
abdominal
cremasteric
plantar
oculocephalic reflex (dolls’ eyes)
Evaluation of comatose pt - If Brainstem intact: Eyes deviate contralaterally Look away from rotation; lag behind If Brainstem injury: Eyes follow direction of head rotation Mimics conscious patient presentation
brudzinski sign
for meningitis: flex the neck and observe involuntary flexion of legs or knees
kernig sign
for meningitis: flex the knee/hip & watch for pain in back/resistance to straightening, shrugging of shoulders
gower sign
seen in pts w/ muscular dystrophy/other muscle diseases - if on floor, pt uses arms to club up own legs to an upright position. extreme muscle weakness
clonus
repetitive, rhythmic contraction of a muscle when attempting to hold it in a stretched state - a few beats are normal. VERY hyperactive DTR’s
romberg sign
pt stands with heels together/eyes closed - POS if balance is lost - cerebellar test
pronator drift
Cerebellar - “Pizza Box Pose” arms out, palms up, closes eyes, see if an arm drifts - provider to tap are to see if it starts to drift or if it easily returns to same position.
decorticate posturing
rigid posture of flexed arms, clenched fists, and
extended legs; characteristic posture of a patient with a lesion at or above the
upper brainstem
decerebrate posturing
rigid posture of stiff, extended arms, pronated
forearms, and exaggerated deep tendon reflexes; posture of a patient who has lost cerebral control of spinal reflexes, usually as a result of an intracranial catastrophe
spasticity
motor disorder characterized by velocity-dependent increased
muscle tone, exaggerated tendon jerks, and clonus; the result of an upper
motor neuron lesion
flaccidity
loss of muscle tone, loss or reduction of tendon reflexes, and
atrophy and degeneration of muscles; caused by lesions of the lower motor
neurons of the spinal cord
paresthesia
an abnormal or unpleasant sensation that results from injury to
one or more nerves; often described by patients as numbness and tingling, or
as a prickly, stinging, or burning feeling
receptive aphagia
inability to understand written, spoken, or tactile speech
symbols, due to disease of the auditory and visual word centers.
expressive aphagia
person knows what he or she wants to say yet has
difficulty communicating it to others
3 types of vaginal specula
- graves (blades curved w a space between closed blades)
- pederson (narrower, and flatter blades)
- pediatric or virginal (smaller in all dimensions)
anteverted/anteflexed uterus
normal position of uterus - fundus will be felt between 2 fingers at level of pubis
gravida
total # of pregnancies, regardless of outcome
para/parity
of births over the gestational age of 24 weeks. alive or stillborn, does not account for multiples
retroverted/retroflexed uterus
abnormal position - uterus tilted towards coccyx. palpate through rectovaginal exam
multiparous
more than 1 birth over gest. age of 24 weeks.
grand-multiparous= 4-6 births.
great-grand-multi= >7 births
corpus of uterus
body of uterus - includes fundus and isthmus - examined during bimanual exam
fundus
convex upper portion of uterus - extends into insertions of fallopian tubes. height of fundus is used to estimate stage of pregnancy
cervix
extends from isthmus of uterus into vagina. assessed during speculum exam. epithelial collection (pap smear) at cervical os
nulliparous/nulliparity
has not carried a pregnancy to 24 wks
cervical motion tenderness
during bimanual exam, locate cervix w the palmar surface of fingers. grasp cervix between fingers and move from side to side, watching pts face for discomfort
cystocele
bladder hernia that protrudes into vagina
rectocele
protrusion or herniation of the posterior vaginal wall w anterior wall of rectum through vagina.
urethrocele
pouchlike protrusion of urethral wall
uterine prolapse
descent or herniation of the uterus into or beyond the vagina
ectropion
endocervical columnar epithelium protrudes out through external os of cervix
rooting reflex in infant
o Touch the corner of the infant’s mouth. When hungry the infant
will move their head and open mouth on the side of stimulation.
o Present at birth and disappears by 3-4 months.
tonic neck reflex in infant
o With infant lying supine and relaxed, turn his or her head to one
side; look for extension of the arm and leg on the side to which
the head is turned and for flexion of the opposite arm and leg.
Turn their head to the other side and observe the reversal.
o The reflex usually diminishes at 3-4 months and disappears by
6 months.
o Concern is raised if the infant never exhibits this reflex.
o The reflex must disappear before the infant can roll over or bring
the hands to the face.
startle reflex in infant
o Supporting the infant in semi sitting position, allow the head and
trunk to drop to a 30-degree angle.
o Look for symmetric abduction and extension of the arms; fingers fan out and thumb and index finger form a “C”; the arms then adduct in an embracing motion followed by relaxed flexion. The legs may also follow this pattern.
oDiminishes in strength by 3-4 months and disappears by 6
months.
cephalohematoma
A mass composed of clotted blood, located between the
periosteum and the skull of a newborn. It is confined between suture lines and
usually is unilateral. Caused by rupture of periosteal bridging veins due to
pressure and friction during labor and delivery. The blood reabsorbs gradually
within a few weeks of birth. Diagnosed by X-ray of infant’s head.
caput succedaneum
diffuse edema of the fetal scalp that crosses the suture
lines. Head compression against the cervix impedes venous return, forcing
serum into the interstitial tissues; swelling reabsorbs within 1 to 3 days;
Diagnosed by exam of scalp.
milia
white pinhead-size, keratin-filled cyst; In the newborn, milia occur on the
face and, less frequently, on the trunk, and usually disappear without treatment
within several weeks. Diagnosed by physical exam of skin.
port wine stain
(aka: nevus flammeus) A large reddish-purple nevus of the
face or neck, usually not elevated above the skin. It is considered a serious
deformity due to its large size and color. Diagnosed by physical exam of skin.
hemangioma
a dull red benign lesion, usually present at birth or appearing
within 2 to 3 months thereafter. This type of birthmark is usually found on the
face or neck and is well demarcated from the surrounding skin. It grows rapidly
and then regresses
mongolian spots
blue or mulberry-colored spots usually located in the sacral
region; may be present at birth in Asian, American Indian, black, and Southern
European infants and usually disappears during childhood. Diagnosed by
physical exam of skin.
ADLs
(Activities of Daily Living): ➢ Bathing and grooming ➢ Ambulation (walking around) ➢ Transfers (chair to bed, wheelchair to toilet, etc) ➢ Toileting ➢ Eating ➢ Dressing
IADLs
(Instrumental Activities of Daily Living): These are often lost first with impairment and often have to be taken over by a family member or caregiver. ➢ Writing ➢ Reading ➢ Cooking ➢ Cleaning ➢ Shopping ➢ Laundry ➢ Using telephone ➢ Outdoor activities ➢ Managing medications ➢ Managing money ➢ Transportation
