Physical Diagnosis Exam 4 Flashcards
Do all “hip clicks” mean DevelopmentalDysplasia of the Hip (DDH)?
No
Palmar Grasp
Timing: present at birth, disappears by 6 months
Elicitation: stroking of palmar surface with finger
Response: hand will close around finger and tighten
Lordosis
anterior curve of lumbar spine just above buttock- seen from lateral view
A small amount of curvature in kyphosis and lordosis is normal
May be congenital, or related to abdominal weight from pregnancy or obesity
Structures in the joint (articular)
Joint capsule
articular cartilage
synovium and synovial fluid
intr-articular ligaments
juxta-articular bone
F A S T
Facila droop
Arm weakness
Speech difficulty
Time to call 911
Peripheral Nerves
31 pairs
8 Cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
Level of care
Problem focused
1 organ system
Spinal cord length
Extends from medulla to L1-L2
Breasts in 2nd trimester
growth continues, minor leakage may occur
Hip flexion muscle
Iliopsoas (knee to chest)
Moro Reflex (“startle Reflex”)
Timing: present at birth, disappears by 6 months
Elicitation: while laying supine gently pull up on arms or hold child and gently allow head to fall back about 3cm, can also occur from loud sound or sudden movement
Response: infant throws back head, extends out the arms and legs, cries, then pulls the arms and legs back in
Which of the following statements regarding reinforcement when assessing reflexes is true?
A. Used when reflexes are symmetrically hyperactive
B Technique involves isometric contraction of other muscles
C. Supports the unsteady patient
D. All of the above
B. Technique involves isometric contraction of other muscles
Used when reflexes are symmetrically diminished or absent
Osteoporosis & Osteopenia risk factors
over 50 low bmi tobacco alcohol low physical activity 1st degree relative some drugs
Murmurs in geriatrics
Common to hear systolic aortic murmur – 1/3 over age 60 and 50% of those over 85.
thumb opposition Nerves
C8, T1, median nerve
MSK localized vs diffuse
Localized is one joint
Diffuse is multiple joints
TRANSVERSE PALMAR CREASE
A common variant, found in approximately 5% of newborns
A single palmar creases is also associated with Down’s syndrome (Simian crease)
3 D’s in Neuro
“three Ds” – delirium, dementia, and depression
Plantar Fasciitis
Plantar pain upon getting out of bed
associated with a bony exostoses on calcaneus i.e. a “spur”
Inflammation of the plantar fascia as it inserts into anterior calcaneus
Elbow: Biceps and triceps, wrist-(radial nerve) – flexion Nerves
(C5, C6)
Anal Refelex Nerves
S2-S4
Fundal height = Just above symphysis pubis
12 weeks
Which Cranial Nerve involves palpation of the temporal and masseter muscles?
CN I
CN III
CN V
CN VII
CN V
Club Foot
The feet are plantar-flexed and inverted. Because this is a bony deformity, this position is rigid.
Ankle Reflex Nerve
S1
What should you never fail to consider in shouldr pain
Cardiac issues
Hip Extension Nerves
S1 G. maximus
Cobb Angle
Theangleformedbytheintersectionoftwolines drawnonaspinalradiograph
Greater than 10° of curvature measured by the Cobb angle defines scoliosis
Osteoporosis & Osteopenia numbers
30 million people/12 million are male
4 levels of care
Detailed
HPI = Extended ROS = Extended PMH/SH = Petinent
Vertex presentation
Head first delivery
Meningeal signs
Brudzinkis sign
Supine, neck up
Kernigs sign
Supine leg raised
Meniscus test
McMurray
Dysdiadochokinesis
The inability to perform rapid alternating movements
Where is the line for posterior superior iliac spine
Imaginary line along the posterior–superior iliac spines crosses the joint at S2.
4 levels of care
Expanded problem focused
HPI = Brief ROS = Problem Pertinent PMH/SH = N/A
AD CAVA DIMPLS
Admit note
Flaccidity or Hypotonia
Decreased or loss of muscle tone causing limb of affected place to be loose
(lower motor neuron system lesion or GB, spinal cord injury or Stroke)
TIA
acute loss of focal brain or monocular function
less than 24 hours
Temporary / partial blockage
Bursae
pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures
Ankle Jerk reflex nerve
S1-S2
Review of Systems – Common Positives
2nd trimester
may begin to have intolerance to heat, experience ”hot flashes”,
back discomfort, breast tenderness, abdominal expansion,
hair and nail changes, BP decrease
Stroke
acute loss of focal brain or monocular function
Greater than 24 hours
complete blckage
Which Cranial Nerves involves the gag reflex?
CN III and IV
CN IX and X
CN X and XI
CN XI and XII
CN IX and X
Bicep reflex nerve
C5-C6
Kyphosis
posterior curve of thoracic spine at level of ribs- seen from lateral view
A small amount of curvature in kyphosis and lordosis is normal
Galeazzi Sign
Knees bent, check height and symmetry of knees
When legs appear symmetric this is a negative Galeazzi sign
Unequal knee height is positive
Review of Systems – Common Positives
3rd trimester
increased ligamentous laxity, increased curvature of lower spine,
leg cramps, foot and ankle swelling, slight temperature increase,
shortness of breath, ”colostrum” (yellow watery pre-milk) may leek from nipples.
Iliac Crest level
L4
Knee exam for mild effusions
Bulge sign
most common chronic disability of childhood
Cerebral palsy
most frequent is hip dislocation
4 levels of care
Problem focused
HPI = Brief ROS = N/A PMH/SH = N/A
Musculoskeletal disease affect how many people in us
1 out of 2
3 out of 4 over 65
10% of ambulatory visits
200 billion in lost wages
oral presentation
Pertinent physical exam findings
Offer assessment
Describe plan
problem pertinent ROS
inquires about the system directly related to the problem identified in the HPI.
Rooting Reflex
Timing: present at birth, disappears by 4 months
Elicitation: stroking the cheek with a finger
Response: infant turns head toward the side being stroked with mouth open
CLINODACTYLY
Acongenitaldefectinwhich one ormoretoes or fingers are abnormallypositioned
Plantar Response Nerves
L5-S1
Review of Systems in pregnancy
Careful attention to mood.
Ask about stressors, sleep, appetite, energy.
GU/Reproductive - last menstrual period, vaginal discharge, pain, vaginal bleeding, dysuria
Skin – pruritic areas, rash, color/texture changes
Stroke prevention
Exercise Nutrition No tobacco Social determinates Aspirin
Strain
injury to the bone-tendon unit at the myotendinous junction or the muscle itself
Mechanism by muscle contraction
Geriatric pulmonary
Rales may be present
(crackles) (coarse breath sounds)
Increase in anteroposterior diameter of chest
Types of dystonia
Anterocollis (neck bent forward)
Lateroocollis (neck bent sideways)
retrocollis (neck bent backward)
Torticollis ( Neck rotated)
What are some causes of abnormal newborn reflexes?
Low birth weight at birth Premature birth (<36 weeks) Traumatic birth Severe illness in infancy Trauma or injury in infancy
SPondylolisthesis
Step offs
forward slipping vertebrae
mostly in L4,L5,S1
due to birth defect, degenerative disease, vertebral fracture
backache, nerve root pressure, herniated disc, pain down legs
Knee reflex Nerve
L2-L4
Lawton ADL
Phone Shopping Food Prep House Keeping Laundry Mode of transportation Responsibility of own medications Ability to handle finance
Oligoarticular
2 - 4 joints
Geriatric pulse
loss of arterial pulsations is not typical and demands further evaluation
Level of care
Expanded problem focused
2-7 organ systems
Time fram for acute vs chronic in musculoskeletal
Acute = less than 6 weeks
Chronic = 12 weeks
tendons
collagen fibers that connect muscel to bone
What is the difference between comprehensive and focused assessments
Comprehensive Assessment
For patients that the PA sees for the first time in office or hospital.
Includes all the elements of the health history and complete PE.
Focused Assessment
Problem-oriented assessment
Well visits of returning patients
Urgent care-type or acute concerns such as sore throat or knee pain
Handgrip strength Nerves
C7, CG, T1
Documentation for billing
Code that represents
Level of E/M service performed
The three key components when selecting the appropriate level of E/M services provided are
history,
examination,
medical decision making.
Pregnancy health counseling
1/5 Pregnant women experience some form of partner abuse
Caution re: eating processed meats, raw and undercooked seafood, eggs, smoked salmon, unpasteurized milk
Plantar Grasp
Timing: present at birth, disappears by 9 months
Elicitation: stimulation of plantar surface with thumb/object
Response: curling of toes around thumb/object
DTR reflex Grade
0 no response 1 diminshed 2 normal 3 brisk 4 Over brisk, hyperactive
1 reason for stroke in geriatrics
Carotid bruits
Arcus Senilis
Grey ring around eye
Anterior nerve root
Ventral
Motor
Articular
Joint
Which dermatome area is involved with Plantar reflex?
L4-L5
L5-S1
S1-S2
S2-S3
L5-S1
Musculoskeletal changes in pregnancy
Exaggerated lumbar lordosis
Increased ligamentous laxity
Pelvic ligaments relax to prepare for labor and birth.
4 Cardinal features of inflammation
swelling, warmth, redness in combination with pain
Delirium
Delirium – “a temporary state of confusion”
Hip Adduction Nerves
L2, L3, L4, adductors
complete ROS
inquires about the system(s) directly related to the problem(s) identified in the HPI
plus all additional (minimum of ten) organ systems.
Glove and stocking pattern Sensory causes
Diabetes most common cause
Diabetes alcohol B12 def CRF Drugs Leprosy Paraneoplastic
Ankle Flexion Nerves
S1, Gastrocnemius
Spherical joint (ball and socket)
Convex surface in concave cavity
Wide-ranging flexion, extension, abduction, adduction, rotation, circumduction
Shoulder, hip
Synovial joint
Freely movable
Shoulder, Knee
Which cranial nerve is involved with corneal reflex?
CN II
CN III
CN IV
CN V
CN V
Hip Extension muscle
Gluteus maximus (stick leg back)
Breasts in first trimester
swelling of breasts, darker areola, small bumps within the areola
Aging changes symmetry
changes due to aging are symmetrical – if asymmetry exists in your physical exam of patient – look for alternate cause
presbycusis
hearing acuity decreases
Dermatome
band of skin innervated by the sensory root of a single spinal nerve
pertinent PFSH
is a review of the history areas directly related to the problem(s) identified in the HPI.
Geriatric PMI
PMI may be displaced do to kyphosis (makes palpation of PMI less reliable as indicator of cardiomegaly)
Elbow: Biceps and triceps, wrist extension Nerves
(C6, C7, C8)
Stepping Reflex
Timing: present at birth, disappears by 2 months
Elicitation: hold infant upright and touch feet to solid surface then bring to a forward leaning position
Response: one foot will lift up and then step forward in an apparent walking motion
Neuro coordination tests
Point to point Gait hop in place Romberg pronator drift toe, heel walk rapid alternating movements
S3 in geriatrics
hearing an S3 strongly suggests failure/volume overload,
Postural tremors
Anxiety, Hyperthyroidism, Essential tremors
tremor when trying to hold limb still against gravity
Geriatric History
Acute illness present differently – less likely to have a fever with infections, less likely to report CP with MI
Geriatric patients tend to underreport
Exercise guidlines
150-300 minute per week
moderate
75-150 minutes
vigorous
4 levels of care
Comprehensive
HPI = Extended ROS = Complete PMH/SH = Complete
Hagar sign
palpable softening of the cervical isthmus
What is Gelling
“Gelling” phenomenon – decreased active and passive ROM and stiffness upon awakening (this is a sign of articular pain)
cartilage
collagen matrix overlying bony surfaces
Cardiac changes in pregnancy
BP decrease
increased HR
increased blood volume
increased CO
S3 normal in pregnant women
S4 in 15%
Stenosis and murmur may be present
Pavlik Harness
Treatment for Developmental Dysplasia of the Hip
= Newborn-6 months old
Pavlik Harness is rarely successful after age 6 months and surgery is required
Two phases of gait
swing 40%
stance 60%
LCL test
Varus
Knee goes outward
foot goes inward
Bow legged
Geriatric fall numbers
1 in 3 persons over age 65 fall per year
Leading cause of fatal and nonfatal injuries among older adults
30% will have lasting debility
Sucking reflex
Timing: present at birth, disappears by 5 months
Elicitation: place finger into infant’s mouth touching lips and gently touch palate
Response: infant begins to suck
complete PFSH
A review of two or all three of the areas (Past, Family or Social)
Rigidity
Increased resistance that persists throughout the movement arc.
(Parkinson’s)
Genetically determined disorders characterized by progressive degeneration of skeletal muscle leading to atrophy, progressive weakness
Muscular dystrophy
9 major types
duchenne/becker most common
Chadwick sign
Bluish tint to vagina walls/cervix
Ankle Extension Nerves
L4, L5 tibailis anterior
Documentation for billing
Code that represents
Setting of service
Office or other outpatient setting: Preventive visits vs. Acute visits
Hospital inpatient: Comprehensive vs. Focused
Emergency department (ED): Emergent visits
Nursing facility (NF) or Assisted Living Facility (ALF): Chronic visits
Bilateral weakness in both upper and lower extremities and urinary frequency
cervical myelopathy until proven otherwise.
Breech Presentation
Butt first
Systemic symptoms
Malar Rash (lupus)
Scaly plaques, pitting of nails in Psoriatic arthritis
Red based papules, pustules, vesicles on distal
extremities – Gonococcal arthritis
Target/Bulls eye patch – Lyme disease
Levels of alertness
Lethargy (speak loudly)
Obtunded (Shaken patient)
Stupor (painful stimuli)
Coma (no response)
Pain and temp nerve tract
Spinothalamic tract
Determining uterine size
Landmarks – symphysis pubis and the umbilicus
Use left hand to palpate the fundus, determining height of the fundus
Fundal height location used to estimate gestation –
Just above symphysis pubis ~12 weeks
Halfway between symphysis and umbilicus ~16 weeks
At umbilicus ~22 weeks
General rule – measurement in centimeters = gestational age
leukorrhea of pregnancy
Vaginal secretions may become thicker, white
Coordinating eye, head, and body movements applies to which area of the nervous system?
Motor System
Cerebellar System
Vestibular System
Sensory System
Vestibular System
Newborn hand crease
Most newborns have two major creases on the palm, neither of which completely extend from one side of the palm to the other.
Hip – flexion Nerves
(L2, L3, L4, Psoas),
Scoliosis
lateral curve of spine (always abnormal)
Scoliosis is best seen from posterior view with patient leaning forward
Level of care
Detailed
2-7 organ systems examined
with an expanded exam of the affected and other symptomatic or related organ systems
finger – abduction and adduction Nerves
C8, T1, ulnar
4 levels of care
Problem Focused
Expanded problem focused
Detailed
Comprehensive
Fundal height = Halfway between symphysis and umbilicus
16 Weeks
Recommendation for bone density screening
women over 65
post menopausal women under 65
men over 70
Resting tremors
parkinsons
Neck pain with radiation of pain to upper extremity
cervical radiculopathy
Spacticity
Increased muscle tone
upper motor neuron or corticospinal tract system lesions or Stroke
Diadochokinesis
Ability to perform rapid alternating movements
Chorea
huntingtons, aids, immune, genetic, pregnancy, neuroleptic, levodopa, rheumatic fever
(dance like movement)
Monoarticular
1 joint
Geriatric vasculature
Giant cell arteritis
Temporal arteritis
Knee Flexion Nerves
L4, L5, S1, S2, hamstrings
Tricep Nerve
C6-C7
Posterior Nerve root
Dorsal
Sensory
PCL Test
Posterior Drawer
Newborn reflexes
Rooting Sucking Grasp Moro Stepping Tonic Neck Galant
Abdominal reflexes Nerves
T8-T10 (upper)
T10-T12 (lower)
Extra articular structures
periarticular ligamnets
tendons
bursae
muscle, bone, skin
fascia
Brief HPI elements
one to three HPI elements.
Ex. – location, quality, and duration
Hip abduction Nerves
L4, L5, S1, GMM
Review of Systems – Common Positives
1st trimester
frequent urination, lightheadedness, heartburn,
constipation, veins become visible, tender breasts,
pregnancy “glow” to skin, mood changes/lability,
nausea/vomiting
Galant Reflex
Timing: present at birth, disappears by 6 months
Elicitation: lie infant on stomach and lightly stroke the side
Response: infant will laterally flex toward the stimulation side
extended ROS
inquires about the system directly related to the problem(s) identified in the HPI
and a limited number (two to nine) of additional systems
Breasts in 3rd trimester
significant darkening, likely enlarged nipples, stretch marks may be present
Pregnancy weight changes
gain 25-35 punds
Extended HPI
at least four elements of the present HPI
or
the status of at least three chronic or inactive conditions
example = five HPI elements – location, quality, duration, context, and modifying factors
Cartilaginous joint
Slightly moveable
Vertebrae
Respiratory changes in pregnancy
Increased tidal volume
Increased respiratory rate
Respiratory alkalosis
Muscle strength grade
0-5 0 being no muscle contraction 1 barely a trace of contraction 2 active movement with no gravity 3 active movement against gravity 4 active movement with some resistance 5 active movement against full resistance
Geriatric Syndromes
multifactorial condition that involves the interaction between identifiable situation-specific stressors and underlying age-related risk factors, resulting in damage across multiple organ systems
Daily orders
Daily orders are used to change any admission order or for further investigation or treatment
Knee exam for major effusions
Balloon Sign
also ballottement
Condylar joint
Convex or concave
Movement of two articulating surfaces not dissociable
Knee; temporo-mandibular joint
Clonus
a hyperactive response required for assigning a reflex grade of 4, usually elicited at the ankle
How do you identify scoliosis
Inspection
Forward bend test
Use of a scoliometer
Radiographs
Glove and stocking pattern Motor causes
Motor causes Guillen barre Palsy toxicity porphyria (liver disorders)
Diabetes most common cause (sensory)
Tonic neck Reflex
Timing: present at birth, disappears by 7 months
Elicitation: turn infants head to one side
Response: the arm on the side the head is turned stretches out and the opposite arm bends up at the elbow, often called the “fencing” position”
Documentation for billing
Code that represents
Patient type
New patient
not seen by provider in last 3 years
Established patient
seen by provider in last 3 years
Level of care
Comprehensive
8 or more organ systems
Katz ADL
Bathing Dressing Toileting transferring continence feeding
When do you order Xrays for scoliosis
ATR ≥7° in patients with body mass index (BMI) <85thpercentile
ATR ≥5° in patients with BMI ≥85thpercentile
Sarcopenia
decline in muscle tissue due to aging process
GI changes in pregnancy
Increased reflux Nausea & vomiting (due to hormonal changes) Increased symptoms of heartburn Decreased gastric motility Constipation
Skin Changes in pregnancy
Pigmentation – areola, inner thighs, labia, neck may darken
Striae gravidarum (stretch marks)
Pruritic urticarial papules and plaques
Pre-existing skin disorders may flair
Linea Nigra – dark line of skin from symphysis pubis to umbilicus due to hormonal changes
occurs in ~80% of pregnancies
Fundal height = At umbilicus
22 weeks
orthopedic trauma in children numbers
1 in 3-4
Phases of gait
Heelstrike
Foot flat
Midstance
Pushoff
Ankle Sprain
Mechanism: Inversion forces
Most common injury of the ankle
Most common ligament injured—anterior talo-fibular ligament
ACL test
Lachmans
anterior Drawer
Knee Extension Nerves
L2, L3, L4, quads
MCL test
Valgus
Knee goes inward
Foot goes outward
Knock kneed
Dystonia
Involuntary muscle contraction and spasm
AMNIOTIC BAND SYNDROME
Amputations of digits or limbs
Barlow maneuver
A test used to identify an unstable hip that can be passively dislocated.
The infant is placed in a supine position with the hip flexed to 90º and in neutral rotation. The examiner adducts the hip while applying a posterior force on the knee to cause the head of the femur to dislocate posteriorly from the acetabulum.
A palpable clunk or “hip click” may be detected as the femoral head exits the acetabulum.
Majortiy of adults tested are deficient for
Vitamin D
Ortolani maneuver
Identifies a dislocated hip that can be reduced.
From an adducted position, the hip is gently abducted while lifting or pushing the femoral trochanter anteriorly.
In a positive finding, there is a palpable clunk or “hip click” as the hip reduces back into position.
Neuro prevention and counseling
Preventing stroke or TIA
Reducing risk of peripheral neuropathy
Detecting the “three Ds” – delirium, dementia, and depression
Most follow-up progress notes (focused assessments) use what format??
SOAP Format
Documentation for billing
Code that represents
Code that represents
Patient type
Setting of service
Level of E/M service performed
4 regions of brain
Cerebrum
diencephalon
brainstem
cerebellum
NAVEL
Nerve (Lateral) Artery Vein Empty Space Ligament (Medial)
Sprain
involves collagenous tissue such as ligaments and tendons
Mechanism by twist or stretch
Which of the following are not considered a test for sensation?
Asterixis
Stereognosis
Graphesthesia
Two-point discrimination
Asterixis
Newborn Reflexes
Definition: Inborn behavioral patterns that develop in utero
Primitive
Infantile
Infant
Developmental
present at birth then gradually disappear during the first 3-12 months postnatal
4 systems of Coordination of muscle movement
Motor system Muscle Cerebellar system(rhythm, posture) Vestibular system (balance) Sensory system (position)
Fibrous joint
Not moveable
Sutures of skull
Polyarticular
more than 4 joints
Intentional tremors
MS
tremor when reaching for something
actinic purpura
Purple skin patches
Hinge Joint
Flat, Planar
Motion in one plane; flexion, extension
Interphalangeal joints of hand and foot; elbow
Most common ankle injury
Ankle sprain
Most common ligament injured—anterior talo-fibular ligament
Ankle Eversion
Walk on inside of foot
outside of foot is facing up
ankle rolls inwards
Ankle inversion
walk on outside of feet
ankle rolls outward
medial portion of foot is facing up
When to refer pediatrics with scoliosis to ortho
Cobb angle between 20 and 29° in premenarchal girls or boys age 12 - 14 years
Cobb angle >30° in any patient
Progression of Cobb angle of ≥5° in any patient
WHO most common debilitating injuries
Osteoarthritis
Back/neck pain
Fractures due to fragility
Brachioradialis (supinator) Nerve
C5-C6
Newborn Reflexes are Considered Absent
Absent during the neonatal period
Asymmetric (suggesting hemiplegia or monoplegia)
Persist beyond the age by which they should have
normally disappeared
ligaments
ropelike bundles of collagen fibers that connect bone to bone
