Physical Exams 2: Block 1 Flashcards
What are the two motor pathways and what do they control?
Corticospinal (pyramidal)- cerebral cortex connecting to spinal motor neurons to control torso and limbs
Corticobulbar- upper motor neurons of CNs to control muscles of face, head and neck and terminate in the motor neurons in the brainstem
How does the L side of the brain control the R side of the body?
What happens of these motor neurons are damaged?
Corticospinal tracts cross the spinal cord in the medulla
Above- motor impairment on contralateral side
Below- motor impairment on ipsilateral side
Damage to an Upper Motor neuron results in ?
Damage to a Lower Motor neuron results in ?
UMN- increased muscle tone and exaggerated DTRs
LMN- absent muscle tone and DTRs
What neuron tract carries the impulse that inhibits muscle tone?
What is the sequence of flow for sensory pathways?
Corticospinal tract
Impulses from skin/muscle/tendons/viscera
Peripheral nerves/dorsal roots
Spinal cord (pain, temp, position, touch)
Spinothalamic tract/Posterior Column
Sensory cortex of brain
Once sensations like pain, temp and crude touch synapse w/ secondary neurons, how to they get to the thalamus?
How are sensations like postition, vibration and fine touch perceived?
Cross and ascend in Spinothalamic tract
Directly into posterior columns
What type of sensation are and are not sensed in the thalamus?
How is full perception of stimuli achieved?
Perceives pain, cold, pleasant
No fine distinctions are made
Third group of neurons send impulses to sensory cortex and higher discrimination is made
A lesion in the sensory cortex may impair ? but leaves ? intact
What type of PT presentation suggests Dz of posterior columns?
Impaired perception of pain, touch and position; leaves finer discrimination intact (person can’t tell size/shape/texture of object in hand)
Loss of position and vibration senses but other senses are preserved
What Sxs mean transection of spinal cord
What are the 4 guiding questions of a neuro exam?
Loss of all sensation, paralysis and hyperactive DTRs
Does PT have Dz
Is there localization/symmetry
What is the pathophysiology of the finding
Wat is the DDx
General assessment of a PTs mental status starts where?
How is orientation assessed?
How to assess cognitive function?
How intellectual function assessed?
First meeting- LOC, Appearance, Affect
ANO x 3
Long term- presidents
Short term- 3 words
Count back by 7s, spell 5 letter word
Chart on Slide 28
Pg 147-171
Where do CNs 3-12 arise from?
Where do CNs 1 and 2 originate?
Diencephalon and brain stem
Brain
What CNs control pupil constriction, opening eye lid and most EOMs?
Which ones control EOM?
2 and 3
3, 4, 6
What CNs control swallowing, raising of palate and gag reflex
Which ones contribute to voice and speech?
9 and 10
5 7 9 10 12
While assessing EOMs, a loss of conjugate movements in any direction will cause ?
How are nystagmus’ names?
Diplopia
Direction of quick component
Define 3rd nerve palsy?
Define Anisocoria
Ptosis- drooping of upper eye lid
Difference of >0.4mm of pupil diameters
Table 7-10,
Pg 277
A lesion on ? CN causes an absent blinking reflex with the corneal reflex test?
What is the different results of a peripheral injury, like Bell’s Palsy, and a central lesion, like a stroke, on the muscles of the face?
Sensory 5 or Motor 7
Palsy- affects upper and lower face
Stroke- only lower face
What nerves are the motor area and pull the palate up during “aahh”?
How are both motor and sensory areas of these nerves tested?
A lesion here will cause what result to be seen?
9 and 10
Gag reflex
Paralysis causes pulling the uvula to unaffected side
A lesion on ? CN will cause hoarseness or difficulty swallowing during the gag reflex?
What are the functions of CN11?
Unilateral lesion on 10, vagus
Unilateral absence of reflex can mean lesion on 9 or 10
Carry efferent motor fibers to innervate SCM (turn head) and Trap muscles (raise shoulders)
Trapezius muscle weakness with atrophy and fasciculations indicates ?
What type of result will be seen in the shoulder as a result of the muscle’s weakness?
Peripheral nerve d/o
Drooped shoulder, scapula is displaced down and laterally
A unilateral cortical lesion of CN12 causes ? result?
A distal lesion of C12 will cause what tongue result?
Protruded tongue deviates away from side of lesion
Deviates to weak side
Sensory system carries stimuli such as pain/temp, position/vibration, light touch and discriminative sensation through which pathways?
Pain/temp- spinothalamic
Position/vibration- posterior column
Light tough- both paths
Discriminative sensation- cerebral cortex
When testing vibration and sensory sensation, what areas of the body are tested first?
Mapping out dermatomes help with an exam how?
Finger and toe
Localize neurological lesions to a specific level of the spine, particularly in spinal cord injuries
What is the organization that own dermatome mapping?
What are the land mark dermatome levels?
American Spinal Injury Association
C3- front of neck C6- thumb C8- ring and little finger T4- nipples T10- umbilicus L1- inguinal L4- knee L5- anterior ankle/foot L4,L5,S1- posterior ankle and foot S5- perianal
Define Analgesia
Define Hypalgesia
Define Hyperalgesia
Absence of pain sensation
Decreases sensitivity to pain
Increased sensitivity to pain
Which dermatomes need to be checked bilaterally?
All 3 branches of trigeminal C5-T2 T4 T10 T12 L2-S1
What part of a sensory test is often omitted if pain sensation is normal?
What size of tuning fork is used to test PTs vibration sense?
Temp
128Hz
What tests are included in testing discriminatroy sensations?
Stereognosis- name objects held in hand
Graphesthesia- numbers drawn on hand
2 point discrimination- normal <5mm on finger pads
Point localization
Define Asterognosis
When is graphesthesis testing used?
Inability to recognize objects held in hand
If stereognosis is too painful or difficult for PT
How do we grade motor strength
0: no contraction detected
1: barely detectable flicker
2: movement w/ gravity eliminated
3: movement against gravity only
4: movement w/ some resistance
5: movement against full resistance w/out fatigue
How many muscle groups represent the motor innervation by the cervical/lumbar spinal cord
What muscles are not tested
10 groups
Abdominal muscles, T10-11
Hamstrings- innervated by levels of other muscles
What nerves control areas of the upper extremity?
C5- elbow flexor (bicep) C6- radial; wrist extensor C7- elbow extensor (tricep) C8- median; grip and thumb opposition T1- ulnar; pinky abduction
What nerves control areas of the lower extremity?
L2- psoas hip flexion L3- quad, knee extension L4- tibialis anterior, ankle dorsiflexion, inversion L5- hallucis longus, great toe extension S1- gastrocnemius, plantar flexion
What neurons are innervated during DTR tests?
In order for a DTR to fire, what all needs to be intact?
Afferent and Efferent
Sensory, spinal cord synapse, motor fibers, neuromuscular junction, muscle fibers
What is the path of a signal to elicit a DTR response?
How are reflexes graded?
Tapping - sensory - peripheral nerve - spinal cord - anterior horn - crosses neuromuscular junction - contraction/completion
4- very brisk w/ clonus 3- brisker than average, not specifically indicative of Dz 2- normal 1- low normal 0- absent
An abnormal reflex at tricep, bicep, brachioradialis, patellar or achilles means a lesion where?
Bicep- C5 Brachioradialis- C6 Tricep- C7 Patellar- L4 Achilles- S1
A cutaneous reflex on upper/lower abdomen, plantar or anal region signify what areas of the NS?
Upper abdomen- T8-10
Lower abdomen- T10-12
Plantar- L5-S1
Anal- S2-4
Hyperactive reflexes can indicate lesions where?
How do you prove/disprove an issue?
Descending corticospinal tract
Weakness, Spasticity, Pos Babinski
Hypo active/absent reflexes imply ? issue
How do you prove/disprove these issues?
Dz in spinal nerve roots, spinal nerves, plexus or peripheral nerves
Lower motor neuron findings of weakness, atrophy or fasciculations
What type of reinforcement can accent/increase a PTs diminished/difficult reflexes
Isometric contraction
Diminished arm reflexes- clench teeth, squeeze knees together
Diminished leg reflexes- lock fingers and pull against each other
Define the Babinski reflex
Plantar reflex- normal is toe flexion
Abnormal=positive, dorsiflexion and toe fanning from CNS lesion in corticospinal area or unconscious from drug/alcohol intoxication or postictal period
If a reflex seems hyperactive, what is the follow on test?
What part of the brain helps w/ keeping the body upright in space?
Test for ankle clonus
Sustained clonus= CNS dz
Cerebellum
Coordination of muscle movement requires what four areas of the NS to function together?
What function is usually not tested in a routine neuro exam?
Motor- strength
Cerebellar- rhythm/posture
Vestibular- balance/coordination
Sensory- position
Vestibular function
How do you assess PTs coordination during a cerebellar exam?
Rapid alternating movements
Point to point movements
Gait
Standing- Romberg, Pronator drift
Define Dysdiadochokinesis
Define Dysmetria
Cerebellar issues- one rapid movement can’t be followed by follow on rapid movement
Finger over shoots target when PT point nose to out stretched finger target and worsened by eyes closed
What PE finding suggests a PT has a loss of position sense?
What do abnormal Heel-to-Shin tests mean?
Nose to finger test is over shot by PT
Cerebellar Dz if heel over shoots knee and oscilates side to side down shin
Lost position sense of heel lifted too high and PT tries to look
Define Ataxic
What type of gait test can reveal hidden ataxia?
Uncoordinated gait and can be due to cerebellar Dz, loss of position sense or intoxication
Tandem walking
What PE test mainly tests a PTs position sense?
What abnormal findings can be seen and what do the represent?
Romberg
Ataxia- from dorsal column dz and loos of position sense
Cerebellar ataxia- PT has difficulty standing w/ feet together regardless if eyes are open or not
What PE test is both sensitive and specific for a corticospinal tract lesion?
Other than drifting, what other finding can be indicative of an issue?
Pronator drift, signifies lesion in contralateral hemisphere
Downward drift of arm w/ flexion of fingers and elbow
Define Brudzinski sign
Define Kernig Sign
Elevated head bends/elevates knees
Extends knee from raised leg position, positive is pain in neck, back or head upon knee extension
Define Articular Structures
Define Extra-Articular Structures
Capsule, Articular Cartilage, Synovium/Fluid, lIgaments, Juxta-Bone
Periarticular Ligaments, Tendons, Bursae, Muscle, Fascia, Bone, Nerve and Overlying sking
What are the 3 types of joints?
Synovial- freely moveable, bones don’t touch and are covered by articular cartilage and separated by synovial cavity which is lined by membrane and secretes fluid, membrane surrounded by joint capsule
Cartilage- slightly moveable, discs separate surfaces- ribs-sternum, epiphyseal plates of long bones
Fibrous- immoveable, bones connected by fibrous CT, intervening layers of tissue holds bones together- sutures, distal talofibular joingt, teeth/socket
What are the 5 types of synovial joints?
What is the most active joint in the body?
B/Socket, Condylar, Saddle, Hinge, Pivot
TMJ
What type of joints are in between the tib/fib and along the plates of the cranium?
What type are between the spinal vertebrae and the manubrium-rib?
Syndesmosis, Suture
Symphisis, Synchondrosis
What is assessed during the General Information part of a MSK exam?
What is assessed during the inspection?
What is assessed in the surrounding areas?
Appearance, Proportions, Ease of movement
Malalignment, deformity, fasciculation or tremors
Skin changes and atrophy
Acute involvement of only one joint suggests ? issue
What issue affects several joints symmetrically
Trauma, Septic arthritis, Gout
RA
How do you grade muscle strength?
0- no contraction detected 1- barely detectable/flicker 2- movement w/ no gravity 3- movement against gravity only 4- movement w/ some resistance 5- movement against full resistance and no fatigue
What muscle opens the jaw?
What muscles close it?
External pterygoids
Masseter, Temporalis and Internal pterygoids
Define TMJ Syndrome
What finding wold be seen 2-3wks post-rotator cuff tear?
Unilateral chronic pain w/ chewing/clenching often associated w/ stress
Can have swelling/dec ROM and Trismus
Atrophy of Supraspinatus and Infraspinatus
Lateral to medial, what are the bony land marks of the shoulder?
Which landmark do the rotator cuff muscles insert?
Great tubercle, AC joint, Coracoid process
Great tubercle
What movements are Flex, Extend, Abd, Add, Internal and External rotation movements for the shoulder?
Flex= raise arm up and over head (0-180)
Extend= raise arms behind (0-60)
Abduct- raise arms out and overhead
Add= cross arms across body
Internal- reach behind, touch scapula
External- brush hair/arm to shoulder level, bend elbow and rotate forearm to ceiling
What does each special test assess in the shoulder? Cross over Apley scratch Neers/Hawkins Suprspinatus strength (empty can) Infraspinatus strength Drop arm Forearm supination
ACJ Overall rotation Cuff tendonitis/tear Cuff tendonitis/tear Cuff of biceps tendonitis Cuff tear Bicep tendonitis
What special test is done to assess the subscapularis Muscles?
Where is the ulnar nerve in relation to the olecranon?
Lift off test
Posterior between olecranon process and medial epicondyle
What do each of the following movements use for muscles? Flexion Extension Supination Pronation
Flex- bicep, brachialis, brachioradialis
Extend- tricep
Supinate- bicep, supinator
Pronate- pronator teres/quadratus
Thenar or hyperthenar atrophy are signs of ? issue
What structures make up the snuff box?
Thenar- median nerve compression
Hypothenar- ulnar nerve compression
Distal to radial styloid
Extensor Pollicis Brevis and Abductor Pollicus Longus
What are the movements of the thumb?
Flex- move across palm to 5MCP joint Extend- across palm and away from fingers Abduct- anterior and away from palm Adduct- toward palm Opposition- touch thumb to each finger
What parts of the hand are innervated by nerves from the carpal tunnel.
What tests can be done to assess for carpal tunnel?
Median Nerve-> pulp of index finger
Ulnar nerve-> pulp of pinky finger
Radial nerve-> dorsal web space of thumb and finger
Tinel Sign- tap median nerve
Phalen Sign- hold wrist flexed x 60sec and assess for numb/tingling; Pos= median nerve affected
Finklesteins- fist the thumb w/ wrist ulnar deviation; Pain= de Quervian Tenosynovitis
What does C5 do for Motor, Reflex and Sensation
M: deltoid and bicep
R: bicep
S- outter upper arm
What does C6 do for Motor, Reflex and Sensation
M: bicep curl, wrist extendors- carpi rad longus and brevis
R: forearm
S: outter lower arm and thumb
What does C7 do for Motor, Reflex and Sensation
M: tricep extension, wrist flexion, finger extension
R: back of elbow
S: middle finger
What does C8 do for Motor, Reflex and Sensation
M: interossei muscles, finger flexors
R: NONE
S: medial forearm and pinky/ring finger
What does T1 do for Motor, Reflex and Sensation
M: interossei muscles
R: none
S: medial elbow
When assessing gait, define Stance Phase
When do most gait problems occur?
Define the Swing Phase
Foot on ground and bears weight
Weight bearing/stance phase
Foot moving forward and bears no weight
How far wide should the gait base be ?
What is the only part of the gait that does NOT have knees flexed?
2-4”
Heel strike
Top of the iliac crest is at what lumbar level?
Pubic symphsis should be at the same level of ? structure
L4
Greater trochanter
How is the inguinal ligament best palpated during exam?
What is the sequence of structures that bisect w/ the inguinal ligament
Ipsilateral heel on opposite knee
NAVEL
What are the 3 bursae in the hip and how are the palpated?
Psoas- below inguinal ligament on deeper plane
Trochanteric- overlying greater trochanter
Ischiogluteal- overlying the ischial tuberosity and NOT palpable unless inflamed
What muscles are involved for movements of Flex, Extend, Abd, Add, Internal and External rotation movements for the hip?
Flex- ilipsoas Extend- gluteaus max Abduct- max and minimus Adduct- adductors, pectineus, gracilis External- obterator, quad femoris, gemuli Internal- gluteus medius and minimus
Define Genu Varum
Define Genu Valgrum
Bow leg
Knock knee
What does swelling over patella indicate?
What does swelling over infrapatellar bursitis mean?
What does swelling over medial tubercle suggest?
Prepatellar bursitis
Infrapatellar bursitis
Anserine bursitis
What movement makes palpation of the medial meniscus easier to palpate?
How far above the knee is the suprapatellar pouch?
Tibia slightly internally rotated
10cm
What is a Baker’s Cyst
What’s the difference signs for a minor and major effusion in the knee?
Popliteal cyst
Bulge sign= minor
Ballottment- major
What muscles are responsible for knee flexion, extension, rotation?
Flex- hamstring group
Extend- quads
Internal rotate- sartorius, gracilis, semitendinous, semimembranous
External rotation- bicep femoris
What special tests can be done for a knee exam?
McMurray- click/pop along medial joint w/ valgus stress, external rotation and leg extension= posterial medial meniscus tear
Valgus test- pain/gap in medial joint= MCL injury
Varus test- pain/gap in lateral joint= LCL injury
A/P Drawer- unequal= ACL/PCL injury
Lachman- forward excursion of tibia, most sensitive for ACL
What muscles are used in ankle movement
Plantar flexion- gastrocoleus, plantaris, tibialis posterior and soleus
Dorsiflexion- tibialis anterior, extensor digitus longus, extesnor hallicus longus
Inversion- tibialis posterior and anterior
Everson- peroneus longus and brevus
What movements does the tibiotalar joint do
What movements does the subtalar joint do
dorsiflexion/plantar flexion
inversion/eversion of foot
What movements does the transverse tarsal joint do?
What movements does the MTP joints do?
Inversion/eversion of forefoot
Toe flexion
What is the Motor, Reflex and Sensation offered by L4
M: tibialis anterior (foot inversion)
R: patellar tendon
S: sensation to medial arch of foot
What is the Motor, reflex and Sensation offered by L5
M: extensor digitorum longus
R: NONE
S: middle 3 toes
What is the Motor, Reflex and Sensation offered by S1
M: peroneus longus and brevus
R: achilles
S: lateral arch of foot
What 4 landmarks should be visible when examining the spine?
C7 and T1
Paravertebral muscles
Iliac crest
PSIS
Facet joints of the neck are protected by ? muscle
Sciatic nerve is located between what 2 structures
Trapezius
Greater trochanter and Ischial tuberosity
When assessing Pts spine, offer stabilization for movements except for ?
Define Patrick’s Test
Flexion
Flexion Abduction External Roation- tests for SI joint problems like sacroiliitis
What are the 3 shafts of the penis?
Size range for testes?
Two corpus cavernosum
Corpus spongiosum w/ urethra forms bulb
3.5-5.5 w/ L lower than R
Testes produce what two things?
What covers each of the testes except for ? location
Testosterone, sperm
Tunic vaginalis
Path of sperm from testes to urethra
Spermatic cord contains what structures?
Through external inguinal ring, over ureter to prostate, merges w/ seminal vesicle
Vessels, nerves, Vas Deferens, muscles
Lymphatic from penile and scrotal surfaces drain where?
Where do lymphatics from the testes drain to?
Inguinal nodes
Abdomen
What are landmarks for hernias?
External ring that allows vas deferens passage is palpable on what location?
Where is the non-palpable internal ring?
ASIS, pubic tubercle and inguinal ligament in between
Above and lateral to pubic tubercle
1cm above midpoint of inguinal ligament
What is a second route for potential hernias?
How do you estimate the location?
Femoral canal below inguinal ligament
Index finger on R femoral artery, next medial finger on femoral vein, third finger on canal/empty space
What separates the colon from the anus?
How many lobes of prostate surround urethra and can be palpated? What structures are not palpable here?
Pectinate/denate line, visible w/ proctoscope only
3, two lateral are palpable against anterior rectal wall and be 2.5cm long
Median lobe and seminal vesicle are NOT palpable
What issues are examined for in males w/ PTs standing?
What 3 issues can cause irritative voiding Sxs
Hernias
Varicoceles- variscosities of pampiniform plexus around spermatic cord and gravity dependent and nearly always L sided
UTI, STI, BPH
What 3 issues can cause hematuria
Define Phimosis
Nephrolithiasis, Cancer, Excessive exercise
Tight prepuce that can’t retract over glans
Define Paraphimosis
Define Smegma
Tight prepuce that can’t be returned back to original position
Cheese/white material that acumulates under skin
Define Balanitis
Define Balanoposthitis
Inflammation of glans
Inflammation of glans and prepuce
Define Hypospadias
Define Epispadias
Congenital ventral displacement of meatus
Dorsal displacement of meatus, can be associated w/ incontinence
What does yellow/clear discharge from penis mean?
What does induration along ventral surface of the penis mean?
Non/Gonococcal urethritis
Urethral stricture or carcinoma
Define Pearly Penile Papules
Define Peyronies Dz
Skin colored bumps that form row around glans
Considered normal variant, not contagious and ASx
Dec w/ age but can remain for life
Palpable, non-tender plaque along dorsum of penis causing crooked/painful erections in middle age/older men
Define Penis CA
Define Tinea Cruris
Non-atender indurated nodule/ulcer limited to uncircumcised men
Jock itch, unilateral lesions starting in crural folds
Define as half-moon shaped plaque w/ scaling
Take sample for KOH examination
Define Erythrasma
How do different skin infections appear under Wood’s Lamp
Infection of major skin folds caused by bacteria Corynebacterium Minutissiumum but can be confused for Tinea Cruis
C. Mint glows coral red under Wood’s Lamp but negative hyphae on KOH
Tinea- none
Poorly developed scrotum contours can be indicative of ? issue
What 3 issues can cause scrotal swelling?
Cryptorchidism- atrophied L testis outside of scrotum in inguinal canal and no palpable epididymis. Even w/ Tx, huge increase for CA.
Indirect hernia- intestines come through external ring and won’t allow examiner’s finger above it
Hydrocele
Edema
Define Epidermoid Cyst
What parts of the scrotum can be evaluated w/ tranillumination?
Benign dome shaped white/yellow papules from occluded follicles that fill w/ keratin debris
Hydrocele- transilluminates
Blood, tissue, testis, tumors and most hernias DONT
Define Hydrocele
How do male genital warts appear on exam?
Nontender fluid filled mass inside of tunica vaginalis
Examiner can get finger above the mass (scrotal hernias won’t allow finger above it)
Condylomata Acuminata
ASx/ithcy/painful papules/plaques of various shapes but can be cauliflower-like usually caused by HPV 6 or 11
How do Genital Herpes appear?
How does Primary Syphilis appear
Scattered groups of vesicles 1-3mm
90% are HSV-2 w/ a 2-7 day incubation period; need to DDx from Zoster and Albicans
Red papule, becomes chancre 2cm in diameter w/ clean/red/smooth borders; heals in 3-8wks
Treponema Pallidum, spirochete, after 9-90 day incubation
PT may have inguinal lymphadenopathy w/in 7 days
Define Chancroid
Red papule/pustule then turns into deep painful ulcer w/ ragged margins from Haemophilus ducreyi, anaerobic bacillus, after 3-7 day incubation and half w/ lymphadenopathy
How does Gonococcal Urethritis present
How does Non-Gonococcal Urethritis present
Inflammation of urethra from G w/ yellow discharge and irritative voiding Sxs
Inflammation of urethra from Chlamydia w/ clear discharge and irritative voiding Sxs
Define Acute Orchitits
How do tumors of the testis appear?
Unilaterally inflamed painful testes from mumps/viral infection
Painless nodule
Define Spermatocele
Define Epididymitis
Painless, moveable cystic mass above testis that transilluminates and contains sperm
Inflammed epididymis causing tender pain and swelling that can pass to scrotum, relieved w/ lifting scrotum
Define Varicocele
Define Prehn’s Sign
Varicose veins of spermatic cord usually on L side and can be associated w/ infertility
R sided= concern for vena cava obstruction by tumor
Lack of relief of pain when scrotum is elevated, used to support Dx of torsion along w/ absent Cremaster reflex
What are the types of hernias?
Indirect- most common; exits external inguinal ring and is palpable w/ fingers but can’t get finger above it
Direct
Femoral
Define Pilonidal Cyst and Sinus
How does rectal CA feel upon exam compared to polyps?
Small tuft of hair/halo of erythema marks opening of sinus
Generally ASx but abscess causes swelling, pain
Sessile mass w/ edges, stony consistency and irregular contours
Polyps= pedunculated and are round, smooth and semi-mobile
How do you grade the prostate size
1= 1-2cm 2= 2-3cm 3= 3-4cm 4= more than 4cm
How does BPH present upon exam?
How does bacterial prostatitis present?
Symmetrically enlarged, smooth and firm/rubbery w/ possible obliteration of median sulcus
Fever, UTI Sxs, low back pain
Prostate can be swollen/boggy/warm
Caused by E Coli, Enterococcus, and Proteus
Men <35- consider N Gonorrhea and Chlamydia
How does chronic bacterial prostatitis present
What is the most frequent non-skin CA Dx in the US?
ASx, Sxs of dysuria, mild pelvic pain w/ normal feeling gland w/out tenderness/swelling
Cultures show E Coli
Prostate CA, also the second leading cause of CA death in men
What are the Risk Factors for prostate CA
Inc w/ each decade after 50
Higher in AfAm
Fam Hx
Saturated fats/animal source fats
What are the components/sequence of a well woman exam?
Define Gravida and Parity
Breast, External/Internal pelvic, Bimanual, Rectal (Sxs, +50) Microscopy/lab
of pregnancies, # of deliveries
Preterm delivery is what weeks?
Abortions occur before ? week
20-36
20
Define Polymenorrhea Define Oligo Define Menor Define Metro Define Postcoital
<21 days between menses Infrequent Excessive flow Intermenstrual bleeding Suggestscervical polyps/CA; in older PTs means atrophic vaginitis
What preparation needs to be done by female PTs prior to a well woman exam?
Vaginal opening is AKA?
No douche/intercourse 24hrs prior
Empty bladder
Introitus
Define Condyloma Latum
How do genital warts appear in female PTs?
Secondary Syphilis on Female PT
Shallow ulcer w/ red bases
Define Cystocele
Define Cystourethrocele
Define Retrocele
Bladder hernia into vagina
Herniation of bladder neck and urethra into vagina
Prolapsed wall between rectum and vagina
What causes Bacterial Vaginosis
What are the S/Sxs of an infection
Anaerobic bacteria
Gray/white malodorous coating of vaginal wall causing fishy/musty smell
How many degrees is the spatula rotated and what is collected?
How many degrees is the cytobrush rotated and what is collected?
360 to collect cells from external os
180 to collect endocervical cells
Both replaced by CytoBroom
How does BME of the uterus change w/ pregnancy?
12wks- palpable at pubis symphysis
16wks- midway between pubis and umbilicus
20wks- at umbilicus
More than 20wks- 1cm for every week of gestation
When is a rectovaginal exam required?
When are DREs for FOT done?
Uterus is not palpable due to retroflexion
All PTs >50y/o or has any rectal complaints
What changes are seen in female PTs during menopause?
Gray/sparse pubic hair Small/flat/dry labia Gaping/constricted introitus Narrow/atrophic vagina Smaller uterus Non-palpable uterus Weaker rectal tone
What is the target site of sampling during a PAP smear?
__% of HPV infections are ASx and resolve within ?yrs
Transformation zone
90, 2yrs
What is the most important risk factor for cervical cancer?
What HPV strains cause genital warts?
Persistent infection w/ high-risk HPV sub-types (HPV 16 and 18)
6 and 11
Breasts extend from __ to __
Where does it extend superficially
2nd rib to 6th rib, sternum to mid-axillary line
Pec major, inferior margin at serratus anterior
Define Inflammatory Ridge
What are the 3 types of breast tissue?
Bilateral thickening of inferior border
Glandular, fibrous and fat
How many lobes per breast?
What do these lobes drain into?
15-20
Lactiferous ducts that drain into sinuses at nipple
What supplies the breast with blood?
What 3 things are contained w/in the areola?
Internal Mammary and Lateral thoracic artery
Sebaceous, smooth muscle and occasional hair
Where does breast lymph drain to?
Where does the upper arm and retro-areolar areas drain to?
Anterior and central nodes
Arm- lateral nodes
Retro-aerolar- central
Where does deep breast lymphatic drainage go to?
How much time spent on breast exams yields the highest sensitivity?
Internal mammary nodes and supraclavicular nodes
5-10 for both
How do breasts change in time of menses?
How does this correlate to the best time for a breast exam?
Swell and more nodular from increased estrogen
5-7 days after onset
When laying supine for breast exam, examiner should spend ?min/breast
What type of findings suggest CA?
3
Hard, Irregular, Poorly circumsized, fixed to skin/tissue
What types of drugs can cause non-pregnant lactation
What can cause unilateral bloody discharge from 1-2 ducts?
Dopamine agonists
Intraductal pappiloma
Ductal carcinoma in situ
Paget’s Dz of the breast
What is needed for PTs presenting with Serous, Green, Black, non-bloody multiductal discharges?
What type of post-surgical finding can suggest recurrence?
Reassurance
Masses, Nodularity, Changes in color
Define Fibroadenoma
Define Cysts
Benign non-tender tumor usually at 15-25y/o
Round, disc-like and mobile
Benign tender findings between 15-25y/o that mimic fibroadenomas
Define Fibrocystic changes
What causes edema of breast skin, what is it AKA and where is it seen
Cobble stone texture w/ periodic/intermittent breast pain w/ Sxs peaking before menses
Lymphatic blockage, Peau d’Orange
Lower portion of breast/areola
When palpating male areola and breast tissue, if a nodule if found greater than ? size needs to be distinguished between what two issues?
> 2cm
Pseudogynecomastia- soft fatty enlargement of obesity
Gynecomastia- benign firm disc of glandular enlargement that may be tender
What is the most common important risk factor for breast cancer?
What are the modifiable risk factors?
Age
Breastfeeding for less than 1yr Postmenopausse obesity HRT Cigarettes/ETOH Sedentary Contraception
What are the non-modifiable risk factors for breast cancer?
What are the 3 models used for assessing breast cancer risks
FamHx, Inheritence, Hx, Endogenous hormones
BRCAPRO- used for high risk women to assess BRCA 1/2
Gail- PTs over 50 w/ no FamHx or one affected 1* relative and have annual mammograms
Claus Model- assesses high risk females and incorporated FamHx for both female and 1/2 relative w/ age of onset
What are the most common screening modalities for breast CA?
Mammogram and CBE
Define the Corticospinal/pyramidal tract
Mediate voluntary movement and integrate skill/movements
Carry inhibitory signals
Define the Basal Ganglia System
Motor pathways between the cerebral cortex, ganglia, brain stem and spinal cord to help maintain tone, movement and gross automatic movements like walking
Define the Cerebellar System
Receives sensory and motor input and coordinates motor activity, equilibrium and controls posture.
A cortical stroke lesion on the Cerebral Cortex will cause what motor, sensory, and DTR effects?
Chronic contralateral weakness/spasticity
Flexion stronger than extension
Hip is externally rotated
Contralateral sensory loos in face. limbs and trunk on same side as motor deficits
Increased DTRs
A brain stem stroke of acoustic neuroma on the brain stem will cause what motor, sensory and DTR effects?
Contralateral weakness and spasticity, diplopia and dysarthria
No typical sensory findings
Inc DTRs
Trauma to or a tumor on the spinal cord will cause what motor, sensory and DTR effects?
Bilatera weakness and spaticity
Dermatomal sensory deficit on the trunk at level of lesion
Inc DTRs
Parkinsonism at the subcortical gray matter/basal ganglia will cause what motor, sensory and DTR effects?
Bradykinesia, Rigidity and tremors
Sensation intact
Normal or decreased DTRs
Cerebellar stroke or brain tumor will cause what motor, sensory and DTR effects?
Hypotonis, ataxia, nystagmus and dysmetria
Sensory intact
Normal or dec DTRs
Polio, amyotrophic lateral sclerosis of the anterior horn will cause what motor, sensory and DTR effects?
Weak/atrophy in segment/focal pattern or fasciculations
Sensation intact
Dec DTRs
A herniated cervical/lumber disc affecting the spinal roots or nerves will effect motor, sensory and DTRs how?
Weak and atrophy in root-innervated pattern, sometimes w/ fasciculations
Sensory deficits at dermatomes
Dec DTRs
Trauma to a peripheral nerve/mononeuropathy will effect motor, sensory and DTRs how?
Weak and atrophy in peripheral nerve distribution; sometimes w/ fasciculations
Sensory loss in nerve pattern,
Dec DTRs
Peripheral polyneuropathy from alcohol or diabetes will lead to peripheral nerves/polyneuropathy and have what effect on motor, sensory and DTR functions?
Weak and atrophy distally, possible fasciculations
Stocking/glove sensory deficit
Dec DTRs
Myasthenia gravis causing neuromuscular junction issues will have what motor, sensory and DTR effects?
Fatigue
Intact sensation
Normal DTRs
Myscular dystrophy will have what effect on motor, sensory and DTR function?
Proximal weakness
Sensation intact
Normal or Dec DTRs
Define Anisocoria
Defected constriction/dilation of a pupil
Constriction to light/near effort= PNS
Dilation= SNS
What does it mean if Anisocoria is greater in light?
What does it mean if it’s greater in darkness?
Pupil can’t constrict
Due to trauma, open angle glaucoma, impaired PNS
Pupil can’t dilate
Horner Syndrome
Define Adie Pupil
Tonic pupil
Large regular unilateral pupil size w/ reduced or absent reaction to light
Caused by denervation of PNS
What would be seen in CN3 paralysis?
Large/fixed pupil to light and near effort
Ptosis from paralysed LP msucle w/ down and lateral deviation of the eye
Define Horner Sydrome
Pupil is small w/ brief reflex to light but dilates slowly
Tirad= miosis, ptosis and anhydrosis
If hereditary, affected iris is lighter in color
Define Argyll Robertson Pupils
Small irregular pupils bilaterally
Constrict w/ near and dilate w/ far vision but NO reaction to light
Seen in neurosyphylis and rarely in diabetes
Why doesn’t blindness cause anisocoria?
As long as SNS and PNS innervation remain normal, no changes.
Blind eye will constrict w/ consensual reaction but not from direct stimulation
When conducting MSK exam, warmth can be indicative of what four issues?
What two jaw structures have a disc between them to act as a cushion?
Arthritis, Tendinitis, Bursitis, Osteomyelitis
Madible condyle and temporal bone articulating surface
What are the 4 muscles of the rotator cuff?
SITS
Supraspinatus, Infraspinatus, Teres Minor, Subscapularis
What are the painful shoulder maneuvers and findings on exam for Rotator Cuff Tendonitis
Impingement Syndrome- repetition causes inflammation of supraspinatous tendon w/ max tenderness beneath the tip of the acromion
What are the PE findings for rotator cuff tears
The most common clinical problem of the shoulder
RC Tears- RC muscles compress humeral head into glenoid fossa
Subscapularis- internal rotation
Supraspinatus- elevation
Infraspinatus/TM- external
Trauma/chronic wear on acromion and coracoacromial ligament
Shrug of shoulder and Drop arm test are Pos on PE
What are the PE findings of Calcific Tendinitis
Degeneration of supraspinatus tendon from Ca Salts
Usually +30 women
Max tenderness below tip of acromium w/ inflamed subacromial bursa
What are the PE findings seen in Bicipital Tendinits
Inflammation resembling/co-existing w/ rotator cuff tendinitis
Max tenderness at Bicep Groove
Supinate raised elbow, pain in groove or w/ resisted fwd flexion is Pos for test
What are the PE finding Frozen Shoulder exam
Progressive restriction of A/PROM especially w/ external rotation and localized tenderness
Associated w/ MI that has decreased shoulder movement
What is seen on PE for acromioclavicular arthritis
Degenerative changes with most tender on AC joint
Inc pain w/ movement of scapula and arm abduction
What will be seen on PE with an anterior disclocation of the humerus
Anterior subluxatio/dislocaiton from fall or forced throwing
Pos apprehension sign is seen
Inferior, multi-directional or rarely, posterior dislocations also seen
What is seen in Olecranon Bursitis and how is it treated
Trauma, gout or RA causes swelling superficial to OProcess, aspirate for Dx and relief
How are elbow nodules in RA PTs characterized?
How does arthritis present?
Non-tender and firm
Can be attached to underlying periosteum
Inflammation/fluid felt along process/epicondyles causing stiff/pain and dec ROM
How does Epicondylitis present?
Lateral Epicondylitis- tennis elbow- repetitive extension of wrist or pro/supination of elbow
Pain will be 1cm distal to lateral epicondyl and inc w/ resisted wrist extension
Medial Epicondylitis- Golfer elbow from repetitive wrist flexion from throwing
Max tenderness lateral/distal to medial condyle and inc w/ resisted wrist flexion
What hand deformities are seen in chronic RA?
Swan neck- hyperextension of PIP and fixed flexion of DIP
Boutonniere- persistent flexion of PIP joint w/ hyperextension of DIP joint
When/where are Heberden nodules seen?
How do you tell the difference between Chronic Tophi Gout and RA?
Hard/painless nodules on dorsolateral aspects of DIP joints in OA
Tophi involvement is less symmetrical than RA and can ulcerate/leak white urates
Define Dupuytren Contracture
Define Trigger finger
Thickened band under 4th finger near distal palmar crease
Painless nodule on flexor tendon in palm near MC head
Define Acute Tenosynovitis
Define Felon
Inflammation along tendon sheath of distal digit from Staph A, Step, Gonorrhea or C Albicans. Can spread to thenar space
Finger tip injury causing infection in an enclosed fasical space of distal phalaynx pulp usually from Staph A
If vesicle is present- consider Herpetic Whitlow, seen in health care workers exposed to HSV in saliva
Flat feet can arise from what 4 underlying issues
Bunions are AKA ?
Posterior Tibial Tendon Dysfunction, Obsity, Diabetes, Prior Injury
Hallux Valgus
Define Morton Neuroma
Tenderness in 3/4th metatarsal space that radiates w/ squeezing
Sxs include hyperesthesia, numbness, aching and burning
Define Hypospadias
What type of scrotal changes can be seen in HF and Nephrotic Syndrome PTs?
Urethral meatus is in inferior surface of penis
Pitting Edema- skin is taut
Since testis are usually 3.5cm or smaller, what does a size 2cm or smaller indicate?
What do soft testis indicate?
Klinefelters
Cirrhosis Myotonic Dystrophy Estrogen Hypopituitary Post-orchitis
What is the difference between early discovery of testis lump and late finding?
Primary Syphilis and Chacroids need to be distinguished from?
Late- testis feel heavier
Both from Granulosum Inguinale from Klebsiella
Chacroid needs to be distinguished from ? 4 microbes
Where are anal fissures typically found?
Primary Syphilis
Genital Herpes
Lymphogranuloma Venereum
Granulosum Inguinale
Posterior midline
What does rectal cancer feel like during DRE?
What does peritoneal metastases cause to be found during DRE?
Firm nodule w/ rolled edges of ulcerated CA
Rectal shelf
If PT is female- shelf is formed in the rectouterine pouch behind cervix and uterus
