Practical I Flashcards
McMurray Test
tests the medial and lateral menisci
one hand on the heel, one hand on the knee;
flex the knee;
extend the knee while
- medial meniscus: external rotation of knee
- lateral meniscus: internal rotation of knee
Anterior Drawers Test
tests the anterior collateral ligament
feet flat, knees flexed, hands on the tibia, pull forward
Posterior Drawers Test
tests the posterior collateral ligament
feet flat, knees flexed, hands on the tibia, push backward
Lachman Test
tests anterior collateral ligament
one hand on distal femur, one hand on proximal tibia, pull femur up and push tibia down, vice versa
Valgus Test
tests medial collateral ligament
one hand on heel, one hand on lateral femur, abduct ankle and push femur medially
Varus Test
tests lateral collateral ligament
one hand on heel, one hand on medial femur, adduct ankle and push femur laterally
Thompson Squeeze Test
tests Achilles tendon
foot hangs off table, toes pointed down, squeeze calf
Cross Body Shoulder Adduction Test
tests adhesive capsulitis and rotator cuff
cross arm over chest
Apley Scratch Test
tests adhesive capsulitis and rotator cuff
touch opposite scapula
Painful Arc Test
tests Subacromial Impingement/Rotator Cuff Tendinitis Disorder
abduct arm 180 degrees
positive = pain 60-120 degrees
Neer Impingement Test
tests Subacromial Impingement/Rotator Cuff Tendinitis Disorder
hand on scapula, raise arm up
Hawkins Impingement Test
tests Subacromial Impingement/Rotator Cuff Tendinitis Disorder
flex shoulder 90 degrees, palm pronated, rotate internally
External Rotation Lag Test
tests supraspinatus and infraspinatus disorder
arm flexed 90 degrees, fully externally rotate
Internal Rotation Lag Test
tests subscapularis disorder
dorsum of hand on lower back, pull arm off back
Drop Arm Test
tests Supraspinatus Tear or Bicipital Tendinitis
abduct shoulder 90 degrees, release arm
positive = weakness
External Rotation Resistance Test
tests infraspinatus disorder
adduct and flex arm, thumbs up, resist inward pressure
Empty Can Test
tests supraspinatus/rotator cuff tear
thumbs down, resist downward pressure
Finkelstein Test
tests de Quervain’s tenosynovitis
grasp thumb against palm and rotate downwards
Hand Grip Test
tests hand grip
grasp 2nd and 3rd fingers
Thumb Abduction Test
tests carpal tunnel
resist downward pressure on thumb
Tinel Sign Test
tests carpal tunnel
tap median nerve of wrist
positive = numbness, tingling of fingers
Phalen Test
tests carpal tunnel
dorsum of hands touching each other, hold for 60 seconds
why is getting a good history key
to address the patient’s needs and concerns
therapeutic relationship with patients
best clinical decision making for each patient
more effective in achieving outcomes
in up to 90% cases, can figure out diagnoses from history
interview skills include:
open-ended questions
active listening
empathic responses
expanding/clarifying questions
nonverbal communication
summarization
transitions
empowering patient
amish wives don’t generally interact with
male physicians
muslim females tend not to
shake hands with male physicians
identifying cultural humility helps to
create a better rapport with patients
people whose gender identity doesn’t correspond to their birth-assigned sex and/or stereotypes associated with that sex
transgender
HPI stands for ___ and details ___
History of Present Illness;
chief complaint
7 attributes of symptom
O - onset P - position, palliating/provoking factors Q - quality R - radiation S - site, severity T - timing A - associated symptoms
normal vital signs include:
temperature: 97-99 F
respiratory rate: 12-20 breaths per min
heart rate: 60-100 bpm
blood pressure: 120/80 - 140/90
SpO2 (pulse ox): 95%
core temperature is ideally measured in ___ but is not practical unless patient is ___
arterial line;
critically ill and in the ICU
rectal temperature is considered
core temperature
oral, axillary, tympanic, temporal temperature readings can have
room for error
locations to check heart rate/pulse
radial carotid brachial femoral dosalis pedis medial malleolus
check for respiratory rate
visual inspection
listening on chest or neck
respiratory distress =
abdominal muscle use + tachypnea
Kussmaul breathing is characterized by ___ and can occur in patients with ___
deep, rapid, and labored breathing; diabetic ketoacidosis (DKA)
stethoscope diaphragm is used for
high-pitched sounds, firm pressure
stethoscope bell is used for
low-pitched sounds, light pressure (blood pressure)
how to measure bp accurately
correct BP cuff size (length and width), patient sits and relaxes, brachial artery at heart level, right arm is most proximal to the heart, auscultatory gap
normal oxygen saturation
90%
reflex hammer is used on
biceps, triceps, brachialis, patellar tendon, achilles tendon
visual acuity of 20/200 means
person at 20 feet can read print that a person with normal vision can read at 200 feet
keep the eye chart card ___ from eye
15 inches
name of eye chart
Snellen eye chart
tuning forks are used to check for
air/bone conduction and lateralization
tuning fork tests include
Weber Test
Renne Test
a ___ is a head to toe assessment and ___ of a patient that includes the patient’s ___
general survey;
observation;
appearance and demeanor
a general survey includes:
general appearance, apparent state of health, level of consciousness, signs of distress, skin color / obvious lesions, grooming / personal hygiene, facial expressions, odors, posture, gait / motor activity, height / weight
apparent state of health includes:
acute vs chronically ill, frail, fit, robust
level of consciousness includes:
awake, alert, responsive to u and others
signs of distress include:
cardiac/respiratory - clutching of chest, pallor, diaphoresis, labored breathing/wheezing
pain - wincing, sweating, protecting areas, facial grimacing
anxiety - fidgety, cold/moist palms, inexpressive, flat affect, poor eye contact
skin color / obvious lesions include:
pallor (pale skin), cyanosis (blue skin), jaundice (yellow skin), rashes, bruises, lesions, tattoos/piercings
grooming / personal hygiene include:
dressed - weather appropriate, clean, holes, excessive (covering rashes, marks, anorexia, pregnancy)
unusual jewelry - piercings, copper bracelets (arthritis)
hair/nails - unkept (depression, dementia, psychosis)
facial expressions include:
observe at rest, during conversation about specific topics, during PE, in interaction with others
eye contact (sustained, unblinking, averted quickly, absent)
flat affect, immobile face
odors include:
fruity/alcohol/acetone, uremia, liver failure, infections, GI bleed
posture, gait, motor activity include:
preferred posture (sitting upright - Lsided heart failure, learning forward with arms braced - COPD)
restless v quiet
involuntary motor activity, immobile body parts
walking smoothly, comfortably, confidently, balanced, limping, fear of falling, loss of balance, other movement disorder
height and weight include:
v short stature - genetic disorders / anomalies
long limbs in proportion to trunk - genetic disorders
height loss - bone disorders
generalized fat - obesity
truncal fat with thin limbs - endocrine disorders
weight loss - cancer, endocrine disorders, infection, depression, diabetes, successful dieting
initial systematic clinical evaluation and examination of the patient
history and physical
starting point of the patient’s story as to why they sought medical attention
history
physical exam that follows history
physical
SOAP stands for
Subjective
Objective
Assessment
Plan
observations that are verbally expressed by the patient
Subjective
the Subjective includes:
chief complaint HPI Past Medical History Past Surgical History Social History Family History Allergies Medications Review of Systems
the reason for the visit stated in patient’s own words
chief complaint
chronological description of the development of the present illness from the first sign/symptom
History of Present Illness
included in and HPI
onset location duration quality aggravating and alleviating factors radiation treatment severity
onset
when did the symptoms start?
what was the pt doing at the time the symptoms started?
location
what is the location of the pain? (point to it)
radiation
does the pain/symptom go anywhere else?
duration / time
how long did the symptom last?
is it constant or does it diminish? How long does it last / go away for?
does it hurt right now?
quality / characteristics
description of the symptom (sharp, throbbing, stabbing, aching, pressure)
aggravating / provoking factors
what makes it worse?
alleviating / palliating factors
what makes it better?
treatment
have you tried something to help the symptoms?
have you sought medical attention before today?
has this happened before? what helped with it previously?
severity
on a scale of 1-10, how bad is it?
affiliated symptoms
are there any other symptoms associated with the CC?
past medical history (PMH)
onset of previous diagnosis
where was it diagnosed / who is treating it
previous treatment for the diagnosis
what was the severity of it
past surgical history (PSH)
age of pt during procedure
where and who performed it
why? any complications with the surgery?
any follow ups?
social history (SH)
Drug history (alcohol, tobacco, marijuana) - how often? when was the last? hospitalization for withdrawal?
occupation
sexual history - currently sexually active? have you ever been? how many sex partners? men, women, both? do u use protection against STDs? what kind? how often?
recent travel - where, when, how (car, plane)?
diet and exercise - what does diet consist of? how often do u eat? do u exercise? how often? what kind?
family history (FH)
only relevant to blood relatives - relation to pt, what conditions, alive or deceased, age of diagnosis
allergies (All)
include allergen and reaction
medications (Meds)
all prescription and non-prescription medications patient is taking - dosage, administration, frequency
review of systems (ROS)
constitutional symptoms (fever, weight change, chills, night sweats, fatigue, malaise)
eyes (eye pain, swelling, redness, foreign body, discharge, vision changes)
ENT/mouth (hearing changes, ear pain, nasal congestion, sinus pain, hoarseness, sore throat, rhinorrhea, swallowing difficulty)
cardiovascular (chest pain, SOB, PND (feeling suffocated during strenuous activity), claudication, edema, palpitations)
respiratory (cough, sputum, wheezing, smoke exposure)
GI (nausea, vomiting, diarrhea, constipation, pain, heartburn, anorexia, dysphagia, melena, flatulence, jaundice)
genitourinary (urinary frequency, hematuria, urinary incontinence, urgency, flank pain, urinary flow changes, hesitancy)
musculoskeletal (joint swelling / stiffness, back pain, neck pain, injury history)
skin (lesions, hair changes, breast/skin changes, nipple discharge)
neuro (weakness, numbness, loss of consciousness, dizziness, headache, coordination changes, recent falls)
psych (anxiety / panic, depression, insomnia, personality changes, delusions, social issues, memory changes, violence/abuse history, eating concerns)
endocrine (temperature intolerance)
heme/lymph (bruising, bleeding, transfusion history)
allergic/immunologic (hives, itching, seasonal / environmental allergies)
physician findings on the patient
vital signs (temp, HR, BP, RR, SpO2, ht, wt, BMI)
gen survey (acute distress, conversant, pleasant, cooperative, appears stated age)
PE (HEENT, CV, Pulmo, ab, extrem, neuro, MSK, GU, Skin, Psych, OMM)
A&O
mental status - alert and oriented
alert contains
awake and alert vs sleepy, drowsy, lethargic, unresponsive
oriented contains
person (name/DOB), time (today’s date), place (where r u), and situation (why r u here)
Assessment
list of problems, diagnosis, system based
Plan
tests, imaging, medications, OMT, referrals/consults, follow-up
hand hygiene with alcohol based hand rub should be performed when
before touching pt
before exiting pt’s care are after touching pt or environment
contact with blood, fluids, wound dressing
after glove removal
use soap and water when
hands are visibly soiled (blood) or after caring for pt with known/suspected disease (diarrhea)
standard precautions include
hand hygiene, PPE, safe injection practices, safe handling of contaminated equip or surfaces, respiratory hygiene and cough etiquette, patient isolation
universal precautions include
prevent parenteral, mucous membrane, and noncontact exposures to bloodborne pathogens
4 cardinal techniques of examination
- inspection
- auscultation
- percussion
- palpation
close observation of details of pt’s appearance, behavior, movement (facial expression, mood, body habits) and conditioning (skin, eye, gait)
inspection
use of diaphragm and bell of stethoscope to hear heart, lung, bowel sounds (location, timing, duration, pitch, intensity)
auscultation
use of striking / plexor finger to deliver rapid tap or blow against distal pleximeter finger to evoke sound wave (resonance / dullness from underlying tissue / organs)
percussion
tactile pressure from fingerpads to assess areas of skin elevation, depression, warmeth, tenderness, oulses, contours and sizes of organs
palpation
sequence of PE
head to toe, right to left
PE for newborns
APGAR: 5 components to classify the neurologic recovery from the stress of birth and immediate adaptation to extrauterine life
birth weight, feeding (breast/formula), jaundice
examine fontanelles (bulging - increased intracranial pressure; depressed - dehydration)
reflexes, hips (Barlow and Ortolani Test)
PE for infants
examine in parent’s lap, head to toe can be out of order, developmental milestones, congenital heart murmurs, hips
PE for adolescents
puberty, scoliosis, mental health, addiction, sexual behavior
reflects analysis of the pt’s health status and documents the unique features of the pt’s history, exam, lab / test results, assessment, and plan in formal written format
clinical record
ionizing radiation and light strikes a photosensitive surface = latent image that is processed to get visible image
Xray
xray is the source of
invisible electromagnetic radiation
discovered by Wilhelm Roentgen in 1895
Xray
PACS
picture archiving, communications, and storage system
allows digital archiving
PACS
pros of xray:
inexpensive, easy to perform
cons of xray:
limiting range of densities, ionizing radiation
radiographic densities
darkest - air black - fat gray - soft tissue / fluid silver - calcium / bone white - metal
absorbs all xrays
metal (bullets, barium)
absorbs least xrays
air
rule of twos
views abnormalities joints sides occasions visits opinion/specialists investigations
objects closer to the detector will appear
closer to true size
objects farther from detector will appear
larger and less clear
spine through the heart
penetration
at least 8-9 posterior ribs
inspiration
spinous process should fall equidistant between medial ends of the clavicles
rotation
AP films will magnify heart slightly
magnification
clavicle normally has “s” shape and medial end superimposes on 3rd or 4th rib
angulation
X-ray image obtained without contrast
“plain” films
when chemicals were used in the dark room
“Wet Read”
x-ray contrast can be used for
GI: barium/iodine
x-ray fluoroscopy can be used for
real-time images; helping during procedures
xray view when all structures are superimposed
planar view
abdominal anatomy
bones - spine, ribs, pelvis base of lungs stomach - only if air-filled liver/spleen kidneys/bladder small intestine / colon
mottled appearance of colon
stool present
how does a CT scan work
passing x-rays from multiple angles at one level, produce images with better resolution representing a specific “slice” of the body
what does CT stand for
computed tomography
CT contrast IV used to
better visualize vessels, solid organs, tumors
CT contrast oral used to
better visualize bowel
pros of CT include
excellent spatial resolution
can image bowels, solid structures, and biliary tree to some extent (gallbladder)
cons of CT include
radiation
expensive
+/- contrast needed for resolution
some limitations with imaging biliary tree (not as sensitive for dilation)
how does ultrasound work
transducer with piezoelectric element is stimulated by electricity to generate sound waves that propagate and encounter structures with different acoustic impedances (resistance to sound). At interfaces btwn structures with diff impedances, some sound is reflected back to the transducer while the rest is transmitted deeper. The piezoelectric elements vibrate as they receive reflected sound and produce a voltage that can be detected.
The time to detection determines the location and strength of the returned sound which determines brightness
how does MRI work
uses a magnetic field and radio waves to take pictures inside the body using contrast of fluid density.
pros of MRI include
helpful to collect pictures of soft tissue (organs and muscles that don’t show up on xray)
bone doesn’t vibrate, so eliminated
excellent spatial resolution
no radiation
can differentiate blood vs soft tissue
can image bowels, solid structures, and biliary tree to some extent (gallbladder)
cons of MRI include
can’t use with metal implants, pacemakers or metal staples on arterial or venous structures
the titanium, titanium alloy, and zirconia used in dental implants are not ferromagnetic metals
expensive
+/- contrast needed for resolution
not sensitive for biliary dilation
how to read MRI
know if contrast / no contrast
think about gradation of fluid of object with weighting in the image
always recheck side of abnormality or variance
ultrasound hand positioning
It is essential to hold the iQ close to the imaging base to allow you to brace your hand during the study.
ultrasound adjust the gain
Overall gain should be set sufficiently high to visualize structures of interest, but sufficiently low to avoid false echoes.
ultrasound adjust the depth
Depth should be optimized to center the area of interest in the middle of the screen (from top to bottom)
ultrasound fanning
Fanning or tilting the iQ moves the imaging plane from a static window.
ultrasound sliding
Sliding or translating the iQ allows you to move to additional imaging windows.
ultrasound left renal exam
An introduction to the basic technique for evaluating the left kidney for hydronephrosis.
ultrasound right renal exam
select abdomen preset place iQ in pt's mid to anterior right axillary line with indicator towards head and fan towards bed to visualize kidney pt takes deep breath follow kidney inferiorly fan towards bed and ceiling
heart is closer to film ___ vs further from film ___
PA; AP
hounsfield unit
CT - window level / width
the vertebral column contains ___ vertebrae stacked on the ___
24; sacrum and coccyx
a typical vertebra contains sites for ___ as well as ___ for the spinal nerve roots and peripheral nerves
joint articulations, weight bearing, and muscle attachments;
foramina
anteriorly, the ___ supports weight bearing while posteriorly, the ___ encloses the spinal cord
vertebral body;
vertebral arch
the ___ projecting posteriorly in the midline and the two transverse processes at the junction of the ___ and the ___ attach to the ___
spinous process;
pedicle; lamina;
muscles
there are two ___ on each side of the vertebra, one facing up and one facing down, at the junction of the pedicles and laminae, often called ___
articular processes;
articular facets
encloses the spinal cord
vertebral foramen
formed by the inferior and superior articulating process of adjacent vertebrae that creates a channel for the spinal nerve roots
intervertebral foramen
in the cervical vertebrae, creates a channel for the vertebral artery
transverse foramen
spinous process of posterior iliac crest
L4
in arthritis, tenderness occurs at the facet joints between
C5 and C6
step-offs
a spinous process seems. unusually prominent or recessed in relation to the one above it
step-offs occur in ___ which may compress the spinal cord
spondylolisthesis
forward slippage of one vertebrae
spondylolisthesis
tendersness over the sacroiliac joint is common in
sacroiliitis and ankylosing spondylitis
pain with percussion occurs in vertebral
osteoporotic fractures, infection, and malignancy
lateral and rotatory curvature of the spine brings head to the midline
scoliosis
increasing kyphosis
thoracic kyphosis
loss of long thoracic nerve innervation to the serratus anterior muscle
winged scapula
occur in unequal leg lengths, scoliosis, and hip abduction or adduction
unequal iliac crest
spasm occurs in degenerative and inflammatory muscle disorders, overuse, prolonged contraction from abnormal posture
paravertebral muscles
lies midway btwn the greater trochanter and the ischial tuberosity as it runs through the sciatic notch
sciatic nerve
is seen with a herniated disc or nerve root impingement from a mass lesion
sciatic nerve tenderness
ball and socket joint created by the head of the femur in the acetabulum
hip joint
provides leverage for movement of the femur
hip joint
action of iliopsoas
flexion and internal rotation
action of gluteus maximus
extension
action of gluteus medius and minimus
abduction
action of adductors
adduction
which leg/hip muscles do external rotation
obturators, quadratus femoris, superior/inferior gemelli
stance phase of gait
heelstrike, foot flat, midstance, push-off
normal gait
2-4 inches between heels
inguinal structures
nerve, artery, vein, empty, lymphatics (NAVEL)
bulges - hernias or aneurysms
lymph nodes - if palpable could be infected
most commonly injured ligament with inversion and eversion
anterior talofibular ligament
freely movable joint (knee, shoulder)
synovial joint
bones covered by articular cartilage and contain cavity to cushion joint movement
synovial joint
slightly movable (vertebral bodies of spine)
cartilaginous joints
immovable (skull sutures)
fibrous joints
ball and socket, wide flexion, extension, adduction, abduction, rotation, circumduction (hip, shoulder)
spheroid joints
flat, planar, slightly curved, only gliding motion in single plane, flexion, extension (interphalangeal joints, elbow)
hinge joints
movement of 2 articulating surfaces not dissociable (knee, TMJ)
condylar joints
structures including joint capsule, articular cartilage, synovium, synovial fluid, intraarticular ligaments, juxtaarticular bone
articular structures
composed of collagen matrix which allows the cartilage to change shape in response to pressure load = cushion for underlying bone
articular structures
includes the periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin
extra-articular structures
rope-like bundles of collagen fibrils that connect bone to bone
ligament
collagen fibers connecting muscle to bone
tendons
pouches of synovial fluid that cushion the movement of tendons and muscles overbone or other joint structures
bursae
4 cardinal features of inflammation
swelling
warmth
redness
pain
attaches scapula to trunk
axio-scapular group
attaches humerus to trunk
axiohumeral group
repeated shoulder motion, sharp pain, weakness lifting arm overhead
rotator cuff tendinitis
injury from fall, trauma or repeated impingement, chronic shoulder pain, night pain; may see atrophy of muscles
rotator cuff tear
acute disabling attacks of shoulder pain (30+ yrs, female), arm held close to side, motion limited by pain
calcific tendinities
diffuse, dull aching pain, progressive restriction of active and passive ROM, localized tenderness, unilateral (40-60 yrs)
adhesive capsulitis (frozen shoulder)
elbow is made of
humerus and 2 bones of forearm (radius and ulna)
3 articulations of the elbow bones
humeroulnar joint
radiohumeral joint
radioulnar joint
muscle groups of elbow
biceps (flexion)
brachioradialis (flexion)
brachialis (extension)
triceps (extension)
pronator teres (pronation)
supinator (supination)
between olecranon process and skin, can’t palpate unless inflamed
olecranon bursa
runs posteriorly in the ulnar groove between the medial epicondyle and olecranon process
ulnar nerve
adjacent to the lateral epicondyle
radial nerve
on the ventral forearm, medial to brachial artery and antecubital fossa
median nerve
swelling of olecranon bursa
olecranon bursitis
develop at pressure points of elbow, firm and nontender, can occur in pts with rheumatoid arthritis or acute rheumatic fever
rheumatoid nodules
felt between olecranon process and epicondyles; boggy, soft, fluctuant swelling, pain, stiffness, restricted motion
arthritis of elbow
pain and tenderness 1 cm distal to lateral epicondyle; pain worse with extension of wrist with resistance
lateral epicondylitis (tennis elbow)
tenderness lateral and distal to medial epicondyle; wrist flexion against resistance increases pain
medial epicondylitis (pitcher’s, golfer’s, little league elbow)
distal radius, distal ulna 8 small carpal bones
wrist (So Long To Pinky, Here Comes The Thumb)
8 carpal bones, 5 metacarpals, 5 phalanges
hand
wrist joints
radiocarpal, distal radioulnar, intercarpal
hand joints
metacarpophalangeal, proximal interphalangeal, distal interphalangeal
important for hand movement
tendons and shafts
channel beneath palmar surface of wrist and proximal hand
carpal tunnel
provides sensation to palm and palmar surface of most of thumb, 2nd, 3rd, and half of 4th digits
median nerve
pulp of index finger
median nerve
pulp of fifth finger
ulnar nerve
dorsal web space of thumb and index finger
radial nerve
median nerve compression from carpal tunnel syndrome
thenar atrophy
ulnar nerve compression
hypothenar atrophy
audible range of human ear
20Hz - 20KHz
infrasound
< 20 Hz
ultrasound
20 KHz <
1 - 20+ MHz
depth of ultrasound
amount of time it takes to receive an image
brightness of ultrasound
volume; louder = brighter
peaks on soundwave
compressions
drops in sine waves
rarefractions
distance between peak and peak, trough and trough
wavelength
time btwn peak and peak, trough and trough
period
how high pressure the compression is
amplitude (pitch)
amount of sound waves that travel past a certain point in a certain period of time
frequency
resolution
increase frequency – increase resolution
decrease frequency – decrease resolution
penetration
increase frequency – decrease penetration
decrease frequency – increase penetration
CT without intravenous contrast ___ vs with intravenous contrast ___
non bright aorta; bright aorta
measure of radiodensity (CT)
hounsfield unit
allows to adjust contrast levels (CT)
window width/levels
