Test 1 Flashcards
When inspecting all four quadrants, you want to look at skin color and skin characteristics.
This can include jaundice, scars, dilated veins, rashes and lesions and…. A ___ sign is when there is ecchymosis (discoloration of the skin resulting from bleeding underneath) of the FLANKS and a __ sign is when there is ecchymosis of the UMBILICUS
^Both can result from some form of hemorrhage (escape of blood from a ruptured blood vessel) via pancreatitis, or an etopic pregnancy
Striae are seen on the stomach in ___ syndrome (hypercortisolism)
Jaundice, ascites, and Caput Medusae (dilated veins) can be indicative of ___
Grey Turner’s Sign
Cullen’s Sign
Cushing’s syndrome
Portal hypertension
Name the quadrant
1) Appendix
2) Liver
3) Spleen
4) Sigmoid colon
5) Gallbladder
6) Cecum
7) Ovaries
The stomach, pancreas, and part of the liver overly in the ___ region
1) RLQ
2) RUQ
3) LUQ
4) LLQ
5) RUQ
6) RLQ
7) RLQ and LLQ
Epigastric
One must ___ before percussing or palpating because these maneuvers may alter the frequency of bowel sounds
^So name the 4 steps in order*
Ascultate
1) Inspect, 2) Auscultate, 3) Percuss, 4) Palpate
When auscultating for bowel sounds, use the ___ of the stethoscope to listen to all 4 quadrants. A normal bowel sound is __-___ clicks or gurgles per minute and abnormal sounds are ___ pitched or decreased/absent sounds and this can suggest early ____
Grating sounds with respiratory variation called ___ can be indicative of inflammation of the ____ surface of an organ
Venous hum, a soft humming nose, can be indicative of increased collateral circulation between portal and systemic venous systems
Also where would you listen on the stomach for Bruits? Friction Rubs? Or Venous Hums?
Diaphragm
5-35
High, intestinal obstruction
Friction rub, peritoneal
Bruits = Abdominal arteries (Renal, iliac, femoral)
Friction Rubs = Liver and Spleen
Venous Hums = Epigastric and Umbilical Regions
Absent sounds are when there are no sounds for more than __ minutes, decreased sounds are where there are non for __ minute (common post-surgery), and increased bowel sounds can be indicative of diarrhea or early bowel obstruction
2, 1
When listening to vascular sounds, use the ___ of the stethoscope and if one hears ___, is suggests vascular occlusion
Bell
Bruits (woosh woosh sound)
What two sounds are we listening for while percussing the abdomen?
___ is a high pitched sound caused by air filled viscera and is found in the majority of the abdomen
___ is heard over solid organs as a non-resonating/flat sound without echos.
^** The liver and splen, fluid in the peritoneum, or feces gives a dull note***
Protuberant abdomen with tympanic sounds throughout can indicate ___
Tympany and dullness
Tympany
Dullness
Intestinal obstruction (since huge loops of air build up)
*** PROBS A TEST QUESTION
The expected liver span is ___-___ cms and located at the ___ line in the ___ quadrant
The expected spleen span is from ribs ___-___ at the ___ line in the ___ quadrant
6-12 cm, midclavicular, right upper quadrant
Ribs 6-10, mid-axillary line, left upper quadrant
So when percussing the liver, we can percuss at the right midclavicular line in the RLQ and we should hear a ___ sound and as we percuss cephalad we will reach a __ sound once we get to the lower border of the liver
If we start at the right midclavicular line in the RUQ we will hear a ___ sound (because of the lung) and as we percuss caudad we will reach a ___ sound once we get to the superior boarder of the liver
Tympanic, Dull
Resonant, Dull
During palpation, you would want to examine the tender areas ___ (First or Last?)
First, start off with light palpation using the fingers to lightly touch the skin, up to __ cms in depth
Next, use moderate palpation and lightly touch the skin ___-__ cms in depth
Deep palpation is __ or more cms in all found quadrants
Last
1
2-3
3
___ pain is hard to locate and usually palpated in the midline at level of structure involved
^** Often involved in acute appendicitis at first where the pain starts around your umbilicus
___ pain comes from inflammation in the parietal peritoneum and is more severe and easy to localize
Name where the pain would most likely be felt
1) Acute cholecystitis (Gallbladder)
2) Acute Pancreatitis
3) Early Acute Appendicitis
4) Late Acute Appendicitis
5) Acute diverticulitis (colon)
Visceral
Parietal
1) RUQ
2) Epigastric
3) Periumbilical (aka umbilical region)
4) RLQ
5) LLQ
___ is pain upon removal of pressure, rather than the application of pressure to the abdomen
** This tests for ___
Patients can also guard voluntarily or involuntarily
An abdomen that is hard, is called rigidity and this is a __ reflex
Rebound tenderness
Peritoneal inflammation
Involuntary
When palpating the liver, the doctor places the left hand behind the patients back, supporting their right ___ and __ ribs and lightly presses anterior. At the same time, you place your right hand just below the ___ in the right ___ line, with fingers point cephalad or oblique and try to palpate it during ____ (inhalation or exhalation?)
11th and 12th
Costal margin, mid-clavicular, inhalation
To test for ascites, you can perform the shifting dullness test which is when you percuss the borders of tympany and dullness while the patient is supine, and then you have the patient lay on their side and percuss again
A ___ test is if the boarders stay the same, and a ___ test is if dullness shifts to dependent side and tympany to top side and this can be indicative of ascites
You can also do a fluid wave test so you have the patient lie supine, place hands over chest, have assistant place ulnar aspect of hands mindline, and then you hit one flank.
A __ test is no impulse felt on the other flank, and a ___ test is when the impulse is transmitted to the other flank and this is indicative of ascites
Negative (normal), positive
Negative (normal), positive
Rebound tenderness or pain at McBurney’s point, which is located __ of the distance from the __ to the ___, may suggest ____ or peritoneal irritation
Pain in the Right Lower Quadrant, where our appendix sits when we push on the Left Lower Quadrant is called a __ sign
^*** So both of these test for appendicitis
1/3, ASIS, Umbilicus, appendicitis
Rovsing’s sign
What two tests can be used to look at Gallbladder dysfunctions?
___ sign is when you palpate deep under the right costal margin during INSPIRATION, then you have them exhale while keeping your position, then you ask them to inhale again and you observe pain or sudden stop in inspiratory effect
^ This tests for acute ___ or ___
___ sign is when a gallbladder is enlarged, but NOT tender and this can be secondary to ___ disease or cancer
Murphy sign and Courvoisier’s sign
Murphys sign
Cholecystitis (inflamed gallbladder) or cholelithiasis (hardened deposit in the gallbladder aka gallstones)
Courvoisier’s sign, pancreatic
The spleen should ___ be palpable, if it is then it’s called splenomegaly
The spleen is percussed starting from the cardiac border of the left ___ line and the percussing laterally towards the mid axillary line
If you have a tympanic sound laterally in the midaxillary line, splenomegaly is ___ (is or isn’t) likely, but if you hear dullness at midaxillary line, it ___ (is or isn’t) likely
NOT
Anterior axillary
Isn’t, Is
The normal aorta is to the the ___ of midline and has a width of __-__ cms
We expect to feel pulsations in an ___-___ direction, however it would be unexpected to feel a prominent ___ pulsation and more than 3 cms in diameter
The kidney is palpated behind the patient, just below and parallel to the ___ rib in the RUQ and LUQ
Left, 2-3
Anterior-inferior, Lateral
12th
Name how you perform the test, what’s a positive test, and what dysfunction it suggests
1) Iliopsoas muscle test
2) Obturator muscle test
3) Heel strike
4) Lloyds punch (also called kidney punch, or costovertebral angle tenderness CVA)
1) Flex hip against resistance, + test = abdominal pain, Irritation of psoas muscle from inflammation of the appendix (Appendicitis)
2) Flex hip, with knee bent, and INTERNALLY rotate the leg at the hip (aka swing leg out), + test = right hypogastric pain, irritation of obturator muscle from inflammation of the appendix (Appendicitis)
3) Strike patients heel, + test = pain, appendicitis
4) Tap area of back overlying the kidneys (costovertebral angles), + test = pain, Kidney infection (pyelonephritis) such as in a perinephric abscess) or renal stones
If a mass is palpable and you must determine if it is an abdominal wall mass vs intraabdominal mass, then you can have the patient lie supine and palpate for it again
If the mass remains palpable, it is an ____ wall mass and if it is no longer palpable, it is a ___ wall mass (since it is now obscured by muscular contraction)
Abdominal wall, Intraabdominal wall
Name the sympathetic levels
1) Esophagus
2) Stomach
3) Liver
4) Gallbladder
5) Small intestine
6) Colon
7) Pancreas
8) Appendix
Name the parasympathetic levels
1) Upper portion (esophagus thru transverse colon)
2) Lower portion (descending colon, sigmoid colon, rectum)
1) T2-T8
2) T5-T9
3) T6-T9
4) T6-T9
5) T9-T11
6) T10-L2
7) T4-T11
8) T12
1) Vagus nerve (OA,AA)
2) Pelvic splanchnic nerve (S2,S3,S4)
The Tdap vaccine is for Tetanus diphtheria and for acellular pertussis.
You are to give one dose of Tdap and then every ___ years thereafter give a Td booster
The Tdap should also be given ___ PER pregnancy usually around 32-36 weeks.
Also if you have a puncture wound or laceration, if your Td booster was not within the previous ___ years another will be given
10
Once
5
The HPV vaccine should be given in __ doses for women up the the age of 26 and for men up to the age of 21 (although if men are sexually active with other men it can be given up to the age of 26)
It is also recommended for all boys and girls starting at the age of ___
**^Not recommended in for pregnant women and HPV4 is for males and HPV2 or 4 is for females
3
11
__ doses of the varicella vaccine should be given for anyone who hasn’t had documentation of 2 varicella vaccines in their lifetime OR if the patient ___ (has or has not) had chicken pox
** Even if the patient has had shingles they should get the varicella vaccine
Should they get this if they are pregnant?
2, has not (so if you have had chicken pox you don’t need the vaccine)
No
All adults over the age of 65, those who smoke, and residents of nursing homes should all get the ___ vaccine
___ years after the first dose, you must re-dose people who have chronic renal failure, nephrotic syndrome, or functional/anatomic asplenia
If a patient has had the dose before the age of 65, they get ____ more dose at or after the age of 65
Pneumococcal
5
One
Starting at the age of ___ ALL ADULTS should get ___ dose of the the Varicella Zoster shot (Shingles shot), even if they have had a previous case of the shingles
The goal of this shot is not to prevent just the painful rash, but the ___, which is debilitating
**DO NOT get this shot if you have severe immunodeficiency
Should you get this shot if you are pregnant?
60, 1
postherpetic neuropathy
NO
All people age 6 months or older should have an ANNUAL vaccine called the ____ vaccine except if a patient has ___ allergies
Influenza, egg
Screening is testing for an ____ patient where as testing is testing a ____ patient for a specific disease
Asymptomatic (just because he or she is at a certain age and it is recommended), symptomatic (because the symptoms may point to a specific cause)
Cervix cancer screening aka ___ smears are NOT necessary before the age of ___.
Once the patient reaches this age, it is recommended that every ___ years to the age of 65 a pap smear is performed
^**once women reach 65 or higher it is not recommended unless they are at high risk for cervical cancer
For women over the age of 30 and want to lengthen the screening interval, they can do a Pap and ___ screening every __ years instead
** Also don’t screen women who have had a hysterectomy with removal of the cervix
Pap (papanicolaou), 21
3
HPV, 5
___ check for breast cancer in women and most docs start these screenings around the age of ___, then continue to screen every year
^** THE AAFP says start at the age of __ and do it every __ years
Mammogram, 40
50, 2
Gonorrhea and Chlamydia screenings are recommended in women up to the age of ___ and younger or in older women at an increased risk for the disease
^**Insufficient evidence for men
24
Adults ages __ to ___ should be screened for HIV and ALL ___ women should be screened for HIV
18 to 65, pregnant
Colorectal cancer screenings such as a fecal occult blood test or colonoscopy should be started at the age of ___ and continue until the age of ___
** You should most likely not screen those 76 to 85
50, 75
The HSPSTF/AAFP recommends ___ (for or against?) routine screening of PSAs (prostate specific antigen) for prostate cancer
^**For men who have a primary relative with prostate cancer, they may consider testing at age 45 or 50
Against
Screening for Abdominal Aortic Aneurysms in Men should be done ____ by ultrasonography in men aged ___-___ who have ever smoked
For women, there is currently NO evidence to suggest any benefits or harms for screening at ages 65-75 and have smoked
Once, 65-75
Terminology from GI cases
1) Eructations are ____
Dark stools is called ____ and indicates and ___ GI bleed
Bright red stools are ___ GI bleeds
Burps
Melana, upper
Lower
Inflamed gallbladder
Gallstones
Obstipation
Hypoparathyroidism, aka to little secretion of PTH can result in ___calcemia
^** If a patient comes in acting crazy due to the recent removal of the parathyroid gland then this could be the case.
A sign to test for hypocalcemia is the ___ signs, which is causes by tapping on specific places on the face or the __ sign where you elevate pressure in a blood pressure cuff and the arm curls up
Hypocalcemia
Chovstek sign
Trousseaus
Hyperparathyroidism results in ___calcemia
What are the symptoms associated with this?
Hypercalcemia
Bones, groans, abdominal moans and psychic groans
In graves disease, which is a autoimmune disease that causes TSIs (Thyroid Stimulating Immunoglobulins) to cause an ___ T3 and T4 secretion and a ___ TSH secretion
AKA this is associated with ___thyroidism
What are the symptoms?
Increased, Decreased
Hyperthyroidism
Bulging eyes (Exophthalmos), Tachycardia, and Goiter.
**Also heat intolerance, nervousness, etc…
In Hashimoto’s thyroiditis, an autoimmune disease that destroys the thyroid has occurred aka a primary disorder and this causes ____ T3 and T4 levels, which feedback to cause ___ TSH
** AKA this is associated with ___thyroidism
**^ Sign include depression, cold sensitivity, constipation, dry and brittle nails and hair, etc…
Decreased, Increased
Hypothyroidism
In Cushings syndrome, this is a ___ disorder so that means the ____ is effected. An adrenal tumor causes ___cortisolism and this leads to ___ ACTH and ___ CRH levels
Cushings Disease is a ___ disorder so that means the ____ is effected. A pituitary tumor causes ___ ACTH levels and ___cortisolism, which leads to ___ ACTH and ___ CRH
^** Cushings disease is the most common cause of ___ form
Primary, adrenal gland, hyper, decreased, decreased
Secondary, pituitary, increased, Hypercortisolism, no effect on ACTH, decreased
Endogenous (aka overproduction of cortisol)
^** Not exogenous, which would be due to taking medications etc.
In ___ disease, autoimmune antibodies destroy the adrenal gland and this causes ___cortisolosim, which causes a feedback to ___ ACTH and ___ CRH levels
Addison’s (Primary), hypocortisoloism, Increase, Increase
Myxedematous Facies is seen in chronic ___ or ___ syndrome
Hypothyroidism, Cushings
Hyperpigmentation of the hands (due to increased ACTH, which is a product of MSH (activates melanocytes), and staining of the buckle mucosa are signs for ___
Addison’s disease
A round moon-shaped and/or red face and purple streaks across the skin (called striae) are signs for ___
Cushing syndrome
In Diabetes mellitus, ___opathy of the eyes or ___ of the feet and hands can be a clinical finding
^** You screen for Neuropathy using a ___
Retinopathy, Neuropathy
Monofilament
Name all 7 parts of the 7 step protocol
1) Know yourself
2) Create a plan
2) What does the patient know
4) How much does the patient want to know
5) Sharing the information
6) Responding to patient, family feelings
7) Planning and follow-up
When language is a barrier, you ___(should or shouldn’t) use a family as a primary translator
**Instead, use a skilled professional translator or consider telephone translation services
Shouldn’t
Cervical spine has 7 vertebral segments, and __and ___ are atypical
The articulation between C2 and C3, and the rest of the cervical joints are considered typical
The upper cervical facets align in a plane pointing towards the ___, and the lower ones point towards the ___
C1 (the atlas) and C2 (the axis)
Eye, opposite ASIS
The joint of ___, is an uncovertebral joint from C__-C__ that consists of the lateral aspect of the vertebral bodies having a superior projection (called an uncinate process), which articulates with the super-adjacent vertebrae (aka the one above it) to help support the lateral sides of the cervical intervertebral discs to protect from __
Luschka, C3-C7
Herniation
The OA joint is primarily ____ and minor motions in SB and rotation AKA it is a modified type 1 mechanics, which means rotation and SB are ___ direction
**^The occiput rotates and sidebands to the opposite side
The AA joint is primarily _____ motion aka the atlas rotates in relation to the axis
C2-C7 has rotation and SB motion occur at the ___ side aka it is a modified type 2 mechanics
Flexion and extension, opposite
Rotational
Same
The curvature of the cervical spine is ___
The anterior triangle consists of ___
The posterior triangle consists of ___
Lordosis
Mandible, SCM, midline
SCM, Trapezius and Clavicle
For observing the thyroid, the patient tips their head ___ and the doctor locates the thyroid cartilage and cricoid cartilage
^** Your adam’s apple is thyroid cartilage
The thyroid gland is located below the ___ cartilage
When looking at tracheal deviation, one can use the spaces between the ___ and ___ for landmarks
Back
Cricoid
Thyroid and SCM
To hear the carotid pulse and auscultate for bruits, one must use the ___ of the stethescope
Bell
For the thyroid exam, the patient ___ their neck to relax the SCMs
Then, contact just below the ___ cartilage to palpate the thyroid gland and have the patient swallow so that the thyroid gland rises
The isthmus of the thyroid gland overlies the __-__ tracheal rings
The anterior surface of the lateral lobe should be about the size of the ____ of the thumb and feels somewhat rubbery
Flex
Cricoid
2nd-4th
Distal phalanx
If the thyroid gland is enlarged, and a bruit is heard over the lateral lobes then this can indicate ___
___ can be simple (non-nodular) or multinodular
The thyroid will feel soft in ___, it will feel firm in ___, and it will feel tender in ___
Hyperthyroidism
Goiters
Graves disease, Hashimoto’s thyroiditis and malignancy, Thyroiditis
Increased size of lymphnodes is called ___ and normally this is seen in HIV/AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis
The name given for an infectious cervical lymphadenitis (**lymphadenitis is the same thing as lymphadenopathy - LAD) is ___
LAD (lymphadenopathy)
Scrofula
Name the muscles involved and degree of motion
1) Flexion
2) Extension
3) Rotation
4) Side bending
*Also make sure you block linkage in the thoracic spine
Segmental motion consists of ____ motion which induces side bending or load and springing motion which induces ___
1) 45-90. SCM, scalene, prevertebral muscles
2) 70-90. Splenius capitus, splenius cervicis, intrinsic spinal muscles
3) 70-90. SCM, intrinsic spinal muscles
4) 20-45. Scalenes, intrinsics
Translational, rotation
To test for motor (muscle strength) it is graded on a scale of +___/___ for normal strength
Name how you would test the various vertebral segments
1) C1
2) C2-C4
3) C5
4) C6
5) C7
6) C8
7) T1
+5/5
1) Resist rotation of head
2) Scapular elevation
3) Shoulder abduction (deltoid)
4) Elbow flexion (biceps) or wrist extension
5) Elbow extension or wrist flexion
6) Finger flexion
7) Finger abduction
For the sensory exam, which is scored +__/___ for normal you can check various places, name them
1) C1-C4 (name all 3)
2) C4
3) C5
4) C6
5) C7
6) C8
7) T1
+2/4
1) Lesser occipital - sensory behind ear/mastoid
Greater auricular - Jaw angle, front of mastoid
Cervical cutaneous - Anterolateral neck
2) Superior shoulder/lateral neck
3) Lateral upper arm (over deltoid)
4) Lateral forearm
5) Middle finger
6) Right/little finger, medial wrist and forearm
7) Medial elbow and upper arm
For deep tendon reflexes, C5 tests ___, C6 is ___ and C7 is ___
Remember, the cervical nerve roots exit ___ their numbered vertebra, so the C5 root for example would be between vertebra ___ and ___, etc…
Biceps, Brachioradialis, triceps
Above, C4-C5
Compression neuropathy is nerve entrapment by some kind of structure, such as musculoskeletal or myofascial tissue, which produces paresthesias in the area of the distribution of the nerve and this creates a SD and can decrease muscle strength.
The most common sites include the ____ and the ___
****The intervertebral foramen site would be for central neuropathy and the thoracic outlet for scalene muscles, 1st ribs, clavicle, and pec minor aka peripheral neuropathy ***
Intervertebral foramen and thoracic outlet
To test for central neuropathy multiple tests can be performed including the…
1) __ test, where the head and neck are in a neutral position and an axial loading force caudally is applied.
^ This looks for an ___ extremity pain, paresthesias, or numbness
2) ___ test, where the hand is under the patients chin and other hand around the occiput, where a distraction force is applied
^ Positive test is when alleviation of symptoms occurs and this can indicate ___ compression or neuropathy
3) ___ test induces extension, rotation, and side-bending ___ affected side and then an axial force is applied in order to test for nerve root compression/irritation on ipsilateral side
4) ___ test is when the patient holds breath and bears down
^** This is due to increased ____ pressure, in which the pressure inside the space occupying the lesion in the cervical canal can cause pain in the cervical spine as well as radiation of pain to dermatomal distribution
Compression
Upper
Distraction, central
Spurlings, towards
Valsalva
Intrathecal
The thoracic outlet boundaries are ___, ____, and ____
Remember, the ___ duct passes through left side of the thoracic outlet and the ___ duct passes through the right thoracic outlet to drain the body’s right upper quadrant
**The brachial plexus, subclavian a. And subclavian v. all pass through the outlet
1st rib, 1st thoracic vertebra, manubrium
Thoracic duct, right lymphatic duct
Adson’s test is for the ____ compression by tight ____ muscles or the ___ and used to test TOS
To perform this test, the radial pulse is located on the arm of the affected side and the patients arm is ___ducted, ___ (extended or flexed?) and ___ rotation of the shoulder; all while palpating the radial pulse.
Then, the head is extended and rotated toward the affected side, which would be looking at ____ etiology.
Then the head is extended and rotated away from affected side, which would be looking at ___ etiology
**A + test = loss or change in pulse or reproduction of symptoms and indicates compression of the subclavian artery
Subclavian artery, scalene muscles or 1st rib
Abducted, Extended, External rotation
1st rib
Tight scalene muscles
Roos/EAST (Elevated Arm Stress Test) looks at compression of the ___ artery due to TOS
To perform this test the patients shoulder is ___ducted and ____ rotated 90 degrees with elbows flexed to 90 degrees
The patient opens and closes their fist for up to 3 minutes and a + test = reproduction of symptoms, increased pain at shoulder, paresthesia, etc.
Subclavian artery
Abducted, externally rotated
Wright’s hyperabduction test looks for neurovascular bundle compression (specifically, subclavian artery) due to a tight ___ for TOS
To perform this test, the radial pulse on the ipsilateral side is located, the doc ___ ducts the patients arm, with some ___ (flexion or extension?)
+ Test = loss or change in pulse or reproduction of patients symptoms and once again, it indicates subclavian impingement due to pec minor
Pectoralis minor muscle
Abducts, extension
In the ____ test, also called the (military or Halstead test), NV bundle compression (specifically the subclavian artery) by the ___ and ____ is being tested for in this TOS
Here, the ipsilateral wrist as contacted to feel the radial pulse, and the shoulder is ___, with the elbow ___ and wrist ___. Then a caudal pressure is applied to the shoulder
+ test = decreased radial pulse
Costoclavicular test, clavicle and rib 1
Extended, extended, supinated
There are various other special tests such as the ____ test, which has the patient lie supine and the neck is flexed forward. Resistance when the neck is flexed forward is a + test
This is indicative of possible ______ or ____
** It is important to make sure there is no injury to the C-spine before performing this test
Nuchal rigidity
Acute bacterial meningitis, subarachnoid hemorrhage
When the patient is supine, the the neck is flexed and the hips and knees start to flex as well, this is called a ___ sign, which can be indicative of ____ inflammation
^AKA meningitis
Brudzinskis
Meningeal
In athletics, when the neck is flexed to 30 degrees, lordosis is lost and if an ___ load is applied (which accounts for 1/2 of c-spine injuries in sports) then the soft tissue is no longer protected and force is transmitted to bone, resulting in greater risk for spinal injuries
Axial
There are various types of fractures
1) Axial compression injuries aka a burst fracutre result in a ____ fx (C__), such as a **diving injury
2) Extension injuries result in C__, ____fx (C2), or teardrop fx
^** C2 aka hangman’s fracture is when the arches are fractured
3) Flexion injuries result in ____ subluxation, or ___ fx
^** So wedge fracture is due to hyperflexion injuries
Jefferson fx (C1)
C1, Hangmans
Anterior, wedge
Most common injury of motor vehicle accidents is C__ and most common sports injuries are C5,C6,C7
C1
The intervertebral discs are named for the vertebra ___ it aka below L2 (second lumbar vertebra) would be the ____ lumbar disc
The ____ is a soft mucoid central core and is surrounded by an ____, which is a concentric lamellae of collagenous fibers
^** This is thicker ____ compared to ___
Above, second
Nucleus pulposus, annulus fibrosis
Anterior, posterior
___ connect posterior elements to the vertebral body and act as a protector against significant disc herniations of the ___ vertebrae
The TP are lateral projections in the ___ horizontal plane as their spinous processes
Inferior articular processes have facets that face __ and superior articular processes have facets that face ___
^** These facets form ____ joints with those above and below
Pedicle, same
Same
Laterally, medially
Zygapophyseal
One of the most common lumbar congenital abnormalities that occurs when the articular pillars on one side of the vertebral unit are twisted, causing an uneven plane for the joints to match up is called ____
^**This is assessed via asymmetric muscle tension and altered spinal motions
Zygapophyseal joint tropism
The iliac crest marks the ___ spinous process
L4
The major motions of the lumbar vertebrae are __ and ___, along with ___ and ___
^Remember, SB and R are coupled motions (Type 1 or Type 2)
Flexion and extension, side bending and rotation
“Listing” of the trunk to one side such as gluteal or trendelenburg gait can be indicative of muscle weakness or a disc herniation
___ disease can be assessed if shuffling or fenestrated gaits are observed
Parkinsons
___ is a fracture of the pars interarticularis, and shows up as a scottie dog fracture on an xray
____ is the forward slippage of the vertebra which may compress a spinal cord
^** This can be palpated via vertebral ____, which are spinous processes that are unusually prominent or recessed
Tenderness over the sacroiliac joint is common in what two diseases?
Spondylolysis
^** DON’T CONFUSE WITH Spondylosis (aka osteoarthritis)
Spondylolisthesis
“Step offs”
Sacroiliitis and Ankylosing spondylitis
When inspecting and evaluating skin conditions, Patches of hair can indicate __,skin tags or fibrous tumors are common in ___, etc.
Spina Bifida, Neurofibromatosis
Name the degree of motion and which primary muscles aid in the Gross movements
1) Flexion
2) Extension
3) Lateral bending
4) Rotation
Also perform segmental movements
1) 40-90: Posas, quad lumborus, abdominal msucles (PAQ)
2) 20-45: Deep intrinsic (ex: erector spinae and transversospinalis)
3) 15-30: Abdominal and intrinsic back muscles
4) 3-18: Abdominal and intrinsic back muscles
Sciatic nerve tenderness can be palpated or asssesed by placing the patient in a ___ position with their hips ___
The sciatic nerve is made up of the __-__ nerve roots and lies midway between the greater trochanter and Ischial tuberosity (aka the sciatic notch)
**^ Tenderness can suggest herniated disc or mass lesion impinging on the contributing nerve roots
Lateral recumbent, flexed
L4-S3
Lumbar nerve roots exit ___ their named vertebra and the ___ plexus provides sensory and motor for the lower extremity
Below, Lumbosacral
Muscle testing as part of a full neurological exam can test various actions for specific nerve roots
Name the nerve root being tested, muscle, and the major nerve
1) Have the patient flex their hip while seated
2) Have the extend their knee while seated
3) Have the patient try to abduct their hips (move from closed together to wide apart)
4) Have the patient plantarflex their ankle
1) L1, Iliopsoas, Femoral N.
2) L4, Quadriceps, Femoral and Obturator N.
3) L5, Gluteus medius, Superior Gluteal N.
4) S1, Gastrocnemius, Tibial N (from sciatic nerve)
Asking the patient to walk on their heels for strength testing of the foot dorsiflexors checks for the ___ nerve root
___ radiculopathy is the most common radiculopathy affecting the lumbosacral spine
Asking the patient to walk on their toes for strength testing of the plantarflexors checks for the ___ nerve root
L5
L5
S1
For the sensory portion of the neurological exam, just know where L1, L2, and L3 go. Along with L4, which passes along the anterior portion of the ___, L5 which is the lateral aspect of the shin, and S1 which goes along the is the lateral ____
Knee cap, malleolus
DTRs are ___synaptic and unilateral loss of ankle reflex is a significant neurological sign
Hyperactive reflexes may indicate ___ motor neuron lesions (such as CNS lesions along the descending corticospinal tract)
^** Weakness, spasticity, and + babinskis sign
Hypoactive reflexes may indicate ___ motor neuron lesions
^** Weakness, atrophy, and fasciculations
Delayed relaxation phase of reflexes is common in patients with ___ and this is often seen in the ___ reflex
Mono
Upper
Lower
Hypothyroidism, ankle
The knee (patellar) reflex is primarily ___
The ankle (achilles) reflex is ___
^** Have the patient ____ their ankle and watch and feel for plantar flexion
L4
S1
Dorsiflex
95% of disc herniations occur at ___-___ spinal levels (the spine angles are sharply posterior)
Ipsilateral calf wasting and weak dorsiflexion make a dx of ___ 5 times more likely
L5-S1
Sciatica
For the Straight Leg Raise (also called Lasegue’s Test), the patient is supine and you raise the ____ patients leg to cause flexion at the hip and then you ___flex the foot
+ Test is radiating pain into the ipsilateral leg, and the pain normally occurs from 30-60 degree because the dura is not stretched until ___ degrees and if this is the case, its lumbar disc etiology aka radiculopathy due to disc herniation (most often L5-S1)
^**If its greater than 70 degree, then it can still represent nerve root irritation, but there is an increased likelihood of mechanical low back pain due to muscle strain or joint disease
Remember from our old lectures, if its less than 15 degree than its a ___ compartment problem as the IT band passes over the greater trochanter
Ipsilateral, Dorsiflex
30
Lateral
Diagnostic accuracy of the straight leg raise test is limited by its low ___, but its high ___
A test with increased specificity is the ____ test
Specificity, sensitivity
Contralateral (crossed) straight leg
The Contralateral (crossed) straight leg raise test is the raising of the ____ leg by the examiner
+ test is when radicular pain is produced in the ___ leg once the unaffected leg is lifted
This test has ___ specificity and ___ sensitivity for disc herniation
Unaffected
Affected
High, low
The ___ sign is a test for malingering or functional weakness, aka “conversion disorder”
In this test, the doc places hand under the heel of the ___ leg and the patient is asked to flex the ____ leg against resistance while maintaining extension at the knee.
If the patient is actually trying, their contralateral leg should push down as they attempt to raise the affected (weak) leg by flexing at the hip
A + sign would be ___ downward force of the unaffected (contralateral) leg
^** This test is based on synergistic contraction where there is an involuntary extension of a normal leg when flexing a contralateral leg against resistance
Hoover’s
Contralateral, Ipsilateral
No
In the ___ test, the patient lies supine and flexes both hips and knees to the chest, then the affected leg is dropped towards the table
^**When the patient flexes the hips and knees to the chest, this flattens lumbar ___ and stabilizes the pelvis
A + Thomas test is when there is the inability to fully extend their leg on the involved side aka it raises off the table and this indicates ___
**Iliopsoas hypertonicity is a common finding in acute and chronic lower back pain
Thoams
Lordosis
Hip flexor contraction (aka iliopsoas tension, shortening, or contraction)
The Gaenslen test is used to determine if the lower back pain is due to an ___ dysfunction
+Test is ___ pain
SI joint
Posterior pelvic
A sharp or burning pain radiating down the posterior or lateral aspect of the leg and can go down all the way to the foot or ankle is most likely ___.
^** Often associated with numbness or tingling
Sciatica due to disc herniation usually increases with coughing, sneezing, or performance of the ___ maneuver
Sciatica
Valsalva
For the Kernig’s sign, a + test is when there is increased resistance to leg ___ at the knee and pain behind the knee, which is indicative of ___/___ irritation
This sign is paired with ___ testing and ___ sign classically for a patient with meningeal signs since it has low sensitivity
Extension
Meningeal/dural
Nuchal rigidity and Brudzinskis
For the Stork Test, a + test is when pain in the lower back is felt as it stresses the ___ elements of the spine on the ipsilateral side
This is indicative of a possible ___ defect or stress fracture and if it is a bilateral fracture then there is an increased risk for ___
Posterior
Pars, spondylolisthesis
___ is a condition of spinal nerve root compression usually by massive disc protrusion, fracture/trauma or tumors
No single test for this syndrome, but various clinical features include pain, ___/___ dysfunction aka overflow incontinence, sensory loss of perineum, decreased anal sphincter tone, or bilateral sciatica
**The syndrome requires emergent management and surgical decompression with 48 hours before permanent nerve damage occurs
Cauda Equina syndrome
Bowel/Bladder
Spina Bifida is a congenital malformation, usually from the failure of the ___ fusion in the vertebrae, which can lead to neural tube defects in the lumbar spine
There are 3 separate types of varying spina bifida
Name them
1) Coarse patch of hair around L5-S1 and NO spinal cord protrusion
2) Meninges forced out between the vertebra but NO spinal cord protrusion
3) Spinal cord protrudes
Lamina
1) Spina Bifida Occulta
2) Meningocele
3) Myelomeningocele
___ angle is normally 30-40 degree and represents the angle of the ___-___ junction and is usually measured via standing lateral X-ray films
Ferguson’s Angle, Lumbosacral
What are the grades for spondylolisthesis?
Grade 1 - 25%
Grade 2 - 50%
Grade 3 - 75%
Grade 4 - 100%
For translation on the cervical spine, if you are restricted to translation to the right, that means you are side bent ___ and rotated ___
Right (since you are restricted to left SB), left
When performing HVLA to the C-spine, sometimes you can occlude the ____ artery and this can cause complications
Vertebral
___ injuries are a form of hyperflexion-hyperextension injuries and the ____ component is the one that usually causes the most harm since flexion is limited by the chin but nothing limits extension until the head strikes the back of the seat
Whiplash
Hyperextension
During whiplash, superficial soft tissues are injured due to the abrupt elongation that initiates an acute ___ reflex and microhemorrhase and subsequent edema over the following days serve as foci for muscle irritability
The first muscle to be injured is the ___, followed by deeper muscles
Stretch
SCM
C-spine Hyperextension can lead to the tearing of the ___ longitudinal ligament and hyperflexion can lead to tearing of the ___ longitudinal ligament
Anterior, Posterior
___ and ___ nerves along with ___ nerve irritation can produce much of cephalgia and neck pain associated with whiplash
Vertigo, syncope, migraines, etc. can be due to a vertebral artery compression usually at C__-C__ level where it makes an acute turn to enter the skill
Greater and lesser occipital, suboccipital
C1-C2
For the treatment of C-spine injuries, first during the ___ stage you could treat with icepacks, NSAIDs, passive ROM daily, etc…
For the ___ stage (1 week to 1 month) more aggressive ME, HVLA, lymphatic drainage, continued NSAIDs, TCAs at a low dose (A type of Anticholingergics), Active and Passive ROM etc…
For the ___ stage (1 to 3 months or longer) OMT is used to treat the whole body, HVLA to entire body, Increased physical therapy, etc…
Acute
Early chronic
Late chronic
KNOW THIS CARD***
Twisting of the neck is called ___
If you have SCM spasms, you get ____ and this is called ___
If you have Trap spasms, you get ____ and this is called ___
If you have Spasms in the Anterior Neck muscles, you get ___ and this is called ___
If you have Spasms in the Posterior Neck Muscles, you get ___ and this is called ___
Torticollis
Rotation, Torticollis
Lateral tilt, Laterocollis
Flexion, Anterocollis
Extension, Retrocollis
If the SCM can not lengthen to accommodate the child’s growing neck, it is called ___ torticollis
^** The SCM may feel ropy, and “olive” type of structure
Congenital
For adult torticollis you DO NOT need imaging, but for congenital torticollis you do
Normally you would get a __ for imaging
X-ray
Which spines have a lordotic curve and which ones have a Kyphotic curve?
For lordosis, there is an anterior ___ and for kyphosis there is an anterior ___
C-spine and L-spine = Lordosis
T-spine = Kyphotic
Convexity, Concavity
Scoliosis is the abnormal curvature in the ___ plane (side bending) aka the lateral curvature of the spine
SB and rotation occur to the __ side and you name it for the side of ___ aka the side that it bends towards
Coronal
Opposite, Convexity
The most common curve for scoliosis is the ___ curve and this is in the ___ spine
If there is convexity to the right in the thoracic region, its called a ___ curve
If there is convexity to the right in the thoracic and lumbar vertebra, its called a ___ cruve
^** Single lumbar curves are not common
Double Major, Thoracolumbar
Right single thoracic
Single right thoracolumbar
Infantile idiopathic scoliosis, ages 0-3, is more common in males and the only type where convexity to the ___ is most common and should be referred to ortho if Cobb angle is greater than __ degree
^**Usually thoracolumbar
Left, 35
Juvenile idiopathic scoliosis, ages 4-9, should be referred to ortho if Cobb angle is greater than __ degree
20
In adolescent idiopathic scoliosis, ages 10 and up, the most common curve type is the ___
Double major (right thoracic and left lumbar)
For congenital scoliosis, partial unilateral vertebrae are called ___ vertebrae, and complete unilateral is called ___ (which can have partial segmentation or non-segmented)
There is also unilateral unsegmented bar or bloc vertebrae (bilateral) dysfunctions associated with failure of segmentation
^** Urinary tract, cardiac, and spinal dysraphism are other related anomalies with congenital scoliosis
Wedged, hemivertebrae
What test can be used to look for scoliosis?
Adam’s Forward Bend Test
For Cobbs angle you take the most cephalad vertebra who’s ___ surface angles ___ the curve and the most caudal vertebra who’s ___ surface angles ___ the curve and where they cross in the Cobbs angle
Superior, Into
Inferior, Into
Referral to an Ortho can be done if the Cobb angle is greater than __ degrees, or if it progresses more than ___ degree
^**Some will refer if its more than 10 degree
If the curve in an adolescent is greater than ___ degree, it will require surgery
Braces can usually work for curves between 20-40 degrees
20, 5
40
The physiologic changes during the dying process include weakness and fatigue, ___ appetite, ___ fluid intake, decreased blood perfusion (Tachycardia, Mottling of skin, Cyanosis), neurologic dysfunction, loss of ability to ___ eyes, pain
Pain, Dyspnea, Asthenia, Anorexia, Dry mouth, and Mental confusion are all signs of the last ___ weeks of life
Decreased, decreased, close
Two
Retained audible respiratory secretions are called ___ and this normally occurs __-__ hours before death
Respirations with mandibular movement (jaw moving increases with breathing) is __-__ hours before death
Cyanosis of extremities is __-__ hours before death
No radial pulse is __-__ hours before death
Death rattle, 24-60
2-6
1-5
1-3
Terminal delirium, changes in respiration, the loss of the ability to swallow (aka no more __ reflex), loss of sphincter control, pain, etc.. Are just more ways to know someone is dying
Gag
When giving someone medications, Buccal mucosal or oral should first be considered, followed by rectal and then other ways… You want to choose the ___ (least or most?) invasive route for administration
Least
If a family member is driving to see their dying whoever, then if you call them to tell them the person has died, you must have them ____, give a brief alert and then the news
Pull over/park
Where is pain associated with the biliary tree pathology likely referred to?
Where is pain associated with the duodenal and pancreatic pathology classically referred to?
Right shoulder
Back
