Written comp review Flashcards
What sort of exam does a first-time patient in office or hospital get?
Comprehensive assessment
Which exam includes all elements of health history and complete physical exam?
Comprehensive assessment
Which exam covers base-line for future assessments?
Comprehensive assessment
What type of exam for a PT who is known-well and coming in for routine care?
Focal/Problem-oriented assessment
What type of exam for specific “urgent care” like sore throat or knee pain?
Focal/Problem-oriented assessment
Which exam is addressed to symptoms and specific body system?
Focal/Problem-oriented assessment
What is the sequence of physical exam?
Head to toe
Which side to exam PT on?
PT’s right side, even if lefty
3 goals of exam sequence?
- Maximize PT comfort
- Avoid unnecessary changes in position
- Enhance clinical efficiency
Normal BP for age 18-60?
Systolic <120
Diastolic <80
Prehypertensive age 18-60?
Systolic=120-139
Diastolic=80-89
Stage 1 range HTN in 18-60?
Systolic=140-159
Diastolic 90-99
Stage 2 range HTN in 18-60?
Systolic ≥160
Diastolic ≥100
4 end-organs damaged by HTN?
- Eyes
- Brain
- Heart
- Kidneys
Is home/ambulatory or office BP measurment more predictive of CV disease and end-organ damage?
Home/ambulatory
What is home/ambulatory BP measurement for HTN with automated device?
≤135/85
HTN: Office manual or automated avg how many times? Occasions?
Average of two separate occasions
HTN: Office manual or automated avg for Stage 1 HTN? (actual numbers)
≥140/90 (aka Stage 1 HTN)
Asleep/nocturnal HTN measurment?
> 120/70 (<10% of daytime values)
What is Masked HTN? What are the home and office measurments?
Office blood pressure <140/90, but an elevated daytime blood pressure of >135/85 on home or ambulatory testing
What does Masked HTN a risk for?
Increased risk for CV disease and end-organ damage
White Coat HTN measurment?
≥140/90
White Coat HTN is what type of response?
Anxiety response
White Coat HTN and risk for what?
Normal to slight increased CV risk
Does White Coat HTN require treatment?
No tx required
Cuff bladder width what % of upper arm?
40%
Cuff bladder length what % of upper arm?
80%. Almost long enough to encircle arm.
Standard cuff measurment? Good for what arm circumference?
12x23cm. Good for 28cm arm circumference.
Where should brachial artery be when assessing BP?
At level of heart
BP if brachial artery is below heart?
Elevated BP
BP if brachial artery is above heart?
Low BP
Systolic: when to stop inflating cuff and what to feel for?
Feel radial art until disappears. Note that number and add 30. Deflate, wait 15-30 sec, and reinflate to check systolic.
Systolic: What is avoided when inflating, adding 30, then reinflating?
Ausculatory gap
Which side of stethoscope over brachial artery for BP?
Bell
How many mmHg to deflate cuff in BP?
2-3mmHg
Systolic: What is heard?
2 consecutive beats
Diastolic: What is heard?
Disappearance point ater muffling sound
Diastolic: Which heart condition causes muffling to never disappear?
Aortic regurg
BP: Round to nearest what?
2 mmHg
How long to wait between taking BP?
2 or more minutes
If two BPs differ by more than ___mmHg take additional readings
5mmHg
BP: ≥10mmHg difference between arms which 3 conditions?
- Subclavian steel syndrome
- Supravalvular Aortic Stenosis
- Aortic Dissection
What will Coarctation of Aorta and Occlusive Aortic Disease to do BP and pulses in extremities?
Upper ext=Higher systolic BP
Lower ext=Lower systolic BP, delayed/diminished femoral pulses
Which 3 CNs are sensory only?
1, 2, 8
Which 5 CNs are motor only?
3, 4, 6, 11, 12
Which 4 CNs are both motor and sensory?
5, 7, 9, 10
How to test CN 1 Olfactory?
Occlude each nostril for patency. Then PT closes eyes and smells through one nostril to identify scent.
How to test CN 2 Optic?
Test visual acuity with charts. Test visual fields by controntation. Fundoscopic exam.
How to test CN 3 Oculomotor?
Pupilary reaction to light and near response. Ptosis (levator palpebrae muscle) and medial rectus muscle (convergance).
How to test CN 4 Trochlear?
Superior oblique muscle. Vertical diplopia.
How to test CN 6 Abducens?
Lateral rectus muscle. Moves eye out/lateral.
CNs 3, 4, and 6 control what 3 things about the pupil?
Pupil size, shape, reaction to light
How to test CN 8 Vestibularchocolear?
Whisper in one each while closing off opposite ear.
Rinne Test=bone conduction
Webber test=lateralization
How to test CN 11 Spinal Accessory?
Head turn against resistance to test SCM. Inspect trap muscles for fasiculations or atrophy, shoulder droop, scapula downward drop.
How to test CN 12 Hypoglossal?
Observe tongue for atrophy or fisculations. Stick tongue out and it deviates to weak side. Also word articulation problems.
3 questions which frame neuro exam?
- Is mental status intact?
- Are findings symmetric?
- Where is lesion?
What is the most sensitive indicator of brain injury?
Change in PTs level of mentation
What seen in Upper Motor Neuron Lesion? (hint: 5)
- Hypertonia
- Hyperreflexia
- No fasciculations
- No atrophy
- Babinski
What seen in Lower Motor Neuron Lesion?
- Hypotonia
- Hyporeflexia
- Has fasciculations
- Has atrophy
- Normal plantar reflex
Range of reflex grading?
0-4
Reflex grade 0?
No response
Reflex grade 1+?
Diminished response
Reflex grade 2+?
Normal
Reflex grade 3+?
Brisk, maybe normal.
Reflex grade 4+?
Hyperactive. Brisk with clonus.
Which reflex grade has clonus?
4+
Can plain films rule out C-spine fx?
No
where are the most important missed injuries in the spine?
C1-C2 levels
Why measure infant head?
Reflects brain and cranium rate of growth
what is an uncle herniation?
brain herniation through the foramen magnum (Seen in babies when brain grows and skull doesn’t)
Define Proptosis
AKA exophthalmos.
Eye protrusion.
Proptosis/Exophalamos seen in which dz?
Graves
Define Hyperopia
Far sighted
Define Myopia
Near sighted
Define Presbyopia
Aging vision
Define Scomata
Specks in vision where can’t see
3 causes of diplopia?
- Brainstem
- Cerebellum
- CN problems
Horizontal Diplopia due to palsy of which 2 CNs?
3 or 6
Vertical Diplopia due to palsy of which 2 CNs?
3 or 4
Diplopia in one eye with other eye closed due to problem where? (hint: 2 possible places)
- Cornea
2. Lens
Define Coloboma
Defect/hole in iris
Define hyphema
Blood in anterior chamber of eye
Define hypopon
Pus in anterior chamber of eye
Describe near reaction
Pupils constrict (miosis) when look from far to near
Convergence due to which CN and muscle?
CN 3, medial rectus
Define miosis
Pupils constrict
Define mydriasis
Pupils dialate
Describe Marcus Gunn Pipil
Partial dilation of pupils when light shined into eye with optic nerve damage
Which condition: Partial dilation of pupils when light shined into eye with optic nerve damage
Marcus Gunn Pupil
Describe Tonic/Adie Pupil
Dilated large pupil. Slow to no reaction to light.
Which condition: Dilated large pupil. Slow to no reaction to light.
Tonic/Adie pupil
accommodation of the lens is controlled by what muscle?
cilliary muscle
Horner Syndrome 3 signs?
- Ptosis
- Miosis
- Anhydrosis
Describe Argyll Robertson Pupils
Bilateral small and irregularly shaped pupils. Do not react to light.
Which condition: Bilateral small and irregularly shaped pupils. Do not react to light.
Argyll Robertson Pupils
Define Anisocoria
Unequal pupil size
difference of >.4mm in the diameter of one pupil
Color, size, and light reflex arteries in eye?
Light red, small, bright light reflex
Color, size, and light reflex veins in eye?
Dark red, large, absent light reflex
Normal introcular pressure range?
10-22mmHg
Describe Style/hordeolum. 2 causes? Which way does it point?
Painful, tender, red eyelid. Points outside lid.
- S Aureus
- Blocked meibomian gland
Describe Chalazion. Which way does it point?
Painless nodules due to blocked meibomian gland. Points inside lid.
Describe Xanthelasma
Yellow cholesterol plaque on eye lid
Describe Corneal Arcus
Thin white/gray arc at edge of cornea
Describe Keyser Fleischer Ring. Cause?
Golden to red brown ring. Copper deposits.
Describe corneal scar
Opacity of lens
Color nuclear cataract? Need what to see?
Gray with flashlight
what is pinguecula?
harmless yellowish triangular nodule in the bulbar conjunctiva on either side of iris
Describe peripheral cataract
Spokelike shadows
what is entropion?
inward turning of the lid
what is the ectropion?
lower lid margin turns outward, exposing palpebral conjunctiva
Which wall does the breast lay against?
Anterior thoracic wall
what is nystagmus?
involuntary jerking movement of the eye with quick and slow components (horizontal, vertical or rotary)
Breast goes from which rib to which rib?
(Clavicle ) 2nd rb to 6th rib
Breast horizontal borders?
Sternum to midaxillary line
What is the male loose, wrinkled pouch?
Scrotum
Scrotum how many compartments?
2
2 compartments of the Scrotum?
- Tunica vaginalis
2. Epididymis
Scrotum’s Tunica vaginalis covers what? Where doesn’t it cover?
Covers Testis, not posteriorally
Scrotum’s epididymis covers what and where?
Posterolateral surface of testis
Epididymis shape?
Comma-like
Job of epididymis
Reservoir for storage, maturaiton, and transport of sperm
2 types if inguinal hernia?
- Direct
2. Indirect
What pokes through in inguinal hernia?
Loops of bowel thorugh weak areas into inguinal canal
Which 2 hernias are above the inguinal ligament?
- Indirect
2. Direct
Which is the most common inguinal hernia?
Indirect hernia
Which hernia affects men over 40 and women rarely?
Direct hernia
Which hernia is more common in women?
Femoral
Indirect Inguinal Hernia goes into where?
Scrotum
What direction Direct Inguinal Hernia bulge?
Anteriorally
Which hernia is below the inguinal ligament?
Femoral
What is a herniation of the rectum into the posterior vaginal wall?
Rectocele
What is a bulge of the upper 2/3 of ant vaginal wall?
Cystocele
What is a tight prepuce (foreskin) which cannot retract over glans penis?
Phimosis
Describe Phimosis
Tight prepuce (foreskin) which cannot rectract over glans penis
What is a tight prepuce (foreskin) which is retracted and cannot be returned
Paraphimosis
Describe paraphimosis
A tight prepuce (foreskin) which is retracted and cannot be returned
What is an inflammation of the glans penis?
Balanitis
Describe Balanitis
Inflammation of the glans penis
What is a tender and painful scrotal swelling called?
Epididymitis
Describe Epididymitis
Tender and painful scrotal swelling
What is a twist of the sermatic cord causing acutely painful, tender, and swollen scrotum?
Testicular torsion
Decribe testicular torsion
A twist of the sermatic cord causing acutely painful, tender, and swollen scrotum
Which side of stethoscope to hear high-pitch sounds of S1 and S2?
Diaphragm
Diaphragm for which pitch sounds?
High-pitch
Which side of stethoscope for mitral regurg, aortic regurg, and preicardial friction rubs
Diaphragm
Bell of stethoscope for which pitch sounds?
Low-pitch
S3 and S4 hears with which side of stethoscope?
Bell of stethoscope
S3 and S4 which pitch?
Low-pitch
Pitch of mitral stenosis? Which side of stethoscope?
Bell of stethoscope
What causes the S1 sound?
When mitral and tricuspid valves slam shut
Where is S1 loudest?
Apex
What immediately follows S1?
Carotid upstroke
S1->carotid upstoke->S2
What causes the S2 sound
Aortic and pulmonic valves slam shut, and blood ejected out of left ventricle
Where is S2 loudest?
At base
S3 normal in who?
Children, preggers, well-trained athelets
S4 represents what pathology?
LVH
5 spots for cardiac auscultation?
- Apical
- Pulmonic
- Erb’s point
- Tricuspid area
- Mitral area
Which side of stethoscope to use with cardiac auscultation
Diaphragm
Which sides of stethoscope to use for Tricuspid and Mitral area?
Diaphragm and bell
What does JVP measure/reflect?
Pressure in right atrium
Which vein to use for JVP?
Right internal jugular vein
Where to measure for JVP?
Meniscus (high point) of pulsations
JVP measures height of colums in relation to which angle?
Sternal angle
How much to add to column measurement in JVP?
5cm
What is normal JVP measurement?
≤9cm
High JVP measurement?
> 9cm
Bed at which angle for JVP? Lighting?
30º. Tangential lighting.
JVP: what to do to bed if PT is hypovolemic?
Lower head of bed
JVP: what to do to bed if PT is hypervolemic?
Raise head of bed
What is Kussmal’s Sign?
JVP rises with inspiration (normally goes down)
What called when JVP rises with inspiration?
Kussmal’s Sign
In normal heart what happens to JVP waveform when pressure put on liver?
Transient rise
In heart with right sided failure what happens to JVP waveform when pressure put on liver?
Progressive rise in CVP then JVP waveform
Describe Hepato Jugular Reflex
Normal heart= increased blood volume only causes transient increase of JVP
R-sided heart impaired=progressive rise in CVP and JVP waveform
3 types of pain
- Patietal pain
- Visceral pain
- Referred pain
Which pain is steady aching, localized over involved structure, and worse with movement like cough or ambulance ride?
Patietal Pain
Which pain in due to stretching/distentin of hollow abdominal organs and difficult to localize?
Visceral Pain
Renal Colic causes which type of pain?
Visceral pain
Which pain is felt in distance sites due to dermatomal innervation at same spinal level?
Referred pain
What causes Pleuritic Chest Pain?
Irritation of parietal pleura with deep inspiration. Viral pleurisy, pericarditis, pulmonary embolism, pneumomia.
Which pain is worse with cough or movement?
Parietal Pain
Describe Murphy’s Sign
Sharp increase in RUQ tenderness with inspiration
Murphy’s Sign for which condition?
Acute cholecystitis
3 appendix signs?
- Rovsing
- Psoas
- Obturator
Rovsing Sign when…?
RLQ pain during LLQ pressure
Which sign is RLQ pain during LLQ pressure?
Rovsing Sign for appendix
How many Psoas Signs are there?
TWO!
Which sign: Pain of psoas muscle with rise thigh against hand at knee or flex leg at hip
Psoas Sign
Which sign: Flex right thigh at hip, bend knee, int rotate causes right hypogastric pain
Obtorator Sign
Subluxation vs dislocation: which is temporary and partial?
Subluxation
Shoulder subluxation can also be called what?
“Shoulder joint instability”
Should joint instability (temporary and partial dislocation) is most consistent with what type of ortho problem?
Subluxation
What happens with a true shoulder dislocation?
Humerus comes out of socket (the glenoid)
ROM and pain with shoulder dislocation?
Poor ROM. LOTS OF PAIN!
What 2 things are the main shoulder joint stabilizers?
- Ligaments
2. Capsule complex
Arm position in anterior shoulder dislocation?
Slight abduction and external rotation
Humeral head and void in anterior shoulder dislocation?
In patients who are thin, the prominent humeral head can be felt anteriorly and the void can be seen posteriorly (sulcus sign) in the shoulder.
Arm position in posterior shoulder dislocation?
Arm in adduction and internal rotation
Why are posterior shoulder dislocations easy to miss?
PT appears to be only guarding extremity
Which 2 radiograph views for shoulder dislocation?
- AP
2. Axillary
Shoulder dislocation: Which view to get if axillary view cannot be obtained?
Y-view
Which view required for posterior shoulder dislocation or might be missed?
Orthogonal view
What is the most important treatment of an acute shoulder dislocation?
Prompt reduction of the glenohumeral joint
After determining the direction of the dislocation what is the most important next step in treatment?
Relaxation of the shoulder musculature
How does one verify successful shoulder reduction?
Post-reduction films
Which tx for common anterior shoulder dislocations?
Hippocratic Method. For common anterior dislocations, one of the oldest methods of reduction. The clinician places their foot in the patient’s axilla while gentle longitudinal traction is applied (may be utilized with or without int./ext. rotation of shoulder).
Describe Stimson Technique technique
Stimson Technique—The clinician has the patient lie prone on an examining table, allowing the affected arm to hang off the bed. Again, longitudinal traction and int./ext. rotation are applied to the arm. Weights can also be added to the patient’s wrist to facilitate reduction.
Which tx for shoulder dislocation has always worked for Orrahood?
Fried Maneuver—Taught to this PA by his then supervising physician, Dr. Fried, circa 2001.
Patient lies supine, and an assistant applies counter traction to the patient’s chest wall; the clinician begins maneuver with forced long axial traction of the affected extremity, followed by slow, gentle abduction to roughly 90 degrees (or until resistance encountered) and subsequent external rotation applied.
How long to immobilize arm after post-reduction? With what?
Sling and swath for 1-3 weeks.
What should be encourages while PT in sling for shoulder dislocation?
Elbow, wrist, and hand ROM should be encouraged.
T or F
After diagnosing an anterior shoulder dislocation (with an associated axillary
nerve injury), the clinician should expect, and subsequently plan for,
prolonged sequelae from said nerve injury.
False
Injury to the axillary nerve during shoulder dislocation has been reported to be as high as what?
40%
When do perform a detailed neurovascular exam with a shoulder dislocation?
Before and after reduction
When does Apprehension Sign occur?
Paltellar dislocation
Which sign: Knee placed at 30 degrees flexion, and lateral pressure is applied. Medial instability results in apprehension by the patient.
Apprehension Sign
4 phases of wound healing?
- Hemostasis/Coagulation phase
- Inflammation phase
- Proliferation/migratory phase
- Remodeling phase
When does hemostasis/coagulation phase occur in wound healing?
Immediately after wound
What is formed, constricted, and seals in Hemostasis/Coagulation Phase of wound healing?
Platelet plug forms. Vessels constrict. Thrombus seals wound.
When does Inflammatory Phase occur in wound healing?
First 2-3 days after injury
What do WBCs to in Inflammatory Phase of wound healing?
WBCs remove necrotic tissue and control infection.
When does Proliferation/Migratory Phase occur in wound healing? How long does it last?
2-3 days after injury. Lasts 2-3 weeks.
Which tissue migrates across top of wound in Proliferation Phase?
Granulation tissue. Forms capillaries and epithelial cells.
What proliferate into wound during Proliferation/Migratory Phase of wound healing? What do they create?
Fibroblasts proliferate into wound. Create structure.
When does Remodeling Phase occur in wound healing?
Days to weeks after injury
What forms in Remodeling Phase of wound healing? What contractures?
Collagen forms, scar contracture.
What is the strength of the scar in Remodeling Phase?
80% of original wound up to one year
What to confirm before repairing wounds?
Neurovascular and sensori-motor condition
When to update tetanus shot? (Hint: 2 cases)
- ≥10y since last
2. 5y plus wound is tetanus prone
When is a wound considered tetanus prone? (Hint: 4)
- 6h+
- > 1cm deep
- Stellate lacerations
- Soiled with feces, saliva, gunshot, puncture, burn, or frostbit
Which tetanus shot to use if between 6 weeks and 6 years old?
DTaP
Which tetanus shot to use if 11 years or older?
Tdap
Which animal causes most infections with bite?
Cats
Motto when suturing?
“Approximate, don’t stangulate”
Range of suture size?
00 to 10-0
Which suture size is larger- 00 or 10-0?
00 is larger. 10-0 is smaller.
Most commonly used suture sizes?
3-0 to 6-0
2 non-absorbable monofilamented sutures?
Ethilon and Prolene
Which suture material is absorbable for dermal and fascial closure?
Vicryl
Which suture material is absorbable for mucosal and scrotal closure?
Vicryl
Ways to do primary wound closure?
Suturing, stapling, taping, etc
Primary wound closure and wound edges?
Wound edges approximated
Timeframe for primary wound closure?
6-12h
Primary wound closure and cosmetic outcome good or bad?
Good!
Which wound closure not to use is cosmetic is a concern?
Staples
When does delayed primary closure occur?
When primary closure inappropriate
When is primary closure inappropriate and required delayed primary closure? (hint: 2)
- Infection
2. Severely contaminated
Delayed primary closure is a period of time when what type of healing occurs?
Secondary healing prior to closure
Timeframe for delayed primary closure?
48-96h
When to avoid staples for wound closure?
Avoid in cosmetic areas
Staples good for which areas?
Scalp, torso, genital areas
Most common type of suture knot?
Square knot
Most common type of suture technique?
Simply interrupted
When is horizontal mattress used? (hint: wound edges)
To pull wounde edges together over distance
When is vertical mattress used? (hint: wound edges)
Used when wound edges tend to invert or on concave surfaces
When to remove sutures from eyelid?
3 days
When to remove sutures from cheek?
3-5 days
When to remove sutures from nose, forehead, or neck?
5 days
When to remove sutures from ear or scalp?
5-7 days
When to remove sutures from arm, leg, hand, foot, chest, back, and abdomen?
7-10 days
1% Lidocaine blocks what? What intact?
Blocks painful stimulant. Pressure and touch intact.
2% Lidocaine blocks what? What intact?
Block all stimuli including pressure and touch. Nothing intact.
Max dose of Lidocaine?
4mg/kg
How much volume for average finger numbing?
No more than 5mL
Where to avoid epi? (hint: 4 places)
- Digits
- Nose
- Ear
- Penis
Goal of splinting?
To stabilize/immobilize until seen by ortho
When it PT seen by ortho after splint places?
2-3 days (another slide says follow up w/n 3-5d after injury)
When to splint?
Immediately after injury
What direction to wrap injury?
Distal to proximal
When to evaluate circulation, sensory, and motor when splinting?
Before and after splint placed
Plaster splint sets in how many minutes?
2-8 minutes
Plaster splint max strength in how long?
24h
DIP Joint Splint must not be removed for how many weeks?
8 weeks
How long is a cast on for?
4-6 weeks
When to put on a cast?
After post-traumatic swelling resolved, 5-7d
2 most common spots to do LP?
- L3-L4
2. L4-L5
PT position for LP if need opening pressure?
Lateral recumbant (on side with knees to chest)
LP opening pressure normal range?
18-20mm H2O
CSF volume to collect?
4-8ml
How many tubes for CSF collection?
4
Tube 1 CSF for what?
Cell count and diff
Tube 2 CSF for what?
Glucose and protein
Tube 3 CSF for what?
Culture and gram stain
Tube 4 CSF for what?
Cell count and diff
Normal CSF protein range?
15-45
Elevated CSF protein can mean?
Infection
CSF WBC above 5 means what?
Possible infection
Increased CSF neutrophil means what type of infection?
Bacterial
Increased CSF lymphocytes means what type of infection?
Viral (aseptic meningitis)
Normal CSF RBC?
<10
What is a yellow color in CSF called?
Xanthochromia
Xanthochromia means what?
Possible SAH
Xanthochromia vs traumatic tap?
Traumatic tap isn’t caused by SAH while Xanthochromia can be from SAH.
Normal CSF glucose range?
50-80
Low CSF glucose can mean what?
Bacterial meningitis, sarcoidosis, syphillis, SAH
Variable CSF glucose can mean what?
Viral
Serum hyperglycemia can do what to CSF glucose?
Mask CSF hypoglycemia
Xanthochromia is produced from lysis of what?
RBCs
Xanthochromia helps to differentiate from what complication?
Traumatic tap
N. Menigitidis gram and shape?
Gram negative diplococci
H. Flu gram and shape?
Gram negative bacilli
Staph and Strep gram and shape?
Gram positive cocci
Opening pressure above 30 can mean what? (hint: 2)
- Bacterial infection
2. Pseudotumor cerebri
When to get help for: Sudden vision loss, flash of light/floaters, any chemical to eye, and diplopia?
Right now. Ocular emergency!
When to get help for: Ocular pain, foreign body, corneal abrasion
Today. Ocular urgency.
When to get help for: Itchty eyes, painful bump on eyelip
This week. Ocular priority.
When to get help for: Vision change over last few months, bump on eye, non-painful bump on lid
Next available appointment. Ocular routine.
Ascites and flanks?
Bulging and dullness
Ascites and fluid?
Fluid shift
What does cyanosis suggest?
Hypoxia
What does diaphoresis and somnolence suggest?
Hypercapnia and respiratory acidosis
What does assisted ventilations do to ICP?
Decreases ICP
What do assisted ventilations do to hypercarbia and acidosis?
Corrects hypercarbia and acidosis
Can do blind Nasotracheal Intubation if PT is apenic?
CI’d due to increased risk of esophageal intubation
Can do blind blind Nasotracheal Intubation and coagulopathy?
CI’d due to risk of epistaxis
Cricothyotomy CI’d before what age?
8
Airway of choice in children and PT with tracheal injury?
Tracheotomy
Does a CXR rule out esophageal intubation?
Nope!
Which airway used when gag reflex present?
Nasopharyngeal
Which airway used when gag reflex absent?
Oropharyngeal
Most common type of intubation?
Orotracheal
When to ventilate prior to orotracheal intubation?
Hypoxic or apenic
Orotracheal head position?
Sniffing position
Miller Blade shape and where does it go?
Straight. Under epiglottis.
McIntosh Blade shape and where does it go?
Curved blade. Anterior to epiglottis in vallecula.
Best method to confirm placement of endotracheal tube?
See tube pass through cords
When to do Rapid Sequence Intubation?
PT with full stomach
RSI and preoxygenation aka?
Nitrogen washout
What does preoxygenation before RSI do to O2?
Creates O2 reservoir. Sat 90% up to 8 minutes.
How to do preoxygenation for RSI?
100% O2 with tight fitting mask. 8 deep breaths over 60 seconds.
Preoxygenation in RSI CI’d in who?
PT with severe COPD or asthma
in what diseases is nystagmus seen?
cerebellar disease, gait ataxia, dysarthria and vestibular disorders
what diseases is ptosis seen in?
3rd nerve palsy, Horner syndrome, myasthenia gravis
how do you test corneal reflex of CN V?
touch cornea with find wisp of cotton -> should see blinking
sensory -> CNV (if don’t blink then CNV lesions)
motor -> CNVII
bells palsy is what type of CNVII injury?
peripheral injury that affects both upper and lower face
central injury of CNVII affects what part of the face?
lower face
what are the 6 components of the sensory portion of neuro exam?
(1) pain
(2) temperature
(3) position (proprioception)
(4) vibration
(5) light touch
(6) discriminative sensation (EYES CLOSED)
how do you test for pain for sensory neuro exam?
sharp pin or stick of broken q-tip
use blunt and sharp end at random -> ask pt if it feels sharp or dull
how do you test for temperature for sensory neuro exam?
fill 2 test tubes with hot and cold water -> ask pt if it feels hot or cold
when is temperature test excluded from neuro exam?
if pain sensation is normal
how do you test for position (proprioception) for sensory neuro exam?
grasp big toe and move it up and down while pts eyes are closed and ask them what position the big toe is in
if sense is impaired, move more proximal ankle joint
how do you test vibration for sensory neuro exam?
use low pitched tuning forking (128 hx)
tap tuning fork and place over DIP and ask pt what they feel
how do you test light touch for sensory neuro exam?
cotton wisp
how do you test discriminative sensation?
stereognosis, graphesthesia, two-point discrimination, point localization, extinction
what is stereognosis?
ability to identify an object by feeling it
what is graphesthesia?
number identification
-do this with arthritis
draw number on pts hand and have pt identify number while drawing
what is a normal two-point discrimination?
<5mm distance that can be identified from one or 2 points
what is point localization?
touch a point on pts skin, ask pt to open both eyes and point to that location
what is extinction?
stimulate one side or simultaneously corresponding areas on both sides of the body
damage to upper motor neuron lesion above the cross over point causes impairment on what side?
impairment develops on contralateral side
damage to upper motor neuron lesion below the cross over point causes impairment on what side?
motor impairment occur son the ipsilateral side
lower motor neuron lesion causes what impairment and on what side?
ipsilateral weakness and paralysis
gag reflex is absent with lesions in what CNs?
CN IX and maybe CNX
hyperactive reflexes mean lesions where?
CNS lesions of corticospinal tract
hypoactive reflexes mean lesions where?
lesions of the spinal nerve roots, spinal nerves, plexuses
PNS
what 4 conditions elevate right atrial pressure (JVP >9cm)?
(1) HF
(2) Tricuspid valve disease
(3) Pulmonic stenosis
(4) Pericardial disease
what is the a wave? when does it occur?
atrial contraction
occurs just prior to S1 and before the carotid upstroke
what does an increased a wave mean?
increased resistance to right atrial emptying
what 4 conditions cause absent a waves?
(1) RV hypertrophy
(2) Pulmonary valve stenosis
(3) COPD with associated pulmonary HTN
(4) Restrictive cardiomyopathy
what is the v wave?
increased atrial pressure as venous return increases after systole
occurs when tricuspid valve closes, the chamber begins to fill, and the right atrial pressure begins to rise again
what condition causes prominent (increased) v waves?
severe tricuspid regurgitation
pleuritic chest pain is persistent or not persistent?
persistent
what muscle do the breasts overlie?
pectoralis major
what muscle does the inferior margin of the breasts overlie?
the serratus anterior
tail of breast aka
tail of spence
what are the 4 views for inspection of breasts?
(1) arms at sides
(2) arm overhead
(3) arms pressed at hips
(4) leaning forward
when doing inspection of breasts, pt is in what position?
sitting up and disrobed to waist
what are vitreous floaters?
moving debris inside vitreous humor, often protein fragments
what position is pt in when doing palpation of breasts?
supine with arm above head and shoulder raised on rolled towel/sheet
what degree is the arm in palpation of the axillae?
pts arm shouldn’t be more than 30 degrees of abduction
what is rectocele d/t?
weakness or defection the endopelvic fascia
what is cystocele d/t?
weakened anterior supporting tissues
ascites reflects increased hydrostatic pressure in what 5 conditions?
(1) cirrhosis
(2) HF
(3) constrictive pericarditis
(4) IVC
(5) hepatic vein obstruction
what method of knot tying is used mostly in the ER?
instrument knot typing
what are you looking for in A of ABCS of lateral c-spine film interpretation?
check for a smooth line at the anterior and posterior aspect of the vertebral bodies and suinolaminal line
what are you looking for in B of ABCS of lateral c-spine film interpretation?
carefully check each vertebral body to ensure that the anterior and posterior heights are similar
what are you looking for in C of ABCS of lateral c-spine film interpretation?
check the intervertebral joint spaces and the facet joints
what does ABCS stand for in interpretation of the lateral c-spine film?
A = alignment
B = bones
C = cartilage
S = soft-tissue spaces
what are you looking for in S of ABCS?
look for prevertebral swelling, esp at C2-C3 (> 5mm) and check the predental space which should be < 3mm in adults and < 5mm in children
when are flexion-extension view of the c-spine used?
if ligamentous injury is suspected
those with severe neck pain and normal cervical radiographs or those with suspicious abnormal radiographs
flexion-extension view of the c-spine should be performed only in what patients?
alert, cooperative patients and must be supervised by a clinician
what are the indications for CT?
identify vertebral fx’s and some correctable problems such as hematomas
what are the indications for MRI?
useful to evaluate injury to the spinal cord itself or rupture of the intervertebral discs
also demonstrates areas of contusion and edema within the cord, as well as areas of compression
what is anterior cord syndrome?
loss of fxn in the anterior 2/3 of spinal cord
what is lost in anterior cord syndrome?
loss of voluntary motor fxn, pain and temp sensation below the level of injury
what is preserved in anterior cord syndrome?
posterior column fins of position and vibration
what is needed immediately for anterior cord syndrome?
immediate neurosurgeon consult
what is central cord syndrome?
injury to the central portion of spinal column
more UE involvement than LE
can occur +/- x or ligamentous disruption
what is brown squared syndrome? what are findings?
hemisection of the spinal cord usually from penetrating trauma
contralateral sensation of pain and temp is lost
motor and posterior column fins are absent on the side of the injury
what is spinal shock? when can extent of cord injury be determined?
temporary concussive like condition in which the cord reflexes and anal wink are absent
extent of cord injury can’t be determined until reflex return
what difference b/w anterior and posterior vertebral heights indicates fx?
> 3mm
