1: History and Physical Exam - Mahoney Flashcards by Elle B

cc should contain…

age
race
sex
occupation
referred by

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who needs to be asked about pregnancy?

women 12-50 yo

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what ROS questions should be asked in regards to DM?

type
duration
last accucheck
last Hgb A1C
last time checked by family physician

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gravida vs. para

of pregnancies

of births

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THE CHADS

thyroid
heart
emphysema
cancer
hypertension
asthma
diabetes
stroke

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what info do you need about meds?

dosage
amount
frequency
route 
length of time taking med
last taken

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CPMS clinic policy regarding foot exams

wash hands AND apply gloves prior to any exam or tx of feet

wash hands after visit completed

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normal pulse

2/4

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pulse with a thrill or bruit

4/4

can be associated with a wide pulse pressure (greater than 60 mmHg)

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FACTS and wide pulse pressure

fevere
aortic insufficiency
complete heart block
thyrotoxicosis
systolic hypertension

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pulses that should always be reported and for each limb separately

dorsalis pedis pulse and posterior tibial pulse

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technique for CFT capillary fill time

apply firm digital pressure to the tip of a toe for 3 sec

after releasing your finger, the skin blanches white

a delay beyond 3 sec of return to normal skin color indicates decrease arterial flow into the capillary bed

avoid pressing over toenail to cause blanching due to frequency of thick nails which makes evaluation of the CFT difficult

any delay in CFT can be associated with either vasospasm or structural changes to the lg vessels supplying the microcirculation

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non-pitting vs. pitting edema

pitting - prtn poor exudate

non-pitting - prtn rich exudate

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method for checking edema

press firmly with your thumb for at least 5 sec over area of max swelling

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pitting edema scale

1+ indentation 2 mm
2+ indentation 4 mm
3+ indentation 6 mm
4+ indentation 8 mm

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how do you test for turgor and mobility?

lift a fold of skin and note the ease with which it is moved (mobilitiy) and the speed with which it returns into place (turgor)

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flat, non-palpable less than .5 cm

macule

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flat, non-palpable greater than .5 cm

patch

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palpable, solid less than .5 cm

papule

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palpable, solid .5-1 cm

nodule

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palpable, solid greater than 1 cm

tumor

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palpable, solid elevated surface formed by coalescence of papules greater than .5cm in size

plaque

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clear, fluid filled less than .5 cm

vesicle

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clear, fluid filled greater than .5 cm

bulla

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cloudy, pus filled less than .5 cm

pustule

cloudy, pus filled greater than .5 cm

abscess

0A ulcer classification

no break in skin | no inf. or ischemia

IA ulcer classification

to subcutaneous | no infection or ischemia

IIA ulcer classification

to tendon | no infection or ischemia

IIIA ulcer classificiation

to bone | no inf. or ischemia

IB ulcer classification

to subcutaneous | infection

IIB ulcer classification

to tendon | infection

IIIB ulcer classification

to bone | infection

IC ulcer classification

to subcutaneous | ischemia

IIC ulcer classification

to tendon | ischemia

IIIC ulcer classification

to bone | ischemia

ID ulcer classification

to subcutaneous | ischemia and infection

IID ulcer classification

to tendon | infection and ischemia

IIID ulcer classification

to bone | infection and ischemia

normal hip ROM

``` 45 internal and external rotation 45 abduction 20 adduction 120 flexion 0-15 hyperextension ```

normal knee ROM

130 flexion | 15 hyperextension

normal ankle ROM

``` 10 dorsiflextion (knee extended and flexed) 50 plantarflexion ```

STJ normal ROM

20 inversion | 10 eversion

1st MPJ normal ROM

60 dorsiflexion | 5-10 plantarflexion

1st ray normal ROM

10 mm total ROM

movement against gravity but not against added resistance

3/5

movement at joint, but not against gravity

2/5

b/c normal pod msk exam occurs in sitting position with feet elevated, active movement of the foot and ankle against resistance implies that the muscle strength rating is at least..

2/5

early loss of strength is usually seen in

extensor digitorum brevis weakness is normal after 65 yo

more sever m. strength loss seen with

ankle dorsiflexion most severe loss seen with ankle plantarflexion

mediate voluntary movement, particularly fine, discrete, conscious movement

corticospinal or pyramidal tract problem could be CVA

helps to maintain m. tone and to control body movements, especially gross automatic movements such as walking

extrapyramidal tract problem could be parkinsons

receives both sensory and motor input and coordinates muscular activity - maintains equilibrium and helps control posture

cerebellar system problem could be seen as a loss of the sense of balance

after entry into the dorsal (posterior sensory) spinal cord, the sensory impulse proceeds along one of two courses:

posterior column | lateral spinothalamic tract

pt complains of burning, cramping

lateral spinothalamic tract

sharp and dull pain temp crude touch

lateral spinothalamic tract

composition of lateral spinothalmic tract

aka small tract C and Adelta fibers

composition of large fiber tract

a alpha fibers aka posterior column

position vibration fine touch

posterior column

patient complains of pins and needles or electric shock sensation

posterior column

SWM tests which tract?

lateral spinothalamic

describe how to use the SWM

using a 5.07 SWM apply pressure to 1st, 3rd,5th metatarsal heads and toes, the plantar arch, the plantar hell, beneath the 5th metabase and the dorsal midfoot inability to detect the pressure in more than 3 areas suggests the potential for neurotrophic ulceration, especially in the diabetic

describe the sharp dull test

use th cotton tip and opposite end to test dull vs. sharp along at least 2 dif dermatomes ask pt to close eyes then touch asking "which is sharper the first touch or the second touch or are they same?"

sensory tests for posterior column

vibration position sense 2pt discrimination

describe the vibration test

use a 128 cyc/sec tuning fork over IPJ of hallux, ask pt to tell you when it stops vibrating place tuning fork over DIPJ of your index finger - vibration should extinguish withing 10 SECONDS if sensed found to be decreased, proceed more proximally over bony prominences until vibration felt and note area of normal pallesthesia

normal minimal distance at which the pt can discriminate one from two pts on the tip of great toe

5-6 mm

when is an absent achilles reflex normal?

after 80 yo

using reinforcement to facilitate observation of reflexes in LE

jendressic maneuver document as "reflex with reinforcement" knee: L2,3,4 ankle: S1,2

deep reflexes are dependent on 5 things. They are NOT dependent upon higher levels of motor function in brain and cord.

``` intact sensory n. functional synapse in spinal cord intact motor n. fiber NMJ competent m. ```

normal reflex grade

2/4 4/4 may be associated with clonus and indicates UMN disease 0/4 no response, LMN disease

reflex and dermatome patterns ***

``` hip - L23 knee - L34 ankle - L45 achilles- S12 back of knee - L5,S1 butt - L45 ```

ankle reflex associated with which n. roots?

S1,2

normal babinski (superficial reflex)

flexing fanning and dorsiflexion is abnormal and indicates UMN disease

how do you do the bedside babinski

remove pt socks in bed or after placing bedsheet under heel, pull it out from under heel and over toes

if pt can stand on tiptoes but not on heels =

peripheral neuropathy stand on heels but not on tiptoes = spinal lesion

hop in place with each foot

intact motor system in legs normal cerebellar function good position sense

another word for diagnosis

impression

why might a child present with a limp?

Hip AVN Kohler's disease (AVN of navicular) tarsal coalition child abuse

what should you ask about fetal movements?

was the mother aware of fetal movements beginning in 4th mo of pregnancy?

APGAR *** =

``` appearance (skin color) pulse (heartbeat) grimace (response to touch or pin-prick) activity (muscle tone) respirations (breathing) ``` taken immediately and 5 min post birth desirable score greater than 7 less than 5 - 20% chance breathing difficulty

no hand preference until the age of...

2 if before 2 could be neuromuscular prob

lift head

3 mo

control head position while sitting

6 mo

crawl

6 mo

pull self to stand

9 mo

walk

14 mo

ascend stairs with 2 hand support

18 mo

run forward

2 yr

pedal tricycle

3 yr

balance or hop on one foot

4 yr

heel-toe walk

5 yr (normal heel-toe gait)

skip one foot at a time

6 yr

1: History and Physical Exam - Mahoney Flashcards

(92 cards)