MIDTERM Flashcards
(210 cards)
1
Q
Draping patient - abdomen
A
Patient in supine position
Keep drape over, ask patient to reach under the drape pulling their gown up to thee level of the inferior breasts
This allows the patient to control the procedure
Now you are able to examine the abdomen by lowering the drape
2
Q
Thomas test
A
Anterior/iliopsoas compartment.
- Pt supine and pulls knees to chest
- One leg is lowered to the table to test the flexibility of the hip flexors
+Test: inability to fully extend, or extended leg raises off table
Tests: hip flexors contraction
3
Q
DDx of Lateral knee pain?
A
Lateral collateral L sprain
Lateral meniscus tear
IT band tendinitis
4
Q
Ankle sprain
A
- Lateral ankle sprains are most common sprain, most are related to sports injury
- Lateral ankle sprain —> lateral ankle L (from anterior talofibular (AFT “always tear first) or calcaneofibular LOs) injury secondary to foot inversion and plantar flexion
- Medial ankle sprain —> medial ankle L (deltoid L complex) to forced eversion -
Syndesmotic sprain (high ankle sprain) —> dorsiflexion and/or eversion with external rotation and sprain the distal tibiofibular syndesmosis
5
Q
Social history - FEDTACOS
A
Food
Exercise
Drugs
Tobacco
Alcohol
Caffeine
Occupation
Spirituality, sexual relationships, and safety
6
Q
Tuning fork - air conduction
A
Lasts longer, hold fork external auditory meatus
7
Q
HIP - complaint specific for knee complaint
A
- Traumatic or atraumatic
- Precipitating factors/events? Sports?
- Recreational or occupational activities?
- Able to bear weight?
- Knee locking, popping (ligament injury), or giving out?
8
Q
What is ROS
A
Review of symptoms is an inventory of body systems obtained by asking a serious of questions to identify signs and/or symptoms the patient may be experiencing or has experienced
—General, skin, HEENT, neck, breast, respiratory, CVS, GI, GU, endocrine, neurologic, MSK, hematologic/immunologic, psychiatric
**Time savers: define a time frame that patients may have experienced theses symptoms**
9
Q
General appearance
A
Check for alertness/consciousness
Ex: alert, somnolent, listless, lethargic, comatose, easy to arouse
**Can use Glasgow coma scale
—> Best response 15
—> Comatose 8 or less
—>Totally unresponsive 3**
10
Q
Gait
A
Objective of observing the patient’s gait is to assess the impact of the pt’s hip condition o their overall mobility by observing the ability to perform simple movements
-Ask pt to walk in examination room (toe to heel walk)
11
Q
Palpation - 1/4 techniques of examination
A
Performed with your hands, superficial and deep
12
Q
What is the result of using a BP cuff that is too small?
A
BP will read high
13
Q
Great toe Dermatome
A
L4-L5
14
Q
Why do we obtain ROS?
A
- Identify co-existing medical conditions
- Build your case medically and legally
—> provide documentation of medical considerations that you can link to the medical assessment of your patient
- Provide accurate billing information
15
Q
Elbow specialty test - Valgus stress test
A
- Arm slightly abducted and externally rotated
- Forearm supinator and flexed to approx. 30 degrees
- Sight medial directed valgus stress is applied to elbow joint
+Test: pain/tenderness, increased laxity
Tests: sprained medial (ulnar) collateral ligament
16
Q
Normal RR
A
14-20 breaths per minute
17
Q
Most common causes of shoulder pain - Chronic
A
Rotator cuff disorders
Adhesive capsulitis
Shoulder instability
Shoulder arthritis
18
Q
Ophthalmoscope
A
To examine the:
—Fundus, retina, posterior chamber of eye
—The pupillary reflex (directs and consensual)
—Red reflex, which is the normal reflection of the retina
19
Q
Morton’s neuroma
A
- Inflammation and thickening of tissue that surrounds the nerve between toes (most commonly between 3rd and 4th toes)
- Pt feels like they are walking on a marble
- Palpable in 3rd web space, replicate burning pain
- Can have radiation of pain and numbness of toes
Test: Mulder’s sign: clicking sensation upon palpation with one hand on the third web space and other hand compressing transverse arch together
20
Q
FICA - spirituality and religion
A
F - faith and belief
I - importance
C - community
A - address in care or assessment & plan
21
Q
Process for developed and working through a DDX
A
- Develop broad DDX -Based on CC, age, sex, race
- Narrow DDX - HPI, PMHx, PSHx, etc.
- Develop working DDX -Most common/likely diagnosis and IgE threats
- Pursue working DDX -Therapeutic interventions and diagnostic testing
- Assessment and plan (primary and secondary DX) -Tx, disposition, documentation
22
Q
Ottawa Knee Rule
A
If one criteria is +, need imaging:
- Age >55 years
- Inability to bear weight for four steps (unable to transfer weight twice) immediately after injury or in the emergency setting
- Inability to flex knee to 90 degrees
- Tenderness over head of fibula or isolated to patella without other bony tenderness
23
Q
Diaphragm of stethoscope
A
Larger circle
Used for higher frequency sounds such as breath and heart sounds
24
Q
Reflex patellar
A
L4 nerve root
25
Patrick (Fabere) test
- Allows assessment of the hip and sacroiliac joint
- The examiner Flexes, ABducts, Externally Rotates, and Extend the affected leg so that the ankle of that leg is on top of the opposite knee
- Affected leg is then slowly lowered toward the table
**+Test**: affected leg remains above the opposite leg and may be indicative of hip disease, iliopsoas spasm, or sacroiliac disease
26
Internal rotation ROM of hip
30-40
Iliopsoas
27
Posterolateral calf/little toe dermatome
S1
28
Active listening skills
Smile
Eye contact
Posture
Mirroring
Minimize distraction
29
Inspection - 1/4 techniques of examination
Assess appearance of age, posture, mobility, asymmetry, color changes
30
Dx and Tx of plantar fasciitis
Dx: clinical
- TTP over the medial plantar calcaneal region;
Pain worsens with passive dorsiflexion
Tx: typically self-limited, rest, NSAIDs, stretching exercises, orthotics, glucocorticoid injections —\>Roll stretch, place cold bottle of water/can of soda underneath foot
31
ROM - flexion of hip
With knee straight: 90
With knee flexed: 120-135
Iliopsoas M. —\>Innervated by: Femoral N. (L2-4) and ventral rami of lumbar (L1-2)
32
CAGE questions - alcohol
Useful to screen for patients who drink more than one drink daily or who drink a lot on the weekends, can open door to conversation about getting help
C: Has anyone ever suggested you cut back?
A: Are you ever annoyed wen people talk about your drinking?
G: Do you ever feel guilty about your drinking?
E: Do you ever need a drink in the morning to steady your nerve (an eye opener)?
33
Lumbar radiculopathy
Particularly involving L4-L5
Causes lateral hip pain that extends over a much wider area
Radiating down the leg and into the foot with or without associated foot numbness
Sharp shooting pain
34
What info to gain for full HPI
- Past medical history
- Past surgical history
- Current medications —\> Rx, OTC, supplements —\> dose, timing, positive or negative
—\>Reminder to ask about OCPs for females
- Allergies (medications, and reaction, environmental, food)
- Family history: mom, dad, siblings, kids
- Social history
35
ROM extension of hip
15-30
Gluteus Maximus M
—\>innervated by inferior gluteal nerves (L5-S1,S2)
36
Dx and Tx of PAPS
-Clinical: medial knee pain, tenderness over proximal medial tibia, and absence of local swelling
Tx: weight loss, quadriceps-strengthening exercises, NSAIDs Glucocorticoid injection into bursa
37
Bone fractures in shoulder
Clavicle - most occur in kids and young adults
Proximal humerus - most commonly in the elderly
Scapular - associated with blunt trauma
38
OA - classic presentation
Gradual onset, potentially ASYMMETRIC joint pain and stiffness commonly in DIP, PP, 1st carpometacarpal, hip, knee Cervical, lumbar joints
Pain worse with activity but relieved with stress
Joint stiffness last \<1 hour after waking up and improves with activity
39
Consensual pupillary light reflex
When light shines in one eye, contralateral (opposite side) pupil also constricts
40
DDx of Medial knee pain?
Medial collateral L sprain
Medial meniscal tear
Pes anserine bursitis
Medial plica syndrome
41
Phalen’s sign
- Place dorsal aspects of patient’s hands together and force into wrist flexion
- Hold for 60 seconds
**+Test:** any reproduction of sxs of paresthesia in the distribution of median N.
**Tests**: Carpal tunnel syndrome
42
Techniques of examination (in order)
Inspection, Auscultation, Percussion, and Palpation
43
Shoulder pain —\> traumatic
**Bone**
-fractures and dislocations
**Soft tissue**
-myofascial, acromial clavicular, rotator cuff
**Joint** (intra-articular)
-cartilage (labrum), hemarthrosis, joint capsule
44
Elbow specialty test - Tinel test
-Tap between olecranon and medial epicondyle in ulnar groove
**+Test**: elicits tingling sensation down forearm
**Tests**: ulnar nerve entrapment
45
Finkelstein test
-Ask pt to make a fist encompassing their thumb and ulnar deviate the wrist
**+Test**: increased pain in first dorsal compartment
**Tests**: DeQuervain’s tenosynovitis
46
Squeeze test
- Wrap hands around leg proximal to the ankle, contacting distal tibia/fibula with both thenar eminences
- Squeeze for 2-3 seconds, then rapid release
**+Test**: Pain at syndesmosis
**Tests**: Syndesmosis pathology (high ankle sprain)
47
Hawkin’s test
**Tests**: rotator cuff or subacromial bursa impingement
- Flex shoulder and elbow to 90
- Passively rotate the humerus into internal rotation
- This opposes rotator cuff against coracoacromial ligament and acromion
**+Test**: pain
48
“Little league elbow”
-Group of problems related to stress of throwing in young athletes
—\>pain over the medial epicondyle, initially after throwing (repetitive valgus distraction forces), progresses to persistent pain
—\>most common elbow injury during childhood
—\> as bone development matures, most common injury seen evolves (apophysitis —\> avulsion —\> ligamentous injury)
49
Rheumatoid arthritis - etiology
Etiology: autoimmune, inflammatory arthritis of unclear etiology
50
Thompson test
- Patient prone with foot off the table
- Squeeze the pt’s calf
- Observe for plantar flexion
**+Test**: Absence of plantar flexion
**Tests**: Achilles’ tendon rupture
51
Etiology of PFPS
Maybe overuse of knee vs patellar maltracking due to quadriceps weakness
-Large Q angle? (B/w ASIS and patella)
52
Olecranon bursitis
FLies superficial to posterior elbow joint
- Posterior elbow distention and discomfort due to overuse “student’s elbows” or “miners elbow” or athletic pain
- Region is often painless
ROM normal
53
Shoulder pain
3rd most common MSK complaint
The only joint in the human body where tendons (rotator cuff) pass between bones (acromion and humerus)
54
Dislocation of glenohumeral joint
50% of all major joint dislocation
-3 types
—\>anterior dislocation: most common, accounting for 95-97%
—\>posterior: 2-4%
—\>inferior: luxatio erect, which means “to place upward”: 0.5%
55
Drop-arm test
**Tests** full thickness tear of supraspinatus
- Pt abducts arm to 90
- Then slowly drops arm
**+Test**: arm will drop or gentle tap on wrist will cause arm to drop
56
Adduction ROM of hip
20-30
Adductor longus/brevis/magnus, pectineus, gracilis Ms.
Adductor longus innervated by: Obturator nerve (L2-4)
57
Examination of the hip - sources of referred pain to the hip from?
- Lumbar spinal nerves (straight leg raise)
- Sacroiliac joint (palpation of the joint)
- Lateral femoral cutaneous nerve (sensation in the upper outer thigh)
- The lower abdominal vascular structures (low extremity pulses)
58
Labral loading
Central compartment of the hip
- Flex the pt’s knee and hip to 90
- Load into the femur towards the innominate
**+Test**: Pain
**Tests**: labral or cartilaginous pathology
59
Top causes of life threatening joint pain
Septic arthritis
Referred pain
- \> Acute MI
- \> Intraperitoneal hemorrhage
- \> lung pathology
60
Bell of stethoscope
Smaller circle
Used for lower frequency sounds such as bruits
61
Otoscope grasp in adults and children \>12 months
Pull up, out and back
62
Visualization with ophthalmoscope
Hold device in right hand and use right eye to examine patient’s right eye
—Perform bilaterally
Move light lateral (15 degrees out) to medial until over the iris then move toward the patient
Identify pupillary light reflex and red reflex
63
Giving out sensation of knee pain suggests?
Ligamentous rupture or patellar subluxation
64
Talar tilt test
- Grasp distal tibia/fibula with one hand and inferior calcaneus with the other
- Blocking motion of the calcaneus on the talus
- INVERT the talus to evaluate ROM
**+Test**: laxity, increased ROM, or pain
**Tests**: calcaneofibular L pathology/tear; also tests some ATF (lateral ankle sprain)
65
Tredelenburg gait
- Pt shifts the torso over the affected hip, thereby reducing the load on the hip and decreasing pain
- Suggests the presence of hip joint disease and/or weakness of the gluteus medius muscle
66
Joint exam
- Inspection
- Palpation
- Range of motion
- Specialty testing
- Always compare to opposite extremity
67
Skin exam - general examination
Color: pale, jaundice, cyanosis, reddened
Condition: dry, pigmented, diaphoretic, rash
Lesions: location, macular, popular, petechial
\*\*Screen for melanoma with ABCDE\*\*
\*\*Exam hair and nails\*\*
68
Osteoarthritis arthritis (OA) - risk factors
- Most common form of arthritis in adults
- Age \>50, obesity, female, joint trauma, genetics
69
Specialty tests for rotator cuff
Painful arc - most sensitive and specific
Neer impingement
Hawkins
Yergason sign
Empty can
Drop arm test
Diagnostic: X-ray not helpful, US or MRI test of choice
Tx: rest, ice, NSAIDs and PT
70
LGBTQIA
Lesbian
Gay
Bisexual
Transgender
Queer or questioning
Intersex
Asexual or allied
A question you may use: In the past, have you had sexual relationships with men, women, or both? How about now?
71
Anterior cruciate ligament (ACL) injury
- Most commonly injured knee L
- Contact injury: 30%
- Non-contact injury: 70%; sudden deceleration with change in direction
- Sudden onset of severe knee pain with large effusion developing with 2 hours typically from hemarthrosis
- Pt can report “popping sensation” or knee instability (giving out)
- Can lead to osteoarthritis 10-20 years after the initial injury
72
Insertion of otoscope
-Approx 1/4 to 1/2 length of speculum (1-2 cm into ear)
—Identify canal, tympanic membrane, and reflected cone of light
73
Snellen eye chart
Example: 20/20 is normal and 20/40 means that the test subject sees at 20 feet what a normal person sees at 40 feet
Chart is held ~14 inches from eyes
\*\*Test both eyes open, then covering one eye at a time
74
Forefoot adduction
20
75
RA - classic presentation
SYMMETRIC JOINT PAIN, joint swelling, joint stiffness of hands, wrists, feet, knees, and other joints
—\> joint stiffness lasts \>1 hour after waking up and improves throughout the day
CLINICAL PEARL: commonly involves joints: wrists, MCPs, PIPs
76
Ottawa Ankle Rule
Ankle/foot XRs should be obtained in patients with the following:
1. TTP over medial malleolus or lateral malleolus or inability to bear weight immediately after injury
2. Tenderness over base of 5th metatarsal or navicular instability to bear weight immediately after injury
77
78
Achilles tendonitis
- Inflammation at Achilles’ tendon
- Presents as sharp heel pain and stiffness at mid-Achilles tendon to insertion
- Pain with worse with strenuous exercising, better with walking
- Micro tears in tendon causes swelling and thickening
- Commonly associated with tight calf muscles, sudden change in activity, poorly fitting shoes, incorrect running technique
79
Joint pain —\> traumatic —\> extra-articular
**Bone** —\> fractures, dislocations
**Soft tissue** —\> ligaments, tendons, bursae, macula, fascia, nerve
80
Reflex biceps
C5 nerve root
\*\*Thumb in between tendon and hammer - on patient’s AC fossa\*\*
81
Exam findings - RA
Edema Synovitis
Ulnar deviation
Swan neck deformities
Boutonnière deformities
Rheumatoid nodules
Positive MCP squeeze test
82
Most common causes of shoulder pain - acute
Rotator cuff injuries
Fractures/dislocation
Acromioclavicular joint injuries
Myofascial
83
Anterior hip or Groningen pain
Suggests primary involvement of the hip joint itself
Gradual onset of pain in association with variable degrees of impaired movement is consistent with osteoarthritis
84
Tennis elbow test
-Pain with resisted wrist extension with elbow in full extension
**+Test**: pain/tenderness around lateral epicondyle
**Tests**: lateral epicondylitis
85
Tuning fork - vibratory sense
Place handle on patella (knee cap) and compare left and right for duration
86
Auscultation - 1/4 techniques of examination
Performed with a stethoscope
— listen to lung, heart, GI vascular sounds
87
Dupuytren’s contracture
Caused by progressive fibrosis of palmar fascia which results in gradual joint stiffness and inability to fully extend the finger
88
Dx and Tx of Ankle sprain
Clinically Dx
- Lateral: anterior drawer test, talar tilt test
- Medial: eversion test
- Syndesmotic sprain: squeeze test
\*Ottawa ankle rules to determine if making needs to be done\*
Tx: RICE, NSAIDs, splinting, PT, immobilization of high ankle sprains
89
Joint pain —\> a traumatic —\> extrinsic (referred)
Systemic disease (lupus/RA)
Referred (from heat)
90
What is the result of using a BP cuff that is too large (wide?)
BP will read low on a small arm and high on a large arm
91
Examination of edema
- Press firmly for 5 seconds
0: Absent
1+: barely detectable, slight pitting (2 mm), disappears rapidly
2+: slight indentation (4 mm); 10-15 sec
3+: Deeper indentation (6 mm); \>1 min
4+: very marked indentation (8 mm); 2-5 min
92
Daily activities and exercises
CDC recommends:
-Adults:
—\>get 150 minutes per week of moderate activity (brisk walking)
—\>strength training 2 days of the week that focuses on all major muscle groups
-Children and adolescents 6 years and older:
—\>1 hour or more of daily physical activity
93
DeQuervain’s tenosynovitis
- Pain and inflammation from repetitive overuse of tendons in first dorsal compartment
- Pt c/o dorsolateral wrist and thumb pain w/ occasional radiation into lateral hand and thumb
- Pt’s will have grip weakness
- Maybe worsens with thumb movements
Possible inflammation sites: tendon sheath, abductor pollicis longus, extensor pollicis brevis
RF: females, ages 30-50, repetitive activities, new mothers (picking up children)
Finkelstein test
Tx: thumb spica splint, NSAIDs, steroid injection, surgery
94
Intimate partner violence, when to screen?
Best time to screen is during well-patient visit, also OK to screen in response to specific visits where injury or illness makes you suspect something is going on
\*\*Screening should be done while patient is clothed\*\*
95
Turf toe
- Inflammation and pain at base of 1st MTP
- Presents as pain and bruising at base of great toe
- Caused by hyperextension of great toe causing damage to the joint capsule
- Severe cases can damage sesamoids and flexor tendon
- Commonly associated with activities performed on hard surfaces
96
Cross arm test
**Tests**: AC joint pathology
-Physician passively adducts pt’s arm across their chest and rests pt’s hand on their opposite shoulder
**+Test**: pain in AC joint with end range adduction
97
Antalgic gait
Spends a shorter time weight bearing on the affected hip side because of pain
98
Tuning fork - bone conduction
Less than air condition, hold handle at mastoid process posterior to the ear
99
Meniscal injuries
- Medial or lateral
- Acute: sudden change of direction in which the knee is twisted or rotated while the corresponding foot is planted
- Chronic: often from degenerative changes seen in older patients
- Slow onset knee pain with swelling or effusion over the next 24 hours
- \> degree of pain related to severity of meniscal tear
- If untreated, pts may report “locking” or “catching” of knee during extension
100
Reflex brachioradialis
C6 nerve root
101
Direct pupillary light reflex
When light shined in the eye, the ipsilateral (same side) pupil constricts
102
Empty can test
**Tests** rotator cuff pathology (specifically supraspinatus)
- Flex pt’s shoulders to 90 while horizontally abducting to 45
- then internally rotate both arms so thumbs are pointing down
- Press down on forearm while pt resists
**+Test**: pain or weakness
103
Most common conditions affecting the hip
Trochanteric and gluteus medius bursitis, osteoarthritis, and fractures of the femur
104
The five P’s in obtaining sexual history
Partners
Practices - asking about ways (oral, vaginal, anal), if they use condoms
Prevention of pregnancy
Protection from STIs
Past history of STIs
105
Scale for grading reflexes
0+ reflex absent
1+ somewhat diminished, low normal
2+ average, normal
3+ brisker than average, possibly but not necessarily indicative of disease
4+ very brisk, hyperactive with clonus (rhythmic oscillations between flexion and extension)
106
External rotation ROM of hip
40-60
Internal and external obturators, quadratus femoris, superior and inferior gemelli Ms.
107
Iliotibial band syndrome (ITBS)
- Second most common cause of knee pain from overuse after PFPS; commonly seen in runners or cyclists
- Slow onset, diffuse, lateral knee pain and/or leg pain; intermittent, sharp or burning pain that can progress to constant/deep
108
Dx and Tx of ITBS
**Dx**: clinical:
—\>Noble test: pt in lateral decubitus position with knee passively flexed to 60 degrees (+Test if TTP over lateral femoral epicondyle during maneuver)
—\>Focal tenderness of ITB where is courses over lateral femoral condole
**Tx**: Rest, ice, NSAIDs, ITB stretching and hip abduction strengthening, glucocorticoid injection
109
Apparent state of health
Healthy, sick/ill, frail, obese
Signs of distress: wincing, diaphoresis, grimacing, posturing
110
Scour test
Central compartment of hip. “Omega”
- Flex and externally rotate pt’s hip
- Load into the socket and articular through annular ROM
**+Test**: Pain
**Tests**: labral or articular cartilage pathology
111
Transition statements in obtaining sexual history
IMPORTANT!!
“Now I’d like to move our conversation to sexuality, which is an important aspect of your complete health history”
“I ask all of my patients a few questions about sexual health, so... do you have any concerns about your sex life?”
\*\*AVOID saying something like, “If you’d prefer not to talk about this, we don’t have to”
112
Eversion test (ankle/foot)
- Grasp distal tibia/fibula with one and hand plantar surface of the mid-foot with the other
- Evert the foot to evaluate ROM
**+Test**: Laxity, increased ROM, or pain
**Tests**: Deltoid ligament pathology (medial ankle sprain)
113
Extremity exam
- Inspection
- Palpation
- Range of motion
- Specialty testing
- Neurovascular status
—Neuro: reflexes, motor/sensory
—Vascular: pulses/capillary refill, always check pulses distal to the injury
114
Risk factors of PFPS
Females, running, squatting, going up and down stairs, quadriceps weakness, patellar instability
115
Anterior knee pain
Patellar subluxation or dislocation
Tibial apophysitis (Osgood-sclatter lesion)
Jumpers knee (patellar tendinitis)
Patellofemoral pain syndrome (chondromalacia patellae)
116
Dx of ACL injury
- Clinically
- Anterior drawer test or Lachman’s test
- Knee MRI or arthroscopy can confirm
**Tx:** May need surgery. If not: RICE (rest, ice, compression, elevation) NSAIDs, PT
117
Classic presentation of PFPS
- Anterior knee pain that worsens while knee is flexed during weight bearing activities (pain under patella)
- Pain worsens with ASCENDING OR DESCENDING STAIRS or PROLONGED SITTING (movie-goer sign)
118
Lower anterior thigh pain
Poses the greatest clinical challenge
-Primary disease of the hip joint, primary and secondary lesions of the upper femur, stress fracture of the femoral neck, and upper lumbar radiculopathy
119
Plantar fasciitis
- One of the most commons cases of foot pain in adults
- Most likely biomechanical overuse causing microtears in the plantar fascia resulting in degeneration of fibrous tissue or acute inflammation
- Sharp, stabbing, medial, plantar heel pain
120
Gout flare
RF: hyperuricemia, males, diet high in purines (red meat), alcohol, thiazide diuretics, CKD, etc
- Caused by precipitation of monsodium urate (MCU) crystals in a joint space —\> inflammatory rxn
- Sudden onset monoarticular joint pain with marked swelling and redness (any joint but most commonly, 1 metatarsophalanageal joint)
121
Referred causes of shoulder pain
Neurological: herpes zoster, brachial plexus lesion
Abdominal
Cardiovascular: MI, axillary vein thrombosis
Pulmonary: upper lobe PNA, PE
122
Golfer’s elbow test
-Pain with resisted flexion with elbow in full extension
**+Test:** pain/tenderness around medial epicondyle
**Tests:** medial epicondylitis
123
Dislocation
Compete lack of contact between 2 articular surfaces
124
What should impairment of ROM and severe pain at the endpoints of motion of the hip make you do next?
Immediate evaluation for osteonecrosis, occult fracture, acute synovitis, or metastatic involvement of the femur
IF ROM is normal - palpation of the trochanteric bursa is perform
125
Rotator cuff injury
SITS (supraspinatus, infraspinatus, teres minor, subscapularis)
-supraspinatus - most often injuries
\*\*Painful arc test\*\*
**Sx:** shoulder pain (over lateral deltoid) more prevalent with overload activity and at night; weakness
Can have impingement syndrome, tendon injury (acute), or tendinopathy
126
Palpation of joint/extremity
Is the joint warm?
Is there tenderness?
Is there edema/effusion?
What hurts?
127
Popping sensation of knee pain suggests?
Ligamentous tear or rupture
128
Trigger finger
Caused by disparity in size of flexor tendon to surrounding retinacular pulley system system/sheath, impairing gliding of flexor tendon
**Classic presentation:** painless to painful snapping, catching, or locking of fingers during flexion
129
The most sensitive indicator of joint disease
ROM - hip pain
130
Meralgia paresthetica
Lateral hip pain associated with paresthesias, hypesthesia, and other sxs in the anterolateral thigh area
-Lateral femoral cutaneous nerve entrapment
Not always associated with hip pain
131
Normal HR
60-100 bpm
132
1st metatarsophalangeal flexion
45
133
Apprehension - FABER (1/3)
Central compartment of the hip.
- Pt’s hip is flexed, abducted, and externally rotated
- Physician induces further external rotation by applying a posterior force at the knee (figure four)
**+Test:** anterior subluxation of hip or apprehension/pain
**Tests:** labral pathology - or impingement
134
Anterior hip pain that is neither aggravated by direct pressure nor repetitive flexion of the hip suggests?
The presents of an inguinal hernia, lower abdominal pathology or less commonly
- referred pain from high lumbar spinal nerve roots
135
Short leg limp
Secondary to leg length discrepancy
-Characterized by an increase in the up and down movement of the head and shoulders as the body falls onto the short leg and then rises up on the long leg
136
Universal precautions
A. Protect the patient and provider from spread of infectious disease
B. Gloves used in presence of blood or other bodily fluids
C. Hand washing before and after wearing gloves
137
Domestic violence - SAFE
S: stress/safety
A: afraid/abused
F: friends/family
E: emergency plan
138
Slower onset knee pain within 24-36 hours of injury of mild to moderate knee effusion suggests?
Meniscal tear or ligamentous sprain
139
Laws of personal space
1.5 feet - intimate
\*\*4 feet - personal \*\*
10 feet - social
140
Straight leg test
-Neurologic pain which is reproduced **between 30-70** degrees of hip flexion is suggestive of lumbar disc hernia at the L4-S1 nerve roots
**-Pain less than 30:** acute spondylolisthesis, gluteal abscess, disc protrusion or extrusion, tumor of buttock, acute dural inflammation, malingering patient
**-Pain greater than 70:** tightness of hamstrings, gluteus Maximus, or hip capsule; or pathology of the hip or sacroiliac joints
141
Homan’s sign
- Pt laying or sweating with knee extending
- Dorsiflexion the pt’s foot; can apply lateral compression to calf
**+Test:** Pain with dorsiflexion
**Tests:** Thrombophlebitis or acute deep vein thrombosis (DVT)
\*Can also observe accompanying signs of edema, erythema, and warmth of lower leg —\> would need to order a Venous Doppler to rule out clot\*
142
Pearls for the joint exam
Always compare the joint/extremity with the pathology to the opposite, “normal” extremity
Be systematic, do your exam the same way every time
Be flexible with examining a patient with an acutely injured joint —\> do not ever force a ROM or specialty test that treated increases the patient’s pain
143
BP cuff dimensions on arm
Width of the cuff should be ~40% the upper arm circumference
Length of the cuff should be ~80% upper arm circumference
144
Posterior hip (gluteus) pain
Least common pain pattern affecting the hip -It is most often a sign of sacroiliac joint disease, lumbar radiculopathy herpes zoster
Extensive examination and radiographic testing
145
Percussion - 1/4 techniques of examination
Perform with your hands
—flatten fingers over thorax/abdomen
—strive the distal knuckle with 3rd finger too elicit sound
—note the sound difference when percussing over a hollow organ vs bone
—\> dull sounding = fluid
—\> flat sounding = solid
—\> tympanic sounding = air
146
Apprehension test
**Tests** for glenohumeral instability
- Pt seated or supine
- Shoulder abducted to 90 and elbow flexed at 90
- Stabilize shoulder with one hand
- Force arm into external rotation
**+Test:** patient apprehensive of repeated dislocation
147
Joint pain —\> traumatic —\> intra-articular
**Bone**
—\> fractures, dislocations
**Soft tissue**
—\> joint capsule, articular cartilage, synovium, synovial fluid, intra-articular ligaments
148
Final question to ask when obtaining sexual history
What other thinks about your sexual health and sexual practices should we discuss to help ensure your good health?
149
Patrick’s (FABER) 2/3
Lateral compartment of the hip.
- Pt’s hip is flexed, abducted, and externally rotated (figure 4)
- Physician braces contralateral ASIS
- Pt externally rotates/abducts a/g resistance
**+Test:** pain or weakness
**Tests:** gluteus medius pathology
150
Neurovascular reflexes
Check the reflexes in affected extremity
Record from 0/4 - 4/4
2/4 normal
151
Acromioclavicular joint injuries
Usually occurs from direct trauma to the superior or lateral aspect of the shoulder (acromion) with the arm adducted
Spectrum of injuries: AC sprain/ligament rupture, sprain/rupture of CC ligaments
**PE:** tenderness over AC joint
Anterior-posterior radiographs including both AC joints or US
152
Neurologic (muscle strength)
Compare strength with opposite extremity
Think about what muscles/nerves you are testing
Record 0/5-5/5
Always assess and document motor and sensory function distal to soft tissue injury of fracture
153
Sublaxation
Residual contact between 2 articular surfaces - shifted but still connected
154
Inspection for pelvic obliquity
- Screening maneuver for leg length discrepancy
- Pt asked to stand with feet together
- Hands are places on top of the iliac crease and the level of the pelvis is estimated
- Asymmetry of the iliac crests is seen with leg length discrepancy, pelvis fracture, scoliosis, and unilateral paraspinal muscle spasms
155
Labral distraction
Central component of the hip
-Distract pt’s femur away from innominate
**+Test:** improvement of pain
**Indicated:** labral or cartilaginous pathology
156
Dx of Meniscal injuries
- Clinically
- Medial or lateral joint line tenderness, loss of smooth passive motion of knee, inability to fully extend knee or squat
- Positive McMurray’s test
Tx: RICE, crutches if bad, PT, or surgery for severe cases
157
Posterior knee pain
Popliteal cyst (baker’s cyst)
Posterior cruciate L injury
158
ROM - plantarflexion ankle/foot
55-65
159
Orientation
Person, place, time and situation
160
Dx and Tx of Gout
Dx: Arthroentesis: negative birefringent needle-shaped crystals on polarized light \*\*
—\> serum uric acid levels
—\> gouty tophi
Tx: NSAIDs, colchicine, glucocorticoids
Prevention: Allopurinol
161
Subtalar inversion and eversion (lock out talus)
5
162
Inspection
Look at joint.
Look at extremity.
Compare.
Splinting?
Symmetric?
Color?
Scars?
163
Tinel’s sign of wrist
- Tap over the transverse carpal ligament/flexor retinaculum with either the tip of the finger or reflex hammer
- Pt’s wrist is held in extension
**+Test:** parasthesia/numbness/tingling//pain radiating to thumb, index, and middle finger
**Tests:** Carpal tunnel syndrome
164
Rapid onset of knee pain (within 2 hours) of large, tense knee effusion suggests?
ACL rupture OR tibial plateau fracture
165
Red disposal container
Supplies contaminated with body fluid or potentially infectious debris
166
Ober’s test
Lateral compartment of the hip.
**+Test:** restricted ROM
**Indication:** tight IT band
167
Ankle inversion ROM (no locking out)
20
168
Pes Anserinus Pain Syndrome (PAPS) —\> Pes anserinus refers to the insertion site of the conjoined tensions of sartorius, gracilis, and semitendinosis
- Common cause of medial knee pain
- Maybe referred mechanical knee pain (OA, obesity) vs true bursitis
- Sudden onset medial knee pain inferior to the medial joint line
—\>worsened by repetitive knee flexion and extension
169
RA - risk factors
Females, smoking, obesity, Fhx RA, HLA-DRB1 genotype
170
ROM of shoulder
Flexion: 180
Extension: 60
Abduction: 180
Internal rotation: 90
External rotation: 90
Horizontal Abduction: 40-55
Horizontal adduction: 130-140
171
Pain
Remember to give patient a scale
10 being worst possible pain 0 is no pain
172
Painful Arc Test \*\*
**Test for subacromial impingement and rotator cuff tendon injury**
\*A positive test is shoulder pain from 60-120 of abduction\*
173
Position patient while using ophthalmoscope
Have pt look over examiner’s shoulder, place the hand NOT used to hold the ophthalmoscope on patient’s head (forehead)
174
Shoulder pain —\> atrauamatic
Intrinsic
- overuse injuries, shoulder instability (rotator cuff tendinopathy or impingement syndrome)
- subacromial bursitis
- inflammatory synovitis
- adhesive capsulitis (frozen shoulder)
- bicipital tendinitis, osteoarthritis
- myofascial pain, septic arthritis, gout, pseudo gout
Extrinsic/referred
175
Jump sign
Lateral compartment of the hip.
- Pt seated
- Pressure is applied to greater trochanter
**+Test:** Pt withdraws or “jumps” with pressure
**Tests:** Trochanteric bursitis
176
6 positions for a PE
Sitting
Standing
Supine
Prone
Left/right lateral recumbent
177
General appearance
Alertness/consciousness
Orientation
Apparent state of health
Pain assessment
Apparent age
Special considerations (race/ethnicity)
Dress, grooming, and personal hygiene
Facial expression
Odors of body and breath
Posture/gait/motor activity
178
Valgus deformity
Distal part of limb directed away from midline
“Knock knees”
179
Tibial Apophysitis (Osgood-Schlatter disease)
- 9-14 years old in those who play sports and had recent rapid growth spurt
- Secondary repetitive strain and chronic avulsion of the secondary ossification center (apophysis) of the tibial tuberosity
- Presents as gradually worsening anterior knee pain
- low-grade ache that can cause a limp -
Exam: tenderness of body prominence over tibial tuberosity
-Usually self-limited and gets better with time
180
Popliteal cyst (Baker’s cyst)
- Posterior aspect of knee
- Comes from bursa
- Commonly associated with OA, RA, or meniscal tears
- Most are asymptomatic and incidental detected on imaging
**Dx:** Foucher’s sign: cysts softens or disappears with knee flexion to 45 degrees
**Tx:** asymptomatic- no tx;
symptomatic —\> treat underlying joint disorder when present
181
ROM - dorsiflexion ankle/foot
15-20
182
Diabetic neuropathy
- Complication of DM causing gradual loss of nerve fibers
- Loss of vibratory sensation along with impaired pain, light touch, and temperature sensations
- Test pressure sensation suing a monofilament test (plantar aspect), vibration using a tuning fork, and superficial pain using a pinprick
- Complete exam includes: examining pulses, checking for skin lesions (sores, ulcers, open wounds, etc.)
183
Joint pain —\> a traumatic —\> intrinsic (the joint in general)
**Extra-articular**
—\> bone, soft tissue (myofascial injury, overuse injuring, bursitis, joint instability)
**Intra-articular**
—\> bone, soft tissue (arthritis, synovitis, capsulitis)
184
Varus deformity
Distal part of limb directed toward midline
“Bowlegs”
185
Ganglion cyst
- Common soft tissue finding of wrist/hand
- Seen typically in 2nd-4th decades of life
- Etiology unclear
**Class presentation:** potentially painful, smooth, firm to rubbery cystic lesion that can be seen in wrist, hand, feet, etc.
\*typically seen on dorsal wrist but can on palmar\*
**Clinical Dx** —\> 50% spontaneously resolve
186
Patrick’s (FABER) 3/3
Anterior/iliopsoas compartment of the hip.
- Pt’s hip flexed, abducted, and externally rotated.
- Physician braces contralateral ASIS
- Pt internally rotates/adducts a/g resistance
**+Test:** anterior or medial groin pain/weakness
**Tests:** iliopsoas insufficiency or pathology
187
What is the most common somatic dysfunction associated with the cuboid and navicular bones?
Plantar flexion
-During plantarflexion, the lateral aspect of the navicular bone drops plantar as well as the medial aspect of the cuboid bone dropping plantar
188
Dx and Tx - PFPS
- Pain with squatting
- CAN get knee XR, US, or MRI
**Tx:** PT with hip and quadriceps strengthening (particularly the vastus medialis m). Rest ice, NSAIDs, patellar bracing
189
Recurrent knee effusion suggests?
Meniscal tear
190
Locking sensation of knee pain suggests?
Meniscal tear
191
Scaphoid fracture
- Most commonly fractures carpal bone
- Blood supply to bone is poor and can result in avascular necrosis
- Pain in anatomical snuff box
- 20% of initial XRs will be normal
—\>if suspicion is high for fx, place patient in thumb spica cast, repeat wrist XR in 7-14 days
192
Reflex Triceps
C7 nerve root
193
Ankle eversion (no locking out)
10-20
194
Early symptom of hip disease
Difficulty putting on shoes which requires external rotation of the hip which is the first motion to be lost with degenerative disease of the hip
—Followed by loss of abduction and adduction; hip flexion is the last movement lost
195
Never impingement
**Tests** subacromial bursa or rotator cuff impingement
- Stabilize pt’s shoulder
- With forearm pronates, passively flex shoulder to fuller flexed position
**+Test:** pain
196
Vascular (pulses, cap refill)
Check the peripheral extremity pulses
Record from 0/4-4/4
197
OOOLD CAAARTS
Onset (when it started, what were you doing when it started, has this happened before?
Location
Duration
Character
Alleviating/aggravating factors and associated symptoms
Radiation
Timing
Severity
198
Expressing empathy - NURSE
N - name
U - understand
R - respect
S - support
E - explore
199
Elbow specialty test - varus stress test
- Arm slightly abducted
- Internally rotated
- Elbow to approx 15 degrees
- A slight lateral directed varus stress is applied to the elbow joint
**+Test:** pain/tenderness
**Tests:** sprained lateral (radial) collateral ligament
200
Steps to obtain HPI
1. Set the stage for the interview - welcome, use pt’s name, introduce
2. Elicit the CC and set an agenda for the visit
3. Open the history of present illness (non-focused) - open ended questions
4. Continued the patient-centered history of present illness (focused)
5. Transition to the clinician-centered process
201
Nursemaid elbow
- Radial head instability
- Annular ligament tear and/or radial head subluxation from annular ligament
- Trauma from extending a child’s arm
- Pain with palpation of radial head with anterior displacement of radial head and restriction to posterior glide
202
Otoscope grasp in children \<12 months
Pull down and out and then back on the auricle
203
Carpel tunnel syndrome
- Entrapment of median N.
- Pain and parenthesis
- Chronic cases: may develop atrophy of thenar eminence Ms.
- Pt will have grip weakness and weakness with thumb abduction
204
The Principles of Osteopathic Philosophy
1. The body is a unit; the person is a unit of body, mind, and spirit
2. The body is capable of self-regulation, self-healing, and health maintenance
3. Structure and function are reciprocally interrelated
4. Rational treatment is based upon an understanding of basic principles of body unity, self-regulation, and the interrelationship of structure and function
205
Patellofemoral pain syndrome (PFPS)
-Most common cause of anterior knee pain in adolescents and adults \<60 years
206
1 metatarsophalanageal extension
70-90
207
Anterior drawer test - ankle/foot
- Grasp posterior calcaneus with one and hand distal tibia/fibula with the other hand
- Monitor anterior talus
- Provide anterior force on calcaneus with stabilizing the distal tibia/fibula
- Normal springing of calcaneus back to neutral should occur
**+Test:** pain, no springing, excessive motion/laxity
**Test:** ATF ligament pathology/tear - lateral ankle sprain
208
Reflex Achilles
S1 nerve root
209
Forefoot abduction
10
210
Abduction ROM of hip
45-50
Gluteus medius and minimus Ms.
—\>Innervated by superior gluteal nerves (L5,S1)
