Subjective Data 1. Joint P___ S____ness S_____, H_____, R______ 2. Muscles P____ (c___) W_______ 3. Bones P____ De_____ T_____ (fractures, sprains, dislocations) 4. _______ Assessment (ADL's) 5. Self-care ______ ( Alcohol, tobacco, athlete that uses proper protective equipment) 6. Family Hx (2) 7. ______ exposure ( Occupation, hobbies, rock climber?)

1. Join Pain Stiffness Swelling, heat, redness 2. Muscles Pain (cramps) Weakness 3. Bones Pain Deformity Trauma 4. Functional 5. Behaviors 6. Osteoporosis, RA, osteogenesis imperfecta, other genetic disorders 7. Environmental

Assessing Joint Pain Ask patient to ____ to pain Be specific with _____ of pain, associated mechanism of injury if present ( ie MVA) Is the pain l_____ or d_____ Is it ____ or ____ articular ( inside or outside of joint) Is it a____ or ch____ Is it in_____ or ___-inflammatory ( is it hot, swollen, red)

point onset localized, diffuse intra, extra acute, chronic inflammatory, non-inflammatory

Common and/or Concerning Symptoms ___ back pain N___ pain Monoarticular or Polyarticular ____ pain In_____ or In____ joint pain ( arthritis vs. septic joint) Joint pain with ____ features such as fever, rash, chills, anorexia, weight loss, weakness Joint pain with associated with symptoms from another ____ system ( ex Hep C can cause liver failure, arthritis type sx, muscle pain, weakness, and vascular issues)

Low Neck Joint Inflammatory, Infectious systemic organ system

Joint Pain with the Following = What Systemic Disorder? 1. Butterfly Rash = 2. Scaly rash and pitted nails of psoriasis = 3. Papules, pustules or vesicles on reddened base found on distal extremities = 4. Expanding erythematous patch = 5. Hives =

1. Lupus 2. Psoriatic arthritis 3. Gonococci arthritis 4. Lyme 5. Serum Sickness

Joint pain with the following = what Systemic Disorder? 1. Erosion or scaling on the penis and crusting scaling papules on the soles and palms of the feet = 2. Red bruning itching eyes = 3. Preceding sore throat = 4. Diarrhea, abdominal pain, cramping = 5. Mental status changes, facial weakness, stiff neck =

1. Reiter's syndrome 2. Reiter's syndrome 3. Acute rheumatic fever, gonococci arthrtis 4. Arthritis with ulcerative colitis, sclerodema 5. Lyme with CNS involvement

Osteoporosis Screening for all women \> __ or Younger with increased ____ factors Post _____ women _____ or ____ ethnicity Th__ build, weight \ couldn't walk

65 risk menopausal Caucasian, Asian Thin, 154 calcium D Tobacco, Alcohol Corticosteroids\

Recommended Dietary Intake Vitamin D and Calcium Age 19-50 Calcium mg/day = Vit D IU/day = Age 50-71 Calcium mg/day = Vit D IU/day = Age \>71 Calcium mg/day = Vit D IU/day =

19-50 1,000 600 50-71 W 1,200 M 1,000 600 both M/W \>71 1,200 600

Physical Exam Techniques of Examination: Overview of Each of the _Major Joints_ Inspect for joint s_____, al____, or any bony d_____ Inspect and palpate surrounding tissues for any skin ch___, no____, or muscle _____ Palpate for c_____ (crunching or grinding sensation esp over patella) Assess any deg_____ or inf_____ changes, especially sw_____, w____, te____, or r______ Perform range of ____; use spoint specific m______ to test: Joint function and stability Integreity of l_____ tendons, and b_____

symmetry, alignment, deformities changes, nodules, atrophy crepitus degenerative, inflammatory, swelling, warmth, tenderness, redness motion, maneuvers ligaments, bursae

Techniques of Joints Examination of _Major Joints_ (cont.) Be alert to signs of inflammation and _____ Swelling 1. The s_____ membrane, which can feel b___ od doughy 2. Effusion from excess synovial f___ within the joint space; or 3. Soft tissue structures such as b____, t____, and tendon sheaths Warmth Tenderness Loss of Function Deformity

arthritis 1. synovial, boggy 2. fluid 3. bursae, tendons

Order of the Examination Inspection S___ and Con___ of joint Sk___ and ti____ over joint Palpation Skin t_____ M____, b___ articulations, area of joint c____ Range of _____ Muscle s_____ No percussion or auscultation but test ROM and muscle strength

Inspection Size, Contour Skin, tissue Palpation temperature Muscles, bony, capsule Motion Strength

Mechanical Whiplash/Cervical Strain Cervical Radiculopathy (herniated disc) Cervical Myelopathy (cord compression)

Mechanical Aching pain, cervical _____ muscles and ligaments Spasm, stiffness, tightness in sh____ and ___ back Duration ____ Any radiation, paresthesia, weakness? __ maybe present PE: p____ tenderness along paraspinal muscles, pain with ____ but usally no decreased _ _ _, no n_____ deficits

paraspinal shoulder, upper weeks No HA point, movement, ROM, neurologic

Whiplash/Cervical Strain Aching _____ pain and stiffness ( involving the ligaments of cervical spine, fairly common after ___ even slow 25-30 mph) Begins ___ after the injury O_____ HA, dizziness, malaise, and fatigue present Can be ____ lasting \> 6 months Caused by forced h_____/e____ Decreased _ _ _, perceived weakness, or upper extremities

Paracervical, MVA day Occipital chronic hyperflexion/extension ROM

Cervical Radiculopathy ( Herniated disc) ____ burning or tingling pain in neck and ___ arm P_____ and weakness in affected arm Nerve root compression C_ most affected Caused by h_____ d___ PE: weakness of ___ceps if C7 involved, weakness in __ceps if C6 involved

Sharp, one Parasthesia C7 herniated disc triceps, biceps

Cervical Myelopathy (cord compression) ___ pain with __lateral weakness and paresthesia in ___ upper and lower extremities H___ clumsiness, p____ parasthesia and g___ changes possible, urinary f_____ Neck ____ exacerbates symptoms Caused by cervical sp______ from degenerative disc or cervical stenosis or trauma PE: ____reflexia, _____ Babinski's, g___ changes Requires neck i______ and n______ evaluation

Neck, BL, both Hand, palmar, gait, frequency flexion spondylosis hyperreflexia, positive, gait immobilization, neurosurgical

Back Pain ____ is the pain? ______ (over the vertebrae) Consider injury, disc herniation, vertebral collapse, spinal cord mets and rarely epidural abscess ____ the midline Consder muscle strain, sacroiliac inflammation (sacroilitis), trochanter bursitis, sciatica, hip arthritis and possibly renal causes such as pyelonephritis or stones Does it ____? If so where? Do you have any n______ or t____? Do you have any ______ symptoms with the pain? _____ retention or overflow incontinence C______ symptoms

Where Midline Off the Midline Radiate numbness, tingling associated urinary constitutional

Red Flags for Back Pain Age \> __ History of ______ Unexplainted weight ___ Pain lasting longer than a ___ or not _____ to treatment Sudden loss of b___/b___ control Hx of __ d___ use ( potential for sepsis) Presence of in_______

\>50 Cancer weight loss month, responding to tx bowel/bladder IV drug infection

Mechanical Low Back Pain Sciatic (Radicular Low Back Pain) Lumbar Spinal Stenosis Chronic Back Stiffness

Mechanical Low Back Pain Aching pain in the l______ area; may ____ into lower leg, especially along L5 or S1 Usually ____ (\<3 months), ___pathic, b____ and self-l_____ Usually worse s_____ and t____ motion 97% of low back presentations, __-__yo and w___ related PE: paraspinal muscle t______, pain with _____, loss of lumbar l_____ ( curvature) ___ motor or sensory impairment

lumbosacral, radiate acute, idiopathic, benign, self-limiting standing, twisting 30-50, work tenderness, movement, lordosis Not most common: spinal stenosis, herniated discs, vertebral fractures, sacroiliac joint pain Mechanical - arises from spinal structures: bones, ligaments, joints, discs, nerves, meninges

Sciatica (Radicular Low Back Pain) Sh_____ pain below the knee, commonly into the L5 or S1 typically accompanies low back pain ( ppl will say starts in the middle of my butt cheeks) Associated n_____ and weakness Bending, sitting, sneezing, coughing, straining during bowel movements often ____ pain Disc ______ common especially if calf _____ is present PE: ___ straight leg ( test for herniated disc at L5, pain present between 30-70 degrees when bending leg) Negative straight leg makes dx ______

Shooting numbness worsen herniation, wasting positive unlikely

MSK Flashcards by Felita Salim

Subjective Data

Joint
- P___
- S____ness
- S_____, H_____, R______
Muscles
- P____ (c___)
- W_______
Bones
- P____
- De_____
- T_____ (fractures, sprains, dislocations)
_______ Assessment (ADL’s)
Self-care ______ (Alcohol, tobacco, athlete that uses proper protective equipment)
Family Hx (2)
______ exposure (Occupation, hobbies, rock climber?)

Join
- Pain
- Stiffness
- Swelling, heat, redness
Muscles
- Pain (cramps)
- Weakness
Bones
- Pain
- Deformity
- Trauma
Functional
Behaviors
Osteoporosis, RA, osteogenesis imperfecta, other genetic disorders
Environmental

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Assessing Joint Pain

Ask patient to ____ to pain
Be specific with _____ of pain, associated mechanism of injury if present (ie MVA)
Is the pain l_____ or d_____
Is it ____ or ____ articular (inside or outside of joint)
Is it a____ or ch____
Is it in_____ or ___-inflammatory (is it hot, swollen, red)

point
onset
localized, diffuse
intra, extra
acute, chronic
inflammatory, non-inflammatory

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Common and/or Concerning Symptoms

___ back pain
N___ pain
Monoarticular or Polyarticular ____ pain
In_____ or In____ joint pain (arthritis vs. septic joint)
Joint pain with ____ features such as fever, rash, chills, anorexia, weight loss, weakness
Joint pain with associated with symptoms from another ____ system (ex Hep C can cause liver failure, arthritis type sx, muscle pain, weakness, and vascular issues)

Low
Neck
Joint
Inflammatory, Infectious
systemic
organ system

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Joint Pain with the Following = What Systemic Disorder?

Butterfly Rash =
Scaly rash and pitted nails of psoriasis =
Papules, pustules or vesicles on reddened base found on distal extremities =
Expanding erythematous patch =
Hives =

Lupus
Psoriatic arthritis
Gonococci arthritis
Lyme
Serum Sickness

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Joint pain with the following = what Systemic Disorder?

Erosion or scaling on the penis and crusting scaling papules on the soles and palms of the feet =
Red bruning itching eyes =
Preceding sore throat =
Diarrhea, abdominal pain, cramping =
Mental status changes, facial weakness, stiff neck =

Reiter’s syndrome
Reiter’s syndrome
Acute rheumatic fever, gonococci arthrtis
Arthritis with ulcerative colitis, sclerodema
Lyme with CNS involvement

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Osteoporosis

Screening for all women > __ or
Younger with increased ____ factors
- Post _____ women
- _____ or ____ ethnicity
- Th__ build, weight < _____ lbs
- Low dietary ______
- Vitamin ___ deficiency
- T____ or A____ use
- Use of _______* ex) i had a pt addicted to prednisone, fractures -> couldn’t walk

65
risk
- menopausal
- Caucasian, Asian
- Thin, 154
- calcium
- D
- Tobacco, Alcohol
- Corticosteroids*

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Recommended Dietary Intake Vitamin D and Calcium

Age 19-50
- Calcium mg/day =
- Vit D IU/day =
Age 50-71
- Calcium mg/day =
- Vit D IU/day =
Age >71
- Calcium mg/day =
- Vit D IU/day =

19-50
- 1,000
- 600
50-71
- W 1,200 M 1,000
- 600 both M/W
>71
- 1,200
- 600

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Physical Exam

Techniques of Examination: Overview of Each of the Major Joints

Inspect for joint s_____, al____, or any bony d_____
Inspect and palpate surrounding tissues for any skin ch___, no____, or muscle _____
Palpate for c_____ (crunching or grinding sensation esp over patella)
Assess any deg_____ or inf_____ changes, especially sw_____, w____, te____, or r______
Perform range of ____; use spoint specific m______ to test:
- Joint function and stability
- Integreity of l_____ tendons, and b_____

symmetry, alignment, deformities
changes, nodules, atrophy
crepitus
degenerative, inflammatory, swelling, warmth, tenderness, redness
motion, maneuvers
- ligaments, bursae

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Techniques of Joints Examination of Major Joints (cont.)

Be alert to signs of inflammation and _____
- Swelling
  1. The s_____ membrane, which can feel b___ od doughy
  2. Effusion from excess synovial f___ within the joint space; or
  3. Soft tissue structures such as b____, t____, and tendon sheaths
- Warmth
- Tenderness
- Loss of Function
- Deformity

arthritis
1. synovial, boggy
2. fluid
3. bursae, tendons

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Order of the Examination

Inspection
- S___ and Con___ of joint
- Sk___ and ti____ over joint
Palpation
- Skin t_____
- M____, b___ articulations, area of joint c____
Range of _____
Muscle s_____
No percussion or auscultation but test ROM and muscle strength

Inspection
- Size, Contour
- Skin, tissue
Palpation
- temperature
- Muscles, bony, capsule
Motion
Strength

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Test Muscle Strength

Apply _____ force
Grade muscle strength: grade __-__
Full ROM with gravity eliminated (passive motion) =
Full ROM with gravity but not against resistance (moderate weakness) =
No contraction, complete paralysis, no visible or palpable movement =
Full ROM against gravity, with full resistance (normal muscle strength) =
Full ROM against gravity, with some resistance =
Slight contraction, but very severe weakness, weak contraction visible but extremity doesn’t move =

opposing
0-5
2
3
0
5
4
1

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Cervical Spine

Inspect: _____ of head and neck
Palpate: _____ processes and muscles
Motion: and Expected R____
- Chin to ____
- Lift ____
- Each ___ to shoulder
- Turn ___ to each shoulder

alignment
spinous
Range
- chest
- chin
- ear
- chin

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Neck Pain

(4)

Mechanical
Whiplash/Cervical Strain
Cervical Radiculopathy (herniated disc)
Cervical Myelopathy (cord compression)

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Mechanical

Aching pain, cervical _____ muscles and ligaments
Spasm, stiffness, tightness in sh____ and ___ back
Duration ____
Any radiation, paresthesia, weakness?
__ maybe present
PE: p____ tenderness along paraspinal muscles, pain with ____ but usally no decreased _ _ _, no n_____ deficits

paraspinal
shoulder, upper
weeks
No
HA
point, movement, ROM, neurologic

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Whiplash/Cervical Strain

Aching _____ pain and stiffness (involving the ligaments of cervical spine, fairly common after ___ even slow 25-30 mph)
Begins ___ after the injury
O_____ HA, dizziness, malaise, and fatigue present
Can be ____ lasting > 6 months
Caused by forced h_____/e____
Decreased _ _ _, perceived weakness, or upper extremities

Paracervical, MVA
day
Occipital
chronic
hyperflexion/extension
ROM

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Cervical Radiculopathy (Herniated disc)

____ burning or tingling pain in neck and ___ arm
P_____ and weakness in affected arm
Nerve root compression C_ most affected
Caused by h_____ d___
PE: weakness of ___ceps if C7 involved, weakness in __ceps if C6 involved

Sharp, one
Parasthesia
C7
herniated disc
triceps, biceps

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Cervical Myelopathy (cord compression)

___ pain with __lateral weakness and paresthesia in ___ upper and lower extremities
H___ clumsiness, p____ parasthesia and g___ changes possible, urinary f_____
Neck ____ exacerbates symptoms
Caused by cervical sp______ from degenerative disc or cervical stenosis or trauma
PE: ____reflexia, _____ Babinski’s, g___ changes
Requires neck i______ and n______ evaluation

Neck, BL, both
Hand, palmar, gait, frequency
flexion
spondylosis
hyperreflexia, positive, gait
immobilization, neurosurgical

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Spine

Inspect: while person s_____
Palpate: _____ processes
Motion and expected r____
- Bend ___ways, ___ward
- ____ shoulders to each side
Straight leg R_______ (while laying on back)
Measure leg length dis______

stands
spinous
range
- sideways, backwards
- Twist
Raising
discrepancy

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ROM Spine

How many degrees lateral bending? and twisting/rotation?

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Back Pain

____ is the pain?
- ______ (over the vertebrae)
  - Consider injury, disc herniation, vertebral collapse, spinal cord mets and rarely epidural abscess
- ____ the midline
  - Consder muscle strain, sacroiliac inflammation (sacroilitis), trochanter bursitis, sciatica, hip arthritis and possibly renal causes such as pyelonephritis or stones
Does it ____?
- If so where? Do you have any n______ or t____?
Do you have any ______ symptoms with the pain?
- _____ retention or overflow incontinence
- C______ symptoms

Where
- Midline
- Off the Midline
Radiate
- numbness, tingling
associated
- urinary
- constitutional

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Red Flags for Back Pain

Age > __
History of ______
Unexplainted weight ___
Pain lasting longer than a ___ or not _____ to treatment
Sudden loss of b___/b___ control
Hx of __ d___ use (potential for sepsis)
Presence of in_______

>50
Cancer
weight loss
month, responding to tx
bowel/bladder
IV drug
infection

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Low Back Pain

(4)

Mechanical Low Back Pain
Sciatic (Radicular Low Back Pain)
Lumbar Spinal Stenosis
Chronic Back Stiffness

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Mechanical Low Back Pain

Aching pain in the l______ area; may ____ into lower leg, especially along L5 or S1
Usually ____ (<3 months), ___pathic, b____ and self-l_____
Usually worse s_____ and t____ motion
97% of low back presentations, __-__yo and w___ related
PE: paraspinal muscle t______, pain with _____, loss of lumbar l_____ (curvature)
___ motor or sensory impairment

lumbosacral, radiate
acute, idiopathic, benign, self-limiting
standing, twisting
30-50, work
tenderness, movement, lordosis
Not

most common: spinal stenosis, herniated discs, vertebral fractures, sacroiliac joint pain*
Mechanical - arises from spinal structures: bones, ligaments, joints, discs, nerves, meninges*

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Sciatica (Radicular Low Back Pain)

Sh_____ pain below the knee, commonly into the L5 or S1 typically accompanies low back pain (ppl will say starts in the middle of my butt cheeks)
Associated n_____ and weakness
Bending, sitting, sneezing, coughing, straining during bowel movements often ____ pain
Disc ______ common especially if calf _____ is present
PE: ___ straight leg (test for herniated disc at L5, pain present between 30-70 degrees when bending leg)
Negative straight leg makes dx ______

Shooting
numbness
worsen
herniation, wasting
positive
unlikely

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**Lumbar Spinal Stenosis** * "\_\_\_\_\_\_\_" pain in the back or legs with walking that can improve with rest or lumbar _____ (hard to differentiate from sciatica) * Pain vague but usually \_\_lateral, with numbness in one or both legs (*not able to walk long distances without resting-if severe enough can get dropfoo*t) * Hypertrophic degenerative disease, \_\_\_\_ning of the ligament causing ______ of the spinal canal * Common age \> \_\_ * PE: posture flexed \_\_\_ward, lower extremity w\_\_\_\_\_ ,\_\_\_\_\_ reflexes

* "pseudoclaudication", flexion * bilateral * thickening, narrowing * \>60 * foward, weakness, diminished

**Chronic Back Stiffness** * **\_\_\_\_\_\_ \_\_\_\_\_\_\_** * ****Chronic inflammatory disease, progressive stiffness of the spine * Age onset \< 40 * Insidious onset * Progressive postural changes

**Ankylosing Spondylitis**

**Chronic Back Stiffness** * **\_\_\_\_\_ _____ \_\_\_\_ ____ (\_\_\_\_)** * ****Non-inflammatory disease * Calcification and ossification of spinal ligaments * Age onset \> 50 * Decreased range of spinal motion, particulary thoracic movement * *No cure but PT, weight control, pain relievers, sometimes surgery recommended*

**Diffuse idiopathic skeletal hyperostosis (DISH)**

**Nocturnal Back Pain, Unrelieved by Rest** * Consider ______ \_\_\_\_\_\_\_ to the spine from cancer of p\_\_\_\_\_, b\_\_\_\_, l\_\_\_\_, th\_\_\_\_\_, k\_\_\_\_\_, M\_ * PE: loss of normal lumbar l\_\_\_\_\_, muscle s\_\_\_\_\_, l\_\_\_\_\_ immobility of spine * **C\_\_\_\_\_\_ E\_\_\_\_\_ S\_\_\_\_\_\_**

* **metastatic malignancy,** prostate, breast, lung, thyroid, kidneys, MM * lordosis, spasm, lateral * **Cauda Equina Syndrome**

**Cauda Equina Syndrome** * **\_\_\_** back pain associated with _____ symptoms, **\_\_\_\_\_ anesthesia** (*major red flag: numbness in all areas that touch saddle of the horse)* * _______ of the spinal nerve root * Surgical ______ as the compression is often caused by a tumor, ruptured disk, infection fracture, or narrowing of the spinal canal * *May get __ before surgery if not yet available to shrink*

* low, associated, **saddle anesthesia** * Compression * emergency * *RT*

**Sacroilitis** * L\_\_\_\_\_\_\_ pain radiates to b\_\_\_\_, g\_\_\_\_, and _____ thigh * ______ by extensive use, prolonged exercise (*sitting, standing, exacerbation from getting up from chair)* * PE: t\_\_\_\_\_\_ at ___ joint * Can be an _____ injury or related to _____ illness * *Systemic inflammatory conditions that can cause (3): usually an earlier symptom of these* * *Traumatic injury causes (2)*

* Lumbosacral, buttocks, groin, posterior * Aggravated * tenderness at SI joint * overuse, systemic * *Ankylosing spondylitis, Psoriatic arthritis, OA* * *MVA, fall*

**Shoulders** * ***Inspect:*** j\_\_\_ (*look for any swelling, asymmetry, muscle atrophy, deformities)* * ***Palpate:*** sh\_\_\_\_\_ and ax\_\_\_\_ (*see if you can palpate underlying structures: acromion process, bursa, down the humerus, rotator cuff tendons under axilla)* * ***Motions:*** and expected r\_\_\_\_ * Arms f\_\_\_\_ and \_\_ * Arms b\_\_\_\_ back and hands \_\_ * Arms to sides and up over \_\_\_\_ * Touch hands ____ head

* joint * shoulders, axilla * range * forward and up * behind back, hands up * side -\> over head * behind

**Rotator Cuff Tendonitis (Impingement Syndrome)** * Usually caused from ______ or \_\_\_ * Common in (2) * ____ pain that is present both with _____ and at \_\_\_\_ * Pain radiating from the ___ of the _____ to the ___ of the \_\_\_ * Sudden pain with ____ and _____ movements * Tenderness just below the ___ of the \_\_\_\_\_

* overuse, fall * young adults, middle age athletes * minor, activity and rest * front of shoulder - side of arm * lifting, reaching * tip, acromion

**Drop Arm Test** * What does it test for? * Fully ____ arm to _____ level * Ask pt to ____ it slowly * (\_\_\_ arm briskly) * + test =

* Rotator cuff injury/tear * abduct, shoulder * lower * tap * Pt cannot hold or control lowering their arm *Assesses for weakness in supraspinatus muscle (1/4 of rotator cuffs)*

**Empty Can Test** * What does it test for? * Elevate arms to ___ degrees * _____ rotate so thumbs point \_\_\_ward * Apply \_\_\_ward pressure * Positive test =

* Rotator cuff tear or impingement of the supraspinatus tendon, tendonitis * 90 * internally, downward * downard * weakness

**Aply Test** * What does it test for? * Ask pt to touch opposite _____ using these two motions * *Assesses ROM of glenohumoral joint*

* rotator cuff disorder or adhesive capsulitis * scapula

**Rotator Cuff Tears** * Injury from a f\_\_\_ or repeated im\_\_\_\_\_ may weaken the rotator cuff * Causing a partial or complete \_\_\_, usually after age \_\_ * Weakness, _____ of supraspinatus and infraspinatus muscles, pain, and tenderness may ensue * In a complete tear of the supraspinatus tendon, active ____ and forward ____ at the g\_\_\_h\_\_\_\_ joint are severely impaired, producing characteristics of a ______ shoulder and a ____ drop arm test

* fall, impingement * tear, \>40 * atrophy * abduction, flexion, glenohumeral, shrugging, positive * Athletes such as rowers, weightlifters, construction, assembly line workers - any with repetitive motions*

**Dislocated Shoulder** * Shoulder instability from _____ dislocation of _____ bone * The shoulder seems to "\_\_\_ out of the joint" * Any shoulder movement may cause \_\_\_, and pts hold the arm in _____ position * The rounded lateral aspect of the shoulder appears \_\_\_\_\_ * *Common causes: t\_\_\_\_, f\_\_\_\_ players* * *Tx: usually sedation, then ____ of shoulder*

* anterior, humerus * slip * pain, neutral * flattened * *trauma, football* * *relocation*

**Adhesive Capsulitis (Frozen Shoulder)** * F\_\_\_\_ of the g\_\_\_\_\_ joint c\_\_\_\_ * Manifested by d\_\_\_\_, d\_\_\_, aching pain in the shoulder and p\_\_\_\_ restriction of active and passive range of motion * Usually no _____ tenderness * Usually \_\_\_lateral and occurs in ppl aged \_\_-\_\_ * Antecedent painful disorder of the shoulder and other condition that has ______ shoulder movements

* Fibrosis, glenohumeral, capsule * diffuse, dull, progressive * localized * unilateral, 50-70 * decreased ## Footnote *Sometimes seen after pt has a sling for awhile*

**Acromioclavicular Arthritis** * Is it rare? * Occurs from ___ injury resulting in _____ changes in the joint * Tenderness localized to _ \_ joint * Pain with \_\_\_duction

* Not un-common * prior, degenerative * AC * Adduction

**Elbow** * ***Inspect***: joint in f\_\_\_\_ and e\_\_\_\_\_ positions * ***Palpate:*** j\_\_\_\_ and b\_\_\_ prominences * Motion and expected r\_\_\_\_ * B\_\_\_ and s\_\_\_\_ elbow * P\_\_\_\_ and s\_\_\_\_\_ hand

* flexed, extended * joint, bony * range * Bend, straighten * Pronate, supinate

**Olecranon Bursitis** * S\_\_\_\_\_ and I\_\_\_\_\_ of O\_\_\_\_\_ B\_\_\_\_ * May result from t\_\_\_\_ or be associated with rh\_\_\_\_ or g\_\_\_\_ arth\_\_\_\_\_ * ____ \_\_ appearance or redness due to inflammation of bursa * The swelling is s\_\_\_\_\_\_\_ to the olecranon process

* Swelling, Inflammation, Olecranon Bursa * trauma, rheumatoid, gouty arthritis * Goose egg * superficial

**Arthritis** * S\_\_\_\_\_ inflammation or fluid, felt in the g\_\_\_\_ between the olecranon process and epicondyles on either side * Palpate for b\_\_\_\_, soft or fluctuant swelling and for tenderness * Causes can be rh\_\_\_\_, g\_\_\_\_, osteo\_\_\_\_\_, t\_\_\_\_ * Pain s\_\_\_\_\_ or restricted movement

* Synovial, grooves * boggy * rheumatoid, gout, osteoarthritis, trauma * stiffness

**Rheumatoid Nodules** * Sub\_\_\_\_\_ nodules may develop at pressure _____ along the extensor surface of the u\_\_\_\_ in pts with RA or Acute rheumatic fever * They are f\_\_\_ and \_\_tender, and are ___ attached to overlying skin * They may or may not be attached to underlying peri\_\_\_\_ * They may develop in area of the olecranon bursa, but often occurs more d\_\_\_\_\_\_

* Subcutaneous, points, ulna * firm, nontender, not attached to skin * periosteum * distally

**Lateral Epicondylitis** * Also known as a "\_\_\_\_\_ elbow" * Follows r\_\_\_\_\_ ex\_\_\_\_ of the w\_\_\_ or p\_\_\_-s\_\_\_\_ of the f\_\_\_\_\_ * Pain and tenderness develop \_cm d\_\_\_ to lateral epicondyle and possibly in the extensor muscles close to it * When the patient tries to ____ the wrist against r\_\_\_\_, pain \_\_\_\_\_

* "Tennis elbow" * repetitive extension, wrist, pronation-supination of the forearm * 1cm distally * extend, resistance, pain increases

**Medial Epicondylitis** * p\_\_\_\_'s, g\_\_\_\_\_'s, or Little _____ elbow * Follows repetitive wrist \_\_\_\_\_, as in th\_\_\_\_\_ * Tenderness is maximal just l\_\_\_\_ and d\_\_\_ to the medial epicondyle * Wrist flexion against resistance increases \_\_\_\_\_

* pitcher's, golfer's, little league * flexion, throwing * lateral, distal * pain

**Techniques of Examination: Overview for** **_Wrist and Hand_** * **Inspect**: p\_\_\_\_ and d\_\_\_ surfaces of wrist and hand for swelling, deformities, surface contour, alignment of wrist and fingers, and any bony deformities * At rest, the fingers should be slightly f\_\_\_\_ and aligned almost in p\_\_\_\_ * **Palpate** * Distal radius and ulna at the wrist on lateral and medial surfaces, the g\_\_\_\_ of each wrist, radial styloid bone anatomical s\_\_\_\_, the eight ___ bones, compress the ____ joints by s\_\_\_\_\_, an palpate the MCP, PIP, and DIP joints for swelling or tenderness

* Inspect: palmar, dorsal * flexed, parallel * Palpate * groove, snuffbox, carpal, MCP, squeezing

**Techniques of Examination: _Wrist and Hand_** * **__****Range of Motion** * **\_\_\_\_\_:** flexion, extension, ulnar (\_\_\_\_\_) and radial (\_\_\_\_\_) deviation * \_\_\_\_\_: flexion, extension, abduction (fingers spread \_\_\_\_), adduction (finger back \_\_\_\_) * \_\_\_\_\_: flexion, extension, abduction (thumbs move away from \_\_\_\_), adduction (thumb moves ____ palm), o\_\_\_\_ (thumb touches each finger) * Test **hand ____ strength** *(\_\_\_\_ your fingers to not hurt yourself)* * Test **s\_\_\_\_\_\_** on the palmar and dorsal surfaces innervated by the median, ulnar, and radial nerves

* **Range of Motion** * ******Wrist:** abduction, adduction * **Fingers:** apart, together * **Thumb:** palm, toward, opposition * **Grip,** *cross* * **Sensation**

**Dupuytren's Contracture** * The first sign of thickened p\_\_\_\_\_\_ overlying the f\_\_\_\_ tendon on the ____ finger and possibly the l\_\_\_\_\_ finger at the level of the distal palmar crease * Subsequently the skin in this area p\_\_\_\_\_, and a thickened fibrotic\_\_\_\_ develops between palm and finger * Flexion c\_\_\_\_\_\_ of fingers may gradually ensue * *Increased risk in alcohol ____ disease, D \_, thy\_\_\_\_ issues, ep\_\_\_\_\_* * *May be mild with skin _____ or if severe enough may require surgery to ____ tension from the fibrotic cord*

* plaque, flexor, ring, little * puckers, cord * contracture * *liver, DM, thyroid, epilepsy* * *changes, release*

**Trigger Finger** * Caused by a painless n\_\_\_\_ in a flexor ____ in the palm, near the metacarpal \_\_\_\_ * The nodule is too big to enter easily into tendon _____ during ____ of the fingers from a flexed position * The finger extends and flexes with an audible \_\_\_; as the nodule pops into the tendon sheath * Watch, listen, and palpate the nodule as the patient flexes and extends the fingers

* nodule, tendon, head * sheath, extension * snap (*can be loud and violent snap)*

**De Quervan's Tenosynovitis** * Pain with ______ over the tendon sheath of what finger? * ____ may be present * N\_\_\_\_\_ of thumb and index finger * More common in what gender? Can occur 3-4 wks after \_\_\_\_\_ * F\_\_\_\_\_ test * Make a ____ with the thumb \_\_\_\_\_ * F\_\_\_ the wrist, tenderness along the ___ edge of the wrist * *Fairly c\_\_\_\_\_, usually t\_\_\_\_\_, caused by the overuse - gardening, racket sports, carrying a baby around* * *Tx = _ \_ _ \_ - tends to be self-limiting*

* palpation, thumb * Swelling * Numbness * Females, pregnancy * Finklestein test * fist, enclosed thumb * Flex, outer * *common, temporary* * *RICE*

**Carpal Tunnel Syndrome** * _______ of the ______ nerve as it travels through the carpal \_\_\_\_ * Pain, n\_\_\_\_\_\_, and t\_\_\_\_\_ along the distribution of the median nerve * Th\_\_\_\_ atrophy may be present * Ph\_\_\_\_ test: hold for __ sec, compresses median nerve, illicit pain tingling * Tinels t\_\_\_\_\_ over the median nerve produced numbness or tingling

* Compression, median, tunnel * numbness, tingling * Thelnar * Phalen, 60 sec * tapping * Bottom left = thelnar muscle - atrophy of this when severe* * Phalen test: back of hands together, within 60 sec will feel pain or tinger = + test* * Tx: initially splints to keep wrists from flexing downward, surgery if severe*

**Hip** * ***Inspect:*** as person \_\_\_\_, *pay attention to their g\_\_\_* * ***Palpate:*** with person in what position? * Motion and expected range * Raise leg (*Should be able to get up to ___ degrees)* * Knee to \_\_\_\_ * Flex knee and hip, swing foot ___ and \_\_\_ * Swing leg l\_\_\_\_, m\_\_\_\_ * Stand and swing leg ____ (*hyperextension of hip, should get at least __ degrees)*

* stands, *gait* * supine * Range * *90* * Chest * in, out * laterally, medially * back, *15*

**Assess Gait** * ____ = the time the foot is on the ground bears weight * Most hip problems appear during what phase? * _____ = movement of the foot foward, non-weight bearing * Wide base suggests _____ disease or ____ problems * Swinging; due to lack of ___ flexion * Pelvic ___ on opposite side: Hip dislocation, arthritis, leg length discrepancy

* Stance * Stance phase * Swinging * Cerebellar dx, foot problems * knee * drop

**Bursitis** * Bursitis is an inflammation or degeneration of the \_\_\_-like structures that protect the ___ tissues from underlying ___ prominences * Pain just with movement? * Sw\_\_\_\_\_ * _______ tenderness over site of inflammation * If effusion present - ____ fluid to assess for infection, gout

* sac, soft, bony * movement and rest * Swelling * Localized * aspirate

**Hip Abnormalities** * **Flexion Deformity** * ****Excess \_\_\_\_ * As the opposite hip is _____ (with the thigh against the chest), the affected hip does not allow for full leg \_\_\_\_\_, and the affected thigh appears \_\_\_\_\_ * **Hip osteoarthritis** * ****Restricted \_\_\_duction * Restrictions of internal and external \_\_\_\_\_

* Flexion Deformity * lordosis * flexed, extension, flexed * Hip osteoarthritis * abduction * rotation

**Knee** * **Inspect:** j\_\_\_\_ and m\_\_\_\_ * **Palpate** * Motion and expected range * _____ knee * _____ knee * Check knee while \_\_\_\_

* joint, muscle * ROM * bend * extend * ambulate

**Specific Tests for Effusion of the Knee** **(2)**

**Bulge Sign Ballottement of Patella**

**Bulge Sign** * *Have pt ____ knee joint, you want to ___ the fluid to the suprapatellar pouch and apply ____ pressure -\> ____ and watch for fluid w\_\_\_\_*

* *extend, milk, medial, tap, wave*

**Ballottement of Patella** * *Apply pressure \_\_\_wards towards foot, with one hand while pushing patella \_\_\_wards towards femur - if present of fluid you should see fluid ___ as well*

* *downwards, backwards, wave*

**Test for Stability of the** **Lateral Collateral Ligaments (LCL)** (1) **Medial Lateral Ligaments (MCL)** (1)

**Varus Test** **Valgus Test**

**Varus Test** * ***\_\_\_\_\_\_*** *(or Varus) Stress Test* * Place one hand against the _____ surface of the knee and the other around the ____ ankle * Push _____ against the knee and pull ____ at the ankle to open the knee joint on the lateral side (*varus stress)* * Pain or gap in the lateral joint line points to ligamentous l\_\_\_\_ and a partial ___ of the *lateral collateral ligament.*

* *Adduction* * medial, lateral * laterally, medially * laxity, tear

**Valgus Test** * With the patient supine and the knee slight flexed, move the thigh about ___ degrees laterally to the side of the table * Place one hand against the ____ knee to stabilize the femur and the other hand around the ____ ankle * Push _____ against the knee and pull _____ at the ankle to open the knee joint on the medial side (*valgus stress)* * Pain or gap in the medial joint line points to ligamentous _____ and a partial ___ of the *medial collateral ligament.* * MCL or LCL more common?

* 30 * lateral, medial * medially, laterally * laxity, tear * MCL injuries more common

**ACL Tests** | (2)

**Lachman's Test** **Anterior Drawer Test**

**Lachman's Test** * Assesses the integrity of the \_\_\_\_ * Place the knee at __ degree flexion and ____ rotated * Grasp the distal femur on the ____ side with one hand and the proximal ____ with the other * Pull the tibia \_\_\_ward while stabilizing the femur * Estimate the degree of forward ______ of the tibia * Forward excusion = ACL \_\_\_\_

* ACL * 15, externally * lateral, tibia * forward * excursion * ACL tear

**Test for Stability of the Anterior Cruciate Ligaments** **(1)**

**Anterior Drawer Test**

**Anterior Drawer Test** * With the patient supine, hips flexed and knees flexed __ degrees and feet __ on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings * Draw the tibia ____ and observe it it slides forward (like a \_\_\_\_) from under the \_\_\_\_\_ * Compare the degree of forward movement with that of the _____ knee * **Positive Anterior Drawer Sign** = A forward j\_\_\_\_ showing the contours of the upper tibia, making an ____ tear 11.5x more likely

* 90, flat * foward, drawer, femur * opposite * jerk, ACL tear

**Test for Stability of the Posterior Cruciate Ligament** **(1)**

**Posterior Drawer Test**

**Posterior Drawer Test** * Position the patient and place your hands in the positions described as the anterior drawer teset * Push the tibia ______ and observe the degree of ____ movement in the femur * Isolated *PCL tears* are \_\_\_\_\_

* posteriorly, backward * rare

**McMurray's Test** What does it test for?

**Meniscal Injury**

**McMurray's Test for Meniscal Injury** * With the patient supine, grasp the ____ and flex the \_\_\_\_ * Cup your other hand over the ____ joint with fingers and thumb along the medial and lateral joint line * From the heel, rotate the lower leg ____ and \_\_\_\_\_ * Then push on the ____ side to apply a ____ stress on the medial side of the joint * At the same time, rotate the leg _____ and slowly ____ it * If a _____ is felt or heard at the joint line during flexion and extension of the knee, or if tenderness is noted along the joint line, further assess the _____ for a posterior \_\_\_\_

* heel, knee * knee * internally, externally * lateral, valgus * externally, extend * click, meniscus, tear

**Ankle/Foot** * ***Inspect:*** with person s\_\_\_\_, s\_\_\_\_\_, and w\_\_\_\_\_ * ***Palpate:*** j\_\_\_\_ * Motion and expected range * Point ___ down, up * Turn ___ out, in * Flex and straighten \_\_\_

* sitting, standing, walking * joints * ROM * toes * soles * toes

**Thompson Test** * Assess for a complete? * Position of patient * Examiner _____ the ____ muscles * Squeezing the calf should cause the tendon to _____ and the foot will \_\_\_ * What indicates a Achilles tendon rupture?

* Achilles Tendon rupture * Face down on exam table, foot hanging off the edge * squeezes, calf * contract, flex * None or reduced movement

**Gout** * The metatarsophalangeal of the ___ toe may be the first joint involved in *a\_\_\_\_\_ gouty a\_\_\_\_\_\_\_* * It is characterized by a very painful and tender, h\_\_, dusky r\_\_ swelling that extends ______ the margin of the joint * It is easily mistaken for \_\_\_\_\_\_ * Acute gout may also involve the d\_\_\_\_\_ of the foot * Caused by buildup of s\_\_\_\_ u\_\_\_\_ or u\_\_\_ a\_\_\_ which is a by product of **\_\_\_\_\_\_** * *For an acute episode - probably just ___ modification* * *Tx: _____ for inflammation*

* great toe, *acute gouty arthritis* * hot, dusky red, beyond * cellulitis * dorsum * sodium urate, uric acid, **purines** * *diet* * *steroids*

**Pseudo-Gout** * From **\_\_\_\_\_\_-\_\_\_\_\_\_\_ deposition (CPPD)** * ____ or \_\_\_\_-articular joint pain caused by a build up c\_\_\_\_\_ p\_\_\_\_\_ in the joint * Inflammation of the joint and p\_\_\_articular area maybe present * Older population \> __ yrs of age * Difficult to distinguish between \_\_\_\_ * Requires _____ of synovial fluid for definitive diagnosis

* **calcium-pyrophosphate** * Mono, poly, calcium-pyrophosphate * peri * \>60 * gout * aspiration

**Flat Feet (PesPlanus)** * Signs of *flat feet* may only be apparent when patient \_\_\_\_, or may become \_\_\_\_\_\_. * The longitudinal arch _____ so that the sole approaches or touches the f\_\_\_\_. * The normal concavity on the medial side of the foot becomes c\_\_\_\_\_ * Tenderness may be present from the medial m\_\_\_\_\_ down along the medial plantar surface of the foot * Swelling may develop _____ to the malleoli * Inspect the shoes for excess ____ on the inner sides of the soles and heels

* stands, permanent * flattens, floor * convex * malleolus * anterior * wear

**Plantar Fasciitis** * What is it? * Planta fasciitis is one of the most common causes of? * Age \_\_-\_\_, younger in r\_\_\_\_\_ * Risk factors * O\_\_\_\_\_ * _____ standing or jumping * ____ feet * ______ ankle dorsiflexion * Heal s\_\_\_\_\_

* Inflammation of the plantar fascia * heel pain * 40-60, runners * Risk factors * Obesity * Prolonged * Flat * Reduced * spurs

**Hallux Valgus** * In *Hallux valgus* - the great toe is abnormally \_\_ducted in relationship to the first metatarsal, which itself is deviated \_\_\_\_\_. * The head of the first metatarsal may _____ on its ____ side, and a ___ may form at the pressure point * This bursa may become in\_\_\_\_

* abducted, medially * enlarge, medial , bursa * inflamed

**Other Feet Abnormalities** * **Pes Varus =** * **Pes Valgus =**

* *Developmental condition that results in limb deformity and foot turned **inward,** these pts tend to have flat feet* * *Feet turned slightly **outward**, somewhat common 20% in adults*

A painful conical thinkening of skin that results from _recurrent pressure_ on normally _thin skin_ = * The apex of the corn points \_\_ward and causes \_\_\_ * Corns characteristically occur over ___ prominences such as the __ toe * When located in moist areas such as pressure points between the 4th and 5th toes, they are called ___ corns

**Corns** * inward, pain * bony, 5th * soft

**Callus** * Like a corn, a callus is an area of greatly thickened skin that develops in a region of recurrent p\_\_\_\_\_ * Unlike a corn, a callus involves skin that is normally \_\_\_\_, such as the sole, and is usually \_\_\_\_\_ * If a callus is painful *especially in one particular spot,* suspect an underlying p\_\_\_\_ w\_\_\_\_

* pressure * thickened, painless * plantar wart

**Plantar Wart** * Caused by? * Common on the ___ of the foot * Can be tender and painful with \_\_\_\_\_\_

* HPV * ball * ambulation

**Arthritis** ## Footnote **(2)**

**Osteoarthritis** **Rheumatoid Arthritis**

**Osteoarthritis** * D\_\_\_\_\_\_ joint disease * Breakdown of c\_\_\_\_\_ in the joint * ___ related * \_\_\_-inflammatory, can be \_\_lateral * Affects kn\_\_\_, h\_\_\_, h\_\_\_\_, sp\_\_\_\_, w\_\_\_\_\_ * _____ stiffness \< 1 hr and ___ day pain, pain after a\_\_\_\_ * _______ Nodes at DIP * _______ Nodes at PIP * _______ Nodes at MCP

* Degenerative * cartilage * Age * NON-inflammatory, unilateral * knees, hips, hands, spine, wrists * Morning, late, activity * **Heberden's** * **Bouchard's** * NONE

**Rheumatoid Arthritis** * **\_\_\_\_\_\_\_ disorder with chronic ______ of the _____ membrane and surrounding tissue** * S\_\_\_\_\_ involvement of hands and feet, wrist, ankle, elbows, knees * Occurs at what age? * Morning stiffness how long? * Joints are t\_\_\_\_, w\_\_\_, r\_\_\_, sw\_\_\_\_\_ * ____ hx * F\_\_\_\_\_ * **\_\_\_\_\_\_\_\_\_** Deformity of PIP * **S\_\_\_\_ n\_\_\_\_** deformity of finger

* **Autoimmune, inflammation, synovial** * Symmetric * any age * \> 1 hour * tender, warm, red, swollen * Family * Fatigue * **Boutonniere** * **Swan neck** ## Footnote *Muscular atrophy as disease progresses*

Arthritic disorder causing inflammation of the joints Inflammation of the intestinal, urinary tract, eyes and skin

**Reactive Arthritis (Reiter's Syndrome)**

**Reactive Arthritis (Reiter's Syndrome)** * Symptoms do not occur all at ____ and are not always present with joint \_\_\_\_ * Most commonly found organism: ***Ch\_\_\_\_\_ Trachomatis, Y\_\_\_\_, Sa\_\_\_\_\_, Sh\_\_\_\_, Camp\_\_\_\_, Escheria \_\_\_\_, C\_\_\_\_ d\_\_\_\_,*** and ***Ch\_\_\_\_ pneumoniae*** * Diagnosis based on good ___ and ____ exam * *Tx (2)*

* once, pain * ***Chlamydia, Yersinia, Salmonella, Shigella, Campylobacter, E.coli, C.diff, Chlamydia*** * history, physical * *abx and anti-inflammatories*

**MSK Complain: "Joint Pain"** 1. You decide is it * ___ or ___ articular * Is it a\_\_\_\_ or ch\_\_\_\_ * Is ______ present * How ____ joints involved 2. Non-articular condition-consider * T\_\_\_\_/F\_\_\_\_ * F\_\_\_\_\_ * P\_\_\_\_ rheumatic * Bu\_\_\_\_ * Ten\_\_\_\_

1. You decide is it * Intra, Extra * acute, chronic * inflammation * many 2. Non-articular * Trauma/Fracture * Fibromyalgia * Polymyalgia * Bursitis * Tendinitis

**MSK Complain: "Joint Pain" cont** * Intra articular \< 6 weeks * (5) * Intra articular \> 6 weeks * Is i\_\_\_\_\_ present * Is there prolonged _____ stiffness * Is there s\_\_\_\_ tissue swelling * Are there s\_\_\_\_ symptoms * Is the _ \_ _ or _ \_ _ elevated * No for inflammation * Think non-inflammatory arthritis such as (1) * Yes for inflammation * Ask how ____ joints involved? * \> 3 joints increased risk for (1) * \< 3 joints think (2)

* Intra-articular \< 6 weeks * Acute arthritis * Infectious arthritis * Gout or Pseudo-gout * Reiter's syndrome * Early presentation of chronic arthritis * Intra-articular \> 6 weeks * inflammation * morning * soft * systemic * ESR, CRP * No inflammation * Osteoarthritis * Yes inflammation * many * RA * Psoriatic or Reiters arthritis

**Pain Syndromes** **(2)**

**Polymyalgia Rheumatica** **Fibromyalgia**

**Polymyalgia Rheumatica** * Chronic self-limiting pain with _____ etiology * Usually \>\_\_ yo, can occur with (1) * _____ pain around hips, shoulders, neck * Onset (2), Can be ___ time pain * Swelling and edema maybe present over dorsum of h\_\_\_, w\_\_\_, f\_\_\_\_ * Muscles t\_\_\_\_ but *not inflamed,* warm or red * Joint _____ in arm * Pain will not limit \_\_\_\_\_\_ * May have associated de\_\_\_\_\_, an\_\_\_\_\_, weight \_\_\_\_ * *Can resolve spontaneously, but usually ppl will be on _____ for 1-2 years*

* unclear * \>50, **giant cell arteritis (temporal arteritis)** * Symmetric * Abrupt or Insidious, night * hands, wrist, feet * tender * stiffness * movement * depression, anorexia, weight loss * *steroids*

**Fibromyalgia** * Chronic MS pain disorder affecting the ___ \_\_\_\_\_ * Felt to be related to a\_\_\_\_\_ pain signaling that amplifies pain response * Pain "\_\_\_ \_\_\_\_" neck, shoulders, hands, low back and knees, *Sometimes have* trigger points on exam + *\_\_\_\_\_ of pain* * ______ can shift, maybe exacerbated by \_\_\_, imm\_\_\_\_\_ * Associated with fatigue, depression/anxiety, headaches, cognitive f\_\_\_\_ "fibromyalgia f\_\_\_" * *Tx: Pain \_\_\_, physical \_\_\_\_\_, _____ modification - whatever helps*

* soft tissue * aberrant * "all over" * region * Pattern, cold, immobility * fogginess "*fibromyalgia fog"* * *meds, therapy, lifestyle*

MSK Flashcards

(91 cards)