PCM Review (Test 1) Flashcards
1
Q
Body Position and Patient Skills
A
- Right Lateral Renumber: Patient lying on RIGHT SIDE (left side up)
ABDOMINAL EXAM:
1) INSPECTION:
- LOOK at your Patient
- Are they Responsive? Are they Agitated? Do they look Sick?
2) AUSCULTATION (Use Stethoscope to Identify Sounds):
- Heart, Lungs, Abdomen (If Indicated), Vessels (Renal, Abdominal, Carotids, Etc [If Indicated])
- Lungs: Deep Breath IN and OUT through Mouth at each Lung Lobe Location
3) PERCUSSION (Tap with 3rd Finer over Last Joint):
- DULL (Fluid) vs FLAT (Solid) vs TYMPANIC (Air)
4) PALPATATION
**RESPIRATION has the AUSCULTATION LAST!!!!!!!!
**ALWAYS CHECK BILATERALLY- You don’t want to miss something like a diminished Pulse Pressure on One side and find out later that was a CRUCIAL aspect of the DIFFERENTIAL!
2
Q
Osteopathic Structural Exam
A
1) Body = UNIT
2) Body = Self- Regulatory Mechanisms
3) Structure and Function are RELATED
4) Using 1 through 3 —> RATIONAL THERAPY
5) OSE uses Musculoskeletal Exam even in NOT CHIEF COMPLAINT
***Use LAY TERMS so that you patient feel a part of the CONVERSATION because they are YOUR BEST TOOLS!!!!
3
Q
Opthalmoscope
A
EYES
- Hand on Patient: Use Your RIGHT eye to examine patients RIGHT Eye —–> Start LATERALLY —> Move MEDIALLY —–> RED REFLEX!!!!!!!!
- DIRECT PUPIL LIGHT REFLEX: That pupil CONSTRICTS vs CONSENSUAL (Light in Eye 1 —> Constriction of Eye 2)
4
Q
Otoscope
A
EARS
- Adults: Up, Out, and AWAY
- CONE of LIGHT and TYMPANIC MEMBRANE
5
Q
Snellen Chart
A
- Visual ACUITY TESTED: Hold at about 14 Inches from EYES
- Normal 20/20
- 20/40 means that the test subject sees at 20 feel what fNormal person sees at 40 Feet!
6
Q
Oropharynx
A
- Light + “AHHHHHH” —-> Examine Mucosa, Pharynx, Uvula, Tonsils, Etc
7
Q
BP Cuff (Spygmomanometer)
A
- Choose what fits the PATIENT —> Wrap Cuff over BRACHIAL ARTERY—-> Fill —> Listen
- 1st Sound Heard: 1st Korotkoff Sound (Systole)
- 2nd Sound: Last Korotkoff Sound (Diastole)
8
Q
Tuning Fork
A
HEARING
- Air Conduction > Bone Conduction
- AC: In from of EAM
- BC: Bone area BEHIND EAR
Vibratory Sense:
- On the KNEE CAP and Compare Bilaterally
9
Q
Reflex Hammer
A
DEEP TENDON REFLEX
- Make Sure the Patient is Relaxed
- Graded from 0 to 4 (2/4 is NORMAL)
- 3/4: HYPER and 0,1: HYPO
Upper Extremity:
- C5: Biceps, Strike THUMB
- C6: Brachioradialis, Strike LIGAMENT
- C7: Triceps, Strike LIGAMENT
Lower Extremity:
- L4: Patella, Strike TENDON
- S1: Achilles, Strike TENDON
10
Q
Stethoscope
A
1) Bell= Bruits (LOW Pitched)!!!!!!!!!!!
2) Diaphragm= Heart/ Lungs (HIGH Pitched)!!!!
***NEVER Listen OVER CLOTHES!!!!!
11
Q
Standards (CDC)
A
CDC:
- Prevent SPREAD of Disease
- CLEAN GLOVES
- WASH hands before AND AFTER WEARING GLOVES!!!
12
Q
Anatomic Position
A
- When diagnosing, be able to determine where things are at (Medial, Lateral) you need to Know where it should be!!!!!
- Ex: Is the Ulna MEDIAL or LATERAL to the Radius?
* * Ulna is MEDIAL
Be familiar with TERMS, they will be Involved in EVERYTHING from here on out!!!
- Medial/ Lateral
- Deep/ Superficial
- Proximal/ Distal
- Ipsilateral (Same Side)/ Contralateral (Opposite Side)
- Anterior/ Posterior (Ventral/ Dorsal)
- Superior/ Inferior (Cephalic/ Caudad)
- Prone/ Supine
13
Q
Coronal/ Frontal Plane
A
- Divides the Body into ANTERIOR and POSTERIOR (Face or FRON versus Back of the Head)
- Motion: SIDE BENDING!!!!
- Anterior/ Posterior AXIS!!!!
14
Q
Sagittal
A
- Divides the Body into RIGHT and LEFT
- Motion: Forward/ Backward Bending aka FLEXION/ EXTENSION (Touch Your Toes)
- Right/ Left AXIS!!!!!
15
Q
Transverse
A
- Divides the Body into SUPERIOR and INFERIOR (Upper versus Lower)
- Motion: ROTATION
- LONGITUDINAL (Superior/ Inferior) AXIS!!!!!!
16
Q
Axis
A
- Imaginary Line around which Motion Occurs
- PERPENDICULAR to the PLANE!!!!
17
Q
Gravitational Line
A
1) Head: External Auditory Canal
2) Arms: lateral Head of the Humerus
3) Spine: 3rd Lumbar Vertebrae
4) Sacrum: Anterior 1/3 of the Sacrum
5) Hip: Greater Trochanter
6) Knee: Lateral Condyle of the Knee
7) Ankle: Lateral Malleolus
- ***Related to Posture:
- Goal: The Body wants to MAINTAIN EYE LEVEL!!!!!!
18
Q
Scoliosis
A
- S SHAPED curve (Lateral Curve)
- Side Bending
- CORONAL PLANE
19
Q
Rotated
A
- Looking a a DIFFERENT DIRECTION
- Rotated
- TRANSVERSE PLANE
20
Q
Kyphosis
A
- HUNCHED OVER
- Bent FORWARD/ Flexion
- SAGITTAL PLANE!!!!!!!
- Concave: ANTERIOR
- Convex: POSTERIOR
21
Q
Lordosis
A
- Extremely ARCHED
- Bench BACKWARD/ Extension
- SAGITTAL PLANE!!!!!
22
Q
Pectus Excavatum
A
- Funnel Chest. Abnormal DEPRESSIOn
- “Excavate” —> “Dig a Hole”
23
Q
Pectus Carinatum
A
- PIGEON CHEST
24
Q
Review the Osteopathic Approach
A
- Landmarks
- If one ASIS is HIGHER than the Other, what place is the DYSFUNCTION in???
CERVICAL and LUMBAR= Lordosis!!!!!!
THORACIC and SACRUM = Kyphosis!!!!!!!
25
Dubins Clinical Correlation
- If a patient comes in with a headache, you would ask them about Vision Problems because the Optic Nerve can be involved with Cranial Problems
26
Interview Basics I
O- Onset
L- Location
D- Duration
```
C- Characteristics
A- Alleviating Factors
A- Aggravating Factors
A- Associated Symptoms
R- Radiation
T- Timing
S- Severity
```
***Be sure to ask OPEN ENDED QUESTIONS!!!!!!!
27
Soap Note
Subjective: Something you get from talking to them
- CC
- HPI
- PMH
- PSH
- Meds
- SH
- Alls
- FH
Objective: Something you get from the Physical Exam
- Vital Signs
- Heart
- Lungs
- OSE
Assessment: Relating it to a Diagnosis
- Restatement of the Chief Complaint followed by 3 Differential Diagnosis
Plan: What will you do for them
- OMT
- Meds
- Diagnostic (EKG, Radiology)
- Self-Care Instructions (Quit Smoking, No weight Bearing)
- Follow up
28
Address Emotions with NURS
N: NAME the Patient's Expressed EMOTION
U: Make an UNDERSTANDING Statement
R: RESPECT the Patient (Praise them, acknowledge Plight)
S: Offer SUPPORT
****Ask them why they're agitated, DO NOT ASSUME!!!!!!!
29
Discuss the rationale behind and Demonstrate ability to obtain a Substance use History with attention to the CAGE Questions
ALCOHOL:
- DO they Consume it? What form?
- A response of "LESS THAN 24 HOURS AGO" to this last question has a POSITIVE PREDICTIVE vale of 68% and a NEGATIVE PREDICTIVE Value of 98% for ALCOHOL ABUSE!!!!!!!!!
Consider "CAGE"ing them: Have you ever....
1) Felt the need to CUT BACK on your Drinking?
2) Felt ANNOYED by criticism of your Drinking?
3) Had GUILTY feeling about your Drinking?
4) Take a morning EYE OPENER?
*** If 2 OR MORE of these are YES-----> 90% SENSITIVITY and SPECIFICITY for ALCOHOL DEPENDENCE!!!!!!!!!!!
NIAA Safe Drinking Limits:
1) Men: 14 or fewer drinks per week, no more than 4 drinks per Day
2) Women and those above 65: 7 drinks per week, or more than 3 in a day!
30
Tobacco
- What form
| - Pack Years: (Years Smoking) x (Packs/day)
31
Street Drugs
- What they use?
- How much?
- Share needles?
***Ask other questions like if they have ever had a problem using Addicting Substances (Divorce, Job Loss, Delirium, Tremers for Alcohol Withdrawal, Emphysema from Cigarettes)
32
Discuss the rationale behind and demonstrate ability to obtain a Sexual History with attention to the 5 Ps!!!!!
1) Partners:
- Men, Women, Both: How many, over how long
2) Prevention of Pregnancy:
- What Method
3) Protection from STDs:
- What do they do/ do they use Condoms
4) Practices:
- For understanding wish of STIs- Vaginal, Anal. Oral Sex
5) Past History of STDs:
- Have you or your partner had an STI ever?
33
Discuss the Rationale behind and demonstrate ability to screen for risk of Domestic Violence and other issues of Personal Safety
- If you suspect DOMESTIC VIOLENCE a good opening question: "Have you ever been Hit, Slapped, Kicked, or Otherwise hurt physically by someone? Yes? ------> Ask the SAFE Questions!!!!!!
S: Safety/ Stress
- What stress do you experience in your relationship? Should I be concerned about your safety?
A: Afraid/ Abuse
- Are there situations in your relationships where you have felt afraid?
F: Friends/ Family
- Are your friends, parents, or siblings aware that you've been hurt?
E: Emergency Plan
- Do you have a safe place to go and resources you need in an Emergency?
34
Discuss the Rationale behind and Demonstrate ability to elicit a patient's Spiritual Beliefs, Diet, Exercise, and Caffein Use
Diet:
- 24 hour recalls "tell me what you ate in the last 24 Hours"
- Eating habits
- Ex: Bulimia "Are you satisfied with your eating habits?"
Special Dietary area to consider asking about:
1) Na INTAKE:
- Hypertensive?
- Heart Failure or Renal Patients?
- Do they add Salt to the cooking, or eat a High Sodium Food (soups, restaurant meals)
2) FAT:
- Thinking about Cholesterol and Vascular disease
- Ex: Dairy, Egg, Raw Meat, Organ Meats
3) CAFFEINE:
- Thinking about Nervousness, Tremors, Palpitations, Sleep Disturbances.
- Note Caffeine can come in many forms (Soda, Coffee, Tea, Supplement, "pre-workout"
4) FIBER: GI Problems
5) DAIRY: GI Problems- maybe lactose Intolerant and they'd don't know
6) WHEAT: Gluten Enteropathy
35
CDC Exercise Recommendations
- CDC recommendations get 150 Minutes per week of Moderate Activity (brisk walking) and strength Training 2 days of the week that focus on All Major Muscle Groups
36
Faith/ Spirituality
FICA:
FAITH and BELIEVE: Do you consider yourself a spiritual or religious person?
IMPORTANCE: What importance does faith have in your life
COMMUNITY: Are you a part of spiritual or religious community?
ADDRESS IN CARE: Asking them if they want you to Address these issues int heir care
37
When entering patient room
- Handshake
- Introduce yourself (Student Doctor First Name, Last Name)
- Hand Sanitizer
- Sit
- Explain your role
38
Physical Exam
- Heart
- Lungs
- OSE
- 1 to 2 Specific Tests
39
What is Biomechanics
- The Study and Function of Biological Systems by looking at the STATICS, DYNAMICS, and MECHANICS of MATERIALS (What they're like when still, then in motion, how they work together)
40
We need Biomechanics to Understand Human Physical Performance
- How motions are PERFORMED
- How we CONTROL MOTION
- How forces (Internal and External) affect the human body and tissues
41
Leonard Da Vinci
- First to STUDY in the context of MECHANICS
| - Analyze MUSCLE FORCES as acting along point son attachment and Joint Function
42
Galileo Galilei
STRENGTH of BONES:
- Increasing Body Mass Correlated with an INCREASE in BONE DIAMETER
- LOAD Bearing Strength
- Suggested that BONES are hollow to MAXIMIZE STRENGTH and MINIMIZE STRENGTH
43
What is GAIT CYCLE
- One GAIT is from a HEEL STRIKE to a HEEL STRIEK on the SAME FOOT!!!!
- Two Phases:
1) STANCE: When the foot is on the Ground
2) SWING: Foot not on the Ground
- There are Changes in the Average Step Length, Cadence, and Speed when considering Age, Pain, Disease, or Fatigue!!!!!
44
Lets Start Walking
1) CONTACT
- LATERAL aspect of the CALCANEUS strikes the Ground
- TIBIA INTERNALLY ROTATES and the CALCANEUS to EVERT, thus the TALUS Drops and ADDUCTS (The Foot is currently a Shock Absorber)
- PRONATION!!!!!!!!!!!
- EXTENSOR DIGITORUM LONGUS and TIBIALIS ANTERIOR relax slowly to LOWER the FOOT to the GROUND
2) MID-STANCE
- Before we can HEEL-OFF, we must GET FLAT-FOOTED: the Rear foot as FULLY PRONATED. Metatarsals hit the Ground, and the BODY'S CENTER of GRAVITY MOVES SO THAT IT IS OVER THE FOOT!!!!!
- To get HEEL-OFF, the SUBTALAR JOINT RESUPINATES, which LOCKS the MIDTARSAL JOINT: The foot is now a RIGID LEVER!!!!!
- POSTERIOR TIBIALIS prevents OVERPRONATION and is an ACTIVE SUPINATOR!!!!!
45
Take a Step
1) PROPULSION
- Heel- Lift becomes TOE-OFF
- The Center of Gravity Passes over the METATARSALS and begins to PULL THE HEEL UP!!!
- MTP JOINTS (Especially 1st MTP) EXTEND: WINDLASS Effect of Plantar Fascia (ELEVATING ARCH, ASSISTING SUPINATION)
- Supination means we have a RIGID LEVEL: We can now PROPEL the FOOT FORWARD via Maximal Contraction of GASTROCNEMIUS-SOLEUS and HAMSTRINGS!!!!
- Phase CONCLUDES with Body Weight moving OVER GREAT TOE before all Weight is TRANSFERRED to OTHER FOOT
2) SWING:
- FOOT DORSIFLEXES to Keep TOES from HITTING the GROUND
- FOOT SUPINATES (Gets it further away from the Ground, Stabilizes it in Preparation for the FIRST Jarring MOMENT of HEEL STRIKE)
46
Review of Gait
1) STANCE:
- From Heel Strike (Initial Contact) to Toe Off (Pre-Swing)
- Approximately 60% of the CYCLE
- Foot is on the Ground and Bearing Weight
- This is when Most Problems Occur
2) SWING:
- From Toe Off to HEEL STRIKE
- Foot is Moving FORWARD and is NON WEIGHT BEARING
* ***PRESWING PHASE is 50-60% of the STANCE PHASE!!!!!!!
- About to Initialize Swing
47
Requirements for Gait
1) STABILITY in STANCE
- Need a stable foot, Ankle, Knee, Hip, and Torso
2) FOOT CLEARANCE in SWING
- Coordination of Ankle Dorsiflexion, Knee Flexion, and Hip Flexion
3) Pre-POSITION for INITIAL CONTACT
- Ready to PLACE FOOT in the DESIRED LOCATION, Ready to ABSORB WEIGHT
4) Adequate STEP LENGTH
- Too SHORT, EXPENDS too much ENERGY for too Little Progress
- Too LONG, will make BALANCE DIFFICULT and will Strain Ligaments and Muscle
5) ENERGY Conservation
- Center of GRAVITY barely moves Vertically
- HIP DROPS on the Side of the NON WEIGHT BEARING side to COMPENSATE
- PELVIS rotates FORWARD on the SIDE Ready for HEEL STRIKE: "Lengthens" the FEMUR!!!!!!!
48
Pathologic Gaits (Antalgic)
- PAINFUL
49
Pathologic Gaits (Anthrogenic)
- Stiff
50
Pathologic Gaits (Ataxic)
- UNSTABLE (Imagine a Dizzy person Staggering)
51
Pathologic Gaits (Parkinson or Festinating)
- SHUFFLING, Slow
52
Pathologic Gaits (Steppage)
- HIGH KNEES to compensate for FOOT DROP
53
Pathologic Gaits (Hemiplegic)
- NO FLEXION of Knee or Ankle, SEMICIRCLE made with HIP!!!!
54
Anatomical Relationship of Scapula
1) T3: Spine fo Sacpula
| 2) T7: Inferior Angle of Scapula
55
GH joint and Muscles
1) FLEXION: Deltoid and Coracobrachialis
2) EXTENSION: Latissimus Dorsi and Teres Major
3) ABDUCTION: Supraspinatus and Mid Deltoid
4) ADDUCTION: Pec Major and Latissimus Dorsi
5) External Rotation: Infraspinatus and Teres Minor
56
SC Joint
1) ABDUCTION: Pt Shrugs Shoulders
- Distal End of Clavicle: SUPERIOR
- Proximal End of Clavicle: INFERIOR
2) ADDUCTION: Pt Lowers Shrugged Shoulder
- Distal End of Clavicle: INFERIOR
- Proximal End of Clavicle: SUPERIOR
3) HORIZONTAL FLEXION: Pt Raises Hand in Air
- Distal End of Clavicle: ANTERIOR
- Proximal End of Clavicle: POSTERIOR
4) HORIZONTAL EXTENSION: Pt Lowers Arms
- Distal End of Clavicle: POSTERIOR
- Proximal End of Clavicle: ANTERIOR
***KNOW DERMATOME PATTERN OF ARM
57
Muscle Weakness of Shoulder
1) APLEY SCRATCH TEST: Test Pt ROM!!!!
- 2 Parts:
1) ABDUCTION and EXTERNAL ROTATION
2) ADDUCTION and INTERNAL ROTATION
2) LIFT OFF TEST: Subscapularis Weakness
- Arm INTERNAL ROTATION and ADDUCTION (Like being Handcuffed)
- Pt TRY to LIFT OFF: If Cannot = Positive Sign!!!!
58
GH Instability
1) APPREHENSION Test: Positive if Pt Apprehensive
- Shoulder Abducted to 90 Degrees and Elbow Flexed to 90 Degrees
- Bring into EXTERNAL ROTATION, look for APPREHENSION
2) SULCUS Sign: Positive if SULCUS Appears
- Grasp Elbow and apply INFERIOR Traction
- Look for SULCUS to DEVELOP in GH Joint!!!!!
59
Long Head of Biceps
1) YERGASON TEST:
- Arm at 90 Degrees at Side, Doctor monitors at BICIPITAL GROOVE!!!!!
- Have Pt EXTERNALLY ROTATE and SUPINATE ARM
- If Pain or Popping, POSITIVE TEST
2) SPEEDS TEST:
- Pts Arm Extend out in FRONT
- Have Pt Keeping Arm STRAIGHT try to FLEX SHOULDER against RESISTANCE
- Pain or Tenderness, Positive Test
60
Rotator Cuff Impingement
1) NEER IMPINGEMENT:
- Passively Flex a Pts Fully PRONATED Forearm
- If Pain, SUBACROMIAL or ROTATOR CUDD IMPINGEMENT
2) HAWKINS TEST:
- Exact Same Setup as APPREHENSION TEST
- Move arm in INTERNAL ROTATION (Like a Hawks Wing), Instead of external rotation
- If Pain, SUBACROMIAL or ROTATOR CUFF IMPINGEMENT!!!
61
Rotator Cuff
1) EMPTY CAN TEST
- Flex Pts Arms to 90 Degrees and ABDUCT to 45 Degrees and INTERNALLY ROTATE till Thumbs Point Down (Like EMPTYING out two cans)
- Press Down on Arm: Pain or Weakness = POSITIVE TEST, Supraspinatus Pathology!!!!!!
2) DROP ARM TEST:
- ABDUCTS arms to Between 90 to 180 Degrees
- Slowly lower arms, if drop or gentle Tap causes them to Drop = POSITIVE TEST
- FULL THICKNESS TEAR SUPRASPINATUS!!!!
62
Muscle Reflexes
1) C5: Biceps Tendon
2) C6: Brachioradialis
3) C7: Triceps
63
Valgus/ Varus Testing
- Test Stability of MCL/ LCL in Elbow
- Valgus Testing: Make a L around the ELBOW Joint
- Pain or Laxicity = MCL Pathology
- Varus Testing: Make a gap so a R can fit in it
- Pain or Laxicity = LCL pathology
64
Ulnar Nerve Entrapment
- Tinels Sign
- Tap between Olecranon and Medial Epicondyle
- Positive Sign: Tingling Down Forearm
65
Golfers and Tennis Elbow
- Wrist Flexors Attach to Medial Epicondyle
- Wrist Extensors to Lateral Epicondyle
GOLFERS Elbow: Test Flexion of Wrist Against Resistance
- Pain at Medial Epicondyle: Positive Test
- Epicondylitis
TENNIS Elbow: Test Extension of Wrist Against Resistance
- Pain at Lateral Epicondyle: Positive Test
- Epicondylitis
66
Coupled Motion at Wrist
1) FLEXION: Dorsal Carpal Glide
2) EXTENSION: Ventral Carpal Glide
3) Ulnar Deviation: Ulnar ABDUCTION
4) Radial Deviation: Ulnar ADDUCTION
67
Median Nerve Testing
1) OK SIGN: Pt Cannot make an OK sign with Thumb and Index
- Sign of Anterior Interosseous Pathology (Branch of Median Nerve)
2) TINELS SIGN: Tap over the Transverse Carpal Ligament
- Pain or Tingling = Positive CTS
3) PHALENS SIGN: DORSUM of hands put together, hold for 60 seconds
- Pain or Tingling = Positive Test CTS
68
De Quervian's Tensosynovitis
- Possible Inflammation for Overuse/ repetitive use of a Muscle in:
1) ABDUCTOR POLLICIS LONGUS
2) EXTENSOR POLLICIS BREVI
FINKELSTEINS TEST:
- Have Pt make fist Entrapment Thumb
- Then ULNAR DEVIATE TOWARDS WRIST (Perform a Hammering motion)
- POSITIVE SIGN: Pain
69
Hip Muscles
1) Flexors: Iliopsoas, Sartorius, Rectus Femoris, IT
2) Extensor: Glut Max, Hamstrings
3) Adduction: Adductor Longus
4) Abduction: Glut Med, Sartorius
5) External Rotation: Sartorias, Glut Med, Glut Min
***Tight Hamstrings ---> Decrease Hip Flexion ----> EXTENSION DISFUNCTION!!!!!!
- Be familiar with angles
- Muscle strength 0/5
70
Innervation and Sensation
INNERVATIONS:
1) Flexion: Femoral N (L2-L4)
2) Extension: Inferior Gluteal N (L5-S2)
3) Abduction: Superior Gluteal N (L5-S1)
4) Adduction: Obturator N (L2- L4)
SENSATIONS:
1) Dermatomes (L1-L3)
2) Anterior Femoral Cutaneous (L2-L4)
3) Lateral Femoral Cutaneous (L2-L3)
4) Posterior Femoral Cutaneous N (S2)
71
Compartments
1) Central:
- Labrum, Ligamentum Teres, Articular Surfaces
- Log Roll, C-Sing, Labral Loading/ Distraction, Scour, Apprehension: FABER
2) PERIPHERAL:
- Femoral Neck, Synovial Lining
- Ely's, Rectus Femoris
3) LATERAL:
- Gluteus Maximus, Gluteus Minimus, Piriformis, IT Band, Trochanteric Bursa
- Jump Sign, Straight Leg Raise, Ober's, Piriformis, Trendelenburg, Patricks: FABERS
4) ANTERIOR:
- Iliopsoas Insertion, Iliopsoas Bursae
- Patricks: FABERS, Psoas Test, Thomas Test
72
FABERS Three Tests
1) Central: Passive work by doc, patient not active
2) Lateral: Patient ABDUCTS against Resistance
3) Anterior: Patient ADDUCTS against Resistance
73
OSE
- Name dysfunctions for where they like to live
- Check BILATERALLY
- Be able to take these clinical tests and know what a positive fining is and what is meant for the patient Clinically
74
Trendelenburg
- Everything wants to be eye level, so if we stand on our Right leg, out Right Muscles will have to work harder to CONTRACT and maintain an EVEN BALANCE
- If there is something wrong with OUR RIGHT Muscle Group, then it will not be able to COMPENSATE---> HIP DROP on the LEFT!!!
75
Knee
- Flexion: 145-150 (Hamstrings, Tibial Divison of Sciatic N)
- Extension: 0 (Quads, Femoral N)
Q ANGLE:
- About 15 Degrees
- Females have a wider Q Angle
Sensation/ DTR/ Strength:
- Candycane Stripe/ Barbershop
- L4: PATELLA and Medial Malleolus
- S1: Achilles
Grade:
- No Movement: 0
- Gravity Only: 3
- Resistance: 5
76
Knee Orthopedic Testing
1) MCL: Valgus Stress Testing, Neutral and Slight Flexion
- Positive test: Increased Laxity, Pain, Elaborated Endpoint
- Indicated MCL disruption and/ or Joint Capsule Injury
2) LCL: Varus Stress Test
- Increased Laxity, Pain, Elaborated Endpoint
- Indicated LCL Disruption and/ or Joint Capsule Injury
3) ACL: Lachmans and Anterior Drawer
- Pos Test: Increased Laxity, Excessive Movement (Compare Bilaterally), Pain
- Indicated ACL Sprain/ Tear
4) PCL: Reverse Lachmans and Posterior Drawer
- Pos Test: Increased Laxity, Excessive Movement, Pain
- Indicates PCL Sprain/ Tear
5) Patella: Laxity/ Apprehension, Compression, Glide
- Push Medial and lateral
- Grade 1-4!!!!
- If Apprehensive, Previous dislocation or Instability
- Compression: Positive Pain or CREPITUS with Compression. Indicated Articular Surface abnormal/ Injury
- Glide: Pos Pain, Crepitus, Catching with Movement. Indicated Articular Surface Damage
6) Menisci: MCMURRAY and APLEY
A) Medial Meniscus: Internal Rotation and VARUS
- Positive with Pain, Clicking indicated Possible Meniscus Tear
B) Lateral Meniscus: External Rotation and VALGUS
- Positive with Pain, Clicking indicates possible Meniscus Tear
C) Apley Compression: Positive Pain with Compression/ Rotation ---> Nonspecific Meniscal or Collateral Ligament
D) Apley Distraction: Positive Pain with Distraction/ Rotation ----> COLLATERAL LIGAMENT DAMAGE!!!!
77
Other Knee Pathology
1) Unhappy Triad ACL, MCL, Lateral Meniscus!!!!
2) Chondromalacia: No CARTILAGE, Bone on Bone
3) Hamstring Strain: Quick, Explosive Motions
4) ITBS: Overuse
5) Patellar Tendonitis: "JUMPER's KNEE" and Quadriceps Tendonitis
6) Osgood- Schlatter's: Adolescents; Slight AVULSION of TIBIAL TUBEROSITY!!!!
78
Ankle/ Foot
Anatomy and ROM:
1) Plantar Flexion: 50-65 (Post Compartment, Tibal N)
2) Dorsiflexion: 15-20 (Ant Compartment, Deep Fibular N)
3) Inversion: 20-30
4) Eversion: 10-20
Sensation/ DTR/ Strength:
1) Achilles Tendon: S1
2) L4, L5, S1-----> MEDIAL to LATERAL on FOOT
3) Strength same as other joints
79
Ankle/ Foot Ligamentous Testing
1) Anterior Drawer Test:
- Pos Test= Pain or Gapping
- Indicates ATF Ligament Sprain or Tear
2) Talar Tilt Test:
- Pos Test = Pain or Gapping
- Indicates CALCANEOLFIBULAR (CF) Ligament Sprain or Tear
3) EVERSION TEST:
- Pos Test = Pain, Increased ROM, Laxity
- Indicates DELTOID Ligament Sprain or Tear
4) Squeeze/ Cross Leg Test:
- Pos Test = Pain
- Indicates HIGH ANKLE SPRAIN (Syndesmosis)
80
Other Clinical Lower Leg/ Foot PAthology
1) Achilles Tendon Rupture: THOMPOSON TEST!!!!!
2) Venous THROMBOSIS:
A) HOMANS: Nonspecific
B) MOSES: Anterior Compressive Force, Posterior Tibial Vein
3) Morton's Neuroma: Walking on a MARBLE
4) Plantar Fasciitis: Plantar Aponeurosis ---> MFR
5) Turf Toe: 1st Toe Hyperextension
6) Achilles Tendonitis: Pain, Inflammation at Base of Tendon
7) Calf Strains: Gastroc vs Soleus
- Knee Flexion removes GASTROC from Planter Flexion
- Plain/ Inability to Plantar Flex = SOLEUS MUSCLE!!!!!
81
Upper Respiratory Clinical Considerations
1) ACUTE BACTERIAL RHINOSINUSITIS:
- 10 or more days without Improvement, High Fever (102), Purulent Discharge ---> BACTERIAL
- AMOXICILLIN (If Allergic to Resistant Bug, then DOXYCYCLINE)
- FLUSH SINUSES
2) DIZZINESS:
- ENT, CV, RESP, NEURO Causes
- Differentiate Lightheadedness vs Vertigo/ Spinning vs Imbalance if Possible:
1) LIGHTHEADEDNESS: usually from HYPOTENSION/ CV Causes of HYPERVENTILATION
2) VERTIGO: ENT dz (Meniere's, BPPV, Labyrinthitis)
A) Meniere's: Vertigo + Tinnitus (Ringing) + Hearing Loss
B) BPPV: Episodic Vertigo (Perform Dix Hallpike to Help Diagnose, Epley Maneuver to Treat)
C) Labyrinthitis: Hearing Loss, Vertigo (Non episodic), often associated WITH INFECTION (Fever)!!!!!!
82
Upper Respiratory Clinical Considerations Continued
1) STREPTOCOCCAL PHARYNGITIS: Group A beta-Hemolytic Strep (S. pyrogens)
- Red, Inflamed Throat, Fever, Inflamed Tonsils with Exudate (fluid)
- Important to Completely Diagnose and Treat since sequel includes
- CENTOR SCORE:
- 1 pt for each: Fever, Cervical Adenopathy, Tonsillar Exudate, No Cough, Age (1 pt for age 15 yrs)
2) EARACHES: AOM, OE, OM with Effusion:
A) AOM: Behind ear drum, Diagnosed with Infection (red, Swollen, Angry Looking)
- Kids have POOR drainage, EUSTACHIAN TUBE more HORIZONTAL!!!!!!!
B) Otitis Externa: In Ear Canal, Swimmers Ear!!!!
C) OM with Effusion: Fluid Buildup, not with a diagnosed Infection (Not red, just bulging with Fluid)
- DO NOT GIVE antibiotics
- Treat with OMT
83
Grading Tonsils
0: In Fossa
+1: Less than 25%
+2: Between 25% and 50%
+3: Between 50% and 75%
+4: Greater than 75%
- All closed up
84
Physical in regards to Cardiac Function
1) Inspection
2) Palpation
3) Percussion
4) Auscultation
- Quiet Room
- Gown Patient
- Sitting, Supine, Left Lateral Decubitus
85
Principles of Physical Exam
Auscultation:
1) S1:
- MITRAL and TRICUSPID Closure
- Beginning of Ventricular Systole
2) S2:
- AORTIC and PULMONIC Closure
- Marks end of Systole, and beginning of Diastole!!!
86
Heart Sounds
1) Aortic Ventricle: 2nd ICS to the RIGHT of STERNUM
2) Pulmonic Valve: 2nd ICS to the LEFT of STERNUM
3) Tricuspid: 4th ICS at LSB
4) Mitral: APEX of Heart, 5th ICS to the LEFT at MIDCLAVICULAR LINE
87
S1 and S2
S1:
- LOUDEST at APEX!!!
- Beginning of Systole
S2:
- LOUDEST at BASE!!!
- End of Systole
88
Normal Expiration and Inspiration
Expiration:
- S1 S2 SINGLE SOUND
Inspiration
- Splitting of S2 because of INCREASED VENOUS return during INSPIRATION and MORE TIME for RV to DELIVER BLOOD to the LUNG (Delayed P2)
89
Murmurs Grading System
Grade:
1: Barely audible, faint
2: Soft, but easily heard, quiet
3: Loud, without a Thrill
4: Loud with a Thrill
4: Loud with minimal contact between Stethoscope and Chest- THRILL
5: Loud, can be heard without a Stethoscope- THRILL
90
Midsystolic Murmur
- Begins after S1 and stops before S2
91
Pansystolic Murmur
- Starts with S1 and stops at S2 without gap between murmur and heart sounds
92
Late Systolic Murmur
- Usually starts in Mid or Late Systole and persists up to S2
93
Early Diastolic Murmur
- Starts immediately after S2, without a discernible gap, then usually fades into silence
94
Mid diastolic Murmur
- starts a short time after S2
95
Preload
- Stretching of Myocytes prior to CONTRACTION. Its the EDP at the beginning of Systole
**INCREASE in PRELOAD causes an INCREASE in Active Force development up to a LIMIT
96
Afterload
- Load on Heart during EJECTION of Blood from Ventricle
- Ventricle pressure at end of Systole (ESP)
**INCREASE in Afterload causes a DECREASE in Volume of Blood ejected each Beat!
97
Contractility
- Capacity to produce Active Force at a specified PRELOAD
- INCREASE in Contractility causes an INCREASE in ability to work
- DECREASE in Contractility causes a DECREASE in ability to work
98
Rate
- Heart Rate number of Cardiac Cycles per Minute
| - Increase output of blood/ minute, but DECREASE output/ beat; VERY HIGH Rate (> 150/ min)
99
Stroke Volume (SV)
- Blood ejected from Ventricle per beat (= EDV-ESV)
100
End Diastolic Volume (EDV)
- Volume of blood in Ventricle at end of DIASTOLE; the PRELOAD
101
End Systolic Volume (ESV)
- Volume of Blood remaining in Ventricle at end of Systole
102
Cardiac Output (CO)
- Volume of Blood per minute pumped out by the Heart (CO = SV x HR)
103
Ejection Fraction (EF)
- Measure Contractility (EF= SV/ EDV)
- Normal: 50-60%
- Mod Reduced: 30-39%
- Mildy Reduced: 40-49%
- Severely Reduced: 15-29%
104
Kussmauls Sign
- VENOUS COLUMN (JVP) rises during Inspiration, rather than Falls
- Seen in Right Heart Failure, CONSTRUCTIVE PERICARDITIS or RV Infarction!!!!
