Physical Diagnosis Exam 4 Flashcards
(213 cards)
1
Q
Do all “hip clicks” mean DevelopmentalDysplasia of the Hip (DDH)?
A
No
2
Q
Palmar Grasp
A
Timing: present at birth, disappears by 6 months
Elicitation: stroking of palmar surface with finger
Response: hand will close around finger and tighten
3
Q
Lordosis
A
anterior curve of lumbar spine just above buttock- seen from lateral view
A small amount of curvature in kyphosis and lordosis is normal
May be congenital, or related to abdominal weight from pregnancy or obesity
4
Q
Structures in the joint (articular)
A
Joint capsule
articular cartilage
synovium and synovial fluid
intr-articular ligaments
juxta-articular bone
5
Q
F A S T
A
Facila droop
Arm weakness
Speech difficulty
Time to call 911
6
Q
Peripheral Nerves
A
31 pairs
8 Cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
7
Q
Level of care
Problem focused
A
1 organ system
8
Q
Spinal cord length
A
Extends from medulla to L1-L2
9
Q
Breasts in 2nd trimester
A
growth continues, minor leakage may occur
10
Q
Hip flexion muscle
A
Iliopsoas (knee to chest)
11
Q
Moro Reflex (“startle Reflex”)
A
Timing: present at birth, disappears by 6 months
Elicitation: while laying supine gently pull up on arms or hold child and gently allow head to fall back about 3cm, can also occur from loud sound or sudden movement
Response: infant throws back head, extends out the arms and legs, cries, then pulls the arms and legs back in
12
Q
Which of the following statements regarding reinforcement when assessing reflexes is true?
A. Used when reflexes are symmetrically hyperactive
B Technique involves isometric contraction of other muscles
C. Supports the unsteady patient
D. All of the above
A
B. Technique involves isometric contraction of other muscles
Used when reflexes are symmetrically diminished or absent
13
Q
Osteoporosis & Osteopenia risk factors
A
over 50 low bmi tobacco alcohol low physical activity 1st degree relative some drugs
14
Q
Murmurs in geriatrics
A
Common to hear systolic aortic murmur – 1/3 over age 60 and 50% of those over 85.
15
Q
thumb opposition Nerves
A
C8, T1, median nerve
16
Q
MSK localized vs diffuse
A
Localized is one joint
Diffuse is multiple joints
17
Q
TRANSVERSE PALMAR CREASE
A
A common variant, found in approximately 5% of newborns
A single palmar creases is also associated with Down’s syndrome (Simian crease)
18
Q
3 D’s in Neuro
A
“three Ds” – delirium, dementia, and depression
19
Q
Plantar Fasciitis
A
Plantar pain upon getting out of bed
associated with a bony exostoses on calcaneus i.e. a “spur”
Inflammation of the plantar fascia as it inserts into anterior calcaneus
20
Q
Elbow: Biceps and triceps, wrist-(radial nerve) – flexion Nerves
A
(C5, C6)
21
Q
Anal Refelex Nerves
A
S2-S4
22
Q
Fundal height = Just above symphysis pubis
A
12 weeks
23
Q
Which Cranial Nerve involves palpation of the temporal and masseter muscles?
CN I
CN III
CN V
CN VII
A
CN V
24
Q
Club Foot
A
The feet are plantar-flexed and inverted. Because this is a bony deformity, this position is rigid.
25
Ankle Reflex Nerve
S1
26
What should you never fail to consider in shouldr pain
Cardiac issues
27
Hip Extension Nerves
S1 G. maximus
28
Cobb Angle
The angle formed by the intersection of two lines drawn on a spinal radiograph
Greater than 10° of curvature measured by the Cobb angle defines scoliosis
29
Osteoporosis & Osteopenia numbers
30 million people/12 million are male
30
4 levels of care
| Detailed
```
HPI = Extended
ROS = Extended
PMH/SH = Petinent
```
31
Vertex presentation
Head first delivery
32
Meningeal signs
Brudzinkis sign
Supine, neck up
Kernigs sign
Supine leg raised
33
Meniscus test
McMurray
34
Dysdiadochokinesis
The inability to perform rapid alternating movements
35
Where is the line for posterior superior iliac spine
Imaginary line along the posterior–superior iliac spines crosses the joint at S2.
36
4 levels of care
| Expanded problem focused
```
HPI = Brief
ROS = Problem Pertinent
PMH/SH = N/A
```
37
AD CAVA DIMPLS
Admit note
38
Flaccidity or Hypotonia
Decreased or loss of muscle tone causing limb of affected place to be loose
(lower motor neuron system lesion or GB, spinal cord injury or Stroke)
39
TIA
acute loss of focal brain or monocular function
less than 24 hours
Temporary / partial blockage
40
Bursae
pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures
41
Ankle Jerk reflex nerve
S1-S2
42
Review of Systems – Common Positives
| 2nd trimester
may begin to have intolerance to heat, experience ”hot flashes”,
back discomfort, breast tenderness, abdominal expansion,
hair and nail changes, BP decrease
43
Stroke
acute loss of focal brain or monocular function
Greater than 24 hours
complete blckage
44
Which Cranial Nerves involves the gag reflex?
CN III and IV
CN IX and X
CN X and XI
CN XI and XII
CN IX and X
45
Bicep reflex nerve
C5-C6
46
Kyphosis
posterior curve of thoracic spine at level of ribs- seen from lateral view
A small amount of curvature in kyphosis and lordosis is normal
47
Galeazzi Sign
Knees bent, check height and symmetry of knees
When legs appear symmetric this is a negative Galeazzi sign
Unequal knee height is positive
48
Review of Systems – Common Positives
| 3rd trimester
increased ligamentous laxity, increased curvature of lower spine,
leg cramps, foot and ankle swelling, slight temperature increase,
shortness of breath, ”colostrum” (yellow watery pre-milk) may leek from nipples.
49
Iliac Crest level
L4
50
Knee exam for mild effusions
Bulge sign
51
most common chronic disability of childhood
Cerebral palsy
most frequent is hip dislocation
52
4 levels of care
| Problem focused
```
HPI = Brief
ROS = N/A
PMH/SH = N/A
```
53
Musculoskeletal disease affect how many people in us
1 out of 2
3 out of 4 over 65
10% of ambulatory visits
200 billion in lost wages
54
oral presentation
Pertinent physical exam findings
Offer assessment
Describe plan
55
problem pertinent ROS
inquires about the system directly related to the problem identified in the HPI.
56
Rooting Reflex
Timing: present at birth, disappears by 4 months
Elicitation: stroking the cheek with a finger
Response: infant turns head toward the side being stroked with mouth open
57
CLINODACTYLY
A congenital defect in which one or more toes or fingers are abnormally positioned
58
Plantar Response Nerves
L5-S1
59
Review of Systems in pregnancy
Careful attention to mood.
Ask about stressors, sleep, appetite, energy.
GU/Reproductive - last menstrual period, vaginal discharge, pain, vaginal bleeding, dysuria
Skin – pruritic areas, rash, color/texture changes
60
Stroke prevention
```
Exercise
Nutrition
No tobacco
Social determinates
Aspirin
```
61
Strain
injury to the bone-tendon unit at the myotendinous junction or the muscle itself
Mechanism by muscle contraction
62
Geriatric pulmonary
Rales may be present
(crackles) (coarse breath sounds)
Increase in anteroposterior diameter of chest
63
Types of dystonia
Anterocollis (neck bent forward)
Lateroocollis (neck bent sideways)
retrocollis (neck bent backward)
Torticollis ( Neck rotated)
64
What are some causes of abnormal newborn reflexes?
```
Low birth weight at birth
Premature birth (<36 weeks)
Traumatic birth
Severe illness in infancy
Trauma or injury in infancy
```
65
SPondylolisthesis
Step offs
forward slipping vertebrae
mostly in L4,L5,S1
due to birth defect, degenerative disease, vertebral fracture
backache, nerve root pressure, herniated disc, pain down legs
66
Knee reflex Nerve
L2-L4
67
Lawton ADL
```
Phone
Shopping
Food Prep
House Keeping
Laundry
Mode of transportation
Responsibility of own medications
Ability to handle finance
```
68
Oligoarticular
2 - 4 joints
69
Geriatric pulse
loss of arterial pulsations is not typical and demands further evaluation
70
Level of care
| Expanded problem focused
2-7 organ systems
71
Time fram for acute vs chronic in musculoskeletal
Acute = less than 6 weeks
Chronic = 12 weeks
72
tendons
collagen fibers that connect muscel to bone
73
What is the difference between comprehensive and focused assessments
Comprehensive Assessment
For patients that the PA sees for the first time in office or hospital.
Includes all the elements of the health history and complete PE.
Focused Assessment
Problem-oriented assessment
Well visits of returning patients
Urgent care-type or acute concerns such as sore throat or knee pain
74
Handgrip strength Nerves
C7, CG, T1
75
Documentation for billing
Code that represents
Level of E/M service performed
The three key components when selecting the appropriate level of E/M services provided are
history,
examination,
medical decision making.
76
Pregnancy health counseling
1/5 Pregnant women experience some form of partner abuse
Caution re: eating processed meats, raw and undercooked seafood, eggs, smoked salmon, unpasteurized milk
77
Plantar Grasp
Timing: present at birth, disappears by 9 months
Elicitation: stimulation of plantar surface with thumb/object
Response: curling of toes around thumb/object
78
DTR reflex Grade
```
0 no response
1 diminshed
2 normal
3 brisk
4 Over brisk, hyperactive
```
79
#1 reason for stroke in geriatrics
Carotid bruits
80
Arcus Senilis
Grey ring around eye
81
Anterior nerve root
Ventral
| Motor
82
Articular
Joint
83
Which dermatome area is involved with Plantar reflex?
L4-L5
L5-S1
S1-S2
S2-S3
L5-S1
84
Musculoskeletal changes in pregnancy
Exaggerated lumbar lordosis
Increased ligamentous laxity
Pelvic ligaments relax to prepare for labor and birth.
85
4 Cardinal features of inflammation
swelling, warmth, redness in combination with pain
86
Delirium
Delirium – “a temporary state of confusion”
87
Hip Adduction Nerves
L2, L3, L4, adductors
88
complete ROS
inquires about the system(s) directly related to the problem(s) identified in the HPI
plus all additional (minimum of ten) organ systems.
89
Glove and stocking pattern Sensory causes
Diabetes most common cause
```
Diabetes
alcohol
B12 def
CRF
Drugs
Leprosy
Paraneoplastic
```
90
Ankle Flexion Nerves
S1, Gastrocnemius
91
```
Spherical joint
(ball and socket)
```
Convex surface in concave cavity
Wide-ranging flexion, extension, abduction, adduction, rotation, circumduction
Shoulder, hip
92
Synovial joint
Freely movable
Shoulder, Knee
93
Which cranial nerve is involved with corneal reflex?
CN II
CN III
CN IV
CN V
CN V
94
Hip Extension muscle
Gluteus maximus (stick leg back)
95
Breasts in first trimester
swelling of breasts, darker areola, small bumps within the areola
96
Aging changes symmetry
changes due to aging are symmetrical – if asymmetry exists in your physical exam of patient – look for alternate cause
97
presbycusis
hearing acuity decreases
98
Dermatome
band of skin innervated by the sensory root of a single spinal nerve
99
pertinent PFSH
is a review of the history areas directly related to the problem(s) identified in the HPI.
100
Geriatric PMI
PMI may be displaced do to kyphosis (makes palpation of PMI less reliable as indicator of cardiomegaly)
101
Elbow: Biceps and triceps, wrist extension Nerves
(C6, C7, C8)
102
Stepping Reflex
Timing: present at birth, disappears by 2 months
Elicitation: hold infant upright and touch feet to solid surface then bring to a forward leaning position
Response: one foot will lift up and then step forward in an apparent walking motion
103
Neuro coordination tests
```
Point to point
Gait
hop in place
Romberg
pronator drift
toe, heel walk
rapid alternating movements
```
104
S3 in geriatrics
hearing an S3 strongly suggests failure/volume overload,
105
Postural tremors
Anxiety, Hyperthyroidism, Essential tremors
tremor when trying to hold limb still against gravity
106
Geriatric History
Acute illness present differently – less likely to have a fever with infections, less likely to report CP with MI
Geriatric patients tend to underreport
107
Exercise guidlines
150-300 minute per week
moderate
75-150 minutes
vigorous
108
4 levels of care
| Comprehensive
```
HPI = Extended
ROS = Complete
PMH/SH = Complete
```
109
Hagar sign
palpable softening of the cervical isthmus
110
What is Gelling
“Gelling” phenomenon – decreased active and passive ROM and stiffness upon awakening (this is a sign of articular pain)
111
cartilage
collagen matrix overlying bony surfaces
112
Cardiac changes in pregnancy
BP decrease
increased HR
increased blood volume
increased CO
S3 normal in pregnant women
S4 in 15%
Stenosis and murmur may be present
113
Pavlik Harness
Treatment for Developmental Dysplasia of the Hip
= Newborn-6 months old
Pavlik Harness is rarely successful after age 6 months and surgery is required
114
Two phases of gait
swing 40%
| stance 60%
115
LCL test
Varus
Knee goes outward
foot goes inward
Bow legged
116
Geriatric fall numbers
1 in 3 persons over age 65 fall per year
Leading cause of fatal and nonfatal injuries among older adults
30% will have lasting debility
117
Sucking reflex
Timing: present at birth, disappears by 5 months
Elicitation: place finger into infant's mouth touching lips and gently touch palate
Response: infant begins to suck
118
complete PFSH
A review of two or all three of the areas (Past, Family or Social)
119
Rigidity
Increased resistance that persists throughout the movement arc.
(Parkinson’s)
120
Genetically determined disorders characterized by progressive degeneration of skeletal muscle leading to atrophy, progressive weakness
Muscular dystrophy
9 major types
duchenne/becker most common
121
Chadwick sign
Bluish tint to vagina walls/cervix
122
Ankle Extension Nerves
L4, L5 tibailis anterior
123
Documentation for billing
Code that represents
Setting of service
Office or other outpatient setting: Preventive visits vs. Acute visits
Hospital inpatient: Comprehensive vs. Focused
Emergency department (ED): Emergent visits
Nursing facility (NF) or Assisted Living Facility (ALF): Chronic visits
124
Bilateral weakness in both upper and lower extremities and urinary frequency
cervical myelopathy until proven otherwise.
125
Breech Presentation
Butt first
126
Systemic symptoms
Malar Rash (lupus)
Scaly plaques, pitting of nails in Psoriatic arthritis
Red based papules, pustules, vesicles on distal
extremities – Gonococcal arthritis
Target/Bulls eye patch – Lyme disease
127
Levels of alertness
Lethargy (speak loudly)
Obtunded (Shaken patient)
Stupor (painful stimuli)
Coma (no response)
128
Pain and temp nerve tract
Spinothalamic tract
129
Determining uterine size
Landmarks – symphysis pubis and the umbilicus
Use left hand to palpate the fundus, determining height of the fundus
Fundal height location used to estimate gestation –
Just above symphysis pubis ~12 weeks
Halfway between symphysis and umbilicus ~16 weeks
At umbilicus ~22 weeks
General rule – measurement in centimeters = gestational age
130
leukorrhea of pregnancy
Vaginal secretions may become thicker, white
131
Coordinating eye, head, and body movements applies to which area of the nervous system?
Motor System
Cerebellar System
Vestibular System
Sensory System
Vestibular System
132
Newborn hand crease
Most newborns have two major creases on the palm, neither of which completely extend from one side of the palm to the other.
133
Hip – flexion Nerves
(L2, L3, L4, Psoas),
134
Scoliosis
lateral curve of spine (always abnormal)
Scoliosis is best seen from posterior view with patient leaning forward
135
Level of care
| Detailed
2-7 organ systems examined
with an expanded exam of the affected and other symptomatic or related organ systems
136
finger – abduction and adduction Nerves
C8, T1, ulnar
137
4 levels of care
Problem Focused
Expanded problem focused
Detailed
Comprehensive
138
Fundal height = Halfway between symphysis and umbilicus
16 Weeks
139
Recommendation for bone density screening
women over 65
post menopausal women under 65
men over 70
140
Resting tremors
parkinsons
141
Neck pain with radiation of pain to upper extremity
cervical radiculopathy
142
Spacticity
Increased muscle tone
| upper motor neuron or corticospinal tract system lesions or Stroke
143
Diadochokinesis
Ability to perform rapid alternating movements
144
Chorea
huntingtons, aids, immune, genetic, pregnancy, neuroleptic, levodopa, rheumatic fever
(dance like movement)
145
Monoarticular
1 joint
146
Geriatric vasculature
Giant cell arteritis
| Temporal arteritis
147
Knee Flexion Nerves
L4, L5, S1, S2, hamstrings
148
Tricep Nerve
C6-C7
149
Posterior Nerve root
Dorsal
| Sensory
150
PCL Test
Posterior Drawer
151
Newborn reflexes
```
Rooting
Sucking
Grasp
Moro
Stepping
Tonic Neck
Galant
```
152
Abdominal reflexes Nerves
T8-T10 (upper)
| T10-T12 (lower)
153
Extra articular structures
periarticular ligamnets
tendons
bursae
muscle, bone, skin
fascia
154
Brief HPI elements
one to three HPI elements.
Ex. – location, quality, and duration
155
Hip abduction Nerves
L4, L5, S1, GMM
156
Review of Systems – Common Positives
| 1st trimester
frequent urination, lightheadedness, heartburn,
constipation, veins become visible, tender breasts,
pregnancy “glow” to skin, mood changes/lability,
nausea/vomiting
157
Galant Reflex
Timing: present at birth, disappears by 6 months
Elicitation: lie infant on stomach and lightly stroke the side
Response: infant will laterally flex toward the stimulation side
158
extended ROS
inquires about the system directly related to the problem(s) identified in the HPI
and a limited number (two to nine) of additional systems
159
Breasts in 3rd trimester
significant darkening, likely enlarged nipples, stretch marks may be present
160
Pregnancy weight changes
gain 25-35 punds
161
Extended HPI
at least four elements of the present HPI
or
the status of at least three chronic or inactive conditions
example = five HPI elements – location, quality, duration, context, and modifying factors
162
Cartilaginous joint
Slightly moveable
Vertebrae
163
Respiratory changes in pregnancy
Increased tidal volume
Increased respiratory rate
Respiratory alkalosis
164
Muscle strength grade
```
0-5
0 being no muscle contraction
1 barely a trace of contraction
2 active movement with no gravity
3 active movement against gravity
4 active movement with some resistance
5 active movement against full resistance
```
165
Geriatric Syndromes
multifactorial condition that involves the interaction between identifiable situation-specific stressors and underlying age-related risk factors, resulting in damage across multiple organ systems
166
Daily orders
Daily orders are used to change any admission order or for further investigation or treatment
167
Knee exam for major effusions
Balloon Sign
also ballottement
168
Condylar joint
Convex or concave
Movement of two articulating surfaces not dissociable
Knee; temporo-mandibular joint
169
Clonus
a hyperactive response required for assigning a reflex grade of 4, usually elicited at the ankle
170
How do you identify scoliosis
Inspection
Forward bend test
Use of a scoliometer
Radiographs
171
Glove and stocking pattern Motor causes
```
Motor causes
Guillen barre
Palsy
toxicity
porphyria (liver disorders)
```
Diabetes most common cause (sensory)
172
Tonic neck Reflex
Timing: present at birth, disappears by 7 months
Elicitation: turn infants head to one side
Response: the arm on the side the head is turned stretches out and the opposite arm bends up at the elbow, often called the "fencing" position”
173
Documentation for billing
Code that represents
Patient type
New patient
not seen by provider in last 3 years
Established patient
seen by provider in last 3 years
174
Level of care
| Comprehensive
8 or more organ systems
175
Katz ADL
```
Bathing
Dressing
Toileting
transferring
continence
feeding
```
176
When do you order Xrays for scoliosis
ATR ≥7° in patients with body mass index (BMI) <85th percentile
ATR ≥5° in patients with BMI ≥85th percentile
177
Sarcopenia
decline in muscle tissue due to aging process
178
GI changes in pregnancy
```
Increased reflux
Nausea & vomiting (due to hormonal changes)
Increased symptoms of heartburn
Decreased gastric motility
Constipation
```
179
Skin Changes in pregnancy
Pigmentation – areola, inner thighs, labia, neck may darken
Striae gravidarum (stretch marks)
Pruritic urticarial papules and plaques
Pre-existing skin disorders may flair
Linea Nigra – dark line of skin from symphysis pubis to umbilicus due to hormonal changes
occurs in ~80% of pregnancies
180
Fundal height = At umbilicus
22 weeks
181
orthopedic trauma in children numbers
1 in 3-4
182
Phases of gait
Heelstrike
Foot flat
Midstance
Pushoff
183
Ankle Sprain
Mechanism: Inversion forces
Most common injury of the ankle
Most common ligament injured—anterior talo-fibular ligament
184
ACL test
Lachmans
| anterior Drawer
185
Knee Extension Nerves
L2, L3, L4, quads
186
MCL test
Valgus
Knee goes inward
Foot goes outward
Knock kneed
187
Dystonia
Involuntary muscle contraction and spasm
188
AMNIOTIC BAND SYNDROME
Amputations of digits or limbs
189
Barlow maneuver
A test used to identify an unstable hip that can be passively dislocated.
The infant is placed in a supine position with the hip flexed to 90º and in neutral rotation. The examiner adducts the hip while applying a posterior force on the knee to cause the head of the femur to dislocate posteriorly from the acetabulum.
A palpable clunk or “hip click” may be detected as the femoral head exits the acetabulum.
190
Majortiy of adults tested are deficient for
Vitamin D
191
Ortolani maneuver
Identifies a dislocated hip that can be reduced.
From an adducted position, the hip is gently abducted while lifting or pushing the femoral trochanter anteriorly.
In a positive finding, there is a palpable clunk or “hip click” as the hip reduces back into position.
192
Neuro prevention and counseling
Preventing stroke or TIA
Reducing risk of peripheral neuropathy
Detecting the “three Ds” – delirium, dementia, and depression
193
Most follow-up progress notes (focused assessments) use what format??
SOAP Format
194
Documentation for billing
| Code that represents
Code that represents
Patient type
Setting of service
Level of E/M service performed
195
4 regions of brain
Cerebrum
diencephalon
brainstem
cerebellum
196
NAVEL
```
Nerve (Lateral)
Artery
Vein
Empty Space
Ligament (Medial)
```
197
Sprain
involves collagenous tissue such as ligaments and tendons
Mechanism by twist or stretch
198
Which of the following are not considered a test for sensation?
Asterixis
Stereognosis
Graphesthesia
Two-point discrimination
Asterixis
199
Newborn Reflexes
Definition: Inborn behavioral patterns that develop in utero
Primitive
Infantile
Infant
Developmental
present at birth then gradually disappear during the first 3-12 months postnatal
200
4 systems of Coordination of muscle movement
```
Motor system Muscle
Cerebellar system(rhythm, posture)
Vestibular system (balance)
Sensory system (position)
```
201
Fibrous joint
Not moveable
Sutures of skull
202
Polyarticular
more than 4 joints
203
Intentional tremors
MS
tremor when reaching for something
204
actinic purpura
Purple skin patches
205
Hinge Joint
Flat, Planar
Motion in one plane; flexion, extension
Interphalangeal joints of hand and foot; elbow
206
Most common ankle injury
Ankle sprain
Most common ligament injured—anterior talo-fibular ligament
207
Ankle Eversion
Walk on inside of foot
outside of foot is facing up
ankle rolls inwards
208
Ankle inversion
walk on outside of feet
ankle rolls outward
medial portion of foot is facing up
209
When to refer pediatrics with scoliosis to ortho
Cobb angle between 20 and 29° in premenarchal girls or boys age 12 - 14 years
Cobb angle >30° in any patient
Progression of Cobb angle of ≥5° in any patient
210
WHO most common debilitating injuries
Osteoarthritis
Back/neck pain
Fractures due to fragility
211
Brachioradialis (supinator) Nerve
C5-C6
212
Newborn Reflexes are Considered Absent
Absent during the neonatal period
Asymmetric (suggesting hemiplegia or monoplegia)
Persist beyond the age by which they should have
normally disappeared
213
ligaments
ropelike bundles of collagen fibers that connect bone to bone
