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402 Cards in this Set
- Front
- Back
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SOAP?
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Subjective, Objective, Assessment, Plan
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When should you use a Comprehensive assessment vs. a Focused?
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Usually established vs. non established pt
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What is included in Subjective Hx?
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Pt generated info, what pt tells you, Hx from CC to ROS
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What is included in Objective data?
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Exam generated, detect during, PE findings
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pack years
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ppd x years smoking
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CAGE questionnaire?
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Cut, Annoyed, Guilty, Eye-Opener (2 or more)
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3Ds of cultural humility
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self awareness, respectful communication, collaborative partnerships
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Different types of pain?
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Nociceptors or somatic - tissue
Neuropathic- Damage to NS Psychogenic- issues that affect pt's report of pain Idiopathic- No ID |
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General Appearance: SOMETEAMS?
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Symmetry
Old Mental Acuity Expression Trunk Extremeties Appearance Movement Speech |
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BMI Calculation?
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Weight in lbs x 703/Height in^2
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SOAP?
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Subjective, Objective, Assessment, Plan
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When should you use a Comprehensive assessment vs. a Focused?
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Usually established vs. non established pt
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What is included in Subjective Hx?
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Pt generated info, what pt tells you, Hx from CC to ROS
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What is included in Objective data?
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Exam generated, detect during, PE findings
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pack years
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ppd x years smoking
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CAGE questionnaire?
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Cut, Annoyed, Guilty, Eye-Opener (2 or more)
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3Ds of cultural humility
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self awareness, respectful communication, collaborative partnerships
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Different types of pain?
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Nociceptors or somatic - tissue
Neuropathic- Damage to NS Psychogenic- issues that affect pt's report of pain Idiopathic- No ID |
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General Appearance: SOMETEAMS?
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Symmetry
Old Mental Acuity Expression Trunk Extremeties Appearance Movement Speech |
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BMI Calculation?
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Weight in kg /Height m^2
or Weight (lbs) x 700/ Height (in) |
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What is the classification of BMI?
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Underweight <18.5
Normal 18.5-24.9 Overweight 25-29.9 Obesity I 30-34.9 II 35-39.9 Extreme Obesity III >40 |
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What could be the cause of a short stature?
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Turner's syndrome, childhood renal failure, dwarfism, osteoporosis, vertebral compression fractures
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Why should you assess general body proportions?
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Marfan's syndrome pts have long limbs in proportion to trunk
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How much does water comprise of human weight?
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60-65%
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What is lean body mass?
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Tissue devoid of extractable fat. Higher in men, increases with exercise, lower in women and elderly.
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What is the primary energy reserve of the body? How is it stored? White vs. brown?
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fat
-stored as triglyceride -White adipose= repository for triglycerides, cushion, insulator Brown adipose= heat production |
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What is appropriate body fatness?
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Women 20-25% (12% essential)
Men 12-15% (3% essential) |
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What is the Hamwi method for calculating ideal body weight?
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Females: 100lb. for first 5 feet of height +5 lbs. for each inch over 5 ft
Males: 105lbs for first 5 feet + 6lbs for each inch after that Large Frame: +10% Small Frame: -10% |
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What should you do if the pt BMI is over 25?
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Assess the pt for additional RFs for heart disease and other obesity-related diseases:
HTN, high LDL, Low HDL, high triglycerides, high Blood glucose, FHx of premature heart disease, Physical inactivity, Smoking |
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If the pt BMI is >25 and has two or more RFs what should you do?
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Encourage weight loss.
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When should you measure waist circumference?
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BMI >35
Pt in standing position, measure waist just above hip bone |
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How many inches indicate excess body fat?
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>35 in. women
>40 in. in men |
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What does a rapid change in weight suggest?
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fluid status
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What are weight loss mechanisms?
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anorexia, dysphagia, vomiting, insufficient food supplies, GI malabsorption, increased metabolic requirements, malignancy, eating disorders, depression, renal failure, endocrine disorders
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What can be used as energy status indicators?
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Albumin (3.5 - 5.2 g/dL)
Prealbumin (19-43 mg/dL) |
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What is the use of albumin detection?
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-Major protein in plasma (~60% total plasma)
-used to assess adequacy of caloric intake, specifically protein |
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What is pre albumin used for?
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-More accurate reflection of protein-energy status when compared with albumin
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What are RFs for malnutrition?
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Poverty, advanced age, physical disability, emotional or mental impairment, lack of teeth or ill-fitting dentures, alcoholism, drug abuse, hospitalization
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S/S of malnutrition?
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-Weakness, cold intolerance
-Apathy or irritability -Pallor -Dry and easily pluck able hair -Dependent edema -Flaky dermatitis -Xerosis -Cranial bossing -Winged scapula -Muscle wasting -Wasting of subcutaneous fat stores -Angular cheilosis -Glossitis, filiform papillary atrophy -Hepatomegaly -Splenomegaly |
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What is marasmus?
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-Combined energy and protein deficiency
-Can be secondary to cancer, AIDS, CHF, COPD |
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What is kwashiorkor?
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Deficiency of protein in the presence of adequate calories.
-Typically seen in weaning infants at birth of a sibling in areas with inadequate foods containing protein |
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What is Pica?
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Ingestion of nonnutritive substance for a period of at least one month.
-Dirt, ice, stones, paint, starch -May be linked to iron deficiency |
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DASH?
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Dietary Approaches to Stop Hypertension
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What is the systolic pressure?
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Max. pressure exerted on arterial wall at the peal of left ventricular contraction
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Diastolic?
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Min. pressure on arterial wall during left ventricle relaxation
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How to take BP? Which is systolic, diastolic?
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-Inflate 30mmHg over point where pulse disappears.
-Release valve slowly, note the point sounds reappear, this is systolic -Sound become muffled and disappear, the last sound heard is the diastolic. |
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What is the optimal BP? F/U?
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<120/<80
Recheck in 2 years |
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What is normal BP? f/u?
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<130/<85
Recheck in 2 years |
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What is high normal BP? F/U?
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130-139/85-89
Recheck in 1 year |
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What is BP in stage 1 HTN? F/U?
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140-159/90-99
Confirm w/in 2 mo |
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What is stage 2 HTN? f/u?
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160-179/100-109
Eval in 1 mo |
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What is stage 3 HTN? f/u?
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180 and above/110 and above
evaluate immediately or within 1 week |
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Normal heart rate?
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60-100 per minute
-radial most accessible, may need to use femoral/carotid in emergencies |
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To assess heart rate amplitude...
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Absent pulse = 0
Weak = 1 Normal = 2 Bounding = 3 |
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Pulsus alternans
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an ominous medical sign that indicates progressive systolic heart failure. a pattern of a strong pulse followed by a weak pulse over and over again.
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Pulsus bigeminus
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indicates a pair of hoofbeats within each heartbeat. Concurrent auscultation of the heart may reveal a gallop rhythm of the native heartbeat.
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Pulsus bisferiens
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an unusual physical finding typically seen in patients with aortic valve diseases. Examiner will observe two pulses to each heartbeat instead of one.
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Pulsus tardus et parvus
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a slower than normal rise in the tactile pulse caused by an increasingly stiff aortic valve. Loss of compliance in the aortic valve makes it progressively harder to open, thus requiring increased generation of blood pressure in the left ventricle.
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Pulsus paradoxus
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a condition in which some heartbeats cannot be detected at the radial artery during the inspiration phase of respiration.
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Tachycardia
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an elevated resting heart rate. In general an electrocardiogram (ECG) is required to identify the type of tachycardia.
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Normal respiration?
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16-20 per minute
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Apnea
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a term for suspension of external breathing. During apnea there is no movement of the muscles of respiration and the volume of the lungs initially remains unchanged. gas exchange within the lungs and cellular respiration is not affected
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Kussmaulo breathing
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is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also renal failure. It is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or depth of respiration
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Cheyne-Stokes respiration
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an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.[
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Biot's respiration,
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sometimes also called ataxic respiration- an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea.[
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What is a normal temp?
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98.6F or 37C
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When is a fever significant?
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>100.4F or 38C
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When is there hyperthermia?
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oral temp > 106F (41.1C)
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Hypothermia?
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Rectal temp <95F (35C)
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Tetrad of techniques
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Inspection
Palpation Percussion Auscultation |
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What is fatigue a common symptom of?
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depression. anxiety but also consider infections (hep, mono, TB), also endocrine disorders, CHF, COPD, kidneys, liver, electrolyte imbalance, anemia, malignancies, nutritional deficiencies and medications.
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What does localized weakness in a neuroanatomical pattern indicate?
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possible neuropathy or myopathy
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What do recurrent shaking chills suggest?
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More extreme swings in temperature and systemic bacteremia
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How does 70% of all sensory info reach the brain?
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Eyes
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What are primary causes of visions loss in older adults?
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Retinopathy, glaucoma, cataracts and macular degeneration
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Young people can lose sight how?
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Trauma, HIV opportunistic infections. Toxoplasmosis and CMV retinitis
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How to test far vision?
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snellen chart
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How to test near vision?
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Rosenbaum Chart
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How do you test peripheral vision?
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Confrontation
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OS, OD, OU?
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OS=left
OD=right OU=both |
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What is normal vision for a >6yo?
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20/20
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A 3yo presents with 20/50 vision, is this normal?
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Yes, <3yo this is normal
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What is normal vision for a <4yo? <5yo?
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20/40 ; 20/30
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What is meant by 20/400?
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Pt sees at 20 feet what a normal person sees at 400
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How do you test the extra ocular mm and innv?
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-Corneal light reflex
-Six fields of cardinal gaze -cover-uncover (LR6SO4)3 |
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What does it mean if the light does not shine in the same place as the cornea in the corneal light reflex?
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Possible strabismus (lack of muscle coordination)
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What is a blow out fracture?
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a break in the bony orbital floor or walls caused by blunt trauma to eye or orbit
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What is orbital cellulitis?
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Infection of eye tissues posterior to the orbital septum
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What is lid lag associated with?
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hyperthyroidism, which could also present as protrusion of the eyeball (exophthalmos)
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What does bilateral exophthalmos indicate? Unilateral?
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-Infiltrative ophthalmopathy of Graves' hyperthyroidism.
-Graves' disease or a tumor or inflammation in the orbit |
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What causes ptosis?
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myasthenia gravis, damage to the oculomotor nerve, damage to the sympathetic nerve supply (hornet's syndrome). A weakened muscle, relaxed tissues, and the weight of hermiated fat. May also be congenital.
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Hordeolum
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A painful, tender red infection in a gland at the margin of the eyelid
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Chalazion
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subacute, non tender and usually painless nodule of a meibomian gland. May become acutel ly inflamed but, unlike a stye, usually points inside the lid rather than on the lid margin
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Xanthalasma
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Slightly raised, yellowish, well-circumscribed plaques that appear along the nasal portions of one or both eyelids. May accompany lipid disorders.
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Dacryocystitis
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Inflammation of lacrimal sac. Swelling between lower eyelid and nose.
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What nerve is responsible for the corneal reflex protective blink?
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CNV, trigeminal
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If Pt doesn't blink with wisp of cotton...
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sensory deficit to CNV or
Motor deficit to CNVI May have overall reduced sensitivity if pt is a contact wearer ONLY use cotton, no gauze, could cause corneal abrasion |
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What is a corneal arcs?
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Thin grayish-white arc not quite at the edge of the cornea. Accompanies normal aging. In young people, suggests possible hyperlipoproteinemia. Usually benign.
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Nuclear Cataract? Peripheral Cataract?
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Nuclear- looks gray when seen by a flashlight. If the pupil is widely dilated, the gray opacity is surrounded by a black rim.
Peripheral- Produces spokelike shadows that point inward- gray against black, as seen with a flashlight, or black against red with an opthalmoscope. |
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S/S of corneal abrasion?
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Pain, photophobia, FB sensation, excessive squinting, reflex production of tears
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What can unequal pupils indicate?
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neurological damage, glaucoma, iritis or drug ingestion
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Is a fixed non reactive pupil bad
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yes
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Tonic Pupil (Adie's Pupil)
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Pupil is large, regular, and usually unilateral. Reaction to light is severely reduced or even absent. Near reaction, although very slow, is present. Slow accommodation causes blurred vision.
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Small, irregular pupils that accommodate but do not react to light. Seen in central nervous system syphilis.
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Argyll Robertson Pupils
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PERRLA
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Pupils
Equal Round Reactive Light Accommodation |
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What does the absence of a red reflex indicate?
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Cataract, Detached retina, retinoblastoma, artificial eye has no red reflex
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Hyphema
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Blood in the anterior chamber of the eye. Pool of blood in iris or cornea.
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What does AV nicking indicate?
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HTN
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Normal cup to disc ration
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1/3 to 1/4
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Diabetic Retinopathy
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non proliferative/proliferative exudates
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Optic disc swelling that is caused by increased intracranial pressure.
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papilledema
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What are the 3 layers of the TM? What does the TM separate?
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Separates the external and middle ear
-skin, fibrous tissue and mucous membrane |
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What is the upper portion of the TM called which provides little support?
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Pars flaccida
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What is the lower portion of the TM called which is taut?
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Pars tensa
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What is the umbo?
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Center, attached to the tip of malleus
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What does the middle ear do?
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-transmits sound vibrations across bony ossicle chain to inner ear
-protects auditory apparatus from intense vibrations -equalizes air pressure on both side of TM to prevent rupture |
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What are the auditory ossicles?
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The malleus (hammer), incus (anvil) stapes (stirrup)
-linked in a chain and vibrate in place |
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What part of the ear links the middle ear with the nasopharynx to equalize air pressure?
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Eustacian tube
-normal fxn keeps nasopharynx contaminants from middle ear -opens during yawning/swallowing |
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URI/allergies can obstruct
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middle ear drainage ->otitis media effusion
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What is the closed fluid filled space within the temporal bone called?
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inner ear
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What structures maintain equilibrium within the ear?
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vestibule and semicircular canal
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What structure contains cristae?
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Semicircular canals. These respond to body movement, control balance
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What is the organ of hearing?
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cochlea
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What can low set ears indicate?
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congenital disorders
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Where should the cone of light be?
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4-6 in R ear
6-8 in L ear |
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How can you test for auditory acuity?
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whisper test
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How can you test for conductive vs. sensorineural hearing loss?
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Weber test- strike tuning fork and place on top of its head.
Normal=Equal hearing in both ears If materializes to impaired ear=conductive hearing loss If lateralized to good ear =sensorineural hearing loss |
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What does the Rinne Test for?
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-Compares air conduction to bone conduction
-Strike tuning fork with hand and place on mastoid process -When pt tells you tone stops move to front of ear Air conduction=2x bone conduction |
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Rinne's Test:
If in hearing loss ear bone>air= |
conductive hearing loss
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Rinne's Test:
If in hearing loss ear air>bone= |
sensorineural hearing loss
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What does red/swollen mucosa inside the nose indicate? Pale/blue?
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viral rhinitis ; allergic rhinitis
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What does angular cheilitis fissuring at angles indicate?
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nutritional deficiency, edentulous, overgrowth of candida
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On the lips what is rapidly developing, tense swelling, usually allergic and does not itch?
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Angioedema
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What is characteristic on the lower lip, plaque/ulcer/nodular. Due to prolonged sun exposure.
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lip carcinoma
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What does the rise of the soft palate indicate?
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CN X
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What midline structures in the neck should you identify?
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1-mobile hyoid bone just below the mandible
2-thyroid cartilage, readily identified by the notch on its superior edge 3- cricoid cartilage 4-tracheal rings 5-thyroid gland |
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What should you inspect the trachea for?
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Any deviation from the midline position. Masses in the neck may push it to one side.
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Tracheal deviation may also signify important problems in the thorax like...
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mediastinal mass
atelectasis large pneumothorax |
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What are the 10 sets of lymph nodes?
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1-preauricular
2-posterior auricular 3-occipital 4-tonsillar 5-submandibular 6-submental 7-superficial cervical 8-posterior cervical 9-deep cervical chain 10-supraclavicular |
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What is a tonsillar node that pulsates?
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it is really the carotid artery
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What is a small, hard, tender "tonsillar node" high and deep between the mandible and the sternomastoid?
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probably the styloid process
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What can an enlargement of the left supraclavicular node indicate?
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BAD. Possible metastasis from a thoracic or an abdominal malignancy.
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What does a hard/fixed node indicate?
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malignancy
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What do tender nodes indicate?
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inflammation
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Should you worry about small, mobile, discrete, contender nodes?
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"shotty" no
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What is a goiter
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enlarged thyroid gland
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What does a soft thyroid indicate? Firm? Tender? Localized systolic or continuous bruit?
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Soft in Graves' disease
Firm in Hashimoto's thyroiditis/malignancy Tenderness in thyroiditis A localized systolic or continuous bruit may be heard in hyperthyroidism. |
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What are symptoms of hyperthyroidism?
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nervousness, weightless despite increase appetite. Excessive sweating and heat intolerance. Palpitations. Frequent bowel movements. Muscular weakness of the proximal type and tremor.
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What are the signs of hyperthyroidism?
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warm, smooth, moist skin? , with graves disease, eye signs such as state, lid lag and exophthalmos. Increase systolic and decrease diastolic blood pressures. Tachycardia or atrial fibrillation. Hyperdynamic cardiac pulsations with an adan accentuated S1. Tremor and asc mm weakness.
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S/S of hypothyroidism?
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Fatigue, lethargy. Modest weight gain with anorexia. Dry, coarse skin and cold intolerance. Swelling of face, hands, and legs. Constipation. Weakness m cramps, arthralgias, paresthetisas, impaired memory and hearing.
Dry coarse cool skin, sometimes yellowish from carotene, with non pitting edema and loss of hair. Periorbital puffiness |
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A decrease systolic and increase diastolic blood pressure and bradycardia and in late stages hypothermia indicate what?
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Hypothyroidism
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When using the otoscope to inspect inside the nose, which of the following structures is not visible?
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Superior turbinate
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When palpating the thyroid, which of the following is true?
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The thyroid isthmus may not be palpable
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Steps to palpating thyroid:
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1-flex neck slightly forward
2-index fingers below cricoid cartilage 3-pt to sip water feel for thyroid isthmus rising up, often but not always palpable 4-dispalce trachea to the right with the fingers of the left hand; with the R hand palpate laterally for the R lobe in space to find lateral margin -lateral lobe feels somewhat rubbery |
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If the thyroid gland is enlarged what should you do?
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Listen over the lateral lobes with a stethoscope to detect a bruit, a sound similar to a cardiac murmur but of non cardiac origin
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When do you use standard precautions?
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This is minimum infection prevention practices that apply to ALL pt care, regardless of suspected or confirmed infection status of the pt, in any setting where healthcare is delivered.
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When do you use transmission based Precautions?
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For its known or suspected to be infected or colonized with infectious agents which require additional control measures to effectively prevent transmission.
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What do you apply standard precautions to?
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Blood, all bodily fluids, secretions and excretion, except sweat, regardless of whether or not they contain blood
Non intact skin (cuts, scratches and badly chapped skin) Mucous membranes |
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Key points about PPE
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-Don before contact with the pt, generally before entering the room
-use carefully - don't spread contamination -Remove and discard carefully, either at the doorway or immediately outside pt room, remove respirator outside of room -imm perform hand hygiene |
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Sequence of Donning PPE
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1-Gown
2-Mark or Respirator 3-Goggles or face shield 4- Gloves |
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Sequence of Removing PPE
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1-Gloves
2-Face shield or goggles 3-Gown 4-Mask or respirator |
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Immediately following exposure to blood?
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-Wash needlesticks and cuts with soap and water
-flush splashes to the nose, mouth, or skin with water -Irrigate eyes with clean water, saline, or sterile irritants -report exposure to proper departments ASAP |
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When should Hep B exposure Tx be administered?
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24hrs, no later than 7 days
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When should Hep C exposure Tx be administered?
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No vaccine and no post-exposure Tx that will prevent infection
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When should HIV exposure Tx be administered?
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-No vaccine available
-Post Exposure Prophylaxis (PEP) is recommended for certain occupational exposures that pose a risk -Choice of antiretroviral drugs dependent on multiple factor -Tx should be started within hours |
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What are included in Transmission-Based Precautions?
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-Contact Precautions
-Droplet Precautions -Airborne Precautions |
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Contact Precautions
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Intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or patient’s environment
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Droplet Precautions
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Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions
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Prevent transmission of infectious agents that remain infectious over long distances when suspended in the air
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airborne precautions
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elements of a Respiratory Protection Program
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-Medical Evaluation
-Fit testing -Training -Fit checking before use |
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How to perform a fit check?
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Inhale - respirator should collapse
Exhale - check for leakage around the face |
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Types of informed consent?
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Implied-immediate (ER)
General-Hospital admissions Special-req. for high risk procedures |
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The eye exam should always include what?
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Visual acuity
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When should you refer?
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Suspected globe rupture, globe laceration, intraocular foreign body
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What should you do for expected globe rupture?
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Immediate referral
Do not use topical agents on the eye Cover both eyes with a Fox shield to reduce the movement of the injured eye |
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Eyelid Laceration Tx
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Immediate referral to ophthalmologist in almost all circumstances
Superficial, horizontally oriented lacerations potentially repaired in primary care |
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Corneal Abrasion
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Cause pain, tearing, photophobia, foreign body sensation, and gritty feeling
Symptoms can be worsened by exposure to light, blinking and rubbing Discomfort typically begins instantly after the injury and lasts minutes to days |
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Initial considerations
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Obtain detailed history of the injury
Determine risk for penetrating injury Determine need for immediate flushing related to splash injury Determine potential for presence of foreign body Identify allergies: anesthetic, fluorescein, topical antibiotics |
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Eye exam includes...
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-eye deformity
-pupil rxn -extraocular movements -fundus -obvious FBs -apply 1 - 2 drops anesthetic -mosten fluorescein strip with anesthetic -insert strip on lower conjunctiva -pt to blink |
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How to evert the lid
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instruct pt to look downward, apply cotton-tipped applicator against mid-portion of lid, gently grasp eyelashes and flip the lid over the applicator
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What serves as a protective coating from foreign particles and water. And its acidic nature prevents bacterial growth?
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Cerumen
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What composes cerumen?
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Secretions and ceruminous apocrine glands, desquamated skin, bacteria of normal skin flora, and depilated hair
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What causes the accumulation of cerumen impaction?
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-Obstruction of cerumen elimination by ear canal disease
-Narrowing of the ear canal -Failure of skin migration -Overproduction |
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What are indications for cerumen impaction?
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-To visualize the ear canal and tympanic membrane in the setting of otologic complaints-hearing loss, poorly functioning hearing aid, ear pain, ear fullness, unexplained fever, dizziness
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Contraindications for cerumen removal?
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-Suspected TM rupture
-Inability to visualize TM when rupture suspected -Tympanostomy tubes -Uncooperative pt -referallt to ENT |
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Ways to remove cerumen?
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Curette, lavage, ceruminolytics, prevention (mineral oil)
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What are the 3 layers of the skin?
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Epidermis
Dermis Subcutaneous tissue |
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What are appendages of the skin
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hair, nails, sebaceous and sweat glands
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Which hair makes up the scalp and eyebrows?
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Terminal hair - coarser, pigmented
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What is vellus hair?
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short, fine, less pigmentation
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Sebaceous glands present on all surfaces except...
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palsm/soles; they produce a fatty substance secreted onto skin surface thru hair follicles
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Which type of sweat glands are widely distribute?
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Eccrine- open directly onto the skin surface and help control BT
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Which sweat glands are found in the axilla and groin, stimulated by emotional stress
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apocrine
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Café-Au-Lait Spot
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Uniformly pigmented macule or patch with a somewhat irregular border, usually 0.5 to 1.5 cm in diameter; benign.
Six or more such spots, each with a diameter of >1.5 cm, however, suggest neurofibromatosis. |
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Erythema "slapped cheeks"
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Erythema infectiosum (Fifth disease)
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Mobility and turgor
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Note ease with which it lifts up (mobility) and speed with which it returns to place (turgor)
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What can cause decrease mobility and turgor
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Decreased mobility in edema, scleroderma
Decreased turgor in dehydration |
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Pityriasis Rosea
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Reddish oval ringworm-like lesions
front and back trunk, upper thighs |
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Tinea versicolor
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tan flat, scaly lesions, upper chest and upper back
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Patterns and shapes:
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linear annular cluster serpentine dermatomal
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Macule, patch
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Macule—Small flat spot, up to 1.0 cm
Patch—Flat spot, 1.0 cm or larger seen in hemangioma, cafe au laid, vitiligo |
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Palpable elevations
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Plaque—Elevated superficial lesion 1.0 cm or larger, often formed by coalescence of papules
Papule—Up to 1.0 cm Nodule—Marble-like lesion larger than 0.5 cm, often deeper and firmer than a papule Cyst—Nodule filled with expressible material, either liquid or semisolid Wheal—A somewhat irregular, relatively transient, superficial area of localized skin edema |
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Palpable elevations with fluid filled cavities
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Vesicle—Up to 1.0 cm; filled with serous fluid
Bulla—1.0 cm or larger; filled with serous fluid Pustule—Filled with pus ex. herpes simplex, insect bite, acne small pox, |
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Where might you see finger clubbing?
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Seen in congenital heart disease, interstitial lung disease and lung cancer, inflammatory bowel diseases, and malignancies.
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White Spots (Leukonychia)
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Trauma to the nails is commonly followed by non-uniform white spots that grow slowly out with the nail.
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Transverse Linear Depressions (Beau's Lines)
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-Bilateral transverse depressions of the nail plates resulting from temporary disruption of proximal nail growth from systemic illness.
-Seen in severe illness, trauma, and cold exposure if Raynaud's disease is present. |
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HARRM Risk Factors for Melanoma
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History of previous melanoma
Age over 50 Regular dermatologist absent Mole changing Male gender |
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ABCDE: Screening Moles for Possible Melanoma
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A for asymmetry
B for irregular borders, especially ragged, notched or blurred C for variation or change in color, especially blue or black D for diameter ≥6 mm or different from other moles, especially changing, itching or bleeding E for elevation or enlargement |
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Hairy leukoplakia, Kaposi's sarcoma, herpes simplex virus (HSV), human papillomavirus (HPV), cytomegalovirus (CMV), molluscum contagiosum, candidiasis, squamous cell carcinoma, psoriasis (often severe), seborrheic dermatitis (often severe)
May indicate what... |
AIDS
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Acanthosis nigricans, candidiasis, neuropathic ulcers, peripheral vascular disease
Could indicate what... |
Diabetes
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Xanthomas (tendon, eruptive, and tuberous), xanthelasma (may occur in healthy people)
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Dyslipidemia
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Dry, rough, and pale skin; coarse and brittle hair; myxedema; skin cool to touch; thin and brittle nails
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Hypothyroidism
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Warm, moist, soft, and velvety skin; thin and fine hair; vitiligo; pretibial myxedema (in Graves' disease); hyperpigmentation (local or generalized)
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Hyperthyroidism
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Pallor, pruritus, hyperpigmentation, uremic frost
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Chronic renal disease
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Jaundice, spider angiomas and other telangiectasias, palmar erythema
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liver disease
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Dry, scaly, shiny atrophic skin; dystrophic, brittle toenails; cool skin; hairless shins; ulcers; pallor; cyanosis; gangrene
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peripheral vascular disease
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Melasma, increased pigmentation of areolae, linea nigra, palmar erythema, varicose veins, striae, spider angiomas, hirsutism
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pregnancy
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Erythematous rash that begins on wrists and ankles, then spreads to palms and soles; becomes more purpuric as it generalizes
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rocky mountain spotted fever
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Erythematous, maculopapular, discrete rash that begins on head and spreads to trunk and extremities, petechiae on soft palate
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Roseola infantum (HSV 6) and Rubella (German measles)
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Erythema of cheeks (“slapped cheeks”) followed by red, pruritic, reticulated (net-like) rash that starts on trunk and proximal extremities
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Erythema infectiosum (fifth disease)
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Erythematous, maculopapular rash that begins on head and spreads to trunk and extremities, lesions become confluent on face and trunk, Koplik spots on buccal mucosa
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Rubeola (measles)
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Generalized, pruritic, vesicles on an erythematous base (“dewdrop on a rose petal”) rash begins on trunk and spreads peripherally, lesions appear in crops and are in different stages of healing
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Varicella (chickenpox)
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What and where is a synovial joint?
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Freely movable, knee and shoulder
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ROM and where Spheroidal?
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Ball and socket- wide range flexion, extension, abduction, adduction, rotation, curcumduction, shoulder and hip
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Hinge?
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Motion in one plane, flexion, extension-IP joints of hand and foot, elbow
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Condylar?
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mvmt of 2 articulating surfaces not dissociable- knee, TMJ
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Cartilaginous joint?
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Slightly movable-vertebral bodies of spine
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immovable joint ie skull structures
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fibrous
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What are the 7 features of joint pain?
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Location
Quality Quantity Timing Setting Remitting Associated S/S |
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3 tips for assessing joint pain
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-Point to the pain
-Mechanism of injury -Determine whether pain is localized or diffuse, acute or chronic, inflammatory or noninflammatory |
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Signs and Symptoms of inflammation and arthritis?
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1-Swelling - synovial membrane, effusion with joint space, soft tissue structures such as bursae, tendons and tendon sheath
2-Warmth 3-Tenderness 4-Redness |
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RFs for Osteoporosis
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Postmenopausal status in white women
Age older than 50 years Weight less than 70 kg Family history of fracture in a first-degree relative History of fracture Higher intakes of alcohol Women with delayed menarche or early menopause Current smokers Low levels of 25-hydroxyvitamin D Use of corticosteroids for more than 2 months Inflammatory disorders of the musculoskeletal, pulmonary, or gastrointestinal systems celiac sprue, chronic renal disease, organ transplantation, hypogonadism, anorexia nervosa |
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What is the most active joint in the body?
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TMJ, a condylar synovial joint
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What are the TMJ mm?
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The principal muscles opening the mouth are the external pterygoids.
Closing the mouth are the muscles innervated by Cranial Nerve V, the trigeminal nerve— the masseter the temporalis the internal pterygoids |
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TMJ inspection?
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-Symmetry
-Swelling or redness -To locate joint place tips of index fingers just in front of tragus of each ear and ask pt to open mouth. Fingers should drop in space. -ROM, TTP? -Palpate Mastication mm |
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Range of motion is three-fold:
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opening and closing
protrusion and retraction (by jutting the jaw forward) lateral, or side-to-side, motion. |
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TMJ abnormalities?
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-Facial assymety
-Pain with chewing also in trigeminal neuralgia, temporal arteritis -swelling, tenderness, decreases ROM, inflmmation or arthritis -dislocation may be seen in trauma -palpable crepitus, clinkcking -pain and tenderness on palpation in TMJ S |
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3 Joints and 3 large bones of the shoulder
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Acromioclavicular joint
sternoclavicular joint glenohumeral joint humerus scapula clavicle |
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What joint is not normally palpable?
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Glenohumeral, ball and socket, allows large ROM
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3 principle mm groups
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axioscapular
scapulohumeral axiohumeral |
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What does the scapulohumeral group do?
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rotates the shoulder laterally (the rotator cuff) and depresses and rotates the head of the humerus.
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What rotator cuff m originates on the anterior surface of the scapula and crosses the joint anteriorly; inserts on lesser tubercle
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subscapularis
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cross the glenohumeral joint posteriorly; insert on the greater tubercle
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infraspinatus and teres minor
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runs above the glenohumeral joint; inserts on the greater tubercle
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supraspinatus
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axioscapular group
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This group attaches the trunk to the scapula
Includes trapezius, rhomboids serratus anterior levator scapulae These muscles rotate the scapula. |
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This group attaches the trunk to the humerus
Includes pectoralis major and minor latissimus dorsi. These muscles produce internal rotation of the shoulder. The biceps and triceps connect the scapula to the bones of the forearm involved in shoulder movement, particularly abduction. |
Axiohumeral group
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Inspection of rotator cuff...
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Observe the shoulder and girdle anteriorly, inspect the scapulae and related muscles posteriorly.
Note any swelling, deformity, muscle atrophy or fasciculations or abnormal positioning. Look for swelling of the joint capsule anteriorly or a bulge in the subacromial bursa under the deltoid muscle. Survey the entire upper extremity for color change, skin alteration, or unusual bony contours. |
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Should palpation...
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Sternum
Sternoclavicular joint Clavical Corocoid process Glenohumeral joint line Acromioclavicular joint Acromion Subacromial bursa Bicipital groove and tendon Humerus Spine of scapula Medial scapular border SITS muscles, trapezius, paraspinal muscles Axilla |
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What does the 1st 120 degrees of ABduction and what does the remaining 60 degrees of motion
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GH= 1st 120 degrees
Scapula= last 60 degrees of motion |
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If there is pain in Abduction in the 1st 120 degrees? Last 60?
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120 = rotator cuff
last 60=AC joint |
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What test stressed the AC joint?
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Scarf test/ crossover test - hand to opposite shoulder
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What tests adduction?
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drop arms behind head
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Apley Scratch Test
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Internal rotation and adduction, flex arm to 180 and extend to 60.
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In a Wall Push up what does a winged scapula suggest?
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Damage to the lateral scapular thoracic Nerve.
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Passive ROM
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Not really useful if patient has full active ROM
Look for crepitus While palpating shoulder, move patient through Abduction External rotatation Internal rotation |
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How to test for impingement
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Passive abduction
Neers test full flexion and internal rotation Hawkins maneuver 90 degrees flexion, adduction and internal rotation |
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How to test the Supraspinatus for a rotator cuff pathology?
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Resisted isometric adduction
Empty can test Empty can and stress |
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How to test the IT for SITS pathology?
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Resisted isometric external rotation
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How to test the subscapularis for a rotator cuff pathology?
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Resisted isometric internal rotation
Scapular lift off w/ and w/o resistance |
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What does the drop arm test testing for?
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aBduct arm to 90, then slowly adduct arm
Rotator cuff patholoy |
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What causes anterior shoulder pain?
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Biceps tendon
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How do you open up to bicipital groove?
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Flex elbow and externally rotate
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What is the Yergasons Test?
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Elbow Flexed to 90, supinate and resist pronation (Biceps Tendon)
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Speeds Test
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Arm flex to 90, resist (Biceps tendon)
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How to test AC joint stability?
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Common site for osteoarthritis
Scarf test/crossover test Scratch test |
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GH Joint Stability
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Anterior and posterior stability
Sulcus sign pull down on humerus |
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Apprehension Test
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Anterior dislocation is most common
Pt does not want to externally rotate in aBduction bc they will feel shoulder starting to dislocate Will resist test May allow if shoulder stabilized |
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Myotome Testing of Upper Extemity
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C5
“boring” C6 “beer, please” C7 “show me the money” C8 “too cheap” T1 “five bucks” |
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to fibrosis of the glenohumeral joint capsule, manifested by diffuse, dull, aching pain in the shoulder and progressive restriction of active and passive range of motion, but usually no localized tenderness. Chronic.
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Adhesive capsulitis/frozen shoulder
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is uncommon, usually arising from direct injury to the shoulder girdle with resulting degenerative changes. Tenderness is localized over the acromioclavicular joint. Glenohumeral joint motion is not painful, but movement of the scapula, as in shoulder shrugging, is painful.
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Acromioclavicular arthritis
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usually results from a fall or forceful throwing motion, then becomes recurrent. The shoulder seems to “slip out of the joint” when the arm is abducted and externally rotated, causing a positive apprehension sign for anterior instability when the examiner places the arm in this position. Any shoulder movement may cause pain, and patients hold the arm in a neutral position. The rounded lateral aspect of the shoulder appears flattened. Dislocations may also be inferior, posterior (relatively rare), and multidirectional.
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Anterior dislocation
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Elbow palpation
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Olecranon process
Epicondyles Grooves b/t olecranon and epicondyles Ulnar nerve b/t olecranon and medial epicondyle |
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Testing Elbow ROM - Flexion
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Biceps brachii, brachialis, brachioradialis
“Bend your elbow.” |
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Testing Elbow ROM - Extension
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Triceps brachii, anconeus
“Straighten your elbow.” |
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Testing Elbow ROM - Supination
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Biceps brachii, supinator
“Turn your palms up, as if carrying a bowl of soup.” |
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Testing Elbow ROM - Pronation
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Pronator teres, pronator quadratus
“Turn your palms down.” |
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Olecranon Bursistis
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Swelling and inflammation of the olecranon bursa may result from trauma or may be associated with rheumatoid or gouty arthritis. The swelling is superficial to the olecranon process.
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Synovial inflammation or fluid is felt best in ...
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grooves between the olecranon process and the epicondyles on either side. Palpate for a boggy, soft, or fluctuant swelling and for tenderness (arthritis)
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Rheumatoid Nodules
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Subcutaneous nodules may develop at pressure points along the extensor surface of the ulna in patients with rheumatoid arthritis or acute rheumatic fever. They are firm and nontender, and are not attached to the overlying skin. They may or may not be attached to the underlying periosteum. They may develop in the area of the olecranon bursa, but often occur more distally.
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Wrist and Hand Palpation
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Distal radius and ulna
Radial styloid and anatomical snuffbox Carpal bones Metacarpals Phalanges |
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Wrist ROM
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Flexion
Extension Ulnar deviation Radial deviation Grip strength |
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Finger ROM
-Flexion, Extension, Adduction, Abduction, Opposition |
Flexion
Flexor carpi radialis, flexor carpi ulnaris “With palms down, point your fingers toward the floor.” Extension Extensor carpi ulnaris, extensor carpi radialis longus, extensor carpi radialis brevis “With palms down, point your your fingers toward the ceiling.” Adduction (radial deviation) Flexor carpi ulnaris “With palms down, bring your fingers toward the midline.” Abduction (ulnar deviation) Flexor carpi radialis “With palms down, bring your fingers away from the midline” Opposition (thumb only) |
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de Quervains inflammation of what
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inflammation of the abductor pollicis longus and extensor pollicis brevis tendons and tendon sheaths.
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TESTING MEDIAN NERVE COMPRESSION
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Tinel's, Phalen's,
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Wrist and hand sensation- pulp of index, pulp of fifth digit, web space of thumb and index
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Pulp of index finger
Median nerve Pulp of 5th digit Ulnar nerve Web space of thumb and index finger Radial nerve |
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Tender, painful, stiff joints in rheumatoid arthritis, usually with symmetric involvement on both sides of the body. The proximal interphalangeal, metacarpophalangeal, and wrist joints are the most frequently affected. Note the fusiform or spindle-shaped swelling of the proximal interphalangeal joints in acute disease.
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acute rheumatoid
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Note the swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints. Range of motion becomes limited, and fingers may deviate toward the ulnar side. The interosseous muscles atrophy. The fingers may show “swan neck” deformities (hyperextension of the proximal interphalangeal joints with fixed flexion of the distal interphalangeal joints). Less common is a boutonnière deformity (persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint). Rheumatoid nodules are seen in the acute or the chronic stage.
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Chronic RA
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Heberden's nodes on the dorsolateral aspects of the distal interphalangeal joints from bony overgrowth of osteoarthritis. Usually hard and painless, they affect the middle-aged or elderly; often associated with arthritic changes in other joints. Flexion and deviation deformities may develop. Bouchard's nodes on the proximal interphalangeal joints are less common. The metacarpophalangeal joints are spared.
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Osteoarthritis
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The deformities of long-standing chronic tophaceous gout can mimic rheumatoid arthritis and osteoarthritis. Joint involvement is usually not as symmetric as in rheumatoid arthritis. Acute inflammation may be present. Knobby swellings around the joints ulcerate and discharge white chalklike urates.
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CHRONIC TOPHACEOUS GOUT
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thickened plaque overlying the flexor tendon of the ring finger and possibly the little finger at the level of the distal palmar crease. Subsequently, the skin in this area puckers, and a thickened fibrotic cord develops between palm and finger. Flexion contracture of the fingers may gradually ensue.
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DUPUYTREN’S CONTRACTURE
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Hypothenar atrophy suggests...
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ulnar nerve disorder
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thenar atrophy
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suggests a median nerve disorder such as carpal tunnel syndrome.
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Ganglion Cyst
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Ganglia are cystic, round, usually nontender swellings along tendon sheaths or joint capsules, frequently at the dorsum of the wrist. Flexion of the wrist makes ganglia more prominent;
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What is different in Acute tenosynovitis than arthritis? What is it?
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Unlike arthritis, tenderness and swelling develop not in the joint but along the course of the tendon sheath, from the distal phalanx to the level of the MCP joint. The finger is held in slight flexion; finger extension is very painful. If the infection progresses, it may extend from the tendon sheath into the adjacent fascial spaces within the palm. Early diagnosis and treatment are important.
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Where are the concave curves of the spine? Convex?
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concave curves of the cervical and lumbar spine
convex curves of the thoracic and sacrococcygeal spine. |
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What contributes to the risk for disc herniation and subluxation, or slippage, of L5 on S1?
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Mechanical stress at this angulation. Vertebral angles sharply posterior at the lumbosacral junction
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What muscles assist with flexion?
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Muscles attaching to the anterior surface of the vertebrae, including the psoas muscle and muscles of the abdominal wall
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Landmarks to ID
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Spinous processes
more prominent at C7 and T1 and more evident on forward flexion Paravertebral muscles on either side of the midline Iliac crests Posterior superior iliac spines marked by skin dimples. A line drawn above the posterior iliac crests crosses the spinous process of L4. |
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Palpation of bones
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Palpate the spinous processes of each vertebra with your thumb.
In the neck palpate the facet joints that lie between the cervical vertebrae about 1 inch lateral to the spinous processes of C2-C7. These joints lie deep to the trapezius muscle and may not be palpable unless the neck muscles are relaxed. In the lower lumbar area, check carefully for any vertebral “step-offs” to determine whether one spinous process seems unusually prominent (or recessed) in relation to the one above it. Identify any tenderness. Palpate over the sacroiliac joint, often identified by the dimple overlying the posterior superior iliac spine. |
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What does low back pain warrant?
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Recall that low back pain warrants careful assessment for cord compression, the most serious cause of pain, because of risk for paralysis of the affected limb
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Palpating the sciatic N
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Palpate over the sacroiliac joint, often identified by the dimple overlying the posterior superior iliac spine
With the hip flexed and the patient lying on the opposite side, palpate the sciatic nerve Largest nerve in the body, Nerve roots from L4, L5, S1, S2, and S3. The nerve lies midway between the greater trochanter and the ischial tuberosity as it leaves the pelvis through the sciatic notch. |
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Where do flexion and extension in the head primarily occur? Rotation? Lateral Bending?
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occur primarily between the skull and C1, the atla.rotation at C1-C2; the axis
lateral bending at C2-C7. |
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Tenderness, loss of sensation, or impaired movement warrants
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careful neurologic testing of the neck and upper extremities
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Neck ROM, flexion, extension, rotation, lateral bending
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Flexion
Sternocleidomastoid, scalene, prevertebral muscles “Bring your chin to your chest.” Extension Splenius capitus and cervicis, small intrinsic neck muscles “Look up at the ceiling.” Rotation Sternocleidomastoid, small intrinsic neck muscles “Look over one shoulder, and then the other.” Lateral Bending Scalenes and small intrinsic neck muscles “Bring your ear to your shoulder.” |
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Pain or tenderness with these maneuvers, particularly with radiation into the leg, warrants...
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careful neurologic testing of the lower extremities.
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MM responsible for spinal flexion
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Psoas major, psoas minor, quadratus lumborum; abdominal muscles attaching to the anterior vertebrae, such as the internal and external obliques and rectus abdominis
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Testing for spinal flexion
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“Bend forward and try to touch your toes.”
Note the smoothness and symmetry of movement, the range of motion, and the curve in the lumbar area. As flexion proceeds, the lumbar concavity should flatten out. |
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How to test spinal extension? What mm involved here?
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Deep intrinsic muscles of the back, such as the erector spinae and transversospinalis groups
“Bend back as far as possible.” Support the patient by placing your hand on the posterior superior iliac spine, with your fingers pointing toward the midline. |
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Spinal rotation?
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Abdominal muscles, intrinsic muscles of the back
“Rotate from side to side.” Stabilize the patient's pelvis by placing one hand on the patient's hip and the other on the opposite shoulder. Then rotate the trunk by pulling the shoulder and then the hip posteriorly. Repeat these maneuvers for the opposite side. |
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Spinal lateral bending...
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Abdominal muscles, intrinsic muscles of the back
“Bend to the side from the waist.” Stabilize the patient's pelvis by placing your hand on the patient's hip. Repeat for the opposite side. |
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Examples of spine abnormalities...
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scoliosis, unequal shoulder heights, unequal heights of the iliac crests or pelvic tilt
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What causes unequal shoulder heights...
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Scoliosis
"winging" of the scapula (from loss of innv of serratus anterior m by long thoracic n) |
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What do unequal heights of the iliac crest (pelvic tilt) suggest...
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-unequal leg length
-scoliosis and hip abduction or adduction may also cause a pelvic tilt |
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What is "listing" of the trunk to one side seen in...
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herniated lumbar disc
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Birthmarks, port-wine stains, hairy patches, and lipomas often overlie bony defects
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Spina bifida:
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Café-au-lait spots (discolored patches of skin)
skin tags fibrous tumors |
Neurofibromatosis:
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Café-au-lait spots (discolored patches of skin)
skin tags fibrous tumors |
Neurofibromatosis:
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Ankylosing spondylitis may produce
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sacroiliac tenderness.
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Pain on percussion may arise from
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osteoporosis, infection, or malignancy.
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Rheumatoid arthritis may also cause tenderness of the
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intervertebral joints.
Tenderness at C1-C2 in rheumatoid arthritis suggests possible risk for subluxation and high cervical cord compression. |
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What does neck stiffness signal...
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signals arthritis, muscle strain, or other underlying pathology that should be pursued.
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Limitations in range of motion can arise from
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stiffness from arthritis, pain from trauma, or muscle spasm such as torticollis.
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Lateral deviation and rotation of the head suggest ...
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torticollis, from contraction of the sternocleidomastoid muscle.
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Spasm occurs in...
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degenerative and inflammatory processes of muscles, prolonged contraction from abnormal posture, or anxiety.
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Sciatic nerve tenderness suggests...
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a herniated disc or mass lesion impinging on the contributing nerve roots.
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Where are herniated intervertebral discs MC?
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L5-S1 or L4-L5
produce tenderness of the spinous processes, the intervertebral joints, the paravertebral muscles, the sacrosciatic notch, and the sciatic nerve. |
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Ankle is what kind of joint? Bones?
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Hing, tibia, fibula and Talus
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What are the main joints of the foot and ankle?
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tibiotalar joint- between the tibia and the talus
subtalar (talocalcaneal) joint. metatarsophalangeal joints, proximal to the webs of the toes proximal and distal interphalangeal joints of the toes |
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What are the landmarks of the ankle?
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medial malleolus, the bony prominence at the distal end of the tibia
lateral malleolus, at the distal end of the fibula calcaneus, or heel- lodged under the talus and jutting posteriorly |
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What is the mvmt of the ankle joint limited to?
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dorsiflexion and plantart flexion
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What is plantar flexion powered by?
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gastrocnemius, posterior tibial m and toe flexors. Tendons run behind the malleoli
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What are the dorsiflexor muscles?
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anterior tibial and toe extensors
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protecting against stress from eversion (ankle bows inward).
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medially, the triangle-shaped deltoid ligament
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What ligament is most at risk for injury from inversion?
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anterior talofibular ligament
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What are the lateral 3 ligaments of the ankle that are less substantial?
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anterior talofibular
calcaneofibular posterior talofibular |
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Where does the achilles tendon attach?
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gastroc and soleus to posterior calcaneus
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Where does the plants fascia insert?
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Medial tubercle of the calcaneus
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Palpation of Ankle...
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1-Anterior-TTP?
2-Achilles 3-Heel 4-Malleoli 5-Metatarsophalangeal joints 6-grooves between heads of metatarsals |
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Ankle ROM
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ankle Flexion (plantar flexion)
gastrocnemius, soleus, plantaris, tibialis posterior “Point your foot toward the floor.” ankle Extension (dorsiflexion) tibialis anterior, extensor digitorum longus, and extensor hallucis longus “Point your foot toward the ceiling.” inversion tibialis posterior and anterior “Bend your heel inward.” “E” version peroneus longus and brevis “Bend your heel outward.” |
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What are the ottawa rules?
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X-rays are only required if there is any pain in the malleolar zone and any one of the following:
Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus OR bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus OR inability to bear weight both immediately and in the emergency department for four steps |
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Exclude who from ottawa?
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preggers and drunks
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According to OTTAWA when is a foot x ray indicated?
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pain in mid foot and either
TTP 5th metatarsal TTP navicular inability to bear weight imm and in ER for 4 steps |
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Pt with Sx of hyperesthesia, numbness, aching, burning from metatarsal heads into the 3rd and 4th toes
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Morton's Neuroma - Tenderness over plantar surface, 3rd and 4th metatarsal heads, from probable entrapment of the medial and lateral plantar nn
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What is hammer toe?
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2nd toe, hyperextension at metatarsophalangeal joint w/flexion at proximal interphalangeal joint
-corn frequently develops |
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Where does stability of the hip joint arise?
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-Deep fit of the head of the femur into the acetabulum
-Strong Fibrous articular capsule -mm Crossing the joint |
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Anterior bony structures of the hip?
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-Iliac crest at the level of L4
-Iliac tubercle -Anterior superior iliac spine (ASIS) -Greater trochanter -Pubic Symphysis |
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Posterior bony Structures...
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-PSIS
-Greater Trochanter -Ischial Tuberosity -Sacroiliac Joint |
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Four powerful muscle groups move the hip?
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-Flexor (iliopsoas)
-Extensor (Glut max) -Adductor -Abductor (glut med and min) |
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What are the 3 principal bursae at the hip?
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-psoas (also termed iliopectineal or iliopsoas)
-trochanteric -ischial (or ishiogluteal) |
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Stance and Swing gaits?
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Stance - when foot on ground and bears weight (60% of walking cycle)
Swing - when foot moves forward and doesn't bear weight (40% of cycle) |
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Observe for gait:
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width of the base
should be 2 to 4” from heel to heel shift of the pelvis flexion of the knee. |
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NAVEL
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Nerve
Artery Vein Empty Space Lymph node |
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What can you not palpate unless it is inflamed?
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Ischiogluteal bursa
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Hip ROM: Flexion
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-Pt supine, place hand under Lumbar spine
-Pt bend each knee in turn up to chest and pull it against abdomen -back touches hand, further flexion must arise from hip itself -normally ant thigh to chest wall almost -note whether opposite thigh remains fully extended or resting on table |
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Hip ROM: Extension
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"Lie face down, then bend your knee and lift it up"
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Hip ROM: Abduction
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"Lying flat, move your lower leg away from the midline"
-press down on opp ASIS -W/other hand grasp ankle and abduct extended leg until you feel iliac spine move -do both at same time for max |
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Hip ROM: Adduction
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"lying flat, bend your knee and move your lower leg toward the midline"
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Hip ROM: Internal and External rotation
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Flex the leg to 90° at hip and knee, stabilize the thigh with one hand, grasp the ankle with the other, and swing the lower leg
Medially for external rotation at the hip and Laterally for internal rotation. It is the motion of the head of the femur in the acetabulum that identifies these movements. |
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external ROM
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Lying flat, bend your knee and turn your lower leg and foot across the midline.”
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internal ROM
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“Lying flat, bend your knee and turn your lower leg and foot away from the midline.”
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What is the largest joint in the body?
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Knee, hinge, femur, tibia and patella
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Why is there inherent instability of the knee joint?
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Dependant on ligaments to hold in place
-in addition the lever action of the femur on the tibia and lack of padding from fat or muscle, makes the knee highly vulnerable to injury |
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What are the muscle groups of the knee?
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Move and support the knee
Quadriceps femoris extends the leg. Hamstring muscles flex the knee. |
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MCL
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broad, flat ligament connecting the medial femoral epicondyle to the medial condyle of the tibia. The medial portion of the MCL also attaches to the medial meniscus.
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connects the lateral femoral epicondyle and the head of the fibula.
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LCL
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crosses obliquely from the anterior medial tibia to the lateral femoral condyle, preventing the tibia from sliding forward on the femur.
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ACL
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crosses from the posterior tibia and lateral meniscus to the medial femoral condyle, preventing the tibia from slipping backward on the femur.
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PCL
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bursa lies 1 to 2 inches below the knee joint on the medial surface, proximal and medial to the attachments of the medial hamstring muscles on the proximal tibia. It cannot be palpated due to these overlying tendons.
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Pes anserine
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bursa that communicates with the joint cavity, also on the posterior and medial surfaces of the knee.
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semimembranous
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Inspection of knee
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Observe gait for a smooth, rhythmic flow as the patient enters the room.
knee should be extended at heel strike and flexed at all other phases of swing and stance. Check alignment and contours of the knees. Look for atrophy of the quadriceps muscles. Look for loss of the normal hollows around the patella, a sign of swelling in the knee joint and suprapatellar pouch Note any other swelling in or around the knee Look for any scars, lesions |
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Position of pt for knee palpation?
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Edge of table, knees in flexion
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Patellar grind test
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With the patient supine and the knee extended, compress the patella against the underlying femur.
Ask the patient to tighten the quadriceps as the patella moves distally in the trochlear groove. Check for a smooth sliding motion, grinding or pain is abnormal. |
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Palpate any thickening or swelling in the suprapatellar pouch
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start 10 centimeters above the superior border of the patella, well above the pouch, and feel the soft tissues between your thumb and fingers.
move your hand distally in progressive steps, trying to identify the pouch. continue your palpation along the sides of the patella. note any tenderness or warmth greater than in the surrounding tissues. |
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Check three other bursae for bogginess or swelling
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prepatellar bursa
anserine bursa popliteal fossa |
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The Bulge Sign (for minor effusions).
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With knee extended, place the left hand above the knee and apply pressure on the suprapatellar pouch, displacing or “milking” fluid downward. Stroke downward on the medial aspect, apply pressure to force fluid into the lateral area. Tap the knee just behind the lateral margin of the patella with the right hand.
(Detecting fluid in knee) |
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How do you detect major effusions in the knee?
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The balloon sign: Place the thumb and index finger of your right hand on each side of the patella; with the left hand, compress the suprapatellar pouch against the femur. Feel for fluid entering (or ballooning into) the spaces next to the patella under your right thumb and index finger.
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Ballotting the patella
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To assess large effusions, you can also compress the suprapatellar pouch and “ballotte” or push the patella sharply against the femur. Watch for fluid returning to the suprapatellar pouch.
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Thompson
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To test the integrity of the Achilles tendon, place the patient prone with the knee and ankle flexed at 90°, or alternatively, ask the patient to kneel on a chair. Squeeze the calf and watch for plantar flexion at the ankle.
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Knee ROM
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Flexion
Hamstring group: biceps femoris, semitendinosus, and semimembranosus “Bend or flex your knee.” Or “Squat down to the floor.” Extension Quadriceps: rectus femoris, vastus medialis, lateralis, and intermedius “Straighten your leg.” Or “After you squat down to the floor, stand up.” Internal Rotation Sartorius, gracilis, semitendinosus, semimembranosus “While sitting, swing your lower leg toward the midline.” External Rotation Biceps femoris “While sitting, swing your lower leg away from the midline.” |
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Meniscus damage
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A click or pop along the joint with valgus/varus stress, external/internal rotation, and leg extension suggests a probable tear of the posterior portion of the medial meniscus.
The tear may displace meniscal tissue, causing “locking” on full knee extension. |
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Mcmurray test
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lateral meniscus
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MCL assessment
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Abduction (or Valgus) Stress Test. With the patient supine and the knee slightly flexed, move the thigh about 30° laterally to the side of the table. Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle. Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side (valgus stress).
Pain or a gap in the medial joint line points to ligamentous laxity and a partial tear of the medial collateral ligament. Most injuries are on the medial side. |
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LCL assessment
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Adduction (or Varus) Stress Test. Now, with the thigh and knee in the same position, change your position so you can place one hand against the medial surface of the knee and the other around the lateral ankle. Push medially against the knee and pull laterally at the ankle to open the knee joint on the lateral side (varus stress).
Pain or a gap in the lateral joint line points to ligamentous laxity and a partial tear of the lateral collateral ligament. |
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How to assess ACL?
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A forward jerk showing the contours of the upper tibia is a positive anterior drawer test
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LAchman's test
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ACL
Place the knee in 15° of flexion and external rotation. Grasp the distal femur with one hand and the upper tibia with the other. With the thumb of the tibial hand on the joint line, simultaneously move the tibia forward and the femur back. Estimate the degree of forward excursion. -Significant forward excursion indicates an ACL tear |
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PCL assessment
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Anterior Drawer Test
-Push the tibia posteriorly and observe the degree of backward movement in the femur. |
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Interpretation of fractures:
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AABCDS
Adequate Film Alignment Bony Landmarks Cartilaginous Space Disc Space Soft tissues |
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Four Parallel Lines
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1. Anterior vertebral line (anterior margin of vertebral bodies) 2. Posterior vertebral line (posterior margin of vertebral bodies) 3. Spinolaminar line (posterior margin of spinal canal) 4. Posterior spinous line (tips of the spinous processes)
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Prevertebral Soft Tissue:
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Nasopharyngeal space (C1) - 10 mm (adult)
Retropharyngeal space (C2-C4) – 6mm Retrotracheal space (C5-C7) - 14 mm (children), 22 mm (adults). |
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Dens Fractures
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Type 1 - chip
Type 2 - big process Type 3- more than just the spike |
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Flexion Tear Drop Fracture
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Hyperflexion fracture with high mortality
Description: posterior ligament disruption and anterior compression fracture of the vertebral body. |
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Clay Shovler's
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MOI: Hyperflexion
Unlike with Anterior Subluxation injury the posterior ligament remains intact producing avulsion fracture of the spinous process Stable fxr |
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Hyperextension Injury
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Hyperextension Dislocation
Avulsion Fx anterior arch C1 Fx posterior arch of C1 Extension tear drop fracture Laminar Fx Traumatic Spondylolisthesis (Hangman’s Fx” |
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Bennett's
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Intra-articular fracture/dislocation of base of 1st metacarpal
Small fragment of 1st metacarpal continues to articulate with trapezium Lateral retraction of 1st metacarpal shaft by abductor pollicis longus Comminuted Variety-Rolando Fracture |
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Lisfranc Fx
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fractures and dislocations that occur at the junction between the tarsal bones of the midfoot and the metatarsals of the forefoot
-Suspect it is present if there is a gap of more than 5 mm between bases of 1st and 2nd metatarsals or 1st (medial) and 2nd (middle or intermediate) cuneiforms On lateral view, bones of the midfoot will be subluxed or dislocated in a plantar direction |
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Elbow Fx
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Adults-radial head
Peds-supracondylar Joint effusion without discrete fracture (positive posterior fat pad or anterior sail sign), represents an occult fracture until proven otherwise. |
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Jones Fx
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Fracture involving the base of the 5th metatarsal (usually 1.5mm distal to tubercle). Don’t confuse with avulsion fxr or apophysis.
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Pseudo Jones Fracture
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(unfused apophysis)
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Wrist Fx
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Scaphoid Fracture is mc fxr in wrist
2nd mc is triquetral |
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Ankle Fx
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Medial, lateral and posterior malleolus.
Ottawa ankle rules-pain in malleolar region and 1 of following (a) proximal bone tenderness (fibula) (b) Distal fibula or tibia bone pain (c) inability to bear weight for 4 steps. Maissoneuve fracture. |
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C2-Hangman’s Fx
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hyperextension and distraction.
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Flexion Tear drop Fx
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Description: posterior ligament disruption and anterior compression fracture of the vertebral body. Mechanism: hyperflexion and compression (e.g. diving into shallow water)
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