Clinic Entrance: Diagnosis
When observing gate, loot at...
(1) symmetry (2) balance (3) distance between feet (width) (4) length of stride (5) arm swing (6) heel strike
What do you evaluate lesions when examining the thorax for?
(SEV COMETS PD) -size -elevation -vascularity -color -odor -margins -exudate -texture -shape -pattern -distribution
When bronchial sounds are abnormal (heard anywhere other than manubrium) what is the underlying cause?
(normal = over the manubrium) When the alveoli are fluid-filled, collapsed, or replaced by solid substances (consolidation)
What is the typical color of new stretch marks?
(straie) red, pink, or brown typically darker
Which spinal nerve would a "far lateral" disc herniation compromise in the low back? Aka?
Aka foraminal disc herniation. -It would affect the spinal nerve with the same numeric designation.
What is pectoralis minor syndrome? Aka?
Aka hyperabduction syndrome. It is compression under the pectoralis minor muscle-tendon.
What is a Nursemaid's elbow?
Aka pulled elbow. This is when the radial head partially dislocates from the annular ligament. Toddlers 1.5-4 years old typically.
Ddx rhinophyma with _________.
Alcoholism
Causes of chronic laryngitis
Alcoholism Smoking Hypothyroidism Trauma (at the neck) Compression of recurrent laryngeal nerve by aortic aneurysm or tumor
What test is for vascular patency?
Allen's test
Condition characterized by loss of hair in round or oval areas without visible inflammation of skin that may exhibit broken off, stubby hairs
Alopecia areata
Fleeting blindness AKA
Amaurosis Fugax
Uremia or kidney failure leads to a _________ odor.
Ammonia
Diagnose macular degeneration with the ___________.
Amsler grid
What does a stridor indicate?
An urgent sign that suggests a partial obstruction of the trachea or mainstem bronhi from aspiration
Baldness seen in middle-aged and older adults that is genetically determined
Androgenetic alopecia
"Active crows feet" at mouth AKAs
Angular stomatitis Cheilosis Periech
Unequal pupils
Anisocoria
Tongue tied, congenital (short frenulum)
Ankyloglossia
Absence of nail
Anonychia
4 possible reasons for monoplegia (LE)
Anterior cerebral artery CVA, contralaterally T2-12 spinal cord injury, ipsilaterally Lumbosacral plexus lesion, ipsilaterally Spinal nerves or peripheral nerve lesion, ipsilaterally
Canker sore AKA
Aphthous ulcer
With normal cervical rotation, the chin ________ the ________, but does not quite become parallel to it.
Approximates the shoulder.
The low side of the tonsilar arches is the side of the _________.
Arches
Pale gray blue discoloration around the colored portion of the eye
Arcus senilis
Miotic pupil associated with syphilis
Argyll-Robertson Pupil
Spider angiomas (AKA _________) is associated with increased _________.
Arterial spiders Estrogen
Purpose of Romberg test
As a standing examination, the Romberg test is often performed early in the exam, and direct JPS testing in the lower extremity would be done as a follow-up to a positive Romberg test
What causes ataxic breathing?
Brain damage at the medullary level
What is Hawkin's test?
Bring the arm up into flexion at 90 degrees, then internally rotate. Indicative of Impingement syndrome.
4 Causes of Uvula Edema (interferes with breathing)
Bronchitis Smoking Allergic reaction (anaphylactic) Asthma
Attrition is the process in aging where teeth are worn down & ___________ is exposed.
Brown dentin
Fundoscopic exam with papilledema will appear _________ & _________.
Bulging Inverted disc (button)
Vesicle greater than 1cm in diameter
Bulla (Examples: Blister, pemphigus vulgaris)
Most common bulbous autoimmune disease
Bullous pemphigoid
"Miner's elbow" and "Turf elbow" are two popular names for this condition: a) Medial epicondylitis b) Lateral epicondylitis c) Olecranon bursitis d) Medial growth plate fracture
C
According to Hoppy, triceps strength is mediated primarily by: a) C5 b) C6 c) C7 d) C8 e) T1
C
According to Jobe, the best position for evaluating supraspinatus muscle strength is with abduction to ____ degrees in the ________ plane with ________ rotation. a) 60, saggital, internal. b) 90, scapular, external. c) 90, scapular, internal. d) 50, coronal, external.
C
The C6 neurologic level is the *primary* innervation of the ________ DTR. a) Triceps b) Biceps c) Brachioradialis d) Deltoid
C
The soft tissue structures of the suprahumeral space include from superior to inferior: a) Supraspinatus tendon, infraspinatus muscle, teres major muscle. b) Supraspinatus tendon, subdeltoid bursa, subacromal bursa. c) Subdeltoid bursa, supraspinatus tendon, glenohumeral joint capsule. d) Deltoid muscle, infraspinatus muscle, subacromial bursa.
C
A positive Wrist Drop test would indicate possible: a) Radial nerve palsy b) Median nerve palsy c) Ulnar nerve palsy d) Axillary nerve palsy
B
The carpal bone most likely to be fractured by a fall on the outstretched extended wrist: a) Capitate b) Scaphoid c) Triquetrum d) Pisiform
B
The coracoid process can be palpated ________ to the lateral third of the clavicle. a) Superior b) Inferior c) Posterior d) Medial
B
The most forceful pushing posture of the forearm - wrist complex is: a) Supination, flexion b) Pronation, extension c) Supination, extension d) Pronation, flexion
B
The normal carrying angle of the elbow is approximately: a) 0-5 degrees varus b) 5-15 degrees valgus c) 15-25 degrees varus d) 25-40 degrees valgus
B
Upon hand radial deviation (abduction), the examiner can palpate the Triquetrum gliding: a) Radial b) Lateral c) Medial d) Anterior
C
To perform Cozen's test for lateral epicondylitis, the patient's wrist is positioned in ________ and the patient is told to ________ the examiner's efforts. a) Flexion, resist b) Extension, resist c) Extension, move with d) Flexion, move with
B
To perform the active version of the ________ Test, the examiner shows the patient haw to maximally flex the wrist and pronate and extend the elbow. a) Farmer's b) Mills c) Field's d) Valley's
B
Which of the following maneuvers is most likely to cause impingement of the soft tissue contents of the suprahumeral joint space? a) Gray's T b) Hawkin's T c) Thompson's T d) Strutin's T
B
Which of the following tests is based on the idea of displaced tenderness to palpation with joint movement (A pain that disappears)? a) Shoulder Apprehension test. b) Subacromial bursa (Dawbarn's) test. c) Abbott Saunders test. d) Yergason's test
B
Which of these structures is/are anterior to the body of the scapula? a) Scapular spine b) Subscapularis muscle c) Teres minor muscle d) Infraspinatus
B
Smooth Tongue (AKA atrophic glossitis) can be caused by...
B vitamin deficiency Anemia Chemo
What is the significance of Bakody's sign?
Cervical radiculopathy (C5-7). -This position relieves traction on the brachial plexus and cervical spinal nerves. -*Exacerbation of arm pain/paresthesia suggests Pectoralis Minor (hyperabduction) syndrome.*
Plugged meibomian gland
Chalazion
Firm button like lesion that ulcerated and may crust, very contagious
Chancre
What is pleural friction rub similar to in sound?
Chest hair rubbing under the stehtoscope
What are periods of deep breathing alternated with periods of apnea (regularly, irregular breathing)?
Cheyne-stokes breathing
blocked Eustachian tubes are more common in ___________ due to ____________ leading to fluid accumulation.
Children Horizontal tube
Normal = cone of light should point to ___________.
Chin
Pityriasis rosea on the back usually has ____________ pattern lesions.
Christmas tree
Causes of Sialolithiasis
Chronic infection Dehydration Sjoren's syndrome Idiopathic
3 Causes of Tonsil Hyperplasia (protrusion beyond pillars)
Chronic infection Obesity Thyrotoxicosis
When eyes are able to accommodate, it is because the _________ allows the lens to relax, giving it a ____________ shape.
Ciliary body Rounded/curved
Symptoms of blocked eustachian tubes
Clogged feeling w/ intermittent pain Ear feels "full" Decreased hearing
Clonus at the ankle
Clonus at the ankle may be produced by rapid dorsiflexion of the foot resulting in quick stretch of the plantarflexors.
clonus at the wrist
Clonus at the wrist may be produced by rapid extension of the wrist resulting in quick stretch of the wrist flexor musculature
Contents of Inner ear
Cochlea Vestibule Semicircular canals Nerves Vestibular apparatus
What ortho/neuro tests indicate a rotator cuff tear?
Codman's drop arm test.
Portion of nose between nares
Columna/Columella
What is costoclavicular syndrome?
Compression in the costoclavicular space.
2 causes of Saddle Nose
Congenital Syphilis Untreated septal hematoma
2 causes for limited lingual protrusion
Congenital short frenulum Elderly (cancer @ base of tongue)
Miotic
Constricted pupils
With CN X lesion, the uvula will deviate toward the ___________.
Contralateral side (Ahhh test)
Light stripe wider than normal, but does not cover entire artery
Copper Wiring
What follow-up tests should be performed following a positive Neri's Bowing sign?
Correlate this test with other sciatic-radiculopathy orthopedic tests, and neurologic examination, as tight hamstrings can cause this sign.
Bullous pemphigoid trx
Corticosteroid
Viral/bacterial rhinitis
Coryza
What orthopedic tests may help identify costoclavicular syndrome?
Costoclavicular test (Eden's test)
Microinfarctions causing swelling of terminal nerve fibers, caused by hypertension
Cotton wool exudate/patches
Tests for Strabismus
Cover/Uncover Cardinal field of gaze
What tests indicate lateral epicondylitis?
Cozen's test or Mill's test.
Epidermoid cyst exudate is __________ colored, pasty and smells like ___________.
Cream Rancid cheese
Dysfunction of CN VI
Cross eyed
When moving the trachea side to side, the patient may hear ________ which is normal, but should not be painful.
Crunching
Dried serum, blood or purulent exudates, slightly elevated, size varies, brown, red, black, tan or straw colored
Crust (Examples: scab, eczema)
What is periumbilical ecchymosis called?
Cullen's sign
Retinal detachment patients experience vision loss like a _____________, have increased ____________ and ___________.
Curtain across eye Floaters Sparks of light
What does violaceous/purple stretch marks suggests?
Cushings syndrome
Painful conditions that may cause nodules on pinna
Cutaneous cyst Chondrodermatitis Nodularis helicis Hematoma from trauma
Elevated circumscribed, encapsulated lesion in dermis or subcutaneous layer, filled with liquid or semisolid material
Cyst (Examples: Sebaceous cyst, cystic acne)
Froment's Sign is the innate substitution of a(n) ________ Nerve function (1st IP joint flexion) for a(n) ________ Nerve function (CMC adduction). a) Ulnar, radial b) Radial, medial c) Radial, antebrachial d) Median, ulnar
D
Pick the normal ratio of scapular to humeral motion (scapulohumeral rhythm) during abduction of the shoulder. a) 3:1 b) 1:5 c) 2:6 d) 1:2
D
The Shoulder Apprehension Test is quite effective (and affective) because: a) Arm internal rotation with flexion is uncomfortable. b) Shoulder adduction is usually weak. c) It exaggerates shoulder flexion. d) It reproduces a common mechanism of dislocation.
D
The deltoid muscle, glenohumeral joint, arm mechanism (during abduction) is an example of a Class ________ Lever System. a) I b) II c) Many people guess C if they don't know the answer but in this case it would be a mistake. d) III
D
The lower trapezius inserts on the ________. a) Medial border of the scapular body. b) Sternoclavicular joint c) Inferior angle of the scapula. d) Medial aspect of the scapular spine.
D
The most appropriate diagnostic procedure for assessing frozen shoulder syndrome (Adhesive Capsulitis) is: a) Inspection b) Static palpation c) Muscle testing d) ROM testing
D
The most common direction of lunate dislocation is: a) Medial b) Lateral c) Posterior d) Anterior
D
The primary stabilizer of the A-C joint against S-I shearing dislocation (superior separation of the clavicle with a horizon sign) is the: a) A-C ligament b) Costoclavicular ligament c) Posterior deltoid muscle d) Coracoclavicular ligament
D
Which of the following bursae is usually irritated in shoulder impingement syndrome? a) Supinatus b) Infraspinatus c) Subcoracoid d) Subacromial
D
Which of the following tests is utilized in the diagnosis of CTS: a) Boss's b) Walton's c) Phillip's d) Phalen's
D
What is murphy's punch?
a "punch" over the costovertebral angle
What is atelectasis?
a collapsed lung with a bronchial plug
What sound does a pleural friction rub cause?
a crackling, grating sound caused by inflamed, roughened pleural surfaces
What causes a wide split?
a delayed closure of the pulmonic valve (pulmonic stenosis/right bundle branch block) or early closure of the aortic valve (mitral regurgitation)
When basic sensory functions are intact, and cortical sensory tests are abnormal ("agnosis"), what is suspected?
a lesion of the somatosensory association cortex in the contralateral parietal lobe is indicated.
What can a flail chest cause?
a puncture to the lung=collapse
What is an abnormal finding when percussing the spleen and what does it indicate?
a tone that changes to dull when the patient inhales; an enlarged spleen
What is an example of a neoplastic mass?
a tumor
What is ochronosis?
a type of alkoptonuria that presents w/ darkened pinna, nose, sclera, and other cartilages/tendons
What tests are performed to assess the function of the somatosensory cortex in the parietal lobe?
Discriminate gnosis tests (stereognosis, graphognosis, & extinction)
Where does conscious proprioception testing begin?
Distally and work proximally until sensation is fely
How to test anterior tibialis?
Dorsiflex and invert patients foot, do opposite
3 causes of Congenital Macroglossia
Down's syndrome Cretinism Myxedema (hypothyroidism)
Miotic pupils under 2mm could be due to...
Drugs Horner's syndrome Sun
___________ result from dry macular degeneration, atherosclerosis, or hypertension.
Drusen bodies
Sjoren's syndrome is ___________, _______________, & _____________.
Dry eyes Dry mouth Arthritic joint pain
How is thoracic rotation ROM measured?
Dual-inclinometer ROM. With patient standing in a forward flexed position with the thoracic spine in as horizontal position as possible, place the inclinometers over T1 and T12 SPs and instruct the patient to rotate. Subtract the T12 reading from the T1 reading.
How is thoracic ROM typically measured?
Dual-inclinometer methd with the patient seated. One over T1 and the other over T12. Subtract the T12 reading from the T1 reading.
How is thoracic lateral flexion measured?
Dual-inflinometer method. Place one over T1 and the other over T12. Subtract T12 from T1 reading.
What is Dupuytren's contracture?
Dupuytren's contracture is a hand deformity that usually develops over years. The condition affects a layer of tissue that lies under the skin of your palm. Knots of tissue form under the skin, eventually creating a thick cord that can pull one or more fingers into a bent position. May be able to treat with Active Release Technique. Flexion fracture secondary to being dislocated.
Cutaneous sensation to the medial side of the proximal forearm and the medial aspect of the distal arm is provided by: a) C5 b) C6 c) C7 d) C8 e) T1
E
What is scissor gate
Each leg is advanced slowly and the thighs tend to cross forward of each other on each step
What does SLR with medial rotation do?
Further sensitizes the sciatic tract. -The addition of medial hip rotation to a SLR will often worsen spinal/leg symptoms. It probably sensitizes the common peroneal division more than the tibial division of the sciatic nerve.
Boil (walled-off, deep pus)
Furuncle
What is the Lewin-Gaenslen test?
Gaenslen's test performed with the patient on their side. -The patient is placed on the unaffected side draws that knee toward the chest. The examiner stands behind the patient, stabilizes the sacrum with one hand and extends the lower extremity on the affected side.
What innervates the intrafusal fiber within the muscle spindle and set the sensitivity of the muscle spindle to stretch?
Gamma motor neurons
Congenital anonychia
Generally affects entire limb bud of hand or foot 1 or more limbs may be affected
What is a contraindication for the Naffzigger test?
Geriatric patients. Caution should be used when testing patients with suspected atherosclerosis. Lightheadedness, dizziness, or syncope may occur.
What is a sharply angled kyphosis due to a collapse of a vertebrae called?
Gibbus
Tunnel vision, found through the confrontation test is indicative of __________.
Glaucoma
CN IX
Glossopharyngeal
If there is dysfunction, sound will be heard in the ________.
Good ear
Painless conditions that may cause nodules on pinna
Gouty tophi RA Leprosy (Hansen's dz) Carcinoma Keloid
Where do you grab the extremity when testing conscious proprioception?
Grab it by the sides
What is the Trendelenburg test?
It assesses the ability of the gluteus *medius* to stabilize the pelvis on the femur. -With the patient standing and holding onto a support for balance if necessary, the examiner observes from behind and instructs the patient to raise one foot off the floor. The examiner observes the level of the iliac crest, sacral dimples, or gluteal folds. -Drooping of the pelvis on the unsupported side indicates weakness of the gluteus medius on the supported side.
What breathing instructions do you give the patient when auscultating the carotid arteries?
Inhale and hold breath
Tinea cruris
Inner thighs (jock itch)
During tracheal breath sounds is inspiratory shorter or longer than expiratory? Is there a pause between exhale and inhale?
Inspiratory EQUALS expiratory and there IS a pause
What is the elevated arm stress test (EAST)?
Instruct the patient to abduct their arms to 90 degrees with elbows straight and palms facing down. The patient opens and closes their fists for 2 minutes.
What is the intermittent claudication test?
Instruct the patient to abduct their arms to 90 degrees with elbows straight, and then to externally rotate their arms so that their palms face up. The patient open and closes their fists for 1 minute.
What is Roos test?
Instruct the patient to abduct their arms to 90 degrees with the elbows bend 90 degrees, and then to externally rotate their arms (hostage position). The patient opens and closes their fists for 3 minutes.
Candida in folds of skin, under breasts or between legs
Intertrigo
If you recognize Peutz-Jeghers syndrome, the patient needs an early screen for ___________.
Intestinal cancer
Tonometry tests for _______________.
Intraocular pressure
What is Lindner's test?
Involves flexion of the cervical spine in order to stretch the dura and provole low back and lower extremity complaints due to radiculopathy.
Lateral flexion with cervical compression narrows what?
Ipsilateral IVF
Argyll-Robertson pupils will be ___________, will have __________ to light, a reaction to ___________, and an _________ reaction to near objects.
Irregular No reaction Painful stimulus Intact, but diminished
What is bursitis?
Irritation of the subcutaneous olecranon bursa by acute trauma or by repetitive irritation as in crawling on one's elbows.
How is the sitting laseque test a malingering test?
It acts as a malingering test because it is essentially a seated version of the SLR, but you can say that you are checking the feet or some other distractor.
What is a CROM device and what is its advantage?
It attaches the measurement instruments to the patients head and eliminates a source of examiner error.
What does yellow skin with yellow sclera indicate and what disease is it associated with?
Jaundice; liver disease (sclera is most accurate)
What condition is pulse alternans associated with?
Left ventricular failure
Accommodation tests the ____________.
Lens - ciliary mm
3 possible reasons for paraplegia
Lesion of the medial aspect of the motor cortex bilaterally. For example, parasaggital meningioma in the falx cerebri. Transection of the spinal cord between T2 & T12 Lesion of the lumbosacral plexus bilaterally
External inspection of the ear includes looking for...
Lesions Deformities Size Shape Symmetry Exudate
Normal nail angle
Less than or equal to 160
Thin, lacy, spiderweb like white lines on mouth/gums
Lichen planus
Thickening of skin in response to repeated scratching
Lichenification
Rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation; often involves flexor surfaces of extremities
Lichenification (Examples: chronic dermatitis)
Strip of sclera is visible at patient directs gaze downward
Lid Lag
How do you test the plantar reflex?
Lightly stroke the lateral aspect of the sole of the foot across the ball of the foot
What is the Naffzigger test (jugular compression test)?
Like the Valsalva Maneuver, this test increases intrathecal pressure and helps identify space-occupying lesions causing radiculopathy. It is much faster and easier to use the Valsalva maneuver. -With the patient seated or supine, the examiner compresses the jugular veins for 30-45 seconds. -Compressing the jugular veins backs up venous drainage from the head. The backup in the dural venous sinuses may lead to decreased absorption of CSF, resulting in increased CSF pressure.
Medial epicondylitis aka?
Little league elbow or golfer's elbow.
What is subacute combines systems disease caused by?
Long term B12 deficency
Reedy nails have ____________ & are ______________.
Longitudinal ridging Clinically insignificant
Typical wallenberg presentation?
Loss of P/t in ipsilateral face and contraletal body
ataxia
Loss of smoothness or accuracy of movement
Most common causes of contact dermatitis
Lotions Soaps Detergents Metals Latex Poison oak/ivy Chemicals
What is the intensity of the bronchial expiratory sounds? Pitch?
Loud; high pitch
Viral sore throat
Low fever Myalgia Posterior nodes enlarged
Most common location for labial carcinoma is _________.
Lower lip
What bone of the hand has no muscle attachments?
Lunate
What is the most common carpal dislocation? How does it typically dislocate?
Lunate. Dislocates anteriorly.
3 possible reasons for quadriplegia
Motor cortex lesion (bilateral), sparing the face region of the homunculus Transection of the cervical cord above C5 (most common cause) Bilateral brachial plexus & lumbosacral plexus lesions
3 possible reasons for hemiplegia
Motor cortex lesion contralaterally, sparing the face portion of the homunculus Lesion in the medulla contralaterally (below CN VII innervation of the face) Cervical cord lesion above C5 ipsilaterally
2 possible reasons for monoplegia of the upper extremity
Motor cortex, contralaterally Brachial plexus, ipsilaterally
ALS is a member of what group of diseases?
Motor neuron diseases
Causes of xerostomia
Mouth breathing Obstruction of ducts Sjoren's Rx
Translucent squishy bluish-colored cyst on lip, cheek or tongue
Mucocele
Redness & swelling of stenson's ducts opening (opposite 2nd upper molar) indicates possible ___________.
Mumps
What is a positive finding for gallbladder palpation?
Murphy's sign
Motor fx of CN V
Muscles of mastication Medial & lateral pterygoids Tensor tympani
Can fibrillations be seen?
NO
Severe illnesses can result in decreased ___________ & ___________.
Nail Hair growth
Onychomycosis
Nail fungus
Angle of nail
Nail plate that exits cuticle
External openings of nose
Nares
When the TM is retracted, the cone of light will be _____________ & the Eustachian tube will be ________.
Narrow Blocked
Wings of nose
Nasal ala
Abnormal growth in nose resembling raw hamburger
Nasal cancer
Macroglossia later in life becomes a _________
Neoplasm (occlusion of lymphatics)
Proliferative diabetic retinopathy patients will have ___________.
Neovascularization
Lichen Simplex Chronicus AKA
Neurodermatitis
Appears to be wider space between arteries & veins
Nicking
Pephigus vulgaris will have _____________ and is common in ______(age).
Nikolsky's sign 40-60
Will the marks for diaphragmatic excursion be at the same level on the right and left side?
No because of the liver the right will be higher but the distance should be the same
Fundoscopic findings with complete retinal detachment
No red response
Conduction deafness findings at the Rinne test
No sound in air
Should all areas on the right side of the thorax be percussed before the left side?
No, percussion should be compared bilaterally so alternating sides
Elevated firm, circumscribed lesion, deeper in dermis than papule, 1-2cm diameter
Nodule (Examples: erythema nodosum, lipoma)
What is trigger finger?
Nodule on the flexor tendon and the finger gets stuck in flexion. Typically occurs due to repetitive microtrauma. -A fibrous nodule develops on the finger flexor tendon near the base of the proximal phalanx. Usually occurs on the thumb or index finger and is not problematic until it becomes large enough to get snagged under the flexor retinaculum.
Partially lost sensorineural findings w/ Rinne Test
Normal 2:1, but decrease in total time at the bad ear or <20 seconds on mastoid
2+
Normal DTR
Cherry angiomas at 30 y.o. Are _____________.
Not clinically significant
Normal position of TM
Not retracted or bulging, no lesions, distinct cone of light
What ortho/neuro tests indicate a SLAP lesion?
O'Brien's test
Testing lateral rectus
Observe lateral movement of eye
CN III
Occulomotor
Normal nail plate color is ________.
Off-white
Yellow nails are caused by...
Old are Diabetes Feet in warm/sweaty enviro for long periods
Fetor oris/halitosis is bad breath due to...
Old food Lung abscess Pyloric obstruction
CN I
Olfactory
How is the doctor positioned when palpating the spleen?
On the right side of the patient and their left hand reaches across the patient placing it under the patients left ribcage
Dual inclinometer method of measuring lumbar ROM.
One at T12 and one at S1.
Where does the palmar cutaneous branch of the median n come off of? Where do you test sensations?
PROXIMAL to carpal tunnel sensation in the lateral palm and thenar region
Signs & sx for open angle glaucoma
Pain less Slow insidious onset Positive confrontation Hard eye Negative shadow test Unilateral or bilateral (mostly bilateral) *refer to optometrist or ophthalmologist
Signs & sx for closed angle glaucoma
Painful Rapid onset Visual disturbance Hard eye + shadow test, ciliary flush and pupil dilation Unilateral *immediate ER referral
Macular degeneration causes ______________.
Painless loss of central vision
A common location for kaposi's sarcoma at the mouth is on the ________.
Palate
Lunula
Pale white moon out of cuticle
Molluscum contagiosum is not on _________ & _______, it lasts up to _______, and when they are beginning to heal, the papules will develop an ________________ around it.
Palms Soles 6 months Erythmatous inflammation halo
Components of the sinus exam
Palpation Transillumination of sinuses Assess for positional exacerbation of pain (lean over) Radiographic views (fluid/tumor)
Best identification of Actinic Keratosis is __________.
Palpation (sandpaper texture)
Increased ICP can cause ______________ (AKA ____________).
Papilledema Choked disc
An elevated, firm, circumscribed area less than 1cm diameter
Papule (Examples: wart, elevated moles, lichen planus)
Transection of the cord between T2-12 results in what?
Paraplegia
Paronychium inflammation
Paronychia
Skin around the nail, may be tender when ingrown or infection is present
Paronychium
2 parts of the TM
Pars tensa Pars flaccida
Clubbing of nails is associated with ....
Pulmonic conditions (fibrosis, cancer, emphysema) Cardiac conditions (cyanosis, Congenital heart dz)
Distinguish seborrheic keratosis from melanoma by a _________ and its __________.
Punch biopsy Greasy look & feel
PERRLA
Pupils are Equal, Round, React to Light, Accommodate
4 Ps of Lichen Planus
Purple Polygonal Papules Pruritis
Red/purple macules or patches caused when small blood vessels leak blood under skin
Purpura
Elevated superficial lesion, similar to a vesicle but filled w/ purulent fluid
Pustule (Example: impetigo, acne)
Purulent gums with infected pockets between gums & teeth
Pyorrhea-periodontal dz
What quadrant do you start the abdominal exam on?
Right lower quadrant in clockwise direction except if there is pain do that quadrant last
What side does the doctor stand on during the abdominal exam?
Right with the exception of the left kidney
Rhinophyma is idiopathic, may be an extreme case of __________, is ___________, hypertrophy of ________________ leading to a ____________ nose.
Rosacea Disfiguring Sebaceous glands/tissues Bulbous, red
Ddx Rosacea vs Acne
Rosacea = later age onset & no comedones
Testing CN VIII - cochlear (hearing)
Rub Weber Rinne
Everters
S1 Superficial peroneal N
toe walk tests what spinal and peripheral n
S1 tibial
Glut max
S1 inferior gluteal N
plantarflexors
S1 tibial
What are the normal heart sounds?
S1 and S2
Testing the plantar flexors is testing?
S1 tibial
DTR for Achilles
S1 tibial (S1,2)
Testing glut max is testing?
S1/ inferior glut n
Testing the everters is testing?
S1/ superficial peroneal
Anal Reflex tests what spinal nerves
S2-5
Inspecting Nails
S3 CBPALP Size Shape Symmetry Color Bed Plate Angle Lunula Paronychium
What are the abnormal heart sounds?
S3 and S4
What is the mitral maneuver used to better detect?
S3. S4. low-pitched murmurs, and mitral stenosis
What is Hibb's test?
SI joint test, but also stresses the hip joint and stretches the piriformis muscle. -With the patient prone, stand on the side opposite to that being tested. Stabilize the pelvis by placing a hand on the sacrum and then flex the knee to 90 degrees and rotate the foot outward. -SI pain indicates lesion. Hip pain indicates a hip disorder. -Moving the foot laterally causes internal rotation on the hip. Piriformis spasm would cause restriction of the hip rotation.
What is a SLAP lesion?
SLAP stands for Superior Labrum Anterior to Posterior, which describes the tear in the superior aspect of the glenoid labrum. The several types of SLAP tears may be the result of macro trauma or repetitive loading.
What is considered to be a "powerful sensitizing addition to the SLR?"
SLR with adduction. -The sciatic tract is lateral to the ischial tuberosity and the addition of adduction to a SLR (or simply adduction in neutral) will add further tension to the nervous system.
Mite infestation burrowing on sides of hands, legs & genitals
Scabies
Heaped-up, keratinized cells; flaky skin, irregular, thick or thin/dry or oily/variation in size
Scale (Examples: flakes with seborrheic dermatitis following scarlet fever or flaking following a drug reaction, dry skin)
What does a positive intermittent claudication test indicate?
Scalenus Anticus syndrome
What does a positive elevated arm stress test (EAST) indicate?
Scalenus anticus syndrome
What is the most reliable sign of a scaphoid fracture?
Scaphoid fracture test (handshake test). The patient's hand is pronated and gently stressed by ulnar deviation. Elicits pain in the anatomic snuffbox.
What is the second-most common carpal dislocation? Hos does it typically dislocate?
Scaphoid. Usually dislocates anterior and laterally and projects on end on the P-A wrist film.
Thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis
Scar (AKA Healed wound or surgical incision)
Piriformis syndrome aka?
Sciatic neuropathy
Oral Candida albicans can ____________, while leukoplakia cannot.
Scrape off
___________ is a benign epithelial tumor that may resemble melanoma
Seborrheic Keratosis
Sensory fx of CN V
Sensation to face (V1-3) General sensation to anterior 2/3 of tongue Corneal reflex (w/ CN VII & III) Jaw Jerk (maxillary reflex) Occulocardiac reflex (w/ CN X)
Trigeminal nerve fx
Sensory & Motor
Vestibulocochlear nerve fx
Sensory - Cochlear & Vestibular
Facial nerve fx
Sensory - Taste @ Anterior 2/3 tongue Motor - Mm of facial expression, corneal reflex efferent limb, stapedius Parasympathetic - lacrimal Glands & salivary glands
Glossopharyngeal nerve fx
Sensory - posterior 1/3 of tongue (sensation & bitter), oropharynx (gag reflex), afferent carotid sinus reflex Motor - stylopharyngeus Parasympathetic - parotid glands
Olfactory nerve function
Sensory - smell
Vagus nerve fx
Sensory - taste Motor - Pharynx, Efferent gag reflex/carotid sinus reflex/oculocardiac reflex
Optic nerve function
Sensory - vision
Separates sides of nose
Septum
Tympanosclerosis may follow ____________ and usually has no _____________. It is clinically __________ and is a healed ________.
Severe otitis media Hearing impairment Insignificant Perforation
Clincal findings of Keratosis Obturans
Severe pain Mild hearing loss Often w/ bronchitis
What is a positive Lhermitte's sign?
Sharp pain down the spine and into the upper or lower extremities.
What ortho-neuro tests indicate possible adhesions?
Shoulder depression test and other tests that may cause stretching of the nerve roots.
Test the CN XI trapezius fx
Shoulder shrug - resistance
Salivary calculi causing submandibular swelling associated with eating
Sialolithiasis
Test the __________________ for tenderness.
Side, tip & center
Cancer of the tongue is most common in what places?
Sides Base Under
What is the significance of percussion?
Significant local pain in a traumatized area is suggestive of fracture.
Light stripe as wide as the artery, making it look silver
Silver wiring
What is Deyerle's test?
Similar to Bowstring test except seated. -The knee is extended until pain is created or exacerbated. The knee is then flexed slightly and pressure is applied into the popliteal fossa.
What is the Laguerre test?
Similar to Fabere test, but the ankle is held above the knee rather than rested on it. -"Laguerre is Fabrere in the air."
What is Ely's sign?
Similar to Nachlas test, but without pelvic stabilization. -With the patient prone, the examiner flexes the patient's knee, bringing the heel toward the ipsilateral buttock. -Positive sign is when the pelvis on the side being tested ligts off the table. It is indicative of tight rectus femoris.
What are cogwheel breath sounds?
Similar to vesicular, but inspiratory phase is interrupted by several short pauses
_________ is not visible through the TM.
Stapes (ossicle)
While performing the H in space, watch the patients eyes for ____________ & ___________.
Strabismus Nystagmus
Scarlet fever causes _________ tongue.
Strawberry
Canker sores occur due to...
Stress Trauma Allergies
What is a wheeze that is entirely/predominately inspiratory?
Stridor
creamasteric refelx
Stroke the proximal medial thigh in a downward direction
How to test the anal reflex?
Stroking the perianal area
Abnormal findings when moving trachea
Stuck (suspect cancer of neck)
Nystagmus
Stutter/shakey eyes with movement
____________ is well-demarcated liver shape area of redness on the sclera of eye.
Subconjunctival hemorrhage
What can cause piriformis syndrome?
Subluxation of either the sacrum or femur may cause spasm of the muscle and entrapment of the sciatic nerve.
Bacterial sore throat
Sudden severe onset High fever Red Swollen tonsils Loose yellow exudate Anterior nodes enlarged
Enophthalmus
Sunken eyes
Most common type of melanoma
Superficial spreading
Extraocular muscles include...
Superior Rectus Inferior Rectus Medial rectus Inferior oblique
How is the patient positioned in an abdomen exam?
Supine with knees bent
When performing the lymph node exam, beware of exiting nerves at...
Supraorbital notch Infraorbital foramen Point of larynx Supraclavicular fossa
If a sensory deficit is identified, what do you test next?
Surrounding areas
Virchow's nodes
Suspicious node at the Left Supraclavicular fossa (metastasis from GI)
Inspect for __________ or __________ during the TMJ exam.
Swelling Redness
What is Yeoman's test?
Tests SI joint and lumbar spine. -With the patient prone, apply pressure to the suspected SI joint and flex the heel to the ipsilateral buttock while extending the hip by lifting the knee off the table. -Pain in the region of the SI joint indicates SI joint lesion. Also stresses the lumbar spine, can have tight quads, and may elicit sciatic-like sensation down anterior thigh.
What structures are normally damaged with an AC joint separation/sprain?
The AC joint itself and the AC ligament, but more importantly the coracoclavicular ligament (which consists of the conoid and trapezoid).
What is the most commonly dislocated joint in the body?
The PIP. It is rarely reported and documented since it is usually self-reduced. The mechanism of injury is typically forced hyperextension.
What can a depressed chest (funnel chest) cause?
can compress the heart and great vessels causing murmurs
What breast mass is most common over age 50; irregular, stellate, firm, adheres to adjacent tissue, nontender (usually)
cancer
Bacterial infection extending deeper into subcutaneous tissues
cellulitis
What disease are intention tremors associated with?
cerebellar dx
Athetosis is most often seen in?
cerebral palsy
Where do the cervical nerves exit?
cervical spinal nerves exit above the vertebra with the corresponding number
What does pressing the stethoscope firmly to the chest wall do to distinguish between chest hair and pleural friction rub?
chest hair sound will decrease with pressure and pleural friction rub sound will increase
Who are tics most often seen in?
children
Who are rachitic rosary seen in?
children with rickets (severe vitamin D deficiency)
What type of tumors cause cerebellar ataxia
children: primary tumors adults: mets
What is another name for a scar?
cicatrix
When testing sensory tests, should the patients eyes be open or closed?
closed
If the cell body dies, what happens?
collateral re innervation
What do you do if you suspect the pt has polyneuropathy?
compare vibration sense between the distal and proximal parts of the extremities
Screening of vibration should minimally include what?
comparing vibration in the distal lower extremity (or also the distal upper extremity)
What does bronchophony and whispered pectoriloqy suggest?
consolidation
secondary afferent lesions cause what type of sensory loss?
contra
What is the normal Anal relfex
contraction of the external anal spinchter
BG lesions present _______ to the side of the BG lesion
contralateral
a lesion in the VP nucleus of thalamus causes what type of sensory loss
contralateral
a lesion in the tertiary will cause what type of sensory loss?
contralateral
Where does the the upper part of the facial nucleus receive innervation from?
contralateral innervation from corticobulbar
Facial weakness due to UMN lesion (corticobulbar tract) results in what?
contralateral lower half of the face
How is the patient's arm positioned when palpating the posterior thorax between the scapula?
crossed arms in front
How should the patient's arms be positioned in diaphragm expansion?
crossed in front
How should the patients arms be positioned for posterior percussion of the thorax?
crossed to the front
What breast mass is seen age 25-50; soft, firm, round, mobile, and tender?
cyst
How is Kemp's test sensitive to antalgic lean?
Since a lateral disc protrusion may cause the patient to lean away from the side of leg pain, Kemp's test may exacerbate the radicular pain when bending the patient toward the side of leg pain. Since a medial protrusion may cause the patient to lean toward the side of leg pain, Kemp's test may exacerbate the radicular pain when bending the patient away from the leg pain.
Single inclinometer method of measuring lumbar ROM.
Single inclinometer at T12.
What is a firm nodule near the umbilicus called and what does is suggest?
Sister Mary Joseph's nodule (can ulcerate); metastatic cancer
Observe ________ & _______ of the lunula. Normal is ___________.
Size Color Pale white pink
Keratoconjunctiva Sicca = AKA ______________
Sjoren's syndrome
Scleroderma is an autoimmune disorder that causes stiffening and thickening of the _________ and affects the internal organs, particularly the __________, _________, & __________, along with Raynaud's.
Skin Lungs heart GI
Dry macular degeneration has ___________ onset.
Slow insidious
Arteries appear...
Small Light stripe Brighter red No visible pulsation Usually overpass veins
Nail pitting is ______________ and associated with _______.
Small pits in the nail plate Psoriasis
What type of fiber transmit pain and temp?
Smaller diameter primary afferent in the peripheral and spinal nerves and then transmits up the CONTRALATERAL spinothalamic tract
Hairy tongue is caused by...
Smoking Antibiotics Poor oral hygiene
TMJ palpation: Normal
Smooth ROM Snapping or clicking (maybe)
Normal lymph nodes (Texture, tender, moveable, size)
Soft No Yes Small
M/c distribution sites for melanoma in African Americans/Asians
Soles Palms Nailbeds Mucous membranes
Nerve (sensorineural) deficit findings at Weber test
Sound at the good ear
Conduction loss findings at Weber test
Sound increased at bad ear
The ratio for the rinne test
Sound should be heard @ ears at a 2:1 ratio to the mastoids
Conduction
Sound with ear plugged @ bad ear
Abnormal Chvostek's sign
Spasm at ipsi facial mm when tapping parotid
What ortho/neuro tests indicate biceps tendinitis?
Speeds test
CN XI
Spinal Accessory nerve
What is radiculapthy?
Spinal Nerve disorder commonly from Disc herniation or IVF stenosis
Small red lines under nails, may be benign & arise from microtraumas or cardiac s/sx of subacute bacterial endocarditis
Splinter Hemorrhages
what are fibrillations
Spontaneous contractions of the individual muscle cells
Faster growing carcinoma
Squamous cell carcinoma
What is the Valsalva maneuver?
This exam *increases intrathecal (CSF) pressure* and helps to identify radiculopathy caused by a space-occupying lesion. -With the patient seated, the examiner instructs the patient to take a deep breath, hold it, and "bear down" as if trying to move their bowels. -Be cautious, because the patient may become lightheaded or pass out during, or shortly after this test.
If Beau's lines are only at one nail, it is more likely due to _________.
Trauma
Onycholysis is most commonly caused by __________.
Trauma (Or psoriasis, or fungus)
Acquired anonychia
Trauma most often at one limb
Supinator syndrome motor weaknes
Triceps, brachioradialis, and supinator spared wrist extensors partially spared *Weakness of wrist extensors and finger extensors*
What is the Handshake test?
Tries to stretch structures attached to the scaphoid. Take their hand as if to hand shake and then ulnar deviate. -Positive finding is pain in anatomical snuffbox region.
CN V
Trigeminal
CN IV
Trochlear
Primary complaints of pt w/ senile form of cataracts
Trouble driving at night due to glare
Elevated & solid lesion, may or may not be clearly demarcated, deeper in dermis, greater than 2cm diameter
Tumor (Examples: neoplasms, benign tumor, lipoma)
Tracheal deviation could be due to...
Tumor Atelectasis Large pneumothorax Large pleural effusion
Conchae AKA
Turbinates
What do thrills and increase pulsations suggest?
Turbulent blood flow
What is the point of 2 point discrimination?
Two-point discrimination evaluates the patient's ability to perceive two closely applied stilmuli as distinct, rather than blended together as one
Structures of superficial middle ear
Tympanic membrane
Deposit of hyaline/scar tissue in TM
Tympanosclerosis
Where do you measure the upper and lower extremity for symmetry?
UE: 3' above and below the elbow LE: 6' above and below the knee
What will cause spastic hemiparesis gate?
UMN lesion (C1-4 lesion or cerebrovascular dx)
What causes scissor gate
UMN lesion resulting in bilateral spastic weakness of the legs cerebral palsy or cord compression
Where does the demyelination affect in MS?
UMNs in the subcortical region, brainstem or spinal cord.
Most common cause of cataracts
UV radiation
Loss of epidermis & dermis, concave, varies in size
Ulcer
Arcus senilis is clinically significant if the patient is __________ and indicates ________.
Under 40 y.o. Hyperlipidemia
What can cause T4 syndrome?
Unknown, but may be related to sympathetic innervation of the upper extremity from the T2-8 region of the spine.
S/sx of laryngitis
Unproductive cough Pain Redness Swollen
Radial N entrapment in the triangular space motor weakness
Weakness from triceps down *Triceps may be partially spared* (brachioradialis, supinator, finger and wrist extensors)
Label 9-13 using the provided choices. Answers on next slide.
a) Hamate b) Ulnar N. c) Median N. d) Extensor tendons e) Scaphoid tubercle ab) Palmaris longus ac) Flexor tendons ad) Pisiform ae) Transverse carpal ligament bc) Radial N. bd) Lunate
What is Schepelman's test?
With the patient seated, they laterally bend to each side. -Pain on the side of lateral flexion (concave side) indicates intercostal neuritis. -Pain on the opposite side (convex side) indicates intercostal myofascitis, or possible pleural inflammation,
When a patient with ascites is lying supine where will the fluid collect?
around the flanks
What does diffuse blue-grey skin with 2-10mm dark macules indicate?
arsenic build up
What does bulging flanks suggests?
ascites
What is vibration testing?
assesses the function of the large-diameter tactile afferents in peripheral & spinal nerves, and transmission up the dorsal column-medial lemniscus pathway in the CNS
What does abnormal retraction during inspiration suggest?
asthma, COPD, airway obstruction
place for tibial nerve entrapment
at medial ankle (tarsal tunnel syndrome)
When are resting tremors more pronounced? When do they disappear?
at rest during voluntary movement
What body position may enhance S3?
at the apex in the Left lateral decubitus position
Where do you look for palpations in JVP?
at the suprasternal notch between the SCM attachments
How are the patients arms positioned when doing respiratory expansion?
at their sides
What is S4 called?
atrial gallop
What conditions cause fixed splitting?
atrial septal defect and right ventricular failure
How do you determine if there is an absence of bowel sounds?
auscultate for 5 minutes
Where is breast cancer most commonly to metastasize to?
axilla
what is the most important pathologic relax sign
babinski sign
Why is the placatory systolic taken?
because of the presence of the auscultory gap
When there is an area of hyper sensation where do you start testing?
begin in the area of normal sensation and more to hyper sensitive area
When in the cardiac cycle is an opening snap heard?
beginning of diastole
Where do all other nerves (T &L) exit?
below the vertebrae
Where can bronchovesicular sounds be heard normally?
between the scapulae and anterior 1st and 2nd intercostals
musculocutaneous entrapment motor weakness
biceps
Where does the facial N receive UMN innervation from?
bilateral corticobulbar tracts
What does polyneuropathy do to DTR's
bilateral loss of the distal extremities DTR's
What is the gold standard for breast cancer diagnosis?
biopsy
What do you observe for in the lips and nail beds during the thorax inspection?
blue coloring = cyanosis
What is slow breathing?
bradypnea
What should the doctor avoid when auscultating the thorax?
breathing on the stethoscope tubing because it can create extraneous noises
Portion of nose between eyes
bridge
3+ DTR
brisker than average
What are the breath sounds, transmitted voice sounds, and tacile fremitus for an airless lung (consolidation) lung?
bronchovesicular/bronchial louder/clearer/more distinct voice sounds increase in tactile fremitus
What does a whooshing sound when auscultating arteries indicate?
bruit which means turbulent flow
What is Kemp's test?
*This low back test is similar in mechanism to the modified Spurling test in the cervical spine.* -With the patient seated or standing, bend the patient obliquely backward. If the patient is standing, it is necessary to stabilize the pelvis. -Creation or exacerbation of radicular pain in the lower extremity indicates radiculopathy. -Creation or exacerbation of low back pain indicates local joint involvement.
What are the contents of the carpal tunnel?
-*Median nerve* -Flexor carpi radialis -Flexor pollicis longus -Flexor digitorum superficialis -Flexor digitorum profundus
What follow-up tests should be done with a positive Bakody's sign?
-*Orthopedic tests for cervical radiculopathy.* -Cervical compression test and variations. -Cervical distraction test. -Intrathecal pressure tests (Valsalva, etc.) -*Evaluation of cervical spinal nerve function (sensory, motor, reflex).* -Add obliques to routine cervical x-ray series; consider advanced imaging.
What is the orientation of the elbow in extension? Flexion?
-10-15 degrees valgus is extension. -10 degrees varus in flexion.
How can multi-segmental ROM examinations be performed?
-Actively first, with the patient performing the movement. -Passively, with the doctor bringing the region through the ROM.
What is the recommended management procedure for piriformis syndrome?
-Adjust the sacrum, ilium, and femur, as appropriate. -Fast stretch manipulation of the piriformis muscle. -Sciatic nerve "flossing" (subacute or chronic stage). -Post-isometric relaxation (hold contraction 3-5 sec., relax 3x). -Muscle work (trigger point, spray & stretch). -Stretching (supine with knee to chest, contralateral hand pulls knee toward midline). -Physiotherapy
What is the chiropractic management procedure for facet syndrome?
-Adjustment -Exercise/stretching (pelvic tilt and abdominal strengthening, hip flexor stretching). -Weight loss, avoidance of provocative positions like extension.
What are the management suggestions for T4 syndrome?
-Adjustment of involved segments. -Treatment of myofacial TPs. -Postural advise -Exercise to restore strength of upper traps and rhomboids. -Stretching of tight pectorals.
What orthopedic tests may help identify cervical rib syndrome?
-Adson's test -Modified Adson's test
What orthopedic tests may help identify scalenus anticus syndrome?
-Adson's test -Modified Adson's test
What ortho-neuro tests indicate possible cervical rib syndrome?
-Adson's test -Modified Adson't test
What ortho-neuro tests indicate possible scalenus anticus syndrome?
-Adson's test -Modified Adson't test
What are the examination findings in TOS?
-Aggravation of symptoms on orthopedic tests. -Neurologic exams are commonly negative. -Vascular exams are commonly negative.
Describe a scaphoid fracture. Aka?
-Aka FOOSH (falling on outstretched extended hand) fracture. -Diagnostic standard is xray. -History of trauma, pain in the anatomical snuffbox and a positive Handshake test. -May compromise blood flow to the bone, leading to avascular necrosis and degenerative change.
What is a Colle's fracture? Aka?
-Aka dinner fork fracture because if has the appearance of a dinner fork in profile. -It usually results from a fall on the outstretched extended wrist and causes posterior dispaceent of the radial fragment which breaks. It may be accompanied by a fracture of the ulnar styloid.
What is ulnar nerve entrapment? Aka?
-Aka handlebar palsy. -The ulnar nerve may be entrapped in the Tunnel of Guyon or more proximally in the forearm or elbow. -This can cause weakness in the ulnar innervated intrinsic muscles of the hand as well as numbness and tingling in the medial aspect of the hand. -Adductor pollicis weakness (Positive Froment's test).
What is Wright's test? Aka?
-Aka hyperabduction test. -Tests for Pectoralis Minor Syndrome. -With the patient seated, palpate the radial pulse noting its intensity and then slowly abduct the patient's arm to 180 degrees while monitoring the radial pulse for decreased amplitude.
What is Baseball finger? Aka?
-Aka mallet finger, mountain fracture. -Results from the sudden forced flexion of the distal phalanx. -The extensor tendon avulses the posterior/proximal part of the bone where it attaches. -The distal third phalanx is the most prominenet bone and therefore the most susceptible to fracture.
What is Smith's fracture? Aka?
-Aka reverse Colle's. -It may result from a fall on the flexed wrist and involves an anterior displacement of the fractured distal radius.
What is Bakody's sign? Aka?
-Aka shoulder abduction relief sign. -The patient presents with the palm of the affected upper extremity (P/T/N radicular complaint) on top of their head. The patient states that this position lessens their upper extremity pain/paresthesia complaints.
What is Cozen's test?
-Aka tennis elbow test. Elbow at 90 degrees flexion, with hand pronated and extended. Pull on the hand against resistance. -Positive test indicates lateral epicondylitis.
What is the upper limb tension test (ULTT)? Akas?
-Aka the SLR of the upper extremity. -Aka the upper limb neurodynamic test (ULNT). -The procedure tensions peripheral nerves in the upper extremity (possibly with a median nerve bias), the brachial plexus, and cervical spinal nerves. -With the patient supine or seated and the patient's elbow bent, the examiner abducts the patient's upper extremity to slightly above 90 degrees and then externally rotates the extremity. The examiner then extends the patient's wrist and slowly extends the elbow. If the patient's UE symptoms have not been created or exacerbated, then instruct the patient to laterally flex the head away from the side being examined.
Describe a triquetrum fracture.
-An avulsion fracture. -Usually thr result of a forced radial deviation which will cause the ulnar collateral ligament to pull off a piece of the triquetrum.
What is the typical history of someone with lumbosacral radiculopathy?
-Low back pain; leg pain & paresthesia (leg pain/paresthesia may dominate over low back pain). -Previous history of low back & diffuse buttock - posterior thigh pain (sclerogenic pain). -The current trauma may be minimal. -Symptoms are commonly aggravated by: Sitting (increase intrathecal pressure - IVD syndrome) or by coughing, sneezing, straining to move bowels (Dejerine's triad).
What are the categories of causes of low back pain? Which are *red flags*?
-Mechanical -Radiculopathy *-Non-mechanical (fracture, tumor, infection, etc).* *-Cauda equina syndrome* *-Visceral referred pain*
What causes radiculopathy?
-Mechanical compression due to disc herniation or DJD (bone spurs/IVF stenosis). -Inflammation in the absence of direct mechanical compression. -Trauma/fracture and neurofibromas.
What four peripheral nerves cross over the elbow joint?
-Median -Ulnar -Radial -Musculocutaneous
What procedures should follow a positive maximum cervical compression maneuver?
-Modified Spurling test -Cerical distraction test -Valsalva maneuver -*Neurologic exam of the sensory, motor, and reflex functions of the cervical spinal nerves.*
What may cause a positive Lhermitte's sign?
-Multiple Sclerosis -Myelopathy associated with cervical spondylosis and spinal canal stenosis. -Central disc protrusion/prolapse. -Tumor
What tests should be administered following a positive Lhermitte's sign?
-Neurologic exam. -MRI -Electrodiagnostic tests.
What are the normal and abnormal findings for the straight leg raise?
-Normal is 70-80 degrees without pain. -Abnormal is any restriction, and/or pain in the back or the leg. With regard to sciatica and radiculopathy, P/T/N below the knee would be a more specific positive finding. Dull posterior thigh pain suggests tight hamstrings.
What follow-up tests should be performed after a positive Valsalva maneuver?
-Orthopedic exams (Naffzigger, cervical vompression, cervical distraction). -Neurologic exam of spinal nerve functions. -Diagnostic imaging
What additional tests should follow a positive Valsalva maneuver?
-Orthopedic exams (Naffzigger/jugular compression test, cervical compression tests, cervical distraction test). -Neurologic exam of spinal nerve functions. -Diagnostic imaging.
What other tests should be done following a positive cervical distraction test?
-Orthopedic exams (cervical compression tests, shoulder abduction relief sign, intrathecal pressure tests/ Valsalva). -*Examination of the neurologic functions of the cervical spinal nerves (senrosy, motor, reflex)*.
What procedures should follow a positive Modified Spurling test?
-Orthopedic exams (other compression tests, cervical distraction test, valsalva meneuver). -*Neurologic exam of the sensory, motor, and reflex functions of the cervical spinal nerves.*
What follow-up tests should be performed following a positive Adson or modified Adson test?
-Other TOS orthopedic tests (costoclavicular, Eden's Wright's, EAST, etc.). -Allen's test -Rule out other conditions that may produce a similar clinical finding.
What follow-up tests should be performed following a positive Naffziger test?
-Other cervical orthopedic exams for radiculopathy. -Neurologic assessment of spinal nerve function. -Diagnostic imaging.
What other tests should be administered following a positive Naffzigger test?
-Other cervical orthopedic exams for radiculopathy. -Neurologic assessment of spinal nerve function. -Diagnostic imaging.
What follow-up tests should be performed after a positive Sitting Laseque test?
-Other sciatic nerve stretch - nerve root tension tests. -Other orthopedic exams (Well leg raise, valsalva, Kemp's). -Neurologic assessment.
What other tests should be performed following a positive Bechterew's?
-Other sciatic nerve stretch-nerve root tension tests. -Well Leg Raise -Intrathecal pressure tests (Valsalva, Naffzigger). -Kemp's -Neurologic assessment of lumbosacral nerve root function.
What other tests should be performed following a positive Bowstring test?
-Other sciatic stretch-nerve root tension tests. -Valsalva Kemp's -Neurologic assessment
What are the red flags for spinal fracture?
-Over 70 years old. -History of trauma in young adult. -History of less severe trauma in an osteoporotic or elderly individual. -Prolonged use of corticosteroids.
What is Reverse Cozen's test?
-Tests the wrist flexor/pronator group. -Elbow at 90 degrees flexion, with hand supinated and flexed. Pull on the hand against resistance. -Positive test indicates medial epicondylitis.
What follow-up tests should be performed after a positive straight leg raise finding?
-Tests to help differentiate a nerve etiology from joint or muscle etiology (Braggard, sicard, Bowstring). -Other nerve tension tests (sitting Laseque, Becherew, Neri's Bowing). -Other orthopedic tests (WLR, Valsalva, Kemp's). -Neurologic exam to assess the integrity of the lumbar nerve roots (sensory, motor, reflex).
What are some breast cancer risks?
-being female -personal or family history of breast cancer -advancing age (>50 years) -never having children or having the first child after 30 -early menarche (<12 years) -late menopause (>55 years) -being obese
When auscultating the thorax what 3 things should you listen for?
-breath sounds -any adventitious sounds (abnormal) -if abnormalities heard then listening to the spoken and whispered voices
Gait of cerebellar ataxia
-broad based gate -varying degrees of unsteadiness and staggering are present -difficulty doing turns -balace not affected closing eyes
What should an area of abnormal breath sounds be assessed for when looking at transmitted voice sounds?
-bronchophony -whispered pectoriloqy -egophony
What are some conditions of the liver?
-cirrhosis -hepatitis -cancer
What changes do you inspect for when evaluating the peripheral vasculature?
-color (rubor, pallor, cyanosis) -trophic skin changes (shiny, thinning of hair, hair loss, edema) -stasis dermatitis
What conditions can cause a lack of ventilating lung tissue?
-complete ariway obstruction (tumor, foreign object, tick mucus plug) -pneumonectomy -paralyzed diaphragm -atelectasis
What are common adventitious sounds?
-crackles (rales) -wheezes -rhonchi
When palpating the thorax what does decreased vibration mean and what is an example?
-decreased density; emphysema OR -decreased transmission of air to the chest wall; pleural effusion/pneumothorax
What are the features of arterial occlusion?
-decreased or absent pulse -pallor -cold/cool skin
What are crackles?
-discontinuous, intermittent, nonmusical, and brief sounds. -can be fine or coarse -can be inspiratory, expiratory, or both -scanty or profuse
What should you inspect for during a heart exam?
-dyspnea -cyanosis -edema
If the doctor does not hear breath sounds what should be done?
-ensure the stethoscope is functioning -the patient is breathing deeply -the room is quiet
What are some additional risk factors?
-genetic BRAC-1 and BRAC-2 - radiation exposure especially as a child -drinking alcohol/smoking -chemical exposure (unsure which exactly) -being black/asian/ or pacific islander descent -increase in white population in US but they have an increase survival rate
What are the vital signs?
-height -weight -BP -pulse -respiratory rate -temperature
Signs associated with sensory ataxia
-impairment of JPS in toes and ankles would be present -impairment of vibration in the toes might be present -lower extremity ataxia might be present, especially with the eyes closed -vertigo, nausea, and nystagmus would not be expected
What are 2 conditions that can cause the pleura to become inflamed?
-infection -pulmonary infarction
When would tracheal deviation contralateral from the lesion be seen?
-large pneumothorax -tumor -large pleural effusion
What characteristics do you need to identify when you auscultate heart sounds?
-location -timing (systole/diastole) -frequency (high/low pitch) hear it better with diaphragm or bell depending -intensity (grade 1-6) -Quality (clicking, thud, blowing) -duration -radiation -rate and rhythm
What can be a probable cause for unilateral impaired movement during respiration? (4)
-loss of lung function -pleural effusion/pneumothorax -problem with the diaphragm -lobar pneumonia
What does decreased lung expansion suggest? (4)
-lung problems -diaphragm problems -pleural effusion/pneumothorax -lobar pneumonia
During palpation of the thorax what should you look for throughout the entire back?
-masses -tenderness
When using deep palpation for masses what will be palpable with the head and shoulder raised and what will be obscured?
-masses in the abdominal wall will remain palpable when the patient raises their head and shoulders -masses intra-abdominally will be obscured by the muscular contraction
What abnormal processes can cause a flat percussion tone in the thorax?
-massive pleural effusion -pneumonectomy -massive atelectasis
What murmurs can be heard on systole?
-mitral/tricuspid regurgitation -aortic/pulmonic stenosis
What are some causes of a positive splenic percussion sign/ enlarged spleen?
-mononucleosis -malaria -hemolytic anemia -increased RBC destruction
What are the features of venous stasis?
-normal pulse -no pallor -normal temperature -pitting edema -stasis dermatitis
What can metamorphosing breath sounds indicate?
-occluded bronchus suddenly opening or shifting of a bronchial plug -foreign body -tumor -secretions
What are the 2 positions of the light sources for eye inspection?
-overhead -tangential (side)
What are the characteristics of thrombophlebitis?
-palpable cords -redness -heat -A-P tenderness positive Homan's sign -edema (measure calf circumference)
How are masses categorized?
-physiologic -inflammatory -vascular -neoplastic -obstructive
What are examples of pleural processes that can prevent sound from being transmitted to the chest wall?
-pleural effusion -pneumothorax
What abnormal processes may cause a dull percussion note in the thorax?
-pneumonia -atelectasis -pulmonary edema -pulmonary fibrosis -lung tumors -mediastinal tumors -pleural thickening/fibrosis -pleural effusion -pleural tumor -paralyzed diaphragm -enlarged heart, spleen, or liver -pericardial effusions
What characteristics do you assess when palpating for peripheral vasculature?
-rate -amplitude -rhythm -contour (mainly on radial)
What abnormal processes can cause a hyperresonant percussion in the thorax?
-small pneumothorax (open or closed) -emphysema (general or local) -acute asthmatic attack -compensatory emphysema above a pleural effusion (skodaic resonance)
When can cheyne-stokes breathing be seen?
-sometimes sleeping children -heart failure -uremia -drugs -brain damage
What arteries do you palpate when doing a peripheral vasculature exam>?
-temporal aa -carotid -brachial aa -radial aa -ulnar aa -aorta -femoral aa -popliteal aa -posterior tibial aa -dorsal pedal aa
What does a liver with cancer feel like on palpation? -tenderness? -nodules? -texture? -margin?
-tender: possible -nodule: yes -texture: hard -margin: irregular
What are some findings when palpating a liver with hepatitis? -tenderness? -nodules? -texture? -margin?
-tender: yes -nodules: no -texture: soft -margin: smooth
What do you look for when palpating the abdomen?
-tenderness -nodules -guarding
What are some things that are found when there is liver cirrhosis? -tenderness? -nodules? -texture? -margin?
-tenderness: no -nodules: maybe -texture: firm -margin: regular or irregular
What are abnormal processes that can cause a tympanic percussion in the thorax?
-tension pneumothorax -large pneumothorax -large pulmonary cavity -emphysematous bullae under tension
Where is there a normally a hyper-resonant tone and what is a pathological example of a hyper-resonant tone?
-there should be nothing that has a hyper-resonant tone normally -pathological: emphysema/pneumothorax
What are some examples of airless lungs that would increase transmitted voice sounds and tactile fremitus?
-tumor -pneumonia -atelectasis with patent bronchus -pulmonary infarction
What can enlargement of the kidney be caused from?
-tumor -polycystic kidney(bilateral) -hydronephrosis
Signs of Vestibular ataxia
-vertigo, nausea, and nystagmus would be present -limb ataxia might be present when standing, but absent when lying down -JPS and vibration in the toes would be expected to be normal
What are the 4 primary breath sounds?
-vesicular -bronchovesicular -bronchial -tracheal
How do you do 2 pt discrimination?
. If the patient is able to distinguish the stimulations, progressively decrease the distance between the points. Determine the minimum distance at which the patient can accurately distinguish the stimuli. Compare sensitivity side-to-side and to the reference range for the area
What are the exam findings for a modified Spurling's test?
-Creation or exacerbation of *local cervical spine pain* suggests joint involvement (subluxation, DJD, trauma, etc.). Ill-defined, diffuse pain into the shoulder or arm may be present due to sclerogenic referral. -Creation or exacerbation of pain, tingling, and numbness in the upper extremity (especially in a dermatomal distribution) suggests *cervical radiculopathy*.
What are the exam findings and indications for the cervical compression test?
-Creation or exacerbation of local cervical spine pain suggests *joint involvement* (subluxation, DJD, trauma, etc.). Ill-defined, diffuse pain into the shoulder, or arm, and may be present due to sclerogenic referral. -Creation or exacerbation of pain, tingling, and numbness in the upper extremity (especially in a dermatomal distribution) suggests *cervical radiculopathy* (which can result from disc herniation or IVF stenosis).
What are the findings for the Adson and modified Adson tests?
-Creation or exacerbation of the patient's complaint of pain and paresthesia in the upper extremity (often in lower trunk, C8-T1 distribution). -Decreased intensity of the radial pulse.
What are the positive findings and significance of the costoclavicular and Eden's tests?
-Creation or exacerbation of the patient's upper extremity pain, tingling, and numbness. -Decreased amplitude of the radial pulse. -Indicates TOS, most likely costoclavicular syndrome.
Where should the cuff be?
1 inch above the cubital crease with the arrow above the brachial artery
13. List the vital signs and give the normal values. Measure blood pressure. Describe the rationale for your actions and the normal and abnormal findin gs as well as the significance of abnormal findings
1 the vital signs include height, weight, temperature, blood pressure, pulse rate, respiratory rate 2. Measure BP 3. normal BP is 120/80, prehypertension 130-139/80-89, optimal BP 110-119/60-79, hypertensiion 140/90, hypotension less than 100/60 for hypertension to be diagnosed there has to be 3 consecutive readings of 140/90 or greater 4 palpatory systolic is performed to avoid the auscultory gap so that we don't misread BP
What are the criteria for diagnosing lumbosacral radiculopathy?
1) Leg pain is the dominant symptom when compared to the low back pain (the leg pain affects only one leg & follows a typical sciatic distribution). 2) Paresthesia is localized to a dermatomal distribution 3) Ortho exam: SLR (reduced by 50%), positive bowstring, positive WLR. 4) Neuro exam: 2 of 4 neurologic signs present (Altered sensation, Motor weakness, Atrophy, Altered reflex activity) 5) Contrast study positive & corresponds to the clinical level.
What are common sites for hernias? (5)
1) umbilicus (infants) 2) epigastric 3) incision/ surgical sites 4) inguinal 5) femoral
Risk factors for Glaucoma
1. >65 y.o. 2. African American 3. Diabetes mellitus 4. Myopia 5. Family hx 6. Prolonged corticosteroid use
Causes of Gum recession
1. Aging 2. Poor oral hygiene 3. Aggressive tooth brushing
Characteristics of Suppurative Otitis Media
1. Beefy red TM 2. Pus behind 3. Bulging TM 4. Very painful (acute even more painful) 5. Fever may be higher *Bacterial
What other conditions need to be ruled out before diagnosing TOS?
1. Cervical radiculopathy. 2. Sclerogenic referred pain from cervical structures. 3. Shoulder disorders. 4. Entrapment/compression neuropathies in the UE. 5. Vascular problems in the upper extremity. 6. Heart attack 7. Etc.
6 things about Tympanic Membrane
1. Color 2. Position 3. Landmarks 4. Perforations 5. Fluid level 6. Cone of light *red response normal
What are the positive findings and significance for Wright's (hyperabduction) test?
-Creation or exacerbation of the patitne's complaint of pain and paresthesia in the upper extremity (often in a lower trunk, C8-T1 distribution). -Decreased intensity of the radial pulse. -Significance is TOS, most likely Pectoralis Minor syndrome.
What are the abnormal findings and significance of the brachial plexus stretch test?
-Creation/exacerbation of P/T/N in the upper extremity in a brachial plexus distribution (potentially in a multiple dermatome distribution). -Significance is brachial plexus irritation (TOS, etc.). Cervical radiculopathy is also possible.
3 Effects of excessive cerumen
1. Conduction hearing loss 2. Coughing in children (CN X) 3. Tinnitus & dizziness (CN VIII)
When you are testing sensation what 3 things do you want to make sure of?
1. Distribute the stimuli so that you're testing the peripheral nerve and spinal dermatome 2. comparing bilaterally 3. comparing distal and proximal areas ipsilaterally
Testing CN III
1. Eye Movements 2. Accommodation 3. Consensual light reflex (with CN II) 4. Convergence
abnormalities assoc. with cerebellar ataxia
1. Gait ataxia 2. Truncal ataxia ("titubation") 3. Hypotonia 4. Pendular DTRs (excessive swinging) 5. Speech dysarthria 6. Cognitive-affective syndrome 7. Ocular dysmetria (flocculonodular lobe & vermis
What is the procedure of JVP?
1. Identify the highest point of pulsation and extend a card horizontally frim this point to make a right angle with a centimeter ruler pointed vertically from the sternal angle. 2. this distance is measured in cm is the jugular venous pressure.
Oral candidiasis is common in...
1. Immunocompromised 2. Diabetic 3. Increased use of antibiotics or corticosteroids
What are the abnormal findings and significance of the upper limb tension test (ULTT)?
-Creation/exacerbation of P/T/N in the upper extremity. -Significance is not specific, but is sensitive to possible peripheral nerve disorder (median nerve bias), possible brachial plexus irritation, or possible cervical radiculopathy.
What are the abnormal findings and significance of the brachial plexus tension test?
-Creation/exacerbation of the patient's symptoms of P/T/N in the upper extremity. -Significance is brachial plexus irritation or possible cervical radiculopathy.
What conditions are the DDX for facet syndrome?
-DJD -Annular tears -Radiculopathy (disc herniation, IVF/lateral recess stenosis). -Strain/sprain
Characteristics of Acute Toxic Labyrinthitis
1. Inner ear infection 2. Inflammation 3. Viral 4. Associated w/ prior respiratory infection 5. Decreased balance (episodic) 6. Unilateral hearing loss 7. Tinnitus 8. Nystagmus
Risk factors for Meniere's dz & Labyrinthitis
1. Large amounts of alcohol 2. Hx of allergies 3. Fatigue 4. Viral infection, respiratory/ear 5. Smoking 6. stress 7. Some Rx (aspirin)
Characteristics of Serous otitis media
1. Low fever or none 2. Amber fluid behind TM 3. TM normal or refracted 4. Blocked Eustachian tube, membrane retracts 5. Less pain (mild) *Viral
Causes of cerebellar ataxia
1. MS 2. Alcohol abuse (Anterior lobe syn) 3. cerebrovascular (post. circulation) 4. Tumors
ROM w/ TMJ
1. Open jaw as wide as possible 2. Protrude jaw
What are the exam findings and significance for the cervical distraction test?
-Decreased *local pain* suggests joint involvement (subluxation, DJD). -Decreased *pain, tingling, & numbness in the upper extremity* suggests cervical radiculopathy (due to IVF stenosis or IVD P/P). -*Discomfort or pain may be produced by this procedure as a result of soft tissue injury*.
Characteristics of Allergic rhinitis
1. Pale-blue swollen mucosa 2. Watery discharge 3. No fever 4. Sneezing, itching, watery eyes
Palpate the posterior thorax, including tactile fremitus and respiratory expansion. Describe the normal and abnormal findings as well as the significance of abnormal findings.
1. Palpate the posterior thorax: Arms are crossed to the front. "palpate for general tenderness and masses at the intercostal mm, soft tissue, costovertebral and costotransverse joint, upper and middle trap, and rhomboids." 10 general areas. 2. Tactile fremitus: Palpate 4 areas on each side around the scapula. Have the patient say 99 in a slow deep voice using the ulnar edge of the hand. "Normal is symmetrical vibration side to side. Abnormal is if there is an increased intensity of vibration to one side which would indicate a mass or consolidation/lobar pneumonia or if there was a decreased intensity of vibration indicating decreased density from obstructed airway, pleural effusion, or emphysema." 3. Respiratory expansion: Thumbs at the level of T10 the patient's arms are at their sides and have the patient take 3 deep breaths to assess if expansion is symmetrical. "Normal is symmetrical expansion. Abnormal is assymmetrical expansion which can indicate a lung issue like a collapsed lung, pleural effusion, lobar pneumonia, or a diaphragm issue."
Testing CN I
1. Patency of airway 2 Identify familiar aromas 3. Examine internal nose
What are the steps in breast cancer diagnosis?
1. clinical breast exam 2. mammogram (2 different screenings 2nd is to get a clearer image) 3. ultrasound 4. biopsy 5. breast MRI
common places of entrapment for Axillary N
1. glenohumeral dislocation 2. in quadrangular space
places of radial N entrapment
1. in axilla (Crutch/Sat. Night palsy) 2. triangular space 3. spiral groove of the humerus 4. supinator syndrome
place for musculocutaneous N entrapment
1. in coracobrachialis
What are visible signs of breast cancer?
1. lump 2. skin dimpling 3. change is contour 4. change in the nipple 5. nipple discharge 6. change in skin texture (peau d' orange=feels like orange skin) 7. eczema-like rash (sign of paget's disease in nipple)
places for ulnar N entrapment
1. medial epicondyle/cubital tunnel 2. tunnel of Guyon
What are the grading scale for murmurs?
1= faint barely audible 2= faint, able to hear 3= moderately loud no thrust/thrill 4= loud with thrust/thrill 5= very loud, audible with stethoscope, tilted on chest wall thrust/thrill 6= loud thrust/thrill, audible with stethoscope off chest
Why does Wallenberg syndrome happen?
1st order P/t afferents from the face dip down into the medulla before the decussate and 2nd order afferents decussate and ascend to synapse in the thalamus
With normal cervical flexion, the chin should approach within _________ of the chest.
2 fingers breaths.
What is the average distance for finger tip sensation with 2 point discrimination
2-5 mm
What is the normal range for thoracic lateral flexion?
20-40 degrees.
Normal vision is _______ and legally blind is _______.
20/20 20/200
How many breaths is respiratory expansion performed over?
3
Palpate each side of the thyroid gland with ________ fingers, the middle being at the level of the _______.
3 Cricoid cartilage
How many areas should be palpated on the anterior thorax?
3 areas bilaterally = 6 total
How do you diagnose hypertension?
3 readings of 140/90 or greater (in consecutive days)
Normal findings for opening the mouth as wide as possible
3+ finger widths
Where would you feel for pulsations from the right ventricle?
3, 4, 5 intercostal spaces at the left sternal border
Herpes simplex is contagious for _____________ and lasts from prodrome until ______________. Confirm herpes simplex with a __________.
3-4 weeks Healed over Tzanck smear
What should the distance be for diaphragmatic excursion?
3-6 cm between the 2 marks
What is the normal range for thoracic rotation?
30 degrees or greater.
What is the normal size of the heart on the left side, measured from the mid-sternal line the 3, 4, and 5 intercostal space?
3= 4cm 4= 6cm 5=7-10cm
What is the size of the diameter of a normal aorta?
3cm
How many areas should be palpated on the posterior thorax?
4 areas bilaterally = 8 total
Where do you auscultate for bowel sounds?
4 quadrants
Pityriasis rosea lasts ________ and is not contagious.
4-6 weeks
Lindsay nail is _____ white & _____ pink/red at the tip. They are associated with ______________ in early ___________.
40 60 Increased nitrogenous waste Renal failure
How is the patient positioned during the mitral maneuver?
45 degrees on their left side= "left lateral decubitus"
What is the normal range of bowel sounds?
5-34 per minute
What is the normal reading for thoracic flexion?
50 degrees or greater.
Risk factors for Melanoma
50+ typical moles 5+ atypical moles Red hair Inability to tan Sunburn Kindred (fam hx)
Which tuning forks can you use for the Weber & Rinne test?
512 or 256Hz
The sternal angle in how many cm above the right atrium?
5cm
When percussing the anterior thorax how many areas should be percussed?
6 areas bilaterally = 12 areas total
Acute Toxic Labyrinthitis lasts ________.
6-8 weeks
What is the normal pulse rate?
60-100
What are causes for abdominal distenstion?
7 Fs= -Fat -Flatus -Fetus -Fluid (ascites) -Fatal growth (tumors) -Fibroid -Fecal obstruciton
When percussing the posterior thorax how many areas are there?
7 areas bilaterally = 14 total
How many arteries are to be auscultated in the abdominal exam and what are they?
7; aorta, renal (2), iliac (2) , and femoral (2)
Terry's nails are when the nail is _____ white and _____ pink at the tip. They are associated with __________.
80% 20% Hepatic cirrhosis
Answers
9) AC - Flexor tendons 10) BD - Lunate 11) AE - Transverse Carpal lig. 12) C - Median N. 13) AD - Pisiform
For over ____% of patients with acute low back problems, no special interventions or diagnostic tests would be required within the first month of symptoms.
95%
What is the normal temperature?
98.6 degrees F
Conduction loss findings w/ Rinne Test
< 2:1 ratio
A ________ angle is created at a joint when the part distal to the joint moves away from the midline (laterally). a) Valgus b) Lapin c) Trigh d) Varus
A
A valgus bending load on the elbow creates a compression load at which of the following: a) Humero radial joint b) Medial collateral ligament c) Wrist flexor/pronator group d) Trochlear condyle
A
Apley's Scratch Test for the shoulder is a quick and useful technique for checking ________. a) Functional AROM. b) Tendency to dislocate. c) Muscle strength. d) Glenohumeral joint end play.
A
Cutaneous sensation to the fifth digit is most often supplied by which spinal nerve? a) C8 b) C7 c) C6 d) C5
A
List the contents of the suprahumeral space from superior to inferior: a) Subdeltoid bursa, supraspinatus tendon, glenohumeral joint capsule. b) Subscapular bursa, teres minor muscle, A-C joint capsule. c) Deltoid muscle, popliteus bursa, plantaris muscle. d) Supraspinatus muscle, infraspinatus muscle, teres minor muscle.
A
The examiner perform the supine shoulder anterior instability test and produces an anterior shoulder "clunk." His/her next maneuver should be: a) Humeral head reduction pushing A to P. b) Adjustment of the A-C joint. c) Dialing 911. d) Humeral head reduction pulling S to I.
A
The overhand throwing motion, tennis serve, and golf swing all put a ________ load on the dominant elbow during acceleration. a) Valgus b) Varus c) Trunk d) Viral
A
When entrapped by the pronator teres, this structure may produce symptoms similar to those of carpal tunnel syndrome. a) Median nerve b) Ulnar nerve c) Radial nerve d) Musculocutaneous nerve
A
Which of the following active ROM findings is most indicative of shoulder impingement syndrome? a) Painful middle arc of abduction. b) Moderately restricted external rotation. c) Painful scapular protraction. d) Extension restricted by pain.
A
What is a Ganglion cyst?
A benign fluid-filled tumor which often appears on the dorsal surfact of the wrist. Usually an outpouching or herneation of the joint capsule or a tendon sheathe. -Thought to be secondary to mechanical irritation and tend to come and go.
Fleeting blindness suggests ____________ traveled to _________ then spontaneously dissolved. It indicates an increased risk for _________.
A blood clot Retina Stroke
What is facet syndrome?
A condition of low back pain (well-localized) with referred pain (buttocks, lower extremity above the knee), associated with lumbar posterior joint dysfunction. -May be associated with DJD, or acute synovial fold ("meniscoid") entrapment. -Onset may be associated with arising from a flexed position.
What are the positive findings and significance of Allen's test?
-Delayed filling (greater than 10 seconds) indicates insufficiency of the artery, possibly due to stenosis or thrombosis, etc. -Delayed filling in both radial and ulnar arteries may indicate simultaneous involvement of both arteries, or possibly obstruction proximally (brachial, axillary, or subclavian artery).
What creates LMN lesions
-Disease or injury may affect LMNs at their cell bodies or anywhere along their axonal path to the neuromuscular junction -At the brainstem, this includes the cell bodies in the cranial nerve motor nuclei or their axons in associated cranial nerves (III-VII, IX-XII). -At spinal levels, this could include the cell bodies in the anterior horns of the spinal cord, anterior root of the spinal nerve, spinal nerves, plexi, or peripheral nerves
What are the Variosus intermittent claudication tests?
-Elevated Arm Stress Test (EAST). -Intermittent claudication test. -Roos test
Describe a lunate fracture.
-FOOSH mechanism. -Possibility of developing avascular necrosis and early degenerative change.
What tests indicate SI joint lesion?
-Fabere Patick test. -Laguerre test -Gaenslen's test -Nachlas test -Ely's sign -Yeoman's test -Hibb's test -Iliac compression test -Sacroiliac stretch test (gapping test). -Sacroiliac resisted abduction test.
What is Reverse Mill's test?
-Flex shoulder and with hand prone, extend the wrist. -Positive test indicates medial epicondylitis.
What are the movements of the thumb?
-Flexion/extension -Abduction/adduction -Opposition (combined carpometacarpal extension and abduction with metacarpophalangeal flexion).
What are the wrist/hand ROMs?
-Flexion: 80 -Extension: 70 -Abduction (radial deviation, valgus): 20 -Adduction (ulnar deviation, varus): 45 -Pronation: 90 -Supination: 80-90 -MCPs, PIPs, DIPs: Bilateral comparison
What are the lumbar ROMs?
-Flexion: 90 -Everything else: 30
What are the contraindications for the Naffzigger test?
-Geriatric patients. -Caution should be used when testing patients with suspected atherosclerosis. (Lightheadedness, dizziness, or syncope may occur).
What ortho/neuro tests are associated with the wrist/hand?
-Handshake -Finkelstein's -Pinch -Froment's -Tinel's -Phalen's -Reverse Phalen's
What is Froment's test?
-Have them hold a dollar bill between the thumb and first finger while keeping their hand straight. -Positive finding is if their thumb or fingers bend. -Tests ulnar nerve and suggests median nerve recruitment.
What is the Pinch test?
-Have them hold a dollar bill between the tip of their thumb and first finger. -Positive finding is if their fingers come together like they are making a shadow puppet. -Tests median nerve.
What ortho/neuro tests indicate impingement syndrome?
-Hawkin's test -Painful middle arc of abduction.
Upon inspection, what may cause hyperlordosis? Hypolordosos?
-Hyperlordosis: Possible weak muscles (abdominals, gluteus maximus, hamstrings). Possible tight muscles (psoas). -Hypolordosis: Often seen in acute conditions.
What are the positive findings and significance of the Kernig test?
-Inability to extent the leg due to pain is a positive finding. -Flexion of the opposite hip and knee may occur. -Suggests possible *meningitis*. -Correlate the exam findings with other signs and symptoms of meningitis on the history and exam.
What other factors should we look for upon inspection?
-Inflammation (SHARP). -Signs of recent trauma (cuts abrasions, bruises). -Signs of old trauma/surgery (scars). -Signs of possible underlying body and/or neural pathology (lipomata, port-wine spots, spina bigida, cafe-au-lait spots, pedunculated tumors, neurofibroma).
For every exam make sure to:
-Introduce yourself (use intern NOT doctor) and ask for the patient's name -tell the patient if they have any pain or discomfort during the exam to let you know -Explain to the patient all the procedures to the patient and verbalize everything throughout
What is the mechanism associated with the Soto-Hall test?
-It compresses the vertebral bodies anteriorly. -It posteriorly tractions the nuchal ligament and pulls on the spinous processes. Posterior musculature is stretched.
What is Finkelstein's test?
-It is a very sensitive test so there are a lot of false positives. -Have them grab their thumbs with their own fingers and pull down (ulnar deviate). -Indicative of stenosing tenosynovitis.
What tests help identify radicular/sciatic problems?
-Kemp's test -Lindner's test
What are the variations of the cervical compression test?
-Lateral flexion (Jackson's test). -Flexion -Extension -Rotation
What is antalgic lean?
-Leaning *away* from the side of radicular pain means there is *posterolateral protrusion*. -Leaning *toward* the side of radicular pain means there is *posteromedial* protrusion.
Where can the median nerve become entrapped?
-Ligament of Struthers -Pronator teres.
What are the possible findings for the maximum cervical compression maneuver?
-Local cervical spine pain suggests *joint involvement* (subluxation, DJD, trauma, etc). Ill-defined, diffuse pain into the shoulder or arm may be present due to sclerogenic referral. -Pain, tingling, and numbness in the upper extremity (especially in a dermatomal distribution) suggests *cervical radiculopathy*.
What is a gurgling rale sometimes called?
death rattle
superficial reflexes for UMN lesion
decreased or absent
LMN lesions muscle stretch reflexes
decreases
What is parkinson dx caused from?
degeneration of the substantia nigra portion of the basal ganglia resulting in a decrease of dopaine
What is subacute combined systems dx (posterolateral sclerosis)
degenerative condition of the spinal cord
axillary N entrapment motor weakness
deltoid teres minor
What is MS
demyelinating disease of the CNS.
What is Guillain-Barre syndrome?
demyelinating disorder of the PNS. (More severe cases may involve axonal destruction and a more protracted recovery period)
What is funnel chest?
depression of the lower portion of the sternum
what does syringomyelia destroy?
destroys decussating second order 2nd order P/t resulting in bilateral loss of pain/temp in the corresponding involved levels of the cord
polyneuropathy is commonly due to what?
diabetes
What causes bradypnea?
diabetic coma, drug-induced respiratory depression, increased intracranial pressure
What part of the stethoscope do you use to listen for bowel sounds?
diaphragm
What part of the stethoscope is an opening snap heard?
diaphragm
Which part of the median N passes through the carpal tunnel?
digital branches
Tourette's syndrome
disorder in children characterized by repetitive vocal and motor tics (males 3:1)
tandem stance is performed with the ____ foot in front
dominant
If L5 is intact, what would the patient be able to do?
dorsiflexion of the foot would be stronger, and control of extension of the toes would be gained.
What is bisferien's pulse?
double sensation problems with aortic valve and severe aortic regurgitation
What does a tympany tone sound like?
drum-like
Why do pathological reflexes occur with UMN lesions?
due to loss of UMN inhibition
What is the normal percussion tone at the 6 intercostal space during a heart exam?
dull due to the liver
When is the physiological splitting of S2 heard?
during inhalation but it disappears on exhalation
What is uncomfortable awareness of breathing disproportionate to activity level? (difficulty breathing)
dyspnea
When in the cardiac cycle is S3 heard?
early in diastole right after S2
What are high-pitched sounds with a sharp, clicking quality that occurs shortly after S1?
early systolic ejection sounds
The LMN is the ______ component of the DTR arc
efferent
Normal creamasteric reflex respinse
elevation of the ipsilateral testis due to contraction of the cremasteric muscle.
What auscultation points do you perform the aortic maneuver at?
every point on the left except the aortic spot
What are causes of hyperpnea?
exercise or anxiety
Where will you feel the resistance when doing passive ROM with a LMN lesion
extending the elbow and dorsiflexing the foot
+ Gonda sign
extension of the big toe
+ Shaefer
extension of the big toe
+ babinski sign
extension of the big toe
+ chaddock sign
extension of the big toe
+ gordon
extension of the big toe
+ oppenheim
extension of the big toe
cerebral accidents of the middle artery result in what?
face and upper extremity weakness and associated UMN signs contralaterally.
What does LMN impairment of the facial N cause?
facial weakness in the entire side of the face ipislaterally
How is the doctor positioned when palpating the liver using the direct method?
facing the head of the table angled at 45 degrees with the doctor's left hand under the lower right ribcage (mirrored image?)
Type 3 fibers
fast pain/ temp
What is the infant's respiratory rate compared to the adult?
faster up to 44BPM
What is a positive finding for palpating the kidney in the entrapment method?
feeling the kidney push between the hands
What is the ideal patient position for taking BP?
feet on the floor with back support with the arm at heart level or below (no muscle contraction
What breast mass is seen at age 15-25; round, mobile, and nontender?
fibroadenoma
What breast mass is seen at age 25-50; nodular, rope-like densities?
fibrocystic changes
common place for common peroneal n entrapment
fibular neck
What must you test for the interossei?
finge adduction and abduction
How to do oppenheim sign?
firmly stroke down the anterior tibialis with thumb and forefinger
What are multiple rib fractures that causes paradoxical movements of the thorax called?
flail chest
what is the normal plantar relax?
flexion of the toes
Reason for steppage gate
foot drop/ paresis of the dorsiflexors (L5 lesion, common perineal N lesion)
Do you have the patient hold their breath when listening to arteries?
for aorta and renal arteries yes, but iliac and femoral arteries no
What do you auscultate the carotids for?
for bruits
Motor weakness in pronator teres syndrome
forearm flexor weakness thenar eminence muscles
because the upper part of the facial nucleus receives corticobulbar innervation from both sides of the motor cortex the _______ is spared
forehead
Where do you auscultate for the iliac arteries?
from ASIS halfway across to the midline bilaterally
What set the sensitivity of resistance to stretch?
gamma motor neurons
Where is weakness with UMN?
general weakness UE: post weaker than ant LE: dorsi weaker than plantar
What does exquisite tenderness through the abdomen with board-like muscular rigidity suggest?
generalized peritonitis
What is alkoptonuria?
genetic condition in which homogentisic acid is deposited in the CT
What is high BP?
greater than 140/90
What is considered elevated JVP?
greater than 3-4 cm above the sternal angle or greater than 8-9cm above the right atrium
What is a Tic?
habitual, repetitive, sterotypical muscle contractions most commonly involving the face, mouth, eyes, neck, and shoulders (blinking, clearing the throat, sniffling, etc.)
Where is the auscultation of the aorta?
halfway between the xiphiod and umbilicus
What is the entrapment method of palpating the kidney?
hand placement is one hand on top of the patient just below the lowest ribs and one hand underneath. On the exhale, push hands together and hold them together while the patient inhales
What is the condition of excess iron storage that causes blue-grey, bronze, or black skin discoloration that darkens in the sun?
hemochromatosis
What does Grey turner's and cullen's sign suggest?
hemorrhagic pancreatitis
What frequency are the S1 and S2 and what part of the stethoscope are they best heard with?
high frequency therefore the diaphragm
What does a resonant tone sound like?
higher pitch and lighter
If the L1,2,3 levels are spared, what will the patient be able to do?
hip flexion function will be progressively stronger (isopsoas), and some control of hip adduction (L2-4) and knee extension (L2-4) would be gained.
What do you instruct the patient to do when auscultating the liver and spleen for bruits?
hold their breath
overshooting (hypermetria) is associated with ______ dysfunction while hypometria is associated with _______ dysfunction
hyper: cerebellar Hypo: parietal lobe contralaterally
What are increased bowel sounds known as and what does it indicate?
hyperperistalsis; diarrhea/early obstruction
What is rapid deep breathing?
hyperpnea
What are some pathologies associated with S4?
hypertension, cardiomyopathy, coronary artery disease, aortic stenosis
Postural tremors are seen in...
hyperthyroidism stress/anxiety essential tremor/familiar tremor excessive caffeine
What do peripheral N lesions do to DTR?
hypo or areflexia
Decreased touch sensation
hypoesthesia
What is the clinical significance of hernias?
if easily reduced it is less of a concern, but if it is not reducible then gangrene can occur and there needs to be a referral
What are fasciculations?
if the muscles are relatively superficial, the mm contraction can be seen as a twitching beneath the surface
What is collateral reinnervation?
if the nerve cell that originally innervated the muscle cells has died due to disease or injury, axonal sprouting from adjacent LMNs may occur
When would you take the pulse at the carotid artery?
if the patient has tremors
When are bronchovesicular breath sounds abnormal?
if they are heard in any area besides between the scaps or over the sternum; it occurs when there is a combination of ventilating and non-ventilating alveoli
When would a tracheal displacement ipsilateral to the lesion be seen?
in atelectasis with bronchial plug
When is S4 heard?
in late diastole
cerebral accidents of the anterior artery result in what?
in lower extremity weakness and associated UMN signs *contralaterally*
Where do axons of the cortical UMNs converge?
in the subcortical region and pass through the posterior limb of the internal capsule between the thalamus and the lentiform body
What is the significance of conscious proprioception?
inclement of type 2 primary afferents in peripheral or spinal nerves or dorsal column medial lemniscal system
When palpating the thorax what does increased vibration mean and what is an example?
increased density; pneumonia
Why are muscle reflexes increased with UMN lesions?
increased muscle stretch due to loss of UMN inhibition
What populations are barrel chest (altered ratio 1:1) seen in? What is the cause?
infants, elderly caused by emphysema and COPD
What do friction rubs indicate?
inflammation of the liver or spleen capsule= infection, post-biopsy, tumor (timed with breathing and sounds like dry leather rubbing together)
What is thrombophlebitis?
inflammed clots in the veins (leg veins most common)
What is a physiological split and the murmur of tricuspid stenosis and pulmonic stenosis accentuated by?
inhalation
What are the breathing instructions for the hook method of liver palpation?
inhale and hold
What are the breathing instructions for the patient when palpating the liver using the direct?
inhale and hold(mirrored image?)
What are the breathing instructions for patients when percussing the liver?
inhale deeply and hold your breath
During vesicular breath sounds, is inspiratory shorter or longer than expiratory? Is there a pause between exhale and inhale?
inspiratory sound is longer than expiratory (3:1) and there is NO pause
During bronchovesicular breath sounds is inspiratory shorter or longer than expiratory? Is there a pause between exhale and inhale?
inspire EQUALS expire and there is NO pause
How do you palpate for fremitus?
instruct the patient to say "99" in a slow deep voice each time the ball/ulnar part of your hand touches their back
What areas do you inspect for pulsations from heaves and lifts?
intercostal spaces
What is the Jendrassik maneuver?
interlock fingers together and pull while dr is performing lower extremity DTRs
what part of the cerebellum is associated with coordination of the limbs?
intermediate zone of the spinocerebellum
What is the intensity expiratory bronchovesicular sounds? Pitch?
intermediate; intermediate
What kind of guarding will persist despite relaxation maneuvers and what does this suggest?
involuntary; peritonitis
primary afferent lesions cause what type of sensory loss??
ipsi
Sensory loss with brown seguard syndrome
ipsilateral fine touch and 2 point discrimination and vibration loss below the umbilicus and contralateral pain and temp below the umbilicus
What can kyphoscoliosis do to the thorax?
it can distort the underlying lungs and may make interpretation of lung findings difficult
If the cell body survives what happens?
it regrows and re innervates the muscle cells
What effect does pressure have on jugular and carotid pulsations?
jugular= eliminates it carotid= does not eliminate it
What effect does patient position have on jugular and carotid pulsation?
jugular= level of pulsation decreased as patient becomes more upright carotid= level pulsation unchanged by patient position
What is the effect of inspiration on jugular and carotid pulse?
jugular= level of pulsation descends with inspiration carotid= unchanged by inspiration
What is the quality of jugular and carotid pulsations?
jugular= soft, undulating and double carotid=vigorous and single
Who can a physiologic S3 be heard in?
kids, young adults, and 3rd trimester of pregnancy
If the L4 level of the Spinal cord is intact, what would the pt be able to do>
knee extension (quadriceps) would be normal, and some control of dorsiflexion and inversion of the foot would be gained
What is an abnormal spinal curvature and vertebral rotation known as?
kyphoscoliosis
What type of pulse would be associated with hyperthyroidism, fever, anemia, and decreased compliance of the aortic walls as in aging?
large and bounding pulse
What does the middle cerebral artery supply?
lateral and inferior portion of the motor cortex that controls the motor function of the face and upper extremity
axillary N entrapment sensory alteration
lateral aspect of the proximal arm
musculocutaneous entrapment sensory alteration
lateral forearm
Is the kidney typically palpable?
no
Should the other fingers besides the pleximeter be in contact with the skin?
no
is rombergs test a sensitive diagnostic test?
no
Does Motor ataxia associated with cerebellar dysfunction get worse when they close their eyes?
no (negative romberg)
Should you be able to percuss the spleen at the anterior axillary line?
no if you can that would indicate splenomegaly
If the murphy's punch is negative does that mean there is no pyelonephritis?
no it could mean that there is a deeper glomerulanephritis occurring
What is a 1 on muscle strength grading scale
no motion but slight contractabilty
What is a 0 on muscle strength grading scale
no motion, no contractabilty
Will cerebellar, basal ganglia and somatosensory system lesions produce weakness anywhere?
no, but they will produce disordered movement (coordination, speed and involuntary movements)
single leg is performed standing on the _____leg
non dominant
How does the normal spleen feel?
non-palpable
What does cogwheel breath sounds represent?
non-uniform inflation of the alveoli which can indicate fibrosis or a normal variant
Where is there a normally a tympany tone and what is a pathological example of a tympany tone?
normal: abdomen and puffed out cheek pathological massive pneumothorax/gastric air bubble
Where is there normally a dull tone and what is a pathological example of a dull tone?
normal: liver pathological: tumor/lobar pneumonia
Where is there normally a resonant tone and what is a pathological example of a resonant tone?
normal: normal lung pathological: simple chronic bronchitis
Where is there a normally a flat tone and what is a pathological example of a flat tone?
normal: thigh pathological: massive pleural effusion
Are lymph nodes tender normally, during infection, during cancer, and when calcified
normal= no infection= yes cancer= maybe calcified= no
What are the lymph nodes size normally, during infection, during cancer, and when calcified?
normal= small infection= enlarged cancer= enlarged greater than 2cm is suspicious calcified= variable
What is the texture of normal, infection, cancer, calcified?
normal= soft infection= boggy (rubbery) cancer=hard calcified= hard
Are lymph nodes moveable normally, during infection, during cancer, or when calcified?
normal= yes (in 4 directions) infection=yes cancer=no calcified= yes
What is the normal sound when auscultating arteries?
nothing
What is an example of an obstructive mass?
obstructed bladder or impacted feces
During flail chest how does the fracture move?
on inspiration the injured area moves in and on expiration it moves out
What is the capture method of palpating the kidney?
one hand is placed on top of the patient and one hand is underneath the patient takes a deep breath in, the doctor presses the their hands together then the patient exhales
1+ (R)
only present with reinforcement
Where do you percuss the spleen?
over the 10th intercostal space at the anterior axillary line
Where is egophony heard primarily?
over the meniscus of a pleural effusion
Where is the liver percussed?
over the midclavicular line and mid sternal line
Where can tracheal breath sounds be heard normally?
over the trachea
Hypermetria
overshooting or past pointing
What part of the fingers do you use to palpate for signs of heart dysfunction?
pads
What is a positive finding for murphy's punch and what does it indicate?
pain provoked by the test indicates pyelonephritis (or kidney stones)
What is blumberg's sign and what does it indicate?
pain that is increased on rapid withdrawal of pressure; the area of tenderness is likely the location of peritonitis
What is the typical color of old stretch marks?
pale, silvery/white, glossy
Splitting that appears on expiration and disappears on inspiration is called what?
paradoxical splitting
What are absent bowel sounds known as and what does it suggests
paralytic ileus (or just ileus); late obstruction or generalized peritonitis
Disease with resting tremor
parkinsons dx
What is lead pipe rigidity or cogwheel rigidity associated with?
parkinsons dx
What does high pitched, intermittent rushes of sounds in the bowel suggest?
partial obstruction
What does a persistent, localized wheeze suggest?
partial obstruction of a bronchus from a foreign body or tumor
Are early systolic ejection sounds pathological or benign?
pathological
agraphognosis AKA agraphesthesia
patient is unable to correctly identify the numbers or letters, but can feel the touch on their hand
When can gurging rales be heard?
patients that are moribund/very ill
What is an aka of pigeon chest? What can cause it?
pectus carinatum/keel chest rickets
What is an aka for funnel chest?
pectus excavatum
What is used to estimate the liver span?
percussion
What can give a false positive for vibration sensation
performing test while feet are still cold
If there is pain with percussion locally or away from percussion what does it possibly indicate?
peritonitis
When is a wide split heard?
persists throughout respiration
location of sciatic N entrapment
piriformis
What do you do once you take the palpatory systolic blood pressure?
place the bell of the stethoscope over the brachial artery , then pump the cuff slowly to be accurate and increase pressure to 30mmHg over the palpatory systolic and drop the pressure 2-3mmHg
If S1 is intact, what would the patient be able to do?
plantarflexion and eversion of the foot would be added. S2 function would add to the strength of plantarflexion and eversion of the foot
What are some causes of tachypnea?
pleurisy or rib fracture
2 limb coordination tests
point to point tests rapid alternating movement
Guillain-Barre syndrome is considered a ___________neuropathy
polyradiculoneuropathy
What does the presence of air under the skin produce?
popping sound
Guillain-Barre syndrome is often ______ or _______
post viral or post vaccination
How many areas do you auscultate on the posterior thorax? Anterior thorax?
posterior: 7 bilateral = 14 total anterior: 6 bilateral = 12 total
When can diastasis recti occur? What is the clinical significance?
pregnancy, obesity, and infancy (congenital) and there is no clinical significance
fasciculation's with LMN lesions
present
pathological reflex with UMN lesions
present
1+ DTR
present but diminished
How to do Gonda test
press down 2nd toe and release with a snap
How can you obliterate venous hum?
pressing on the jugular vein
What is obstructive breathing? Examples?
prolonged expiration due to narrowed airways; -asthma -COPD -bronchitis -emphysema
AKA's for parkinsons gate
propulsion gate festinating gate
What is an example of a physiologic mass?
psoas sign or pregnant uterus
How to test for glut max?
pt face down, have them bring knee to 90 and lift leg off table. doctor pushes down while patient resist
What are fine crackles associated with?
pulmonary fibrosis and early pneumonia
What can right ventricular failure be caused by?
pulmonary hypertension or pulmonic valve stenosis
At which auscultation area would you listen for a split of S2?
pulmonic
Vascular insuffiecnecy of the anteromedial medulla may result in...
quadriplega
Peritonsilar abscess due to advanced strep
quinsy throat
What are tender nodules at the costochondral junctions called?
rachitic rosary
What is tachypnea? examples?
rapid and shallow breathing rib fracture; pleurisy (scheplmann's test helps detect this)
Hemiballism
rapid, flailing movements of the proximal extremities.
What is stasis dermatitis?
red brown patchy due to pooling or RBC lysis
What causes a heart murmur?
regurgitation and stenosis
the major risk associated with Guillain-Barre syndrome
respiratory invovement
What do late inspiratory crackles represent and what are some examples?
restrictive pulmonary disease are typically more numerous than early inspiratory and vary with patient positioning; -interstitial fibrosis -asbestosis (early sign before X-ray) -pneumonia -pulmonary congestion (heart failure)
UMN lesions will do what to the plantar reflex?
result in extension rather than the normal flexion
What does jugular venous pressure reflect?
right arterial pressure or central venous system
What causes a split sound?
right bundle branch block
What is the most common cause os elevated JVP?
right ventricular failure
What can be cause JVP?
right ventricular failure, tricuspid stenosis, constrictive pericarditis, or obstruction of the superior vena cava
Patients are categorized by the most ______ paralyzed motor root
rostral (ex C7 quadriplegia means UMN down to C6 is still ok)
What can cause obstruction?
scar tissue adhesion, tumor, hernia, volvus, telescoping, or foreign object
How is the patient positioned during the aortic maneuver?
seated and leaned forward 25 degrees
What do rhonchi sounds suggest?
secretions in large airways
ulnar N entrapment in the tunnel of guyot sensation weakness
sensation alteration in ventral branch, sensation in dorsal branch spared
Sensory alteration in pronator teres syndrome
sensory alteration in territories of both palmar and digital branches
Balance is a combination of ______ and ______
sensory input (vestibular, visual, and proprioceptive) and motor output
What do early inspiratory crackles represent and what are some examples?
severe airway obstruction not silenced by cough or postural changes; -chronic bronchitis -asthma -emphysema
sensory loss with syringomyelia
shawl like pattern of pain in temperature is lost
When do you test temperature?
should be tested whenever the presence of a neurologic problem suggests that evaluation of temperature sense may be important in the total assessment of the patient
Should the BP be different from both sides?
should be within 10mmHg
What does diffuse blue-grey skin that is darkened by the sun indicate?
silver excess
Dystonia
similar to athetosis, but often involves larger portions of the body, including the trunk
What is it when the heart, liver and stomach are all located on the opposite side from their normal locations?
situs inversus
For JVP, how should the head be positioned?
slightly away from the doctor
What is bradypnea? Examples?
slow breathing; -drug-induced -diabetic coma -increased cranial pressure
Type 4 fibers
slow pain/temp
What are the breathing instructions when auscultating the thorax?
slow, deep, and quietly through an open mouth
Athetosis
slower, more twisting/writhing movements than chorea. (face and distal extremities most commonly involved)
What type of pulse would be associated with heart failure, hypovolemic shock, and severe aortic stenosis?
small, weak pulse
What is the intensity of vesicular expiratory breath sounds? what is the pitch like?
soft; low pitch
What does a dull tone indicate?
solid organ
What are metamorphosing breath sounds?
sounds that change during inspiration from faint vesicular to bronchial
Muscle tone with UMN lesion
spastic (knife clasp)
AKA for scissor gate
spastic paraparesis gate
What may a paradoxical pulse and pulse alternans require in order to detect?
sphyngmomanometry
What is the pulse amplitude with a paradoxical pulse?
sphyngyonmanometry on quiet inspiration
How to do Shaefer test?
squeeze the achilles
How to do Gordon test?
squeeze the gastroc
When there is an area of decreases sensation where do you start testing?
start in location with decreased sensation and move towards the normal areas
Symptoms of Guillain-Barre
starts as paresthesia in the extremities, but shortly develops into progressive motor weakness disorder.
What do bruits indicate?
stenosis, obstruction ,or aneurysm (timed with the heart)
polyneuropathy sensory loss pattern
stocking and glove
what is the loss of sensation in polyneuropathy
stocking and glove due to the distal ends of the peripheral nerves being affected
How to do chaddock sign?
stoke the lateral aspect of the foot
What is parkinson gate?
stooped posture Difficulty initiating movement shuffled, short steps turns around stiffly with numerous short steps reduced arm swing resting temor blank facial expession
How to test for the babinski sign
stroking the lateral aspect of the sole of the foot and curling into the ball of the foot
What is it called when there is popping sound as a result of air under the skin, completely unrelated to the respiratory cycle, and the air pockets are pushed back and forth?
subcutaneous emphysema
Is sensory testing subjective or objective
subjective
causes of cerebellar dysfunction
sublux cerebellar diaschisis trauma alcohol MS CVA Tumors
Salivary glands invovled in CN VII
submaxillary and sublingual glands
Involvement to the Artery of Adamkiewicz may result in what?
sudden onset of ischemia to the anterior 2/3 of the cord, resulting in *bilateral weakness with UMN signs, and pain/temperature loss in the lower extremities*.
What is it called when someone has a quadruple rhythm of 4 heart sounds and at rapid heart rates the S3 and S4 merge into one loud extra heart sound?
summation gallop
What is the patient's starting position for measuring jugular venous pressure?
supine with head elevated 30 degrees
What does S1 mark the beginning of?
systole
Would a physiological murmur most likely be heard during systole or diastole?
systole
What is rapid shallow breathing called?
tachypnea
type 2 fibers:
tactile
a + rombergs may result from damage to
tactile trasmissione pathway (DCML)
What do you instruct the patient to do when auscultating for friction rubs?
take a deep abdominal breath/ breath slowly, deeply, and quietly with an open mouth
What lighting is used when measuring JVP?
tangential
How many times do you tap when percussing the abdomen and what should be the position of the hands?
tap 2-3 times in each area; keep the wrist loose and the plexor at about 90 degrees to the pleximeter
How to do Rossolimo sign?
tapping the ball of the foot
14. Examine the peripheral vasculature of the head, neck, upper extremities and abdomen. Compare and contrast arterial vs venous occlusion. Describe the normal and abnormal findings as well as the significance of abnormal findings.
temporal, carotid, brachial, radial, ulnar, and abdominal aorta abnormal findings for peripheral vasculature would be rubor, pallor, or cyanotic color throphic changes like shiny hair loss edema and stasis dermatitis which is patchy red/brown due to lysis of RBC normal findings are symmetrical rate rhythm amplitude and contour arterial occlusion would have a decreased/absent pulse, pallor, cool/cold skin venous occlusion would have normal pulse, no pallor, normal temperature, pitting edema, and stasis dermatitis dont' forget to auscultate the carotids
When do you loo for the apical impulse?
the 5th intercostal space 7-10 cm from mid-sternal
What is a pleximeter?
the DIP of the middle finger that is firmly placed against the patient's skin
Where would you auscultate the pulmonic valve?
the Left 2nd intercostal space sternal border
Where would you auscultate the 2nd tricuspid?
the Left 5th intercostal space sternal border
What is Stereognosis?
the ability to perceive and recognize the form of an object without seeing it
what is stereognosis?
the ability to recognize an object placed in the hand via tactile info about its shape size ect.
What is pulse alternans?
the amplitude/strength alternates but the rhythm remains normal.
What does lymphedema feel like?
the area is soft in the early stages then goes to hard, indurated, and non-pitting
What part of the stethoscope do you use for the auscultation of the mitral maneuver?
the bell
What are the methods for palpating the kidney?
the capture method and the entrapment method
If there is a large amount of fluid due to ascites what will the percussion of the central abdomen and the flanks?
the center of the abdomen will have a tympany tone and the flanks will have a dull sound
What should you inspect for tangentially during a heart exam?
the chest rise and fall aka "heaves and lifts"
What part of the stethoscope do you use to auscultate the thorax?
the diaphragm
What part of the stethoscope do you use to perform the aortic maneuver?
the diaphragm
How do you palpate the gallbladder?
the doctor feeds the palpating hand under the ribcage on the patient's exhale hold the hands in the region of the gallbladder as the patient inhales
How is the doctor positioned in the hook method?
the doctor is positioned facing the patients left foot
How does the doctor perform palpation of the spleen?
the doctor presses in with the palpating hand after the patient exhales
What may be needed in order to see pulsations for elevated JVP?
the head of the table may need a greater angle of elevation
What is a positive finding for palpating the kidney using the capture method?
the kidney slips out of the hands
Where would you auscultate Erb's point?
the left 3rd intercostal space sternal border
Where would you auscultate the 1st tricuspid?
the left 4th intercostal space sternal border
Where would you auscultate the mitral valve?
the left 5th intercostal space midclavicular line/ 7-10 cm from the mid-sternal line
Where do you best hear a mid-systolic click?
the mitral area
What auscultation point do you perform the mitral maneuver?
the mitral spot
Hypometria
the moving body part may stop prior to reaching the target and hesitate before continuing on to the target
What is puddle sign?
the patient is on their hands and knees for several minutes and the doctor places a stethoscope on the lowest point of the abdomen and flicks the abdomen on the side closest ot the doctor and continues to flick the abdomen while moving the stethoscope further away and when the edge of the puddle has passed the sound becomes louder
What is conscious proprioception testing?
the patient's ability to identify the direction of small passive movements of their joints
What is the middleton maneuver?
the patient's fist is under the rib cage
What is consolidation?
the process by which alveoli fill with fluid and cells
Why do both UMN lesions and LMN lesions cause superficial reflexes to be reduced?
the refer arc involve both ascending and descending spinal cord- bran pathways
Where would you auscultate the aortic valve?
the right 2nd intercostal space sternal border
Which jugular vein should the examiner focus on in JVP?
the right jugular vein
Which population may the kidney be palpable?
the right one may be palpable on thin individuals and kids
How is the doctor positioned for palpation of the gallbladder?
the same as the direct method of liver palpation which is the doctor facing the head of the table angled at 45 degrees
LMN lesions are isolated to _________
the specific distribution of the LMNs affected (radicular or peripheral nerve distribution; rarely a plexus distribution).
If the spleen is palpable what does that mean?
the spleen is 2.5-3 times the normal size
What is done to the pleximeter when you percuss the abdomen? and what is it called?
the tip of the other middle finger briskly taps against the DIP joint of the pleximeter. The other middle finger is called a plexor
In normal adults what do the dimensions of the rib cage look like? What is the ratio width to depth? What does an altered ratio mean?
the width (axilla-axilla) is larger than the depth (A-P) 2:1 Barrel chest (1:1)
The romberg test is only considered positive if....
their balance becomes worse when they *close their eyes*
What does a hyper-resonant tone mean?
there is more air than usual
What does a flat tone indicate?
there is more dense tissue due to solid or fluid
If there is truly no breath sounds heard at auscultation what could this indicate?
there is no ventilating lung under the stethoscope or there is a pathology within the pleural space preventing sound vibration from passing from the lung to the chest wall
Inability to perceive hot or cold
thermanesthesia
Exaggerated sensitivity of hot or cold
thermhyperesthia
decreased temperature sensitivity
thermhypesthesia
What is normal to hear if the patient speaks or whispers when listening to lungs?
they should be muffled and indistinct
How can lymph nodes become calcified?
this is clinically significant. This is an insignificant sign of a healed lymph node
What do you feel for when palpating during the heart exam?
thrills and increase pulsation
At what vertebra level is respiratory expansion performed at?
thumbs positioned at T10
Why do we percuss before palpating the spleen?
to avoid rupturing an enlarged spleen
Why do you take the palpatory systolic?
to avoid the ausculatory gap and to tell us what the systolic will be about
Chorea
to brief, rapid, jerky involuntary movements commonly involving the distal extremities
What is the goal of conscious proprioception testing?
to determine the minimum amount of joint movement that the patient can distinguish
What is jugular venous pulsations used to do?
to estimate the jugular venous pressure
Where are the patients feet for the romberg test?
together
What is an intention tremor?
tremor appears during movement and may get worse as the target is neared
What are postural tremors?
tremors that develop when the part is actively maintaining a posture e.g. holding the arms forward, etc.
Radial N entrapment in the spiral groove of humerus motor weakness
triceps spared weakness from brachioradialis down (supinator, wrist extensors, finger extensors)
How do you palpate the aorta?
try to assess the width of the aorta by placing 2 hands wide apart in the upper abdomen on either side of the aorta and while angling the hands toward the midline press slowly and deeply into the abdomen to feel the edges of the aorta
A dull percussion over the gastric area might indicate?
tumor
What does a dull percussion over the midline of the lower abdomen indicate?
tumor, impacted feces, full bladder, asacites, pregnant uterus/fibroids
What is the predominant percussion sound in the 4 quadrants of the abdomen?
tympany
When do umbilical hernias in infants heal?
typically spontaneously in 1-2 years
If you suspect an aneurysm, how should the aorta be assessed?
ultrasound
places for lat. fem. cutaneous N entrapment
under inguinal ligament
What is spastic hemiparesis?
upper extremity is fixed and there is decreased heel strike. The lower extremity may be circled outward
How do you palpate the liver with the direct method?
use small circular motions to explore the entire lower marigin of the liver(mirrored image?)
What are the 9 quadrants of the abdominal area used for?
use this when there is a more central issue to get a better description of the issue
How do you palpate the liver using the hook method?
using the middleton maneuver
Which is usually diminished first, tactile or pain and temp?
usually tactile
Clubbed nail angle
180 or greater
Infection lymph nodes (Texture, tender, moveable, size)
Boggy Yes Yes Enlarged
What is a 2 on muscle strength grading scale
Full ROM with gravity removed
What do pulsations in the right side of the abdomen suggest?
aortic aneurysm
What is an example of a vascular mass?
aortic aneurysm
What maneuver helps enhance a pericardial friction rub?
aortic maneuver
How can the sound of rubbing chest hair be avoided?
applying water to the hair diminishes the sound
What is the grating sound produced when 2 ends of a fractured rib are rubbed together?
Bone crepitus
What does ALS affect?
Both UMN and LMN's
Bilateral hearing loss findings with Rub Test
Both sides less than arms length
Normal findings for jaw protrusion
Bottom teeth in front of upper
Causes of ptyalism
Difficulty swallowing Infections Neoplasms Neurodisorders Myasthenia Gravis CN XII paralysis
When the TM is bulging, the cone of light will be _________.
Diffuse
Sensation alteration in carpal tunnel syndrome
Digital branches affected, palmar branches spared
Mydriasis
Dilated pupils
Tinea infections are spread in more ways than ____________.
Direct contact
Fx of Conchae
Filter & increase smell
Groove under nose
Filtrum
How do you test for cerebellar coordination?
Finger to nose with eyes closed
List the carpal bones of the hand.
"Some Lovers Try Positions That They Can't Handle." -Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid, Capitate, Hamate.
What are adventitious sounds?
"added" sounds that are superimposed on the usual breath sounds
What creates the S2 heart sound?
"dub" aortic and pulmonic valves closing
What creates the S1 heart sound?
"lub" mitral and tricuspid valves closing
What exam findings may there be with someone who has lumbosacral radiculopathy?
-Antalgic lean (Away from pain suggests posterolateral disc hernation. Towars pain suggests posteromedial disc herniation). -Decreased lumbar lordosis. -Muscle spasm and segmental dysfunction. -Reduced ROM and provocative pain. -Positive nerve root tension tests (SLR, Braggard, bowstring, sitting Laseque, Bechterew, slump, Neri's bowing sign). -WLR, Fajersztajn's, Kemp, valsalva, Milgrim's. -Hypoalgesia.hypoesthesia or hyperalgesia, hyperesthesia may be found int he dermatome of the affected spinal nerve. -Muscle weakness in the muscles of the associated spinal nerve myotome. -DRY may be hyporeflexic or areflexic. -Advanced imaging (MRI, CT) confirm presence of disc herniation.
Where can the radial nerve become entrapped?
-Arcade of Frohse in the supinator muscle.
What is the mechanism of the straight leg raise?
-As the leg is raised, movement occurs at the hip joint, followed by the SI joint, and then the lumbar joints. -Tension is first developed in the sciatic nerve, and then as the leg is raised higher, in the contributing nerve roots (particularly L5, S1, and S2). -The first 35 degrees of hip flexion takes up the slack in the sciatic nerve, and there is no dural movement. Between 35-70 degrees, the contributing nerve roots tense over the intervertebral disc. The nerve roots are essentially fully stretched by approximately 70 degrees, and little further deformation of the roots occurs above this level.
What is the role of auscultation in an ortho-neuro examination?
-Assessment of blood vessels for bruits. -Assessment of heart, lungs, and abdomen to help rule out visceral referred pain.
What are the red flags for cancer or infection?
-Back pain not improved with rest. -History of cancer -Patient over age of 50 years -Unexplained weight loss -Urinary infection -Immunosuppresion -Intravenous drug use -Prolonged use of corticosteroids.
What other conditions may produce positive findings with percussion?
-Bone infection (osteomyelitis). -Bone tumor -Nuchal or supraspinous ligament sprain.
What named fractures are associated with the metacarpals?
-Boxer's -Barroom fracture
What muscles flex the elbow?
-Brachialis mainly. -Brachioradialis -Biceps
What muscles make up the wrist extensor/supinator group?
-Brachioradialis -Extensor carpi radialis longus. -Extensor carpi radialis brevis. -Extensor digitorum. -Extensor carpi ulnaris. -Supinator.
What tests indicate possible meningeal irritation?
-Brudzinski sign -Kernig test
What follow-up tests should be performed following a positive Kernig test?
-Brudzinski's test. -Check temperature. -Emergency referral (lumbar puncture/CSF study, antibiotic therapy).
What are the symptoms of piriformis syndrome?
-Buttock pain. -Leg pain & paresthesia may travel down the sciatic nerve in a common peroneal and/or tibial distribution (may mimic lumbosacral radiculopathy). -Stretching or contraction of the muscle may create or exacerbate symptoms.
What are the DDXs for T4 syndrome?
-Carpal tunnel syndrome/pronator teres -Thoracic outlet syndrome -Cervical radiculopathy -Polyneuropathy (diabetes, etc.) -Vascular disease -Psychogenic
What ortho-neuro tests indicate possible IVF stenosis (with radiculopathy)?
-Cervical compression test and variations (lateral flexion/Jackson's, flexion, extension, rotation, modified Spurling). -Cervical distraction test.
What ortho-neuro tests indicate possible joint involvement (facet, degeneration) without radiculopathy?
-Cervical compression test and variations (lateral flexion/Jackson's, flexion, extension, rotation, modified Spurling). -Cervical distraction test.
What ortho-neuro tests indicate possible IVD syndrome (with radiculopathy)?
-Cervical compression test and variations (lateral flexion/Jackson's, flexion, extension, rotation, modified Spurling). -Cervical distraction test. -Foraminal compression test *in flexion*. -Shoulder abduction relief sign (Bakody's). -Intrathecal pressure tests (*Valsalva, Naffzigger*).
What tests indicate possible soft tissue trauma?
-Cervical distraction test. -Shoulder depression test. -Other tests that cause stretching of soft tissues. -*O'Donahue's test* (differentiates strain vs sprain).
What are the findings/significance of the Soto-Hall test?
-Cervical joint disorder (subluxation, DJD, trauma). -Posterior cervical muscle spasm or strain. -Posterior cervical ligament sprain. -Fracture of the vertebral bodies (compression) or spinous process. -If cervical myelopathy is present, pain may radiate down the spine and into the upper or lower extemities (see Lhermitte's sign). -If meningitis is present, the hips and knees may flex (see Brudzinski's sign).
Thoracic outlet syndrome (TOS) includes what syndromes?
-Cervical rib syndrome. -Scalenus anticus syndrome. -Costoclavicular syndrome. -Pectoralis minor syndrome (hyperabduction syndrome).
What follow-up tests should be performed if there is a positive Brudzinski sign?
-Check temperature. -Kernig's test -Emergency referral (Lumbar puncture/CSF study, antibiotic therapy).
Is the radius on ulna articulation convex on concave or vice versa?
-Convex on concave proximally. -Concave on convex distally.
What ortho-neuro tests indicate possible costoclavicular syndrome?
-Costoclavicular test -Eden's test
What are the findings and significance of the Naffzigger test?
-Creation or aggravation of *upper extremity pain & paresthesia suggests spinal nerve compression by a space-occupying mass* (disc protrusion, tumor, osteophyte).
What are the findings and significance of the shoulder depression test?
-Creation or aggravation of pain & paresthesia in the upper extremity, especially in a dermatomal distribution, suggests *nerve root dural sleeve adhesions*. -More commonly, neck and shoulder pain is created or aggravated by this test, when *muscle spasm, strain, or ligament sprain* is present. -Depression of the shoulder may cause depression of the clavicle and narrowing of the costoclavicular space causing upper extremity pain if *costoclavicular syndrome* is present.
What are the exam findings for facet syndrome?
-Possible hyperlordosis. -Localized paravertebral tenderness, facet joint tenderness. -Spinous process tenderness with percussion. -Extension, ipsilateral rotation, extension-rotation to the symptomatic side produce/aggravate symptoms. -Orthopedic tests (SLR may be restricted and painful, but pain does not extend below the knee. LBP during Goldthwaite's, Kemp's, Yeoman's and Ely's tests, but does not extend below knee). -Neurologic exams are usually negative.
What is Phalen's test?
-Press backs of hands together and hold for 30-60 seconds. -Tests median nerve for carpal tunnel syndrome. -Compresses the nerve.
What is Reverse Phalen's test?
-Press palms of hands together in a "reverend position" and hold for 30-60 seconds. -Tests median nerve for carpal tunnel syndrome. -Stretches the nerve.
What are the findings and significance of the Valsalva maneuver?
-Production or exacerbation of radiation into the upper extremity, especially in a dermatomal pattern. -A positive finding suggests that a radiculopathy due to compression by a space occupying mass (disc protrusion/prolapse, tumor, osteophytes) is present.
What muscles make up the wrist flexor/pronator group?
-Pronator teres -Flexor carpi radialis. -Palmaris longus. -Flexor carpi ulnaris.
Where can the ulnar nerve become entrapped?
-Proximal or distal to the cubital tunnel. -Flexor carpi ulnaris. -Interosseous membrane.
How should Bakody's sign be reported?
-Relief of arm pain/paresthesia with the arm abducted suggests (or indicates) cervical radiculopathy. -Cervical radiculopathy is suggested (indicated) by a Shoulder Abduction Relief sign on the right.
What is the rationale/mechanism of the O'Donahue test?
-Resisted motion primarily stresses muscle and tendon (contractile elements). Muscles hurt when you contract them if they are injured. -Passive motion (stretching) primarily stresses ligaments (non-contractile elements). Ligaments hurt when stretched if they are injured. -Combination strain-sprain injuries will result in pain on both resisted contraction and passive stretching. -Since strained muscles may also hurt during passive stretching, strains may present with pain during resisted contraction and passive stretching.
What tests indicate possible fracture/dislocation?
-Rust sign -Soto-Hall test
What are the red flags for cauda equina syndrome?
-Saddle anesthesia -Urinary retention or overflow incontinence. -Fecal incontinence, loss of anal sphincter tone. -Sexual dysfunction.
What are the potential sites of compression of structures involved in TOS?
-Scalene triangle (between the anterior and middle scalene muscles, and the first rib). -Costoclavicular space (between the first rib and clavicle). -Pectoralis minor (under the pectoralis minor or tendon).
What are the 4 subgroups of TOS that are commonly ientified?
-Scalenus anticus syndrome -Cervical rib syndrome -Costoclavicular syndrome -Pectoralis minor syndrome (aka hyperabduction syndrome).
Which bones make up the bony arch of the carpal tunnel?
-Scaphoid -Lunate -Triquetrum -Pisiform
What ortho/neuro tests indicate glenohumeral instability (chronic)?
-Shoulder apprehension test. -Anterior instability (clunk) test.
What is the significance of the straight leg raise?
-Significance is relative to the angle at which pain is elicited or exacerbated. -Between 0-35 degrees of hip flexion may be due to: SI joint disorder, or sciatic neuropathy (Piriformis syndrome, etc.) -Between 35-70 degrees of hip flexion may be due to radiculopathy associated with IVD protrusion, or IVF stenosis. -Above 70 degrees of hip flexion suggests lumbar joint pain.
What are abnormal findings for percussion?
-Significant local pain. -Radicular pain.
What are the examination findings of piriformis syndrome?
-Since the piriformis is an external rotator to the femur, excessive toeing out (foot flare) may be present. -Decreased internal rotation of the hip. -Deep palpation in the buttock may create or exacerbate the leg pain. -Piriformis muscle test may aggravate the buttock and leg pain. -Positive SLR, Braggard's test. -Negative valsalva, Kemp's, WLR. -Their may be sensory, motor, or reflex abnormalities in the common peroneal and/or tibial nerve distributions of the sciatic nerve. -Sensation in the posterior thigh would likely be WNL since it is innervated by the posterior femoral cutaneous branch of the sacral plexus.
What is Mill's test?
-Stress test for muscles that originate over the lateral epicondyle. Flex wrist and extend shoulder. -Positive test indicates lateral epicondylitis.
What ortho/neuro tests indicate glenohumeral instability (acute dislocation)?
-Sulcus sign -Dugas test
What are the findings and significance of a positive Beever's sign?
-Superior movement of the umbilicus indicates weakness/paralysis of the lower abdominals. Bilateral lower abdominal weakness might result from bilateral T10-T12 spinal nerve lesion, or more likely bilateral spinal cord lesion with UMN lesion at the T10 level of the spinal cord. -Lateral deviation of the umbilicus indicates weakness/paralysis of the contralateral abdominals. Such weakness may result from unilateral T10-T12 spinal nerve lesion, or more likely spinal cord injury and UMN lesion above T7 contralateral to the umbilical deviation. -Deviation of the umbilicus up to one side would indicate weakness of the contralateral lower abdominal muscles. Weakness of the lower abdominal muscles on one side might result fromT10-T12 spinal nerve lesion, or spinal cord injury with UMN lesion at T10.
What tests may help DDX lumbar from SI problems?
-Supported forward bending test (belt test). -Goldthwaite's test.
In the primary care setting for patients with leg symptoms, the neurologic examination can safely be limited to a few tests. What are they?
-Testing dorsiflexion strength of the ankle and the great toe, with weakness suggesting L5 and some L4 dysfunctions. -Testing ankle reflexes to evaluate S1 root dysfunction. -Testing light touch sensation in the medial (L4), dorsal (L5), and lateral (S1) aspects of the foot. -The straight leg raising (SLR) test.
places for median N entrapment
1. carpal tunnel syndrome 2. pronator teres syndrome
What is the Straight Leg Raise?
-The SLR is primarily known as a test for lumbosacral radiculopathy, sciatic neuropathy, and their causes (IVD protrusion and IVF stenosis, and piriformis syndrome). -The doctor stands facing the supine patient on the side of involvement. Place one hand under the heel and the other on the knee. Slowly flex the hip while maintaining the knee extension. Extimate the angle at which pain or restriction occurs. -The test may also be painful and/or restricted due to tight hamstrings, hip joint, SI joint, or lumbar joint disorders. - So it is NOT diagnostic for LS Radiculopathy.
When visually estimating cervical ROM, what should the doctor do?
-The measurement should be recorded in 5 degree increments. -Look for reference points from neutral that suggest full ROM. -Look for symmetry of motion.
What are the findings of T4 syndrome?
-The symptoms often awaken the patient, or are present upon arising. (Must DDx from CTS and TOS). -Headache is commonly associated. -Onset is usually nontraumatic. Postural strain associated with prolonged sitting has been implicated. -Women are affected more commonly than men (4:1). -The neurologic exam is negative.
What is O'Brien's test?
-The test is best performed with the patient in a relaxed sitting position but can also be performed in standing. The arm to be tested should be in 90 degrees of flexion and about 10 degrees of adduction. The patient then internally rotates the arm, pronating at the elbow and essentially pointing the thumb to the ground. -The examiner provides a downward force distally on the arm while the patient resists with an upward force. The examiner can also instruct the patient to simultaneously externally rotate the arm while the examiner resists this as well. The test is then repeated but with the arm in neutral rotation. -The test is considered positive if there is pain and/or clicking when the arm is in full internal rotation but not when the arm is in neutral rotation. -Indicates SLAP lesion.
Describe the quality of the pain, tingling, and numbness in the upper extremity due to TOS.
-The upper extremity pain is often diffuse. -The paresthesia and numbness may be diffuse or localized. -Compression of the brachial plexus may present localized tingling and numbness depending upon the portion of the plexus affected. For example, if the lower trunk of the brachial plexus (formed by C8 & T1 spinal nerves) is affected (common), paresthesia and numbness will present in the medial aspect of the upper extremity. -With vascular compromise, the tingling and numbness may be more diffuse.
What is Lhermitte's sign?
-This sign *suggests myelopathy* (spinal cord disorder) of the cervical spinal cord. -With the patient seated, passively flex the patient's head toward their chest.
What is Minor's sign?
-This sign may be present in lumbar radiculopathy, but it is a *non-specific* sign, as it may be present with non-radicular lumbar and sacroiliac disorders. -The patient is observed supporting their back as they rise from a seated position. -The patient may support their weight on the unaffected lower extremity, keeping the affected lower extremity flexed.
What structures should you check when you suspect TOS?
-Tightness of scalene muscles. -Tightness of pectoralis muscles. -Palpation of supraclavicular fossa for cervical rib or fibrous bands. -Cervico-thoracic region. -Clavicle, ribs, etc.
What are some predisposing factors for facet syndrome?
-Trauma, microtrauma -Obesity -Increased lumbar lordosis -Increased sacral base angle -Increased disc angles
What muscles extend the elbow?
-Triceps mainly. -Anconeus
What is a barroom fracture?
-Usually the fourth or fifth metatarsal head. -Result of a roundhouse punch to anything that is harder than the metacarpals themselves.
What physical exam findings are associated with carpal tunnel syndrome?
-Weakness/atrophy of the intrinsic hand muscles innervated by the median nerve. -Altered sensation in the median nerve distribution. -Positive Phalen's test and reverse Phalen's test.
What is the typical history of someone with facet syndrome?
-Well-localized unilateral low back pain and tenderness. -Referred hip/groin, buttock, or thich pain (above the knee). -Pain may have developed arising from a forward flexed poition; patient may be stuck in forward flexed antalgic posture.
What is the costoclavicular test?
-With the patient seated and hands resting at their sides, the examiner stands behind the patient and reaches forward to palpate the radial pulse, noting its strength. -The examiner brings the patient's arms back and then instructs the patient to bring their shoulders "back and down" and the "flex their chin to their chest." -Note if amplitude of the radial pulse has decreased, and question the patient about creation or exacerbation of arm pain or paresthesia.
What are the Adson and modified Adson tests?
-With the patient seated, the examiner palpates the radial pulse noting its strength, and then slightly abducts, extends, and externally rotates the patient's arm. -The patient is instructed to rotate their head *ipsiliaterally*, extend their head, and take a deep breath and hold for 10 seconds. -For modified, the patient rotates their head *contralaterally.* -The examiner checks the radial pulse for decreased intensity and questions the patient aboud creation or aggravation of symptoms of arm pain or paresthesia.
What ortho-neuro tests indicate possible pectoralis minor syndrome?
-Wright's test (hyperabduction test)
What orthopedic tests may help identify pectoralis minor syndrome (hyperabduction syndrome)?
-Wright's test (hyperabduction test). -Elevated Arm Stress Test (EAST).
What organs may be tender in a healthy individual?
-aorta -cecum -sigmoid -ovaries
What are the murmurs heard during diastole?
-aortic/pulmonic regurgitation -mitral/tricuspid stenosis
What are examples of localized peritonitis? (location?)
-appendicits (right lower quadrant) -diverticulitis (Left lower quadrant) -cholecystis (right upper quadrant/shoulder); -pancreatitis (epigastric) -duodenal ulcer (epigastric)
What are examples that can cause wheezing?
-asthma -COPD -bronchitis
What are examples of pathologies that can cause bronchial breath sounds?
-atelectasis with patent bronchus -lung tumor -pneumonia -pulmonary infarction
Percuss the posterior thorax, including diaphragmatic excursion. Describe the normal and abnormal findings as well as the significance of abnormal findings. List the 5 percussion tones and give 1 pathology for each tone.
1. Percuss posterior thorax: The patient should have their arms crossed in the front. percuss 14 areas 7 on each side comparing bilaterally as you go down and around the scapula. "Normal percussion sound of the lung is resonant. Abnormal sounds are flat which indicates a large pleural effusion, dull indicating consolidation so lobar pneumonia, hyper-resonant indicating emphysema, and tympany indicating a large pneumothorax." 2. Diaphragmatic excursion: The patient crosses their arms in the front. The patient holds an inhale and mark the dull tone then holds an exhale to mark. "Normal is 3-6cm between the marks and should be symmetrical, but the left side will be lower due to the liver that is on the right.
Lymph nodes to palpate
1. Preauricular 2. Postauricular 3. Occipital 4. Tonsilar 5. Submandibular 6. Submental 7. Superficial cervical 8. Deep cervical 9. Posterior cervical 10. Supraclavicular
Testing mm of facial expression
1. Smile 2. Frown 3. Squeeze eyes closed 4. Puff cheeks out 5. Pout 6. Pucker lips 7. Lift eyebrows
Testing CN II
1. Snellen chart 2. Confrontation 3. Direct & Consensual light reflex 4. Funduscopic exam
3 ways to fest finger flexors?
1. Squeeze Dr's crossed fingers 2. flex fingers and doctor tries to unfelt them 3. Dynamometer
5. Perform superficial and deep palpation of the abdominal quadrants along with rebound tenderness. Palpate the liver and gallbladder. Describe the normal and abnormal findings as well as the significance of abnormal findings
1. The patient's legs should be bent superficial palpation: Start at the RLQ circular motions in all 4 quadrants "feeling for masses, pain, or guarding which would indicate abnormal" 2. deep palpation. All 4 quadrants the patient should breath with an open mouth "exploring any masses or tenderness which would be abnormal. Involuntary guarding suggests peritonitis." 3. Rebound tenderness: 1 time in each quadrant slowly put hands in then quickly pull them off and the patient should point to pain that they may feel. "Rebound tenderness or blumberg sign is when there is increased pain on the withdrawal of pressure and this can indicate peritoneal inflammation." 4. Liver: Using the direct method. Face the patient's head 45 degrees and 1 hand is below the ribs. The patient holds an inhale and do circular motions. "normal liver is soft, no nodules, with have a smooth marigin and will not be tender. Abnormal would be tender, firm/hard, or irregular which can be from cirrhosis, hepatitis, or cancer." 5. Gallbladder: Same position as liver direct method feed into the liver with both thumbs as the patient exhales and hold the pressure as the patient inhales "if there was pain this would be a positive murphy's sign which is indiciative of cholecystitis"
6. Perform superficial and deep palpation of the abdominal quadrant along with rebound tenderness. Percuss and palpate the spleen. Describethe normal and abnormal findings as well as the significance of abnormal findings.
1. The patient's legs should be bent superficial palpation: Start at the RLQ circular motions in all 4 quadrants "feeling for masses, pain, or guarding which would indicate abnormal" 2. deep palpation. All 4 quadrants the patient should breath with an open mouth "exploring any masses or tenderness which would be abnormal. Involuntary guarding suggests peritonitis." 3. Rebound tenderness: 1 time in each quadrant slowly put hands in then quickly pull them off and the patient should point to pain that they may feel. "Rebound tenderness or blumberg sign is when there is increased pain on the withdrawal of pressure and this can indicate peritoneal inflammation." 4. Spleen: "I would percuss the spleen before perform palpation" Dr left hand reaches across the patient under their ribs and slightly pulls up on the ribcage. On patient inhale and hold "Normal is when the spleen is not palpable. Abnormal is if it is palpable this indicates splenomegaly which can be caused by mononucleosis, malaria, hemolytic anemia, or increase RBC destruction."
Perform superficial and deep palpation of the abdominal quadrants along with rebound tenderness. Palpate the kidneys and perform Murphy's punch. Describe the normal and abnormal findings as well as the significance of abnormal findings.
1. The patient's legs should be bent superficial palpation: Start at the RLQ circular motions in all 4 quadrants "feeling for masses, pain, or guarding which would indicate abnormal" 2. deep palpation. All 4 quadrants the patient should breath with an open mouth "exploring any masses or tenderness which would be abnormal. Involuntary guarding suggests peritonitis." 3. Rebound tenderness: 1 time in each quadrant slowly put hands in then quickly pull them off and the patient should point to pain that they may feel. "Rebound tenderness or blumberg sign is when there is increased pain on the withdrawal of pressure and this can indicate peritoneal inflammation." 4.Kidneys: Do go on Left side when palpating L kidney. 1 inch above umbilicus midline. Stay on patient's R side Using the entrapment method place 1 hand on top and 1 hand under the patient's ribcage. On the exhale push your hands together then the patient inhales. "Normal would be not palpating anything. Abnormal is when the patient inhales and you feel the kidney push the hands apart which indicates enlarged kidney that can be a result of polycystic kidney, tumor, or hydronephrosis." 5. Murphy's punch: The patient is seated with the back towards the doctor. The doctor places a hand on the pack as the costovertebral angle and punchs the hand with the other hand. "Normal would be no pain. Abnormal is if this produces pain indicating pylonephritis."
Screening tests for Glaucoma
1. Tonometry 2. Ophthalmoscope or slit lamp 3. Visual field test *also palpate eyes
4 causes of Septal Perforation
1. Trauma 2. Surgery 3. Cocaine 4. Heavy metal exposure
Weakness can be associated with what? (4 things)
1. UMN lesions 2. LMN lesions 3. NMJ disease 4. muscle disease (myopathy)
What things do you observe while looking at a patients breathing?
1. breathing (respiratory rate) 2. effort (use of accessory muscles) 3. observe symmetry of respiration movement 4. check intercostal space for abnormal retraction during inspiration 5. check skin for abnormalities
Percuss the abdominal quadrants and the spleen. Describe the procedures and findings for one of the ascites tests. Describe the normal and abnormal findings as well as the significance of abnormal findings.
1. percuss all 4 quadrants of the abdomen multiple times in each quadrant state "normal percussion creates a sound of tympany. Abnormal sounds include dull, resonant, hyperresonant, or flat which be from a tumor, ascites, pregnancy, or a full bladder." 3. the spleen: start are the 10th intercostal space between the midaxillary line and anterior axillary line and percuss as the patient exhales. Percuss toward armpit. State, "Normal is hearing tympany abnormal would be hearing a change for tympany to dull this indicates splenomegaly which is caused by mononucleosis, malaria, hemolytic anemia, and increased rbc destruction." 3. Ascites: shifting dullness is a test that is performed on the patient's side. starting with the side that is up percuss down toward the table. The side that is up will percuss as tympany and as you move closer to the table it will change to dull if there is fluid. this test is most appropriate for patient's that have at least 500ml of fluid in their abdomen.
Percuss the abdominal quadrants and the liver. Describe the pro cedures and findings for one of the ascites tests. Describe the normal and abnormal findings as well as the significance of abnormal findings.
1. percuss all 4 quadrants of the abdomen multiple times in each quadrant state "normal percussion creates a sound of tympany. Abnormal sounds include dull, which be from a tumor, ascites, pregnancy, or a full bladder." 2. the liver: go to the midclavicular line and have the patient inhale and hold. female patients should move breast. start around the umbillicus and percuss up until you hear a dull sound then down from the breast area. The to the mid sternal line do the same. state, "Listening for a change from tympany to dull to mark the borders. Normal for the midclavicular line is 6-12cm and midsternal 4-8cm. hepatomegaly is when it exceeds this measurement" 3. Ascites: shifting dullness is a test that is performed on the patient's side. starting with the side that is up percuss down toward the table. The side that is up will percuss as tympany and as you move closer to the table it will change to dull if there is fluid. this test is most appropriate for patient's that have at least 500ml of fluid in their abdomen.
Modifications of Rombergs
1. perform in tandem position 2. perform with single leg 3. perform standing on foam cushion
Characteristics of Coryza
1. red/swollen nasal mucosa 2. Watery thick discharge 3. Fever
3 types of gait to be examined
1. regular 2. tandem 3. heel walk/ toe walk
Major characteristics of parkinsons
1. resting tremor 2. rigidity 3. slow movement and difficulty initiating movement
What must you consider when identifying a lesion?
1. the distribution of the weakness 2. associated findings on other aspects of the motor exam, reflex exam, and sensory exam 3. history.
LMN's may affect
1. the neuron's cell body in the CNS 2. the axon in the PNS
What are some pathologies that can cause cardiac enlargement?
1. thicker blood (like polycythemia or dehydration) 2. obesity 3. atherosclerosis 4. ventricular dilation/hypertrophy 5. effusive pericarditis
12. Auscultate the heart and carotid arteries. Perform the aortic maneuver. Describe a physiological split S2. D escribe the normal and abnormal findings as well as the significance of abnormal findings.
1.Auscultate the heart: with the diaphragm and the bell over APETTM A 2 on R P 2 on L E 3 on L T 4 on L T 5 on L M 5 mid clavicular "Normal is S1 and S2 sounds S1 is the start of systole while S2 is the beginning of diastole. Abnormal heart sounds are S3 and S4 S3 is ventricular gallop as seen in kids and 3rd trimester of pregnancy. S4 is atrial gallop as seen in hypertension, coronary artery disease and aortic stenosis." "diastolic murmurs are from aortic/pulmonic regurgitation or mitral/tricuspid stensosis. Systolic murmurs can be from mitral/tricuspid regurgitation and aortic/pulmonic stenosis." 2. Auscultate the carotid aa: with the diaphragm and instruct the patient to hold on their breath "normal would be hearing nothing and abnormal would be bruits indicating stenosis or obstruction." 3. aortic maneuver: with the diaphragm the patient sitting listen to all APETTM except the A and lean the patient forward 25 degrees and ave the patient ehale and suspend respiration. "the aortic maneuver is preformed to better auscultate S3/S4 or splits. The physiological split of S2 is heard on inhalation and disappears on inhalation and is heard at the pulmonic auscultation spot."
Auscultate the heart and carotid arteries. Perform the mitral maneuver. Describe the normal and abnormal findings as well as the significance of abnormal findings.
1.Auscultate the heart: with the diaphragm and the bell over APETTM A 2 on R P 2 on L E 3 on L T 4 on L T 5 on L M 5 mid clavicular "Normal is S1 and S2 sounds S1 is the start of systole while S2 is the beginning of diastole. Abnormal heart sounds are S3 and S4 S3 is ventricular gallop as seen in kids and 3rd trimester of pregnancy. S4 is atrial gallop as seen in hypertension, coronary artery disease and aortic stenosis." "diastolic murmurs are from aortic/pulmonic regurgitation or mitral/tricuspid stensosis. Systolic murmurs can be from mitral/tricuspid regurgitation and aortic/pulmonic stenosis." Auscultate the carotid aa: with the diaphragm and instruct the patient to hold on their breath "normal would be hearing nothing and abnormal would be bruits indicating stenosis or obstruction." 2. Mitral maneuver: listen with the bell the patient is laying on their left side at a 45 degree angle over the M in APETTM "the mitral maneuver is preformed to better auscultate S3/S4 or splits."
A person is given the score of one row below the row in which they miss _______.
1/2 the letters
What is the carrying angle of the elbow?
10-15 degrees valgus in extension.
What are the locations in which confrontation is performed?
11 & 1 9 & 3 7 & 5
What is optimal BP?
110-119/60-79
What is the normal BP?
120/80
what is high normal BP?
130-139/85-89
What is the normal respiratory rate?
14-20
Normal respiratory rate?
14-20 breaths per minute
What is Tinel's test?
A percussion test that can be used to reproduce symptoms of peripheral nerve entrappment, especially radial nerve.
What is an auscultatory gap? Found in what kind of people
A period of silence while taking BP but the systolic pressure is actually higher. People w/ hypertension
What is the significance of Lhermitte's sign?
A positive sign suggests cervical myelopathy. Lhermitte's sign is NOT diagnostic for MS. Some people say that it is pathognomonic. You can have MS without Lhermitte's sign and vice versa.
What is a rhonchi?
A prolonged, LOW-pitched, musical sound with a snoring quality
What is osteochondritis dessecans?
A rare condition involving fragmentation of the articular cartilage that is a result of excessive repetitive loading. The fragments can accumulate and the elbow joint and may produce a crunching or crepitus sound.
What is meningitis?
A serious, potentially deadly disease. Emergency medical attention is necessary.
What is the splashing sound called that is heard upon shaking a patient who has both air and fluid in the pleural cavity?
A succussion splash
Before taking measurements with an inclinometer, what should be done?
A warm-up should be performed prior to the measurements, consisting of flexion-extension twice, left & right rotation twice, left & right lateral flexion twice, and one additional flexion & extension.
What is frozen shoulder syndrome? Aka?
Aka adhesive capsulitis. It is characterized by rapid onset of extreme limitation of the active and passige range of motion of the glenohumeral joint accompanied by extreme pain if one violates the restricted ROM. Typically idiopathic and self resolving.
Which of the following are increased risk factors for the development of Carpal Tunnel Syndrome symptoms (Please choose all correct answers): a) Rheumatoid Arthritis b) Acute trauma to the wrist. c) Repetitive wrist movements. d) Sustained isometric wrist/hand contractions.
A, B, C
At end range elbow extension, which 3 of these forces prevent further movement? a) Elbow flexor tension b) Olecranon process/olecranon fossa compression. c) Posterior capsule tension d) Anterior capsule tension
A, B, D
Regarding Lever Systems in humans, which metaphors are normally used? (Choose 3). a) Muscles generate force to move the lever. b) Tendons act as power and resistance lever arms. c) Bones function as lever arms. d) Joints act like fulcrums.
A, C, D
Punctate bleeding when psoriasis scales are picked off
Auspitz sign
What is the horizon sign?
AC joint separation creates a "bump."
Ddx Rosacea vs. SLE
ANA blood test (+ SLE)
What areas do you palpate during the heart exam?
APETTM spots the intercostal spaces
CN VI
Abducens
What is the painful middle arc of abduction test?
Abducting the arms elicits pain in the middle of the ROM. Indicative of impingement syndrome, so then perform Hawkin's test.
Condition characterized by velvety hyperpigmentation of skin mainly in skin folds
Acanthosis nigricans
Ketonemia/acidosis leads to a _______ odor.
Acetone
__________ is a condition that causes the lip to lose its redness and become scaley & exerted, common among men who work outdoors
Actinic Cheilitis
Most common precursor lesion of squamous cell carcinoma = ___________
Actinic Keratosis (Solar keratosis)
Most common cause of hoarseness
Acute laryngitis
A pupil (often unilateral) that is sluggish to respond to light, larger than normal, & has a slow worm like constriction
Adie's Pupil
Chiro management of Meniere's dz
Adjust Herbal diuretics therapy <Na+ in diet
When do you test "gnosis tests'?
After the basic sensory perception tests are performed, certain sensory tests can be utilized to test the ability of the sensory cortex to service knowledge from the sensory imputs
Normal ROM varies with what?
Age and gender.
How to do finger to nose test
Ask the patient to alternately touch the index finger of each hand to the tip of their nose. Observe the smoothness and accuracy of the movement. Note any "dysmetria", or "intention" tremor.
Holmes' rebound test
Ask the patient to flex their forearm against the examiner's resistance (turn patient's face away and shield with your other hand.) Suddenly remove your pressure. Normally, the patient can quickly check the movement of the forearm. With CB dysfunction, however, there is failure of the antagonists to contract and agonists to relax, and the forearm continues to swing upward
Rapid alternating movements in LE
Ask the patient to tap your hand as quickly as possible with the ball of their foot. Ask the patient to tap the knee several times with the alternate heel. This can be combined with the heel-to-shin test.
Finger to finger to nose test
Ask the patient to touch their nose and then reach out to touch the examiner's finger (positioned such that the patient must almost fully extend). Repeat several times with your finger in different locations.
heel to shin test
Ask the supine patient to place the heel of one foot on the opposite kneecap and then slide the heel down the shin. .
ABCDE rule of Melanoma
Asymmetrical Borders irregular Color (irregular, not uniform) Diameter >5mm Elevation/enlarged
For sensory testing do you need to test both Pain and temp? or just one or the other?
At least one aspect of both pain/temp & tactile function should be assessed in the area(s) examined, since pain/temp & tactile travel through primary afferent fibers with different susceptibility to injury and diseases, and then travel in different ascending tracts
motor ataxia.
Ataxia associated with cerebellar lesions
sensory ataxia
Ataxia associated with impairment of conscious proprioception/JPS
What is breathing that may shallow or deep and stops for short periods (irregularly irregular breathing)?
Ataxic breathing
Copper & silver wiring are associated with ______________, ______________ & ______________.
Atherosclerosis Arteriosclerosis Hypertensive retinopathy
Thinning of skin surface & loss of skin markings, skin translucent & paper like
Atrophy (Examples: striae, aged skin)
Auscultate the abdominal quadrants, the liver and the spleen. Palpate the aorta. Describe the normal and abnormal findings as well as the significance of abnormal findings.
Auscultate: 1. first, warm up the diaphragm with your shirt and tap to ensure the stethoscope is on the diaphragm setting. 2.Using the diaphragm auscultate 2-3 times in all 4 quadrants starting with the RLQ (unless they have pain) make sure to come medially to the umbilicus because of the sigmoid colon. count to 5 for each auscultation State, "bowel sounds/borborygmi has a normal rate of 4-35 sounds per minute. Hyperperistalsis indicates early obstruction. The absence of bowel sounds is called paralytic ileus and this indicates late bowel obstruction and generalized peritonitis. High pitched intermittent rushes of sounds indicates parital obstruction." 3. Palpate the aorta with knees bent. 2 hands around midline of the umbilicus slowly going deep to abdomen and feel the pulse. should be no larger than 3cm if it is then an ultrasound will be performed. 4. Auscultate the liver and spleen for friction rubs -friction rubs of the liver right below the ribs of the right with diaphragm patient breathes with an open mouth. -for the spleen between the anterior axillary line and midaxillary line and the 10th rib the patient breathes deeply with an open mouth State "normal is hearing nothing, abnormal is hearing friction rubs would indicate hepatomegaly for the liver and splenomegaly for the spleen" 5. Auscultate the arteries of the liver and spleen no sound is normal abnormal is bruits which indicates turbulent flow from stenosis or obstruction
Auscultate the abdominal quadrants and abdominal arteries. Palpate the aorta. Describe the normal and abnormal findings as well as the significance of abnormal findings.
Auscultate: 1. first, warm up the diaphragm with your shirt and tap to ensure the stethoscope is on the diaphragm setting. 2.Using the diaphragm auscultate 2-3 times in all 4 quadrants starting with the RLQ (unless they have pain) make sure to come medially to the umbilicus because of the sigmoid colon. count to 5 for each auscultation State, "bowel sounds/borborygmi has a normal rate of 4-35 sounds per minute. Hyperperistalsis indicates early obstruction. The absence of bowel sounds is called paralytic ileus and this indicates late bowel obstruction and generalized peritonitis. High pitched intermittent rushes of sounds indicates parital obstruction." 3. Palpate the aorta: with knees bent 2 hands around midline of the umbilicus slowly going deep to abdomen and feel the pulse. should be no larger than 3cm if it is then an ultrasound will be performed. 4. auscultate the arteries with the BELL If you hear heartbeat tell the patient to hold their breath -aorta 1/2-2/3 between the xiphoid and the navel -renal just 1 inch lateral to the aorta bilaterally below the ribs (the left is a little further out) -Splenic artery- while listening to the L renal go lateral (about nipple line) -Hepatic artery just below rib cage on R -common iliac 1/2 way across the ASIS to umbilicus -femoral 1 inch above or below the midpoint of the inguinal ligament (figure 4 with legs and it will point to the femoral) State, "normal sounds for arteries is no sound, if there is whooshing sound due to turbulent blood flow from stenosis or obstruction this is called bruits."
Osteogenesis imperfecta causes __________, and would be associated with ___________ & __________ findings.
Blue sclera Brittle bones Decreased hearing
What sign means rebound tenderness?
Blumberg's sign
What is the aka for ataxic breathing?
Biot's
Ddx pityriasis rosea from secondary syphilis with a _________.
Blood test
Tinea corporis
Body in ringworm annular lesions
M/c distribution sites for melanoma in white females
Back Upper chest Lower legs
M/c distribution sites for melanoma in white males
Back & chest
3 B's: ___________, ____________, ____________, indicate acute _______________________.
Bad breath Bad taste Gingival Bleeding Necrotizing Ulcerative Gingivo-Stomatitis
Veins turns or dilates at arteries
Banking
Autosomal dominant disorder with multiple skin cancer lesions and "palmoplantar pits" and other abnormalities, including skeletal malformation
Basal cell Nevus syndrome (Gorlin's)
M/c skin cancer
Basal cell carcinoma
Most common skin cancer
Basal cell carcinoma
Rodent ulcers are associated with _____________.
Basal cell carcinoma
What named fractures are associated with the phalanges?
Baseball/mallet finger.
Why is an increased lumbosacral disc angle a risk factor for facet syndrome?
Because an angle more than 15 degrees can cause facet imbrication.
What can chest hair rubbing on the stethoscope be confused with sometimes when auscultating the thorax?
Because chest hair creates a crackling sound, do not confuse it with the sound of shivering or muscular contractions for adventitious lung sounds
Why is an increased sacral base angle a risk factor for facet syndrome?
Because it increases the shearing and compressive forces on the lumbosacral posterior joints.
Shapes of nail
Bell Oval Square (Should all be consistent)
Ex of LMN facial N weakness
Bells Palsy
Xanthelasma is ____________ and may suggest __________.
Benign Hyperlipidemia
Choose 3 muscles which take origin on the medial epicondyle. a) Brachioradialis b) Extensor carpi radialis c) Flexor carpi ulnaris d) Pronator teres e) Palmaris longus
C, D, E
A transection at which levels will result in a respiratory compromise?
C1-3
Deltoid Spinal and peripheral N
C5 Axillary
Testing the deltoid is testing what
C5 / axillary nerve
DTR for Bieceps
C5 musculocutaneous (C5,6)
Elbow flexors (biceps)
C6 musculocutaneous
Wrist Extensors
C6 Radial
Most common spinal nerves affected by cervical radiculapthy
C6 & 7
Testing the biceps is testing what
C6 / musculocutaneous nerve
Testing the wrist extensors is testing what?
C6 Radial
DTR for brachioradialis
C6 radial (c5,6)
Wrist Flexors
C7 Median and Ulnar Nerves
Elbow extensors (triceps)
C7 Radial
Finger Extensors
C7 Radial
Testing the wrist flexors is testing what?
C7 Median and Ulnar N
DTP for triceps
C7 radial (C7,8)
Testing the finger extensors is testing what?
C7/ Radial
Testing the triceps is testing what
C7/ Radial
Finger flexors
C8 Median and Ulnar N
Testing finger flexors is testing what?
C8/ Median and ular
Direct eye does NOT constrict and consensual does NOT =
CN II @ direct
Direct eye DOES constrict but consensual does NOT =
CN III @ consensual eye
Direct eye does NOT constrict but consensual DOES =
CN III @ direct eye
Causes of ptosis
CN III lesion Horner's syndrome Myasthenia Gravis
Unilateral dry eyes indicates...
CN VII
Tongue deviation with protrusion is due to a ________ lesion.
CN XII
What would help you differentiate between medulla lesions and C1-4 levels of the cord?
CN findings such as weakness of the tongue
What is a paradoxical pulse caused by?
COPD, pericardial tamponade, and constructive pericarditis
CREST syndrome
Calcinosis cutis Raynaud's Esophageal dysfx Sclerodactyly Telangiectasia
Negative rub test =
Can hear @ arms length
Single nodule at the thyroid indicates...
Cancer
What is varicose veins around the umbilicus called and what does is indicate?
Caput medusa; portal hypertension
Collection of infected, abscessed boils
Carbuncle
Eye movements & extraocular mm are tested with the _________________.
Cardinal fields of gaze (H in space)
Clouding opacity of lens that interferes with vision
Cataracts
Diabetes mellitus predispositions pts to ___________ 10-20 years after onset.
Cataracts
An absent red reflex with the fundoscopic exam could be due to ____________, ____________, ____________ or a ___________.
Cataracts Detached retina Retinoblastoma False eye
"Danger zones" for basal cell carcinoma
Center of face Near eyes & nose Sulcus behind ears
Cherry red Macula indicates __________ in adults or ____________ in infants.
Central artery occlusion Tay-Sach's dz
Snellen chart tests __________ with the __________.
Central vision rosebaum card
reasons for balance problems
Cerebellar dysfunction Inner ear / vestibular dysfunction Loss of conscious proprioception (joint position sense - JPS)
Although most commonly used for low back involvements, the Naffzigger test may also be effective in evaluating the ________ and ________ regions.
Cervical and thoracic.
What sounds does the diaphragm and bell protect?
Diaphragm= high-pitched sounds bell=low-pitched sounds
What is a division in the linea alba called?
Diastasis recti
Lacrimal gland inflammation at lateral side
Dacryoadenitis
Lacrimal duct inflammation at medial side (punctum)
Dacryocystitis
Function of tensor tympani & stapedius
Dampen continuous loud noises (not sudden)
Tensor tympani fx
Dampens continuous loud noise (Not stapedius)
Stapedius fx
Dampens continuous loud noises
Gray tooth in which pulp is not viable, painless
Dead tooth
Elderly will have change in nail color due to _____________.
Decreased blood flow
Yellow nail syndrome occurs due to ________________.
Decreased lymphatic circulation (systemic)
What are the positive findings and significance for the intermittent claudication test, elevated arm stress test (EAST), and Roos test?
Development of 1 or more of the following on the symptomatic side, significantly earlier than on the asymptomatic side, suggests the presence of TOS: -Pain, paresthesia in the arm or hand, or cramping in the forearm. -Palor of the distal extremity. -Weakness of the shoulder with the arm drooping down.
What is it called when the heart is situated on the right side?
Dextra cardia
Acanthosis Nigricans is associated with __________.
Diabetes
Dot/Blot Hemorrhage's = ________________.
Diabetic retinopathy
Microaneurysm is pathognomonic for _______________.
Diabetic retinopathy
Polyneuropathy at the toes is possible with ____________.
Diabetics
__________ are highly susceptible to Intertrigo.
Diabetics
What does S2 mark the beginning of?
Diastole
How should a true measurement of ROM be taken with an inclinometer?
Each measurement should be performed 3 times and averaged. -If the average is less than or equal to 50 degrees, each of the three consecutive measurements must fall within 5 degrees of the mean. -If the average is greater than 50 degrees, then each of the 3 measurements must fall within 10% of the mean. -The ROM measurements may be repeated up to 6 times to obtain 3 consecutive ROM measurements. -If after 6 measurements there is still inconsistency, the ROM measurements are considered invalid.
Chondrodermatitis nodular is helicis is on the ________ and is different from squamous & basal cell carcinoma.
Ear
Otorrhea
Ear discharge
Purpura Icm diameter or greater
Ecchymosis
Eyelid turned outward is ___________.
Ectropion (Clinically insignificant)
If yellow nail syndrome is suspected, check for associated _________. Discoloration will be more _________ than fungal infections.
Edema Uniform
Elbow Quiz
Elbow Quiz
What is epicondylitis?
Elbow injuries that are most commonly due to overuse or repetitive stress. Include lateral and medial epicondylitis.
What does it suggest of the apical impulse is shifted to the left?
Enlarged heart
At the base of the neck, when the patient swallows, look for ...
Enlarged, visible goiter or nodules (substernal goiter)
When palpating the thyroid gland, look for...
Enlargement Masses Tenderness Nodules
Leukonychia
Entire nail is totally white Clinically insignificant
What is piriformis syndrome?
Entrapment of the sciatic nerve in the piriformis muscle. -Usually the sciatic nerve passes below the piriformis muscle, but in approximately 15% of the population the nerve may pass throught muscle itself.
Eyelid turned inward is __________ and can possibly cause _____________.
Entropion Corneal abrasion
Pterygium is caused by ___________ & is clinically _________.
Environmental trauma Significant
Most common cutaneous cyst
Epidermoid cyst (Wen)
Where is the pericardial friction rub typically best hearD?
Erb's point
Loss of part of the epidermis, depressed, moist, glistening, follows rupture of a vesicle or bulla
Erosion (AKA Varicella, variola post rupture)
Target lesions that burn or itch
Erythema multiforme
Lhermitte's sign should be reported whenever flexion of the neck produces pain radiating down the spine regardless of position.
Ex// During the Soto-Hall or Brudzinski tests.
Loss of epidermis; linear hollowed out crusted area
Excoriation (Examples: abrasion or scratch, scabies)
What are the instructions to the patients for the aortic maneuver?
Exhale and hold their breath
Lid lag can occur with __________.
Exophthalmus
Hyperthyroidism s/sx
Exophthalmus Skinny Heart palpitations Warm/hot Increased oily skin/hair Increased bowel movements
During bronchial breath sounds is inspiratory shorter or longer than expiratory? Is there a pause between exhale and inhale?
Expiratory is LONGER than inspiratory (2:3) and there IS a pause
Graphognosis test
Explain to the patient that you will be drawing numbers or letters on their hand (or other body parts), and asking them to identify the number or letter with their eyes closed. Be sure to draw the number or letter so that it is right side up from the patient's perspective (as if they were reading it from a paper held in their hand).
Extinction test
Explain to the patient that you will be touching them either on the right, on the left, or simulataneously on both sides, and asking them to say where they felt the touch(s). Have them close their eyes, and then randomly touch the right and left sides, and both sides simultaneously.
Linear crack or break from epidermis to dermis, may be moist or dry
Fissure (Examples: athletes foot, cracks @ corner of mouth)
Clinically insignificant transverse fissures of the tongue
Fissured (scrotal) tongue
What are the instructions to tell a patient when percussing the spleen?
Have the patient exhale then percuss then have the patient inhale
Common distribution of psoriasis
Extensor surfaces of extremities Scalp L-spine
Test for CN IV
Eye movement down and in
Near vision
Eyes converge slightly & pupils constrict
Strabismus
Eyes don't track together
+ rossolimo sign?
FLEXION on the toes
Atopic eczema is commonly at the ...
Face Elbows Knees Hands Feet Primarily on flexor surfaces
Distribution of Basal Call Carcinoma
Face Neck Scalp
CN VII
Facial
T/F only women need to be aware of the signs of breast cancer since men cannot develop breast cancer
False
T/F Normal Rinne test = (-)
False Positive = normal
True/false: shoulder pads in football help to prevent AC joint separation.
False, because the clavicle still gets ramed into the ribs, pushing it up and away from the joint.
Tinea pedis
Feet (athletes foot)
Mildew odor from end-stage liver failure
Fetor hepaticus
What is it called when there is a wide splitting that does no vary with respiration?
Fixed splitting
Muscle tone with LMN lesions
Flaccidity
Individual suddenly loses vision but then it abruptly returns
Fleeting blindness
Nail bed
Flesh under the nail plate Holds nail
What is the normal ROM for cervical flexion, extension, lateral flexion, and rotation?
Flexion - 50 Extension - 60 Lat flexion - 40 Rotation - 80
What is Brudzinski sign?
Flexion of the head causes stretching of the dural sac and spinal cord. -With the patient supine, the examiner flexes the patient's head to their chest (without sternal stabilization). -Positive sign is flexion of the hips and knees.
What are the ROMs + Degrees of ROM for the elbow?
Flexion: 135 Extension: 0 Pronation: 90 Supination: 90
Benign myelination of optic nerve fibers appears as ______________ at ________.
Fluffy white borders Disc border
Bacterial infection around the hair root, often S. Aureus following trauma (scratch, shave)
Folliculitis
Benign, painless yellow spots on lips
Fordyce Spots
Motor weakness in carpal tunnel syndrome
Forearm SPARED thenar muscle weakness
ulnar N entrapment in the medial epicondylar groove / Cubital tunnel motor weakness
Forearm flexors hypothenar muscles interossei
ulnar N entrapment in the tunnel of guyon motor weakness
Forearm flexors spared Weak hypothenar mm and interossei
With normal cervical extension, the plane of the face does not become horizontal, however a line between the ________ and the ________ does become parallel to the floor.
Forehead and the tip of the nose.
What are coarse crackles found with?
Found with: -bronchiectasis -bronchitis -late-stage pneumonia (air through section or air popping the alveoli)
Unilateral enophthalmus is often due to ___________, bilateral is often due to ________________.
Fracture (refer out) Malnourishment/dehydration
What do you palpate for when doing a thorax exam?
Fremitus
CN III carries response _____________ to constrict the pupil.
From the brain
Abnormal findings when palpating eyes
Frozen grape/marble feeling
What is a 3 on muscle strength grading scale
Full ROM against gravity
What is a 5 on muscle strength grading scale?
Full ROM against gravity and normal resistance
What is a 4 on muscle strength grading scale
Full ROM against gravity and some resistance
How does the doctor perform respiratory expansion?
Grasp the patient around the rib cage making sure plenty of skin is between their thumbs and keep their fingers rigid then ask the patient to inhale deeply and observe the expansion/distance between the 2 thumbs.
Exophthalmus is seen in patients with _____________ or due to ___________.
Grave's dz Tumor (esp if unilateral)
Fundoscopic findings with partial retinal detachment
Gray, wrinkled section of retina
Normal color of tympanic membrane
Gray/pink
What is ecchymosis around the flanks called?
Grey turner's sign
Observe _______, ________, _________, & _________ of the nail plate.
Grooves Ridges Texture Color
Polyps of the ear
Growth at external ear
Painless Tertiary syphilis lesion most common at the midline of tongue
Gumma
What is produced when air passes through large amounts of pulmonary secretions in the trachea?
Gurgling rale
What is the sequence of the abdominal exam?
HIIPPRONEL (ausculatate/instrument first before percussion and palpation)
DTR's with UMN lesions
HYPERrelexia
DTR's for LMN lesions
HYPOreflexia
What other radiographic sign may be present with facet imbrication?
Hadley's S curve.
Tinea Barbae
Hair follicles (mainly @ chin, advise men to use electric razor)
Hypothyroidism s/sx
Hair loss (lateral 1/3 eyebrow) Weight gain Cold often
Yellowish or brown-black papillae on anterior tongue
Hairy tongue
With normal cervical lateral flexion, the head moves approximately ________ to the shoulder.
Half way
Tinea Manuum
Hands
Verruca vulgaris common distribution
Hands Elbows Knees Feet (verruca plantaris)
Cancer lymph nodes (Texture, tender, moveable, size)
Hard Maybe No Enlarged
Calcified lymph nodes (Texture, tender, moveable, size)
Hard No Yes Variable *check existing xrays
Nail plate
Hard part of the nail that you cut
How to do reinforcement for upper extremity?
Have the patient clench their teeth
When you test light touch, how do you get the patient to tell you when they feel something?
Have them say "yes" when they feel the touch
Tinea capitis
Head or scalp (m/c kids)
Dysfunction of CN I could be due to ___________ or ___________.
Head trauma Local nose damage
What are the signs and symptoms of meningitis?
Headache, stiff neck (nuchal rigidity), fever, and elevated temperature.
Cauliflower ear
Healed hematoma
Nerve (sensorineural) deafness w/ Rinne test
Hear nothing
Sensorineural
Hear sound at good ear
Red lunula indicate _____________.
Heart failure
Painful vesicles that erupt & crust, lasting 3-4 weeks
Herpes Simplex
Erythema multiforme is associated with...
Herpes simplex Mycoplasma pneumonia Upper respiratory infections
Weber test
Hold tuning fork at the crown of head
Inflamed hair follicle on eyelid
Hordeolum (AKA stye)
What ortho/neuro tests indicate A-C joint separation?
Horizon sign
Beau's lines are _________________ & can indicate ____________________ due to ____________.
Horizontal/transverse grooves An interrupted growth cycle for a period of time Systemic illness
Veins crossed over arteries and appears excessively elevated
Humping
Chorea are seen in
Huntingtons dx Sydenhams chorea
Risk factors for lingual cancer
Hx of tobacco use HPV infection
Trx for ichthyosis vulgaris
Hydrating skin/humidity
Treatment of rhinitis Medicamentosa
Hydration Netti pot
What is increased pinprick sensitivity?
Hyperalgesia
What pathologies could heave and lift pulsations indicate?
Hypertension, valve stenosis, pulmonary hypertension
Flame hemorrhages = _____________.
Hypertensive retinopathy
Fine tremor of the tongue is due to ___________.
Hyperthyroidism
What do sighing respirations suggest?
Hyperventilation which is a common cause of dizziness and dyspnea
What is decreased pinprick sensitivity?
Hypoalgesia
Abnormal Chvostek's sign indicates ___________.
Hypocalcemia
CN XII
Hypoglossal
________ is when the pt cannot speak, but has no pathology.
Hysterical aphonia
Fish scale like hyperkeratosis most prominent at lower legs
Ichthyosis vulgaris
Diffusely enlarged thyroid with no nodules may indicate ___________ or __________.
Infection Hyper/hypothyroidism
Which turbinates are visible with standard nasoscopic exam?
Inferior & middle
What are the instructions for the patient when auscultating the carotid artery?
Inhale and hold
What is Turyn's test?
If extension of the big toe with the leg resting creates or exacerbates the patient's back or leg pain. A positive test suggests radiculopathy due to a large disc protrusion.
What is Sicard's test?
If the big toe is extended instead of dorsiflexion of the foot during the Braggard test.
When is extinction identified?
If the patient feels both the touches on the right & left sides when applied individually, but only feels the touch on one side when touches were applied bilaterally at the same time
astereognosis AKA stereoagnosis
If the patient is unable to correctly identify the object, although they can feel that there is something in the hand
How can you palpate the lunate and capitate?
If you flex your wrist, you can make the lunate glide posteriorly. If you feel in the hole, you can feel the capitate and the tip of the lunate.
Atopic eczema is associated with increased _______.
IgE
What kind of referral is needed if you suspect retinal detachment?
Immediate ER
Tinea infection predispositions
Immune compromised Diabetes Humidity/skin damp & warm
Acute Necrotizing Ulcerative gingivo-stomatitis is most common in _____________ and people under _______________.
Immune compromised (HIV) Extreme stress
Hairy leukoplakia is most common is __________ individuals and is due to ___________ infection.
Immunocompromised Epstein-Barr
Staph infection occurring most commonly in kids that presents with red macules that become vesicles or pustules that may develop eruption of golden crust with stuck on appearance
Impetigo
What is the mechanism of injury for lateral epicondyltis?
Improper backhand technique, equipment problems, or repetitive supination with wrist extension at work.
Cleft palate must be surgically corrected because it ____________ & ____________.
Improves respiration Eating
reason for Extinction testing
In some patients with apparently normal sensation, simultaneous bilateral stimulation may reveal an inability to perceive sensation on one side
What predisposes the lower lumbar spinal nerve roots to developing radiculopathy secondary to spondylosis?
In the lumbar spine, the IVF area decreases in volvume from L1-L5, whereas the circumference of the corresponding spinal nerve increases.
When can diminished vesicular sounds be heard?
In: -elderly -thick-walled -emphysema
When can harsh vesicular sounds be heard?
In: -kids -thin-walled -after exercise
Cause of subconjunctival hemorrhage
Increased intrathecal pressure Idiopathic (Not clinically significant)
Scabies is more visible with ___________ and itching increases at _______.
India ink Night
What is Libman's test?
It attempts to identify the patient's pain threshold. It is not specifically a malingering test, but may identify patients who have unusually low pain thresholds. -With the patient seated, apply gradually increasing pressure to the mastoid process, and instruct the patient to let them know when the pressure becomes unncomfortable. -If the patient expresses discomfort immediately or shorly after pressure begins and is still limited, the patient has a low pain threshold.
How can the Sitting Laseque test be used to see if someone is faking injury?
It can be performed under the guise of checking curculation, or the feet in order to try to identify false reporting during the SLR.
Cauliflower ear is clinically significant because...
It can cause hearing loss
What does the medial collateral ligament consist of?
It includes three ligaments. -The anterior oblique tightens upon extension. -The posterior oblique tightens upon flexion. -The transverse oblique is mainly supportive.
Head flexion with compression does what?
It increases loading of the anterior part of the vertebral motor unit (disc, vertebral body). Disc compression anteriorly, with possible increased bulging posteriorly, may exacerbate radicular symptoms when disc protrusion/prolapse is present.
Head extension with compression does what?
It increases loading of the posterior aspect of the vertebral motor unit; disc compression will occur posteriorly, and the IVFs will be narrowed. -Radicular symptoms may be exacerbated when IVF stenosis is present. (Radicular symptoms due to disc p/p may be somewhat reduced since the disc may be displaced anteriorly).
What is Fajersztajn's test?
It is a Braggard test performed after a positive WLR. -With the patient supine, the unaffected leg is raised until pain is created or exacerbated on the contralateral side. The leg is lowered slightly to ease the pain on the contralateral side and the foot is dorsiflexed. -Increase in radicular symptomatology indicates disc protrusion/prolapse, usually medial to the nerve root.
What is a Boxer's fracture?
It is a break in the second or third Metacarpal as in a straight ahead blow or a jab.
What is the brachial plexus tension test?
It is a combination of shoulder abduction external rotation with elbow flexion to produce maximum stretch on the brachial plexus. -With the patient seates, abduct the involved upper extremity to the point of pain, or to the end of ROM. While supporting the patient's upper extremity, ask the patient to externally rotate and then to bent the elbow and place their hand behind their head.
What is carpal tunnel syndrome?
It is a coupled condition involving entrapment of the medial nerve in the carpal tunnel. The nerve may become fibrosed to adjacent structures including the transverse carpal ligament or a finger flexor tendon. -May be secondary to any systemic problem with the nervous sustem or may be primary due to repetitive micro trauma (*overuse*).
What is Magnuson's sign?
It is a malingering test. -The patient is asked to point to the site of their pain. Distract the patient by performing some irrelevant test and then ask the patient to point to the site of their pain. -Note if the patient was able to point to the same site.
What is the Flexed-hip test?
It is a malingering test. -The test is similar to the Goldthwaite's test, but it is performed with the knee flexed rather than with a straight leg. -With the patient supine, the examiner places their superior hand under the patient's lumbar spine and their inferior hand under the patient's knee to lift the lower extremity by flexing the knee and then flexing the hip. -Note when the patient reports LBP and/or leg pain relative to when you feel the lumbar spine begin to move.
What is the pelvic rotation test?
It is a malingering test. -With the patient standing, the examiner grasps the sides of the patient's pelvis and instructs the patient to rotate their spine. The examiner simultaneously rotates the patient's pelvis to that the spine and pelvis rotate as a unit. -By rotating the spine and pelvis as a unit, lumbar movement is limited. -If the patient complains that LBP is created or exacerbated, malingering is suggested.
What is the Plantarflexion test?
It is a malingering test. -With the patient supine, they are instructed to raise each leg individually until pain is felt in the back or the leg. The examiner notes the angle of hip fexion. The examiner places one hand under the patient's knee and the other under the heel. The examiner bends the knee slightly and while maintaining slight knee flexion, raises the patient's lower extremity to a level that is lower than the level at which the patient originally reported the low back or leg pain. Plantarflex the foot. -If the patient reports that the plantar flexion causes low back pain, then suspect malingering.
What is impingement syndrome? Aka?
It is a mechanical impingement of the soft tissue contents of the suprahumeral space (subacromial bursa, supraspinatus tendon, and rarely the superior aspect of the joint capsule), usually leading to bursitis and/or tendinitis. -Aka swimmer's shoulder.
What is Sitting Laseque test?
It is a seates sciatic nerve - spinal nerve tension test. (Seated version of the SLR). -With the patient seated and with no backrest, the examineer slowly extends the patient's leg at the knee. -If the knee extension creates or exacerbates the back or leg P/T/N (especially below the knee, and in a dermatome distribution), sciatic neuropathy, or radiculopathy is indicated.
What is Allen's test?
It is a test for patency of the radial and ulnar arteries. -It is not specifically a TOS test, but is commonly done prior to Wright's (hyperabduction) test. -The patient is instructed to raise their arm so that their hand is up by their head. The patient opens and closes their hand several times and then holds a fist while the examiner compresses the radial and ulnar arteries at the wrist and then lowers the hand below heart level. Instruct the patient to open the fist, then release the radial artery and time how long it takes blood to flush back into the hand. Repeat the procedure testing the ulnar artery.
What is the Thomas test?
It is a test for the length of the psoas muscle. -Instruct the patient to draw one knee to their chest and note whether the knee on the opposite side lifts off the table.
What can yellow skin color indicate?
Jaundice or carotenemia (carrots)
What is Adam's test?
It is an assessment to help differentiate functional vs structural scoliosis. -The patient with lateral spinal curvature stands, with the examiner observing from behind. The patient flexes forward from the waist and the examiner observes whether the lateral spinal curvature remains unchanged or reduces in severity. -If the curvature decreases, then it is considered a functional adaptation. -If the lateral curvature remains unchanged, it is considered structural.
Is the Homan's test still performed today?
It is not recommended because it can turn thrombophlebitis into an embolis
What is the Bowstring test?
It is performed as a follow-up to a positive Straight Leg Raise. -At the positive SLR level, the examiner rests the patient's leg on their shoulder and bends the patients knee slightly to reduce the pain. The examiner then applies thumb pressure into the popliteal fossa. -If the thumb pressure recreates the pain that was previously aggravated by the SLR, nerve involvement (sciatic neuropathy, or radiculopathy) is indicated. -Local pain in the popliteal region would not be considered a positive finding.
How do you differentiate between cervical rib and scalenus anticus syndrome?
It is primarily based on x-ray and the presence or absence of a cervical rib. -Can also attempt to palpate the presence of a cervical rib in the supraclavicular fossa, and palpate for hypertonicity of the scalene muscles.
What is the significance of Rust's sign?
It is seen in marked cervical strain-sprain injuries (especially the anterior compartment). -*This should be considered a sign of cervical instability, and a contraindication to ROM and orthopedic biomechanical stress exams until instability due to fracture, dislocation, or severe sprain is ruled out by x-rays.*
What is DeQuervain's stenosing tenosynovitis?
It is swelling of the sheath surrounding the tendon of the extensor pollicis brevis and/or abductor pollicis longus as they pass over the radial styloid process. -Positive Finkelstein's test. -Pain and crepitus over the radial styloid.
What is the Helbig and Lee formulated criteria for facet syndrome?
It is used to more accurately diagnose facet syndrome and to predict which patients are likely to experience satisfactory results of facet joint injection. -Low back pain associated with groin or thigh pain (30 pts). -Well-localized paraspinal tenderness (20 pts). -Reproduction of pain with extension-rotation (30 pts). -Significant corresponding radiographic changes (20 pts). -Subtract 10 pts if there is pain below the knee. -A score or 60 pts or more indicates a very high probability of satisfactory response to facet joint injection (prolonged relief for 6 months or more).
What typically causes impingement syndrome?
It is usually due to repetitive overuse or cyclical loading injury and is most common secondary to activities which involve repetitive over head reaching (swimmer's shoulder).
What is biceps tendon instability?
It may be secondary to a trauma or may be the result of repetitive loading into abduction with external rotation. This may cause tearing or plastic deformation of the transverse ligament especially in a patient with a shallow bicipital groove.
What is thoracic outlet syndrome (TOS)?
It refers to a group of disorders involving compression of the neural (brachial plexus) and/or vascular (subclavian-axillary artery and axillary-subclavian vein) structures in the thoracic outlet.
When should instrumentation be used during an exam?
It should always be used for medico-legal reasons such as Workman's comp, disability evaluation, and personal injury cases.
What happens if the examiner presses too hard with the bell?
It would function more like a diaphragm and won't hear low pitched as well
Are jugular pulsations or carotid pulsations palpable?
Jugular=no carotid=yes
Deep purple colored firm lesions that may occur in mouth or other parts of the body
Kaposi's sarcoma
Circular golden brown band on the posterior surface of cornea
Kayser-Fleischer ring
Irregular shaped, elevated, progressively enlarging scar; grows beyond boundaries of wound; caused by excess collagen formation during healing
Keloid
Small, spiny hyperkeratosis around hair follicles on extensor surfaces or cheeks
Keratosis Pilaris
Desquamation keratin often in young patient
Keratosis obturans
"A few ________ ________ on the medical history can help ensure that a serious underlying condition (red flags), such as cancer or spinal infection, will not be missed."
Key Questions
If bacterial sore throat goes untreated, it can affect the __________ or _________.
Kidneys Heart
Alopecia areata is most common in ________ and is associated w/...
Kids Hashimoto's, Myasthenia Gravis, vitiligo
Areas that are repeatedly scratched or subjected to trauma have increased likelihood of developing psoriasis = _____________
Koebner Phenomenon
Spoon nails (AKA ______________) are ________ & ___________ due to iron deficiency anemia.
Koilonychia Concave Thin
White spots with red areola found opposite the molars
Koplik spots
What is the deep breathing as a result from metabolic acidosis that can be fast, normal in rate or slow?
Kussmaul breathing (sometimes change in breath odor)
Psoas
L1,2,3 Branches of Lumbar plexus
Testing the Psoas is testing what?
L1,2,3/ branches of LP
Quads
L2-4 femoral
Adductors
L2-4 obturator
Testing the adductors is testing?
L2-4 obturator
Testing the quads is testing
L2-5/ femoral
Anterior Tib
L4 deep perineal N
DTR for Quads
L4 femoral (L2,3,4)
What does the plantar reflex test?
L4, 5 S1, 2
Testing the anterior Tib is testing?
L4/ deep peroneal
heel walk tests what spinal and peripheral N
L5 common peroneal
Dorsiflexors
L5 deep peroneal
Glut med
L5 superior gluteal
Most common spinal nerves in lumbosacral radiculapthy?
L5 & S1
Testing Glut med is testing?
L5 / superior gluteal n
What are the most commonly affected low back spinal nerves for lumbosacral radiculopathy?
L5 and S1
EHL
L5 deep peroneal
Testing the EHL is testing
L5 deep peroneal
DTP for posterior tib
L5 tibial
Medial hamstring
L5 tibial partial of sciatic (L4,5, S1,2)
Why may gait be distributed?
LBP, extremity pain, deformity or neurologic lesions
What type of fibers transmit tactile sensation?
Large diameter afferent fibers in the peripheral & spinal nerves and then up the IPSILATERAL dorsal column
Veins appear...
Larger Small or no light stripe Darker red May appear to pulse
Test the CN XI SCM function
Lateral flex & rotate towards, resist
What is the procedure for determining the size of the left border of the heart through percussion during a heart exam?
Lateral to medial (resonant to dull) in 3, 4, 5 intercostal spaces
Positive accommodation test
Pt can't focus close up, lens cannot accommodate
impairment of the DCML may be due to____ or _____
MS or Cervical spondylotic myelopathy
Enlarged tongue
Macroglossia
A flat, circumscribed area that is a change in the color of skin (less than 1cm diameter)
Macule (Examples: freckles, flat moles, petechiae, measles, scarlet fever)
Ossicles of the ear
Malleus hits incus hits stapes
Predisposed to lens subluxation
Marfan's syndrome
Palpate TMJ: Muscles =
Masseters Temporalis Internal pterygoids (CN V)
The rinne test is performed by placing the 512Hz tuning fork on the __________ and then in front of the _______.
Mastoids Ears
What is located just below the middle of a line connecting the ASIS to the umbilicus?
McBurney's point (appendix)
Which line of mensuration can indicate facet imbrication?
Mcnab's line.
Koplik spots are pathognomonic for __________.
Measles (rubeola)
What is the most common mechanism for strain/sprain of the elbow?
Medial collateral ligament may be sprained by an acute Valgus overload or by repetitive loading (throwing baseball).
Most deadly skin cancer
Melanoma
Inner ear swelling endolymph sack, usually unilateral & self-limiting
Menieres dz
What is the significance of a positive Brudzinski sign?
Meningitis
Polyps are most common at the ___________.
Middle meatus
Tongue shows migratory patches of smooth red areas lacking papillae
Migratory (Geographic) glossitis *not clinically significant
Polyps are associated with ___________, and chronic _______________.
Mildew/fungus Otitis externa (swimmer's ear)
Bursitis aka?
Miners elbow or turf elbow.
Before losing vision with macular degeneration, the patient may report ______________ or ______________.
Missing letters when reading Blurry/wavy lines (when looking at straight line)
What are the pathologies associated with S3?
Mitral regurgitation and congestive heart failure
Removal of basal cells, esp at danger zones
Moh's surgery
Viral infection characterized by 1-2mm shiny white-to-flesh colored dome shaped papules that have small central umbilicus
Molluscum Contagiosum
If both Anterior & posterior nodes are enlarged, it can indicate _________.
Mono
Occulomotor nerve function
Motor - Extra-ocular muscles, Levator palpebrae, Constrictor pupillae, ciliary muscles
Hypoglossal nerve fx
Motor - Intrinsic mm of tongue
Abducens nerve fx
Motor - Lateral Rectus
Trochlear nerve fx
Motor - Superior Oblique mm
Spinal accessory fx
Motor - trapezius, SCM
Splitting of nails, plate separates from the bed
Onycholysis
Weakness of ocular mm
Ophthalmoparesis
Paralysis of ocular mm
Ophthalmoplegia
Intrinsic mm of the tongue will be weak on the _________ of the lesion.
Opposite side
CN II
Optic
Chalky white disc = _____________, suggesting _________.
Optic Atrophy Long term increased ICP
Inflammation of optic nerve & suggests MS
Optic neuritis
White, curdy patches on the tongue or mucosa that can be scraped off
Oral Candidiasis (Thrush)
Complications of teen or adult mumps
Orchitis Oophoritis
Middle ear structures
Ossicles Canal Stapedius Tensor tympani
What is degenerative joint disease (DJD)?
Ostroarthritis is the end stage for many mechanical injurues to joints. It can develop in the AC joint where an inferior osteophyte might irritate or damage the supraspinatus tendon. Typically manifests with pain, stiffness, and decreased ROM. X-ray will show decreased medial joint space and suprahumeral (subacromial) space, subchondral sclerosis, and osteophytic changes.
What follow-up tests should be done after a positive costoclavicular or Eden's test?
Other TOS orthopedic tests (Adson's, modified Adson's, Wright's, EAST, etc.)
What follow-up tests should be performed after a positive Wright's (hyperabduction) test?
Other TOS tests (Adson's, modified Adson's, costoclavicular, Eden's, EAST, etc.)
Fungus & bacteria growth on external ear
Otitis Externa
Fungal infection at external ear, itchy
Otomycosis
Structures of deep middle ear
Oval & round window
Rhinitis Medicamentosa is often due to _______________.
Overuse of nasal drops
Atelectasis with bronchial plug: percussion; trahcea; breath sounds; adventitious sounds; fremitus; voice sounds?
P: dull T: ipsilateral deviation B: absent A: absent F: decrease V:-
Consolidation (pneumonia, pulmonary edema): percussion; trahcea; breath sounds; adventitious sounds; fremitus; voice sounds?
P: dull T: midline B: bronchovesicular/bronchial sounds A: late inspiratory crackles F: increased V: pectroiloqy and bronchophony
Small Pleural effusion: percussion; trahcea; breath sounds; adventitious sounds; fremitus; voice sounds?
P: dull T: midline B: over effusion absent; below effusion bronchial A: none F: decrease over effusion V: egophony at meniscus
Large pleural effusion: percussion; trahcea; breath sounds; adventitious sounds; fremitus; voice sounds?
P: flat T: contralateral deviation B: over effusion absent; below effusion bronchial A: none F: decrease over effusion V: egophony at meniscus
small pneumothorax: percussion; trahcea; breath sounds; adventitious sounds; fremitus; voice sounds?
P: hyperresonant T: midline B: decreased/absent A: None F: decrease V: decrese/absent
Emphysema: percussion; trahcea; breath sounds; adventitious sounds; fremitus; voice sounds?
P: hyperresonant T: midline B: diminished vesicular A: wheezes F: decreased V: decreased
Chronic bronchitis: percussion; trahcea; breath sounds; adventitious sounds; fremitus; voice sounds?
P: resonant T: midline B: normal A: crackles, wheezes, rhonchi F: normal V: normal
large pneumothorax: percussion; trahcea; breath sounds; adventitious sounds; fremitus; voice sounds?
P: tympany T: contralateral deviation B: decreased/absent A: None F: decrease V: decrese/absent
In the upper extremities what do you check with vibration
PIP, MCP, ulna styloid, olecranon processes and clavicles
In the lower extremities what do you check with vibration
PIP, MTP, malleoli, tibial tubercles, patellas and ASIS's
What is Codman's drop arm test?
Passively raise the patient's arm to 90 degrees of abduction. The patient then lowers the arm back to neutral with the palm down. If the patient's arm drops suddenly or experiences pain, then the test is considered positive. Indicative of rotator cuff tear.
A flat, non-palpable irregular-shaped macule greater than 1cm diameter
Patch (Examples: vitiligo, port-wine stains, Mongolian spots, cafe au lait patch)
Accommodation test
Patient looks @ far wall Present a business card 8-10 inches from pt's face & have them read
What is glenohumeral instability?
Patients with this condition usually have a history of traumatic shoulder dislocation, most commonly in the anterior inferior direction which tears the glenohumeral ligament as well as the fibrous joint capsule and/or the labrum.
Out of broncophony and pectoriloqy which test is the most sensitive physical diagnostic test for consolidation?
Pectoriloqy
Hutchinson's teeth are _______ shaped, notched teeth associated with _____________.
Peg Congenital syphilis
What is IVD syndrome?
Percussion may create or aggravate radicular pain.
What is the Slump test?
Perform the sitting Laseque test. If negative for radicular symptomatology, dorsiflex the patient's foot (increases sciatic nerve tension). If still negative for radicular symptomatology, have the patient slump, flexing their head and thoracic spine (adds cord/meningeal contraction). If still negative, you may have the patient bear down as if straining to move their bowels. -Indicates lumbosacral radiculopathy.
Tooth tender to tapping
Periapical abscess
Loss of sensation may be due to what?
Peripheral spinal N lesion, radicuopathy, LMN lesion, CNS involvement
Glaucoma is the loss of ______________.
Peripheral vision
Visual field test is a test for _____________ which would be _______ if glaucoma is present.
Peripheral vision Decreased
Confrontation is testing ___________ and the test is performed by ___________ in 3 different spots bilaterally.
Peripheral vision Wiggling your fingers w/ flexed wrists
Purpura less than 3mm diameter
Petechiae
Prominent pigmented spots on the lips & buccal mucosa associated with multiple intestinal polyps
Peutz-Jeghers Syndrome
Slightly raised, benign, fatty structure under conjunctiva
Pinguecula
Skin condition that first appears with a 1-2cm herald or mother patch that is followed 1-2 weeks later by generalized rash of smaller lesions on the ab, chest, trunk
Pityriasis Rosea
Excessive growth of eye tissue that can obstruct vision
Pterygium
Drooping of lid
Ptosis
What is the chest expansion test?
Place a tape measure around the patient's chest (at the T4/nipple level; for females, the tape measure may be places around the chest below the breasts). Have the patient exhale fully and take the measurement. Have the patient inhale fully and take the measurement. Determine difference between measurements. -Normal finding is 1.5-2 inches. -Measurement less than 1.5 may be due to pain from rib fracture or subluxation, ankylosing spondylitis, underlying lung or pleural disease.
How can a tuning fork be used to assess suspected fracture?
Placing a *128 Hz* turing fork on the superficial body process produces significant local pain if there si a fracture. -A negative finding *does not* rule out fracture or the need for radiographic studies.
Elevated, firm, and rough lesion with flat top surface greater than 1cm diameter
Plaque (Examples: psoriasis, seborrheic & actinic keratosis)
What is the sound produced by inflamed pleurae?
Pleural friction rub
What is the follow up for a suspected cerebellar lesion?
Point to point and rapid alternating moving tests of limb coordination
Causes of decreased proprioception to feet
Polyneuropathy (diabetes) DCML lesion (MS, cervical spondylotic myopathy)
Pale, semi-translucent growth often associated with chronic allergic rhinitis
Polyps
Gingival hyperplasia is a red flag for ___________.
Possible leukemia
What is gibbus from?
Pott's disease = Tuberculosis (TB) of the spine or trauma
Actinic Cheilitis is potentially ___________.
Pre-cancerous
If white, thickened, raised patches on tongue cannot be scraped off, it is likely they are _________.
Precancerous
Accommodation is lost with aging (>40 y.o.), this is called _________.
Presbyopia
clonus with UMN lesions
Present
S/Sx of brain stem lesion @ the nausea & vomiting center at the medulla
Projectile vomiting Neurological vomiting No associated nausea
What are wheezes?
Prolonged, HIGH-pitched, musical sounds with hissing/shrill quality, narrowed airway
Testing the intrinsic mm of tongue
Protrusion of tongue Mm strength
Lichen Simplex chronicus is characterized by paroxysms of _____________ in response to minimal external stimuli and may be associated with _________.
Pruritus Emotional stress
Skin condition with erythmatous papules and plaques that are covered with silver-white scales.
Psoriasis
Increased saliva =
Ptyalism
transection of the spinal cord above C5 results in what?
Quadriplegia
What is clonus
Quick stretch of the spastic muscles results in a repetitive series of muscle stretch reflex contractions.
What is Homan's sign?
Quickly dorsiflex the foot and a positive sign is pain in the calf
Quiz 1
Quiz 1
Quiz 3
Quiz 3
What is the most common fracture of the elbow in adults?
Radial head. Typically due to direct impact on the capitellum or may be a secondary dislocation. Associated with landing on the outstretched extended upper extremity.
What is the mechanism of the well leg raise?
Raising the unaffected leg tractions the sciatic nerve and lumbar nerve roots on that side, and causes the contralateral nerve roots to be pulled toward the midline.
If the mucocele is on the floor of the mouth, it is called a __________ and is caused by __________ or _____________.
Ranula Trauma Obstruction of salivary duct
Wet macular degeneration has _____________ onset, and is caused by abnormal vessels that ___________ under the macula.
Rapid Hemorrhage
What is hyperpnea (hyperventilation)? examples?
Rapid, deep breathing -anxiety -exercise -metabolic acidosis
Scleroderma X-rays will show _____________.
Rat bite necrosis (painful ulceration @ fingertips)
What is Dugas test?
Reach to the opposite shoulder and then bring elbow to chest (third step in the Cochran maneuver to fix a dislocated shoulder). Indicates GH instability (acute dislocation).
Abnormal color of tympanic membrane
Red/Amber
What is the expected percussion tone along the right sternal border in the 3, 5 intercostal space during a heart exam?
Resonant
Treatment for vocal nodules
Rest 3-6 months Speech therapy
Dark colored pigment deposits in retina that initially cause loss of peripheral & night vision in a young person
Retinitis Pigmentosa
What tests indicate medial epicondylitis?
Reverse Cozen's and reverse Mill's tests.
White radial scars at the mouth angles from healed syphilis
Rhagades
Beefy red nasal mucosa in patient with chronic congestion without significant rhinorrhea or sneezing
Rhinitis Medicamentosa
Consensual reflex occurs by shining light in the _______ and the _______ constricts.
Right eye Left pupil
Direct reflex occurs by shining light in the ________ and the _______ constricts.
Right eye Right pupil
What is the couples movement of the proximal row of carpal bones?
They rotate and glide in the opposite direction.
TMJ palpation: Abnormal
Swollen Tender
Chancre is the primary lesion of ___________ and is a firm, ___________ lesion that ulcerated and may crust.
Syphilis Button like
Longitudinal fissures
Syphilitic glossitis
Multinodular thyroid indicates...
Systemic metabolic conditions (Grave's dz, Hashimotos)
Interossei
T1 Ulnar
Testing interossei is testing what?
T1/ Ulnar
Lower abdominal reflexes test what spinal nerves?
T10-12
upper abdominal reflexes test what spinal nerves?
T7-10
What does a positive Roos test indicate?
TOS in general.
What is TOS symptomatology?
TOS symptoms vary depending upon whether the neural or vascular structures are affected, and the severity of the compression. Commonly: -Pain, tingling, and numbness in upper extremity. -Symptoms that are commonly caused or aggravated by certain positions of the head, shoulder, or upper extremity, *especially abduction of the arm, and depression of the shoulders.*
What is the significance of the Adson and modified Adson tests?
TOS, most likely either cervical rib or scalenus anticus subgroups. -Does not differentiate between the two. -Presence of a cervical rib on x-ray will support a diagnosis of cervical rib syndrome, while absence will support scalenus anticus syndrome.
If there is bronchophony and pectoriloqy when auscultating what should you expect for tactile fremitus?
Tactile fremitus should be increased
what are the sensory/ weakness loss from Brown squared syndrome
Tactile loss ipsi P/T loss contra Loss of all sensation ipsi at level of lesion Weakness ipsi below level (due to lesion of UMNs)
Chvostek's sign
Tap area of parotid gland
What is Tinel's test?
Tap over area of peripheral nerve to see if you can elicit symptoms.
Madonna's fingers become __________ with ________________ bound skin.
Tapered Waxy, hardened, tightly
Veins narrow at arteries
Tapering
Testing rapid alternating movement in UE
Tapping index finger to thumb (IP joint) Patting the thigh Pronation-supination (alternately pat the thigh with the palm and dorsum or the hand)
Fine, irregular, red lines produced by capillary dilation
Telangiectasia
Superficial blood vessels that are dilated and appear as red strands on the skin
Telangiectasia
The muscles of mastication include...
Temporalis Masseters
Patients with optic neuritis will experience ________________ and ____________.
Temporary bouts of blind spots Pain with eye movement
Lateral epicondylitis aka?
Tennis elbow
What name sign is indicative of a scaphoid dislocation?
Terry Thomas sign, because he had a gap in his teeth. Refers to the gap between the scaphoid and the lunate.
Yellow nails are _______ & _________, and often associated with ____________.
Thick Porous Fungal infections
What is the Well Leg Raise test?
The WLR test is a SLR on the unaffected side. Slowly raise the unaffected leg with the knee straight. -Positive finding is production/exacerbation of back and leg pain on the uninvolved side (contralateral to the leg being raised). -This is one of the *best clinical indicators of radiculopathy due to IVD syndrome*, especially medial herniations. -*High specificity, but low sensitivity* (True positive).
Why is Graphognosis
The ability to recognize letters or numbers written on skin without seeing it
What does the anterior cerebral artery supply?
The anterior cerebral artery supplies the medial and superior portion of the motor cortex that controls lower extremity function.
What are inclinometers?
The are instruments which measure angular displacement relative to gravity.
If the hand radially deviates, what happens to the proximal row of carpal bones?
The carpal row moves in the ulnar direction. The capitate glides ulnarly and toward the proximal row to pack tight.
What is the mechanism of the cervical compression test?
The downward pressure compresses the facets, vertebral bodies, disc, and narrows the IVF.
Risk in the danger zones of basal cell carcinoma is that is can ulcerated to ___________.
The dura mater
What is the Valsalva maneuver?
The exam increases intrathecal (CSP) pressure and helps to identify radiculopathy caused by a space-occupying lesion. -The patient bears down as if to go to the bathroom. -Positive finding is the production or exacerbation of radiation into the upper extremity, especially in a dermatomal pattern. -A positive finding suggests that a radiculopathy due to compression by a space occupying mass (disc protrusion/prolapse, tumor, osteophytes).
What is the Spurling test?
The examiner places one hand on top of the patient's head and delivers a vertical blow to the top of the patient's head with the other hand.
What is the shoulder apprehension test.
The examiner stands either behind or at the involved side, grasps the wrist with one hand and passively externally rotates the humerus to end range with the shoulder in 90 degrees of abduction. Indicates GH instability (chronic).
How mobile are the metacarpals?
The first, fourth, and fifth metacarpals tend to be more mobile. The second and third are relatively fixed. When you cup your hand, you are cupping around the second and third metacarpals.
What is the mechanism of Neri's Bowing sign?
The forward flexion stretches the sciatic nerve and its contributing nerve roots. The hamstrings muscles are stretched, strain is placed on the low back.
Drusen bodies are often seen at _____________.
The fovea of the macula
What do heaves and lifts indicate?
The heart is working too hard
What causes cardiac enlargment?
The heart working too hard
What is the most common fracture of the elbow in children?
The humerus above the condyles. This is a supracondylar fracture and is associated with landing on the outstretched extended upper extremity.
What is steppage gate?
The knee is raised higher than normal to allow the drooping for to clear the ground and the foot slaps down
What is the cervical distraction test?
The main purpose of this test is to see if decreased pressure on cervical spiine structures reduce pain. -With the patient seated, the examiner stands at the side of the patient and places one hand under the patient's chin and the other under the base of the occiput (or one hand on either side of the head without pressing in on ears). With gradually increasing force, lift the patient's heat to remove it's weight from the neck. Hold for 30-60 seconds.
What is the most commonly strained ligament of the elbow?
The medial collateral ligament.
Where does the wrist flexor/pronator group of muscles originate from?
The medial epicondyle.
What can cause AC joint separation/sprain?
The most common mechanism of injury is a superior to inferior shear load on the acromion process or the entire shoulder girdle.
Why does atrophy occur with LMN lesions?
The muscle cells in the motor units that have lost their innervation undergo secondary degeneration. Loss of the "trophic" influence of the LMN results in loss of muscle bulk or atrophy of the muscle
What is the mechanism of injury for medial epicondylitis?
The overhand throwing motion, side arm motion, golf swing, and tennis serve all produce a *Valgus stress on the elbow*. Tensile stress on the medial side structures including the MCL and the wrist flexor pronator tendon. It also produces compression stress in the lateral joint between the radius and the capitellum.
What is T4 syndrome?
The patient complains of upper-to-mid thoracic discomfort and stiffness, associated with pain, tingling, and numbness of one or both upper extremities. -The pain, tingling, and numbness tends to encircle the hand, and possibly more proximal areas ("glove"-like).
How is diaphragm excursion performed?
The patient holds an inhale and the doctor uses percussion to mark the diaphragm then the patient holds an exhale to mark the diaphragm
What is Rust's sign?
The patient presents with both hands supporting or "cradling" the cervical spine, or the patient supports or "cradles" the cervical spine when rising from a supine position. (BPUS = 3.5)
What is Speeds test?
The patient supinates and flexes the shoulder 10 times, then 10 times against resistance. Indicates biceps tendinitis.
What areas are affected the most in subacute combined systems dx (posterolateral sclerosis)
The posterolateral regions of the spinal cord are predominantly affected, involving the dorsal columns, and UMNs in the lateral column (LCST and RST).
What is the weight-bearing articulation of the elbow?
The radius articulation with the humerus.
How to do toe to finger test
The supine patient is asked to reach and touch the examiner's finger with their big toe. Repeat several times with your finger in different locations.
Where does the wrist extensor/supinator group of muscles originate from?
The supracondylar ridge.
What is Hoover's test?
The test is used to differentiate true leg weakness/paralysis from feigned or hysterical leg weakness/paralysis. -With the patient supine, place hands under the patient's heels and instruct the patient to life the affected leg. Feel for increased downward counter-pressure under the other heel. It is natural to exert some downward counter-pressure with the other lower extremity. When a patient is trying to raise a weak/paralyzed lower extremity, it would be expected that the downward pressure on the opposite leg would be accentuated. -If no counter-pressure is felt, malingering is suspected.
Draw a shematic of the glenohumeral joint. With arrows, distinguish rocking (rolling, rotation) from gliding (sliding, translation) during abduction. State the third coupled movement of the humerus that occurs during abduction.
The third coupled movement is external rotation.
Once the membrane potential begins to creep closer to excitation threshold, what happens?
The unhealthy motor units become more excitable and can begin to contract spontaneously
What is the Dual inclinometer measurement of cervical ROM?
The use of 2 inclinometers, one on the head and the other at T1, helps to eliminate any contribution of upper thoracic movement to the total measurement, thus potentially providing a more accurate measurement of the cervical motion.
What typically causes a rotator cuff tear and what is typically affected?
There is usually a macrotrauma, but often the tendon has already degenerated and weakened. Order of stuff affected is SITS (supraspinatus, infraspinatus, teres minor, and subscapularis).
What do LMN lesions interrupt in the reflex arc?
Therefore, LMN lesions interrupt the muscle stretch reflex arc resulting in diminished or absent reflexes ("hyporeflexia" or "areflexia").
What are the intermittent claudication test, elevated arm stress test (EAST), and Roos test?
These TOS tests are similar in that they all involve the patient clenching and unclenching their fists while the arms are abducted. They differ with regard to the specific arm position utilized and the duration of the repeated opening and closing of the fist.
What is the Spurling test and modified Spurling test?
These are compression tests with the head in the maximal cervical compression maneuver position. The modified version is preferred because a more comtrolled force is utilized.
What inhibits pathologic reflexes
These responses are inhibited by cortical influences conveyed by the pyramidal (corticospinal) tract
What do the costoclavicular and Eden's test do?
They *decrease the space between the clavicle and the 1st rib* (costoclavicular space) and may cause compression of the neurovascular bundle.
What are Malingering tests?
They are used to identify suspected feigned or magnified complaints.
What is the Fabere Patrick test?
This examination stresses the SI joint via the hip joint. -With the patient supine, flex the knee on the side being tested, then abduct and externally rotate the hip, bringing the foot across the opposite knee. Stabilize the opposite ASIS and exert downward pressure on the knee (hip extension). -Pain in the SI region indicates SI disorder. Restricted motion of the hip, or pain in the hip or inguinal region may indicate a hip disorder.
What is the Skin pinch test?
This is a malingering test. -Pinch the skin segment by segment over a region of the spine and note which segments the skin pinch is pain provocative. -If the patient complains of pain over many segments, then may be magnifying their symptoms.
What is Mannkopf's test?
This is a malingering test. -Place the patient in a comfortable position whigh will allow palpation of the identified painful area and also the radial pulse. Palpate the radial pulse and note baseline pulse rate. Apply presure to the painful region to provoke pain and recheck the pulse rate. -Increase pain should provoke sympathetic effects that would increase the patient's pulse rate by at least 10 bpm (5-10% of baseline).
What is Burn's bench test?
This is a malingering test. -The patient kneels on a low stool or table and the examiner supports the patient's ankles to stabilize them. The patient is instructed to bend forward to touch the floor. -Much of the movement comes from hip flexion rather than lumbar flexion so if the patient is complaining of LBP and can not perform the test, malingering is suspected.
What is the Axial loading test?
This is a malingering test. -With the patient seated or standing, the examiner places both hands on top of the patient's head and applies downward axial loading pressure and notes whether the procedure produces or exacerbates LBP and/or leg pain. -Axial loading may produce cervical or shoulder pain, but would not be expected to cause or exacerbate LBP and/or lower extremity pain.
What is Neri's Bowing sign?
This is a sciatic nerve stretch. Nerve root tension test performed in the standing position. -Instruct the standing patient to bow forward and note flexion of the knee on the symptomatic side. -The sign is present if the patient flexes the knee on the affected side. -Indicates sciatic neuropathy or radiculopathy.
What is Beever's sign?
This is a test of neural innervation of the abdominal muscles. -With the patient supine and abdomen exposed, they hook their fingers behind their head and raise their head and upper torso off the table (partial sit-up). Observe any movement of the umbilicus. -Deviation of the umbilicus indicates weakness/paralysis of the opposing portion of the abdominal muscles, which may result from thoracic spinal nerve lesion, or possible UMN lesion.
What is the maximum cervical compression maneuver?
This is an active motion test utilizing a combination of 2 head positions to narrow the IVF. With the patient seated, the examiner instructs the patient to rotate and extend their head (compression is not applied).
What is the brachial plexus stretch test?
This is an upper extremity tension test that mainly stretches the brachial plexus, but may also stretch the cervical spinal nerves. -With the patient seated, ask them to laterally flex the head away from the affected side then to extend the upper extremity.
What is the O'Donahue test?
This procedure attempts to differentiate strain (muscle and/or tendon injury) from sprain (ligamentous injury). -With the patient seated, have the patient perform active cervical motion against your resistance, or apply resistance sufficient to prevent motion such that an isometric contraction occurs. Then take the cervical spine through passive ROM.
What is the mechanism associated with Allen's test?
This procedure decreases blood flow into the hand. When one artery is released blood should flow through the anastamotic arch in the hand and fill the entire hand. Normally, the hand should fill within 3-5 seconds. Release of the radial artery will normally cause faster filling than release of the ulnar artery.
What is Kernig's test?
This procedure tractions the sciatic nerve, lumbar spinal nerves, and ultimately the meninges. -With the patient supine, the hip and knee are flexed to 90 degrees. The examiner then attempts to extend the leg at the knee.
What is Bonnet's test?
This test adds internal rotation and adduction of the hip to the SLR test. -The hip motions cause stretching of the piriformis muscle and may exacerbate sciatic pain due to entrapment in the piriformis muscle (piriformis syndrome). -Inticates sciatic neuropathy due to entrapment in the piriformis muscle (*piriformis syndrome*).
What is the supported forward bending test (Belt test)?
This test helps differentiate lumbar and sacroiliac disorders. -Part 1: Unsupported lumbar flexion. Patient standing. Ask the patient to bend forward at the waist. Note pain in the lumbar or SI region. -Part 2: Supported lumbar flexion. Stabilize the patient's sacrum with your hip and support the ilia with your hands. Ask the patient to bend forward again. Note pain. -Pain elicited upon unsupported flexion, but reduced upon supported flexion (which stabilizes the SI joint) indicates a *sacroiliac lesion*. -Pain elicited upon both unsupported & supported flexion indicates a *lumbar lesion*.
What is the Naffzigger (jugular compression) test?
This test increases intrathecal pressure and helps identify space-occupying lesions causing radiculopathy. -With the patient seated or supine, the examiner comrpesses the jugular veins for 30-45 seconds. -Compressing the jugular veins backs up venous drainage from the head. The backup in the dural venous sinuses may lead to decreased absorption of CSF, resulting in increased CSF pressure. -Creation or aggravation of upper extremity pain & paresthesia suggests spinal nerve compression by a space-occupying mass (disc protrusion, tumor, osteophyte).
What is Milgrim's test?
This test is known as an intrathecal pressure test, but also causes other biomechanical stresses. -With the patient supine, instructs them to raise both legs several inches off the table and hold. -Positive finding is inability to raise the legs or hold them up due to low back or leg pain. -Since this test increases intrathecal pressure, some consider a positive test to be indicative of radiculopathy due to a space-occupying lesion, such as a herniated disc. ( A negative test after 30 seconds, would make pathology of intrathecal origin unlikely.) However, since this test causes biomechanical stress on the lumbar spine, (such as possible arching of the lumbar spine and jamming of the facets), the inability to perform the test would not specifically indicate disc herniation and radiculopathy.
What is Soto-Hall test?
This test is often noted as a test for fracture, however pain and restriction is more commonly due to cervical joint disorder or posterior soft tissue involvement. -If fracture is suspected, the radiographic exam should be done prior to ROM and orthopedic exams. -With the patient supine, the examiner places their caudal hand on the patient's sternum and exerts slight pressure to prevent the thoracic spne from flexing during the test. The examiner's cephalad hand is placed under the occiput and passively flexes the patient's head to their chest.
What is the Braggard test used for?
This test is performed as a follow-up to an abnormal SLR in order to help differentiate pain of nerve etiology (sciatic neuropathy, or radiculopathy) from that of other causes (SI or lumbar joint disorder, or tight hamstrings). -*The leg is lowered slightly to reduce strain* on all the structures possible responsible for the increased pain on SLR (hamstrings, hip joint, SI joint, lumbar joints, and sciatic nerve). *The foot is then dorsiflexed in order to recreate the tenson on the nerve structures*. -When the test recreates the pain that the SLR previously created, it *indicates that the origin of the pain is neural* (sciatic neuropathy or radiculopathy).
What is the shoulder depression test?
This test is primarily known as a test for nerve root dural sleeve adhesions, however, it also causes stretching of muscles, and ligaments. -With the patient seated, the examiner stands behind the patient and laterally flexes the patient's head away and then depresses the shoulder. -This procedure causes stretching of muscles/tendons, ligaments, and spinal nerves on the side of shoulder depression.
What is Goldthwaite's test?
This test may help differentiate pain due to lumbar and SI disorders. -With the patient supine, place one hand under the patient's lumbar spine and with the other hand under the ankle, raise the patient's leg. Feel for the point at which lumbar spine movement occurs. -Positive finding is low back pain. -If low back pain occurs before the examiner feels lumbar movement, a lesion of the SI joint is presumed. The occurrence of low back pain, as the examiner feels the lumbar spine begin to move, indicates a lumbar lesion.
What is the Nachlas test?
This test stresses the SI joint and the lumbar spine. -With the patient prone, apply pressure to the sacrum and flex the heel to the ipsilateral buttock. -Pain in the region of the SI joint indicates SI involvement. Lumbar pain indicates lumbar involvement. Aching, pulling sensation in the anterior thigh indicates tight quadriceps. Sciatic-like sensation down the anterior thigh indicates femoral neuropathy or upper lumbar radiculopathy.
What is the prone extension test?
This tests help to differentiate functional vs structural kyphosis. -With the patient lying prone, they clasp their hands behind their back and lift their head and upper torso off the table. -If the hyper kyphosis decreases, it is functional. If not, then it is structural.
What else may cause pain and restriction upon leg extension (aside from meningitis)?
Tight hamstrings, lumbar radiculopathy, sciatic neuropathy, etc.
Menieres dz sx
Tinnitus (severe) Decreased hearing Vertigo Lasting months to years
If the patient says that the vibration doesn't feel the same bilaterally, what do you ask them next?
To explain how they feel different
What is the primary purpose of percussion of osseous structures?
To investigate suspected fractures.
Why is thorax and abdomen percussion necessary?
To rule out visceral referred pain in order to DDX from back pain.
What is the purpose of the cervical compression test and its variations?
To see if increased pressure on the cervical spine structures creates or exacerbates pain.
TB rarely causes nodules on the __________, but is most common at the _____. They are painful.
Tongue Tip
AKA Adie's pupil
Tonic pupil
Concretions due to food particles lodged in tonsilar crypts mixing with bacteria & mucus
Tonsilloliths (AKA Tonsil stones)
Maxillary sinus congestion can lead to __________.
Toothaches
The tongue will deviate _________ the side of the CN XII lesion.
Toward
CN II carries light __________.
Towards the brain
TMJ exam: Palpate with the tips of your fingers in front of the _________ & ask the patient to ___________.
Tragus Open mouth
What forms the roof of the carpal tunnel?
Transverse carpal ligament
Distribution of Squamous Cell carcinoma
Upper chest & back Lower lip (actinic Keilitis) Genitals (HPV) Head Neck Forearms Shins
Auscultate the posterior thorax for breath sounds, egophony and either bronchophony or pectoriloquy. Describe the normal and abnormal findings as well as the significance of abnormal findings.
Use the diaphragm 1. the patient's arms are crossed in the front and the patient is to breath deeply quietly and slowly through an open mouth. auscultate 14 areas 7 on each side comparing bilaterally. "Normal breath sounds are bronchovesicular between the scapular; vesicular over the majority of the lung field; and bronchial over the manubrium; tracheal sounds over the trachea. Abnormal breath sounds are bronchovesicular breath sounds heard anywhere that isnt between the scapula and bronchial sounds anywhere that is not over the manubrium. Absent breath sounds is also abnormal. If adventitious sounds are present that is also abnormal like crackles, wheezes, and rhonchi. If abnormal sounds are present then I would perform transmitted voice sounds which are egophony, bronchophony, and whispered petoriloqy." 2. Egophony: Auscultate and have the patient say "ee" this is an abnormal sound and it would be heard as "ay" with a nasal quality which this is heard over the meniscu of a pleural effusion. 3. Bronchophony: Auscultate and have the patient say "99" this is an abnormal sound and is heard as 99 being louder and clearer and more distinct. Normally "99" is not distinct but more muffled.This would be heard in patients with consolidation like lobar pneumonia. 4. whispered pectoriloqy: This is performed by the patient whispers 99 and this is an abnormal sound tht results in a louder and more distinct sound of "99" this would be heard in lobar pneumonia.
_________ will be present with quinsy throat & symptoms include....
Uvula deviation Unilateral swelling, sore throat at 1 side, referred pain to ipsi ear, increased pain with jaw opening
CN _____ = tensor tympani mm
V
CN ____ = stapedius mm
VII
CN X
Vagus
What is the most common way for things to break in the body?
Valgus collapse.
What test would indicate MCL lesion?
Valgus stress test would be positive for pain or an altered feel/function.
Size of nail _________ and should be compared _________.
Varies Bilaterally
Changes of color in nails can mean changes in ________________.
Vascularity
What is the continuous murmur that is loudest in diastole and is sometimes heard best above the clavicle with radiations to the 1st and 2nd interspaces of children?
Venous hum
What creates the apical impulse?
Ventricular contraction
Condition characterized by benign epithelial hyperplasia with surface hyperkeratosis that contain pathognomonic "red or brown dots" that are thrombosed capillary loops
Verruca Vulgaris
Vestibular CN VIII dysfunction
Vertigo Disequilibrium (Positive Romberg's) Past-pointing Nystagmus Caloric test/Barany test
Elevated, circumscribed, superficial, not into dermis; filled with serous fluid, less than 1cm diameter
Vesicle (Examples: Chicken pox, Shingles)
CN VIII
Vestibulocochlear
Erysipelas is the most common cause of ________________ in a healthy agent & the most common causative agent is __________.
Virulent soft tissue infections Group A Streptococcus
Causes of angular stomatitis
Vitamin B deficiency Hypersalivation Anemia Ill-fitting dentures Candida albicans (yeast)
Scurvy, a _________ deficiency, causes ____________ gums that bleed easily.
Vitamin D Fragile, swollen
___________ (AKA singer's nodules) are calluses on vocal cords due to overuse or improper use.
Vocal nodules
Treatment of hordeolum
Warm compress 3-4x/day Wash well
What are "red flags?"
Warning signs of possible serious underlying pathology.
What auscultation points are at the base of the heart?
aortic and pulmonic
Elevated, irregular shaped area of cutaneous edema, solid, transient, variable diameter
Wheal (Examples: insect bites, urticaria, allergic reaction)
What is cervical rib syndrome?
When a cervical rib (congenital variant, extra rib off C7) causes the compression.
What pathologies can produce bronchovesicular sounds?
When in less advanced stages: -partial atelectasis -early pneumonia -small tumors -pulmonary edema
When should a patients jugular venous pulsations not be visible?
When the patient is sitting upright
What is scalenus anticus syndrome?
When the scalene muscles are responsible for the compression (spasm, hypertrophy, or congenital variations in tendon attachments).
What is bronchophony?
When you ask the patient to say "99" and the sound is louder, clearer and more distinct than normal
What is egophony?
When you ask the patient to say "ee" and the sound is head as "ay" with a nasal quality
What is whispered pectoriloqy?
When you ask the patient to whisper "99" and the sound is louder, clearer, and more distinct than normal
What side do you palpate the kidney?
Whichever kidney you palpate
Describe the lumbosacral spinal nerve to disc relationship.
While low back spinal nerves exit below the vertebral body with the same numeric designation, they start to exit the cauda equina at a higher level and travel down obliquely to reach their IVF. They cross the posterolateral aspect of the disc above, and are subject to compression at that level. Thus, although the anatomic reason differs, the formula mentioned above for the relation between disc herniations and cervical spinal nerves also applies for the low back.
Color pattern of Raynaud's phenomenon
White Blue Red
White lines that weave through lichen planus papules
Wickham's striae
Clubbing of nails is when the nail angle is greater than 180 and has __________ and extra _________ of the nail bed.
Widened Springiness/floating
Kayser-Fleischer ring indicates __________ & an associated exam finding would be _____________.
Wilson's disease Blue lunula
Blue Lunula occur with __________ due to the _____________ at the liver.
Wilson's dz Copper metabolism dysfunction
What disease is the wing beating tremor seen in?
Wilsons
With cerebellar disease what will the patient do in heel to shin test?
With cerebellar disease, the patient may miss the knee, and may zig-zag as the heel is slid down the shin - "dysmetria".
What is the sulcus sign?
With the arm straight and relaxed to the side of the patient, the elbow is grasped and traction is applied in an inferior direction. With excessive inferior translation, a depression occurs just below the acromion. The appearance of this sulcus is a positive sign. It indicates GH instability (acute dislocation).
What is Yergason's test?
With the hand supinated and the elbow at 90 degrees, instruct the patient to "push up," then externally rotate their shoulder. Indicative of biceps instability.
What is the Sacroiliac Resisted Abduction test?
With the patient lying on their side, and with their inferior limb flexed at the hip and knee, the superior leg is abducted. The examiner applies downward pressure on the abducted limb against the patient's resistance. -SI pain indicates lesion.
What is Eden's test?
With the patient seated, the examiner palpates the radial pulse and then depresses the patient's shoulder unilaterally. Associated with the costoclavicular test.
What is Bechterew's test?
With the patient seated, they extend the knee on the symptomatic side. If the test is negative then they extend both knees together. -Extension of the knee causes traction on the sciatic nerve and its contributing nerve roots. Extension of both knees together may cause an increase in intrathecal pressure. -Indicates sciatic neuropathy or radiculopathy (especially radiculopathy due to disc protrusion).
What could it mean if you can feel the pulse in the upper abdomen?
aortic aneurysm
What is the Belt test?
With the patient standing, ask them to bend forward at the waist and note any pain in the lumbar or SI region. Then stabilize the patient's sacrum with your hip and support the ilia with your hands. Ask the patient to bend forward again and note any pain. -Pain with unsupported flexion and not on supported flexion indicates SI lesion. -Pain with both indicates a lumbar lesion.
What is Gaenslen's test?
With the patient supine and the affected side close to the edge of the table, have the patient draw the knee on the unaffected side toward their chest. Slowly lower the involved extremity over the edge of the table and press downward on the extended leg while pushing the patient's knee into their chest. -Pain in the SI joint indicates SI joint lesion.
What is the anterior instability (clunk) test?
With the patient supine, stabilize the inside of the shoulder with your knee and then pull on their shoulder to try to dislocate it. Indicative of GH instability (chronic).
What is the Sacroiliac stretch test (gapping test)?
With the patient supine, the examiner crosses their arms and applies a downward and lateral pressure to the anterior superior iliac spines. -SI pain indicates lesion (sprain of anterior sacroiliac ligaments).
Stereognosis test
With the patient's eyes closed, place a familiar object (key, paper clip, button, or coin) in the patient's hand and ask the patient to identify the object. perform with multiple objects, compare bilaterally
What is the Iliac compression test?
With the patitne lying on their side, the examiner exerts a strong downward pressure on the ilium. -SI pain indicates lesion.
Demographic of Rosacea pts
Women 30-60 Irish descent
_________ is used to identify tinea infections.
Wood's lamps
What psychosocial factors may influence symptoms and treatment outcomes?
Work status, typical job tasks, education level, pending litigation, worker's compensation or disability issues, failed previous treatments, substance abuse, and depression, etc.
Lichen Planus commonly occurs at ...
Wrists Shins Lumbars
Fatty plaques at eyes due to increased cholesterol
Xanthelasma
Dry mouth or decreased saliva
Xerostomia
What ortho/neuro tests indicate biceps tendon instability?
Yergason's test
Is sensory intact with ALS?
Yes
Will the sound of inflamed pleura diminsh after a few respiratory cycles?
Yes
Can axonal regrowth occur?
Yes in the PNS
Are you suppose to repeat the procedure after testing sensation once and finding a deficit?
Yes, repeat to confirm
Can cervical rotation be measured with an inclinometer?
Yes, with the patient supine. A compass may be utilized to measure rotation with the patient seated.
Gate of + romberg (sensory ataxia)
a. broad-based and unsteady b. tends to watch the feet for guidance while walking c. balance is adversely affected by closing the eyes or when in thhe dark d. the feet may be brought down with a slap.
15. Examine the carotid arteries and the peripheral vasculature of the abdomen and lower extremities. Describe the normal and abnormal findings as well as the significance of abnormal findings.
abdominal aorta, femoral, popliteal, posterior tibial, and dorsal pedis abnormal findings for peripheral vasculature would be rubor, pallor, or cyanotic color throphic changes like shiny hair loss edema and stasis dermatitis which is patchy red/brown due to lysis of RBC normal findings are symmetrical rate rhythm amplitude and contour arterial occlusion would have a decreased/absent pulse, pallor, cool/cold skin venous occlusion would have normal pulse, no pallor, normal temperature, pitting edema, and stasis dermatitis dont' forget to auscultate the carotids
what is graphognosis
ability to recognize letters or numbers drawn on skin
What do you check for in the intercostal spaces?
abnormal retraction during inspiration
What should you try to observe when inspecting the thorax?
abnormalities of the skin like skin cancer, vascular abnormalities, hairy moles, masses, and lesions
Where do you auscultate for the femoral arteries?
above or below the mid-point of the inguinal ligament
clonus with LMNs lesions
absent
fasciculation's with UMN lesion
absent
pathologic reflexes with LMN's lesions
absent
0(R)
absent (areflexia)
superficial reflexes for LMN lesions
absent ot decreased
Does Poliomyelitis affect UMNs or LMNs
affects cell bodies of LMN's
When are heaves and lift pulsations normal?
after exercise
Disease or injury to the internal capsule can damage...
all of the UMN fibers coming from the motor cortex
Light touch perceived as painful
allodynia
Transection of C5-T1
allow portions of upper extremity motor function to remain intact in a proximal-to-distal progression.
dysmetria
alteration of the smoothness and/or accuracy of the movement
Is S4 always abnormal?
always except in well trained athletes
what is a dermatome?.
an area of skin innervated by the sensory fibers of a single spinal nerve.
What would an abnormal percussion tone in the 3-5 intercostal space during a heart exam indicate?
an enlarged heart
What is an example of an inflammatory mass?
an inflammed diverticuli
Inability to feel light touch
anesthesia
What is pigeon chest?
anterior displacement of the sternum
What supplies 2/3 of the cord
anterior spinal artery
Where do you auscultate for the renal arteries?
laterally to the aorta auscultation point below the ribs bilaterally
What is the most common cause of paradoxical splitting?
left bundle branch block
Where do you auscultate for the spleen?
left costal margin
How to test glut med?
legs on table into V and have patient hold while you try to bring legs together
atrophy with UMN lesion
less dramatic
What is hypotension?
less than 100/60
What is a common benign fatty tumor?
lipoma
Where do you listen for friction rubs?
liver and spleen
Which organs do auscultate to listen for bruit?
liver and spleen
What is the difference between localized and general lymphadenopathy?
local= lesion in the drainage area general= enlarged nodes in at least 2 non-contiguous lymph node regions
Where are the pyramids of the medulla located? What are they vascularized by?
located anteromedially and are vascularized by the anterior spinal artery
What are you looking for with abdominal reflexes?
looking for muscle contraction
ulnar N entrapment in the medial epicondylar groove / Cubital tunnel sensory loss
loss in both ventral and dorsal branches
What is the intensity of tracheal expiratory breath sounds? Pitch?
loud and harsh (louder than bronchial); high pitched
What frequency are the S3 and S4 heart sounds and what part of the stethoscope are they best heard with??
low frequencyheard best with the bell and the mitral maneuver
Where is the largest radicular contribution? Whats its name?
lower thoracic region (Artery of Adamkiewicz).
What is enlargement of lymph nodes, with or without tenderness. May be localized or generalized
lymphadenopathy
What is swelling due to obstruction of the lymph channels such as by a tumor, fibrosis, or inflammation.
lymphedema
Where are vesicular breath sounds typically found?
majority of the lung field
Where can bronchial breath sounds be heard normally?
manubrium
How does the normal liver feel on palpation?
marigins are soft, regular, and smooth
4+ DTR scale
markedly hyperactive; may be associated with clonus
a Parasaggital meningioma (falx cerebri) will result in what?
may compromise both sides of the motor cortex resulting in weakness in both lower extremities.
What is the first step to taking BP?
measure the palpatory systolic bilaterally
What part of the cerebellum is challenged when the person is standing and performing a coordination test?
medial vermal zone
What is the normal measurement for liver percussion over the mid-clavicular line and mid-sternal line?
mid-clavicular: 6-12 cm mid-sternal: 4-8cm
What is the high-pitched sound heard during systole that often occurs in patients with a mitral valve prolapse?
mid-systolic click
Where do you listen for the liver?
midpoint of the right costal margin
What auscultation points are at the apex of the heart?
mitral
What is an opening snap associated with?
mitral stenosis
When should a self-exam be performed?
monthly 5-7 days after onset of menses
A person with C7 quadriplegia will still have
more complete control of the shoulder, elbow flexion (c5,6) and some wrist extension (C6,7)
atrophy with LMN lesion
more dramatic
Weakness with LMN lesions
more focal (distribution fits spinal or peripheral N)
What is lymph dependent on?
movement
dysdiadochokinesis
movements are clumsy, irregular, and slow
What effect does squatting have on mid systolic click?
moves it later in systolic
How do fasciculation's begin to occur?
muscle cells of the motor units that have lost their innervation begin to undergo secondary degeneration. The lesion causes the muscle cell membrane potientia to creep closer to the excitation threshold
Pathologic S3 is called what?
ventricular gallop
What are the breath sounds, transmitted voice sounds, and tacile fremitus for normal air-filled lung?
vesicular muffled/ indistinct voice normal tactile fremitus
What does a + rombergs test mean?
visual input was compensating for a balance problem, and sensory ataxia (impaired conscious proprioception/JPS) or vestibular ataxia is suggested.
What kind of guarding will decrease on exhalation
voluntary
Weakness associated with crutch palsy
weakness from the biceps down (triceps, brachioradialis, supinator, wrist extensors, finger extensors)
Weakness associated with internal capsule stroke
weakness of the entire opposite side, with the exception of the forehead (hemiplegia/hemiparesis).
Causes of waddling gate
weakness of the proximal muscles (muscle disease- myopathy)
What is rousing sign and what does this suggest?
when tenderness increases in the lower right quadrant when pressing the lower left quadrant; appendicitis
What is the waddling gate?
when the foot is lifted off the ground, the pelvis on that side drops. the patient may throw the trunk to the opposite side prior to lifting the leg in an attempt to compensate
What are harsh vesicular sounds?
when the normal ratio of inhalation to exhalation (3:1) is maintained and the pitch is normal, but they are more coarse sounding than usual
What is murphy's sign and what does it suggest?
when the patient abruptly stops inhaling due to pain; suggests choleysitis
What are diminished vesicular sounds?
when the vesicular sounds seem more distant than usual
When is puddle sign seen?
when there is a small amount of fluid as alittle as 120ml
When is a respiratory compromise usually present?
when there is interruption between the brainstem and the spinal levels from which the phrenic nerve arises.
What is shifting dullness and when is it most appropriate for it to perform??
when there is tympany at the center of the abdomen but dull at the flanks and there must be 500ml of fluid in the abdomen for it to occur
What is knife clasp phenomenon
where initially the resistance to passive ROM is very high, but then drops off quickly.
When may lymphedema occur?
with axillary node dissection and radiation
How to do the romberg test
with pt's feet together observe their balance, then have them close their eyes and observe their balance
What part of the stethoscope do you use to auscultate the heart?
with the bell or diaphragm
If S2-4 is intact, what would the patient be able to do?
would allow control of voluntary bladder and bowel sphincters.
What portion of the patient should be bare?
xiphoid process to pubis symphysis