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NYCC Ruddy review pa

sp01 site, Drs. Finn & Homack, and wikipedia

QuestionAnswer
When viewing a CERVICAL FRACTURE, look for PRE-VERTEBRAL soft tissue abnormalities
Sclerosis of L5 pedicle: (3) Mets, Agenesis, or Osteoid osteoma
What is the probable cause of a missing lamina? Laminectomy (hemilaminectomy)
Oppenheimer Anterior scalloping due to pulsations caused by an abdominal aortic aneurysm
Protrusio acetabuli likely causes: (2) RA Bone softening dz like Paget's
Otto's Pelvis
Juxtarticular osteoporosis RA
Rf+ RA, SLE, Scleroderma (CREST)
Is blood work warranted for DJD? NO
Ortho tests for hip DJD: (4) Patrick, Fabere, Ely, Hibbs
Non-descended scapulae Sprengle's deformity
Bilateral SI problem Enteropathic athritis (gut) or Ankylosing Spondylitis
Klippel-Fiel (3) Sprengle's non-descended scapulae, non-union defect of lamina, web neck
Ortho for Ankylosing Spondylitis (2) Lewin & Forrestier
Cervical rib ortho tests positive for TOS (2) Halstead & Adson's
Cloaca of bone Entrance of infection. Should be a clean hole. Sequestrum will be 'in the middle part.' Involucrum is a bone collar. Blood work = elevated ESR, fever, CBC w/ diff
Structures that go through the POSTERIOR PONTICLE Vertebral Artery & 1st Cervical Nerve (goes to suboccipital triangle)
For kids, rule out (2) Infection and Tumor (osteosarcoma and Ewing's)
DISH Disc spaces ARE maintained, FLOWING hyperostosis (candle wax appearance). Associated w/ DIABETES. Do HLA B-8 test.
Paget's bloodwork ALK PHOS. Late stage Pagets can become osteosarcoma.
Bilateral HAND x-ray of 55 year old FEMALE d/dx: Bilateral RA or gout. SPOTTY CARPAL sign. Labs = ESR & Rf+
49 year old male with cervicothoracic pain TOS, DISH (loves LUNG area). Film presented will show mid-body hyperostosis. Disc space MAINTAINED. Two clinical conditions = adult onset DM, osteoporosis
50 year old MALE with lower back pain Prostate or lumbar aneurysm. Most significant finding = 8cm AAA. DOPPLER US and vascular study.
APOM, lateral, and AP cervical views shown with NO trauma 2 significant findings: AGENSIS of DENS (i.e., non-union). Is it STABLE or NOT? Is there radiating arm pain? Anytime there is upper cervical instability, consider cervical myelopathy.
28 year old with neck pain and no history of trauma Severe carotid artery calcification, especially at bifurcation [C3 level]
14 year old with knee pain. Views are bilateral AP and Lateral Cortical erosion at tibial tuberosity (not an O-S disease). FRAGMENTATION ---SEPTIC ARTHRITIS
Older, long standing LBP, recent exacerbation, cannot walk without pain Grade I-II, SPONDYLOLYTIC SPONDYLOLISTHESIS. No pedicle = most significant finding then becomes OSTEOLYTIC METS. Refer out.
Mid back, thoracic film of male with MARGINAL SYNDESMOPHYTES ANKYLOSING SPONDYLITIS: SHINY CORNER sign = increased sclerosis at corner. HLA-B27, (+) ESR
YOUNG male with GROIN pain LEGG-CALVE-PERTHES dz. Avascular necrosis could result. Complicated by non-union, fragmentation.
Female, constant KNEE pain GIANT CELL TUMOR or OSTEOSARCOMA [both at distal femur]. LYTIC, SOAP bubbly appearance. This was a malignant case (film Ruddy uses)
Puncture wound at LB INFECITON and/or DISCITIS. Present with low grade fever and fatigue.
63 y.o. with chronic LBP Late stage ANKYLOSING SPONDYLITIS shows BAMBOO spine, TROLLEY TRACK sign, DAGGER sign. Exonerative? arthropathy. HLA-B27 +. MARGINAL syndesmophytes.
What is a marginal syndesmophyte? Associated with ANKYLOSING SPONDYLITIS: Marginal syndesmophyte formation = thin vertical dense spicules bridging the vertebral bodies. Ossification of outer fibers of annulus fibrosus. Not anterior longitudinal ligament.
Melhorosis means candle waxing, flowing hyperostosis
bridging osteophytes Reiter's
non-marginal syndesmophytes DJD
MVA with a cervical series and oblique. Why oblique shot? Arm pain; encroachment of IVF; facet dislocation or perched (partially dislocated). Diagnosis: Encroachment
Lymph node evaluation series of 3 each: locations?
35 yo male: 3 week hx of chronic mid and LBP. Perform LUMBAR ROM, Kemp's, Yeoman's, Patrick-Fabere's Pain on both SI. SOF of back pain. Limited ROM and painful. Dx: ANKYLOSING SPONDYLITIS (ie, 35 yo male w/ limited ROM, especially in extension)
34 yo female: neck and shoulder pain Perform ACTIVE ROM of cervical. Distraction. Bakody's. Cervical compression. Maximal foraminal compression. Muscle test for C5 and C6.
34 yo female rugby player w/ band-like pain in LB Milgram's (pilgrim of lifting legs), SLR, Braggard's, Laguerre in the air, Nachlas (anterior thigh pain)
Zone of CAPERNICUM Salter-Harris fx
Posterior spinal line, aka? Posterior SPINOLAMINAR line (lines posterior length of canal)
When George's line moves, the ____________ moves, too. spinolaminar line
Anterior shoulder pain: any visceral conditions? Upper lobe tumors (Pancoast)
Mass in distal FEMUR, young patient, not painful, extremely common: Osteochondroma. Pedunculated more common than sessile.
Possible sequelae of osteochondroma? 98% of time there is no complication but 2% risk of malignant. Pedunculated more common than sessile.
25 year old female w/ LBP has a lateral lumbar film Trauma, kidney, urinary tract? Repetitive UTI (lower pelvic pain) can come PYELO/GLOMERULONEPHRITIS = flank pain. Will show WBC CASTS in urinalysis.
Gross compression fx w/ step defect Means NEW fx. What else shows me it is a recent fracture? ZONE OF IMPACTION. Mechanism of trauma? HYPERFLEXION
Lateral and oblique spinal views are missing a spinous process. Body is gone. Dx? LYTIC METS or MULTIPLE MYELOMA. Sx: Fatigue with weight loss and PAIN AT NIGHT. Follow up with this question: Does the pain keep you awake at nigh or is is pain you can bear to sleep through?
Review the following techniques: Cross body pull, Beside (called reinforced tp?), Crossed pisiform, Pisiform mam push, Spinous pull move on L3,PI ilium side posture PULL move, Posterior sacrum on L, Flexion restriction of L5/S1... GH joint restriction A-P glide, fibular head anterior
Physical exam: ascultate and describe the valves Aortic (R 2nd ICS), Pulmonic (L 2nd ICS), Erbs (L 3rd ICS along mid-clavicular line), Tricuspid (L 6th ICS parasternal), Mitral (L 6 ICS mid-clavicular line)
Patient with radiating leg pain. Perform BEEVOR'S, Spinal percussion, Schepelmann's, Kernig, Brudzinski's Know spinal level for above and below umbilicus: (T10 @ umbilicus, T12 PS, T7 xyphoid, T4 nipple line)
Shooting pain down both legs upon Brudzinski's myelopathy from meningeal irritation
Always ask what kind of pain the pain-tient is experiencing, not just 'is that painful?' Why? Because tingling is different from shocking dysthesia, radiation, pressure, etc.
Dizziness and apparent nausea upon turning head. Tests to perform? Weber's, Swivel chair, deKleyn's, Barre-leiou (COW) test. Check for UE proprioreception.
deKleyn's test? Pt. Supine with head extended off the end of the table, active rotation & hyperextension, to each side for 15 seconds
Barré-Leiou's sign test, George's cerebrovascular craniocervical functional test, Maigne's test, Hautant's test, Underberg's test, Hallpike maneuver, and deKleyn's or Wallenberg's tests. All are variations of the same theme: extreme rotation and extension of the head designed to provoke cerebral ischemia during positional change of the cervical spine.
A test is positive if it provokes signs or symptoms of vertebrobasilar insufficiency (eg, nystagmus or symptoms of vertigo, dizziness, tinnitus, visual blurring, nausea, or faintness). A positive test is considered a contraindication to cervical manipulation. One of the most commonly used tests is deKleyn's test.
Positive deKelyn's results for VBA insufficiency (+)vertigo, nystagmus, dizziness or nausea indicates basilar artery insufficiency
George's Screening Procedure Pt. Seated, history, bilateral blood pressure, subclavian & carotid artery bruit tests, vertebrobasilar artery functional maneuver
Positive George's procedure for VBA insufficiency (+)high risk history (+)10mm Hg difference from side to side or feeble radial pulse is indicative of subclavian stenosis (+)subclavian or carotid bruit indicative of arterial stenosis (+)vertigo, nystagmus, dizziness or nausea during functional maneuve
Vertebrobasilar artery functional maneuver Pt. Seated, active rotation & hyperextension of head to each side for 3-5 seconds
Positive results for vertebrobasilar artery functional maneuver (+)vertigo, nystagmus, dizziness, nausea, faintness indicates vertebrobasilor artery insufficiency indicative of vertebral, basilar artery insufficiency
Barre-Leiou test Pt. Seated, active rotation of head from side to side, slowly then accelerate
Positive results for Barre-Leiou test (+)vertigo, nystagmus, dizziness indicates vertebral artery insufficiency
Hallpike maneuver test Pt. supine with head extended off the end of the table, passive extension, rotation & lateral flexion to each side for 15 seconds
Positive results for Hallpike maneuver test (+)vertigo, nystagmus, dizziness or nausea indicates vertebrobasilar artery insufficiency
Hautant test Pt. Seated with arms forward & hands supinated, active rotation & hyperextention of head to each side
Positive results for Hautant test (+)drifting of arms indicates vertebrobasilar insufficiency
Underburg's test Pt. standing with arms forward & hands supinated, with eyes closed, active rotation & hyperextention of head, Pt. Then marches in place for 15 sec., repeat for opposite side
Positive results for Underburg's test (+)drifting of arms or loss of balance indicates vertebrobasilar or carotid artery insufficiency
WEBER test result: Lateralization of tuning fork to Right? Sensory neuro loss on Left, OR air conduction block on the Right. Neuro, opposite. Block, same. Tell examiner you would do the follow up test [Rinne] given this finding.
What MUST you do first as part of the SWIVEL CHAIR test? the Barre-Leiou test.
Swivel test is simply an increase in speed of the _______________ test. What is the positive of a swivel chair test? Barre-Leiou. A positive SWIVEL CHAIR test: patient becomes nauseous and dizzy.
D/Dx positive swivel chair test? Cervicogenic vertigo, VBAI
Chest pain. Perform posterior fremitus and ascultate the lung field. State all the findings and do sternal compression posteriorly. Pt cross arms. Review changes in case of pneumonia and emphysema upon fremitus, breathing, percussion, etc. Pt. supine, press down on sternum. Pain (+) could be rib, thoracic, etc.
In healthy adults, there are two normal heart sounds often described as a lub and a dub (or dup), that occur in sequence with each heartbeat. These are the first heart sound (S1) and second heart sound (S2), produced by the closing of the AV valves and semilunar valves
Heart murmurs are generated by turbulent flow of blood, which may occur inside or outside the heart. Murmurs may be physiological (benign) or pathological (abnormal). Abnormal murmurs can be caused by stenosis restricting the opening of a heart valve, really turbulence as blood flows through it. Abnormal murmurs occur with valvular insufficiency (or regurgitation), allowing backflow bc incompetent valve closes halfway.
The first heart tone, or S1, forms the "lub" of "lub-dub" and is composed of components M1 and T1. What causes the "Lub" sound? It is caused by the sudden block of reverse blood flow due to closure of the atrioventricular valves, i.e. tricuspid and mitral (bicuspid), at the beginning of ventricular contraction, or systole.
The S1 sound results from reverberation within the blood associated with the sudden block of flow reversal by the valves.[1] If M1 occurs slightly after T1, then the patient likely has a dysfunction of conduction of the left side of the heart such as a left bundle branch block.
The second heart tone, or S2, forms the "dub" of "lub-dub" and is composed of components A2 and P2. What causes the "dub" sound? It is caused by the sudden block of reversing blood flow due to closure of the semilunar valves (the aortic valve and pulmonary valve) at the end of ventricular systole, i.e. beginning of ventricular diastole.
he S2 sound results from reverberation within the blood associated with the sudden block of flow reversal into the ventricles by the aortic and pulmonic cusps. When does an S2 split occur? Splitting of S2, also known as physiological split, normally occurs during inspiration.
A widely split S2 can be associated with? right bundle branch block, pulmonary stenosis and atrial septal defect.
You perform fremitus. The patient has an increase in "99" sound. Meaning? any consolidation
You perform fremitus. The patient has a decrease in "99" sound. Meaning? Pneumothorax, or any air in pleural space
You perform lung percussion. The patient has a hyper-resonance. Meaning? Emphysema, because lungs are 'bags of air' all over. There is no expansion area left because the lungs are fully expanded, fully inflated.
How will hyper-resonant lung breath sound? Distant, far away.
You perform percussion over a patient's lungs and it sounds dull. Meaning? Consolidation. Dull thud over pneumonia. Normal diaphragm excursion.
You ascultate a patient's lungs and hear no vesicular sounds over the middle lobe, just wheezes and crackles. Meaning? Middle lobe consolidation (pneumonia)
Any entity (trauma) that makes the lung go away makes ________ go away. fremitus
You ascultate and percuss a patient's lung fields; you hear resonance and vesicular breath sounds. Meaning? Normal lungs: resonance and vesicular breath sounds
You ascultate the lungs but hear no breath sounds on the left lower lobe. The percussion resonates like a drum. Only the right side is inflating when the patient breathes. Meaning? Pleural effusion (can be spontaneous) and if fluid is bloody, it could be a hemothorax. This is a DRUM resonance because it is full of blood. If it were a pneumothorax, it would be full of air and have a typmpanic sound.
Zero diaphragmatic excursion on one side, +5 excursion on the other. Meaning? Hemidiaphragm. could be Pneumothorax or hemothorax. Depends on the resonance sound: is it typmpanic (air = pneumothorax) or drum like (fluid = pleural effusion of fluid, perhaps blood/hemothorax).
Why doesn't pneumonia resonate either tympany or drum like? Because it is SOLID, ie, conSOLIDation. It sounds DULL. Think of an idiot with a consolidated, thick mind, dullard.
You ascultate a patient's left upper lung field: there is no vesicular (breath) sound, no fremitus when you palpate. There is no diaphragmatic excursion on the left, either. There IS hyper-resonance and tympany in the upper left field. Pneumothorax! It's all air, no lung.
Normal diaphragm excursion 3-5 cm
Correct technique for ascultation of lung field Double tap diaphragm - they may give you a dead scope. Hold diaphragm tightly against chest. Listen for one full breath. If adventitious sound heard, ask patient to cough and listen again. Compare bilaterally. Keep in mind underlying anatomy.
Upon ascultation of lung, you hear adventitous sound. Why ask patient to cough? Because bronchitis can be cleared by coughing.
What is proper placement above clavice when ascultating and testing with hand for fremitus? Fully clear the clavicle.
4 lung field distinctions (ie, vesicular) Tracheal (loud, high, harsh, over extrathoracic trachea), Bronchial (loud, high, tubular over manubrium), Bronchovesicular (moderate, rustling, tubular, over main bronchi), Vesicular (soft, low, gentle rustling, over peripheral lung)
In what patients might it be normal to hear a gallop rhythm? (S3) Children and athletic adults (LUB-duppa). Otherwise, suggests congestive heart failure due to anemia, hyperthyroid, pregnancy
What does an S3 gallop rhythm sound like? Milk hitting the side of an empty pail, getting more muffled as it fills up. Noise during fill stage as liquid hits empty vessel.
S2 split late closure of semilunar valves (aorta and pulmonic)
Crackles and rales/change in breath sound congestion, fluid, asthma, etc.
On the chest x-ray of patient for which you just ascultated, percussed, or palpated for fremitus, what should you look for? CARDIOMEGALY (the normal heart size is half the chest cavity)
19 yo male with midback pain. Perform AROM thoracolumbar, chest expansion, Kemp's, rib motion, and explain normal findings. Pulling sensation upon bending down seated = Right thoracolumbar paraspinal. Male chest expansion 2", female 1.5". D/dx Schuermann's, Ankylosing Spondylitis, muscular hypertonicity.
What radiograph to order for Scheurmann's? AP, lateral thoracic. Look for multiple Schmorl's nodes, irregular endplates, angular wedging, hyperkyphosis
Female comes in holding her arm. FOOSH fall. Perform Codman's, drop, Apley's scratch, Yergason, AROM for shoulder. Drop on Codman, watch eccentric return, too. Apley's = ER & ABd over head, INR & ADd behind back. Yergason's - biciptial instability (transverse humeral ligament over b. tendon) - patient tries to flex and supinate against resistance (Speed test).
D/dx shoulder problem GHJ (apprehension test), supraspinatus (Neer's, Hawkins Kennedy, Gerber's lift off, Codman's, Supraspinatus press test), bicipital tendinitis (Yergason's, Abbot Saunders, Speed), ACJ sprain (Scarf, O'Briens)
evaluation of shoulder Protraction (GH flexed to 90 degrees), Retraction (GH flexed to 90 degrees), Elevation (arm at side, lift pt's elbow), Depression. Flexion, Extension, Adduction across body, Abduction, Internal and external rotation arm at side, then at 90 degrees
Normal acromiohumeral space measurement? 7-11 cm
Hoover's, Mankopf's, Magnuson's, Burn's bench tests MALINGERING tests
Left wrist and hand pain. What tests? Froment's, Finkelstein's, Tinnel tap at elbow, at wrist, English's, Bunnell-Littler. Where is the sustained paresthesia going?
Right knee pain. What tests? Slocum, Lachmann, AP drawer, PA drawer, Apley's compression, Patellar ballottement? (Clark's). McMurray's is NOT a pain test - it's a test for meniscus. Can do varus, valgus for pain, too.
Created by: hecutler