Advanced Physical Assessment
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| The foot and ankle, upon inspection, you look for | nodules (RA), deformities, tenderness, arthritis- plantar fasciitis of the heel
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| Test- Ottawa ankle rules- ankle xr indications | boney tenderness at the lateral malleolar zone, boney tenderness at the medial malleolar, inability to walk four weight bearing steps immediately after the injury and in the emergency department
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| Test- Ottawa foot rules | get XR when- bone tenderness at Navicular bone, bone tenderness at base of the 5th metatarsal, inability to weight bear both immediately and in the ED
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| Test- Most common joint to get sprained is the | ankle ATFL (anterior talofibular ligament)- pt will have point tenderness and swelling over involved ligament(s) (can bear wt) and NOT over the malleoli, which is a fracture.
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| The second most common is a sprain of ankle is | both the ATFL and the CFL (calcaneofibular ligament).
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| Sprain vs strain | sprain a joint and strain a muscle
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| Achilles tendonitis | describes inflammation middle portion of posterior ankle- quinolones/levo can cause-improper shoes and inadequate stretching prior to athletic activities- worse when standing/walking down stairs.
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| Flat feet/pes planus | not always abnormal- examine shoes-
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| Plantar fasciitis: | a common inflammation of the plantar fascia at its origin on the calcaneus- overuse injury that develops of repeated overstretching of the plantar fascia- 1st arising from bed you feel it
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| Morton’s neuroma | perineural fibrosis of the common digital nerve=Tenderness over the plantar surface between the 3rd and 4th metatarsal heads
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| Neuropathic wart | under foot- painless- diabetic pts
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| Plantar wart | under foot- HPV
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| Podagra | gout- red inflamed, give nsaids, steroids, cochesine- chronic allopurinol
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| How many types of lordosis do we have? | 2- cervical and lumbar- also, thoracic kyphosis (aging)
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| Test- Herniated intervertebral discs, most common at | L5 – S1 or L4 – L5, may cause tenderness- will ask about L4-5 or L5-S1, not both
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| Test- the most important test for the spine | straight leg raises- for herniated disc-
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| Test- An ipsilateral positive straight leg test | same leg that has issue is lifted- feels pain- is a sensitive test for the presence of radiculopathy-compressed nerve root- (80% sensitive, 40% specific)
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| Test- A contralateral (crossed) positive straight leg test | opposite leg is lifted- feels pain- is a more specific test for the presence of radiculopathy- compressed nerve root- (90% specific).
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| Cervical Radiculopathy: (from Nerve Root Compression) | Sharp burning or tingling pain in the neck and ONE arm, with associated paresthesias and weakness.
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| Physical Signs of cervical radiculopathy | C7 root is MOST often affected, with weakness in triceps and finger flexors and extensors. C6 root will cause weakness in biceps, brachioradialis, wrist extensors
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| C5 | Shoulder abduction, Elbow flexion (palm up) for deltoid and biceps, sensory left arm below deltoid, deep tendon reflex is the bicep
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| C6 | Elbow flexion (thumb up), Wrist extension for Brachioradialis, Extensor carpi radialis longus, sensory is thumb and radial hand- DTR is brachioradialia
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| C7 | Elbow extension, Wrist flexion for Triceps, Flexor carpi radialis- sensory Index, long finger, ring finger, DTR- triceps
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| .Cervical Myelopathy | from Cervical Cord Compression- bilateral-Neck pain with BILATERAL weakness and paresthesias in BOTH upper and lower extremities- canbe caused by Cervical spondylosis, RA, (para) central herniation
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| Cervical myelopathy physical findings | Hyperreflexia; clonus at the wrist, knee, or ankle- + Babinski and Lhermitte sign: neck flexion results in sensation of electrical shock
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| simple muscle strain is the most common cause of | low back pain- on exam, the paraspinal muscles may be palpably spasming, ROM ↓
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| Lumbosacral disc herniation | The discs between the L4-5 and L5-S1) are the most commonly herniated discs (most weight-supporting ones).
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| Radicular pain (AKA radiculopathy) typically is a | unilateral- burning/ shock- like pain that starts in the buttocks and shoots down the leg on the affected side (layman’s term: “sciatica”), following the dermatome of the compressed nerve root
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| Leg pain that goes past the knee | indicates a pinched nerve from a herniated disc, while buttock or leg pain that does not extend past the knee may be referred pain from the back, but is not from a pinched nerve root.
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| The straight leg raise test (SLR) is a valuable maneuver to assess | compression of the nerve roots contributing to the sciatic nerve, as occurs with a lumbosacral herniated disc:
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| An ipsilateral positive straight leg test is a | sensitive test for the presence of radiculopathy
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| A contralateral (crossed) positive straight leg test is a | more specific test for the presence of radiculopathy
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| neurogenic claudication | pain in buttocks and legs that worsens with prolonged upright standing or walking- relieved when sitting
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| Vascular claudication is | relieved by standing at rest, while neurogenic needs to sit
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| shopping cart sign | Standing straight makes pain worse/while leaning forward alleviates the pain-pts often fine when walking/leaning on the shopping cart, but when walking the few minutes across the parking lot to their car, they are in severe pain- lumbar spine stenosis
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| Cauda Equina Syndrome | lower back pain and leg pain- often bilateral) associated with lower extremity weakness and bowel/ bladder symptoms (incontinence)- saddle anesthesia- does it feel weird when you wipe- do rectal exam-
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| Screening for scoliosis is best done by | the “Adam’s forward bend test”- use scoliometer- forward bend device- 7 degrees or higher is a referral d/t curvature of 20 degrees or more
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| Test- Osgood-Schlatter Disease “hurts at my knee” | A traction apophysitis (inflammation of a bony outgrowth) of the anterior aspect of the tibial tubercle- inflammation of anterior patellar tendon-self-limiting d/o- common in boys between 9-15 yo
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| Muscular dystrophy/Duchenne | Muscle atrophy and weakness with a waddling gait- A positive Gower sign- Progressive loss of function, including ability to walk
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