PhysicalExamination


 Central retinal artery occlusion findings include amaurosis fugax, a red conjunctiva, a pale fundus, a cherry-red spot at the fovea, and “boxcarring” of the retinal vessels. REF

Trismus is most universally associated with peritonsillar abscess REF

Examine for a pt with solitary thyroid nodule: REF
When evaluating a patient with a solitary thyroid nodule, red flags indicating possible thyroid cancer include male gender; age <20 years or >65 years; rapid growth of the nodule; symptoms of local invasion such as dysphagia, neck pain, and hoarseness; a history of head or neck radiation; a family history of thyroid cancer; a hard, fixed nodule >4 cm; and cervical lymphadenopathy. Ref: Welker MJ, Orlov D: Thyroid nodules. Am Fam Physician 2003;67(3):559-566.



Ottawa Ankle Rules
The Ottawa ankle rules have been designed and validated to reduce unnecessary radiographs. Radiographs should be obtained for all patients with an acute ankle injury who meet any of the following criteria: inability to take four steps, either immediately after the injury or when being evaluated; localized tenderness of the navicular bone or the base of the fifth metatarsal; or localized tenderness at the posterior edge or tip of either malleolus.

HR changes as a function of respiration:
1. vagus nerve is parasympathetic - stimulation results in an increase HR.
2. the nucleus ambiguous gives rise to the vagus nerve
3. inhalation suppresses vagal activity which increases HR.
4. exhalation resumes normal vagal activity which presents as a decrease in HR.
5. The R-R interval decreases during inspiration.

The absence of tachypnea is the most useful clinical finding for ruling out CAP in children. In febrile children, the absence of tachypnea has a high negative predictive value (97.4 percent) for pneumonia. Fever alone can increase the respiratory rate by 10 breaths per minute per degree Celsius. REF
 
Shoulder pain DDX by age group. (Dr. DesJardins)
 
Teen-20
    - instalbility - traumatic and autraumatic
    - overuse
    - labral tear
 
30.40.50
    - RCT - trauma (insidious)
    - AC arthritis
    - Impingement / RC tendonitis / Subacromial bursitis/ RC Syndrome
                                                              |
60s                                                         |
    - Same                                                |
    - Increased RCT    ----------------------  (Frozen shoulder)
    - inreased arthritis
 
XR findings in OA
    - joint space narrowing
    - sclerosis
    - subchondral cysts
 
Bankheart test
 
Knee Examination

1. Effusion 
    - Check medial and lateral aspects of the medical patella.
    - Check the bursal space around knee esp. in the superior aspect.
    - Check the superior and inferior aspects of tibial plateau for point tenderness (meniscus).
    - Check for point tenderness over the anserine bursa.

2. Bend knee 20 degrees.
    - Lachman test (ACL)
    - Valgus stress test for medial collateral ligament damage.
    - Varus stress test for lateral colateral ligament damage.

3. Bend knee 90 degrees.
    - McMurray - any twisting will cause pain the setting of a meniscal tear.
    - Posterior horns of meniscus are actually the causative factor in pain.


Shoulder and Knee

This physical finding is diagnostic for what ? "With the patient standing on tiptoe, the heel should deviate in a varus alignment, but this does not occur on the involved side. A single-leg toe raise should reproduce the pain, and if the process has progressed, this maneuver indicates progression of the problem". REF  Here is an image of the affected structure.

Most specific test for SCFE ?

How to diagnose plantar fasciitis and what are the sx of stress fx ? REF
NB: new Plantar fasciitis is an overuse injury due to microtrauma of the plantar fascia where it attaches at the medial calcaneal tubercle. TX: Achilles tendon stretching. REF

How to diagnose patellofemoral stress syndrome ? REF Medial Retinac

How do you dx a stress fracture ? REF

Exactly where does plantar fasciitis hurt ? REF

How to diagnose fremoroacetabular impingment ? REF

FADIR test Hip flexion, adduction and internal rotation - Pain to hip  =  femoroacetabular impingement.
- Think Darth FADIR with F.I.

FABER test Hip flexion, abduction and external rotation - Pain to groin =  OA
- Think Marc FABER with OA.

How to dx Tarsal coalition. REF

Miller-Fisher Test - Gate improvement p 30 ml CSF tap = ventriculoperitoneal shunt indicated for NPH

Thompson Test - passive plantar foot flexion when the calf is squeezed.

Shoulder Examination Redacted From: http://www.youtube.com/watch?v=VSrLbzZzJU8

Neer's sign: http://www.youtube.com/watch?v=k21FNtBjQ14

Drop arm test: http://www.youtube.com/watch?v=taVMaab9e8c

Knee Examination: http://www.fammed.wisc.edu/our-department/media/623/knee-exam

Hand Anatomy and Infections: REF

Down's Syndrome - speckled irises (Brushfield spots), atlantooccipital and atlantoaxial instability.
Turner syndrome - webbed neck.
Holt-Oram syndrome - Hypoplasia of the radius and phocomelia.
Willams syndrome - Supravalvular aortic stenosis.
Prader-Willi - hypoplastic penis and scrotum.
Caffey disease - increased levels of alkaline phosphatase.
Child abuse - posterior rib fractures.
Rickets - decreased mineralization and bowing of the lower extremities.
Ascorbic acid deficiency - coiled, fragmented corkscrew hairs on the thigh and buttocks.

Cardiac

HOCM and mitral valve prolapse are the only conditions that have a murmur that increases with standing.

-- To differentiate use hand grip - in HOCM it decreases the M and in MVP it increases the M.



Shoulder
1. Inspection
2. Palpation
3. ROM
4. Strength
5. Special Tests

1. Inspection
Gross abnormality
Deformity
Trauma
Swelling of AC joint
Erythema
Warmth
Bilateral Asymmetry
Muscle atrophy esp. of the Supraspinatus, Infraspinatus or Deltoid

2. Palpation
1. Sternoclavicular joint noting any pain
2. Clavicle
3. AC joint (look for the soft spot just posterior to the end of the clavicle)
4. Acromion
5. Subacromial bursa
6. Bicipital groove (anterior superior humoral head)
7. Greater tuberosity which is just anterior to the lateral border of the acromion.
8. Spine of the scapula
9. Supraspinatus
0. Infraspinatus

3. ROM
1. Forward Flexion to 180 degrees (A-Men)
2. Extension to 40 degrees posterior (A-Bird)
3. Abduction from 0 to 180 degrees
4. Abduction of arms down at the sides back to 0 degrees.
5. External rotation with arms at sides and flexed 90 degrees to about 45 deg.
-- Apply scratch test to superior medical aspect of opposite scapula
6. Internal rotation to 65 deg.
-- Reach both hands up the back as far as possible (use inf. border of opp. scapula T7)

4. Strength
1. Flexion
2. Extension
3. External Rotation (Infraspinatus and Teres Minor)
4. Internal Rotation to test subscularis.
5. Jobes test with arms out and thumbs down (dump cans) have pt push up against your hands.
6. Subscularis with Lift Off Test

Special Tests for Rotator cuff, Impingement problems, Biceps tendon Labial tears Shoulder Instability

1. Drop Arm test for rotator cuff test (specifically the supraspinatus). Pt will not be able to hold shoulder at 90 degree and it will drop to her side.

2. Impingement tests of the area under the acromioclavicular joint that rotator muscles traverses.

-- Neer's sign Stabilze scapula, Pronate the affected arm, Passively forward flex the arm as high as possible, this pinches the rotator cuff muscles under the coracoacromial arch.  A positive test is any pain reported by the patient.

-- Hawkins test is performed by forward-flexing the patient's arm to 90 degrees, bending the elbow and then forcibly internally rotating the humerus.  This drives the greater tuberosity  under the coracoacromial arch impinging the supraspinatus tendon. REF

-- Steves test is performed by having the patient forward flex her arm against residence with the palm supinated pain indicates biceps tendon or labral pathology.

-- Obrien's test is a more sensitive for labral tears. Forward flex the patient's arm to 90 degrees then adduct it 20 degrees and internally rotate it so that the thumb is down. Ask the patient to resist the downward pressure. Next, externally rotate the arm so that the thumb is up and ask to patient to resist downward pressure. A positive test is pain or painful clicking which occurs when the patient's thumb is down and then is somewhat relieved when the patient's thumb is back up.

-- Crank test for labral pathology by abducting the patient arm in scapular plane, flexing the elbow, and applying a gentle axial load to the glenohumoral joint while internally and externally rotating the humerus. A postive test is pain, catching or painful clicking.

-- Apprehension test for glenohumoral joint stability which can be performed with the patient standing or sitting. With one had stabilize the scapula then rotate the arm into 90 degrees abduction then externally rotate the humerus. A positive test is a look of apprehension on the patient's face. The relocation test is applied after a positive apprehension test by applying posterior pressure on the proximal humerus and noting the patient's sense of relief. The anterior relief test for anterior shoulder instability can be performed with the patient in the same position  as for the relo test. A positive test is the report of pain or a feeling of instability on release of pressure from the proximal humerus.

First Version for Smart Phrase redacted from the above.

Shoulder Examination

Inspection:

Palpation: Digital examination of bony landmarks including the acromioclavicular joints, the medial and lateral heads of the clavicles,

Range of motion: Strength: 5/5 in the shoulder and upper extremities bilaterally with symmetrically equal strength on internal and external rotation, abduction and adduction of the upper extremities and shoulders.

Inspection
No gross abnormality
No assymmetry of the upper extremeities or torso. 
No deformity, no rash, no bruising.
No sign of muscular atrophy of the supraspinatus, infraspinatus or deltoid.
No trauma.
No swelling of the AC joint.
No erythema.

Palpation - for tenderness, swelling, irregularity.
None - sternoclavicular joint.
None - clavicle.
None - AC joint.
None - acromion tenderness.
None - subacromial bursa.
None - bicipital groove (anterior superior humoral head)
None - greater tuberosity (just anterior to the lateral border of the acromion).
None - spine of the scapula.
None- supraspinatus.
None - infraspinatus.

ROM - Symmetric bilaterally with no limitations. 
Patient felt initially that he could not raise the left arm above the level of the shoulder on abduction, however subsequent testing did not reveal limitation to motion or remarkable tenderness.
Yes - Forward Flexion to 180 degrees (A-Men)
Yes - Extension to 40 degrees posterior (A-Bird)
Yes - Abduction from 0 to 180 degrees
Yes - Abduction of arms down at the sides back to 0 degrees.
Yes - External rotation with arms at sides and flexed 90 degrees to about 45 deg.
          -- Appled 'scratch test' to superior medical aspect of opposite scapula
Yes - Internal rotation to 65 deg.
         -- Could reach both hands up the back as far as possible (usually inf. border of opposite scapula is at approximately T7)

Strength
5/5 - Flexion
5/5 - Extension
5/5 - External Rotation (Infraspinatus and Teres Minor)
5/5 - Internal Rotation to test subscularis.
5/5 - Jobes test with arms out and thumbs down (dump cans) have pt push up against your hands.
5/5 - Subscularis with Lift Off Test

Neg - Neer
Neg - Hawkins
Neg - Steve
Neg - Obrien
Neg - Crank
Neg - Apprehension


Subpages (1): workups
Comments