Advanced Health Assessment Test 1

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Facilitation
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Encourage continuation of story Similar to active listening Phone etiquette
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Reflection
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Repeating part of the what the person just said Similar to echoing
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Empathy
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Recognizes a feeling and puts it into words states the unstated
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Therapeutic Communication
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Facilitation Silence Reflection Empathy Clarification Confrontation Interpretation Explanation
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Clarification
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Used to summarize words, clear up ambiguous language use, simplify Confirm that you are correct before moving on
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Confrontation
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Focuses the person’s attention on a certain action, feeling, or statement
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Interpretation
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Based on your inference or conclusion
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Explanation
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Inform the person Factual and objective information
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OLD CARTS
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Onset Location Duration Characteristcis Associated symptoms Relieving or aggravating factors Treatment Severity (pain scale) and signs of understanding
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History of Present Illness
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The 7 attributes of a symptom OPQRST
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Family History
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Pedigree or Genogram should include at least 3-4 generations
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Episodic History
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Includes chief complaint, HPI, pertinent past history and any relevant family history
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Head examination
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Start with palpation and inspection Hair distribution Masses or lesions Foreign objects
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Inspection of the face
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Look for symmetry Assess cranial nerves V (Trigeminal) and VII (Facial)
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CN V: Trigeminal
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Mixed. Motor=chewing. Sensory = face and scalp, cornea, mucous membranes and nose.
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CN VII: Facial
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Mixed. Motor = facial muscle, closing eyes, labial speech, closing mouth. Sensory = taste, anterior 2/3 of tongue. Parasympathetic – tear and saliva production
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Nodes to palpate and name
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Post auricular, Pre auricular, occipital, submandibular, Anterior and posterior cervical chains, supraclavicular
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Lymphadenitis
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most frequent form of extrapulmonary TB. Depends of immunosuppression of children with HIV. Presents as painless, firm, red , usually matted mass, localized in one region. Fine needle aspiration demonstrates cytologic evidence of granuloma, but smears or cultures are usually negative. TB skin test is almost always positive.
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Physical examination of eye
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Know structures Inspect lids and external structures Pupillary reaction Extraocular movements – 6 positions retinal exam with opthalmoscope Visual acuity and visual fields Sclera should be white and conjunctiva should be clearC
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Diopter
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Farsighted – green (+) or black Nearsighted – red (-)
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Papilledema
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occurs when there is increased brain pressure caused by tumor, head injury, or other problems causing swelling of the optic nerve. Vision usually no affected initially and it is a bilateral condition. Patient may have symptoms of intracranial pressure like headache, nausea, and vomiting.
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Optic disk edema
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Usually caused by: increased intracranial pressure – papilledema infarction inflammation infiltration by cancer
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Location of Macula
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Two disc diameters temporal to disc
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Examining the eye
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Allergies: both eyes usually involved. Glaucoma gets immediate referra Periorbital cellulitis: can lead to more serious infection so may send to ER
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Conjunctivitis
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Rarely painful Bacterial/classic: green discharge Allergic: clear discharge
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Chalazion
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Higher up on the lid
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Hordeolum
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right on the lid next to eye (on the bottom lid)
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uveitis
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emergent referral, goes right up to the limbus
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Pterygium
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growth across the limbus, tissue
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Pinguecula
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bump in the sclera caused by dust/UV light. See in migrant farm workers.
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Flourescin stain
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look for corneal abrasion, hepatic keratitis, ulcers. Use different color stains and lights
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Cranial nerve II
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Fundascopic exam – Pupillary light reflex The patient stares into the distance as the examiner shines the penlight obliquely into each pupil. Pupillary constriction should be noted on the eye examined (direct response) and on the opposite eye (consensual response). The swinging flashlight test involves moving the light between the two pupils. Normally both direct and consensual responses are elicited when the light shines on an eye, and some dilation will occur during the swing between., visual fields, and visual acuity.
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Opthalmoscopic exam
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Right eye to right eye and vice versa Farsighted use green (+ or black) Nearsighted use red or – Look for red reflex first. If no reflex, may have detached retina or tumor (esp in kids). Needs referral.
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Opthalmoscopic exam know how
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When you look at the disk, the patient is ok. It is when you look at the macula that the pt tears up or gets uncomfortable. Big vessels are veins and the little vessels are arteries. Follow the vessels to the optic disc. 1st thing to assess is the state of the vessels and the 2nd thing is the optic disc.
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AV nicking
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HTN narrows the arteries and creates indentions in the veins, where the arteries cross the vein. Rigid arterioles compress the vein as they cross within a common adventitial sheath. Thickening of vessels.
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Retinopathy
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microaneurysms, retinal hemorrhages, and cotton wool spots associated with Diabetes. Vision loss occurs. Disc to cup ratio should be 1 to 2
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Hints for using opthalmascope
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Use a smaller light because brightness of light allows for less light so pupil doesn’t constrict too much. Red free lense (green light) is better viewing of the vessels, specifically for nicks and for neo-vascularization. Blue light is used with flourescin for corneal abrasions as is slit
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Loss of vision
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\”shade coming down\” Aura reduced color less bright \”looking through smoke\” last 2-3 hours
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Extraocular movements for CN III, IV, and VI
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6 cardinal fields of gaze Cover and uncover eye Corneal light reflection test PERRLA – direct, consensual, accommodation -The examiner tests ocular movements by standing one meter in front of the patient and asking the patient to follow a target with eyes only, and not the head. The targets is moved in an \”H\” shape and the patient is asked to report any diplopia. Then, the target is held at the lateral ends of the patient’s visual field. Nystagmus should be noted. One or two beats is a normal finding. The accommodation reflex is tested by moving the target towards the patient’s nose. As the eyes converge, the pupils should constrict. The optokinetic nystagmus test is optional and involves asking the patient to look at a moving strip of horizontal lines. Nystagmus is normally observed.
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Anoscoria
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Unequal size of the pupils Need to darken the room Can be caused by head injury, Horner’s syndrome
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Accomodation
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move finger in to the nose and back out to see if pt is following your finger appropriate and pupils adjust accordingly
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Cover test
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Cover on eye and the weak eye will wander. When the paper is removed, the eye will go back into the right place. Muscle weakness test.
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Strabismic amblyopia EOMs
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use corneal light reflex, Hirshburg’s test, and the Cover test
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Cranial Nerve VIII
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Ear exam Can the person hear? Examine external ear structures Otoscope exam Any inflammation of the middle ear? Always question for external ear pain: Dental problems, TMJ, cervical, mouth or facial disorders.
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Peripheral ear
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Canal, ear drum, ossicles, round window, cochlea
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Hearing and the brainstem
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location of sound indentification of sound 0 decibels heard by person with normal hearing
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Cerebral cortex and hearing
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interpretation Reaction
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Conductive hearing loss
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External otitis (acute and chronic) wax Exostoses/osteomas Acute otitis media Otitis media with effusion TM performance Chronic suppurative otitis media (safe or mucosal CSOM or cholesteatoma) Otosclerosis
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Sensorineural hearing loss
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occupational or noise induced loss presbycusis meniere’s disease ototoxicity – systemic and topical cochlear otosclerosis trauma acoustic neuromas sudden loss
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Vestibular apparatus
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detects position and movement of the head. Consists of the saccule, the utricle, and three semicircular ducts these are parts of a system of tubes and cisterns, the membranous labyrinth, that is entombed in the petrous part of the temporal bone The membranous walls are separated from the lining of the bony labyrinth by perilymph, a fluid similar to CSF The fluid inside the membranous labyrinth is endolymph, a liquid similar to intracellular fluid, with a high concentration of potassium and a low concentration of sodium
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Focus ear history
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Age: acute otitis media declines after age 6 Fever: high fever more likely a systemic infection URI: organisms forced up the eustachian tube Previous infections: chronic otitis can result in anatomical changes family history: child is two times more likely if parent or sibling
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Environment exposure (ear)
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smoke exposure swimming b/c protective wax is lost airplane travelers and divers: failure of the eustachian tube to open which causes pain, tinnitus, and temporary deafness
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Physical exam of the ear
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inspect external ears palpate external ears inspect ear canals inspect tympanic membranes test hearing acuity (CN VIII) Weber and Rinne test
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Red ear drum
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A red ear drum does not always mean otitis media. If a child has been crying, their ear drums will be red.
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Weber Test
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If hearing complaints on history If fails hearing test Ask patient to tell you which side they hear louder Normal finding: equally loud Abnormal: sound heard better in one ear – the good ear
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Rinne Test
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Place tuning fork on mastoid process unless it is infected When pt tells you the sound disappears, place the tuning fork in front of their ear 1 or 2 cm. Normal is AC > BC.
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Cranial Nerve I
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Olfactory – don’t generally test
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Nose exam
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examine nasal septum examine nasal turbinates Inspect the face Regional exam of the head and neck examine teeth and mouth nasal mucosa and turbinates inspect for masses Check for discharge: color? Transilluminate the sinuses Palpate the sinuses and for facial fullness Check lungs Do neuro testing
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Diagnostic testing for nose
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Nasal smear testing sinus x-rays – not done as much anymore CT of sinuses skin testing for allergies Cranial nerve I: olfactory
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Cranial nerves IX, X, XII
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Inspect the mouth and throat by examining the buccal mucosa, tongue, and sublingual area for the presence of ulcers. Note the location, number and size of lesions if present. Types of lesions Inspect the posterior pharynx and observe swallowing Movement of tongue Say \”ah\” Edema, color, exudate presences and condition of tonsils. GRADE TONSILS If ENLARGED Must have a light Use gloves or tongue blades
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Throat
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For sore throat: pharyngitis. Inspect the entire anterior and posterior pharynx. Note any lesions and their locations.
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Goals of throat assessment and diagnosis
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Identify patients with Group A beta hemolytic strep Reduce the possibility of sequelae of peritonsillar abscess Identify epiglottis
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Peritonsilar abscess
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Emergent! Don’t look into throat with blade b/c can spasm and occlude airway See often with strep
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3 Most Important Questions in Neuro exam
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1. Is the mental status intact? 2. Are the right and left sides symmetric? 3. If asymmetric, does the causative lesion lie peripherally or centrally?
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Lethargy
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requires a loud verbal stimulus to arouse
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Stupor
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require tactile stimulation to arouse
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Coma
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unable to arouse with noxious stimulus
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Dysarthria
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disturbance in motor control of speech and difficulty of articulation
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Dysphonia
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difficulty with phonation
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dysphagia
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difficulty with swallowing
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Aphasia
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difficulty with language broken into sensory and motor
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Fluency
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rate and accuracy of language and thoughts. Best done by having patient describe a picture
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Comprehension
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able to perform a series of actions that are asked of patient. For example, take your right hand and touch your left ear. Can make 1, 2, or 3 step commands.
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Naming
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able to identify common objects as well as more complex parts of projects
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Repetition
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able to repeat a sentence such as \”no ifs, ands, or buts\”
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Reading and writing
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part of language exam
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Wernicke’s Aphasia
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Also called fluent or sensory aphasia or receptive aphasia Difficulty with comprehension, typically called fluent speech Difficulty with naming and repetition Paraphasic errors Lesion is in posterior superior temporal lobe
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Broca’s Aphasia
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Called motor aphasia or non-fluent aphasia Patients have marked impairment in fluency Unable to name and repeat Lesion in the front operculum
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Outpatient Mental Status exam
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1. Attention: should be assessed early in the exam (have patient recall random digits. Should be able to recall 7 forward digits 2. Memory testing: mini-mental status 3. Perseverance: difficulty holding attention 4. Apraxia: inability to perform complex motor task (for example, show me how you would hammer a nail with your hands)
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Cranial Nerve I – olfactory
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can be damaged in frontal lobe disorder, aging, smoking, cocaine use Test each nostril with eyes close. Use strong, easily identifiable odors Rare disorders cause this such as a large meningioma of the frontal lobe on the cribiform plate.
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Cranial Nerve II: Optic
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Visual acuity is the vital sign of the eye For acuity, use the Snellen chart For visual fields, use confrontation Do fundoscopic exam
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Cranial Nerve III: Oculomotor
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Controls most eye movements Pupillary constriction and accommodation Vertical and horizontal movements of the eyes Muscles innervated include the medial, superior, inferior rector and inferior oblique
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PCOM aneurysm
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Pupil involvement with complete third nerve palsy
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Cranial Nerve IV: Trochlear
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Moves the superior oblique muscle Medial rotation \”down and in\”
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Cranial Nerve V: Trigeminal
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supplies sensation to the face, nasal/bucchal mucosa, and teeth. 3 major divisions: opthalmic (V1): corneal reflex Maxilliary (V2): sensory function Mandibular (V3): motor function -Light touch is tested in each of the three divisions of the trigeminal nerve and on each side of the face using a cotton wisp or tissue paper. The ophthalmic division is tested by touching the forehead, the maxillary division is tested by touching the cheeks, and the mandibular division is tested by touching the chin. Be careful not to test the mandibular division too laterally, as the mandible is innervated by the great auricular nerve (C2 and C3). A common mistake is to use a stroking motion, which will trigger pain and temperature nerves. Instead, a point stimulus should be applied. For pain and temperature repeat the same steps as light touch but use a sharp object and a cold tuning fork respectively. Corneal reflex is conducted along with the facial nerve section of the test. Note the sensory innervation of the cornea is provided by the trigeminal nerve while the motor innervation for blinking the eye is provided by the facial nerve.- Muscles of mastication (temporalis, masseter) should be inspected for atrophy. Palpate the temporalis and masseter as the patient clenches the jaw. The pterygoids can be tested by asking the patient to keep the mouth open against resistance, and move from side to side against resistance. A jaw jerk reflex can be tested by placing a finger over the patient’s chin and then tapping the finger with a reflex hammer. Normally the jaw moves minimally.
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Disease Involving the Trigeminal Nerve
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Tic Doloureaux (Trigeminal Neuralgia) which affects the V2 and V3 territory Cavernous sinus lesions Herpes Zoster infection of the nerve
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Cranial Nerve VI: abducens
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Movement of the lateral rectus muscle: \”Away from the nose\” Impaired abduction
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Cerebral Sinus Venous Thrombosis
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Occurs in younger women typically due to hypercoagulable conditions, use of OCP’s, dehydration, and pregnancy Bilateral 6th nerve palsies are a marker of ICP
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Cranial Nerve VII: Facial
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Motor function: muscles of facial expression Parasympathetic: lacrimal, submaxillary, submandibular glands Sensory: anterior 2/3 of the tongue Upper motor neuron vs. Lower motor neuron facial palsy? Lower involves forehead and upper spares the forehead. Upper means it is in the brain tissue and lower means it is in the nerve itself Inspect for facial asymmetry and involuntary movements. Motor 1) Raise both eyebrows 2) Frown 3) Close both eyes tightly so that you can not open them. Test muscular strength by trying to open them 4) Show both upper and lower teeth 5) Smile 6) Puff out both cheeks Sensory : test for taste
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Cranial Nerve VIII: Vestibulacochlear
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Responsible for hearing, balance, and awareness of position. Auditory testing Rinne/Weber test
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Rinne/Weber Test
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Normally AC>BC If BC> AC = conductive hearing loss If AC>BC with hearing loss = sensorineural hearing loss With Weber test: conductive hearing loss: tone is louder on the affected side. Sensorineural hearing loss: tone is louder on normal side Conduction diseases involve the bone, auditory canal, tympanic membrane Sensorineural affects the nerve itself
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Cerebellopontine Angle Tumor
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Involves: CN V (V1): corneal CN VII: taste anterior 2/3 of tongue CN VIII: hearing loss
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Cranial Nerve IX: Glossopharyngeal
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Supplies sensation to the pharynx, posterior 1/3 of tongue, tympanic membrane Test \”gag reflex\” Check for symmetrical elevation of the soft palate
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Cranial Nerve X: Vagus
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Motor fibers to the Pharynx and Larynx. Tested along with Cranial Nerve IX. Should see midline uvula Evaluate for dysphonia and dysarthria
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Cranial Nerve XI: Spinal accessory
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Supplies the SCM and trapezius muscles Ask patient to shrug their shoulders and turn head side to side
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Cranial Nerve XII: Hypoglossal
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Supplies the motor fibers of the tongue Ask patient to stick out their tongue and check to see if it is midline
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Motor exam: muscle bulk
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Assess for atrophy, fasciculations, and compare their contours for symmetry
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Motor exam: muscle tone
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Check for resistance to passive movement: spasticity, hyperreflexia, clonus, cogwheeling
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Motor exam:
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focus on the body position, involuntary movements, charas of muscles and coordination
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Spasticity
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resistance varies with speed and direction of passive movement. Has increased reflexes.
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Rigidity
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increased muscle tone of flexors and extensors and resistance to passive movement. Does not have increased reflexes.
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Hypotonicity
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Loss of normal tone with flabby and soft muscle
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Fasciculations
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twitches of the muscles at rest
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Grading Muscle Strength: ABSENT (0)
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no contraction
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Grading muscle strength: Trace (1)
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slight contraction
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Grading muscle strength: Weak (2)
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Movement with gravity eliminated
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Grading muscle strength: Fair (3)
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Movement against gravity
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Grading muscle strength: Good (4)
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Movement against gravity with some resistance
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Grading Muscle strenght: Normal (5)
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Movement against gravity with full resistance
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Coordination
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All four areas of the nervous system must function in an integrated way: 1. Motor – strength 2. Cerebellum 3. Vestibular 4. Sensory system Assess rapid alternating movements, point to point movements, gait, and standing
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Rapid alternating movements
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Fingers (FFM): dysdiadokinesia (abnormal alternating movements) Finger – Nose – Finger (FNF): past pointing Heel to shin: ataxia (abnormal trajectory and oscillatory movements to target) Appendicular versus truncal:
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Gait assessment
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Walk: observe posture, balance, arm swing Heel to toe: \”tandem walking\” Walk on toes and then heels: observe balance
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Romberg test
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the patient stands with feet together and the arms at their sides. Note any swaying (slight is ok). Ask pt to close eyes for additional testing.
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Pronator drift
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sensitive and specific for a lesion in the contralateral hemisphere
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Superficial reflexes
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Abdominal: umbilical response Cremasteric: testicular response Corneal Anal reflex
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Deep Tendon reflexes
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Biceps – C5 Brachioradialis – C6 Triceps – C7 Patellar – L4 Achilles – S1
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DTR scale
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0 – no response 1+ – diminished response 2+ – normal 3+ – increased 4+ – hyperactive
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Cervical Disc Disease
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Patient is exhibiting myelopathy at C5-C6 and C6-C7 levels Exhibited by weakness of right bicep and tricep and reflex increased Reflexes increase because of cord involvement
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Sensory exam Components
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Light touch Pain Vibration sense Proprioception Tactile Localization Discriminative sensations
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Light touch
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compare bilaterally Start distally Work proximally if abnormal or absent
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Pain
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sharp or dull? Compare sensations
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Vibration sense
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tap tuning fork place vibrating instrument onto DIP \”Do you feel buzz? Tell me when it stops?\”
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Propioception
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Move toe up and down. Pt closes eyes and tell you the position of their toe
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B12 deficiency (subacute combined degeneration
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Degeneration of the posterior columns of the spinal cord due to B12 deficiency Profound sensory ataxia and gait instability Sometimes have mental status changes
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Discriminative senses
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Two point discrimination: touch finger pad in two places, alternate double stimulus irregularly. Normal <5mm Test Point localization: briefly touch a point on the patient's skin with their eyes close. Have them open their eyes and touch the place that you previously touched.
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Stereognosis
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Place an object in their hand and have them name what it is
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Graphesthesia
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Draw a number in their hand
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Coma
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potential life threatening even affecting the two hemispheres, the brainstem or both
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Brain death exam
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Oculocephalic reflex: \”doll’s eyes\” Cold caloric stimulation
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MSK Common or concerning symptoms
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Low back pain Neck pain Monoarticular or polyarticular joint pain Inflammatory or infectious joint pain Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, weakness Joint pain with symptoms from other organ systems
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MSK terminology
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Articular: joint related Nonarticular: around the joint
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Synovial joints
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freely movable E.g. Knee, shoulders
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Cartilaginous joints
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slightly movable e.g. vertebral bodies
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Fibrous joints
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immovable e.g. skull structures
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Important MSK questions in addition to OLDCARTS for HPI
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1. point to the pain 2. is pain localized, diffuse, acute, chronic? 3. Mechanism of injury: When did it occur? Did you hear a click or pop when it happened? 4. Is there any swelling or dislocation? 5. Has it improved with therapeutics or rest? 6. FEVER or CHILLS? red flag!
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Inspect joints for:
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symmetry, edema, ecchymosis, erythema, deformity, abnormal position, broken skin or rashes
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Inspect muscle tone for:
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atropy, tremory, fasciculations
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Palpation
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unaffected joint first area surrounding site of pain, working towards the site Check for tenderness, derm changes, warmth, nodules, muscle atrophy, crepitus, crunching, adenopathy. Watch their face to assess for tenderness.
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Active ROM
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the patient moves their joint or limb Note any limits, apprehension in movement, differentiate b/w true strength and ROM limitations vs. limitations in ROM or strength due to pain Look for joint instability Look for increased mobility
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Passive ROM
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Provider assisted movement gently test the limits of noted AROM Look for joint instability Look for increased mobility
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ROM terminology
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Flexion Extension Abduction Adduction External rotation Internal rotation deviation pronation supination inversion eversion
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Neck Pain Common Conditions
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Neck spasm, cervical disc problems, thoracic outlet syndrome, torticollis, herpes zoster, osteoarthritis or spinal stenosis, spondylolisthesis, ankylosing spondylitis, infection, malignancy
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Red flag during MSK history
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Age greater than 50, fever, weight loss, numbness
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Neck Pain – muscle spasms
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either traumatic or nontraumatic neck pain, limited ROM
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Neck pain – cervical disk injury
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traumatic injury, worse with tilt to affected side, numbness or tingling to the affected dermatones, may not have pain or radicular pain
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Neck Pain physical exam
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– Inspection with gown or shirt removed Check stance, gait, posture, expressions, pain behavior – Comprehensive general physical exam: 1. neuro evaluation: cranial nerve testing, upper limb sensation, reflexes 2. Palpation of vertebral and paravertebral areas 3. ROM
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Active ROM Cervical Spine
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Extension Flexion: check nucchal rigidity. Pain cannot place chin to chest while other ROM is intact. Lateral bending Rotation
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Brudzinskis sign
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when head comes up, the knees also come up
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Kernig’s sign
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When knees come up, the head comes up
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Low Back Pain common conditions
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Back strain Acute disc herniation Osteoarthritis or spinal stenosis Spondylolistehesis Ankylosing spondylitis Infection Malignancy
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Back Strain ROS
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low back, buttock, posterior thigh, aching pain, spasm, increased with activity or bending, limited motion due to pain
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Acute disc herniation ROS
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low back to lower leg pain, sharp, shooting or burning pain, paresthesia in leg, pain better with standing, increased with bending or sitting
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Osteoarthritis ROS
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low back to lower leg, often bilateral, ache, shooting pain, \”pins and needles\” sensation, increased with walking, especially up an incline, decreased with sitting
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Shoulder pain common conditions
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Rotator cuff injury cervical disk disease
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Rotator cuff injury ROS
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history of trauma, pain accompanied by weakness
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Impingement
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More chronic and positional Bursitis Tendonitis
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Cervical disk disease
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pain radiating below elbow decreased cervical range of motion
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Shoulder pain physical exam Inspection
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Posture sitting or standing expressions, behavior symmetry muscle atrophy edema derm discoloration
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Shoulder pain physical exam palpation
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sternum, clavicle, neck vertebrae, shoulder joint, and elbow
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Shoulder pain physical exam AROM
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lateral raise (abduction and adduction) Flexion and extension Internal and external rotation (Apley Scratch test) Circumduct
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Shoulder pain physical exam PROM
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hand on shoulder to be examined Grasp humerus and move through ROM
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shoulder pain physical exam strength testing
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Neers and Hawkins tests
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Assessment of rotator cuff
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Test all 4 muscles: supraspinatus with \”empty can\” test, Teres Minor and Infraspinatus with \”no wings\” test, and subscapularis with \”lift off\” test Drop Arm test for supraspinatus tears
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Humeral Head displacement
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Use apprehension test

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