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The Physical Exam

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by

Adam Savage

on 8 December 2014

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Transcript of The Physical Exam

Sensation
The Physical Exam
The most significant diagnostic tool
Goals:
- developing patient trust
- gaining insight into impact of pain
on patient's level of functioning
- identifying potential causes
4 Main Categories:
Motor
Reflexes
Coordination
Pain Terminology:
Nociceptive
Neuropathic
Somatic
Visceral
- discrete, intense
- carried via sensory fibers
- diffuse, poorly localized
- carried via sympathetic fibers
- pain caused by activation of nociceptive afferent fibers; transmitted to spinal cord, thalamus, and cerebral cortex
- pain caused by a primary lesion or dysfunction in the pereipheral or central nervous system
Central
Peripheral
Examples:
- thalamic pain syndrome
- poststroke pain
- postspinal cord injury
Examples:
- postherpetic neuralgia
- painful diabetic neuropathy
- complex regional pain syndrome
Anatomic Distributions
- Central / Spinal Nerve Root
- Peripheral Nerve
Dermatomes
most accurate distally (digits)
Neural Anatomy
Dysesthesia - unpleasant or abnormal sensation with or without stimulus

Hyperesthesia - sensation out of proportion to the stimuli applied

- Allodynia - pain in response to a
non-noxious stimuli
- Hyperalgesia - severe pain in
response to a mild noxious stimuli

Neuralgia - pain in distribution of nerve or group of nerves

Radicular pain - pain perceived as arising from spinal nerve root

Radiculopathy - objective sensory or motor loss in a spinal nerve root as confirmed by a neurologic test
Inspection
Hypertrophy -> overuse
Atrophy , Fasciculations -> lower motor neuron disorder
Palpation
Identify pain generators, myofascial trigger points
Tone
Hypotonia - a decrease in the normal expected muscular resistance to passive manipulation
Hypertonia - greater than expected resistance
Spaticity - velocity dependent increase in tone with joint movement
Rigidity - a generalized increase in muscle tone
Strength
Proximal weakness ~ myopathy
Distal weakness ~ peripheral nerve lesion, polyneuropathy, radiculopathy
UMN lesion: + Babinski - up-going great toe on plantar
reflex testing
+ Hoffman - thumb and index finger
flexion with tapping of 3rd or 4th digit
A sensitive indicator of cerebellar function and equilibrium

Finger-Nose-Finger
Heel-Knee-Shin

Gait , Heel and Toe Walk , Tandem Gait


Romberg's test - patient standing, feet together, eyes closed
A Directed Pain Examination
-> a standardized and consistent exam
-> reproducible despite time and examiners
Examination

Inspection

Palpation

Percussion -

Range of Motion

Sensory, Motor, & Reflexes - nerves, dermatomes, grades

Provocative maneuvers - sensitive and specific to region of interest
Observation begins as soon as the patient arrives.
How do they interact with office staff? In the waiting room? etc.

Mannerisms

Coordination

Gait

Consider vitals (BP, temp), labs (blood sugar, INR)

Initial observations may indicate the necessity for a mental status exam.
Orientation - Person, Place, Time
3 Objects - recall now and at 10 min
Information - basic knowledge
Judgement - appropriate
Spell WORLD backwards
Serial 7s from 100, or 3s from 30
Proverb - abstract or concrete
Similarities - watch/ruler
Hallucinations - visual/auditory
Suicidal / Homicidal ideation
Mood
Depression
Inspection and description of the affected region

Symmetry

Cutaneous Landmarks

Infection / Rash

Scars - traumatic / surgical

Atrophy / Hypertrophy / masses / lymph nodes

Sensory - hyperesthesia or allodynia

Vasomotor - temperature, skin color

Sudomotor (sweating) , edema

Trophic changes - hair, nail, skin
Gross sensory changes

Masses / Lymph nodes / lipomas

Trigger Points / muscle contractures

Pulses

Tenderness to palpation over any specific structure
Spinous Processes, Paraspinous musculature, SI joint, Greater Troch, etc.
Always start with least painful area to use as a control.
Pain on percussion may indicate
- fracture
- abscess
- infection

Over specific sensory nerve
- Tinel's sign - ulnar tunnel, carpal tunnel
- occipital neuralgia
Active test limited by patient's effort and report of limitation
Evaluate flexion, extension, abduction, adduction, internal and external rotation when applicable.

Describe in degrees and reason for limitation.
Supranormal ROM:
- joint
- connective tissue
- ligament laxity

Limited ROM:
- pain
- structural abnormalities (strictures, arthritis)
Examining Specific Regions
Normal
Antalgic - avoidance of bearing weight on affected limb or joint secondary to pain
Abnormal - secondary to balance, neurologic, and musculoskeletal disorders.
Observe for tilt, pelvic motion, drifting, etc.
= Dorsiflexion
tests L4-5 function
= Plantar flexion
tests S1-2 function
Face
- Symmetry
- Oral inspection
- Percussion

- Temperomandibular joint

- Cranial Nerves
Chvostek's sign
Cervical Spine
ROM: flexion 0-60, extension 0-25,
lateral flexion 0-25, rotation 0-80

Cervical Nerve Roots
Landmark - Nerve - Muscle - Reflex
C4 – shoulder – dorsal scapular – levator scapulae (shoulder shrug) – none
C5 – lateral elbow – musculocutaneous – biceps – biceps
C6 – thumb – radial – extensor carpi, radialis, longus, brevis – brachioradialis
C7 – middle finger – radial/median – triceps – triceps
C8 – little finger – anterior interosseous/ulnar – flexor digitorum profundus – none
T1 – medial elbow – ulnar, deep branch – dorsal interossei (spread fingers) – none
Provocative Tests
Distraction
vs
Compression
Spurling's Maneuver
Facet Loading
Lumbosacral Region
the only major articulation in the face
the most common location of pain

note spinal curvature
kyphosis
lordosis
scoliosis
ROM: flexion 0-90, extension 0-30
lateral flexion 0-25, rotation 0-60
Landmark - Nerve - Muscle - Reflex
L2 – mid-anterior thigh – femoral – psoas, iliacus – none
L3 – medial femoral condyle – femoral – quadriceps femoris – patellar (L4 is more)
L4 – medial malleolus/large toe – deep anterior – tibialis – patellar
L5 – lateral leg, dorsum of foot – deep lateral, peroneal (extend large toe, evert foot) – medial hamstring
S1 – lateral heel, small toe – sciatic – hamstrings - achilles

Provocative tests
Straight-Leg
Raise
provokes lumbar radicular symptoms via stretch force,
accentuated by ankle dorsiflexion & chin to chest
Seated SLR
Facet Loading
lateral rotation and extension
Sacroiliac Joint Dysfunction
Patrick Faber Test
Yeoman's Test
Gaenslen's Test
Piriformis Syndrome
Laseque
Pace
Freiberg
Lumbar Radic
flexion + internal rotation
flexion + resistance to abduction
extension + int. rot.
gentle axial load with extension and rotation
The Confounding Patient
The physical exam relies on an honest patient for cooperation and effort, and the validity may be diminished by lack of participation, pain behaviors, and secondary gains.
Hoover Test - tests malingering with regard to paralysis/weakness
Waddell's signs: 3 or more is indicative of a nonorganic source for patient pain.
Abnormal tenderness - pt complains of nondermatomal pain or pain to light touch.
Simulation testing - pain reported in a region not being tested.
Distraction testing - different results when pt distracted
Regional disturbances that don't follow anatomic distribution.
Overreaction - disproportionate responses
Questions?
References
Essentials of Pain Medicine. Benzon. 3rd Ed.
Google
Full transcript