NR 509 Advanced Physical Assessment
Articular structures include joint capsule and articular cartilage, the synovium and
synovial fluid, intra-articular ligaments and juxta-articular bone
o Articular disease involves:
Swelling
Tenderness of the joint
Crepitus
Instability “locking”
Deformity
Limits active and passive range of motion due to stiffness or pain
Extra-articular structures include periarticular ligaments, tendons, bursae, muscle,
fascia, bone, nerve and overlying skin
o Extra-articular disease involves:
“point of focal tenderness in regions adjacent to articular structures
Limits active range of motion
RARELY causes swelling, instability, joint deformity
Know the sources of joint pain (pg. 627 algorithm)
Nonarticular conditions: trauma/fracture, fibromyalgia, polymyalgia rheumatica,
bursitis, tendinitis
Intra-articular (acute, < 6 weeks): acute arthritis
o infectious arthritis
o gout
o pseudogout
o Reiter syndrome
Intra-articular (chronic, > 6 weeks): chronic inflammatory arthritis vs chronic
noninflammatory arthritis
o Chronic inflammatory arthritis with 1-3 joints involved:
Indolent infection
Psoriatic arthritis
Reiter syndrome
Periarticular JA
o Chronic inflammatory arthritis with >3 joints involved:
Psoriatic arthritis or Reiter syndrome (no symmetry)
rheumatoid arthritis if not RA then systemic lupus, scleroderma,
polymyositis
*Know what causes saddle numbness and urinary retention (pg. 678?)
CES (cauda equina syndrome) most commonly results from a massive herniated disc in the
lumbar region.
A single excessive strain or injury may cause a herniated disc.
However, disc material degenerates naturally as a person ages, and the ligaments that hold it
in place begin to weaken. As this degeneration progresses, a relatively minor strain or
twisting movement can cause a disc to rupture.
Med C
, The following are other potential causes of CES:
Spinal lesions and tumors
Spinal infections or inflammation
Lumbar spinal stenosis
Violent injuries to the lower back (gunshots, falls, auto accidents)
Birth abnormalities
Spinal arteriovenous malformations (AVMs)
Spinal hemorrhages (subarachnoid, subdural, epidural)
Postoperative lumbar spine surgery complications
Spinal anesthesia
Know how retinal detachment presents (p.217)
Sudden, painless vision loss that is unilateral
Know what the word obtunded means (p. 769)
The obtunded patient opens eyes and looks at you but responds slowly and is somewhat
confused. Alertness and interest in the environment are decreased.
Know what cranial nerve you’re assessing when checking lateral gaze (p. 237)
Cranial nerve VI: abducens
Know what should be listed under adult illnesses in health history (pg. 10)
Medical illnesses: such as diabetes, hypertension, hepatitis, asthma, and HIV. Also
hospitalizations, number and gender of sexual partners, and risk-taking sexual practices
Surgical: dates, indications, and types of operations
Obstetric/Gynecologic: obstetric history, menstrual history, methods of contraception,
and sexual function
Psychiatric: illness and timeframe, diagnoses, hospitalizations, and treatments
Know what conditions do not have red reflexes (p. 239)
Absence of red reflex suggests an opacity of the lens (cataract), or possibly the vitreous
(or even an artificial eye).
Less commonly, a detached retina, or in children a retinoblastoma may obscure this
reflex.
Know the signs of seasonal allergies (p. 27)
itching, watery eyes, sneezing, ear congestion, postnasal drainage
Know how optic neuritis presents (p. 217)
Sudden visual loss that is unilateral and can be painful, associated with multiple sclerosis
Know how pityriasis rosacea presents (p. 912)
Med C
, Oval lesions on trunk, in older children often in a Christmas tree pattern, sometimes a
Harold patch (a large patch that appears first)
Know what is listed under present illness (p. 9)
Complete, clear, and chronologic description of the problems prompting the patient’s
visit, including the onset of the problem, the setting in which it developed, it’s
manifestation and any treatments to date.
(OLDCART) Onset, Location, Duration, Characteristics, Aggravating factors, Relieving
factors, Treatments (past)
Know where the acromion process is (be able to identify it on a picture)
Located between the clavicle and the shoulder
*Know what to do if you have a + finding on physical exam but otherwise negative work-up (p.
30)
Know what can cause falsely high BP’s (p. 127)
If the brachial artery is below the heart level, the blood pressure reading will be higher. If
the cuff is too small (narrow) the blood pressure will read high.
If the cuff is too large (wide) the BP will read high on a large arm
Know how to check for nystagmus (p. 737)
Nystagmus is seen in cerebellar disease especially with
o gait ataxia
o dysarthria (increases with retinal fixation
o vestibular disorders (decreases with retinal fixation)
o internuclear ophthalmoplegia
Med C
, Identify any nystagmus, an involuntary jerking movement of the eyes with quick and
slow components.
Note the direction of the gaze in which it appears, the plane of the nystagmus (horizontal,
vertical, rotary, or mixed), and the direction of the quick and slow components.
Nystagmus is named for the direction of the quick component.
Ask the patient to fix his or her vision on a distant object and observe if the nystagmus
increases or decreases.
Know what yellow sclera indicates (p. 234)
A yellow sclera indicates jaundice
Pg. 72 - Know how to get a patient to open up when he seems upset
• The first step to effective reassurance is simply identifying and acknowledging the patient’s
feelings. For example, you might simply say, “You seem upset today.” This promotes a
feeling of connection. Meaningful reassurance comes later, after you have completed the
interview, the physical examination, and perhaps some laboratory tests. At that point, you
can explain what you think is happening and deal openly with any concerns. Reassurance is
more appropriate when the patient feels that problems have been fully understood and are
being addressed.
• Another way to affirm the patient is to validate the legitimacy of his or her emotional
experience. Saying something like, “Your accident must have been very scary. Car
accidents are always unsettling because they remind us how vulnerable we are. Perhaps
that explains why you still feel upset,” validates the patient’s response as legitimate and
understandable
• Moving closer or making physical contact like placing your hand on the patient’s shoulder
conveys empathy and can help the patient gain control of upsetting feelings. The first step
to using this important technique is to notice nonverbal behaviors and bring them to
conscious level.
Pg. 27 - Know the signs of degenerative pain
Page 696
Pg. 289 - Know how otosclerosis presents with Weber and Rinne test
Otosclerosis condition that affects the tiny middle ear bone known as the stapes.
Stapes can become stuck, limiting its ability to vibrate (vibrations are crucial for hearing)
Conductive hearing loss
Weber test
o Tuning fork at vertex
o Sound is heard in the impaired ear
o Room noise not well heard, so detection of vibrations improves
Rinne test
o Tuning fork at external auditory meatus; then on mastoid bone
o BC longer than or equal to AC (BC > AC or BC = AC)
Med C
