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Patient Evaluation, Assessment and Management
History and Physical Examination, Documentation
- Obtain a complete history, including history of present illness, comorbid conditions, social and family history
- Perform a complete physical examination including:
- Head & Neck (inspection, funduscopic)
- Chest (including detection of pulmonary or pleural abnormalities)
- Cardiovascular system
- Peripheral vascular system
The foundation of the MKS
involves three things: LOOKing at a joint/limb, FEELing the joint/limb and MOVEing the
joint/limb. LOOK, FEEL, MOVE: that’s all there is! So, if you remember nothing else in examining the spine, upper and
lower limbs, you’ll hit the high points if
Local bony/tendinous areas for tenderness
First, ask the patient to move actively,
Then, you move the joint/limb passively,document range.
Examine the joint/limb for stability.
In a nutshell, shoulder pain may be caused by arthritis, instability (recurrent dislocation or the feeling that the shoulder
dislocate) or rotator cuff disease. So, you should always (but not exclusively):
for deltoid, supraspinatus wasting
for old surgical scars
the A.C. joint
to examine for instability
to examine for impingement
The most common elbow problems you will see are the lateral and medial “tennis elbow”:
for steroid atrophy, at the site of the poorly placed injection
distal and slightly anterior to the bony prominence of the lateral epicondyle.
also feel the medial elbow, the epicondyle and the flexor sponator origin.
to make sure that the patient can move from 30 degrees
flexion to 130 degrees
flexion (the functional area).
The wrist is
complex. You should be able to identify surface landmarks (bony, usually) and palpate them for
tender points as an indication for underlying pathology.
for obvious deformity, such as in R.A.
for localized swelling, redness
ulnar styloid: Clue: TFCC injury
radial styloid: 1
dorsal compartment (de Quervains) tenosynovitis
snuffbox scaphoid fracture
lunate exactly ½ way between radial and ulnar styloids
triquetrum (the round bone immediately distal to the ulnar styloid): Clue: L
pisiform, hook of
hamate bony prominence in proximal ulnar palm: Clue: P
T arthritis, hamate fracture
Wrist exam, continued
flexion, extension, radial + ulnar deviation
provocative test: ask about the WATSON test for scapholunate instability
Also, exceedingly complex, the hand has a lot packed into a small space. Examination should be
based on history:
pain, numbness, tingling, weakness, deformity, and functional loss all point to specific diagnoses. In any hand exam, you
muscle wasting: thenars, interossei
deformity of fingers, fixed or correctable, dynamic, boutonniere, swan neck
check: Clue: re: psoriasis, liver disease, nutrition, etc.
sensory exam: 2
discrimination for each digital nerve static points
longitudinally oriented, look for differences:
between digital nerves of the same finger
between fingers in the same hand
between the same finger on R+L hands
check for sudomotor activity (i.e. sweating)
signs of median or ulnar nerve irritation
median: Phalen, median N compression, percussion for Tinels
ulnar: elbow flexion, ulnar H compression, percussion for Tinels
for crepitus: tendinitis
- trigger finger
for base of thumb pain
- for a compressible ‘bump’ that transilluminates
get a comparison between hands of the MCP, PIP and DIP ranges,
ctive and passive
more important than the actual values, are the trends: improving? deteriorating?
Remember “hip” pain can be felt in the groin, buttock or thigh; these sites of pain may also be referred from the lumbar
gait, for an antalgic or Trendelenburg
abductor wasting, scars
- for greater trochanteric tenderness (bursitis)
look for the hip going into external rotation when it is flexed (sign of arthritis)
Do not forget to measure real (from the ASIS) and apparent (from the umbilicus) leg lengths.
Questions: If your/someone’s RIGHT hip is arthritic and painful, to which side will the trunk shift on
walking? Upon standing unsupported on the RIGHT LEG? Which hand will hold the cane? Why?
In the acute setting, the knee may be swollen and painful. Often aspiration (STERILE!!) and some intra-articular lidocaine
will allow for a comfortable examination.
- for swelling, scars, redness
for valgus (knock-knees) or varus (bow-leg) alignment with the patient standing
- the bones
- the ligaments
- MCL origin, midsubstance insertion
- LCL origin, midsubstance insertion