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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
    - Abdomen
    - Neurologic system
    - Extremities

Physical Examination
The foundation of the MKS exam 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 you:

  1. Examine VISUALLY for: Muscle wasting Scars Open Wounds Asymmetry Obvious Deformity Gait Redness
  2. PALPATE for: Local bony/tendinous areas for tenderness Swelling Warmth
  3. MOVE: First, ask the patient to move actively, document range. Then, you move the joint/limb passively,document range. Examine the joint/limb for stability.

Shoulder Exam:
In a nutshell, shoulder pain may be caused by arthritis, instability (recurrent dislocation or the feeling that the shoulder w ill dislocate) or rotator cuff disease. So, you should always (but not exclusively):

  1. LOOK:
    - for deltoid, supraspinatus wasting
    - for old surgical scars
  2. FEEL:
    - the A.C. joint
  3. MOVE:
    - to examine for instability
    - to examine for impingement

Elbow Exam:
The most common elbow problems you will see are the lateral and medial “tennis elbow”:

  1. LOOK:
    - for steroid atrophy, at the site of the poorly placed injection
  2. FEEL:
    - 1 cm distal and slightly anterior to the bony prominence of the lateral epicondyle.
    - also feel the medial elbow, the epicondyle and the flexor sponator origin.
  3. MOVE:
    - to make sure that the patient can move from 30 degrees flexion to 130 degrees flexion (the functional area).

Wrist Exam:
The wrist is exceedingly complex. You should be able to identify surface landmarks (bony, usually) and palpate them for tender points as an indication for underlying pathology.

  1. LOOK:
    - for obvious deformity, such as in R.A.
    - for localized swelling, redness
  2. FEEL:
    - ulnar styloid: Clue: TFCC injury
    - radial styloid: 1 st 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
    - T tear
    - pisiform, hook of hamate bony prominence in proximal ulnar palm: Clue: P
    - T arthritis, hamate fracture basic data 2 Wrist exam, continued
  3. MOVE:
    - flexion, extension, radial + ulnar deviation
    - provocative test: ask about the WATSON test for scapholunate instability

Hand Exam:
Also, exceedingly complex, the hand has a lot packed into a small space. Examination should be focused based on history: pain, numbness, tingling, weakness, deformity, and functional loss all point to specific diagnoses. In any hand exam, you should:

  1. LOOK:
    - muscle wasting: thenars, interossei
    - deformity of fingers, fixed or correctable, dynamic, boutonniere, swan neck
    - nails: Always check: Clue: re: psoriasis, liver disease, nutrition, etc.
  2. FEEL:
    - local tenderness
    - sensory exam: 2 point discrimination for each digital nerve static points longitudinally oriented, look for differences: a) between digital nerves of the same finger b) between fingers in the same hand c) between the same finger on R+L hands
    - check for sudomotor activity (i.e. sweating)
    - check for provocative 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 - 1 st dorsal compartment
    - flexor tendons
    - extensor - for triggering/clicking
    - trigger finger - for base of thumb pain
    - arthritis
    - for a compressible ‘bump’ that transilluminates
    - ganglion
  3. MOVE:
    - get a comparison between hands of the MCP, PIP and DIP ranges, both a ctive and passive
    - more important than the actual values, are the trends: improving? deteriorating?

Hip Exam:
Remember “hip” pain can be felt in the groin, buttock or thigh; these sites of pain may also be referred from the lumbar spine. LOOK: - at the gait, for an antalgic or Trendelenburg - Trendelenburg test - abductor wasting, scars

  1. FEEL:
    - for greater trochanteric tenderness (bursitis)
  2. MOVE:
    - active, THEN passive
    - 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?

Knee Exam:
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.

  1. LOOK:
    - for swelling, scars, redness
    - for valgus (knock-knees) or varus (bow-leg) alignment with the patient standing
    - patellar tracking
  2. FEEL:
    - the bones
    - the ligaments
    - MCL origin, midsubstance insertion
    - LCL origin, midsubstance insertion

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