Ortho Notes Clinical Examination Pocket Guide PDF

Always at your side... Ortho 2nd Edition Notes Clinical Examination Pocket Guide Dawn Gulick Includes...  Wipe-free Forms  Illustrated Pain Referral  Medical Red Flags Patterns  Toolbox Tests  Il...

Always at your side... Ortho 2nd Edition Notes Clinical Examination Pocket Guide Dawn Gulick Includes...  Wipe-free Forms  Illustrated Pain Referral  Medical Red Flags Patterns  Toolbox Tests  Illustrated Palpation  Illustrated Special Tests Pearls  Test Sensitivity  Abbreviations & Symbols & Specificity  Pharmacologic Summary  Differential Diagnosis  Contacts Phone/E-Mail Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph. e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail: Name Ph: e-mail:  2nd Edition Ortho Notes Clinical Examination Pocket Guide Dawn Gulick, PhD, PT, ATC, CSCS Purchase additional copies of this book at your health science bookstore or directly from F. A. Davis by shopping online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis Note’s Book F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2009 by F. A. Davis Company Copyright © 2009, 2005 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher: Margaret Biblis Acquisitions Editor: Melissa Duffield Manager of Content Development: George W. Lang Developmental Editor: Yvonne Gillam Art and Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recom- mended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted stan- dards at the time of publication. 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ALERTS/ WRIST & ANKLE & SHOULDER ELBOW SPINE HIP KNEE ALARMS HAND FOOT Look for our other Davis’s Notes Titles Coding Notes: Medical Insurance Pocket Guide ISBN-13: 978-0-8036-1536-6 Derm Notes: Dermatology Clinical Pocket Guide ISBN-13: 978-0-8036-1495-6 ECG Notes: Interpretation and Management Guide ISBN-13: 978-0-8036-1347-8 MA Notes: Medical Assistant’s Pocket Guide ISBN-13: 978-0-8036-1281-5 Medical Notes: Clinical Medicine Pocket Guide ISBN-13: 978-0-8036-1746-9 Mobilization Notes: A Rehabilitation Specialist’s Pocket Guide ISBN-13: 978-0-8036-2096-4 Neuro Notes: Clinical Pocket Guide ISBN-13: 978-0-8036-1747-6 Provider’s Coding Notes: Billing & Coding Pocket Guide ISBN-13: 978-0-8036-1745-2 PsychNotes: Clinical Pocket Guide, 2nd Edition ISBN-13: 978-0-8036-1853-4 Rehab Notes: Evaluation and Intervention Pocket Guide ISBN-13: 978-0-8036-1398-0 Respiratory Notes: Respiratory Therapist’s Guide ISBN-13: 978-0-8036-1467-3 Screening Notes: Rehabilitation Specialists Pocket Guide ISBN-13: 978-0-8036-1573-1 Sport Notes: Rehabilitation Specialists Pocket Guide ISBN-13: 978-0-8036-1875-6 For a complete list of Davis’s Notes and other titles for health care providers, visit www.fadavis.com  1 Medical Screening Have you ever experienced or been told you have any of the following conditions? Cancer Chronic bronchitis Diabetes Pneumonia High blood pressure Emphysema Fainting or dizziness Migraine headaches Chest pain Anemia Shortness of breath Stomach ulcers Blood clot AIDS/HIV Stroke Hemophilia Kidney disease Guillain-Barré syndrome Urinary tract infection Gout Allergies (latex, food, drug) Thyroid problems Asthma Multiple sclerosis Osteoporosis Tuberculosis Rheumatic/scarlet fever Fibromyalgia Hepatitis/jaundice Pregnancy Polio Hernia Head injury/concussion Depression Epilepsy or seizures Frequent falls Parkinson’s disease Bowel/bladder problems Arthritis Have you ever had any of the following procedures? X-ray Blood test(s) CT scan Biopsy MRI EMG or NCV Bone scan EKG or stress test Urine analysis Surgery ALERTS/ ALARMS  Normal Vital Signs & Pathologies That Influence Them Age Infant Child Adolescent Adult & Elderly Increases Due to: Decreases Due to: T 98.2° 98.6° 98.6° 98.6° Infection, exercise, ↓ Hematocrit & hemoglobin, narcotics, ↑ blood sugar ↓ blood sugar, aging HR 80–180 75–140 50–100 60–100 Infection, Narcotics, ↓ Hematocrit & acute MI, hemoglobin, ↑ K+ ↓ blood sugar, anxiety, anemia, pain, ↓ K+, exercise 2 RR 30–50 20–40 15–22 10–20 Infection, Narcotics ↓ Hematocrit & hemoglobin, ↑ blood sugar, anxiety, pain, acute MI, asthma, exercise SBP 73 90 115 30 bpm Sudden change in mentation Facial pain with intractable headache Sudden onset of angina or arrhythmia Abdominal rebound tenderness Black, tarry, or bloody stools Generalized Systemic Red Flags Insidious onset with no known mechanism of injury Symptoms out of proportion to injury No change in symptoms despite positioning or rest Symptoms persist beyond expected healing time Recent or current fever, chills, night sweats, infection Unexplained weight loss, pallor, nausea, B&B changes (constitutional symptoms) Headache or visual changes Bilateral symptoms Pigmentation changes, edema, rash, nail changes, weakness, numb- ness, tingling, burning Psoas test for pelvic pathology = supine, SLR to 30° & resist hip flexion; (+) test for pelvic inflammation or infection is lower quadrant abdominal pain; hip or back pain is a (-) test Blumberg’s sign = rebound tenderness for visceral pathology—in supine select a site away from the painful area & place your hand perpendicular & push down deep & slow then lift up quickly; (–) = no pain; (+) = pain on release (+) McBurney’s point (appendix) = 1⁄3–1⁄2 the distance between the R ASIS & umbilicus (+) Kehr’s sign (spleen) = violent L shoulder pain ALERTS/ ALARMS ALERTS/ ALARMS Visceral Innervation & Referral Patterns Segmental Innervation Viscera Referral Pattern(s) C3–5 Diaphragm C-spine T1–5 Heart Anterior neck, chest, left UE T4–6 Esophagus Substernal & upper abdominal T5–6 Lungs T-spine T6–10 Stomach Upper abdomen & T-spine Pancreas Upper abdomen, low T-spine, & upper L-spine Bile duct Upper abdomen, mid T-spine T7–9 Gallbladder Right UQ, right T-spine Liver Right T-spine T7–10 Small intestine Mid T-spine T10–11 Testes/Ovaries Lower abdomen & sacrum T10–L1 Kidney L-spine, abdomen T10–L1 Uterus T/L & L/S junction S2–4 Prostate Sacrum, testes, T/L jctn T11–L2, S2–4 Ureter Groin, suprapubic, medial thigh Bladder Sacral apex, suprapubic Gallbladder Liver Heart Lungs & diaphragm Liver Heart Spleen Heart Liver Stomach Stomach Gallbladder Pancreas Liver Small Colon intestine Appendix Ovaries, Kidney uterus, Bladder testicles Bladder 4  5 Lung Heart Spleen Liver Stomach Gallbladder Colon Pancreas Colon Small intestine Rectum Source: From Gulick, D. Screening Notes: Rehabilitation Specialist’s Pocket Guide. FA Davis, Philadelphia, 2006, pages 11-12. ALERTS/ ALARMS  ALERTS/ ALARMS Early Warning Signs of Cancer “CAUTIONS” = Red Flags of Cancer C = Change in bowel & bladder lasting longer than 7–10 days A = A sore that fails to heal in 6 weeks U = Unusual bleeding or discharge T = Thickening/lump (breast or elsewhere) I = Indigestion, difficulty swallowing, early satiety O = Obvious change in wart or mole A = Asymmetrical shape B = Border irregularities C = Color—pigmentation is not uniform D = Diameter >6 mm (bigger than a pencil eraser) E = Evolution (change in status) N = Nagging cough or hoarseness (rust-colored sputum) S = Supplemental signs/symptoms 10–15 lb wt loss in 10–14 days Changes in vital signs Frequent infections (respiratory or urinary) + change in DTRs + proximal muscle weakness + night pain + pathologic fracture >45 years old Cardiovascular Signs to Discontinue Exercise Resting HR 130 Cold, clammy, cyanotic Irregular pulse; palpitations PO2 250 mg/dL Dizziness, syncope O2 saturation 100°F Chest pain (with or without UE SBP >250 or DBP >120 mm Hg radiation) Fall in SBP >10 mm Hg Isolated R biceps or mid-thoracic Cognitive changes pain in females 6  7 Signs & Symptoms of Specific Organ Pathology Pulmonary Cough with or without blood Sputum SOB or DOE Clubbing of nails Chest pain Wheezing Pain with deep inspiration Pain ↑ when recumbent & ↓ on involved side ↓ O2 saturation Signs of a PE Pleural pain SOB Rapid RR Rapid HR Coughing up blood Hepatic R UQ pain Weight loss Ascites/LE edema Carpal tunnel syndrome (bilateral) Intermittent pruritus Weakness & fatigue Dark urine/clay-colored stools Asterixis (liver flap) = flapping tremor resulting from the inability to maintain wrist extension with forearm supported Jaundice, bruising, yellow sclera of the eye Pain referral to T-spine between scapula, R shoulder, R upper trap, R subscapular region ALERTS/ ALARMS  ALERTS/ ALARMS Gastrointestinal Epigastric pain with radiation to the back Blood or dark, tarry stool Fecal incontinence or urgency Tenderness @ McBurney’s point Pain/symptoms that change with eating Nausea, vomiting, bloating Diarrhea or absence of bowel mov’t Food may help or aggravate px Weight loss, loss of appetite Renal (+) Murphy’s test = percussion over kidney Fever; chills Blood in urine (hematuria) Cloudy or foul-smelling urine Painful or frequent urination Pain is constant (stones) Back pain at the level of the kidneys Costovertebral angle tenderness Prostate Men >50 yo Difficulty starting or stopping urine flow Change in frequency Nocturia Incontinence/dribbling PSA level >4 ng/mL Sexual dysfunction 8  9 Gynecological Cyclic pain Abnormal blooding Nausea, vomiting Vaginal discharge Chronic constipation Low BP (blood loss) Missed or irregular periods Tasks That May Aggravate & Incriminate Visceral Pathology GB = forward bending Kidney = lean to affected side Pancreas = sit up or lean forward Esophagus = swallowing GI = eating Heart = cold air or exertion Renal = side bending away from involved side Signs & Symptoms of Hyperglycemia Blood glucose >180 mg/dL Skin is dry & flushed Fruity breath odor Blurred vision Dizziness Weakness Nausea Vomiting Cramping Increased urination LOC/seizure ALERTS/ ALARMS  ALERTS/ ALARMS Signs & Symptoms of Hypoglycemia Blood glucose 24 bpm Peak flow 15% within 5 min of use of inhaler Signs & Symptoms of Marfan’s Syndrome (inherited autosomal dominant disorder) Disproportionately long arms, legs, fingers, & toes (tall—lower body longer than upper body) Long skull with frontal prominence Kyphoscoliosis Pectus chest (concave) Slender ↓ sub-q fat Weak tendons, ligaments, & joint capsules with joint hypermobility Defective heart valves = murmur High incidence of dissecting aortic aneurysm Hernia Sleep apnea Dislocation of eye lens; myopia “Thumb sign” = oppose the thumb across the palm, if tip of thumb extends beyond the palm, the test is (+) 10  11 Signs & Symptoms of Depression Sadness; frequent/unexplained crying Feelings of guilt, helplessness, or hopelessness Suicide ideations Problems sleeping Fatigue or decreased energy; apathy Loss of appetite; weight loss/gain Difficulty concentrating, remembering, & making decisions Signs & Symptoms of Lyme’s Disease Note: This is a multisystemic inflammatory condition. The transmission of the tick spirochete takes ~ 48 hrs. Blood work is used to confirm the disease, not to diagnose it. Clinician should r/o GBS, MS, & FMS. Early Localized Stage Rash with onset of erythema within 7–14 days (range is 3–30 days) Rash may be solid red expanding rash or a central spot with rings (Bull’s-eye) Average diameter of rash is 5”–6” Rash may or may not be warm to palpation Rash is usually not painful or itchy Fever Malaise Headache Muscle aches Joint pain Early Disseminated Stage ≥ 2 rashes not @ the bite site Migrating pain Headache Stiff neck Facial palsy Numbness/tingling into extremities Abnormal pulse Sore throat Visual changes ALERTS/ ALARMS  ALERTS/ ALARMS 100°–102° fever Severe fatigue Late Stage Arthritis of 1–2 larger joints Neurological changes—disorientation, confusion, dizziness, mental “fog,” numbness in extremities Visual impairment Cardiac irregularities Dementia Scales Score Maximum Task Orientation: 5 What is the (year) (season) (date) (day) (month)? 5 Where are we (state) (country) (town) (building) (floor)? Registration: 3 Name 3 objects: 1 second to say each. Ask the patient all 3 after you have said them. Give 1 pt for each correct answer. Repeat them until he/she learns all 3. Count & record trials: ________ Attention & Calculation: 5 Serial 7s. Score 1 point for each correct answer. Stop after 5 answers. (Alternative question: Spell “world” backward.) Recall: 3 Ask for the 3 objects repeated above. Give 1 point for each correct answer. Language: 2 Name a pencil & watch. 1 Repeat the following, “No, ifs, ands, or buts.” 3 Follow a 3-stage command: “Take a paper in your hand, fold it in half, & put it on the floor.” 1 Read & obey the following: “Close your eyes.” 1 Write a sentence. 1 Copy the design shown: 30 Total score (Normal ≥24) 12  13 Deep Tendon Reflexes Grade Response Jendrassik’s Maneuver 0 Absent; areflexia For UE = patient crosses LEs at ankles 1+ Decreased; hyporeflexia & then isometrically abducts LEs For LE = patient interlocks fingertips & 2+ Normal then isometrically pulls elbows apart 3+ Hyperactive; brisk 4+ Hyperactive with clonus Cranial Nerves Nerve Function Test I. Olfactory Smell Identify odors with eyes closed II. Optic Vision Test peripheral vision with 1 eye covered III. Oculomotor Eye movement Peripheral vision, eye chart, reaction & pupillary to light reaction IV. Trochlear Eye movement Test ability to depress & adduct eye V. Trigeminal Face sensation Face sensation & clench teeth & mastication VI. Abducens Eye movement Test ability to abduct eye past midline VII. Facial Facial muscles Close eyes & smile; detect various & taste tastes—sweet, sour, salty, bitter VIII. Vestibulocochlear Hearing & Hearing; feet together, eyes open/ (Acoustic) balance closed x 5 sec; test for past-pointing IX. Glossopharyngeal Swallow, voice, Swallow & say “ahh” gag reflex Use tongue depressor to elicit gag X. Vagus Swallow, voice, reflex gag reflex XI. Spinal Accessory SCM & trapezius Rotate/SB neck; shrug shoulders XII. Hypoglossal Tongue mov’t Protrude tongue (watch for lateral deviation) ALERTS/ ALARMS  ALERTS/ ALARMS Neural Tissue Provocation Tests (NTPT) MEDIAN NERVE TEST Position: Supine or sitting with contralateral cervical SB & ipsilateral shoulder depressed Technique: Extend UE in plane of scapula with elbow extended, forearm supinated, & wrist/fingers extended Interpretation: + test = pain or paresthesia into median nerve distribution of UE Statistics: Sensitivity = 94%; specificity = 22% RADIAL NERVE TEST Position: Supine or sitting with contralateral cervical SB & ipsilateral shoulder depressed Technique: Extend UE with elbow extended, forearm pronated, wrist flexed, & fingers extended Interpretation: + test = pain or paresthesia into radial nerve distribution of UE Statistics: Sensitivity = 97%; specificity = 33% ULNAR NERVE TEST Position: Supine or sitting with ipsilateral shoulder depressed Technique: Abduct shoulder to 90° with ER, flex elbow, pronate forearm, extend wrist/fingers in an attempt to place the palm of the hand on the ipsilat- eral ear Interpretation: + test = pain or paresthesia into ulnar nerve distribution of UE 14  15 Brachial Plexus C4 C5 C6 C7 T1 Radial nerve Axillary nerve Musculocutaneous nerve Ulnar nerve Median nerve ALERTS/ ALARMS ALERTS/ ALARMS Axillary Nerve Axillary nerve Musculocutaneous Nerve Musculocutaneous nerve 16  17 Radial Nerve Radial nerve ALERTS/ ALARMS ALERTS/ ALARMS Median Nerve Median nerve 18  19 Ulnar Nerve Ulnar nerve ALERTS/ ALARMS ALERTS/ ALARMS Lumbosacral Plexus Iliohypogastric nerve Ilioinguinal L1 nerve L2 Lateral cutaneous L3 nerve of thigh L4 Genitofemoral nerve L5 Femoral S1 nerve S2 Lumbosacral S3 trunk S4 Obturator nerve Sciatic Inferior nerve rectal nerve Posterior cutaneous Perineal Dorsal nerve of nerve nerve thigh Pudendal of penis nerve 20  21 Femoral, Obturator, Sciatic, Tibial, & Common Peroneal Nerve Femoral nerve Sciatic nerve Common peroneal nerve Tibial nerve Obturator nerve Posterior branch Anterior branch ALERTS/ ALARMS ALERTS/ ALARMS Deep & Superficial Peroneal Nerves Common peroneal nerve Superficial Common peroneal peroneal nerve nerve Deep peroneal nerve 22  Pharmacologic Summary by Drug Classification Nonnarcotic Analgesic Indications = Pain, fever Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Acetaminophen Upset stomach, rash, Barbiturates = ↓ effects & ↑ liver toxicity Tylenol bruising, anemia Anacin–3 Warfarin = ↑ anticoagulant effect Liquiprin 23 Panadol Doses >15g are toxic Caffeine = ↑ analgesic effects Acephen to liver & kidney; Alcohol = ↑ risk of liver damage (not recommended Tempra may be fatal if consuming ≥ 3 glasses of alcohol/day ALARMS ALERTS/  Analgesic & NSAID Indications = RA, OA, JRA, pain, fever, prevent thrombosis, reduce risk of MI, TIA, CVA Anti-inflammatory doses are > analgesic doses Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Acetylsalicylic acid (ASA) Not recommended for children All NSAIDs: Aspirin Tinnitus, nausea, prolonged Can ↓ cardioprotective effects of Ecotrin bleeding time, rash, GI distress, low-dose aspirin Empirin bruising Can ↑ risk of bleeding when used Bayer with ginkgo, vitamin E, warfarin, Aspergum Plavix, & heparin Ibuprofen GI px, dyspepsia, nausea, Can ↑ BP (COX-2 inhibitors ↑ BP to 24 Motrin dizziness, rash, hepatitis, h/a a lesser extent than nonselectives) Nuprin Can ↑ neurotoxicity when used Advil with lithium Can produce acute renal failure Sulindac Not recommended for children Are gastric irritants & can produce Clinoril GI px, h/a, rash, constipation, nephrotoxicity dizziness, liver damage, epider- mal necrosis syndrome Meloxicam (preferential Seizures, cardiac arrhythmias, MI, inhibition of COX-2 over hemorrhage, asthma, erythema, COX-1) anaphylactic reaction, anxiety, abdominal pain, coughing Exercise concerns: Negative effect on myogenesis & regeneration (anabolic effects) ALARMS ALERTS/  Analgesic & NSAID—cont’d Indications = RA, OA, JRA, pain, fever, prevent thrombosis, reduce risk of MI, TIA, CVA Anti-inflammatory doses are > analgesic doses Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Naproxen Not recommended for children All NSAIDs: Naprosyn Tinnitus, GI px, constipation, h/a, dizziness, Can ↓ cardioprotective effects of Anaprox rash, edema, ecchymoses low-dose aspirin Diflunisal Not recommended for children Can ↑ risk of bleeding when used Dolobid GI px, diarrhea, dyspepsia, rash, h/a, dizziness, with ginkgo, vitamin E, warfarin, insomnia Plavix, & heparin Can ↑ BP (COX-2 inhibitors ↑ BP to 25 Piroxicam Not recommended for children a lesser extent than nonselectives) Feldene Greater risk of GI bleeding than other NSAIDs Can ↑ neurotoxicity when used Dizziness, h/a, edema, rash, pruritus, hepatitis with lithium Can produce acute renal failure Are gastric irritants & can produce nephrotoxicity Exercise concerns: Negative effect on myogenesis & regeneration (anabolic effects) Continued ALARMS ALERTS/  Analgesic & NSAID—cont’d Indications = RA, OA, JRA, pain, fever, prevent thrombosis, reduce risk of MI, TIA, CVA Anti-inflammatory doses are > analgesic doses Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Indomethacin H/a, drowsy, dizziness, nausea, GI px, consti- All NSAIDs: Indocin pation, pancreatitis Can ↓ cardioprotective effects of Etodolac Not recommended for children low-dose aspirin Lodine Dyspepsia, slightly less GI px than other Can ↑ risk of bleeding when used NSAID, nausea, diarrhea, CHF, dizziness, ↑ BP, with ginkgo, vitamin E, warfarin, blurred vision Plavix, & heparin Can ↑ BP (COX-2 inhibitors ↑ BP to 26 Ketoprofen Not recommended for children a lesser extent than nonselectives) Orudis Dyspepsia, h/a, dizziness, insomnia, tinnitus, Can ↑ neurotoxicity when used with peripheral edema lithium Can produce acute renal failure Are gastric irritants & can produce nephrotoxicity Exercise concerns: Negative effect on myogenesis & regeneration (anabolic effects) ALARMS ALERTS/  Analgesic & NSAID—cont’d Indications = RA, OA, JRA, pain, fever, prevent thrombosis, reduce risk of MI, TIA, CVA Anti-inflammatory doses are > analgesic doses Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Diclofenac Not recommended for children All NSAIDs: Voltaren Nephrotic px, GI px, h/a, edema, dizziness, Can ↓ cardioprotective effects of Cataflam hypoglycemia low-dose aspirin Nabumetone Not recommended for children Can ↑ risk of bleeding when used Relafen Abdominal pain, diarrhea, dyspepsia, dizziness, with ginkgo, vitamin E, warfarin, h/a, dyspnea, diaphoresis Plavix, & heparin Can ↑ BP (COX-2 inhibitors ↑ BP to 27 Celecoxib Not recommended for children a lesser extent than nonselectives) (COX-2 inhib) h/a, GI px, dizziness, ↑ BP, erythema Can ↑ neuro toxicity when used Celebrex with lithium Can produce acute renal failure Are gastric irritants & can produce nephrotoxicity Exercise concerns: Negative effect on myogenesis & regeneration (anabolic effects), i.e., may delay muscle healing ALARMS ALERTS/  *Narcotic Analgesic: APAP = Acetaminophen Indication = Pain Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions APAP/hydrocodone** Dizziness, nausea, vomiting, con- Antihistamines, antipsychotics, or Vicodin fusion, constipation, rash, pruritus, antianxiety agents = ↑ CNS depression Lortab depression MAO inhibitors= ↑ effects APAP/codeine** Nausea, drowsiness, constipation, Antipsychotics, antianxiety agents, or Tylenol #3 nausea, vomiting, SOB, pruritus alcohol = ↑ CNS depression ↓ respiration (body builds up Anticholinergics with codeine = paralytic tolerance after 2 wks) ileus Muscle relaxers = ↑ CNS effects 28 APAP/oxycodone Lightheaded, dizziness, nausea, Percocet vomiting, apnea, respiratory Tylox distress, hypotension, rash, constipation, pruritus Exercise concerns: Reduced exercise capacity due to respiratory depression especially with COPD; guard ambulation to prevent falls *ALL opioids are addicting; withdrawal symptoms may appear in 6–10 hours & last 5 days. Symptoms may include body aches, diarrhea, fever, gooseflesh, insomnia, irritability, loss of appetite, nausea, vomiting, runny nose, shivering, & stomach cramps. **Should not be taken with MAO inhibitors. ALARMS ALERTS/  *Narcotic Analgesic: ASA = Aspirin Indication = Pain Generic name Adverse reactions Interactions (Brand names) (Most frequent are bolded) (All interaction effects of ASA apply) ASA/codeine** Dizziness, nausea, ↓ respiration, MAO inhibitors, insulin, anticoagulants, Empirin with codeine constipation, tinnitus, h/a, vomit- methotrexate, or sulfonamides = ↑ effects Take with food ing, pruritus, rash NSAIDs = peptic ulcers Alcohol = ↑ CNS depression ASA/oxycodone Lightheaded, nausea, dizziness, Muscle relaxants = ↑ CNS effects, impair Percodan vomiting, euphoria, pruritus, judgment apnea, constipation, circulatory Analgesics, phenothiazines, tranquilizers, depression, hemorrhage, or alcohol = ↑ CNS depression 29 hypotension ACE inhibitors = ↓ pain relief Anticoagulant or NSAID = ↑ bleeding Methotrexate = ↑ toxicity Exercise concerns: Negative effects on myogenesis & regeneration (anabolic effects) *ALL opioids are addicting; withdrawal symptoms may appear in 6–10 hours & last 5 days. Symptoms may include body aches, diarrhea, fever, gooseflesh, insomnia, irritability, loss of appetite, nausea, vomiting, runny nose, shivering, & stomach cramps. **Should not be taken with MAO inhibitors. ALARMS ALERTS/  Muscle Relaxers/Antispasmodics Indications = Manage spasticity (muscle tone), reduce muscle guarding Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Baclofen Drowsiness, nausea, dizziness, CNS depressants or alcohol = ↑ depression Lioresal weakness, confusion, vomiting, high fever, h/a, rash, paresthesias Carisoprodol Orthostatic hypotension, drowsiness, CNS depressants or alcohol = ↑ depression Soma (addictive) dizziness, h/a, vertigo, agitation, insomnia Cyclobenzaprine Drowsiness, dry mouth, dizziness, CNS depressants or alcohol = ↑ depression 30 Flexeril (use not arrhythmias, confusion, transient MAO inhibitors or Tramadol = may cause recommended visual hallucinations seizures & death for > 2–3 wks) Diazepam Drowsiness, pain, phlebitis at injec- CNS depressants or alcohol = ↑ depression Valium (long-term tion site, dysarthria, constipation, Digoxin = risk of toxicity dependency) ↓ HR, ↓ RR Smoking = may ↓ effects Tizanidine Somnolence, sedation, hypotension, Antihypertensives = ↓ BP Zanaflex dry mouth, UTI, dizziness, bradycardia, Baclofen, alcohol, or other CNS depressant constipation = additive effect Oral contraceptive = ↓ tizanidine clearance Exercise concerns: Interferes with strengthening goals ALARMS ALERTS/  ACE Inhibitors Indication = High BP Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Captopril Dry cough, rash, dizziness, abdomi- Antacids = ↑ effects Capoten nal pain, neutropenia Digoxin = ↑ digoxin levels Enalapril Weakness, dry cough, dizziness, h/a, Diuretics or phenothiazines = hypotension Vasotec hypotension NSAIDs = ↓ antihypertensive effects Insulin = ↑ hypoglycemia Lisinopril Dizziness, nasal congestion, dry Lithium = lithium toxicity Zestril cough, orthostatic hypotension, Prinivil diarrhea, h/a, fatigue, nausea 31 Fosinopril Dizziness, dry cough, h/a, fatigue, Monopril diarrhea, nausea Quinapril Somnolence, pruritus, dizziness, dry Accupril cough, hemorrhage Exercise concerns: No effect on exercise capacity ALARMS ALERTS/  ACE Receptor Blockers Indication = High BP Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Losartan K+ Dizziness, h/a, weakness, fatigue, Due to ↑ K+ levels, should not be taken Cozaar chest pain, diarrhea, anemia, flu-like with K+ supplements, salt substitutes con- symptoms taining K+, or K+-sparing diuretics Candesartan Dizziness, h/a, runny nose, URI NSAIDs & ASA = ↓ antihypertensive effects Atacand Irbesartan Anxiety, chest pain, diarrhea, dizzi- Avapro ness, flu, h/a, fatigue, nausea, upset 32 stomach, sore throat, UTI, vomiting Exercise concerns: No effect on exercise capacity ALARMS ALERTS/  Ca++ Channel Blockers Indication = Angina Generic name Adverse reactions (Most (Brand names) frequent are bolded) Interactions Diltiazem LE edema, h/a, 1° Digoxin = elevated digitalis levels Cardizem heart block, arrhythmia, Anesthetics = ↑ anesthetic effects & depression of cardiac Dilacor bradycardia, nausea, contractility Diltiaz rash, dizziness, fatigue, Cyclosporine = ↑ cyclosporine level Tiazac 1° heart block Diazepam = ↑ CNS depression Verapamil Hypotension, AV block, Beta-blockers = heart failure Calan constipation, dizziness, Cardiac glycoside = ↑ digitalis levels nausea, h/a, arrhythmia, Antihypertensives = hypotension dyspnea Cyclosporine = ↑ levels 33 Grapefruit juice = ↑ drug level St. John’s wort = ↓ drug level Alcohol = ↑ alcohol level Amlodipine Edema, h/a, fatigue, When combined with another antihypertensive = hypotension Norvasc nausea, flushing, rash, When combined with an alpha blocker = hypotension & reflex Amvaz LE edema, dizziness tachycardia Nifedipine Dizziness, h/a, weak- Verapamil = ↓ effects Procardia ness, flushing, periph- Antifungals or erythromycin = ↑ effects eral edema, nausea Fentanyl = severe hypotension Cimetidine = ↑ plasma level of nifedipine Beta blockers = hypotension Ginkgo or grapefruit juice = ↑ effects St. John’s wort = ↓ drug effect ALARMS ALERTS/ Exercise concerns: Drugs may cause arthralgia/myalgia that may negatively influence exercise capacity  *Beta Blockers/Antihypertensives Indications = Angina, arrhythmias, hypertension Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Propranolol ↑ LDL cholesterol, bradycardia, fatigue, Verapamil or diltiazem = hypotension Inderal lethargy, hypotension, lightheaded, Epinephrine = severe peripheral InnoPran abdominal cramping, rash, Raynaud’s, vasoconstriction bronchospasm in asthmatics Insulin = hypoglycemia Phenothiazines = ↑ adverse reactions NSAIDs = ↓ antihypertensive effect Atenolol ↑ LDL cholesterol, dizziness, fatigue, Ca++ channel blockers or prazosin = Tenormin hypotension, bradycardia, nausea, LE ↑ hypotension 34 pain, rash, bronchospasms, orthostatic Cardiac glycosides = severe bradycardia hypotension Insulin = may alter dosage NSAIDs = ↓ antihypertensive effects Timolol ↑ LDL cholesterol, bronchospasms, NSAIDs = ↓ antihypertensive effect Blocadren fatigue, bradycardia, extremity pain, weakness, impotence Metoprolol ↑ LDL cholesterol, fatigue, dizziness, Cardiac glycosides = severe bradycardia Lopressor depression, hypotension, bradycardia, MAO inhibitors, cimetidine, hydralazine, Toprol nausea, rash, bronchospasms prazosin, or verapamil = additive effects; hypotension & bradycardia Labetalol ↑ LDL cholesterol, dizziness, nausea, Cimetidine = ↑ labetalol plasma levels Normodyne fatigue, hypotension Verapamil = additive effects ALARMS ALERTS/ Trandate NSAIDs = ↓ antihypertensive effect *Should not be taken with MAO inhibitors  *Beta Blockers/Antihypertensives—cont’d Indications = Angina, arrhythmias, hypertension Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Carvedilol ↑ LDL cholesterol, asthenia, dizziness, Cimetidine = ↑ carvedilol plasma levels Coreg fatigue, hypotension, diarrhea, hyper- MAO inhibitors = bradycardia & ↓ BP glycemia, wt gain, URI Ca++ channel blockers = conduction *May produce bronchoconstriction in disturbances patients with asthmatic conditions NSAIDs = ↓ antihypertensive effect Exercise concerns: As a result of a blunting of HR, exercise to 20 bpm above resting HR; beta blockers mask symptoms of & delay recovery from hypoglycemia 35 Antilipemics Indications = Reduce LDL, total cholesterol, & triglyceride levels Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Atorvastatin Constipation, muscle pain, flatulence, Antacids = ↓ plasma level of atorvastatin Lipitor ↑ liver transaminase, dyspepsia, Digoxin or erythromycin = ↑ plasma level rhabdomyolysis of atorvastatin BCP = ↑ plasma level of BCP Erythromycin, niacin, or antifungals = ALARMS ↑ risk of myopathy ALERTS/ Exercise concerns: Muscle weakness & cramping, myalgia  Diuretics Indications = Edema, hypertension Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Furosemide Dehydration, muscle cramps, Antihypertensives or Ca++ channel blocker = (loop diuretic) hypokalemia, hypocalcemia ↑ risk of hypotension & arrhythmias Lasix (osteoporosis), cardia arrhythmias Loop + thiazide diuretic = ↑ risk of hypotension Thiazide Dizziness, muscle weakness, cramps, & arrhythmias Esidrix thirst, hyperglycemia, stomach Cardiac glycosides = ↑ risk of digoxin toxicity Hydrodiuril discomfort with K+ loss Lozol NSAIDs = inhibit diuretic response Zaroxolyn Sun = photosensitivity 36 K+ sparing Dizziness, weakness, fatigue, h/a, Aldactone diarrhea, dry mouth, muscle cramps Dyrenium Exercise concerns: Diminished exercise performance; limited muscle endurance; volume depletion; ↑ risk of heat-related illness; muscle cramps 2° hypokalemia ALARMS ALERTS/  Antidepressants Indication = Depression, OCD, anxiety Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Amitriptyline Orthostatic hypotension, tachycardia, Contraceptives = ↑ antidepressant level & ↑ Elavil dry mouth, stroke, arrhythmia, lethargy, tricyclic-induced akathisia confusion, dry mouth, urinary reten- Clonidine or epinephrine = extreme tion, blurred vision, constipation hypertension MAO inhibitors = severe excitation Quinolones = life-threatening arrhythmias (↑ QTc interval) Alcohol = CNS depression 37 Sun = photosensitivity Doxepin Drowsiness, dizziness, dry mouth, Contraceptives = ↑ antidepressant level Sinequan orthostatic hypotension, blurred Clonidine or epinephrine = extreme Adapin vision, tachycardia, diaphoresis, con- hypertension Zonalon stipation, seizures, confusion, urinary MAO inhibitors = severe excitation retention Quinolones = life-threatening arrhythmias Alcohol = CNS depression Sun = photosensitivity Bupropion Insomnia, agitation, dry mouth, MAO inhibitors = ↑ risk of toxicity Wellbutrin tremor, abnormal dreams, h/a, Nicotine = hypertension Zyban excess sweating, tachycardia, Levodopa = ↑ risk of adverse reactions nausea, constipation, vomiting, Sun = photosensitivity dizziness, rhinitis, anorexia, blurred Prednisone or phenothiazine = ↑ risk of ALARMS ALERTS/ vision, wt gain, seizures seizures  Antidepressants—cont’d Indication = Depression, OCD, anxiety Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Fluoxetine* Nervousness, somnolence, insomnia, Beta blockers = heart block, bradycardia Prozac anxiety, drowsiness, h/a, tremor, MAO inhibitors or St John’s wort = serotonin dizziness, weakness, nausea, syndrome diarrhea, dry mouth, anorexia, Antipsychotics = ↑ concentration of antipsy- akathisia chotics (extrapyramidal signs) Warfarin = ↑ bleeding Alcohol = ↑ depression Sertraline* Fatigue, h/a, tremor, dizziness, insom- Benzodiazepines = ↑ effects 38 Zoloft nia, somnolence, dry mouth, nausea, MAO inhibitors, triptans, isoniazid, or diarrhea, male sexual dysfunction, St John’s wort = serotonin syndrome suicidal behavior, akathisia Warfarin = ↑ bleeding Exercise concerns: Improved motor performance following ischemic stroke *Should not be taken with MAO inhibitors. ALARMS ALERTS/  Decongestants, Antihistamines, & Bronchodilators Indications = Bronchospasms, COPD, emphysema Generic name Adverse reactions (Brand names) (Most frequent are bolded) Interactions Albuterol Tremor, nervousness, h/a, hyperactiv- CNS stimulant = ↑ CNS effects Proventil ity, tachycardia, nausea, vomiting, MAO inhibitors or antidepressants = ↑ adverse Ventolin muscle cramps, hypocalcemia, cough, CV effects Brethine hyperglycemia Beta blockers = contraindicated, may cause bronchoconstriction Pirbuterol Tremor, nervousness, dizziness, Beta blockers = contraindicated, may cause Maxair tachycardia, nausea, vomiting, cough, bronchoconstriction hyperglycemia MAO inhibitors or antidepressants = ↑ effects 39 Salmeterol Nasopharyngitis, URI, h/a, tremor, Beta blockers = contraindicated, may cause Serevent nausea, nervousness, tachycardia, bronchoconstriction discus myalgia MAO inhibitors or antidepressants = ↑ risk of severe CV effects Exercise concerns: Diminished exercise performance; limited muscle endurance; systemic administration may ↑ hyperglycemia ALARMS ALERTS/  ALERTS/ ALARMS Abbreviations & Symbols Specific to Orthopedics Please note: This list is not comprehensive and is subject to modification by various facilities to meet the needs of their patient population. ā..............before A.............assistance AAA...........abdominal aortic aneurysm AAROM........active, assistive range of motion Abd...........abduction ABG...........arterial blood gases ACL...........anterior cruciate ligament A.C............before meals Add...........adduction ADLs..........activities of daily living ad lib..........as desired AE............above elbow AFib...........atrial fibrillation AFO...........ankle foot orthosis AK............above knee AMA..........against medical advice amb..........ambulation ANS...........autonomic nervous system AP............anterior-posterior APL...........abductor pollicis longus ARD...........adult respiratory distress AROM.........active range of motion ASA..........aspirin ASCVD........arteriosclerotic cardiovascular disease ASIS..........anterior superior iliac spine ATFL..........anterior talofibular ligament A-V...........arterio-venous B.............bilateral BBB...........bundle branch block B&B..........bowel & bladder BE............below elbow BID...........twice daily BK............below knee BMI...........body mass index BMR..........basal metabolic rate 40  41 BM............bowel movement BOS...........base of support BP............blood pressure BRP...........bathroom privileges BS............breath sounds BUN..........blood urea nitrogen Bx............biopsy c̄..............with Ca++..........calcium CA............cancer CABG.........coronary artery bypass graft CAD...........coronary artery disease CBC...........complete blood count CC............chief complaint CCE...........clubbing, claudication, edema CHF...........congestive heart failure CHI...........closed head injury CKC...........closed kinetic chain CN............cranial nerve CNS...........central nervous system c/o............complaints of CO............cardiac output COPD.........chronic obstructive pulmonary disease CP............cerebral palsy CP............chest pain CPK...........creatine phosphokinase CPM..........continuous passive motion CPP...........closed packed position CPR...........cardiopulmonary resuscitation CSF...........cerebral spinal fluid CT............computed tomography CTS...........carpal tunnel syndrome Ctx............cervical traction CVA...........cerebral vascular accident CXR..........chest x-ray D/C...........discharge DDD...........degenerative disc disease DDX...........differential diagnosis DF............dorsiflexion DIP............distal interphalangeal DJD...........degenerative joint disease ALERTS/ ALARMS  ALERTS/ ALARMS DM...........diabetes mellitus DNR...........do not resuscitate DOB...........date of birth DOE...........dyspnea on exertion DPT...........diphtheria, pertussis, tetanus DSD...........dry sterile dressing DTR...........deep tendon reflexes DVT...........deep vein thrombosis Dx............diagnosis EAA...........essential amino acids BL............estimated blood loss EEG...........electroencephalogram ECK, EKG......electrocardiogram EMG..........electromyogram ENT...........ear, nose, throat EOMI..........extra-ocular motion intact EPB...........extensor pollicis brevis ER............external rotation ESR...........erythrocyte sedimentation rate ETOH..........ethyl alcohol ev............eversion Ex............exercise Ext............extension F.............frequency FAQ...........full arc quads FB............feedback f/b............followed by FCU...........flexor carpi ulnaris FDP...........flexor digitorum profundus FEV...........forced expiratory volume flex...........flexion FOOSH........fall on outstretched hand FPL...........flexor pollicis longus FRC...........functional residual capacity FUO...........fever of unknown origin FVC...........forced vital capacity FWB..........full weight bearing Fx............fracture f/u............follow-up GB............gallbladder GI.............gastrointestinal 42  43 Grav. 1........number of pregnancies (para = births) GSW..........gunshot wound GTO...........Golgi tendon organ GTT...........glucose tolerance test GU............genitourinary GXT...........graded exercise tolerance H&H..........hematocrit & hemoglobin HA............headache Hct............hematocrit HDL...........high density lipoprotein HEENT........head, ears, eyes, nose, throat Hgb...........hemoglobin HIV...........human immunodeficiency virus HNP...........herniated nucleus pulposus H/O...........history of HOB...........head of bed HP............hot pack HPI............history of present illness HR............heart rate HTN...........hypertension Hx............history I..............independent I + D...........incision & drainage I + O..........input & output ICS..........intercostal space ICU...........intensive care unit IDDM..........insulin dependent diabetes mellitus I/E ratio........inspiratory/expiratory ratio IM............intramuscular inv............inversion IP.............interphalangeal joint IPPB...........intermittent positive pressure breathing IR.............internal rotation IRDM..........insulin resistant diabetes mellitus ITB............iliotibial band IV.............intravenous JODM.........juvenile onset diabetes mellitus JRA...........juvenile rheumatoid arthritis JVD...........jugular vein distension KAFO..........knee ankle foot orthosis KUB...........kidney, ureter, bladder ALERTS/ ALARMS  ALERTS/ ALARMS L.............left LBP...........low back pain LBQC..........large-base quad cane LCL...........lateral collateral ligament LDH...........serum lactic dehydrogenase LE............lower extremity LKS...........liver, kidney, spleen LLB...........long leg brace LLC...........long leg cast LLQ...........left lower quadrant LMN..........lower motor neuron LMP...........last menstrual period LOC...........loss of consciousness LOS...........length of stay LP............lumbar puncture LTG...........long-term goal LUQ...........left upper quadrant MAFO.........molded ankle foot orthosis MAL..........midaxillary line max...........maximum MCL...........midclavicular line MCL...........medial collateral ligament MCP..........metacarpal phalangeal MH...........moist heat min...........minimum MI............myocardial infarction mm...........muscle MMR..........measles, mumps, rubella MMT..........manual muscle test mod...........moderate MOI...........mechanism of injury MRI...........magnetic resonance imaging MRSA.........methicillin-resistant Staph. aureus MS............multiple sclerosis MTrP..........myofascial trigger point MTP...........metatarsal phalangeal MVA..........motor vehicle accident MWD..........microwave diathermy n/a............not applicable N + V..........nausea and vomiting NAD..........no acute distress 44  45 NCV...........nerve conduction velocity ng............nasogastric NIDDM........noninsulin dependent diabetes mellitus NKA...........no known allergies NKDA.........no known drug allergies nn............nerve NPO...........nothing by mouth NSA...........no significant abnormality NSAID.........nonsteroidal anti-inflammatory drug NSR...........normal sinus rhythm NWB..........non-weight bearing 02.............oxygen OA............osteoarthritis OB............obstetrics OKC...........open kinetic chain OOB..........out of bed OPP...........open packed position ORIF..........open reduction, internal fixation OT............occupational therapy P + A..........percussion and auscultation P + PD.........percussion + postural drainage p.............after PA............posterior-anterior PAC...........premature atrial contraction PAO2..........alveolar oxygen PaO2..........peripheral arterial oxygen content PAP...........pulmonary artery pressure PCL...........posterior cruciate ligament PD............postural drainage PDR...........Physicians’ Desk Reference PE............pulmonary embolus PEEP..........positive end expiratory pressure PERLA.........pupils equal reactive to light accommodation PF............plantar flexion PFT...........pulmonary function tests PID............pelvic inflammatory disease PIP............proximal interphalangeal PMH..........past medical history PNF...........proprioceptive neuromuscular facilitation P.O............by mouth POD...........post-op day ALERTS/ ALARMS  ALERTS/ ALARMS PR............pulse rate PRE...........progressive resistive exercises prn............as necessary PROM.........passive range of motion PSIS..........posterior superior iliac spine pt.............patient PTB...........patellar tendon bearing PTFL..........posterior talofibular ligament PVC...........premature ventricular contraction PVD...........peripheral vascular disease PWB..........partial weight bearing Px............problem q2°............every two hours R.............right RA............rheumatoid arthritis RBC...........red blood count/cells RCL...........radial collateral ligament RHD...........rheumatic heart disease RLQ...........right lower quadrant r/o............rule out ROM..........range of motion ROS...........review of systems RPE...........rate of perceived exertion RR............respiratory rate RUQ..........right upper quadrant RV............residual volume Rx............treatment s̄...............without S.............supervision S1............first heart sound S2............second heart sound SAQ...........short arc quad SBQC.........small base quad cane SC............straight cane SC............sternoclavicular SCI............spinal cord injury SCM..........sternocleidomastoid SGOT.........serum glutamic-oxaloacetic transaminase SI.............sacroiliac SLB...........short leg brace SLP...........speech & language pathology 46  47 SLR...........straight leg raises SOAP.........subjective, objective, assessment, plan SOB...........short of breath s/p............status post SPC...........single-point cane STG...........short-term goal SV............stroke volume SWD..........short wave diathermy Sx............symptoms S & S..........signs and symptoms TB............tuberculosis TBI............traumatic brain injury TENS.........transcutaneous electrical neuromuscular stimulation TE............therapeutic exercise TFCC..........triangular fibrocartilage complex TFL...........tensor fascia latae TFM...........transverse friction massage THL...........transverse humeral ligament THR...........total hip replacement tid............three times daily TKE...........terminal knee extension TKR...........total knee replacement TLC...........total lung capacity TMJ...........temporomandibular joint TOS...........thoracic outlet syndrome TPR...........temperature, pulse, respiration TPR...........total peripheral resistance TTP...........tender to palpation TTWB.........toe touch weight bearing TURP..........transurethral resection of prostate TV............tidal volume TVH...........total vaginal hysterectomy Tx............treatment or traction UCHD.........usual childhood disease UCL...........ulnar collateral ligament UE............upper extremity ULNT..........upper limb neurodynamic test(s) UMN..........upper motor neuron URI...........upper respiratory infection US............ultrasound UTI...........urinary tract infection ALERTS/ ALARMS  ALERTS/ ALARMS UV............ultraviolet VC............vital capacity VMO..........vastus medialis obliquus V/O...........verbal order VPC...........ventricular precontraction VS............vital signs VTO...........verbal telephone order WBAT.........weight bearing as tolerated WBC..........white blood count/cells WBTT.........weight bearing to tolerance WBQC.........wide-base quad cane WC...........wheelchair WFL...........within functional limits WNL..........within normal limits WP............whirlpool XCT...........chemotherapy XRT...........radiation therapy yo............years old 1°.............primary 2°.............secondary <.............less than >.............greater than ↑.............increase ↓.............decrease ||..............parallel 48  49 Interpretation of Statistics Sensitivity True positive rate Proportion of patients who have a pathology that the test identifies as positive SnNout = Sensitivity, a Negative test rules out the diagnosis Calculation = a/(a+c) Specificity (SpPin) True negative rate Proportion of patients who have a pathology that the test identifies as negative SpPin = Specificity, a Positive test rules in the diagnosis Calculation = d/(b+d) Truth/Gold Standard Present Absent (+) Test a b a+b (–) Test c d c+d a+c b+d a+b+c+d ALERTS/ ALARMS SHOULDER Anatomy Middle scalene muscle Cervical vertebrae Anterior scalene muscle Brachial plexus Subclavian artery and vein Clavicle Coracoid process 1st rib 2nd rib 3rd rib 4th rib Pectoralis minor 5th rib muscle Scalene triangle Costoclavicular space Coracopectoral space Brachial Clavicle (cut) plexus 50  51 Supraspinatus tendon Acromion process Supraspinatus muscle Coracoid process Subscapularis tendon Biceps tendon Teres Long head minor of biceps muscle Short head Infraspinatus of biceps muscle Teres major muscle Long head of triceps Lateral head of triceps Coracoclavicular ligament Trapezoid Conoid Acromioclavicular ligament ligament ligament Acromion Clavicle process Coracoacromial Coracoid ligament process Coracohumeral Scapula ligament Transverse ligament Biceps brachii Capsular tendon ligaments Humerus SHOULDER  SHOULDER Medical Red Flags Pericarditis Sharp anterior chest & shoulder pain ↑ temp, HR, RR Cardiac ischemia Neck, jaw, left arm, & chest pain SOB Palpitations ↑ BP Syncope Pulmonary pathology Neck, shoulder, mid-thorax pain Cough Fever Shallow & ↑ RR Sources of right shoulder/scapula pain Gallstones—8Fs Fertile = 3rd trimester of pregnancy Female Fat Forty Fair Food–fatty intake Family history Flatulence Peptic ulcer (lateral border of scapula) Diaphragm Liver abscess, hepatic tumor Sources of left shoulder pain MI Diaphragm Ruptured spleen Pancreas 52  53 Toolbox Test Shoulder Pain & Disability Index (SPADI) Pain Scale: How severe is your pain? 0 = no pain.....................10 = worse pain imaginable At its worst? 0 1 2 3 4 5 6 7 8 9 10 When lying on the involved side? 0 1 2 3 4 5 6 7 8 9 10 Reaching for something on a high shelf? 0 1 2 3 4 5 6 7 8 9 10 Touching the back of your neck? 0 1 2 3 4 5 6 7 8 9 10 Pushing with the involved arm? 0 1 2 3 4 5 6 7 8 9 10 Disability Scale: How much difficulty do you have… 0 = no pain.....................10 = worse pain imaginable Washing your hair? 0 1 2 3 4 5 6 7 8 9 10 Washing your back? 0 1 2 3 4 5 6 7 8 9 10 Putting on an undershirt or pullover sweater? 0 1 2 3 4 5 6 7 8 9 10 Putting in a shirt that buttons down the front? 0 1 2 3 4 5 6 7 8 9 10 Putting on your pants? 0 1 2 3 4 5 6 7 8 9 10 Placing an object on a high shelf? 0 1 2 3 4 5 6 7 8 9 10 Carrying a heavy object of 10 pounds? 0 1 2 3 4 5 6 7 8 9 10 Removing something from your back pocket? 0 1 2 3 4 5 6 7 8 9 10 Pain Scale Score: Disability Scale Score: Total Score: Scoring: Summate the scores & divide by the number of scores possible. If an item is deemed not applicable, no score is calculated. Multiple the total score by 100. The higher the score, the greater the impairment. Source: From Roach, KE, Buudimanmak, E, Songsirideg, N, Yongsuk, L. (1991). SHOULDER  Quick DASH (Disabilities of the Arm, Shoulder, & Hand) Please rate your ability to do the following activities in the last week by circling the number below the No Mild Moderate Severe appropriate response. Difficulty Difficulty Difficulty Difficulty Unable 1. Open a tight or new jar 1 2 3 4 5 2. Do heavy household chores 1 2 3 4 5 (wash walls, floors) 3. Carry a shopping bag or briefcase 1 2 3 4 5 4. Wash your back 1 2 3 4 5 5. Use a knife to cut food 1 2 3 4 5 54 6. Recreational activities in which 1 2 3 4 5 you take some force or impact through your arm, shoulder, or hand (golf, hammering, tennis, etc.) Not At All Slightly Moderately Quite A Bit Extremely 7. During the past week, to what 1 2 3 4 5 extent has your arm, shoulder, or hand problem interfered with your normal social activities with SHOULDER family, friends, neighbors, or groups? Continued  Quick DASH (Disabilities of the Arm, Shoulder, & Hand)—cont’d Not Slightly Moderately Very Limited Limited Limited Limited Unable 8. During the past week, were you 1 2 3 4 5 limited in your work or other regular daily activities as a result of your arm, shoulder, or hand problem? Please rate the severity of the None Mild Moderate Severe Extreme following symptoms in the last week. 9. Arm, shoulder, or hand pain 1 2 3 4 5 10. Tingling (pins & needles) in your 1 2 3 4 5 55 arm, shoulder, or hand No Mild Moderate Severe So Difficult, Difficulty Difficulty Difficulty Difficulty I Can’t Sleep 11. During the past week, how much 1 2 3 4 5 difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? Quick DASH Score = [(sum of responses/number of responses) – 1 ] × 25 SHOULDER A Quick DASH score cannot be calculated if more than 1 item is not answered SHOULDER Referral Patterns Muscle Pain Referral Patterns Supraspinatus Infraspinatus 56  57 Subscapularis Teres Minor Biceps Brachii SHOULDER  SHOULDER Palpation Pearls Rotator Cuff Muscles Supraspinatus With UE back in Infraspinatus In prone on elbows, maximal extension & IR, palpate palpate posterior-lateral of acromion from the supraspinatus fossa to (just inferior to inferior angle of the tendon anterior to a-c joint acromion) Subscapularis In side-lying, Teres Minor In prone on elbows, maneuver the relaxed UE to allow palpate just inferior to infraspinatus you to slide your thumb under the axillary/lateral border of the scapula Supraspinatus tendon Acromion process Coracoid process Supraspinatus muscle Subscapularis tendon Biceps tendon Teres Long head minor of biceps muscle Short head of biceps Infraspinatus muscle Teres major muscle Long head of triceps Lateral head of triceps 58  59 ROM Rotational Lack Reach overhead (left figure) as far as possible down the back & mark the most inferior point of the fingers. Reach up the back as far as possible (right figure) & mark the most superior point of the fingers. Measure distance between the marks. This is the rotational lack. measure Apley Scratch Test for Quick Screen 3 components: 1. Hand to opposite shoulder 2. Hand behind back to opposite scapula 3. Hand behind back to inferior angle of opposite scapula SHOULDER  SHOULDER Capsular Patterns Location of Capsular Tightness Restrictions in Motion Mobility Deficits Posterior capsule ↓ Horizontal adduction, IR, & end Weak ER range flexion Poor scapular ↓ Posterior glide stability Posterior-inferior ↓ Elevation, IR, & horizontal capsule adduction Posterior-superior ↓ IR capsule Anterior-superior ↓ End range flexion & extension, Weak RC capsule ↓ ER & horizontal abduction (+) NTPT Night pain Anterior capsule ↓ Abduction, extension, ER, & horizontal adduction Osteokinematics of the Shoulder Normal Abnormal Normal ROM OPP CPP End-feel(s) End-feel(s) Elevation 55°–70° Maximal Flexion = elastic, Empty = 165°–170° abduction abduction firm – bony contact subacromial & ER Abduction = elastic bursitis IR/ER 30° Scaption = elastic Hard capsular = 180° total horizontal IR/ER = elastic/ frozen shoulder abduction firm Scapulo- Horiz add = soft Capsular = ER Humeral tissue > abduction > IR Rhythm Extension = firm 2:1 (120°:60°) Horiz abd = firm/ elastic 60  61 Arthrokinematics for Shoulder Mobilization To facilitate elevation: To facilitate abduction: Humeral head spins Humeral head rolls superior Glenohumeral Joint posterior & glides inferior/posterior Concave surface: To facilitate IR: To facilitate ER: Glenoid fossa Humeral head rolls Humeral head rolls anterior posterior & glides & glides posterior anterior Convex surface: To facilitate horizontal To facilitate horizontal Humeral head adduction: abduction: Humeral head rolls Humeral head rolls lateral & medial & glides glides medial on glenoid lateral on glenoid Convex surface: To facilitate elevation: To facilitate depression: Sternoclavicular Joint Medial clavicle Lateral clavicle rolls Lateral clavicle rolls down- Concave surface: upward & medial ward & medial clavicle Disk & manubrium clavicle glides inferior glides superior on disk & on disk & manubrium manubrium Concave surface: To facilitate retraction: To facilitate protraction: Medial clavicle & Medial clavicle & disk Medial clavicle & disk rolls disk rolls & glides posterior & glides anterior on Convex surface: on manubrium manubrium Manubrium SHOULDER  SHOULDER Strength & Function Force Couples of the Shoulder Elevation = trapezius, rhomboid, SA Upward rotation = upper/lower trapezius & SA Abduction = supraspinatus, subscapularis, & deltoid Downward rotation = lower trapezius, latissimus, & pectoralis minor Stabilization of the humeral head = RC & long head of biceps Upper Levator trapezius scapulae Rhomboids Serratus anterior Lower trapezius Latissimus dorsi pectoralis major & minor Upward scapular Downward scapular rotation rotation 62  63 Neuromuscular Relationships of the Cervical Spine Root Nerve Muscle Sensation Reflex C3–4 Spinal accessory Trapezius ∅ ∅ C5 Dorsal scapular Levator scapula ∅ ∅ Rhomboids C5–6 Lateral pectoral Pectoralis major ∅ ∅ Pectoralis minor C5–6 Subscapular Subscapular ∅ ∅ Teres major C5–6 Long thoracic Serratus anterior ∅ ∅ C5–6 Suprascapular Supraspinatus Top of ∅ Infraspinatus shoulder C5–6 Axillary Deltoid Deltoid ∅ Teres minor Anterior shoulder C5–7 Musculocutaneous Coracobrachialis Lateral Biceps Biceps & brachialis forearm C5–T1 Radial Triceps Dorsum Triceps Wrist ext/finger flex of hand C6–7 Thoracodorsal Latissimus dorsi ∅ ∅ SHOULDER  SHOULDER Brachial Plexus—Roots, Muscles, & Function Nerve Root Muscle Function Radial C5–8, T1 Anconeus, brachioradialis, Weak supination, wrist ECRL, ECRB, extensor extensors, finger flexors, digitorum, APL, ECU, thumb abductors extensor indices, extensor Weak grip due to loss of digiti minimi wrist stabilization Median C6–8, T1 Pronator teres, FCR, Weak pronation, wrist palmaris longus, FDS, flexion & RD FPL, pronator quadratus, Weak thumb flexion & thenar eminence, lateral abduction 2 lumbricales Weak grip & pinch Ape hand Ulnar C7–8, T1 FCU, palmaris brevis, Weak wrist flexion & UD hypothenar eminence, Weak 5th finger flexion adductor pollicis, medial Weak finger abd/ 2 lumbricales, interossei adduction Benediction sign Special Tests Neural Tissue Provocation Tests See Alerts/Alarms–page 14. 64  65 Shoulder Tests EMPTY CAN TEST Purpose: Test supraspinatus muscle Position: Seated Technique: Elevate UE 30°–45° in plane of the scapula with IR, resist elevation Interpretation: + test = reproduction of pain &/or weakness Statistics: Pain: sensitivity = 44%–100% & speci- ficity = 50%–99% Weakness: sensitivity = 77% & specificity = 68% Source: From Gulick, D., 2008, page 108. FULL CAN TEST Purpose: Test supraspinatus muscle Position: Seated Technique: Elevate UE 30°–45° in plane of the scapula with ER, resist elevation Interpretation: + test = reproduction of pain &/or weakness Statistics: Pain: sensitivity = 66% & specificity = 64% Weakness: sensitivity = 77% & specificity = 74% Source: From Gulick, D., 2008, page 109. DROPPING SIGN Purpose: Test infraspinatus muscle Position: Seated Technique: Shoulder at side with 45° of IR & 90° elbow flexion, resist ER Interpretation: + test = reproduction of pain &/or weakness Statistics: Sensitivity = 20%–42% & specificity = 69%–100% Source: From Gulick, D., 2008, page 109. SHOULDER  SHOULDER HORNBLOWER’S (PATTE TEST) Purpose: Test teres minor muscle Position: Seated Technique: Shoulder in 90° abd & elbow flexed so that the hand comes to the mouth (blowing a horn) Interpretation: + test = repro- duction of pain &/or inability to maintain UE in ER Source: From Gulick, D., 2008, page 110. RENT SIGN Purpose: Diagnosis RC tears Position: Seated with UE in full ext & clinician’s hand under the flexed elbow Technique: Stand behind pt with fingertips in the anterior margin of the acromion; IR/ER UE & palpate for an eminence & a rent; compare bilaterally Interpretation: + test = presence of a palpable defect in RC Statistics: Sensitivity = 95% & specificity = 96% GERBER’S LIFT-OFF SIGN Purpose: Test subscapularis muscle Position: Seated Technique: Hand in the curve of lumbar spine, resist IR Interpretation: + test = repro- duction of pain &/or weakness; inability to lift off Statistics: Sensitivity = 62%–89% & specificity = 98%–100%; tears >75% are often required to pro- Source: From Gulick, D., 2008, page 110. duce a + test 66  67 BELLY PRESS OR NAPOLEON SIGN Purpose: Test subscapularis muscle Position: Seated with hand on belly Technique: Press the hand into belly Interpretation: + test = reproduction of pain &/or inability to IR; substitution may result in UE elevation or wrist flexion Statistics: Sensitivity = 25%–40% & specificity = 98%; tears >50% are often required to produce a + test Source: From Gulick, D., 2008, page 111. BEAR-HUG TEST Purpose: Test subscapularis muscle Position: Seated with palm of hand on opposite shoulder (elbow in front of body) Technique: Resist IR by attempting to pull hand off the shoulder Interpretation: + test = inability to hold the hand against the shoulder or weakness >20% of contralateral UE Statistics: Sensitivity = 60% & speci- ficity= 92%; tears of 30% can be detected with this test HAWKINS/KENNEDY TEST Purpose: Test for impingement Position: Seated Technique: Place shoulder in 90° of flexion, slight hori- zontal adduction, & maximal IR Interpretation: + test = shoulder pain due to impinge- ment of supraspinatus between greater tuberosity against coracoacromial arch Statistics: Sensitivity = 72%–92% & specificity = 25%–66% SHOULDER  SHOULDER NEER’S TEST Purpose: Test for impingement Position: Seated Technique: Passively take UE into full shoulder flexion with humerus in IR Interpretation: + test = pain may be indicative of impingement of the supraspinatus or long head of the biceps Statistics: Sensitivity = 68%–95% & specificity = 25%–68% IMPINGEMENT RELIEF TEST Purpose: Confirm impingement Position: Seated Technique: Perform an inferior glide of GH joint while elevating UE to Neer position Interpretation: + test = reduction or no pain when elevation is accompa- nied by an inferior glide SULCUS SIGN Purpose: Assess for inferior instability or AC px Position: Sitting with shoulder in neutral & elbow flexed to 90° Technique: Palpate shoulder joint line while using proximal forearm as a lever to inferiorly distract humerus Interpretation: + test = ≥ 1 finger-width gap @ the shoulder joint line or AC joint APPREHENSION TEST Purpose: Assess for anterior instability Position: Supine Technique: Abduct the shoulder to 90° & then begin to ER Interpretation: + test = pain or apprehension by the client to assume this position for fear of shoulder dislocation 68  69 JERK TEST Purpose: Assess posterior instability Position: Sitting with UE in IR & flexed to 90° Technique: Grasp client’s elbow & load the humerus proximal while pas- sively moving the UE into horizontal adduction Interpretation: + test = a sudden jerk/clunk as the humeral head subluxes posteriorly; a second jerk/clunk may occur when the UE is returned to the abducted position Statistics: Sensitivity = 73% & specificity = 90% SPEED’S TEST Purpose: Assess for biceps tendonitis or labrum problem Position: Seated with shoulder ele