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Surgery is a mainstay of the rapy depending on anatomical staging and is usually reserved for jobless depression symptoms 10mg prozac mastercard. Ureterovaginal prolapse or rectovaginal prolapse Reference: Hacker &Moores Essentials of Obstetrics and Gynecology 5th depression symptoms urdu generic prozac 10mg on-line. A Penicillin B Cefalexin C Tetracyclin D Erythromycin Answer :c emedicine depression line definition generic prozac 20 mg amex. Inject her with progesterone answer: D or C Several studies have indicated that the likelihood of preterm delivery increases with decreas ing cervical length bipolar depression symptoms mania prozac 20 mg for sale. A cervical length of 25–30 mm before 32 weeks gestation seems to in crease the risk of preterm delivery. If examination and ultrasound show that you have an ab normally short cervix, and you’re less than 24 weeks pregnant, your practitioner may recom mend “cerclage”, a procedure in which she stitches a band of strong thread around your cervix to reinforce it and help hold it closed. However, there’s a lot of controversy about whether cerclage should be used in this situation. Vulva Uptodate: • heavy bleeding: uterus • staining, spotting, light bleeding: genital tract • brown: uterus, cervix, upper vagina • red: genital tract • postcoital: cervical 168)Pt e hirsutism , obese x-ray shows cystic ovary , she wants to conceive , best Tx! Pregnant lady in the 8 wks gestation came e hx of bleeding for the last 12 hrs + abd pain , she passed tissue. Some of the more common complications of Rh disease for the fetus and newborn baby in clude the following: Anemia (in some cases, the anemia is severe with enlargement of the liver and spleen) Jaundice-yellowing of the skin, eyes, and mucous membranes. Severe anemia with enlargement of the liver and spleen Hydrops fetalis-this occurs as the fetal organs are unable to handle the anemia. The heart begins to fail and large amounts of fluid build up in the fetal tissues and organs. A herpes simplex B syphillis C chanchroid lesion D herpangia Answer: A Herpes Simplex viruses generally cause mucocutaneous infection, that is, cells of the skin and the mucous membranes are infected. The typical rash has been described as "dew drops on a rose petal", it consists of vesicles (blisters) that are initially clear and then crust over, typically with yellowish exudate. These vesicles are generally painful, and further, the area of skin and/or mucosa and the sub cutaneous tissues in the region where the rash will appear commonly becomes sensitive and even swollen before eruption of the vesicles. Tissue swelling may increase as the rash blossoms, and then, generally over a course of a week to 2 weeks, resolves completely leaving no scarring. It case of infertility) 1 try more 2 semen analysis 3 genetic study Answer: A 195) Lady with lower abdominal pain, Vaginal examination fornices tenderness , suprapu bic tenderness, purulent vaginal discharge Answer: B A definitive diagnosis of adenomyosis can only be made from histological examination of a hysterectomy specimen. However, vaginal delivery may be a rea sonable option in select cases when delivery is imminent. Refrrence : Uptodate 199) During delivery something happened C/S was required, what type of anesthesia A Colposcopy Answer : Laparoscopy 201) you’re a gynecologist in clinic, a lady come to you with profuse vaginal discharge, diagnosis Her2 = Trastuzumab or Tamoxifen Answer: B 204) Old lady did hysterectomy and bilateral oophorectomy histology showed Ovarian gem cell theca something What other findings A chronic salpingitis B endometrial hyperplasia C uterine navus F cervical something Answer: B Ref: emedicine. A inadequate urine output B fever Answer ; A ( by urologist resident ) 214) Lady with lower abdominal pain, Vaginal examination; fornices tenderness ,supra pubic tenderness, purulent vaginal discharge Acute appendicitis Answer ; B 215)-Lady with cyclic abdominal pain , heavy bleeding, not in contraceptive , trying to conceive , what is the investigation Give Tocolytic Answer : A High blood pressure with epigastric pain may indicate early eclampsia. Urine dipstick analysis is appropriate to detect the proteinurea & the need for delivery. Answer : B 219)-pregnant in 3 trimister she compline if swelling in lower limb what will you do A Coagulase B Oxidase Answer : A 222) Painless genital ulcer + lymph nodes enlargement Uterine body Answer: C 225) Women deliver baby (dawn syndrome) and she want to know about future pregnancy A Ruptured appendex B Ruptured EctopicPregnancy* C Ruptured Ovarian Cyst Answer: B 7. Pt did pap smear three times and was negative and then had menstrual abnormalities. A Metrondozole cream 4times 7days B Metrondozole tablet C Clindamycine tablet D Clindamycine cream Answer: depend on other Signs/Symptoms and Discharge color in history. Ephedrine Antidote For hypertension, 5 mg phentolamine mesylate diluted in saline may be administered slowly intravenously, or 100 mg may be given orally. Cool applications and dexamethasone 1 mg/kg, administered slowly intra venously, may control pyrexia. Diagnostic Criteria for Premenstrual Syndrome at least one affective and one somatic symptom during the 5 d before menses in each of the three prior menstrual cycles 7 . Progesterone Answer: A We diagnose menopause as 12 months of amenorrhea in the absence of other biological or physiological causes. The optimal management of poor labor progression in the active phase is to confirm that the patient is in the active phase (cervix is at least 5 to 6 cm), administer oxytocin, and wait four hours. We prescribe clindamycin 300 mg orally twice daily for seven days or metronidazole 500 mg orally twice daily for seven days. Chocolate Cysts Chocolate cysts (Ovarian endometriosis)Chocolate cysts are affecting women dur ing their reproductive period and may cause chronic pelvic pain associated with menstrual periods (menstrual cramps, endometriosis. Pregnant 8 week of gestation presented with sever abdominal pain followed by heavy bleeding Examination reveals tens abdomen. Pregnant women are recommended to receive the same antiviral dosingas nonpregnant persons. It is best to start antiviral medications within the first 48 hours of developing symptoms, but antivirals can also be used after this time period. A 75-mg capsule of oseltamivir (Tamiflu) twice per day for 5 days is the recommended first choice antiviral. D & C Answer: A Small amount of spotting associated with the normal implantation of the embryo into the uterine wall, called implantation bleeding. This is usually very minimal, but frequently occurs on or about the same day as your period was due. A longer hospital stay is a reasonable option for women who do not have sufficient support at home to manage care during the first postoperative day. Give Tocolytic Answer: A High blood pressure with epigastric pain may indicate early eclampsia. Urine dipstick analysis is appropriate to detect the proteinurea & the need for delivery. The technique measures blood volume changes in the leg as a change in electrical resistance (impedance. Oxidase Acute and subacute breast implant infections are commonly due to gram positive pathogens such as coagulase-negative staphylococci, Propionibacterium species, Staphylococcus aureus, and streptococci. This soon ulcerates to produce the classic chancre(s) of primary syphilis, a 1 to 2 centimeter painless ulcer with a raised, indurated margin that may be genital or extra-genital. However, given data that fibroids can shrink substantially and that there is substantial regression during the postpartum period, expectant management appears to be a reasonable option for some women. We order an initial imaging study (usually an ultrasound) to confirm that a pelvic mass is a fibroid and not an ovarian mass. After an initial evaluation, we perform annual pelvic exams and, in patients with anemia or menorrhagia, check a complete blood count. If symptoms or uterine size are increasing, we proceed with further evaluation and patient counseling regarding treatment options. Inject her with progesterone Answer: D Several studies have indicated that the likelihood of preterm delivery increases with decreas ing cervical length. A cervical length of 25–30 mm before 32 weeks gestation seems to in crease the risk of preterm delivery. If examination and ultrasound show that you have an ab normally short cervix, and you’re less than 24 weeks pregnant, your practitioner may recom mend “cerclage”, a procedure in which she stitches a band of strong thread around your cervix to reinforce it and help hold it closed. However, there’s a lot of controversy about whether cerclage should be used in this situation. Irritation or pain in the vulva, vagina and the area between your vagina and anus (per ineum) Pain during sexual intercourse. However, given data that fibroids can shrink substantially and that there is substantial regression during the postpartum period, expectant management appears to be a reasonable option for some women.
The intravenous antibiotics with subsequent conversion analysis did not find significant differences for treat to oral antibiotics mood disorder games discount prozac generic. The mean length of stay of those patients There is inadequate evidence to recommend a was 0 ventilatory depression definition purchase prozac without prescription. World Journal of Emergency Surgery (2016) 11:34 Page 10 of 25 Timing of appendectomy and in-hospital delay to the second model depression mental health definition buy prozac 20 mg, only a few perforations can be pre vented by a speedy operation after the patients have ar Does in-hospital delay increase the rate of complica rived at the hospital bipolar depression 5-htp cheap 10mg prozac visa. Kelly) Similarly, others have found that the trends for non perforating and perforating appendicitis radically differ the management of most intra-abdominal acute surgical and it is unlikely that perforated appendicitis is simply conditions has evolved significantly over time and many the progression of appendicitis resulting from delayed are now managed without emergency operation. They studied 4529 patients who were inflammation and infection, and delay to operation allows admitted with appendicitis over 8 years and 4108 increasing tension in the wall with ischemia, necrosis and (91 %) patients underwent appendectomy with perfor perforation. There were three inde with all cases of appendicitis, as discussed below, and pendent predictors of perforation: age > 55 years, emergency operation is not always needed. Whatever the cause for oping advanced pathology increased with time and it delay, the real issue is if it will lead to more complica was associated with longer length of hospital stay and tions: there are numerous studies looking at the question antibiotic treatment as well as postoperative compli of in-hospital delay and indirect evidence can be cations [77]. No clinically signifi current diversity in practice appears to be caused by cant difference was found in outcome measures, including lack of high-level evidence although this is beginning overall morbidity and serious morbidity or mortality. It should be noted that the danger of per authors concluded that the results did not change when foration is possibly overstated and that negative ex disease severity was excluded from the model suggesting ploration is not benign [36]. The perforation rate, of more than 12 h, age over 65 years, time of admission therefore, should not be used as a quality measure of the during regular hours, and the presence of co-morbidity management of patients with suspected appendicitis [36]. Perforation He also notes that the increasing proportion of perfora was associated with a higher re-intervention rate and tions over time is explained by an increase in the number increased hospital length of stay. They concluded that in of perforations according to the traditional model and elderly patients with co-morbidity and suspected appendi mainly by selection due to resolution of non-perforated citis, a delay of surgery of more than 12 h should be appendicitis according to the alternative model. World Journal of Emergency Surgery (2016) 11:34 Page 11 of 25 As can be seen, the evidence is conflicting but recently – Primary or secondary closure of the wound They found that the most recent meta-analysis reported that the laparo timing of operation was not related to risk of complex scopic approach of appendicitis is often associated with appendicitis. Seven studies on children question of whether in-hospital delay is safe and not were included, but the results do not seem to be much associated with more perforations cannot be answered different when compared to adults. However, delays authors conclude the in those clinical settings where should be minimised wherever possible to relieve pain, surgical expertise and equipment are available and to enable quicker recovery and decrease costs. One review – Mesoappendix dissection: endoclip, endoloop, showed no difference in mortality [86]. Ligation or diagnostic tool in fertile women, in can be used also invagination of the stump In conclusion, there is no strong current choice over open appendectomy in pregnant pa evidence as to the preferred modality of appendectomy, tients. However, low grade evidence No major benefits have also been observed in lap shows that laparoscopic appendectomy during pregnancy aroscopic appendectomy in children, but it reduces might be associated with higher rates of foetal loss [98]. World Journal of Emergency Surgery (2016) 11:34 Page 13 of 25 open appendectomy [107], did not show any advantages Statement 5. In Peritoneal irrigation does not have any advantages perforated appendicitis the issue of using endoloops or over suction alone in complicated appendicitis. Whilst earlier securing the blood supply, or a small number of endo studies initially reported advantages with routine use clips, appearing to be really useful in case of mobile of endostaplers in terms of complication and opera cecum avoiding the need of an additional port. In tive times [116], more recent studies have repeatedly addition, potential hazards of diathermy are avoided, demonstrated no differences in intra or post the appendicular artery can be ligated under direct operative complications incidence between either vision, and smoke is not created [110]. Al nabsorbable foreign body is left in the peritoneal cavity though operative times maybe longer (but it is prob and may slip or become detached. Moreover, it requires ably biased by the learning curve) [120], the more experience especially in case of inflamed appendix operative costs were invariably and significantly lower with the risk of bleeding [111–113]. Endoloops were at differences are present in surgical time and conversion least as safe and effective as endostapler also in to open rate [111]. All three methods gave acceptable complication stapler over endoloops for stump closure for both rates. However, the need of evacuate of the smoke could when appropriate skills/learning curve are available. In addition, there is no inversion over simple ligation, either in open or lap evidence for any short-term or long-term advantage in aroscopic surgery. Scoring systems for intra-operative grading of appendicitis the practice of leaving intra-abdominal drains is also and their clinical usefulness widely used when complicated/perforated appendicitis is found. Mostly from paediatric experiences, it seems that What are the histopathological criteria for the use of drainage and irrigation is associated with appendicitis of clinical importance Gomes) Previous studies in children with perforated appendicitis have already reported a significantly lower incidence of the systematic review by Swank et al. Most drainage group (n = 228) and the no drainage group patients with malignant neoplasms, parasite infection (n = 225) after emergency open appendectomies and and granulomatosis underwent additional investigation found no significant differences between the two or treatment [133]. The author assesses three im Drains are not recommended in complicated ap portant disease aspects: appendix gross appearance, pendicitis in paediatric patients. Drains did not prove any refers to inflammation outside the appendix and its efficacy in preventing intra-abdominal abscess and most common causes are gynaecological disorders like seem to be associated with delayed hospital discharge. Similar result were achieved also in at laparoscopy in the absence of any other obvious Di Saverio et al. World Journal of Emergency Surgery (2016) 11:34 Page 15 of 25 pathology appeared to be an effective treatment for re the prospective study by Gomes et al. The appendix was citis is performed, even if another diagnosis cannot be graded by the surgeon upon its visual appearance: found at laparoscopy [136]. On the other hand, in the grade 0 (normal looking), 1 (redness and oedema), 2 retrospective study by Phillips et al. This was then compared with a the removal of a normal looking appendix in the ab biochemical-histologic assessment of the removed ap sence of other explanatory pathology [137]. The authors conclude that negative appendec the biochemical-histological diagnosis changed for 48 tomy should not be undertaken routinely during lapar (25. H ow ever,the intra-operative diagnosis alone is insufficient for score still needs to be validated within a multicentre identifying unexpected disease. Interestingly, the surgeon’s termining optimal grade disease management and experience did not affect the disagreement rate. Nonetheless, the clinical significance of these Role of percutaneous drainage and Interval early and/or mild forms of microscopic appendicitis is Appendectomy or immediate surgery. World Journal of Emergency Surgery (2016) 11:34 Page 16 of 25 the study with highest level of evidence about the 2 months [145], up to 38 % after 12 months [70]. In order conservative treatment of complicated appendicitis to avoid this quite high chance of recurrence, some with abscess or phlegmon is the meta-analysis by authors recommend routine elective interval append Simillis et al. The system (847 treated with conservative treatment and 725 with atic review by Hall et al. Data revealed that conservative treat studies for a total of 127 cases of non-surgical treat ment was associated with significantly less overall ment of appendix mass in children: after successful complications (wound infections, abdominal/pelvic ab non-operative treatment, the risk of recurrent appen scesses, ileus/bowel obstructions, and re-operations) if dicitis was found to be 20. However, this means difference was found in the duration of the first that 80 % of children may not need interval append hospitalization, the overall hospital stay and the dur ectomy. Overall, the complications reported included from 60 patients with appendicular abscess treated ei wound infection, prolonged postoperative ileus, ther with immediate laparoscopic surgery (30 pa hematoma formation, and small bowel obstruction, tients) or with conservative treatment (30 patients. In the laparos Because of its consistent morbidity, after successful copy group there were significantly fewer unplanned conservative management, the routine indication to readmissions (3 % versus 27 %, P = 0. Some authors recom group, instead, required more additional interventions mend routine interval appendectomy, not to avoid the (surgery or percutaneous drainage) (30 % versus 7 %, risk of recurrence, but to rule out possible P = 0. In the retrospective study by patients in the laparoscopy group and in four (13 %) Carpenter et al. The rate of un out of 24 patients with complicated appendicitis eventful recovery was 90 % in the laparoscopy group (7. The these data brought to the conclusion that several fac incidence of neoplasms was significantly higher in the tors support the use of immediate surgery in patients patients underwent interval appendectomy than in the with appendicular abscess [145]. However, it should immediate appendectomy group (five patients, 28 % be highlighted that laparoscopic appendectomy as vs. Average hos Preoperative and postoperative antibiotics pital stay was also not statistically different between the two groups. The study demonstrated that an antimicrobial Should Preoperative antibiotics prophylaxis be given
If one uses the status approach depression symptoms in adolescent males buy prozac with visa, patients with a history of a mental illness or memory impairment may be considered incapacitated depression resources order cheap prozac line. Psychiatric conditions or other medical conditions that can result in incapacity may have resolved or may be under control with appropriate therapy that mitigates the condition’s impact on patient capacity for decision making anxiety symptoms in teens cheap prozac online master card. Patients with memory impairment or dementia may also be able to express wishes regarding treatment depression analysis test generic prozac 10mg overnight delivery. The functional approach, which determines the patient’s ability to function in a particular context to make decisions that are authentic expressions of the patient’s own values and goals. Determining whether a patient is capacitated for a particular medical decision entails assessing whether the patient is able to: & Comprehend the risks and benefits of the recommended intervention, risks and benefits of reasonable alternative intervention, and the risks and benefits of no intervention. Assessment of patients’ competence to consent to treatment, N Engl J Med 357:1834–1840, 2007. Assignment of a person to an inpatient psychiatric facility without patient consent when the appropriate criteria are met. The patient must be unable to provide informed consent owing to a mental illness and, owing to the same mental illness, pose a danger to themselves or to others. The obligation prospectively to explain medical interventions in language and concepts the patient can comprehend even if the patient is deemed to be not capable of full informed consent, such as children or mentally impaired adults. The patient’s agreement is elicited, even though the final decision requires parental, guardian, or other legally authorized decision maker’s permission. A generic term for any of several types of patient instructions, oral or written, for providing guidance and direction in advance of a person’s potential incapacity. The instructions and authorization in an advance directive do not take effect until the person loses decisional capacity and the advance directive ceases to be in effect if or when the patient regains capacity. Designation by a capacitated patient of the person the patient chooses to make medical decisions during any period when the patient is incapacitated, whether during surgery, temporary unconsciousness or mental condition, as well as irreversible condition of lost decisional capacity. The decisions the designated person can make include withholding or withdrawal of treatment in life-limiting circumstances. If a patient has not made a living will or designated a person to make decisions during periods of patient incapacity, state statutes determine the order of priority for persons related to or close to the patient to assume the role of making medical decisions on the patient’s behalf. These are typically called “surrogates” or “proxies,” but they differ from decision makers designated by the patient in the way they are selected, and in many cases, they bear a greater burden of demonstrating that they know what the patient would want. What are the standards of decision making for those chosen either by the patient or by statute to make decisions for the incapacitated patient In some cases, this will not be the same as what others may think is in the patient’s best interest. If there is substantial uncertainty about what the patient would have chosen for herself or himself, then the traditional best interest standard is the appropriate basis for decision making. Orders that give direction regarding interventions at the time of death or cardiopulmonary arrest. Patient-directed measures such as advance directives or statutory next of kin decisions should be the basis for underlying medical decisions that entail informed consent or refusal issues at the end of life. Patients should be encouraged to discuss their wishes for end-of-life care with family members or close friends and physicians while still able to clearly express these wishes. Forms such as Preferences of Life-Sustaining Treatment can designate the patient’s specific requests to accept or decline therapies at the end of life. Patients are frequently unaware of the numerous, complex therapies related to end-of-life care and may not be able to write down what is wanted. Designation of a surrogate decision maker with whom the patient discusses her or his values and goals related to end-of-life care and also ensure the patient’s wishes will be respected. The term used to replace the traditional definition of death by cessation of heartbeat and respiration. In the most conservative definition of this term, it refers to whole brain death, cessation not only of higher cortical function but of brainstem function as well. The provision of a lethal amount of a medication that the patient voluntarily takes to end his or her life. Oregon and Washington established legislation to allow these prescriptions, and other states are considering the issue. Jonsen A, Siegler M, Winslade W: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, ed 6, New York, 2006, McGraw-Hill Medical. When I see a new patient, I find it valuable, at the first meeting, consciously to look at the hands. Clues to diseases in the nervous system, heart, lung, liver, and other organs can be found there. That is why the “laying on of hands” is so important for the physician and patient. John Stone (1936–2008) “Telltale Hands” from In the Country of Hearts: Journeys in the Art of Medicine, 1990 It’s the humdrum, day-in, day-out everyday work that is the real satisfaction of the practice of medicine;. What interviewing skills can help the physician identify all the significant issues to the patient during the visit Remaining open-ended and encouraging the patient to “go on” until all the pertinent issues have been expressed by the patient. Other facilitative techniques to keep the patient talking include a simple head nod or saying, “and,” or “what else Physicians too often interrupt the patient and direct the remaining interview, only focusing on what the physician deems important. A patient may have other, significant issues that are not immediately expressed, and the physician may miss this “hidden agenda” if the patient is interrupted. Once the patient has listed the concerns, the patient and physician can then decide which ones will be addressed. How can the physician understand more clearly what the patient is trying to describe By rephrasing the response in the physician’s words or simply restating what the patient said. Sometimes the physician simply needs to ask, “Can you find other words to describe your pain The number needed to treat that quantifies the number of patients who will require treatment with a therapy (and who will have no benefit) in order to ensure that at least one of the adverse events that the therapy should prevent does not occur. Other organizations such as the American Cancer Society and American Gastroenterology Association have different recommendations. Preventive Services Task Force recommendation statement, Ann Intern Med 149:627–637, 2008. The Task Force recommended against routine screening in women aged 40-49 years and suggested biennial screening (if appropriate and desired by the patient) for patients aged 50–74 years. The benefits of screening in women > 75 years old are unknown owing to lack of evidence. Other groups have suggested that women of average risk continue to receive annual mammograms, starting at an earlier age. Preventive Services Task Force Recommendation Statement, Ann Intern Med 151:716–726, 2009. For this group who likely received chest radiation, mammography should begin at age 25 years or 8 years after chest radiation exposure, whichever is earlier. The evidence is also unclear as to whether treatment of prostate cancer, when discovered, prolongs life. Currently trials are under way to try to more clearly identify appropriate prostate cancer screening tests. At age 21 years or within 3 years after the onset of sexual activity, whichever is sooner. Do women who have had a total hysterectomy (with cervix removal) for nonmalignant reasons need Pap smears Coronary artery disease, myocardial infarction, and death from a cardiovascular event. Ask the patient about: & Cushing’s syndrome: weight gain, central obesity, easy bruising, “moon” facies, abdominal striae. Pheochromocytoma, which is a rare tumor of the adrenal gland that produces excess adrenaline and arises from the central portion of the adrenal gland. Most commercially sold licorice in the United States does not contain significant amounts, although glycyrrhizic acid may be found in chewing tobacco.
Syndromes
- You have symptoms of neuralgia, especially if over-the-counter pain medications do not relieve your pain
- Transfusion problems
- Were born to a hepatitis-B infected mother
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- Fever and chills
- Do you have any other symptoms like itching, flaking, or redness of your scalp?
Thus bipolar depression for dummies buy generic prozac 10mg, a patient whose knee pain is caused or the air resistant depression definition cheap 10mg prozac visa, holding the medial malleoli together depression angle definition prozac 10 mg for sale. Because exacerbated by weightbearing with the knee flexed may extension is normally symmetric depression symptoms bereavement effective prozac 10 mg, the knees should fall consciously or instinctively keep the knee in full exten to the same level. Because this causes the involved limb to be functionally longer than the normal one, the patient may walk with a stilted or vaulting type of motion. A stiff knee gait is also one of the abnormalities that can occur in the presence of a weak quadriceps. Patients with more severe quadriceps weakness, such as that seen after poliomyelitis, may actually thrust the knee into hyperextension or recurvaturn to prevent it from collapsing as they propel themselves forward. Active extension should also be least to neutral, so that the thigh and the lower leg are in assessed. This is usually If active extension does not seem full, the examiner may 10° or less, but it may be even greater in some loose lift the heel to see whether greater passive extension is jointed individuals. This is usually If one knee does not passively extend as far as the due to an extensor mechanism problem, such as quadri other, a flexion contracture is said to be present. It should be of extension may be due to pain, swelling, arthritic remembered, however, that patients with sciatica or tight change, or a mechanical block, such as that produced by hamstrings may also have difficulty fully extending the a displaced meniscus tear. Complete inability to extend a torn anterior cruciate ligament or postoperative scar tis the knee against gravity suggests an extensor mechanism sue (especially after anterior cruciate ligament recon disruption such as a quadriceps tendon rupture, patellar struction) may also inhibit full extension. This pathologic hyperextension may be Flexion is usually assessed by asking the supine patient due to posttraumatic bony deformity or posterior liga to flex the knee as far as possible. If the hyperextension is due to ligament should be able to get the heel close to the ipsilateral but injury, other signs of pathologic ligament laxity should be tock, or even touching it (Fig. Flexion to 110° is usually suffi ure loss of extension is the prone hanging test. The patient cient to allow patients to descend stairs and complete is asked to lie prone with the lower limbs from the knee other daily activities. Measuring and comparing the downward projecting beyond the end of the examination heel-to-buttock distance is a good way to assess small table. The patient is encouraged to relax fully, both through amounts of loss of flexion (Fig. A is commonly due to effusion, arthritic change, or knee flexion contracture causes the ipsilateral heel to come patellofemoral pain. Measuring always done because it is of limited clinical significance the heel height difference can provide a fairly accurate esti and may often produce pain. In an pain localized to one joint line, however, it may signify a individual of average build, each centimeter of heel height tear of the respective meniscus. In this position, height difference of 8 cm reflects a flexion contracture of however, the obligate hip extension tightens the rectus about 8°. This method is particularly useful for following up femoris, which originates above the knee, and this may patients with pathologic flexion contractures because small limit knee flexion to less than would be possible with degrees of improvement can be reliably detected. Finally, it may allow the examiner to make a presumptive diagnosis by Palpation of the knee has several uses. First, it allows the documenting point tenderness on a specific anatomic examiner to become oriented with the joint by identify structure. This is particularly important in the presence of already described may be palpated for identification or obesity or edema, when landmarks that might be visible to elicit tenderness. Second, it allows the next are only those in which palpation is most com monly useful. However, it has been suggested that the lateral reti fruitful venues for palpation. Because the patella is such naculum itself may sometimes be the true source of pain. Patellar facet tender as excessive lateral pressure syndrome, very little lateral ness is a common finding in cases of patellofemoral pain. If the reveals that tenderness is localized to the lateral quadriceps is adequately relaxed, it should feel flaccid and patellofemoral ligament, a tight band about 1 cm wide the patella should feel loose when the examiner shifts it connecting the lateral border of the patella to the lateral from side to side. This can in this position, the index Finger or thumb of the other sometimes be palpated as a palpable fibrous band run hand is worked under the medial facet as far as possible ning longitudinally between the patella and the medial and pressed upward. Then the plica over the medial femoral condyle and make it more examiner reverses the process, shifting the patella laterally prominent. Palpation of other portions of the extensor mechanism is indicated if the history or inspec tion raises the question of localized pathology. Figure 6-31 shows the common sites of tenderness in Osgood-Schlatter disease, Sinding-Larsen-Johansson disease, patellar tendini tis, and quadriceps tendinitis. In the presence of quadriceps tendon rupture, the examiner may be able to palpate a gap as well as tenderness when the patient attempts to perform a straight-leg raise. Palpating the patellar tendon during an attempted straight-leg raise is also a good way to check for rupture of this structure. If the ten don is ruptured, it remains flaccid, and a gap, usually just distal to the patella, may be palpable (see Fig. By far the most common location is in the proximal patellar tendon just distal to the infe rior tip of the patella. In addition to eliciting pain, the examiner should feel a spongy crepitant sensation when firmly palpating this area with a fingertip. Palpable or vis ible swelling of the tendon is present in more severe cases of patellar tendinitis. Palpation for tibiofemoral joint line tenderness is another important part of a basic knee examination. This may be done are superficial and should be palpated when injury to in either the seated or the supine position {see Fig. Careful palpation usually of the medial joint line with an index finger and then repeatedly presses with the tip of the finger while pro gressing posteriorly around the side of the joint (Fig. The finding of tenderness at the middle to the pos terior portions of either joint line is highly suspicious for pathology localized to the tibiofemoral compartment, most commonly a meniscus tear or osteoarthritis. Tenderness that is elicited only at the anterior por tion of the joint line is usually nonspecific. An exception to this statement is found in the knee that is locked, or unable to fully extend, owing to a displaced bucket han dle fragment of a torn medial meniscus. In this condition, a longitudinal tear allows a long strip of meniscus to dis place anterior to the medial femoral condyle and prevent extension. In the presence of such an injury, exquisite ten derness usually is found at the point where the curvature of the medial femoral condyle meets the medial joint line (Fig. Bucket handle tears also occur in the lateral meniscus, although much less often, but such a charac Figure 6-33. Palpation of the typical point of maximal tenderness teristic point of tenderness is found less frequently than in a patient with a locked knee due to a displaced bucket handle tear of in medial meniscus tears. In this case, the detection of excessive anserinus bursa can also be due to a stress fracture of the valgus laxity (see the Manipulation section) distinguishes medial tibial plateau (see Fig. This condi medial joint line, flexion of the knee makes the lateral tion usually is associated with tenderness at the direct joint line easier to locate and palpate (Figs. In severe cases, tenderness may be more diffuse because there is injury to other lateral and posterolateral structures. The iliotibial band is a fairly common site of tenderness in runners and other athletes. When a condition called iliotibial band friction syndrome, or ili otibial band tendinitis, is present, the tenderness is usually maximal at the point where the iliotibial band crosses the lateral epicondyle because this condition is thought to arise from friction between these two structures (Fig. Tenderness of the lateral joint line is most com the knee against resistance during palpation. The pulsations If the ligament is tender but palpable, a mild injury is sug of the popliteal artery, however, can usually be felt, espe gested. Inability to identify the ligament at all suggests a cially when the knee is flexed and the surrounding muscles Figure 6-36. Injury to the femoral nerve or herni patient in the prone position by flexing the knee with the ation of the L3 to L4 disk can also lead to quadriceps lower leg supported. The popliteal artery can also be located by feel and palpated with the patient in the supine Such a measurement does not truly distinguish between position (Fig. Using a landmark that appears symmetric and easily identifiable Muscle Testing in both knees, such as the proximal pole of the patella or Muscle testing for the knee is relatively straightforward, the tibial tubercle, the examiner uses a tape measure to because only two major muscle groups are involved.
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