NR509 iiMid-Term iiStudy iiGuide
• Articular iistructures iiinclude iijoint iicapsule iiand iiarticular iicartilage, iithe iisynovium
iiandisynovial iifluid, iiintra-articular iiligaments iiand iijuxta-articular iibone
o Articular iidisease iiinvolves:
▪ Swelling
▪ Tenderness iiof iithe iijoint
▪ Crepitus
▪ Instability ii“locking”
▪ Deformity
▪ Limits iiactive iiand iipassive iirange iiof iimotion iidue iito iistiffness iior iipain
• Extra-articular iistructures iiinclude iiperiarticular iiligaments, iitendons, iibursae,
iimuscle,ifascia, iibone, iinerve iiand iioverlying iiskin
o Extra-articular iidisease iiinvolves:
▪ “point iiof iifocal iitenderness iiin iiregions iiadjacent iito iiarticular iistructures
▪ Limits iiactive iirange iiof iimotion
▪ RARELY iicauses iiswelling, iiinstability, iijoint iideformity
Know iithe iisources iiof iijoint iipain ii(pg. ii627 iialgorithm)
• Nonarticular iiconditions: iitrauma/fracture, iifibromyalgia, iipolymyalgia
iirheumatica,ibursitis, iitendinitis
• Intra-articular ii(acute, ii< ii6 iiweeks): i i acute iiarthritis
o infectious iiarthritis
o gout
o pseudogout
o Reiter iisyndrome
• Intra-articular ii(chronic, ii> ii6 iiweeks): iichronic iiinflammatory iiarthritis iivs
iichronicinoninflammatory iiarthritis
o Chronic iiinflammatory iiarthritis iiwith ii1-3 iijoints iiinvolved:
▪ Indolent iiinfection
▪ Psoriatic iiarthritis
▪ Reiter iisyndrome
▪ Periarticular i i JA
o Chronic iiinflammatory iiarthritis iiwith ii>3 iijoints iiinvolved:
▪ Psoriatic iiarthritis iior iiReiter iisyndrome ii(no iisymmetry)
▪ rheumatoid iiarthritis iiif iinot iiRA iithen ii iisystemic iilupus,
iiscleroderma,ipolymyositis
*Know iiwhat iicauses iisaddle iinumbness iiand iiurinary iiretention ii(pg. ii678?)
• CES ii(cauda iiequina iisyndrome) iimost iicommonly iiresults iifrom iia iimassive iiherniated iidisc iiin
iitheilumbar iiregion.
• A iisingle iiexcessive iistrain iior iiinjury iimay iicause iia iiherniated iidisc.
• However, iidisc iimaterial iidegenerates iinaturally iias iia iiperson iiages, iiand iithe iiligaments iithat iihold
iiitiin iiplace iibegin iito iiweaken. iiAs iithis iidegeneration iiprogresses, iia iirelatively iiminor iistrain iior
twisting iimovement iican iicause iia iidisc iito iirupture.
, The iifollowing iiare iiother iipotential iicauses iiof iiCES:
• Spinal iilesions iiand iitumors
• Spinal iiinfections iior iiinflammation
• Lumbar iispinal iistenosis
• Violent iiinjuries iito iithe iilower iiback ii(gunshots, iifalls, iiauto iiaccidents)
• Birth iiabnormalities
• Spinal iiarteriovenous iimalformations ii(AVMs)
• Spinal iihemorrhages ii(subarachnoid, iisubdural, iiepidural)
• Postoperative iilumbar iispine iisurgery iicomplications
• Spinal iianesthesia
Know iihow iiretinal iidetachment iipresents ii(p.217)
• Sudden, iipainless iivision iiloss iithat iiis iiunilateral
Know iiwhat iithe iiword iiobtunded iimeans ii(p. ii769)
• The iiobtunded iipatient iiopens iieyes iiand iilooks iiat iiyou iibut iiresponds iislowly iiand iiis
iisomewhaticonfused. iiAlertness iiand iiinterest iiin iithe iienvironment iiare iidecreased.
Know iiwhat iicranial iinerve iiyou’re iiassessing iiwhen iichecking iilateral iigaze ii(p. ii237)
• Cranial iinerve iiVI: iiabducens
Know iiwhat iishould iibe iilisted iiunder iiadult iiillnesses iiin iihealth iihistory ii(pg. ii10)
• Medical iiillnesses: iisuch iias iidiabetes, iihypertension, iihepatitis, iiasthma, iiand iiHIV. iiAlso
iihospitalizations, iinumber iiand iigender iiof iisexual iipartners, iiand iirisk-taking iisexual
iipractices
• Surgical: iidates, iiindications, iiand iitypes iiof iioperations
• Obstetric/Gynecologic: iiobstetric iihistory, iimenstrual iihistory, iimethods iiof
iicontraception,iand iisexual iifunction
• Psychiatric: iiillness iiand iitimeframe, iidiagnoses, iihospitalizations, iiand iitreatments
Know iiwhat iiconditions iido iinot iihave iired iireflexes ii(p. ii239)
• Absence iiof iired iireflex iisuggests iian iiopacity iiof iithe iilens ii(cataract), iior iipossibly iithe
iivitreousi(or iieven iian iiartificial iieye).
• Less iicommonly, iia iidetached iiretina, iior iiin iichildren iia iiretinoblastoma iimay iiobscure
iithisireflex.
Know iithe iisigns iiof iiseasonal iiallergies ii(p. ii27)
• itching, iiwatery iieyes, iisneezing, iiear iicongestion, iipostnasal iidrainage
Know iihow iioptic iineuritis iipresents ii(p. ii217)
• Sudden iivisual iiloss iithat iiis iiunilateral iiand iican iibe iipainful, iiassociated iiwith iimultiple iisclerosis
Know iihow iipityriasis iirosacea iipresents ii(p. ii912)
, • Oval iilesions iion iitrunk, iiin iiolder iichildren iioften iiin iia iiChristmas iitree iipattern,
iisometimes iiaiHarold iipatch ii(a iilarge iipatch iithat iiappears iifirst)
Know iiwhat iiis iilisted iiunder iipresent iiillness ii(p. ii9)
• Complete, iiclear, iiand iichronologic iidescription iiof iithe iiproblems iiprompting iithe
iipatient’sivisit, iiincluding iithe iionset iiof iithe iiproblem, iithe iisetting iiin iiwhich iiit
iideveloped, iiit’s iimanifestation iiand iiany iitreatments ii to iidate.
• (OLDCART) iiOnset, iiLocation, iiDuration, iiCharacteristics, iiAggravating iifactors,
iiRelievingifactors, iiTreatments ii(past)
Know iiwhere iithe iiacromion iiprocess iiis ii(be iiable iito iiidentify iiit iion iia iipicture)
• Located iibetween iithe iiclavicle iiand iithe iishoulder
*Know iiwhat iito iido iiif iiyou iihave iia ii+ iifinding iion iiphysical iiexam iibut iiotherwise iinegative iiwork-up
ii(p.i30)
Know iiwhat iican iicause iifalsely iihigh iiBP’s ii(p. ii127)
• If iithe iibrachial iiartery iiis iibelow iithe iiheart iilevel, iithe iiblood iipressure iireading iiwill iibe
iihigher. iiIfithe iicuff iiis iitoo iismall ii(narrow) iithe iiblood iipressure iiwill iiread iihigh.
• If iithe iicuff iiis iitoo iilarge ii(wide) iithe iiBP iiwill iiread iihigh iion iia iilarge iiarm
Know iihow iito iicheck iifor iinystagmus ii(p. ii737)
• Nystagmus iiis iiseen iiin iicerebellar iidisease iiespecially iiwith
o gait iiataxia
o dysarthria ii(increases iiwith iiretinal iifixation
o vestibular iidisorders ii(decreases iiwith iiretinal iifixation)
o internuclear iiophthalmoplegia
, • Identify iiany iinystagmus, iian iiinvoluntary iijerking iimovement iiof iithe iieyes iiwith iiquick
iiandislow iicomponents.
• Note iithe iidirection iiof iithe iigaze iiin iiwhich iiit iiappears, iithe iiplane iiof iithe iinystagmus
ii(horizontal,ivertical, iirotary, iior iimixed), iiand iithe iidirection iiof iithe iiquick iiand iislow
iicomponents.
• Nystagmus iiis iinamed iifor iithe iidirection iiof iithe iiquick iicomponent.
• Ask iithe iipatient iito iifix iihis iior iiher iivision iion iia iidistant iiobject iiand iiobserve iiif iithe
iinystagmusiincreases iior iidecreases.
Know iiwhat iiyellow iisclera iiindicates ii(p. ii234)
• A iiyellow iisclera iiindicates iijaundice
Pg. ii72 ii- iiKnow iihow iito iiget iia iipatient iito iiopen iiup iiwhen iihe iiseems iiupset
• The iifirst iistep iito iieffective iireassurance iiis iisimply iiidentifying iiand iiacknowledging iithe
iipatient’sifeelings. iiFor iiexample, ii you iimight iisimply iisay, ii“You iiseem iiupset iitoday.” iiThis
iipromotes iia iifeeling iiof iiconnection. iiMeaningful iireassurance iicomes iilater, iiafter ii you iihave
iicompleted iithe iiinterview, iithe iiphysical iiexamination, iiand iiperhaps iisome iilaboratory iitests.
iiAt iithat iipoint, ii you ii can iiexplain iiwhat iiyou iithink iiis iihappening iiand iideal iiopenly iiwith iiany
iiconcerns. iiReassurance iiisimore iiappropriate iiwhen iithe iipatient iifeels iithat iiproblems iihave
iibeen iifully iiunderstood iiand iiare iibeing iiaddressed.
• Another iiway iito iiaffirm iithe iipatient iiis iito iivalidate iithe iilegitimacy iiof iihis iior iiher
iiemotional iiexperience. iiSaying iisomething iilike, ii“Your iiaccident iimust iihave iibeen iivery
iiscary. iiCar iiaccidents iiare iialways iiunsettling iibecause iithey iiremind iius iihow iivulnerable
iiwe iiare. iiPerhapsithat iiexplains iiwhy iiyou iistill iifeel iiupset,” iivalidates iithe iipatient’s
iiresponse iias iilegitimate iiandiunderstandable
• Moving iicloser iior iimaking iiphysical iicontact iilike iiplacing iiyour iihand iion iithe iipatient’s
iishouldericonveys iiempathy iiand iican iihelp iithe iipatient iigain iicontrol iiof iiupsetting iifeelings.
iiThe iifirst iistepito iiusing iithis iiimportant iitechnique iiis iito iinotice iinonverbal iibehaviors iiand
iibring iithem iito iiconscious iilevel.
Pg. ii 27 ii - ii Know iithe ii signs ii of iidegenerative ii pain
Page ii696
Pg. ii289 ii- iiKnow iihow iiotosclerosis iipresents iiwith iiWeber iiand iiRinne
iitestiOtosclerosis iicondition iithat iiaffects iithe iitiny iimiddle iiear iibone iiknown iias iithe
iistapes.
• Stapes iican iibecome iistuck, iilimiting iiits iiability iito iivibrate ii(vibrations iiare iicrucial iifor iihearing)
• Conductive iihearing iiloss
• Weber iitest
o Tuning iifork iiat iivertex
o Sound iiis iiheard iiin iithe iiimpaired iiear
o Room iinoise iinot iiwell iiheard, iiso iidetection iiof iivibrations iiimproves
• Rinne iitest
o Tuning iifork iiat iiexternal iiauditory iimeatus; iithen iion iimastoid iibone
o BC iilonger iithan iior iiequal iito iiAC ii(BC ii> iiAC iior iiBC ii= iiAC)
o While iiair iiconduction iithrough iithe iiexternal iior iimiddle iiear iiis iiimpaired,
iivibrationsithrough iibone iibypass iithe iiproblem iito iireach iithe iicochlea
• Articular iistructures iiinclude iijoint iicapsule iiand iiarticular iicartilage, iithe iisynovium
iiandisynovial iifluid, iiintra-articular iiligaments iiand iijuxta-articular iibone
o Articular iidisease iiinvolves:
▪ Swelling
▪ Tenderness iiof iithe iijoint
▪ Crepitus
▪ Instability ii“locking”
▪ Deformity
▪ Limits iiactive iiand iipassive iirange iiof iimotion iidue iito iistiffness iior iipain
• Extra-articular iistructures iiinclude iiperiarticular iiligaments, iitendons, iibursae,
iimuscle,ifascia, iibone, iinerve iiand iioverlying iiskin
o Extra-articular iidisease iiinvolves:
▪ “point iiof iifocal iitenderness iiin iiregions iiadjacent iito iiarticular iistructures
▪ Limits iiactive iirange iiof iimotion
▪ RARELY iicauses iiswelling, iiinstability, iijoint iideformity
Know iithe iisources iiof iijoint iipain ii(pg. ii627 iialgorithm)
• Nonarticular iiconditions: iitrauma/fracture, iifibromyalgia, iipolymyalgia
iirheumatica,ibursitis, iitendinitis
• Intra-articular ii(acute, ii< ii6 iiweeks): i i acute iiarthritis
o infectious iiarthritis
o gout
o pseudogout
o Reiter iisyndrome
• Intra-articular ii(chronic, ii> ii6 iiweeks): iichronic iiinflammatory iiarthritis iivs
iichronicinoninflammatory iiarthritis
o Chronic iiinflammatory iiarthritis iiwith ii1-3 iijoints iiinvolved:
▪ Indolent iiinfection
▪ Psoriatic iiarthritis
▪ Reiter iisyndrome
▪ Periarticular i i JA
o Chronic iiinflammatory iiarthritis iiwith ii>3 iijoints iiinvolved:
▪ Psoriatic iiarthritis iior iiReiter iisyndrome ii(no iisymmetry)
▪ rheumatoid iiarthritis iiif iinot iiRA iithen ii iisystemic iilupus,
iiscleroderma,ipolymyositis
*Know iiwhat iicauses iisaddle iinumbness iiand iiurinary iiretention ii(pg. ii678?)
• CES ii(cauda iiequina iisyndrome) iimost iicommonly iiresults iifrom iia iimassive iiherniated iidisc iiin
iitheilumbar iiregion.
• A iisingle iiexcessive iistrain iior iiinjury iimay iicause iia iiherniated iidisc.
• However, iidisc iimaterial iidegenerates iinaturally iias iia iiperson iiages, iiand iithe iiligaments iithat iihold
iiitiin iiplace iibegin iito iiweaken. iiAs iithis iidegeneration iiprogresses, iia iirelatively iiminor iistrain iior
twisting iimovement iican iicause iia iidisc iito iirupture.
, The iifollowing iiare iiother iipotential iicauses iiof iiCES:
• Spinal iilesions iiand iitumors
• Spinal iiinfections iior iiinflammation
• Lumbar iispinal iistenosis
• Violent iiinjuries iito iithe iilower iiback ii(gunshots, iifalls, iiauto iiaccidents)
• Birth iiabnormalities
• Spinal iiarteriovenous iimalformations ii(AVMs)
• Spinal iihemorrhages ii(subarachnoid, iisubdural, iiepidural)
• Postoperative iilumbar iispine iisurgery iicomplications
• Spinal iianesthesia
Know iihow iiretinal iidetachment iipresents ii(p.217)
• Sudden, iipainless iivision iiloss iithat iiis iiunilateral
Know iiwhat iithe iiword iiobtunded iimeans ii(p. ii769)
• The iiobtunded iipatient iiopens iieyes iiand iilooks iiat iiyou iibut iiresponds iislowly iiand iiis
iisomewhaticonfused. iiAlertness iiand iiinterest iiin iithe iienvironment iiare iidecreased.
Know iiwhat iicranial iinerve iiyou’re iiassessing iiwhen iichecking iilateral iigaze ii(p. ii237)
• Cranial iinerve iiVI: iiabducens
Know iiwhat iishould iibe iilisted iiunder iiadult iiillnesses iiin iihealth iihistory ii(pg. ii10)
• Medical iiillnesses: iisuch iias iidiabetes, iihypertension, iihepatitis, iiasthma, iiand iiHIV. iiAlso
iihospitalizations, iinumber iiand iigender iiof iisexual iipartners, iiand iirisk-taking iisexual
iipractices
• Surgical: iidates, iiindications, iiand iitypes iiof iioperations
• Obstetric/Gynecologic: iiobstetric iihistory, iimenstrual iihistory, iimethods iiof
iicontraception,iand iisexual iifunction
• Psychiatric: iiillness iiand iitimeframe, iidiagnoses, iihospitalizations, iiand iitreatments
Know iiwhat iiconditions iido iinot iihave iired iireflexes ii(p. ii239)
• Absence iiof iired iireflex iisuggests iian iiopacity iiof iithe iilens ii(cataract), iior iipossibly iithe
iivitreousi(or iieven iian iiartificial iieye).
• Less iicommonly, iia iidetached iiretina, iior iiin iichildren iia iiretinoblastoma iimay iiobscure
iithisireflex.
Know iithe iisigns iiof iiseasonal iiallergies ii(p. ii27)
• itching, iiwatery iieyes, iisneezing, iiear iicongestion, iipostnasal iidrainage
Know iihow iioptic iineuritis iipresents ii(p. ii217)
• Sudden iivisual iiloss iithat iiis iiunilateral iiand iican iibe iipainful, iiassociated iiwith iimultiple iisclerosis
Know iihow iipityriasis iirosacea iipresents ii(p. ii912)
, • Oval iilesions iion iitrunk, iiin iiolder iichildren iioften iiin iia iiChristmas iitree iipattern,
iisometimes iiaiHarold iipatch ii(a iilarge iipatch iithat iiappears iifirst)
Know iiwhat iiis iilisted iiunder iipresent iiillness ii(p. ii9)
• Complete, iiclear, iiand iichronologic iidescription iiof iithe iiproblems iiprompting iithe
iipatient’sivisit, iiincluding iithe iionset iiof iithe iiproblem, iithe iisetting iiin iiwhich iiit
iideveloped, iiit’s iimanifestation iiand iiany iitreatments ii to iidate.
• (OLDCART) iiOnset, iiLocation, iiDuration, iiCharacteristics, iiAggravating iifactors,
iiRelievingifactors, iiTreatments ii(past)
Know iiwhere iithe iiacromion iiprocess iiis ii(be iiable iito iiidentify iiit iion iia iipicture)
• Located iibetween iithe iiclavicle iiand iithe iishoulder
*Know iiwhat iito iido iiif iiyou iihave iia ii+ iifinding iion iiphysical iiexam iibut iiotherwise iinegative iiwork-up
ii(p.i30)
Know iiwhat iican iicause iifalsely iihigh iiBP’s ii(p. ii127)
• If iithe iibrachial iiartery iiis iibelow iithe iiheart iilevel, iithe iiblood iipressure iireading iiwill iibe
iihigher. iiIfithe iicuff iiis iitoo iismall ii(narrow) iithe iiblood iipressure iiwill iiread iihigh.
• If iithe iicuff iiis iitoo iilarge ii(wide) iithe iiBP iiwill iiread iihigh iion iia iilarge iiarm
Know iihow iito iicheck iifor iinystagmus ii(p. ii737)
• Nystagmus iiis iiseen iiin iicerebellar iidisease iiespecially iiwith
o gait iiataxia
o dysarthria ii(increases iiwith iiretinal iifixation
o vestibular iidisorders ii(decreases iiwith iiretinal iifixation)
o internuclear iiophthalmoplegia
, • Identify iiany iinystagmus, iian iiinvoluntary iijerking iimovement iiof iithe iieyes iiwith iiquick
iiandislow iicomponents.
• Note iithe iidirection iiof iithe iigaze iiin iiwhich iiit iiappears, iithe iiplane iiof iithe iinystagmus
ii(horizontal,ivertical, iirotary, iior iimixed), iiand iithe iidirection iiof iithe iiquick iiand iislow
iicomponents.
• Nystagmus iiis iinamed iifor iithe iidirection iiof iithe iiquick iicomponent.
• Ask iithe iipatient iito iifix iihis iior iiher iivision iion iia iidistant iiobject iiand iiobserve iiif iithe
iinystagmusiincreases iior iidecreases.
Know iiwhat iiyellow iisclera iiindicates ii(p. ii234)
• A iiyellow iisclera iiindicates iijaundice
Pg. ii72 ii- iiKnow iihow iito iiget iia iipatient iito iiopen iiup iiwhen iihe iiseems iiupset
• The iifirst iistep iito iieffective iireassurance iiis iisimply iiidentifying iiand iiacknowledging iithe
iipatient’sifeelings. iiFor iiexample, ii you iimight iisimply iisay, ii“You iiseem iiupset iitoday.” iiThis
iipromotes iia iifeeling iiof iiconnection. iiMeaningful iireassurance iicomes iilater, iiafter ii you iihave
iicompleted iithe iiinterview, iithe iiphysical iiexamination, iiand iiperhaps iisome iilaboratory iitests.
iiAt iithat iipoint, ii you ii can iiexplain iiwhat iiyou iithink iiis iihappening iiand iideal iiopenly iiwith iiany
iiconcerns. iiReassurance iiisimore iiappropriate iiwhen iithe iipatient iifeels iithat iiproblems iihave
iibeen iifully iiunderstood iiand iiare iibeing iiaddressed.
• Another iiway iito iiaffirm iithe iipatient iiis iito iivalidate iithe iilegitimacy iiof iihis iior iiher
iiemotional iiexperience. iiSaying iisomething iilike, ii“Your iiaccident iimust iihave iibeen iivery
iiscary. iiCar iiaccidents iiare iialways iiunsettling iibecause iithey iiremind iius iihow iivulnerable
iiwe iiare. iiPerhapsithat iiexplains iiwhy iiyou iistill iifeel iiupset,” iivalidates iithe iipatient’s
iiresponse iias iilegitimate iiandiunderstandable
• Moving iicloser iior iimaking iiphysical iicontact iilike iiplacing iiyour iihand iion iithe iipatient’s
iishouldericonveys iiempathy iiand iican iihelp iithe iipatient iigain iicontrol iiof iiupsetting iifeelings.
iiThe iifirst iistepito iiusing iithis iiimportant iitechnique iiis iito iinotice iinonverbal iibehaviors iiand
iibring iithem iito iiconscious iilevel.
Pg. ii 27 ii - ii Know iithe ii signs ii of iidegenerative ii pain
Page ii696
Pg. ii289 ii- iiKnow iihow iiotosclerosis iipresents iiwith iiWeber iiand iiRinne
iitestiOtosclerosis iicondition iithat iiaffects iithe iitiny iimiddle iiear iibone iiknown iias iithe
iistapes.
• Stapes iican iibecome iistuck, iilimiting iiits iiability iito iivibrate ii(vibrations iiare iicrucial iifor iihearing)
• Conductive iihearing iiloss
• Weber iitest
o Tuning iifork iiat iivertex
o Sound iiis iiheard iiin iithe iiimpaired iiear
o Room iinoise iinot iiwell iiheard, iiso iidetection iiof iivibrations iiimproves
• Rinne iitest
o Tuning iifork iiat iiexternal iiauditory iimeatus; iithen iion iimastoid iibone
o BC iilonger iithan iior iiequal iito iiAC ii(BC ii> iiAC iior iiBC ii= iiAC)
o While iiair iiconduction iithrough iithe iiexternal iior iimiddle iiear iiis iiimpaired,
iivibrationsithrough iibone iibypass iithe iiproblem iito iireach iithe iicochlea
