Physical Exam (work In Progress).docx

Stanford Medicine 25: 1) Gaits: a) Hemiplegic: This is the most common gait. The patient stands with unilateral weakness on the affected side, arm flexed, adducted and internally rotated. Leg on same side is in extension with plantar flexion of the foot and toes. When walking, the patient will hold his or her arm to one side and drags his or her affected leg in a semicircle (circumduction) due to weakness of distal muscles (foot drop) and extensor hypertonia in lower limb. This is most commonly seen in stroke. With mild hemiparesis, loss of normal arm swing and slight circumduction may be the only abnormalities. b) Diplegic: Patients are involved on both sides with [extensor] spasticity in lower extremities worse than upper extremities (tip-toe). The patient walks with an abnormally narrow base, dragging both legs and scraping the toes. There may be scissoring of legs due to tightness of hip adductors. c) Parkinsonian: The patient will have rigidity, bradykinesia and universal flexion. Head, neck will be stooped, the upper extremities are also in flexion with the fingers extended. Marche a petits pas (festination). Patients can have difficulty initiating steps or may tend to accelerate them. Parkinson’s disease or DIP (atypical antipsychotics, antiepileptic drugs, CCB, gastrointestinal prokinetics). d) Cerebellar (ataxic): Wide-based gait with clumsy and staggering movements. Resembles the gait of acute alcohol intoxication. While standing still, their body goes into titubation. Patients will tend to fall towards the side of the cerebellar injury. e) Myopathic: Hip girdle muscles (abductors) are responsible for keeping the pelvis level when walking. If you have weakness on one side, this will lead to a drop in the pelvis on the contralateral side of the pelvis while walking (Trendelenburg sign). With bilateral weakness, you will have dropping of the pelvis on both sides during walking leading to waddling. This gait is seen in patient with myopathies, such as muscular dystrophy. f)

Neuropathic (steppage): Seen in patients with foot drop (weakness of foot dorsiflexion), the cause of this gait is due to an attempt to lift the leg high enough during walking so that the foot does not drag on the floor. If unilateral, causes include peroneal nerve palsy and L5 radiculopathy. If bilateral, causes include amyotrophic lateral sclerosis, Charcot-Marie-Tooth disease and other peripheral neuropathies including those associated with uncontrolled diabetes.

2) Fundoscopic exam: a) Vessels emerge from the nasal side of the disc. Arteries are narrower than the veins. The cup-to-disc ratio is normally 0.5 (this is increased in glaucoma). b) Optic disc blurring in the setting of increased cranial pressure is referred to as papilledema (tumors, sinus thrombosis, hydrocephalus, meningitis, malignant hypertension). c) Roth spot (retinal hemorrhages with white or pale centers) typically caused by immune complex mediated vasculitis often resulting from bacterial endocarditis.

d) AV nicking (chronic hypertension stiffens and thickens arteries which will then compresses a venule resulting in bulging on either side of the crossing) and cotton wool spots (fluffy white patches caused by damage to nerve fibers because of axoplasmic material accumulation from ischemia – this is found in diabetes and hypertension). Cholesterol emboli. Flame hemorrhages (necrotic vessels bleeding into retina), copper-wire arterioles (central light reflex occupies most of the width of the arteriole), silver-wire arterioles (reflex occupies all the width). 3) Ankle-brachial index: a) ABI is the systolic pressure at the ankle, divided by the systolic pressure at the arm. It is a s/s metric for the diagnosis of peripheral arterial disease. Major cardiovascular societies advise measuring an ABI in every smoker or diabetic over 50 years and all patients over 6070. b) Blood pressure cuff and handheld doppler to measure the SBP in brachial and posterior tibial or dorsalis pedis artery.