ANP Certification Musculoskeletal Flash Cards.txt

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ANP Certification Musculoskeletal Flash Cards.txt
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ANP Certification Musculoskeletal Flash Cards
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  1. What non-med things cause decrease in bone mass?
    Soda, Smoking, menopause, caffeine
  2. What non-med things cause increase in bone mass?
    Aerobic exercise
  3. Osteoporosis screening age
    DEXA scan at age 65, unless high risk factors
  4. What is the primary cause of DJD?
    Obesity
  5. Gout deposits consist of? What are they called? Where do they go?
    Uric acid, tophaceous, in joints, SubQ and Connective tissues
  6. How much fluid needed orally for gout pt?
    3 Liters /day
  7. Scleroderma- what TLCs, etc. to do to minimize effects?
    Avoid chilled, do ROM, stop smoking
  8. Multiple Sclerosis- what can exacerbate in daily grooming?
    Hot showers may exacerbate s/s.
  9. Should MS patients exercise?
    Be sure to rest in between and flexibility exercises are good
  10. What exercises should be avoided in lumbar spinal stenosis?
    Lumbar extensions worsen radiculopathy by increasing laxity of ligaments
  11. What is example of a ball and socket joint (Spheroidal)
    Shoulder, Hip
  12. Example of a hinge joint?
    Elbow, and IP joints of hands/feet
  13. Example of a condylar joint?
    Knee, TMJ
  14. What is stiffness and limited motion after inactivity called?
    Gelling. Seen in Rheumatoid Arthritis
  15. Anterior Drawer, what does it test? How do you perform?
    The Anterior Drawer Test is used to assess for instability of the ankle. Laxity upon anteriorly moving heel is typically due to a sprain of the anterior talofibular ligament.
  16. What is crossover test and what does it assess?
    Arm goes across chest, assesses acromioclavicular joint
  17. Apley scratch test?
    Put arm behind back and try to touch shoulder blade from above and then below. Difficulty suggests rotator cuff disorder
  18. What is the Apley Compression Test?
    Patient is in prone position, bend up knee. Pushing down on foot. Positive test indicates meniscus damage. Pain, click, or knee lock.
  19. What is the drop arm sign/test? What does it assess? How do you do it?
    Assesses tear of rotator cuff (supraspinatus) have patient abduct arm out to side at 90 degrees and then slowly lower. Positive test will have non-smooth motion.
  20. What causes characteristic shrugging of shoulder?
    Rotator cuff tear
  21. What is tennis elbow?
    Lateral epicondylitis
  22. Pitcher or golfer elbow?
    Medial epicondylitis
  23. Where can you locate Heberden's nodes and Bouchard's nodes? What disease?
    Heberden's nodes on DIP (D in node and DIP) Bouchard's nodes are in PIP joint. These are found in osteoarthritis
  24. What is the deformity typical with Rheumatoid Arthritis?
    IP, MCP and wrist joint with ulnar deviation, typically symmetrical
  25. What atrophy is seen in long standing carpal tunnel syndrome due to compression of the median nerve?
    Thenar eminence atrophy
  26. What is Dupytren's contractures and how do they occur?
    Flexion contractures of 3rd, 4th and/or 5th fingers due to nodular thickening of the palmar fascia
  27. Colles' Fracture?
    Reveals tenderness of the distal radius
  28. deQuervain's tenosynovitis & gonococcal tenosynovitis?
    Tenderness over the extensor and abductor tendons of the thumb at the radial styloid. An inflammation. Also, when bending thumb in ROM, it may be jerky motion
  29. What is the test for deQuervain's tenosynovitis?
    Finkelstein's test. Make fist over thumb and then bend wrist in ulnar deviation. Positive test is pain in wrist (extensor pollicis brevis and abductor pollicis longus tendons)
  30. When does increased thoracic kyphosis occur?
    With age
  31. What is torticollis?
    Muscle spasm of neck
  32. What limited ROM does arthritis of the hip cause?
    Restricts internal rotation of the hip, especially sensitive indicator in arthritis
  33. What does patellar tendon tenderness and inability to extend the leg?
    Suggests partial or complete tear of the patellar tendon
  34. What does a positive bulge or balloon sign in the knee suggest? How is it elicited?
    Can be seen if effusion in knee joint. Elicited by moving over the bursa then looking for bulge or fluid wave.
  35. What does balloting the patella do?
    Compress the patellar pouch and ballotte (push) the patella sharply against femur and watch for fluid.
  36. How do you assess injury to the Medial collateral ligament (MCL)?
    Abductor (valgus) stress test. Hold knee in medially while pulling ankle laterally. Pain equals positive partial tear of MCL
  37. How do you assess injury to the lateral collateral ligament (LCL)?
    Adductor (Varus) stress test. Hold knee laterally while pushing the ankle medially.
  38. Who do you assess the Anterior Cruciate Ligament (ACL)?
    By performing the Anterior Drawer Sign.
  39. How do you perform the Anterior Drawer Sign? And what does it assess?
    Supine position. Knees bent with feet flat on table. Cup hands around the knee and draw the tibia forward (anteriorly). A forward movement or jerking movement is positive for ACL tear.
  40. How do you perform the Lachman Test? & What does it assess?
    Lay flat. Knee flexed and externally rotated. One hand on femur other on tibia and move tibia forward and femur back. Forward excursion indicates ACL tear. Better diagnostic test than the anterior drawer test.
  41. What does posterior drawer test?
    Posterior Cruciate Ligament tear. Bend leg out laterally and push on tibia posteriorly and look at degree of femur posterior movement.
  42. What does the McMurray Test check?
    Meniscus. Checks for ligamental damage of medial meniscus and lateral meniscus
  43. How do you perform the McMurray Test?
    If a click is felt in join line during flexion and extension of knee. Or if tenderness is noted along joint line. Perform test by bending leg out laterally, and then grasp heel and flex knee. Rotate lower leg internally and then externally to assess medial and lateral meniscus.
  44. What is the Thomas Test?
    Evaluates Hip function and ROM
  45. What motion is unable to be performed in presence of Achilles tendon rupture?
    Cannot plantar flex the foot. Also, may have flat footed gait.
  46. What is seen in plantar fasciitis?
    Focal heel pain on palpation
  47. What is seen in Carpal Tunnel syndrome when assessing thumb?
    Thumb weakness on abduction
  48. What does patient complain of in carpal tunnel?
    Numbness and pain of ventral surface of first three digits of hand. Worse at night. Suggestive of median nerve compression.
  49. How do you test Tinel's sign?
    Tinel's-TAP median nerve and will complain of electric or tingling sensation in area of nerve distribution
  50. How do you test Phalen's signs?
    Hold patients hand in acute flexion, or alternatively have patient hold own hands with dorsal surfaces together in acute flexion. Hold either test for 60 seconds. This compresses median nerve and causes numbness and tingling along median nerve.
  51. What does a positive straight leg raise indicate?
    Sharp pain radiation down back of leg in L5-S1 distribution is highly suggestive of compression of nerve root, HNP. And dorsiflexing foot will further increase pain.
  52. What is a positive crossed leg raise?
    Pain in affected leg when opposite leg is raised.
  53. Definition of involvement in Rheumatoid arthritis?
    Chronic inflammation of synovial membranes with secondary erosions of adjacent cartilage and bone with damage to ligaments and tendons
  54. Are joints in RA or OA warm or not?
    RA has warm, tender joints. OA is rarely warm, rarely tender
  55. What arthritis has subcutaneous nodules
    RA
  56. What is process with Gout?
    Inflammatory reaction to microcrystals of sodium urate
  57. Where would you find a Boutonniere deformity?
    Finger of someone with chronic RA. Persistent flexion of the PIP join with hyperextension of DIP.
  58. Swan neck deformity is found?
    Chronic RA, hyperextension of PIP with fixed flexion of DIP
  59. Where are fusiform or spindle-shaped swellings noted?
    On PIP joints in acute RA disease
  60. Systemic Lupus Erythematous (SLE) diagnosis criteria?
    Presence of 4 indicators, which can include: +ANA, +Antiphospholipid antibody, malar rash, arthritis with inflammation, hematological disorder, renal disease, pleuritis, pericarditis, etc.
  61. What glands are affected in Sjogren's syndrome?
    Exocrine glands.
  62. How is Sjogren's syndrome diagnosed?
    Biopsy of salivary gland for positive presence of mononuclear cell infiltration
  63. What can cause increased risk for Carpal Tunnel Syndrome?
    Pregnancy, untreated hypothyroidism, repetitive motion
  64. What is acroparesthesia?
    Waking at night with pain and numbness of fingers
  65. Spinal curvature changes and assessment findings are noted in chronic low back pain?
    Straightening of LS curve, paraspinal tenderness, spasm, decreased LS flexion, decreased lateral bending,
  66. Medications for initial Gout attack?
    NSAID. Indomethacin 50 to 75mg load, then 25-50mg Q8h x 10 days or Naproxen 750mg load then 250 mg q8h x 10 days. And Colchicine
  67. What drug can be given to terminate an acute Gout attack?
    Colchicine, must be given within first 48 hours of first attack.
  68. How is Colchicine dosed in an acute attack?
    0.5mg tablets q1hour until diarrhea. Two tablet loading dose.
  69. When is maintenance therapy started after the first initial attack is over?
    Wait 4-6 weeks after initial attack prior to starting maintenance therapy.
  70. What is given in maintenance therapy?
    Allopurinol given once daily for over producers. Probenecid is given for under excretors.
  71. What other diseases may cause increase in gout rate?
    Psoriasis, lympho or myeloproliferative disorder, chronic hemolytic anemia.
  72. What lab values need to be monitored while on Allopurinol for side effects?
    CBC, affects bone marrow function
  73. What goes wrong in gout attacks?
    Excessive production or decreased excretion of uric acid.
  74. Where does purine come from?
    Byproduct of protein metabolism
  75. What drugs can cause Gout attack?
    Thiazide diuretic, niacin, ASA, ETOH, cyclosporine
  76. Allopurinol use in Gout?
    Takes weeks to start working. Decreased uric acid production
  77. Who is more prone to osteoporosis?
    Men and women are equally prone, men just get it later in life.
  78. Common fx in Osteoporosis?
    Colles fx (distal radius) vertebral fx, and hip fx
  79. What portion of bone is lost in osteoporosis?
    Trabecular bone(cancellous bone)
  80. What role does loss of estrogen play in osteoporosis?
    Causes bone loss to be greater than bone replacement.
  81. Hepatitis A exposure, when does IgM anti HAV titer peak?
    Peaks during 1st week. Gone by 3-6 months.
  82. When does IgG peak with Hepatitis A disease?
    Peaks after had HAV x 1 months, but will stay elevated for years
  83. Osgood-Schlatter disease
    During growth spurt. Knee pain. Worsens with squatting, walking up/down stairs. Tender swollen tibial tuberosity. Pain upon knee extensive and passive hyperflexion.
  84. What is most often seen in a prepatellar bursitis?
    Effusion
  85. What is seen in Reactive Arthritis?
    Poly arthritis, conjunctivitis, urethritis Cant see, Cant pee, Cant climb a tree
  86. What illness can precipitate Reactive Arthritis?
    Acute diarrhea from shigella, Salmonella, Campylobacter or STD Chlamydia.
  87. Lumbar-sacral strain physical assessment findings?
    Neuro exam WNL. Muscle spasm and stiffness. No dx tests needed. Keep moving.
  88. Lumbar radiculopathy caused by
    Typically due to L5-S1, L4-L5 disk bulges causing irritation or damage of nerves.
  89. S/S of lumbar radiculopathy vs. strain?
    Abnormal Neuro findings. Altered DTRs, sensory loss, pain with straight leg raise test. Burning, electric shock pain.
  90. Treatment of Lumbar radiculopathy?
    Conservative, most resolve 4-6 weeks when disk moves back
  91. What is L4 nerve root Reflex, Motor, and sensory?
    Knee Jerk. Foot dorsiflexion. Sensation medial calf
  92. What is L5 nerve root Reflex, Motor, and sensory?
    No reflex check. Great Toe dorsiflexion. Sensation Medial foot.
  93. What is S1 nerve root Reflex, Motor, and sensory?
    Ankle Jerk. Foot eversion. Sensation lateral foot
  94. What is noted in Lumbar Spinal Stenosis?
    Improvement of symptoms when bending forward. Radiating leg pain, can be bilateral. Pseudoclaudication. If s/s greater than one month- start imaging, MRI, EMG.
  95. Treatment for lumbar spinal stenosis?
    PT, NSAIDS, Epidural steroid injection
  96. What conditions would a spinal x-ray be indicated?
    Not routinely. But, if suspected: major trauma age <50, minor trauma age >50, malignancy, Paget's, scoliosis, infection.
  97. When is a MRI/CT Indicated for back issues?
    Evaluate persistent low back pain with s/s of radiculopathy or spinal stenosis.
  98. Definition of Osteopenia?
    BMD is 1.0 to 2.5 SD below norm. (T score -1 to -2.5)
  99. Definition of osteoporosis?
    BMD is >2.5 SD Below norm. (T score at or below -2.5)
  100. At what age should be screening for osteoporosis begin with person with one or more risk factors for osteoporosis ?
    Postmenopausal women <65 Men 50-70
  101. At what age should be screening for osteoporosis begin with person with NO risk factors for osteoporosis ?
    Women age >65 without risks Men >70 without risks
  102. What are the risk factors for Osteoporosis?
    Female. Advancing age. FHx of osteoporosis. Small and thin. Low estrogen levels. Poor Calcium/Vit D intake. Excessive odium, protein, caffeine. Inactivity. Tobacco use. ETOH abuse.
  103. What medications are implicated in cause of osteoporosis?
    Long Term corticosteroid use. Some anticonvulsants.
  104. Presence of what co-existing illnesses cause increase osteoporosis?
    Anorexia nervosa, RA, GI diseases
  105. What areas of body is the DEXA scan performed?
    Femoral neck, total hip, or spine
  106. What are the clinical features of osteoarthritis on xray?
    Joint space narrowing. Becomes bone-on-bone
  107. Navicular fx?
    Due to fall forward onto wrist. Pain with deep palpation of anatomical snuff box
  108. Hip fx assessment?
    Anterior groin and thigh pain which may radiate to knee. Fx leg is shorter. Leg will be abducted, externally rotated
  109. Pelvic fx?
    Difficulty walking, pain with hip movement, and bladder/fecal incontinence
  110. How long should RICE be ordered in acute injury?
    For 48 hours post injury. No ROM, no heat, no exercise. If done too early, will cause increased inflammation and joint damage
  111. How does Glucosamine and Chrondroitin work?
    Glucosamine effect seen after 2weeks to 3 months. Side effect of bronchospasm. Chrondroitin has synergistic effect
  112. Osteoarthritis is most commonly see in what joints?
    Fingers most common. Then Knee and Hip and spine
  113. What are the risks for OA?
    Age, joint overuse, + FHx, contact sports, obesity
  114. When should Celebrex be held?
    In sulfa allergy patient
  115. What is characteristic of OA pain?
    Pain and stiffness gets worse as day progresses
  116. What do joints look like on exam in OA?
    Smooth, cool joints, course crepitus
  117. What can be noted in knees of OA?
    Knee join effusions
  118. What is found on xrays of OA?
    Osteophytes, bone cysts, joint space narrowing.
  119. Treatment of OA?
    Tylenol, NSAIDS, Cox2 inhibitors, steroid injection, or surgery
  120. What is characteristic of RA pain?
    Pain and stiffness is worst in morning, better as day goes on.
  121. What is RA?
    Systemic autoimmune disorder
  122. What joints are affected in RA?
    Generalized aching joints, especially fingers, hands, and wrists.
  123. What arthritis is characteristically symmetrical?
    Rheumatoid arthritis
  124. Which arthritis has a greater joint involvement & what joints?
    RA, hands, PIP,MCP, wrists, elbows, ankles, shoulders.
  125. What arthritis has soft tissue swelling?
    RA
  126. What arthritis typically affects DIP?
    OA
  127. What is found on xrays of RA?
    Bony erosions and joint space narrowing
  128. What is treatment for RA?
    Want to treat early to preserve function, limit deformity, and decrease inflammation and pain.
  129. Treatments medications for RA?
    Systemic oral corticosteroids for short course of 2-8 wks only. Plaquinil. Methotrexate.
  130. What is best way to decrease deformity and preserve function in RA?
    Early use of DMARDs- Disease modifying agent for rheumatoid arthritis disease. Methotrexate. Minocycline, hydroxychloroquine, monoclonal antibodies. Occasional steroid injections.
  131. What is maximum steroid injection allowed per joint per year?
    3 injections/joint/year
  132. What is Ankylosing Spondylitis? What does it affect?
    A chronic inflammatory disease affecting spine and SI joint causing severe arthritic changes. Can also affect hips, feet, shoulders
  133. What musculoskeletal test is altered in ankylosing spondylitis?
    Unable to have full ROM of lower spine
  134. What does CXR reveal on Ankylosing spondylitis?
    Bamboo spine.
  135. What can ankylosing spondylitis progress to?
    Spinal stenosis
  136. What is cauda equina syndrome?
    Acute pressure on sacral nerve root with results in pain, inflammation and ischemic nerve changes.
  137. What neuro test is positive in cauda equina syndrome?
    Pain on straight leg raise
  138. What is the Spurling Test and what does it check for?
    Pain or numbness noted in upper extremity when examiner pushes on the top of the head
  139. What neuro change can be noted in cauda equina syndrome?
    Loss of bowel and bladder sphincter tone.
  140. What is the definition of tendinitis? How is it treated?
    Micro tears in tendon which result in inflammation and pain. Usually due to repetitive injury. RICE
  141. What is the definition of sprain?
    Sprain is a LIGAMENT damage partial or complete. Grade I to III.
  142. What is see in a Grade III ligamentous sprain?
    Grade III is complete rupture of ligaments, complete instability. TX is orthopedic consult,
  143. What area is sprained the most?
    Ankle. Due to Inversion injury. Jumping, running.
  144. What is seen on exam with sprains?
    Edema, bruising, pain
  145. What is supraspinatus tendinitis?
    One of the main tendons in rotator cuff. Common cause of shoulder pain due to inflammation. Causes pain with elevation and abduction. Local point tenderness over tendon of anterior shoulder.
  146. What may be seen in tendinitis on exam?
    Bursitis often occurs with tendinitis
  147. What injury is seen in tennis elbow?
    Extensor tendon of lateral epicondyle is affected.
  148. What injury is seen in golf elbow?
    Extensor tendon of medial epicondyle is affected
  149. What is epicondylitis?
    Weakness and tenderness. Requires conservative treatment of NSAIDS and spot or short cast to stop movement to rest
  150. What does patient complain about with a meniscus tear of the knee?
    Joint locks up, pop sound and cannot kneel or squat
  151. What is treatment for meniscus tear?
    RICE, NSAIDS, arthroscopic repair if not better in 4-6 weeks
  152. Prevention exercises for meniscus tear?
    Quadriceps straight leg raises to strengthen
  153. What is seen in a baker's cyst?
    Pain pressure or asymptomatic ball-like mass in popliteal fossa that
  154. What is seen in a ruptured baker's cyst?
    Resembles cellulitis appearance. Rupture of baker's cyst causes leakage of synovial fluid, inflammation, tenderness, swelling
  155. What joints are commonly affected by bursitis?
    Subdeltoid, olecranon, trochanter, prepatellar
  156. How is ROM limited in bursitis?
    Pain limited ROM only.
  157. What typically causes bursitis?
    Joint overuse, trauma, infection, arthritis
  158. What is MOA of corticosteroids and NSAIDS for pain control?
    Inhibit COX 1 and COX 2.
  159. Most common location for cervical disk problem?
    C5-C6
  160. T-4 innervation
    Nipple Line
  161. T-10 innervation
    Umbilicus
  162. L-1 innervation
    Inguinal
  163. C-6 Innervation
    Thumb
  164. L-4 Innervation
    Knee, Quadriceps
  165. C-7 Innervation
    Fingers 2 and 3
  166. C-8 Innervation
    Fingers 4 and 5
  167. L-5 Innervation
    Foot, sole and ankle
  168. S-2,3 Innervation
    Scrotum
  169. S-5 Innervation
    Perineal
  170. Biceps Reflex tests
    C5, C6
  171. Triceps Reflex tests
    C6, C7
  172. Knee Reflex tests
    L2, L3, L4
  173. Ankle Reflex tests
    S1
  174. Plantar Reflex tests
    L5, S1
  175. What does positive Babinski look like and what does it indicate?
    CNS lesion
  176. Goals of Sports physical?
    Decrease risk of exercise inducted cardiac death and decrease the progression of CV function caused by exercise
  177. What are the common causes of exercise related death in younger than 35 years of age?
    Often occurs during team sport. Congenital Heart malformations, HCM, congenital Coronary artery abnormalities
  178. What are the common causes of exercise related death in older than 35 years of age?
    Due to atherosclerosis
  179. What are important questions to ask during a Sports Physical?
    Prior chest pain, syncope, SOB, hx murmur, HTN, + FHx of Sudden death, Marfans, Long QT, cardiomyopathy, arrhythmias.
  180. What is important to assess in a Sports Physical?
    Check for murmurs supine and then standing.
  181. What is a Still's Murmur?
    Vibratory, Innocent Murmur
  182. What is the criteria for an innocent functional flow murmur?
    Murmur that become more faint with standing
  183. What does exercise cause when exercising with positive hypertrophic cardiomyopathy?
    Exercise can cause outflow obstruction
  184. What is the dose of calcium for osteoporosis?
    1200 to 1500 mg daily for women. 1000 mg daily for men
  185. What is the dose of vitamin D for osteoporosis?
    600 � 900 IU daily
  186. What role does the SERM Raloxifen (Evista) play in osteoporosis?
    Safe alternative to Estrogen supplement, does not adversely affect breast or uterus
  187. How do Biophosphonates work on the bone in osteoporosis?
    Inhibits osteoclast activity and increases bone mass and decreases bone fracture
  188. How should a patient be instructed to take a Biophosphonate?
    Full glass of Water, Empty stomach x1 hour, erect x 1 hour
  189. What is the definition of Fibromyalgia?
    Central Pain Syndrome
  190. What happens in Fibromyalgia?
    Sensitization of CNS, causing diffuse hypersensitivity to pain. Also noted to see low serotonin.
  191. What diagnostic exam and criteria for diagnosis of Fibromyalgia?
    Need presence of tender Points specific to certain diagnostic locations, pectoral muscle at 2nd rib, shoulder, trapezius, piriformis area. Need pain in axial skeleton plus 4 other quadrants, more than 3 months. Need 11 out of 18 spots positive. (9 pairs)
  192. What other symptoms are noted with Fibromyalgia?
    Cognitive changes, constipation or diarrhea, altered moon
  193. Non pharmaceutical Treatment of Fibromyalgia?
    Physical activity, trigger point injection, topical capsaicin,
  194. Non pharmaceutical Treatment of Fibromyalgia?
    Pregabalin (Lyrica) and Duloxetine (Cymbalta) FDA approved for Fibromyalgia pain. Trazodone for sleep, TCAs. Antiepileptics Gabapentin.
  195. Osteomalacia, what is it and what causes it?
    Softening, rubbery deposit in bone causes an abnormal collagen matrix. Due to Vitamin D Deficiency.
  196. What lab results are noted in Osteomalacia?
    Increased Alkaline phosphatase and decreased serum calcium, serum phosphorus, creatinine, and urinary calcium.
  197. What drugs can cause Vitamin D Deficiency?
    Dilantin and Phenobarbital. Need 2-5x recommended Vitamin D Supplement
  198. What medical problems can cause Vitamin D Deficiency?
    Gastric Bypass, Liver and Renal disease
  199. What is the Hollick's recommendation for Vitamin D Supplementation in deficiency state?
    50,000 IU Vitamin D once a week x 8 weeks. Then 50,000 IU twice monthly plus daily lose dose supplements
  200. How do you instruct cane walking?
    Place can on side of GOOD leg. Move it in conjunction with affected leg. Cane should be at height of greater trochanter.
  201. What is Dorsal Kyphosis?
    Age related increase in convexity of T spine
  202. What is Lordosis?
    Pregnancy or obesity related increase in lumbar concavity
  203. What is the Thompson Test?
    Tests of Achilles tendon rupture by squeezing calf. If positive rupture, absent foot movement is noted
  204. What nerve test is done to diagnose Myasthenia Gravis?
    RNS test. Repetitive nerve stimulation test.
  205. Comminuted Fracture dx?
    Bone fragments in many pieces
  206. Open Fracture (compound) dx?
    Broken ends of bone poke through skin
  207. Closed Fracture (simple) dx?
    Even break, but no skin involvement
  208. Compression Fracture dx?
    Crushed bone
  209. What assessment is noted in a anterior dislocation of the shoulder?
    More common. Unable to shoulder shrug, positive pain and arm lengthening
  210. What is the largest joint in the body?
    Knee
  211. Will HNP show up on xray?
    No
  212. What is subluxation?
    Partial joint location

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