重要physical examination你好我是XXX可以給檢查么

OrthopaedicCervicalspine你好，我是XXX，可以給你檢查么？chaperonforfemalepatientwashandgelhandposition:sitexposure:undonethetopbuttonanddowntobothclavicleskinpigmentation:redness,discoloration,bruisingskinintact:scar,ulceration,sinus,fistulaunderskin:swelling,musclewastingbony:torticollis:headispulledtotheaffectedside,chintiltedtothecongenital:SCM,withfacialacquired:protectivemusclespasmfromtonsillarorV.Binfection,orKlippel-Feilsyndrome,vertebralmalalignment,trauma,upperrespiratoryinfection.Lookatthesidefromcervicalanyasymmetryinthesupraclavicular痛不痛temperature:tenderness:spinousprocessfromocciputtoT1,lalaspectofsupraclavicularfossa:cervicalflexion:chintochest(chincantouchthesternoclavicularjoint),80oextension:seetheceiling(noseandforeheadshouldbehorizontal),50ola lflexion:eartoshoulder,rotation:lookbackwardovertheshoulder(chinshouldbeintheneofshoulder),80oSpecialthoracicoutletsyndrome:Adson’ssign:fromasittingposition,extendthearmandrotateheadtotheipsila lsidefollowingdeepinspirationandchecktheradialpulseWrighttest:Fromasittingpositionandholdthearmupandback(hyperabduction),withrotatingoutwardandchecktheradialRoo’stest:Fromasittingposition,holdbothelbowsatshoulderheightwhilepushingshouldersbackandaskpatienttorepeatedlyopenandclosethehandsforseveralminutes.NeurologicalandneurologicalexaminationofULs.vascularstatusofULs.shoulderexamination.Xray:lal,AP,pegview.saythankshelptocoverandstandwash/gelhandShoulder你好，我是XXX，可以給你檢查么？chaperonforfemalepatientwashandgelhandposition:standorsitexposure:shirtoffInspection(anterior,side,skinpigmentation:redness,discoloration,bruisingskinintact:scar,ulceration,sinus,fistulaFront:skin,prominentsternoclavicularjointoracromioclavicularjoint,claviculardeformity,deltoidwasting.Side:skin,swelling.Back:skin,supraspinatus,infraspinatuswasting,abnormalscapula,webbingoftheneck,wingingscapula(pushwall)Above:skin,asymmetryofsupraclavicularfossae,swellingoftheshoulder,deformityofthe痛不痛temperature:tenderness:circumferencial:sternoclavicularjoint,clavicle,acromioclavicularjoint,acromion,coracoidprocess,supraclavicularfossa,spineofscapula,lalborderofscapula,inferiorpoleofscapula,medialborderofscapulasubacromialspace,glenohumeraljointline(anterior,lal,posterior),greatertuberosityofhumerus,bicipitalgroove.axillawhenabduction:osteomas,lipomas,abduction:activeto180o,observeDifficultininitiationofabduction:majorcuffpainfularc(slowlyabduction,passively-60-120o:cuffimementin140-180o:cuffimementinACJorcoracoacromiallig.OrOAofacromioclavicularPassivelyassistedabductionwithE.R.,ifactiveabductionislimited:fullrangeindicatesintactglenohumeraljointHoldthearminverticalposition:indicatingintactdeltoidandaxillaryLowerthearmtotheside,Suddendropsign:majorcuffIfactiveandpassiveabductionarerestricted,fixtheangleofscapula,abductthearm,absenceofmovementindicatesafixedglenohumeraljoint.adduction:armtooppositeshoulderforOAofacromioclavicularjointforwardflexion:active,165oextension:active,60oexternalrotation:atelbow90oflexion,60oScreening:handsbehindthehead,pullbothelbowinabduction:100inextension:70internalrotation:Screening:cehandbehindtheshoulderbladeashighaspossible(6ththoracicinabduction:70inextension:70crepitus:ceonehandontheshoulder,withmiddlefingerontheACJ,abductthearmwiththeotherhand.Directthecrepituscomingfromtheshoulderandlocateitssource(glenohumeralandACJ)Specialrotatorcuffexamination:imement:Neerimementsign(Neertest:injectionofxylocaine)andHawkin’scross-bodyadductionglenohumeralinstabilitytest:firstlydolaxityapprehensiontest:shoulderabduction90o,relocationtest:lyingjerksulcuslongheadofbiceps:rupture:Popeyebulge(shoulderflexionwithelbowflexion bicepstendinitis:Speedtest,shoulder90oforwardflexion,elbowextended,forearmYergason’stest:resistedsupinationwithelbowflexedtoInstabilitytest:shoulderabduct90owithelbowflexion90o,fingersonthebicipitalgroove,shoulderI.R.feelthedislocationandhearclick.musclepowerordeficiencytest:deltoid:abduction atsupraspinatus:Jobe’stest(armelevatedwiththumbdown infraspinatusandteresminor:externalrotationsubscapularis:lift-offserratusanterior:wingingscapulawhenpushingtheneckandelbowexaminationdistalpulseneurologicalexaminationofupperlimbsaythankshelptocoverandstandwash/gelhandElbow你好，我是XXX，可以給你檢查么？chaperonforfemalepatientwashandgelhandposition:standexposure:shirtoffInspection(cubetalfossaforanterior,crossarmforlalandposterior,handbehindheadforskinpigmentation:redness,discoloration,bruising,hairskinintact:scar,ulceration,sinus,fistulaunderskin:generalized(effusion):thehollowsseenintheflexedelbowaboveolecranon,radiohumerallocalized:rheumatoidnodule,olecranonmusclewasting:forearm&bony:cubitalvalgus,cubitalvaruscarryingangle:11oformen,13ofor痛不痛temperaturetenderness:medialepicondyle, lepicondyle,olecranon: ljointline,headofradius:pronateandsupinateforcrepitus,injuriesofradialhead,OA,osteochondritisdissecansantecubitalfossa:onbothsidesofbicepstendonwhileflexingandextendingtheelbowthrough20o:myositisossificans&loosebodies.medialjointline,headofulna,ulnarnerve:rollthenerveintheflexion:145oextension:pronation:75osupination:80oSpecialelbowinstability:lal lligament:varusstresstest(0oand30medial lligament:valgusstresstest(0oand30ulnarnerve:tinel’ssignandflexionforcubitaltunnelsyndrometenniselbow:Thomsen’test(extendwristandelbow Tenniselbowsign(flexelbowandpronationandthenextendgolfelbow:golfelbowsign(flexelbowandsupinationandthenextendshoulderandhandexaminationdistalpulseneurologicalexaminationofupperlimbsaythankshelptocoverwash/gelhandWrist你好，我是XXX，可以給你檢查么？chaperonforfemalepatientwashandgelhandposition:standexposure:sleeverolleduptoelbowskinpigmentation:pitting,redness,discoloration,bruisingskinintact:scar,ulceration,sinus,fistulapalm:localized:ganglioninwristandpalm,rheumatoidnodulesorradialandulnarside:prominenceofanteriorandposterioranteriordeQuervain’sdorsum:ganglionsonwrist,carpus,extensor痛不痛temperaturetenderness:dorsalaspectofabductorpollicislongusandbrevis:deQuervain’smedianN,ulnarcrepitus:radioulnarjoint:radiocarpaljoint:dorsiflexion,palmarflexion,radialdeviation,ulnardorsiflexion:screeningtest:holdforearmorprayerpositionandpalmarflexion:holdforearmorreverseprayerpositionandulnardeviation:35oradialdeviation:20opronationsupinationSpecialDistalradioulnarjointlaxity:Onehandholdthecarpal,theotherholdthedistalulna,thenmoveitinvolaranddorsalCarpalinstability:Middlecarpalneckandelbowexaminationneurologicalexaminationofarmsaythankshelptocoverandstandwash/gelhandHand你好，我是XXX，可以給你檢查么？chaperonforfemalepatientwashandgelhandposition:sitexposure:sleeverolleduptoelbow,askforapillowandcebothhandsonthepillow,dorsumsideup!Dorsumskinnailchanges:pitting,vasculiticbruising,purpura,thinningoftheskin,psoriaticques,goutytophi,rheumatoidsurgicaldorsalwrist:previoussynovectomyorarthrodesisinunderskin:ganglioninwristandpalm(ifinthedorsum,askthepatienttoflexthemovewithextensormoreobviouswhenwristisspindlingofthefingers,fusiformmuscledorsal1stdorsalbonydeformities:OA:Heberden’snodule,bouchard’s“thereareHeberden’snodeatbaseofthedistalphalanges,andBouchard’snodesatPIP.Thereissquarehanddeformityduetosubluxationofthebaseofthefirstmetacarpal”RA:ulnardeviationoffinger,radialdeviationofwrist,Swan-neckdeformity,boutonnieredeformity,Z-shapedthumb,subluxationatMCPjoint“thereissymmetricaldeformingpolyarthropathyofthejointswithspindlingofthefingers,affectingtheMCPandPIPjointsbutsparingtheDIPjoints.”fingermalletthumbifthereisnoobvioussigns,AskforOKsignandotherscreeningtest.Palmarskin:palmarerythma,pallorinpalmersurgicalscars:carpaltunnelsyndrome(mayhavetinyunderskin:wastingofthenarandbonydeformity:areanyfingersheldinaattitudeofClawOtherulnaraspectofthewristposition:handbehindtheirheadscarsaroundthemedialepicondyleulnarrheumatoidpsoriaticgouty痛不痛TemperatureTenderness:canonlybeperformedataffectedjoint.lumps:rheumatoidDupuytren’scontracture(nodularthickeningoftheTriggerfinger(A1BonyMovementandFingermovement:makeafistandburythespreadtheirfingersapartandsqueezeyourfingers,toassesstheThumbmovement:opposethumbtoeachwristmovement:radialandulnardeviationofthewristfunctiontest:pickupacoinfromtheunfastenandrefastenthegarmentpretendtouseaSpecialtendon:flexordigitorumflexordigitorumflexorpollicisextensorpollicischecktheneurovascularstatusassessthefunctionalstatusexaminethespine,foot.examinetheextra-articularmanifestationofrheumatoiddiseaseeyes,skin,Askthepatientsomequestionstoinvestigatetheeffectoftheconditionoftheirlife.RequestXrayforhandandspinesaythankshelptocoverandstandwash/gelhandNeurologicalexaminationofupper你好，我是XXX，可以給你檢查么？chaperonforfemalepatientwashandgelhandposition:sitexposure:sleeverolleduptoelbow,askforapillowandcebothhandsonthepillo,palmsideup!skinpigmentation:redness,discoloration,bruisingskinintact:ulceration,sinus,underskin:swellingSystemicapproachfordeformity&musclewasting,dorsumandpalmside!HandandDeformity:simianthumb,benedictionsign(makeafist),clawhand(extendfingers),wristdropandfingerdrop(extendthewrist),Klumpke’spalsy,MyelopathyhandMusclewasting:pulpatrophy,thenarandhypothenarwasting,firstwebwasting,dorsalForearmandDeformity:cubitalvalgusorWasting:forearmwasting,lalandmedialforearmflexorArmandWasting:armanddeltoidmusclewastingdeformity&musclewasting:medianthenarwasting(simianthumb),pulpatrophy,lalforearmflexorbenedictionulnarhypothenarwasting,firstwebwasting,medialforearmflexorclawcubitalvalgusorradialwristarmaxillarydeltoidmuscleErb’spalsy:waiter’stipdeformity,upperKlumpke’spalsy:hypothenarandthenarwasting,clawhand,lowerMyelopathyhand:fingerescapesign,fastgripandreleasetest(20timesin10dermatome:patientlookatceilingandmakethetwoarmclosetoeachotherandcomparebytestquicklyfortoughandpainshoulder(C5—axillarysnuffbox(C6—radialmiddlefinger(C7—medianlittlefinger(C8—ulnarmedialelbow(T1—medialbrachialcutaneousindividualnerve:mediantipsofthumbandindexlalaspectofulnartipsoflittleulnaraspectofdorsumandradialfirstwebradialaspectofbackofaxillarylalaspectoflalaspectofmuscletonemyotomes:deltoid(C5--axillarybiceps(C5--musculocutaneousextensorofwrist(C6--radialtriceps(C7--radialflexordigitorumprofundus(C8—medianinterossei(T1--ulnarIndividualnerve:MedianabductorpollicisflexorpollicislongusandFDPofindex(A.I.N):screeningtestOKpalpatethemediannerve(betweenFCRandPL,forciblyflexthetinel’ssignandphalen’stestandtourniquetulnarfirstdorsalabductordigitiadductorpollicis:Froment’sflexorcarpiRadialExtensoroffingersandExtensorofSupinator:extendtheaxillarynerve:musculocutanousnerve:elbowSpecialreflex:bicepsreflex(C5/6–musculocutaneoussupinator(C6–radialtriceps(C7–radialcarpaltunnelsyndrome:Phalentest(flexionofwristforUlnartunnelsyndrome:PalpatetheSpurlingtest,Lhermitte’ssignNeckexaminationvascularstatusofULssaythankshelptocoverandstandwash/gelhandmedianinthecarpeltunnel;inthewrist(laceration);attheelbow(elbowdislocation),intheforearm(anteriorinterosseousnerve)justdistaltotheelbow(pronatorentrapmentsyndrome)ulnarc wrist(laceration)distaltoelbow(compressionoftwoheadsofFCU)ulnartunnelsyndromeplexusradial

arminfrontofbelowCompletesensoryexamination:vibration,jointpositionsense,pain,Back你好，我是XXX，可以給你檢查么？chaperonforfemalepatientwashandgelhandposition:standwithbacktodoctorexposure:withtrouserdownInspectionfromskinpigmentation:redness,discoloration,bruising,café-au-laitspots,hairspatches,skinintact:scar,ulceration,sinus,fistula.underskin:swelling,musclewasting.bonystandingposition:shoulderandhiplevelarelevelorifyes,askpatienttosittoexcludecompensatoryscoliosis(legbendforwardtoexcludeposturalscoliosisbeforediagnosingastructuralInspectionfromLumbercurvature:flatteningorreversalofnormallumbarlordosis.bonydeformity:kyphosis:itispostureorifyes,askpatienttobendforward,anincreasedcurvaturewhichisregularand posturekyphosisifnot,itisfixed,senilekyphosis(osteoporosis,osteomalacia,pathologicalfracture),Schermann’sdiseaseandankylosingspondylitis.Angularkyphosis:Causes:fracture,TB,congenital痛不痛temperature:tenderness:spinousprocessfromT1down,noteanylalaspectofsacroiliacjoint:mechanicalbackpain,orsacroiliacjointflexion:touchhis/hertoes,normal:cantouchthegroundorwithin7cmfromitSchober’smethod:<5cmindicatesextension:la lrotation:seated,measuredbetweentheneofshoulderandpelvis.Specialprolapsedintervertebraldisc:screeningthehip:rotationin90ostraightlegLyingdown,raisethelegfromthecouch,stopwhenthepatientcominsofparaesthesiaorbackpainorlegpain.Ruleouthamstringtightness.Performbilally.Backpain:suggestscentraldiscLegpain:suggestslalprolapses,painmustbebelowBragard’stest:LowerdowntheleganddorsiflextheBowstringtest:FlexthekneeandapplyfirmpressureinthepoplitealSitingpositiontest:legsoverthecouch,lifttheleguntilthekneeisfullyextended,notetheReverseLaseguetest:femoralnervestretchtest,highlumbardiscSacroiliacjointtest:flexthehipandknee,andforciblyadductthePelviccompressionorbytryingopenoutthepelviswiththumbshookedaroundtheanteriorHeel-hips-occiputtest:knownaswalltestforAS.neurologicalexaminationofLLs.vascularstatusofLLs.Hiporkneeexamination.Xraysaythankshelptocoverandstandwash/gelhandHip你好，我是XXXchaperonforfemalewashandgelposition:standinexposure:trousersInspection(stand,oftenomittedinCommentonthepresenceofanywalkingaids.Front:pelvictilting,quadricepswasting,rotationaldeformity.Side:lumbarlordosis(fixedflexiondeformity),shortleg.Back:glutealwasting,scoliosis.CommentontheskintestGait:antalgicgait,stiffkneegait,instabilitygait(thrust)Inspectionskinpigmentation:redness,discoloration,bruisingskinintact:scar,ulceration,sinus,fistulaunderskin:swelling,quadricepswastingbony:rotationaldeformity“theRlegliesin/heldinexternalrotationwithapparentLegdiscrepancy:Obvious,ifnotobvious,measureapparentlengthandtrueIfpositive,Galeazzi’stest,Bryanttriangleconfirmthelocationof“thegreatthrochanterissomewhat痛不痛temperature:tenderness:Femoralhead:rotatethelegmediallyandlaAdductorLesstrochanter:e.r.theIschial“posterioranddeeppressureelicitsmildThomastestandflexion cingthehandbehindthepatient’sFlexthegoodhipasfaraspossibleandholdit,lumarlordosisisobliPositiveornot,therangeofflexionofaffectedWatchthepatient’sfaceforsigns Abduction:holdbothASISwiththeforearm,45oAdduction:holdbothASISwiththeforearm,25oInternalrotation:straight(twomethods,35o)andflexion90o(45o)Externalrotation:straight(45o)andflexion90o(45o)extension10o(canbeomitted)“flexionofgoodhipfrom0to120,flexionofbadhipfrom20to120,implyinganFFDofthebadhipof20”“markedlossofmovementattheTrendelenburgtest,ifsupineatfirst.(howtoexinthepositiveTrendelenburgtest)Gait.Assesstheextension.neurologicalexaminationofLLsvascularstatusofLLslookathandandfootforotherarthropathy.backandkneeexaminationrayssayhelptocoverandKnee你好，我是XXX，可以給你檢查么？chaperonforfemalepatientwashandgelhandposition:stand,oftensupineinosceexposure:trousersandsocksoffInspection(stand,oftenomittedinCommononthepresenceofanywalkingaids.Front,side,backinspection(seeasfollows)gait:antalgicgait,stiffkneegait,instabilitygait(thrust)squatInspection(supine,isomittedwhenstandinginspectionSkinpigmentation:Redness,discoloration,bruisingSkinintact:arthroscopicportalscars(anteromedicaland lmidlinelongitudinalincision:Ulceration,sinus,Underskin:Confinedwithinthesynovialandsuparpalarpouch:effusion,pyarthrosis,Extendsbeyondthejoint lar larMeniscusObviousQuadricepswasting(especiallyvastusmedialis,askthepatienttopushlegstowardtheifnotobvious,measurecircumference15cmabovetibialtuberosity.(omittedinOSCE)Bonyalignment: (putthepatient’sLLinneutralpostionandputthekneestogether,lookatthegapbetweenvalgus,varus,fixedflexion,TemperatureJointeffusion:Palartaptest(onehandcompresssuprapalarbursaandtapon Fluiddiscementtestorcross-fluctuationtest(sweep edialsidefirstandthenlalwithpopoutofthedimple)Palarhollowtestandbulgetest(forsmallTenderness:(atthesametime,forosteophytes.)withknee45oflexion:tibialtuberosity,palarligament,medialjointline,medialtibialcondyle,medialfemoralcondyle,medialcollalligament,laljointline,fibularhead,lalfemoralcondyle,lalcollalligament.Extensorwithextension(extensorapparatus):tibialtuberosity,palartendon,lowerpoleofpala,medialandlalborderofpala,upperpoleofpalar.Movethepalarintwones,pressureonpala.PoplitealfossaLumpcharactersQuadriceps:(omittedinosce)pushheelagainstbedtofeelthebulkofDorsiflextheinvertedextension:Activeextension:askthepatienttopointtheirtoestotheceiling(extensorPassiveextension:onehandliftingheelandonehandpushpaIfextensorlagispositive:”thekneelackX°ofPassivelycorrected:weakSpringyblock:bucket-handlemeniscusRigidblock:arthriticflexion:heeltobottom(135°)passive:SpecialCruciateligaments:Posteriorsag:heeltogetherwithknee45oflexionorliftheelforknee90oflexion,indicatingposteriorcruciateligamentinjury.Anteriordrawertest:don’tforgettodisengagethe1+:0-2+:6-3+:11-4+:>=Posteriordrawertest antest:flextheknee30o,mostsensitiveforACLinjury.Colla lLig.Valgusstresstest(0oandVarusstresstest(0oandIfvarusstresstest(+),commonperonealnervetest.Meniscus:McMurray’stest:Medialmeniscus:palpateposteromedialjointline,e.r.thelegandvarus lmeniscus:palpatepost ljointline,i.r.thelegandvalgus ClicksorpainsuggestingFull 90o:posterior extension:middleandanteriorApprehensiontest:pushpa lalalatextensionandflexInspectionandpalpation(proneLookforbursae,whenkneeextended:Baker’scyst.

ThemusclepowerofthelowerDistalsensation(commonperonealN,ifvarusdeformitypresentorvarustestpositive)andneurologicalexaminationoflowerlimb.saythankshelptocoverandstandwash/gelhand

Ankleandfoot你好，我是XXX，可以給你檢查么？chaperonforfemalepatientwashandgelhandposition:standexposure:trousersoffforbilalfootInspection(standing&lookatlegs,ankles,feet,arches,toes:skinskincorn,ulceration,sinus,underskin:swelling,musclebonydeformity:(anterior,posterior,side,onefootinfrontofthegenuheel:varusorproportionalor ntigradefoot,eversionor ying:intrinsicmuscleweakness,medialarch:pescavusortoes:halluxvalgus,bunion,hammer-toe,malletgait:footdrop,asktowalkontiptoe,asktowalkoninspectionheels:calcanealprominencewithoverlyingbursitis:dorsum:5thmetatarsalheadorBigtoe:Halluxvalgus torychanges:redness,Underoroverridethe2nd2ndtoemaysubluxateatMTPHalluxThickeningatMTPExcesscallusunderthegreatHalluxElevated:subungualUnevenintextureandgrowth:suggestingfungalinfectionorToes:Ifnotproportional,FlexthetoesandnotetherelativelengthsoftheClawCurlyHammerMalletQuinitiCorns:BetweentheSole:Hyperhidrosis,fungalinfection,athlete’sfoot,ulceration,pesCallus:weightbearingVerruca:tarwart,don’toccuratpressureareas(differentfromGreatpalpationtendernessinmedialmalleolus,medialanklejointline,mediallalmalleolus,lalanklejointline,lalAchillestendon(ntarflexion tendernessintarsaltunnelgreattoe:morton’sneuroma(between2nd-3rdmetatarsal ntarflexion:holdshinandgripdorsalflexion:holdshinandgripinversion:holdankleandgriplowereversion:holdankleandgriplowercurltheextendthekneeandbackperipheralvascularneurologicalexaminationoflowersayhelptoHalluxExposure–bila llowerInspectioninstanding:halluxvalgusandpronation,bunion,metatarsalLessertoesusuallyclawtoedeformityorcrossSignsof Midfootandflatfoot;tip-toelyingdown:SoleforPalpationmovement:PassivecorrectivethevalgusIPJ(interphalangealvalgus);MTPJ(normaldorsalflexion>65degree;halluxrigidus);TMTJ(hypermobilityorarthritis);Offer:WatchthepatientExamineher/hisAssesstheeffectoftheconditiononher4angles:HVangle,Interphalangealangle,IMA,CongruencyofMTPJ,arthritisofLessertoedeformity(ruleoutRA,OAandothersystemicDDX–juvenilehalluxvalgus,generalligamentlaxity;interphalangealvalgus;MTPJarthritis/Neurologicalexaminationoflower你好，我是XXX，可以給你檢查么？chaperonforfemalepatientwashandgelhandposition:standingexposure:exposelowerlimb.Inspectioninstandingskinpigmentation:redness,discoloration,bruisingskinintact:ulceration,sinus,underskin:swellingmusclewastingoflowerlimbfromfoottothigh.deformity:Clawfoot:tibialverveFootGait:Wide-basedgait:cerebellarStiff“walkingthroughmud”gait:spaticStamgait:sensoryataxia(shouldhavepositiveRomberg’sgaitasStooped,hesitantshufflinggaitwithnoarmswing:Parkinson’sHigh-step:footdrop(maybefromperonealnerveOnelegstiffwithsemicircularswingand larmflexed:Lumbarlordosis,swayingtrunkandwaddlinggait:DuchennemusculardystrophyandproximalBroad-based“walkingonice”gait:apraxia,seniledegenerativedisease(especiallyoffrontalOrders:“Walkinlineputtingyourheeltoyourtoelikethis”:“walkontiptoes”,“nowwalkonyourRombergPalpationinsupineMuscletone:Maneuver:rolleachthighgentlyfromsidetoside(hip),liftthekneeacoupleofinchesandleftitdrop(knee) ,jerkiness,spasmandlackofdermatome:comparebytestquicklyfortoughandpainmid-pointofinguinallig.:betweenL1&themedialfemoralcondyle:medialmalleolus:thedorsum3rdmetatarsophalangealjoint:thelalheel:poplitealfossamidline:ischialtuberosity:sensorylossdistributionforsinglenerve:frontofthemedialsideofthelegandfoot(saphenousSciaticBelowkneeexcepttheterritoryofsaphenouscommonperonealdeep:firstwebsuperficial:thelalsideofleganddorsumofTibialSoleoffoot,nailbedsanddistalphalanx: land nter laspectoffoot:sural lcutanousnerveofthe laspectofthemyotomes:flexion:L2 internalextension:L4 externalextension:L3flexion:L5dorsiflexion:L4ntarflexion:S1eversion:L5greattoeandflexion:S1Individualnerve:iliopsoasquadriceps,Sartorius,CommonperonealSuperficial:everttheDeep:dorsiflexthefoot,extensionthegreattibialsoleus emius:lossofallthemusclesofthesoleofthefoot:toesciaticnerve:commonperonealnerve+tibialnerve+LalcutanousnerveofthePressureoverthelalportionoftheinguinalSpecialreflex:kneereflex:anklereflex:pathologicalreflex:Babinski’ssignclonusBackexaminationandjointexaminationvascularstatusofLLssaythankshelptocoverandstandwash/gelhandLowerlimbarterial你好，我是XXX，我可以檢查你的身體嗎？chaperonforfemalepatientwashandgelhandposition:supineexposure:fromgrointotoeandcoverexternalgenitaliaInspection(fromgrointoskin:Colorinthelowerlimbespeciallyinlowerleg:pale,varyingdegreeofrednessorPurplebluecyanosedappearance:severeischaemiaduetodeoxygenatedbloodPurpleredwithincreasedtemperature:Mottleddiscolorationwithbluestreaksaroundwhitepatches:acutePallor:chronicAtrophyofpulp,hairloss,shiny ethickenedbecauseofslownailVenousgutteringatrestorduringtheLookforscars,ulceration,gangrenefromabovetobelow,raisethelegtothigh,foot:heelandtoesarecommonlysole,dorsum:theheadof1stand5thtoes:inter-digitalweb,surgicalveinflapsforcoverageofulcersorgroinnormalforexample:“thereisanulceroverXXX,whichisxxcmindiameterandellipticalinshape.aboutthepain)theulcerandsurroundingtissuesaretender.ThedepthisconsideredasverydeepwithexposureofXXX.Itsedgeispunchedout(/slo)withbluegreycoloredsurroundingskin.Thebasecontainsgreyyellowsloughcoveringwithoutgranulationtissue(usuallyabsentinarterialulcer).Otherwise,thereisnodischarge/purulentdischargelikelyduetoinfection”ruleoutvenousulcer:neithervaricoseveinorRuleoutneuropathiculcer:thesurroundingtissuesareabletoappreciateGangrene:site,size,shape,edge,color;tenderness,consistency,“Thereisapatchofdeadtissueover(XXX),withbrown/darkblue/blackcolorandcrinkled,witheredappearance.Thetissueisnotpainfulbutthehealthyskinarounditisconstantlypainful.”Drygangrene:“Theconsistencyishardshowingshrunkentissue.ItalsoshowslinedemarcationfromadjacentnormalWetgangrene:“Thedeadtissueisnotshriveledbutsoftandboggy,probablyduetoimpairedvenousdrainageorinfection.Thelineofdemarcationispurulentandnotclear(wetgangrene)”Ruleoutdiabetic/gasgangrene:nottissueUnderskin(omitted)Musclewasting:muscleTenderornot(whetherthepatienthasrestpain)temperature:usedorsumofhandandcomparetodeterminetheedgefromgrointodefinethelevelatthewhichthesechangescapillaryrefilltime:compresshardonbigtoefor5sandrefilling<2s,revealingthesmallvesseldisease.pulses:keepinmindthatbothofthebila lvesselmaybefemoralA(mid-inguinalpoplitealA(30oflexion,easy poplitealposteriortibialdorsalispedisWhenthepulsecannotbeHand-heldDopplertodeterminethepresenceofpulsesandcharacterofPalpatethegraft,ifthepatienthas.SpecialAuscultation:onlycarryoutauscultationafterpalpationwhengraftisfound,otherwisethisstepmaybeskipped.bruit:aorta,renalA,femoralA,superficialfemoralAatadductorhiatus(2/3thewaybetweenASIStoadductortubercle)Buerger’stest(onelegdiseaseraiseboth,2legsdiseaseraiseonebyone):raiselegslowlyuntilpallorandnotetheBuergerNormal=90<50osevere<20ocriticalDependentrubor(reactivehyperemia):footdownbedsideanddefinethecapillaryrefillingfromwhitetopink(>15sDiagnosis&differentialPVD.Diabeticfoot.Keypoints:ItisanischemicThelevelofP.E.:Neurologicalexamination:diabeticTherestofvasculartree,especiallythecarotidcardiacexaminationforrhythmandinvestigation:TheABPIUSor“thisgentleman’srightlowerlimbsshowedacute/chronicischemicchangessecondarytoperipheralarterialvasculardisease.TheischemiaiscriticalevidencedbyXXX.ThediseasedlevelwaslikelylocatedonXXXbecause(basedonpresenceofischemicsignsbelowandtemperaturechangeandalsothepulsesbypalpation)”Thencommentonpresenceofsurgicalscarsandgrafting(material,bypasscircuitandthrill)saythankshelptocoverhandExaminationofvaricose你好，我是XXX，我可以檢查你的身體嗎？chaperonforfemalepatientwashandgelhandposition:standwithonefootstepforward,anexternalrotationofthediseasedlimbexposure:trousersoffuptogroinInspection(anterior,posterior,fromankletowardsvaricosevein:(C2)“oninspectionthereareprominentsuperficial,dilatedveinsonspiderveins(intradermalveins),reticularbulging petentcommunicatingInthedistributionlongsaphenousvein:shortsaphenousvein: lookatthegroinandlowersaphenovarix:blue-tinged,compressiblebulgeintheifpresent,docoughimpulse lveinatinguinalandabdomen:indicatedeepvenousSkinchanges:especiallyatgaiterare