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Geriatric foot exam
Terms in this set (87)
How should you examine the foot?
Superficial to deep
In what order should you examine the foot?
3. Palpation of bony and soft tissues
4. ROM, passive action
5. Tendon reflexes
At the beginning of the foot exam you should watch the patient ambulate with shoes _______ and ______.
On and off
What should you look for in a pt's shoes?
Stability of sole
What is included in the skin portion of foot exam?
1. Ask about problems with the feet - previous history and current status
2. Check the foot, including between the toes for sores, calluses, infection, fissure, cracks, deformities, point tenderness
If pt has history of amputation or ulceration they are ____% more likely to have them again
What two pulses do you check?
What tests should you do if pulses are absent?
1. Doppler Ultrasound
2. Ankle Brachial Index
Along with checking pulses, what else should be included in the foot exam?
1. Monofilament test
2. Vibration sensation
3. Observe ambulation
4. Check shoes
To check vibration sensation use a _______ hz tuning fork.
What test is used to check peripheral neuropathy?
Gradual onset of numbness, prickling or tingling in your feet or hands, which can spread upward into your legs and arms, that indicates peripheral neuropathy
Stocking glove loss
During monofilament exam use a ____ g monofilament
*show them not sharp
How do you apply 10 g monofilament during exam?
Press until it bends
Hold 1 second then release
If the patient cannot feel the monofilament in any area, then ____________exists.
If patient is unable to feel a _______ monofilament, they have lost protective sensation of their feet
Fungal infection of the nails
What are the five types of onychomycosis
1. Distal lateral Subungal Onychomycosis (DLSO)
2. White superficial onychomycosis (WSO)
3. Proximal Subungal Onychomycosis (PSO)
4. Endonyx Onychomycosis (EO)
5. Candidal Onychomycosis
What type of onychomycosis?
Subungual hyperkeratosis and onycholysis, yellow white in color
Yellow streaks and/or yellow onycholytic areas in the central portion of the nail plate
Distal lateral subungal onychomycosis (DLSO)
Where will the concentration of hyphae in distal lateral subungal onychomycosis (DLSO) be the greatest?
What is the treatment of Distal lateral subungal onychomycosis (DLSO)?
Remove nail plate and obtain sample by curettage from the nail bed
What type of onychomycosis?
Confined to toe nails
Small, white, speckled or powdery patches on surface of nail plate
Nail becomes rough and crumbles easily
White Superficial Onychomycosis (WSO)
How should you get a nail surface sample in White Superficial Onychomycosis (WSO)?
What type of Onychomycosis?
Leukonychia in the proximal nail plate that moves distally with nail growth
Marked periungual inflammation
Proximal Subungal Onychomycosis
How should you treat proximal subungal onychomycosis (PSO)?
Pare the overlying nail plate
Where should you take the sample from in proximal subungal onychomycosis (PSO)?
Ventral nail plate
What type of onychomycosis:
Milky white discoloration of nail plate
No evidence of subungual hyperkeratosis or onycholysis, nail plate surface and thickness are normal
What type of Onychomycosis:
Affects all or several digits
Total onychomycosis associated with periungual inflammation
The digits often take on bulbous or drumstick appearance
Where should samples for Candidal Onychomycosis be taken from?
Nail bed closest to proximal or lateral edges
What labs should you get for onychomycosis?
Microscopy of 20% KOH in dimethyl sulfoxide (DMSO) to screen for hyphae
Before performing labs for onychomycosis, what should be done to sample?
Pulverize nail scrapings or clippings
When culturing onychomycosis samples containing dermatophytes require _____ in the culture to grow.
Less effective tx as monotherapy (but an option) for onychomycosis?
Topical antifungals usually insufficient as monotherapy
*Ciclopirox olamine and efinaconazole
How long must topical anti fungals be applied?
To nail bed every day for 48 weeks
What is the most effective treatment for onychomychosis?
*higher cure rates/ fewer adverse effects
What may impede efficacy of onychomychosis treatment?
Additional treatment options of onychomychosis that provide functional relief more important than cosmetic, clinical cure?
1. Mechanical, chemical (urea compound), or surgical nail ablation
2. Laser therapy as adjunctive treatment with oral.
Deviation of the tip of the great toe toward the outer or lateral side of the foot
Prominence of the dorsal medial eminence of the first metatarsal
(T/F) hallux valgus can be caused by footwear
*but can maintain an abnormal stretch and deviation
Who is more likely to get bunions or hallux valgus
3. Familial history
What happens during walking that causes hallux valgus?
The adductor tendon, extensor hallucis longus, and flexor hallucis longus tendons cause the metatarsal to deviate medially and hallux laterally.
During walking the adductor tendon, extensor hallucis longus, and flexor hallucis longus tendons cause the metatarsal to deviate (laterally / medially) and hallux (laterally / medially).
Strain or inflammation of the plantar fascia
When are sx of plantar fasciitis worse?
Weight bearing after rest
_______% of plantar fasciitis resolve spontaneously after a year.
Non pharm tx that can help with plantar fasciitis
1. Rest and ice, gentle passive stretch
2. Exercises (calf stretch, foot/ankle circles, toe curls)
3. Silicone heel inserts, shoes (running, arch supported, etc.)
What should you avoid if you have plantar fasciitis
Unsupported, barefoot walking
What is the first line pharmacologic treatment of plantar fasciitis?
If plantar fasciitis is unresponsive to NSAID treatment, what is the next step in the pt's management?
Methylprednisone 20-40 mg with 1% lidocaine injection
Muscle tendon imbalance causing contraction of the proximal or distal interphalangeal joint, or both
Hammer Toe (DIGIT FLEXUS)
Hammer toe (digit flexus) can be secondary to?
Poor fitting shoes
Muscular stance/ imbalance
tx of hammertoe (minimal dz)
Better footwear, pads that alter stance
tx of hammertoe (severe)
Surgical treatment involving fusion of one or more joints
Which of the following is more likely to be found on a non-weight bearing surface (corn/ callus)?
Diffuse thickening of the stratum corneum secondary to repeated friction and pressure.
When can a callus be tender?
Only under direct pressure
Thickened area with a central core that is often tender over a pressure point typically on non-weight bearing surface
Tx of corns or callus
1. Pads/ change footwear to alleviate trauma or pressure
3. Salicylic acid or creams with urea can be used, but can cause damage to healthy surrounding tissue if not properly applied
4. Sharp debridement using scalpel or Callus shaver
Hyperkeratotic lesion caused by papillomavirus
How does a plantar wart differ in appearance from callus?
Tends to mimic a callus but has a stippled appearance.
Tender when pinched side to side whereas a callus is only tender to direct pressure
A pt presents with hyerpkeratotic lesion with a stippled appearance on the sole of their foot. What is the most likely diagnosis?
Plantar wart tx
*if it does not resolve spontaneously
1. Freezing with liquid nitrogen
3. Laser surgery
4. Vaccination against HPV
A patient presents with:
-Numbness, paresthesia (tingling), muscle weakness, burning pain (worse at night), muscle wasting
-Symptoms may be experienced over several days, weeks, or years
Motor, sensory, and autonomic fibers can be involved
What is the common underlying cause of peripheral neuropathy?
What is the second most common underlying cause of peripheral neuropathy?
Pathophysiology of neuropathy
1. Physical injury or repetitive stress causing entrapment
2. Small vessel disease, vasculitis can damage peripheral blood supply resulting in nerve ischemia
3. Toxins, infectious process
What autoimmune diseases can cause peripheral neuropathy?
Acute demyelinating neuropathy
What type of nerves does Chronic inflammatory demyelinating polyneuropathy (CKDP) leave intact?
What type of nerves does Chronic inflammatory demyelinating polyneuropathy (CKDP) damage?
Sensory and motor nerves
Many chronic neuropathies get (better/ worse) over time
In diabetic neuropathy, nerve damage occurs in a(n) (ascending/ descending) pattern
Methods to evaluate peripheral neuropathy
Deep tendon reflexes
Loss of vibratory perception in less than ____ is abnormal in any age.
sharp and dull stimuli have them distinguish
"Which is sharper, the first application, the second application, or are both the same?"
Inability to distinguish between the two points to loss of nocioceptive fibers relative to low-threshold mechanoreceptor fibers
Position sense: Loss of joint movement indicates loss of __________.
large diameter nerve fibers
Deep tendon reflexes diminish with age but may be absent after the age of ______.
Which type of peripheral neuropathy damages both sensory and motor nerves but leaves autonomic nerves intact?
Chronic inflammatory demyelinating polyneuropathy (CKPD)
What further testing can be done to measure damage to large nerve fibers?
Nerve Conduction Velocity (NCV)
Why would you want to do a skin bx on peripheral neuropathy pt?
Examine nerve fiber endings
What test detects abnormal electrical activity in motor neuropathy by recording electrical activity within muscle tissue?
What test can you use to rule out tumors, herniated discs or other structural abnormalities?
What test can you use to evaluate level of nerve damage/inflammation?
What test can you use to examine nerve fiber endings?
What is the end result of peripheral neuropathy?
Develops at pressure points and can be very extensive because of lack of sensation
May be a small superficial lesion with cellulitis and osteomyelitis in the deeper tissues
What is the most common location of neuropathic ulcers?
THIS SET IS OFTEN IN FOLDERS WITH...
Geriatrics Test 1: Old feet
Physiology of Aging
Geriatric Demographics - Questions
The Physiology of Aging - Questions
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