Physical Examination of the Limbs (MBBS India)

Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Diagnosis of meningitis is made on clinical grounds with a thorough neurologic examination. CSF analysis is an important diagnostic tool, as it is difficult to identify the exact cause clinically. Management of meningitis includes immediate broad-spectrum antibiotics and supportive therapy to prevent complications. Specific treatment depends on the etiology of meningitis. Delay in treatment can lead to permanent neurologic defects and death.

Examination of the lower limbs involves assessment of the hips, knees, ankles, and feet to evaluate for signs of pathology. The examination includes inspection, palpation, assessment of range of movement, and provocative maneuvers. A good history should be taken and concurrently used with the exam findings to obtain a presumptive diagnosis.

Examination of the upper limbs is the portion of physical examination involving the assessment of the shoulder, elbow, forearm, wrist, and hand to evaluate for signs of pathology. The examination includes inspection, palpation, tests of range of movement, and provocative maneuvers. A good history should be taken and concurrently used with the exam findings to obtain a presumptive diagnosis.

Knee pain is a common presentation to primary care physicians. The diagnosis can be challenging as the pain may arise from the joint, surrounding tissues, or referred to the joint from distant structures. The differential diagnosis of knee pain is broad and categorizing the various diagnoses related to the timing (acute or chronic) is useful. A thorough understanding of pertinent anatomy, appropriate physical examination, and common problems of the knee joint are essential for diagnosis and proper management of knee pain. Exercise-based therapy is often the 1st-line management of many knee disorders, but surgical intervention is warranted for specific diagnoses.

The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. The muscles of the hand are classified as extrinsic (forearm-based) or intrinsic (hand-based) depending on the location of the muscle belly. These muscles are also grouped by area or type: thenar, hypothenar, lumbricals, and interossei.

Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Diagnosis of meningitis is made on clinical grounds with a thorough neurologic examination. CSF analysis is an important diagnostic tool, as it is difficult to identify the exact cause clinically. Management of meningitis includes immediate broad-spectrum antibiotics and supportive therapy to prevent complications. Specific treatment depends on the etiology of meningitis. Delay in treatment can lead to permanent neurologic defects and death.

Acute shoulder injuries are a common reason for visits to primary care physicians and EDs. Common acute shoulder injuries include acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Evaluation of acute shoulder pain requires an understanding of the mechanism of injury, as well as the appropriate physical examination and radiologic studies needed in the acute setting. A focused history and physical examination is essential and should include inspection, palpation, and a thorough neurovascular exam. Imaging begins with plain radiographs and is occasionally supplemented by MRI or CT imaging. Management includes pain control and varies based on diagnosis.

Shoulder pain is considered chronic when present for > 6 months. Common conditions resulting in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and joint arthritis. Shoulder pain can be intrinsic or extrinsic to the joint. The potential of serious causes of referred pain to the shoulder such as cardiovascular and abdominal etiologies should be considered. A focused history and physical examination is essential and should include inspection, palpation, range of motion (ROM), and provocative testing. Imaging often includes plain radiographs occasionally supplemented with MRI. Management varies related to specific disorders and frequently requires physical therapy.

The wrist connects the forearm to the hand. It consists of 8 carpal bones, multiple joints, and various supporting ligaments, as well as the distal bones of the forearm and the proximal portion of the 5 metacarpal bones of the hand. The wrist is crucial for the functioning of the upper limb, and it provides stability while positioning the hand for intricate motions.

The shoulder complex comprises the glenohumeral joint, sternoclavicular joint, acromioclavicular joint, and the scapulothoracic articulation, and connects the upper limb to the trunk. This group of joints consists of the clavicle, scapula, and humerus bones, multiple muscles and supporting ligaments, cartilage, and bursae. The muscles ensure the mobility and stability of the shoulder and upper limb and are divided into 3 groups: anterior axioappendicular, posterior axioappendicular, and scapulohumeral muscles.

Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Systemic inflammation can lead to extraarticular manifestations such as rheumatoid nodules, interstitial lung disease, Felty syndrome, and pericarditis. Prolonged and severe disease can lead to irreversible joint deformities. Diagnosis is based on strong clinical suspicion and confirmed by the presence of rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, and characteristic imaging. Management involves long-term disease-modifying antirheumatic drugs (DMARDs), biologic agents, and physical therapy. Glucocorticoids and nonsteroidal antiinflammatory drugs (NSAIDs) are the treatment of choice for acute exacerbation.

Hand and wrist pain is very common among the general population. Up to 30% of adults will have hand pain during their lives, and half of all cases progress to chronic pain. The causes of hand and wrist pain can be classified into mechanical (e.g., fractures, inflammation, ligament tear), neurologic (e.g., nerve entrapment), and systemic (e.g., autoimmune arthritis). Reaching an accurate diagnosis involves following an evidence-based systematic approach. Treatment includes reducing stress on the ligaments, pain management, and surgery.

The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. To provide that link, the motions of the elbow include extension and flexion as well as pronation and supination of the forearm.

Ankle pain accounts for up to 20% of cases of musculoskeletal complaints in outpatient clinics. The most common etiologies of foot and ankle pain can be categorized into arthritis, trauma, sprains, and systemic causes. The diagnosis is clinical with imaging and/or laboratory studies to confirm the suspected diagnosis. Management involves rest, ice packs, compression, elevation, and nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical repair is rarely needed.