a glistening, taut appearance suggests
ascites
a bluish periumbilical discoloration is known as ___ and suggests __
cullen’s sign
intraabdominal bleeding
Recent origin color of straie
pink or blue
color of straie over time
silvery white
What can produce straies
abdominal tumors, ascites, pregnancy, or weight gain
straie remains purplishs in what disease
cushing disease
a pearl-like, enlarged and sometimes painful umbilical nodule is known as __
Sister Mary Joseph’s nodule
Sister Mary Joseph’s nodule may be the first sign of waht
intraabdominal malignancy
the abdominal profile fromt he rib margin to the pubis
contour
Expected contour
flat, round, and scaphoid
expected contour in children
rounded or convex
Where should the maximum height of convexity be in an adult?
at the umbilicus
distention from the umbilicus to they symphysis can be caused by
an ovarian tumor, pregnancy, uterine fibroids, or distened bladder
distension of the upper half, avoce the umbilicus, can be due to
tumor, pancreatic cyst, or gastric dilation
hernia cause by defect in abdominal muscularture that develops after a surgical incision
incisional hernia
protrusion of the navel indicates
umbilical hernia
typical adult herniation occurs during
pregnancy, longstanding ascites or when intrathoracic pressure is repeatedly increased, as in chronic respiratory disease
Hernia that occurs in the midline of the epigastrum
hernia of the linea alba
characteristics of a hernia of the linea alba
contains fat and is felts as a small tender nodule
separation of the rectus abdominis muscle
diastasis recti
common causes of diastasis recti
pregnancy and postpartum period
males exhibit what type of movement with respiration
primarily abdominal movement
females exhibit what type of movement with respiration
costal movement
limited abdominal motion is associated with respiration may indicate
peritonitis
surface motion from peristalsis is seen as ___ and may also indicate
rippling movement across the abdomen
intestinal obstruction
loud prolonged gurgles (stomach growling)
borborygmi
increased bowel sounds may occur with
gastroenteritis, early intestinal obstruction or hunger
high pitched tinkling sounds in the abdomin suggest
intestinal fluid and air under pressure
decreased bowel sounds occur with
peritonitis and paralytic ileus
Where do you listen for friction rubs?
over liver and spleen
high pitched rubs heard in associated with respiration
friction rubs
friction rubs may indicate
inflammation of the peritoneal surface of the organ from tumor, infection or infarct
Occurs with increased collateral circulation between the portal and systemic venous systems
venous hum
the predominant sound in the abdomen because air is present in the stomach and intestines
tympany
___ is heard over organs and solid masses
dullness
a lower liver border that ismore than ________ below the costal margin may indicate organ enlargment or downard displacement of the diaphragm
2-3cm (3/4- 1 inch)
begin percussion for the upper border of the liver around __
3rd intercostal space on right midclavicular line
Upper border of the liver is usually around ___ intercostal space
5th
The usual span of the liver is about
6-12cm or 2.5-4.5inches
liver span is usually greater in
males and in tall individuals
Usual span of the liver at the midsternal line is
4-8cm or 1.5- 3inches
Where do you percuss the spleen
just posterior to the midaxillary line on the left
what is the semilunar region defined by the 6th rib superiorly, midaxillary line laterally, and left costal margin inferiorly
Traube’s space
What does Traube’s space overlie
the fundus of the stomach
____ is known as the speen going forward and downward with inspiration
splenic percussion sign
Tympany produced by gastric bubbles is ___ in pitch than that of tympany of the intestines
lower
depress abdominal wall in ____ and in a __ motion for light palpation
no more than 1cm deep
circular motion
___ palpation is useful in identifying muscular resistance and areas of tenderness
light palpation
Boardline hardness of the abdominal wall overlying areas of peritoneal irritation
rigidity
use side of the hand with ___ palpation
moderate
as the patient inspires, the organ is displaced ____
downward
how do you check for liver tenderness when the liver is not palpable
use indirect fist percussion
palpable tender gallbladder indicates
cholecystitis
palpable nontender gallbladder indicates
common bile duct obstruction
what test do you perform if you suggest choleystitis
Murphy sign
patients with splenomegaly from infectious mononucleosis have a small risk for
spontaneous splenic rupture
liver edge tends to be ___ and the kidney edges tends to be ___
sharp
round
where do you palpate for the aorta
left of midline
a pathologic incrase in fluid in the peritoneal cavity
ascites
signs of ascites
protuberant abdomen or bulging flank when supine
shifting dullness of percussion
easily detected fluid wave
alvarado score is also known as
MANTRELS
MANTRELS stands for
Migration of pain Anorexia Nausea/vomitting Tenderness in RLQ Rebound pain Elevation of temp Leukocytosis Shift to the left
Scoring tool that uses pain with cough, hopping or rebound tenderness with percusioon in place of RLQ
Pediatric Appendicitis Score
Scoing tool that uses patient age, history, physical exam, and laboratory findings
Ohmann Score
Ohmann score is used to assess risk of
appendicities
Rebound tenderness is used to assess for
peritoneal inflammation
a sharp stabbing pain at the site of peritoneal inflammation during the rebound tenderness test is a positive ____
Blumberg sign
Rebound tenderness of McBurney’s point suggests
appendicities
When is an iliopsoas muscle test performed
to assess for appendicities
When do you perform an obturator muscle test
when you suspect a ruptured appendix or pelvic abscess due to irritation of the obturator muscle
How to perform an obturator muscle test
have patient lay supine, flex right leg at the hip and knee 90 degrees, rotate the leg laterally and medially
Where is pain felt during the obturator muscle test when there is irritation of the obturator muscle
right hypogastric region
A palpation technique used to assess an organ or mass
ballottement
extensive outward curvature of the spine
kyphosis
extensive inward curvature of the spine
lordosis
spine curved side to side
scoliosis
muscle wasting occurs after injury as a result of
pain, disease of muscle, or damage to motor neurons
synovial thickening can be felt synovium is ____ bc of inflammation
edematous or hypertrophied
tenosynovitis can cause ___ with ____
crepitus with movement of a tendon inside the tendon sheath
passive range of motion often excees active range of motion by ____ degrees
5
what is used to precisely measure the angle of motion
goniometer
disability is present when muscle strength is ___
grade 3 or less
What grade is it when there is full range of motion against gravity but not against resistance
3
rounded mound on palm under thumb
thenar eminence
deviations of the fingers on the ulnar side and swan neck, or boutonniere deformities of fingers indicate
RA
where/how do you palpate the radiocarpal groove
with thumbs on dorsal side of hand
bony overgrowths in the distal interphalangeal joint, which are felt as hard, nontender nodules usually 2-3 mm in diamtere but sometimes encompassing entire joint are associated with __
osteoarthritis
bony overgrowths that are located along distal interphalangeal joint are called
Heberden nodes
bony overgrowths that are located on proximal interphalangeal joints are called
Bouchard nodes
painful swelling of prox. interphalangeal joints that causes spindle-shaped fingers are associated with
acute stage of RA
cystic, round, nontender swellings along tendon sheaths or joint capsules that are more prominent w/ flexion may indicate
ganglia
Expected metacarpophalangeal flexion
90 degrees
Expected metacarpophalngeal hyperextension
30 degrees
Expected flexion of the wrist
90 degrees
Expected hyperextension of the wrist
70 degrees
Expected radial motion
20 degrees
expected ulnar motion
55 degrees
subcutaneous nodules along pressure points of the ulnar surface may indicate
RA or gouty tophi
expected carrying angle between humerus and radius with passive extension
5-15 degrees laterally
lateral angle exceeding 15 degrees
cubitus valgus
a medial carrying angle
cubitus varus
Palpate the extensor surface of the ulna, olecranon process, and medial and lateral epicondyles of the humerus when the patient’s elbow is at ___ degrees
70 degrees
- boggy, soft, or fluctuant swelling
- point of tenderness at lateral epicondyle or along the grooves of olecranon process and epicondyles
- increased pain w/ pronation and supination of the elbow
all indicate
epicondylitis or tendonitis
expected flexion of the elbow
160 degrees
expected extension of the elbow
180 degrees or back to 0
Expected pronation and supination of elbow when flexed at 90 degrees
90 degrees for both
asymmetric shoulder contour and when one shoulder has hollows in the rounding contour indicate
shoulder dislocation
winged scapular, an outward prominence of scapula indicate
injury to serratus anterior muscle nerve
Where do you palpate biceps groove
anterior aspect of humerus
where do you palpate the insertion of supraspinatus, infraspinatus, and teres minor
near greater tuberosity of humerus
Expected shoulder flexion
180 degrees
Expected hyperextension of the shoulders
50 degrees
Expected shoulder abduction
180 degrees
Expected adduction of shoulder
50 degrees
Expected internal rotation of shoulder
90 degrees
Expect external rotation of shoulders
90 degrees
What is assessed when the patient tries to resist opposing pressure during a shoulder shrug
shoulder strength
CN XI
Where do you put your fingers when locating the temporomandibular joint
anterior to tragus of each ear
Expected space between upper and lower teeth when the jaw is open
3-6cm
Expected lateral movement of the jaw
1-2cm in each direction
testing strength of temporalis and masseter muscles also tests
CN V
Cervical spine should be ___
concave
Expected flexion of the cervical spine
45 degrees
Expected lateral bending of the cervical spine
40 degrees
Expected rotation of of the cervical spine
70 degrees
What is testing when the patient resists opposing forces of cervical spine movements
- strength of sternocleidomastoid and trap muscles
- CN XI
major landmarks of the back
C7, T1, scapulae, iliac crest, paravertebral muscles
Head should be positioned directly over the
gluteal cleft and the vertebrae
curve of thoracic spine should be
convex
curve of lumbar spine should be
concave
a form of structural kyphosis with a sharp angular deformity
gibbus
a gibbus is associated with
a collapsed vertebrae from osteoporosis
lateral curvature or rib hump when bending over indicates
scoliosis
Expected flexion of the waist
75-90 degrees
expected hyperextension of the waist
30 degrees
Expected lateral bending of the waist
35 degrees bilaterally
Expected rotation of the upper trunk is __ degrees forwards and backwards
30 degrees in both directions
Expected flexion of the hip
90 degrees
Expected hyperextension of the hip
30 degrees or less
Expected hip flexion with knee flexed
120 degrees
Expected abduction of hip
45 degrees
Expected adduction of hip
30 degrees
Expected internal rotation of the hip
40 degrees
Expected external rotation of the hip
45 degrees
what does FABER stand for
Flex
ABduct
Externally Rotate
Major landmarks of knees and legs
tibial tuberosity, medial an lateral tibial condyles, medial and lateral epicondyles of the femur, adductor tubercle of the femur, patella
loss of natural concavities of knees suggest
knee effusion
expected angle between the femur and tibia
less than 15 degrees
genu valgum
knock knees
genu varum
bowlegs
excessive hyperextension of the knee with weight bearing
genu recurvatum
genu recurvatum indicates
weakness of the quadriceps muscles
when the knee appears convex
knee effusion
fullness in the popliteal space may indicate
popliteal cyst or baker cyst
Expected knee flexion
130 degrees
Expected extension/ hyperextension of knee
full extension and up to 15 degrees of hyperextension
landmarks of the ankle
medial malleolus, lateral malleolus, achilles tendon
pes varus
in-toeing
pes valgus
out-toeing
The foot should have a __ arch
longitudinal arch
a foot that remains flat even when not bearing weight
pes planus
a high instep
pes cavus
pes cavus is associated with
claw toes
hyperextension of the metatarsophalangeal joint with flexion of the toes proximal joint
hammertoe
a flexion deformity at the distal interphalangeal joint
mallet toe
hyperextension of the metatarsophalangeal joint with flexion of the toes proximal AND distal joints
claw toe
lateral deviation of the great toe, which may cause overlapping with the second doe
hallux valgus
an inflammed painful bursa at a pressure point
bunion
inflamed metatarsophalangeal joint of great toe suggests
gouty arthritis
spondyloarthritis or xanthelasma of hyperlipidemia can cause
tendonitis
expected dorsiflexion
20 degrees
expected plantar flexion
45 degrees
expected inversion
30 degrees
expected eversion
20 degrees
Expected abduction of ankle
10 degrees
expected adduction of ankle
20 degrees
what innervates palm of hand, palmar surface of thumb, index and middle fingers and half of ring finger
median nerve
thumb abduction test isolates what muscle
abductor pollicis brevis (innervated by median nerve)
weakness with thumb abductor test indicates
carpal tunnel syndrome
numbness and paresthesia in the distribution of the median nerve during the phalen test indicate
carpal tunnel syndrome
Positive tinel sign indicates
carpal tunnel syndrome
positive neer test indicates
rotator cuff inflammation or tear
What test forward flexes the patient’s arm up to 150 degrees while depressing the scapula (presses greater truberosity and supraspinatus muscles against the anteroinferior acromion)
Neer test
positive hawkins test indicates
rotator cuff inflammation or tear
what test abducts the shoulder to 90 degrees, flexes elblow to 90 degrees then internally rotates arm to its limit
hawkins test
what muscle is being assessed when you have the patien place the arm in 90 degrees of abduction, 30 degrees of forward flexion, and internally rotate (thumbs pointing down)
supraspinatus muscle
what muscle is being assessed when you ahve the patient hold the arm at the side, elbow flexed 90 degrees, and rotate the forearm medially against resistance
subscapularis muslce
what muscles are being assessed when the patient holds the arm at the side, elbow flexed 90 degrees, and rotate the armlatearlly against resistance
infraspinatus and teres minor
straight leg raising test is used to test for
nerve root irritation of lumbar disk herniation at L4, 5, and S1 levels
crossover pain with the straight leg test indicates
sciatic nerve impingements
radicular pain below the knee with straight leg raising test indicates
disk herniation
femoral stretch test or hip extension test is used to detect
inflammation of nerve root L1, 2, 3 and sometimes L4
what test is used to detect flexion contractures of the hip that may be maksed by excessive lumbar lordosis
thomas test
what test detects weak hip abductors muscles
trendelenburg test
what is used to determine the presence of excess fluid or an effusion of the knee
ballottement or bulge sign
what test is used to detect a torn medial or lateral meniscus
McMurray test
rotating the foot and knee outward to lateral position applies __ stress
valgus stress
rotating the foot and knee inward applies __ stress
varus stress
what test is used to dectect torn ACL or PCL
anterior or posterior drawer test
anterior or posterior movement of the knee of ___ during the drawer test is an unexpected finding
greater that 5mm
what test is used to assess ACL integrity
Lachman test
what tests are used to assess instability of LCL and MCL
varus (abduction) and valgus (adduction) stress tests
varus force of knee is directed ___ and laxity indicates injury to what ligament
toward the midline (laxity indicated injury to MCL)
valgus force of knee is directed ___ and laxity indicates injury to what ligament
away from the midline (laxity indicated injury to MCL)