Lab Practical Flashcards
Yeoman
Patient prone, dr flexes patient’s leg to ipsilateral butt then extends thigh
P: Pain DEEP in the SI joint
I: Sprain of the anterior SI ligaments
Deep voice: Yo man, put my leg down!
Dawbarn
Patient seated, palpate shoulder for tender spot (subacromial bursa), note tenderness, continue pressure while abducting extended arm past 90*.
P: Decrease in pain and/or tenderness
I: Subacromial bursitis
Fromet Paper Sign
DON’T TEST THUMB/INDEX
Patient tries to hold paper squeezed b/w fingers
P: The patient is unable to maintain grip on paper
I: Ulnar nerve paralysis
Accommodation reflex
State what you are observing for and what neurological structure is being evaluated
Move object to and away from patient, they focus on it.
Convergence of eyes w/ pupillary constriction
Afferent: Optic (CN II)
Efferent: Oculomotor (CN III)
Int Center: Occipital cortex
Weber Test
State what you are observing for and what neurological structure is being evaluated
Place handle of 512 Hz vibrating tuning fork on midline of skull
“can you hear this? and is it equal in both ears or more loud in one or the other?”
( - ) Normal: Sound is equal in both ears
( + ) Conductive deafness: Sound lateralizes to the bad ear
( + ) Sensorineural deafness: Sound lateralizes to the good ear
Palpate the peripheral pulses of the neck and upper extremity Left Side Only
State the definition of the amplitude of a pulse
rhythm
rate
contour
2-3 seconds Carotid Subclavian Brachial Radial Ulnar
amplitude- height or intensity of pulse
rhythm- regularity of heart pattern
rate- number of pulsations per min
contour- pulse wave, should be rounded or smooth
You suspect your patient has a kidney stone perform a test to confirm this state the positive finding for this test, no indication required
Murphy’s Punch
Palm of hand over posterior costovertebral angle (T10-T12), strike back of hand w/ ulnar surface of fist.
Should thud w/ no pain or tenderness
Pain indicates inflamed kidney (nephritis - stones, infection, etc)
Muscle Test the S1 nerve root
Dr instructs patient how to position for muscle test.
Plantar flexion: Gastrocnemius and soleus (Tibial N.)
Plantar flexion and eversion: Peroneus longus & brevis (Superficial Peroneal N.)
Hip extension: Gluteus maximus (Inferior Gluteal N.) knee bent
Reflex of the C7 Nerve Root
Triceps (broad end of hammer)
L4-L5-S1 Dermatome evaluation
L4: Medial leg, behind med malleolus, up med side of big toe
L5: Antero-lateral tibia, dorsum of foot, 3 middle toes
S1: Lateral leg, behind lat malleolus and up pinky toe
Bony palpation of the elbow (right side only)
Medial epicondyle Medial supracondylar line of humerus Lateral epicondyle Lateral supracondylar line of humerus Groove of Ulna Trochlea Olecranon Olecranon fossa Radial head
Wright test
AKA Hyper-abduction Maneuver
Patient seated, find radial pulse, bring arm out to tension and hyper abduct slowly
P: Pain &/or paresthesia, decreased or absent pulse, pallor.
I: Compression of axillary artery by pectorals minor or coracoid process. Thoracic Outlet Syndrome
Perform a a test to evaluate for a SacroIliac pathology
Lewin Standing: Goldwait test Laguerre test Gaenslen test Lewin-Gaenslen test Hibb test Pelvic rock test (pain in either hip joint, SI joint lesion) Nachlas test Yeoman Test Minor sign
Shoulder depressor test
Patient seated, actively laterally flexes, support head and press down on shoulder for 3 seconds.
P: Localized pain on side being tested INDICATES Dural sleeve adhesion, Muscular adhesion or contracture, Muscle spasm, or Ligamentous injury
P: Radiating pain on side being tested INDICATES Neurovascular bundle compression, Dural sleeve adhesions, or TOS
P: Radiating pain on opposite side being tested INDICATES Foraminal encroachment w/ nerve root compression
Graphesthesia
State what you are observing for and what neurological structure is being evaluated
Eyes closed, pt identifies #’s or letters traced on palm of hand (tell them which category is used and angle for THEIR perspective)
Observing for pt’s ability to identify traced outline; testing integrity of Somatosensory cortex
Mitral maneuver no verbalization required
Patient lies on back, place BELL @ mitral area (mid-clavicle), patient then leans 45* towards their left side, “Take a deep breath & hold”
Female: drop left arm off table and use right arm to cover both breasts.
Respiratory excursion
State the normal finding and 2 conditions associated with an abnormal finding
Patient seated, from behind tissue pull w/ ball of hand T8-T10, thumbs along S.P.’s; 3 deep breaths; watch thumbs diverge.
LAG indicates pathology such as Pneumonia, Bronchitis, Fractured rib, Collapsed lung
Muscle test the C5 nerve root
Dr instructs pt how to position arm
Shoulder abduction: Deltoid (Axillary N.)
Forearm flexion: Biceps (Musculocutaneous N.)
Reflex of the S1 nerve root
Achilles tendon (broad end of hammer; foot in slight dorsiflexion proximal portion of tendon)
L3-L4-L5 Dermatome evaluation
L3: Lateral to medial above knee
L4: Medial leg, post med. malleolus, up medial big toe
L5: Anterolateral tibia, foot dorsum, middle 3 toes
Cervical spine bony palpation
Anterior: Hyoid, Thyroid cartilage, 1st cricoid ring, Mandible
Posterior: Occiput, Mastoids, Inion (EOP), Superior nuchal line, S.P’s of cervicals, Facet joints
Lachman Test
Patient supine, knee in slight (30*) flexion, dr grabs proximal tibia & distal femur, pull tibia forward to feel jt play
P: Gapping w/ tibia moving away from the femur
I:Anterior cruciate ligament or posterior oblique ligament instability
Cozen Test
Pt seated, show: “put your wrist in this position(EXTENSION), I will try to pull down, resist,” one hand over fist, other below wrist, Hold for > 3 seconds
P: Pain over the lateral epicondyle
I: Lateral epicondylitis (Tennis Elbow)
Maximal Foraminal Compression Test
Pt seated w/ dr standing behind, pt hyperextends head then turns head one direction (while extended), Bilateral.
P: Pain on concave side
I: Foraminal encroachment w/ or w/o nerve root compression.
Abdominal reflex
State what you are observing for and what neurological structure is being evaluated
Use smooth edge of reflex hammer to lightly stroke abdomen in all 4 quadrants, starting @ umbilicus and going out diagonally
Umbilicus deviation to stroked side. Absence is normal only if bilateral (Beevor sign)
Afferent: Upper T7-T10; Lower T11-T12
Integrating Center: Spinal cord T7-T12
Efferent: Upper T7-T10; Lower T11-T12
Perform a test to identify a sensorineural hearing loss State what you are observing for and what neurological structure is being evaluated
Weber (512 Hz tuning fork, center of skull, sound even?)
or
Rinne ((512 Hz fork on mastoid, no longer heard move to ear, should hear twice as long as on bone)
-evaluating cochlear portion of vestibularcochlear nerve, CN VIII
Obturator Sign
State the pathological finding and the associated indication
Pt supine, instruct pt to flex hip and knee to 90*, dr supports knee (superior hand) and ankle (inf hand), Pt internally/externally rotates HIP against resistance of dr.
P: Increased pain
I: Ruptured appendix or pelvic abscess
Auscultate the abdomen for bruits
State the pathological finding, no indication requred
Using BELL, auscultate:
Aorta (one inch up, one inch LEFT of umbilicus)
Renal arteries (2” up, 2” R and L) HOLD BREATH
Common Iliac arteries (2” down. 2” R and L)
Pathological findings are bruits: signs of turbulent blood flow.
Muscle Test the L4 nerve root
Foot Dorsiflexion & Inversion BILATERALLY!
Tibialis Anterior muscle (Deep peroneal nerve)
Reflex of the C5 nerve root
Biceps (Musculocutaneous N.)
Thumb tractions tendon inferior, strike thumb w/ point of hammer
C6-7-8 Dermatome
C6: Lateral forearm and palmar side of thumb and index
C7: Palmar side of middle finger
C8: Medial forearm and palmar side of pinky & ring finger
Bony Palpation of the shoulder (right side only)
Sternoclavicular articulation, Clavicle, Coracoid process, Acromioclavicular articulation, Acromion, Greater tuberosity of humerous, Lesser tuberosity…, Bicipital groove, Spine of scapula, Body of scapula, Scapulothoracic articulation (pt puts their ipsilateral hand in back waist band)
ThomPson test
Patient Prone, leg up to 90* by examiner, dr squeezes belly of calf (look at foot - expect plantar flexion)
P: Absence of foot plantar flexion motion
I: Achilles tendon ruPture
Perform an orthopedic test to evaluate tarsal tunnel syndrome in your patient
Tinel Foot Sign
Dr taps medial plantar nerve (post to med. malleolus) w/ point of hammer
P: Paresthesia radiating into the foot
I: Tarsal tunnel syndrome
Anterior apprehension test
Patient seated, dr abducts arm and flexes elbow to 90*, externally rotate arm (Look @ their face, don’t grab wrist, support hand behind GH)
P: Noticeable look of apprehension or alarm on face w/ possible pain
I: CHRONIC anterior dislocation of GH joint
Dysmetria of the upper extremity
State what you are observing for and what neurological structure is being evaluated
Index finger test (nose to finger, 4 quadrants) OR Heal-Shin (seated, heel down shin)
Looking for tremors or lack of coordination
Tests Cerebellum
Psoas sign
State what you are observing for and what the finding would indicate
Patient supine, dr’s superior hand on ipsilateral iliac crest (fingers down), inferior hand on thigh, patient raises straight leg against resistance. RIGHT SIDE ONLY
P: Increase in pain
I: Appendicitis
Millgrams test
Patient supine, DR raises both legs 2-3” asks patient to hold in this position for 30 secs
P: Inability to perform test and/or low back pain
I: Weak abdominal muscles or space occupying lesion
Aortic maneuver
Pathological finding
Patient seated, use DIAPHRAGM at right sternal border (aortic area) or left sternal border (Erbs point), ask patient to take deep breath in and learn forward while exhaling completely.
Listening for high pitched murmurs
Reflex of C6 nerve root
Brachioradialis
Broad side of reflex hammer
Soft tissue of lumbar spine
- Anterior abdominal muscles (supine)
- Paraspinal muscles (unit and indiv) - I Love Spine (Lateral to medial): Iliocostalis, Longissimus, Spinalis
- Gluteus Maximus (sacrum to greater trochanter)
- Gluteus Medius (Greater trochanter to iliac crest)
- Sciatic nerve (Between greater troch and ischial tube)
- Hamstrings (unit and indiv) Biceps femoris (lateral), Semitendinosus (under gluts and median - not an adductor), Semimembranosus (most medial)
Hoover sign
(Hoover: patients SUCK because they LIE - malingering)
Patient supine, dr puts one hand under healthy leg and asks patient to lift opposite leg.
P: Lack of counter-pressure on the healthy side
I: Lack of organic basis for paralysis (malingering/hysteria)
Nachlas test
Pt prone, dr takes heel to ipsilateral butt WHILE stabilizing pelvis preventing hip flexion
P: Pain in buttock and/or pain in lumbar region
I: Sacroiliac joint lesion or lumbar pathology
Jackson compression test
Pt seated and THEY laterally flex their head, dr stands behind, clasp hands over head (w/ elbows on sides of head) and apply increasing downward pressure. Perform bilaterally.
P: Exacerbation of localized cervical pain
I: Foraminal encroachment w/o nerve root pressure or facet pathology
P: Exacerbation of cervical pain w/ a radicular component
I: Foraminal encroachment w/ nerve root compression
Perform a neurological test to evaluate the dorsal columns
State what you are observing for, no indication required
Pallesthesia
Light Touch
Joint Position Sense
Romberg Test
Stereognosis
State what you are observing for and what neurological structure is being evaluated
Pt identifies familiar objects w/ eyes closed w/ light touch
Observing ability to identify objects, indicates involvement of somatosensory cortex
Perform a test to evaluate for the presence of pneumonia State what you are observing for, no indication required
Patient seated, from behind tissue pull w/ ball of hand T8-T10, thumbs along S.P.’s; 3 deep breaths; watch thumbs diverge.
LAG indicates pathology such as Pneumonia, Bronchitis, Fractured rib, Collapsed lung
Rebound Tenderness
State the clinical significance of Rovsing and Blumberg signs
Pt supine, dr gently and deeply presses into abdomen w/ fingers extended and quickly releases.
Looking for the return to position (rebound) of the structures which were compressed.
Pain in any quadrant upon rebound = Blumberg’s Sign = Peritonitis
Pain in Rt lower quadrant (@ McBurney’s Pt) when rebounding in Lft lower quadrant = Rovsing’s Sign = Appendicitis
C7 - 8 - T1 Dermatome
C7: Middle finger (palmar side)
C8: Medial forearm, medial 2 digits
T1: Medial elbow joint
Bony palpation of the foot & ankle (right side only)
Medial malleolus, Lateral malleolus, Talus, Navicular, Cuboid, 3 Cuneiforms, 5 Metatarsals, Metatarsophalangeal joints, Calcaneus, Sustentaculum, Navicular tubercle
Laguerre’s Test
Pt supine, dr puts affected leg into figure 4 position (hip flexion, ext rotation, and abduction), stabilize contralateral ASIS while putting downward pressure on knee.
P: Pain in the hip joint
I: Hip joint pathology
P: Pain in the sacroiliac joint
I: Sacroiliac joint pathology
Perform a test to identify meningeal irritation/meningitis in your patient
Look for Kernig Sign
Pt supine, dr flexes pt’s hip and knee to 90* then extends leg completely
P: Inability to fully extend the leg and/or pain (usually in neck region)
I: Meningeal irritation/meningitis
Anterior Innominate Test akas?
AKA Mazion Pelvic Maneuver AKA Advancement Sign
Pt standing, dr instructs pt to step one leg forward 2-3 ft, pt then instructed to bend forward from the waist and touch front foot with both hands (front leg straight)
Inability to bend more than 45* from the waist due to
P: Radiating pain along sciatic nerve (unilateral or bilat)
I: Sciatic neuralgia or radiculopathy, etc. possibly due to lumbar disc pathology
OR
P: Low back pain
I: Anterior (rotational) displacement of ilium relative to sacrum
Evaluate the motor branch of CN VII
State what you are observing for, no indication required
Facial Nerve (CN VII) Inspect face for asymmetry (@ rest and in motion), ask pt to: Raise eyebrows, Close eyes tight, Puff out cheeks, Show teeth, Smile, Frown
Observing for symmetry of face muscles at rest and in motion
Perform a test to identify a conductive hearing loss in your patient
State what you are observing for and what neurological structure is being evaluated
Weber test
512 Hz tuning fork on midline of skull, ask pt to compare intensity of sound
Normal = sound equal in both ears
Conductive hearing loss = sounds lateralizes to bad ear
Testing sensory Cochlear portion of vestibulo-cochlear n.
Egophony of the Posterior Thorax
State the pathological finding and what this finding would associate
Pt speaks in normal tone and volume, ask pt to say the letter “E” when dr places diaphragm on skin
Pathological if “E” sounds like an “A” - indicates consolidation of lungs such as Pneumonia
Palpate the peripheral pulses of the abdomen and RIGHT lower extremity
Define what contour is in reference to the peripheral pulses
Use 2 fingers to palpate:
Abdominal aorta ( 1 ) (1” up and over)
Femoral ( 2 ) (pt makes triangle w/ hands over groin)
Popliteal ( 2 ) (behind knee)
Dorsalis pedis ( 2 ) (dorsum of foot b/w 1st & 2nd toe)
Posterior tibialis ( 2 ) (posterior to MEDIAL malleolus)
Contour describes the pulse wave in a healthy artery; should be rounded, smooth, or domed shaped.
Muscle test the C8 nerve root
Finger flexion: Flexor digitorum superficialis, Flexor digitorum profundus, Lumbricals (Median & Ulnar N.)
Reflex of the L4 nerve root
Patellar tendon
broad side of hammer
Retinacular Test (left hand only)
Pt seated, place DIP joint in neutral (extended) and try to flex Distal Interphalangeal joint, repeat w/ PIP flexed
P: Flexion of the distal interphalangeal joint cannot be achieved
I: Joint capsule contracture
P: Flexion of the distal interphalangeal joint is achieved
I: Tight retinacular ligament
Linder’s sign
Pt supine, dr flexes pt’s head toward chest
P: Pain along sciatic distribution or sharp, diffuse pain in leg
I: Sciatic radiculopathy
Uvular reflex
State what you are observing for and what a positive finding would indicate
Instruct pt to open mouth, stick out tongue and say “ahh”
Observing for symmetrical rising of soft palate (uvula) upon phonation; Unilateral paralysis = one side does not rise and uvula will deviate to normal side
Just in case:
Afferent: Glossopharyngeal N (CN IX)
Integrating center: Medulla
Efferent: Vagus N (CN X)
Palpate the peripheral pulses of the neck and upper extremity (left side only)
State the definition of the amplitude of a pulse
2 fingers palpate each spot one at time bilateral 3-5 secs: Carotid Subclavian Brachial Radial
Amplitude = the height or intensity of the pulse
Percuss and mark the location of the gastric air bubble
No verbal component required
Percuss down midclavicular line, make one mark at superior edge of tympanic sound
C4 - 5 - 6 Dermatome
C4: Nape of neck to A-C joint
C5: Lateral arm
C6: Lateral forearm, thumb and palmar side of index index
Perform an orthopedic test to evaluate for medial epicondylitis
Golfer Elbow Test
Pt seated, instruct pt to extend elbow supinate hand and flex wrist in a fist, dr triest to extend wrist
P: Pain over medial epicondyle
I: Medial epicondylitis
Bechterew test
Pt seated, instruct pt to extend knee at a time, extend opposite knee, then both at same time.
P: Reproduction of radicular pain or inability to perform correctly due to tripod sign.
I: Sciatic radiculopathy
Beevor sign
Pt supine, dr instructs pt to cross arms across chest and perform a partial sit-up
*seen with ALS
P: Superior or inferior movement of the umbilicus
I: Superior mvmt of umbilicus indicates spinal cord lesion and/or nerve root involvement at T10 or weak lower abdominal muscle
Inferior mvmt of umbilicus indicates nerve root involvement and/or spinal cord lesion at T7-T10 or weakness of upper abdominal muscle
Indirect Light Reflex
State what you are observing for and what neurological structure is being evaluated
Shine light into one eye, look in the other eye for pupillary constriction
observing for contralateral pupillary constriction, should this not occur it could be a lesion in the ipsilateral optic nerve, contralateral occulomotor nerve, or in the midbrain
Afferent: Ipsilateral Optic N (CN II)
Integrating center: Midbrain
Efferent: Contralateral Oculomotor N (CN III)
Palpate the lymph nodes of the head and neck
State the normal finding and identify the clinical characteristics of a patient who has an infection
Occipital Post auricular Pre auricular Tonsillar (angle of mandible) Submandibular Submental Facial Anterior cervical chain Posterior cervical chain Supraclavicular
Normal lymph nodes are mobile and non-tender
Swollen, tender, and non-movable lymph nodes could indicate infection
Standard Maneuver
Identify the significance of Murphy’s sign
Palpate for livers edge (usually not felt - if felt should be smooth, even, and non-tender)
Dr stands on pt’s right, place left hand under 11-12th ribs pulling P-A, right hand on abdomen fingers extended and pointing to head at midclavicular line, pt breathes normally then takes a deep breath and holds, as pt exhales dr pushes in an up gently and deeply
Murphy’s sign = reflex apnea (gasping/shocked breath) positive for inflamed gallbladder AKA Cholecystitis
Perform a test to evaluate a patient for Bicipital Tendonitis
Speed Test
Pt seated w/ forearm supinated and elbow flexed to 45*, dr places fingers on bicipital groove, instruct pt to extend elbow w/ hand going upward against dr’s resistance
P: Pain and or tenderness in bicipital groove
I: Bicipital tendinitis
Adam’s sign
Pt standing w/ shirt off, dr stands behind looking for evidence of scoliosis, instruct pt to bend forward at waist w/ fingers extended and hands together, observe for change in scoliosis
P: A “c” or “s” shaped scoliosis is observed to straighten
I: Evidence of a functional scoliosis, trauma or subluxation
P: A “c” or “s” shaped scoliosis does not straighten
I: Evidence of a pathologic or structural scoliosis
Goldwaith’s sign
Pt supine, dr places fingers of superior hand under interspinous space of lower lumbars (skin on skin!), dr then raises pt’s extended leg (SLR)
P: Localized pain in the low back or radiating pain down the leg
I: Lumbo-sacral problem if pain occurs after spinous processes have moved.
Possible sacroiliac problem with pain occurring before spinous’s have moved.
Plantar Reflex
State the normal and abnormal findings
State what a pathologic finding would indicate
Stiff stroke to lateral curve of foot, normal for toes to curl, pathologic if toes flare
Auscultate for friction rubs
State what you are observing for, no indication required
Use diaphragm to auscultate liver (mid clavicle - pts rt) and spleen (midaxillary - pts left) over the ribs, take deep breath in and out 3 times through the mouth
Listening for grating sound - inflamed organ
Tactile Fremitus
State the normal finding
Give 2 examples for increased fremitus
Pt says “99” when being felt by dr’s ball of hand (lung apices, inter scapular area, triangle of auscultation, medial/lateral lung)
Normal = transmission of spoken word thru lung & soft tissue
Increased fremitus = Lung consolidation, compressed lung or tumor
Muscle Test the C7 Nerve root
Elbow extension: Triceps (Radial N.)
Wrist flexion: Flexor carpi radialis (Median N.), Flexor carpi lunaris (Ulnar N.)
Finger extension: Extensor digitorum communis, Extensor indices profundus, extensor digiti minimi (Radial N.)
Soft tissue of the wrist (right side only)
Radial artery, Ulnar artery, Palmaris longus tendon, Thenar eminence, Hypothenar eminence, Palmar aponeurosis, Carpal tunnel region, Tissues surrounding PIPs, DIPs, and distal tufts
Adduction stress test of the elbow
AKA Lateral Collateral Ligament Test
Pt seated, dr stabilizes medial arm and applies adduction (Varus) pressure on pt’s lateral forearm
P: Excessive gapping and pain
I: Instability of lateral collateral ligament
Hibbs test
Pt prone, stabilize pelvis on side dr standing on, lift OPPOSITE leg to bring knee to 90* then maximally flex knee and push leg away from dr (pt’s internal rotation)
P: Pain in the hip region
I: Hip joint pathology
P: Pain in the buttock or pelvic region
I: Sacroiliac joint lesion
Turyn’s sign
Pt supine, dr dorsiflexes big toe of effected extremity.
P: Pain in the gluteal region or radiating sciatic pain.
I: Sciatic radiculopathy
Pallesthesia (right hand only)
State what you are observing for and what neurological structure is being evaluated
Vibration - 128 Hz fork on 3 bony spots per limb distal to proximal
“Tell me when you feel it and when it stops”
Testing ability to sense vibration and integrity of ascending dorsal column tract
Evaluate for a pathologic reflex in the lower extremity
State what you are observing for and what a pathological finding would indicate
Ankle clonus
Pt supine, one hand under calf and quickly and forcibly dorsiflex the foot and release
Observing for continued involuntary contraction (sustained plantar flexion) indicates an abnormal response and upper motor neuron lesion
Percuss and mark the borders of the liver state the normal finding
Give normal
Give 2 examples for hepatomegaly
Percuss superior border of liver starting on right side at midclavicular line over an area of resonance moving S - I, mark when you hear dullness (5th to 7th intercostal), percuss upward from resonant area at midclavicular line and mark inferior border where dullness is heard (costal margin or slightly below)
normal live is 6-12 cm
alcoholic fatty liver or hepatitis
C5 - 6 - 7 Dermatome
C5: Lateral arm
C6: Lateral forearm, thumb and palmar side of index
C7: Middle finger
Bony palpation of the knee (left side only)
Patella, Medial tibial plateau, Medial femoral condyle, Lateral tibial plateau, Lateral femoral condyle, Fibula head, Tibial tubercle
Perform an orthopedic test to determine if your patient has a medial meniscal tear
McMurray Sign
Pt supine, dr flexes patients hip and knee to 90*, applies external rotation to knee, place hand on lateral knee, flexes knee completely and applies Valgus (knee inward) stress while extending knee. Then internal rotation to knee w/ Varus (knee out) while extending leg.
P: Clicking sound or pain by knee joint
I: Tear of medial meniscus if positive on external rotation ; lateral meniscus if positive on internal rotation
The higher the leg is raised during extension when positive is elicited, the more posterior meniscus injury
OR
Apley Compression Test
pt prone, knee at 90 use knee to stabilze their thigh. internally rotate, push the tibia, externally rotate, push tibia
P: patient points to the side of pain
I: pain on medial side is medial meniscus tear, pain on lateral side is lateral meniscus tear
Apley’s scratch
Pt seated, instruct to place affected hand behind their head to touch opposite superior angle of scapula; then they place hand behind back to touch inferior angle of opposite scapula
P: Exacerbation of pain
I: Degenerative tendinitis of rotator cuff tendons (usually supraspinatus)
Bonnet’s sign
Pt supine, dr strongly internally rotates and adducts affected leg across midline then performs SLR
P: Pain in posterior thigh or leg
I: Immediate pain is sciatic neuropathy from piriformis syndrome
2 point descrimination (right hand only)
State what you are observing for and what neurological structure is being evaluated
Pt’s eyes closed, start w/ wide 2-point touch repeating till only one is felt, repeat @ 3 points hands and arm
Determining the smallest area in which two points can separately be perceived; evaluates somatosensory cortex
Extraoccular eye movement
State the action and innervation of the lateral rectus & inferior oblique muscles
Pt follows dr’s finger in a wide “H” in the air starting in the center and ending in starting position
Observing for nystagmus, parallel eye movement or normal conjugate
Lateral rectus abductus eye innervated by Abducens N.
Inferior oblique elevates and abducts eye innervated by Oculomotor N.
Palpate the lymph nodes of the axilla (right side only)
State the normal finding and the findings associated with a patient with cancer
Palpate for size, consistency, mobility, condition
Lateral axillary - Medial portion of arm and biceps tendon
Medial axillary - Up and in armpit, adduct arm; women cover breast tissue
Anterior axillary - Under pec w/ fingers, use thumb to drag pec nodes; females cover breast
Posterior axillary - Under latissimus using thumb and fingers
Leg length discrepancy test
Pt supine, dr uses cloth measuring tape to measure from ipsilateral ASIS to medial malleolus, then contralateral leg for True leg length discrepancy, for apparent discrepancy measure from umbilicus to each medial malleolus
P: Different measurements
I: True = bony abnormality above or below the level of trochanter difference (anatomical short leg)
Apparent = pelvic obliquity (tilted pelvis)
Bakody’s sign
Shoulder abduction test
Pt seated, instruct pt to place palm of affected side flat on top of hear
P: Decrease or absence of radiating pain
I: Cervical foramina compression, nerve root entrapment (usually C5-C6, this motion elevates supra scapular nerve and relieves traction to upper brachial plexus)
Thomas test
Pt supine, instruct pt to bring one knee to chest and hold, look for lumbar curve to flatten and other leg should stay straight
P: Lumbar spine maintains lordosis (should flatten) and hip or leg flexes
I: Contracture of the hip flexors (iliopsoas)
Perform a test to evaluate for a vestibular lesion in your patient state what you are observing for, no indication required
Fakuda Step Test
Pt closes eyes and marches in place for 50 steps w/ arms out in front
P: Turning of body position to one side
Auscultate for venous hum
State the pathologic finding and a condition that would be associated with this finding
Use BELL, listen 3-5 seconds, take a breath and hold
Epigastrium - right under xyphoid
Base of neck (bilateral) - pt looks to opposite side and looks up, listen ant to SCM in supraclavicular triangle
Pathological to hear low-pitched continuous sound; associated w/ Anemia, Pregnancy, Thyrotoxicosis
Palpate and mark the location of the spleen
State the normal finding and state a condition that would present with splenomegaly
At or posterior to midaxillary line on left side percuss S-I and make one mark where dullness is heard
Normal findings are splenic dullness from 6th to 10th intercostal space, associated w/ mononucleosis
Muscle test the L5 nerve root
Foot dorsiflexion: Proneus tertius; extensor hallicus longus; extensor digitorum longus/brevis (Deep Peroneal N.)
Big toe dorsiflexion: Extensor hallicus longus (Deep Peroneal N.)
Toes 2,3,4 dorsiflexion: Extensor digitorum longus & brevis (Deep Perineal N.)
Hip & pelvis abduction: Gluteus medius & minimus (Superior Gluteal N.)
Halstead test
Pt seated, dr finds radial pulse in neutral position, w/ other hand traction arm to floor, dr asks pt to lift chin and if negative (pulse doesn’t disappear), rotate head to opposite side.
P: Pain and/or paresthesia, decreased or absent pulse, pallor.
I: Compression of the neurovascular bundle by scalenus antics or cervical rib
Bunnel Littler Test (left hand only)
Pt seated, dr places metacarpophalangeal joint in extension and flexes proximal interphalangeal joint, then flexes mcp joint few degrees and tries to flex PIP again
P: Flexion of proximal interphalangeal joint cannot be achieved
I: Joint capsule contracture
P: Flexion of proximal interphalangeal joint is achieved
I: Tight intrinsic muscles
Posterior Apprehension test
Pt supine, dr flexes pt’s shoulder and elbow to 90*w/ arm bent across chest, dr presses arm into table and internally rotates shoulder (arm towards feet) looking @ face
P: Look of apprehension or alarm on the face w/ possible pain
I: Chronic posterior dislocation of the glenohumeral joint
Tromner’s Test
State what youre observing for and what this finding would indicate
Support back of hand and flick tips of three middle fingers or tap center of palm
Observing for flexion of fingers and thumbing indicates Upper Motor Neuron lesion
Auscultate the abdomen for bowel sounds (Right lower quadrant only)
State the findings for the assessment of all 4 quadrants and what the finding would indicate
Use diaphragm and listen for frequency and character in 3 spots per quadrant, 3-5 seconds each
Hyperactive = > 35 sounds / minute Normoactive = 5 - 35 sounds / minute Hypoactive = 1 - 4 sounds / minute Absent = 0 bowel sounds after 5 continuous minutes
You suspect your patient has a ruptured appendix, perform a test to confirm this
State the positive finding, no indication required
Obturator Sign - Unilateral test
Pt supine, instruct pt to flex right hip and knee to 90*, dr supports knee (superior hand) and ankle (inf hand), Pt internally/externally rotates HIP against resistance of dr.
P: Increased pain
I: Ruptured appendix or pelvic abscess
Muscle test the C6 nerve root
Wrist extension: Extensor carpi radialis longus and brevis, extensor carpi ulnaris (Radial N.)
Soft tissue of the knee (right side only)
Quads (unit and individually) Vastus Lateralis Vastus Medialis Rectus Femoris Vastus Intermedius Pre patellar Bursae Infra patellar Tendon Superficial Infra patellar Bursae Medial collateral ligament Lateral collateral ligament Medial meniscus Lateral meniscus Pes anserine area Sartorius Gracilis Semintendinosus Gastrocnemius muscle Popliteal fossa
Rigid or Supple Flat feet test
Pt seated, dr examines presence of Medial Longitudinal Arch, repeat w/ pt standing
P: Absence of medial longitudinal arch in both positions
I: Rigid flat feet
P: Presence of medial longitudinal arch while seated w/ a loss of the arch while standing
I: Supple flat feet
Ely’s heel to buttock test
Pt prone, dr flexes affected knee to 90*, then brings heel to CONTRALATERAL buttock an hyperextends thigh off table, stabilize ipsilateral iliac crest
ELY = 3 letters; 3 Positives and Indicators
P: Inability to raise the thigh
I: Iliopsoas spasm
P: Pain in the anterior thigh
I: Inflammation of lumbar nerve roots
P: Pain in the lumbar region
I: Lumbar nerve root adhesions
Gordon’s sign ??
State what you are observing for and what neurological structure is being evaluated
Pt supine, dr squeezes calf, look at foot
Normal: nothing happens
Pathological if babinski response present
Indicated Upper Motor Neuron Lesion
Perform a test to evaluate the presence of apraxia in your patient
State what you’re observing for and what this finding would indicate
Instruct patient to pretend to comb their hair or brush teeth, dr does not demonstrate how to perform action
Observing ability to recall task and follow a complex motor command testing mental status
You suspect your patient has appendicitis, perform a physical examination test to confirm this
State what you are looking for, no indication required
Psoas sign: pt supine, dr presses thigh into table and pt lift’s right leg against resistance
Looking for pain
Auscultate the vessels of the abdomen
State what you are observing for and what this finding would indicate
Use BELL To listen to:
Aorta
Renals
Common iliacs
Listening for bruits evidence of turbulent blood flow
Muscle test the T1 nerve root
Finger abduction: Dorsal interossei (Ulnar N.)
Finger adduction: Palmar interossei (Ulnar N.)
Allen’s Test (right hand only)
Pt seated, dr instructs pt to raise his/her hand above heart level w/ arm and elbow at 90*, open and close fist for 60 seconds then make a fist, dr occludes radial and ulnar artery, lower arm, pt opens fist and dr releases one artery, observe both hands for fill time; repeat w/ other artery
P: A delay of more than 10 seconds (Evans 5 sec) in returning a reddish color to the hand
I: Radial or ulnar artery insufficiency. The artery occluded is not the artery being tested
Perform a test to determine the stability of the ACL
Lachmant Test (or Drawer) Pt supine, dr puts knee to 30* flexion, grasp proximal tibia and distal femur and pull tibia forward to feel joint play
P: Gapping w/ tibia moving away from the femur
I: Anterior cruciate ligament or posterior oblique ligament instability
Schempelman’s sign
Pt seated w/ arms fully abducted above head, dr instructs pt to laterally flex thoracics to left then right side
P: Pain on the concave side
I: Intercostal neuritis
P: Pain on convex side
I: Fibrous inflammation of the pleura (possible intercostal myofascitis)
Evaluate CN I
State what you are observing for and what neurological structure is being evaluated
Any changes in ability to smell or taste, using penlight inspect nostrils, instruct pt to occlude one nostril w/ eyes closed and ask: Do you smell anything? Can you identify the smell?
Inspecting their ability to smell and olfactory nerve
Fakuda Step Test
State what you are observing for and what neurological structure is being evaluated
Pt marches in place w/ eye’s closed 50 steps
P: Turning of body position to one side
I: Side of vestibular portion of cranial nerve 8
Murphy’s punch state the normal finding and a condition for a pathologic finding
Murphy’s Punch - BILATERAL
Palm of hand over posterior costovertebral angle (T10-T12), strike back of hand w/ ulnar surface of fist.
Should thud w/ no pain or tenderness
Pain indicates inflamed kidney (nephritis - stones, infection, etc)
L5 - S1 - S2 Dermatome
L5: Anterolateral tibia, dorsum of foot, 3 middle toes
S1: Lateral leg, post lateral malleolus, lateral pinky toe
S2: Superior to politeal fossa, down joint and medial
Cervical distraction test
Pt seated, dr grasps pt’s head w/ both hands and gradually presses up (keep hands off TMJ and ears)
P: Diminished or absence of localized cervical pain
I: Foraminal encroachment
P: Diminished or absence of radiating pain
I: Nerve root compression
P: Increase of cervical pain
I: Muscular strain, ligamentous sprain, myospasm, or facet capsulitis
Trendelenburg test
Pt stands and shifts weight onto affected side, observe level of hips, stand in front & offer hand for support
P: High iliac crest on supported side and low crest on elevated leg
I: Weak gluteus medius muscle on supported side
ROM: Cervical Spine
Flexion: 50*
Extension: 60*
Left/Right lateral flexion: 45*
Left/Right rotation: 80*
ROM: Elbow
Flexion: 150*
Extension: 0*
Forearm supination: 80*
Forearm pronation: 80*
Anvil test
Pt supine, dr elevates leg w/ knee extended, makes fist and strikes inferior calcaneus
P: Localized pain in long bone or in hip
I: Possible fracture of long bones or hip joint pathology
ROM: Foot & ankle
Dorsiflexion: 20* Plantarflexion: 50* Subtalar inversion: 5* Subtalar eversion: 5* 1st Metatarsalphalangeal joint flexion & extension
ROM: Hip
Standing: Flexion: 120* Extension: 30* Abduction: 45* Adduction: 45* Internal rotation: 45* External rotation: 45*
Seated:
Flexion & adduction (how mom sits)
Flexion, abduction & external rotation (how dad sits)
ROM: Shoulder
Flexion: 180* Extension: 60* Abduction: 180* Adduction: 50* External rotation: 90* Internal rotation: 70* Scapular retraction Scapular protraction Scapular elevation
Fajersztajns’s Test
Pt supine, dr performs SLR on healthy leg to 75* or until pain down affected leg, if no pain dorsiflex foot
P: Pain down affected leg (Cross over sign)
I: Medial disc protrusion
P: Decrease in pain down affected leg
I: Lateral disc protrusion
ROM: Wrist and Hand
Wrist flexion: 80* Wrist extension: 70* Wrist ulnar deviation: 30* Wrist radial deviation: 20* Finger abduction Finger adduction Finger flexion Finger extension Thumb flexion Thumb extension Finger opposition
Soft Tissue Palpation Shoulder
- rotator cuff muscles
- supraspin, infraspin, teres minor, subscapularis - subacromical bursae
- subdeltoid bursae
- axillary borders
- pec major
- serratus anterior
- axillary lymph nodes
- latissimus dorsi
- bicipital tendon - SCM
- biceps
- deltoid (group and indiv)
- traps
- rhomboids
Soft Tissue of Elbow
- ulnar nerve
- wrist flexors (unit and indiv)
- pronator teres
- flexor carpi radialis
- palmaris longus
- flexor carpi ulnaris - medial collateral lig
- supracondylar lymph
- brachial artery
- triceps
- lateral collateral lig
- biceps
- olecranon bursa
- elbow flexors muscles (mobile wad of three)
- brachioradialis
- extensor carpi radialis longus/brevis
Bony Palpation of Hand
- radial styloid process
- scaphoid
- lunate
- listers tubercle
- triquetrum
- pisiform
- trapezium
- trapezoid
- capitate
- hook of hamate
- ulnar styloid process
- metacarpals
- phalages
ROM lumbar
flexion 25
extension 30
lateral flexion 25
rotation 30
