OSCE PRACTICAL

PERCUSS FOR GASTRIC AIR BUBBLE

** 1 MARK ** Patient supine. Percuss for the gastric air bubble in the area of the left lower anterior rib cage down the midclavicular line on the left side. NORMAL: Tympany INDICATES: Location of the fundus of stomach

DEEP PALPATION OF ABDOMEN

*** KNEES FLEXED ON TABLE *** Patient supine. Palpate (3) areas per quadrant assessing all (4) quadrants. Using the palmar surface of the fingers, pressing deeply and evenly into the abdominal wall with a flat hand approximately 1 1⁄2 to 2 inches deep or deeper if patient is obese, using a pressing circular motion utilizing the bimanual method. Patient's knees flexed with flat feet on the table. VERBALS: Pain, Tenderness, Muscle guarding, Masses

VENOUS HUM IN ABDOMEN

*** use BELL Patient supine. Place the bell of the stethoscope below the tip of the xiphoid process and ask the patient to hold their breath while listening for 3-5 seconds minimum POSITIVE: Soft, low pitched, continuous sound that is louder during diastole INDICATES: Increased collateral venous circulation

MAJOR ARTERIES OF THE ABDOMEN FOR BRUITS

*** use BELL Patient supine. Place the bell at the areas listed below for a minimum of 3-5 seconds in each spot. Abdominal Aorta: Under the xiphoid process and slightly left.*suspend respiration*Renals: Two inches above and two inches lateral from umbilicus. Bilateral.*suspend respiration* Common Iliac's: Two inches down and two inches lateral from umbilicus. Bilateral POSITIVE: Harsh, whooshing sound (bruit) INDICATES: Possible vascular disease

DAWBARN TEST:

***Deep palpation of the shoulder elicits a well-localized tender area of the subacromial bursa. Patient seated, examiner applies pressure below the affected acromial process. Examiner continues to apply pressure while abducting the patient's arm slightly past 90 degrees. P: Decrease in pain and or tenderness I: Subacromial Bursitis

FRICTION RUBS

***use diaphragm of stethoscope - 3 breaths through the mouth Patient supine. Place the diaphragm on the Liver (mid-clavicular line, 6th-10th intercostal spaces) and then the spleen (posterior to the mid-axillary line, 6th-8th intercostal spaces) and ask the patient to take 3 deep breaths in and out through their mouth. POSITIVE: High Pitched sandpaper rubbing sound associated with respiration INDICATES: Inflammation of peritoneal surface of the liver and/or spleen from infection, tumors or infarct.

NORMAL BREATH SOUNDS (Posterior)

**SEATED ONLY** Patient seated. Examine the posterior thorax with the patient's arms folded across the chest with hands resting, if possible, on the opposite shoulders. This position swings the scapulae laterally and increases access to the lungs fields. Have the patient breathe deeply through the mouth exaggerating normal respiration. Utilizing the diaphragm of the stethoscope firmly on the skin, ask the patient to breathe IN AN OUT THROUGH THE MOUTH while examiner evaluates thethorax in symmetric locations comparing one side of the chest and then the other at each level in a ladder-like pattern as shown on page 275 of the textbook. - Apices: #1,2 - Interscapular: # 5-6 - Triangles of Auscultation: # 7-8 - Medial Base: # 9-10 - Lateral: #17-18 VERBALS: Listen for characteristics: Pitch, intensity, duration of the normal breath sounds - Bronchial (best heard over trachea) - Broncho-vesicular (best heard over the main bronchus and upper right posterior lung field) - Vesicular (best heard over the periphery of the lung)

SOFT TISSUE PALPATION FOOT AND ANKLE:

1) Tibialis posterior tendon 2) Spring ligament 3) Tibialis anterior tendon 4) Deltoid ligament 5) Fibular/peroneus brevis 6) Achilles tendon 7) Plantar aponeurosis 8) Anterior talofibular ligament 9) Posterior tibial artery 10) Dorsal pedal artery

SPECIAL TESTING: VOCAL RESONANCE (posterior)

**SEATED ONLY** Patient seated. Examine the posterior thorax with the patient's arms folded across the chest with hands resting, if possible, on the opposite shoulders. This position swings the scapulae laterally and increases access to the lungs fields. Utilizing the diaphragm of the stethoscope firmly on the skin, have the patient recite numbers, names, or other words while examiner evaluate one location bilaterally on the following areas: apices bilaterally, the interscapular areas, the triangles of auscultation, medial lungs and lateral lungs. Comparing side to side. NORMAL: The sounds transmitted are usually muffled and indistinct and are best heard medially.

NORMAL BREATH SOUNDS (ANTERIOR)

**SEATED ONLY** Patient seated. Have the patient breathe deeply through the mouth exaggerating normal respiration. Utilizing the diaphragm of the stethoscope firmly on the skin, ask the patient to breathe IN AN OUT THROUGH THE MOUTH while examiner evaluates thethorax in symmetric locations comparing one side of the chest and then the other at each level in a ladder-like pattern as shown on page 275 of the textbook. - Apices: #19-20 - "Above the Breast Tissue": # 21-22 - Medial Base: # 23-24 - Lateral: #25-26 VERBALS: Listen for characteristics: Pitch, intensity, duration of the normal breath sounds - Bronchial (best heard over trachea) - Broncho-vesicular (best heard over the main bronchus and upper right posterior lung field) - Vesicular (best heard over the periphery of the lung)

ROM FOOT AND ANKLE:

- Dorsiflexion: 20 - Plantarflexion: 50 - Subtalar Inversion: 5 - Subtalar Eversion: 5 - 1st MTP joint flexion - 1st MTP joint extension

ROM HIP and PELVIS:

- Flexion 120° - Extension 30° - Abduction 45° - Adduction 45° - Internal rotation 45° - External rotation 45° - Flexion and Adduction - Flexion, Abduction and External Rotation

UMNL tests:

- Hoffman - Tromner - Ankle Clonus BABINSKI - Oppenheim - Chaddock - Gordon - Schaefer

CORNEAL REFLEX

- RESPONSE: Blinking and tearing of the eye upon touching the cornea w/ a cotton wisp - AFFERENT: Trigeminal Nerve V - INTEGRATING CENTER: Pons - EFFERENT: Facial Nerve VII

INDIRECT LIGHT

- RESPONSE: Contralateral pupillary constriction whenlight is shined in the eye - AFFERENT: Optic nerve II (ipsilateral to light source) - INTEGRATING CENTER: Midbrain - EFFERENT: Oculomotor Nerve III (Contralateral to light source)

ACCOMODATION

- RESPONSE: Convergence of the eyes with pupillary constriction - AFFERENT: Optic nerve II - INTEGRATING CENTER: Occipital cortex - EFFERENT: Oculomotor Nerve III

INTERSCAPULAR REFLEX

- RESPONSE: Drawing inward of the scapula when skin or inter scapular space is irritated - AFFERENT: T2-T7 spinal nerves - INTEGRATING CENTER: T2-T7 Spinal cord - EFFERENT: Dorsal scapular nerve

GAG/PHARYNGEAL

- RESPONSE: Gagging upon touching the back of the throat w/ a tongue depressor - AFFERENT: Glossopharyngeal Nerve IX - INTEGRATING CENTER: Medulla - EFFERENT: Vagus Nerve X

DIRECT LIGHT REFLEX

- RESPONSE: Ipsilateral pupillary constriction whenlight is shined in the eye - AFFERENT: Optic nerve II (ipsilateral to light source) - INTEGRATING CENTER: Midbrain - EFFERENT: Oculomotor Nerve III (ipsilateral to light source)

PLANTAR REFLEX

- RESPONSE: Plantar flexion (curling) of toes upon stroking sole of foot - AFFERENT: Tibial nerve - INTEGRATING CENTER: Spinal cord S1-S2 - EFFERENT: Tibial Nerve

CILIOSPINAL

- RESPONSE: Pupillary dilation when examiner pinched the base of the neck at the cervical sympathetic chain - AFFERENT: Cervical sympathetic chain - INTEGRATING CENTER: T1-T2 spinal cord - EFFERENT: Cervical sympathetic chain

CAROTID SINUS

- RESPONSE: Reduction in heart rate when examiner presses the carotid sinus - AFFERENT: Glossopharyngeal Nerve IX - INTEGRATING CENTER: Medulla - EFFERENT: Vagus Nerve X

OCULOCARDIAC

- RESPONSE: Reduction in heart rate when examiner presses the eye - AFFERENT: Trigeminal V - INTEGRATING CENTER: Medulla - EFFERENT: Vagus Nerve X

ABDOMINAL REFLEX

- RESPONSE: Umbilicus deviation to the stroked side. Absence is normal only if bilateral (see Beevor sign) - AFFERENT: Upper T7-10 Lower T11-12 - INTEGRATING CENTER: Spinal Cord T7-T12 - EFFERENT: Upper T7-10 Lower T11-12

ROM WRIST and HAND:

- Wrist flexion 80 - Wrist extension 70 - Wrist ulnar deviation 30 - Wrist radial deviation 20 - Finger abduction - Finger adduction - Thumb flexion (MCP) - Thumb extension (MCP) - Finger flexion (MCP) - Finger extension (MCP) - Finger Opposition

SOFT TISSUE PALPATION WRIST AND HAND:

1) Ulnar artery 2) Radial artery 3) Palmaris longus tendon 4) Carpal tunnel region 5) Thenar eminence 6) Hypothenar eminence 7) Palmar aponeurosis 8) Tissues surrounding proximal interphalangeal joints 9) Tissues surrounding distal interphalangeal joints 10) Distal tufts of fingers

BONY PALPATION FOOT AND ANKLE:

1) Calcaneus 2) Sustentaculum tali 3) Medial malleolus 4) Lateral malleolus 5) T alus 6) Navicular 7) Cuboid 8) 3 Cuneiforms 9) 5 Metatarsals 10) Metatarsophalangeal joints

SOFT TISSUE PALPATION HIP and PELVIS:

1) Femoral triangle borders - Sartorius - Adductor longus - Inguinal ligament 2) Quadriceps muscles (palpate as a unit and individually) - Vastus Lateralis - Vastus Medialis - Vastus Intermedius - Rectus Femoris 3) Greater trochanteric bursa 4) Gluteus medius 5) Gluteus maximus 6) Sciatic nerve 7) Cluneal nerves 8) Hamstrings - Biceps femoris - Semitendinosus - Semimembranosus

BONY PALPATION LUMBAR SPINE

1) Lumbar spinous processes 2) Sacral tubercles 3) Iliac crest 4) PSIS (Posterior Superior Iliac Spine)

BONY PALPATION OF ELBOW:

1) Medial epicondyle 2) Medial supracondylar line of the humerus 3) Groove of the ulnar nerve 4) Trochlea 5) Olecranon 6) Olecranon fossa 7) Lateral epicondyle 8) Lateral supracondylar line of the humerus 9) Radial head

SOFT TISSUE PALPATION LUMBAR SPINE:

1) Paraspinal muscles (palpate as a unit and individually) superficial layer • Spinalis • Longissimus • Iliocostalis 2) Sciatic nerve 3) Gluteus Maximus 4) Gluteus Medius 5) Hamstrings - Biceps femoris - Semitendinosus - Semimembranosus **FLIP** 5) Anterior abdominal muscles

BONY PALPATION KNEE:

1) Patella 2) Medial tibial plateau 3) Tibial tubercle 4) Medial femoral condyle 5) Lateral tibial plateau 6) Lateral femoral condyle 7) Fibula head

SOFT TISSUE PALPATION KNEE:

1) Quadriceps muscles Quadriceps muscles (palpate as a unit and individually) - Vastus Lateralis - Vastus Medialis - Vastus Intermedius - Rectus Femoris 2) Infrapatellar tendon 3) Bursae • Prepatellar • Superficial infrapatellar 4) Medial meniscus 5) Lateral meniscus 6) Pes anserine area • Sartorius • Gracilis • Semitendinosus 7) Popliteal fossa 8) Lateral collateral ligament 9) Medial collateral ligament 10) Gastrocnemius muscle

WRIST AND HAND BONY PALPATION:

1) Radial styloid process 2) Scaphoid (Navicular) 3) Lunate 4) Lister's tubercle (Dorsal tubercle) 5) Triquetrium 6) Pisiform 7) Trapezium 8) Trapezoid 9) Capitate 10) Hook of hamate 11) Ulnar styloid process 12) Metacarpals 13) Phalanges

SOFT TISSUE PALPATION OF CERVICAL SPINE

1) Sternocleidomastoid muscle 2) Anterior lymph node chain 3) Posterior lymph node chain 4) Thyroid gland 5) Carotid pulse 6) Supraclavicular fossa 7) Trapezius muscle 8) Greater occipital nerves 9) Superior nuchal ligament

SOFT TISSUE PALPATION ELBOW:

1) Ulnar nerve 2) Wrist flexor muscles (palpate as a unit and individually) - Pronator teres - Flexor carpi radialis - Palmaris longus - Flexor carpi ulnaris 3) Medial collateral ligament 4) Supracondylar lymph nodes 5) Brachial Artery 6) Triceps muscle 7) Lateral collateral ligament 8) Biceps 9) Olecranon bursa 10) Elbow Flexors muscles "mobile wad of three" (palpate as a unit and individually) - Brachioradialis - Extensor carpi radialis longus - Extensor carpi radialis brevis

C5 NERVE ROOT

1. Disc level: C4 2. Muscle tests: SHOULDER ABDUCTION (deltoid - axillary nerve) FOREARM FLEXION (biceps - musculocutaneous nerve) 3. Reflex: Bicep 4. Sensation: Lateral arm and shoulder

C6 NERVE ROOT

1. Disc level: C5 2. Muscle tests: WRIST EXTENSION (extensor carpi radialis longus and brevis, and extensor carpi ulnaris - radial nerve) 3. Reflex: Brachioradialis 4. Sensation: Anterior lateral forearm, palm, thumb, and 2nd digit

C7 NERVE ROOT

1. Disc level: C6 2. Muscle tests: ELBOW EXTENSION (triceps - radial nerve) WRIST FLEXION (flexor carpi radialis-median nerve, flexor carpi ulnaris - ulnar nerve) FINGER EXTENSION (extensor digitorum communis, extensor indicis profundus, extensor digiti minimi - radial nerve) 3. Reflex: Triceps 4. Sensation: 3rd digit, middle of palm

C8 NERVE ROOT

1. Disc level: C7 2. Muscle tests: FINGER FLEXION (flexor digitorum superficialis, flexor digitorum profundis, lumbricals - median and ulnar nerves) 3. Reflex: NONE 4. Sensation: 4th and 5th digits, antero-medial hand and forearm

L4 NERVE ROOT

1. Disc level: L3 2. Muscle tests: FOOT DORSIFLEXION & INVERSION (tibialis anterior - deep fibular nerve) 3. Reflex: PATELLAR TENDON 4. Sensation: Medial aspect of leg, medial foot, medial aspect of big toe

L5 NERVE ROOT

1. Disc level: L4 2. Muscle tests: FOOT DORSIFLEXION (tibialis anterior and peroneus tertius - both deep fibular nerve) BIG TOE DORSIFLEXION (extensor hallucis longus - deep fibular nerve) TOES 2, 3, & 4 DORSIFLEXION (extensor digitorum longus and brevis - deep fibular nerve) HIP & PELVIS ABDUCTION (gluteus medius & minimus - superior gluteal nerve) 3. Reflex: NONE 4. Sensation: Lateral leg, dorsum of foot, and middle 3 toes

S1 NERVE ROOT:

1. Disc level: L5 2. Muscle tests: FOOT PLANTARFLEXION (Gastrocneius & Soleus - tibial nerve) FOOT PLANTAR FLEXION & EVERSION (fibularis longus & brevis - superficial fibular nerve) HIP EXTENSION (Gluteus maximus - inferior gluteal nerve) 3. Reflex: ACHILLES 4. Sensation: Posterior aspect of the leg, lateral aspect of foot, and lateral aspect of little toe

T1 NERVE ROOT

1. Disc level: T1 2. Muscle tests: FINGER ABDUCTION (dorsal interossei - ulnar nerve) FINGER ADDUCTION (palmer interossei - ulnar nerve) 3. Reflex: NONE 4. Sensation: antero-medial arm (digital aspect of arm to proximal aspect of forearm)

ROM: SHOULDER

1. Flexion: 180 2. Abduction: 180 3. External Rotation: 90 4. Internal Rotation: 70 5. Extension: 60 6. Adduction: 50 7. Scapular Retraction 8. Scapular Protraction 9. Scapular Elevation

SOFT TISSUE PALPATION: SHOULDER

1. Rotator Cuff Muscles - Supraspinatus - Infraspinatus - Teres Minor - Subscapularis 2. Subacromial Bursa 3. Subdeltoid Bursa 4. Axillary Borders - Pec Major - Serratus Anterior - Axillary lymph nodes - Latissimus Dorsi - Bicipital Tendon 5. Prominent muscles of region - SCM - Biceps - Deltoids (whole) > A, M, P - Trapezius - Rhomboids (whole) > Minor/Major

BONY PALPATION: SHOULDER

1. Sternoclavicular Articulation 2. Clavicle 3. Coracoid process 4. Acromioclavicular articulation 5. Acromion 6. Greater tuberosity of Humerus 7. Bicipital Groove 8. Lesser Tuberosity of the Humerus 9. Spine of Scapula 10. Body of Scapula 11. Scapulothoracic articulation

ANKLE CLONUS

Continued involuntary contraction (sustained plantar flexion) of foot upon quick forcible dorsiflexion of the foot

BONY PALPATION HIP AND PELVIS:

ANTERIOR: 1. ASIS 2. Iliac Crest 3. Iliac tubercle 4. Greater Trochanter POSTERIOR: 1. PSIS 2. Ischial Tuberosity 3. Coccyx

NERVE ROOT PROCEDURE:

Always use the MRS system in the correct order, any deviation will result in a loss of points 1) Muscle - test and name the muscle/s and nerve for each neurological package being tested 2) Reflex - test and name the appropriate reflex being tested; if no reflex it must be stated. 3) Sensation - test the appropriate dermatome for the neurological package and its corresponding dermatome above and below following the format enclosed from Hoppenfeld.

BONY PALPATION OF CERVICAL SPINE:

Anterior Aspect 1) Hyoid Bone 2) Thyroid Cartilage 3) First Cricoid Ring 4) Mandible Posterior Aspect 1) Occiput 2) Inion (EOP) 3) Superior Nuchal Line 4) Mastoid Processes 5) Spinous Processes of Cervical Vertebrae 6) Facet Joints

OPPENHEIM SIGN

Application of pressure to anterior tibia stroking downward

Jendrassik Maneuver aka

Reinforcement test Pt. hooks hands or feet together and pulls on the clenched hands or feet at the moment the reflex is performed

HOFFMAN

Clawing of fingers and thumb (flexion and adduction of thumb w/flexion of the fingers) upon flicking tip of middle finger into extension

HYPERABDUCTION MANEUVER aka WRIGHT TEST

Compression of the axillary artery by pectoralis minor or coracoid process. Thoracic outlet syndrome POSITIVE: Pain and/or paresthesia, decreased or absent pulse amplitude, pallor. INDICATES: Compression of the axillary artery by pectoralis minor or coracoid process. Thoracic outlet syndrome.

TINEL FOOT SIGN

Doctor taps the region of the medial plantar nerve, posterior to the medial malleolus POSITIVE: Paresthesia radiating into the bottom of the foot. INDICATES: Tarsal tunnel syndrome

BABINSKI

Dorsiflexion of the big toe and fanning or splaying of other toes uponstimulation of the plantar surface of the foot (lateral to medial)(Plantar Reflex))

VESTIBULO OCULAR REFLEX

Dr. holds patient's head and instructs patient to fix vision on the doctor's face. Observe and note spontaneous nystagmus. Dr. then turns patient's head into rotation, lateral flexion, and flexion and extension. INDICATES: Normal patient should maintain eye contact with eyes moving at the same speed in the opposite direction of head movement. Inability to maintain fixation or spontaneous nystagmus indicates a vestibular lesion.

NERI BOWING TEST

Examiner instructs patient to bend forward from the waist. POSITIVE: Pain accompanied by flexion of the knee on the affected side and body rotation away from the affected side. INDICATES: Positive with a variety of low back pathologies. Lumbar disc lesion or lumbosacral strain or sacroiliac strain.

LEWIN STANDING TEST

Examiner instructs patient to bend forward slightly at the waist with knees slightly flexed. Examiner first brings one knee into complete extension. Next the examiner brings the other knee into complete extension. Finally the examiner brings both knees into complete extension. POSITIVE: Radiating pain down the leg causing flexion of the patient's knee or knees. INDICATES: Gluteal, lumbosacral or sacroiliac pathologies.

MINOR SIGN

Examiner instructs patient to stand. Observe for abnormal motion. POSITIVE: Patient needs support in moving from a seated to standing position (hand on back or thigh). INDICATES: Sciatica, lumbosacral or sacroiliac joint lesion

ROM OF LUMBAR SPINE

Flexion 25 Extension 30 Left lateral bending 25 Right lateral bending 25 Left rotation 30 Right rotation 30

ROM CERVICAL SPINE:

Flexion 50 Extension 60 Lateral bending left 45 Lateral bending right 45 Left rotation 80 Right rotation 80

TROMNER

Flexion of the fingers and thumb upon tapping palmar surface of middle 3 fingers

ROM KNEE:

Flexion: 135 Extension: 0 Internal rotation External rotation

ROM ELBOW:

Flexion: 150 Extension: 0 Forearm Supination: 80 Forearm Pronation: 80

BLUMBERG'S SIGN

POSITIVE: Sharp pain upon rebound in any of the 4 quadrants INDICATES: Peritonitis

ROVSING'S SIGN

POSITIVE: Sharp pain upon rebound in the right lower quadrant when pressing into the LLQ INDICATES: Appendicitis

RIGID OR SUPPLE FLAT FEET TEST:

Patient is seated and then stands, examiner observes patient's feet while seated and while standing. POSITIVE: (1) Absence of medial longitudinal arch in both positions. (2) Presence of medial longitudinal arch while seated with a loss of medial longitudin arch while standing. INDICATES: (1) Rigid flat feet (2) Supple flat feet

PAINFUL ARC TEST:

Palm facing down, the patient is instructed to elevate their arm from their side slowly (ACTIVELY) up to 180 degrees of full abduction. POSITIVE: 1) Pain worse between 70 degrees and 110 degrees of shoulder abduction 2) Pain worse at 160 degrees or above of shoulder abduction INDICATES: 1) Impingement syndrome with supraspinatus pathology 2) A/C joint involvement

HAWKIN KENNEDY TEST:

Passive internal rotation of the shoulder in 90 degrees of forward flexion with the elbow flexed to 90 degrees while the scapula is stabilized posteriorly. POSITIVE: The supraspinatus tendon is jammed up against the anterior surface of the Coraco-acromial ligament due to narrowing of the subacromial space. Posterior pain implicates stretch of the Teres Minor and Infraspinatus tendons. INDICATES: Local pain indicates supraspinatus tendinitis and impingement. Anterior pain is anterior impingement syndrome posterior pain is posterior impingement syndrome.

PALPATORY SYSTOLIC BP

Patient Seated. Free the arm of clothing and apply a cuff of appropriate size around the upper arm. Center the deflated bladder over the brachial artery (use cuff arrows as a guide), just medial to biceps tendon, with the lower edge 2-3 cm above the antecubital crease. Make sure the cuff is snug and secure so that 1-2 fingers can fit underneath in the inferior edge of the cuff. Flex the patient's arm to be at the level of the heart and support it comfortably. Establish the radial pulse, using the finger pads of the 2nd and 3rd fingers. Inflate the cuff pressure up slowly to approximately 60 mmHg while monitoring the radial pulse. Continue to increase the pressure in increments of ~10 mmHg until the radial pulse disappears. Once the radial pulse disappears-Quickly inflate the cuff 30 mm Hg above the level where the radial pulse disappeared. Release cuff pressure at approximately 2-3 mm Hg / second until the pulse returns. The pressure where the radial pulse reappears is the Palpatory systolic blood pressure. Immediately deflate the cuff completely. Report findings in mm Hg. VERBALS: Wait 15-30 seconds before re inflating the cuff on the same arm.

LASEGUE TEST

Patient Supine. Hip and leg bent to 90 degrees. Slowly extend the knee (keeping hip at or close to 90 degrees) POSITIVE: Reproduction of posterior thigh pain before 60 degrees INDICATES: Lumbosacral or sacroiliac lesions, subluxation syndrome, disk lesions, spondylolisthesis, adhesions or foraminal encroachment.

SPECIAL MANEUVER FOR MITRAL MURMUR

Patient begins supine. BELL is placed at the 5th ICS midclavicular line for 3- 5 seconds. The patient is then assisted into the Left Lateral Decubitus position and asked to take a deep breath in and hold while the mitral area is listened to for 3-5 seconds. VERBALS: Mitral Murmurs are low pitched and heard with the bell

PERIPHERAL ARTERY PALPATION

Patient can be seated or supine for Neck and Upper Extremity pulses. Patient must be supine for Abdomen and Lower extremity pulses. Palpate the arterial pulses to assess the heart rate and rhythm, contour and amplitude. Pulse must be held for 3-5 seconds. If abnormality is detected, pulse would be assessed for 60 seconds. Define bolded words. **Compare side to side.** NECK & UPPER EXTREMITY - Carotid - Subclavian - Brachial - Radial - Ulnar ABDOMEN & LOWER EXTREMITY - Abdominal aorta - Femoral - Popliteal - Posterior Tibial - Dorsalis Pedis

KEMP TEST

Patient either seated or standing with arms crossed in front of the chest. Examiner stands behind patient and stabilizes at the (opposite) PSIS. With other hand examiner reaches around patient and grasps patient's shoulder. Examiner passively brings shoulder back and obliquely pushes shoulder towards opposite PSIS POSITIVE: 1) Pain usually radicular, recreating existing sciatic pain 2) Pain - local INDICATES: 1) Disc protrusion:• In medial disc protrusion Kemps will be positive as the patient is leaning AWAY from the side of pain.• In lateral disc protrusion Kemps will be positive as the patient is leaning INTO the side of pain. 2) Localized pain may indicate lumbar spasm or facet capsulitis.

GAENSLEN TEST:

Patient in the supine position with the affected side of the sacroiliac joint as close to the edge of the table as is possible. The patient then grasps the unaffected leg just below the knee and approximates the knee to his chest. The examiner then places a downward pressure on the affected thigh until it is lower than the edge of the table. POSITIVE: Pain on the affected SI joint stressed into extension. INDICATES: General sacroiliac joint lesion, anterior sacroiliac ligament sprain, or inflammation of the SI joint.

HALLPIKE DIX MANEUVER

Patient is seated with head turned 45o to the right or left. Examiner quickly brings the patient into the supine position with head extended off the table. Examiner notes any nystagmus. Patient is then brought to the seated position. Repeat with head turned to the opposite direction POSITIVE: Nystagmus starting 2-5 seconds after movement and stopping within 30 seconds INDICATES: Benign positional vertigo

O' DONOGHUE MANEUVER

Patient is seated, examiner grasps the patient's head with both hands and passively and slowly takes the cervical region through a range of motion. The examiner then takes the cervical region through active resister ROM POSITIVE: 1) Pain during passive range of motion. 2) Pain during resisted range of motion. INDICATES: 1) Ligamentous sprain. (Passive ROM stresses ligaments) 2) Muscle/tendon strain. (Active ROM stresses muscles and tendons)

LAGUERRE TEST:

Patient is supine, examiner grasps the affected leg, flexes and externally rotates the hip and abducts the thigh (this test is similar to Patrick except the ankle of the affected leg is not resting on the contralateral knee). Examiner applies pressure to the end range of motion while stabilizing the contralateral ASIS (rest ankle on forearm and with other hand reach under arm to stabilize). POSITIVE: Pain in hip joint or SI joint INDICATES: Hip joint or sacroiliac joint pathology (mechanical problem)

ALLIS SIGN (Galeazzi Sign) = (Pediatric Test used for 1 month-2 year olds, and can be used in adults)

Patient is supine, examiner instructs patient to place both feet flat (approximate great toes and medial malleoli bilateral) on the bench while flexing both knees to 90 degrees. POSITIVE: Difference in height and anteriority of knees INDICATES: (1) If one knee is inferior = ipsilateral congenital hip dislocation or tibial discrepancy (anatomical short leg) (2) If one knee is anterior = ipsilateral congenital hip dislocation or femoral discrepancy (contralateral anatomical short leg)

BUCKLING SIGN (CIPRIANO)

Patient is supine, examiner performs a SLR on the patient. POSITIVE: Pain in the posterior thigh with sudden knee flexion (buckle). INDICATES: Sciatic radiculopathy

BOWSTRING SIGN

Patient is supine, examiner places patient's leg on their shoulder and first applies pressure to the biceps hamstring muscle if pain is not elicited then apply pressure to the biceps and semimembranosis tendons then to the popliteal fossa. POSITIVE: Pain in the lumbar region hamstrings and/or dull posterior thigh pain. INDICATES: Sciatic radiculopathy or Tight hamstrings

WELL LEG RAISING TEST

Patient is supine. Examiner performs a SLR on the patient's unaffected leg to 75o or until it produces pain down the affected leg. POSITIVE: 1) Pain down affected leg. 2) Decrease in pain down affected leg INDICATES: 1) Medial disc protrusion. 2) Lateral disc protrusion.

FAJERSTAJN TEST aka WELL-LEG-RAISING TEST of FAJERSZTAJN

Patient is supine. Examiner performs a SLR on the patient's unaffected leg to 75o or until it produces pain down the affected leg. If no change in the patient's symptoms then sharply dorsiflex the patients foot. POSITIVE: 1) Pain down affected leg. 2) Decrease in pain down affected leg INDICATES: 1) Medial disc protrusion. 2) Lateral disc protrusion.

PITTING EDEMA

Patient is supine. Press finger over the bony prominence of the tibia or 1⁄2 inch above medial malleolus for several seconds. Compare bilateral. POSITIVE: A Depression that does not rapidly refill and resume its original contour INDICATES: Orthostatic (pitting) Edema. Conditions leading to pitting edema are cardiac, liver, & kidney disorders

ARTERIAL BRUITS OF HEAD AND TORSO

Patient is supine. Utilizing the bell of the stethoscope, hold on each artery for 3-5 seconds for laboratory evaluation. (*) indicate breath suspension. - Temporal - Carotid* - Subclavian* - Abdominal Aorta* - Renal's* x2 - Common Iliac's x2 - Femoral POSITIVE: Harsh, whooshing sound (bruit) INDICATES: Turbulent flood flow within an artery, possibly due to atherosclerosis or a clot.

VENOUS HUMS OF THE NECK

Patient is supine. Utilizing the bell of the stethoscope, hold on each vein for 3-5 seconds for laboratory evaluation. (*) indicate breath suspension. • Base of the neck (bilateral)*- turn head/lookup POSITIVE: Soft, continuous low-pitched sound that is louder during diastole. INDICATES: Increased Collateral Venous Circulation.

SKIN TEMPERATURE ON THE EXTREMITIES

Patient is supine. Utilizing the dorsum of the hand. Begin at the lateral arm and work to the distal phalanges, assessing bilateral simultaneously for temperature change. Continuing from mid-thigh to the distal phalanges with same procedure. VERBALS: Normal is equal temperature. Cool/Cold skin is decreased blood flow to the area and warm skin is increased blood flow to an area.

FEMORAL STRETCH TEST (femoral nerve traction test)

Patient lies on the unaffected leg side, hip and knee slightly flexed, patient straightens back and flexes the neck. On the affected side the knee is flexed and the thigh is extended by the examiner at the hip approximately15o, stretching femoral nerve POSITIVE: Pain on the anterior portion of the thigh. INDICATES: Traction on the femoral nerve indicating involvement of the 2nd, 3rd and 4th lumbar nerve roots.

PELVIC ROCK TEST aka ILIAC COMPRESSION TEST:

Patient lies on their side. Examiner places both hands on the lateral portion of the patient's ilium. Examiner exerts cautious downward pressure (lateral to medial) on the patient's ilium. Test bilaterally. POSITIVE: Pain or pressure in either sacroiliac joint INDICATES: Sacroiliac sprain, inflammation or fracture.

LEWIN GAENSLEN TEST:

Patient lying on his unaffected side, instruct patient to flex his inferior leg. Examiner grasps the superior leg and brings into extension while stabilizing the lumbosacral joint (extension of the leg stresses the sacroiliac joint and anterior joint ligaments on the side of leg extension). POSITIVE: Pain on the affected SI joint stressed into extension. INDICATES: General sacroiliac joint lesion, anterior sacroiliac ligament sprain, or inflammation of the SI joint.

FUKUDA STEP TEST

Patient marches in place, eyes closed for 50 steps POSITIVE: A turning to one side INDICATES: Vestibular lesion on the side of rotation

APPREHENSION TEST FOR PATELLA

Patient supine (or seated with quadriceps relaxed and resting over examiners leg at a 30 degree flexion), examiner pushes the patella laterally. POSITIVE: Apprehension, distress of facial expression, contraction of quadriceps to bring patella back in line. INDICATES: Chronic patella dislocation or pre-disposition to dislocation.

OBER TEST:

Patient on their side, examiner flexes the affected knee while abducting and extending the hip. Perform bilaterally. POSITIVE: Affected thigh remains in abduction. (Normal biomechanics, the thigh/hip will adduct.) INDICATES: Contraction of the iliotibial band or tensor fascia lata, (usually secondary to synovitis of the hip, secondary to trauma of the gluteus medius and maximus)

THOMPSON TEST

Patient prone with leg flexed to 90 degrees by examiner. Examiner squeezes the belly of the calf muscle of the affected leg. POSITIVE: Absence of foot plntarflexion motion INDICATES: Achilles tendon rupture

APLEY DISTRACTION TEST

Patient prone, examiner flexes patient's affected knee to 90 degrees. Examiner places their knee on the patient's affected thigh for stabilization. Examiner grasps the patient's distal tibia/fibula and attempts to distract the knee joint in a neutral position. Then repeat while rotating the tibia internally and externally. POSITIVE: Patient will point to side of pain INDICATES: Pain on the medial side indicates medial collateral ligament tear. Pain on the lateral side indicates lateral collateral ligament tear

APLEY COMPRESSION TEST

Patient prone, examiner flexes patient's affected knee to 90 degrees. Stabilize patient's thigh with your knee (optional), Place downward pressure on the patient's distal tibia/fibula in neutral and then again while internallyand externally rotating the patient's leg. POSITIVE: Patient points to side of pain INDICATES: Pain on medial side is medial meniscus tear. Pain on the lateral side indicates lateral meniscus tear.

YEOMAN TEST:

Patient prone, examiner flexes patient's leg to ipsilateral buttock and then extends thigh POSITIVE: Pain deep in the SI joint. INDICATES: Sprain of the anterior sacroiliac ligaments.

ELY HEEL TO BUTTOCK TEST:

Patient prone, examiner flexes the knee of the patient's affected leg to 90 degrees. Examiner then approximates the heel of the affected leg to the contralateral buttock and hyperextends the thigh off the table POSITIVE: (1) Inability to raise the thigh. (2) Pain in the anterior thigh. (3) Pain in the lumbar region. INDICATES: (1) Iliopsoas spasm.(2) Inflammation of lumbar nerve roots. (3) Lumbar nerve root adhesions.

ELY HEEL TO BUTTOCK TEST

Patient prone, examiner flexes the knee of the patient's affected leg to 90 degrees. Examiner then approximates the heel of the affected leg to the contralateral buttock and hyperextends the thigh off the table. POSITIVE: (1) Inability to raise the thigh. (2) Pain in the anterior thigh. (3) Pain in the lumbar region. INDICATES: (1) Iliopsoas spasm. (2) Inflammation of lumbar nerve roots. (3) Lumbar nerve root adhesions

ELY SIGN (Ely Test - Cipriano):

Patient prone, examiner passively flexes the patient's knee toward the ipsilateral buttock POSITIVE: Hip on side being tested will flex causing the buttock to raise off the table. INDICATES: Rectus femoris or hip flexor contracture.

HIBB TEST:

Patient prone, examiner stabilizes pelvis on near side while grasping the opposite ankle and flexing the knee to 90 degrees (to observe for the presence of Ely Sign. The examiner maximally flexes the knee and then slowly internally rotates the thigh (pushing lateral on the leg). Compare bilateral. POSITIVE: (1) Pain in the hip region. (2) Pain in the buttock/pelvic region. INDICATES: (1) Hip joint pathology. (2) Sacroiliac joint lesion

NACHLAS TEST:

Patient prone, examiner takes the heel of the affected leg and approximates it to the ipsilateral buttock while stabilizing the pelvis to prevent hip flexion. POSITIVE: Pain in the sacroiliac region, or the lumbosacral region or if pain radiates down the leg. INDICATES: Sacroiliac or lumbosacral lesion.

ANTERIOR SLIDE TEST:

Patient seated and the examiner instructs patient to place hands on the waist with the thumbs pointing posterior. With one hand stabilize the scapula and clavicle and with the opposite hand, grasp the humerus and place an anterior to superior force into the shoulder. The patient will then push back against the examiner. POSITIVE: Popping, cracking and crepitus is noticed with pain on the antero-superior aspect of the shoulder. INDICATES: Superior or anterior glenoid labrum tear.

SCHEPELMANN SIGN

Patient seated arms fully abducted and raised over head, examiner instructs patient to laterally flex thoracic spine to the left side and then to the right side. POSITIVE: Pain on the concave or convex side. INDICATES: Pain on the concave side indicates intercostal neuritis (Thoracic dermatomes can be evaluated in the corresponding intercostal spaces) while pain on the convex side indicates fibrous inflammation of the pleura (or possible intercostal myofascitis).

MILLS TEST (maneuver) (Evans):

Patient seated at rest with forearm supinated. In a smooth continuous motion the Dr. passively maximally flexes the patient's fingers and wrist. While maintaining wrist and finger flexion, the Dr. passively extends the patient's elbow (the forearm is now pronated) POSITIVE: Pain over the lateral epicondyle INDICATES: Lateral epicondylitis (tennis elbow)

TRACHEAL POSITION

Patient seated or supine. Examiner will note the position of the trachea by palpating either side to ensure it is in the midline. (Alternate: Place an index finger in the suprasternal notch and move it gently, side to side. These spaces should be equal on both sides) Normal: trachea should be in the midline directly above the suprasternal notch. POSITIVE: Deviation of trachea INDICATES: Underlying pathology

ADSON TEST

Patient seated with arms at side and elbows fully extended. Examiner finds radial pulse in neutral position, slightly abducts affected arm and has patient take a deep breath and hold, then instruct patient to rotate head and elevate chin toward examiner while holding the breath. Note positive or negative findings, if negative then rotate head to the opposite side and repeat the procedure. POSITIVE: Pain and/or paresthesia, decreased or absent pulse amplitude, pallor. INDICATES: Compression of the neurovascular bundle by scalenus anticus or cervical rib.

IMPINGEMENT SIGN:

Patient seated with arms at side. Examiner passivly abducts patient's arm (hand should be pronated) and moves it fully through passive flexion to 180° if possible (the motion will jam the greater tuberosity and anterior/inferior surface of the acromion narrowing the subacromial space). POSITIVE: Pain in shoulder INDICATES: Overuse injury to the supraspinatus and possibly biceps tendon

FORAMINAL COMPRESSION TEST:

Patient seated with examiner standing behind. Examiner clasps their hands over patient's head and exerts gradual increasing downward pressure. Examiner repeats this procedure with the patient's head rotated right and then left. POSITIVE: 1) Exacerbation of localized cervical pain. 2) Exacerbation of cervical pain with a radicular component. INDICATES: 1) Foraminal encroachment or facet pathology without nerve root compression. 2) Foraminal encroachment or facet pathology with nerve root compression

JACKSON COMPRESSION

Patient seated with examiner standing behind. Patient laterally flexes their head to one side and examiner clasps their hands over patient's head and exerts increasing downward pressure. Perform bilaterally. POSITIVE: 1) Exacerbation of localized cervical pain 2) Exacerbation of cervical pain with a radicular component INDICATES: 1) Foraminal encroachment or facet pathology without nerve root compression 2) Foraminal encroachment or facet pathology with nerve root compression

MAXIMAL CERVICAL COMPRESSION

Patient seated with examiner standing behind. The examiner instructs the patient to rotate the head and hyperextend the neck over the shoulder on the side of rotation. Perform bilaterally. POSITIVE: Pain on the concave side INDICATES: Foraminal encroachment with or without nerve root compression (based on presence or absence of radicular component)

SPEED TEST:

Patient seated with forearm supinated, and elbow flexed to 45 degrees. Examiner places their fingers on patient's bicipital groove with their opposite hand on the patients forearm. Instruct the patient to flex their shoulder, maintain supination and completely extend the elbow as the doctor applies resistance. POSITIVE: Pain and/or tenderness in the bicipital groove INDICATES: Bicipital tendinitis

SPINAL PERCUSSION TEST:

Patient seated with head in slight flexion, percuss each cervical spinous process(es) and the associated musculature with the pointed end of a reflex hammer. POSITIVE: 1) Local pain 2) Radiating pain INDICATES: 1) Possible fractured vertebrae, ligamentous involvement (spinous pain), and muscular involvement (muscular pain). 2) Possible disc pathology.

SULCUS SIGN WITH LOAD AND SHIFT:

Patient seated with the elbow flexed to 90 degrees and the shoulder in the neutral position for rotation. Grasp the wrist with one hand and with the other, place a downward force on the forearm. If sulcus sign appears, then grasp the proximal humerus and move "shift" the humerus both anterior and posterior through the glenoid fossa. POSITIVE: This motion attempts to dislocate the shoulder inferiorly. A sulcus that appears on the antero-lateral will indicate shoulder instability and is graded. INDICATES: Inferior shoulder instability (MDI) and possible inferior dislocation. A +1 sulcus indicates less than 1cm, +2 indicates 1-2 cm's and +3 indicates more than 3cm's.

TINEL WRIST SIGN:

Patient seated with wrist supinated, examiner taps over the palmar (volar) surface of the wrist. (flexor retinaculum - over carpal tunnel region). POSITIVE: Reproduction of pain, tenderness and/or paresthesia in the median nerve nd rd th distribution area (thumb, 2 , 3 , and the lateral 1⁄2 of the 4 digit). INDICATES: Median Neuritis, possibly Carpal Tunnel Syndrome

ANTERIOR APPREHENSION TEST:

Patient seated, examiner abducts the patient's shoulder, flexes the patient's elbow and then gradually externally rotates to the patient's shoulder. P: Patient will have a noticeable look of apprehension or alarm on their face with possible pain. I: Chronic anterior dislocation of the glenohumeral joint.

COSTOCLAVICULAR MANEUVER aka EDEN TEST

Patient seated, examiner finds radial pulse in a neutral position and instructs patient to sit erect, force shoulders back (chest out) and touch chin to chest and hold breath. POSITIVE: Pain and/or paresthesia, decreased or absent pulse amplitude, pallor. INDICATES: Compression of the neurovascular bundle between the clavicle and 1st rib.

YERGASON TEST (CIPRIANO):

Patient seated, examiner flexes patients elbow to 90 degrees. Examiner stabilizes patient's elbow with one hand and exerts slight inferior traction. Examiner uses their other hand and adds resistance to the distal portion of the radius. Examiner offers resistance while patient is instructed to externally rotate their humorous and slightly supinate the forearm. POSITIVE: 1) Localized pain in the bicipital groove. 2) Audible click. INDICATES: 1) Bicipital Tendinitis 2) Subluxation or dislocation of the biceps tendon. (Due to a possible tear of the transverse humeral ligament.)

ABBOTT-SAUNDERS TEST:

Patient seated, examiner fully abducts and externally rotates the patient's affected arm. Examiner places their fingers on the patient's bicipital groove and then slowly lowers the patient's affected arm to their side. Posterior to the mid- axillaory line. POSITIVE: Palpable and/or audible click INDICATES: Subluxation or dislocation of the biceps tendon. (Due to a possible tear of the transverse humeral ligament.)

BRACELET TEST

Patient seated, examiner gives mild to moderate compressive pressure to dorsum of patient's wrist (thumb encircles radial side of wrist, index finger encircles ulnar side, then squeeze wrist) and then have patient attempt to make a fist. Perform bilaterally. POSITIVE: Acute forearm, wrist and hand pain INDICATES: Significant for Rheumatoid Arthritis. (Confirm with diagnostic imaging and laboratory tests)

PATRICK TEST aka FABERE sign

Patient supine, examiner flexes, abducts and externally rotates the patient's hip so that the ankle rests above or below the contralateral knee. Examiner then extends the hip by pushing just proximal to the knee while stabilizing the contralateral ASIS. POSITIVE: Pain in hip region INDICATES: Hip joint pathology

DRAWER SIGN ANKLE (anterior drawer sign of ankle):

Patient seated, examiner grasps just proximal to the ankle with one hand and around the calcaneus of the affected foot with the other hand. Examiner pulls (draws) the calcaneus anteriorly and pushes the tibia posteriorly, the reverse procedure by pulling the ankle anterior and calcaneus posterior. POSITIVE: Translation with the talus moving away from or toward the tibia INDICATES: 1) With tibia pushed/ foot pulled; a tear/instability of the anterior talofibular ligament. 2) With tibia pulled/foot pushed; a tear/instability of posterior talofibular ligament.

BECHTEREW TEST

Patient seated, examiner instructs patient to extend one knee at a time alternately, then both together. POSITIVE: Reproduction of posterior thigh pain or inability to perform correctly due to tripod sign. INDICATES: Sciatic radicuopathy

PHALEN SIGN and REVERSE PHALEN SIGN aka PRAYER SIGN:

Patient seated, examiner instructs patient to flex both wrists to maximum degree and approximate until reproduction of symptoms or 60 seconds. Prayer sign = maximally extend wrist (palms together), elbows same level as shoulders reproduction of symptoms or 60 seconds. POSITIVE: Reproduction of pain and/or paresthesia in the median nerve distribution area nd rd th (1st, 2 , 3 and the lateral 1⁄2 of the 4 digit). INDICATES: Median Neuritis, possibly Carpal Tunnel Syndrome

DUGAS TEST:

Patient seated, examiner instructs patient to place the hand of the affected side on the opposite shoulder and then bring the affected elbow to the chest. P: Inability to perform either of the movements OR increased pain I: Acute dislocation of Glenohumeral joint

BAKODY SIGN (shoulder abduction test)

Patient seated, examiner instructs patient to place the palm of the affected side flat on top of their head. POSITIVE: Decrease or absence of radiating pain. INDICATES: Cervical foraminal encroachment, nerve root entrapment (usually C5/C6 level because this motion elevates the suprascapular nerve and relieves traction on the upper brachial plexus).

FINKELSTEIN TEST:

Patient seated, examiner instructs patient to place their thumb across the palmar surface of the hand and make a fist. Have patient ulnar deviate their hand. POSITIVE: Pain distal to the radial styloid process INDICATES: Stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons (DeQuervain's Disease).

ALLEN TEST:

Patient seated, examiner instructs patient to raise their hand above the heart level of their head and to open and close their fist for 60 seconds. Examiner occludes both the radial and ulnar artery at the wrist and then lowers the patient's arm with the fist closed and allows the fist to rest on patient's thigh. Examiner instructs patient to open closed fist and releases digital pressure over one artery while keeping the other artery occluded. Record the filling time, while comparing color to the other hand. Then repeat procedure for other artery. POSITIVE: A delay of more than 10 seconds (Evans 5 sec.) in returning a reddish color to the hand. INDICATES: Radial or ulnar artery insufficiency. The artery held (occluded) by the examiner is not the artery being tested.

VALSALVA MANEUVER:

Patient seated, examiner instructs patient to take a deep breath and hold while bearing down as if straining during a bowel movement. POSITIVE: Radiating pain from site of lesion (usually recreating the complaint in cervical thoracic or lumbar area of the spine) INDICATES: Nerve root entrapment by a disc lesion (space occupying lesion).

COZEN TEST:

Patient seated, examiner instructs the patient to extend the elbow and pronate the hand. The examiner instructs the patient to make a fist and place wrist into extension. The examiner instructs patient to resist as examiner tries to place the patient's wrist into flexion. POSITIVE: Pain over the lateral epicondyle INDICATES: Lateral Epicondylitis (tennis elbow)

GOLFER ELBOW TEST:

Patient seated, examiner instructs the patient to extend the elbow and pronate the hand. The examiner instructs the patient to make a fist and place wrist into flexion. The examiner instructs patient to resist as examiner tries to place the patient's wrist into extension. POSITIVE: Pain over the medial epicondyle INDICATES: Medial Epicondylitis

DROP ARM TEST/ aka CODMAN DROP ARM TEST:

Patient seated, examiner passively abducts patients arm to slightly over 90 degrees and then removes the support, if patient can maintain arm position, then the examiner instructs the patient to slowly lower their arm. P: Patient will not be able to lower the arm slowly or the arm drops suddenly. I: Rotator cuff tear, usually the supraspinatus tendon.

BUNNEL-LITTLER TEST (patient presents w/difficulty flexing the PIP joint):

Patient seated, examiner places metacarpophalangeal joint in extension and tries to flex the proximal interphalangeal joint. If no flexion is possible then there is either a joint capsule contracture or tight intrinsic muscles. To differentiate, examiner places the metacarpophalangeal joint in a few degrees of flexion and attempts to move the proximal interphalangeal joint into flexion. POSITIVE: (1) Flexion of the proximal interphalangeal joint cannot be achieved. (2) Flexion of the proximal interphalangeal joint is achieved. INDICATES: 1. Joint Capsule Contracture 2. Tight Intrinsic Muscles

RETINACULAR TEST (patient presents w/difficulty flexing the DIP joint):

Patient seated, examiner places proximal interphalangeal joint in neutral and tries to flex the distal interphalangeal joint. If no flexion is possible then there is either a joint capsule contracture or tight retinacular ligaments. To differentiate, examiner places the proximal interphalangeal joint in a few degrees of flexion and attempts to move the distal interphalangeal joint into flexion. POSITIVE: (1) Flexion of the distal interphalangeal joint cannot be achieved. (2) Flexion of the distal interphalangeal joint is achieved. INDICATES: (1) Joint capsule contracture. (2) Tight retinacular ligament.

SHOULDER DEPRESSION TEST:

Patient seated, examiner stabilizes patient's laterally flexed head while pushing down on shoulder. POSITIVE: Pain and/or paresthesia on the side being tested INDICATES: Brachial plexitis or dural sleeve adhesion

TINEL ELBOW SIGN

Patient seated, with a reflex hammer, examiner taps with the reflex hammer over the groove between the medial epicondyle and the olecranon process. POSITIVE: Pain and/or tenderness at the site being tapped and paresthesia in the ulnar nerve distribution area (fingers 4, 5). INDICATES: Neuroma of the ulnar nerve.

SPECIAL MANEUVER FOR AORTIC MURMUR

Patient seated. (Ask patient to sit up) Locate the Aortic area and place the DIAPHRAGM at the 2nd ICS just lateral to the sternum to the right (or Erb's point at the 3rd ICS just lateral to the sternum on the left). Ask the patient to lean forward and exhale completely and to stop breathing in expiration for 3- 5 seconds while crunched over. VERBALS: Aortic Murmurs are high pitched and heard with the diaphragm

DIAPHRAGMATIC EXCURSION

Patient seated. Ask patient to breathe deeply and hold. Percuss along the scapular line until a change in note from resonance to dullness is heard. This is the lower border of the diaphragm. (Breathe in allows the diaphragm to move down.) Mark the point with a skin pencil at the scapular line. Ask the patient to take several breaths and then to exhale as much as possible and hold. Percuss up from marked point and make a mark at the change from dullness to resonance, bilateral. Remind the patient to start breathing. Allow the patient to breathe and then repeat the procedure on the other side. Measure and record the distance in centimeters between the marks on each side. Right side marks will be slightly higher due to the liver mass. Normal: 3-5 cm POSITIVE: Limited measurement INDICATES: Pathologies of pulmonary (e.g. result of emphysema (bilateral limited movement), abdominal (result of massive ascites, tumor), or superficial pain (e.g fractured rib)

VOCAL RESONANCE: EGOPHANY

Patient seated. Ask patient to recite the letter "E" while listening with the diaphragm at the apices, interscapular areas, triangles of auscultation, medial lungs & lateral lungs (see above). POSITIVE: Increased clarity and nasal quality of "E" becoming "A" INDICATES: Presence of consolidation in the lung

VOCAL RESONANCE: WHISPERED PECTORILOQUY

Patient seated. Ask patient to recite the number "ninety-nine" in a whisper while listening with the diaphragm at the apices, interscapular areas, triangles of auscultation, medial lungs & lateral lungs (see above). POSITIVE: Increased clarity and loudness of spoken sounds INDICATES: Presence of consolidation in the lung

VOCAL RESONANCE: BRONCHOPHANY

Patient seated. Ask patient to recite the number "ninety-nine" in their normal speaking voice while listening with the diaphragm at the apices, interscapular areas, triangles of auscultation, medial lungs & lateral lungs (see above). POSITIVE: Increased clarity and loudness of spoken sounds INDICATES: Presence of consolidation in the lung

LYMPH NODES OF HEAD AND NECK

Patient seated. Check for: size; consistency; mobility; condition. Using the palmar surface of the fingers extended move with rotational pressure and movement of the finger pads over the areas listed: - Occipital - Post-auricular - Pre-auricular - Tonsillar - Submandibular - Submental - Facial - Anterior cervical chain - Posterior cervical chain - Supraclavicular Normal lymph nodes are non-palpable. POSITIVE: (1) Enlarged, hard, immobile, non-tender (2) Enlarged, soft, mobile, tender INDICATES: 1. Cancer 2. Infection

PERCUSSION OF POSTERIOR THORAX

Patient seated. Examine the posterior thorax with the patient's arms folded across the chest with hands resting, if possible, on the opposite shoulders. This position swings the scapulae laterally and increases access to the lungs fields. Hyperextend the third digit of your non-dominant hand and press its distal interphalangeal join firmly on the source to be percussed. Avoid contact by any other part of the hand. The dominant third digit should be perpendicular and poised to strike the non-dominant DIP joint. Strike using the tip of the dominant finger twice in between the ribs in the intercostal space. Percuss the thorax in symmetric locations comparing one side of the chest and then the other at each level in a ladder-like pattern as shown on page 275 of the textbook. - Apices: #1,2 - Interscapular: # 3-6 - Triangles of Auscultation: # 7-8 - Medial Base: # 9-10 - Lateral: #17-18 NORMAL: Resonance ABNORMAL: Dullness indicates mass or fluid in the lung (Lung Cancer or Pneumonia) Hyper-resonance indicates trapped air in the lung (Emphysema, Atelectasis or Pneumothorax)

TACTILE FREMITUS (Posterior Thorax)

Patient seated. Examine the posterior thorax with the patient's arms folded across the chest with hands resting, if possible, on the opposite shoulders. This position swings the scapulae laterally and increases access to the lungs fields. To detect fremitus (vibration) use either the ball of the hand or the ulnar surface of hand to optimize the sensation. Ask the patient to repeat the words "ninety-nine" or "blue moon", etc. each time the posterior thorax is touched. For comparison, palpate both sides simultaneously and symmetrically. Check for symmetry of vibration in the following areas: Apices, Interscapular area, Triangle of Auscultation, Medial base of lungs, & lateral base of lungs. Normal: Symmetry of vibration POSITIVE: (1) Increase Fremitus (2) Decreased or Absent Fremitus INDICATES: (1) Fluid or a solid mass within the lungs e.g. Lung Consolidation (2) Excess air in the lungs e.g. Emphysema

PALPATION OF POSTERIOR THORAX

Patient seated. Examine the posterior thorax with the patient's arms folded across the chest with hands resting, if possible, on the opposite shoulders. This position swings the scapulae laterally and increases access to the lungs fields. Using the palmar surface fingers extended move with rotational pressure and movement of the finger pads to begin at the apices, the interscapular areas, triangles of auscultation, medial and lateral lung fields. Compare side to side (e.g. Apices to apices, etc.) VERBALS: Pain, tenderness, masses, sensations and further assess for any abnormalities

MURPHY'S PUNCH

Patient seated. Examiner places palm of their hand over the right posterior costovertebral angle (Region should be from T10 to T12) and strike their dorsal surface of the hand with the ulnar surface or the fist of their other hand. Repeat this maneuver over the left costovertebral angle. POSITIVE: Increased pain over the kidney INDICATES: Nephritis or inflamed kidney

RESPIRATORY EXCURSION (posterior thorax, T8-T10)

Patient seated. Examiner stands behind the patient and places thumbs along the spinous processes at the level of 10th rib with palms lightly in contact with the posterolateral surface (taking a tissue pull with the ball of the hand from axillary to mid-line and use thumbs as markers). Ask patient to take a deep breath in and out through their mouth. Repeat this process 3 times. Normal: Watch for symmetry of movement bilaterally. POSITIVE: Loss of symmetry in the movement of the thumbs INDICATES: Underlying lung problem on one or both sides

MORTON TEST

Patient supine, examiner grasps the affected forefoot with one hand and applies transverse pressure across the metatarsal heads. POSITIVE: Sharp pain in the forefoot. INDICATES: Metatarsalgia or neuroma (usually at the 3rd and 4th metatarsal interspace).

APLEY TEST:

Patient seated. Have him/her place the affected hand behind the head and touch the opposite superior angle of the scapula = Apley scratch superior Then patient is instructed to place the hand behind the back to touch inferior angle of scapula = Apley scratch inferior POSITIVE: Exacerbation of pain INDICATES: Degenerative tendinitis of the rotator cuff tendons (usually supraspinatus)

TEMPORAL ARTERIES:

Patient seated. Palpate the patient's temple's area (posterior and superior to the zygomatic arch of the front bone as it passes laterally to the temporal fascia). Palpate one artery at a time for 3-5 seconds using the finger pads of digits two and three. A normal pulse should be felt equally. POSITIVE: Absent pulse on one side or a thick, hard, or tender artery INDICATES: Temporal arteritis

THYROID GLAND FOR SOFT BRUITS

Patient seated. Place bell of the stethoscope on either side of the thyroid cartilage over the thyroid gland. Perform bilateral. Ask patient to suspend respiration. POSITIVE: Soft bruits heard over the gland INDICATES: Hypermetabolic state of the thyroid gland; such as hyperthyroidism & thyroid cancer

LATERAL COLLATERAL LIGAMENT TEST (Adduction stress test):

Patient seated. When testing patient's left elbow, examiner places the patient's left supinated hand between his/her right elbow and his/her side and places his/her right index finger onto the lateral collateral ligament. The examiner places his/her left hand onto the medial side of the joint line of the patient's elbow. Afterextending the elbow and slightly flexing the elbow, the examiner places a medial to lateral pressure into the joint line while mildly adducting the forearm. POSITIVE: Excessive gapping and pain INDICATES: Medial collateral ligament tear and/or instability

MEDIAL COLLATERAL LIGAMENT TEST (Elbow, Abduction stress test):

Patient seated. When testing the patient's left elbow, examiner places the patient's left supinated hand between his/her left elbow and his/her side and places his/her left index finger onto the medial collateral ligament. The examiner places his/her right hand onto the lateral side of the joint line of the patient's elbow. After extending the elbow and slightly flexing the elbow, the examiner places a lateral to medial pressure into the joint line while mildly abducting the forearm. POSITIVE: Excessive gapping and pain INDICATES: Medial collateral ligament tear and/or instability

TINEL ELBOW SIGN:

Patient seated. With a reflex hammer, examiner taps over the groove between the medial epicondyle and the olecranon process. POSITIVE: Pain and/or tenderness at the site being tapped and paresthesia in the ulnar nerve distribution area (fingers 4,5). INDICATES: Neuroma of ulnar nerve

TRACHEAL TUG

Patient seated. With patient's head slightly extended, position the index finger and thumb of one hand on each side of the trachea below the thyroid isthmus. POSITIVE: A downward tugging sensation, synchronous with the pulse INDICATES: Aortic aneurysm

THYROID GLAND

Patient seated.For examining the thyroid from behind: position two fingers of each hand on the sides of the trachea just beneath the cricoid cartilage Displace the trachea to the left and with three fingers of your left hand palpate the left lobe. Repeat for right side.For examining the thyroid from front: position two fingers or the thumb and push the thyroid gland from behind the tracheoesophageal groove and use the other hand to palpate the gland. Repeat procedures for other side POSITIVE: Nodules, tenderness, enlargement INDICATES: Thyroid dysfunction

SWALLOWING TEST:

Patient seated: examiner instructs the patient to swallow POSITIVE: Difficulty in swallowing INDICATES: Lesion at anterior portion of cervical spine. Possibly esophageal or pharyngeal injury, anterior disc defect, muscle spasm or osteophytes etc.

CERVICAL DISTRACTION TEST:

Patient seated: the examiner grasps the patient's head with both hands and gradually exerts upward pressure keeping hands off TMJ and ears. POSITIVE: 1) Diminished or absence of local cervical pain. 2) Diminished or absence or radiating pain. 3) Increase of cervical pain. INDICATES: 1) Foraminal encroachment without nerve root compression 2) Foraminal encroachment with nerve root compression 3) Muscular strain, ligamentous sprain, myospasm or facet capsulitis.

ROOS TEST aka E.A.S.T (elevated arm stress test)

Patient sitting or standing, instruct patient to bring arms out in front of their body, bend the elbows to 90°. The patient then externally rotates the arms and opens and closes their fists bilaterally at a moderate pace for up to 3 minutes. POSITIVE: Ischemic pain, heaviness of the arms, or numbness and tingling of the hand. INDICATES: Thoracic outlet syndrome on side involved

L'HERMITTE SIGN

Patient sitting or supine, examiner passively flexes patient's head to the chest POSITIVE: Electric shock-like sensations down the spine and/or through extremities INDICATES: Dural irritation or spinal cord injury. Spinal cord inflammation (eg. multiple sclerosis), or compression (myelopathy) due to degeneration and canal stenosis.

ADAM SIGN

Patient standing, with examiner standing behind patient, examiner looks for evidence of scoliosis. Examiner instructs patient to bend forward at the waist. Examiner observes for evidence of a change in the scoliosis. POSITIVE: 1) A scoliosis is observed to straighten. 2) A scoliosis does not straighten (look for rib humping or muscular imbalance). INDICATES: 1) Negative: evidence of a functional scoliosis, trauma or subluxation 2) Positive: evidence of a structural scoliosis

BELT TEST (Supported Adam test, supported forward bending test)

Patient standing. Have patient bend forward and note for presence of low back pain. With patient standing, stabilize patient's iliac crests and brace iliac crest against patient's sacrum. Have patient bend forward as youimmobilize the pelvis. POSITIVE: Low back pain INDICATES: 1) pain while bending with the sacrum stabilized and unstabilized = Lumbar involvement 2) Pain during sacrum non-stabilized bending, and no pain during sacrum stabilized bending = pelvic involvement

TRENDELENBURG TEST:

Patient stands on foot of involved side of hip problem. Observe level of hips POSITIVE: High iliac crest on supported side and low crest on side of elevated leg INDICATES: Weak gluteus medius muscle on the supported side

GOLDTHWAIT SIGN

Patient supine examiner places the fingers of their superior hand under the interspinous spaces of the patient's lower lumbar vertebrae. Examiner then raises one of the patient's extended legs. POSITIVE: Localized pain, low back or radiating pain down the leg. INDICATES: Lumbo-sacral or sacroiliac pathology. Pain occurring after the lumbar spinouses move = possible lumbo-sacral problem. Pain occurring before the lumbars move = possible sacroiliac problem.

PALPATION OF LYMPH NODES of the THORAX &/or AXILLA

Patient supine or seated. HIGHLY recommended that the examiner utilize gloves. Using the palmar surface of the fingers extended move with rotational pressure and movement of the finger pads over the areas listed: Supraclavicular (above the clavicle), Infraclavicular (below the clavicle), Epitrochlear (above the medial epicondyle), Lateral Axillary (medial humerus), Medial Axillary (along lateral chest wall), Anterior Axillary (along Pectoralis muscle group), and Posterior Axillary (along latissimus dorsi muscle group). Normal lymph nodes are non-palpable. CANCER: Enlarged, non-tender, hard, non-mobile INFECTION: Enlarged, tender, soft, mobile

PATELLA BALLOTTEMENT TEST

Patient supine with knee extended. Anterior to posterior pressure is applied over the patella. POSITIVE: A floating sensation of the patella INDICATES: A large amount of swelling in the knee.

DREYER SIGN

Patient supine with knee extended. The patient is instructed to raise and then lower the leg. The examiner then applies circumferential pressure around the distal thigh to give anchorage to the quadriceps and instructs the patient to raise the leg again. With the force removed the patient is again asked to raise the leg. POSITIVE: Inability to raise the leg, peripatellar pain (without compression)Able to raise the leg, reduction in peripatellar pain when thigh pressure is applied. INDICATES: Patella fracture

LEG LENGTH DISCREPANCY:

Patient supine, (True) examiner takes a cloth measuring tape and measures from ipsilateral ASIS to the medial malleolus of the same leg. Examiner then measures from contralateral ASIS to the medial malleolus of the opposite leg. (Apparent) Examiner takes a cloth tape measure and measures from the umbilicus to the medial malleolus of one leg and then measures from the umbilicus to the medial malleolus of the opposite leg. POSITIVE: Different measurements INDICATES: True = bony abnormality above or below the level of the trochanter difference (anatomical short leg). Apparent = pelvic obliquity (Tilted pelvis).

PATELLA FEMORAL GRINDING TEST (aka CLARKE SIGN)

Patient supine, affected knee extended examiner uses the web of the hand to move the patella to an inferior position. Examiner instructs patient to tighten the quadriceps muscles as the examiner continues to hold the patella in the inferior direction. POSITIVE: Retropatellar pain and the patient is unable to hold the quadriceps contraction. INDICATES: Degenerative changes of the patellar facets and /or within the trochlear groove (chondromalacia patella).

TURYN SIGN

Patient supine, examiner dorsiflexes the big toe of the affected extremity with the leg on the table (no hip flexion). POSITIVE: Pain in the posterior thigh. INDICATES: Sciatic radiculopathy

ANVIL TEST:

Patient supine, examiner elevates the affected leg while keeping the knee extended. The examiner then makes a fist and strikes the affected leg's inferior calcaneus. POSITIVE: Localized pain in long bone or in hip joint INDICATES: Possible fracture of long bones, or hip joint pathology.

MCMURRAY SIGN:

Patient supine, examiner flexes patient's affected hip to 90 degrees and the affected knee to 90 degrees. Examiner grasps the distal tibia of the affected leg and applies external rotation to the knee. Examiner places their hand on the lateral aspect of the affected knee and applies a valgus stress. Examiner maintains the external rotation and valgus stress on the knee and extends the affected leg slowly to the top of the table while palpating the medial knee joint line. (Occasional variance = repeat with internal rotation and varus stress.) POSITIVE: Clicking sound or pain in knee joint INDICATES: - Tear of medial meniscus if positive on external rotation - Tear of lateral meniscus if positive on internal rotation - The greater the angle the knee is flexed when the positive is elicited, the more posterior the meniscal injury.

BRUDZINSKI SIGN

Patient supine, examiner flexes patient's head to the chest. POSITIVE: Involuntary knee flexion. INDICATES: Meningeal irritation or nerve root lesion (classic test for meningitis)

LINDNER SIGN

Patient supine, examiner flexes patient's head toward the chest. POSITIVE: Pain in the posterior thigh or leg. INDICATES: Sciatic radiculopathy

SOTO-HALL SIGN

Patient supine, examiner flexes patient's head toward their chest while exerting downward pressure on patient's sternum with hypothenar eminence of inferior hand. POSITIVE: Generalized pain in the cervical region, which may extend down to the level of T2. INDICATES: Non-specific test for structural integrity of cervical region.

POSTERIOR APPREHENSION TEST:

Patient supine, examiner flexes patient's shoulder, flexes patient's elbow and internally rotates the patient's shoulder. Examiner places his/her hand on the patient's distal humerus and gradually applies increasing posterior pressure. P: Patient will have a noticeable look of apprehension or alarm on their face with possible pain. I: Chronic posterior dislocation of the glenohumeral joint.

DRAWER TEST

Patient supine, examiner flexes the hip and the knee of the patient's affected leg until the foot is flat on the table (90° of knee flexion). Examiner sits on the foot of the patient's affected leg. Examiner grasps behind the patient's flexed knee and exerts a pushing and pulling pressure into the affected knee. POSITIVE: (1) Gapping > 6mm (tibia moves posterior) when the leg is pushed. (2) Gapping > 6mm (tibia moves anterior) when the leg is pulled. INDICATES: (1) Torn posterior cruciate ligament. (2) Torn anterior cruciate ligament.

BOUNCE HOME TEST

Patient supine, examiner flexes the patient's knee and grasps the patient's heel and knee of the affected leg. Examiner pulls affected leg slowly into extension (passively). POSITIVE: The knee does not go into full extension (slight flexion remains). INDICATES: Diffuse swelling of the knee, accumulation of fluid, possibly due to a torn meniscus.

MORTON TEST:

Patient supine, examiner grasps the affected forefoot with one hand and applies transverse pressure across the metatarsal heads. POSITIVE: Sharp pain in the forefoot. INIDCATES: Metatarsalgia or neuroma (usually at the 3rd and 4th metatarsal interspace).

BEEVOR SIGN

Patient supine, examiner instructs patient cross their arms across the chest and perform a partial sit up. POSITIVE: Superior or inferior movement of the umbilicus. INDICATES: Superior movement of the umbilicus is indicative of a spinal cord lesion at the level of T11-12 or lower abdominal weakness. Inferior movement of the umbilicus is indicative of nerve root involvement T7 - T10.

HOOVER SIGN (used to differentiate organic vs. hysterical leg paralysis)

Patient supine, examiner instructs patient to lift the affected leg while the examiner places one hand under the heel of the non-affected leg (healthy side). POSITIVE: Lack of counter-pressure on the healthy side INDICATES: Lack of organic basis for paralysis (Malingering/hysteria). With organic hemiplegia, the patient will still exert downward pressure when attempting to raise paralyzed leg.

KERNIG SIGN

Patient supine, examiner passively flexes patient's hip to 90 degrees and the patient's knee to 90 degrees. Examiner extends patient's leg completely or to the point of pain. POSITIVE: Inability to fully extend the leg and/or pain usually in the neck region. INDICATES: Meningeal irritation/ meningitis.

KERNIG SIGN

Patient supine, examiner passively flexes patient's hip to 90 degrees and the patient's knee to 90 degrees. Examiner extends patient's leg completely. POSITIVE: Inability to fully extend the leg and/or pain usually in the neck region INDICATES: Meningeal irritation/ meningitis.

SICARD SIGN

Patient supine, examiner performs an SLR on the patient. Examiner lowers the raised leg (5 degrees) from the point of pain and sharply dorsiflexes patient's big toe. POSITIVE: Posterior thigh and leg pain. INDICATES: Sciatic radiculopathy

BRAGARD SIGN

Patient supine, examiner performs an SLR on the patient. Examiner lowers the raised leg (5 degrees) from the point of pain and sharply dorsiflexes patient's foot. POSITIVE: Radiating pain and/or dull posterior thigh pain. INDICATES: Sciatic radiculopathy

LACHMAN TEST

Patient supine, examiner puts the patient's knee at a 30 degrees angle of flexion and from this angle the examiner grasps both the proximal end of the tibia with one hand and the distal end of the femur with the other, and attempts to pull the tibia forward (anterior) in order to feel the joint play. (variation of Drawers test) POSITIVE: Gapping of the tibia moving away from the femur INDICATES: Anterior cruciate ligament or posterior oblique ligament instability.

MILGRAM TEST

Patient supine, examiner raises both of patient's legs 2-3 inches off the table and instructs patient to hold legs off the table for 30 seconds. POSITIVE: Inability to perform test and/or low back pain. INDICATES: Weak abdominal muscles or nerve root entrapment by a disc lesion (space occupying lesion).

HOMANS SIGN

Patient supine, examiner raises patient's leg about 12" off the table or 30° to 45° with knee in extension. Examiner then dorsiflexes the patient's foot. There are sources that Do Not recommend squeezing the calf due to danger of thrombus formation possibly being released into the venous system. POSITIVE: Deep pain in calf INDICATES: Deep vein thrombophlebitis

(SLR) STRAIGHT LEG RAISER

Patient supine, examiner raises patient's leg slowly to 90o or to the point of pain. POSITIVE: Radiating pain and/or dull posterior thigh pain. INDICATES: Sciatic radiculopathy or tight hamstrings. Positive between 35 - 70 degrees = possible discogenic sciatic radiculopathy > 70 degrees = tight hamstrings

MEDIAL COLLATERAL LIG. TEST aka ABDUCTION STRESS TEST aka VALGUS STRESS TEST (knee)

Patient supine, examiner stabilizes the lateral thigh of the patient's affected leg. Examiner grasps just proximal to the medial ankle of the affected leg and gradually pushes laterally (to open medial side of joint). POSITIVE: Gapping and/or elicited pain above/at/or below joint line INDICATES: Tear and/or instability of the medial collateral ligament

LATERAL COLLATERAL LIG. TEST aka ADDUCTION STRESS TEST aka VARUS STRESS TEST (knee)

Patient supine, examiner stabilizes the medial thigh of the patient's affected leg. Examiner grasps just proximal to the lateral ankle of the affected leg and gradually pushes medially (opening the lateral side of the joint). POSITIVE: Gapping and/or elicited pain above/at/or below joint line INDICATES: Tear and/or instability of the lateral collateral ligament

BONNET SIGN

Patient supine, examiner strongly internally rotates and adducts the affected leg across the midline and then performs a straight leg raiser test. POSITIVE: Pain in posterior thigh or leg. INDICATES: Immediate pain is sciatic neuropathy from piriformis syndrome

THOMAS TEST:

Patient supine, the examiner places their hand under the patients lower back and the examiner instructs patient to approximate each knee one at a time to their chest and hold. The examiner observes to see if either leg raises off the table. POSITIVE: Lumbar spine maintains lordosis (should flatten) and hip or leg flexes. INDICATES: Contracture of the hip flexors, most likely the iliopsoas muscle.

IDENTIFY THE LOCATION & SIZE OF HEART

Patient supine. Male Patients: Begin at the left 3rd ICS and tapping along the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from a resonant to a dull note marks the cardiac border. Mark a VERTICAL LINE. Go to the 4th ICS and tapping along the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from resonant to dull note marks the cardiac border. Mark a VERTICAL LINE. Go to the 5th ICS and tapping along the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from resonant to dull note marks the cardiac border. Mark a VERTICAL LINE. • The left 3rd, 4th, and 5th Intercostal Spaces - Make 3 vertical marks Female Patients: Begin at the left 3rd ICS and tapping along the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from a resonant to a dull note marks the cardiac border. Mark a VERTICAL LINE. Skip to the 5th ICS and tapping along the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from resonant to dull note marks the cardiac border. Mark a VERTICAL LINE. • The left 3rd and 5th Intercostal Spaces - Make 2 vertical marks Percuss down the right sternal border beginning at Aortic Area. Dullness is heard at the 6th intercostal space indicating the superior border of the liver.• Make 1 horizontal mark (males and females) VERBALS: Identify the anatomical locations and sound changes that are expected.

PERCUSS FOR LIVER SIZE

Patient supine. Superior Border of the Liver: ➢ Begin superior liver percussion at the right midclavicular line over an area of resonance. [Always begin with an area of resonance and proceed to an area of dullness, because that sound change is easier to detect than the change from dullness to resonance]. ➢ Continue downward until the percussion tone changes to one of dullness, which is the upper border of the liver and mark. ➢ The upper border usually begins at the 5th to 7th intercostal spaces. An upper border below this may indicate downward displacement or liver atrophy. Inferior Border of the Liver: ➢ Begin inferior liver percussion at the right midclavicular line over an area of tympany and proceed to an area of dullness. ➢ Percuss upward along the midclavicular line to determine the lower borde of the liver and mark. ➢ The lower border is usually at the costal margin or slightly below it. NORMAL: Usual span of the liver is approximately 6 to 12 cm (2.5 to 4.5 inches). INDICATES: A span greater than this may indicate liver enlargement (hepatomegaly) A lesser span suggests atrophy

CHECK THE 5 CARDIAC AREAS FOR PULSATIONS

Patient supine. Beginning at the jugular notch and palpating to angle of Louis go 45 degrees to the patient's right to locate the Aortic Area, located at the 2nd intercostal space on the right just lateral to the sternum. Using fingerpads, rest here for 3-5 seconds to evaluate for pulsations. Then going from the jugular notch and palpating down to the angle of Louis go 45 degrees left to the Pulmonic area, the 2nd intercostal space on the left just lateral to the sternum. Pause 3-5 seconds to evaluate for pulsations. Drop to the next intercostal space- Erb's Point, located at the 3rd intercostal space, just lateral to the sternum- Pause 3-5 seconds. Drop to the next intercostal space - Tricuspid area, located at the 4th intercostal space, just lateral to the sternum. Pause 3-5 seconds. Drop to the next intercostal space, in line with the midclavicular line, pause for 3-5 seconds at the mitral area, located at the 5th intercostal space. A slight pulsation should be felt normally. POSITIVE: Intense impulse that rhythmically lifts your fingers INDICATES: Possible cardiac hypertrophy

CHECK THE 5 CARDIAC AREAS FOR THRILLS

Patient supine. Beginning at the jugular notch and palpating to angle of Louis go 45 degrees to the patient's right to locate the Aortic Area, located at the 2nd intercostal space on the right just lateral to the sternum. Using the BALL of the hand, rest here for 3-5 seconds to evaluate for pulsations. Then going from the jugular notch and palpating down to the angle of Louis go 45 degrees left to the Pulmonic area, the 2nd intercostal space on the left just lateral to the sternum. Pause 3-5 seconds to evaluate for thrills using the BALL of the hand. Drop to the next intercostal space- Erb's Point, located at the 3rd intercostal space, just lateral to the sternum- Pause 3-5 seconds using the BALL of the hand. Drop to the next intercostal space - Tricuspid area, located at the 4th intercostal space, just lateral to the sternum. Pause 3-5 seconds using either the BALL of the hand or the ULNAR surface. Drop to the next intercostal space, in line with the midclavicular line, pause for 3-5 seconds at the mitral area, located at the 5th intercostal space using either the BALL of the hand or the ULNAR surface POSITIVE: A fine, palpable, rushing vibration INDICATES: Grade IV murmur or higher

OBTURATOR SIGN

Patient supine. Examiner flexes and lifts patient's leg to flex patient's hip to 90 degrees and knee to 90 degrees. Examiner places superior hand on patient's right knee and inferior hand around patient's right ankle. Patient internally and externally rotates their right hip against resistance, given by the examiner. UNILATERAL. POSITIVE: Increased pain in Right Lower Quadrant. INDICATES: Ruptured appendix or pelvic abscess

GALLBLADDER PALPATION

Patient supine. Examiner places their left hand under the patient at the 11th and 12th ribs pulling posterior-anterior and superior to elevate the gallbladder toward the abdominal wall. Placing the right hand on the abdomen fingers pointing toward the head and extended so the tips rest on the right midclavicular line at the costal margin. Have the patient take a deep breath while examiner uses their finger pads to palpate inferior to the liver and gallbladder POSITIVE: Increased pain and reflex apnea (Murphy's SIGN). INDICATES: Cholecystitis

PALPATE FOR LIVER'S EDGE USING STANDARD MANEUVER

Patient supine. Examiner places their left hand under the patient at the 11th and 12th ribs pulling posterior-anterior and superior to elevate the liver toward the abdominal wall. Place your right hand on the abdomen at the level of the umbilicus, fingers pointing toward the head and extended so the tips rest on the right midclavicular line. Have the patient breath normally a few times and then take a deep breath. Try to feel the liver's edge as the diaphragm pushes it down to meet your fingertips (normal=nonpalpable). Alternative method: Hooking maneuver POSITIVE: Nodules, Tenderness, Irregularity INDICATES: Liver disease

POSSIBLE RIB FRACTURES

Patient supine. Examiner will use a knife-edge (hypothenar) with ONE hand and depress the sternum with gradual increasing pressure or until the point of pain. (Alternative method to test rib fractures: 128 Hz tuning fork) POSITIVE: Pain radiating from site of fracture INDICATES: Possible rib fracture

COSTOCHONDRITIS:

Patient supine. Examiner will use a knife-edge (hypothenar) with both hands and apply pressure on the costochondral junction bilaterally with gradual increasing pressure or until the point of pain. POSITIVE: Pain at the costochondral junction INDICATES: Inflammation at the costochondral junction

CHECK FOR APICAL IMPULSE (S1):

Patient supine. Feel for the apical impulse using finger pads and identify its location by the left 5th intercostal space and the distance from the midsternal line/midclavicular line. Note the amplitude. NORMAL: Normal size is approximately 1 cm (rib space) ABNORMAL: Displacement of the apical impulse right or left

PERCUSSION OF ANTERIOR THORAX:

Patient supine. Hyperextend the third digit of your nondominant hand and press its distal interphalangeal join firmly on the source to be percussed. Avoid contact by any other part of the hand. The dominant third digit should be perpendicular and poised to strike the nondominant DIP joint. Strike using the tip of the dominant finger twice in between the ribs in the intercostal space. Percuss the thorax in symmetric locations comparing one die of the chest and then the other at each level in a ladder-like pattern as shown on page 275 of the textbook: - Apices: # 19-20 - "Above Breast Tissue"- # 21-22 - Medial base: # 23-24 - Lateral: # 25-26 NORMAL: Resonance ABNORMAL: Dullness indicates mass or fluid in the lung (Pneumonia or Lung Cancer) Hyper-resonance indicates trapped air in the lung (Emphysema, Atelectasis or Pneumothorax)

LISTEN IN MITRAL AREA FOR S1 AND PALPATE CAROTID PULSE (check for pairing of the 2)

Patient supine. Locate the optimal area for S1 at the 5th ICS midclavicular area with the DIAPHRAGM. Palpate the carotid pulse on the anterior portion of the SCM near the angle of the jaw. Pair the two for 3-5 seconds Ask the patient to take a deep breath in, exhales and hold. VERBALS: S1 and carotid pulse should be synchronous

LISTEN AT S1 OPTIMAL LOCATION DURING SYSTOLE

Patient supine. Locate the optimal area for S1 at the 5th ICS midclavicular area. Using the DIAPHRAGM at the 5th ICS midclavicular line for 3-5 seconds. VERBALS: S1 is heard loudest at the apex during systole. I am listening for accentuated, diminished and splitting of S1, abnormal heart sounds and mitral murmurs.

LISTEN @ PULMONIC AREA TO S2 DURING DIASTOLE

Patient supine. Locate the optimal area for S2 at the 2nd ICS on the left overt the Pulmonic area just lateral to the sternum. Using the DIAPHRAGM at the location for 3-5 seconds VERBALS: S2 is heard loudest at the base during diastole. I am listening for accentuated, diminished, and splitting of S2, abnormal heart sounds and pulmonic murmurs.

PERFORM KIDNEY ENTRAPMENT

Patient supine. On the right side, place one hand under the patient's right flank and the other hand at the right costal margin. Ask the patient to take a deep breath. At the height of inspiration, press the fingers of your two hands together to capture the kidney between the fingers. Ask the patient to breathe out and hold the exhalation while you slowly release your fingers. If you have entrapped the kidney you may feel it slip beneath your fingers. Same procedures for the left kidney except doctor moves to the left side of patient. POSITIVE: Increased pain over the kidney INDICATES: Nephritis

LIGHT PALPATION OF ABDOMEN

Patient supine. Palpate (3) areas per quadrant assessing all (4) quadrants. Using the palmar surface of the fingers, depress the abdominal wall no more than 1cm depth using a light and even pressing circular motion. VERBALS: Pain, tenderness, muscle guarding and masses

PALPATE THE ABDOMINAL AORTA PULSE

Patient supine. Palpate deeply and slightly to the left of the midline of the umbilicus and feel for the aortic pulsation 3-5 seconds using finger pads. Note rate (speed), rhythm (regularity), amplitude (force) and contour (smoothness). Bend knees if needed. POSITIVE: Prominent lateral pulsation or inferior to superior pulsations INDICATES: possible abdominal aortic aneurysm

SCAN ABDOMINAL REGION (PERCUSS)

Patient supine. Percuss (3) times per quadrant in all (4) quadrants of the abdomen for a sense of overall tympany and dullness. Work in a sequential, clockwise order using the third digits of each hand (over the distal interphalangeal joint). POSITIVE: Detect the presence of fluid, air, or solid masses INDICATES: Size and shape of the organs

PERCUSS URINARY BLADDER

Patient supine. Percuss ASIS to ASIS using the 3rd digit of each hand POSITIVE: Dullness of suprapubic area INDICATES: Distended Bladder

PERCUSS THE SPLEEN

Patient supine. Percuss the spleen just posterior to the mid-axillary line on the left side. Percuss in several directions beginning at areas of lung resonance focusing between the 6-9th rib NORMAL: Dullness INDICATES: Location of the spleen

BOWEL SOUNDS

Patient supine. Place diaphragm of stethoscope in 3 areas per quadrant for 5 seconds (15 seconds per quadrant), in each of the 4 quadrants (one minute total) and hold it in place with light pressure. Work in sequential and clockwise fashion while listening to bowel motility. VERBALS: Listen for frequency and character Hyperactive (> 35/min)Normoactive (5-35/min)Hypoactive (1-4/min) Absent (0 bowel sounds, but you must listen for 5 continuous minutes)- Medical Emergency (obstruction or perforation)

PSOAS SIGN

Patient supine. Place hand over the lower right thigh and left hand over the ASIS. Ask the patient to raise the right leg, flexing at the hip while adding resistance. The leg is to remain on the exam table until patient is asked to lift against resistance. UNILATERAL POSITIVE: Increased pain in RLQ INDICATES: Appendicitis

PALPATE AROUND UMBILICUS

Patient supine. Use the finger pads to palpate around the umbilicus POSITIVE: Bulges, Nodules, and/or irregularities INDICATES: Possible abdominal hernia

PALPATE THE URINARY BLADDER

Patient supine. Using finger pads palpate in the suprapubic region working ASIS to ASIS. POSITIVE: Smooth rounded dense mass INDICATES: Distended bladder

AUSCULTATE FOR LOW PITCHED GENERAL CARDIAC SOUNDS

Patient supine. Using the BELL. Beginning at the jugular notch and palpating to angle of Louis go 45 degrees to the patient's right to locate the Aortic Area, located at the 2nd intercostal space on the right just lateral to the sternum. Rest bell here for 3-5 seconds to evaluate. Then going from the jugular notch and palpating down n to the angle of Louis go 45 degrees left to the Pulmonic area, the 2nd intercostal space on the left just lateral to the sternum. Pause 3-5 seconds to evaluate. Drop to the next intercostal space- Erb's Point, located at the 3rd intercostal space, just lateral to the sternum- Pause 3-5 seconds. Drop to the next intercostal space - Tricuspid area, located at the 4th intercostal space, just lateral to the sternum. Pause 3-5 seconds. Drop to the next intercostal space, in line with the midclavicular line, pause for 3-5 seconds at the mitral area, located at the 5th intercostal space VERBALS: Listen for Rate and Rhythm

AUSCULTATE FOR HIGH PITCHED GENERAL CARDIAC SOUNDS

Patient supine. Using the DIAPHRAGM. Beginning at the jugular notch and palpating to angle of Louis go 45 degrees to the patient's right to locate the Aortic Area, located at the 2nd intercostal space on the right just lateral to the sternum. Rest diaphragm here for 3-5 seconds to evaluate. Then going from the jugular notch and palpating down to the angle of Louis go 45 degrees left to the Pulmonic area, the 2nd intercostal space on the left just lateral to the sternum. Pause 3-5 seconds to evaluate. Drop to the next intercostal space- Erb's Point, located at the 3rd intercostal space, just lateral to the sternum- Pause 3-5 seconds. Drop to the next intercostal space - Tricuspid area, located at the 4th intercostal space, just lateral to the sternum. Pause 3-5 seconds. Drop to the next intercostal space, in line with the midclavicular line, pause for 3-5 seconds at the mitral area, located at the 5th intercostal space VERBALS: listen for Rate and Rhythm

PALPATION OF THE ANTERIOR THORAX

Patient supine. Using the palmar surface fingers extended move with rotational pressure and movement of the finger pads to begin at the apices (supraclavicular fossa), below the clavicles, medial and lateral lung fields. Compare side to side (e.g. Apices to apices, etc.) VERBALS: Pain, tenderness, masses, sensations and further assess for any abnormalities

DISTINGUISH A SUPERFICIAL FROM A DEEP MASS

Patient supine. Using the palmar surface of extended fingers, press in the abdominal wall moving the fingers back and forth over the abdominal wall in one location. Ask the patient to do a half sit-up or leg raise with both feet several inches off the table. Re-palpate the area of suspected mass. POSITIVE: (1) Mass remains visible and/or palpable (2) Mass is no longer visible and/or palpable INDICATES: (1) Superficial mass (2) Deep mass

PALPATE FOR SPLEEN

Patient supine. While standing on the patient's right side, reach across with your left hand and place it beneath the patient under the left costovertebral angle. The examiner will pull posterior-anterior to lift the spleen toward the abdominal wall. The examiner will place the palmar surface of their right hand with fingers extended on the patient's abdomen below the left costal margin. Pressing their fingertips anterior-posterior toward the spleen as they ask the patient to take a deep breath. POSITIVE: Palpable spleen INDICATES: Splenomegaly

EPIGASTRIC PULSATIONS

Patient supine. With a hand flattened, press index finger just under the rib cage and up toward the left shoulder and try to feel right ventricular pulsations. POSITIVE: (1) Pulsations coming from superior to inferior (2) Pulsations coming from inferior to superior INDICATES: (1) May indicate right ventricular enlargement (2) May indicate abdominal aortic aneurysm

HEEL WALK

Patient walks on heels. POSITIVE: Inability to perform test. INDICATES: L4-L5 disc lesion (L5 nerve root).

TOE WALK

Patient walks on toes POSITIVE: Inability to perform test INDICATES: L5-S1 disc lesion (S1 nerve root)

AUSCULTATORY BP

Place the diaphragm (or bell) of the stethoscope over the brachial artery (medial to the bicep tendon). Inflate the cuff 30 mmHg above the Palpatory systolic blood pressure. Deflate the cuff slowly 2-3 mmHg per second. Listen for the first consistent and loudest audible sound (Korotkoff sound-phase 1) ,which indicates the systolic blood pressure (ideally within 5-10 mmHg from the palpatory systolic blood pressure) and listen for the last consistent and loudest audible sound ,which indicates the diastolic blood pressure (Korotkoff sound-phase 5). Deflate the cuff completely. Report systolic/diastolic sounds in mm Hg.

RINNE TEST

Place the handle of a vibrating tuning fork against the mastoid bone for bone conduction. Begin counting or timing the interval with a watch. Ask the patient to tell you when the sound is no longer heard, noting the amount of time. Then quickly hold the vibrating fork near the external ear canal without touching the patient (.5 to 1") for air conduction, and again have the patient indicate when the sound ceases. Again, note the amount of time. INDICATES: Normal: Air conduction persists twice as long as bone conduction Abnormal: Conduction deafness: air conduction is absent, equal to, or less than bone conduction. Abnormal: Sensorineural deafness: air conduction and bone conduction are both radically decreased or absent.

WEBER TEST

Place the handle of the vibrating tuning fork on the midline of the skull and ask the patient to compare the intensity of the sound in the two ears. INDICATES: (-) Normal: sound is equal in both ears. (+) Conductive deafness: sound lateralizes to the bad ear. (+) Sensorineural deafness: sound lateralizes to the good ear.

BARANY WHIRLING CHAIR TEST

Seated patient is spun in chair in one direction INIDCATES: Normal: fast component of nystagmus will be in the direction of the spin.

EMPTY CAN TEST:

Shoulder abducted 90 degrees in the scaption plane (scapular plane elevation) with forearm extended and in 40 degrees forward flexion. The shoulder is placed in maximal internal rotation with the thumb pointing downward. The examiner instructs the patient to push back and out while the examiner pushes down and in. POSITIVE: Resistance to the abduction and downward pressure stresses the supraspinatus muscle and tendon insertion. INDICATES: Tear, rupture to the supraspinatus muscle or tendon with possible suprascapular neuropathy.

CHADDOCK SIGN

Stroking down the lateral leg around the lateral malleolus

FAT PAD SQUEEZE TEST OF HEEL:

The examiner depresses the patient's fad pad forcefully and elicits a painful localized response. The examiner then squeezes the heel and fat pad together thereby creating a cushioning effect of the fat pad. Then the forcefull depression is repeated while maintaining the squeeze. POSITIVE: Pain diminishes during this procedure or feels less tender. INDICATES: Lessening of pain rules in fat pad syndrome. If pain remains the same or is worse consider plantar fasciitis, heel spur or calcaneal stress fracture.

TEST FOR PLANTAR FASCITIS

The examiner forcefully dorsiflexes the patient's ankle and then forcefully extends the great toe creating a stretch effect. The examiner then palpates along the medial longitudinal arch while maintaining the passive stretch. POSITIVE: Sharp pain along the medial longitudinal arch INDICATES: Plantar Fasciitis

DISTAL TIBIO-FIBULAR SQUEEZE TEST:

The examiner squeezes the distal third of the tibio-fibular joint for 3-5 seconds. POSITIVE: Pain is reproduced while squeezing or pain is worse when releasing the tib/fib distally as it springs back INDICATES: High ankle sprain of the tibio-fibular ligament and/or the interosseous syndesmosis

REVERSE MILLS TEST:

The elbow is extended and the forearm is supinated. The wrist is then fully passively extended. The test is designed to confirm the golfers elbow test. POSITIVE: Reproduction of pain in the medial elbow INDICATES: Medial epicondylitis or Golfers elbow

VALGUS OVERLOAD TEST OF THE ELBOW

The elbow is placed into 90 degrees of flexion. The examiner then places a valgus stress into the elbow while passively extending the elbow fully (dynamic extension). POSITIVE: Pain in the posterior elbow with a reproduction of a locking or catching sensation or an inability to fully extend the elbow due to pain. INDICATES: Posterior elbow impingement syndrome

FROMENTS PAPER SIGN (alternate):

The examiner asks a patient to hold a piece of paper in their hand between the thumb and index finger with the thumb adducted. The examiner then attempts to pull the paper from the patient's grasp while they attempt to resist POSITIVE: The patient is seen to flex the thumb thereby recruiting the median nerve to compensate for apparent weakness. INDICATES: Weakness or palsy of the adductor pollicus muscle - innervated by the ulnar nerve. Look for wasting of the dorsal thumb web.

SCHAEFER SIGN

Squeezing achilles tendon

GORDON SIGN

Squeezing the calf

MAZION SHOULDER MANEUVER:

The examiner asks the patient to place the hand of the affected shoulder on the unaffected shoulder and bring the elbow toward the chest (like a Dugas position).The patient will then actively raise the elbow toward the forehead. POSITIVE: Inability to actively raise the elbow to the forehead due to pain and/or stiffness INDICATES: Early stage adhesive capsulitis or non inflammatory capsular adhesions

NAVICULAR DROP TEST

The examiner uses a cloth measuring tape (an index card can also be used) and measures the distance between the navicular tubercle and the ground in a non-weight bearing patient. The patient is the instructed to stand and bear weight and the same distance is measured again. It's normal for the navicular to drop into the medial arch to some degree. POSITIVE: The navicular drops more that 5/8" or 1.6cm's on the cloth tape INDICATES: Functional pronation - consider adjusting tarsals or recommending orthotics.

OCULOMOTOR (III), TROCHLEAR (IV), AND ABDUCENS (VI)

The following four tests are for CN III specifically: a. Check for ptosis b. Direct light reflex c. Indirect light reflex d. Accommodation reflex The following will test CN III, IV, and VI combined: a) Extraocular movements with six cardinal fields of gaze. Observe patient's eyes for normal conjugate, or parallel movements of the eyes and nystagmus as you have him/her follow your finger or pencil while it makes a wide "H" in the air: - Trochlear = down and in - Abducens = lateral - Oculomotor all other fields.

MAXIMUM ELBOW FLEXION TEST/COMPRESSION TEST:

The patient is asked to place their elbows in maximum elbow flexion for up to 3 minutes to close down the cubital tunnel. POSITIVE: Reproduction of parasthesias into the ulnar nerve distribution with possible weakness on handshake (power grip). INDICATES: Cubital tunnel syndrome (ulnar nerve entrapment at the cubital tunnel).

MODIFIED OBER TEST:

The patient is side lying with the involved side up. The bottom leg is flexed to allow stability. The patient is moved to the edge of the table and uses their thigh to stabilize the patient's sacrum and pelvis. The involved legs knee is extended completely and the hip is extended slightly. The examiner then lowers the involved leg off the side of the table. POSITIVE: The hip and lateral thigh remains in abduction (does not angle down towards the floor). The patient experiences lateral thigh pain upon this maneuver. INDICATES: Tight TFL (possible contracture) with possible IT band syndrome

TEST FOR SYNOVIAL KNEE PLICA (PATELLAR BOWSTRING):

The patient is side lying with the involved side up. The knee is placed in 30 degrees flexion. The examiner grasps the lateral aspect of the patella with the superior hand and pushes it medially. The inferior hand internally rotates the tibia. The knee is then extended fully and flexed again to 30 degrees. For educational/test purposes the test will be repeated with a lateral pull on the patella and lateral tibial rotation, which can rule in or out a medial or lateral issue. POSITIVE: Popping, snapping, clunking, grinding or stuttering of the patella INDICATES: Medial patella pain is medial knee synovial plica syndrome. Lateral patella pain is lateral knee synovial plica syndrome.

ANTERIOR INNOMINATE TEST aka MAZION PELVIC MANEUVER (advancement sign)

The patient is standing. Examiner instructs patient to advance one leg forward approximately 2-3 feet. Patient is then instructed to bend forward from the waist and touch the advanced foot with both hands (advanced knee should be straight). POSITIVE: The inability to bend at the waist more than 45 degrees, because of either/or (1) radiating pain along the sciatic nerve, either unilateral or bilateral (2) low back pain (lumbar or pelvic regions) INDICATES: (1) sciatic neuralgia or radiculopathy, possibly due to lumbar disc pathology (2) anterior (rotational) displacement of the ilium relative to the sacrum

HIP IMPINGEMENT SIGN

The patient is supine with hip flexed to 90 degrees. The hip is then adducted across the midline of the body and the examiner forcefully internally rotates the hip. POSITIVE: Sharp anterior catching hip pain INDICATES: Hip impingement syndrome

WILSON SIGN

The patient is supine. The knee is flexed to 90 degrees by the examiner. The knee is extended with the tibia medially rotated. The knee is again flexed to 90 degrees and the tibia is laterally rotated and extended. POSITIVE: knee pain increases near 30 degrees of knee flexion with the tibia internally rotated. Pain disappears when the tibia is eternally rotated. INDICATES: osteochondritis dessicans

CRAIG TEST for ANTEVERSION:

The patient lies prone with the involved side's knee flexed to 90 degrees. With the examiners hand grasping the distal tib/fib, the hip is internally rotated until the greater trochanter comes parallel to the table. POSITIVE: If the hip is internally rotated in excess of 30 degrees in order for the greater trochanter to attain a parallel position, the patient is considered to have a structural anteversion.

ANTERIOR APPREHENSION WITH RELOCATION (Jobe relocation test):

The patient lies supine on an examination table. The shoulder is placed into the apprehension position. The examiner attempts to reproduce a sense of instability/ apprehension by externally rotating the shoulder in a controlled manner. If apprehension is reproduced, the examiner then places the heel of their hand on the proximal anterior gleno-humeral joint and gently pushes in an anterior to posterior direction (relocation). POSITIVE: The patient senses relief upon relocation INDICATES: Confirms anterior instability of the GH joint (rules out tendinitis as false positive for anterior apprehension test.)

GODFREY "SAG" SIGN:

The patient lies supine with the involved knee flexed to 90 degrees and the hip flexed to 90 degrees. The examiner grasps the distal tib/fib and asks the patient to perform a gentle hamstring contraction (bring heel to buttock). The examiner then observes the proximal anterior tibio-femoral joint. POSITIVE: The proximal tibia "sags" posteriorly due to lack of a static posterior constraint INDICATES: Tear or sprain of the posterior cruciate ligament. This test is done to confirm injury to this ligament if Drawer test proves inconclusive.

NOBLE TEST:

The patient sits on the table with feet on table, the involved knee flexed to approximately 60 degrees. The examiner places their superior thumb over the lateral femoral condyle with firm pressure where the IT band runs past the knee. The examiner then passively extends the knee to full extension and then flexes the knee back to 60 degrees while maintaining firm pressure with the thumb over the lateral femoral condyle. This can be repeated a few times POSITIVE: Worse pain through 30/40 degrees of flexion/extension (painful arc of the knee) of the knee. INDICATES: IT band syndrome or lateral knee impingement syndrome

LIFT OFF TEST:

The patient will place the back of their hand in the small of their back and attempt to lift the hand off the back. POSITIVE: Inability to actively lift the hand off or away from the back INDICATES: Subscapularis tendinopathy

PATTE TEST (Hornblower sign)

The patient will place the shoulder of the affected side in forward flexion to 90 degrees. The shoulder is then slightly abducted (15-20 degrees). The Elbow is bent to 90 degrees with the palm facing the patient (Hornblower position). The examiner will place their hand at the distal forearm on the dorsal surface. The patient is then instructed to externally rotate against the examiners resistance. POSITIVE: Pain or inability to actively externally rotate against resistance due to weakness INDICATES: Infraspinatus or Teres Minor Tendinopathy

O'BRIEN SIGN:

The patient's shoulder is placed in flexion to 90 degrees and then into full internal rotation and 10 to 15 degrees of horizontal adduction (cross chest). Examiner exerts a downward force against the patient's upward resistance. Repeat the test with the arm supinated. POSITIVE: 1) Pain felt either deeply or 2) Superficially INDICATES: 1) Labrum tear if felt deeply or 2) AC joint problem if felt superficially

NEER TEST

The patient's shoulder is placed into passive forward flexion to end range. POSITIVE: End range pain as the greater tuberosity jams up against the anterior- inferior border of the acromion. INDICATES: Impingement with overuse injury of the supraspinatus muscle or biceps tendon.

PERFORM REBOUND TENDERNESS in all 4 quadrants

This is a maneuver is one ONCE in each of the four quadrants. Patient supine. Instruct patient you are going to perform a test in their abdomen. Hold your hand at a 900 angle to patient's abdomen with the fingers extended. Press gently and deeply into the abdomen region (2-3 inches). Rapidly withdraw your hand and fingers. Perform ONE time per quadrant since it is a provocative test. The return to position (rebound) of the structures which were compressed by your fingers causes a sharp stabbing pain at the site of a problem.

TEST FOR ASCITES: FLUID WAVE (fluid in the abdomen)

This procedure requires three hands, so the patient will have to help the examiner.Patient supine, ask them to press the edge of their hand and forearm firmly a the vertical midline of the abdomen. This position helps stop transmission of wave through adipose tissue. Place your hands on each side of the abdomen and strike one side sharply with your fingertips POSITIVE: Easily detected fluid wave INDICATES: Ascites (pathological increase of fluid in the abdomen) **** SHIFTING DULLNESS & PUDDLE SIGN are other methods

ANKLE DORSIFLEXION TEST (HOPPENFELD) - Patient experiences difficulty dorsiflexing the foot

With the patient seated, the examiner tries to dorsiflex foot of affected leg; first with the knee extended, then again with the knee flexed. POSITIVE: (1) the foot cannot dorsiflex with knee extended, but is able to with knee flexed. (2) the foot cannot dorsiflex in either knee position INDICATES: (1) contracture of the gastrocnemius muscle (2) contracture of the soleus muscle

OLFACTORY NERVE (I)

a) Ask about disorders of sense of smell and of taste (will diminish with loss of smell) b) Using a penlight, make sure nostrils are not blocked. c) Occlude one nostril at a time (eyes should be closed) Have patient sniff familiar and non-irritating odors, use the milder scent first. Ask the patient: 1) Do you smell anything? 2) Can you identify the substance?

FACIAL NERVE (VII)

a) Ask the patient about changes in taste sensations sweet, salty, and sour on the anterior two thirds of the tongue. b) Inspect face for asymmetry (at rest and during motion) Ask the patient to perform the following: - Raise eyebrows - Close eyes tightly - Show teeth - Puff out cheeks - Smile - Frown

OPTIC NERVE (II)

a) Inspect external structures of eye b) Inspect the optic fundi with ophthalmoscope c) Test visual acuity Screen by reading print. Test each eye individually. Screen with shapes and/or colors. d) Confrontation Test Examiner Stands, examine directly in front and level with patient's face Have patient cover one eyeBring object into view from eight different directions (P-A) per eye e) Direct light reflex- ipsilateral pupillary constriction f) Indirect light reflex (consensual reflex)- contralateral pupillary constriction g) Accommodation reflex Test ability of the eyes to adapt for near vision Instruct patient to follow object inward from a distance Convergence of the eyes, constriction of the pupil

HYPOGLOSSAL N. (XII)

a) Inspect tongue for: 1. Atrophy 2. Fasciculations 3. Deviation b) Have patient stick out tongue and test bilaterally with tongue in cheek. Unilateral paralysis = Protruded tongue deviates to involved side.

GLOSSOPHARYNGEAL (IX) & VAGUS N. (X)

a) Note any hoarseness of the voice. b) Ask the patient about change in bitter taste sensation on the posterior third of the tongue. c) Soft Palate Motor Function = Patient says "ah" while doctor shines light in mouth and depresses tongue as necessaryWatch for symmetrical rising of soft palate.Unilateral paralysis = One side of palate does not rise and uvula deviates to the normal side. d) Gag reflex. e) Have patient swallow while you palpate thyroid cartilage. f) Carotid sinus reflex.

TRIGEMINAL (V) OPTHALMIC, MAXILLARY, & MANDIBULAR

a) Oculocardiac Reflex: Take pulse, apply pressure over the patient's closed eye, pulse rate should decrease 2-3 beats per 15 sec. b) Test pain (sharp pinprick) on face bilateral in all 3 divisions (3 places per division for a total of 18 touches) c) Test for light touch to the face with wisp of cotton or brush in all 3 divisions (3 places per division for a total of 18 touches) d) Light touch to anterior 2/3 of tongue, inside cheeks, and hard palate with toothpick. (Use a penlight to view the inside of the mouth) e) Have patient clench teeth, palpate masseter and temporalis muscles at rest & motion. f) Jaw Jerk reflex - elicited by the examiner placing their index finger over the middle of the patient's chin with the mouth slightly open & the jaw relaxed. The index finger is then tapped with a reflex hammer, delivering a downward stroke. Response: Upward movement of the jaw without deviation to either side.

VESTIBULO-COCHLEAR NERVE (VII)

a) Screening tests to confirm side of hearing loss: Finger Rub Test:Assess hearing by rubbing fingers together near the EAM (external auditory meatus), find maximal distance sound can be heard. Whisper Test Have patient close his eyes (to prevent lip-reading) and cover the ear on the side not being tested. Place your head/mouth 2 feet from the ear being tested and whisper words to the patient and ask patient to repeat the words. You can also ask questions to the patient and have the patient answer yes or no to each question. b) Distinguish between perceptive and conductive hearing loss using a 512 Hz tuning fork by using Weber and Rinne tests.

SPINAL ACCESSORY N. (XI)

a) Trapezius Muscle Inspect Palpate Muscle test b) Sternocleidomastoid Muscle Inspect PalpateMuscle test - Ask patient to rotate head to one side. Dr. instructs patient to hold, while Dr. attempts to return the head to neutral

WESTPHAL SIGN:

absence of any DTR (especially patellar; LMNL)