COMPLETE PHYSICAL EXAMINATION OF THE THORAX § Rate ⇒ 14- 20 cycles/ min and I:E of 1: 2- 3

seffcausapinmd™ Lumps, lesions and scars

Extra- thoracic observations ⇒ cyanosis, clubbing in patients with impaired oxygen delivery and
There are several points to remember prior to beginning the examination of the thorax. These include: edema in patients with pleural fluid
1. Even though you may have already recorded the respiratory rate when you took the vital signs, it is wise to again
observe the rate, rhythm, depth, and effort of breathing.
2. Always inspect the patient for any signs of respiratory difficulty.
3. Assess the patient’s color for cyanosis
4. Listen to the patient’s breathing Focus on areas of tenderness and abnormalities in the overlying skin,
5. Inspect the neck. PALPATION
respiratory expansion, and fremitus
6. Also observe the shape of the chest.
7. Most importantly, DRAPE the patient properly. Identify tender areas ⇒ Intercostal tenderness over inflamed pleura
∇ These can also be part of your inspection as you go through with the examination, but the book says these are part of ⇒ Local tenderness from trauma may suggest for rib fractures or
your initial survey of the respiration and thorax. from costochondritis
Examination of the Anterior and Posterior Chest Abnormalities ⇒ Like crepitus (sensation of crackles) in patients with
subcutaneous air or pneumothorax)
INSPECTION RATIONALE/ SIGNIFICANT FINDINGS
Diaphragmatic excursion ⇒ Unequal movement à asymmetry
From a midline position behind the patient, note the
shape of the chest and the way in which it moves, ⇒ Minute amount of movement à poor diaphragmatic excursion
including: ⇒ Normal: 5- 6cm on full inspiration
§ Deformities or asymmetry ⇒ Such as pectus excavatum, pectus carinatum, and barrel chest in Chest expansion ⇒ Unilateral lagging from chronic fibrosis, pleural effusion, COPD,
COPD and asthmatic patients ◦ Place your thumbs on the following landmarks restrictive lung disorders and unilateral bronchial obstruction.
§ Abnormal retraction of the interspaces during ⇒ Retraction is most apparent in the lower interspaces. following cephalocaudal approach:
inspiration Supraclavicular retraction is often associated. Retraction in a. Below the sternoclavicular joint at the level
severe asthma, COPD, or upper airway obstruction. of the 1st rib
§ Impaired respiratory movement on one or both ⇒ Unilateral impairment or lagging of respiratory movement b. At the level of the T4/T5 with your hand
sides or a unilateral lag (or delay) in suggests disease of the underlying lung or pleura such as grasping the axillary portion
movement. chronic fibrosis, pleural effusion, COPD, restrictive lung diseases, c. At the level of T11- T12 or diaphragm
unilateral bronchial obstruction. d. At the level of the 10th ribs (posteriorly)
Inspect the following in both anterior and posterior ◦ As you position your hands, slide them medially
view. just enough to raise a loose fold of skin on each
§ Patient’s level of distress. side between your thumb and the spine (in
⇒ SCM, upper trapezius, pectoralis major
§ Use of respiratory muscles posterior portion)
⇒ Patients w/ asthma/ COPD, sitting and leaning forward with
§ Respiratory positions ◦ Ask the patient to inhale deeply. Watch the
shoulders arched forward.
distance between your thumbs as they move
Breathing patterns: apart during inspiration, and feel for the range
§ Rate ⇒ Tachypnea, bradypnea, apnea, dyspnea and symmetry of the rib cage as it expands and
§ Rhythym ⇒ Cheyne- stokes in uremia and CHF, biots breathing in respiratory contracts.
failure Tactile fremitus
§ Depth
- Fremitus refers to the palpable vibrations
§ Effort ⇒ Such as dyspnea transmit- ted through the bronchopulmonary
 tree to the chest wall when the patient speaks PATHOLOGIC EXAMPLES:
Procedure: § Dullness- pleural effusion, atelectasis, neoplasms and
◦ To detect fremitus, use either the ball (the consolidation
bony part of the palm at the base of the § Hyper- resonance- emphysema and pneumothorax
fingers) or the ulnar surface of your hand § Tympany- very large pneumothorax
to optimize the vibratory sensitivity of the NORMAL AREAS OF DULLNESS
bones in your hand. Ask the patient to § Cardiac dullness- 3- 5th ICS, Left Para- sternal area
repeat the words “ninety-nine” or “one- § Liver span- 4- 6th ICS, Right MCL
one-one.” If fremitus is faint, ask the ⇒ Decreased tactile fremitus in pneumothorax, pleural effusion, § Splenic dullness- 9- 11th rib, Left mid- axillary line
patient to speak more loudly or in a deeper and thick chest § Level of diaphragm- 5- 6 cm diaphragmatic excursion
voice. ⇒ Increased tactile fremitus in mass, consolidation, solid organs Locations for percussion
and thin chest

Percussion of the chest sets the chest wall and underlying tissues into
motion, producing audible sound and palpable vibrations. Percussion
helps you establish whether the underlying tissues are air-filled, fluid-
PERCUSSION
filled, or solid. It penetrates only about 5 cm to 7 cm into the chest,
however, and therefore will not help you to detect deep-seated
lesions.
• Hyperextend the middle finger of your left hand,
known as the pleximeter finger.
• Press its distal interphalangeal joint firmly on the Auscultation of the lungs is the most important examining technique
AUSCULTATION
surface to be percussed. for assessing air flow through the tracheobronchial tree
• Avoid surface contact by any other part of the Auscultation involves:
hand, because this dampens out vibrations. (1) listening to the sounds generated by breathing
• Note that the thumb, 2nd, 4th, and 5th fingers (2) listening for any adventitious (added) sounds, and
are not touching the chest. (3) if abnormalities are suspected, listening to the
• Position your right forearm quite close to the sounds of the patient’s spoken or whispered voice as
surface, with the hand cocked upward. The they are transmitted through the chest wall.
middle finger should be partially flexed, relaxed,
and poised to strike.
Learn to identify five percussion notes.
Adventitious Breath Sounds
§ Crackles may be due to abnormalities of the
lungs (pneumonia, fibrosis, early congestive
heart failure) or of the air- ways (bronchitis,
bronchiectasis).
§ Wheezes suggest narrowed airways, as in
asthma, COPD, or bronchitis.
§ Rhonchi suggest secretions in large airways.
§ Fine late inspiratory crackles that persist from
breath to breath suggest abnormal lung tissue.

Transmitted Voice Sounds

§ Bronchophony- Ask the patient to say “ninety- ⇒ Louder, clearer voice sounds are called bronchophony.
nine.” Normally the sounds transmitted through
the chest wall are muffled and indistinct.
§ Egophony- Ask the patient to say “ee.” You will ⇒ When “ee” is heard as “ay,” an E-to-A change (egophony) is
normally hear a muffled long E sound. present, as in lobar consolidation from pneumonia. The quality
sounds nasal.
§ Pectoriloquy- Ask the patient to whisper “ninety- ⇒ Louder, clearer whispered sounds are called whispered
nine” or “one-two-three.” The whispered voice pectoriloquy.
is normally heard faintly and indistinctly, if at all.

SPECIAL TECHNIQUES IMPORTANT POINTS TO CONSIDER

Clinical Assessment of Pulmonary Function - assess the complaint of breathlessness in an ambulatory
patient is to walk with the patient down the hall or climb one
flight of stairs. Observe the rate, effort, and sound of the
patient’s breathing
Forced Expiratory Time - Ask the patient to take a deep breath in and then breathe out
as quickly and completely as possible with mouth open.
Listen over the trachea with the diaphragm of a stethoscope
and time the audible expiration. Try to get three consistent
readings, allowing a short rest between efforts if necessary.
Identification of a Fractured Rib - An increase in the local pain (distant from your hands)
- By anteroposterior compression of the chest, you suggests rib fracture rather than just soft tissue injury.
can help to distinguish a fracture from soft-tissue
injury. With one hand on the sternum and the other
on the thoracic spine, squeeze the chest. Is this
painful, and where?
COMPLETE PHYSICAL EXAMINATION OF THE CARDIOVASCULAR SYSTEM The following features help to distinguish jugular from carotid artery pulsations:
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There are several points to remember prior to beginning the examination of the CVS. These include:
8. Review the blood pressure and heart rate recorded during the General Survey and Vital Signs at the start of the
physical examination.
9. Take the time to measure the blood pressure and heart rate using optimal technique.
10. Systematically organize your examination following these components:
a. The jugular venous pressure
b. The carotid upstrokes and presence or absence of bruits
c. The point of maximal impulse(PMI)and any heaves, lifts, or thrills
d. The first and second heart sounds, S1 and S2
e. Presence or absence of extra heart sounds such as S3 or S4
f. Presence or absence of any cardiac murmurs.

Jugular Venous Pressure and Pulsations

– JVP reflects pressure in the right atrium, or central venous pressure, and is best assessed from pulsations in the
right internal jugular vein
– jugular veins and pulsations are difficult to see in children younger than 12 years of age, so they are not useful for
evaluating the cardiovascular system in this age group
–
STEPS FOR ASSESSING THE JUGULAR VENOUS PRESSURE (JVP)
• Make the patient comfortable. Raise the head slightly on a pillow to relax the sternomastoid muscles.
• Raise the head of the bed or examining table to about 30°. Turn the patient’s head slightly away from the side you are
inspecting.
• Use tangential lighting and examine both sides of the neck. Identify the external jugular vein on each side, then find the
internal jugular venous pulsations.
• If necessary, raise or lower the head of the bed until you can see the oscillation point or meniscus of the internal
jugular venous pulsations in the lower half of the neck.
Place your ruler on the sternal angle and line it up with something in the room that you know to be vertical. Then place a card
• Focus on the right internal jugular vein. Look for pulsations in the suprasternal notch, between the attachments of the
or rectangular object at an exact right angle to the ruler.
sternocleidomastoid muscle on the sternum and clavicle, or just posterior to the sternocleidomastoid. The table
§ Increased pressure suggests right- sided heart failure or, less commonly, constrictive pericarditis, tricuspid stenosis,
below helps you distinguish internal jugular pulsations from those of the carotid artery.
or superior vena cava obstruction.
• Identify the highest point of pulsation in the right internal jugular vein. Extend a long rectangular object or card
§ In patients with obstructive lung disease, venous pressure may appear elevated on expiration only; the veins collapse
horizontally from this point and a centimeter ruler vertically from the sternal angle, making an exact right angle.
on inspiration. This finding does not indicate congestive heart failure.
Measure the vertical distance in centimeters above the sternal angle where the horizontal object crosses the ruler.
§ Venous pressure measured at greater than 3 cm or possibly 4 cm above the sternal angle, or more than 8 cm or 9
This distance, measured in centimeters above the sternal angle or the atrium, is the JVP. cm in total distance above the right atrium, is considered elevated above normal.
Jugular Venous Pulsations § Bruit- murmur-like sound of vascular rather than cardiac origin.
- Observe the amplitude and timing of the jugular venous pulsations. o Listen for bruit over the carotid arteries if your patient is middle- aged or elderly or if you suspect for CVD
- In order to time these pulsations, feel the left carotid artery with your right thumb or listen to the heart o Ask the patient to hold breathing for a moment so breath sounds would not obscure the vascular sounds
simultaneously
- The a wave just precedes S1 and the carotid pulse, the x descent can be seen as a systolic collapse, the v wave The Brachial Artery
almost coincides with S2, and the y descent follows early in diastole. Look for absent or unusually prominent waves. - reflects aortic pulsations when carotid artery is not suitable for examination due to obstruction, kinking or thrills.
⇒ Prominent a waves indicate increased resistance to right atrial contraction, as in tricuspid stenosis or,
more commonly, the decreased compliance of a hypertrophied right ventricle.
⇒ The a waves disappear in atrial fibrillation.
⇒ Larger v waves characterize tricuspid regurgitation. The Heart
- For most of the cardiac examination, the patient should be supine with the upper body raised by elevating the head
of the bed or table to about 30°.
The Carotid Pulse - Two other positions are also needed: (1) turning to the left side, and (2) leaning forward.
- The carotid pulse provides valuable information about cardiac function and is especially useful for detecting stenosis - The examiner should stand at the patient’s right side.
or insufficiency of the aortic valve. Take the time to assess the quality of the carotid upstroke, its amplitude and
contour, and presence or absence of any overlying thrills or bruits.
- To assess amplitude and contour
a. the patient should be lying down with the head of the bed still elevated to about 30°.
b. When feeling for the carotid artery, first inspect the neck for carotid pulsations. These may be visible just medial
to the sternomastoid muscles.
c. Then place your left index and middle fingers (or left thumb) on the right carotid artery in the lower third of the
neck, press posteriorly, and feel for pulsations.

§ Decreased pulsations may be caused by decreased stroke volume, but may also be due to local factors in the artery - During the cardiac examination, remember to correlate your findings with the patient’s jugular venous pressure and
such as atherosclerotic narrowing or occlusion. carotid pulse. It is also important to identify both the anatomic location of your findings and their timing in the cardiac
§ Amplitude: Small, thready, or weak pulse in cardiogenic shock; bounding pulse in aortic insufficiency cycle.
§ The contour of the pulse wave, namely the speed of the upstroke, the duration of its summit, and the speed of the § Note the anatomic location of sounds in terms of interspaces and their distance from the midsternal,
downstroke. The normal up- stroke is brisk. It is smooth, rapid, and follows S1 almost immediately. The summit is midclavicular, or axillary lines.
smooth, rounded, and roughly midsystolic. The downstroke is less abrupt than the upstroke. § Identify the timing of impulses or sounds in relation to the cardiac cycle.
o Delayed carotid upstroke in aortic stenosis

Thrills and Bruits

§ Thrills- humming vibrations that feel like the throat of a purring cat.
 Location ⇒ 5th ICS, L- MCL
⇒ displaced PMI upward and to the left by pregnancy or a high
left diaphragm
⇒ Lateral displacement from cardiac enlargement in congestive
heart failure, cardiomyopathy, ischemic heart disease.
Displacement in deformities of the thorax and mediastinal shift.
Diameter ⇒ In the left lateral decubitus position, a diameter greater than 3
- In the supine patient, it usually measures cm indicates left ventricular enlargement.
less than 2.5 cm and occupies only one
§ S1 is the first of these sounds, S2 is the second, and the relatively long diastolic interval separates one pair from the interspace. It may be larger in the left lateral
decubitus position.
next.
§ S1 is usually louder than S2 at the apex; more reliably, S2 is usually louder than S1 at the base. Amplitude ⇒ It is usually small and feels brisk and tapping. Some young
o S1 is decreased in first-degree heart block, and S2 is decreased in aortic stenosis. persons have an increased amplitude, or hyperkinetic impulse,
§ “Inching” can then be helpful. especially when excited or after exercise; its duration, however,
§ Use palpation of either the carotid pulse or the apical impulse to guide the timing of your observations. Both occur in is normal.
early systole, right after the first heart sound. ⇒ Increased amplitude may also reflect hyperthyroidism, severe
anemia, pressure overload of the left ventricle (e.g., aortic
INSPECTION and PALPATION RATIONALE/ SIGNIFICANT FINDINGS stenosis), or volume overload of the left ventricle (e.g., mitral
regurgitation).
Careful inspection of: (use tangential light)
§ Apical pulse or PMI Duration ⇒ To assess duration, listen to the heart sounds as you feel the
§ Ventricular movements of left- sided S3 or apical impulse, or watch the movement of your stethoscope as
S4 you listen at the apex.
Use palpation to: ⇒ A sustained, high-amplitude impulse that is normally located
§ confirm the characteristics of the apical suggests left ventricular hypertrophy from pressure overload
impulse. (as in hypertension).
§ detect thrills and the ventricular movements ⇒ If such an impulse is displaced laterally, consider volume
of an S3 or S4 overload.
General palpation: ⇒ A sustained low-amplitude (hypokinetic) impulse may result
◦ First palpate for impulses using your fingerpads from dilated cardiomyopathy.
◦ Use light pressure for an S3 or S4, and firmer S3 and S4 ⇒ A brief mid- diastolic impulse indicates an S3; an impulse just
pressure for S1 and S2. before the systolic apical beat itself indicates an S4.
◦ Ventricular impulses may heave or lift your
fingers. The Left Sternal Border in the 3rd, 4th, and 5th
Interspaces— Right Ventricular Area.
◦ Then check for thrills by pressing the ball of
your hand firmly on the chest.
The Apical Impulse or Point of Maximal Impulse Assess the location, diameter, amplitude, and duration of the apical
(PMI)—Left Ventricular Area impulse.
(If you cannot identify the apical impulse with the
patient supine, ask the patient to roll partly onto the left
side—this is the left lateral decubitus position)
 ⇒ A marked increase in amplitude with little or no change in mitral stenosis. Apply the bell lightly, with just
duration occurs in chronic volume overload of the right enough pressure to produce an air seal with its full
ventricle, as from an atrial septal defect. rim. Use the bell at the apex, then move medially
⇒ An impulse with increased amplitude and duration occurs with along the lower sternal border. Resting the heel of
pressure overload of the right ventricle, as in pulmonic your hand on the chest like a fulcrum may help you
stenosis or pulmonary hypertension. to maintain light pressure.
In patients with an increased anteroposterior (AP) ⇒ In obstructive pulmonary disease, hyperinflated lung may Ask the patient to roll partly onto the left side into the left ⇒ This position accentuates or brings out a left-sided S3
diameter, palpation of the right ventricle in the prevent palpation of an enlarged right ventricle in the left lateral decubitus position. and S4 and mitral murmurs, especially mitral stenosis.
epigastric or subxiphoid area is also useful. parasternal area. The impulse is felt easily, however, high in You may otherwise miss these important findings.
the epigastrium and heart sounds are also often heard best
here. Ask the patient to sit up, lean forward, exhale completely, and ⇒ This position accentuates or brings out aortic murmurs.
The Left 2nd Interspace—Pulmonic Area. ⇒ A prominent pulsation here often accompanies dilatation or stop breathing in expiration. Pressing the diaphragm of your You may easily miss the soft diastolic murmur of aortic
§ As the patient holds expiration, look and feel increased flow in the pulmonary artery. A palpable S2 suggests stethoscope on the chest, listen along the left sternal border regurgitation unless you use this position.
for an impulse and feel for possible heart increased pressure in the pulmonary artery (pulmonary and at the apex, pausing periodically so the patient may
sounds. hypertension). breathe.
§ In thin or shallow-chested patients, the Listening for Heart Sounds.
pulsation of a pulmonary artery may
sometimes be felt here, especially after
exercise or with excitement.
The Right 2nd Interspace—Aortic Area. ⇒ A palpable S2 suggests systemic hypertension. A pulsation
§ This interspace overlies the aortic outflow here suggests a dilated or aneurysmal aorta.
tract. Search for pulsations and palpable
heart sounds.

PERCUSSION RATIONALE/ SIGNIFICANT FINDINGS

Occasionally, percussion may be your only tool IN Under these circumstances, cardiac dullness often occupies a large
MEASURING FOR THE CARDIAC SIZE. area. Starting well to the left on the chest, percuss from resonance
toward cardiac dullness in the 3rd, 4th, 5th, and possibly 6th
interspaces.

AUSCULTATION RATIONALE/ SIGNIFICANT FINDINGS

KNOWING YOUR STETH!
§ The diaphragm. The diaphragm is better for picking
up the relatively high- pitched sounds of S1 and S2,
the murmurs of aortic and mitral regurgitation, and
pericardial friction rubs. Listen throughout the
precordium with the diaphragm, pressing it firmly
against the chest.
§ The bell. The bell is more sensitive to the low-
pitched sounds of S3 and S4 and the murmur of
Attributes of Heart Murmurs § Radiation or Transmission from the Point of Maximal ⇒ A loud murmur of aortic stenosis often radiates into the
§ Timing ⇒ Diastolic murmurs usually indicate valvular heart Intensity. neck (in the direction of arterial flow).
disease. Systolic murmurs may indicate valvular
disease, but often occur when the heart is entirely § Intensity- This is usually graded on a 6-point scale
normal. and expressed as a fraction. (pls see the table
⇒ Systolic murmurs are usually midsystolic or pansystolic. below)
Late systolic murmurs may also be heard. § Pitch. This is categorized as high, medium, or low.
§ Quality. This is described in terms such as blowing,
harsh, rumbling, and musical.

GRADING OF MURMURS
GRADE DESCRIPTION
1 Very faint, heard only after listener has “tuned in”; may not be heard in all positions
2 Quiet, but heard immediately after placing the stethoscope on the chest
3 Moderately loud
4 Loud, with palpable thrill
5 Very loud, with thrill. May be heard when the stethoscope is partly off the chest
6 Very loud, with thrill. May be heard with stethoscope entirely off the chest

shape of murmur
§ Shape

§ Location of Maximal Intensity. This is determined by ⇒ For example, a murmur best heard in the 2nd right
the site where the murmur originates. interspace usually originates at or near the aortic valve.
 IMPORTANT SIDE NOTES IMPLICATIONS
Opening snap (diastole) Mitral stenosis
S3 Occurs during diastole as a result of the rapid deceleration of
column of blood against the ventricular wall
S4 Marks the atrial contraction (precedes the S1)
2ND- 3RD, Left parasternal border Splitting (S2)
Tricuspid area at the lower left Splitting (S1)
Wide and fixed S2 splitting ASD, LV dysfunction
Wide S2 splitting Right bundle branch block, mitral regurgitation, pulmonary stenosis
Paradoxycal splitting Narrow in inspiration, wide in expiration à left BBB
Soft S1 Severe LV dysfunction, CHD, severe MR
Decreased S1 1st degree block
Decreased S2 Aortic stenosis
Thrills with harsh, rumbling murmurs AS, PDA, VSD
Upward apical pulse Pregnant
Laterally displaced apical pulse Cardiomegaly due to CHF, cardiomyopathy, ischemic HD
Decreased apical pulse Obesity, tick chest and increased AP diameter
Increased amplitude Normal: young patient after exercise
Abnormal: hyperthyroidism, severe anemia, pressure overload due
to AS and volume overload due to MR
Increased amplitude, but normal duration ASD
Increased amplitude, increased duration PS, pHPN
Palpable S2 at the pulmonic area pHPN
Palpable S2 at the aortic area HPN
Small weak pulses ◦ Decreased stroke volume (e.g. heart failure, hypovolemia,
severe AS)
◦ Increased PVR (e.g. cold and severe CHF)
Large, bounding pulse ◦ Increased SV and decreased PVR or both (e.g. fever,
hyperthyroidism, aortic regurgitation, AV fistula, PDA
◦ Increased SV due to bradycardia and complete heart block
◦ Decreased compliance (e.g. atherosclerosis)
Bisferiens pulse Increased pulse w/ double systolic peak (e.g. pure AR or AR w/ AS)
Pulse alternans LV failure with left- sided S3
Bigeminal pulse Alternating beat w/ premature contraction
Paradoxical pulse Decreased amplitude during quiet inspiration, pericardial
tamponade, constrictive pericarditis and restrictive lung diseases.
 COMPLETE PHYSICAL EXAMINATION OF THE ABDOMEN Mnemonics: PUSH V LAPS
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There are several points to remember prior to beginning the abdominal examination. These include: Auscultation provides important information about the bowel motility
1. Have patient empty bladder prior to examination Steps:
2. Use proper lighting and warm hands to examine abdomen 1. place the diaphragm of your steth gently on the abdomen
- You can rub your palm together or place them under warm water 2. listen for the sounds and note their frequency
3. Undrape abdomen from above xiphoid process to symphysis pubis. Groin area should be visible with genitalia 3. normal sounds consist of gurgles and clicks occurring at 5- 34
AUSCULTATION
draped. per min
4. Visualize each organ in the region under examination 4. since the bowel sounds are transmitted widely throughout the
5. Begin assessment at patient’s right and proceed to examine all 5 abdominal regions: abdomen, listening in one spot such as RLQ is usually sufficient
RUQ LLQ 5. report no bowel sounds when no significant sounds have been
RLQ Epigastric area recognized for 2 minutes.
LUQ Bowel sounds (normal, increased/decreased,
6. The exam technique sequence is as follows: absent)
Inspection àAuscultation àPercussion àPalpation Frequency
Character
INSPECTION IMPORTANT POINTS TO CONSIDER Bruits and friction rub (aorta, renal, iliac, femoral - listen on the epigastrium and in each upper quadrant, bruits confined
Peristalsis (increased/decreased peristaltic waves) - if you suspect for bowel obstruction (increased) arteries, costovertebral angles) to systole may be heard for pxs w/ high BP
- for very thin people peristalsis is normally visible - bruits in these areas that has both systolic and diastolic components
strongly suggest renal artery stenosis as the cause of HPN
Umbilicus (contour, location, inflammation, hernia)
Peritoneal rubs (RUQ or LUQ) - listen over the liver and spleen for friction rub
Striae (color: red, white, purple) - old silver striae or stretch marks are normal, while pink-
purple striae may be associated to Cushing’s syndrome ◦ friction rub in liver tumor, gonococcal infection around the liver,
splenic infarction
Hernias (abdominal, umbilical, incisional, diastasis
recti, epigastric, inguinal, femoral)
Vascular changes: dilated veins - dilated veins of hepatic cirrhosis or of inferior vena cava - Helps you to assess the amount and distribution of gas in the
obstruction abdomen and to identify possible masses that are solid or fluid- filled
- It can also be used to estimate the span of the liver and spleen
Lesions or rashes (areas of discoloration)
PERCUSSION - In general, most of the areas of the abdomen are tympanitic when
Abdominal contour - bulging flanks of ascites percussed because of gas, but there are also scattered areas of
flat, scaphoid, protuberant, rounded - suprapubic bulge of a distended bladder or pregnant dullness from fluid and feces and solid organs such as liver and
bulging flanks/local bulges uterus or hernias spleen
symmetry - asymmetry from an enlarged organ such as liver and
4 quadrants (clockwise pattern)
visible organs or masses spleen or mass like lower abdominal mass of an ovarian or
visible movement a uterine tumor Tympanitic/ dull - A protuberant abdomen that is tympanitic all throughout suggests
intestinal obstruction
Pulsation (increased/decreased pulsations) - normal aortic pulsation is frequently visible in the
- Large tumor à dull to percussion and the air- filled bowel are
epigastrium
displaced to the periphery
- increased pulsations of an aortic aneurysm or of increased
pulse pressure ◦ Markedly distended bladder can be mistaken for such a tumor
- Dullness on both flanks prompts further assessment for ascites.
Scars (location, appearance) - you may describe or diagram the location
Spleen - Locate for the Traube’s space between a resonant lung above and When identified, map the area of tenderness
Traube’s space the costal margin along the anterior axillary line. Normally, the sound Rebound tenderness - Press down with ur fingers firmly and slowly, then withdraw then
is tympanitic but when dullness in precussion is present, it detects the quickly. Watch and listen to the px for signs of pain. Ask the px “which
presence of splenomegaly one hurts more, when I press or when I let go?”
Splenic percussion sign - Percuss the lowest interspace in the left anterior axillary line. This - If tenderness is felt elsewhere than where you were trying to eliicit the
area is usually tympanitic. Ask the px to take a deep breath and rebound tenderness, that area may be the real source of tenderness.
percuss again. Spleen - With your left hand, reach over and around the px to support and
- (+) splenic percussion sign is noted when a change of tympanitic to press the lower left rib cage and adjacent soft tissue. With your right
dullness on inspiration is present, and this suggests splenomegaly hand below the left costal margin, press in towards the spleen. Begin
Liver - Use light to moderate percussion palpating low enough so can you palpate an enlarged spleen. Ask the
- Begin with identifying the lower border of dullness in the MCL. Starting px to take a deep breath
from the level of the umbilicus with a tympanitic sound, percuss Liver - With your left hand, place it behind the px supporting the right 11th
upwards towards the liver until you first recognized a dull sound; this and 12th ribs and adjacent soft tissues. By pressing your left hand
marks your lower border of liver dullness. forward, the px’s liver may be felt more easily by your right hand.
- Next, establish an upper border of dullness starting from the nipple - Ask the px to take a deep breath or breath with their abd and plapate
line to make sure that u started on a resonant area, percuss the liver edge; note for any tenderness, normally: it is soft, sharp, with
sequentially downwards towards the liver until you hear a liver smooth surface and slightly tender
dullness. Kidney - Usually not palpable
- Now measure the distance between the 2 points, that is your vertical
span of liver dullness w/c is normally 6- 12 cm. You can also measure
Aorta - Press firmly deep in the upper abdomen, slightly to the left of the
midline and identify the aortic pulsations
the midsternal vertical liver span with the same steps but conducted
along the mid- sternal line. SPECIFIC TESTS
- Decreased span of liver dullness: when air is present below the Ascites: shifting dullness/ fluid wave/ballottement Assessing possible ascites:
diaphragm, perforated viscus, hepatitis or CHF - Since the fluid seeks its own level, the dependent area is usually dull
in percussion while the gas filled bowel floats at the center percussion
gives a tympanitic sound.
PALPATION - With px in supine postion, start percussing from an area of tympany
at the center going outward in several directions. Map the border
General palpation (areas of tenderness=facial !!!!!! Ask the px to point areas of tenderness and examine them lasts. between tympany and dullness.
expression of Px, muscular resistance, superficial a. Light palpation Confirming ascites:
organs and masses) - Use pads of first three fingers of one hand and a light, gentle, dipping Test for Shifting dullness:
Light palpation maneuver to examine abdomen - Turn the px onto one side, percuss and mark the boarders again. For
Deep palpation - Identify superficial organs or masses and any areas of tenderness or px w/o ascites, the previously marked areas of tympany and dullness
increased resistance to your hand. If resistance is present, try to usually stay relatively constant.
distinguish voluntary guarding from involuntary muscular spasm - (+) shifting dullness is when the px changes position for supine to
- Always observe the facial expression of the patient as this serves as lateral, areas of dullness shift to dependent areas.
the most accurate assessment of abdominal tenderness. Fluid Wave:
b. Deep palpation - ask the px or an assistant to press the edges of both hands firmly
- Use palmar surface of fingers of one hand and a deep, firm, gentle down the midline of the abdomen.
maneuver to examine abdomen (two hands, one on top of the other, - While you tap one flank w/ ur fingertips, feel on the opposite flank for
may be required if obesity or muscular resistance occurs an impulse transmitted through the fluid.
Peritoneal inflammation - Ask the px to cough and identify where the cough produces the pain. Ballottement: identifying an organ or mass in an ascitic abdomen
 - Straighten and stiffen the fingers of one hand together, place them
on the abdominal surface and make a jabbing movement directly
toward the anticipated structure.
- This movt quickly displaces the fluid so that your fingers can directly
touch the surface of the structure through the abdominal wall.
Appendicitis: Psoas sign, obturator sign, Psoas sign:
Rovsing’s Sign - Pain on passive extension of the right thigh. Patient lies on left side.
Examiner extends patient's right thigh while applying counter
resistance to the right hip
- Anatomic basis for the psoas sign inflamed appendix is in a
retroperitoneal location in contact with the psoas muscle, which is
stretched by this maneuver
Obturator sign:
- Pain on passive internal rotation of the flexed thigh. Examiner moves
lower leg laterally while applying resistance to the lateral side of the
knee resulting in internal rotation of the femur
- Anatomic basis for the obturator sign inflamed appendix in the pelvis
is in contact with the obturator internus muscle, which is stretched by
this maneuver.
Rovsing’s sign:
- Press deeply and evenly in the LLQ, then quickly withdraw your
fingers.
- Pain in the RLQ during a left- sided pressure suggests appendicitis.
- Aka known as referred rebound tenderness
Peritoneal irritation: rebound tenderness Same as above
Acute cholecystitis: Murphy’s sign - Hook fingers under costal margins on the right.
- Have the patient take deep breath.
- Sharp increase in tenderness with sudden stop in inspiration is
positive.
- Positive sign is indicative of gall bladder disease.
Renal disease: Costovertebral Tenderness - Warn the patient what you are about to do.
- Have the patient sit up on the exam table.
- Use the heel of your closed fist to strike the patient firmly over the
costovertebral angles.
- Compare the left and right sides.
- Tenderness elicited suggest kidney infection such as pyelonephritis or
perinephric abscess.
 COMPLETE PHYSICAL EXAMINATION OF THE PVS Ask about:
§ Coldness, numbness, pallor in the legs/feet, ⇒ Decreased arterial perfusion = HAIR LOSS on ant. tibial
daryllantipuesto&seffcausapin™
HAIR LOSS over ant. tibial surface. surface
There are several points to remember prior to beginning the PVS examination. These include: ⇒ Gangrene = “dry”/brown-black ulcers
1. Taking complete vital signs of the patient. Take BP in both arms.
2. Palpate carotid pulse, auscultate for bruits. PAD WARNING SIGNS:
3. Auscultate for aortic, renal and femoral bruits; palpate aorta, and determine maximal diameter. • Fatigue, aching, numbness, or pain that limits walking or exertion in the legs; if present, where?
4. Palpate brachial, radial, ulnar, femoral, popliteal, dorsalis pedis and posterior tibial arteries. • Erectile dysfuntion
5. Inspect ankles and feet for color, temperature, skin integrity; note any ulcerations; check for hair loss, trophic skin
• Poorly healing/ non healing wound of the lower ex
changes, hypertrophic nails.
6. Assessment of the peripheral vascular system relies primarily on inspection of the arms and legs, palpation of the • Any pain at rest
pulses, and a search for edema • Abdominal pain after meals
• First degree relatives with AAA

ANKLE BRACHIAL INDEX (ABI)

- reliable, reproducible, easy to perform
- Uses Doppler utz
Instructions:
1. Px rest in supine position in a warm room for at least 10mins before testing
2. Place bp cuffs on both arms and legs, then apply utz gel over BRACHIAL, DORSALIS PEDIS, and POSTERIOR TIBIAL art.
3. Measure SYSTOLIC pressures in arms
a. Use vascular Doppler to locate brachial pulse
b. Inflate at 20 mmhg above last audible pulse
c. Deflate slowly and record pressure at w/c PULSE BECOMES AUDIBLE
d. Obtain 2 measures in each arm then record average as the BRACHIAL PRESSURE
§ PERIPHERAL ARTERIAL DISEASE (PAD) – stenotic, occlusive, aneurysmal dis of the aorta, its visceral arterial
4. Measure systolic pressures in ANKLES
branches, and the arteries of the lower extremities, EXCLUSIVE of the coronary arteries
§ Age at risk = 50yrs or older and those w/ risk factors a. (same procedure as above)
7. Ask the following before starting the examination. b. Use dorsalis pedis pulse
GENERAL SURVEY RATIONALE/ SIGNIFICANT FINDINGS c. Repeat for post. Tibial arteries

Ask about: Interpretation:

§ Abdominal, flank or back pain? (esp in older ⇒ Abdominal Aortic Aneurysm (AAA)- expanding >0.90 (0.90-1.30) = NORMAL lower extremity blood flow
smokers) hematoma may cause s/sx by compression of the bowel, aortic
<0.89 - >0.60 = mild PAD
§ Constipation? branches or ureters
<0.59 - >0.40 = moderate PAD
§ Distention? <0.39 = severe PAD
§ Urinary retention? Diff voiding? Renal colic?
Ask about:
§ Pain or cramping in the legs DURING ⇒ sx limb ischemia w/ exertion
exertion, relieved by rest w/in 10mins = ⇒ pain w/ walking or prolonged standing, radiating from the
INTERMITTENT CLAUDICATION spinal area into the buttocks, thighs or lower legs/feet
ARMS PALPATION RATIONALE/ SIGNIFICANT FINDINGS
INSPECTION RATIONALE/ SIGNIFICANT FINDINGS THE INGUINAL LN
BOTH arms from fingertips to shoulders. Note the ff: § Superficial inguinal nodes
• Size, symmetry, any swelling § lymphedema of arm and hand § Note size, consistency, discreteness, ⇒ Lymphadenopathy = enlargement of the nodes, WITH OR
• Venous pattern § Venous obstruction = prominent veins in an edematous arm tenderness? WITHOUT tenderness
• Color of skin and nail beds, texture of skin § Raynaud’s disease = wrist pulses: NORMAL, sharply § Non- tender, discrete, up to 1cm-2cm are
demarcated pallor of fingers frequently palpable in NORMAL people
Femoral pulse
PALPATION RATIONALE/ SIGNIFICANT FINDINGS § press deeply below the inguinal lig., and § Partial or complete proximal occlusion = diminished or absent
about midway between the ASIS and symphysis pubis FEMORAL pulse
• Palpate RADIAL PULSE
§ Chronic arterial occlusion = from atherosclerosis, cause
• Feel for BRACHIAL PULSE (if you suspect arterial
§ Aortic insufficiency = bounding carotid, radial, and femoral intermittent claudication
insuff)
pulses § Femoral aneurysm = exaggerated, widened femoral pulse
◦ Feel for epitrochlear nodes
§ Arterial occlusion = asymmetric diminished pulses Popliteal pulse § Popliteal artery aneurysm = exaggerated, widened popliteal
◦ These nodes are difficult or impossible to
identify in most normal people § px knee slightly flexed, legs relaxed pulse
§ if it cannot be felt, try w/ the px prone § Arteriosclerosis obliterans = most commonly obstructs arterial
GRADING OF PULSES circulation in the thigh—
◦ Femoral pulse: NORMAL
GRADE DESCRIPTION
◦ Popliteal pulse: DECREASED or ABSENT
3+ BOUNDING
Dorsalis pedis pulse § absent pedal pulses w/ normal femoral & popliteal pulses
2+ BRISK, EXPECTED (NORMAL)
§ dorsum of foot just lateral to the extensor tendon
1+ DIMINISHED, WEAKER THAN EXPECTED of the big toe
0 ABSENT, UANBLE TO PALPATE Posterior Tibial artery § Sudden arterial occlusion = pain, numbness or tingling. The
§ curve fingers behind and slightly below the medial limb distal to the occlusion becomes cold, pale and pulseless
LEGS malleolus ◦ EMERGENCY TX REQUIRED!
INSPECTION RATIONALE/ SIGNIFICANT FINDINGS
BOTH LEGS from the groin—buttocks—feet. Note the
ff: § Cellulitis- warmth and redness over calf
EXAMINATION OF THE PERIPHERAL VEINS
INSPECTION RATIONALE/ SIGNIFICANT FINDINGS
• Size, symmetry, swelling
• Venous pattern, venous enlargement • Look for edema
• pitting edema (use thumb, at least 2 seconds) § Bilateral edema = present in heart failure, cirrhosis, nephrotic
• Pigmentation, rashes, scars, ulcers
ü over dorsum of each foot syndrome
• Color and texture of the skin, nail beds distribution
ü behind each medial malleolus § Deep iliofemoral thrombosis = painful, pale swollen leg, with
of hair on the lower ex
ü over the shins tenderness in the groin over femoral vein
• Temp of feet and legs (use back of fingers)
• swelling: unilateral or bilateral? § Chronic venous insufficiency = brownish discoloration or ulcers
• Venous tenderness that may accompany DVT? just above the medial malleolus
• Color of skin § Varicose veins = dilated and tortuous, thickened walls
• Redness? o Brownish areas near the ankles? o §
Ulcers?
MEASURING EDEMA Mapping of Varicose Veins
1. With the use of flexible tape, measure the: • Px standing, place palpating fingers gently on a
a. Forefoot vein, w/ the other hand below it and compress the
b. The smallest possible circumference above the ankle. vein sharply
c. The largest circumference at the calf.
◦ Feel for a pressure wave
d. The mid- thigh
◦ A palpable pressure wave indicates that
2. A difference of more than 1cm just above the ankle or 2 cm at the calfs’ unusual in normal people and suggest edema.
2 parts are connected
Possible causes of edema in PVS: EVALUATING THE COMPETENCY OF VENOUS VALVES
1. Recent DVT TRENDELENBURG TEST (retrograde filling)
2. Chronic venous insufficiency from previous thrombosis or incompetence of the valves - Can assess valvular competency in both the
3. Lymphedema communication veins and the saphenous system
• Px supine ü Incompetent valves in COMMUNICATING ARTERIES= rapid
• Elevate one leg to about 90 deg to empty it of filling of the superficial veins while the saphenous vein is
venous blood occluded
SPECIAL TECHNIQUES • Occlude the great saphenous vein in the upper ü Incompetent valves in the SAPHENOUS VEIN = sudden
TEST RATIONALE/ SIGNIFICANT FINDINGS thigh additional filling after release of compression
ALLEN’S TEST • Ask the px to stand
• Ensure patency of the ulnar artery before § Acute Embolic occlusion, Buergers’ dse, Thromboangiitis • NORMALLY: saphenous vein fills FROM BELOW
puncturing the radial artery for blood sample obliterans- absent or diminished wrist pulses (about 35 sec)
collection § Arterial insufficiency = marked pallor on elevation in allen test • After px stands for 20sec, release compression
• Ask px to make a fist with one hand and look for sudden additional venous filling =
• Compress both radial and ulnar arteries firmly NORMALLY THERE IS NONE
• Ask px to open hand into a relaxed, slightly flexed
position
• PALM IS PALE
• Release pressure over ULNAR artery
• If the ulnar artery is patent, PALM FLUSHES
WITHIN about 3 to 5 SECONDS
POSTURAL COLOR CHANGES OF CHRONIC ARTERIAL
INSUFFICIENCY
• Raise legs to about 60 degrees until maximal
pallor of the feet develops (w/in 1 min)
• Ask px to sit up w/ legs dangling down, compare
both feet:
◦ Return of pinkness of skin (N= 10 sec
or less)
◦ Filling of veins of the feet and ankles (N
= 15 seconds)
• Look for any unusual rubor (dusky redness) =
persistence means art. insufficiency
 §
COMPLETE EXAMINATION OF THE MSK Warmth. Use the backs of your fingers to compare the involved joint with its unaffected contralateral joint, or with nearby
tissues if both joints are involved.
seffcausapinmd™ - Warmness may indicate Arthritis, tendinitis, bursitis, osteomyelitis
§ Tenderness. Try to identify the specific anatomic structure that is tender. Trauma may also cause tenderness.
There are several points to remember prior to beginning the MSK examination. These include: - Tenderness and warmth over a thickened synovium may suggest arthritis or infection.
• Inspection for joint symmetry, alignment, bony deformities § Redness. Redness of the overlying skin is the least common sign of inflammation near the joints.
- Redness over a tender joint suggests septic or gouty arthritis, or possibly rheumatoid arthritis.
• Inspection and palpation of surrounding tissues for skin changes, nodules, muscle atrophy, crepitus
• Range of motion and maneuvers to test joint function and stability, integrity of ligaments, tendons, bursae,
especially if pain or trauma
• Assessment of inflammation or arthritis, especially swelling, warmth, tenderness, redness
TEMPOROMANDIBULAR JOINT
TECHNIQUES ASSESS REPORT/ NOTE
• Initial survey of the patient you have assessed general appearance, body proportions, and ease of movement
• It should include inspection, palpation of bony landmarks as well as related joint and soft-tissue structures, Inspection Symmetry Symmetrical
assessment of range of motion, and special maneuvers to test specific movements. Swelling, redness Swelling, redness
INSPECTION Palpate Joint Swelling, tenderness, crepitus/clicking
§ Symmetry Muscles of mastication – masseter, temporalis, Pain, tenderness
- Acute involvement of only one joint suggests trauma, septic arthritis, gout. pterygoid (external, internal)
- Rheumatoid arthritis typically involves several joints, symmetrically distributed. ROM Open/close mouth Full range of motion/
§ Joint deformities or mal- alignment of bones Protrusion/retraction Limited range of motion
- Dupuytren’s contracture sides
- bowlegs or knock-knees
§ Use inspection and palpation to assess the surrounding tissues, noting skin changes, subcutaneous nodules, and muscle SHOULDER
atrophy.
- Subcutaneous nodules in rheumatoid arthritis or rheumatic fever; effusions in trauma; crepitus over inflamed joints, in TECHNIQUES ASSESS REPORT/ NOTE
osteoarthritis, or inflamed tendon sheaths Inspection Shoulder girdle, scapula Symmetry, deformity, unusual contours
§ Note any crepitus, an audible and/or palpable crunching during movement of tendons or ligaments over bone. This may Swelling, redness, abnormal discoloration
occur in normal joints but is more significant when associated with symptoms or signs. Muscle atrophy, fasciculations
§ Testing range of motion and maneuvers Joint capsule Swelling, Bulging in the subacromial bursa
- may demonstrate limitations in range of motion or increased mobility and joint instability from excess mobility of joint Palpate Bony landmarks tenderness
ligaments, called ligamentous laxity. Acromion
- Decreased range of motion in arthritis, inflammation of tissues around a joint, fibrosis in or around a joint, or bony fixation Coracoid process of the scapula
(ankylosis). Ligamentous laxity of the ACL in knee trauma Greater tubercle
§ Testing muscle strength may aid in the assessment of joint function Subacromial bursae, subdeltoid bursae
- Muscle atrophy or weakness in rheumatoid arthritis Sits muscles (lift elbow posteriorly – extend)
Fibrous articular capsule Tenderness, effusion
Be especially alert to signs of inflammation and arthritis.
Tendons of rotator cuff
§ Swelling. Palpable swelling may involve:
1. the synovial membrane, which can feel boggy or doughy ROM Flexion – infront and upward Full range of motion/
2. effusion from excess synovial fluid within the joint space Extension – raise behind (back) Limited range of motion
Abduction – out to the side and overhead
3. soft-tissue structures such as bursae, tendons, and tendon sheaths.
Adduction – cross in front of body
- Palpable bogginess or doughiness of the synovial membrane indicates synovitis, which is often accompanied by effusion.
Internal rotation – behind back & touch
- Palpable joint fluid in effusion, tenderness over the tendon sheaths in tendinitis
shoulder blade
 External rotation – “behind head (brushing Flexion (fist with thumb across)
hair) Extension – open hand
Maneuvers Crossover test (acromioclavicular joint) Adduction and abduction _ spread and
Apley Scratch Test (external rotate-overhead, back together
touch scapula, internal rotate –back, touch Thumb:
scapula) Flex
Neer’s Impingement test Positive/negative Extend
Hawkin’s impingement sign +/- Abduction
Supraspinatus strength (empty can test) Weakness Adduction
Infraspinatus strength Weakness opposition
Forearm supination +/-
Drop arm sign +/-
SPINE
WRIST TECHNIQUES ASSESS REPORT/ NOTE
Inspection Posture
TECHNIQUES ASSESS REPORT/ NOTE
Erect position of head, smooth
Inspection Position of hands in motion Smooth- natural movements
coordinated neck movement
Finger alignment Ease of gait
Palmar and dorsal surface of wrist Swelling over joints Standing: deviations scoliosis, kyphosis
Deformities (wrist finger bones, hand) Skin markings, skin tags
contractures Palpate Spinous processes Tenderness
Contour of the thenar and hypothenar Atrophy Facet joints c2-c7 lateral
eminences Lumbar spinous processes Step offs
Palpate Distal radius and ulna Swelling, bogginess, tenderness Sacroiliac area (dimple) tenderness
groove of the wrist joints Paravertebral muscles Tenderness and spasm
Anatomical snuffbox tenderness Sciatic nerve (hip flexed and lie to other tenderness
Carpals, metacarpals and phalanges tenderess side
Squeeze mcps Swelling, bogginess tenderness ROM Neck Tenderness/pain
PIP and DIP joints Nodules, tenderness Flex, extend, rotate, lateral bending Impairment of movement
ROM Flexion Limitation to range of motion
Extension Full range of motion/no impairment in
Adduction the range of motion of the wrist HIP
Abduction TECHNIQUES ASSESS REPORT/ NOTE
Maneuvers Hand grip strength (patient will grasp) weakness Inspection Gait
Thumb movement (finkelstein test) Pain + - stance
Carpal tunnel - swing
Thumb abduction (with resistance) weakness Observe position for lordosis lordosis
Tinel’s sign (median nerve aching, numbing Anterior and posterior surfaces of the atrophy
compression) numbness, tingling hip
Phalen’s sign Palpate Bony landmarks:
Fingers: Iliac crest
Asis
 Greater trochanter -lateral collateral ligament
Symphysis pubis Patellofemoral compartment
Psis - patella
Ischial tuberosity -patellar tendon
Sacroiliac joint – not palpable -tibial tuberosity
Inguinal ligament Tenderness, enlargement of lymph Patello femoral grinding test Pain, crepitus
Femoral nerve, artery, vein lymph node nodes Suprapatellar pouch Swelling, effusion
Trochanteric bursa Prepatellar bursa over the anserine
Ischiogluteal bursa – not palpable bursa
ROM Flexion Palpation for effusion
Extension Bulge sign
Adduction Balloon sign
Abduction Balloting the patella
External rotation Gastrocnemius and soleus
Internal rotation Achilles tendon - palpate Tenderness, swelling
Maneuvers Flexion – with hand at lumbar spine Flexion deformity of the hip Integrity of achilles tendon: Grasp calf Normal- with plantar flexion
Extension muscles – note for plantar flexion
Abduction ROM Flexion
Adduction Extension
External and internal rotation Internal rotation
External rotation
KNEE Maneuvers Medial and lateral meniscus: Clicking, tenderness
McMurray test
Abduction (valgus) stress test -mcl Pain, gap
TECHNIQUES ASSESS REPORT/ NOTE Adduction (varus) stress test - lcl Pain, gap
Inspection Gait Smooth rhythmic flow Anterior and posterior drawer sign –
Alignment and contours of knee Aligned, contours ACL,PCL
Atrophy of the quadriceps muscles atrophy Lachman test
Swelling around the knee swelling

Palpate Tibiofemoral joint Tenderness, swelling, effusion ANKLE AND FOOT

Irregular bony ridges TECHNIQUES ASSESS REPORT/ NOTE
Medial meniscus tenderness Inspection Surfaces Swelling, deformity, nodules, calluses,
Lateral meniscus corns
Medial joint compartment Palpate Anterior ankle Swelling, tenderness, bogginess
- medial femoral condyle Achilles tendon Nodules and tenderness
- Adductor tubercle Heel tenderness
- medial tibial plateau
Metatarsophalangeal joint tenderness
-medial collateral ligament
Metatarsals and groovees tenderness
Lateral joint compartment
ROM Dorsiflexion (ankle extension)
- lateral femoral condyle
Plantar flexion
- lateral tibial plateau
 Inversion
eversion
Maneuvers Ankle (tibiotalar) joint
Dorsiflex and plantar flex
Subtalar (talocalcaneal) joint
Invert and evert foot – stabilize ankle
Transverse tarsal joint
Stabilize heel – invert and evert forefoot
Metatarsophalangeal joint
Flex toes in relation to the feet

Special Techniques
Measuring the length of the legs
Describing limited motion of joint – degree of movement