Abdominal PA Lecture Notes PDF

ABDOMEN Questions to Ask in History Taking When assessing a patient's past medical history (PMH) related to the abdomen, it is essential to gather detailed information to understand potential underlying conditions. Here are some key questions and points to cover: 1. Hepatitis, Cirrhosis, Gallbladder Problems, Pancreatitis: ○ Have you ever been diagnosed with hepatitis? ○ Do you have a history of cirrhosis? ○ Have you had any gallbladder problems or gallstones? ○ Have you experienced pancreatitis? 2. Any Prior Abdominal Surgeries: ○ Have you ever had any surgeries on your abdomen? If so, what kind and when? 3. Recent Foreign Travel: ○ Have you traveled outside the country recently? If so, where and when? 4. Use of Alcohol/Drugs: ○ Do you consume alcohol? If so, how often and how much? ○ Do you use any recreational drugs? If so, what kind and how frequently? 5. Medications: ○ Are you currently taking any medications, including over-the-counter drugs and supplements? 6. Changes in Appetite: ○ Have you noticed any changes in your appetite recently? 7. Weight Gain/Loss: ○ Have you experienced any recent weight gain or loss? Was it intentional or unintentional? 8. Dysphagia: ○ Do you have any difficulty swallowing? 9. Food Intolerance: ○ Are there any foods that you cannot tolerate or that cause you discomfort? 10. Abdominal Pain: ○ Do you have any abdominal pain? If so, can you describe the pain (location, intensity, duration)? 11. Nausea/Vomiting: ○ Have you experienced any nausea or vomiting recently? 12. Bowel Habits: ○ Have there been any changes in your bowel habits (constipation, diarrhea, frequency, color, consistency)? 13. Heartburn/Reflux: ○ Do you experience heartburn or acid reflux? 14. Excessive Gas (Belching or Flatulence): ○ Do you have excessive gas, either belching or flatulence? Collecting this information can provide valuable insights into the patient's abdominal health and guide further diagnostic and treatment plans. Terminology of Upper GI Tract When discussing or documenting conditions and symptoms related to the upper gastrointestinal (GI) tract, it is important to use precise medical terminology. Here are key terms and their definitions, along with pertinent questions to ask patients experiencing these symptoms: 1. Anorexia: ○ Definition: Lack of appetite. ○ Questions: Have you noticed a decrease in your appetite? When did you first notice this change? 2. Early Satiety: ○ Definition: Feeling full early during a meal or general abdominal fullness. ○ Questions: Do you feel full sooner than usual when eating? How quickly do you feel full after starting a meal? 3. Dysphagia: ○ Definition: Difficulty swallowing. ○ Questions: Do you have trouble swallowing food or liquids? Is it painful or does it feel like food is getting stuck? 4. Odynophagia: ○ Definition: Pain with swallowing. ○ Questions: Do you experience pain when swallowing? Where is the pain located? 5. Regurgitation: ○ Definition: The reflux of food and stomach acid back into the mouth, often with a brine-like taste. ○ Questions: Do you experience a sour or brine-like taste in your mouth? Does food or acid come back up into your mouth? 6. Retching: ○ Definition: Spasmodic movement of the chest and diaphragm like vomiting, but no stomach contents are passed. ○ Questions: Do you experience dry heaving or retching without actually vomiting? 7. Emesis: ○ Definition: Vomiting. ○ Questions: How often are you vomiting, and in what quantity? Can you describe the type of vomit? Is it food, green or yellow bile, mucus, blood, or coffee-ground-like? 8. Hematemesis: ○ Definition: Vomiting of frank blood (upper GI; esophagus) or coffee ground (digested blood) emesis. ○ Questions: Have you vomited blood or material that looks like coffee grounds? When a patient presents with vomiting, it is critical to ask about the quantity and frequency, as well as the type of vomit to assess the severity and possible causes: Quantity and Frequency: ○ How much are you vomiting? ○ How often does it occur? Type of Vomit: ○ Is the vomit primarily food? ○ Is it green or yellow, indicating bile? ○ Is there mucus present? ○ Is there blood (hematemesis) or does it look like coffee grounds? By using this terminology and asking these specific questions, healthcare providers can gather comprehensive and accurate information to diagnose and treat conditions related to the upper GI tract effectively. 4o Termninology Lower GI Here are the terminologies for Lower GI: Diarrhea: Soft or watery stool. Constipation: Hard stool, difficult to pass. Hematochezia: Fresh (bright red) blood (usually per anus) in stool. Melena: Black or tarry looking stools, usually with a foul smell – usually due to upper GI bleed. Acholic: Term used to describe white/light/grey colored stool due to lack of bile resulting from liver/gallbladder diseases. Let me know if you need further information or additional terms! Abdominal Pain- Visceral Abdominal Pain – Visceral Visceral Pain Characteristics: Description: Visceral pain is typically gnawing, cramping, or aching. Localization: This type of pain is often difficult to pinpoint to a specific location. Causes of Visceral Pain: 1. Hollow Organs: ○ Examples: Stomach, colon. ○ Mechanism: Pain occurs when these organs forcefully contract or become distended. 2. Solid Organs: ○ Examples: Liver, spleen. ○ Mechanism: Pain occurs when these organs swell against their capsules. Abdominal Pain- Parietal ChatGPT Abdominal Pain – Parietal Parietal Pain Characteristics: Description: Parietal pain is more severe compared to visceral pain. Localization: This type of pain is usually easily localized, such as in cases of appendicitis. Causes of Parietal Pain: Mechanism: Parietal pain occurs when there is inflammation from the hollow or solid organs that affects the parietal peritoneum. Abdominal Pain- Referred Abdominal Pain – Referred Referred Pain Characteristics: Description: Referred pain originates at different sites but shares innervation from the same spinal level. Example: Gallbladder pain felt in the shoulder. Mechanism: When a person reports abdominal pain, the location of the pain may not necessarily be directly over the involved organ. This is due to shared neural pathways between the involved organ and other parts of the body. General Preparation General Preparation for Abdominal Examination 1. Room and Environment: ○ Ensure the room is warm. ○ Good lighting is essential for a thorough examination. 2. Patient Preparation: ○ Ensure the patient's bladder is empty. ○ Position the patient supine with knees bent and arms at their sides or folded over their chest. 3. Tools and Examiner Preparation: ○ Warm the stethoscope before use. ○ Keep fingernails short to avoid discomfort for the patient. 4. Pain Consideration: ○ Ask the patient to point to any areas of pain and examine those areas last. 5. Order of Examination: ○ Inspection ○ Auscultation ○ Percussion ○ Palpation This order is different to prevent altering bowel sounds, which could affect the accuracy of the examination. Inspection Abdominal Inspection 1. Demeanor: ○ Observe the patient's overall demeanor and behavior for signs of discomfort or distress. 2. Contour: ○ Assess the shape of the abdomen: Flat Rounded Protuberant Scaphoid (markedly concave) ○ Check for symmetry of the abdomen. 3. Skin: ○ Look for any scars, rashes, or lesions on the skin. 4. Hair Distribution: ○ Observe the pattern and distribution of hair on the abdomen. 5. Pulsation or Movement: ○ Look for visible pulsations or movements: An aortic pulse in the epigastric region is normal. An increased amplitude of the aortic pulse may indicate an aneurysm. 6. Umbilicus: ○ Check for any obvious bulging, which could indicate an umbilical hernia. ○ Note any signs of inflammation around the umbilicus. 4o Abnormal- Umbilical Hernia Abnormal Finding: Umbilical Hernia Risk Factors for Umbilical Hernia: 1. Infancy: ○ Common in newborns, especially those born prematurely. 2. Obesity: ○ Increased abdominal pressure due to excess weight can lead to herniation. 3. Multiple Pregnancies: ○ Repeated stretching and increased abdominal pressure during pregnancy. 4. Chronic Cough or Chronic Constipation: ○ Persistent coughing or straining can increase intra-abdominal pressure. 5. Previous Abdominal Surgery: ○ Surgical incisions can weaken the abdominal wall, predisposing to hernias. 6. Ascites: ○ Accumulation of fluid in the abdomen, increasing pressure. 7. Heavy Lifting: ○ Frequent lifting of heavy objects can increase intra-abdominal pressure. 8. Aging: ○ Decreased muscle tone and weakening of abdominal muscles with age. Incisional Hernnia ncisional Hernia Description: An incisional hernia occurs at the site of a previous surgical incision in the abdominal wall. This type of hernia can develop when the abdominal muscles weaken or fail to heal properly after surgery, allowing abdominal contents to protrude through the weakened area. Risk Factors for Incisional Hernia: 1. Previous Abdominal Surgery: ○ Any prior surgical incision in the abdominal wall increases the risk. 2. Obesity: ○ Excess weight puts additional strain on the healing incision site. 3. Infection at Surgical Site: ○ Infections can impair healing and weaken the surgical wound. 4. Poor Wound Healing: ○ Factors such as diabetes, smoking, or poor nutrition can impede proper healing. 5. Excessive Physical Activity Post-Surgery: ○ Strenuous activities or heavy lifting too soon after surgery can disrupt healing. 6. Chronic Coughing or Sneezing: ○ Persistent coughing or sneezing can increase intra-abdominal pressure, stressing the surgical site. 7. Age: ○ Older adults may have weaker abdominal muscles and slower healing processes. 8. Multiple Surgeries: ○ Repeated surgeries at the same site can weaken the abdominal wall further. 9. Malnutrition: ○ Poor nutritional status can impair wound healing and strength. 10. Use of Steroids: ○ Long-term steroid use can weaken tissues and delay healing. Understanding these risk factors can help in the prevention and early detection of incisional hernias, especially in patients who have undergone abdominal surgery. 4o Auscultate Bowel Sounds Auscultation of the Abdomen Using the Diaphragm of the Stethoscope: Start: Begin in the Right Lower Quadrant (RLQ) at the ileocecal valve. Character and Frequency of Bowel Sounds: Normoactive: 5-30 sounds per minute (clicks or gurgles). Hyperactive: Loud, high-pitched sounds (common with diarrhea). Hypoactive: Infrequent bowel sounds (common after recent abdominal surgery or with paralytic ileus). Absent: ○ To declare absent bowel sounds, listen for a full 2-5 minutes without hearing any sounds. Specific Terms: Borborygmi: Prolonged gurgling or rumbling sound, commonly known as stomach growling. Summary of Steps: 1. Preparation: Use the diaphragm of the stethoscope. 2. Starting Point: Begin auscultation in the RLQ. 3. Listening for Bowel Sounds: ○ Count and characterize the sounds. ○ Normoactive: 5-30 sounds/minute. ○ Hyperactive: Loud, high-pitched sounds. ○ Hypoactive: Infrequent sounds. ○ Absent: Listen for a full 2-5 minutes if no sounds are heard. 4. Document Findings: Note the character and frequency of the bowel sounds, and any specific observations like borborygmi (stomach growling sound) Auscultate Vascular Sounds Auscultation of Vascular Sounds Using the Bell of the Stethoscope: Purpose: Listen for bruits, which are abnormal vascular sounds indicating turbulent blood flow. Areas to Auscultate: 1. Aorta: ○ Location: Midline, slightly above the umbilicus. 2. Renal Arteries: ○ Left and right renal arteries. ○ Location: Approximately 2-3 cm above and to the sides of the umbilicus. 3. Iliac Arteries: ○ Left and right iliac arteries. ○ Location: About 2-3 cm below and to the sides of the umbilicus. 4. Femoral Arteries: ○ Left and right femoral arteries. ○ Location: In the groin region, at the midpoint between the anterior superior iliac spine and the pubic symphysis. Steps for Auscultation: 1. Preparation: Use the bell of the stethoscope for better detection of low-pitched sounds like bruits. 2. Listening Points: ○ Aorta: Place the bell slightly above the umbilicus. ○ Renal Arteries: Place the bell 2-3 cm above and lateral to the umbilicus on both sides. ○ Iliac Arteries: Place the bell 2-3 cm below and lateral to the umbilicus on both sides. ○ Femoral Arteries: Place the bell in the groin area. 3. Detection: ○ Listen for any abnormal sounds such as bruits, which may indicate narrowing or blockage of the arteries. By systematically auscultating these areas, you can effectively assess for vascular abnormalities in the abdomen. Percuss for Tympany/Dullness Percussion of the Abdomen Objective: Assess for tympany and dullness to evaluate the presence of gas, fluids, and masses within the abdomen. Procedure: 1. Percussion Technique: ○ Use a zig-zag approach to percuss all four quadrants of the abdomen. 2. Expected Findings: ○ Tympany: This should predominate due to the presence of gas within the gastrointestinal tract. 3. Abnormal Findings: ○ Dullness: Note any large areas of dullness, which may indicate the presence of: Mass or Enlarged Organ: Possible organomegaly or abdominal mass. Fluid: Ascites or other fluid accumulation. Feces: Significant accumulation of fecal matter. Fetus: In cases of pregnancy. Fibroid: Uterine fibroids or other solid masses. Steps for Percussion: 1. Preparation: ○ Ensure the patient is in a supine position. ○ Explain the procedure to the patient. 2. Performing Percussion: ○ Use your fingers to tap on the abdomen in a zig-zag pattern across all four quadrants. ○ Listen for the sounds produced: Tympany: A hollow, drum-like sound indicating the presence of gas. Dullness: A thud-like sound indicating the presence of a solid mass, fluid, or other dense material. 3. Documentation: ○ Note the predominant sound (tympany). ○ Record any large areas of dullness and consider potential causes (mass, fluid, feces, fetus, fibroid). By systematically percussing the abdomen, you can gather important information about the underlying structures and potential abnormalities. 4o Percussion Signs Percussion Signs Ascites (Fluid in the Abdomen) Techniques to Assess for Ascites: 1. Shifting Dullness: ○ Procedure: With the patient in a supine position, percuss from the midline laterally to detect the transition from tympany (air) to dullness (fluid). Mark the area where the sound changes from tympanic to dull. Have the patient roll to one side. Percuss again from the midline to the lateral side. Positive Sign: If the area of dullness shifts to the dependent side and the area of tympany shifts to the top, this suggests the presence of free fluid (ascites). 2. Fluid Wave: ○ Procedure: Have the patient or an assistant press the edge of their hand firmly down the midline of the abdomen to stop the transmission of the wave through the fat. Place one hand on one side of the abdomen and tap with the other hand on the opposite side. Positive Sign: If a fluid wave is felt by the receiving hand, this suggests the presence of ascites. 3. Bulging Flanks: ○ Observation: Observe the patient in a supine position. Positive Sign: The flanks may appear full or bulging, indicating the presence of ascites. Ovarian Mass Techniques to Assess for Ovarian Mass: 1. Localized Dullness: ○ Procedure: Percuss the lower abdomen and pelvic region. Positive Sign: Localized areas of dullness can indicate the presence of a mass, such as an ovarian mass. 2. Distinguishing from Ascites: ○ Procedure: Unlike ascites, an ovarian mass typically does not cause shifting dullness. The dullness remains in a fixed location regardless of the patient's position. Observation: No shifting dullness with changes in position, which helps distinguish it from free fluid. Summary Ascites: ○ Assess using shifting dullness, fluid wave, and observing for bulging flanks. ○ Positive signs include shifting dullness when the patient changes position and the presence of a fluid wave. Ovarian Mass: ○ Assess for localized dullness in the lower abdomen and pelvic region. ○ The dullness does not shift with changes in position, helping to differentiate it from ascites. These techniques can help identify the presence of fluid in the abdomen or an ovarian mass, aiding in the diagnosis and management of abdominal conditions. Percussion Signs Percussion Signs Feces Techniques to Assess for Fecal Impaction: 1. Localized Dullness: ○ Procedure: Percuss the lower abdomen, particularly in the areas corresponding to the colon. Positive Sign: Localized dullness in the regions of the colon, particularly the sigmoid colon, can indicate the presence of fecal matter. 2. Palpation Correlation: ○ Procedure: Following percussion, palpate the area of dullness. Positive Sign: A firm, non-tender mass may be felt, correlating with the percussion findings of feces. Pregnancy Techniques to Assess for Pregnancy: 1. Generalized Dullness: ○ Procedure: Percuss the lower abdomen and pelvic region. Positive Sign: Generalized dullness in the lower abdomen, corresponding to the enlarged uterus, can indicate pregnancy. 2. Abdominal Contour: ○ Observation: Note the shape and contour of the abdomen. Positive Sign: The abdomen may appear protuberant, and dullness will be more pronounced as the uterus enlarges. 3. Fetal Movement: ○ Observation: In later stages of pregnancy, fetal movements may be observed or felt during palpation. Positive Sign: Visible or palpable movements correlate with the percussion findings of generalized dullness. Summary Feces: ○ Assess for localized dullness, particularly in the lower abdomen and sigmoid colon area. ○ Palpate the area of dullness to confirm the presence of a firm, non-tender mass indicating fecal matter. Pregnancy: ○ Assess for generalized dullness in the lower abdomen and pelvic region. ○ Observe the abdominal contour for protuberance. ○ In later stages, look for visible or palpable fetal movements to support the diagnosis of pregnancy. These percussion signs help differentiate between fecal impaction and pregnancy, aiding in the appropriate clinical management. Percussion of Liver Percussion of Liver Span Objective: Measure the span of the liver to assess for hepatomegaly (enlarged liver) or other abnormalities. Procedure: 1. Right Midclavicular Line (MCL): ○ Starting Point (Upper Border): Begin percussion in an area of lung resonance at the right midclavicular line. Percuss downward until you hear a change from resonance to dullness. Draw a mark at the point of dullness (this marks the upper border of the liver). ○ Starting Point (Lower Border): Begin percussion from the area of abdominal tympany at the right midclavicular line. Percuss upward until you hear a change from tympany to dullness. Draw a mark at the point of dullness (this marks the lower border of the liver). ○ Measurement: Measure the distance between the two marks. Normal Liver Span at the Right Midclavicular Line: 6-12 cm. 2. Sternal Line: ○ Upper Border: Percuss down from an area of resonance over the sternum until you detect dullness. Draw a mark at the upper border of the dullness. ○ Lower Border: Percuss up from the area of abdominal tympany until dullness is noted. Draw a mark at the lower border of the dullness. ○ Measurement: Measure the distance between the two marks. Normal Liver Span at the Sternal Line: 4-8 cm. Summary of Steps: 1. Right Midclavicular Line (MCL): ○ Percuss downward from lung resonance to dullness (upper border). ○ Percuss upward from abdominal tympany to dullness (lower border). ○ Measure and record the span (normal: 6-12 cm). 2. Sternal Line: ○ Percuss downward from resonance over the sternum to dullness (upper border). ○ Percuss upward from abdominal tympany to dullness (lower border). ○ Measure and record the span (normal: 4-8 cm). These steps help in accurately assessing the liver span, which is crucial for diagnosing liver enlargement or other hepatic conditions. Liver Scratch Test Liver Scratch Test Purpose: The liver scratch test is used to help define the liver borders, particularly when the abdomen is distended or the abdominal muscles are tense, making traditional percussion challenging. Procedure: 1. Positioning: ○ Place the diaphragm of the stethoscope over the liver area, typically starting at the right midclavicular line below the expected liver border. 2. Starting Point: ○ Begin in the Right Lower Quadrant (RLQ). 3. Performing the Test: ○ Use the fingertip to gently scratch the skin starting in the RLQ. ○ Slowly move the scratching finger upward toward the liver. 4. Listening for the Liver Edge: ○ Listen through the stethoscope for changes in sound. ○ Magnified Sound: When the sound of scratching becomes magnified, you have crossed from a hollow organ (such as the intestines) to a solid organ (the liver edge). 5. Marking the Liver Edge: ○ Note the point where the sound amplification occurs, which indicates the liver edge. Summary of Steps: 1. Preparation: ○ Place the stethoscope over the area where the liver is expected. 2. Starting Point: ○ Begin scratching in the RLQ with the fingertip. 3. Procedure: ○ Move the scratching finger slowly upward towards the liver. ○ Listen for a change in sound amplification through the stethoscope. 4. Identification: ○ When the sound becomes magnified, mark the liver edge. This technique can be particularly useful when traditional percussion methods are not feasible, providing an alternative way to delineate the liver borders accurately. Percussion of the Spleen Percussion of the Spleen Objective: To assess for splenomegaly (enlarged spleen) using percussion. Procedure: 1. Initial Percussion: ○ Position: Locate the left anterior axillary line. ○ Lowest Interspace: Find the lowest intercostal space at the left anterior axillary line. ○ Percuss: Percuss this area, noting the sound. ○ Normal Finding: Tympany (a hollow, drum-like sound) is expected. 2. Percussion with Deep Inspiration: ○ Patient Instruction: Ask the patient to take a deep breath in and hold it. ○ Percuss Again: While the patient holds their breath, percuss the same area again. ○ Normal Finding: Tympany should still be present during deep inspiration. 3. Interpretation of Findings: ○ Positive Splenic Percussion Sign: If the sound changes from tympany to dullness during deep inspiration, this indicates a positive splenic percussion sign, suggesting splenomegaly. Summary of Steps: 1. Preparation: ○ Position the patient in a comfortable, supine position. ○ Locate the left anterior axillary line and the lowest intercostal space. 2. Initial Percussion: ○ Percuss the lowest interspace at the left anterior axillary line. ○ Note the sound (normally tympany). 3. Percussion with Deep Inspiration: ○ Instruct the patient to take a deep breath in and hold it. ○ Percuss the same area again while the patient holds their breath. ○ Note the sound (normally tympany). 4. Interpretation: ○ If the sound changes to dullness during deep inspiration, it indicates a positive splenic percussion sign, which may suggest splenomegaly. This technique helps in the clinical assessment of the spleen size and can indicate the need for further diagnostic evaluation if splenomegaly is suspected. 4o Percussion of the Kidney Percussion of the Kidneys Objective: To assess for costovertebral angle (CVA) tenderness, which may indicate a kidney infection or other renal issues. Procedure: 1. Locating the CVA: ○ Position: The CVA is located at the back, where the lower ribs meet the spine. ○ Patient Position: Have the patient sit or stand. 2. Assessing for Tenderness: ○ Fingertip Pressure: Place the fingertips over the CVA on one side. Apply firm pressure. Observation: Note any tenderness or pain reported by the patient. ○ Fist Percussion: Make a fist with one hand. Use the ulnar surface (the pinky side) of the fist to gently but firmly strike the CVA on one side. Observation: Note any tenderness or pain reported by the patient. 3. Interpretation of Findings: ○ Positive CVA Tenderness: Pain or tenderness elicited by fingertip pressure or fist percussion may suggest a kidney infection (pyelonephritis) or other renal pathology. ○ Differentiation: It's important to note that CVA tenderness can also be musculoskeletal in origin, especially if there's no accompanying symptoms of a urinary tract infection (e.g., fever, dysuria). Summary of Steps: 1. Preparation: ○ Position the patient appropriately (sitting or standing). 2. Locating the CVA: ○ Identify the area where the lower ribs meet the spine on the patient's back. 3. Assessing Tenderness: ○ Fingertip Pressure: Apply firm pressure with the fingertips over the CVA. Observe for any pain or tenderness. ○ Fist Percussion: Strike the CVA gently but firmly with the ulnar surface of the fist. Observe for any pain or tenderness. 4. Interpretation: ○ Positive CVA Tenderness: Indicates potential kidney infection or renal pathology. ○ Consider Differential Diagnosis: Musculoskeletal causes should be considered if there's no other symptoms of kidney infection. This assessment is a useful clinical tool for identifying potential renal issues that may require further investigation or treatment. Light Palpation in all 4 Quadrants Light Palpation in All 4 Quadrants Objective: To gently assess the superficial structures of the abdomen, identify any superficial organs or masses, and differentiate between voluntary and involuntary guarding. Procedure: 1. Preparation: ○ Visualization: Visualize the anatomical structures located in each quadrant before beginning palpation. 2. Technique: ○ Gentle Pressure: Start palpating the abdomen with gentle pressure to reassure and relax the patient. ○ Systematic Approach: Palpate all four quadrants (RLQ, RUQ, LUQ, LLQ). 3. Assessment: ○ Superficial Organs and Masses: Identify any superficial organs or masses during palpation. ○ Guarding: Voluntary Guarding: Conscious flinching or tensing of abdominal muscles. Involuntary Guarding: Uncontrolled muscle spasm, often indicating peritoneal irritation. 4. Relaxation Techniques: ○ For Voluntary Guarding: Conversation: Distract the patient by continuing to take their history during the examination. Hand Placement: Place the patient’s hand over yours or under yours with your fingers curled over while palpating. Breathing Instructions: Tell the patient to breathe out deeply. Tell the patient to breathe through their mouth with their jaw dropped open. 5. Tips for Ticklish Patients: ○ Distraction: Engage the patient in conversation to distract them. ○ Hand Placement: Place the patient’s hand over or under yours to provide a sense of control and reduce ticklishness. ○ Breathing Techniques: Encourage the patient to breathe out deeply to relax the abdominal muscles. Instruct the patient to breathe through their mouth with their jaw dropped open to further promote relaxation. Summary of Steps: 1. Preparation: ○ Visualize the underlying anatomical structures in each quadrant. 2. Technique: ○ Use gentle pressure to palpate all four quadrants systematically. 3. Assessment: ○ Identify any superficial organs or masses. ○ Differentiate between voluntary and involuntary guarding. 4. Relaxation Techniques: ○ Distract the patient, use proper hand placement, and guide their breathing to reduce voluntary guarding. 5. Ticklish Patients: ○ Distract the patient, use hand placement techniques, and guide breathing to manage ticklishness. This approach ensures a thorough and comfortable examination for the patient, allowing for the accurate identification of any superficial abnormalities. Generalized Deep Palpation Generalized Deep Palpation Objective: To assess deeper structures within the abdomen, identify masses or tenderness, and correlate findings with previous percussion notes. Procedure: 1. Preparation: ○ Patient Position: Ensure the patient is in a comfortable supine position with knees slightly bent to relax the abdominal muscles. 2. Technique: ○ Palpation Areas: Palpate deeply in the periumbilical area. Palpate deeply in both lower quadrants (RLQ and LLQ). ○ Bimanual Technique: Top Hand: Place one hand (the top hand) on the abdomen to apply pressure. Bottom Hand: Place the other hand (the bottom hand) underneath the top hand to feel for deep structures. The top hand does the pushing while the bottom hand does the feeling. 3. Assessment: ○ Rebound Tenderness: Apply deep pressure slowly to the abdomen and then release quickly. Positive Sign: If pain increases when pressure is released, this is indicative of rebound tenderness, which may suggest peritoneal irritation (e.g., appendicitis). ○ Correlation with Percussion: Correlate palpable findings (e.g., masses, tenderness) with previous percussion notes to confirm or further investigate abnormalities. Summary of Steps: 1. Preparation: ○ Ensure the patient is lying comfortably with knees slightly bent. 2. Technique: ○ Use the bimanual technique for deep palpation. ○ Palpate deeply in the periumbilical area and both lower quadrants. 3. Assessment: ○ Evaluate for rebound tenderness by applying and quickly releasing deep pressure. ○ Correlate findings with previous percussion notes to assess for consistency and identify any new or confirmed abnormalities. This deep palpation technique helps in the thorough assessment of deeper abdominal structures, aiding in the identification of significant clinical findings. Normally Palpable Structures Normally Palpable Structures During an abdominal examination, several structures may be normally palpable. These include: 1. Liver Edge: ○ Location: Right upper quadrant, just below the right costal margin. ○ Characteristics: The liver edge may be felt as smooth, firm, and slightly tender. It is usually palpable during deep inspiration. 2. Aorta: ○ Location: Midline, above the umbilicus. ○ Characteristics: The aorta can be felt as a pulsatile structure. It is generally about 2.5-3 cm wide in adults. 3. Right Kidney: ○ Location: Right flank, occasionally palpable in thin individuals. ○ Characteristics: The lower pole of the right kidney may be felt as a smooth, firm, rounded mass during deep inspiration. 4. Cecum and Ascending Colon: ○ Location: Right lower quadrant. ○ Characteristics: These structures may be felt as soft and compressible. 5. Sigmoid Colon: ○ Location: Left lower quadrant. ○ Characteristics: The sigmoid colon may be felt as a soft, tubular structure. 6. Bladder (if distended): ○ Location: Suprapubic area. ○ Characteristics: A distended bladder may be felt as a smooth, rounded, firm mass. Summary of Normally Palpable Structures: 1. Liver Edge: ○ Right upper quadrant. ○ Smooth, firm, slightly tender edge below the right costal margin during deep inspiration. 2. Aorta: ○ Midline, above the umbilicus. ○ Pulsatile structure, about 2.5-3 cm wide. 3. Right Kidney: ○ Right flank. ○ Smooth, firm, rounded mass during deep inspiration (more commonly palpable in thin individuals). 4. Cecum and Ascending Colon: ○ Right lower quadrant. ○ Soft and compressible structures. 5. Sigmoid Colon: ○ Left lower quadrant. ○ Soft, tubular structure. 6. Bladder (if distended): ○ Suprapubic area. ○ Smooth, rounded, firm mass. These palpable structures help clinicians assess the normal anatomy and identify any abnormalities during an abdominal examination. 4o Abdominal Tenderness Abdominal Tenderness Types of Abdominal Tenderness: 1. Voluntary Muscle Guarding: ○ Characteristics: Bilateral muscle tensing that is often due to being ticklish or feeling cold. ○ Behavior: This type of guarding will usually decrease with exhalation and relaxation techniques. ○ Management: Encourage the patient to breathe out deeply or distract them to reduce the guarding. 2. Involuntary Muscle Guarding (Rigidity): ○Characteristics: Constant, board-like hardness of the abdominal muscles. ○Cause: This is a protective mechanism associated with acute inflammation of the peritoneum (peritonitis). ○ Clinical Significance: Involuntary guarding indicates a serious underlying condition requiring immediate medical attention. 3. Rebound Tenderness: ○ Technique: Press fingers firmly and slowly into the abdomen. Quickly withdraw the fingers. ○ Positive Sign: Pain that occurs upon the withdrawal of pressure. ○ Indication: This finding suggests peritonitis, indicating acute inflammation of the peritoneum. Conditions Associated with Peritonitis: Causes of Peritonitis: ○ Infection: Bacterial infection following peritoneal dialysis, other intra-abdominal infections. ○ Inflammation: Conditions like pancreatitis. ○ Rupture: Appendicitis, ruptured colon, perforated peptic ulcer. Summary of Findings: 1. Voluntary Muscle Guarding: ○ Mostly bilateral. ○ Decreases with exhalation/relaxation. ○ Commonly due to being ticklish or feeling cold. 2. Involuntary Muscle Guarding (Rigidity): ○ Constant board-like hardness. ○ Indicates acute peritoneal inflammation (peritonitis). ○ Requires urgent medical evaluation. 3. Rebound Tenderness: ○ Pain on quick withdrawal of pressure. ○ Suggests peritonitis. Conditions that Can Cause Peritonitis: Appendicitis: Inflammation of the appendix that may lead to rupture. Ruptured Colon: Due to diverticulitis, trauma, or other conditions. Pancreatitis: Inflammation of the pancreas. Post-Peritoneal Dialysis: Bacterial infection following the procedure. Clinical Approach: Assess Guarding: ○ Distinguish between voluntary and involuntary guarding. Check for Rebound Tenderness: ○ Perform the maneuver carefully to identify rebound tenderness. Evaluate for Peritonitis: ○ Consider the patient's history and clinical presentation to determine the likelihood of peritonitis. Urgent Referral: ○ In cases of suspected peritonitis, arrange for immediate medical evaluation and intervention. Palpation of the Liver Palpation of the Liver Objective: To palpate the liver and assess its size and texture. Procedure: 1. Positioning: ○ Have the patient lie supine with their right knee slightly bent to relax the abdominal muscles. 2. Hand Placement: ○ Left Hand: Place your left hand under the patient's lower ribcage on the right side. Gently lift upwards to support the abdominal contents and bring the liver closer to the abdominal wall. ○ Right Hand: Place your right hand on the right upper quadrant (RUQ), just below the costal margin. Position your fingers so that they are pointing towards the patient's head. 3. Palpation Technique: ○ Instruct the patient to take a deep breath in. ○ As the patient inhales, press your right hand in and up under the ribcage. ○ Feel for the liver edge as it descends with the diaphragm during inspiration. 4. Assessment: ○ Normal Finding: The liver edge should be palpable less than 3 cm below the costal margin at the midclavicular line (MCL) with inspiration. ○ Hepatomegaly: If the liver edge is palpable more than 3 cm below the costal margin, this suggests hepatomegaly (enlarged liver). Summary of Steps: 1. Preparation: ○ Ensure the patient is lying comfortably with their right knee slightly bent. 2. Hand Placement: ○ Left hand under the lower rib cage to lift upwards. ○ Right hand on the RUQ, fingers pointing towards the head. 3. Palpation Technique: ○ Ask the patient to take a deep breath in. ○ Press your right hand in and up under the ribcage as the patient inhales. ○ Feel for the liver edge descending against your fingers. 4. Assessment: ○ Normal liver edge palpable less than 3 cm below the costal margin at the MCL with inspiration. ○ Liver edge palpable more than 3 cm below the costal margin indicates hepatomegaly. By following this method, you can effectively palpate the liver and determine if there is an enlargement, which may warrant further investigation or evaluation. Palpation of Liver- Hook Method Palpation of the Liver – Hook Method Objective: To palpate the liver using the hook method, especially useful in obese patients or when the liver edge is difficult to feel. Procedure: 1. Positioning: ○ Stand at the patient's right shoulder, facing their feet. ○ Ensure the patient is lying supine with their right knee slightly bent to relax the abdominal muscles. 2. Hand Placement and Technique: ○ Hooking Fingers: Place your fingers under the patient's right costal margin (ribcage). Use a hooking motion to position your fingers beneath the ribcage. ○ Patient Instruction: Instruct the patient to take a deep breath in. ○ Palpation: As the patient inhales deeply, feel for the liver edge as it descends and presses against your fingertips. 3. Assessment: ○ Normal Finding: The liver edge should be palpable and feel smooth and firm as it moves down with inspiration. ○ Abnormal Finding: If the liver edge is felt more than 3 cm below the costal margin, it may indicate hepatomegaly (enlarged liver). Summary of Steps: 1. Preparation: ○ Position the patient lying supine with their right knee slightly bent. ○ Stand at the patient's right shoulder, facing their feet. 2. Hand Placement and Technique: ○ Hook your fingers under the patient's right costal margin. ○ Instruct the patient to take a deep breath in. ○ Feel for the liver edge as it descends against your fingertips during inspiration. 3. Assessment: ○ Normal liver edge should be smooth and firm and palpable less than 3 cm below the costal margin at the midclavicular line with inspiration. ○ A liver edge felt more than 3 cm below the costal margin may indicate hepatomegaly. The hook method is particularly helpful when traditional palpation methods are challenging, providing an alternative way to assess liver size and texture. TRY to Palpate the Spleen Palpation of the Spleen Objective: To assess for splenomegaly (enlarged spleen), as the spleen is not normally palpable in a healthy individual. Procedure: 1. Initial Position (Supine): ○ Patient Position: Have the patient lie supine (on their back) with their right knee slightly bent to relax the abdominal muscles. ○ Examiner Position: Stand on the patient's right side. 2. Hand Placement and Technique: ○ Left Hand: Reach your left hand over the patient's abdomen and around the lower left ribs to provide support. ○ Right Hand: Place your right hand on the left upper quadrant (LUQ) with your fingers pointing towards the axilla, just under the left rib margin. ○ Palpation: Push your right hand deeply under the left rib cage. Instruct the patient to take a deep breath in. Normal Finding: Normally, you should feel nothing firm under your fingers. 3. Alternative Position (Right Lateral Decubitus): ○ Patient Position: Have the patient lie on their right side with their hips and knees partially flexed. This position uses gravity to potentially bring the spleen into a more palpable position. ○ Hand Placement and Technique: Repeat the same hand placement and palpation technique as described above. Normal Finding: You should still feel nothing firm if the spleen is not enlarged. Summary of Steps: 1. Initial Position (Supine): ○ Have the patient lie on their back with their right knee slightly bent. ○ Stand on the patient's right side. ○ Reach your left hand over the abdomen and around the lower left ribs for support. ○ Place your right hand on the LUQ, fingers pointing towards the axilla just under the left rib margin. ○ Push deeply under the left rib cage and ask the patient to breathe in deeply. ○ Normally, you should feel nothing firm. 2. Alternative Position (Right Lateral Decubitus): ○ Have the patient lie on their right side with hips and knees partially flexed. ○ Repeat the hand placement and palpation technique. ○ Normally, you should still feel nothing firm. By following these steps, you can effectively assess for splenomegaly. If a firm mass is felt, it may indicate an enlarged spleen, which requires further evaluation. Abnormalities on Palpation Abnormalities on Palpation Enlarged Liver (Hepatomegaly) Characteristics: The liver edge is palpable more than 3 cm below the right costal margin at the midclavicular line. The liver may feel smooth and firm. Possible Causes: Liver diseases such as hepatitis, fatty liver disease, or cirrhosis. Congestive heart failure. Infiltrative diseases such as amyloidosis. Enlarged Nodular Liver Characteristics: The liver edge is palpable and feels irregular or nodular. May be associated with tenderness or firmness. Possible Causes: Cirrhosis, especially if the nodules are small and hard. Metastatic cancer or primary liver cancer (hepatocellular carcinoma). Other chronic liver diseases. Enlarged Gallbladder Characteristics: Palpable as a smooth, firm, and tender mass in the right upper quadrant. Murphy's sign: Pain elicited when pressing under the right costal margin as the patient takes a deep breath. Possible Causes: Cholecystitis (inflammation of the gallbladder). Gallbladder obstruction due to gallstones (cholelithiasis). Biliary tract malignancies. Enlarged Spleen (Splenomegaly) Characteristics: The spleen is palpable below the left costal margin, often extending towards the right lower quadrant. May feel firm or rubbery. Possible Causes: Infections such as mononucleosis, malaria, or bacterial endocarditis. Hematologic diseases such as leukemia, lymphoma, or hemolytic anemia. Liver diseases such as cirrhosis with portal hypertension. Inflammatory conditions like rheumatoid arthritis or systemic lupus erythematosus. Summary of Abnormal Findings on Palpation: 1. Enlarged Liver (Hepatomegaly): ○ Liver edge palpable more than 3 cm below the right costal margin. ○ Smooth and firm. 2. Enlarged Nodular Liver: ○ Irregular or nodular liver edge. ○ Associated with tenderness or firmness. 3. Enlarged Gallbladder: ○ Smooth, firm, and tender mass in the right upper quadrant. ○ Positive Murphy's sign. 4. Enlarged Spleen (Splenomegaly): ○ Palpable below the left costal margin, extending towards the right lower quadrant. ○ Firm or rubbery consistency. These abnormalities can help identify specific conditions that require further diagnostic evaluation and management. Try to Palpate the Kidneys Palpation of the Kidneys Objective: To assess for abnormalities in the kidneys using the capture technique or balloting. Procedure: 1. Positioning: ○ Patient Position: Have the patient lie supine with their knees slightly bent to relax the abdominal muscles. 2. Capture Technique: ○ Left Kidney: Left Hand: Place your left hand behind the patient's left flank and lift upwards to support the kidney. Right Hand: Place your right hand on the left upper quadrant (LUQ), lateral to the rectus abdominis muscle. Breathing Instruction: Ask the patient to take a deep breath in. Palpation: Press your right hand firmly into the abdomen while lifting upwards with your left hand. Try to "capture" the kidney between your hands as the patient inhales. Normal Finding: Normally, the left kidney is not easily palpable. ○ Right Kidney: Left Hand: Place your left hand behind the patient's right flank and lift upwards to support the kidney. Right Hand: Place your right hand on the right upper quadrant (RUQ), lateral to the rectus abdominis muscle. Breathing Instruction: Ask the patient to take a deep breath in. Palpation: Press your right hand firmly into the abdomen while lifting upwards with your left hand. Try to "capture" the kidney between your hands as the patient inhales. Normal Finding: Normally, the right kidney may be slightly more palpable than the left due to its lower anatomical position, but it should still not be easily palpable. 3. Balloting the Kidney: ○ Left Kidney: Place your left hand behind the patient's left flank. Place your right hand on the LUQ. Use a quick, deep pressure with your right hand to try to push the kidney against your left hand. Normal Finding: Normally, the left kidney is not easily palpable. ○ Right Kidney: Place your left hand behind the patient's right flank. Place your right hand on the RUQ. Use a quick, deep pressure with your right hand to try to push the kidney against your left hand. Normal Finding: Normally, the right kidney may be slightly more palpable but should still not be easily palpable. 4. Assessment: ○ Abnormal Finding: An easily palpable, firm, or tender kidney is considered abnormal and may indicate conditions such as hydronephrosis, renal mass, or polycystic kidney disease. Summary of Steps: 1. Preparation: ○ Have the patient lie supine with knees slightly bent. 2. Capture Technique: ○ For the left kidney: Use your left hand to support the flank and your right hand to press into the abdomen. ○ For the right kidney: Use your left hand to support the flank and your right hand to press into the abdomen. ○ Instruct the patient to take a deep breath in and try to "capture" the kidney. 3. Balloting the Kidney: ○ For the left kidney: Place your left hand behind the flank and use your right hand to press quickly and deeply. ○ For the right kidney: Place your left hand behind the flank and use your right hand to press quickly and deeply. 4. Assessment: ○ Normally, the kidneys are not easily palpable. ○ An easily palpable, firm, or tender kidney is abnormal and warrants further investigation. By using these techniques, you can effectively assess the kidneys for any abnormalities that may require further evaluation. Palapation of Aortic Pulsation Palpation of Aortic Pulsation Objective: To assess the width and characteristics of the aortic pulsation to identify any abnormalities such as an aortic aneurysm. Procedure: 1. Positioning: ○ Patient Position: Have the patient lie supine with their legs straight and abdominal muscles relaxed. 2. Hand Placement and Technique: ○ Place both hands with fingers parallel to each other on either side of the midline of the abdomen, just above the umbilicus. ○ Press gently but firmly down into the abdomen with your fingers. ○ Feel for the aortic pulsation between your fingertips. 3. Assessment: ○ Normal Finding: The normal width of the aortic pulsation should be between 2-3 cm. ○ Abnormal Findings: Prominent Lateral Pulsations: May indicate an aortic aneurysm or other vascular abnormality. Periumbilical or Upper Abdominal Mass with Pulsations: Especially concerning if a bruit is present, indicating turbulent blood flow, which can be a sign of an aortic aneurysm or other vascular pathology. 4. Caution: ○ Do Not Perform Deep Palpation: If an abnormal aortic pulsation or mass is detected, avoid deep palpation to prevent the risk of rupturing a potential aneurysm. Summary of Steps: 1. Preparation: ○ Have the patient lie supine with legs straight and abdominal muscles relaxed. 2. Hand Placement and Technique: ○ Place both hands on either side of the midline above the umbilicus. ○ Press gently but firmly to feel for the aortic pulsation. 3. Assessment: ○ Normal aortic pulsation is 2-3 cm wide. ○ Be cautious of: Prominent lateral pulsations. Periumbilical or upper abdominal mass with pulsations, especially if a bruit is present. 4. Caution: ○ Avoid deep palpation if an abnormal aortic pulsation or mass is detected. By following these steps, you can safely assess the aortic pulsation and identify any abnormalities that may require further evaluation or immediate attention. 4o Summary of Special Techniques Summary of Special Techniques Assessing for Ascites 1. Shifting Dullness: ○ Procedure: Percuss the abdomen from the midline laterally while the patient is supine. Mark the transition from tympany to dullness. ○ Position Change: Have the patient roll to one side and percuss again. ○ Positive Sign: Shifting dullness indicates free fluid in the abdomen. 2. Fluid Wave: ○ Procedure: Have the patient or an assistant place the edge of their hand along the midline of the abdomen to stop the transmission of the wave through the fat. Place one hand on one side of the abdomen and tap with the other hand on the opposite side. ○ Positive Sign: Feeling a fluid wave on the opposite side suggests ascites. Assessing for Appendicitis 1. McBurney Point Tenderness: ○ Procedure: Press firmly at McBurney's point (one-third the distance from the anterior superior iliac spine to the umbilicus). ○ Positive Sign: Tenderness at this point suggests appendicitis. 2. Rovsing’s Sign: ○ Procedure: Press deeply in the left lower quadrant and quickly release. ○ Positive Sign: Pain in the right lower quadrant upon release suggests appendicitis. 3. Psoas Sign: ○ Procedure: Have the patient lie on their left side, extend the right leg at the hip while keeping the knee straight. ○ Positive Sign: Pain in the right lower quadrant indicates irritation of the psoas muscle by an inflamed appendix. 4. Obturator Test: ○ Procedure: With the patient lying on their back, flex the right hip and knee, then internally rotate the hip. ○ Positive Sign: Pain in the right lower quadrant suggests irritation of the obturator muscle by an inflamed appendix. Assessing for Acute Cholecystitis 1. Murphy's Sign: ○ Procedure: Place your hand at the right costal margin in the mid-clavicular line. Ask the patient to take a deep breath while you press firmly. ○ Positive Sign: If the patient experiences a sharp increase in pain and abruptly stops inhaling due to pain, this suggests acute cholecystitis. Summary of Techniques: 1. Ascites: ○ Shifting dullness. ○ Fluid wave. 2. Appendicitis: ○ McBurney point tenderness. ○ Rovsing’s sign. ○ Psoas sign. ○ Obturator test. 3. Acute Cholecystitis: ○ Murphy's sign. These special techniques help in the diagnosis of specific abdominal conditions by identifying characteristic signs and symptoms. 4o Assessing for Ascites Assessing for Ascites Objective: To detect the presence of free fluid (ascites) in the abdomen. Clinical Observation: Protuberant Abdomen with Bulging Flanks: ○ A visibly distended abdomen with noticeable bulging of the flanks suggests the presence of ascites. Procedure: 1. Percussion of the Abdomen: ○ Patient Position: Have the patient lie supine. ○ Technique: Start percussing from the midline of the abdomen towards the lateral sides (flanks). Note the sounds as you move your fingers across the abdomen. 2. Findings: ○ Tympany: Percuss the anterior portion of the abdomen. Normal Finding: The anterior portion should be tympanic due to the presence of gas in the intestines. ○ Dullness: Percuss the lateral sides (flanks) of the abdomen. Positive Finding: Dullness along the flanks indicates the presence of fluid, as fluid gravitates to the sides due to gravity. Additional Techniques: 1. Shifting Dullness: ○ Procedure: With the patient lying supine, percuss from the midline to the lateral sides to identify areas of tympany and dullness. Mark the transition points from tympany to dullness. Have the patient roll to one side and wait a few seconds. Percuss again and note any shifts in the areas of tympany and dullness. ○ Positive Sign: If the dullness shifts to the dependent side and the tympany shifts to the top, this confirms the presence of free fluid. 2. Fluid Wave: ○ Procedure: Have the patient or an assistant place their hand firmly along the midline of the abdomen. Tap one side of the abdomen while feeling for a wave on the opposite side with your other hand. ○ Positive Sign: Feeling a fluid wave indicates ascites. Summary of Steps: 1. Clinical Observation: ○ Look for a protuberant abdomen with bulging flanks. 2. Percussion: ○ Percuss the abdomen for areas of tympany (anterior) and dullness (lateral flanks). 3. Additional Techniques: ○ Perform the shifting dullness test to confirm the presence of free fluid. ○ Perform the fluid wave test for further confirmation. These techniques help in accurately diagnosing ascites and assessing its extent, guiding further diagnostic and therapeutic measures. 4o Assessing for Appendicitis Assessing for Appendicitis – McBurney Point Objective: To assess for appendicitis using McBurney point tenderness and rebound tenderness. McBurney Point Tenderness Procedure: 1. Locating McBurney Point: ○ Location: One-third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus on the right side. ○ Technique: Use anatomical landmarks to identify the correct point. 2. Palpation: ○ Press firmly at McBurney point. ○ Ask the patient if they feel pain or tenderness. Clinical Significance: Positive McBurney Point Tenderness: If the patient experiences tenderness at McBurney point, appendicitis is 2 times more likely. Rebound Tenderness Procedure: 1. Technique: ○ Press firmly and slowly at McBurney point or another part of the right lower quadrant. ○ Quickly release the pressure. 2. Assessment: ○ Ask the patient if the pain increases upon release. ○ Note the location and intensity of the pain. Clinical Significance: Positive Rebound Tenderness: If pain increases when the pressure is released, this indicates peritoneal irritation, which is often associated with appendicitis. Summary of Steps: 1. McBurney Point Tenderness: ○ Locate McBurney point (one-third of the distance from ASIS to umbilicus on the right side). ○ Press firmly and assess for tenderness. ○ Positive Sign: Increased likelihood of appendicitis if tenderness is present. 2. Rebound Tenderness: ○ Press firmly and slowly at McBurney point or another area of the right lower quadrant. ○ Quickly release the pressure. ○ Positive Sign: Increased pain upon release suggests peritoneal irritation, often due to appendicitis. These assessment techniques help in the clinical diagnosis of appendicitis, guiding further diagnostic testing and management. Assessing for Appendicitis- Rovsing Signs Assessing for Appendicitis – Rovsing Sign Objective: To assess for appendicitis using Rovsing sign, which is a test for referred tenderness. Rovsing Sign Procedure: 1. Palpation: ○ Location: Palpate the left lower quadrant (LLQ) of the patient's abdomen. ○ Technique: Press firmly and slowly in the LLQ, then quickly release the pressure. 2. Assessment: ○ Ask the patient if they feel pain in the right lower quadrant (RLQ) upon pressing or releasing the pressure in the LLQ. ○ Note the location and intensity of the pain. Clinical Significance: Positive Rovsing Sign: If the patient experiences tenderness or rebound tenderness in the RLQ when the LLQ is palpated, this suggests referred pain and indicates possible appendicitis. Summary of Steps: 1. Palpation: ○ Press firmly and slowly in the left lower quadrant (LLQ). ○ Quickly release the pressure. 2. Assessment: ○ Ask the patient if they feel pain in the right lower quadrant (RLQ). ○ Positive Sign: Tenderness or rebound tenderness in the RLQ upon palpation of the LLQ suggests referred pain and indicates possible appendicitis. Rovsing sign is a useful clinical test to help diagnose appendicitis by identifying referred pain patterns. 4o Assessing for Appendicitis- Psoas Sign Assessing for Appendicitis – Psoas Sign Objective: To assess for appendicitis using the Psoas sign, which indicates irritation of the psoas muscle due to an inflamed appendix. Psoas Sign Procedure: 1. Patient Position: ○ Have the patient lie in the supine position (on their back). 2. Hand Placement and Technique: ○ Place your hand over the patient's right knee. ○ Ask the patient to raise their right thigh against the resistance of your hand. 3. Assessment: ○ Observe and ask the patient if they experience any abdominal pain during this maneuver. ○ Note the location and intensity of the pain. Clinical Significance: Positive Psoas Sign: If the patient experiences abdominal pain with this technique, it suggests irritation of the right psoas muscle, likely due to an inflamed appendix. Summary of Steps: 1. Patient Position: ○ Ensure the patient is lying supine. 2. Hand Placement and Technique: ○ Place your hand over the patient's right knee. ○ Ask the patient to raise their right thigh against your hand's resistance. 3. Assessment: ○ Positive Sign: Abdominal pain during this maneuver indicates a positive Psoas sign, suggesting irritation of the right psoas muscle by an inflamed appendix. This technique helps in the clinical diagnosis of appendicitis by identifying pain resulting from psoas muscle irritation. Assessing for Appendicitis- Obturator Sign Assessing for Appendicitis – Obturator Sign Objective: To assess for appendicitis using the Obturator sign, which indicates irritation of the obturator muscle due to an inflamed appendix. Obturator Sign Procedure: 1. Patient Position: ○ Have the patient lie in the supine position (on their back). 2. Hand Placement and Technique: ○ Flex the patient's right thigh at the hip. ○ Bend the knee. ○ Rotate the hip internally by moving the patient's lower leg outward while keeping the knee bent. 3. Assessment: ○ Observe and ask the patient if they experience any pain in the right hypogastric region (lower abdomen) during this maneuver. ○ Note the location and intensity of the pain. Clinical Significance: Positive Obturator Sign: If the patient experiences right hypogastric pain with this motion, it indicates a positive Obturator sign, suggesting irritation of the obturator muscle by an inflamed appendix. Summary of Steps: 1. Patient Position: ○ Ensure the patient is lying supine. 2. Hand Placement and Technique: ○ Flex the patient's right thigh at the hip. ○ Bend the knee. ○ Internally rotate the hip by moving the lower leg outward. 3. Assessment: ○ Positive Sign: Right hypogastric pain during this maneuver indicates a positive Obturator sign, suggestive of appendicitis. This technique helps in the clinical diagnosis of appendicitis by identifying pain resulting from obturator muscle irritation. Assessing for Acute Cholecystitis- Murphy’s Sign Assessing for Acute Cholecystitis – Murphy’s Sign Objective: To assess for acute cholecystitis (inflamed gallbladder) using Murphy’s sign. Murphy’s Sign Procedure: 1. Patient Position: ○ Have the patient lie supine (on their back). 2. Hand Placement and Technique: ○ Locate the area of the right upper quadrant (RUQ) where the patient experiences pain. ○ Place your fingers under the right costal margin at the mid-clavicular line. ○ Ask the patient to take a deep breath in while you palpate deeply at the site of pain. 3. Assessment: ○ Observe the patient’s response as they inhale deeply. ○ Note if the patient experiences a sharp halt in their breath due to pain when the inflamed gallbladder meets your fingers. Clinical Significance: Positive Murphy’s Sign: A sharp halt in the patient’s breath due to pain during deep palpation of the RUQ indicates a positive Murphy’s sign, suggesting acute cholecystitis. Summary of Steps: 1. Patient Position: ○ Ensure the patient is lying supine. 2. Hand Placement and Technique: ○ Deeply palpate the RUQ at the site of the patient’s pain. ○ Ask the patient to take a deep breath in, which forces the liver and gallbladder downward. 3. Assessment: ○ Positive Sign: A sharp halt in the patient's breath due to pain when the gallbladder meets your fingers indicates a positive Murphy’s sign, suggesting acute cholecystitis. This technique helps in the clinical diagnosis of acute cholecystitis by identifying pain associated with an inflamed gallbladder. MUSCULOSKELETAL SYSTEM Subjective Health History: Questions to Ask Subjective Data – Health History 1. Joints Pain: ○ Location: Which joints are affected? ○ Intensity: Describe the pain on a scale from 0 to 10. ○ Duration: How long has the pain been present? ○ Quality: Is it sharp, dull, throbbing, or aching? ○ Onset: When did the pain start? ○ Aggravating Factors: What activities or movements worsen the pain? ○ Alleviating Factors: What helps relieve the pain? Stiffness: ○ Duration: Is the stiffness worse in the morning or after periods of inactivity? ○ Location: Which joints are stiff? Swelling, Heat, Redness: ○ Presence: Are any joints swollen, warm to the touch, or red? ○ Timing: When do these symptoms occur? Symptoms on One Side or Both: ○ Unilateral vs. Bilateral: Are symptoms present on one side of the body or both? 2. Muscles Pain (Cramps): ○ Location: Where is the muscle pain or cramping? ○ Intensity: Describe the pain on a scale from 0 to 10. ○ Duration: How long do the cramps last? ○ Quality: Is it sharp, dull, throbbing, or aching? ○ Onset: When did the pain start? ○ Aggravating Factors: What activities or movements worsen the pain? ○ Alleviating Factors: What helps relieve the pain? Weakness: ○ Location: Which muscles are weak? ○ Severity: How severe is the weakness? Can you still perform normal activities? ○ Duration: How long has the weakness been present? ○ Onset: When did the weakness start? 3. Bones Pain: ○ Location: Which bones are affected? ○ Intensity: Describe the pain on a scale from 0 to 10. ○ Duration: How long has the pain been present? ○ Quality: Is it sharp, dull, throbbing, or aching? ○ Onset: When did the pain start? ○ Aggravating Factors: What activities or movements worsen the pain? ○ Alleviating Factors: What helps relieve the pain? Deformity: ○ Description: Describe any deformities in the bones. ○ Duration: How long has the deformity been present? ○ Cause: Is there a known cause for the deformity? Trauma (Fractures, Sprains, Dislocations): ○ History: Describe any previous bone injuries. ○ Treatment: What treatment was received? ○ Residual Effects: Are there any lasting effects from the injury? 4. Functional Assessment (Activities of Daily Living) Activities: ○ Difficulty: Are there any difficulties performing daily activities such as dressing, bathing, eating, or walking? ○ Adaptations: Have any adaptations been made to help with daily activities? 5. Self-care Behaviors General: ○ Exercise: What type and how often? ○ Nutrition: Any special diet or supplements? ○ Sleep: Quality and duration of sleep. ○ Stress: How do you manage stress? Specific Symptoms: ○ Stiffness: How do you manage or relieve stiffness? ○ Swelling, Heat, Redness: How do you manage or relieve these symptoms? ○ Pain Management: What methods are used to manage pain (medications, physical therapy, etc.)? This comprehensive health history helps in understanding the patient's subjective experience with musculoskeletal issues and guides further clinical assessment and management. General Order of Examination General Order of the Examination 1. Inspection Size and Contour of Joint: ○ Assess for any swelling, deformities, or asymmetry in the size and shape of the joints. ○ Compare bilaterally for any differences. Skin and Tissues Over Joint: ○ Look for redness, rashes, or other skin changes. ○ Check for any signs of inflammation, such as swelling or warmth. ○ Observe for any muscle atrophy or changes in the surrounding tissues. 2. Palpation Skin Temperature: ○ Compare the temperature of the skin over the joint to the surrounding areas to detect any warmth that may indicate inflammation. Muscles, Bony Articulations, Area of Joint Capsule: ○ Gently palpate the muscles around the joint for tenderness or spasms. ○ Feel the bony structures for any abnormalities, tenderness, or deformities. ○ Assess the joint capsule for swelling, tenderness, or increased fluid (effusion). 3. Range of Motion (ROM) Active Range of Motion: ○ Ask the patient to move the joint through its full range of motion without assistance. ○ Observe for any limitations, pain, or irregular movements. Passive Range of Motion: ○ Move the joint through its range of motion while the patient relaxes. ○ Note any limitations, pain, or resistance. 4. Muscle Testing Apply Opposing Force: ○ Test the strength of the muscles around the joint by asking the patient to resist your force. ○ Compare bilaterally for symmetry and strength. Grading Muscle Strength: ○ Use a standard grading scale to assess muscle strength: 0: No muscle contraction detected. 1: Trace of contraction, but no movement. 2: Active movement with gravity eliminated. 3: Active movement against gravity. 4: Active movement against gravity and some resistance. 5: Active movement against full resistance (normal strength). Summary of Examination Steps: 1. Inspection: ○ Size and contour of the joint. ○ Skin and tissues over the joint. 2. Palpation: ○ Skin temperature. ○ Muscles, bony articulations, and the area of the joint capsule. 3. Range of Motion: ○ Assess both active and passive range of motion. 4. Muscle Testing: ○ Apply opposing force to test muscle strength. ○ Grade muscle strength using the standard grading scale. By following this systematic approach, you can thoroughly assess the joints and surrounding structures for any abnormalities, guiding further diagnostic and therapeutic measures. Tips for Success Tips for Success in Musculoskeletal Examination 1. Orderly Approach Systematic Examination: ○ Move from head to toe. ○ Assess proximal structures before distal ones. ○ Integrate the musculoskeletal exam with the examination of other body systems as you progress through the body. 2. Joint at Rest Relaxation: ○ Ensure the joint to be examined is at rest. ○ The muscles around the joint must be soft and relaxed to accurately assess the underlying joint structures. 3. Symmetrical Comparison Bilateral Assessment: ○ Always compare corresponding joints and muscles on both sides of the body. ○ Look for asymmetries in size, shape, strength, and range of motion. 4. Comprehensive Examination Adjacent Joints: ○ If the patient reports a problem in a specific joint, also examine the joint above and below the affected joint. ○ This helps identify referred pain or compensatory mechanisms that may contribute to the patient's symptoms. Summary of Tips: 1. Orderly Approach: ○ Follow a systematic head-to-toe, proximal-to-distal order. ○ Incorporate musculoskeletal assessments with other system examinations. 2. Joint at Rest: ○ Ensure the joint and surrounding muscles are relaxed. 3. Symmetrical Comparison: ○ Always compare both sides for symmetry. 4. Comprehensive Examination: ○ Examine adjacent joints to identify referred or related issues. Additional Considerations: Patient Comfort: ○ Explain each step to the patient to keep them informed and at ease. ○ Ensure the patient is in a comfortable position to facilitate accurate examination. Thorough Documentation: ○ Document findings accurately and comprehensively. ○ Note any asymmetries, abnormalities, or patient-reported symptoms. Clinical Correlation: ○ Correlate physical examination findings with the patient’s history and reported symptoms. ○ Use findings to guide further diagnostic testing or treatment plans. By adhering to these tips, you can conduct a thorough and effective musculoskeletal examination, ensuring accurate assessment and appropriate management of musculoskeletal conditions. Grading Muscle Strength Grading Muscle Strength Muscle strength is graded on a 0 to 5 scale: 1. Grade 0: No muscular contraction detected. ○ Description: No visible or palpable muscle contraction. ○ Example: Complete paralysis. 2. Grade 1: A barely detectable flicker or trace of contraction. ○ Description: Slight muscle contraction, but no movement of the joint. ○ Example: Flicker of movement upon palpation or observation. 3. Grade 2: Active movement of the body part with gravity eliminated. ○ Description: Movement possible only with gravity removed. ○ Example: Moving a limb horizontally on a flat surface. 4. Grade 3: Active movement against gravity. ○ Description: Movement against gravity but no additional resistance. ○ Example: Lifting a limb against gravity without any added resistance. 5. Grade 4: Active movement against gravity and some resistance. ○ Description: Movement against gravity with some resistance but less than full resistance. ○ Example: Lifting a limb against gravity with partial resistance from the examiner. 6. Grade 5: Active movement against full resistance without evident fatigue; this is normal muscle strength. ○ Description: Full strength, the patient can overcome the examiner's full resistance. ○ Example: Pushing against the examiner's hand with maximum effort and no signs of fatigue. Procedure for Grading Muscle Strength: 1. Ask the Patient to Move Actively Against Your Opposing Resistance: ○ Assign Grade 5: If the patient overcomes your opposing movement with normal strength and without evident fatigue. ○ Assign Grade 4: If the patient can move against gravity and some resistance but not full resistance. ○ Assign Grade 3: If the patient can only move against gravity without any added resistance. ○ Assign Grade 2: If the patient can move the body part only with gravity eliminated. ○ Assign Grade 1: If there is a barely detectable flicker or trace of contraction. ○ Assign Grade 0: If there is no muscular contraction detected. Summary of Muscle Strength Grading: 0: No muscular contraction detected. 1: A barely detectable flicker or trace of contraction. 2: Active movement with gravity eliminated. 3: Active movement against gravity. 4: Active movement against gravity and some resistance. 5: Active movement against full resistance without evident fatigue (normal muscle strength). Using this grading scale, you can accurately assess and document the muscle strength of your patients, providing important information for diagnosis and treatment planning. Skeletal Muscle Movements Skeletal Muscle Movements 1. Flexion ○ Description: Bending a limb at a joint. ○ Example: Bending the elbow or knee. 2. Extension ○ Description: Straightening a limb at a joint. ○ Example: Straightening the elbow or knee. 3. Abduction ○ Description: Moving a limb away from the midline of the body. ○ Example: Raising the arm or leg to the side. 4. Adduction ○ Description: Moving a limb toward the midline of the body. ○ Example: Bringing the arm or leg back toward the body. 5. Pronation ○ Description: Turning the forearm so the palm is down. ○ Example: Rotating the forearm to make the palm face downward. 6. Supination ○ Description: Turning the forearm so that the palm is up. ○ Example: Rotating the forearm to make the palm face upward. 7. Circumduction ○ Description: Moving the arm in a circle around the shoulder. ○ Example: Performing a windmill motion with the arm. 8. Inversion ○ Description: Moving the sole of the foot inward at the ankle. ○ Example: Turning the sole of the foot to face the opposite foot. 9. Eversion ○ Description: Moving the sole of the foot outward at the ankle. ○ Example: Turning the sole of the foot to face away from the opposite foot. 10. Rotation ○ Description: Moving the head around a central axis. ○ Example: Turning the head side to side. 11. Protraction ○ Description: Moving a body part forward and parallel to the ground. ○ Example: Moving the jaw or shoulder blades forward. 12. Retraction ○ Description: Moving a body part backward and parallel to the ground. ○ Example: Moving the jaw or shoulder blades backward. 13. Elevation ○ Description: Raising a body part. ○ Example: Shrugging the shoulders. 14. Depression ○ Description: Lowering a body part. ○ Example: Lowering the shoulders. Summary of Skeletal Muscle Movements: 1. Flexion: Bending a limb at a joint. 2. Extension: Straightening a limb at a joint. 3. Abduction: Moving a limb away from the midline. 4. Adduction: Moving a limb toward the midline. 5. Pronation: Turning the forearm so the palm is down. 6. Supination: Turning the forearm so the palm is up. 7. Circumduction: Moving the arm in a circle around the shoulder. 8. Inversion: Moving the sole of the foot inward. 9. Eversion: Moving the sole of the foot outward. 10. Rotation: Moving the head around a central axis. 11. Protraction: Moving a body part forward and parallel to the ground. 12. Retraction: Moving a body part backward and parallel to the ground. 13. Elevation: Raising a body part. 14. Depression: Lowering a body part. Understanding these movements is crucial for assessing joint function and diagnosing musculoskeletal conditions. 4o Temporomandibular Joint Temporomandibular Joint (TMJ) Trigeminal Nerve (CN V) Test Description: The temporomandibular joint (TMJ) is where the mandible (jawbone) and the temporal bone of the skull come together. It is the most active joint in the body, facilitating essential functions such as speaking and chewing. Functions: Permits jaw movements necessary for speaking and chewing. Movements: 1. Hinge Movement: ○ Description: Allows the jaw to open and close. ○ Example: Biting or yawning. 2. Gliding Movement: ○ Protrusion and Retraction: Description: Allows the jaw to move forward (protrusion) and backward (retraction). Example: Moving the lower jaw forward to protrude the chin or pulling it back. ○ Side to Side (Lateral): Description: Allows the jaw to move side to side. Example: Grinding food or moving the jaw from left to right. Summary of TMJ Movements: 1. Hinge Movement: ○ Permits opening and closing of the jaw. ○ Essential for actions like biting and yawning. 2. Gliding Movement: ○ Protrusion and Retraction: Moves the jaw forward and backward. Important for actions like protruding the chin or retracting the jaw. ○ Side to Side (Lateral): Moves the jaw laterally from left to right. Crucial for grinding food and lateral jaw movements. Understanding the movements and functions of the TMJ is important for diagnosing and treating conditions related to this highly active joint. Temporomandibular Joint Temporomandibular Joint (TMJ) Examination Objective: To assess the temporomandibular joint for abnormalities in structure and function. 1. Inspection Inspect Joint Area: ○ Observe the area around the TMJ for any signs of swelling, asymmetry, or deformity. ○ Check for any visible abnormalities when the mouth is at rest and during movement. 2. Palpation Palpate as Person Opens Mouth: ○ Place your fingers just in front of the tragus of the ear on both sides of the face. ○ Ask the patient to open and close their mouth slowly. ○ Feel for any abnormal movement, tenderness, or crepitus. 3. Note Range of Motion (ROM) Assess ROM: ○ Open Mouth Maximally: Ask the patient to open their mouth as wide as possible. ○ Protrude Lower Jaw and Move Side to Side: Instruct the patient to move their lower jaw forward (protrusion) and then from side to side. ○ Stick Out Lower Jaw: Ask the patient to stick out their lower jaw. Observe for Apop or Click: ○ Clicking or popping sounds when the patient opens their mouth can be normal if they are not associated with pain or crepitus. ○ Crepitus: There should be no grating or creaking sounds, which can indicate joint pathology. 4. Palpate Muscles of Mastication Palpate Muscles: ○ Masseter Muscle: Palpate at the angle of the jaw. ○ Temporalis Muscle: Palpate on the temple area. ○ Pterygoid Muscles: These are more challenging to palpate directly but can be assessed indirectly through jaw movement and function. ○ Ask the patient to clench their teeth and relax to feel the muscle contraction and relaxation. ○ Note any tenderness, swelling, or muscle spasms. Summary of TMJ Examination Steps: 1. Inspection: ○ Inspect the TMJ area for swelling, asymmetry, and deformity. 2. Palpation: ○ Palpate the joint as the patient opens and closes their mouth. ○ Feel for abnormal movement, tenderness, or crepitus. 3. Range of Motion: ○ Assess the patient's ability to: Open the mouth maximally. Protrude the lower jaw and move it side to side. Stick out the lower jaw. ○ Note any popping or clicking sounds and ensure they are not associated with pain or crepitus. 4. Palpate Muscles of Mastication: ○ Palpate the masseter, temporalis, and pterygoid muscles. ○ Assess for tenderness, swelling, or muscle spasms. This comprehensive examination helps identify any abnormalities in the TMJ and associated structures, guiding further diagnostic and therapeutic measures. Bony Landmarks on Shoulder Bony Landmarks of the Shoulder The shoulder is a complex joint comprising several key bony landmarks that are important for anatomical orientation, physical examination, and diagnosis of musculoskeletal conditions. 1. Clavicle (Collarbone) Location: Runs horizontally across the top of the chest, connecting the sternum (breastbone) to the scapula (shoulder blade). Palpation: Easily palpable along its entire length from the sternum to the acromion. 2. Acromion Location: The bony prominence at the top of the shoulder, part of the scapula. Palpation: Found at the end of the clavicle; forms the highest point of the shoulder. 3. Scapula (Shoulder Blade) Key Landmarks: ○ Spine of the Scapula: Location: Runs horizontally across the posterior surface of the scapula. Palpation: Easily felt by moving fingers across the upper back. ○ Acromion: As mentioned above, the lateral extension of the spine. ○ Coracoid Process: Location: A small hook-like structure on the anterior surface of the scapula. Palpation: Can be felt by pressing deeply below the lateral end of the clavicle. 4. Humerus Key Landmarks: ○ Greater Tubercle: Location: Lateral aspect of the proximal humerus. Palpation: Felt just below the acromion when the arm is at the side. ○ Lesser Tubercle: Location: Anterior aspect of the proximal humerus. Palpation: Felt with the arm in external rotation. ○ Intertubercular (Bicipital) Groove: Location: Between the greater and lesser tubercles. Palpation: Felt by externally rotating the arm while palpating the area. 5. Sternoclavicular Joint Location: The junction between the sternum and the clavicle. Palpation: Felt at the base of the neck, near the midline. 6. Acromioclavicular Joint Location: The junction between the acromion and the clavicle. Palpation: Found at the top of the shoulder, where the clavicle meets the acromion. Summary of Bony Landmarks of the Shoulder: 1. Clavicle (Collarbone): ○ Horizontal bone connecting the sternum to the scapula. 2. Acromion: ○ Bony prominence at the top of the shoulder, part of the scapula. 3. Scapula (Shoulder Blade): ○ Spine of the Scapula: Horizontal ridge on the posterior surface. ○ Acromion: Lateral extension of the spine. ○ Coracoid Process: Hook-like structure on the anterior surface. 4. Humerus: ○ Greater Tubercle: Lateral aspect of the proximal humerus. ○ Lesser Tubercle: Anterior aspect of the proximal humerus. ○ Intertubercular (Bicipital) Groove: Between the greater and lesser tubercles. 5. Sternoclavicular Joint: ○ Junction between the sternum and the clavicle. 6. Acromioclavicular Joint: ○ Junction between the acromion and the clavicle. Understanding these bony landmarks is essential for performing a thorough shoulder examination, identifying abnormalities, and guiding further diagnostic evaluation. 4o Shoulder Joint Shoulder Assessment Shoulder Assessment Objective: To comprehensively evaluate the shoulder joint for any abnormalities in structure, function, or strength. 1. Inspection Inspect Joint: ○ Anterior View: Look at the front of the shoulder for any asymmetry, deformity, swelling, or discoloration. ○ Posterior View: Look at the back of the shoulder for any signs of atrophy, swelling, or abnormal contour. 2. Palpation Palpate Shoulders and Axilla: ○ Technique: Use your fingers to gently feel around the shoulder joint and into the axilla. ○ Assessment: Note any atrophy, swelling, heat, or tenderness. Muscle Atrophy: Indicate muscle wasting. Swelling: Suggests inflammation or injury. Heat: Indicates inflammation or infection. Tenderness: May suggest inflammation, injury, or other pathology. 3. Range of Motion (ROM) Palpation During ROM: ○ Place one hand over the shoulder to feel for any crepitus, abnormal movement, or instability while the patient performs ROM exercises. ROM Exercises: ○ Flexion: Arms forward and up. ○ Hyperextension: Arms down and back. ○ Internal Rotation: Arms behind back. ○ Abduction: Arms from the sides up overhead. ○ Adduction: Arms brought down inward across the front of the body. ○ External Rotation: Touch hands behind the head. 4. Assess Strength Strength Testing: ○ Shoulder Shrug: Ask the patient to shrug their shoulders against resistance. ○ Forward Flexion: Ask the patient to lift their arms forward against resistance. ○ Abduction: Ask the patient to lift their arms sideways against resistance. Grading Muscle Strength: ○ Grade 0: No muscle contraction. ○ Grade 1: Slight contraction, no movement. ○ Grade 2: Full ROM with gravity eliminated. ○ Grade 3: Full ROM against gravity. ○ Grade 4: Full ROM against gravity, some resistance. ○ Grade 5: Full ROM against gravity, full resistance (normal strength). Summary of Shoulder Assessment Steps: 1. Inspection: ○ Inspect the shoulder joint from both anterior and posterior views for asymmetry, deformity, swelling, or discoloration. 2. Palpation: ○ Palpate the shoulders and axilla for atrophy, swelling, heat, or tenderness. 3. Range of Motion (ROM): ○ Place one hand over the shoulder to palpate while the patient performs the following ROM exercises: Flexion: Arms forward and up. Hyperextension: Arms down and back. Internal Rotation: Arms behind back. Abduction: Arms from the sides up overhead. Adduction: Arms brought down inward across the front of the body. External Rotation: Touch hands behind the head. 4. Assess Strength: ○ Test strength by asking the patient to perform shoulder shrug, forward flexion, and abduction against resistance. ○ Grade the muscle strength on a scale from 0 to 5. Using this systematic approach ensures a thorough evaluation of the shoulder joint, helping to identify any abnormalities and guiding further diagnostic and therapeutic measures. 4o Shoulder Assessment Shoulder Assessment Objective: To comprehensively evaluate the shoulder joint for any abnormalities in structure, function, or strength, including the assessment of circumduction. 1. Inspection Inspect Joint: ○ Anterior View: Look at the front of the shoulder for any asymmetry, deformity, swelling, or discoloration. ○ Posterior View: Look at the back of the shoulder for any signs of atrophy, swelling, or abnormal contour. 2. Palpation Palpate Shoulders and Axilla: ○ Technique: Use your finge

Abdominal PA Lecture Notes PDF

Document Details

Tags

Related

Summary

Full Transcript

Upgrade to continue