EXAM #3 Study Guide:2022
Rectal/prostate exam position - knee-chest; lithotomy; left lateral with hips and knees
flexed; or standing with the hips flexed leaning on exam table
Rectal/prostate exam position males - left lateral with hips and knees flexed or standing
with the thips flexed leaning on exam table
Rectal/prostate exam position women - most often performed as part of the rectovaginal
examination in the lithotomy position
Rectal/prostate exam procedure - Lubricate index finger of gloved hand, press the pad
against the anal opening, ask patient to bear down then slip tip into anal canal, ask to
tighten sphincter noting tone, palpate for masses, nodules, irregularities, palpate
lateral/posterior/anterior rectal walls, prostate (on anterior wall)
Normal prostate exam - should feel like a pencil eraser— firm, smooth, and
slightlymovable/nontender. Diameter of about 4 cm, with less than 1 cm protrusion into
the rectum. Lobes should feel symmetric, seminal vesicles should not be palpable.
Abnormal prostate exam - greater than 1 cm protrusion into rectum means enlargement,
obliterated median sulcus means hypertrophied or neoplastic nodes, rubbery/boggy
consistency means benign hypertrophy, stony/hard nodularity may mean carcinoma,
prostatic calculi, chronic fibrosis, tender/fluctuant softness means prostatic abscess,
palpable seminal vesicles means inflammation
Extremely tight sphincter - scarring, spasticity from fissure or lesion, inflammation,
anxiety
Lax sphincter - neuro deficit or sexual abuse
Rectal pain - anal fistula, anal fissure, perirectal abscess, thrombosed hemorrhoids
Bidigital palpation - helpful for identifying perianal abscess, press thumb against anus
while palpating with index finger
Rectal prolapse findings - rectum starts to drop down, rectum partially protrudes, rectum
fully protrudes; characterized by feeling of a bulge, bleeding, or pain
Rectal prolapse causes - constipation, diarrhea, gynecologic surgery, pelvic
neuropathies, or severe coughing/straining, age, nerve damage
Hemorrhoid - varicose veins in lower rectum or anus, may be internal or external
External hemorrhoids - may cause itching, bleeding, discomfort; invisible at rest,
protrude on standing, straining; thrombosed are blue, shiny masses at anus
,Internal hemorrhoids - may have no symptoms, are soft swellings not palpable on rectal
exam not visible unless prolapsed, dx w/ proctoscopy
Rectal bleeding causes - anal fissures, anaphylactoid purpura, aspirin use, bleeding &
coagulation disorders, colitis, dysentery, esophageal varices, familial telangiectasia,
foreign body trauma, hemorrhoids, hiatal hernia, hookworm, intussusception, iron
poisoning, Meckel diverticulum, neoplasms, oral steroids, peptic ulcers, polyps, regional
enteritis, strangulated hernia, swallowed blood, thrombocytopenia, volvulus
MS exam sequence - observe gait/posture as patient enters room, inspect (posture,
deformities, symmetry, alignment, hypertrophy), palpate (bones, joints, tendons,
muscles), evaluate ROM and muscle tone, muscle strength (hands, elbows, shoulders,
TMJ, cervical/thoracic/lumbar spine ROM, hips, legs and knees, feet and ankles
Limb measurement - asymmetry in limb size, normal is no more than 1 cm discrepancy
in length and circumference; athletes w/ dominant arm may have greater discrepancy in
circumferences
Leg length - measured from the anterior superior iliac spine to the medial malleolus of
the ankle, crossing the knee on the medial side
Arm length - measured from the acromion process through the olecranon process to the
distal ulnar prominence.
Neer test identifies - shoulder rotator cuff impingement or tear
Hawkins test identifies - shoulder rotator cuff impingement or tear
Katz hand diagram - median nerve integrity
Thumb abduction test - median nerve integrity; isolates strength of the abductor pollicis
brevis muscle, innervated only by median nerve. Place the hand palm up and raise the
thumb perpendicular to it. Apply downward pressure on the thumb to test muscle
strength; full resistance to pressure is expected; weakness associated CTS
Tinel sign - median nerve integrity; strike patient's wrist w/ index or middle finger where
the median nerve passes under the flexor retinaculum and volar carpal ligament;
tingling sensation radiating from the wrist to the hand in the distribution of the median
nerve is positive, suggests CTS
Phalen test - median nerve integrity; hold both wrists in a fully palmar-flexed position
with the dorsal surfaces pressed together for 1 minute, numbness/tingling = CTS
Reverse Phalen tests - hold hands together as if praying, press for 1 minute
, Less likely CTS - Tinel and Phalen tests are ________ than Katz and Thumb test
Straight leg raising - L4, L5, S1 nerve root irritation
Femoral stretch test - L1, L2, L3, L4 nerve root irritation
Ballottement and Bulge sign - effusion in the knee
Ballottement - extend knee, push down on suprapatellar pouch with the web/thumb and
forefinger of one hand, push the patella quickly downward against the femur with other
hand; tapping or clicking will be sensed when the patella is pushed against the femur if
effusion present. Release pressure and keep your finger lightly touching patella, patella
will float out as if a fluid wave were pushing it if effusion present
Bulge sign - knee extended, milk the medial aspect of the knee upward two or three
times, and then milk the lateral side of the patella. Observe for a bulge of returning fluid
to the hollow area medial to the patella
McMurray test - supine, flex one knee, put thumb and fingers on either side of the joint
space. Hold the heel with your other hand, fully flexing the knee, and rotate the foot and
knee outward (valgus stress) to a lateral position. Extend and then flex the patient's
knee. Any palpable or audible click, pain, or limited extension of the knee is a positive
sign of a torn medial meniscus. Repeat while rotating the foot and knee inward (varus
stress) A palpable or audible click, pain, or lack of extension is a positive sign of a torn
lateral meniscus.
Varus stress - McMurray, foot rotated in, sign of torn lateral meniscus
Valgus stress - McMurray, foot rotated out, sign of torn medial meniscus
Varus - abduction
Valgus - adduction
Anterior and posterior drawer test - ACL/PCL instability; supine, knee flexed 45 to 90
degrees, foot flat on the table. Place both hands on the lower leg with the thumbs on the
ridge of the anterior tibia just distal to the tibial tuberosity. Draw the tibia forward, forcing
the tibia to slide forward of the femur. Then push the tibia backward. Knee movement
over 5 mm in either direction is an unexpected finding.
Varus-valgus stress test - medial or lateral collateral ligament instability in knee
Varus-valgus stress test how to - for lateral and medial collateral ligaments; pt supine,
knee extended, stabilize femur with one hand, hold the ankle with other. Apply varus
force against the ankle (toward the midline) and internal rotation. Excessive laxity is felt
as joint opening = injury to the lateral collateral ligament. Repeat w/ valgus force (away
