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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3067_Библиотеки_им_академика_М_И_Перельмана
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40
Thessaly: Remember to
“train” patient on unaffected
leg first. Repeat three times at
5° and 20° of knee flexion.
MCL/LCL: Remember to keep
knee slightly flexed
Meniscus
• Thessaly test
• Positive = pain/weakness
1.
Support patient’s
hands
2.
Ask to “Twist on
bent knee”
• Apley grind
• Positive = pain/crepitus
Medial and Lateral Collateral Ligament
• Valgus stress (MCL)
• Positive = excess motion/pain
• Varus stress (LCL)
• Positive = excess motion/pain
1.
Push down on
heel while twisting
leg
1. External
rotation +
valgus force
on knee
1. Internal
rotation +
varus force
on knee
https://t.me/med1917
41
Remember to retract foreskin if
penis is uncircumcised
Remember to compress to
open the urinary meatus
Hernia Exam: While standing,
have patient bear down or
cough. Note any masses or
bulges that touch your finger.
24 Male Genitourinary
• Inspect
• Pubic hair
• Penis
• Penile shaft and glans
• Scrotum
• Palpate
• Penile shaft/glans penis
• Testes
• Epididymis
• Spermatic cord
• External inguinal ring
Hernias
• Inspect for bulges
• Palpate
• Inguinal hernia using index finger
• Femoral hernia by placing your
second, third, and fourth fingers in
the femoral canal
Testis
Glans
Ductus (vas) deferens
Urinary bladder
Seminal
vesicle
Rectum
Prostate
(covered by fascia)
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42
Squamocolumnar junction may
not be distinctly visible
25 Female Genitourinary
• Inspect
• Cervix
• Os
• Squamocolumnar junction
• Cervical discharge
• Abnormalities
• Lesions
• Polyps
• Nabothian cysts
• Strawberry cervix
Mons pubis
Prepuce of clitoris
Glans of clitoris
Urethral meatus
Labium minus
Labium majus
Anus
• Speculum placement
• Use dominant hand to hold labia open
while inserting speculum at a 45° angle
• Bimanual exam
• Cervical motion tenderness (CMT)
• Uterine size and shape
• Adnexal exam
• Rectovaginal exam (thickness of wall)
https://t.me/med1917
43
Use the pads of your fingers
While assessing the deepest
level, you should feel the chest
wall
Masses can be found at any
depth
Arm elevated overhead of
breast that is examined
26 Breast
Breast Exam
• Inspect
• Changes in skin texture
• Discharge from nipple
• Retraction or indentation of nipple
• Atypical fullness and/or dimpling
• Palpate: three levels of depth
• Superficial
• Intermediate
• Deep
Palpation Patterns
Superficial
Intermediate
Deep
https://t.me/med1917
44
27 Rectal
Rectal and Prostate Exam
• Inspect
• Masses
• Fissures
• External hemorrhoids
• Skin changes/lesions
Positioning
for rectal
exam
Knees
to chest
Left lateral
decubitus/
Sims position
• Palpate
• Anal sphincter tone
• Tenderness
• Nodularity or masses
• Internal/external hemorrhoids
• Prostate (males)
• Tenderness
• Nodules or masses
• Size or enlargement
• Observe for grossly bloody stool
• Test for stool occult blood (guaiac)
Positioning for Rectal Exam
• Left lateral decubitus
• Standing and leaning over
the exam table
• Females: feet in stirrups
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45
Keep the bevel of the syringe
up
28 Procedures
Injections
Intramuscular
90°
Subcutaneous
45°
10–15°
Intradermal
Venipuncture
Tourniquet with slip kno
t
Cephalic vein
Antecubital
fossa
Basilic
vein
Median cubital
vein
Arterial Blood Gases
• Line the needle up with the artery, bevel
side up
• Syringe held at 45° angle or less, much
like you would hold a pencil or a dart
• Enter the artery and allow the syringe to
fill spontaneously
Radial artery
Tying the Tourniquet
• Cross strands
• Tuck one strand under the
other
https://t.me/med1917
46
EKG Lead Placement
• Limb leads
• RA: right arm, place “white on right”
wrist
• LA: left arm, place black (opposite of
white) on left wrist
• RL: right leg, “green is for go” =
right leg on gas pedal
• LL: left leg, red (opposite of green)
on left leg
• Precordial leads
• V1: fourth intercostal space, right
sternal border
• V2: fourth intercostal space, left
sternal border
• V3: between V2 and V4
• V4: fifth intercostal space, left
midclavicular line
• V5: anterior axillary line, same level
as V4
• V6: midaxillary line, same level as
V4
RA:
right
wrist
V1
V6
LA: left
wrist
LL: left leg
Midaxillary
line
Anterior
axillary
line
Midclavicular
line
RL:
right leg
https://t.me/med1917
47
29 Electrocardiogram Interpretation
EKG Reading
• Rate
• Measure number of QRS for 6
seconds (30 big boxes)
• Multiply by 10 = heart rate
• or measure R–R interval distance
in big boxes, then each big box
between QRS = 300, 150, 100,
75, 60, 50, 43
300
150
100
75
60
50
43
• Rhythm
• Normal sinus rhythm
• Must have a P wave before
every QRS and a QRS after every
P wave
• Check for
• Regular or irregular
• Constant PR interval
• QRS wide or narrow
• Axis
• The axis indicates the overall
electrical vector of the heart (mostly
determined by ventricles). It can be
determined in many ways; one of
those is determined by QRS
deflection in lead 1 and lead aVF.
• Lead 1 = 0 degrees
• Lead aVF = +90 degrees
• Look for QRS where the deflection
upward is equal to the deflection
downward (isoelectric)
Be Systematic
• Each big box = 0.20 s
• Each little box = 0.04 s
Normal heart rate 60–100
beats/min
• Tachycardia = rate >100
beats/min
• Bradycardia = rate <60
beats/min
Normal sinus rhythm
Isoelectric lead
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48
Normal sinus rhythm is usually
when QT ≤1/2 length of
preceding RR interval
PR <0.12 s (when associated
with a prolonged QRS),
evaluate for Wolff-Parkinson-
White syndrome (WPW)
EKG Reading Continued
• Axis (continued)
• The axis lies upon a line
perpendicular to the isoelectric
(2 possibilities). The correct
possibility determined by the
quadrant (I and aVF).
• Intervals
• PR: 0.12–0.20 s
• QRS: <0.12 s
• QT varies with rate, therefore use
QTc (QT corrected)
• QTc = QT + 1.75 (ventricular rate =
60 beats/min)
• Normal QTc: <0.43 s male or <0.42 s
female
R
P
Q
S
T
U
aVF
NW LAD
NormalRAD
180°
+120°
aVL
aVR
II
0°
I
III
–90°
+60°
+90°
–150°
–30°
https://t.me/med1917
49
Q wave is significant if it is
greater than 1 box wide
(0.04 s) in leads other than III
and AVR, or if it is greater
than 1/3 the amplitude of the
QRS complex
PQRST Morphology
• P wave
• Normal conduction: P wave upright
in I, II, aVF
• RAE: peaked P >2.5 mm in II
• LAE: biphasic P in V1. Double peaked
P in II
Hallmarks of Infarction
• Q waves—if present
• Anterior: V2–V6
• Inferior: II, III, aVF
• Lateral: I, aVL, V5, V6
• Posterior: tall R in V1–V2
• Normal: R waves small in V1–V2 and
grow larger with lateral progression
and should be prominent by V3–V4
• Poor R wave progression in leads V1–V6
• Precordial leads V1–V6
• R waves small in V1–V2 and grow
larger with lateral progression
• Should be prominent by V3–V4
• Poor R wave progression if it does
not dominate until V4–V5
• Early R wave
• R in V1 and V2 as large as next
several leads (might not always
indicate infarction)
Right
atrial
enlarge-
men
t
Peaked P
II
Left
atrial
enlarge-
men
t
Biphasic
P
VI
https://t.me/med1917
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