rales: Rales, or crackles, are brief, nonmusical, discontinuous sounds. They may be high or low pitched and tend to be heard during inspiration. They may be indicative of fluid or infection in the alveolar spaces, or of inflammation of the interstitium. The latter tend to be very fine, high-pitched, "velcro" like sounds. If the rales clear with coughing, this suggests they are due to secretions in the airway such as can be seen in bronchitis or with prolonged recumbency. Go to page

reactivity to light: When shining a light into the pupil of one eye, pupillary constriction should occur in that eye (the direct response) as well as in the opposite eye (the consensual response). With age, the pupils become slower to react but still react normally. With blindness, there will be a consensual response in the blind eye to light shined in the other eye. A light shined into the blind eye however will elicit neither constriction in the blind eye nor a consensual response in the unaffected eye. Go to page

rebound tenderness: Rebound tenderness is the term used to describe pain elicited for example in the right lower quadrant when the examiner palpates deeply in the left lower quadrant and then withdraws the palpating hand quickly. This is suggestive of focal peritoneal irritation where the pain is felt. Go to page

red reflex: The red reflex is the orange/red glow seen in the pupil when the light from the ophthalmoscope is shined into the pupil. Opacification of the lens such as seen with dense cataracts may cause the red reflex to be absent. Go to page

reinforcement: The reflex response may be augmented by having the patient engage in isometric muscle contraction above the level of the reflex to be tested. For example, if trying to augment the reflexes of the lower extremities, ask the patient to lock his fingers together and pull while you elicit the reflex. In testing upper extremities, ask the patient to clench his teeth. Go to page

renovascular hypertension: Renovascular disease is an important correctable cause of secondary hypertension. Although it accounts for less than one percent of cases of mild hypertension, the incidence increases to 10-45 percent in cases of severe, or refractory hypertension. Most commonly, there is a narrowing of the renal artery(s) as it leads into the kidney. The detection of an abdominal bruit in a patient with poorly controlled or labile hypertension may suggest underlying renovascular disease. Go to page

rheumatoid arthritis: Rheumatoid arthritis causes symmetrical swelling of joints, commonly the joints of the hands. In early disease, the MCP and PIP joints are involved, with swelling and effusions found on exam. Only late in the disease are the DIP joints effected. These joints are tender to the touch or with squeezing. The characteristic joint deformities in established rheumatoid disease include: ulnar deviation, Boutonniere deformity(flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint)or swan neck deformity (hyperextension of the proximal interphalangeal joints with flexion of the distal interphalangeal joints)of the fingers.

rhythm: Normally the radial pulse is felt as having a regular rhythm. If you note an irregular rhythm, try to determine if there is a pattern to the irregularity or if it is entirely irregular. Irregularly irregular rhythms are classically associated with atrial dysrthythmias such as atrial fibrillation. In contrast, irregular rhythms with a pattern are often indicative of premature atrial or ventricular contractions. An EKG however is needed to identify the origin of the rhythm/beats. Go to page

right 2nd intercostal space, palpation of: Pulsations or palpable heart sounds should be considered abnormal here. A pulsation here may suggest an abnormally dilated aorta. A palpable second heart sound would be likely only to be felt in a very thin individual with significant systemic hypertension.

rinne test: The Rinne test, in conjunction with the Weber test, evaluates CN VIII. A 512 Hz tuning fork is used. To perform the Rinne test, place the vibrating tuning fork on the mastoid bone just behind the patient's ear and level with the ear canal (thus testing bone conduction). Ask the patient to tell you when she no longer hears the sound, and then place the "u" of the tuning fork forward close to the ear canal (thus testing air conduction). The Rinne test is negative, or abnormal, if your patient hears the sound longer or louder through bone conduction. This is consistent with conductive hearing loss (especially if the Weber test also lateralizes to that side). If your patient hears the sound longer (or louder) through the air than through the bone, this is normal and is called a normal or positive Rinne test. This may be consistent with a sensorineural hearing loss depending on the results of your Weber test. (The ear with sensorineural hearing loss will have a positive Rinne test and the Weber will lateralize to the "good" ear). Go to page

rotator cuff: The rotator cuff is composed of the tendons of four muscles (supraspinatus, infraspinatus, teres minor and subscapularis) that serve to stabilize the shoulder joint. These muscles insert on the anterolateral surface of the humerus and on the greater tubercle. They aid in rotation of the shoulder and abduction of the arm. Rotator cuff tendonitis is inflammation of the tendons of the supraspinatus and infraspinatus muscles. This is one of the most common causes of shoulder complaints in patients. Patients report pain with reaching, lifting, pushing, pulling, or reaching above their head. Patients also often report pain with lying on the involved shoulder. Typically there is no specific antecedent injury or trauma.