1. Describe the steps to properly transition from the patient interview to the physical exam.

2. Describe how to perform proper hand washing technique.

Cant find anything in the book yet (so definitely change it if this is wrong), but at the OSCE Dr. Chen said to:
1. Roll down the paper towel
2. Wash hands (not sure about a specific time / method)
3. Grab paper towel to dry hands
4. Use paper towel to turn off sink
3. Explain the proper technique for taking a blood pressure.
Setup:
- Avoid smoking or caffeine for 30 min prior
- Quiet and comfortably warm room
- Sit quietly in chair for 5 min with arm supported at heart level
- Arm free of clothing with no fistulas
- Palpate brachial artery
- Position antecubital crease at arm level

Procedure
- Center cuff over brachial artery with lower border 2.5 cm above antecubital crease
- Secure cuff snugly and slightly flex arm
- First estimate systolic by palpation with radial artery inflate cuff until radial disappears, then add 30 mm Hg
Helps avoid auscultatory gap (silent interval that may be present between sp and dp)
- Deflate cuff, wait 15-30 s
- Place BELL over brachial (Korotkoff sounds are low-pitched)
- Inflate cuff to determined level, then deflate 2-3 mmHg/s
- Note the level when beats start (systolic)
- Lower until sounds are muffled and disappear (dp)
Read table on pg. 115 until the end of BP instructions on p.117. In addition, this is what I have down from small
group:
1. Place BP cuff around arm with label artery facing down into cubital fossa
2. Feel for pulse with right hand and pump cuff with left hand while listening to pulse
3. Pump up to 30 mmHg above loss of pulse
4. Slowly release pressure while looking at meter to note the first measurement at which pulse returns. This is
their systolic pressure.
5. Continue to release pressure and on the way down listen to pulse until the last beat. The pressure at which the
pulse is lost is their diastolic pressure.
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4. Identify common potential errors of blood pressure measurement.

- If brachial artery 7-8 cm below heart level, bp will read 6 cm higher
- If brachial artery 6-7 cm higher, bp will read 5 cm lower
- If cuff is too SMALL, bp reads HIGH
- If cuff is too LARGE, bp reads LOW ON SMALL ARM and HIGH ON LARGE ARM
- Avoid slow or repetitive inflations of cuff (venous congestion can cause false readings)
- If sounds are faint, consider erroneous placement of scope, failure to make full skin contact with bell, venous
engorgement, or shock
5. Recognize the normal and abnormal ranges of a blood pressure for an adult.
Category Systolic Diastolic

Normal <120 <80
Prehtn 120-139 80-89
Htn
Stage 1 140-159 90-99
Stage 2 160 100

When systolic and diastolic fall into different categories, use the higher category
6. Describe orthostatic blood pressure and be able to apply the method in a clinical situation.
- Measure bp and hr while supine (after resting 10 min) and standing (within 3 min)
- Systolic normally drops slightly or is unchanged, and diastolic rises when supine>> standing
- Abnormal: systolic drops 20 mmHg or diastolic drops 10 within 3 minutes standing
- Orthostatic hypotension fall in systolic 20, especially accompanied by tachycardia (p. 119)
7. Explain the proper technique for taking a respiratory rate.
- Count the # of respirations in 1 minute either by visual inspection or subtly listening over trachea with stethoscope
during HEENT or chest exam
- Normal = 20 breaths/min (p. 119)
8. Recognize the normal and abnormal ranges of a respiratory rate for an adult. Define tachypnea.
9. Explain the different methods for taking a temperature.
- Oral temp = 37 C or 98.6 F
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- Rectal = higher by .4-.5 C or .7-.9 F, axillary = lower by 1 degree

- Oral temperature shake glass thermometer down to 35C/96F or below, insert under tongue, tell patient to
close both lips, and wait 3-5 min. Then read, reinsert for 1 min, and read it again. Repeat until temp is stable. Hot or
cold liquids and smoking can alter temp
- Electronic temp place disposable cover over probe and insert under tongue, ask patient to close both lips.
Usually takes 10 s
- Rectal temp ask pt to lie on one side with hip flexed, insert 3-4 cm into anal canal pointing toward umbilicus.
Remove after 3 min. If using electronic therm, lubricate probe and wait 10 s for reading
- Tympanic membrane temp make sure canal is clean of cerumen which can lower reading. Aim infrared
beam at tympanic membrane, wait 2-3 s. Higher than normal body temp by about 0.8 C (1.4 F). More variable than
other measurements.
10. Explain the proper technique for taking a pulse.
- Use pads of index and middle fingers and compress radial artery until a max pulsation detected
- If regular rhythm, count for 30 s and multiply by 2
- If unusual or slow rate, count for 60 s
- Normal = 50-90 bpm
11. Recognize the normal and abnormal ranges of a pulse for adults. Define bradycardia and tachycardia.
Sinus bradycardia: <60 bpm
Sinus tachycardia: 100-180 bpm
12. List environmental, disease process, and other factors that may affect heart rate, blood pressure, respiratory rate,
temperature, and pain.
A lot of stuff
13. Distinguish between and acute and chronic pain.
14. Explain the different types of pain (nociceptive or somatic, neuropathic, psychogenic and idiopathic)
15. Calculate the Body Mass Index and be able to interpret the classification of weight by Body Mass Index.
- 60% US adults are obese or overweight and 14% children
- <18.5 underweight, 18.5-24.9 normal, 25-29.9 overweight, 30-34.9 (obese I), 35-39.9 (obese II), >40 extreme
obesity
- Weight (kg)/height (m2)
- Weight (lbs)*700/height (in)/height (in)
16. Distinguish between normal and abnormal vital signs and be able to apply the knowledge to clinical cases.
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17. Demonstrate proper handwashing technique and perform measurement of the vital signs.
18. Demonstrate the assessment of visual acuity and visual fields by confrontation.
Purpose of testing visual acuity is to assess any deviation from normal vision
1. Use a Snellen eye chart
2. Position patient 20 feet from chart
3. Patients who use glasses other than for reading should put them on
4. Ask patient to cover one eye with a card and read the smallest line of print possible (encourage patient to
attempt the next line)
5. A patient who cannot read the largest letter should be positioned closer to the chart; the intervening distance
should be noted
6. Determine the smallest line of print from which the patient can identify more than half the letters
7. Record the visual acuity designated at the side of this line, along with the use of glasses, if any
8. Visual acuity is expressed as two numbers (ex: 20/40) the first number indicates the distance of the
patient from the chart; the second number indicates the distance at which a normal eye can read the line of
letters
Purpose of testing visual fields by confrontation is to assess any deviation from normal boundaries
1. Imagine the patients visual fields projected onto a bowl that encircles the front of the patients head
2. Ask the patient to look with both eyes into your eyes
3. While you return the patients gaze, place your hands about 2 feet apart, lateral to the patients ears
4. Instruct the patient to point to your fingers as soon as they are seen
5. Then slowly move the wiggling fingers of both your hands along the imaginary bowl and toward the line of
gaze until the patient identifies them
6. Repeat this pattern in the upper and lower temporal quadrants
7. Usually a person sees both sets of fingers at the same time; if so, fields are usually normal
19. Define pupillary reactions.
Pupillary reactions: pupillary size changes in response to light and to the effort of focusing on a near object.
Sensory pathway: retina --> optic nerve --> optic tract --> midbrain --> impulses transmitted through the
oculomotor nerve --> constrictor muscles of the iris of each eye
a. Ask patient to look into the distance, and shine a bright light obliquely into each pupil in turn (darken the room if
necessary); look for:
b. Direct reaction (pupillary constriction in the same eye)
c. Consensual reaction (pupillary constriction in the opposite eye)
If the reaction to light is impaired or questionable, test the near reaction in normal room light (test one eye at a
time)
a. Hold your finger about 10 cm from the patients eye
b. Ask the patient to look alternately at it and into the distance directly behind it
c. Watch for pupillary constriction with near effort
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d. Coincident with this constriction, but not part of it, are convergence of the eyes and accommodation, or an increased
convexity of the lens
20. Demonstrate the assessment of visual fields and describe the abnormalities of horizontal defect, blind right eye,
homonymous hemianopsias, bitemporal hemaianopsia, and homonymous quadrantopsias.
21. Identify and describe the actions of the 6 muscles involved with extraocular movements.
Techniques to examine:
1. Ask the patient to follow your finger as you sweep through the six cardinal direction of gaze
2. Making a wide H in the air, lead the patients gaze (1) to the patients extreme right, (2) to the right and upward,
(3) down on the right; then (4) without pausing in the middle, to the extreme left, (5) to the left and upward, and
(6) down on the left
3. Pause during upward and lateral gaze to detect nystagmus
22. Recognize the different abnormal extraocular movements including dysconjugate gaze, nystagmus, and lid lag.
23. Explain how to properly use the ophthalmoscope.
24. Describe the different parts of the normal fundoscopic exam.
25. Identify the anatomy/common structures in the head region which are routinely assessed on the physical exam
including: eye, external ear, nose, sinuses, mouth, and throat
26. Describe the proper techniques for examining the nose and sinuses.
27. Identify the normal landmarks of the tympanic membrane.
28. Explain and demonstrate the proper way to use the otoscope.
29. Describe how to perform the auditory acuity test.
30. Explain the Weber and Rinne tests, and how they are used to distinguish between conduction hearing loss and
sensorineural hearing loss.
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1. Identify the anatomy of the neck and lymph nodes.
For descriptive purposes, divide each side of the neck into two triangles bound by the SCM. This gives you
the anterior and posterior triangles. Deep to the SCM run the carotid artery and internal jugular vein. The external
jugular vein passes diagonally over the surface of the SCM. In the midline, be able to identify the mobile hyoid bone
just below the mandible, the thyroid cartilage (Adams apple), cricoid cartilage, tracheal rings, and thyroid gland. For
lymph nodes, see the picture in the text but be able to identify tonsillar, supraclavicular, submandibular and
submental lymph nodes.
2. Describe normal findings of the neck, lymph nodes, trachea, and thyroid gland.
Inspect the neck, noting its symmetry and any masses or scars. Look for enlargement of the parotid or
submandibular glands, and note any visible lymph nodes. Palpate the lymph nodes. Using the pads of the 2nd and
3rd fingers, palpate the lymph nodes with a gentle rotary motion. The patient should be relaxed, with neck flexed
slightly forward and, if needed, slightly toward the side being examined. You can usually examine both sides at once.
(For the submental node, it is helpful to feel with one hand while bracing the top of the head with the other.) Feel in
sequence for the following lymph nodes: preauricular, posterior auricular, occipital, tonsillar, submandibular,
submental, superficial cervical, posterior cervical, deep cervical chain, supraclavicular. Note their size, shape,
delimitation (discrete or matted together), mobility, consistency, and any tenderness. Small, mobile, discrete,
nontender nodes, sometimes termed shotty, are frequently found in normal persons. Enlarged or tender nodes, if
unexplained, call for reexamination of the regions they drain, and careful assessment of lymph nodes elsewhere so
that you can distinguish between regional and generalized lymphadenopathy. Occasionally you may mistake a band
of muscle or an artery for a lymph node. You should be able to roll a node in two directions: up and down, and side to
side. Neither a muscle nor an artery will pass this test.
3. Describe and demonstrate the steps for palpating the thyroid gland.
a. Find landmarks
i. Notched thyroid cartilage and the cricoid cartilage
ii. Locate the thyroid isthmus (over the 2nd, 3rd, 4th tracheal rings)
b. Steps for palpation (posterior approach)
i. Ask the patient to flex the neck slightly forward to relax the sternomastoid muscles
ii. Place the fingers of both hands on the patients neck so that your index fingers are just
below the cricoid cartilage
iii. Ask the patient to sip/swallow water as before. Feel for the thyroid isthmus rising up under your
finger pads (often palpable)
iv. Displace the trachea to the right with the fingers of the left hand, with the right hand fingers,
palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and
the relaxed sternomastoid. Find the lateral margin. In a similar fashion, examine the left lobe. The lobes are
somewhat harder to feel than the isthmus, so practice is needed.
v. Note the size shape and consistency of the gland and identify any nodules or tenderness.
vi. If thyroid gland is enlarged, listen to the lateral lobes to detect a bruit
4. Identify landmarks and anatomic correlations of the lung and thorax.
The sternal angle is adjacent to the 2nd rib and costal cartilage. This is the level at which the trachea
bifurcates.
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The inferior tip of the scapula is at the level of the 7th rib
The oblique fissure of the lung can be approximated by a string that runs from the T3 spinous process
around the chest to the 6th rib to the midclavicular line
The horizontal fissure runs close to the 4th rib and meets the oblique fissure midaxillary near the 5th rib
The lower border of the lung crosses the midclavicular line at the 6th rib, the 8th rib midaxillary, and
posteriorly at the border of T10
5. Describe the mechanisms of inspiration and expiration.
During inspiration: the diaphragm contracts, the thorax expands, and this decreases intrapleural pressure -
draws air into the alveoli and expands the lungs
Oxygen goes into the capillaries, Carbon Dioxide goes from the blood into the alveoli
As inspiratory efforts stop, chest wall recoils, diaphragm relaxes and rises passively, decreasing thoracic
volume - air flows outward
6. List and describe the common symptoms of the thorax and lung.
Common or concerning symptoms: chest pain, dyspnea, wheezing, cough, blood-streaked sputum
(hemoptysis). Complaints of chest pain or chest discomfort raise the specter of heart disease, but often arise from
structures in the thorax and lung as well. Sources of chest pain are the myocardium, pericardium, aorta, trachea and
large bronchi, parietal pleura, musculoskeletal system and skin of chest well, esophagus, and extrathoracic
structures such as the neck, gallbladder, and stomach. A clenched fist over the sternum suggests angina pectoris; a
finger pointing to a tender area on the chest wall suggests musculoskeletal pain; a hand moving from neck to
epigastrum suggests heartburn. Anxiety is the most frequent cause of chest pain in children. Dyspnea is a nonpainful
but uncomfortable awareness of breathing that is inappropriate to the level of exertion. Anxious patients may have
episodic dyspnea during both rest and exercise, and hyperventilation, or rapid, shallow breathing. At other times, they
may have frequent sighs. Wheezes are musical respiratory sounds that may be audible to the patient and to others.
Wheezing suggests partial airway obstruction from secretions, tissue inflammation, or a foreign body. Cough is a
common symptom that ranges in significance from trivial to ominous. Typically cough is a reflex response to stimuli
that irritate receptors in the larynx, trachea, or large bronchi. Although cough typically signals a problem in the
respiratory tract, it may also be cardiovascular in origin. Cough can be a symptom of left-sided heart failure. In
Mycoplasma pneumoinia there is a dry hacking cough; there is a productive cough in bronchitis, viral or bacterial
pneumonia. Mucoid sputum is translucent, white or gray; purulent sputum is yellowish or greenish. Foul-smelling
sputum is anaerobic lung abscess; tenacious sputum occurs in cystic fibrosis. Hemoptysis is the coughing up of
blood from the lungs; it may vary from blood-streaked phlegm to frank blood. Try to confirm the source of the
bleeding. Blood or blood-streaked material may originate in the mouth, pharynx, or GI tract. Blood originating in the
stomach is usually darker than blood from the respiratory tract and may be mixed with food particles.
7. Describe what inspection can detect.
From a midline position behind the patient, note the shape of the chest and the way in which it moves,
including: deformities or assymetry, abnormal retraction of the interspaces during inspiration (retraction is most
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apparent in the lower interspaces, supraclavicular retraction is often present, retraction occurs in severe asthma,
COPD, or upper airway obstruction), impaired respiratory movement on one or both sides or a unilateral lag in
movement. Unilateral impairment or lagging of respiratory movements suggests disease of the underlying lung or
pleura.
For the anterior chest, observe the shape of the patients chest and the movement of the chest wall. Look
for deformities or asymmetry, abnormal retraction of the lower interspaces during inspiration (due to severe asthma,
COPD, or upper airway obstruction), and local lag or impairment in respiratory movement (underlying disease of lung
or pleura).
See Table with pictures of barrel chest (COPD), traumatic flail chest (multiple rib fractures), funnel chest
(pectus excavatum, what I, Yoni Litwok has), pigeon chest (pectus carinatum, opposite of what I have, sternum sticks
out), and thoracic kyphoscoliosis (abnormal spinal curvatures and vertebral rotation).
8. List and describe normal and the different deformities of the thorax.
a. Chest pain
i. Thoracic and cardiac causes
ii. Keep in mind the myocardium, pericardium, aorta, trachea/large bronchi, parietal pleura,
chest wall (including musculoskeletal system and skin), esophagus, extrathoracic structures
such as the neck, gallbladder and stomach
b. Shortness of breath (Dyspnea) and wheezing
i. Dyspnea = nonpainful but uncomfortable awareness of breathing that is inappropriate for
the level of exertion (shortness of breath)
1. Cardiac or pulmonary disease
ii. Wheezes musical respiratory sounds that may be audible to the patient and to others
c. Cough
i. Reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi
ii. Stimuli include mucus, pus, and blood as well as external agents such as dust, foreign
bodies, or even extremely hot or cold air
iii. Inflammation of the respiratory mucosa and pressure/tension in the air passages from a
tumor or enlarged peribronchial lymph nodes
iv. Cough typically is for a problem in the respiratory tract (it may also be cardiovascular in
origin.
v. Dry? Sputum? Phlegm?
d. Hemoptysis
i. Coughing up of blood from the lungs
1. Be careful b/c blood can come from mouth, pharynx, GI tract and can be mislabeled
9. Describe what palpation can detect and how to perform these maneuvers.
For posterior wall: identify tender areas, assess any observed abnormalities such as masses or sinus tracts, test
chest expansion, feel for tactile fremitus, and palpate and compare symmetric areas of the lungs. To test chest
expansion ask the patient to inhale deeply as your thumbs are placed at the level of the 10th ribs and your fingers on
the lateral rib cage. Fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the
chest wall when the patient speaks. To detect fremitus, use either the ball or the ulnar surface of your hand to
optimize the vibratory sensitivity of the bones in your hand. Ask the patient to repeat the words ninety-nine or one-
to-one.
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For anterior chest: identify tender areas, assessment of observed abnormalities, further assessment of chest
expansion and assessment of tactile fremitus.
See pic for locations of where to feel fremitus. Fremitus is decreased or absent when the voice is soft or when the
transmission of vibrations from the larynx to the surface of the chest is impeded. Causes include an obstructed
bronchus; COPD; separation of the pleural surfaces by fluid, fibrosis, air, or an infiltrating tumor; and a very thick
chest wall.
10. Describe what percussion can detect, and what each percussion note implies and how to perform the technique.
Percussion helps you establish whether the underlying tissues are air-filled, fluid-filled, or solid.
Intensity Pitch Duration Location Pathologic
examples
Flatness Soft High Short Thigh Large pleural
effusion
Dullness Medium Medium Medium Liver Lobar pneumonia
Resonance Loud Low Long Normal lung Simple chronic
bronchitis
Hyperresonance Very Loud Lower Longer None normally Emphysema,
pneumothorax
Tympany Loud High Gastric air
bubble or puffed-
out cheek
Large
pneumothorax
11. Describe the normal sounds that can be detected during auscultation, including location, duration, intensity, and
pitch of the sounds.
Vesicular, or soft and low pitched. They are heard through inspiration, continue without pause through expiration, and
then fade away about one third of the way through expiration.
Bronchovesicular, with inspiratory and expiratory sounds about equal in length, at times separated by a silent
interval. Detecting differences in pitch and intensity is often easier during expiration.
Bronchial, or louder and higher in pitch, with a short silence between inspiratory and expiratory sounds. Expiratory
sounds last longer than inspiratory sounds.
Tracheal breath sounds are very loud, harsh sounds that are heard by listening over the trachea in the neck
**There is a good table of this info in the text
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12. Describe the abnormal lung sounds, including duration, intensity, and pitch of the sounds.
Crackles: discontinuous, intermittent, non-musical, brief
Fine crackles are soft, high pitched and very brief - 5-10 ms
Course crackles are louder, lower pitched and a little longer - 20-30 ms
Wheezes and Rhonchi: continuous, greater than 250 ms, musical, prolonged but not necessarily persisting
throughout the respiratory cycle
Wheezes: high pitched with hissing/shrill quality
Rhonchi: low pitched with snoring quality
Strider: Wheeze that is predominantly inspiratory, louder in neck than over chest wall
Pleural Rub: creaking sounds that resemble crackles accoustically
Mediastinal Crunch: series of precordial crackles that are synchronous with heart beat, not respiration
13. List common lung diseases associated with each abnormal lung sound.
Crackles: pneumonia, fibrosis, early CHF, bronchitis
Wheezing: asthma, COPD, bronchitis
Rhonchi: secretions in large airways, often clear with coughing
Strider: partial obstruction of larynx or trachea
Pleural rub: inflamed pleural surfaces
Mediastinal crunch: mediastinal emphysema
14. Describe the techniques for measuring transmitted voice sounds and understand what they can detect.
If you hear abnormally located broncho-vesicular or bronchial breath sounds, assess transmitted voice sounds. With
a stethoscope, listen in symmetric areas over the chest wall as you:
Ask the patient to say ninety-nine. Normally the sounds transmitted through the chest wall are muffled and
indistinct. Louder, clearer voice sounds are called bronchophony.
Ask the patient to say ee. You will normally hear a muffled long E sound. When ee is heard as ay, an
E-to-A change (egophony) is present, as in lobar consolidation from pneumonia. The quality sounds nasal.
Ask the patient to whisper ninety-nine or one-two-three. The whispered voice is normally heard faintly
and indistinctly, if at all. Louder, clearer whispered sounds are called whispered pectoriloquy.
15. Explain how to assess the pulmonary function.
A simple but informative way to assess the pulmonary function is the walk test. Time an 8-foot walk at the patients
normal pace. Repeat the walk and note the faster time. Also observe the rate, effort, and sound of the patients
breathing.
16. Explain how to assess the expiratory phase of breathing.
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The forced expiratory time test assesses the expiratory phase of breathing, which is typically slowed in obstructive
pulmonary disease. Ask the patient to take a deep breath in and then breath out as quickly and completely as
possible with mouth open. Listen over the trachea with the diaphragm of a stethoscope and time the audible
expiration. Try to get three consistent readings, allowing a short rest between efforts if necessary. Patients older than
60 years with a forced expiratory time of 6 to 8 seconds are twice as likely to have COPD (p. 309).
17. Describe how to identify a fractured rib.
Local pain and tenderness of one or more ribs raise the question of fracture. By anteroposterior compression of the
chest, you can distinguish a fracture from a soft tissue injury. With one hand on the sternum and the other on the
thoracic spine, squeeze the chest. Is it painful, and where? An increase in the local pain (distant from your hands)
suggests rib fracture rather than just soft-tissue injury (p. 309).
18. List and describe both normal and abnormal breathing patterns.
Here are the descriptions of normal and abnormal breathing patterns, it might also be worthwhile to look at page 134
in bates to see graphical descriptions of each individual breathing pattern.
Type of Breathing Finding
Normal Respiratory rate is about 14-20 per min in normal adults and
up to 44 per min in infants
Slow Breathing (Bradypnea) May be secondary to such causes as diabetic coma, drug-
induced respiratory depression, and increased intracranial
pressure
Sighing Respiration Breathing punctuated by frequent sighs should alert you to the
possibility of hyperventilation syndrome - a common cause of
dyspnea and dizziness.
Rapid Shallow Breathing (Tachypnea) Has a number of causes, including restrictive lung disease,
pleuritic chest pain, and an elevated diaphragm
Cheyne-Stokes Breathing Periods of deep breathing alternate with periods of apnea (no
breathing). Children and aging people normally may show this
pattern in sleep. Other causes include heart failure, uremia,
drug-induced respiratory depression, and brain damage
(typically on both sides of the cerebral hemispheres)
Obstructive Breathing In obstructive lung disease, expiration is prolonged because
narrowed airways increase the resistance to air flow. Causes
include asthma, chronic bronchitis, and COPD.
Rapid Deep Breathing (Hyperpnea, Rapid deep breathing has several causes, including exercise,
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Hyperventilation) anxiety, and metabolic acidosis. In the comatose patient,
consider infarction, hypoxia, or hypoglycemia affecting the
midbrain or pons. Kussmaul breathing is deep breathing due
to metabolic acidosis. It may be fast, normal in rate, or slow.
Ataxic Breathing (Biots Breathing) Ataxic breathing is characterized by unpredictable irregularity.
Breaths may be shallow or deep, and stop for short periods.
Causes include respiratory depression and brain damage,
typically at the medullary level.
Physical Exam Session 3
1. Describe the sequence of steps in the cardiac exam.
Page 354 in Bates:
Patient Position Examination
Supine, with head elevated 30 Inspect and palpate the precordium (portion of the body over
the heart): the second right and left interspaces; the right
ventricle; and the left ventricle, including the apical impulse
(diameter, location, amplitude, duration)
Left lateral decubitus (lying on left side) Palpate the apical impulse if not previously detected. Listen
at the apex with the bell of the stethoscope.
Supine, with head elevated 30 Listen to the 2nd right and left interspaces, along the left
sternal border, across to the apex with the diaphragm.
Listen at the right sternal border for tricuspid murmurs and
sounds with the bell.
Sitting, leaning forward, after full exhalation Listen along the left sternal border and at the apex with the
diaphragm.
2. Discuss the anatomy and physiology of the cardiovascular system.
The right ventricle occupies most of the anterior cardiac surface. This chamber and the pulmonary artery form a
wedge-like structure behind and to the left of the sternum. The inferior border of the right ventricle lies below the
junction of the sternum and the xiphoid process. The right ventricle narrows superiorly and joins the pulmonary artery
at the level of the sternum or base of the heart - a clinical term that refers to the superior aspect of the heart at the
right and left 2nd interspaces next to the sternum.
The left ventricle, behind the right ventricle and to the left, forms the left lateral margin of the heart. Its tapered inferior
tip is often termed the cardiac apex. It is clinically important because it produces the apical impulse, identified
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during palpation of the precordium as the point of maximal impulse (PMI). This impulse locates the left border of the
heart and is normally found in the 5th interspace 7 - 9 cm lateral to the midsternal line.
Im not going to go through heart chambers/valves because if youve learned anything in medical school so far thats
probably it. As far as physiology goes, heres a brief synopsis of the events in the cardiac cycle (read pages 326-328
if you want to get more in depth):
during diastole, pressure in the blood-filled left atrium slightly exceeds that in the relaxed left ventricle, and
blood flows from left atrium to left ventricle across the open mitral valve. Just before the onset of ventricular
systole, atrial contraction produces a slight pressure rise in both chambers.
during systole, the left ventricle starts to contract and ventricular pressure rapidly exceeds left atrial
pressure, shutting the mitral valve. Closure of the mitral valve produces the first heart sound, S1.
As left ventricular pressure continues to rise, it quickly exceeds the pressure in the aorta and forces the
aortic valve open. In some pathologic conditions, an early systolic ejection sound (Ej) accompanies the
opening of the aortic valve. Normally, maximal left ventricular pressure corresponds to systolic blood
pressure.
As the left ventricle ejects most of its blood, ventricular pressure begins to fall. When left ventricular
pressure drops below aortic pressure, the aortic valve shuts. Aortic valve closure produces the second heart
sound, S2, and another diastole begins.
3. Distinguish when to use the bell versus the diaphragm.
p. 363 - The diaphragm is better for picking up relatively high-pitched sounds of S1 and S2, the murmurs of aortic
and mitral regurgitation, and pericardial friction rubs. Listen through the precordium with the diaphrgam, pressing it
firmly against the chest.
The bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis. Apply the bell
lightly, with just enough pressure to produce an air seal with its full rim. Use the bell at the apex, then move medially
along the lower sternal border. Resting the heel of your hand on the chest like a fulcrum may help you maintain light
pressure. Pressing the bell firmly on the chest makes it function more like a diaphragm by stretching the underlying
skin. Low-pitched sounds such as S3 and S4 may disappear with this technique; an observation that may help to
identify them. In contrast, high-pitched sounds such as midsystolic click, an ejection sound, or an opening snap will
persist or get louder.
4. Describe the anatomic locations best suited for auscultation of S1 and S2.
- The best place to hear the S1 sound is at the apex of the heart or approximately the 5th interspace on the left lateral
to the midsternal line and the best place to hear the S2 sound is at the base of the heart or the 2nd interspace on the
right parasternally.
5. Describe the physiologic correlates of S1 and S2.
**S1 is the first heart sound and it occurs due to closure of the mitral/tricuspid valves (AV Valves). The first heart
tone, or S1, forms the "lub" of "lub-dub". It is caused by the sudden block of reverse blood flow due to closure of the
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atrioventricular valves , i.e. tricuspid and mitral (bicuspid), at the beginning of ventricular contraction, or systole . When
the ventricles begin to contract, so do the papillary muscles in each ventricle. The papillary muscles are attached to
the tricuspid and mitral valves via chordae tendineae, which bring the cusps or leaflets of the valve closed (chordae
tendineae also prevent the valves from blowing into the atria as ventricular pressure rises due to contraction). The
closing of the inlet valves prevents regurgitation of blood from the ventricles back into the atria. The S1 sound results
from reverberation within the blood associated with the sudden block of flow reversal by the valves.
**S2 is the second heart sound and it occurs due to closure of the pulmonic/aortic valves (semilunar valves). The
second heart tone, or S2, forms the dub of lub-dub. It is caused by the sudden block of reversing blood flow due
to closure of the semilunar valves which are the aortic valve and pulmonary valve , at the end of ventricular systole ,
i.e. beginning of ventricular diastole . As the left ventricle empties, its pressure falls below the pressure in the aorta ,
aortic blood flow quickly reverses back toward the left ventricle, catching the aortic valve pocketlike cusps and is
stopped by aortic (outlet) valve closure. Similarly, as the pressure in the right ventricle falls below the pressure in the
pulmonary artery , the pulmonary (outlet) valve closes. The S2 sound results from reverberation within the blood
associated with the sudden block of flow reversal.
6. Identify physiologic and paradoxical splitting of S2.
Listen for physiologic splitting of S2 in the 2nd or 3rd left interspace. The pulmonic compononent of S2 is usually too
faint to be heard at the apex or aortic area, where S2 is a single sound derived from aortic valve closure alone.
Normal splitting is accentuated by inspiration and usually disappears on expiration. In some patients, especially
younger ones, S2 may not become single on expiration. It may emerge when a patient sits up.
Paradoxical or reversed splitting refers to splitting that appears on expiration and disappears on inspiration. Closure
of the aortic valve is abnormally delayed so that A2 follows P2 in expiration. Normal inspiratory delay of P2 makes
the split disappear. The most common cause of paradoxical splitting is left bundle branch block.
7. Describe what palpation in the cardiac exam can detect.
p. 356 - palpation is valuable for detecting thrills, the timing of S1 and S2, and the ventricular movements of S3 or S4
Begin with general palpation of the chest wall. First palpate for heaves, lifts, or thrills, using your fingerpads.
Hold them flat or obliquely on the body surface. Ventricular impulses may heave or lift your fingers.
Check for thrills, formed by the turbulence of underlying murmurs, by pressing the ball of your hand firmly on
the chest. If subsequent auscultation reveals a loud murmur, go back to that area and check for thrills again.
Use firm pressure for an S1 and S2 and lighter pressure for S3 and S4. When palpating for S1 and S2 place
your right hand on the chest wall and your left index and middle fingers on the right carotid artery in the
lower third of the neck. Identify S1 which occurs just before the carotid upstroke. Now identify S2 which
occurs after the carotid upstroke.
Be sure to assess the right ventricle by palpating the right ventricular area at the lower left sternal border
and in the subxiphoid area, the pulmonary artery in the left 2nd interspace, and the aortic area in the right
2nd interpsace
8. Describe how to assess the point of maximal impulse.
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p. 357 - the apical impulse represents the brief early pulsation of the left ventricle as it moves anteriorly
during contraction and touches the chest wall. Note that in most examinations the apical impulse is the point
of maximal impulse, or PMI; however, some pathologic conditions may produce a pulsation that is more
prominent than the apex beat, such as an enlarged right ventricle, a dilated pulmonary artery, or an
aneurysm of the aorta
if you cannot identify the apical impulse with the patient supine, ask the patient to roll party only the left side
(left lateral decubitus position); palpate again, using the palmar surfaces of several fingers. If you cannot
find the apical impulse, ask the patient to exhale fully and stop breathing for a few seconds
when you have found the apical impulse, make finer assessments with your fingertips, and then with one
finger
Assess the location, diameter, amplitude and duration of the apical impulse
Location: try to assess the location with the patient supine, because the left lateral decubitus
position displaces the apical impulse to the left; locate two points: the interspaces, usually the 5th
or possibly the 4th, which give the vertical location; and the distance in centimeters from the
midsternal line, which gives the horizontal location
Diameter: it usually measure less than 2.5 cm and occupies only one interspace; it may feel larger
in the left lateral decubitus position
Amplitude: estimate the amplitude; it is usually small and feels brisk and tapping; some young
people have an increased amplitude, or hyperkinetic impulse, especially when excited or after
exercise; its during, however, is normal
Duration: duration is the most useful characteristic of the apical impulse for identifying hypertrophy
of the left venticle; to assess duration, listen to the heart sounds as you feel the apical impulse, or
watch the movement of your stethoscope as you listen at the apex. Estimate the proportion of
systole occupied by the apical impulse. Normally it lasts through the first of systole, and often
less, but does not continue to the second heart sound
9. Explain how to screen for coronary heart disease and stroke.
p.341
The challenge for health care professionals is to engage greater numbers of patients, at an earlier stage of
their disease, in comprehensive cardiovascular risk reduction to expand the benefits of primary prevention.
The continuing message is that adoption of healthy life habits remains the cornerstone of primary
prevention.
The imperative is to prevent the first episode of coronary disease or stroke or the development of aortic
aneurysm and peripheral vascular disease because of the still-high rate of rst events that are fatal or
disabling.
As a first step, clinicians need to identify not only elevated blood pressure but also other well-studied risk factors for
coronary heart disease (CHD).
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Risk factor screening for adults beginning at 20 years
Global absolute CHD risk estimation for all adults 40 years and older. The goal of global risk estimate is to
help patients keep their risk as low as possible. Note that diabetes, or 10-year risk of more than 20%, is
considered equivalent to established CHD risk equivalents.
10. Understand the lifestyle modifications to reduce high blood pressure.
p. 345 - Lifestyle modifications for hypertension can lower systolic blood pressure from 2 to 20 mm Hg
Optimal weight, or BMI of 18.5-24.9 kg/m2
Salt intake of less than 6 grams of sodium chloride or 2.4 grams of sodium per day
Regular aerobic exercise such as brisk walking for at least 30 mins per day, most days a week
Moderate alcohol consumption per day of 2 drinks or fewer for men and 1 drink or fewer for women (2 drinks
= 1 oz ethanol, 24 oz beer, 10 oz wine, or 2-3 oz whiskey)
Dietary intake of more than 3,000 mg of potassium
Diet rich in fruits, vegetables, and low-fat dairy products with reduced content of saturated and total fats
11. Describe how to evaluate jugular venous pulse, the carotid upstroke, and detect the presence of carotid bruits.
p351 Jugular venous pulse -
Observe the amplitude and timing of the jugular venous pulsations.
To time them, feel the left carotid artery with your right thumb or listen to the heart simultaneously. The a wave just
precedes S1 and the carotid pulse, the x descent can be seen as a systolic collapse, the v wave almost coincides
with S2, and the y descent follows early in diastole. Look for absent or unusually prominent waves.
P353 - Carotid upstroke
After increasing pressure until you feel maximal pulsation, slowly decrease pressure until you best sense arterial
pressure and contour; then assess:
The contour of the pulse wave (speed of the upstroke), the duration of its summit, and the speed of the
downstroke. The normal upstroke is brisk. It is smooth, rapid, and follows S1 almost immediately. The summit is
smooth, rounded and roughly midsystolic. The downstroke is less abrupt than the upstroke.
RED TEXT - Delayed carotid upstroke - AORTIC STENOSIS
P353 - BRUIT
During palpation of the carotid artery, you may detect humming vibrations, or thrills, that feel like the throat
of a purring cat. Routinely, but especially in the presence of a thrill, listen over both carotid arteries with the
diaphragm of your stethoscope for a bruit, a murmur like sound of vascular rather than cardiac origin.
Listen for carotid bruits if patient middle aged or elderly, or if you suspect cerebrovascular disease.
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To assess: ask the patient to hold breathing for a moment so that breath sounds do not obscure the
vascular sound, then listen with the bell. Heart sounds alone do not constitute a bruit.
RED TEXT - Note that an aortic valve murmur may radiate to the neck and sound like a carotid bruit
The prevalence of asymptomatic carotid bruits increases with age (8 percent in people 75 years or older),
with 3 fold increase risk of ischemic heart disease and stroke. presence of carotid bruit does not predict the
degree of underlying stenosis.
12. Describe and characterize heart murmurs.
Murmurs can be described in many different ways, the first way they are described in by when they occur:
- Midsystolic murmur: begins after S1 and stops before S2. There are brief gaps between the murmur and the
heart sound. The easiest one to identify is the gap between the murmur and S2 which also helps distinguish this
murmur from a pansystolic murmur.
-Pansystolic murmur: also called a holosystolic murmur starts at S1 and ends at S2 with no gaps between the
murmur and the heart sounds.
-Late systolic murmur: usually starts in mid or late systole and persists up to S2.
-Early Diastolic murmur: starts immediately after S2 with no discernible gap and then fades into silence before S1.
-Middiastolic murmur: Starts a short time after S2 and it may fade away or merge into a late diastolic murmur.
-Late diastolic murmur: Starts late in diastole and continues into S1.
Murmurs can also be characterized by its shape (determined by its intensity over time) there are four ways to classify
these:
- a crescendo murmur grows louder, a decrescendo murmur grows softer, a crescendo-decrescendo murmur first
rises in intensity then falls and a plateau murmur that has the same intensity throughout.
Finally murmurs can also be classified by the location of maximal intensity (site where the murmur originates), the
radiation or transmission from the point of maximal intensity (can tell you the direction of blood flow) and its intensity
(graded on a 6 point scale)
13. Explain how to grade murmurs using the 6 point scale.
p. 368
Grade 1 Very faint, heard only after listener has tuned in may not be heard in all positions
Grade 2 Quiet, but heard immediately after placing the stethoscope on the chest
Grade 3 Moderately loud
Grade 4 Loud, with palpable thrill
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Grade 5 Very loud, with thrill. May be heard when the stethoscope is partly off the chest
Grade 6 Very loud, with thrill. May be heard with stethoscope entirely off the chest
14. Describe and discuss the techniques to help distinguish between the murmurs of mitral valve prolapse,
hypertrophic cardiomyopathy from aortic stenosis.
- A murmur from a mitral prolapse will be heard over the apex of the heart and it will radiate to the left axilla. It is soft
to loud in intensity (if loud it is associated with apical thrill). It is of medium to high pitch and is harsh and holosystolic
(pansystolic). Unlike tricuspid regurgitation, it doesnt get louder in inspiration.
- A murmur from aortic stenosis is heard over the right second intercoastal space and it often radiates to the carotids,
down the left sternal border even to the apex. It is sometimes soft but often loud, with a thrill. Its pitch is medium,
harsh; crescendo-decrescendo may be higher at the apex. It is often a harsh sound and it is heard best with the
patient sitting and leaning forward.
- A murmur from hypertrophic cardiomyopathy is heard at the 3rd or 4th left interspaces and radiates down the left
sternal border to the apex, possibly to the base but not to the neck. The intensity is variable, the pitch is medium and
the quality is harsh. The sound decreases with squatting, increases with straining down from valsalva and standing.
15. Describe pulsus alternans and paradoxical pulse.
p. 370 - In pulsus alternans, the rhythm of the pulse remains regular, but the force of the arterial pulse alternates
becomes of alternating strong and weak ventricular contractions. Pulsus alternans almost always indicates severe
left-sided heart failure and is usually best felt by applying light pressure on the radial or femoral arteries. You can use
a blood pressure cuff to confirm your finding. After raising the cuff pressure, lower it slowly to the systolic level; the
initial Korotkoff sounds are the strong beats. As you lower the cuff, you will hear the softer sounds of the alternating
weak beats.
Paradoxical pulse is a greater than normal drop in systolic pressure during inspiration. As the patient breathes,
quietly if possible, lower the cuff pressure slowly to the systolic level. Note the pressure level at which the first sounds
can be heard. Then drop the pressure very slowly until sounds can be heard throughout the respiratory cycle. Again
note the pressure level. The difference between the two levels is normally no greater than 3 or 4 mm Hg.
16. Describe anatomically the location of the major structures of the peripheral vascular system.
p. 472 - 474
Arteries, Upper limb:
Brachial artery, at the bend of the elbow just medial to the biceps tendon
Radial artery, on the lateral flexor surface
Ulnar artery, on the medial flexor surface, although overlying tissues may obscure the ulnar artery
Two vascular arches (deep and superficial palmar arches, yeah Anatomy!) within the hand in interconnect
the radial and ulnar arteries, doubly protecting circulation to the hand and fingers against possible arterial
occlusion
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Arteries, Lower limb:
Femoral artery, just below the inguinal ligament, midway between the ASIS and pubic symphysis
Popliteal artery, an extension of the femoral artery that passes medially behind the femur, palpable just
behind the knee.
Dorsal pedis artery, on the dorsum of the foot just lateral to the extensor tendon of the big toe
Posterior tibial artery behind the medial malleolus of the ankle
Leg veins have weaker wall structure, thus they are more susceptible to irregular dilation, compression, ulceration
and invasion by tumors. One-way valves and contraction of the calf muscles during walking both serve as a venous
pump, squeezing blood upward against gravity and preventing backward flow.
Great saphenous vein, originates on the dorsum of the foot, passes just anterior to the medial malleolus,
continues up the medial aspect of the leg, and joins the femoral vein of the deep venous system below the
inguinal ligament
Small saphenous vein, which begins at the side of the foot, passes upward along the posterior calf, and
joins the deep venous system in the popliteal fossa.
17. Identify the anatomy of the lymphatic system and lymph nodes.
p. 475-476 - Lymph nodes are round, oval, or bean-shaped structures that vary in size according to their location.
Some lymph nodes, such as the preauriculars, if palpable at all, are typically very small. The inguinal nodes, in
contrast, are relatively larger; often 1 cm in diameter and occasionally even 2 cm in an adult. Only the superficial
lymph nodes are accessible to physical examination. These include the cervical lymph nodes, the axillary nodes, and
the nodes in the arms and legs.
The axillary lymph nodes drain most of the arm. Lymphatics from the ulnar surface of the forearm and hand, the little
and ring fingers, and the adjacent surface of the middle finger, however, rain first into epitrochlear nodes. These are
located on the medial surface of the arm approximately 3 cm above the elbow. Lymphatics from the rest of the arm
drain mostly into the axillary nodes. A few may go directly into the infraclaviculars.
The superficial inguinal nodes of the lower limb include two groups. The horizontal group lies in a chain high in the
anterior thigh below the inguinal ligament. It drains the superficial portions of the lower abdomen and buttock, the
external genitalia (but not the tests), the anal canal and perianal area, and the lower vagina. The vertical group
clusters near the upper part of the saphenous vein and drains a corresponding region of the leg. In contrast,
lymphatics from the portion of the leg drained by the small saphenous vein (the hell and outer aspect of the foot) joint
he deep system at the level of the popliteal space.
18. Describe the grading system for the peripheral pulses.
p. 482 - Recommended Grading of Pulses
3+ Bounding (carotid, radial, and femoral pulses in aortic insufficiency)
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2+ Brisk, expected (normal)
1+ Diminished, weaker than expected (asymmetric diminished pulses in arterial occlusion from
atherosclerosis or embolism)
0 Absent, unable to palpate
19. Describe how to assess and grade pitting edema.
p. 487 - Press firmly but gently with your thumb for at least 5 seconds over the dorsum of each foot, behind each
medial malleolus, and over the shins. Look for pitting; a depression caused by pressure from your thumb. Normally
there is none. The severity of edema is graded on a four-point scale, from slight to very marked.
20. Describe how to evaluate the arterial supply to the hands and legs, the competency of venous valves, and how to
map varicose veins.
p. 488 - If you suspect arterial insufficiency in the arm or hand, try to feel the ulnar pulse as well as the radial and
brachial pulses. Feel for it deeply on the flexor surface of the wrist medially. Partially flexing the patients wrist may
help you. the pulse of a normal ulnar artery, however, may not be palpabale. The Allen test is useful to ensure the
patency of the ulnary artery before puncturing the radial artery for blood samples. See page 489.
p. 490 - If pain or diminished pulses suggest arterial insufficiency, look for postural color changes. Raise both legs to
about 60 degrees until maximal pallor of the feet develops, usually within a minute. Then ask the patient to sit up with
legs dangling down. Compare both feet, noting the time required for:
Return of pinkness to the skin, normally about 10 seconds or less.
Filling of the veins of the feet and ankles, normally about 15 seconds.
Look for any unusual rubor (dusky redness) to replace the pallor of the dependent foot. Normal responses
accompanied by diminished arterial pulses suggest that a good collateral circulation has developed around an arterial
occlusion. Color changes may be difficult to see in darker-skinned persons, so inspect the soles of the feet for these
changes.
The physical exam of the Abdomen
1. Apply health promotion and counseling to patients on topics such as alcohol abuse, Hepatitis A, B, C, and Colon
Cancer.
When asking about alcohol use, recall current definitions of risky or hazardous drinking and harmful drinking. Risky or
hazardous drinking for women is more than 7 drinks per week or more than 3 drinks per occasion; for men it is more
than 14 drinks per week or more than 4 drinks per occasion. Sorry Sandra. Harmful drinking is drinking that causes
physical social, or psychological harm from alcohol use but does not meet the criteria for dependence. Use the 4
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CAGE questions. Initial counseling of 15 minutes with follow up reduces consumption by 13-34% over 6-12 months.
Know FRAMES:
Feedback based on thorough assessment
Responsibility
Advice on behavior change
Menu of options for making change
Empathy about the difficulty of changing
Self-efficacy in achieving change
Transmission of Hepatitis A is fecal-oral (yummy). Fecal shedding in food handlers leads to contamination of water
and foods. A vaccine is recommended for certain populations. Hepatitis B poses more serious risks. Transmission
occurs during contact with infected body fluids such as blood, semen, saliva and vaginal secretions. Because up to
30% of patients have no identifiable risk factors, hepatitis B vaccine is recommended for all young adults not
previously immunized. Pregnant women should be screened at their first prenatal visit. Hepatitis C is transmitted by
repeated percutaneous exposures to blood and is present in 2% of U.S. adults. Infected patients are often
asymptomatic. More than 70% develop chronic liver disease. Routine screening is not recommended since it is rare.
For colorectal cancer, one of the following tests should be done beginning at age 50: fecal occult blood test annually,
flesible sigmoidoscopy every 5 years, annual FOBT plus flexible sigmoidoscopy every 5 years, double-contrast
barium enema every 5 years, and colonoscopy every 10 years. Most colorectal cancers are sporadic, but 20% occur
in patients with risk factors including prior colon cancer and family history.
2. Describe the proper techniques for assuring patient comfort for the abdominal exam.
p. 434
Before you begin palpation, ask the patient to point to any areas of pain so you can examine these areas
last.
Warm your hands and stethoscope. To warm your hands, rub them together or place them under hot water.
You can also palpate through the patients gown to absorb warmth from the patients body before exposing
the abdomen.
Approach the patient calmly and avoid quick, unexpected movements. Watch the patients face for any
signs of pain or discomfort. Make sure you avoid long fingernails.
Distract the patient if necessary with conversation or questions. If the patient is frightened or ticklish, begin
palpation with the patients hand under yours. After a few moments, slip your hand underneath to palpate
directly. lol.
3. Demonstrate the proper technique for draping the patient for the abdominal exam.
-Your goal with draping is to visualize one area of the body at a time. For the abdominal exam, only the abdomen
should be exposed. Adjust the gown to cover the chest and place the sheet or drape at the inguinal area.
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4. Identify and describe the anatomical landmarks of the abdominal wall and pelvis.
-See picture at beginning of chapter. Anatomical landmarks include xiphoid process, rectus abdominis muscle,
costal margin, midline overlying linea alba, umbilicus, iliac crest, anterior superior iliac spine, inguinal ligament, pubic
tubercle, and symphysis pubis.
5. Describe the location of the major organs in the abdomen using anatomic terms.
-In the right upper quadrant you have the liver (the lower margin is palpable at the right costal margin), the
gallbladder and duodenum (which are not generally palpable). At a deeper level the lower pole of the kidney may be
felt. The abdominal aorta often has visible pulsations in the upper abdomen. The stomach is located under the ribs
and is not palpable
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-In the left upper quadrant the spleen is lateral to and behind the stomach. it upper border rest against the
diaphram and it is protected by ribs 9, 10 and 11. The pancreas is located here, but in healthy people it is not
palpable.
-In the lower left quadrant you can feel the sigmoid colon and portions of the transverse colon. In the lower midline
are the bladder, the sacral promontory and in women the uterus and ovaries.
-In the lower right quadrant are bowel loops and the appendix at the tail of the cecum. In healthy people there are
no palpable findings in the lower right quadrant.
- Also in the abdomen are the kidneys that are posterior organs which are protected by the 11th and 12th
ribs.
6. Describe the sequence for performing the abdominal exam.
Inspect, Auscultate, Percuss, Palpate
7. Describe the normal and abnormal findings that can be detected with inspection of the abdomen.
--On inspection of the abdomen note:
-The skin - describe or diagram any scars, look for any old silver striae or stretch marks that are abnormal (pink-
purple striae are characteristic of Cushings syndrome) Note any dilated veins which can be indicative of hepatic
cirrhosis or inferior vena cava syndrome. Also note any rashes or lesions
Observe the contour and appearance of the umbilicus and any inflammation or bulges suggesting a hernia.
Observe the contour of the abdomen and see if it is round, protuberant (caused by fat, a tumor, being
pregnant, or have ascitic fluid or scaphoid (markedly concave or hollowed). Also look to see in the flanks bulge
which is common in ascities. You can also have suprapubic bulges that are seen with a distended bladder, pregnant
uterus or hernias. You want to make sure the abdomen is symmetric because asymmetry can be caused by an
enlarged organ or tumor. Look for a large spleen or liver that has descended below the rib cage, in a normal
abdomen this would not be found.
To check for peristalsis observe for several minutes because increased peristaltic waves are indicative of
intestinal obstruction. You should not see peristalsis on a normal person
The normal abdominal aortic pulsation is frequently visible in the epigastrum. Increased pulsation is a sign
of an aortic aneurysm or of increased pulse pressure.
8. Describe the technique of auscultation of the abdomen and describe normal and abnormal findings.
9. Describe the technique of percussion in the abdominal exam and describe normal and abnormal findings.
Percussion helps assess the amount and distribution of gas in the abdomen and to identify possible masses
that are solid or fluid-filled
Percuss the abdomen lightly in all four quadrants to assess the distribution of tympany and dullness.
Tympany usually predominates because of gas in the GI tract, but scattered areas of dullness from fluid and
feces are also typical.
A protuberant abdomen that is tympanitic throughout suggests intestinal obstruction
Note any large dull areas that might indicate an underlying mass or enlarged organ
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Pregnant uterus, ovarian tumor, distended bladder, large liver or spleen
On each side of a protuberant abdomen, note where abdominal tympany changes to the dullness of solid
posterior structures
Dullness in both flanks prompts further assessment for ascites
Briefly percuss the lower anterior chest, between the lungs above and costal margins below. On the right,
you will usually find the dullness of the liver; on the left, the tympany that overlies the gastric air bubble and
the splenic flexure of the colon
In situs inversus (rare), organs are reversed: air bubble on the right, liver dullness on the left
10. Describe the techniques of light and deep palpation in the abdominal exam and recognize normal and abnormal
findings.
Light palpation: feeling the abdomen gently is especially helpful for identifying abdominal tenderness,
muscular resistance, and some superficial organs and masses. It also serves to reassure and relax the
patient.
Keeping your hands and forearms on a horizontal plane, with fingers together and flat on the abdominal
surface, palpate the abdomen with a light, gentle, dipping motion. When moving your hand from place to
place, raise it just off the skin. Moving smoothly, feel in all quadrants.
Identify any superficial organs or masses and any area of tenderness or increased resistance to your hand.
If resistance is present, try to distinguish voluntary guarding from involuntary guarding. To do this:
Try all the relaxing methods you know
Feel for the relaxation of abdominal muscles that normally accompanies exhalation
Ask the patient to mouth-breath with the jaw dropped open
Involuntary rigidity (muscular spasm) typically persists despite these maneuvers. It indicates peritoneal
inflammation
Deep palpation: This is usually required to delineate abdominal masses. Again using the palmar surfaces
of your fingers, feel in all four quadrants. Identify and masses and note their location, size, shape,
consistency, tenderness, pulsations, and any mobility with respiration or with the examining hand. Correlate
your palpable findings with their percussion tones.
Abdominal masses may be categorized in several ways: physiologic (pregnant uterus),
inflammatory (diverticulitis of the colon), vascular (an abdominal aortic aneurysm), neoplastic
(carcinoma of the colon), or obstructive (a distended bladder or dilated loop of bowel)
11. Describe the manuevers for the complete examination of the liver.
p. 439-443
Percussion: Measure the vertical span of liver dullness in the right midclavicular line. Starting at a level
below the umbilicus (in an area of tympany, not dullness), percuss upward toward the liver. Identify the
lower border of dullness in the midclavicular line. Next, identify the upper border of liver dullness in the
midclavicular line. Starting at the nipple line, lightly percuss from lung resonance down toward liver dullness.
Now measure in centimeters the distance between your two points; the vertical span of liver dullness.
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Normal liver spans are generally greater in men than in women and greater in tall people than in short
people.
To assess percussion tenderness of a nonpalpable liver, place your left hand flat on the lower right rib cage
and then gently strike your hand with the ulnar surface of your right fist. Ask the patient to compare the
sensation with that produced by a similar strike on the left side.
Palpation: Place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs
and adjacent soft tissues below. Place your right hand on the patients right abdomen lateral to the rectus
muscle, with your fingertips well below the lower border of liver dullness, and gently press in and up. Ask the
patient to take a deep breath, and and try to feel the liver edge as it comes down to meet your fingertips.
Note any tenderness. If palpable at all, the normal liver is soft, sharp, and regular, with a smooth surface.
On inspiration, the liver is palpable about 3 cm below the right costal margin in the midclavicular line. Try to
trace the liver edge both laterally and medially. Describe or sketch the liver edge, and measure its distance
from the right costal margin in the midclavicular line.
12. Describe the manuevers for the complete examination of the spleen.
p. 443-445
Splenomegaly: when a spleen enlarges, it expands anteriorly, downward, and medially, often replacing the
tympany of the of stomach and colon with dullness of a solid organ. It then becomes palpable below the
costal margin. Percussion suggests but does not confirm splenic enlargement (60-80% sensitivity, 72-94%
specificity).
Percussion: Percuss the left lower anterior chest wall between lung resonance above and the costal
margin, an area termed Traubes space. As you percuss along the routes (see p. 443 pictures), note the
lateral extent of tympany. Check for a splenic percussion sign by percussing the lowest itnerspace in the left
anterior axillary line; this area is usually tympanitic. Then ask the patient to take a deep breath, and percuss
again. When spleen size is normal, the percussion note usually remains tympanitic.
Palpation: With your left hand, reach over and around the patient to support and press forward the lower
left rib cage and adjacent soft tissue. With your right hand below the left costal margin, press in toward the
spleen. Ask the patient to take a deep breath, and try to feel the tip or edge of the spleen as it comes down
to meet your fingertips. Note any tenderness, assess the splenic contour, and measure the distance
between the spleens lowest point and the left costal margin. Repeat with the patient lying on the right side
with legs somewhat flexed at the hips and knees. In this position, gravity may bring the spleen forward and
to the right into a palpable location.
13. Describe the manuevers for the complete examination of the kidneys.
p. 445-446
Palpation, left kidney: Move to the patients left side, and place your right hand behind the patient, just
below and parallel to the 12th rib, with your fingertips just reaching the costovertebral angle. Lift, trying to
displace the kidney anteriorly. Place your left hand gentily in the left upper quadrant, lateral and parallel to
the rectus muscle. Ask the patient to take a deep breath. At the peak of inspiration, press your left hand
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firmly and deeply into the light upper quadrant, just below the costal margin, and try to capture the kidney
between your two hands. Ask the patient to breathe out and then to stop breathing briefly. Slowly release
the pressure of your left hand, feeling at the same time for the kidney to slide back into its expiratory
position. If the kidney is palpable, describe its size, contour and tenderness.
Palpation, right kidney: To capture the right kidney, return to the patients right side. Use your left hand to
left from in back and your right hand to feel deep in the left upper quadrant. Proceed as before.
Percussion: You may note tenderness when examining the abdomen, but also search for it at each
costovertebral angle. Pressure from your fingertips may be enough to elicit tenderness, but if not, use fist
percussion. Place the ball of one hand in the costovertebral angle and strike it with the ulnar surface of your
fist. Use enough force to cause a perceptible but painless jar or thud in a normal person.
14. Describe the maneuvers for assessing ascites, appendicitis, pyelonephritis, acute cholycystitis, ventral hernias,
and mass in the abdominal wall.
p. 448-451
Ascites: A protuberant abdomen with bulging flanks suggests the possibility of ascitic fluid. Because ascitic
fluid characteristically sinks with gravity, whereas gas-filled loops of bowel float to the top, percussion gives
a dull note in dependent areas of the abdomen. Look for such a pattern by percussion outward in several
directions from the central area of tympany, and map the border between tympany and dullness.
Test for shifting dullness: After mapping the borders of tympany and dullness, ask the patient to
turn onto one side. Percuss and mark the borders again. In a normal person without ascities, the
borders between tympany and dullness usually stay relatively constant.
Test for a fluid wave: Ask the patient to press the edges of both hand firmly down the midline of the
abdomen. This pressure helps to stop the transmission of wave through fat. While you tap one
flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the
fluid.
Appendicitis: Ask the patient to point to where the pain began and where it is now. Ask the patient to
cough. Search carefully for an area of local tenderness. Feel for muscular rigidity. Perform a rectal
examination and, in women, a pelvic examination. Check the tender area for rebound tenderness.
Check for Rovsings sign (pain the in the right lower quadrant during left-sided pressure) and for
referred rebound tenderness, a psoas sign, an obturator sign, and cutaneous hyperesthesia (see p.
450 for details).
Pyelonephritis: Pain with pressure or fist percussion of the kidneys suggests pyelonephritis but may also
have a musculoskeletal cause.
Acute cholycystitis: Look for Murphys sign. Hook your left thumb or fingers of your right hand under the
costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. A
sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphys sign.
Ventral hernias: If you suspect but do not see an umbilical or incisional hernia, askt he patient to raise both
head and shoulders off the table. The bulge of a hernia will usually appear with this action.
26
Mass in the abdominal wall: Ask the patient either to raise the head and shoulders or to strain down, thus
tightening the abdominal muscles. A mass in the abdominal wall remains palpable; an intra-abdominal mass
is obscured by muscular contraction.
Session 5: Physical Exam of the Upper Musculoskeletal System
1. Distinguish between the three primary types of joint articulation.
Synovial joints: bones do not touch each other and joint articulations are freely moveable. ex. knee, shoulder
Cartilaginous joints: joints are slightly moveable. ex. vertebral bodies of the spine
Fibrous joints: intervening layers of fibrous tissue or cartilage hold the bones together. The bones are almost always
in direct contact, which allows no appreciable movement. ex. skull sutures
2. Explain the structure of synovial joints.
Spheroidal (ball and socket) joints have a convex surface in a concave cavity. They allow a wide range of rotatory
movement. ex. shoulder, hip
Hinge joints are flat, planar, or slightly curved, allowing only a gliding motion in a single plane. ex. interphalangeal
joints of hand and foot; elbow.
In condylar joints the articulating surfaces are convex or concave, termed condyles. The movement of two articulating
surfaces is not dissociable. ex. knee, TMJ
3. Identify the anatomy of the temporomandibular joint, shoulder, elbow, wrist and hand joints.
p. 586-603
TMJ: Most active joint in the body. It is formed by the fossa and articular tubercle of the temporal bone and
the condyle of the mandible. It lies midway between the external acoustic meatus and the zygomatic arch. It
is a condylar synovial joint.
The principle muscles opening the mouth are the lateral (external) ptyerygoids. Closing the mouth
are the muscles innervated by CN V3, the masseter, temporalis, and medial (internal) pterygoids.
Shoulder: Largely uninhibited by bony structures. Derives mobility from shoulder girdle, structures are
divided into dynamic and static stabilizers. Dynamic stabilizers = SITS muscles; Static stabilizers = bony
structures, labrum, articular capsule, and glenohumeral ligaments. Three different joints articulate at the
shoulder:
Glenohumeral joint: Head of humerus articulates with shallow glenoid fossa of the scapula; ball-
and-socket joint, allowing flexion, extension, abducction, adduction, rotation, and circumduction of
the arm.
Sternoclavicular joint: medial end of clavicle articulates with upper sternum
Acromioclavicular joint: lateral end of clavicle articulates with acromion process of scapula.
Muscle groups: SITS (supraspinatus, infraspinatus, teres minor, subscapularis); axioscapular
group (trapezius, rhomboids, serratus anterior, leavtor scapulae) rotate the scapula;
axiohumeral group (pectoralis major, minor, latissimus dorsi) internal rotation of shoulder
27
Elbow: Formed by humerus, radius, and ulna. The bones have three articulations; the humeroulnar joint,
the radiohumeral joint, and the radioulnar joint, which share a large common articular cavity and an
extensive synovial lining.
Muscles traversing the elbow include the biceps and brachioradialis (flexion), the triceps
(extension), the pronator teres (pronation), and the supinator (supination).
Olecranon bursa between the olecranon process and skin; normally not palpable but swells and
becomes tender when inflamed.
Wrist and Hands: Wrist includes distal radius, ulna, and eight small carpal bones. Hand includes five
metacarpals, with proximal, middle and distal phalanges. Thumb lacks a middle phalanx.
Wrist joints: Radiocarpal joint, distal radioulnar joint, intercarpal joints. Radiocarpal joint provides
most of flexion and extension at wrist because ulna does not articulate directly with carpal bones.
Hand joints: Metacarpophalangeal jionts, proximal interphalangeal joints, distal interphalangeal
joints.
Muscle groups: Two radial and one ulnar muscle provide wrist extension. Intrinsic muscles of hand
attaching to metacarpals are involved in flexion (lumbricals), abduction (dorsal interossei), and
adduction (palmar interossei) of the fingers.
Carpal tunnel: a channel between the palmar surface of the wrist and proximal hand, contains the
sheath and flexor tendons of the forearm muscles and the median nerve provides sensation to
palm and palmar surface of most of thumb, second and third digits, half of fourth digit, innervates
thumb muscles of flexion, abduction and opposition.
Flexor retinaculum: transverse ligament that holds the tendons and tendon sheath in place.
4. Describe how to assess the range of motion for the TMJ, shoulder, elbow, wrist, and hand joints and be able to
identify the principle muscles affecting movement.
TMJ - (muscles of mastication: the masseter, medial pterygoid, lateral pterygoid and the temporalis) Range of motion
is three-fold: Ask the patient to demonstrate opening and closing, protrusion and retraction (by jutting the jaw
forward), and lateral, or side-to-side, motion.
Shoulder - (SITS muscles) Watch for smooth, fluid movement as you stand in front of the patient and ask the patient
to
1. raise (abduct) the arms to shoulder level (90) with palms facing down (tests pure glenohumeral motion);
2. raise the arms to a vertical position above the head with the palms facing each other (tests
scapulothoracic motion for 60, and combined glenohumeral and scapulothoracic motion during adduction for the
final 30;
3. place both hands behind the neck, with elbows out to the side (tests external rotation and
abduction);
4. place both hands behind the small of the back (tests internal rotation and adduction). (Placing your hand on the
shoulder during these movements allows you to detect any crepitus.)
28
Elbow - (Brachialis, Brachioradialis, Triceps brachii and Anconus, Supinator, With the patients arms at the sides
and elbows flexed to minimize shoulder movement, ask the patient supinate, or turn up the palms, and to pronate, or
turn down the palms.
Wrist - (wrist extensors and flexors) At the wrist, test flexion, extension, and ulnar and radial deviation.
1. Flexion: With the patients forearm stabilized, place the wrist in extension and place your fingertips in the patients
palm. Ask the patient to flex the wrist against gravity, then against graded resistance
2. Extension: With the patients forearm stabilized, place the wrist in flexion and put your hand on the patients dorsal
metacarpals. Ask the patient to extend the wrist against gravity, then against graded resistance
3. Ulnar and radial deviation: With palms down, ask the patient to move the wrists laterally and medially
Hand - (Extensors, Flexors, Thenar, Hypothenar) Test flexion, extension, abduction, and adduction of the fingers
1. Flexion and extension: Ask the patient to make a tight fist with each hand, thumb across the knuckles, and then
extend and spread the fingers. The fingers should close and open smoothly and easily. At the MCPs, thefingers may
extend beyond the neutral position. Also test flexion and extension at the PIP and DIP joints.
2. Abduction and adduction: Ask the patient to spread the fingers apart (abduction) and back together (adduction).
Check for smooth, coordinated movement.
3. Thumb: Assess flexion, extension, abduction, adduction, and opposition. Ask the patient to move the thumb
across the palm and touch the base of the 5th finger to test flexion, and then to move the thumb back across the
palm and away from the fingers to test extension. Next, ask the patient to place the fingers and thumb in the neutral
position with the palm up, then have the patient move the thumb anteriorly away from the palm to assess abduction
and back down for adduction. To test opposition, or movements of the thumb across the palm, ask the patient to
touch the thumb to each of the other fingertips.
5. Describe the techniques to examine the temporomandibular joint.
Inspection and palpation: Inspect face for symmetry. Inspect TMJ for swelling or redness. (Swelling may appear as
a rounded bulge about cm in front of the external auditory meatus). To locate and palpate the joint, place tips of
your fingers just in front of the tragus of each ear and ask pt to open his/her mouth. Fingertips should drop into the
joint spaces as the mouth opens. Check for smooth range of motion; note swelling or tenderness. Snapping or
clicking may be felt or heard in normal people.
Palpate the muscles of mastication: 1) masseters - externally at the angle of the mandible; 2) temporal muscles -
externally during clenching and relaxation of the jaw; 3) pterygoid muscles - internally between the tonsillar pillars at
the mandible.
Range of motion and maneuvers: TMJ has glide and hinge motions in its upper and lower portions, respectively.
Grinding or chewing consists primarily of gliding movements in the upper compartments. Range of motion is 3 fold,
so ask pt to demonstrate all: 1) opening & closing, 2) protrusion & retraction (jutting jaw forward), 3) lateral (side-to-
side). [Note: Normally, as mouth opens wide, 3 fingers can be inserted between incisors. With normal protrusion of
the jaw, bottom teeth can be placed in front of the upper teeth.]
6. Describe the techniques to examine the shoulder.
p591-599
29
Inspection.
Observe the shoulder and shoulder girdle anteriorly, and inspect the scapulae and related muscles posteriorly. Note
any swelling, deformity, muscle atrophy or fasciculations (ne tremors of the muscles), or abnormal positioning.Look
for swelling of the joint capsule anteriorly or a bulge in the subacromial bursa under the deltoid muscle. Survey the
entire upper extremity for color change, skin alteration, or unusual bony contours.
Palpation.
Begin by palpating the bony landmarks of the shoulder; then palpate any area of pain.
Beginning medially, at the sternoclavicular joint, trace the clavicle laterally with your ngers. Find acromion,
coracoid process, greater tubercle, biceps tendon in intertubercular groove.
To examine the subacromial and subdeltoid bursae and the SITS muscles,rst passively extend the humerus by
lifting the elbow posteriorly. This rotates these structures so that they are anterior to the acromion. Palpate carefully
over the subacromial and subdeltoid bursae. The underlying palpable SITS muscles are:
Supraspinatusdirectly under the acromion
Infraspinatusposterior to supraspinatus
Teres minorposterior and inferior to the supraspinatus rupture of therotator
(The fourth muscle, the subscapularis, inserts anteriorly and is not palpable
Ask patient to flex/extend, abduct/adduct, internally/externally rotate.
30
7. Describe the techniques to examine the elbow.
1. Locate and palpate ulna, olecranon process and bursa, medial and lateral epicondyles, ulnar nerve. Note
tenderness, swelling, warmth, redness, nodules.
2. Assess range of motion:
a. flexion/extension
b. supination/pronation.
3.
4. Normal range of motion is:
5. Flexion 135+
31
6. Extension 0-5
7. Supination 90
8. Pronation 90
9.
10. 8. Describe the techniques to examine the wrist and hands.
a. Observe hands for:
i. symmetry, swelling, erythema, deformities of wrist, fingers, angulation from radial or ulnar
deviation.
ii. thenar and hypothenar eminences.
iii. Note any thickening of flexor tendons, flexion contractures.
b. Locate and palpate
i. radiocarpal joint noting and swelling, bogginess or tenderness.
ii. anatomical snuffbox, the 8 carpal bones and the 5 metacarpal bones and proximal, middle
and distal phalanges.
iii. compress MCP joints noting swelling, tenderness, nodules or bogginess.
iv. thumb and PIP and DIP joints for swelling, tenderness or nodules.
c. Assess (movement):
i. range of motion of wrist:
ii. flexion/extension and ulnar and radial deviation.
iii. grip strength of hand.
iv. flexion/extension of fingers and abduction/adduction.
v. flexion/extension, abduction/adduction and opposition of thumb.
d.
e. Normal range of motion is:
f. Flexion 80
g. Extension 70
h. Ulnar deviation 30
i. Radial deviation 20
i. Assess sensation in fingers on palmar and dorsal surface of hand.
j.
k.
l. 9. Describe the normal and abnormal findings that can be detected with examination of
the wrists and hands.
m. Inspection-
n. Observe position of hands in motion to see if movements are smooth and natural
o. NORMAL- at rest, fingers should be slightly flexed and aligned almost in parallel.
p. ABNORMAL- guarded movement suggests injury. Poor finger alignment seen in flexor
tendon damage.
q. NORMAL- inspect palmar and dorsal surfaces of wrist and check for swelling over
joints
32
r. ABNORMAL- diffuse swelling in arthritis or infection; local swelling from cystic ganglion
(SEE 649-651)
s. ABNORMAL- not deformities of wrist, hand, or finger bones, as well as any angulation
from radial/ulnar deviation
t. Osteoarthritis- Heberdens nodes a thte DIP joints, Bouchards nodes at the PIP joints
u. Rheumatoid arthritis- symmetric deformity in PIP, MCP, and wrist joints wiht ulnar
deviation
v. ABNORMAL- thenar atrophy in median nerve compression; hypothenar atrophy in
ulnar nerve compression
w. ABNORMAL- flexion contractures in ring, 5th, and 3rd fingers (Dupuytrens
contracture) arise from thickening of palmar fascia (649)
x. Palpation-
y. Palpate distal radius and ulna on medial and lateral surfaces
z. ABNORMAL- tenderness over distal radius in Colles Fracture. Swelling or tenderness
suggests rheumatoid arthritis if bilateral and of several weeks duration
aa. Palpate radial styloid and anatomical snuffbox
bb. ABNORMAL- tenderness over extensor and abductor tendons of the thumb at radial
styloid in de Quervains tenosynovitis and gonococcal tenosynovitis.
cc. Tenderness over snuffbox in scaphoid fracture
dd.
ee. Palpate the 8 carpal bones, then each of 5 metacarpals, then proximal, middle, distal
phalanges.
ff. ABNORMAL- pain in MCPs due to synovitis...MCPs are often boggy or tender in
rheumotoid arthritis (rarely in osteoarthritis) Pain with compressioni n posttraumatic
arthritis
gg.
hh. Palpate each PIP joint from both medial lateral aspects by joining thumb and index
finger
ii. ABNORMAL- PIP changes seen in rheumotoid arthridis. Bouchards nodes in
osteoarthritis. Pain at base of thumb in first carpometacarpal arthritis.
jj.
kk. Palpate along each DIP joint with same technique
ll. ABNORMAL- DIP joints get Heberden nodes in osteoarthritis (see picture on 605)
mm.
nn. 10. Explain the different techniques to assess rotator cuff disorders, bicipital tendinitis,
epicondylitis, and carpal tunnel syndrome.
oo. Apley scratch test: touch opposite scapula from above and below. Difficulty suggests
rotator cuff disorder
pp. Neers impingement sign. Press on scapula and raise the patients arm; pain is a
positive sign for possible rotator cuff tear.
33
qq. Hawkins impingement sign: with the shoulder and elbow flexed to 90 degrees, palm
facing down, rotate the arm internally. Pain is a positive sign for possible rotator cuff
tear.
rr. Empty Can test: Elevate the arms to 90 degrees and internally rotate the arms with
the thumbs pointing down, as if emptying a can. Ask the patient to resist as you place
downward pressure on the arms. Weakness (testing the supraspinatous) is a positive
sign indicating possible rotator cuff tear
ss. Infraspinatous strength: Arms at side, elbows flexed to 90 degrees, thumbs up. Patient
presses forearms out against resistance. Weakness is positive for possible rotator cuff
tear or bicipital tendinitis.
tt. Forearms supination: Flex the patients forearm to 90 degrees at the elbow and
pronate the patients wrist. Provide resistance when the patient supinates the forearm.
Pain is a positive sign indicating inflammation of the long head of the biceps tendon
(bicipital tendinitis) and possible rotator cuff tear.
uu. Drop Arm sign: Ask the patient to fully abduct the arm to shoulder level; if the patient
cannot hold the arm fully abducted at shoulder level, the test is positive, indicating a
rotator cuff tear.
vv. Lateral epicondylitis (tennis elbow): Pain and tenderness 1 cm distal to the lateral
epicondyle and extensor muscles close to it. When the patient tries to extend the wrist
against resistance, pain increases.
ww. Medial epicondylitis (pitcher/golfers elbow): Tenderness is maximal just lateral and
distal to the medial epicondyle. Wrist flexion against resistance increases pain.
xx. Thumb abduction test: Ask patient to raise the thumb straight up against downward
resistance; weakness of the abductor pollicis longus muscle is a positive sign for carpal
tunnel disease
yy. Tinels sign: Tap lightly over the course of the nedian nerve in the carpal tunnel; aching
and numbness is a positive sign.
Phalens sign: Ask the patient to hold the wrists in flexion for 60 seconds (compresses the median nerve).
Numbness and tingling in the median nerve distribution within the 60 seconds is a positive sign.
1. Identify the anatomy of the spine, hip, knee, ankle, and foot.
Spine: Concave curves = cervical and lumbar; convex curves = thoracic and sacrococcyeal. !he
vertebral column contains "# vertebrae stacked on the sacrum and coccyx. $nteriorly, the vertebral body
supports %eiht bearin. !he posterior vertebral arch encloses the spinal cord.
o &ertebral foramen: encloses the spinal cord. Intervertebral foramen create channel for spinal
nerve roots. !ransverse foramen for vertebral artery.
o !he spine has slihtly movable cartilainous 'oints bet%een the vertebral bodies and bet%een the
articular facets. (et%een the vertebral bodies are the intervertebral discs. )note: vertebral column anles
sharply posterior at the lumbosacral 'unction and becomes immovable. !he mechanical stress at this
anulation contributes to the risk for disc herniation and subluxation, or slippae, of *+ on S1.
o !rape,ius and latissimus dorsi form lare outer layer of muscles. !hey overlie t%o deeper muscle
layers.
34
-ip: (all and socket 'oint. !he head of the femur fits into the acetabulum, its stron fibrous
articular capsule.
o $nterior bony landmarks: iliac crest )*#., iliac tubercle, anterior superior iliac spine, reater
trochanter, pubic symphysis.
o /osterior bony landmarks: posterior superior iliac spine, reater trochanter, ischial tuberosity,
sarcoiliac 'oint.
o 0lexor roup: lies anterior, flexes thih; primarily iliopsoas.
o 1xtensor roup: lies posteriorly, extends thih; primarily luteus maximus.
o $dductor roup lies medial, abductor roup lies lateral.
2nee: *arest 'oint in body, hine 'oint involvin femur, tibia, and patella.
o 3uadriceps femoris extends knee; hamstrin muscles flex the knee.
o 4C*: connects medial femoral epicondyle to medial condyle of tibia
o *C*: connects lateral femoral epicondyle and head of fibula
o $C*: crosses obli5uely from anterior medial tibia to lateral femoral condyle, preventin tibia
from slidin for%ard on femur.
o /C*: crosses from posterior tibia and lateral meniscus to medial femoral condyle, preventin
tibia from slippin back%ard on femur.
$nkle and 0oot: principal 'oints of ankle = tibiotalar and subtalar
o /lantarflexion po%ered by astrocnemius, posterior tibial muscle, toe flexors
o 6orsiflexion po%ered by anterior tibial muscle, toe extensors
o 6eltoid liament: protects aainst stress from eversion
o $nterior talofibular liament is most at risk from inversion; also calcaneofibular liament and
posterior talofibular liament
". 6escribe ho% to assess the rane of motion for the spine, hip, knee, ankle, and foot and be able to
identify the primary muscles affectin each movement.
7eck8
0lexion 9 SC4, scalene, prevertebral muscles 9 :(rin your chin to your chest;
1xtension 9 splenius capitus and cervicis, small intrinsic neck muscles 9 :*ook up at the ceilin;
<otation 9 SC4, small intrinsic muscles of neck 9 :*ook over one shoulder, and then at the other;
*ateral bendin 9 scalene and small intrinsic neck muscles 9 :(rin your ear to your shoulder;
Spine:
0lexion 9 psoas ma'or, psoas minor, 5uadrates lumborum; abdominal muscles attachin to the
anterior vertebrae )i.e. internal and external obli5ues and rectus abdominis. 9 :(end for%ard and
try to touch your toes;
1xtension 9 deep intrinsic muscles of the back )erector spinae, transversospinalis roups. 9
:(end as far back as possible.;
<otation 9 $bdominal muscles, intrinsic muscles of back 9 :rotate from side8side;
*ateral bendin 9 ab muscles, intrinsic muscles of back 9 :(end to the side from the %aist;
35
-ip:
= 0lexion 9 iliopsoas 9 :(end your knee to your chest and pull it aainst your abdomen;.
= 1xtension 9 luteus maximus 9 :*ie face do%n then bend your knee and lift it up; >< :*yin
flat, move your lo%er le a%ay from the midline and do%n over the side of the table;.
= $(duction 9 luteus medius and minimus 9 :*yin flat, move your lo%er le a%ay from
midline;.
= $66uction 9 adductor brevis, adductor lonus, adductor manus, pectineus, racilis 9 :*yin
flat, bend your knee and move your lo%er le to%ard the midline.;
= 1xternal rotation 9 internal and external obturators, 5uadrates femoris, superior and inferior
emelli 9 :*yin flat, bend your knee and turn your lo%er le and foot across the midline.;
= Internal rotation 9 luteus medius and minimus 9 :*yin flat, bend your knee and turn your lo%er
le and foot a%ay from the midline.
2nee rane of motion:
= 0lexion 9 hamstrin roup: biceps femoris, semitendinosus, semimembranosus 9 :(end or flex
your knee; or :S5uat do%n to the floor;
= 1xtension 9 3uads: rectus femoris, vastus medialis, lateralis, intermedius 9 :Straihten your le;
or :after you s5uat do%n to the floor, stand up;
= Internal rotation 9 Sartorius, racilis, semitendinosus, semimembranosus 9 :?hile sittin, s%in
your lo%er le to%ard the midline.;
= 1xternal rotation 9 biceps femoris 9 :?hile sittin, s%in your lo%er le a%ay from the midline.;
$nkle and foot :
= $nkle flexion 9 astrocnemius, soleus, plantaris, tibialis posterior 9 :/oint your food to%ard the
floor;
= $nkle extension )dorsiflexion. 9 tibialis anterior, extensor diitorum lonus, extensor hallucis
lonus 8 :/oint your food to%ard the ceilin;
= Inversion 9 !ibialis posterior and anterior 9 :(end your heel in%ard;
= 1version 9 peroneus lonus and brevis 9 :(end your heel out%ard;
@. 6escribe the techni5ues to examine the spine.
Inspection:
observe posture, position of head, ait.
?ith patient stand and hands at sites fine spinous processes CA and !1, paravertebral muscles,
iliac crests, posterior superior iliac spines. Inspect from side and from behind.
/alpation:
/alpate each spinous process, alon %ith facet 'oints in the neck lateral to the spinous processes
%hen the neck is relaxed.
*ook for :step off in the lumbar reion )one spinous process is more or less prominent that the
others..
Sacroiliac 'oint %ith dimple that overlies the posterior superior iliac spine
36
/ercuss spine for tenderness lihtly %ith ulnar surface of a fist
/ara8vertebral muscles for tenderness and spasm
Sciatic nerve: %ith hip flex and patient on opposite side, palpate bet%een reater trochanter and
the ischial tuberosity for the nerve as it leaves the sciatic notch
<ane of 4otion: 7eck
0lexion and extension is performed by the 'oint of the skull and C1
<otation is C18C"
*ateral bendin is C"8CA
Instructions and muscles for each motion:
0lexion: :(rin your chin to you chest; SC4, Scalene, prevertebral muscles
1xtension: :*ook up at the ceilin; splenious capitus and cervicis, small intrinsic neck
muscles
<otation: :*ook over one shoulder and then the other; SC4, Small intrinsic neck
muscles
*ateral (endin: :(rin you hear to your shoulder; Scalenes and small intrinsic neck
muscles
Spinal Column:
Instructions and muscles for each motion:
0lexion: :(end for%ard and try to touch your toes; /soas ma'or, psoas minor, 5uadratus
lumborum, internal and external obli5ues, retuc abdominis
1xtension: :(end back as far as possible; 6eep intrinsic muscles of the back, erector
spinae, transversospinalis roups
<otation: :<otate from side to side; $bdominal muscles, intrinsic muscles of the back
*ateral (endin: :(end to the side form the %aist; $bdominal muscles, intrinsic muscles
of the back.
#. 6escribe the normal and abnormal findins that can be detected %ith inspection of the spine.
torticollis8 lateral deviation and rotation of the head from contraction of the sternocleidomastoid muscle
spinous processes8 more evident on for%ard flexionupriht spinal column
paravertebral muscles on either side of the midline
scoliosis8 lateral and rotatory curvature of the spine to brin the head back to midline
alinment of the shoulders, iliac crests, and luteal folds
une5ual shoulder heihts seen in: scoliosis, SprenelBs deformity of the scapula,
C%ininB of the scapula, contralateral %eakness of the trape,ius
37
une5ual heihts of the iliac crests )pelvic tilt. suest une5ual lenths of the les and disappear
%hen a block is placed under the short le and foot. It may also be caused by scoliosis and hip
abduction or adduction
:*istin; of the trunk to one side is seen %ith a herniated lumbar disc.
posterior superior iliac spines
cervical, thoracic, and lumbar curves
increased thoracic kyphosis occurs %ith ain
skin markins, tas, or masses
birthmarks, port8%ine stains, hairy patches, and lipomas often overlie bony defects such as spina
bifida
cafe8au8lait spots )discolored patches of skin., skin tas, and fibrous tumors in neurofibromatosis
+. 6escribe the techni5ues to examine the hip.
!est flexion at the hip
)*", *@, *#Diliopsoas. by placin your hand on the patientBs thih and askin the patient to raise the le
aainst your hand.
!est adduction at the hips
)*", *@, *#Dadductors.. /lace your hands Ermlyon the bed bet%een the patientBs knees. $sk the patient
to brin both les toether.
!est abduction at the hips
)*#, *+, S1Dluteus medius and minimus.. /laceyour hands Ermly on the bed outside the patientBs
knees. $sk the patient tospread both les aainst your hands.
!est extension at the hips
)S1Dluteus maximus.. -ave the patient push theposterior thih do%n aainst your hand.
F. 6escribe the techni5ues to examine the knee.
!est Gexion at the knee
)*#, *+, S1, S"Dhamstrins. as sho%n belo%. /lacethe patientBs le so that the knee is Gexed %ith the
foot restin on the bed.!ell the patient to keep the foot do%n as you try to straihten the le.
A. 6escribe the techni5ues to examine the ankle and foot.
38
Inspect 9 observe all surfaces of ankles and feet, notin any deformaties, nodules, s%ellin, calluses,
corns.
/alpation 9 ?ith thumbs, palpate the anterior aspect of each ankle 'oint )note: boiness, s%ellin,
tenderness.. 0eel alon $chilles tendon for nodules and tenderness. /alpate the heel, esp the posterior and
inferior calcaneus, and the plantar fascia for tenderness. /alpate for tenderness over the medial and lateral
malleolus )esp if trauma.. /alpate the metatarsophalaneal 'oints for tenderness. Compress the forefoot
bH% the thumb and finers. 1xert pressure 'ust proximal to the heads of the 1st and +th metatarsals.
/alpate the heads of the + metatarsals and the rooves bH% them %ith thumb and index finer. /lace
thumb on the dorsum of the foot and index finer on the plantar surface.
I. <econi,e and differentiate bet%een the different abnormalities of the feet, includin acute outy
arthritis, flat feet, hallux valus, and 4ortonBs 7euroma.
$cut e out y art hri ti s: characteri,ed by a very painful and tender, hot, dusky red s%ellin that
extends beyond the marin of the metatarsophalaneal 'oint of the reat toe; easily mistaken for a
cellulitis )diffuse inflammation of connective tissue %ith severe inflammation of dermal and
subcutaneous layers of the skin.; acute out may also involve the dorsum of the foot
0l at feet : sins of flat feet may be apparent only %hen the patient stands, or they may become
permanent; the lonitudinal arch flatten so that the sole approaches or touches the floor; the
normal concavity on the medial side of the foot becomes convex; tenderness may be present from
the medial malleolus do%n alon the medial8plantar surface of the foot; s%ellin may develop
anterior to the malleoli; inspect the shoes for excess %ear on the inner sides of the soles and heels
-al l ux val us: the reat toe is abnormally abducted in relationship to the first metatarsal,
%hich itself is deviated medially; the head of the first metatarsal may enlare on its medial side,
and a bursa may form at the pressure point; this bursa may become inflamed
4ort onBs neuroma: tenderness over the plantar surface, third and fourth metatarsal heads,
from probable entrapment of the medial and lateral plantar nerves; symptoms include
hyperesthesia, numbness, achin, and burnin from the metatarsal heads into the third and fourth
toes
J. 1xplain the different techni5ues to assess sciatic nerve disorders, ait disorders, knee effusions, knee
bursitis, and meniscus, collateral, and cruciate liament tears.
Sciatic nerve disorders: 6isc herniation most likely if calf %astin, %eak ankle dorsiflexion,
absent ankle 'erk, positive crossed straiht8le raise )pain in affected le %hen healthy le tested.;
neative straiht8le raise makes dianosis hihly unlikely.
Kait disorders: >bserve both the stance and s%in phases of ait. 4ost problems appear durin
the %eiht8bearin stance phase. >bserve the ait for %idth of the base )normal = "8# inches from
heel to heel., shift of the pelvis, and flexion of the knee.
?ide base L cerebellar disease or foot problems
-ip dislocation, arthritis, or abductor %eakness L %addlin ait
*ack of knee flexion interrupts smooth pattern of ait
39
2nee effusions: !ry to palpate any thickenin or s%ellin in the suprapatellar pouch alon the
marins of the patella. Start 1M cm above the superior border of the patella and feel the soft
tissues bet%een your thumb and finers. S%ellinHtendernessH%armth above and ad'acent to the
patella suests synovial thickenin or effusion in the knee 'oint. Specific tests on p. F@M.
(ule sin for minor effusions: a fluid %ave or bule on the medial side bet%een the
patella and the femur is considered a positive sin consistent %ith an effusion
(alloon sin for ma'or effusions: suprapatellar compression e'ects fluid into the spaces
ad'acent to the patella. $ palpable fluid %ave sinifies a positive balloon sin
2nee bursitis: /alpate prepatellar bursa and anserine bursa on the posteromedial side of the knee
bet%een the 4C* and tendons insertin on medial tibia and plateau. Check medial aspect of
popliteal fossa on posterior surface.
/repatellar bursitis: housemaidBs knee, from excessive kneelin.
$nserine bursitis: runnin, valus knee deformity, fibromyalia, osteoarthiritis
/opliteal :bakerBs; cyst: distension of astrocnemius semimembranosus bursa
See tables on p. F@"8F@# for knee maneuvers.
4c4urray and lockin on knee extension L medial meniscus
$bduction )&alus. stress test L 4C*
$dduction )&arus. stress test L *C*
$nterior dra%er sin and *achman test L $C*
/osterior dra%er sin L /C*
1M. 6escribe the special maneuvers to assess le lenth discrepancy and limited motion of a 'oint.
If you suspect that the patientNs les are une5ual in lenth, measure them
patient relaxed in the supine position and symmetrically alined %ith les extended.
?ith a tape, measure the distance bet%een the anterior superior iliac spine and the medial
malleolus.
!he tape should cross the knee on its medial side.
One5ual le lenth may explain of scoliosis
$lthouh measurement of motion is seldom necessary, limitations can be described in derees.
/ocket oniometers )theyBre like protractors. are available for this purpose. In the t%o
examples sho%n belo%, the red lines indicate the rane of the patientNs movement, and
the black lines suest the normal rane.
1. Define the different terminology of the Mental Status Examination.
40
Im not gonna define all these, we know what these words mean so Ill just list them out and if your unsure of some of
them you can find it in the text: level of consciousness, attention, memory, orientation, perceptions, thought
processes, thought content, insight, judgement, affect, mood, language and higher cognitive functions
2. Understand the importance for health promotion and counseling for depression, suicidality, and dementia.
Depression: risk for women is double that of men. Search for depressive symptoms such as low self-esteem,
anhedonia, sleep disorders, failure to find pleasure in daily activities, difficulty concentrating or making decisions.
High risk are young, female, single, divorced, separated, seriously or chronically ill, or bereaved. Also if have past
history of depression. 2 questions: Over the past 2 weeks have you felt down, depressed or hopeless? Over past two
weeks have you felt little interest or pleasure in doing things?
Suicide: rates highest in white men over 85. Risk factors: suicidal or homicidal ideation, intent or plan, access to
means for suicide, symptoms of psychosis or severe anxiety, history of psychiatric illness, substance abuse,
personality disorder, family history of suicide
Dementia: acquired decline in cognitive function, affects 3 to 11% of Americans older than 65. Risk factors:
apolipoprotein E, hypertension, mild cognitive impairment, positive family history
3. Describe a patients level of alertness and orientation.
Determined by the level of activity that the patient can be aroused to perform in response to escalating
stimuli from the examiner.
Increase your stimuli in a step-wise manner, depending on the patient's response.
When you examine patients with an altered level of consciousness, describe and record exactly what you
see and hear.
Level of
Consciousness
(Arousal):
Techniques and Patient Response
Alertness Speak to the patient in a normal tone of voice.
An alert patient opens the eyes, looks at you, and responds fully and appropriately to stimuli
(arousal intact).
Lethargy Speak to the patient in a loud voice. For example, call the patient's name or ask How are you?
Obtundation Shake the patient gently as if awakening a sleeper.
Stupor Apply a painful stimulus. For example, pinch a tendon, rub the sternum, or roll a pencil across a
nail bed. (No stronger stimuli needed!)
Coma Apply repeated painful stimuli. WTF.
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4. Describe the different components of the Mental Status Examination, including appearance and behavior,
speech and language, mood, thoughts and perceptions, and cognitive function.
The mental status examination consists of the following components:
Appearance and behavior
Level of consciousness
Posture and motor behavior
Dress, grooming, and personal hygiene
Facial expression
Manner, affect, and relationship to people and things
Speech and language
Quantity: Is the patient talkative or relatively silent? Are comments spontaneous or only responsive
to direct questions?
Rate: Is speech fast or slow?
Loudness: Is speech loud or soft?
Articulation of words: Are the words spoken clearly and distinctly? Is there a nasal quality to the
speech?
Fluency: This involves rate, flow and melody of the speech and the content and use of words
Mood
Thoughts and perceptions
Thought processes
Thought content
Perceptions
Insight and judgment
Cognitive function
Orientation
Attention
Remote memory
Recent memory
New learning ability
Higher cognitive functions
Information and vocabulary
Calculating ability
Abstract thinking
Constructional ability
5. Explain the variations and abnormalities in thought processes, thought content, and perception.
Variations and abnormalities in thought processes
Circumstantiality Speech characterized by indirection and delay in reaching the point of because of
42
unnecessary detail, although components of the description have a meaningful
connection. (normal ppl speak circumstantially)
Derailment
(loosening of
associations)
Persons speech will shift from 1 subject to others that are unrelated (or related only
obliquely w/o realizing that the subjects are not meaningfully connected). Ideas slip
off the track between clauses, not within them.
Flight of ideas Almost continuous flow of accelerated speech in which a person changes abruptly
from topic to topic. Changes are usually based on understandable associations, plays
on words, or distracting stimuli, but the ideas dont progress to sensible conversation.
Neologisms Invented or distorted words, or words w/ new and highly idiosyncratic meanings
Incoherence Incomprehensible speech (illogic, lack of meaningful connections, abrupt changes in
topic, disordered grammar or word use; shifts in meaning within clauses)
Blocking Sudden interruption of speech in midsentence or before completion of an idea.
Person attributes this to losing the thought. (Occurs in normal ppl too)
Confabulation Fabrication of facts or events in response to questions. Fills in gaps in an impaired
memory.
Perseveration Persistent repetition of words or ideas
Echolalia Repetition of words and phrases of others
Clanging Speech w/ person choosing words on basis of sound, not meaning (rhyming or
punning speech rather than sensible)
Abnormality in thought content
Compulsions Repetitive behaviors or mental acts that a person feels driven to perform to produce
or prevent some future state of affairs, although expectation of such an effect is
unrealistic
Obsessions Recurrent, uncontrollable thoughts, images, or impulses that a person considers
unacceptable and alien
Phobias Persistent, irrational fears, accompanied by a compelling desire to avoid the
stimulus
Anxieties Apprehensions, fears, tensions, or uneasiness that may be focuses (phobia) or free
floating (general sense of dread or impending doom)
43
Feelings of unreality Sense that things in the environment are strange, unreal, remote
Feelings of
depersonalization
Sense that ones self is different, changed, or unreal, or has lost identity or become
detached from ones mind or body.
delusions False, fixed, personal beliefs that are not shared by other members of the persons
culture or subculture. Examples: persecution; grandeur; jealousy; reference (where
person believes that external events, objects, or ppl have a particular and unusual
personal significance); being controlled (by an outside force); somatic delusions
(having a disease, disorder, physical defect); systematized delusions (elaborate
delusions around a single theme)
Abnormalities of perception:
Illusions Misinterpretations of real external stimuli
Hallucinations Subjective sensory perceptions in the absence of relevant external stimuli.
Person may or may not recognize experiences as false. Can be auditory,
visual, olfactory, gustatory, tactile, somatic. (Normal if associated w/
dreaming, sleeping, awakening.)
6. Apply the Mini-Mental Status Examination to patients.
This test is useful in screening for cognitive dysfunction or dementia and following
their course over time. Sample items:
Orientation to time !"hat is the date#$
% egistration !&isten carefully' ()m going to say * words. +ou say them
,ac- after ( stop. %eady# .ere they are/ .O0S1 2pause3' 45% 2pause3' &561
2pause3. 7ow repeat those words ,ac- to me.$ 2Score the 8st trial if done
more than once3.
7aming !"hat is this#$ 2point to pen3
%eading !9lease read this and do what it says$ 2Show e:aminee the words
on the stimulus form3 e:. 4&OS1 +O0% 1+1S
7. Describe the basic cranial nerve testing for CN I-XII.
CN-1 Olfactory: Present the patient with familiar and nonirritating odors. The patients eyes should be closed, and
test one side of the nose at a time (by compressing the opposite side).
CN-2 Optic: Test visual acuity, inspect the optic fundi, visual fields as in HEENT section.
CN-2, CN3 Optic and Oculomotor: Test size, shape, and reactivity to light of pupils. Check the near response for
pupillary constriction, convergence, and accommodation of the lens (as in HEENT)
44
CN 3, 4, 6 Oculomotor, Trochlear, Abducens: Test extraocular movements in the six cardinal directions of gaze, and
look for loss of conjugate movements in any of the six directions, which causes diplopia. Ask which direction makes
the diplopia worse and inspect the eye closely for asymmetric deviation of movement. Determine if the diplopia is
monocular or binocular by asking the patient to cover one eye, or perform the cover-uncover test. Check
convergence of the eyes. Identify nystagmus, including the direction of gaze and the direction of the quick and slow
components. Nystagmus is named for the direction of the quick component. Ask the patient to fix his vision on a
distant object and observe if the nystagmus increases or decreases. Look for ptosis.
CN 5 Trigeminal: (Motor) Palpate the temporal and masseter muscles and ask the patient to clench his teeth, then
move the jaw side to side.
(Sensory) Test the forehead, cheeks, and jaw on each side for pain sensation. Test for sharp and dull sensation.
If an abnormality is found, confirm it by testing temperature sensation. Test for light touch using a fine wisp of cotton.
Corneal Reflex: Ask the patient to look up and away from you. Approaching from the other side, out of the patients
line of vision, and avoiding the eyelashes, touch the cornea (not just the conjunctiva) lightly with a fine wisp of cotton.
Contact lense use diminishes or abolishes this reflex.
CN 7 Facial: Inspect the patients face at rest and in conversation. Ask the patient to raise both eyebrows, frown,
close both eyes tightly so that you cannot open them (to test muscular strength), show both upper and lower teeth,
smile, puff out both cheeks.
CN 8 Acoustic: Assess hearing with the whispered voice test. Test for air and bone conduction (Rinne test) and
lateralization (Weber test).
CN 9, 10 Glossopharyngeal and Vagus: Listen to the patients voice for hoarseness, nasal quality. Is there difficulty
swallowing? Ask the patient to say ah or to yawn and watch the movements of the soft palate and the pharynx for
asymmetries. Test the gag reflex on both sides, though it is absent in certain people (and professions).
CN 11 Spinal accessory: Look for atrophy or fasciculations (fine flickering irregular movements in small groups of
muscle fibers) in the trapezius muscles; compare one side to the other. Ask the patient to shrug both shoulders
upward against your hands. Note the strength and contraction of the trapezii. Ask the patient to turn his head to
each side against your hand. Observe the contraction of the opposite sternomastoid and note the force of the
movement against your hand.
CN 12 Hypoglossal: Listen to the articulation of the patients words. Inspect the patients tongue as it lies on the floor
of the mouth. Look for atrophy or fasciculations. With the patients tongue protruded, look for asymmetry, atrophy, or
deviation from the midline. Ask the patient to move the tongue from side to side, and note the symmetry of the
movement.
8. Define nystagmus.
p. 723-724
Nystagmus is a rhythmic oscillation of the eyes, analogous to the tremor in other parts of the body. Its causes are
multiple, including impairment of vision in early life, disorders of the labyrinth and the cerebellar system, and drug
toxicity. Nystagmus occurs normally when a person watches a rapidly moving object (i.e. a passing train). Nystagmus
usually has both slow and fast movements, but it is defined by its fast phase. The movement of nystagmus may
occur in one or more planes (i.e. horizontal, vertical, or rotary). It is the plane of the movements, not the direction of
the gaze, that defines this variable.
9. Describe the different components of assessing motor strength.
45
Muscle Tone
When a normal muscle with an intact nerve supply is relaxed voluntarily, it maintains a slight residual
tension known as muscle tone.
This can be assessed best by feeling the muscle's resistance to passive stretch.
Persuade the patient to relax.
Take one hand with yours and, while supporting the elbow, flex and extend the patient's fingers,
wrist, and elbow, and put the shoulder through a moderate range of motion.
With practice, these actions can be combined into a single smooth movement.
On each side, note muscle tonethe resistance offered to your movements.
Tense patients may show increased resistance.
You will learn the feel of normal resistance only with repeated practice.
If you suspect decreased resistance, hold the forearm and shake the hand loosely back and forth.
Normally the hand moves back and forth freely but is not completely floppy.
If resistance is increased, determine whether it varies
as you move the limb OR
whether it persists throughout the range of movement and in both directions (ex: during both
flexion and extension)
Feel for any jerkiness in the resistance.
To assess muscle tone in the legs, support the patient's thigh with one hand, grasp the foot with the
other, and flex and extend the patient's knee and ankle on each side.
Note the resistance to your movements.
Muscle Strength
Normal people vary widely in their strength, and your standard of normal, while admittedly rough, should
allow for such variables as age, sex, and muscular training.
A person's dominant side is usually slightly stronger than the other side. Keep this difference in mind
when you compare sides
Test muscle strength by asking the patient to move actively against your resistance or to resist your
movement. Muscles are:
Strongest when shortest
Weakest when longest.
If the muscles are too weak to overcome resistance, test them against gravity alone or with gravity
eliminated.
When the forearm rests in a pronated position, dorsiflexion at the wrist can be tested against
gravity alone.
When the forearm is midway between pronation and supination, extension at the wrist can be
tested with gravity eliminated.
Finally, if the patient fails to move the body part, watch or feel for weak muscular contraction
46
10. Explain the scale for grading muscle strength.
p. 680
0 No muscular contraction detected
1 A barely detectable flicker or trace of contraction
2 Active movement of the body part 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. This is normal muscle strength.
11. Describe the different methods for testing major muscle groups.
12. Explain the different tests to assess for coordination.
Coordinationne nger movements, nger-to-nose
Rapid Alternating Movements
Arms:
Show the patient how to strike one hand on the thigh, raise the hand, turn it over, and then strike the back of the
hand down on the same place. Urge the patient to repeat these alternating movements as rapidly as
possible.Observe the speed, rhythm, and smoothness of the movements. Re-peat with the other hand. The non-
dominant hand often performs somewhat less well.Show the patient how to tap the distal joint of the thumb with the
tip of the index nger, again as rapidly as possible. Again, observe the speed,rhythm, and smoothness of the
movements. The non-dominant side often performs less well.
Legs:
Ask the patient to tap your hand as quickly as possible with the ball of each foot in turn. Note any slowness or
awkwardness. The feet normally perform less well than the hands.
Arms - Finger - to - Nose Test:
Ask the patient to touch your index nger and then his or her nose alternately several times. Move your nger about
so that the patient has to alter directions and extend the arm fully to reach it. Observe the accuracy and smoothness
of movements and watch for any tremor. Normally the patients movements are smooth and accurate. Now hold your
47
nger in one place so that the patient can touch it with one arm and nger outstretched. Ask the patient to raise the
arm overhead and lower it again to touch your nger. After several repeats, ask the patient to close both eyes and try
several more times. Repeat on the other side. Normally a person can touch the examiners nger successfully with
eyes open or closed. These maneuvers test position sense and the functions of both the labyrinth and the
cerebellum.
Legs - Heels - to - Shin Test:
Ask the patient to place one heel on the opposite knee, and then run it down the shin to the big toe. Note the smooth-
ness and accuracy of the movements. Repetition with the patients eyes closed tests for position sense. Repeat on
the other side.
13. Describe the different tests for evaluating the sensory system.
14. Identify the specific spinal segments for the deep tendon reflexes and explain how to elicit the deep
tendon reflexes.
General
Encourage the patient to relax, then position the limbs properly and symmetrically
Hold the reflex hammer loosely btwn your thumb and index finger so that it swings freely in an arc
within the limits set by your palm and other fingers
With your wrist relaxed, strike the tendon briefly using a rapid wrist movement. Your strike should
be quick and direct, not glancing
If the patients reflexes are symmetrically diminished, use Reinforcement (isotonic contraction of
other muscle groups for 10 seconds) to increase reflex activity
; Ex: if leg reflexes are diminished, have the patient to lock their fingers and pull one hand
against the other. Tell the patient to pull just before you strike the tendon.
Biceps (C5, C6)
With the patients arm flexed at the elbow, place your thumb firmly on the biceps tendon. Strike the
hammer so that the blow is aimed through your digit to the tendon
Triceps (C6, C7)
Patient may be sitting or supine. Flex the patients arm at the elbow, with the palm towards the
body, and pull it slightly across the chest. If you cant get the ptnt to relax, try supporting the upper
arm yourself. Strike the triceps tendon above the elbow. Watch for contraction of the triceps muscle
and extension below the elbow.
Supinator or brachioradialis tendon (C5, C6)
Ptnts hand should rest on the abdomen w the forearm slight pronated. Strike the radius w the flat
of the hammer about 1-2 inches above the wrist.
Knee (L2, L3, L4)
Ptnt can be sitting or lying down as long as knee is relaxed and flexed. Briskly tap the patellar
tendon just below the patella. Note contraction of quadriceps w extension of the knee
Ankle (S1)
48
Dorsiflex the foot at ankle. Persuade the ptnt to relax. Strike the Achilles tendon. Watch and feel for
plantarflexion at the ankle. Note also the speed for relaxation after the contraction
If the reflexes seem hyperactive check for ankle clonus. Support the knee in a partly flexed
position. With your other hand, dorsiflex and planterflex the foot several times, encouraging the
patient to relax. Then, sharply dorsiflex the foot. Look for oscillations btwn dorsiflexions and
planatrflexion.
15. Explain the scale for grading reflexes.
p. 696
4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension)
3+ Brisker than average; possibly but not necessarily indicative of disease
2+ Average; normal
1+ Somewhat diminishes; low normal
0 No response (present in diseases of spinal nerve roots, spinal nerves, plexuses or peripheral nerves)
16. Describe the different tests to assess for cutaneous stimulation reflexes.
Abdominal reflexes: lightly but briskly stroke each side of the abdomen, above (T8, T9, T10) and below
(T10, T11, T12) the umbilicus, in the directions illustarated on page 701 (moving towards umbilicus). Note
the contraction of the abdominal muscles and deviations of the umbilicus towards the stimulus. Obesity may
mask and abdominal reflex. In this situation use your finger to retract the patients umbilicus away from the
side to be stimulated. Feel with your retracting finger for the muscular contraction
Plantar Response (L5, S1): stroke the lateral aspect of the sole from the heel to the ball of the foot, curving
medially across the ball. Note movements of the big toe, normally plantar flexion
Anal reflex (S2, S3, S4): using a dull object, stroke outward in the four quadrants from the anus. Watch for
reflex contraction of the anal musculature
17. Explain the tests to assess for meningeal signs, lumbosacral radiculopathy, and metabolic
encephalopathy.
Meningeal signs
Neck mobility. Make sure theres no injury to the cervical vertebrae or cervical cord. Then pt supine, place
your hands behind the pts head and flex the neck forward, until chin touches chest if possible. Normally,
neck is supple and the pt can easily bend head and neck forward.
49
Brudzinskis sign. As you flex the neck, watch the hips and knees in reaction to your maneuver. Normally
they should remain related and motionless. (+ Brudzinskis sign = flexion of hips and knees during neck
flexion)
Kernigs sign. Flex the patients legs at both the hip and the knee, then straighten the knee. Discomfort
behind the knee during full extension occurs in many normal people, but this should not be painful. (+
Kernigs sign = Pain and increased resistance to extending the knee)
Lumbosacral radiculopathy: Straight-leg raise. Do if pt has low back pain with nerve pain that radiates down the leg (if
its in S1 distribution its aka sciatica). Test straight-leg raising on each side in turn. Place pt in supine position. Raise
pts relaxed and straightened leg, flexing the leg at the hip, then dorsiflex the foot. Assess degree of elevation where
pain occurs, quality and distribution of the pain, and the effects of dorsiflexion. (Tightness or discomfort in buttocks or
hamstrings is common!!! Not a positive finding!) Dont forget to examine motor and sensory function at reflexes at the
lumbosacral levels.
Metabolic encephalopathy. ASTERIXIS helps ID metabolic encephalopathy in pts whose mental functions are
impaired. Ask pt to stop traffic but extending both arms with hands cocked up and fingers spread. Watch for 1-2
min, coaxing pt to maintain this position. (Sudden, brief, nonrhythmic flexion of the hands and fingers indicates
asterixis, seen in liver disease, uremia, hypercapnia)
18. Describe the steps to assessing a stuporous or comatose patient.
First asses the ABCs (airway, breathing, and circulation)
Establish the patients level of consciousness
Examine the patient neurologically. Look for focal or asymmetric findings and determine whether impaired
consciousness arises from a metabolic or a structural cause
Interview relatives, friends, or witnesses to establish the speed of onset and duration of unconsciousness,
any warning symptoms, precipitating factors, or previous episodes, and the prior appearance and behavior
of the patient.
Donts when assessing the comatose patient:
Dont dilate the pupils, the single most important clue to the underlying cause of coma
Dont flex the neck if there is any question of trauma to the head or neck
19. Explain the different levels of consciousness.
Level of consciousness: Techniques and patient response
Alertness Speak to the patient in a normal tone of voice. An alert patient opens the eyes, looks at you, and
responds fully and appropriately to stimuli
Lethargy Speak to the patient in a loud voice. A lethargic patient appears drowsy but opens the eyes and
looks at you, responds to questions, and then falls asleep
50
Obtundation Shake the patient gently as if awakening a sleeper. An obtunded patient opens the eyes and
looks at you, but responds slowly and is somewhat confused. Alertness and interest in the
environment are decreased.
Stupor Apply a painful stimulus. A stuporous patient arouses from sleep only after painful stimuli. Verbal
responses are slow or even absent. The patient lapses into an unresponsive state when the
stimulus ceases. There is minimal awareness of self or the environment.
Coma Apply repeated painful stimulus. A comatose patient remains unarousable with eyes closed.
There is no evident response to inner need or external stimuli.
51