Medical Skills Physical Exam

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Physical Exam

Sub-Unit of the Medical Skills Program

MDCN 320 & MDCN 420

UNDERGRADUATE MEDICAL EDUCATIONCORE DOCUMENTClass of 2017 & 20162014-2015 Academic Year

© 2014



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Contents

The Physical Exam Course ..................................................................................................................... 3

Purpose ............................................................................................................................................ 3

Overview ......................................................................................................................................... 3

Responsibilities and Expectations................................................................................................... 4

Scheduling....................................................................................................................................... 4

Reference Material .......................................................................................................................... 5

Evaluation ....................................................................................................................................... 5

Written Medical Record .................................................................................................................. 5

General Objectives .......................................................................................................................... 6

Written Medical Record .................................................................................................................. 7

Written Medical Record Sample ................................................................................................... 11

General Schedules ................................................................................................................................. 15

Year 1 – Class of 2017 .................................................................................................................. 15

Year 2 – Class of 2016 .................................................................................................................. 16

Sessions for Year 1 ............................................................................................................................... 17

General Inspection, Vital Signs and Draping ............................................................................... 17

Lymph Nodes Exam ..................................................................................................................... 24

General Abdominal Exam............................................................................................................. 27

Liver and Spleen Exams ............................................................................................................... 34

Hand and Wrist Exams ................................................................................................................. 42

Cervical Spine and Shoulder Exams ............................................................................................. 50

Ankle, Foot, and Knee Exams ...................................................................................................... 58

Hip and Thoracolumbar Spine Exams .......................................................................................... 68

Jugular Venous Pulse Exam .......................................................................................................... 79

Respiratory Exam.......................................................................................................................... 83

Precordial Exam ............................................................................................................................ 92

Peripheral Vascular Exam............................................................................................................. 98

Sessions for year 2 .............................................................................................................................. 105

Head and Neck Exam .................................................................................................................. 105

Endocrine System ....................................................................................................................... 115

Cranial Nerves Exam .................................................................................................................. 120

Mini-Mental Status Exam (MMSE)............................................................................................ 129

Peripheral Neurological Exam .................................................................................................... 134

References ........................................................................................................................................... 147



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The Physical Exam Course

Dr. Luc Berthiaume Dr. Florence ObianyorCo-chair Co-chairPhone: [email protected] [email protected]

Kerri MartinProgram CoordinatorPhone: [email protected]

The unit co-chairs would like to acknowledge the unbelievably generous contribution of Dr.Heather Baxter in reviewing this core document. Any mistakes that remain are entirely ourown.

Purpose

The purpose of the Physical Examination course is to develop the technical skillsrequired to perform a physical examination, including:o Mastering the examination techniques within individual body regions or

systems;o Use of instruments required during a physical examination;o Integration of these skills into a focused assessment.

These skills will be integrated with other courses in the Medical Skills program.

Overview

The Physical Examination course runs over two years.o The expected time commitment for scheduled physical exam skills sessions is

approximately 28 hours in the first year, and 24hours in the second year. In your first year, you will attend small group sessions where:

o You will learn the proper techniques to examine major body regions orsystems.

Excludes the examination of the endocrine, head/ear/eye/nose/throat (HEENT) andneurological systems.

In your second year, you will attend small group sessions where:o You will learn the proper techniques to examine the endocrine,

head/ear/eye/nose/throat (HEENT) and neurological systems.o You will participate in case-based session where you will use clinical

reasoning and evidence-based medicine to develop a differential diagnosis

and perform physical examination focusing around common presentingcomplaints.

o You will participate in the Well Woman sub-course. You will learn an approach to and practice the examination of the

female breast and female genitalia.o You will participate in the Well Man sub-course.

You will learn an approach to and practice the examination of the malebreast, the male genitalia, and the ano-rectum.



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Responsibi lities and Expectations

Student will be assigned to clinical small groups.o The groups will remain the same for two years.o Each group will need to assign a student leader.

It is the responsibility of the student leader to ensure that a laptop oriPad is available for use during the physical exam session.

o Each group will be assigned one or more clinical skills preceptors for the year. Preceptors will lead the physical exam sessions.

At tendance is 100% mandatory.o It is expected that students will attend all small group sessions in the physical

exam course except under exceptional circumstances.

Come prepared.o Prior to the small group sessions, review the pertinent physical exam

techniques from the core document. Supplement this with a review of a standard physical exam textbook.

Rules around physical examination:o Medical students cannot examine a standardized patient without the preceptor

being physically in the same room as the student and the patient.o Medical students may not examine each other or the preceptor during a

Physical Examination session.

This course requires both small group attendance and independent study.o Small groups will focus on the techniques for physical examination, and

normal physical findings.o Independent study should focus on:

Practice/review of physical exam skills and techniques. Exploration of related topics such as normal physiology, surface

anatomy, expected normals, and differential diagnoses for abnormalfindings.

Students will use the course objectives as outlined in this core document as a guide

for appropriate study topics.

Scheduling

Physical examination sessions will occur at pre-arranged times, as per the publishedtimetable (refer to Osler).

o Year-long individualized schedules will be sent to each group at the beginningof the school year.

Members of small groups may consider meeting as a group, in the Medical SkillsCentre, during their IST to work on physical exam skills, room availability permitting.

o Space for practice may be booked.o Standardized patients are not available for these practice sessions if a

preceptor is not in attendance, due to liability reasons. As part of each systems course, the students will participate in Clinical Correlations

(“core”.)o The physical exam course is meant to teach fundamental skills of the physical

exam and introduce the student to expected normals.o The core sessions are meant to introduce the student to the presentation of

common clinical conditions.For ease of scheduling, the small groups will be the same as for physical exam.



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Reference Material

This core document should be considered as a general guide.o It is not a comprehensive resource for physical exam skills.o It is strongly suggested that you purchase a general textbook on

physical/clinical exam skills.

These resources below are recommended as aids to learning physical exam.o Bickley, L.S. Bates’ Guide to Physical Examination and History Taking. 10th

Edition. Lippincott.o LeBlond, R.F. DeGowin’s Diagnostic Examination. 9th Edition. McGraw-Hill

Medical.o McGee, S.R. Evidence-Based Physical Diagnosis. 2nd Edition.

Saunders/Elsevier.o Orient, J.M. Sapira’s The Art and Science of Bedside Diagnosis. 3rd Edition.

Lippincott Williams &Wilkins.o Seidel, H.M. Mosby's Guide to Physical Examination. 5th Edition. Mosby.o Talley, N.J. Clinical Examination: A Systematic Guide to Physical Diagnosis.

6th Edition. Elsevier Churchill Livingstone.o Walker, H.K. Clinical Methods: The History, Physical, and Laboratory

Examinations. 3rd Edition. Butterworths.

Additional PE Video Clips and Interactive Websites:

www.prep4usmle.com/resources/72

www.conntutorials.com/

www.med.ucla.edu/wilkes/inex.htm

The U of T-developed “The Art and Science of Clinical Medicine” is available

via OSLER.

Evaluation

This course will be primarily evaluated through OSCE-style assessments.o The OSCE stations will be based entirely on the contents of the core

document (i.e., if it is in the core document, unless specified otherwise, youare expected to know it and can be evaluated on it).

o Both years will have a formative and a summative OSCE experience.

In second year, a written medical record detailing a physical examination is required.o Will be done during a case-based physical exam session.o Will be written in a style similar to a hospital or clinic record.o Completion of the written medical record is mandatory. The absence of a completed record will result in an incomplete grade.

Written Medical Record

Further information will be provided at the beginning of the 2nd year case based

sessions.



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General Objectives

Year 1 and first half of Year 2 Develop the technical skills and use of medical instruments required to complete a

physical examination. Perform the physical examination for each of the major body regions or systems.

Recognize expected normals. Identify when a finding is normal. Begin to develop an understanding of the pathophysiology of abnormal clinical

findings.

Second half of Year 2 Develop a structure for a focused history as pertinent to the patient’s complaint. Demonstrate the synthesis of information into a list of possible diagnoses for the

presenting problem. Demonstrate an approach to a detailed, limited physical examination for common

presenting complaints or medical problems. Develop a focused physical examination so as to include or exclude items from the

possible diagnoses for the presenting problem list. Demonstrate the incorporation of clinical reasoning and evidence-based medicine in

the development of a differential diagnosis and during physical examination.



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Written Medical Record

In general, such records usually include information on:

Chief complaint.

Past medical history.

History of present illness.

Drug and allergy history.

Family history.

Social history. Review of systems.

Physical examinations performed and findings.

Differential diagnosis list.

Management plan/recommendations.o Further investigations.o Possible treatments.

Plan of action negotiated/agreed upon with patient.

It is our hope that this exercise and the feedback that will be provided will help youunderstand how to write good notes in your patients’ charts once you enter clerkship. What

you put into this exercise, is what you will get out of it!

The following is a ‘key’ to the accompanying case write up example.ID: identity/identifying features. Usually short e.g. 1 sentence that summarizes the patient’sdemographics

i- Age: years old is often abbreviated y/oii- Sex: Male vs. female. Would avoid adding editorial details such as ‘gentleman’ in

favor of man or womaniii- State if patient has (or lives) with partner/significant other, spouseiv- State if patient has childrenv- Occupation (be brief)

CC: chief complaint. The key is brevity, one (or two) symptoms. Can list duration ofsymptoms.



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Profile/Past Med Hx (past medical history): can list this before or after the history of presentillness (HPI). The key is listing the diagnoses in addition to relevant features that pertain toindividual diagnoses

e.g. Type 2 diabetes history of retinopathy (no photocoagulation), nephropathy (baselinecreatinine 111); no neuropathy, stroke, coronary artery disease.

Meds (medications): can list this before or after the history of present illness (HPI). For each

medication, the following should be listed:i- Drug name (generic as opposed to trade names)ii- Dose with appropriate units (units, g, mg, micrograms)iii- Route: Oral-PO, Via feeding tube nasogastric (NG) vs. nasojejunal (NJ) vs.

Gastrostomy (G-tube) Intravenous (IV), inhalation (inh)iv- Frequency: once daily (OD), twice daily (BID), three times daily (TID), Four times

daily (QID), specific hourly intervals Q?H where? represents the number of hoursbetween doses. Should also add if medication is taken on a ‘as needed’ basis-PRN

e.g.1- Metoprolol 25 mg PO BID

2- Acetaminophen 325 mg PO TID PRN

Alls (allergies): Can list this before or after the history of present illness (HPI). If no drugallergies, can state Nil or NKDA, where the latter stands for no known drug allergies. If thereare allergies, state the medication and the reaction to the medication e.g. penicillin-nauseaand vomiting. The reaction description is very important not only to prevent adverse eventsbut also to ensure that lifesaving medications are not withheld in the event of life-threateningdiseases e.g. documented allergy to ceftriaxone (nausea/vomiting no rash or anaphylaxis)in a patient with bacterial meningitis.

HPI (history of present illness): This section is the most important as it is your opportunity to

‘tell the story’. It is probably easiest to have it point form. In the first part, the reader shouldbe able to ascertain what is the writer’s suspected diagnosis. In the second part, the readershould be able to exclude other pathologies on the differential diagnosis. When you arestarting, it is worthwhile to refer to your blackbook as soon as you hear the chief complaint(or reason for referral) as this will remind you of the relevant questions to ask for a givenpresentation. It is also important to note that the HPI may contain elements from othersections (past history/profile and review of systems) if they are relevant to the case. In thecase write up example provided, there are elements of past history (risk factors for coronarydisease) and review of systems (GI symptoms). It is also noteworthy that pertinentnegatives are as relevant as pertinent positives. If not explicitly stated, the question(s) didnot get asked. At the end of this section, the reader should know the diagnosis or narrow

differential diagnosis as well as which diagnoses from the differential are unlikely.



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SocHx (social history): There are multiple components to this section:i- State if the patient has and/or lives with a partner, spouse, roommate, friendii- List the patient’s people of significance/next of kin in addition to that stated above-

children, siblings, other family members, friendsiii- Cigarette smoking: pack per day x years of smoking= pack yearsiv- Alcohol use: how much per dayv- Drug use: injection, ‘recreational’ drugs, prescription drugsvi- Employment: state the patient’s current occupation. This section should be

extensive if thinking about occupational diseases- for example, a detailed list ofeach job, direct/indirect exposures for each job.

FamHx (family history): List diagnoses in first order relatives. Can build family tree if thinkingof congenital diseases.

ROS (review of systems or functional inquiry): List symptoms by organ system if it was notdone in HPI.

Exam: Should open with a general statement- well groomed vs. unkempt, well vs. unwell,stated vs. younger or older than stated age. Some preceptors would say that this statement

should enable the reader to find the patient in question in a busy waiting room.

Vital Signs: BP, HR, RR, Temp and most include SpO2.

For all other organ systems, list all the pertinent negatives and positives in an organizedfashion- probably best to list according to IPPA. Remember if it is not reported in your writeup, it did not happen.

Investigations: The approach to listing investigations varies according to the situationand/or preceptor. You should list all the investigations in the following circumstances: 1-hospital admission note 2- initial consult note 3- initial clinic visit. For daily hospital progress

notes and repeat clinic visits, it is sufficient to list relevant investigations.

Assessment/Impression: This statement should be limited to one or two sentences. Ideally,it should include up to 10 (but no more) salient findings from the history, physical exam andinvestigations. This statement should have ‘stand alone’ value in so far as disclosing thediagnosis or narrow differential diagnosis.

Issues/Plan: The format is a problem list. It is key to list the problems in order of importanceas this demonstrates the writer’s ability to prioritize and problem formulate. For eachproblem, the diagnosis should be listed or alternatively, the narrow differential diagnosis.Investigations and treatment plans for that problem should also be described, including,

where necessary, the rationale for selecting a particular diagnostic test/approach and/ortreatment strategy.

Additional information regarding case write ups: The sample write up and write upinformation provided to you is an example of a hospital admission write-up for a medicalpatient. Hospital admission notes will vary according to the medical service. As well,progress notes are framed very differently, commonly using the SOAP format where eachletter stands for Subjective (patient’s symptoms), Objective (your observations),

Assessment (problem list) and Plan. Clinic notes will also have a different format dependingon the environment where you are working.



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For example, the documentation in a family medicine may have a similar format aspresented above in so far as the creation of a problem list. However, the plan for eachproblem could be broken down to:

1- over the counter remedies (OTC) meaning interventions that the patient can do forthemselves such as ice elevation, ice and acetaminophen for a swollen joint,

2- prescription remedies such as NSAIDS3- investigations such as x-rays, blood work, ECGs, echo

4- Other health care professionals such as referrals to a specialist, physiotherapist,dietician.

5- Red flags- symptoms that should prompt follow up to the family physician’s officeand/or to the emergency room.



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Written Medical Record Sample

ID: 56 year old man, married with 2 children, car salesman

CC: chest pain x 24 hours

Profile/Past hx:1- LUL lobectomy for NSCLC 2 year ago2- COPD- no home oxygen, no cor pulmonale, ex-smoker, MRC class 13- Hypertension4- Dyslipidemia5- Appendectomy Age 16

Meds:

1- Tiotropium 18 g 1 inh daily

2- Salbutamol 100 g 2 puffs qid prn3- Hydrochlorothiazide 25 mg PO daily4- Ramipril 10 mg PO daily5- Simvastatin 40 mg PO daily

Alls: NKDA

HPI:- chest pain on and off x 24 hours; left sided (no radiation); sharp; worse with

inspiration; no relieving factors; not precipitated by exercise- dyspnea x 72 hours (over weekend), usually dyspnea with vigorous exercise, now

dyspnea with < 1 flight of stairs or < 1 block if ground level- + swelling of ankles bilaterally- no cough, no hemoptysis- cardiac risk factors as noted above (no DM, no famHx); no hx of MI or angina- no orthopnea or PND- no fevers/sweats/chills/anorexia/malaise; pneumovax 2 years ago, yearly flu shot- no wheezing, no improvement in symptoms with increased ventolin, no prior hospital- lost to follow up post lobectomy; unknown cancer status; weight stable recently- no hx GERD, no hx biliary colic, no jaundice

SocHx:- married x 32 years; lives with wife- 2 adult children- car sales x many years- ex smoker- quit 2 years ago (with dx of lung ca)

- EtOH- socially- No drug use (injection or otherwise)

FamHx:- Father: hypertension, alive and well- Mother: died ovarian ca 10 years ago- Brother: Hypertension- Children: healthy



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ROS:-neuro: no headache, diplopia, weakness, numbness or tingling-GI: no diarrhea, abdo pain-Skin: no rashes-MSK: no arthralgias, stiffness

Exam:General: obese middle aged man, looks stated age, mild respiratory distress

VS: BP 150/92 (equal both arms) HR 119 regularly regular RR 26 T 37.3 SpO2 –82% R/A, now 95% on 8 LPM np

HEENT: no jaundice, MMM- no oral lesions, TMs- normal, no lymphadenopathy,no thyromegaly

Resp: + thoracotomy scar, + accessory muscle use, trachea midline-no tug,normal percussion, normal tactile fremitus, breath sounds vesicular- nowheeze or bbs, ? pleural friction rub left

CVS: JVP 7 cm ASA, + kussmauls, bilateral lower extremity pitting edema, coolextremities- no mottling, PPP-no bruits, PMI 5th ICS/MCL- no heaves orthrills, S1S2 +S3 (increases with inspiration) no S4 no murmur no rub

Abdo: appendectomy scar, BS+, obese abdo, no stigmata CLDZ, soft, nontender,

no organomegaly, no massesSkin: no lesions, ? right axillary lymphadenopathyMSK: no active jointsNeuro: not performed

Investigations: ABG (on 8LPM): 7.37/41/67/25 Lactate 1.2Hb 142 WBC 11.9 Neuts 9.2 no left shift Plts 219Na 141 K 3.9 Cl 101 Cr 87 Urea 5.2INR 1.2 aPTT 37

AST 32 ALT 24 ALP 103 Bili 12 GGT 109

ECG: sinus tach, right axis deviation, no ischemic changesCXR: RLL mass, right hilar adenopathy, surgical clips left hila, left

hemidiaphragm elevationsd-dimer: 14tnt: 0.05

Impression:56 year old man, with hx NSCLC presents with chest pain, dyspnea, elevated JVP withkussmaul’s, right sided S3, hypoxemia, positive d-dimer and right lower lobe mass/right hilaradenopathy on CXR. Findings are most suspicious for acute PE and lung cancerrecurrence.

Issues/Plan:1- Chest pain/dyspnea: as above most suspicious for PE. + TnT likely represents

strain from PE- doubt acute coronary syndrome or dissection. PE likelyhemodynamically significant (JVP, kussmaul’s, TnT)Do not suspect

AECOPD as no signs of airflow obstruction on exam + alternative



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Plan:i- CT PE protocol- favor this above V/Q given abnormal CXR + suspicion of cancer

(CT will also provide more detail regarding RLL mass/right hilar adenopathy)ii- Doppler legs: suspect residual DVT given bilateral leg edemaiii- TTE: need to characterize RV performance given exam/ + tnt suggest impaired

performance.iv- Anticoagulation: LMWH should be ok given no indications for thrombolysis

currently despite suspicion of hemodynamically significant PE(normal Cr,

mentation, lactate normal). Tinzaparin 175 u/kg.v- +/- temporary IVC filter depending on Doppler legs- suspect limited

cardiopulmonary reservevi- Will admit to MTU with telemetry given suspect large PEvii- Pulmonary consult re: PE + possible recurrent lung caviii- ICU consult if deterioratesix- For now, work up for recurrent lung ca as cause of hypercoagulability. No

indication for hypercoagulability screen.

2- ? Lung cancer recurrence re: RLL mass/right hilar adenopathy/query rightaxillary lymphadenopathy/suspicion of large PE, thus suspicion of recurrent

ca as reason for hypercoagulability

Plan:i- CT PE protocol- should give further characterization of RLL mass/right hilar

lymphadenopathy. Will speak with radiologist re: upper abdominal cuts to look atliver/adrenals

ii- CT head: no neuro symptoms but suspect extensive cancer + starting onanticoagulation- r/o brain mets

iii- Consider bone scan to look for metsiv- Will need tissue diagnosis- at this point, too ill to consider bronchoscopy. Will ask

Pulmonary as to timing of bronchoscopy. Could consider right axillary LN biopsy

(?size on CT) as might be least invasive. CT will also potentially reveal other sitesfor biopsy/tissue diagnosis.

v- Notify Thoracic Surgeon that performed lobectomy of admission + obtain surgeon’srecords.

3- COPD

Plan:i- No evidence active airflow obstruction. Not known to be CO2 retainer, so target

sats> 92%. Continue bronchodilators (tiotropium/slabutamol)

4- Hypertension

Plan:i- Will hold antihypertensives for now given suspect large PE. Restarting will depend

on clinical evolution/ echo results.



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5- Dysplidemia

Plan:i- Continue Simvastatin.

6- Goals of Care

Plan:

i- Discussion with patient and wife. Outlined above + potential for deterioration.Wishes for R1 GOC in short term. Will review as more details come to light.



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General Schedules

Year 1 – Class of 2017

Introductory lecture on August 19, 2014 (0830-0920).

Tuesday - AM (1030-1220)

Wednesday – PM (1330-1520)

Wednesday - PM(1530-1720)

Session 1 – course 1 (draping/general techniques ) August 19 August 20 August 20

Session 2 – course 1 (lymph nodes exam) August 26 August 27 August 27

Session 3 – course 1 (general abdominal exam) September 2 September 3 September 3

Session 4 – course 1 (liver & spleen exams) September 9 September 10 September 10

Session 5 – course 2 (hand/wrist exams) November 18 November 12 November 12

Session 6 – course 2 (shoulder/cervical spineexams)

Thursday November 20

November 19 November 19

Session 7 – course 2 (ankle/foot/knee exams) November 25 November 26 November 26

Session 8 – course 2 (hip/L-spine exams) December 2 December 3 December 3

Session 9 – course 3 (BP & JVP exams) January 13, 2015 January 14, 2015 January 14, 2015

Session 10 – course 3 (chest exam) January 20, 2015 January 21, 2015 January 21, 2015

Session 11 – course 3 (precordium exam) January 27, 2015

Wednesday January 28, 2015 (0830)

Wednesday January 28, 2015 (10

Session 12 – course 3 (peripheral vascular exam) February 17, 2015 February 18, 2015 February 18, 2015

Session 13 (review) February 24, 2015 February 25, 2015 February 25, 2015

Session 14 (practice OSCE)

ThursdayFebruary 26, 2015 (1030)

Tuesday March 3, 2015 (1030)

Thursday March 5, 2015 (103



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Year 2 – Class of 2016

Well Woman introductory lecture October 20 (0830-1020) for entire classSupplementary lecture October 20 (1030 – 1220) for entire class

Monday - AM (0830-1020)

Thursday - PM (1330-1520)

Thursday - PM (1530-1720)

Session 1 – course 5 (visual fields/cranial nerveexams)

August 11 August 14 August 14

Session 2 – course 5 (MMSE)


Session 3 – course 5 (peripheral neuro exam)


Session 4 (case based*)

November 3 November 6 November 6



Session 6

(case based*)



December 1 December 4 December 4


December 8 December 11 December 11

Well Woman Sub-Unit

* Patient write-up (medical written record) must be handed to the Program Coordinator,Kerri Martin as a demonstration of completion of this assignment. Deadline to hand incompleted patient write-ups is November 29, 2013??.



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Sessions for Year 1

General Inspection, Vital Signs and Draping

Session 1- Course 1

OBJECTIVES for GENERAL INSPECTION, VITAL SIGNS and DRAPING

Cleanse hands prior to examining a patient. Demonstrate proper draping techniques. Identify by inspection common general markers of chronic illness:

Cachexia. Wasting. Obesity. Stated age. Disheveled state. Odor.

Identify by inspection common general markers of acute illness: Position in bed (sitting, upright, reclining). Diaphoresis. Odor. Rash.

Identify common measures of general health status including: Height. Weight. Vital signs.

Pulse. Blood pressure. Respiratory rate. Temperature. Oxygen saturation.

Identify and describe the features of an arterial pulse: Rate. Rhythm. Contour. Amplitude.

Demonstrate the correct technique for the evaluation of: The peripheral palpable blood pressure. The auscultatory blood pressure.

Identify and demonstrate conditions needed to take a blood pressure: Relaxation.

Support for feet. Arm at heart level. Appropriate cuff size. Appropriate cuff placement.

Identify location of brachial artery in antecubital fossa. Demonstrate and explain the technique for identifying pulsus paradoxus.



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COMMON MARKERS OF ILLNESS

Upon entering a room, you should be able to make a quick assessment of a patient’scondition, noticing certain common general markers of illness.

o Chronic illness: Cachexia.

A catabolic state that induces weight loss, including loss of both fatand some fat-free mass.

Wasting.

State of emaciation and weakness, caused by loss of fat-free mass. Obesity. Stated age. Disheveled state. Odor.

o Acute illness: Position in bed. Sitting, upright, reclining. Diaphoresis (sweating). Odor. Rash.

COMMON MEASURES OF GENERAL HEALTH STATUS

Important basic physiological information is provided by the following measurements:o Height.o Weight.o Vital signs.

Pulse. Blood pressure. Respiratory rate. Temperature. Oxygen saturation.

PULSE

Rate.o The radial pulse is typically used to determine the

rate. It can be felt just medial to the radius,

usually using the tips or pads of your indexand middle fingers.

Less often the rate is determined bylistening to the heart (apical rate).

o How you determine the rate depends on whether the pulse is regular or irregular. If the pulse is regular, the rate can be counted for 15 seconds and

multiplied by four to establish beats per minute. If the pulse is irregular, the rate can be counted for 30 seconds and

multiplied by two or can be counted for 60 seconds to establish beats perminute.



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o Normal rate is 60 to 100 beats per minute for adults. Athletes will often have normal rates below 60. A rate below 60 is by definition called “bradycardia”. A rate above 100 is by definition called “tachycardia”.

Rhythm.o Can be regular, regularly irregular or irregularly

irregular.

Contour.

o A normal pulse has a smooth and rapid upstrokeand a more gradual down-stroke.

o The diagram on the side shows a few differenttypes of abnormal pulse contours (this isnot an exhaustive list).

o If you think that the contour or amplitudeof the arterial pulse may be abnormal,check the carotid (see Year 1, sessions 11and 12).

Amplitude.o Can be quantified as:

Thready or weak (easy toobliterate).

Normal (obliterates with moderatepressure).

Bounding (unable to obliterate orrequires very firm pressure).

o If you think that the contour or amplitudeof the arterial pulse may be abnormal,check the carotid (see Year 1, sessions 11and 12).

RESPIRATORY RATE The respiratory rate is typically measured while

appearing to be doing something else (e.g. takingthe pulse) so the patient is unaware that it isbeing measured.

o This is because respiratory rate is the only vital sign which in under voluntarycontrol.

o Tip: if you place the patient’s arm across the chest while palpating pulse, you canalso count respirations. Just keep your fingers on the pulse even after you have

finished taking it. Count for at least 30 seconds and multiply by two to determine breaths per minute.

Normal rate averages about 12-16 breaths per minute.

Also pay attention to the quality of the breaths: shallow, unequal, very deep, etc.



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BLOOD PRESSUREInspection:

Identify the brachial artery in the antecubital fossa.

Place the blood pressure cuff around the arm.o Make sure that the cuff size is appropriate.

The bladder is the inflatable bag part of the cuff. The width of the bladder should be equal to 40%

of the circumference of the limb.

The length of the bladder should be equal to 80% ofthe circumference of the limb.

A cuff bladder that is too small can make the bloodpressure reading artificially high.

A cuff bladder that is too big can make the bloodpressure reading artificially low.

If the cuff size is borderline, err on the side of usingthe larger size cuff.

o Make sure the cuff is placed over the brachial artery. There are usually markings on the cuff that show how

it should be placed.

Place the arm in such a way that it is located at heart level.o If the arm is placed higher, the blood pressure reading will be

artificially low.o If the arm is below the level of the heart, the blood

pressure reading will be artificially high.o If the patient is sitting on a chair, you can usually have

them rest their arm on a table.o If the patient is sitting on the exam bed, you can

usually have their arm rest on a rolled up pillow or youcan support it with your own arm.

Palpation: While having your fingers on the radial pulse of the arm in

which you are measuring the blood pressure, rapidly inflatethe cuff to about 30 mmHg above the level at which the arterial pulsation disappears.

Slowly deflate the cuff while palpating the arterial pulse.o Deflate at approximately 2-4 mmHg per second.

Estimate the palpable systolic pressure (i.e., number at which you can you feel the pulseagain).

Deflate the cuff totally. Auscultation:

Place the diaphragm of your stethoscope over the brachial artery.

Inflate the cuff approximately 20-30 mmHg above the palpable systolic pressure (asobtained in the “Palpation” step above.

Slowly deflate the cuff.o Deflate at approximately 2-4 mmHg per second.

Identify the systolic and diastolic blood pressures.o The number at which you hear two consecutive heart sounds is the systolic

pressure.o The number at which the sound disappears is the diastolic pressure.



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Pulsus Paradoxus:

Normally, during inspiration the systolic and diastolic blood pressures decrease.o When the decrease is exaggerated, it is termed pulsus paradoxus.

You can check for pulsus paradoxus in the following way:o Inflate a cuff until no sounds are heard.o Gradually deflate the cuff until sounds are only audible during expiration.

Note this pressure.o Continue to deflate the cuff until sounds are audible during both inspiration and

expiration. Note this pressure.

o The difference between the two pressures is the pulsus paradoxus. A difference greater than 10 mmHg is abnormal.

Physiological explanation for pulsus paradoxus in simplified terms (you will not be testedon this, for your information only!):

o Normally, when we take a breath in, our intrathoracic pressure decreases whichmakes it easier for venous blood to flow back into the heart, thus more bloodenters the right side of the heart. The fact that more blood enters the right side ofthe heart leads to (pulmonary venous return) flow being reduced into the left sideof the heart. This, in turn, means that there is less blood available to pump out of

the left side of the heart when it contracts. This manifests itself as a decrease insystolic blood pressure.

o In conditions such as cardiac tamponade or pericarditis, there is increasedpressure around the heart and it cannot expand as easily. Hence, when a deepbreath is taken in, the intrathoracic pressure still decreases, but the heartsurrounding being less pliable leads to an exaggeration of the reduction of flowinto the left side of the heart. This means even less blood than usual is availableto be pumped out when the heart contracts. This manifests itself as an evenfurther decrease in systolic blood pressure.

o When this phenomenon was initially discovered by Kussmaul, he was actuallyreferring to the fact that the pulse palpated was of variable strength or not

palpable even though he was still able to auscultate cardiac sounds. Hence, thename is misleading (i.e., not paradoxical), as the direction of change in systolicblood pressure is the same whether you have a medical condition that causespulsus paradoxus or not.



22

Things to Know and Remember:

Blood pressure should be measured in both arms in a new patient.o Normally, the blood pressure should be very fairly similar in both arms (i.e,

systolic pressure is within 10 mmHg).

Blood pressure can be measured in different positions (e.g., supine, sitting, standing).o Should be done routinely in a new patient.o When checking the postural blood pressure, you will want to check the blood

pressure and pulse supine and then immediately afterwards in a standing

position. A fall of more than 20 mmHg in systolic blood pressure or more than 10

mmHg in diastolic blood pressure and an increase in pulse of 30 beats perminute or more is abnormal and is termed orthostatic (postural)hypotension.

Conditions under which a proper blood pressure can be taken:o Patient should be relaxed.

This means that they should not have been smoking, drinking a caffeinatedbeverage or have done any vigorous exercising (such as running to theclinic so as not to be late for their appointment).

o Patient should be seated with the feet supported (or on the floor if sitting in a

chair).o Patient’s arm needs to be at heart level.

The difference between the systolic and diastolic pressures is termed the pulsepressure.

A blood pressure-measuring apparatus is called a sphygmomanometer (Greeksphygmos for “pulsing” and manos for “thin”).

As the blood pressure cuff is being deflated, five different sounds will be heard.o They are called Korotkoff sounds and they are caused by turbulent flow in the

artery.o The sounds are numbered I through V.

Korotkoff sound I is the first sound that you hear and which indicates your

systolic blood pressure level. Korotkoff sound V is when the sound disappears, which indicates your

diastolic blood pressure.

TEMPERATURE

Temperature is not routinely measured unless an abnormality is suspected.

Tympanic measurements are typically used because they are rapid and convenient.o Theoretically tympanic measurements also best reflect the core body

temperature.o Other ways to measure temperature: oral (under tongue), rectal, axillary,

forehead.

The mean tympanic temperature is 36.4˚C.o A fever is usually defined as 38˚C or greater.





24

Lymph Nodes Exam

Session 2 – Course 1

OBJECTIVES for LYMPH NODES EXAM Identify the sites of the major superficial lymph tissue.

Cervical. Occipital. Post-auricular. Pre-auricular. Posterior cervical. Anterior cervical. Submandibular. Submental. Supraclavicular. Infraclavicular.

Epitrochlear. Axillary.

Central. Lateral. Medial. Anterior. Posterior.

Inguinal. Demonstrate the maneuvers involved in the palpation of the major superficial lymphatic

tissues. Describe lymph nodes.

Location. Size. Consistency. Mobility. Tenderness.

LYMPH NODESInspection:

Look for asymmetry in the neck, especially in the supraclavicular andsternocleidomastoid areas.

Observe axillae for asymmetry or masses.

Palpation:

Palpation should involve a rolling motion of the fingers.

If a node is felt, describe it in terms of:o Location.o Size.o Consistency/texture.o Mobility.o Tenderness.



25

Lymph nodes of the head and neck(also called cervical nodes):

o Occipital.o Post-auricular.o Pre-auricular.o Posterior cervical (behind the

sternocleidomastoid muscle).o Anterior cervical (in front of the

sternocleidomastoid).o Submandibular (under the jaw

line).o Submental (under the chin).o Supraclavicular (in supraclavicular fossa).o Infraclavicular (under the clavicle).

Other lymph nodes:o Epitrochlear

Located 3 cm proximal to the medial humeral epicondyle (or just medial tothe muscle belly of the biceps).

Support the patient's flexed arm while palpating.o Axillary.

Place the left hand in the right axilla (or the right hand in the left axilla)with palm toward chest wall.

Point the fingers obliquely toward the apex of the axilla. Hold the patient's elbow with your other hand and adduct the patient’s

upper arm to help relax the muscles. Palpate firmly for the following lymph nodes:

Central.

Lateral.

Medial.

Anterior. Posterior.

Rake the pulps of the fingers along the thoracic cage.o Inguinal

Best felt with the patient lying down. Palpate with rolling motion along the inguinal ligament.

Femoral nodes are felt along the femoral artery from the inguinalligament and extending inferiorly 4-5 cm.



26

GENERAL COMMENTS ON LYMPH NODES

Generally, nodes that are firm and immobile are associated with a metastatic process.

Generally, nodes that are tender, warm, or have overlying erythema (redness) areassociated with infectious or inflammatory processes.

Left supraclavicular nodes may be associated with intra-abdominal carcinomas(Virchow’s node).

If a node is found on one side of the body, remember to compare it to the other side.

OTHER LYMPHATIC TISSUE Other lymphatic tissues include:

o Tonsils.o Peyer’s patch (clumpings of lymphoid tissue

usually found in the ileum).



27

General Abdominal Exam


OBJECTIVES for GENERAL ABDOMINAL EXAM Demonstrate the appropriate positioning of the patient for examination of the abdomen.

Demonstrate the appropriate draping of the patient for examination of the abdomen. Identify surface quadrants and two regions.

RUQ. LUQ. RLQ. LLQ. Periumbilical. Epigastric. Suprapubic.

Identify the surface anatomy of major abdominal organs in the four surface quadrants. Liver.

Spleen. Kidneys. Stomach. Gallbladder. Pancreas. Appendix.

Demonstrate the inspection of the supine abdomen. Movement with respiration. Peristalsis. Scars. Discolorations (striae, veins, ecchymoses).

Masses. General contour (distended, scaphoid, bulging flanks, etc) Hernias. Diastasis rectus.

Percuss all four quadrants. Start away from area of tenderness. Comment on tenderness. Comment on tympany and/or dullness.

Demonstrate the technique of fist percussion for costovertebral tenderness. Demonstrate the technique of palpation.

Start away from area of tenderness.

Superficial. Deep. Comment on tenderness. Comment on masses. Comment on organomegaly Abdominal wall tenderness test.

Describe the technique for the DRE (seen in Well Man sub-unit).

. (Continued on next page) Auscultate the abdomen.

Bowel sounds.



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Pitch. Frequency.

Bruits. Major arterial vasculature (seen in Year 1, Session 12). Enlarged organs.

Demonstrate special tests. Peritonitis.

Guarding. Shake tenderness. Cough tenderness. Percussion tenderness. Rebound tenderness.

Cholecystitis. Murphy’s sign.

Appendicitis. Identify location of McBurney’s point.

Positioning and Draping:

Position the patient so that their abdominal muscles arerelaxed.

o Supine with arms at their sides. o Pillow under their head.

Drape so that the abdomen is visible from the nipples to atleast the pubis symphysis.

Inspection:

Identify four surface quadrants and two regions:o Right upper quadrant (RUQ).o Left upper quadrant (LUQ).o Right lower quadrant (RLQ).o Left lower quadrant (LLQ).o Periumbilical region.o Epigastric region.

Identify surface anatomy of:o Liver (RUQ).o Spleen (LUQ).o Kidneys (LLQ and RLQ).o Stomach (LUQ/epigastric).o Gallbladder (RUQ).o Pancreas (LUQ).o Appendix (RLQ).



29

Inspect for: (inspection from the foot of the bed is sometimes more revealing)o Movement with respiration.o Peristalsis.

A contraction and relaxation (worm-like) of the muscles of the digestivesystem.

o Scars. The diagram of the location of

common surgical scars is for

your information only and willnot be tested in the PhysicalExamination Course.

o Discolorations. Striae. Veins. Ecchymoses.

Periumbilical. o Called Cullen’s sign.o Associated with ectopic pregnancy,

pancreatitis.

Flank.

o Called Grey Turner’s sign.o Associated with pancreatitis,

retroperitoneal hemorrhage.o Masses.o General contour (e.g., distended, scaphoid, bulging

flanks, etc.) o Hernias.

Protrusions of abdominal contents through anabdominal wall defect.

To better assess, have patient lift their headoff the table.

o Diastasis recti. Type of hernia caused by the separation of the

abdominal rectus muscles. To better assess, have patient lift their head off the

table.

Ask patient if the abdomen is painful anywhere before you touchthem!



30

Percussion:

Always begin percussion away from any area of reported tenderness.

Percuss all 4 quadrants of the abdomen.

Percuss the central abdomen (periumbilical region).

Comment on any areas of:o Tenderness. o Tympany.o Dullness.

Percuss for costovertebral angle (CVA) tenderness.o Performed by gently tapping in the CVA region

with the ulnar aspect of the hand either directlyor by placing your other hand over the areafirst.

o This area overlies the kidneys.o Patients with a inflammatory process of the

kidneys (e.g., pyelonephritis, kidney stone,kidney infection) will complain of pain when thisarea is percussed.

Palpation:

Always begin palpation away from any area of reported tenderness.

Always watch a patient’s face for pain when palpating.

Palpate all four quadrants.o Light palpation.

Try to identify areas of tenderness, guarding.o Deep palpation.

Try to identify masses, areas of fullness, organomegaly.

A digital rectal exam (DRE) is part of the abdominal exam.

o Describe the technique in an exam situation. (seen in WellMan sub-unit). Inspect for hemorrhoids, fissures, fistulae, rashes, other

abnormalities. Palpate for sphincter tone, rectal wall, prostate (in

males), masses, presence and color of stool.

Ausculation:

Auscultate for normal bowel sounds.o Auscultate each quadrant.o Comment on:

Pitch.

Normal.

High pitched.

Low pitched. Frequency.

Normal.

Hyperactive.

Hypoactive.



31

o Normal bowel sounds should occur every 5-10 seconds and are high-pitched andgurgling. Loud, high pitched, tinkling, frequent sounds are often associated with a

hyperactive bowel (e.g., diarrhea, constipation or early intestinalobstruction).

Infrequent bowel sounds are association with a hypoactive bowel (e.g.,ileus, bowel obstruction, peritonitis, use of narcotics).

o Bowel sounds are only truly considered absent if no sounds are heard after

listening for 2 minutes in each quadrant.

Auscultate for bruits. (seen in Year 1 – Session 12)o Bruits are “swishing” sounds heard over arteries if there is turbulent blood flow.o Use the stethoscope’s bell.o Major arterial vasculature:

Aorta.

Best heard in midline aboveumbilicus.

Mesenteric arteries.

Best heard in the epigastrium.

Renal arteries. Best heard 5 cm above

umbilicus and 3-5cm to eitherside of the midline.

Iliac arteries.

Best heard just below theumbilicus and 3-5 cm to eitherside of the midline.

Femoral arteries.

Best heard at mid-inguinal point, lateral corner of pubic triangle.o Enlarged organs.

Historically, auscultation was performed before percussion and palpation. The thoughtwas that moving the bowels might alter the bowel sounds. This theory has never beenshown to be true, but many physicians continue to believe that this is the proper order forthe abdominal exam.

Special Tests:Peritonitis

Peritonitis is the inflammation of the peritoneum, a thin tissue that lines the inside of theabdomen.

o Sometimes called “acute abdomen”.o Patients with peritonitis tend to lay very still and breathe very shallow to minimize

any abdominal movements, and thus pain.

Peritonitis can be assessed through the following tests:o Guarding/rigid abdomen.o Shake tenderness.

Bump the bed and watch if this produces pain. Often used to assess for malingerers as bed can be bumped quite

casually. Cough tenderness is a similar test but you watch to see if pain is produced

when the patient coughs.



32

o Percussion tenderness.o Rebound tenderness.

Ask the patient to tell you if it hurts more on pressing down or letting go(you need to explain this test to the patient before you perform it).

Press down slowly but firmly, hold for a second or two, then let gosuddenly.

A positive rebound tenderness test hurts more on letting go as theinflamed perineum “rebounds”

Do as the very last test as patients will not like you afterwards and areunlikely to keep cooperating.

Cholecystitis

Cholecystitis is an inflammation of the gallbladder and can causesevere abdominal pains.

Murphy’s sign. o Ask the patient to breathe out.o Place your fingertips beneath/under the right costal margin in

the mid-clavicular line.o Press in while asking the patient to take a deep breath in.

o Normally, as a patient breathes in, the abdominal content ispushed downward. If there is an inflamed gallbladder, it will be pushed

against your fingers and will create pain, causing thepatient to “catch” his breath (i.e., abruptly stop breathing)

Appendici tis

Appendicitis is an inflammation of the appendix and causes signs of peritonitis.

The usual progression of symptoms: low grade fever dull, constant periumbilical pain anorexia, nausea, vomiting well-localized constant pain over McBurney’s point.

o McBurney’s point is located 2/3 of the

distance from the umbilicus to theanterior superior iliac spine.

All of the peritonitis tests described above willbe positive in a patient with appendicitis.

Below are a few tests to better assessappendicitis.

o (These are for your information only andwill NOT be tested in the PhysicalExamination Course.)

o Rovsing's sign. Palpate in the LLQ. If pain is felt in RLQ,

this is suggestive of appendicitis.o Psoas sign.

Pain on extension of the right thigh issuggestive of an inflamed retro-cecalappendix.

o Obturator sign. Pain on internal rotation of the right thigh at

the hip is suggestive of an inflamed pelvicappendix.



33

o Tenderness on digital rectal examination. Suggestive of an inflamed appendix inferior to the cecum.



34

Liver and Spleen Exams


OBJECTIVES for LIVER EXAM

Identify the expected location of the liver. Inspect for peripheral signs of liver disease.

Scleral icterus. Jaundiced frenulum. Palmar erythema. Thenar atrophy. Dupuytren’s contractures. Clubbing of nails. Terry’s nails. Leukonychia. Asterixis.

Jaundiced skin. Telangectasias. Spider nevi. Petechiae. Gynecomastia. Testicular atrophy. Peripheral edema.

Inspect abdomen. Masses. Scars. Abdominal distension.

Distribution of venous pattern. Caput medusa. Ascites.

Percuss liver span. Upper liver border. Lower liver border. Comment on size.

Demonstrate and explain scratch test. Palpate for liver edge.

Palpation synchronously with deep respiration. Describe the liver edge.

Texture. Tenderness. Pulsatality. Regularity. Nodularity.

Auscultate for bruits. Demonstrate and explain special tests.

Shifting dullness test. Fluid wave test.



35

Inspection for Peripheral Signs of Stigmata of Liver Disease:

Head.

o Scleral icterus.

o Jaundiced frenulum.

Hands.

o Palmar erythema.

o Thenar atrophy.

o Dupuytren’s contractures.

A painless thickening of the

palmar fascia, leading to a

contracture.

o Clubbing of nails.

Loss of the Schamroth sign,

which is the diamond shape

usually created when two fingers

are held together.

o Terry’s nails.

Condition where the nail turns

white proximally, losing the usual

white crescent shape.

o Leukonychia (white nails).

o Asterixis.

As patient to hold up hands as if

they were trying stop a bus.

Look for any flapping of the

wrists. Skin.

o Jaundice.

o Telangectasias.

Small dilated blood vessels on

the skin.

o Spider nevi.

Type of telangectasia that looks

like a spider web.

Have a central blood supply

and are blanchable with central

pressure.

o Petechiae.

Small red or purple spot caused by broken capillaries.

Gynecomastia (in males).

Testicular atrophy (in males).



36

Peripheral edema.

o Should be both inspected and palpated for.

To palpate, press on the anterior tibia (shins) and look for pitting

depressions where you pressed down.

If patient is bed-ridden, make sure to check for edema on coccyx.

Inspection (Central Signs)

The liver is located in the right upper quadrant of theabdomen.

Masses.

o Especially in right upper quadrant.

Scars.

Abdominal distension.

Distribution of venous pattern.

Caput medusa.

o Distended and engorged paraumbilical veins

radiating from the umbilicus. Ascites.

o Look for bulging flanks from the foot of the

bed.

Remember to ask the patient if their abdomen is painful anywhere before you touch it!

Percussion:

Percuss for the liver span.

o Start in the chest and percuss downwards in the mid-

clavicular line for the upper border.

o Begin again, this time in the RLQ and percuss up to find the

lower border.

o Measure the liver span.

It is normally less than 12 cm in males and less than

9-10 cm in females.

If you were unable to locate the lower liver edge with the above method, you can try

using the scratch test.

o This test is less accurate but works well with patients with, for example, severeascites or who are severely obese.

o Place the diaphragm of your stethoscope just above the right costal margin at the

midclavicular line.

o With your fingernail, lightly scratch the skin of the abdomen along the

midclavicular line, moving from below the umbilicus toward the costal margin.

o When your scratching finger reaches the liver’s edge, you will hear the scratching

sound as it passes through the liver to your stethoscope.



37

Palpation:

Palpate for the liver edge.

o You can support the ribs on the right side with your left hand and use a one hand

technique for palpation, or you can use both hands to palpate.

o Start palpating in the RLQ and move towards the right costal margin.

While palpating, ask the patient to take deep breaths in and out through

their mouth. Advance and position your palpating hand on expiration and

make sure that it is in place by the time the patient takes a breath in. As the patient takes a breath in, it creates pressure in the thoracic

cavity, which pushes the abdominal organs downward, making it

easier for them to be felt if your fingertips are already in place.

Describe the liver edge in terms of:

o Texture (e.g., firm or soft).

o Tenderness.

o Pulsatality.

o

Regularity.o Nodularity.

Note: the liver edge is normally soft, non-tender, regular with a sharply

demarcated border and smooth.

Auscultation:

Listen over the liver for any bruits.

Special Tests:

Shifting dullness testo Percuss at the centre of the abdomen then percuss toward the patient’s right flank

and mark where dullness arises.

o Roll patient into the right lateral decubitus position (on their right side) and repeat

your percussion technique.

o With ascites, the area of dullness will shift to the dependent side (i.e., the area of

tympany shifts toward the top).



38

Fluid wave test

o Get the patient to place their hand with their ulnar or radial side pressing down in

the centre of their abdomen and applying some pressure.

o Place your hands on either side of the patient.

o Gently tap one side of the abdomen and feel for the tap

on the other side.

If there is a fluid, you will be able to feel a fluidwave being transmitted to your receiving hand.

If the abdomen is distended because of fatty

tissue (and not ascites), the transmission of the

fatty wave will be stopped by the patient’s hand

before it can reach your receiving hand.



39

OBJECTIVES for SPLEEN EXAM Identify the expected location of the spleen. Identify the expected location for enlargement of the spleen. Inspect left upper quadrant.

Scars. Swelling/masses. Bruising.

Identify the following locations: Traube’s space Castell’s point

Demonstrate percussion at: Traube’s space Castell’s point

Demonstrate the technique for the palpation of the spleen Demonstrate manoeuvres to improve sensitivity of palpation for the spleen.

Palpation synchronously with deep respiration. Positioning of patient on right side. Elevation of left costovertebral angle by the patient.

Demonstrate auscultation for bruits/rubs over the spleen.

The spleen is an intraperitoneal structure that is usually the size of the patient’s fist.

It is usually found beneath the 9th, 10th and 11th ribs.

As it enlarges, it follows the direction of the 10th rib toward the umbilicus, then to the

RLQ.

Inspection:

Inspect the left upper quadrant at rest and with deep inspiration for:

o Scars.

o Swelling/masses.

o Bruising.



40

Percussion:

Percuss over Castell’s point.

o Located at the intersection of the left costal margin and the left anterior axillary

line.

o Ask patient to take a slow deep breath in and then slowly exhale it while

percussing throughout the breath.

o Listen for any changes in tympany.

This area will become dull with inspiration if there is splenomagaly. If there is no splenomagaly, the area should remain tympanic throughout

the inspiration and expiration (i.e., no changes in sound).

Percuss over Traube’s space.

o Located in the triangle formed by the left costal margin, the left anterior axillary

line and a horizontal line at the level of the xyphoid/6th rib.

o This is the area of the gastric air bubble.

o Ask patient to take a slow deep breath

in and then slowly exhale it while

percussing throughout the breath.

o Listen for any changes in tympany.

This area will become dull with

inspiration if there is

splenomagaly.

If there is no splenomagaly, the

area should remain tympanic

throughout the inspiration and

expiration (i.e., no changes in

sound).

Percussion over Castell’s point and/or Traube’s space can also be performed in the

right lateral decubitus position (i.e., with patient laying on their right side).

o This brings the spleen closer to the surface and hence might make it easier to

percuss and palpate.

Palpation:

Palpate for the spleen.

o Can be done with one or two hands.

The two-handed technique involves placing one hand on the

costovertebral angle or beneath the rib cage on the patient's left side,

while the other hand palpates. Lift the CVA or rib cage toward the

examining hand.

Move the hand slowly, so as not to hurt the patient. Use the fingertips or

the side of the fingers. Edge fingers slowly, gently pushing to feel the

spleen edge.

o Palpation for the spleen is much more reliable than percussion to detect

splenomegaly.



41

o Begin palpating lightly at the RLQ, moving toward the left costal margin at the

anterior axillary line.

o Then palpate lightly from the LLQ, moving again toward the costal margin at the

anterior axillary line.

o Repeat these techniques using deep palpation.

If the spleen is not felt with the above techniques:

o Repeat, asking the patient to take deep breaths in and out. Advance andposition your palpating hand on expiration and make sure that it is in place by

the time the patient takes a breath in.

As the patient takes a breath in, it creates pressure in the thoracic cavity,

which pushes the abdominal organs downward, making it easier for them

to be felt if your fingertips are already in place.

o Position the patient on the right side and repeat light and deep palpations, and

palpations with deep inspirations.

o Position the patient supine with their fist at the left costovertebral angle/beneath

the rib cage, stand on the patient's left side and hook your fingers under the

ribcage. Ask the patient to breathe deeply.

o Remember that you can also percuss for the spleen at Castell’s point or over

Traube’s space while the patient is in this position (if not already done earlier).

Auscultation:

Listen over the spleen for bruits and rubs.

o A bruit is a French word for noise. It occurs when there is turbulent blood flow.

Up to 20% of healthy individuals under 40 years old will have abdominal bruits.

o A rub is a dry, grating sound. It is a normal finding over the spleen area.



42

Hand and Wrist Exams


OBJECTIVES for HAND and WRIST EXAMS

Inspect: Dorsum of hand.

Skin –redness, thinning, thickening. Wrist – redness, swelling, deformity, deviation. MCP joints – redness, swelling, deformity, deviation. Spaces between MCP joints. PIP joints – redness, swelling, deformity, deviation. DIP joints – redness, swelling, deformity, deviation. Nail changes.

Palm of hand. Palmar erythema.

Tendon swelling. Contractures. Wasting of thenar eminence. Wasting of hypothenar eminence. Wasting of small muscles of the hand.

Inspect for: Bouchard’s nodes. Heberden’s nodes. Mallet finger. Boutonniere deformities. Swan neck deformities.

Palpate for:

Tenderness. Effusion. Thickening. Temperature.

All of the following structures: Wrist joint.

Distal radial ulnar joint. Radiocarpal joint. Carpal bones.

MCP joints.

Subluxation. Stress testing. Ligament stability.

PIP joints. Ligament stability.

DIP joints. Ligament stability.

Palm of hand. Flexor tendons.

Thickening. (Continued on next page)

Tenderness.



43

Nodules. Soft tissues.

Thickening/contractures. Carpal-metacarpal joint.

Anatomical snuff box. Scaphoid bone.

Demonstrate the evaluation of the following active ranges of motion: Forearm.

Pronation. Supination.

Wrist. Flexion. Extension. Ulnar deviation. Radial deviation.

Hand. Flexion of MCPs.

Fingers. Flexion of PIPs. Flexion of DIPs. Abduction. Adduction. Opposition.

Demonstrate the evaluation of the following passive ranges of motion: Wrist:

Flexion. Extension. Ulnar deviation. Radial deviation.

Demonstrate the evaluation of muscle strength: Forearm.


Wrist. Flexion. Extension. Ulnar deviation. Radial deviation.

Hand. MCPs.

Fingers. PIPs. DIPs. Abduction. Adduction. Opposition.

. (Continued on next page) Assess neurovascular status (seen in Year 1 – Session 12 and Year 2 – Session 3).

Vascular status.



44

Radial pulse. Capillary refill.

Neurosensory status (light touch and pinprick). Median nerve. Ulnar nerve. Radial nerve.

Demonstrate special tests for: Carpal tunnel.

Compression test. Tinnel’s test. Phalen’s sign. Reverse Phalen’s sign.

DeQuervain’s tenosynovitis. Palpation.

Finkelstein’s test.

Inspection (to be done unsupported):Dorsum

Skin: redness, thinning, thickening.

Wrist: redness, swelling, deformity, deviation.

MCP joints: redness, swelling, deformity, deviation.

Spaces between MCP joints: should be valleys.

PIP joints: redness, swelling, deformity, deviation.o PIP joint swelling = Bouchard’s node =

inflammatory and degenerative arthritis. DIP joints: redness, swelling, deformity, deviation.

o DIP joint swelling = Heberden’s node =degenerative arthritis.

o Mallet finger. Flexion at DIP.

Boutonniere’s deformity.o Flexion at the PIP and hyperextension at DIP.

Swan neck deformity.o Hyperextension at PIP and flexion at DIP.

Important Note: In real life, when performing a musculoskeletal exam, it is alwaysnecessary to:

Examine the joint above.

Examine the joint below.

Perform a neurovascular screen.

In this MSK section of the Physical Exam course, you will notice that each joint exam isdescribed in isolation. Furthermore, the neurovascular exams are described in thesessions entitled Peripheral Vascular Exam (Year 1, Session 12) and PeripheralNeurological Exam (Year 2, Session 3). The dispersion of these topics was made tobetter follow the undergraduate course curriculum (e.g., study of neurological concepts

during Course 5).



45

Nail changes.o Such as pitting, ridging, onycholysis (detachment of the nail from the nail bed

distally), “oil spot” (yellowish pigmentation under the nail due to detachment fromnail bed proximally), hyperkeratosis (thickening and hardening of the nail),discoloration.

Palmar

Palmar erythema.

Swelling along length of tendons.

Contractures.

Wasting of thenar eminence.

Wasting of hypothenar eminence.

Wasting of small muscles of the hand (betweenmetacarpal bones).

Palpation:

Feel for: o Tenderness.o Effusion.o Thickening.o Warmth/temperature.

All deformities should be tested to see if they are fixed or reducible.

Wrist

Distal radial ulnar joint.o Flat area located between ulnar styloid and distal radius.

Radiocarpal joint (true wrist joint).o Located at indentation at the end of 3rd metacarpal.o Also palpate along carpal bones.

MCP joints

Located distal to the metacarpal head.

Don’t forget to check the thumb.

Could also do a quick screening exam by squeezing MCPs between forefinger and

thumb. Also look for step sign, indicative of subluxation.

o Flex MCP down. Run finger up to digit. Pathway should be smooth.o If subluxed, you will feel a bump (metacarpal bone).

Also a good time to do stress testing through hyperextension.

Also do testing for ligament stability when joints are fully flexed.o Move the flexed digit from side to side and note any laxity.



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PIP joints

Use both a 2 and a 4 finger examination technique (indexand thumb of one hand on top and below the joint, and indexand thumb of the other hand holding the joint from sides).

Also test for ligament stability when joints are in 15-20o offlexion.

DIP joints

Use both a 2 and a 4 finger examination technique (indexand thumb of one hand on top and below the joint, and indexand thumb of the other hand holding the joint from sides).

Also test for ligament stability when joints are in 15-20o offlexion.

Palm of hand

Flexor tendons.o Feel for:

Thickening. Tenderness.

Nodules. Soft tissues.

o Feel for thickening/contractures.

Radial aspect of wrist

Carpal-metacarpal joint.o Contained within anatomical snuff box.o Palpate for tenderness of scaphoid bone.

Range of Motion:

Active:o Forearm.

Pronation (palm down). Supination (palm up).

o Wrist. Flexion. Extension. Ulnar deviation. Radial deviation.

o Hand. Make fist = rough screen of all joints (MCPs,

PIPs, DIPs).

o Fingers “Karate chop” = rough screen of PIPs and DIPs. Abduction (“spread your fingers apart”). Adduction (“try to keep your fingers together”). Opposition (“form an ‘O’ by putting together the tip of your

thumb and the tip of each finger”).

Passive:



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o Easiest to simply stress the active ROM whenpatient is already doing these motions.

o Wrist: Flexion. Extension. Ulnar deviation. Radial deviation.

Strength Testing: Easiest to test simultaneously as active and passive ROM.

Repeat ROM against resistance:o Forearm.


o Wrist. Flexion. Extension. Ulnar deviation. Radial deviation.

o Hand. Test MCPs’ strength in flexion.

o Fingers. Resist “karate chop” as a screen. Can test individual PIPs and DIPs. When resisting abduction (fingers all spread), use your index finger to try to

push in patient’s index finger, and your little finger to try to push in patient’slittle finger.

Try to pull fingers apart while patient has them adducted. Try to pull each “O” apart by making an “O” with your thumb and same

finger as patient is using to check resistance to opposition.

Neurovascular Status

Refer to Year 1 – Session 12 and Year 2 – Session 3 for complete overview of this topic.For now, however, here is a quick reminder.

Check vascular status:o Radial pulse.o Capillary refill.

Check neurosensory status through light touch and pinprick:o Median nerve.o Ulnar nerve.

o Radial nerve.



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Special Tests:

Carpal tunnel.

o Compression test. Apply pressure directly over carpal tunnel

area. Test can be accentuated by extending the

patient’s wrist. Test result is abnormal if a pain/tingling is

felt in the first 3-3.5 fingers.o Tinnel’s test.

Tap over median nerve as it runs throughthe carpal tunnel (i.e., at the crease of thewrist, but also a few centimeters above and

below it). Test result is abnormal if a pain/tingling is

felt in the first 3-3.5 fingers.o Phalen’s test.

Hold patient’s wrist in forced flexion for 30-60 seconds.

Patient can also do their own forced flexion by putting the dorsum oftheir hands together and being instructed to try to push their elbowsdownward as much as possible.

Test result is abnormal if a pain/tingling is felt in the first 3-3.5 fingers.

o Reverse Phalen’s test.

Hold patient’s wrist in forced extension for 30-60 seconds. Patient can also do their own forced extension by putting the palm of

their hands together and being instructed to try to lift their elbowsupward as much as possible,

Test result is abnormal if a pain/tingling is felt in the first 3-3.5 fingers.



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DeQuervain’s tenosynovitis.o Inflammation of the radial tendon sheaths.o Palpate over tendons/tendon sheath.

Test result is abnormal if a pain is felt underneath palpated area.o Finkelstein’s test.

Ask patient to make a fist after tucking their thumb into their palm. Thenask them to bend their wrist down toward their little finger (ulnar deviation).

This test can be accentuated by having you press down (gently!) toaccentuate the deviation.

Test result is abnormal if a pain is felt in the distal radial forearm.



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Cervical Spine and Shoulder Exams


OBJECTIVES for CERVICAL SPINE

Inspect alignment of head and neck: Anteriorly Laterally Posteriorly

Identify normal lordosis curvature. Palpate for tenderness:

Paravertebral muscles. Trapezius muscles. Sternocleidomastoid muscles. Spinous processes. Interspinous ligaments.

Palpate for increased tone: Paravertebral muscles. Trapezius muscles. Sternocleidomastoid muscles.

Demonstrate the evaluation of the following active range of motions: Flexion. Extension. Rotation. Lateral flexion.

Demonstrate the evaluation of muscle strength against resistance for: Flexion.

Extension. Rotation. Lateral flexion.

Check the following reflexes: Biceps (C5-6). Brachioradialis (C5-6). Triceps (C6-7).

Important Note: In real life, when performing a musculoskeletal exam, it is always

necessary to: Examine the joint above.



In this MSK section of the Physical Exam course, you will notice that each joint exam isdescribed in isolation. Furthermore, the neurovascular exams are described in thesessions entitled Peripheral Vascular Exam (Year 1, Session 12) and PeripheralNeurological Exam (Year 2, Session 3). The dispersion of these topics was made tobetter follow the undergraduate course curriculum (e.g., study of neurological conceptsduring Course 5).



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Inspection:

Alignment of the head and neck.o Check anteriorly, laterally and posteriorly.o Comment on normal or reverse lordosis.o Comment on swelling, wasting, and/or spasms of

muscles.

Observe active range of motion:

o Flexion.o Extension.o Lateral flexion. o Rotation.

Palpation:

Palpate the following muscles for tenderness:o Trapezius.o Paraspinals.

o Sternocleidomastoids.

Palpate the following muscles for spasms:o Trapezius.o Paraspinals.o Sternocleidomastoids.

Palpate:o Spinous processes – for tenderness and

crepitation.o Interspinous ligaments – for tenderness.

Repeat range of motion against resistance (strengthcheck) for:

o Flexion.o Extension.o Lateral flexion.o Rotation.

o Resisted motion needs to held for 5 seconds.

Reflexes:

Check the following reflexes:o Biceps (C5-6).o Brachioradialis (C5-6).o Triceps (C6-7).

Do not forget to demonstratehow you would elicit reflexesin someone who is tense.



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OBJECTIVES for SHOULDER EXAM Identify surface anatomy:

Clavicle. Humerus. Scapula. Scapular spine. Acromio-clavicular joint. Acromion. Sternoclavicular joint. Glenohumeral joint. Deltoids muscles. Supraspinatus muscles. Infraspinatus muscles.

Inspect for: Normal contour of:

Shoulder. Clavicle.

Muscle wasting. Dislocations. Redness. Swelling.

Palpate joints for tenderness, warmth, deformities and/or swelling: Sternoclavicular joint. Clavicle. Coracoid process. Bicipital groove. Biceps tendon. Acromioclavicular joint. Glenohumeral joint. Scapular spine. Subacromial bursa.

Demonstrate the evaluation of active range of motion: Flexion. Extension. Abduction. Adduction. Internal rotation. External rotation. Protraction. Retraction.

Demonstrate the evaluation of passive range of motion: Flexion. Extension. Abduction. Adduction. Internal rotation. External rotation.



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(Continued on next page)

Demonstrate the evaluation of muscle strength against resistance for: Flexion. Extension. Abduction. Adduction. Internal rotation. External rotation.

Demonstrate special tests for : Bicipital tendonitis

On palpation. Yergason’s test. Speed’s maneuver.

Glenohumeral stability Apprehension test.

Frozen shoulder test. Glenohumeral vs. scapulothoracic motion.

Acromioclavicular disorder. Cross-arm test.

Rotator cuff injury Subscapularis

Lift off test. Supraspinatus

Job’s test (“beer can” test).

Drop arm test. Infraspinatus

Resisted external rotation test. Impingement syndrome

Painful arc test. Neer’s test. Hawking’s test.








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Inspection:

Muscle wasting, atrophy and/orswelling of:

o Deltoids.o Supraspinatus.o Infraspinatus.

Abnormalities in the contour of:

o Sternoclavicular joints.o Clavicles.o Acromioclavicular joints.o Acromion.

Palpation:

For tenderness, warmth, deformitiesand/or swelling (one side at a time):

o Sternoclavicular joint.o Clavicle.o Coracoid process.

o Bicipital groove.o Biceps tendon.o Acromioclavicular joint.o Glenohumeral joint.o Scapular spine.

Subacromial bursa for tenderness.

Range of Motion:

Active:o Forward flexion.o Backward extension.o Abduction.o Adduction.o External rotation.o Internal rotation.o Protraction.o Retraction.

Passive:o Only to be checked if active

ROM is limited, except forabduction which should

always be checked activelyand passively: Forward flexion. Backward extension. Abduct ion. Adduction. External rotation. Internal rotation.



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Strength Testing:

Forward flexion.

Backward extension.

Abduction.

Adduction.

External rotation.

Internal rotation.

Special Tests:

Bicipital tendonitis:o On palpation.

Localized tenderness when palpating over the groove.o Yergason’s test.o Speed’s maneuver.

Glenohumeral stability:o Apprehension test.

Checks for anterior shoulder dislocation.

Frozen shoulder test.o Loss of passive range of motion is usually suspect for this problem.o The glenohumeral motion is lost and replaced by a scapulothoracic motion in

order to move the shoulder.o Can be detected by passively attempting to abduct the shoulder while having the

other hand on the scapulothoracic joint.

Acromioclavicular disorder.o Cross-arm test.

Rotator cuff injury:o Subscapularis. Lift off test.

o Supraspinatus. Job’s test (“beer can” test). Drop arm test.

o Infraspinatus. Resisted external rotation test.

Impingement syndrome:o Painful arc test.o

Neer’s test.o Hawking’s test.



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57



58

Ankle, Foot, and Knee Exams


OBJECTIVES for ANKLE and FOOT EXAM

Assess gait. Inspect the ankle for: Swelling. Bruising/discolouration. Redness. Warmth. Scars. Muscle wasting. Deformities (e.g., varus or valgus).

Inspect the foot for: Swelling.

Bruising/discolouration. Redness. Warmth. Scars. Deformities (e.g., hallux valgus, clawing, crowding, hammer toes, cockup

toes). Nail changes. Calluses. Symmetry of the arches. Shape of the arches (e.g., pes planus, pes cavus).

Palpate for tenderness:

Along distal 6 cm of tibia. Along distal 6 cm of fibula. Medial malleolus. Lateral malleolus. Ankle joint capsule. Heel. Across the metatarsalphalangeal joints. Achilles tendon.

Demonstrate the evaluation of the following active range of motions: Plantar flexion. Dorsiflexion. Inversion. Eversion.

Demonstrate the evaluation of the following passive range of motions: Plantar flexion. Dorsiflexion. Inversion. Eversion.

Demonstrate the evaluation of muscle strength of: Plantar flexion. Dorsiflexion.




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Inspection:

Observe gait.o Note any pain when weight bearing.o Note any valgus or varus ankle deformities when walking.

Inspect the ankle anteriorly, laterally and posteriorly for:o Swelling.o Bruising/discoloration.o Redness. o Warmth.o Scars.o Muscle wasting. o Deformities (varus and valgus).

While sitting. While standing. While walking (if not already done during gait).

Inspect the foot anteriorly and laterally for:o Swelling.o Bruising/discoloration.o Redness.o Warmth.o Scars.o Deformities:

Hallux valgus.

Caused by a fixed lateral deviation of the main axisof the big toe.

Inversion.. Eversion.

Demonstrate special tests for: Laxity of anterior talofibular ligament. Achilles tendon rupture (Thompson test). Midtarsal joint sprain.

Assess neurovascular status (seen in Year 1 – Session 12 and Year 2 – Session 3).





In this MSK section of the Physical Exam course, you will notice that each joint exam isdescribed in isolation. Furthermore, the neurovascular exams are described in the

sessions entitled Peripheral Vascular Exam (Year 1, Session 12) and PeripheralNeurological Exam (Year 2, Session 3). The dispersion of these topics was made tobetter follow the undergraduate course curriculum (e.g., study of neurological conceptsduring Course 5).



60

Clawing.

Caused by a fixed flexion deformity. Crowding. Hammer toes.

Caused by hyperextension of the MTP joint,flexion at the PIP and extension at the DIP. Canbe seen in the absence of arthritis.

Cockup toes.

Caused by metacarpal head becomingdisplaced toward the floor and leading to the tipof the toe to lift. Represents synovial inflammation and is alwaysassociated with arthritis

o Nail changes.o Calluses.o Symmetry of the arches with standing.

Asymmetric pes planus (flat foot) may indicatea torn posterior tibial ligament.

o Shape of the arches (pes palnus, pes cavus) whilestanding.

Palpation (while patient is sitting):

Palpate for tenderness:o Along the distal 6 cm of the tibia. o Along the distal 6 cm of the fibula.o Medial malleolus.o Lateral malleolus.o Around the ankle joint capsule.o Around the heel.

Looking for plantar fasciitis.

Palpate the distal margin of the calcaneus for

tenderness of the plantar fascial insertion forplantar fasciitis.

o Across the MTPs. Squeeze 1st and 5th metatarsals between thumb and forefinger. Tenderness suggests inflammation (think early rheumatoid arthritis!).

o Achilles tendon. Also use this opportunity to palpate for any deformities (e.g., rheumatoid

nodules, partial tears).

Range of Motion

Active:o Plantar flexion.o Dorsiflexion.o Inversion.o Eversion.

Passive:o Plantar flexion.o Dorsiflexion.o Inversion.

Immobilize the joints not being tested.



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o Eversion. Immobilize the joints not being tested.

Strength Testing:

Plantar flexion.

Dorsiflexion.

Inversion.

Eversion.

Special Tests:

Laxity of anterior talofibular ligament.o Assessed with anterior drawer test.o Patient’ foot needs to be in a neutral position, hanging in the air.

One hand stabilizes the distal end of the tibia, while the other handis placed on the heel. An anterior force is applied to the heel,attempting to subluxate the talus from beneath the tibia.

o More than 0.5cm of movement or no firm end-point may indicate aproblem with the anterior talofibular ligament.

Achilles tendon rupture.o Assessed with Thompson test.o Have the patient kneel on a chair or lie prone. Give the calf a

hard squeeze. o In a tendon rupture, the foot fails to passively plantarflex when

calf is squeezed.

Midtarsal joint sprain.o Assessed with Hiss test.o Injury to this area of the foot is rare, but is more commonly seen

in athletes participating in sports involving jumping (e.g.,gymnastics) or sports where ankle injuries are common(e.g., football).

o Hold the heel in one hand and the forefoot in the other. Attempt to rotate the hands in opposite directions (i.e.,rotation would occur through the midtarsal (midfoot) joint).

o Pain with this maneuver would make you suspect amidtarsal joint injury.



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OBJECTIVES for KNEE EXAM Describe the surface anatomy of the knee. Assess gait. Identify on inspection of the knee joints:

Differences between the joint symmetry. Normal alignment. Misalignment/deformities (valgus, varus, hyperextension). Patellar tracking. Prominence of tibial tuberosities (e.g., Osgood-Schlatter’s). Related muscle wasting. Related muscle hypertrophy. Scars. Redness. Swelling/masses (e.g., Baker’s cyst). Discoloration/bruising.

Measure quadriceps circumference. Palpate the knee joint for:

Differences in temperature. Joint line tenderness. Crepitus. Tenderness around sides of patella. Medial collateral ligament tenderness. Lateral collateral ligament tenderness.

Check for effusions using the following techniques: Patellar tap. Bulge sign. Ballotment test.

Demonstrate the evaluation of the following active range of motion: Extension

Flexion Demonstrate the evaluation of the following passive range of motion:

Extension Flexion.

Evaluate the stability of the following ligaments: Medial collateral ligament. Lateral collateral ligament. Anterior collateral ligament using:

Anterior drawer test Lachman’s test

Posterior collateral ligament

Examine for meniscal tears using: McMurray’s test Thessaly test

Demonstrate patellar dislocation using apprehension test.



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Inspection (standing):

Bony alignment.o Look for valgus, varus or hyperextension deformity.o A line drawn from the iliac crest should transect the middle toe

Swelling/masses.

o Baker’s cyst (usually seen posteriorly on the medial side). Observe gait.

o Look at and comment on posture, balance, swinging of arms,movement of the legs, smoothness of turns.

o Types of gait: Antalgic: in order to avoid pain during weight-bearing, the time in the

stance phase (foot on the ground) of the injured limb is minimized. Trendelenburg (lurch) gait: when walking, the entire trunk leans

excessively over the hip that is firmly planted on the ground (i.e. thecentre of gravity is kept over the stance leg) while the other side of thebody, leg and upper body, swing forward. This gives the appearance of

the patient “lurching” one side of their body to move forward. Ataxic: an unsteady, uncoordinated walk, employing a wide base and the

feet thrown out. Is often due to cerebellar disease, loss of position sense,or intoxication.

Ask patient to squat to test patellofemoral compartment. o If there is damage on the underside of the kneecap or misalignment of the

kneecap, the knee can develop a creaking noise when squatting. It can alsocause ill-defined pain over the front of the knee.

Inspection (sitting):

Patellar tracking.

o Observe the tracking of the patella as the knee goes fromextension to flexion.

o Abnormal finding if the patella is pulled to the lateral

aspect of the knee (lateral subluxation of the patella). Also called “Grasshopper eyes”.

Prominence of tibial tuberosity.o Pain and swelling at this site may be an indication of

Osgood-Schlatter’s disease, especially in active boysand girls between the ages of 11 and 15. Thesymptoms are caused by repeated stress on thepatellar tendon which is the link between the









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quadriceps and the tibial tuberosity. This stress causes subacute avulsionfractures and inflammation of the tendon, which leads to excess bone growth inthe tuberosity.

Inspection (laying):

Asymmetry between knees.

Masses

Scars and/or lesions.

Muscle atrophy or hypertrophy.o Vastus medialis usually goes first).o Can measure quadriceps by picking a fixed point.

Erythema.

Swelling in medial fossa and/or suprapatellar pouch

Palpation:

Check temperature below, at, and above patella.o The knee cap is usually the coolest part.o Compare with other side.

Check for tendernesso Joint line (one side of the knee at a time)

Try to feel the head of the fibula (lateral),the medial condyle, and the medial tibialplateau.

o Collateral ligaments (medial and lateral). At insertion and origin. Along ligament for tenderness.

o Patellar edges.o Pre-patellar bursa (can also be done later, as part of your check for effusions).

Swelling and tenderness in this area is often called “Housemaid’s sign”.o Suprapatellar bursa area (can also be done later, as part of your check for

effusions). o Pes anserine bursa.

Check for crepitation.o This can be done either here or during checking of range of motion

(flexion/extension).o Place a hand over the knee joint and feel for any creaking/cracking.

Check for effusion:o Bulge sign.

Best to detect small effusions. Milk up medial side and sweep down lateral

side. No bulge means that there is no fluid or that

there is a large amount of fluid.o Ballottement.

Good test to check for large effusions. Compress the suprapatellar pouch, and then

try move the fluid around the knee back/forth between your fingers.



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o Patellar tap. Milk fluid into suprapatellar pouch and trap it there by pushing down on

the pouch. With your index and middle fingers, press down on thepatella.

The test is positive if you feel a “clunk” when the patella touches thefemur and then bounces off the femur.

Range of Motion:

Activeo Flexion.o Extension.

Passiveo Flexion.o Extension.o Feel for crepitus (medial, lateral, patellar area).o Careful not to grab another joint.

Ligament, Meniscus and Patellar Tests:

Medial collateral ligament (MCL).o Create a valgus deformity.o Look for medial aspect “opening”.o Look for instability and pain.

Lateral collateral ligament (LCL).o Create a varus deformity.o Look for lateral aspect “opening”.o Look for instability and pain.

Anterior cruciate ligament (ACL).o Anterior drawer test.

With patient laying down and their foot resting flat on thebed and with the knee in 90o of flexion, attempt to slidetibia forward (“drawer opening”).

Look for instability and pain.o Lachman’s test.

With the patient supine and their knee flexed 20-30o, steady the femur withone hand while grabbing the leg below the knee withyour other hand. Tug the lower leg upwards (i.e., try tomove the tibia on the femur).

Look for instability and pain.

The test findings are abnormal if the anterior tibialmovement is exagerated or there is no solid end pointfelt.



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Posterior cruciate ligment (PCL).o With patient laying down and their foot resting flat on the bed, attempt to slide the

tibia backwards (“drawer closing”).o Look for instability and pain.

Test for meniscus tears:o McMurray’s test.

With patient supine and knee half-way flexed,

grab the foot with one hand and place the otherhand along the medial aspect of the knee.Create a valgus deformity (i.e., apply a valgusforce). While internally rotating the tiba, extendthe knee.

Repeat the test while externally rotating the tibia. The test findings are abnormal if there is a “popping” and pain along the

joint line.

o Thessaly test. While standing on one leg, knee flexed to approximately 20

degrees, the patient “twists”, rotating the femur on the tibiamedially and laterally three times.

The test should be first performed on the patient’s“good” (non-painful) knee so that they can get asense of the amount of flexion and the general feelof the test.

The test should then be performed on the patient’s “bad” (painful)knee.

The test findings are abnormal if the patient’s pain is reproduced (i.e., painon the medial or lateral joint lines or if there is a sensation of locking orcatching).



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Patellar apprehension test.o With the patient supine and their quadricep muscles relaxed, gently push the

patella laterally while slowly flexing the knee.o The test findings are abnormal if the patient reports a feeling of their kneecap

“popping out” or contracts their quads (easier to feel if your handis placed on their quads.



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Hip and Thoracolumbar Spine Exams


OBJECTIVES for HIP EXAM

Describe the surface anatomy of the hip. Anterior superior iliac spine. Posterior superior iliac spine. Pubis symphysis. Inguinal ligament. Iliac crest. Greater trochanter. Trochanteric bursa.

Assess gait. Identify on inspection of the hip joints:

Differences between the joint symmetry.

Normal alignment. Misalignment/deformities. Related muscle wasting. Related muscle hypertrophy. Scars. Redness. Swelling/masses. Discoloration/bruising.

Inspect for: Levelness of the iliac crests. Abductor weakness (Trendelenburg sign).

Measure: True leg length. Apparent leg length. Quadriceps circumference.

Palpate for tenderness: Along the inguinal ligament. Inferior to the inguinal ligament. Over the greater trochanter. Over the anterior superior iliac spine. Over the posterior superior iliac spine. Over the sacro-iliac joints.

Demonstrate the evaluation of the following active range of motions: Flexion. Extension. Abduction. Adduction.

Demonstrate the evaluation of the following passive range of motion: Flexion. Extension. Abduction. Adduction. (Continued on next page) Internal rotation.



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External rotation. Demonstrate the evaluation of muscle strength of:

Hip flexors. Hip extensors. Hip abductors. Hip adductors.

Demonstrate special tests: Thomas’ test. Modified Thomas test.

Inspection:

Comment on surface anatomy of the hip joint by identifying:o Anterior superior iliac spine.o Posterior superior iliac spine.o Pubis symphysis.o Inguinal ligament.o Iliac crest. o Greater trochanter. o Trochanteric bursa.








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Observe gait.o Look at and comment on posture, balance, swinging of arms, movement of the

legs, smoothness of turns.o Types of gait:

Antalgic: in order to avoid pain during weight-bearing, the time in thestance phase (foot on the ground) of the injured limb is minimized.

Trendelenburg (lurch) gait: when walking, the entire trunk leansexcessively over the hip that is firmly planted on the ground (i.e. the centre

of gravity is kept over the stance leg) while the other side of the body, legand upper body, swing forward. This gives the appearance of the patient“lurching” one side of their body to move forward.

Ataxic: an unsteady, uncoordinated walk,employing a wide base and the feet thrownout. Is often due to cerebellar disease, loss ofposition sense, or intoxication.

Trendelenburg sign.o Tests for abductor weakness.o Have the patient stand on one foot.

The iliac crests should stay level. If there is gluteus medius weakness, the

pelvis will sag towards the non-weightbearingside.

Assess levelness of iliac crests.o Unequal heights of the iliac crests (i.e., a pelvic tilt)

suggest unequal lengths of the legs and disappear when a block is placed underthe short leg.

o Scoliosis and hip abduction or adduction may also cause a pelvic tilt.

Leg lengths.o From anterior superior iliac spine (ASIS) to medial malleolus (true leg length).

Best done when patient is supine. Seen in abduction or adduction deformities and scoliosis. A short and externally rotated leg suggests a hip fracture.

o From umbilicus to medial malleolus (apparent leg length).o It is important to distinguish true leg length discrepancy from apparent leg length

discrepancy. True leg length discrepancy points to a hip problem on the shorterside. On the other hand, an apparent leg length discrepancy is usually due to thetilting of the pelvis.

Measure quadriceps circumference bilaterally.



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Palpation:

Inguinal ligament tenderness.o With the patient supine and the heel resting on the

opposite knee, palpate along the inguinal ligament fortenderness.

Iliopsoas bursitis.o To detect, palpate below the inguinal ligament.

Trochanteric bursitis.o To detect, palpate over the greater trochanter.

Range of Motion:

Flexiono With the patient supine, place your hand under the patient’s lumbar spine. Ask

patient to bend each knee in turn to the chest and pull it firmly against theabdomen. Note when the back touches your hand, indicating normal flattening of the

lumbar lordosis. Any further flexion must arise from the hip joint itself.

o Test both active and passive range of motion. Extension

o With the patient lying on their side, ask them to extend the thigh backward.o Test both active and passive range of motion.

Abductiono Stabilize the pelvis by pressing down on the opposite ASIS with one hand.o With the other hand, grasp the ankle and abduct the extended leg until you feel

the iliac spine move. Restricted hip abduction is common in hip osteoarthritis.

o Test both active and passive range of motion.

Adductiono Stabilize the pelvis, hold one ankle, and move the leg medially.o Test both active and passive range of motion.

When testing this movement passively it is helpful to abduct the other legso that you do not have to change the plane of movement when crossingthe midline

Internal rotationo Flex the leg to 90o at the hip and knee. Stabilize the thigh with one hand, grasp

the ankle with the other, and swing the lower leg laterally for internal rotation.o Test only passive range of motion.



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External rotationo Flex the leg to 90o at the hip and knee. Stabilize the thigh with one hand, grasp

the ankle with the other, and swing the lower leg medially for external rotation.o Test only passive range of motion.

Strength Testing:

Easiest to do while doing ROM exams:o Flexion

o Extensiono Abductiono Adduction

Special Tests:

Thomas’ testo In flexion deformities, when flexing the “good hip” to

the chest, the “bad” hip will begin to flex, not allowingthat leg to lay flat. This is called a flexure-contracture.

o The patient is supine, with his pelvis level and squareto his trunk. Stabilize the pelvis by placing your hand

under the patient’s lumbar spine. Have the patient flexboth his hips, bringing his thighs up onto his trunk.Have the patient hold one leg to his chest and let hisother leg down until it is flat on the table. If the thighrises off the table, the test is positive for a hip flexioncontracture. This test does not differentiate between

tightness of the iliopsoas versus the rectus femoris. A flexion deformity may be masked by an increase, rather than a

flattening, in lumbar lordosis and an anterior pelvic tilt.

Modified Thomas test

o This utilizes the same patient position as for the Thomas Test, butin addition, the patient scoots down the table until his knees areapproximately four inches over the edge. Have the patientperform the maneuver for the Thomas Test. If the thigh rises offthe table, attempt to flex the knee on that side. If the knee flexes easily, the tight hip flexor is the iliopsoas

(positive test for iliopsoas). If you are unable to flex theknee, or resistance is felt, the rectus femoris is tight(positive test for rectus femoris).



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OBJECTIVES for THORACOLUMBAR SPINE EXAM Assess gait. Inspect thoracolumbar spine for:

Lordosis. Scoliosis. Kyphosis. Swelling/masses. Redness. Muscles spasms. Scars. Levelness of iliac crests.

Inspect for abductor weakness (Trendelenburg sign). Palpate for tenderness:

Paraspinal muscles.

Spinous processes. Interspinous ligaments. Sacroiiliac joints. Sciatic nerve exit. Bursa

Trochanteric. Ischial.

Palpate for tone of paraspinal muscles. Percuss the spine for tenderness. Demonstrate the evaluation of the following active range of motions:

Flexion. Extension. Lateral flexion. Rotation.

Test strength of nerve roots: L1-2. L2-3. L3-4. L4-5. L5. L5-S1. S1.

Test sensation of nerve roots: L4. L5.

S1. Test reflexes:

Patellar. Achilles.

Describe the technique to assess for saddle paresthesia (seen in Well Man sub-unit).




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Describe the technique to assess anal reflexes (seen in Well Man sub-unit). Describe the technique for the DRE (seen in Well Man sub-unit). Demonstrate special tests:

Modified Schober’s. Straight leg raise. Crossed straight leg raise. Sacroiliac stress.

Standing Inspection:

Spinal curvatures:o Comment on lordosis, scoliosis, kyphosis.

Swelling/masses, redness, muscles spasms, scars.

Levelness of iliac crests. Trendelenburg sign.

o Tests for abductor weakness.o Have the patient stand on one foot.

The iliac crests should stay level. If there is gluteus medius weakness, the

pelvis will sag towards the non-weightbearing side.

Palpation:

Paraspinal muscles for tenderness and tone.

Spinous processes for tenderness. Interspinous ligments for tenderness.

Sacroiliac joints for tenderness.

Percussion:

Percuss the spine for tenderness by thumping (not too hard!) with the ulnar aspect ofyour fist.









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Range of Motion:

Flexion.o Make sure that the patient’s knees remain straight during this test.o Can measure the distance between the fingertips and the floor.o Note the smoothness and symmetry of movement.

As flexion proceeds, the lumbar concavity should flatten out. A persisting lumbar lordosis is suspicious for muscle spasms or ankylosing

spondylitis.

Extension.o Place your hand on the posterior superior iliac spine to give your patient some

support.

Lateral flexion.o Fingertips should easily reach the level of the knees if no abnormalities.

Rotation.o Make sure that the knees are straight, feet stay together, and hips remain facing

forward.o Can also be checked with patient sitting, as this prevents unwanted movement of

the hips/pelvis.

Walking Inspection:

Observe gait.o Look at and comment on posture, balance, swinging of arms, movement of the

legs, smoothness of turns.o Types of gait:


Trendelenburg (lurch) gait: when walking, the entire trunk leansexcessively over the hip that is firmly planted on the ground (i.e. the centreof gravity is kept over the stance leg) while the other side of the body, leg

and upper body, swing forward. This gives the appearance of the patient“lurching” one side of their body to move forward.

Ataxic: an unsteady, uncoordinated walk, employing a wide base and thefeet thrown out. Is often due to cerebellar disease, loss of position sense,or intoxication.

Strength Testing:

Test strength of nerve roots:o L3-4 deep knee bend (squatting) (quadriceps).o L5 heel-walking.o L5-S1 hip extension (gluteus maximus).o S1 toe-walking.



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Sitting Inspection:

Take note of patient’s ability to get onand off the table (e.g., no problems,requires help, seems to beuncomfortable, and so on).

Palpation: Test sensation of nerve roots:

o L4 medial malleolus.o L5 first dorsal web space.o S1 little toe.

Strength Testing:

Test strength of nerve roots:o L1-2 hip flexors.o L2-3 hip adductors.o L4-5 hip abductors.

Reflexes:

L3-4 patellar reflex.

S1 Achilles reflex.

Do not forget to demonstrate how youwould elicit reflexes in someone whowas not able to relax.

Lying on Side Palpation:

Identify the following locations and palpate for tenderness:o Sciatic nerve exit (in buttocks).o Bursas:

Trochanteric. Ischial.

Describe the technique to assess for saddleparesthesia. (seen in Well Man sub-unit).

Describe the technique to assess anal reflex, alsocalled “anal wink”. (seen in Well Man sub-unit)

Describe the technique for a DRE. (seen in WellMan sub-unit)



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Special Tests:

Modified Schober’s test.o Used to assess spinal motion of the lower back.o Use a pen to mark the midpoint between the dimples of

Venus (or can also use the posterior superior iliac spine).Then use a tape measurer to identify and mark twopoints: (1) one point is 10 cm superior to the dimples ofVenus point, and (2) one point that is 5 cm inferior to thedimples of Venus point. Have the patient flex forward asfar as possible. Measure and record the distancebetween the superior and inferior points. Make sure that the patient’s knees remain straight

during this test.o If the distance between the two points is less than 20 cm,

you should suspect that the flexion of the lower back islimited.

Straight leg raise test.

o Commonly used to check for disc protrusionimpinging on nerve roots.

o With patient laying supine, passively flex the hipwhile keeping the knee straight on the side wherethe pain is felt. Stop when patient reports feelingpain. Slowly start lower leg until pain resolves.When pain has resolved, remain at that level andpassively dorsiflex the foot. This test can also be performed with the

patient sitting down, but this decreases thesensitivity of the test.

o Pain felt shooting down the affected leg in thesepositions is an abnormal finding.



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Crossed straight leg raise test.o Usually used in conjunction with the straight leg raise test to confirm the presence

of a lumbar herniated disc.o With patient laying supine, passively flex the hip while keeping the knee straight

on the side opposite to the side where the pain is felt.o Pain felt shooting down the affected leg (i.e., not the one in the air) is an abnormal

finding.

Sacroil iac stress test.o Compression of the pelvis at the level of the SI joints.



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Jugular Venous Pulse Exam


OBJECTIVES for JUGULAR VENOUS PULSE EXAM

Demonstrate the evaluation of: Peripheral palpable blood pressure. (seen in Year 1 – Session 1) Auscultatory blood pressure. (seen in Year 1 – Session 1)

Demonstrate positioning for assessment of the jugular venous pressure. Identify surface anatomy of the course of the internal jugular vein. Identify characteristics and demonstrate maneuvers that differentiate the jugular

venous pulse from the carotid pulse. Biphasic waveform. Occludable. Not palpable. Changes with respiration.

Changes with position. Changes with hepatojugular reflux.

Demonstrate the technique to visualize the shadows of the jugular venous pulsationwith tangential light.

Measure the jugular venous pressure. Demonstrate and explain the hepatojugular reflux. Be aware of the characteristic waves and slopes of the jugular venous pulse. Be aware of the physiologic determinants of the normal waves and slope of the

jugular venous pulse. Describe the Kussmaul’s sign.

Review how to evaluate peripheralpalpable blood pressure andauscultatory blood pressure.

o Refer to notes in Session 1(Year 1).

Recall: the jugular venous pressure is adirect manometer of right ventricularend-diastolic pressure.

Positioning Approach the patient from their right

side as you will be examining the rightside of their neck.

Start by positioning the bed at 30o to45o.

Turn patient’s head slightly to the left.

Raise or lower the head of the bed toimprove viewing if necessary.

o Patients who are verydehydrated may need to have the head of the bed lowered.



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o Patients who are in congestive right-sided heart failure or have some types ofpericardial disease may need to have the head of the bed further elevated.

Inspection

Look between the two heads of the sternocleidomastoid for a pulsation.o The shadows of the pulsation can be visualized by shining a light tangentially

across the patient’s neck.

The internal jugular vein courses from just lateral of the sternal notch, behind and

between the two heads of the sternocleidomastoid muscles, and toward the angle of the jaw.

Differentiating

The jugular venous pulse can be differentiated from the carotid artery.

Jugular Pulse Carotid PulseGenerally not palpable Palpable

Biphasic Single wave form

Occludable No effect

Changes with respiration (↓ with inspiration) No effect

Changes with positioning (↓ in height when sitting up) No effect

Transiently ↑ in height with hepatojugular reflux No effect



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Measuring

The jugular venous pressure can be determined by measuring the vertical distance fromthe sternal angle to the top of the internal jugular wave form.

o Position a ruler on the sternal angle, perpendicular to the floor.o Draw a straight line, parallel to the floor, from the top of the JPV column to the

ruler placed on the sternal angle.

Normal height measured should be ≤ 3 cm.

FYI: we measure from the sternal angle as it is a “stable”

landmark.o Sternal angle is located on average 5 cm above the

midpoint of the right atrium.o Hence, you can calculate the pressure in the right

atrium by: Pressure in right atrium = JVP + 5 cm Normal pressures in the right atrium are 6-9 cm

H2O.

Hepatojugular Reflux

Also known as the abdominal-jugular reflex.

Ask the patient to breathe normally with their mouth open.o This prevents a Valsalva maneuver.

Ensure that the patient does not have any tenderness in the abdomen.

Place your right hand over the liver in the right upper quadrant/epigastrium region.

Apply moderate pressure and maintain the compression until you can see the JVP fallback down or for 15 seconds.

o Moderate pressure means 25-30 mmHg. If you are uncertain how much pressurethat is, inflate a blood pressure cuff, put it on a hard surface, and compress it withyour hand.

The JVP normally rises transiently.o Should return to normal level within 10

seconds or two respiratory cycles.o A sustained elevation (>4 cm) for over

10 seconds is pathological.

Waves and Slopes

a wave – right atrial contraction.o Heart sound S1 occurs with a (and c)

wave.

x descent – right atrial relaxation (↓ in pressure).

c wave – tricuspid valve closure.

o c wave is normally so small that it is not visible to thenaked eye.

x| descent – descent of the base of the heart.

v wave – right atrial filling (from vena cava).o Heart sound S2 occurs with v wave.

y descent – opening of tricuspid valve.



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Kussmaul’s Sign

Is the rise of JPV with inspiration.o Recall that JPV normally decreased with inspiration because of reduced pressure

in the expanding thoracic cavity.

Suggests impaired filling of the right ventricle.o This could be due for example because of fluid in the pericardium or poor

compliance of the pericardium or myocardium.



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Respiratory Exam


OBJECTIVES for RESPIRATORY EXAM Inspect for and comment on normal respiratory pattern.

Rate. Rhythm. Depth. Symmetry.

Observe for and comment on signs of respiratory distress. Stridor. Wheezing. Hoarse voice. Inability to speak in full sentences. Central cyanosis. Peripheral cyanosis. Accessory muscles.

Nasal flaring. Scalene retractions. Sternocleidomastoid use.

Indrawing. Suprasternal. Intercostal. Subcostal. Suprasternal notch/tracheal tug.

Inspect for: Position of trachea. Pectus excavatum. Pectus carinatum. “Barrel chest”. Scoliosis. Kyphosis. Pallor. Nail clubbing. Nicotine stains. General wasting.

Inspect for and explain paradoxical breathing. Palpate chest for:

Tenderness. Rubs. Crepitus. Tactile vocal fremitus. Expansion.

Comment on expansion. Comment on symmetry. (Continued on next page)

Hoover’s sign.



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Percuss chest: Anterior. Lateral. Posterior. Comment on dullness. Comment on hyperresonance.

Demonstrate and explain how to check for diaphragmatic excursion. Auscultate chest:

Anterior. Lateral. Posterior. Identify and localize normal sounds.

Tracheal. Bronchial. Bronchovesicular. Vesicular.

Comment on sounds. Symmetry. Quality.

Comment on adventitious sounds. Wheezes/rhonchi. Crackles/rales. Rubs.

Demonstrate special tests. Egophony. Whispering pectoriloquy.

Positioning and Draping:

Patient should be sitting on either the exam table or a chair.

Patient should be exposed to the waist so that the anterior, lateral and posterior aspectsof the chest can be inspected.

o Female patients can be uncovered intermittently, as needed, during the course ofthe examination.

Inspection:

With the patient at rest, inspect and comment on their normal respiratory pattern.o Rate.

Assess the respiratory rate by counting the number of breaths taken in aminute.

Count for at least 30 seconds and multiply by two to determinebreaths per minute.

Normal rate averages about 12-16 breaths per minute. The respiratory rate is typically measured while appearing to be doing

something else (e.g. taking the pulse) so the patient is unaware that it isbeing measured.

This is because respiratory rate is the only vital sign which in undervoluntary control.



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Tip: if you place the patient’s arm across the chest while palpating pulse,you can also count respirations. Just keep your fingers on the pulse evenafter you have finished taking it.

o Rhythm.o Depth.o Symmetry.

The chest movements should be symmetrical.

Listen for abnormal sounds. (Click here for breath sounds.)o Stridor.

High-pitched musical sound usually heard on inspiration due to anobstruction of the trachea.

Mild stridor. Severe stridor.

o Wheezing. High-pitched whistling sound usually heard on expiration and due to

narrowed airways. Mild wheeze. Severe wheeze.

o Hoarse voice.o Inability to speak in full sentences.

Observe the patient for signs of respiratory distress.o Central cyanosis.o Peripheral cyanosis.o Accessory muscle use.

Nasal flaring. Scalene retractions.

Sternocleidomastoidso Indrawing.

Suprasternal. Intercostal. Subcostal. Suprasternal notch/tracheal

tug.

Inspect the chest for:o Position of the trachea.o Pectus excavatum.

Latin for “hollowed chest”.o Pectus carinatum.

Latin for “pigeon chest”. Sternum protrudes forward.

o “Barrel chest”. Increased anterior-posterior diameter. Associated with emphysema.

o Scoliosis. Spine is curved from side to side.

o Kyphosis. Hunchback.



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Inspect for chronic signs of lung disease. o Pallor.o Nail clubbing.

Loss of the Schamroth sign,which is the diamond shapeusually created when two fingersare held together.

o Nicotine stains.

Hands/nails. Teeth.

o General wasting.o Paradoxical breathing.

The abdomen should distend (diaphragm goesdown) when patient takes a breath in, anddeflate (diaphragm goes up) as patientexpires.

Paradoxical breathing is seen when thediaphragm moves in the opposite directionthan expected, leading the patient to distend

their abdomen as they breathe out and deflateit as they breathe in.

Associated with chronic obstructive lungdisease.

Palpation:

Palpate the patient’s chest for:o Tenderness.o Rubs.

Feels like a roughness, a sandpaper rubbing type of sensation.o Crepitus.

Crackling feeling.

Palpate for tactile vocal fremitus.o Fremitus = palpable vibrations transmitted through the

chest wall when a patient speaks.o Ask the patient to repeatedly say a phrase that causes a

palpable resonance in the chest (e.g., “boy oh boy” or“ninety nine” or “one”).

o Use the ulnar surfaces of both hands to quicklycompare vibrations on both sides of the back and toeasily detect differences.



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Check for chest expansion.o Standing behind the patient, our hands

should grasp either side of the ribcage, somewhere between the nippleline and the umbilical line. Slide yourhands a little towards each other toraise a bit of loose skin folds. Yourthumbs should be lifted slightly off the

chest, that way they can move freelyduring inspiration. Ask the patient toinhale deeply. Normally, in healthy adults, the

thumbs should movesymmetrical apart at least 5 cm.

If one thumb moves more thanthe other, this may indicate a lungproblem on the side that has reducedexpansion.

o An easier (and more accurate) way to measure chest expansion is to measure the

circumference of the patient’s chest at the nipple line (or just below for women) infull expiration, and again at full inspiration. The difference between the twomeasurements is the chest expansion.

Check for Hoover’s sign.o With the patient supine, place your hands along the costal margins with your

thumbs close to the patient’s midline. Ask the patient to breathe out and then

breathe in.o Normally, as the patient breathings in, your thumbs would move apart and return

closer together when the patient expires.o Suspect COPD (chronic obstructive pulmonary disease) if, when the patient

breathes in, your thumbs move even closer together. The chest is usually overinflated and cannot expand normally with

inspiration. As the patient breathes in, the diaphragm pulls the ribs closertogether.



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Percussion:

Percuss the patient’s chest moving from side to side and downwards:o Anteriorly.o Laterally.o Posteriorly.

Comment on areas of:o Dullness.

o Hyperresonnance.

Some percussion tips:o Avoid percussing too close to

the vertebrae or over the scapula.o When percussion posteriorly, have the patient cross their arms on their chest.o Remember to percuss near the right axilla to check the right middle lobe, and

above the clavicles.

Check the diaphragmatic excursion.o This is used to measure the movement of the diaphragm.o Ask the patient to breath normally, and by percussion estimate the level of the

diaphragm.o From this initial level, you will now find the

diaphragm level at expiration and inspiration. Ask the patient to take a deep breath in

and hold it. From the initial level, percussdownward to find the new level of thediaphragm. Make a little mark.

Now ask the patient to take a deep breathout and hold it. From the initial level,percuss upward to find the new level of the

diaphragm. Make another little mark.o Measure the difference between the two marks.

This is normally 5-6 cm.

Auscultation:

Ask the patient to breathe through their mouth and slightly more deeply than normal.o If the patient breathes through their nose, sounds from the nasopharynx could be

transmitted and interfere with proper auscultation.

Use the diaphragm of your stethoscope.

Compare sounds from side to side, and moving downward.

Click here for breath sounds.



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Auscultate the lung fields. o Anteriorlyo Laterally.o Posteriorly.

Identify and localize normal sounds.o Tracheal.

Heard over the trachea.

Harsh, sound like air beingblown through a pipe.

Tracheal sound. o Bronchial.

Heard anteriorly over the 2nd and 3rd intercostals space,over large airways.

Have a hollow, blowingquality, loud, high pitched.

Bronchial sound. o Bronchovesicular.

Heard posteriorly between thescapulae and in the centralanterior chest, due to air moving through the bronchi/bronchioles.

Softer than bronchial sound, with a tubular quality. Bronchovesicular sound.

o Vesicular. Heard throughout the lung fields, due to air moving through the alveoli. Have a soft, blowing quality. Vesicular sound.

Comment on sounds.

o Symmetry.o Quality.

Comment on adventitious sounds. o Wheezes.

Also called “ronchi”. Continuous musical sounds heard mainly on expiration and made louder

by forced expiration. Mild wheeze. Severe wheeze.

o Crackles.

Also called “rales”. Can be fine or coarse. Discontinuous sound as air passes over airway secretions. Fine crackles. Coarse crackles.

o Rubs. Creaking and grating sounds (think: leather on leather). Produced when two inflamed pleural surfaces rub against each other. Pleural friction rub.



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Special Tests:

If abnormalities are noted on percussion or auscultation, consider performing specialtests.

As a general rule, an area of consolidation tends to transmit sounds better than air-filledlung, and air-filled lungs transmit sound better than an area filled with fluid (effusion).

o If you are having trouble remembering this, think of it this way: When you are underwater (fluid) and want to talk to a friend who is sitting

underwater next to you, you need to talk very loudly and even then thingssound muffled and garbled.

When a train is coming down the tracks (consolidation), you can feel thevibrations very strongly if you put your hand on the tracks.

Egophony. o Ask the patient to say “eeeeeee”. o You will normally hear a muffled long “e” sound. o If you are listening over an area of consolidation or fluid, the sound will be heard

as “ay”. For this reason, this test is sometimes referred to as the “bleating goat

test”. o Egophony.

Whispering pectoriloquy. o As the patient to whisper a phrase while you listen with the diaphragm of your

stethoscope over the area of concern. o Normally, the whispered voice is barely/indistinctly heard if at all. o In patients with a consolidation over the area, you will hear the phrase loud and

clear.o Whispered pectoriloquy. (You will hear three sounds – over consolidation, normal,

and over consolidation again.)



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92

Precordial Exam


OBJECTIVES for PRECORDIAL EXAM

Inspect for: Deformities of the chest. Scars. Lifts/heaves. Pulsations. Apex beat.

Identify location of: Aortic valve. Pulmonary valve. Tricuspid valve. Mitral valve.

Palpate for: Lifts/heaves. Thrills.

Palpate for and characterize the apex beat. Demonstrate two techniques to accentuate the apex beat. Auscultate over:

Aortic valve. Pulmonary valve. Tricupsid valve. Mitral valve.

Identify normal heart sounds (S1, S2).

Auscultate for extra/abnormal heart sounds: S3. S4. Split S2. Murmurs. Opening snap. Rubs.

Demonstrate techniques to accentuate murmurs. Mitral murmur. Aortic murmur.

Note location usual radiation of murmurs.

Mitral murmur. Aortic murmur.

Inspect for, identify, and palpate carotid pulse. Characterize carotid pulse in terms of rate, rhythm, amplitude and contour.

(seen in Year 1 – Session 1) Palpate for thrills. Auscultate for bruits.



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Inspection:

The patient must be uncovered to the upper abdomen so a full inspection of theprecordium can be performed.

o Female patients can be uncovered intermittently, as needed during the course ofthe examination.

Inspect the anterior chest for:o Deformities.

o Scars.o Lifts/heaves.o Pulsations (especially in the areas corresponding to the heart valves).o Apex beat.

Usually located in the left 5th intercostals space, midclavicular line.

Identify location of heart valves. (Can also be done during auscultation.)o Aortic valve.

Usually best heard in the 2nd intercostal space of the right sternal border. o Pulmonary valve.

Usually best heard in the 2nd and 3rd intercostal spaces of the left sternal

border, but can extend even further. o Tricuspid valve.

Usually best heard in the 4th intercostal space of the left lower sternalborder.

o Mitral valve. Usually best heard at the apex (around the 5th intercostal space in the mid-

clavicular line).



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Palpation:

Palpate for:o Lifts/heaves.

A lift/heave is a large movement, usually associated with conditions suchas right ventricular hypertrophy.

Best felt with either the ulnar aspect or the heel of the hand along the leftsterna border.

o Thrills.

A thrill is a palpable (small) vibration caused by turbulent blood flow. Best felt with fingertips over the valve areas.

Palpate for the apex beat.o Is only palpable in 30%-50% of adults in the supine position.

In a female with large breasts, you can ask her to move the left breastupwards or to the left if necessary.

o If palpable, describe in terms of: Location. Size

It is usually smaller than a Canadian quarter (< 2 cm) if palpated

supine. Impulse.

Monophasic vs. biphasic. Amplitude. Duration.

Usually lasts less than 2/3 of systole.o If unable to palpate the apex beat, can try to accentuate it by:

Asking the patient to roll unto their left side.

If palpable, characterize as per above. Remember that when theapex beat is palpated while the patient is lying on their side, itsdiameter is often <4 cm.

Asking the patient to exhale fully and stop breathing for a few seconds.

Percussion:

Percussion of the heart area is not done on routine precordial exams.

However, it can be useful with certain conditions.o Dullness is increased with a pericardial effusion.o Dullness is decreased in COPD.

Auscultation:

Hint: in real life, but certainly for an exam, you may want to consider auscultating theprecordium with the patient laying supine, laying on his left side, and sitting up whileleaning forward.

Click here to listen to heart sounds.

Auscultate for S1 and S2.o S1 is the sound made by the closure of the atrioventricular (AV) valves (the mitral

and tricuspid).o S2 is the sound made by the closure of the aortic and pulmonic valves.o To distinguish between S1 and S2, time the sounds with the carotid pulse (check

for carotid bruits first!). S1, pulse, S2.o Auscultate over all 4 valve areas with the diaphragm of your stethoscope.

Most clinicians will start at either the apex or the base of the heart.



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o Normal heart sounds.

Auscultate for S3 and S4.o S3 and S4 are low frequency abnormal diastolic sounds. They occur when there

is rapid ventricular filling. An S3 occurs early in diastole. An S4 occurs as the atria contract (late in diastole), during the ”atrial kick”. Placing the patient in left side accentuates S3 and S4.

o Auscultate at the apex and along the left lower sternal border with the bell of yourstethoscope. Use the beLL when wanting to hear LLow sounds, such as S3/S4 or

murmurs. Do not press on your stethoscope. In fact, it is best if you just place it on

the chest and leave it there.

If you press the bell firmly, the skin acts as a diaphragm and thelow-pitch sounds disappear (you can use this technique to makesure that you really are hearing an S3, S4).

The S3 sound has a gallop rhythm. You can sing (in your head!) the words“Ken-tu-cky” or “slosh-ing-in” to it.

“Slosh-ing-in” is a reminder of the physiology behind the sound:blood flowing into an overfilled, non-complaint left ventricle suddenlydecelerates.

The S4 sound has a triple gallop rhythm. You can sing (again, in yourhead only!) the words “Ten-ne-ssee” or “a-stiff-wall”.

“A-stiff-wall” is a reminder of the physiology behind the sound: bloodpushed by the atrial contraction hit a ventricle that is abnormally stiffdue to hypertrophy or fribrosis.

o S3 and S4 can be heard in healthy young athletes without any heart problems.o S3. o S4.

Auscultate for other heart sounds.o Split S2.

S2 normally splits with inspiration, and when it does, the “dup” sound of S2now sounds like “drup.”

Splitting is best heard with the diaphragm in the pulmonary valve area, butcan be appreciated in only about 50% of healthy adults.

Split S2.

o Murmurs. Are best heard with a bell. A murmur should be defined by its:

Location. Radiation.

Timing in the cardiac cycle.

Intensity (grade from I to VI).o Grade I – can only be

heard with carefullistening.

o Grade II – audible.o Grade III – louder than a grade II murmur.o Grade IV – as loud as a grade III murmur but also has a thrill.



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o Grade V – can be heard when only the edge of thestethoscope touches the chest.

o Grade VI – can be heard without stethoscope.

Pitch.

Quality (e.g., harsh, blowing, rumbling, musical).

Shape (e.g., crescendo, decrescendo, etc).

Things that alter it (respiration, exercise, hand grip, squatting,valsalva, etc.)

Do not worry if you cannot identify all of these characteristics at first! Startby concentrating on just hearing the murmurs, identifying their location,radiation and guessing their intensity. When you are feeling morecomfortable with hearing murmurs, you will also want to determine theirtiming in the cardiac cycle.

Benign (innocent) murmur. Mitral regurgitation. Mitral stenosis. Pulmonic stenosis. Aortic insufficiency.

Early aortic stenosis. Late aortic stenosis. Patent ductus arteriosum.

To accentuate murmurs:

For aortic murmurs, you can ask the patient to sit up, lean forward,exhale completely and stop breathing at the end of expiration.

For mitral murmurs, you can ask the patient to roll unto their leftside.

Radiation of murmurs:

Aortic murmurs radiate to the carotids.

Mitral murmurs radiate towards the axillary line.

o Opening snap. High-pitched sound (use the diaphragm) that occurs in mitral stenosis due

to the sudden opening of the mitral valve. Opening snap.

o Rubs. High pitched (use the diaphragm), scratchy sound caused by pericardial

inflammation. Best heard along the left lower sternal border with the patient sitting up,

leaning forward and briefly holding their breath. Pericardial rub.



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Carotid Artery:

Inspect for neck pulsations just medial to the sternocleidomastoid muscles.

Place your fingers on the right carotid artery in the lower third of the neck, pressposteriorly and feel for the pulsations.

o Avoid pressing on the carotid sinus which lies at the level of the thyroid cartilage.o Never press on both carotids at the same time!o Describe the carotid pulse in terms of: (refer to Year 1 – Session 1)

Rate.

Rhythm. Amplitude. Contour.

o Feel for thrills.

Auscultate for bruits.



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Peripheral Vascular Exam


OBJECTIVES for PERIPHERAL VASCULAR EXAM

Inspect the lower limbs. Color. Hair distribution. Skin thickness. Ulcerations. Varicosities. Edema. Scars. Muscles wasting. In between toes. Nail growth and appearance.

Describe differences in signs of arterial and venous insufficiencies. Skin color. Skin thickness. Hair distribution. Edema. Ulcerations. Insufficiency changes.

Palpate for: Temperature. Capillary refill. Edema.

Measure calf circumference.

Identify the point of palpation of the peripheral arteries. Radial. Brachial. Abdominal aorta. Femoral. Popliteal. Dorsalis pedis. Posterior tibial.

Identify and describe the features of the arterial and brachial pulses. Rate.

Rhythm. Symmetry. Amplitude. Contour.

Identify and describe the symmetry and amplitude of the following pulses. Abdominal aorta. Femoral. Popliteal. Dorsalis pedis.

Posterior tibial. (Continued on next page)



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Demonstrate and explain the technique to assess for a radial-femoral delay. Demonstrate the correct technique for evaluation of: (seen Year 1, Session 1)

The peripheral palpable blood pressure. The auscultatory blood pressure.

Demonstrate and explain the technique for identifying pulsus paradoxus. (seen Year1, Session 1)

Auscultate the peripheral arteries. Brachial. Abdominal aorta. Renal. Iliac. Femoral.

Comment on bruits in peripheral arteries. Identify the surface anatomy of the saphenous veins. Demonstrate special tests for:

Arterial insufficiency. Upper extremities – Allen’s test. Lower extremities – Straight leg raise and refill test.

Venous insufficiency. Lower extremities – Incompetent saphenous vein test.

Inspection:

Inspect the lower limbs for: o Color.

E.g., pallor, cyanosis, redness (rubor), browndiscoloration.

The brown discoloration occurs whenhemosiderin (ferric oxide left from thebreakdown of extravasated hemoglobin)deposits in the dermal layer. It isassociated with chronic venous insufficiency.

o Hair distribution. In arterial insufficiency, there is often decreased hair on the

lateral aspect of the legs. Diabetics often lose hair on their big toes.

o Skin thickness. Skin thickening vs. skin thinning vs. normal thickness.

o Ulcerations. In arterial insufficiency, ulcers often appear on toes and

heels. In venous insufficiency, the ulcers are often located around

the medial malleoli. They are usually shallow and painless.

Pay especially close attention to the foot of a patient whohas lost or altered sensation in their feet (e.g., diabetics).These patients will often be unaware of ulcers as theysimply cannot feel them.

o Varicosities.o Edema.o Scars.



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These can give you a hint as to other vessel-related problems in the body.

Vessels from the legs are sometimes used for heart bypasssurgeries.

Bypass surgeries for obstructions in the legs can also beperformed.

o Muscle wasting. Muscles rely on a good blood supply to keep health. Patients can develop pain when walking/exercising due to

vascular insufficiencies in the leg. They tend to avoid moving toomuch in an effort to avoid pain.

o In between toes. It is important to look for fungal infections and broken down skin

in between toes. Such poor conditions can lead to skin infections andulcers.

o Nail growth and appearance.

Comparison of signs of arterial and venous insufficiency.

Arter ial Insuf ficiency Venous Insuf ficiency

Skin colour Pallor Brown discoloration

Skin thickness Thin skin Thick skin

Hair/Edema Decreased hair laterally Pitting edema

UlcerationsUlceration on toes andheels

Ulcers (medial malleoli), shallowand painless

Insufficiencychanges

Rubor with dependency Stasis dermatitis*

* Stasis dermatitis is the earliest skin change of chronic venousinsufficiency. It is most notably characterized by a brown discoloration(see above).

Palpation:

Temperature.o Run the back of your hand down both legs simultaneously, thus allowing you to

compare both sides at once.o Temperature normally slightly decreases when moving distally.

Check capillary refill time.o Press on a nail (toes or fingers) until it turns white then let go.o Assess how long it takes for the pink color to return.o Normally, the pink color should return within 3 seconds or less.

Assess for edema.o

Differentiate between pitting and non-pittingedema. Non-pitting edema is usually

associated with lymphedema.o To palpate, press on the anterior tibia (shins)

and look for pitting depressions where you

pressed down.

Start looking for edema at the ankle

and move your way up the leg. Note

the highest level at which edema is



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noted.

If patient is bed-ridden, make sure to check for edema on coccyx.

Measure calf circumference.o In order to measure the circumference at the same level, measure a pre-

determined distance below the tibial tuberosities on both legs.o Up to 2 cm difference in calf circumference can be normal.o

Only 1 cm difference in leg circumference is allowed at the level of the ankles.

Palpate the following arteries:o Radial.

Best felt just medial to the radius, usually using the tips or pads of yourindex and middle fingers.

o Brachial. Best felt in the antecubitcal fossa

(inside of elbow).o Abdominal aorta.

Best felt midline, just above the

umbilicus. If possible, try to estimate the diameterbetween your fingers.

A lateral pulsation indicates a possibleaneurysm.

o Femoral. Best felt at mid-inguinal point, lateral

corner of pubic triangle.o Popliteal.

Easier to feel if knee is slightly bent,thumbs are placed on tibial tuberosities,and all other eight fingers dig into the back of the knee. It is usually locatedlaterally.

o Dorsalis pedis. Best felt lateral to the extensor tendon of the big toe. Is absent in 10-15% of normal people.

o Posterior tibial. Best felt slightly behind and below the medial malleolus.

For the radial and brachial arteries, comment on: (seen in Year 1, session 1)o Rate.

Bradychardic vs. normal vs. tachychardic.o Rhythm.

Regular vs. regularly irregular vs. irregularly irregular.o Symmetry.

Compare both sides.o Amplitude.

Absent vs. decreased vs. normal vs. increased vs. bounding.o Contour.

Describe the wave form.

For all the other arteries, comment on:o Symmetry.



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o Amplitude.

Assess for a radial-femoral delay.o Normally, the femoral pulse occurs slightly before the radial pulse.o A radial-femoral delay happens when blood flow to the descending aorta depends

on collateral vessels. In such a case, the radial pulse is felt before the femoralpulse.

Evaluate the peripheral palpable blood pressure. (seen Year 1, Session 1)

Auscultation:

Evaluate the auscultatory blood pressure. (seen Year 1, Session 1)

Demonstrate and explain the technique for identifying pulsus paradoxus. (seen Year 1,Session 1)

Auscultate the following arteries:o Brachial.

Easiest to hear in the antecubitalfossa.

o Abdominal. Easiest to hear midline above the

umbilicus.o Renal.

Easiest to hear 5 cm aboveumbilicus and 3-5 cm to eitherside of the midline.

o Iliac. Easiest to hear just below the

umbilicus and 3-5 cm to either sideof the midline.

o Femoral. Easiest to hear at mid-inguinal

point, at the lateral corner of thepubic triangle.

Comment if any bruits are heard.

Special Tests:

To assess for arterial insufficiency:o In upper extremities – Al len’s test.

Ask the patient to make a tight fist and elevateit to drain it of all blood.

Occlude the radial and ulnar arteries. Lowerthe patient’s hand.

Ask the patient to open their hand. The palmshould be pale.

Release the pressure on either the radial orthe ulnar artery.

You would normally expect the palm to reddenwithin seconds (<5 secs).



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If the palm does not redden within seconds, this suggests an arterialinsufficiency.

If the refill time is different after releasing the radial artery than afterreleasing the ulnar artery, this suggests an occlusion of the slowerof the two arteries.

If the time is delayed equally for both the ulnar and radial arteries,this suggests a more proximal occlusion.

If there is no return of colour to the hand after releasing the ulnar

artery (which continuing to compress the radial artery), this indicatesthat there is no connection between the deep and superficial palmararches.

o In lower extremities – Straight leg raise and refill test. With the patient supine, raise both legs to 45o-60o for about 30 seconds or

until pallor of the feet develops.

This is a difficult test for patients, so be considerate and hold thelegs/feet up for the patient.

If the patient complains of pain at this stage, suspect arterialinsufficiency.

Then ask the patient to sit up and dangle both legs over the side of thebed.

The natural pink coloring should return tothe feet within 10 seconds normally.

You should also be able to see thesuperficial veins of the foot fill within15 seconds.

If the pallor in the feet persists for more than10 seconds, suspect arterial insufficiency.

If the feet develop a dusky cyanotic colour(called rubor) when dangling, this suggest

arterial insufficiency as well. This is why this test is also sometimes called “rubor on dependency

test”.

The rubor is called “reactive hyperemia”. It is due to the dilation ofvessels distal to the occlusion. Then the occlusion is released,blood flow is greatly increased from normal, producing the redcoloring.



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To assess for venous insufficiency:o In lower extremities – Incompetent saphenous vein test.

The greater saphenous vein originates from the femoralvein. It then descends on the anterior thigh towards themedial aspect of the knee, and then descends towardsthe dorsal venous arch of the foot.

Ask patient to stand. Any dilated varicose veins willbecome obvious.

Compress the vein proximally with one hand and placethe other hand 15-20 cm away.

Briskly compress and decompress the proximal site. Normally the hand at the distal site should not feel an

impulse. Any impulse that is transmitted to the distal site

indicates incompetent saphenous valves between thetwo sites.



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Sessions for year 2

Head and Neck Exam

Course 4

OBJECTIVES for HEAD and NECK EXAM Demonstrate inspection of the head and face. Demonstrate the inspection of the eye.

Palpebral fissure. Globe position. Eyelid. Lacrimal glands. Sclera. Palpebral conjunctiva. Cornea. Pupils.

Demonstrate tests for strabismus. Demonstrate the fundoscopic examination.

Red reflex. Disk. Retinal vessels. Retina. Macula.

Demonstrate the examination of the external ear. Inspection. Palpation.

Demonstrate, using the otoscope, the inspection of the ear canal and tympanic

membrane. Demonstrate the inspection of the external aspect of the nose. Demonstrate, using an otoscope, the inspection of the internal aspect of the nose. Demonstrate the examination of the sinuses.

Inspection. Palpation. Transillumination.

Demonstrate the examination of the mouth and oropharynx Lips Teeth Gums Breath Tongue Buccal mucosa



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HEAD

Note any abnormalities or asymmetry in the head and face.

Hairo Distributiono Textureo Patterns of loss.

Skin lesions head and face.

EYESInspection:

Palpebral fissure (area between opened upper/lower eyelids)o Width

Normal Increased (eg exophthalmos) Decreased (eg enophthalmos)

Globe position (inspect from front and side)o Protusion (Exopthalmos)

o Recession (Enopthalmos)

Eyelido Erythemao Edemao Rasheso Crusting/dischargeo Skin lesions eg xanthelasma

Lacrimal gland (upper lid, lateral position)o Erythema of overlying eyelid

Sclera (whites of the eye) and bulbar conjunctiva(overlies sclera)

o Color: white, yellow, blue (osteogenesisimperfecta), red (hemorrhage)

o Lesionso Edema (aka chemosis)



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Palpebral conjunctivao Inspect for colour (erythema with conjunctivitis, pallor with anemia)

Evert lower lid Evert upper lid (especially if looking for foreign body)

Corneao Shine a penlight obliquely to look for

Scars Abrasions Ulcers Foreign bodies

Arcus Senilis (white ring at the limbus [junction between cornea andsclera])

o Fluorescein staining will be demonstrated in another module

Pupilso Sizeo Shape

Regular vs irregular Round vs other

o Symmetry If pupils unequal, termed anisocoria

Tests for Strabismus:

Alternate cover testo Ask patient to fixate on an object at end of the roomo

Cover left eye (with your right hand)o Watch for fixation movement in right eye (if present, called strabismus orheterotropia)

o Uncover left eyeo Cover right eyeo Watch for fixation movement in left eye



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Fundoscopy

Please refer to the diagram below when reading the fundoscopy method text

Methodo Ask the patient to remover their glasseso Ask the patient to look straight at distant object (eg corner of door frame)o If examining patient’s right eye, take opthalmoscope in right hand and position in

front of your right eye (use left hand, left eye if examining patient’s left eye)

o Your free hand can be positioned on the patient’s shoulder for spatial orientationo Dim room lightso Hold opthalmoscope 15 cms and slightly to the right (25 degrees) from patient’s

right eye if examining that eyeo Select “0” on the lens selection disc; look at illuminated lens indicator to

ensure “0” is selectedo Using aperture selection dial, select small aperture; can increase later to large

aperture for a better viewo Look for red reflex (see significance below)o Slowly move toward the patient; optic disk should come in view when the

examiner is 3-5 cm away from the patient

o If the disc is not focused clearly, use the lens selection disk to bring in to focus The far sighted eye requires more plus lenses (green numbers) The near sighted eye requires more minus lenses (red numbers)

o Once the disk is examined, move the light 2 disk diameters temporally to visualizethe macula

o Ask your patient to do following maneuvers to examine periphery Look up (superior retina) Look down (inferior retina) Look temporally (temporal retina) Look nasally (nasal retina)



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Red reflexo Presento Black (eg cataract)

Optic disko Shape (normally round/oval)o Color (normally red/orange)o Physiologic cup: pale area on temporal side of the disc

Normal appearance Papilledema

Retinal vesselso Arteries: bright red with a central stripe (light reflex)

Note width of light reflexo Veins

Differentiate for arteries

No light reflex

Size: veins larger in roughly 4:3 ratio

Color: veins are dark red

Pulsation: unless intracranial pressure is elevated, veins pulsate Look for nicking of veins at arteriovenous crossings

Retinao Scarring: white or presence of pigmento Hemorrhageso Exudates

Maculao 2-3 disk diameters temporally from disko Fovea: smaller, dark red area within macula

Visual fields, visual acuity, papillary responses and extra-ocular movements are coveredYear 2, Course 5, Session 1.



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EARSExternal Examination

Inspect the auricle and surrounding areaso Sizeo Shape

Swellingo Color eg erythemao Deformities eg cauliflower ear

o Discharge Serous Purulent Sanguinous

Palpationo Pain

Without movement (chondritis) With movement (otitis externa)

Internal inspection

Attach a speculum to a light otoscope

Use largest speculum that will fit

In adults, retract the auricle upwards and backwards

In infants and young children, exert downward traction on the auricle

BE GENTLE- the lining of the bony canal is very sensitive

Inspect the ear canalo Swellingo Erythemao Foreign bodies

Cerumen is often present and may need to be removed to observe thetympanic membrane (ear drum)

Inspect the tympanic membrane (ear drum)o Light reflexo Landmarks

Umbo or center of the light reflexo Manubrium of malleus (hammer) extending upwards from umboo Definition of the manubrium (hammer)

Bulging renders indistinct/obscured Retraction sharpens definition

o Perforations



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o Color and sheen Normal

Shiny and gray Abnormal

Yellow (serum)

White or chalky (pus)

Blue (blood)o Fluid- air bubbles

Hearing tests as well as labyrinthine tests are covered when Cranial Nerve VIII is studied inYear 2, Course 5, Session 1.

NOSENasal patency

Place your finger against one side of the nose to occlude it and ask the patient tobreathe in and out with mouth closed

Repeat on the other side.

External Appearance

Sizeo Rhinophyma

Deformitieso Saddle nose

Discharge

Nasal flaring

Internal Appearance

Toolso Otoscope with nasal speculum- most common toolo Examiner’s fingers and lighto Vienna speculum (opens when you squeeze the handles)

Nasal mucosao Color

Ulcerations

Septumo Deviationo Perforation



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Turbinates (inferior and middle)

o Swellingo Coloro Discharge (from middle meatus as it drains frontal, maxillary and anterior ethmoid

sinuses)o Polyps

SINUSESInspection:

Swelling over frontal/maxillary sinus area

Palpation:

Frontal o Press your thumbs up under the bony brow on each side of the nose

Maxillaryo Press up under the zygoma with your thumbs.

Transillumination:

Frontal

Place light under nasal half of supraorbital ridge and look for a bright area in the

forehead



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MOUTH AND OROPHARYNX

Lipso Defects e.g. cleft lip

o Color eg cyanosiso Lesions such as angular stomatitis, ulcerso Examine inner aspect by retracting them with a gloved hand or tongue blade

Teetho Absenceo

Shape eg notchingo Discolorationo Caries

Gumso Retraction of gum margino Inflammation/puso Bleeding gumso Gingival hypertrophy

Breatho Smell

Acetone (DKA) Ammonia (Renal Failure) Fetor (Cirrhosis) NB There are many other breath odors in diseases or ingestions

Tongueo With protusion, assess

Size Deviation Coat of tongue

Color

Thicknesso Inspect under surface of tongue

Frenulum

o Palpate tongue (inside mouth to ensure it isrelaxed)

Masses Sublingual salivary glands Submaxillary ducts



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Buccal Mucosao Color eg cyanosiso Lesions

Vesicles Petechiae Candida Ulcers

o Orifice of parotid duct (opposite upper second molar) Oropharynx

o Uvulao Hard and soft palateo Tonsils

Hyperplasia Ulcers Masses Membrane

o Retropharyngeal area Swelling



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Endocrine System

Course 4

OBJECTIVES for ENDOCRINE SYSTEM Perform a general inspection.

Weight. Stature. Secondary sexual characteristics. Hair. Integument (skin).

Identify the thyroid using surface landmarks. Inspect the neck and upper chest.

Goiter. Erythema overlying thyroid. Thyroidectomy scars. Dilated veins upper chest wall.

Differentiate goiter from other midline cervical masses. Palpate the thyroid in front and/or behind the patient.

Size. Shape. Consistency. Tenderness. Mobility.

Auscultation. Thyroid bruits.

Examine for hyperthyroidism. Differentiate signs of hyperthyroidism from signs of Grave’s disease.

Examine for hypothyroidism.

IMPORTANT REMINDERMany of the endocrine diseases (thyroid disorders, adrenal disorders to name a few) havean impact on many systems/tissues in the body. These systems are covered in detail inother sections of the physical exam course. As you will ascertain in the thyroid section,specifically in the thyroid hormone excess/deficiency sections, an endocrine examencompasses a complete physical examination. ‘Putting together’ a complete physicalexamination is not expected at the end of this session but rather will be expected at the endof the physical examination course.



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GENERAL INSPECTION

Weight

o Fat distribution (central vs. peripheral)

Stature

o Dowager’s hump (osteoporosis)

o Buffalo’s hump (excess steroids)

Secondary sexual characteristics

o Beard growth in femaleso Breast development in males

o Small wrinkles around eyes and mouth (loss of sex steroids)

Hair:

o Male pattern balding / female hirsutism

o Texture

o Dryness

Skin:

o Pigmentation

o Ulcerations of feet and legs

o Skin temperature,

o Moisture/dryness

o Thickness

THYROID EXAMINATIONPrior to beginning the examination of the thyroid, provide the patient with a glass of water.

Nomenclature:

Enlargement of the thyroid gland is termed a goiter.

Inspection:

Inspect from front and side for midline swelling.o NB causes of lateral neck swelling are covered in lymph nodes, head and neck

examinationso Movement of swelling with swallow

Moves up: goiter or thyroglossal cyst

Thyroglossal cyst moves with tongue protrusion No movement: Submental lymph modes, parathyroid gland (rare),

neoplastic infiltration of thyroid (rare)

Erythema (can be seen in thyroiditis)

Scarso Thyroidectomy scar at base of neck

Palpation:

Done in front or behind patient

Landmarkingo Locate the thyroid cartilage (Adam’s apple)o Move down from thyroid cartilage to locate cricoid cartilageo Locate the thyroid isthmus ( 1cm or so below cricoid

cartilage)o Locate the thyroid lobes under the sternocleidomastoids

Repeat palpation while the patient swallows



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Sizeo approximation

Shapeo Diffuse enlargement vs noduleo Characterize nodule

Size Consistency Tenderness

Mobility Consistency

o Soft: normalo Firm: goitero Hard: carcinoma

Tendernesso Can be seen in thyroiditis or hemorrhage into a cyst

Mobilityo Mobile: normalo Non-mobile: carcinoma

Auscultation: Using bell, listen for bruits over each thyroid lobe

o Can be seen in hyperthyroidism

Lymph nodes (covered in Year 1- Session 2)

Examination for cervical lymphadenopathy

EXAMINATION FOR HYPERTHYROIDISMExcess thyroid hormone affects many tissues/systems in the body. Features ofhyperthyroidism are characterized by sympathetic overactivity. Features that are notcharacterized by sympathetic overactivity depend on the underlying etiology of

hyperthyroidism. Features of Grave’s disease (one of the causes of hyperthyroidism) will becovered in this document. The systems affected by hyperthyroidism are covered elsewherein Year 1 and Year 2. Please refer to each system’s section for a detailed description of theexamination maneuver(s).

Vital signs:

HR: Tachycardia, atrial fibrillation

BP: Wide pulse pressure (slight increase in systolic and drop in diastolic)

Temperature: Normal or fever

Neurological:

Motor:o Tremor (fine, found in extended fingers and tongue)o Hyperkinesia (excessive movements)o Generalized weakness

Reflexeso Normal or hyperactive (+/- clonus)

Integument:

Skin: soft, thin and moist

Hair: fine, oily and abundant



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Nails: onycholysis

Head and Neck:

Lid retraction (sclera visible above iris)

Lid lag (upper lid lags behind when observing descent of the eyeball)

Cardiovascular:

Flow murmur

Signs of congestive heart failure

GRAVE’S DISEASEIn addition to signs of hyperthyroidism, Grave’s disease can affect the following systems:

Head and Neck:

Exopthalmos (proptosis)

Chemosis

Periorbital edema

Opthalmoplegia

Integument:

Skino Pretibial myxedema (pink nodules over shins)o Thyroid acropachy (thickening of the skin on dorsa of finger and toes)



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EXAMINATION FOR HYPOTHYROIDISMLack of thyroid hormone affects many tissues/systems in the body. Features ofhypothyroidism are characterized by a slowing of body metabolism. The systems affectedby hypothyroidism are covered elsewhere in Year 1 and Year 2. Please refer to eachsystem’s section for a detailed description of the examination maneuver(s).

Vital signs:

HR: Normal or bradycardia

BP: Normal or elevations in both systolic/diastolic blood pressures Temperature: Normal or hypothermia

Neurological:

Speech is slow

Motoro Hypokinesia (lack of unnecessary movements)o Generalized weakness

Reflexeso ‘Hung reflexes’ (delayed relaxation phase)- seen in knee and ankle

Integument:

Skino cold, dry, thicko hypercarotenemia: palms, circumoral skin yellow

Hair: dry, coarseo Hair loss in lateral third of eyebrows

Nails: dry, brittle

Head and Neck:

Tongue: large

Voice: hoarse, coarse

Cardiovascular:

Edema

Signs of pericardial effusion

Respiratory:

Signs of pleural effusion



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Cranial Nerves Exam


OBJECTIVES for CRANIAL NERVES EXAM Name and examine cranial nerves I through XII:

I – Olfactory. II – Optic.

Visual acuity. Visual fields. Fundoscopy. (seen in Year 1, Session 16) Pupils. Pupillary response.

Direct. Consensual. Relative afferent pupillary defect. Accommodation.

III – Oculomotor. Motor. Pupils. Eyelids. Pupillary response.

Direct. Consensual. Relative afferent pupillary defect. Accommodation.

IV – Trochlear. Motor.

V – Trigeminal.

Sensory. Motor. Reflexes.

VI – Abducens. Motor.

VII – Facial. Motor. Sensory.

VIII – Vestibulo-cochlear. Hearing.

Whispering test.

Weber’s test. Rinne’s test.

Balance. IX – Glossopharangeal.

Motor. Sensory.

X – Vagus. Motor.

Sensory. (Continued on next page)



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XI – Accessory. Motor.

XII – Hypoglossal. Motor.

Cranial nerve I – Olfactory o

Ask patient to identify a recognizable odour (i.e. coffee, peppermint, vanilla), onenostril at a time. Only unilateral loss is of importance.

Cranial nerve II – Optic o Test visual acuity.

Use a hand-held eye chart or a Snellen’s wall eye chart.

Allow patient to wear their glasses.

Test each eye separately.

If a patient requires glasses to read but does not have them (asfrequently happens in the emergency department), you can create a

pinhole in a piece of paper and ask the patient to try reading again.If the visual acuity improves with the pinhole, it is unlikely to be acranial nerve II issue.

If a patient cannot read the largest letter on the chart, hold fingers in frontof each eye, and ask the patient to count them.

If a patient cannot see fingers held up in front of them, test perception ofhand movement in front of them.

If a patient cannot perceive hand movement, try light perception.

o Test visual fields. Are tested by confrontation. Test each eye separately. Have the patient stand (or sit) about an arm’s length away from you, cover

the eye that is not being tested, and stare into your opposite eye (e.g., iftesting the right eye, patient should be looking at your left eye).

Using your wiggling finger (or a pen with a red tip), bring in your fingersdiagonally toward the centre of vision from the four main directions halfwaybetween you and the patient. Ask the patient to tell you when they can firstsee the finger.

Have the patient cover one eye and identify how many fingers arebeing shown in peripheral fields.

Hold both hands in front of patient; ask if the hands look similar in

order to test for hemianopsia and/or midline defects.

o Fundoscopy. Refer Head and Eyes Exams. Look for optic disc (colour, sharpness of borders, size, atrophy),

papilloedema, haemorrhages, exudates.



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o Inspect the pupils. Size. Shape. Symmetry. Regularity.

o Check pupillary response. Reflex governed by afferent component of cranial nerve II and autonomic

component of cranial nerve III. Test each eye separately. Shine a light from the side into one of the eyes and determine the reaction

to light in both eyes.

Normally, the pupil exposed to light will constrict. o Direct response.

Normally, the pupil not exposed to light will also constrict.o Consensual response.

Now move the light from side to side and determine the reaction to light inboth eyes. (swinging flashlight test)

If there is a relative afferent pupillary defect

(RAPD), the affected pupil will dilateparadoxically soon after the light source ismoved from the normal eye to the abnormaleye.

Try it out for yourself.

o Test for accommodation. Ask the patient to look into the distance and then to

focus their eyes on a pen or finger that you hold about30 cm in front of them.

Normally, both pupils should constrict.

Cranial nerve III – Oculomotor o Inspect the pupils.

Size. Shape. Symmetry. Regularity.

o Inspect eyelids for ptosis (drooping). Drooping of the lower eyelid is common old age, but can also be

caused by a cranial nerve VII lesion.

A complete cranial nerve III paralysis would result in the affected eyelooking down and out, and ptosis.

o Check pupillary response. Reflex governed by afferent component of cranial nerve II and

autonomic component of cranial nerve III. Test each eye separately. Shine a light from the side into one of the eyes and determine the

reaction to light in both eyes.

Normally, the pupil exposed to light will constrict.o Direct response.



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Normally, the pupil not exposed to light will also constrict.o Consensual response.

Now move the light from side to side and determine the reaction to lightin both eyes. (swinging flashlight test)

If there is a relative afferent pupillary defect (RAPD), the affectedpupil will dilate paradoxically soon after the light source is movedfrom the normal eye to the abnormal eye.

Lastly, test for accommodation.

Ask the patient to look into the distance and then to focus theireyes on a pen or finger that you hold about 30 cm in front ofthem.

Normally, both pupils should constrict.

o Extra-ocular movements are usually tested together (i.e., cranial nerves III, IVand VI).

o Ask the patient to look up, down, toward their nose, and up and in. Tests the superior rectus, the inferior rectus, the medial rectus and

inferior oblique. Easiest to do this by having patient following your moving finger.

Observe for nystagmus. Ask about diplopia at the extremes of ROM.

Cranial nerve IV – Trochlear o Extra-ocular movements are usually tested together (i.e., cranial nerves III, IV

and VI).o Ask the patient to look down and in.

Tests the superior oblique muscles (remember: “SO4”). Ask about diplopia.

o In a patient with a cranial nerve IV lesion, there isoften a compensatory head tilt away from the lesion. The head tilt is toward the shoulder of the

unaffected eye. An isolated cranial nerve IV lesion is rarely

seen and the ocular findings may be difficult for the non-expert toobserve.



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Cranial nerve V – Trigeminal o This nerve supplies sensation to the face and the muscles of mastication.

o Test sensory function. Compare from side to side. Test all three branches.

Ophthalmic (e.g., scalp).

Maxillary (e.g., cheek).

Mandibular (e.g., chin). Test pinprick and light touch

Before touching the patient’s face, show thepatient on their hand or arm what the twosensations will feel like and check whetherpatient can differentiate between the two.

Do not stroke the skin, only pinpoint touches. Temperature is not routinely tested as its loss usually is seen with loss

of pain sensation.

o Test motor function. Ask the patient to bite down and feel the muscles for

tension.

Temporalis.

Masseters.

o Test the corneal reflex. Afferent component of corneal reflex is mediated by cranial nerve V. Ask the patient to look up and away from you. With a cotton wisp, approach from the side the patient is looking away

from. Gently touch the coloured part of the eye (i.e., the cornea). Lookfor a symmetrical blink reflex. Repeat in the other eye.

Be aware that contact lens wearers have often have a decreasedcorneal reflex.

We do not routinely test this function of cranial nerve V.

o Test jaw jerk (also called masseter reflex). This reflex is mediated by the third branch of cranial nerve V. Ask the patient to let his mouth fall slightly open. Place a finger on the

tip of the jaw and lightly tap it with a reflex hammer. Normally, the mouth will either slightly close or there will be no reaction. The jaw jerk will be greatly exaggerated in an upper motor neuron

lesion above the pons. We do not routinely test this function of cranial nerve V.

Cranial nerve VI – Abducens o Extra-ocular movements are usually tested together (i.e., cranial nerves III, IV and

VI).o Ask the patient to look to the side.

Tests the lateral rectus muscle (remember: “LR6”). In a patient with a cranial nerve VI lesion, there is often a compensatory

head turn.



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The patient will turn their head toward the side of the affected eye. Loss of lateral (temporal) gaze is usually one of the first functions to be lost

with increased intracranial pressure.

Cranial nerve VII – Facial o This nerve supplies the muscles of facial expression and taste to the anterior 2/3

of the tongue.

o Inspect face. Facial asymmetry at rest. Asymmetry of facial expressions. Smoothing of wrinkles on forehead. Sagging of lower eyelid (but could also be due to old age). Smoothing of nasolabial fold. Unilateral drooping of the corner of the mouth. Tics/unusual movements.

o Listen to patient’s speech. Note any difficulties in enunciating nasal sounds (b, m, p).

o Test motor function. Wrinkle forehead Squeeze eyes shut.

Try to open them while patient keeps them shut.

Show teeth.

It is best not to ask patient to smile, as not everyone shows theirteeth when they smile.

Puff out cheeks.

Try to push air out of them while patient tries to

maintain it inside. Purse the lips to whistle. Contract platysma muscles.

Ask patient to pull down the corners of theirmouth and/or tense their neck muscles.

o Test taste on anterior 2/3 of the tongue. We do not routinely test this function of cranial nerve

VII unless there is evidence of lower motor weakness on motorexamination.



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o Be aware of the innervations of muscles of facial expression. Clinically, be able to distinguish between UMN and LMN lesions.

Cranial nerve VIII – Vestibulo-cochlear

o This nerve is responsible for hearing and part of balance.o Testing of hearing should be done without the patient wearing a hearing aid.

o Inspect eardrum. (Refer to Year 1, Session 17) Wax. Other obstructions. Inflammation. Perforation.

o Whispered test.

Rub your fingers together next to one ear while whispering (e.g. a number)in the other.

Try to whisper at the end of your expiration to standardize thevolume.

Whisper about 60 cm away from ear.

o If whispered test is abnormal or partial deafness is suspected for any otherreasons, perform the Weber and Rinne tests. Weber and Rinne tests help to determine if it is sensory or conductive

hearing loss. Weber’s test.

Position a vibrating 256 or 512 Hz tuning fork in the middle of theforehead.

Usually the sound is heard equally in both ears.

A patient with a sensory hearing loss hears the sound louder in thenormal ear.

A patient with a conductive hearing loss hears the sound louder inthe abnormal ear.



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Rinne’s test.

Pronounced “rei-nay”.

Position a vibrating 256 or 512 Hx tuning form on the patient’smastoid process.

Ask the patient to tell you when they can no longer hear the soundof the fork, at which point place the fork next to the patient’s externalmeatus of the ear being tested.

Usually, the sound can still be heard at the meatus after it is no

longer heard through the mastoid.o You should always listen to the fork yourself once the patient

states that they can or cannot hear a sound at their externalmeatus.

A patient with a sensory hearing loss hears the sound at theexternal meatus.

A patient with counductive hearing loss cannot hear the sound at theexternal meatus.

o Balance is initially evaluated with a Romberg test. Ask the patient to stand with feet together and arms at their sides. Then

ask the patient to close their eyes while you stand close by, ready to catchthe patient should they start to fall.

It is normal to be slightly unsteady, but not to the point where it lookslike the patient is going to fall.

A patient without a deficit should be able to maintain this position for up toone minute easily.

Loss of balance indicates cerebellar ataxia, posterior column or vestibulardysfunction.

Loss of balance is termed a positive Romberg sign.

Cranial nerve IX – Glossopharyngeal o Ask the patient to open their mouth, and inspect the palate with a light source.

Note location of uvula. With their mouth still open, ask the patient to say “Ah”.

Observe for symmetrical movement of the soft palate.

Observe for deviation of the uvula. Also tests cranial nerve X.

o Ask the patient to swallow a small amount of water. Observe for regurgitation into the nose or coughing. Also tests cranial nerve X.

o Test gag reflex. Cranial nerve IX is the sensory component and cranial nerve X is the motor

component of this reflex. We do not routinely test this function of cranial nerve IX.

o Test posterior 1/3 of the tongue for taste. We do not routinely test this function of cranial nerve IX.

Cranial nerve X – Vagus o Listen for hoarseness in patient’s voice.



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o Ask the patient to open their mouth, and inspect the palate with a light source. Note location of uvula. With their mouth still open, ask the patient to say “Ah”.

Observe for symmetrical movement of the soft palate.

Observe for deviation of the uvula. Also tests cranial nerve IX.

o Ask the patient to swallow a small amount of water.

Observe for regurgitation into the nose or coughing. Also tests cranial nerve IX.

o Test gag reflex. Cranial nerve IX is the sensory component and cranial nerve X is the motor

component of this reflex.

Cranial nerve XI – Accessory o Innervates the trapezius and sternocleidomastoid muscles.

o Inspect the muscles. Ask the patient to shrug their shoulders.

Feel the bulk of the trapezius muscles. Assess strength by trying to push down on the shrugged shoulder while

asking the patient to resist you.

o Ask the patient to turn their head to one side against resistance. Feel the bulk of the sternocleidomastoid muscles. Remember turning the

head to the left is done by the right sternocleidomastoid muscle and viceversa.

Cranial nerve XII – Hypoglossal o Motor nerve for the tongue.

o Inspect the tongue as it lies on the floor of the mouth. Wasting. Fasciculations.

o Ask patient to stick out their tongue. Deviation.

The tongue will deviate towards the affected side. Fasciculations.

o Test the muscle strength by asking the patient to push the tongue against their

cheek as you apply resistance from the outside with a finger.

o Listen for speech problems. Lingual speech sounds (l,t,d,n) are usually affected.



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Mini-Mental Status Exam (MMSE)


OBJECTIVES for MINI-MENTAL STATUS EXAM

Demonstrate a standard mini-mental status examination, including explanation ofnature and purpose of exam to patient.

Be familiar with the Glasgow Coma Scale.

Mini-Mental Status Exam (MMSE):

The MMSE is a tool consisting of 11 questions that test the following five areas of

cognitive function:

o Orientation.

o Registration.

o

Attention and calculation.o Recall.

o Language.

The maximum score is 30/30.

o A score of 23 or less indicates mild cognitive impairment.

o A score of 10 or less indicates severe cognitive impairment.

Ask each question a maximum of three times.

o If the patient does not answer a question, assign a score of 0 to that question.

o If the patient answers incorrectly, assign a score of 0 to that question.

Do not hint, prompt or ask the question again. Be careful not to provide any physical clues that the answer is incorrect

(e.g., frowning or shaking your head).

o If the patient says “What did you say?”, simply repeat the question (if within the 3

repetition limit). Do not explain or engage in conversation.

Before starting the exam, make sure that you have the following with you:

o A watch.

o A pencil.

o An eraser.

o Some blank paper.

o A piece of paper with “CLOSE YOUR EYES” written in large letters.

o A piece of paper with two 5-sided figures (pentagons), intersecting to make a 4-

sided figure.



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Perform this exam with the patient sitting down and facing you.

o Make sure that the patient can hear you and understands simple conversation.

Obtain the patient’s permission to ask questions.

o E.g., “Can I ask you some questions about your memory?”

Encourage patient to do their best.

o E.g., “I am going to ask you some questions and give you some problems to

solve. Please try to answer as best you can.”

Questionnaire: Max Score

o Orientation (allow 10 seconds for each reply)

What year is this? 1

Accept exact answer only.

What season is this? 1

During the last week of the old season or the first

Week of a new season, accept either season. What month of the year is this? 1

What is today’s date? 1

Accept previous or next date also. What day of the week is this? 1


What country are we in? 1


What province are we in? 1


What town are we in? 1


What is the name of this build ing? 1 Accept name of hospital or building or institution.

What floor of the building are we on? 1

Accept exact answer only.o Memory

I am going to name 3 objects. After I have said all

three objects, I want you to repeat them. Rememberwhat they are, because I am going to ask you to namethem again in a few minutes.

Say name of 3 objects slowly at approximately

one second intervals. E.g., ball, car, man, flag, tree, table, apple, penny, etc.

Please repeat the 3 items for me. 3

Score 1 point for each correct reply on the

first attempt.

Allow 20 seconds for reply.

If patient did not repeat all three items, repeat

them until they are learned or up to a maximum of five times.

o Attention



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Spell the word “world” .

You may help the patient spell the word correctly.

Now spell it backwards. 5

Allow 30 seconds for answer.

Easier to score if you write down patient’s answer.

If the patient cannot spell “world” even with

assistance, score 0.

Correct answer: DLROW.

Score 4 if one letter omitted.

Score 3 if two letters omitted.

Score 3 if two letters reversed.

Score 2 if three letters reversed or omitted.

Score 1 if four letters reversed.

Alternative: can use “serial sevens” instead of “world”.Decide which one to use before starting.Do not use “serial sevens” if patient was unable tospell “world” and vice versa.Subtract 7 from 100 and keep subtracting sevenfrom what is left until I tell you to stop. (score out of 5)

o May repeat instructions up to three times.

o Allow one minute for answers.

o Write down patient’s answers.

o Once patient starts, do not interrupt. Allow

Them to proceed until 5 subtractions havebeen made. If the patient stops before 5subtractions have been made, repeat theoriginal instructions “keep subtracting seven

from what is left” (to a maximum of three times).o Correct answers: 93, 86, 79, 72, 65.

o Subtract 1 point for each incorrect answer,

but do not subtract any points if patient subtractscorrectly from an incorrect answer (e.g., 93, 88,81, 74, 67 would score 4/5).

o Recall (allow 10 seconds)

What were the three objects that I asked you to

remember? 3

Score 1 point for each correct response

regardless of order. Note: it is important that the order of Memory,

Attention and Recall be exact (e.g., cannot doMemory-Language-Recall or Memory-Attention-Language-Recall, etc).



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o Language

Show wristwatch. Ask what is it called? 1


Accept “wristwatch” or “watch.

Do not accept “clock”, “time”, etc.

Show pencil. Ask what is it called? 1


Accept “pencil” only.

Score 0 for “pen”.

I’d like you to repeat a phrase after me: “ No ifs, ands

or buts”. 1


Must be exact.

Read the words on this page and then do what it says. 1

Show patient the sheet with “CLOSE YOUR EYES”

on it.

If patient only reads and does not then close eyes,repeat “read the words on this page and then dowhat it says” to a maximum of three times.

Allow 10 seconds for reaction.

Score 1 point only if patient closes eyes.

Patient does not have to read out loud.

Ask patient if they are right or left handed. Alternate

right/left hand in your instructions (e.g., if the patientis right-handed, ask them to take the piece of paperin their left hand). Take this paper in your right/lefthand, fold the paper in half once with both hands,

and put the paper down on the floor . 3 Score 1 if patient takes paper in correct hand.

Score 1 if patient folds it in half.

Score 1 if patient puts it on the floor.


Place design, pencil, eraser and paper in front of patient.

Ask copy th is design, please. 1

Allow multiple tries until patient is finished

and hands it back.

Score 1 point for correctly copied diagram.

Maximum time allowed to get full score is

one minute. Place pencil and paper in front of patient. Ask, write

a complete sentence on this piece of paper. 1


The sentence should make sense.

Ignore spelling errors.

MMSE Summary (questions only)



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o What is the year, season, month, date, day?

o Where are we: country, province, town, building, floor?

o Repeat three objects.

o Spell WORLD backwards (or serial sevens).

o Recall three objects.

o Name pencil, watch.

o Repeat: “No ifs, ands or buts”.

o CLOSE YOUR EYES.o 3-stage command.

o Copy double pentagons.

o Write a sentence.

Glasgow Coma Scale:

The GCS is an objective neurological scale that records the level of consciousness of anadult patient.

Score is out of 15.o Remember, an inanimate object (e.g., a chair) would still score 3 on this scale!o

Score in the 3 to 8 range are seen in patients in comas. It is sometimes difficult for students to initially remember what each category is score outof. Here is a trick:

o Eye opening category – scored of 4 – think “4-eyes” (what kids call another kidwho wears glasses).

o Motor category – scored out of 6 – think “when someone moves fast, they arefiring on all 6 cylinders!”

o Verbal category – score out of 5 – by default since scale is out of 15 and you willnow remember the maximum score for the other two categories.

Category Response Score

Motor

Obeys commands for movement 6 pointsPurposeful movement to painful stimulus 5 points

Withdraws from pain 4 points

Abnormal (spastic) flexion, decorticate posture 3 points

Extension (rigid) response, decerebrateposture

2 points

None 1 point

Verbal

Oriented 5 points

Confused conversation 4 points

Inappropriate responses but discernible words 3 points

Incomprehensible speech or moaning 2 points

None 1 point

Eye Opening

Spontaneous 4 points

Opens to verbal command 3 points

Opens to pain 2 points

None 1 point



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Peripheral Neurological Exam


OBJECTIVES for PERIPHERAL NEUROLOGICAL EXAM

Motor exam. Inspect general appearance and posture. Bulk and Movement.

Proper draping. Inspect for abnormal muscle movements.

Tics. Tremors.

Postural. Resting. Intention. Physiological.

Fasciculations. Inspect for muscle bulk.

Atrophy. Hypertrophy.

Pronator drift test. Tone.

Palpate muscles. Move joints passively.

Spasticity. Rigidity. Hypotonia.

Assess for clonus.

Strength. Assess for muscle strength.

Individual muscles in upper limbs. Individual muscles in lower limbs.

Describe and apply the muscle strength grade scale. Reflexes.

Ensure optimal positioning. Test major deep tendon reflexes.

Biceps (C5-6). Triceps (C7-8).

Brachioradialis (C6). Patellar (L3-4). Ankle (S1).

Demonstrate reinforcement techniques. Assess for clonus. Describe and apply the deep tendon reflex grade scale. Describe and demonstrate the Babinski sign.


Test superficial reflexes.



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Abdominal (T6-L1). Cremasteric (L1-2). Anal (S1-3). (Seen in Well Man sub-unit.)

Sensory exam. Light touch. Pinprick. Temperature. Vibration. Proprioception. Special tests.

Two point discrimination. Graphesthesia. Stereognosis.

Coordination exam. Romberg test. Upper extremities.

Finger-to-nose test. Rapid alternating movements test.

Lower extremities. Heel-to-knee-to-shin test. Rapid alternating movements test. Finger-to-nose test.

Gait and balance. Inspect gait.

Normal. Heel-to-toe. Toe walking. Heel walking.

Inspect for balance. Compare upper motor neuron lesions and lower motor neuron lesions.

Muscle mass. Muscle strength. Muscle tone. Other motor findings. Deep tendon reflexes. Superficial reflexes. Babinski.

The peripheral neurological exam consists of three large categories:o Motor and reflexes.o Sensory.o Gait, balance, and coordination (cerebellar).



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Motor:

Start with a visual inspection of the patient’s general appearance and posture.o You are looking for any abnormal or unusual positioning of the arms and legs

(e.g., flexion or extension) and/or any abnormal facial features. See summary table at the end of this session for signs of upper vs. lower

motor neuron lesions that would be apparent on inspection.

Bulk and Movement

In order to do a proper inspection for muscle bulk and abnormal movements, it isimportant to drape the patient appropriately.

o You need to properly drape both sides simultaneously as inspection should be acomparison of one side to the other.

Look for abnormal muscle movements.o Tics.

These are sudden, involuntary, repetitive and usually jerky musclemovements.

Usually affect the same muscle group repeatedly.o Tremors.

Postural. A tremor that is only present when a specific posture is assumed.

For example when holding the forearms extended and at shoulderlevel.

Resting.

Present mostly during relaxation of muscles.

A common example of this type of tremor is the “pill-rolling” actionthat some patients with Parkinson’s disease display at rest.

Intention.

Present mostly during deliberate movements, and usually becomemore pronounced toward the end of the movement.

Physiological. Normal fine tremor that most of us experience when

we are anxious or nervous.

Can be accentuated by placing a piece of paperover the extended arm.

o Fasciculations. Random contractions or twitching in parts of a muscle at

rest. They can coarse or fine. You need very good lighting to assess this properly. It actually takes a few minutes to inspect for it well.

Look for muscle bulk.o Compare side to side.

You may want to consider measuring the difference with a measuring tape.

Make sure to pick a steady reference point that will allow forreproducibility of measurements over time and will ensure that bothlimbs are measured at the same level.

o Look for atrophy.o Look for hypertrophy.



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E.g., professional tennis players tend to have their dominant arm muscleslarger than the other arm. This is not an atrophy of the muscles of thesmaller arm, but rather a hypertrophy of the overactive arm.

Perform the pronator drift testo Have the patient sit or stand with their arms

stretched out in front of them, palms facingupwards, and their eyes closed.

o Normally, the patient can hold this position withoutany problems.

o If one of the hands starts to turn the palm inwards(pronate), suspect an upper motor neuron lesion.

o If one of the arms starts to drift upwards, suspectcerebellar disease.

Tone

Palpate the muscles for consistency.o Have the patient grip your index and middle fingers as hard as possible, hold for a

few seconds and then tell them to let go. Myotonia is the inability to relax the muscles after a voluntary contraction. Myotonia can also be elicited by percussing a muscle (for example the

thenar eminence) directly.

Passively move joints to assess for tone.o Spasticity.

Rate-dependent resistance of range of motion. Also called the “clasp-knife” phenomena. Suggests an upper motor neuron lesion.

o Rigidity.

The detection of increased tone is not rate dependent. Rigidity is throughout the movement. Also called “lead pipe”.

o Hypotonia. Decreased resistance during passive range of motion, and muscles are

soft and limp on palpation.

Assess for clonus.o Support and partially flex the knee and briskly dorsiflex the foot with your other

hand, then maintain the foot flexed.

o Normally, no rhythmic oscillating movements should be detected while doing this.o If you can feel the foot rhythmically “tapping” in your hand, the test would be

positive for clonus.

Strength

An easy screening test for lower limb muscle weakness is to ask the patient to squat andthen stand up.

o Older patients in particular might have trouble doing this, in which case you canget them to sit on a low chair and ask them to stand without using their arms topush themselves up.



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Perform movements against resistance to assess for strength.o Muscle strength is graded on a 0 to 5 scale (Medical Council Research scale).

0 – no contraction. 1 – minimal contractions of the muscle. 2 – unable to overcome gravity, but movement in the plane is possible. 3 – movement against gravity, but not against resistance. 4 – partial strength against resistance (can use 4-, 4 and 4+ to indicate

mild, moderate and strong resistance, respectively).

5 – full strength against resistance.o Again, look for differences between sides.

Listed below are the different muscles to be tested.o The muscles, nerves and nerve roots are noted simply for your reference.

If you are looking at the tables and feeling discouraged, thinking “I’ll never remember allof this”, cheer up and go to this website: http://neuroexam.med.utoronto.ca/motor_4.htm

o In this video, you can see how the screening for muscle strength is performed –this is what you are expected to be able to perform.

o Start proximally and move distally.o When doing a screening examination both sides may be done at once. If focal

weakness is suspected then do one side at a time.

Upper extremities

Action Muscle(s) Nerve(s) Nerve Roots

Arm abduction Deltoid Axillary C5, C6

Elbow flexion Biceps Musculocutaneous C5, C6

Elbow extension Triceps Radial C6, C7, C8

Extension at the wrist Forearm extensors Radial C6, C7, C8

Flexion of the wrist Forearm flexors Median and ulnar C6, C7, C8, T1

Wrist abduction Flexor carpi radialis Median C6, C7

Finger flexionFlexor digitorum

superficialis and flexordigitorum profundus

Median, anteriorinterosseous (FDP I&II),

ulnar (FDP III&IV)C7, C8, T1

Abduction of index finger First dorsal interosseous Ulnar C8, T1

Abduction of little finger Abductor digiti minimi Ulnar C8, T1

Thumb abduction(perpendicular to plane of

palm) Abductor pollicis brevis Median C8, T1

Thumb adduction Adductor pollicis Ulnar C8, T1

Thumb extension Extensor pollicis longusPosterior interosseous

(radial)C7, C8



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Lower extremities

Action Muscle Nerve Nerve Roots

Hip flexion Illiopsoas Femoral L1, L2, L3

Hip extension Gluteus maximus Interior gluteal L5, S1, S2

Hip abduction Gluteus medius, gluteusminimus, tensor fasciaelatae

Superior gluteal L4, L5, S1

Hip adduction Adductors Obturator L2, L3, L4

Knee extension Quadriceps femoris Femoral L2, L3, L4

Knee flexion Hamstrings Sciatic L5, S1, S2

Ankle dorsiflexion Tibialis anterior Deep peroneal L5, S1

Ankle plantar flexion Gastrocnemius andsoleus

Tibial S1, S2

Toe extension Extensor digitorumlongus

Deep peroneal L5, S1

Toe flexion Flexor digitorum longus,flexor hallucis longus

Tibial L5, S1, S2

Foot eversion Peroneus longus and

brevis

Superficial peroneal L5, S1

Foot inversion Tibialis posterior Tibial L4, L5

Reflexes

Position yourself in such a way that you will not need to walk from side to side in order tocheck reflexes.

o Compare side to side. Do not do one side entirely before doing the other side.

Also, position yourself in such a way that you can palpate the tendon being tested.o You also want to be able to visualize the muscle connected to the tendon. In

order to elicit a reflex, you simply need to be able to see a muscle contraction. Itis not necessary for the limb to “jump”.

o

Position the limbs with slight tension on the tendon to be tapped, making sure topalpate the tendon to locate it for stimulation.

Test major deep tendon reflexes.o Biceps (C5-6).o Triceps (C7-8).o Brachioradialis (C6 mainly).o Patellar (L3-4).o Ankle (S1).

Note the grade of reflex.o

Deep tendon reflexes are graded on a scale of 0 to 4+. 0 – absent. 1+ – hypoactive. 2+ – normal. 3+ – hyperactive. 4+ – hyperactive with clonus.

o If a reflex is not present, a reinforcement technique should be used. You may want to ask the patient to contract an alternate group of muscles

(for example clench your jaw, make a fist, etc.) when you say “now”.o If reflexes are hyperactive (3+), test the ankle for clonus.



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Support and partially flex the knee and briskly dorsiflex the foot with yourother hand, then maintain the foot flexed.

Normally, no rhythmic oscillating movements should be detected whiledoing this.

If you can feel the foot rhythmically “tapping” in your hand, the test wouldbe positive for clonus.

o Absent reflexes may indicate lower motor neuron disorder.o Hyperactive reflexes suggest an upper motor neuron disorder.

Test the Babinski response.o Be sure to explain how the test will be performed to the patient before attempting

it. This is an unpleasant test for most people, and even more so in someone whohas ticklish feet.

o Using a disposable sharp object (e.g., tongue depressor broken in half or thepointy end of your reflex hammer), stroke the lateral aspect of the foot and thencome across the ball of the foot (just below the toes).

o Normally, a person’s big toe will curl downwards at the MTP joint or will not moveat all.

o An abnormal response can occur if the big toe flexes upwards and the other toesfan out. However, it should be noted that a small percentage of the population that

do not have any upper motor neuron lesions have up-going toes bilaterallyas a normal response to this test.

However, an up-going toe is expected in children under the age of two. Otherwise, an up-going toe might be an indication of an upper motor

neuron lesion.

Test superficial reflexes.o Abdominal (epigastric T6-9, mid-abdomen T9-11, lower abdomen T11-L1).

Gently stroke the abdomen with the dull end of a tongue depressor or yourfinger in all four quadrants toward the umbilicus. Observe for contractions.

Normally, a contraction is observed.

Note that patients who have had abdominal surgeries that have cutacross some of these nerves may have an absent reflex.

Also, up to 20% of patients without any type of lesion do not havethis reflex.

This reflex also disappears during coma, deep sleep, andanesthesia.

This reflex can be difficult to obtain in obese patients.o Cremasteric (L1-2).

Only performed in male patients. Stroke downward the inside of the thigh.



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Normally, the cremasteric muscle will pull up the scrotum and testis on theside being tested.

In patients who are older, have had a hydrocele/varocele/ orchitis,the reflex may no longer be present.

Test both sides.o Anal (S2, 3, 4).

As seen in the Well Man sub-unit.Sensory:

Dr. Keith Brownell has a neat trick to share: assess the dermatomes in a circularmanner.

o Pick a level on the leg/arm and go around it testing for light touch, pinprick and/ortemperature. Then go up a little up, and test all around that level.

o This way, you will know for sure that all the dermatomes have been tested.o You can also mark out where there is loss of sensation and then look up in a book

which dermatome is most likely affected.

Light Touch

Test sensation in thedistribution of dermatomes.

o Compare to theopposite side.

o If a difference isnoted, move up thedermatome.

Pinprick

Test sensation in thedistribution of dermatomes.

o Compare to theopposite side.

o If a difference isnoted, move up thedermatome.

Remember that thissensation can bedecreased/lost/altered aswe age.



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Temperature

Test sensation in the distribution of dermatomes.o Compare to the opposite side.o If a difference is noted, move up the dermatome.

Vibration

Test sensation over the joints.o Make sure that the patient can feel the vibration over their

sternum before testing any other joints.o Use a 128 Hz tuning fork.o Compare to the opposite side.o Start distally and move proximally if sensation is altered.

E.g., start at the toes, move up to ankle, then toknee, then to hip.

Proprioception

Test joint position sensation.o Grasp from the sides either the phalanx that is distal to a DIP (on hands or feet).

While the patient has their eyes open, demonstrate movements “up”, “down” and“neutral”. Then ask the patient to close their eyes. Randomly move the phalanx

up, down, and into neutral position, asking the patient to tell you which way the joint was moved after each movement.

It is important to grasp the phalanx from the sides. If you hold the phalanxfrom the top and bottom, you will inadvertently provide the patient someclues as to which way you are moving their finger.

o Compare to the opposite side.o Start distally.

No need to move proximally if the patient can feel it distally.o In older patients, this sensation is often decreased/altered, so you may have to

move the joint a little more vigorously in order for them to feel it.

Special Tests The following test discriminative (cortical) sensations:

o Two point discrimination. Ask the patient to close their eyes. Touch the patient

with a reshaped paperclip (or two sharp pieces of atongue depressor) with either one or two points. Askthe patient to report how many points they can feeltouching them.

Note the smallest distance at which the patient candistinguish two separate points and not just one.

Compare from side to side.

The following distances are considered normal: Lips and finger pads: 2-4 mm.

Palms of hands: 8-15 mm.

Shins or back: 30-40 mm.



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o Graphesthesia. Ask the patient to close their eyes. With a capped pen or

your finger, write a number in the palm of the hand or thetop of the foot. Ask the patient to tell you which number you

just wrote. You need to make sure that the patient knows when you

are writing a new number.

This can be done by gently “wiping” the surface you

just wrote on or by verbally letting the patient knowthat you will be writing a new number.Stereognosis.

As the patient to close their eyes. Put a commonobject in their hand (e.g., a penny, a comb, andsafety pin, etc). Ask the patient to tell you (withoutlooking!) what object they are holding.

Cerebellar (Coordination):

Perform the Romberg test.o Ask the patient to stand with their feet

together with their eyes open. Observethe balance. FYI: the feet do not have to be

touching, but they do need to befairly close.

o Once the patient is stable, ask them toclose their eyes. Observe the balance.

o Normally, a patient should be able tostand with minimal swaying for up to aminute.

o A patient that looks like they are aboutto fall would be considered to have apositive Romberg test. Make sure when performing this

test that you stand behind orbeside the patient, and beprepared to catch time duringthe entire time that their eyesare closed.

A positive Romberg is often anindication of loss ofproprioception.

Upper extremities

Perform finger-to-nose test.o Ask the patient to touch the tip of thier

own nose with their index finger, andthen your index finger which you holdin front of them and back to their nose.Continue this movement until you askthem to stop.



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When the patient touches your index finger with their index finger, their armshould be fully outstretched.

After a few movements back and forth, you can move your index finger to adifferent location while the patient is moving their arm back towards theirnose. By the time they start reaching out towards your finger, your fingershould no longer be moving.

Test both sides.o As the patient is performing this test, assess for:

Intention tremor. Overshooting (patient’s finger goes past your finger).

Perform rapid alternating movements test.o Ask the patient to pronate and supinate their hand

back and forth in the palm (or on the dorsum) oftheir other hand. This should be done as rapidly as the

patient can manage. Remember to check the other side.

o Disease would be suspected in a patient whose movements are slow and clumsy.

Lower extremities

Perform heel-to-shin test.o Ask the patient to draw a straight line from their ankle to

their knee on their shin using the opposite leg’s heel. Askthem to keep going up and down as accurately as theycan.

o Test both sides.o Normally, a patient can perform this test fairly quickly and

accurately.o A patient whose heel cannot go up and down in a straight

line (wobbles, oscillates from side to side, overshoots) islikely to have a cerebellar problem. This test is usually performed with eyes open. Closing the eyes would not

affect a cerebellar lesion. It might, however, help identify a posteriorcolumn loss.

Perform rapid alternating movements test.o Ask the patient to tap the sole of their foot in your hand as quickly as they can.

Alternatively, you can ask the patient to tap the heel of their foot on theopposite shin as quickly as they can.

Test both sides.

o Disease would be suspected in a patientwhose movements are not rhythmical.

Perform a finger-to-toe test.o With the patient supine, ask them to touch

your index finger with their big toe. The knee should remain bent. This test is rarely performed.

o Look for an intention tremor.



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Gait and Balance:

Observe the patient’s normal gait.o Part of this test includes asking them to turn around quickly.o Look at and comment on posture, balance, swinging of arms, movement of the

legs, smoothness and steadiness of turns.o Types of gait:


Trendelenburg (lurch) gait: when walking, the entire trunk leansexcessively over the hip that is firmly planted on the ground (i.e. the centreof gravity is kept over the stance leg) while the other side of the body, legand upper body, swing forward. This gives the appearance of the patient“lurching” one side of their body to move forward.

Ataxic: an unsteady, uncoordinated walk, employing a wide base and thefeet thrown out. Is often due to cerebellar disease, loss of position sense,or intoxication.

Observe heel-to-toe gait.o This can help you exclude a midline cerebellar lesion.

Observe the patient walking on their toes.o This can help you exclude an S1 lesion.

Observe the patient walking on their heels.o This can help you exclude an L4 or L5 lesion which causes footdrop.

Observe the patient’s balance during all of the above tests.o If there are concerns and it has not yet been done, make sure to test cranial nerve

VIII (vestibulo-auditory).

Comparison of Upper and Lower Motor Neuron Lesions



146

Upper Motor Neuron Lesion Lower Motor Neuron Lesion

Muscle mass Slight loss Decreased/atrophy

Muscle strength Decreased Decreased

Muscle tone Increased (spastic) Decreased (flaccid)

Other motor findingsSuperficial reflexes absent

FasciculationsClonus

Fibrillations*

Deep tendon reflexes Increased Decreased

Superficial reflexesDecreased (abdominal,

cremasteric, anal)Unaffected

Babinski Toe up (positive) Toe down

Coordination Impaired Unimpaired

* Fibrillations are extremely small, irregular contractions of individual muscle fibres thatcannot be seen with the naked eye.

Some Thoughts on the Neurological Exam in Clinical Setting

At this stage of your training, we have broken down the neurological exam into differentsmaller sections, both to help you learn it and to present it in a way similar to which youmight expect to be tested on it for years to come.

However, in reality, there are several things that are done differently in a clinicallysetting.

o An idea of the gait is usually obtained from watching the patient walk down thehallway or around the room.

o The level of consciousness and orientation, nerve palsy, speech impairment,abnormal movements, etc. are often assessed by watching the patient and takinga bit of a history.

o The order in which maneuvers are performed are not always in the exact orderthat they are presented in this document (e.g., cranial nerves are not alwaystested in a I to XII order).

At this point in your training, it is important to learn the different elements, not to be“Speedy Gonzales” when doing your neuro exam.o The order in which the different elements are presented in this Core Document

attempts to demystify the often silent assessment of the patient that is made byexperienced physicians as they enter the room or talk to the patient, and toprovide a structure to your learning.

o As you get to observe physicians doing neurological assessment on patients, takenote of the order in which they do things. You might be able to shave a fewminutes off your neurological assessment during clerkship by simply rearrangingthings a little.



147

References

General Inspection, Vital Signs and Draping

http://forums.studentdoctor.net/showthread.php?p=11182059

http://jxzy.smu.edu.cn/jkpg/UploadFiles/file/TF_06928151856_chapter8%20generalsurvey.pdf

http://doctorsgates.blogspot.com/2010/12/shapes-of-arterial-pressure-waves.html

http://www.bmj.com/content/322/7292/981.full

http://www.health.harvard.edu/newsletters/Harvard_Womens_Health_Watch/2009/August/Experts-call-for-home-blood-pressure-monitoring

http://www.buzzle.com/articles/ear-thermometer-accuracy.html

http://www.123rf.com/photo_4809748_teenage-girl-with-a-thermometer-in-her-mouth.html

http://projectstatistics-4m2f.blogspot.com/

http://www.enema-information.com/rectal-temperature.html

http://www.coolest-gadgets.com/20051115/talking-forehead-thermometer/

http://fcnjwlrf.livejournal.com/817.html

Lymph Nodes Exam

http://anatomyuniverse.com/HeadNeckLymphatics.html

http://www.6abib.com/almalak/malak-100.htm

http://ovariancancerinfo.wordpress.com/2008/11/16/lymph-nodes-female/

http://www.clinicalexam.com/pda/h_ref_lymph_nodes.htm

General Abdominal Exam

http://www.operationalmedicine.org/TextbookFiles/FMST_20008/FMST_1408.htm

http://www.cpmc.org/learning/documents/rg-abdom-prepare.html

http://www.nlm.nih.gov/medlineplus/ency/imagepages/19264.htm

http://www.clinicalexam.com/pda/a_ref_abdominal_scars.htm

http://drkupe.blogspot.com/2011/02/acute-pancreatitis.html

http://en.wikipedia.org/wiki/Grey_Turner%27s_sign

http://www.wsiat.on.ca/english/mlo/hernias.htm

http://doctorsgates.blogspot.com/2010/09/rectus-diastasis.html

http://www.wrongdiagnosis.com/c/closed_angle_glaucoma/book-diseases-5b.htm

http://findarticles.com/p/articles/mi_qa3689/is_200006/ai_n8885636/

http://wonghongweng.blogspot.com/2008/03/gallstones.html

http://www.jultrasoundmed.org/content/26/1/37/F2.expansion.html http://www.medicallecturenotes.com/2010/09/acute-abdomen-part-01.html

http://doctorsgates.blogspot.com/2010/09/rectus-diastasis.html

http://www.darmen.net/appendicitis.html

http://drfelipecastro.blogspot.com/2009/01/blog-post.html

“The Family Guy” screen shot, Fox Broadcasting Company.

Liver and Spleen Exams

http://studydroid.com/printerFriendlyViewPack.php?packId=67542

http://handfacts.wordpress.com/2009/10/06/nail-clubbing-may-signal-lung-heart-stomach-diseases/

http://dermnetnz.org/site-age-specific/ageing.html

http://drugster.info/ail/pathography/2373/

http://www.coolhealthguides.com/petechiae-its-definition-causes-symptoms-and-treatment.html

http://www.nejm.org/multimedia/images-in-clinical-medicine?topic=8&description=images-in-clinical-medicine&searchType=figure&page=4

http://andyourlittledog.com/20110802-super-frizz-fighters-saveyou-from-a-bad-hair-day/?utm_source=rss&utm_medium=rss&utm_campaign=super-frizz-fighters-saveyou-from-a-bad-hair-day

http://usmlestep1challenges.blogspot.com/2009/07/question-6.html

http://www.graphicshunt.com/health/search/1/palmar+erythema.htm

http://littleastonoasis.com/Handexamination.aspx

http://littleastonoasis.com/Handexamination.aspx

http://www.path.utah.edu/casepath/pm%20cases/pmcase4/PMCase4Part3.htm

http://www.beautiful-healthy-fingernails.com/white-spots-on-fingernails.html

http://www.assh.org/Public/HandConditions/Pages/SystemicDiseases.aspx



148

http://surgicalnotes.co.uk/content/caput-medusae

http://hepatitiscnewdrugs.blogspot.com/2010/11/cirrhosis-what-happens-when-spleen-is.html

Hand and Wrist Exams

http://orthoinfo.aaos.org/topic.cfm?topic=a00007

http://www.information-leaflets.stft.nhs.uk/stft-leaflets/leafletpotfolder/public_leaflet_pot/3024.htm

http://meded.ucsd.edu/clinicalmed/joints3.htm

http://skillbuilders.patientsites.com/article.php?aid=293

http://www.emedicinehealth.com/types_of_psoriasis/page7_em.htm

http://hardinmd.lib.uiowa.edu/dermnet/nails3.html http://www.skinsight.com/adult/onycholysis.htm

http://www.mycology.adelaide.edu.au/virtual/2009/ID2-May09.html

http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-0-7234-3541-9..00034-1--s0045&isbn=978-0-7234-3541-9&type=bookPage&from=content&uniqId=272719443-20

http://www.physiographic.com/e_products/graphical_report2.htm

http://www.thesafetybox.org/brunelintro/fistpositions.htm

http://healthmad.com/conditions-and-diseases/joint-deformities-of-the-fingers-and-toes/

http://maroonedmd.blogspot.com/2009/03/anatomical-snuff-box.html

http://www.care2.com/causes/orphaned-grizzly-bears-rescued.html

http://www.spineandsportssolutions.com/page3/page62/page62.html

http://www.tractiphy.com/assessment-of-patients-with-cervical-pain-iv-other-causes-of-neck-pain.html

http://awindiaries.blogspot.com/2011/04/median-nerve-gliding-exercise.html

http://www.sistemanervoso.com/pagina.php?secao=7&materia_id=502&materiaver=1

Cervical Spine and Shoulder Exams

http://www.exrx.net/Muscles/Sternocleidomastoid.html

http://www.fotosearch.com/illustration/rotator-cuff.html

http://www.aafp.org/afp/20000515/3079.html

http://www.physioworks.com.au/injuries-conditions-1/shoulder-subacromial-bursitis

http://yorkievitz.net/RAT/classsite/anatomy/shoulder/index.htm

http://www.healthclick.com/Media/Algorithm.cfm

http://www.massagetherapyreference.com/special-tests/shoulder-orthopedic-tests/#parct

http://www.massagetherapy.com/articles/index.php/article_id/748/Shoulder-Series-2%3A-Supraspinatus-Tendinitis

http://www.blogsperu.com/blog/8882/

http://www.smrehab.cn/a/guanjiekangfu/jianguanjie/20100412/51.html

Ankle, Foot and Thoracolumbar Spine Exams

http://www.reflessologia.it/libro_eng_chapter1b.htm

http://www.graphicshunt.com/health/images/hallux_valgus-1317.htm

http://www.peakorthopedics.com/content/claw-toes-and-hammertoes

http://solecontrolorthotics.com/footdisorders.aspx

http://foreverfitptw.com/Injuries-Conditions/Ankle/Ankle-Anatomy/a~47/article.html

http://www.supercoach.de/thompson.htm

http://www.chiroweb.com/mpacms/dc_ca/article.php?id=42096

http://www.hawaii.edu/medicine/pediatrics/pemxray/v3c03.html

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/

http://destroychronicpain.wordpress.com/problems-we-help-people-with/piriformis-syndrome-pain-in-the-butt/

http://www.accessmedicine.ca/search/searchAMResultImg.aspx?searchStr=leg+bones&rootTerm=straight+leg+raise+test+procedure&searchType=1&rootID=56597

Hip and Knee Exams

http://www.costume-party.co.uk/marilyn-munroe-costume-1644-p.asp

http://www.aafp.org/afp/2003/0801/p461.html

http://www.utswanesthesia.com/regional/?page_id=91

http://www.sports-injury-info.com/trochanteric-bursitis.html

http://www.tosm.net/bakers_cyst.html

http://boneandspine.com/orthopaedic-images/clinical-photograph-of-knee-effusion/

http://www.shoulderkneecenter.com/knee_acl_tear.htm



149

http://www.theosteocareclinic.com/knees/

http://spinalphysio.kornberg.net/osgood.html

http://www.sonicmend.com/info_bursitis.php

http://crashingpatient.com/trauma/050-knee.htm

http://unlocked-cell.com/thessaly/

http://www.gvle.de/kompendium/knie/0101/0020.html

http://www.argonneclub.anl.gov/ARC/PageKnee.htm

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http://www.hkma.org/english/cme/onlinecme/cme201005set.htm

Bates’ Guide to Physical Examination and History Taking, by Lynn S. Bickley, 7th edition, pages 498-499.

Jugular Venous Pulse Exam

http://www.n3wt.nildram.co.uk/exam/cardio/

http://ak47boyz90.wordpress.com/2009/09/10/l2-central-venous-pressure-cvp-jugular-venous-pulse-jvp/

http://www.ncbi.nlm.nih.gov/books/NBK300/

http://www.clinicalexam.com/pda/c_ref_jvp.htm

Respiratory Exam

http://faculty.etsu.edu/arnall/www/public_html/heartlung/breathsounds/contents.html

http://baldwin-emt.org/moodle/mod/glossary/view.php?g=7

http://www.after50health.com/abnormal-findings-of-the-chest-wall-and-breast.html\

http://doctorumit.com/kifozeng.html

http://www.easternsunacupuncture.com/boston-acupuncture-breathing-instruction-stress http://soyte.angiang.gov.vn/wps/portal/!ut/p/c4/04_SB8K8xLLM9MSSzPy8xBz9CP0os3j3oBBLczdTEwML

dwsDA09_LxcjF38fAwNfU_2CbEdFAMTd4DQ!/?WCM_GLOBAL_CONTEXT=/wps/wcm/connect/soyte/soyte/thongtinhoatdong/caulacbotienganh/topic+online+19

http://www.ccjm.org/content/75/4/297.full

http://www.oocities.org/ultradian/rtassess/respassess.htm

http://207.5.42.159/sweethaven/MedTech/RespDisease/lessonMain.asp?mode=1&iNum=0202

http://www.rnceus.com

http://sprojects.mmi.mcgill.ca/mvs/RESP01.HTM

http://davisplus.fadavis.com/tabers21/Animations/animations.cfm?exercise=Adventitious_Breath_Sounds&title=Adventitious%20Breath%20Sounds

http://www.patient.co.uk/doctor/Chest-Deformity.htm

http://www.shahrukh.co.uk/resp/examination2.html

Clinical Examination: A Systematic Guide to Physical Diagnosis, by Nicholas J. Talley and SimonO’Connor, 6th edition, p. 123.

Precordial Exam

http://www.med.umich.edu/lrc/psb/heartsounds/index.htm

http://depts.washington.edu/physdx/heart/demo.html

http://www.cardiologysite.com/auscultation/html/

http://www.prohealthsys.com/physical/heart_exam.php

http://osler.ucalgary.ca/ume/UT/ASCM1/Physical_Examination/ascm1/Precordial/teaching_points.htm

Peripheral Vascular Exam

http://www.dermatlas.net/atlas/imageinfo.cfm?image=238 https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=tp12624&

http://www.medicinenet.com/edema/article.htm#pitting

http://www.sciencephoto.com/media/265470/enlarge

http://www.gndmoh.com/vb/showthread.php?t=1823

http://www.austincc.edu/nursmods/online/online_lev1/Mod1Part2.php

http://lcstudentwiki.wikispaces.com/Bryce+Page+2

http://fitsweb.uchc.edu/student/selectives/TimurGraham/Modified_Allen%27s_Test.html

http://en.wikipedia.org/wiki/Great_saphenous_vein

Cranial Nerves Exam

http://tattooone.kilu.info/

http://www.drjakesloane.co.uk/Bruxism.html



http://articlesofnursing.blogspot.com/2011/06/reflex-tests-jaw-jerk.html

http://www.technomedic.ca/products/Aluminium_Alloy_Tuning_Fork_.shtml

http://www.themcfox.com/health/trigeminal-neuralgia/trigeminal-neuralgia.htm

Bates’ Guide to Physical Examination and History Taking, by Lynn S. Bickley, 7th edition, p. 170.

http://www.matossianeye.com/site/blog/detail/2011/06/16/the-swinging-flashlight-test.html

http://www.themcfox.com/health/trigeminal-neuralgia/trigeminal-neuralgia.htm

http://www.ncbi.nlm.nih.gov/books/NBK373/

http://www.technomedic.ca/products/Aluminium_Alloy_Tuning_Fork_.shtml

http://www.utoronto.ca/neuronotes/NeuroExam/cranial_5b.htm

http://www.med.yale.edu/caim/cnerves/cn4/cn4_6.html http://imueos.wordpress.com/2010/11/07/upper-motor-neuron-lower-motor-neuron-lesions/

http://www.bmj.com/content/329/7465/553.long

MMSE

Malloy DW, Alemayehu E, Roberts R. A Standardized Mini-Mental State Examination (MMSE). Amer. J. ofPsychiatry, 1991; 148:102-105.

http://www.med.mcgill.ca/geriatrics/education/clerkship/Senior_Clerkship/Syllabus/13_AppendixC.4.htm

Peripheral Neurological Exam

http://library.med.utah.edu/neurologicexam/html/motor_anatomy.html

http://wn.com/Motor_System_Examinations

http://www.utoronto.ca/neuronotes/NeuroExam/motor_4.htm

http://www.utoronto.ca/neuronotes/NeuroExam/motor_6.htm http://www.maturespine.com/symptoms/weakness.html

http://medchrome.com/basic-science/anatomy/lesions-of-upper-motor-neurons-and-lower-motor-neurons/

http://emj.bmj.com/content/21/2/216.extract

http://www.wrongdiagnosis.com/f/frolichs_syndrome/book-diseases-5a.htm

http://ytizle.com/Vibratory%20sensation/

http://www.pattersonmedical.ca/app.aspx?cmd=get_product&id=79838

http://www.familypracticenews.com/index.php?id=2934&type=98&tx_ttnews[tt_news]=43976&cHash=da03e20e36

http://cloud.med.nyu.edu/modules/pub/neurosurgery/sensory.html

htt //littl b i k bl t /2010/01/t ill t ti ht l

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Medical Skills Physical Exam