Physical Examination Checklist POM 2 General 1) Wash hands before beginning examinationin the CLASS center, you MUST

use the hand i!es that are "ocated in or near the sin#s $remember that they are not !"umbed) %) &is!"ay a !rofessiona" demeanor to ards the !atient during the exam a) 'ntroduce yourse"f as a medica" student b) Use the !atient(s "ast name c) &ress !rofessiona""y in hite coat )) A!!ro!riate interaction ith the !atientsensiti*ity to !ri*acy, comfort and dignity +) &ra!e the !atient a!!ro!riate"y during each segment of the exam ,) Use !ro!er se-uencing of the examination and !ro!er !acing .) A"" !a"!ation and auscu"tation must be done on bare s#in Vital Signs 1) Ta#e the /0 in one arm $12T3 T4AT 52U 133& 12T TA63 T43 /0 '1 /2T4 A7MS U1L3SS S03C'8'CALL5 '1ST7UCT3& T2 &2 S2) a) Choose a cuff of a!!ro!riate si9e for the !atient b) Center the b"adder of the cuff o*er the brachia" artery i) 'dentify "ocation of the brachia" artery by !a"!ation ii) Lo er border of the cuff shou"d be about %:, cm abo*e the antecubita" crease iii) Secure the cuff snug"y c) 0osition the !atient(s arm so that it is s"ight"y f"exed at the e"bo and at raised to heart "e*e" d) 3stimate the systo"ic !ressure by !a"!ation of the radia" artery $/ates, !! ;.) i) Wait 1, seconds after def"ating the cuff before auscu"tating the /0 e) Ta#e the /0, using auscu"tation i) Listen ith the stethosco!e o*er the brachia" artery ii) 'nf"ate cuff ra!id"y to at "east 1,< mm 4g iii) &ef"ate at rate of %=) mm 4g !er second i*) 1ote systo"ic and diasto"ic !ressures %) Ta#e the radia" !u"se for 1, secs if the rhythm is regu"ar $.< secs if rate is s"o or fast) a) Use the !ads of index and midd"e fingers b) Com!ress the radia" artery unti" a maxima" !u"sation is detected )) Count the res!iratory rate for 1 minute a) Watch mo*ement of the chest a"" Head 1) 'ns!ect the s#u"", sca"!, hair, by !arting the hair in at "east three !"aces %) 'ns!ect the face Ears 1) 'ns!ect the externa" earauric"e or !inna %) 0a"!ate the tragus for tenderness )) Use the otosco!e to ins!ect the interna" auditory cana" and the eardrum and midd"e ear a) Se"ect the "argest a*ai"ab"e s!ecu"um for the otosco!e b) 0osition the !atient(s head to a""o best insertion of the otosco!e c) 0u"" the auric"e gent"y u! ards and bac# ards to straighten the cana" d) 4o"d the otosco!e bet een thumb and fingers $see /ates, ! 1,.) e) 'nsert the s!ecu"um gent"y into the ear cana" i) 'dentify the eardrum ii) 'dentify the cone of "ight iii) 'dentify the ma""eus

+) Assess hearing a) As# the !atient to occ"ude one ear ith a finger and then the examiner his!ers soft"y from 1 to % feet a ay to ard the unocc"uded ear i) Choose short ords $see /ates ! 1,;) b) Chec# air and bone conduction i) Weber test $1) !"ace the base of the "ight"y *ibrating tuning for# firm"y on to! of the !atient(s head $%) As# here the !atient hears it ii) 7inne test $1) 0"ace the base of the "ight"y *ibrating tuning for# on the mastoid bone $%) When the !atient can no "onger hear the sound, -uic#"y !"ace the for# c"ose to the ear cana" and as# hether sound can sti"" be heard Eyes 1) Chec# for *isua" acuity using a Sne""en eye card or eye chart in the exam room %) Assess *isua" fie"ds $/ates, ! 1+,=1+.) a) As# the !atient to "oo# ith both eyes into your eyes b) Whi"e you return the !atient(s ga9e, !"ace your hands about % feet a!art, "atera" to the !atient(s ears: c) 'nstruct the !atient to !oint to your fingers as soon as they are seen d) Then s"o "y mo*e the igg"ing fingers of both your hands a"ong the imaginary bo " and to ards the "ine of ga9e unti" the !atient identifies them e) 7e!eat this !attern in the u!!er and "o er tem!ora" -uadrants )) 'ns!ect externa" eye a) Stand in front of the !atient and sur*ey the eyes for !osition and a"ignment ith each other b) 'ns!ect the eyebro s-uantity and distribution c) 'ns!ect the eye"ids d) 'ns!ect the region of the "acrima" g"ands e) 'ns!ect the con>uncti*a and sc"era i) As# the !atient to "oo# u! as you de!ress both "o er "ids ith your thumbs $/ates ! 1+;), ex!osing sc"era and con>uncti*a f) 'ns!ect the cornea and "ens, using a !en"ight shined ob"i-ue across the eye g) 'ns!ect each iris h) 'ns!ect the !u!i"s for si9e, sha!e and symmetry +) Assess !u!i""ary ref"exes a) To "ightas# the !atient to "oo# into the distance and shine a bright "ight ob"i-ue"y into each !u!i" in turn $turn off the room "ight if necessary) i) 1ote direct reaction!u!i""ary constriction in the same eye ii) 1ote indirect reaction!u!i""ary constriction in the o!!osite eye b) Assess accomodation ? as# the !atient to "oo# a"ternate"y at a !enci" he"d 1< cm from his eye and into the distance direct"y behind it: 2bser*e for !u!i""ary constriction ith near effort ,) Assess 3xtraocu"ar mo*ements a) 8rom % feet in front of the !atient, shine a "ight into the !atient(s eyes and as# the !atient to "oo# at it: 'ns!ect the ref"ections in the corneas, hich shou"d be *isib"e s"ight"y nasa" to the center of the !u!i"s b) As# the !atient to fo""o your finger or !enci" as you s ee! through the six cardina" directions of ga9e i) To the !atient(s extreme right ii) To the right and u! ard iii) To the right and do n ards i*) Without !ausing in the midd"e to the extreme "eft *) To the "eft and u! ards *i) To the "eft and do n ards .) 2!htha"mosco!ic exam $See @Ste!s for using the o!htha"mosco!eA and @Ste!s for examining the o!tic disc and the retinaA in /ates !! 1,% and 1,)

Nose 1) 'ns!ect the anterior and inferior surfaces of the nose a) 0ush gent"y on the ti! of the nose to iden the nostri"s b) Use a !en"ight to *ie the nasa" *estibu"e %) 'ns!ect the inside of the nose using an otosco!e ith the "argest a*ai"ab"e s!ecu"um a) Ti"t the !atient(s head bac# s"ight"y and insert the s!ecu"um $/ates ! 1,B) b) 'ns!ect the inf and mid turbinates and nasa" se!tum )) 0a"!ate the fronta" and maxi""ary sinuses for tenderness $/ates ! 1.< Mouth and Pharynx 1) 'ns!ect the "i!s %) 'ns!ect the ora" mucosa using a good "ight and a tongue b"ade )) 'ns!ect the gums and teeth +) 'ns!ect the hard !a"ate ,) 'ns!ect the tongue and f"oor of the mouth a) As# the !atient to !ut out his tongue b) As# the !atient to !ut his tongue on the roof of his mouth .) 'ns!ect the !harynx a) Tongue in norma" !osition, as# the !atient to say @ahCA but if !harynx not e"" *isua"i9ed use a tongue b"ade b) 'ns!ect the soft !a"ate, tonsi"s and !harynx Neck 1) Assess nec# 72M $/ates ! ,<+) by as#ing the !atient to !erform the fo""o ing maneu*ersD a) 8"exionD touch the chin to the chest b) 3xtensionD "oo# u! at the cei"ing c) 7otationD turn the head to each side, "oo#ing direct"y o*er the shou"der d) Latera" bendingD ti"t the head, touching each ear to the corres!onding shou"der %) 0a"!ate the "ym!h nodes $See /ates ! 1.)=1.+ for s!ecific techni-ue) )) 'ns!ect trachea and fee" for any de*iation by !"acing a finger a"ong one side of the trachea, noting the s!ace, and com!are ith the o!!osite side: +) 'ns!ect the thyroid g"and a) Ti! the !atient(s head bac# b) Locate the cricoid carti"age and ins!ect the region be"o for the thyroid ,) 0a"!ate the thyroid g"and $See /ates ! 1.;) ? may be done either from an anterior or !osterior a!!roach a) 8"ex the nec# s"ight"y for ard b) 0"ace finger of both hands on the !atient(s nec# ith index fingers >ust be"o the cricoid carti"age c) 8ee" for the thyroid isthmus d) &is!"ace the trachea to the right ith the fingers of your "eft handC !a"!ate ith 7 fingers for the right "obe of the thyroid e) 7e*erse the use of the fingers to fee" the "eft "obe of the thyroid Cranial Nerves $/ates, !! ,.;=,;1) 1) 2"factory $C1 ') ? usua""y not tested %) 2!tic $C1 '') ? you ha*e a"ready tested for *isua" fie"ds: Eisua" acuity can be tested ith an eye chart )) 2cu"omotor $C1 ''') ? you ha*e a"ready tested !u!i""ary constriction and the 32M contro""ed by this ner*e +) Troch"ear $C1 'E) ? you ha*e a"ready tested for do n ard, in ard mo*ement of the eye ,) Trigemina" $C1 E) a) Whi"e !a"!ating the tem!ora" and masseter musc"es in turn, as# the !atient to c"ench her teeth b) Chec# the forehead, chee#s and >a on each side for !ain and "ight touch c) Chec# the cornea" ref"ex ith a is! of cotton .) Abducens $C1 E') ? you ha*e a"ready tested for "atera" de*iation of the eye ith your extra=ocu"ar mo*ement maneu*ers

;) 8acia" $C1 E'') a) As# the !atient to raise both eyebro s b) 8ro n c) C"ose both eyes tight"y d) Sho both u!!er and "o er teeth e) Smi"e f) 0uff out both chee#s F) Acoustic $C1 E''') ? you ha*e a"ready assessed hearing and !erformed Weber and 7inne maneu*ers B) G"osso!haryngea" $C1 'H) ? tested together ith C1 H 1<) Eagus $C1 H) a) As# the !atient to say @ahA and atch the mo*ements of the soft !a"ate and !harynx b) Chec# gag ref"ex ith a tongue b"ade 11) S!ina" Accessory $C1 H') a) As# the !atient to shrug both shou"ders against your hands b) As# the !atient to turn her head to each side against your hand 1%) 4y!og"ossa" $C1 H'') a) As# the !atient to !rotrude her tongue b) As# the !atient to !ush the tongue against the inside of each chee# Posterior thorax 1) The !atient shou"d be sitting ith the !osterior thorax ex!osed: %) The doctor assumes a mid"ine !osition behind the !atient )) 'ns!ect the cer*ica", thoracic and u!!er "umbar s!ine $you i"" chec# for 72M of the thoracic and "umbar s!ine to ards the end of the com!"ete !hysica" hen the !atient is standing u!) +) 0a"!ate the s!inous !rocesses of each *ertebra for tenderness ith your thumb or by thum!ing ith the u"nar surface of your fist $/ates ! ,<)) ,) Assess for costo*ertebra" tenderness a) 0"ace the ba"" of one hand in the costo*ertebra" ang"e and stri#e it ith the u"nar surface of your fist $/ates ! )++) .) 'ns!ect the sha!e and mo*ement of the chest a"" a) 0"ace your thumbs at the "e*e" of the 1<th ribs ith your fingers "oose"y gras!ing the rib cage and gent"y s"ide them media""y: b) As# the !atient to inha"e dee!"y and obser*e hether your thumbs mo*e a!art symmetrica""y Posterior thorax lung exam 1) 3xamination techni-ues MUST be !erformed on bare s#in %) 0a"!ate for tacti"e fremitus a) Use either the ba"" of your !a"m or the u"nar surface of your hand for !a"!ation b) As# the !atient to re!eat the ords @ninety=nineA c) 5ou may !a"!ate one side at a time or use both hands simu"taneous"y to com!are sides d) 0a"!ate in four "ocations on both sides of the chest and com!are $/ates ! %%)) )) 0ercuss a) As# the !atient to #ee! both arms crossed in front of the chest b) 0ress the &'0 >oint of the "eft midd"e finger firm"y against the chest a"", a*oiding contact ith other fingers $/ates ! %%)) c) Stri#e this &'0 >oint ith the ti! of the right midd"e finger, s inging from the rist d) 0ercuss in se*en areas on each side $/ates ! %%,) +) Auscu"tate for breath sounds a) 'nstruct the !atient to breathe dee!"y through an o!en mouth b) Listen ith the dia!hragm of the stethosco!e in the same se*en areas in hich you !ercussed !nterior thorax"lung exam 1) 3xamination techni-ues MUST be !erformed on bare s#in

%) The !atient may be either sitting or su!ine: The dra!e shou"d be ad>usted to a""o ex!osure of the area being examined )) 'ns!ect the sha!e of the !atient(s chest and mo*ement of the chest a"" $1/ hen mo*ing from the !ost chest hen you ha*e com!"eted auscu"tating, it is acce!tab"e to auscu"tate the ant chest before ins!ection or !a"!ation) +) 0a"!ate for tacti"e fremitus a) Use the ba"" of the !a"m or u"nar surface of the hand to !a"!ate in ) areas on each side of the anterior chest $/ates ! %)1) ,) 0ercuss the anterior and "atera" chest, com!aring sides, in . areas on each side $/ates ! %)1) a) &is!"ace a oman breast ith your "eft hand or as# her to mo*e her breast for you .) Auscu"tate the anterior chest, com!aring sides in the . areas on each side here you !ercussed: 3HT31&3& 3HAM T3C41'IU3S 827 T43 T427AH A1& LU1GS 1) 0ercussion for dia!hragmatic excursion $/ates, ! %%.) a) &etermine the "e*e" of dia!hragmatic du""ness during -uiet res!iration b) 4a*e the !atient ta#e in a dee! breath and ho"d it and again determine the "e*e" of du""ness c) 4a*e the !atient exha"e com!"ete"y and ho"d it and determine the "e*e" of du""ness d) Measure the distance bet een the "e*e"s of du""ness at maxima" exha"ation and maxima" inha"ation %) 3go!hony a) As# the !atient to say @eeA hi"e auscu"tating o*er the "ung )) Whis!ered !ectori"o-uy a) As# the !atient to his!er @one=t o=threeA or @ninety=nineA hi"e "istening o*er the "ung Axi""ae ? examination of the axi""ae can be !erformed at the !resent >uncture: 't is sometimes !erformed at the end of the exam, or as !art of a breast exam in a fema"e 1) 'ns!ect the s#in of each axi""a $/ates, !! )1<=)11) %) 0a"!ation L axi""a a) As# the !atient to re"ax ith the L arm do n b) Su!!ort the L rist or hand ith your "eft hand c) Cu! together the fingers of your right hand and reach as high as you can to ard the a!ex of the axi""a d) 0ress your fingers to ard the chest a"" and s"ide do n to fee" !otentia" L1 e) To !a"!ate for "atera" grou! of L1, fee" a"ong the u!!er humerus )) 0a"!ation 7 axi""a ? re*erse your hands and fo""o the ste!s abo*e Cardio*ascu"ar 1) The !atient shou"d be su!ine ith the u!!er body raised by e"e*ated the tab"e to about )<J: The dra!e shou"d be arranged to ex!ose the !recordium: 3HAM T3C41'IU3S MUST /3 037827M3& 21 /A73 S6'1: %) The examiner shou"d stand tat the !atient(s right side )) 'ns!ect the !recordium a) "oo# for a!ica" im!u"se b) "oo# for any other mo*ements +) 0a"!ate for !recordium a) Use the !a"mar surfaces of se*era" fingers to "ocate the 0M'can s itch to one fingerti! hen "ocated i) &is!"ace a oman(s breast u! ard or "atera""y, or as# her to do this for you ii) 1ote "ocation of 0M', am!"itude and duration b) 0a"!ate for the 7E im!u"se a"ong the "o er "eft sterna" border ,) Auscu"tation of the heart a) Listen to the heart ith the dia!hragm of your stethosco!e in the 7 % nd 'CS, L %nd 'CS, L )rd or +th 'CS, and the "o er "eft sterna" border $,th 'CS) and at the a!ex $may a"so start at the a!ex and !roceed to the base of the heart) b) Listen to the heart ith the be"" of your stethosco!e in the same fi*e "istening areas .) 'ns!ect the nec# for >ugu"ar *enous !u"sations

a) Turn the !atient(s head s"ight"y a ay from the side you are ins!ecting $/ates ! %.;) b) 7aise or "o er the bed unti" you identify the !u"sations c) 'dentify the highest !oint of !u"sation i) Measure the *ertica" distance of this !oint abo*e the sterna" ang"e ;) 'ns!ect the nec# for carotid !u"sations F) 0a"!ate the carotid !u"sation a) 0"ace your "eft index and midd"e fingers $or thumb) on the right carotid artery i) 1ote am!"itude and contour of the !u"se a*e ii) 1e*er !a"!ate both carotids simu"taneous"y b) Use your right fingers or thumb to !a"!ate the "eft carotid artery B) Auscu"tate the carotid arteries for bruits ith the be"" of the stethosco!e a) As# the !atient to ta#e a dee! breath and ho"d it to e"iminate breath sounds 3HT31&3& 3HAM T3C41'IU3S 827 T43 CA7&'2EASCULA7 3HAM 1) Ste!s for assessing the KE0 $/ates, ! %.;) %) Use of "eft "atera" decubitus !osition to enhance a!ica" sounds $/ates, ! %;1) )) Use of sitting !osition to enhance the murmur of A' +) Timing of S) and S+ $/ates, ! %F<) ,) Attributes of c"assica" heart murmurs of S3M, AS, A', M7, MS $/ates, ! %F1 and Tab"es) !#domen 1) The !atient shou"d be in a su!ine !osition ith arms at side or fo"ded across the chest %) The dra!es shou"d be arranged to ex!ose the abdomen from abo*e the xy!hoid !rocess to the sym!hysis !ubis: )) A!!roach the !atient from his right side +) 'ns!ect the abdomen ,) Auscu"tate the abdomen as the next ste! in the exam after ins!ection a) 0"ace the dia!hragm of the stethosco!e gent"y on the abdomen b) Listen for bo e" sounds i) Listening in one s!ot is sufficient c) Listen for an aortic bruit on the mid"ine >ust abo*e the na*a" .) 0ercuss the abdomen "ight"y in four -uadrants and in the su!ra!ubic and e!igastric areas ;) 0ercuss for "i*er du""ness a) &efine the "o er edge of "i*er du""ness in the mid=c"a*icu"ar "ine, starting at a "e*e" be"o the umbi"icus b) &efine the u!!er edge of "i*er du""ness in MCL, starting in the area of "ung resonance i) Gent"y dis!"ace a oman(s breast as necessary c) Measure in centimeters ith a ru"er the *ertica" s!an of "i*er du""ness in the MCL F) 0ercuss for s!"enic du""ness a) 0ercuss a"ong the L "o er chest a"" bet een the "ung resonance abo*e and the costa" margin mo*ing "atera""y $/ates ! )+1) i) As# the !atient to ta#e a dee! breath and !ercuss again in this area B) 0a"!ate the abdomen "ight"y in four -uadrants a) Use a gent"e, "ight di!!ing motion $/ates ! )),) 1<) 0a"!ate the abdomen dee!"y in a"" four -uadrants a) Use a firmer di!!ing motion 11) 0a"!ate for the "i*er edge a) 0"ace your 7 hand on the right abdomen "atera" to the rectus musc"e, beginning more than ) fingerbreadths be"o the costa" margin b) As# the !atient to ta#e in a dee! breath c) 0a"!ate u! ards trying to fee" the descending "i*er edge, using a roc#ing motion i) May a"so use the @hoo#ing techni-ueA described in /ates ! )+< 1%) 0a"!ate for a s!"een ti!

a) 7each o*er and around the !atient ith your "eft hand to su!!ort and !ress for ard the "o er "eft rib cage b) 0ress in ard to ards the s!"een ith your right hand, beginning at "east ) finger breadths be"o the L costa" margin c) As# the !atient to ta#e in dee! breaths, trying to fee" the s!"een ti! as it comes do n to meet your fingerti!s: 1)) 0a"!ates for aorta by !ressing dee!"y ith one hand on each side of the aorta $/ates, ! )++) 1+) 0a"!ate for the su!erficia" inguina" "ym!h nodes $/ates, ! +,%) 1,) 0a"!ate for both femora" artery !u"ses a) 0ress dee!"y be"o the inguina" "igament $/ates, ! +,%) 3HT31&3& 3HAM'1AT'21 T3C41'IU3S 827 T43 A/&2M31 1) 0a"!ation for the #idneys a) Left 6idney $/ates, ! )+)) i) Mo*e to the !atient(s "eft side ii) 0"ace your 7 hand behind the !atient, >ust be"o and !ara""e" to the 1% th rib ith your fingerti!s reaching the costo*ertebra" ang"e, and "ift, trying to dis!"ace the #idney anterior"y iii) 0"ace your L hand in the LUI, "atera" and !ara""e" to the rectus musc"e i*) As# the !atient to ta#e a dee! breath *) At the !ea# of ins!iration, !ress your "eft hand firm"y and dee!"y into the LUI >ust be"o the costa" margin and try to ca!ture the #idney bet een your t o hands *i) As# the !atient to breathe out and then ho"d it, hi"e you re"ease the !ressure of your L hand, a""o ing the #idney to s"ide bac# into its ex!iratory !osition b) 7ight #idney i) Mo*e to the !atient(s right side ii) S itch the !ositions of your hands and !roceed as abo*e %) Assess for !ossib"e ascites $/ates, ! )+,=)+;) a) Test for shifting du""ness i) With the !atient su!ine, ma! the borders of tym!any and du""ness, by !ercussing out ard from the centra" area of tym!any ii) As# the !atient to turn onto one side and !ercuss and mar# the borders of du""ness one more b) Test for a f"uid a*e i) As# the !atient or an assistant to !ress the edges of both hands firm"y do n the mid"ine of the be""y ii) Ta! one f"an# shar!"y ith your fingerti!s and fee" on the o!!osite f"an# for an im!u"se transmitted through the f"uid c) /a"ottement of organs in ascitic f"uid i) Ma#e a brief >abbing mo*ement ith the fingers of one hand into the !rotuberant abdomen to ards the antici!ated organ )) 0soas sign $/ates, ! )+F) a) 0"ace your hand >ust abo*e the !atient(s right #nee and as# the !atient to raise that thigh against your hand +) 2bturator sign $/ates, ! )+F) a) 8"ex the !atient(s right thigh at the hi!, ith the #nee bent, and rotate the "eg interna""y at the hi! $%%er extremityMS6 and 0artia" 1euro"ogica" $these maneu*ers must be re!eated on both u!!er extremities 1) 'ns!ect the hands, inc"uding each finger, its s#in and >oints, and nai"s a) 0a"!ate any abnorma" >oints %) 'ns!ect the rist )) 0a"!ate the dista" radius and snuff boxC !a"!ate the dista" u"na +) 0a"!ate the radia" !u"se on the f"exor surface of the rist, "atera""y a) Com!are the !u"ses in both arms ,) Chec# 72M of the fingers a) As# the !atient to ma#e a tight fist ith each hand

.)

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F) B) 1<)

11)

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b) 3xtend and s!read the fingers c) As# the !atient to s!read the fingers a!art and bac# together d) As# the !atient to mo*e the thumb across the !a"m and touch the base of the , th finger, and then bac# across the !a"m and a ay from the fingers e) 4a*e the !atient touch the thumb to each of the other fingerti!s Chec# 72M of the rist $/ates ! +BB) a) 8"exion b) 3xtension c) U"nar and radia" de*iation Chec# 72M of the e"bo $/ates ! +B;) a) 8"exion and extensionD as# the !atient to bend and straighten the e"bo b) 0ronation and su!inationD ith arms at his side, and e"bo s f"exed, as# the !atient to turn the !a"ms u! and then do n 0a"!ate for e!itroch"ear "ym!h nodes $/ates ! +,1) a) 8"ex the e"bo to B<J b) 0a"!ate in the groo*e bet een the bice!s and trice!s 'ns!ect the shou"der $/ates, ! +B%) 0a"!ate the shou"der $/ates, ! +B)) a) Locate the acromion !rocess and the acromioc"a*icu"ar >oint b) Locate the greater tuberc"e of the humerus c) Locate the coracoid !rocess of the sca!u"a Chec# 72M of the shou"der $/ates, ! +B)) a) Watch for smooth, f"uid mo*ement as you stand in front of the !atient and as#D i) 7aise the arms to shou"der "e*e" $abduct) ith !a"ms facing do n ii) 7aise the arms to a *ertica" !osition abo*e the head ith the !a"ms facing each other iii) 0"ace both hands behind the nec# ith e"bo s out to the side $externa" rotation and abduction) i*) 0"ace both hends behind the sma"" of the bac# $interna" rotation and adduction) Test Musc"e strength in the u!!er extremity $/ates !! ,;+=,;,): 5ou must com!are sides a) Test gri!as# the !atient to s-uee9e t o of your fingers as hard as !ossib"e and not "et them go b) Test finger abduction!osition the !atient(s hand ith !a"ms do n and fingers s!read: Try to force the fingers together c) Test o!!osition of the thumbthe !atient shou"d try to touch the "itt"e finger ith the thumb against your resistance d) Test extension of the rist by as#ing the !atient to ma#e a fist and resist you !u""ing it do n e) Test f"exion and extension of the e"bo by ha*ing the !atient !u"" and !ush against your hand

3HT31&3& 3HAM 28 K2'1TS 28 T43 U0037 3HT73M'T5 1) Shou"der $/ates, Tab"e 1,=+, !age ,%.=,%;) a) Acromioc"a*icu"ar >oint $/ates, ! +B+) i) 0a"!ate and com!are both >oints for s e""ing or tenderness ii) Adduct the !atient(s arm across the chest b) 7otator cuff $/ates, ! +B+) i) With the !atient(s arm at the side, !a"!ate the three @S'TSA musc"es that insert of the greater tuberosity of the humerus ii) 0assi*e"y extend the shou"der by "ifting the e"bo !osterior"y iii) 2nce again !a"!ate the S'TS musc"e insertions i*) Chec# the @dro! armA sign by as#ing the !atient to fu""y abduct the arm to shou"der "e*e" and "o er it s"o "y c) /ici!ita" tendonitis $/ates, ! +B,) i) 7otate the arm and forearm externa""y and "ocate the bice!s musc"e dista""y near the e"bo ii) Trac# the musc"e and its tendon !roxima""y into the bici!ita" groo*e a"ong the anterior as!ect of the humerus iii) Chec# for tendon tenderness

d) G"enohumera" >oint i) 'ns!ect the shou"der from abo*e ii) 0a"!ate the ca!su"e and syno*ia" membrane beneath the ant and !ost acromion %) 3"bo $/ates, ! +B. and Tab"e 1,=,, ! ,%F) a) Latera" e!icondy"itis $tennis e"bo ) i) 0ain and tenderness at the "at e!icondy"e and !ossib"y in the extensor musc"es c"ose to it ii) 0ain increases hen the !atient tries to extend the rist against resistance b) Media" e!icondy"itis $!itcher(s, go"fer(s or Litt"e League e"bo ) i) Tenderness at the media" e!icondy"e ii) Wrist f"exion against resistance increases the !ain c) U"nar neuro!athy at e"bo )) Wrist $/ates, ! +B;) a) Car!a" tunne" syndrome i) 0ain and numbness on the *entra" surface of the first three digits, es!ecia""y at night, due to median ner*e com!ression in the car!a" tunne" ii) Wea#ness of abduction of the thumb iii) Tine"(s sign ? !ercuss "ight"y o*er the course of the median ner*e in the car!a" tunne" +) 8ingers $/ates, Tab"e 1,=., ! ,)<=,)1) a) Trigger finger b) 8e"on c) 0aronychia d) 8"exor tendon sheath e) Gang"ion &o'er extremityMS6 and 0artia" 1euro"ogica" $these maneu*ers must be re!eated on both "o er extremities 1) The !atient may be sitting or "ying do n and dra!ed so that the externa" genita"ia are co*ered ith the "egs fu""y ex!osed during the exam %) 'ns!ect both feet and an#"ecom!are sides )) 0a"!ate the feet and an#"es $/ates, ! ,1;) a) Assess for !eda" edema!ress firm"y ith your thumb o*er the dorsum of the foot, behind each media" ma""eo"us and o*er the shins $/ates, ! +,,) b) 0a"!ate the anterior as!ect of each an#"e >oint c) 0a"!ate the hee", es!ecia""y the !ost and inf ca"caneus d) 0a"!ate the MT0 >oints e) 0a"!ate the heads of the fi*e metatarsa"s +) 0a"!ate for the !eri!hera" !u"ses of the "egs a) &orsa"is !edisfee" the dorsum of the foot >ust "atera" to the extensor tendon of the great toe b) 0osterior tibia"fee" be"o the media" ma""eo"us of the an#"e ,) Chec# 72M of the an#"e $/ates, ! ,1F) a) &orsif"ex and !"antar f"ex the foot at the an#"e b) 'n*ert and e*ert the foot c) 8"ex the toes .) 'ns!ect the #nee for a"ignment and contours ;) 0a"!ate the #nee ith the #nee in f"exion $/ates, ! ,11=,1)) a) 'dentify the media" femora" condy"e and the media" tibia" !"ateau b) 'dentify the tibia" tuberc"e c) 'dentify the "atera" femora" condy"e and "atera" tibia" !"ateau d) 'dentify the !ate""ar tendon and as# the !atient to extend the "eg e) 0a"!ate the media" co""atera" and "atera" co""atera" "igaments and menisci f) 8ee" for s e""ing abo*e and to the sides of the !ate""a g) Chec# the !re!ate""ar, anserine and !o!"itea" bursae $/ates ! ,1)) F) Chec# 72M of the #nee $/ates ! ,1,)

B) 1<)

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a) As# the !atient to f"ex and extend the #nee hi"e sitting $or by as#ing the !atient from a standing !osition to s-uat and then stand u! again b) Chec# interna" and externa" rotation by as#ing the !atient to rotate the foot media""y and "atera""y 'ns!ect the hi! by obser*ing the !atient(s gait at some time during the exam $/ates ! ,<.) 0a"!ate the surface "andmar#s of the hi! a) Anterior surfaceD "ocate the i"iac crest, i"iac tuberc"e and anterior su!erior i"iac s!ine b) 0osterior surfaceD "ocate the !osterior su!erior i"iac s!ine, the greater trochanter and the ischia" tuberosity Chec# 72M of the hi! $/ates, ! ,<B=,1<) a) 8"exion ith the !atient su!ine, as# him to bend each #nee in turn u! to the chest and !u"" it firm"y against the abdomen b) Abductiongras! the an#"e and abduct the extended "eg unti" you fee" the i"iac s!ine mo*e c) Adductionho"d one an#"e and mo*e the "eg media""y across the body and o*er the o!!osite extremity d) 7otationf"ex the "eg to B< at hi! and #neeC stabi"i9e the thigh ith one hand, gras! the an#"e ith the other and s ing the "o er "eg, media""y and "atera""y Chec# musc"e strength in the L3 $/ates, ! ,;.=,;F) a) Test f"exion at the hi!!"ace your hand on the !atient(s thigh and as#ing the !atient to raise the "eg against your hand b) Test adduction at the hi!s!"ace your hands firm"y on the bed bet een the !atient(s #nees: As# the !atient to bring both "egs together c) Test abduction at the hi!s!"ace your hands firm"y on the bed outside the !atient(s #nees: As# the !atient to s!read both "egs against your hands d) Test extension at the hi!sha*e the !atient !ush the !osterior thigh do n against your hand e) Test extension at the #neesu!!ort the #nee in f"exion and as# the !atient to straighten the "eg against your hand f) Test f"exion at the #nee!"ace the !atient(s "eg so that the #nee is f"exed ith the foot resting on the bed: Te"" the !atient to #ee! the foot do n as you try to straighten the "eg g) Test dorsif"exion and !"antar f"exion at the an#"eas# the !atient to !u"" do n and !ush do n against your hand

3HT31&3& 3HAM 28 K2'1TS 28 T43 L2W37 3HT73M'T5 1) 6nee a) 0re!ate""ar bursitis $housemaid(s #nee) ? s e""ing o*er the !ate""a is suggesti*e b) 0ate""ar tendonitis ? tenderness o*er the !ate""ar tendon c) Chondorma"acia ? !ain ith !ate""ar mo*ement during -uadrice!s contraction is suggesti*e d) 0es anserine bursitis ? s e""ing !ostero=media" to the tibia" tuberc"e $usua""y from running) e) Abduction Stress Test for the MCL $/ates, ! ,1,) f) Adduction Stress Test for the LCL $/ates, ! ,1,) g) Anterior &ra er Sign for the ACL $/ates, ! ,1,) h) Lachman Test $/ates, ! ,1.) i) 0osterior &ra er sign $/ates, ! ,1.) Neurological ? some !arts of the neuro"ogica" exam ha*e been o*en into exam of the head and nec# and extremities $i:e: Crania" 1er*e exam and motor testing): The remaining com!onents of the neuro"ogica" exam are co*ered here 1) Menta" Status 3xam a) Le*e" of a"ertness b) Language function $f"uency, com!rehension, re!etition and naming) c) Memory $short=term and "ong=term d) Ca"cu"ation e) Eisuos!atia" !rocessing f) Abstract reasoning %) Motor function

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a) Gait ? see be"o b) Coordination i) 8ine finger mo*ements ii) 7a!id a"ternating mo*ements and !oint=to=!oint ? described be"o under cerebe""arLcoordination c) 'n*o"untary mo*ements d) 0ronator drift $/ates, ! ,F%) e) Tone ? resistance to !assi*e mani!u"ation f) /u"# g) Strength ? incor!orated into regiona" exams of L3 and U3 )) 7ef"exes $/ates, ! ,FF=,B1) a) /ice!s ref"ex $C,, C.) ith !atient(s arm !artia""y f"exed at the e"bo and !a"m do n, !"ace your thumb or finger firm"y on the bice!s tendon and stri#e ith ref"ex hammer b) Trice!s ref"ex $C., C;) ? f"ex the !atient(s arm at the e"bo ith !a"m to ards the body and !u"" it across the chest: Stri#e the trice!s tendon abo*e the e"bo c) /rachioradia"is $C,, C.) ?The !atient(s hand shou"d rest on the abdomen or the "a! ith the forearm !art"y !ronated: Stri#e the radius about 1=% inches abo*e the rist d) 6nee $0ate""ar) ref"ex $L%, L), L+) ? !atient may be either sitting or su!ine ith #nee f"exed: Ta! the !ate""ar tendon >ust be"o the !ate""a e) An#"e $Achi""es) ref"ex $S1) ? dorsif"ex the foot at the an#"e and stri#e the Achi""es tendon f) 0"antar $/abins#i) res!onse $L,, S1) ? ith a #ey or the ti! of the shaft of a ref"ex hammer, stro#e the "atera" as!ect of the so"e from the hee" to the ba"" of the foot, cur*ing media""y across the ba"" +) Sensory $/ates, ! ,F)=,F+) a) 0ain ? Create a shar! from a bro#en tongue b"ade i) Com!are symmetrica" areas on the t o sides of the body, inc"uding arms, "egs and trun# ii) Com!are the dista" ith the !roxima" areas of the extremities iii) Eary the !ace of your testing and occasiona""y substitute the b"unt end for the !oint, hi"e as#ing @'s this shar! or du""MA or @&oes this fee" the same as thisMA b) Light touch ? using a fine is! of cotton, touch the s#in "ight"y, a*oiding !ressure i) As# the !atient to res!ond hene*er a touch is fe"t: ii) Com!are one area ith another c) Eibration ? Use a "o =!itched tuning for# $1%F 49) i) Set the for# *ibrating and !"ace it firm"y o*er a &'0 of a finger and of the great toe ii) As# hat the !atient fee"s iii) 'f *ibration sense is im!aired, mo*e to more !roxima" bony !rominences d) Koint !osition sense i) Gras! the !atient(s big toe, ho"ding it by its sides and !u"" it a ay from the other toes so as to a*oid friction: ii) &emonstrate @u!A and @do nA iii) With !atient(s eyes c"osed as# him to identify u! and do n mo*ements i*) Com!are sides *) Mo*e more !roxima""y if >oint !osition is im!aired *i) Test K0S in the U3 by mo*ing a finger >oint e) 0ro!rioce!tion $/ates, ! ,F,) ,) Cerebe""arLCoordination $/ates, ! ,;F=,F<) a) 7a!id a"ternating mo*ements i) U3 ? Sho !atient ho to stri#e one hand on the thigh, first ith the !a"m, then ith the bac# of the hand: 4a*e the !atient re!eat these a"ternating mo*ements as ra!id"y as !ossib"e: 7e!eat ith o!!osite hand $1) 27 Sho the !atient ho to ta! the dista" >oint of the thumb ith the ti! of the index finger as ra!id"y as !ossib"e: 4a*e the !atient !erform the action: Chec# the o!!osite hand ii) L3 ? as# the !atient to ta! your hand as -uic#"y as !ossib"e ith the ba"" of each foot in turn b) 0oint=to=!oint mo*ements

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U3 ? as# the !atient to touch your index finger and then his nose a"ternate"y se*era" times: Mo*e your finger about: ii) L3 ? As# the !atient to !"ace one hee" on the o!!osite #nee and then run it do n the shin to the big toe: 7e!eat on the other side .) Gait a) As# the !atient to a"# across the room, then turn and come bac# b) Wa"# hee"=to=toe in a straight "ine c) Wa"# on toes then on hee"s ;) 7omberg Test a) The !atient shou"d first stand ith feet together and eyes o!en and then c"ose both eyes for %<=)< secs ithout su!!ort (ack 1) 72M $/ates, ! ,<,) a) 8"exion ? ith !atient standing, as# him to bend for ard to touch the toes b) 3xtension ? !"ace your hand on the !osterior su!erior i"iac s!ine and ith your fingers !ointing to ards the mid"ine, as# the !atient to bend bac# ard as far as !ossib"e c) Latera" bending ? as# the !atient to "ean to both sides as far as !ossib"e 12T3 T4AT /73AST, G31'TAL A1& 73CTAL 3HAMS 4AE3 12T /331 '1CLU&3& '1 T4'S C43C6L'ST

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