IPES Lab Book - Quick and Dirty Edition (WIP)

8/11/2019 IPES Lab Book - Quick and Dirty Edition (WIP)

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Introduction

to PatientExamination

Skills (IPES)

Laboratory Manual

Quickand DirtyEdition


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Blood Pressure

Instruction: Too tight or painfulDr: Hold at the level of the heart, pump 30mmHg above last pulse sound, deflate at rate

of 2-3mmHg/second

First THUD: systolicblood pressure (maximal contraction of ventricles)Last beat heard: diastolic blood pressure (maximal relaxation of ventricles)Deflate an extra 10-20mmHg after last pulse sound is heart to account for

auscultory gap

Normal Rate: 120/80mmHg

Positive Findings Indications

120-139mmHg (systolic) or 80-

89mmHg (diastolic)

Pre-hypertension

140-159mmHg (systolic) or 90-

99mmHg (diastolic)

Stage 1 Hypertension: stress, obesity, high blood

viscosity, type II diabetes mellitus, high cholesterol,

atherosclerosis>=160mmHg (systolic) or>=100mmHg (diastolic)

Stage 2 Hypertension

80-89mmHg Pre-hypotension

< 90mmHg (systolic) or < 60/50mmHg(diastolic)

Hypotension: hypothyroidism, thin/small person

Ventricles relaxed: mitral & tricuspid valves are opened

Ventricles contracting: semilunar valves are opened

Korotkoff sound (soft pitch): use bellof stethoscope

Heart beat (high pitch): use diaphragm

Head and Neck - EyesConfrontation (CN2 - Optic)Instruction: Cover your opposite eye, test peripheral vision. Any blind spots?


Patient cannot see your fingers when

you do

Scotoma (blind spot), diminished peripheral vision,

glaucoma, macular degeneration, MS, CN2 lesion,

retinal disorder


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Cardinal Fields of Gaze (CN3 - Oculomotor, CN4 - Trochlear, CN6 - Abducens)Instruction: Look straight ahead, follow the tip of my pen without moving your head

Dr: H or *Exs: Trochlear, down and in (LR6, SO4, AO3)

Right sided abducens nerve pathologyL. Rectus


Nystagmus (eye has trouble following

the pen; staggering, shaking)

Eye not following laterallyCN6: Abducens (lateral

rectus muscle) Eye doesnt go down and IN (clinical test) CN4:

Trochlear (superior oblique muscle)

Strabissmus (eye doesnt follow) All other directionsCN3: Oculomotor (med, sup. Inf.Rectus, inf. Oblique muscles)

Lesion to eye muscle

Accomodation (CN3 - Oculomotor - Medial Rectus muscle)Instruction: Patient to keep eye on pen tip, dont move head Dr: Move pen from far to near

Normal Response: constrictionlong ciliary musclesciliary nerves and CN3,

convergence, convexity


Eyes do no converge Lesion to CN3 - Oculomotor

Pupillary Light Reflex (CN2 - Optic, CN3 - Oculomotor)Dr: can use 2 lights or cover above eye to create shadow

Light-pupil constricts----direct light reflex, consensual light reflexUnilateral sensory afferent: optic nerve

Bilateral muscle efferent: oculomotor nerve or EDW nucleus (constriction)

Scenario:

Lack of constriction in L eye, could be EDW or CN III. To decide, performaccommodation

convergence rules out CN III EDWLack of constriction in R eye, light in L constricts L but not R

R oculomotor lesion

Light in L eye, both constrict; Light in R eye, no constriction in either eye

Damage to R optic nerveArgile Robinson pupil:

Far to near accommodates; unreactive to light

Damage to EDW nucleus motor, symptom of Tertiary syphilis disease


Eye does not constrict Damage to Edinger-Westphal Nucleus or CN3 -

Oculomotor (see scenarios)


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Levator Palpebrae Superioris (CN 3 - Oculomotor)

Instruction: Are you wearing contacts? Open against resistanceDr: Hold eye lids closed for 5 seconds

Positive Findings IndicationsAny grade (1-5) less than 5, pain (ask) CN3Oculomotor lesion

Right side is stronger Left sided CN3Oculomotor lesion

Left side is stronger Right sided CN3Oculomotor lesion

Corneal Reflex (CN 5Ophthalmic Divison of Trigeminal: Sensory, CN 7Facial:

Motor to Orbicularis Oculi)Instruction: Use wisp of cotton to lightly touch sclera

Scenario:

Cotton in R eye, both eyes blink; cotton in L eye, no eyes blink

Lesion to L CN V1Cotton in R eye, L doesnt blink

Lesion to L CN7 Facial


One or both eyes fail to blink Afferent or sensory loss to CN5 (trigeminal) Or Efferent or motor loss to CN7 (facial) to

Orbicularis Oculi Muscle

Snellen Eye Chart

Instruction: patient reads smallest line that is readable to themDr: Grading20/20-1 (if only 1 letter is missed on line 8)

If patient misses 3 or more, grade on line above; if only 2 are missed, grade that lineminus 1 or minus 2

20/15patient at 20 ft can see better than someone at 15 ft

Light test - Ophthalmoscope

Instruction: Patient focuses straight ahead at distant object, relaxDr: Use same eye to inspect, focus lens on hand then 18 (2ft away) with hand on

shoulder, find red reflex and move directly towards it, focus past pupil, look lateral to

medial to inspect fovea, arteries, retinal integrity


Opacity, Negative Red Reflex

CataractsAV nicking/hemorrhaging Retinopathy

Papilledema Increased intracranial pressure

Increased cup to disc ratio (>1:2) Glaucoma

Macular Degeneration Old age

Cotton wool patches Diabetes, hypertension


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Head and Neck - EarsGross Hearing (CN 8Cochlear)Instruction: Patient closes eyes, and listens for sliding hands

Dr: If asymmetrical, do Webers and Renees


Patient fails to hear or Asymmetry Hearing Loss (must do further tests)

Webers Test (top of head, confirms Gross hearing)

Instruction: Patient closes eyes, listens for louder earDr: 512 Hz tuning fork at top of head


Lateralization to bad/impaired ear Conductive hearing loss due to obstruction (ex: wax),otitis media, tympanic membrane rupture

Lateralization to good ear Sensory neural hearing loss (CN8 - Cochlear) due topresbycusis (old age degeneration), excessive loud

noise, cochlear damage, otitis interna

Human hears 300-3000Hz

Small tuning fork: 512 Hz

(128 Hz is for vibration sense)Organ of cortihigh pitch/low pitch sounds

Renees Test (Bone conduction vs. air conduction, confirms Webers)Instruction: Patient tells Dr. when sound no longer heard

Dr: Time bone conduction: bottom of tuning fork to mastoid process; then air

conduction: tuning fork parallel to ear. Add bone conduction time for total airconduction time.

Normal Response: 2:1 air:bone ratio


Bone conduction >= air conduction

(Example: 4:1)

Conductive hearing loss

Bone conduction < air conduction

overall time is diminished w/2:1 ratio

intact(Example: 2:1)

Sensory neural hearing loss


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OtoscopeDr: pull pina up and back and put specula in to observe cone of light and ear drum


Absence of cone of light Intracranial pressure

Redness in canal (w/ purulent effusion)

Otitis Media: acute (no pain), externa (pain)Bony exostoses around perimeter Swimmers Ear (common in children)

Perforated tympanic membrane Trauma caused by sharp object put into ear

Amber Fluid behind eardrum Serous effusion

Large chalky white patch tympanosclerosis

Head and Neck

Inspection

Dr: check scalp, scarring, discoloration, asymmetry, is the SCM hypertonic? Spasmotic?Upper cross syndrome, posture, goiter? tracheal deviation, dyspnea

*Dont check both carotids at the same timecould cause them to pass out


Dyspnea from goiter or tumor

Atelectasis collapsed lung

Fluid Pneumothorax

Increased air in lung Trachea deviates away

Fine hair, coarse hair, nits or redness &

scaling on head

Hyperthyroidism, hypothyroidism, lice eggs, or

dermatitis/psoriasis

Asymmetry, masses or scars on neck thyroid problem or past surgery


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Cervical PalpationLymph Nodes1. Pre-auricular

2. Post-auricular3. Occipital

4. Tonsillar

5.

Submandibular6. Submental7. Anterior/superficial cervical

8. Posterior

9. Deep cervical (tilt head to relax SCM)10.Supraclavicular (sentinel)

Sentinal lymph nodes are the primary pathway for spreading malignancy, cancer,

tumor

Dr: Look for hard, fixed, matted, enlarged (Hemf)


Enlarged, warm, tender Active infection

Not warm, non-tender, rubbery Past infection

Hard, fixed, non-tender, not warm Malignancy, cancer

Rubbery, warm, non-tender, larger

than 1cm

lymphoma

Cervical PalpationOther Glands

1. Submandibular

2. Parotid


Enlarged Parotid Gland MUMPS

Thyroid Test

Pt: tilts head back, mouth open slightly, swallows upon locationDr: tests 5 areas (2 superior poles, 2 inferior poles, isthmus) upon swallowing, palpate for

any masses or enlargementNormal Response: Thyroid elevates upon swallowing, symmetry


Enlargement, tenderness,inflammation, nodule (calcification)

Goiter/hyperthyroidism (sweat, exophthalmos, hightemp.); problem with Vagus, infection, not enough

hormones, so thyroid makes more cells to make up forhormone

Enlarged & Soft

Graves disease

Enlarged & Firm Hashimotos thyroiditis or malignancy

Benign or malignant nodules &

tenderness in thyroid

thyroiditis


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Pulse Palpation

Dr: Assess carotid, temporal, submandibular for rate, strength/amplitude, rhythm, depth,distensibility

Positive Findings IndicationsAsymmetry, arrhythmia Clot, thrombus, atherosclerosis

Gag Reflex (CN9 - Glossopharyngeal, CN10 - Vagus)Instruction: Patient sticks out tongue

Dr: Touch soft palate pharyngeal arches and posterior tongue root bilaterally

Normal Response: Symmetrical elevation of Soft Palate (contraction done by Vagus)Scenario:

L posterior arch both contract, R nothing

R glossopharyngeal nerve lesion

Positive Findings IndicationsNo elevation upon touch Afferent CN9 (Glossopharyngeal) Lesion

Asymmetrical elevation of palate upon

touchuvula deviates away from side

of lesion

Efferent CN10 (Vagus) lesion on side that didnt

elevate (opposite uvula deviation)

One side non-response Vagus lesion (CN 10) motor

Bilateral non-response Glossopharyngeal lesion (CN 9) sensory

Vernet-Rideau (CN 10 - Vagus)

Instruction: Say ahhh

Dr: touch soft palate

Normal Response: uvula and pharyngeal arches should elevate symmetrically


Asymmetrical elevation of palate upon

touchuvula deviates away from side

of lesion

Efferent CN10 (Vagus) lesion on side that didnt

elevate (opposite uvula deviation)

Uvular deviation towards good side,

redness, swelling, abscess

Damage to Vagus, figure out which side (its

contralateral to the deviated side) Ex: if deviated to the left, lesion to the right Vagus Vagus lesion (CN 10) motor, herpes, leukopenia


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Head and Neck Nose and Sinuses

Nose Palpation and RhinoscopyInstruction: Tilt head back, push on tip of nose

Dr: Palpate nose for pain and tenderness, look for conchaNormal Response: Can see inferior and middle concha cant see superior


Redness, pale/blue mucosa, nasalpolyps

Allergies, infection/inflammation

Deviated septum trauma

Perforated septum drug use (Cocaine)

Sinus Palpation and Tran illumination

Instruction: Patient tilts head up slightly, opens mouth slightly

Dr: palpates for warmth and tenderness, symmetryNormal Response: Glow should be size of sinus

Frontal Sinus: shine up through supraorbital ridgeMaxillary Sinus: shine down past zygomatic arch through patients open mouth

towards hard palate


A line, dim to the trans illumination Infection

Difference in illumination pathological side=dim side

Warmth, tenderness, swelling sinus infection/congestion, bacteria, virus, sinusitis,congestion

Absence of red glow or presence offluid line

sinusitis, tumor or thickened mucosa


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Cranial Nerve Exam

I Olfactory Smell Test

II Optic Nerve Pupillary Light Reflex

ConfrontationAccomodation

III Oculomotor Pupillary Light ReflexAccommodation

Cardinal fields of gaze

Levator Palpebrae Superioris Ms. Test

IV Trochlear Cardinal Fields of Gaze

V Trigeminal Corneal Reflex (sensory)Ms. Of Mastication (motor)

Pain, temperature, Lt touch (sensory)

VI Abducens Cardinal Fields of Gaze

VII Facial (ant 2/3 tongue taste) Corneal Reflex (motor)Ms. Of facial expression

VIII Vestibulocochlear Webers

Renees

IX Glossopharyngeal (post 1/3 tongue) Gag Reflex (sensory)

X Vagus Vernet-Rideau

Gag Reflex (motor)

XI Spinal Accessory Ms. TestingTrapezius, SCM

XII Hypoglossal Tongue deviation and ms. test

Motor to CN5Trigeminal (Bite Test)

Instruction: Bite down on tongue blade and resist pulling out and pushing down, resistmasseter/pterygoid pressure, open/jut jaw

Dr: Ask if pt has any TMJ problems, observe any deviation, and perform 3 masticationmuscles. Strength tests


< 5 CN5 lesion


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Sensory to CN5Trigeminal (Sharp vs. Dull)

Instruction: This is what it will feel like, Patient closes eyes, point to location ordistinguish between sharp and dull. For light touch, point to where they feel

Dr: Do to each of 3 divisions (V1 - temples, V2 - cheeks, V3 - jaw)

Pain and Temperature (Sharp vs. dull)Light touch (cotton)


Cannot sense Anesthesia

Oversensativity Hyperesthesia

Muscles of Facial Expression (CN 7Facial)

Instruction: raise eyebrows, widen eyes, close eyes tightly, puff cheeks, smile, frown,pout lips, jut jaw

Positive Findings IndicationsAsymmetry, muscle weakness Damage to Facial nerve, Bells Palsey

Spinal Accessory (CN11)Instruction: resists to shrug shoulders and and tries to put head back into neutral

Dr: Trapeziusshrug shoulders; SCMlaterally flex away, rotate towards

Hypoglossal Nerve (CN 12)

Patient: Sticks out tongue, resist against cheek pressure using tongue

Scenario:If tongue deviatesto left, lesion on the left because the right overpowers

R glossopharyngeal nerve lesion


Tongue deviation Deviates to same side as lesion

Muscle test (pressure using tongue) Lesion on weak side

Muscle testing:

< 5 positive finding4 = resistance with some pressure

3 = can resist gravity

2 = weak with gravity

1 = very weak, barely any gravity


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Cervical Region

Auscultation of Carotid ArteryDr: Listen for normal blood flow


Bruits (low pitchuse BELL) Atherosclerosis, arteriosclerosis, occlusion, plaque

Musculoskeletal6 degrees of freedom:Flexion/extension, left/right rotation, L, R lateral flexUse inclinometer for spine

Goniometer for extremities

Neck:

Normal Response: 50 flexion, 60 extension



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5/27/10

Spinal neurology:Muscle testing to particular neuropathymyotome

*Expose shoulders to inspect!

Way to remember:C6extend armmake a 6 with pointer finger and thumb (extend three fingers)

C7flex handmake a 7 (with arm and pointer finger and middle finger pointed down)

C5Biceps musculocutaneous nerve

Flex forearm, fist, have them resist, doctor pull out

Deltoids axillary nerve

Arm up, straight out, bent at elbow, doctor push down on elbow

Positive findings:Weakness grade less than 5

Deltoid: axillary neuropathyBiceps: musculocutaneous neuropathy

Scenario:

a) Weakness or P when he applies pressure, both (bis and delts) weak on theleftindicates a L spinal radiculopathy (C5)

b) Biceps are weak, deltoid is strongperipheral neuropathy

c) Deltoid on L and R = 5Biceps L=5, R=4

Indicates: R sided musculocutaneous (peripheral) neuropathy


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C6

Biceps Musculocutaneous nerve

Flex forearm, fist, have them resist

Brachioradialis Radial nerve

Fist, thumb up, arm 90 degrees, push down on wrist

Wrist Extensors Radial nerve

Arm out, wrist back, resist, doctor push wrist down

Positive findings:

Muscle weakness (grade


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C8

Finger flexors median nerve

Fingers down, arm straight out, doctor pull fingers out, have patient resistPalmer and dorsal interossei ulnar nerve

Finger Ab-Adductors

(C8/T1) Adduction: Put your fingers in between theirstell them, squeeze my fingersResisted Abduction:Tell them to start with their fingers out, doctor tries to push in

L1/L2Iliopsoas femoral nerve

Resisted hip flexion (T12-L3)have thempull knee to shoulder and tell them to resist

Stabilize patients shoulder

Positive finding: femoral nerve neuropathy

L3*Quads (Knee extensors) femoral nerve

Have them kick out against my pressure. One hand resisting knee extension by placing

one hand on anklesquat on side of patient.

Positive finding:iliopsoas and quads weak=femoral neuropathy

L4

*Quads femoral nerveHave them kick out against my pressure (see above)

Tibialis Anterior deep peroneal nerve

(ankle dorsiflexion and inversion)

L5

Extensor hallucis longus deep peroneal nerve

Have patient extend big toeExtensor digitorum longus and brevis deep peroneal nerve

Have patient extend all toes

Gluteus minimus superior gluteal nerveHave pt. sideline, have them abduct top leg

S1

Peroneus longus and brevis superficial peroneal nerve(plantarflexion and eversion)gas pedal, doctor hand on sole of foot, tell pt. push down

Scenario:

Iliopsoas weak, knee extensors strong, indicates L1/L2 radiculopathyAll weak indicates femoral neuropathy


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Dermatomes

C5 lateral bicep

C6 thumb

C7pointer and middle fingers(both sides!) radial nerve dorsal, median nerve ventral

C8pinky and ring fingerT1medial biceps (arms straight out)

L1 inguinal ligament

L2medial thigh

L3above knee cap

L4below knee to big toe

L5side of foot, pinky toe

S1back of calf

*Say Does this feel the same as that?Positi ve finding:

Anesthesia, hypoesthesia

Indications:

HyposensitivityHypoalgesia

Peripheral neuropathy

RadiculopathyScenario:

If pt. feels more on R, it is a L C5, or (whatever dermatome) spinal rediculopathy


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6.2.10

DTR (not peripheral neuropathy)UMN: Brain, Spinal Chord and brain stem

LMN: CNs, peripheral nerves, spinal nerves

Wexler Reflex Scale0: flaccid paralysis /areflexia

+1: Hyporeflexia (LMN dysfunction)

+2 Normal

+3 Hyperreflexia

+4 Hyperreflexia with transient clonus (UMN dysfunction)

+5 Hyperreflexia with sustained clonus

C5Biceps ReflexRest pt. arm on yours, dont hold

Find biceps tendon with doctors hand, doctor places thumb over pt. tendon and strike

thumbstrike in the wristShould see quick flexion

Positive finding:

Hyporeflexia: LMN dysfunctionupper motor neuron lesion/dysfunctionIndicates: C5 spinal radiculopathy or lesion to musculocutaneous nerve

Hyperreflexia: UMN dysfunctionClonus: violent/spastic paralysis

*Not always lesionlook for consistency


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C6Brachioradialis reflexArm out, fist, bring wrist up to find tendon

Flat part of hammer

Positive findings: hyporeflexia

Indications:C6 spinal radiculopathy or radial neuropathy; LMN dysfunctionC7TricepsExtend arm, have their arm drape over yours

Positive findings:Hyporeflexia-

Could indicate: C7 spinal radiculopathy, UMN dysfunction,

Radial neuropathy

Hyperreflexia- UMN dysfunction, possible corticospinal tract

L4Patellar tendonKnee jerk reflexCan feel for tendon on thigh if feet on floor

Positive findings:

Hyperreflexia-UMN dysfunction, corticospinal tract

Hyporeflexia-LMN dysfunction

L5SemitendinosisProne or seatedHit hammer of finger

IF prone, flex knee to find tendonmay not see it, so feel

Postitive findings:

Hypo: LMN or L5 spinal nerve dysfunction/lesionHyper: UMN

S1Achilles TendonDorsiflex the ankle, hold

Positive findings:

~a grade of 2/5 (hyper) would indicate UMN dysfunction, or corticospinal tract

dysfunction


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Testing Light Touch verses PainNo pinwheeluse needle for sharp, cotton for light touch

Remember:Anterior spinothalamic tract: Light touch (AL!)

Lateral spinothalamic tract: Pain

~L afferents to DRG-cross immediatelyFinal: R (opp.) lateral spinothalamic tract

Posterior (Dorsal) Column: 3 functions (stops before medulla which is where it

crosses)

1) 2 point discrimination

2) vibration sense

3) joint position sense

* * * Test distal to proximal because symptoms progress distall y

Light Touch (ant. ST Tract)

Use cotton ballOne side vs. another, touch dermatomes (not testing them)

*Touch L foot, processed through R ant. Tract, R foot, L ant. TractTest along Dermatomes, butNOTtesting dermatomes

One side verses another

At least 2 fingers, 2 toesDoctor say: Point to where you feel

*Light touchis passing through the R hand, to L brain through the anterior

spinothalamic tract (crosses immediately!)

*Painfrom R hand to L brain, through the Lateralspinothalamic tract

Vibration Sense128 hz Tuning fork (bigger)*At least 2 fingers and 2 toesTest vibration at different points following dermatomes (again, NOT testing dermatomes)

Doctor say: tell me when it stops

Testing Posterior columns*From R foot to L brain, R fasciculus and cuneatus (Same side!)

Look for asymmetrical sensitivity

R axillary nerve lesion or axillary nerve (could be peripheral nerve)Passes from L foot, processed R posterior column

Ex: L fasciculus gracilis to Medulla and then R

*Same side until Medulla and then crosses


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*Review:

~Anterior spinothalamic tract (L.touch) and Lateral spinothalamic tract (pain) cross right

away so lesion would be opposite from side of positive finding~Posterior columns (Vibration sense) are detected on the ipsilateral sidedoesnt cross

until medulla

6.3.10Dorsal Columns:

1)2 point discrimination2) vibration sense3)joint position sense

*Always test both upper and lower extremity!

Joint Position Sense(Dorsal columns)1)

StatognosisPatients ability to recognize up or down position of joint

Test at least 2 fingers and 2 toesPositive finding: inability to discern whether the joint is up or downIndication: astagnosis: damage to posterior columns

*WORK PROXIMALLYMCP, Wrist, elbow

2) ArthrostesiaMoving.Not moving

Positive finding:

inability to distinguishIndication:

anarthrostsia-inability to sense joint moving or not

Posterior column damage

3)

GraphesthesiaAsk patient to discern shapes, letters, numbers, etc.Doctor outlines on Pt. hand

Positive finding: unable to determine shape

Indication: Posterior column dysfunction*Position yourself with them so you dont draw upside down

***1 on each hand, 1 on each foot, different shape each limb

Exs: Star, heart, triangle, square, 8

4) StereognosisIdentify household objects: (make sure common)Exs: Key, rubberbanc, quarter, paperclipPositive finding: cant determine what the object is

Indication: posterior column dysfunction


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6.9.10

Pathological ReflexesTo remember: T-up, Ho-down (Traumners and Hoffmans)

*For a normal person, pick three of your favorite path. reflexes

Upper ExtremityHoffmans ReflexHold wrist, bring middle finger up, tap finger nail (dorsal)

*test 2nd

and 3rd

digits of both handsPositive finding:flexing all fingers and thumb (claw)

Indications: UMN or corticospinal tract dysfunction

Traumners ReflexGrasp on side of digit (2 and 3 both hands), flick ventral finger up

Positive finding: flexion of fingers (claw)Indications: UMN or corticospinal tract dysfunction

Rossilimos ReflexHave patient supine (hands and feet)

Tap on metacarpal or metatarsal heads

Positive finding:violent flexion of fingers and/or toes

Indication:UMN/corticospinal dysfunction

Lower Extremity

Babinski ReflexUse butt end of reflex hammer

Place pressure on the bottom of pt. foot starting from heel and circle along the lateral

aspect of the foot to the 1stmetatarsal head. (a curve)

Positive finding:Hyperext of the big toe and fannin of all other toes, abduction.

Indication:UMN lesion, interruption of reflex arc, most likely an interneuron orcorticospinal tract dysfunction

*Hyperflexion is not a positive finding. Youll see if you push too hard.

*This reflex will be positive for a baby until about 1 -2 yrs.

Gondas Reflex

*This Lil piggy gonda market*Hoffmans but for lower extremity!

Hold middle toe up and flex it, tap the toenail with your finger, or you can just flex thetoe. Test two toes on each foot.

Positive Finding: Babinski reflex (fanning out of toes)


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Oppenheims Reflex*Use knuckles to slide down the medial tibiaPositive finding: Babinskys sign

Indication:UMN, corticospinal tract lesion

Chaddocks Reflex*Socks off

Use butt end of reflex hammer, press around and under the lateral malleolusPositive finding: Babinskys sign


Schaeffers ReflexKnees bent, pinch the back of ptsAchilles tendon

Positive finding:Babinskys signIndication:UMN, corticospinal tract lesion

Gordons ReflexSqueeze calvesPositive finding: Babinskys sign


*My dads name is Gordon and he has big calves cuz he runs! ;)

Mendel BechterewKnees straight, tap on cuboid with point part of reflex hammerPositive finding: Clawing (most others babinsky)

Indication:Corticospinal tract between thoracic and lumbar spine

Babinski sign Toe-Clawing

Schaffers Reflex

Gordons Reflex

Chaddocks Reflex

Oppenheims Reflex

Babinski Reflex

Gondas Reflex

Mendel Bechterew

Traumners

Rossilimos

Hoffman (2,3rd

fingers of hand)


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Jaw JerkAka: Mandibular reflex

*DTR for trigeminal nerve*Use Wexler scale

Rest ptschin on index finger, place thumb below lower lip. Tap on your thumb with

reflex hammer*Jaw should slightly close

Positive finding:Hyporeflexia, hyperreflexia

Indication: Hypo: LMN or trigeminal nerve dysfunctionHyper: UMN or corticobulbar tract dysfunction

Chvosteks SignTap on cheek bone

*Not a test for the parotid gland or facial nerve. Tap where facial nerve is superficial.

Positive finding:Pt. will show facial expressions

Indication: Lesion to CN VII. If facial expressions on only one side, indicates facialnerve lesion

Superficial Abdominal Reflexes*Should have them!

*Testing T7-T12 spinal nervesUse butt of hammer

Stroke out from umbilicus to all four quadrants. Look for umbilicus to jerk or deviate

from where you are applying the stimulus

Positive finding: No deviationIndication:adipose tissue, baby, UMN or corticospinal tract dysfunction

Scenario: If L upper quadrant is the only one without reflex, indicates LMN spinal nervelesion to T7, T8, T9 on the left*If lower quadrant, T10, T11, T12

Beevors Reflex*Another for superficial abdominal reflexes

Have Pt. do a crunch

Look at umbilicusshould stay relative to midlinePositive finding:May deviate to one side if asymmetrical muscle weakness

Indication: LMN lesion to T7-T12 spinal nerves*The lesion will be 180 degrees away from the umbilical deviation. Polar opposite!

Scenario:If umbilicus deviates to UL quadrant, there is an issue with the R T10-T12

spinal nerves


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Heart, Lung & Abdomen

Heart Percussion

Instruction: Patient supine, relax, breathe normallyDr: Percuss 3 strips from Right axillary area toward sternum followed by 3 strips startingat lower left quadrant moving medial to lateral and inferior to superior toward the heart


Dullness outside normal area Cardiomegaly: hypertrophic cardio myopathy or

dilated cardio myopathy

Heart PalpationInstruction: Patient supine, relax, breathe normally

Dr: Palpate at 6 points: Aortic, Pulmonic, Erbs, Mitral, Bicuspid, Epigastic


Heaves, lifts or thrills Cardiac heart failure

At location 2 Valvular stenosis

At location 3 Cardiomegaly (ectopic)

Heart Auscultation

Instruction: Patient supine, relax, breathe normallyDr: Listen at 5 points: Aortic, Pulmonic, Erbs, Mitral, Bicuspid


Murmurs, clicks, snaps

At location 1 Valvular Stenosis

At location 2 Regurgitation

S3 heart sound Possibly normal if patient is < 40, Well trained athlete,

dilated cardiomyopathy

S4 heart sound Well trained athlete, hypertrophic cardiomyopathy

Chest Excursion

Instruction: Patient seated, relax, inhale and exhale completely

Dr: place thumbs at T10 take tissue slack L to M


Asymmetry Fibrosis of lung, pleural effusion, lobar pneumonia


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Chest ExpansionInstruction: Patient seated, relax, breathe in

Dr: tape measure at nipple line


< 2 in males< 1 in females

Aukylosing spondylitis or lung pathology

Lung InspectionInstruction: Patient supine, relax, breathe normally

Dr: Percuss at least 7 points bi-laterally


Pectus Excavatum Hollow chest

Pectus Carinatum Pigeon chest

Cynaotic (blue in color) blue bloater, member of the blue man group

Barrel chested

pink puffer, pursed lips, emphysema

Lung Percussion

Instruction: Patient seated, relax, breathe normallyDr: Percuss at least 7 points bi-laterally


Dullness Tumor, pneumonia, consolidation

Tympanic/hyper-resonant Emphysema, pneumothorax

Lung Fremitus (Palpation)

Instruction: Patient says Toy boat or ninety-nineDr: Feel for vibrations at 3 places bi-laterally


Increased fremitus (vibration) Consolidation of pneumonia or cancer

Decreased fremitus (vibration) Pleural Effusion, pneumothorax, emphysema


28/30

Lung AuscultationInstruction: Patient supine, relax, breathe normally

Dr: Palpate at 6 points: Aortic, Pulmonic, Erbs, Mitral,Bicuspid, EpigasticNormal Response: no extra lung sounds

Positive Findings IndicationsRales, crackles (discontinued dots) Pneumonia, atelectasis

Wheezes (whistling) Asthma, bronchitis

Rhonchi (gurgle) COPD or tumor

Stridor (continuous high pitch) Airway obstruction by laryngeal tumor

Abdomen Inspection

Instruction: Patient supine, knees bent, relax, breathe normally

Dr:


Visible peristalsis

Intestinal obstructionIncreased pulsations Aortic aneurysms

Bulging flanks Ascites

Distension Fat, fluid, feces

Abdomen AuscultationInstruction: Patient supine, relax, breathe normally

Dr: Listen in all for quadrants for at least 1 minute


Bruits Hypertension

< 5 bpm

Paralytic ileus, obstruction> 34 bpm Early obstruction, gastroenteritis, hunger

Abdomen PercussionInstruction:

Dr:


Large area of dullness Organomegaly, Tumor, ascites

Abdomen Palpation

Instruction:Dr:


Masses or pulsation cancer, aneurysm

Hepatomegaly cirrhosis, hepatitis

Splenomegaly mononucleosis, hematolytic anemia

Kidney Pain/tenderness kidney stones, severe UTI


29/30

Rebound TendernessInstruction: Im going to press lightly on yourbelly in four spots. Please let me know if

you experience any pain or tenderness.Dr: Perform rebound tenderness test on each quadrant.

Positive Findings IndicationsPain upon quick release Peritonitis

Rovsings SignInstruction: Im going to press lightly on your lower belly here on the left side. Please

let me know if you experience any pain or tenderness.

Dr: Perform rebound tenderness test on the lower left quadrant.


Rebound tenderness from LLQ

increased pain in LRQ

Appendicitis

Psoas/Obturator SignInstruction: Im going to be bending your right leg, please let me know if you experience

any pain or tenderness.

Dr: Standing on patients right side, ask patent to flex the leg on the hip againstresistance. If doing obturators sign, flex the thigh on the hip and internally rotate the

hip.


Pain in RLQ Appendicitis

Murphys SignInstruction: Im going to be placing my hand just under your rib cage and applying slight

pressure while you take a deep breath. Please let me know if you experience any pain ortenderness.

Dr: Doctor places gentle pressure at right mid-axillary line just beneath the rib cage and

increases pressure during patients inspiration.


Increase in pain with sudden stop of

inspiration when palpating gallbladder

Acute cholecystitis


30/30

Murphys PunchInstruction: Im going to be pressing my fist against your back in two places. Please let

me know if you have any pain or tenderness.Dr: Doctor places his/her hand over the kidneys and punches gently with the ulnar side of

fist.


Pain in kidneys upon punch Glomerulonephritis, kidney infection, Lumbar

subluxation/pain

Jar Test

Instruction: Please stand on your toes and drop down onto your heelsDr: Stand close enough to catch patient if they are unstable. Watch for pain indicators


Pain in abdomen upon dropping or

striking heels

Peritonitis, appendicitis

Date post:	02-Jun-2018
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IPES Lab Book - Quick and Dirty Edition (WIP)

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