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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?
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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)
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
< 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)
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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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
Indication:UMN, corticospinal tract lesion
Schaeffers ReflexKnees bent, pinch the back of ptsAchilles tendon
Positive finding:Babinskys signIndication:UMN, corticospinal tract lesion
Gordons ReflexSqueeze calvesPositive finding: Babinskys sign
Indication:UMN, corticospinal tract lesion
*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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
< 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
Positive Findings Indications
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
Positive Findings Indications
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
Positive Findings Indications
Increased fremitus (vibration) Consolidation of pneumonia or cancer
Decreased fremitus (vibration) Pleural Effusion, pneumothorax, emphysema
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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:
Positive Findings Indications
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
Positive Findings Indications
Bruits Hypertension
< 5 bpm
Paralytic ileus, obstruction> 34 bpm Early obstruction, gastroenteritis, hunger
Abdomen PercussionInstruction:
Dr:
Positive Findings Indications
Large area of dullness Organomegaly, Tumor, ascites
Abdomen Palpation
Instruction:Dr:
Positive Findings Indications
Masses or pulsation cancer, aneurysm
Hepatomegaly cirrhosis, hepatitis
Splenomegaly mononucleosis, hematolytic anemia
Kidney Pain/tenderness kidney stones, severe UTI
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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.
Positive Findings Indications
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.
Positive Findings Indications
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.
Positive Findings Indications
Increase in pain with sudden stop of
inspiration when palpating gallbladder
Acute cholecystitis
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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.
Positive Findings Indications
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
Positive Findings Indications
Pain in abdomen upon dropping or
striking heels
Peritonitis, appendicitis