Clinical Sciences Diagnosis Laboratory Manual July 2008

CLINICAL DIAGNOSIS LABORATORY MANUAL
FOREWORD
The purpose of this Clinical Sciences Laboratory Manual is to serve as a starter kit to help the student build a solid foundation of skills that will be utilized throughout your education at Life University. This manual cannot be used as a sole reference source for state boards or national boards. All reference sources for boards should be obtained from that individual state or the National Board of Chiropractic Examiners (NBCE). Any examination or testing procedure that you are taught in class that is not listed in this manual may also be used for testing and should be referenced in the required textbook for that course. This manual does not exclude you from reading or using the textbook(s) required or recommended in each respective course. If this manual is lost, misplaced, stolen, or missing for any reason you will be required to obtain another copy from the library and not from your lecture instructor or the Clinical Sciences Division. Each course will have further instructions or addendums to include to this packet so please ensure that you understand what is expected of you for your course. Good luck as you proceed in your journey through Life University and in Chiropractic!!
CLINICAL SCIENCES DIVISION
VISCERAL DIAGNOSIS
DIAG 2725
COURSE OUTLINE
WEEK 1
HOUR 1 Introduction to course Discuss laboratory syllabus Discuss final examination Necessary equipment for course Explain the concepts of inspection, palpation, percussion, and auscultation Suetm sr dn h l t eet o ( sys t n ute it e u t b k MobGuide to Physical d s a e cr x o Examination, 5th edition) the following items before coming to class Week 2: * * * * * * HOUR 3 HOUR 4 Inspection Palpation Percussion Auscultation Measurement of Vital Signs Blood Pressure Measurement Chapter 3, pg. 53-54 Chapter 3, pg. 54 Chapter 3, pg. 54-56 Chapter 3, pg. 57 Chapter 3, pg. 57-60 Chapter 14, pg. 476-480
HOUR 2
Perform and explain the Blood Pressure and Vital Signs Student Practice
WEEK 2
HOUR 1 HOUR 2 Blood Pressure/ Vital Signs practice Teach Gowning for Head and Neck Exam Perform and explain the Head and Neck Exam Student Practice Clinical Integration of the Head and Neck Exam
HOUR 3 HOUR 4
WEEK 3
HOUR 1 HOUR 2 HOUR 3 HOUR 4 Blood Pressure/ Vital Signs practice Perform and explain the Vascular Exam Teach Blood Vessels for Vascular Exam/Gowning Student Practice Clinical Integration of the Vascular Exam
WEEK 4
HOUR 1 HOUR 2 HOUR 3 HOUR 4 Blood Pressure/ Vital Signs practice Perform and explain the Chest and Lung Exam (Posterior) Student Practice Clinical Integration of the Chest and Lung Exam (Posterior)
WEEK 5
HOUR 1 HOUR 2 HOUR 3 HOUR 4 Blood Pressure/ Vital Signs practical Blood Pressure/ Vital Signs practical Perform and explain the Chest and Lung Exam (Anterior) Student Practice
WEEK 6
HOUR 1 HOUR 2 HOUR 3 HOUR 4 Clinical Integration of the Chest and Lung Exam (Anterior) Review Perform and explain the Heart Exam Clinical Integration of the Heart Exam/ Student Practice
WEEK 7
HOUR 1 HOUR 2 HOUR 3 HOUR 4 Perform and explain the Abdomen Exam Student Practice Continue the Abdomen Exam Clinical Integration of the Abdomen Exam/Student Practice
WEEK 8
HOUR 1 HOUR 2 HOUR 3 HOUR 4 Review Student Practice Clinical Integration Student Practice
CLINICAL SCIENCES DIVISION 5
WEEK 9 & 10
HOURS 1-4 Testing
Laboratory Examinations
1. Each student will perform one of the following or any area of the following examinations during the final laboratory practical: Vascular examination, Head and Neck (combined as one exam) Chest and Lungs Heart Abdomen
2. The purpose of the examination is to apply practical examination techniques and as well as integrative analysis upon patient presentation up to the level of instruction at this point. Clinical application will be introduced in class and integrative thinking will be demonstrated. 3. Each student has 12 minutes to complete the entire examination process. The format of each exam must be followed exactly to receive full credit. Any deviation from the order will result in a five point reduction. 4 T e t et i b g e a ili s xm nt no e f t s dn s b i tpoe y s s v a . h s dnwl e i n v as n ea i i tvryh t et ait o rpr as s il u l v t g ao i e u ly l e t signs. The vital signs exam is worth 10 points of the practical examination. Partial credit may be given at t i t c r d c t n K o l g o t m wlb epc d h n r t i r i . nwe e fe s i e xet . e su o s s eo d r l e 5. Laboratory final examinations, including the vital signs examination, are worth 50 points totally. The maximum points for lab is 50 points which will come from the practical exam (vitals (10 pts.) and practical (40 pts). Students that are unable to demonstrate hands on proficiency during the practical will not be allowed to pass the class even if their total points are passing. Students must have a passing grade in both the lecture and the lab to complete and pass the class successfully. 6. The student is responsible for adequate preparation for the final examination. 7. If a student does not show up to take the final laboratory examination during their assigned time, the only acceptable excuses are those listed in the Student Handbook, Section II; Excuses. 8. The student is only allowed to miss 4 lab classes = 8 hours of lab (excused or unexcused). Missing 5 or more classes will result in an automatic failure of the lab course and the student will not be allowed to tk te ia l oaoy rc clIite tdnrso s it t ke u wt te t i ta a eh f la rtr pat a tsh s et ep ni ly o ep p i h mae a h t n b i . u s bi h rl is presented during their absences.
Laboratory Decorum
1. Students in this lab are expected to be both Doctor and patient. T el s ai i Mob P yi l xmiai H n b o ,th edition, demonstrates the amount of h iut t n n sys h s aE a n t n a d ok 5 l r o c o patient exposure for each examination as will be demonstrated in lab. 2. While participating in lab, students will be expected to gown their patient properly as well as be able to demonstrate proper gowning technique for a male as well as a female patient. 3. The final lab may be administered by any Clinical Sciences Laboratory Instructor.
Contributing Source
MO B G I ET S YS U D O PHYSICAL EXAMINATION (Seidel, Ball, Dains, Benedict)
Equipment for Course

1. Adult Blood Pressure Cuff 2. Stethoscope Bell & Diaphragm 3. Eyebrow marking pencil 4. 2 Gowns (oversized velcro fasteners) 5. Thermometer 6. Sterile covers for thermometer 7. Watch 2nd hand 8. Underwear/shorts Men boxer briefs Women bikini panty 9. Small tape measure cloth
GREETING A PATIENT
Hello, I am _____________________________. I will be conducting a patient examination today. Anything we discuss during this visit will be completely confidential. Iyu ae n qet n o cne dr goaapi m n p ae o ohs to ask. f o hv ay usos rocr ui t ys po t et l s d nt eitate i n n d n ,e If at anytime you experience any discomfort or pain during the examination, please let me know. Do I have your permission to proceed?
Before I begin any physical examination on my patient, I will assess my ptn s ili s I i c aet v as n. wl heck the pulse for rate, rhythm, amplitude, i t g l and contour, respiratory rate, temperature, and blood pressure.
Vital signs
1. Pulse Rate Rhythm Amplitude Contour 2. Respiratory Rate 3. Temperature 4. Blood Pressure
Vital signs Explanation

Pulse Palpate each arterial pulse for the following: 1. Rate Pulsations per 60 seconds Resting pulse rate for a normal adult should be between 60 to 90 pulsations per minute 2. Rhythm Regularity of the heart pattern. An irregular heart pattern, which then continues in the same regular pattern over and over, may indicate sinus arrhythmia. A pattern less, unpredictable rhythm may indicate heart disease. 3. Amplitude Height or intensity of the pulse. Measured using the following scale: 4 = bounding 3 = full 2 = expected 1 = diminished 0 = absent 4. Contour Description of the pulse wave in a healthy artery. Should be either rounded, smooth or domed shaped. Each wave is compared to the following wave for any differences.
Blood pressure
Pr hr m aue et fn ni da s a i ac capacity. e pe l esr n o a i v ul cr o sular i a m di dv
Respiratory rate
Wa hh re n f lfh ptn s hsw i t y r t . t t i ad a o t aet cet h eh be h c es l e i l e ae Count the number of cycles during 60 seconds.
Temperature
A ss etfn ni da s oye pr ue s s no a i v ul bd t e t . em di m ar Measured in one of the following ways: Oral Axillary Rectal Tympanic membrane: not reliable if the patient has tympanic tubes or implants.
Blood Pressure Explanation Palpatory Systolic

This should be performed before taking the auscultatory blood pressure. Helps to avoid errors of underestimating the systolic pressure. This event may occur if the patient has an auscultatory gap.
Place the blood pressure cuff so that:
Center of bladder is over the brachial artery (use cuff arrows as a guide). Inferior edge of the cuff should be 2-4 cm above the antecubital fossa. T e ufhu b su eog o t ptn s r ,o hth dc ra olgt-2 fingers up h cfsol e ng nuh n h aet a s t t ot cn n e1 d e i m a e o y underneath the inferior edge of the cuff. Establish the radial pulse, using the finger pads of the 2nd and 3rd fingers. Inflate the cuff pressure up until the radial pulse disappears. Quickly inflate the cuff 30 mm Hg above the level where the radial pulse disappeared. Release cuff pressure at approximately 3 mm Hg / second. The pressure where the radial pulse reappears is the palpatory systolic pressure.
Auscultation
Check both arms using the bell (or diaphragm) of the stethoscope. Wait 15-30 seconds before reinflating the cuff on the same arm. Place the bell of the stethoscope over the brachial artery. The arm should be level with the heart (if possible). Inflate the cuff 30 mm Hg above the palpatory systolic pressure. Release the cuff pressure 3 mm Hg / second. Listen for first loudest audible sound (Korotkoff) which indicates systolic b/p. Listen for the last loudest audible sound that indicates diastolic b/p. Normal adult blood pressure ranges: Systolic blood pressure 100-140 mm Hg Diastolic blood pressure 60-90 mm Hg Pulse pressure 30-40 mm Hg
Additional Blood Pressure Notes Technique

The patient should have rested for at least 5 minutes and ideally should not have eaten or smoked for 30 minutes. T eptn sa sol b r t g f eo c t n, n psi e s t th bah l r r ( t h aet r hu e e i , r f l h g ad oio d o h t r i a e a h i m d sn e oi tn a e c a ty t e antecubital fossa) is at heart level - roughly level with the 4th interspace at its junction with the sternum. Whnt ptn i sa d r t gt a o at l alt aoet ptn sw i i sib . h e h aets et ,e i h r n a e il bv h aet a ts u al T e e i e sn e m b te e i s t e ptn s w e oto uprt a m y a eh b o pesr aet o n f rtspoth r a r s t l d r ue i f e m i e o s . If the brachial artery is much below heart level, blood pressure appears falsely high.
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Cuff Size
Cuffs that are too short or too narrow may give false high readings. Using a regular size cuff on an obese arm may lead to a false diagnosis of hypertension. A loose cuff or a bladder that balloons outside the cuff leads to false high readings. Period of ventricular contraction. Pressure in the left ventricle rises rapidly, then levels off, and starts to fall as most of its blood is ejected from the left ventricle into the aorta and from the right ventricle into the pulmonary artery. Systole is indicated by the first heart sound, palpable apex beat and peripheral pulse. Period of ventricular relaxation. Ventricular pressure falls almost to zero, and blood flows from atrium to the ventricle. Late in diastole, ventricle pressure rises slightly during atrial contraction. Ventricular diastole begins with the onset of the second heart sound and ends with the onset of the first heart sound.
Systole
Diastole
Blood Pressure
Should be taken in both arms. Normally there may be a difference in pressure of 5-10 mm Hg. Pressure difference of 10-15 mm Hg suggests arterial compression or obstruction on the side with the lower pressure. Blood pressure readings tend to be higher in the right arm. The arm that has the higeted gi acp da bi t c ss t t ptn s reb o pesr hs r i s cet s e g h l eto h aet t l d r ue an e n e o e i u o s . Lack of symmetry between the left and right extremities suggests impaired circulation. Compare the strength of the upper extremity pulses with those of the lower extremities and the left with the right. Ordinarily, the femoral is as strong as or stronger than the radial pulse. If this is reversed or if the femoral pulsation is absent, coarctation of the aorta must be suspected. Coarctation of the aorta is a congenital stenosis or narrowing most commonly of the aortic arch. A silent interval that may be present between the systolic and diastolic pressure. Widens with systolic hypertension in elderly persons (loss of arterial pliability) or drops in diastolic pressure usually seen in chronic severe aortic regurgitation.
Auscultatory Gap
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Head and Neck Examination

Patient seated Neck exposed below the clavicles
Inspection
1. Hair Color Distribution 2. Head Position Tilt Rotation 3. Scalp Surface 4. Skull Size Shape Symmetry Condition 5. Face Shape Symmetry Structural abnormalities 6. Battle Sign 7. D Mue e Sign e st ts 8. Neck Symmetry of muscles Webbing Masses 9. Tracheal Position 10. Patient Swallowing 11. Distended Veins or Arteries 12. Skin Color Variations 13. Ranges of Motion
Palpation
1. Skull Symmetry Condition 2. Scalp Freely moveable 3. Hair Texture 4. Temporal Arteries Thickening or hardness 5. Hyoid Bone 6. Thyroid 7. Cricoid Cartilages
8. Patient Swallowing 9. Thyroid Gland 10. Tracheal Tug 11. Lymph Nodes (check for: size; consistency; mobility; condition) Occipital Postauricular Preauricular Tonsilar Submandibular Submental Facial Anterior cervical chain Posterior cervical chain Supraclavicular
Auscultation
Use bell of stethoscope to listen for arterial bruits 1. Temporal Arteries 2. Over Eyes (not recommended) Thyroid Gland (soft bruits) Patient seated with neck exposed
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Head and Neck Examination Explanation Inspection

1. Hair noting color and distribution Palpate the hairline behind the ears and crown of the head. It should be smooth, symmetrically distributed and have no split or cracked ends. Fine, silky hair is associated with hyperthyroidism. 2. Head Position Head should be held upright and still. Tilt Favors a good eye or a good ear with unilateral hearing or vision loss. Can also be shortening of the sternocleidomastoid muscle (torticollis). Rotation Head should be centered over the neck and trunk. 3. Scalp surface Lesions, scabs, parasites, nits and hair loss. 4. Skull Size, shape, symmetry and condition. 5. Face Shape and symmetry At rest, movement and expression. Look for tics, muscle spasms, edema, puffiness, lack of expression and/or excessive perspiration. Structural abnormalities Of the mouth, eyelids, eyebrows and nose. 6. Battle sign Bruising over a mastoid Cause: Skull fracture. 7. DeMusette sign Jerking and bobbing of the head. Associated with: Tremor Nodding movement synchronized with the pulse indicates aortic insufficiency. 8. Condition of the neck Symmetry of muscles SCM and trapezius muscles. Webbing: Chromosomal anomalies. Masses: Enlarged thyroid gland. Edema: Local infection. 9. Tracheal position The trachea should be centered with no lateral deviation or pulsations.
10. Patient swallowing Space occupying lesion. Thyroid tissue that glides upward when swallowing may be enlarged thyroid. 11. Distended veins or arteries Hypertension. 12. Skin color variations Variations according to race, sex, and body type. Some slight asymmetry is common. 13. Ranges of motion Movement should be smooth, painless, and not cause dizziness. Flexion, extension, rotation, and lateral bending.
Palpation
1. Skull Gentle rotary movement noting symmetry & smoothness. Bones are indistinguishable. Ridge of sagittal suture may be felt on some people. 2. Scalp Freely moveable on skull with no tenderness, swelling or depression on palpation. 3. Hair texture Palpate the hairline behind the ears and crown of the head. It should be smooth, symmetrically distributed and have no split or cracked ends. Fine, silky hair is associated with hyperthyroidism. 4. Temporal arteries Thickening or hardness. If thick and hard it is a possible temporal arteritis. 5. Hyoid bone Located adjacent to C3. 6. Thyroid and cricoid cartilage Located adjacent to C4 & C5 for thyroid cartilage and C6 for cricoid cartilage. 7. Patient swallowing Thyroid cartilage movement should be smooth, painless, symmetrical and midline. It should be smooth and rhythmic. There should be no need to swallow twice. Difficulty in swallowing may be an enlarged thyroid gland or a space-occupying lesion in the anterior spine. 8. Palpate thyroid gland Noting nodules, tenderness, size, shape, configuration, consistency, and tenderness.
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9. Tracheal tug Use the thumb and 2nd finger to palpate each side of the trachea just below the thyroid isthmus. If a downward tug sensation is felt with a synchronous pulse, this is evidence of an aortic aneurysm. 10. Lymph nodes (size; consistency; mobility; condition) Occipital nodes at the base of the skull Postauricular nodes located superficially over the mastoid process Preauricular nodes located in front of the ear Tonsillar nodes at the angle of the mandible Submandibular nodes halfway between the angle and the tip of the mandible Submental nodes in the midline behind the tip of the mandible. Facial nodes located in the maxillary region Anterior cervical chain nodes at the anterior border of the SCM Posterior cervical chain nodes along the posterior border of the SCM Supraclavicular nodes located just above the clavicle
Auscultation
1. Temporal arteries for bruits (Bell) 2. Over the eyes (Bell) 3. Thyroid gland for soft bruits (Bell) If a hypermetabolic state is present, there will be an increased blood supply in the area.
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Patient is supine Patient is disrobed to the waist
Vascular Examination
Inspection
1. Venous Pulsations in the Jugular Veins (45 angle) 2. Fundoscopic Exam 3. Skin Color 4. Skin Thickness 5. Finger and Toe Nails 6. Hair Condition on the Extremities 7. Ulcerations 8. Edema 9. Stasis Dermatitis 10. Path of the Greater Saphenous Vein: Tortuosity Dilation 11. Path of the Lesser Saphenous Vein: Tortuosity Dilation
Palpation
1. Arterial Pulses (Palpate the following arteries for: rate, rhythm, amplitude, contour) Carotid Abdominal Aorta Subclavian Femoral Brachial Popliteal Radial Dorsalis Pedis Ulnar Posterior Tibialis 2. Palpate Arterial Wall Thickness (not recommended) 3. Skin Temperature of the Extremities 4. Edema (pitting; ankle region)
Auscultation
1. Arterial Bruits (bell of the stethoscope) Temporal Carotid Subclavian Abdominal Aorta Femoral 2. Venous Hum (bell of the stethoscope) Epigastrium Base of the neck (bilateral)
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Vascular Examination Explanation

Inspection
1. Venous pulsations in jugular veins Patient must be in a reclining position at a 45-degree angle. Reliable indication of the volume and pressure in the right side of the heart Variation may indicate: Right ventricle fails because of left ventricular failure Constrictive pericarditis Superior vena cava obstruction. Observe the left and right jugular veins for symmetry. Distention on one side only suggests a localized abnormality. When the vein pressure increased because of intracardiac events, the veins are distended bilaterally. 2. Funduscopic exam: Red light reflex Disc/cup ratio Vessels General background Macula 3. Skin color Variations according to race, sex and body type: Pallor: White Rubor: Red Cyanosis: Blue Jaundice: Yellow 4. Skin thickness Areas of pressure (callus) such as the palms, soles of the feet and elbows. Note whole body for moles, eczema, scars, keloids, psoriasis, seborrhea and ulcerations. 5. Abnormalities of the finger and toe nails Paronchia: Hang nail Clubbed nails: Respiratory or heart problems Spooned nails (Koilonchia): Iron deficiency anemia, fungal infection, hypothyroidism Pitted: Psoriasis Broad and flat: Secondary syphilis 6. Hair condition on extremities Note the color, quality and quantity of the hair. Note for hair loss, which can be either localized or generalized. Note for inflammation of hair follicles.
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7. Ulcerations crater-like circumscribed lesion of the skin resulting from tissue death (necrosis) A Accompanies some infectious, inflammatory or malignant conditions. 8. Edema Swelling resulting from an excessive accumulation of serous fluid in the tissues of the body. Possible Causes: Venous obstruction Increased capillary fluid pressure Renal failure Congestive heart failure Corticosteroid usage Inflammatory responses 9. Stasis dermatitis Persistent inflammation of the skin of the lower legs with a tendency toward brown pigmentation Commonly associated with venous incompetence. usual consequences are increased edema, secondary bacterial infection, and eventually ulceration. The 10. Pathway of Greater Saphenous Vein Starting at the medial malleolus, medial calf, medial knee, medial thigh and ends at the femoral vein. Tortuosity: Having many twists and turns. Dilation: To become wider. 11. Pathway of Lesser Saphenous Vein Starting at the lateral malleolus, posterior calf and ends at the popliteal vein. Tortuosity: Having many twists and turns. Dilation: To become wider.
Palpation
Use the distal pads of the second and third fingers. Palpate firmly however do not occlude the artery. The thumb may be used to feel for the brachial and femoral pulses due to the tendency of the arteries to move or roll during palpation.
1. Arterial pulses (feel for these qualities): Rate: Count the number of pulsations for 60 seconds or count the number of pulsations for 30 seconds and double the count. Average resting pulse rate 60 to 90 pulsations per minute. Rhythm: The regularity of the heart pattern. An irregular heart pattern, which continues in a regular pattern, may indicate sinus arrhythmia. Patternless, unpredictable rhythm may indicate heart disease. Amplitude: The height or intensity of the pulse. Measured using the following scale: 4 = bounding 3 = full 2 = expected 1 = diminished 0 = absent
Contour The description of the pulse wave in a healthy artery. Should be either rounded, smooth, or domed shaped. Compare each wave to the following wave for any differences. 2. Feel for the following arterial pulses: Carotid: In the neck, just lateral to below thyroid cartilage at the level of C3. Do NOT palpate both CAROTID ARTERIES at same time. Subclavian: At base of neck, mid clavicular. Brachial: Just medial to biceps tendon. Radial: Lateral and ventral side of wrist. Ulnar: Medial and ventral side of wrist. Abdominal Aorta: One inch superior and one inch lateral to left of the umbilicus. Femoral: Inferior and medial to the inguinal ligament. Popliteal: Press firmly in popliteal fossa. Dorsalis pedis: Medial dorsum of the foot. Posterior Tibialis: Behind medial malleolus. 3. Palpate artery wall thickness Not recommended. Possibility exists of dislodging a piece of plaque from an artery wall. Skin temperature of extremities Use the back of the hand. Coolness or coldness to the touch may suggest reduced blood flow to that area. Increased heat may suggest inflammatory process or pooling of blood to an area. 4. Edema Swelling resulting from an excessive accumulation of serous fluid in the tissues of the body. Possible Causes: Venous obstruction Increased capillary fluid pressure Renal failure Congestive heart failure Corticosteroid usage Inflammatory responses
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Auscultation
1. Bruit Use the bell of the stethoscope and ask the patient to hold their breath. Bruits are low-pitched unexpected sounds that may indicate local obstruction or vigorous blood flow. Listen over the following area: Temporal Carotid Subclavian Abdominal aorta Femoral 2. Venous hum Use the bell of the stethoscope and ask the patient to hold their breath. The head should be turned to one side and titled slightly upward. When present it is a low-pitched continuous sound that is louder during diastole. Common in children and usually has no pathologic significance. It is caused by turbulent of blood flow in the internal jugular veins. In adults it usually occurs with: Anemia Pregnancy Thyrotoxicosis Intracranial arteriovenous malformation Must not be confused with carotid bruit, patent ductus arteriosus or an aortic regurgitation Listen over the following areas: Epigastrum - Area is located in the soft tissue just below the xiphoid process Base of neck Auscultate over the supraclavicular space at the medial end of the clavicle and along the anterior border of the SCM.
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Signs of Vascular Abnormalities

*Supplemental Notes for Lecture*
Arterial insufficiency
1. 2. 3. Decrease or absent pulse Pallor Coolness or coldness of extremity
Venous stasis
1. 2. 3. 4. 5. Normal pulses Normal color or cyanosis Normal temperature Pitting edema Stasis dermatitis
Signs Common to Both Arterial Insufficiency and Venous Stasis

1. 2. 3. 4. Atrophy of skin with hair loss Ulceration Pain Gangrene
Thromboplebitis
1. 2. 3. 4. 5. Palpate for tenderness P-A at calves Note any palpable cords Redness Heat (use back of hand) H ma s n o ns i g
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Signs of Vascular Abnormalities Explanation

Arterial Insufficiency
1. 2. Decrease or absent pulse Pallor A white color to the skin or mucous membranes. Causes: Edema Vasoconstriction Exposure to cold Severe pain Hemorrhage Shock and/or lack of breathing. 3. Coolness or coldness of extremity
Venous Stasis
1. 2. Chronic venous insufficiency manifested by edema and dilated superficial veins. Patient may complain of fullness, aching or tiredness in the leg or have no discomfort. Normal pulses Normal color or cyanosis A blue color of the lips, ears, nails of the hands and feet. Due to hemoglobin not bound to oxygen or possible pulmonary or cardiac difficulty. 3. Normal temperature 4. Pitting edema Excessive accumulation of interstitial fluid. Press index finger over medial malleolus for several seconds. A depression that does not rapidly fill and resume its original shape is evidence of orthostatic edema. Edema with thickening and ulceration of the skin = deep venous obstruction or valvular incompetence. 5. Stasis dermatitis Persistent inflammation of the skin of the lower legs with a tendency toward brown pigmentation. Indicates venous incompetence. The usual consequences are increased edema, secondary bacterial infection and eventually ulceration.
Signs Common to both Arterial Insufficiency and Venous Stasis

1. Atrophy of skin with hair loss Wasting away of the skin. 2. Ulceration A localized defect due to the sloughing off of inflammatory necrotic tissue. 3. Pain Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was palpated. May be classified as: Burning Gradual or sudden onset Dull Aching Sharp Lancinating Cramping Throbbing Knifelike
4. Gangrene Tissue death due to loss of blood supply. Followed by a bacterial infection and putrefaction (enzymatic decomposition producing a foul smelling odor).
Thrombophlebitis
Thrombosis and inflammation of the venous walls. May precede or follow clot formation. Causes: The lesion may occur without previous cause Mechanical or chemical trauma Suppurative disease Ischemia, anemia Polycythemia Leukemia. Positive sign is deep pain in the calf. 1. 2. 3. 4. 5. Palpate for tenderness at calves If thrombosis is present calf should be tender. Note any palpable cords If thrombosis is present the vein should be thicker. Redness If thrombosis is present calf should be red. Heat Use the back of the hand. If thrombosis is present calf should be hot. H ma s n o ns i Source Cipriano pp 360-360f. g Instruct: Ptnsp e E a i ra e ptn se apoi a l3 dges i aetui . xm n r ss aet l prx ty 0 er wt i n e i i g m e e h ke iet s nE a i rhn osl e t ptn sotn suee t nen x ni . xm n t drf xsh aet fo ad qezsh e o e e ie e i e calf. (There are sources that Do Not recommend squeezing the calf due to danger of thrombus formation possibly being released into the venous system.) Positive: Deep pain in the calf. Indicates: Thrombophlebitis
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Examination of the Chest and Lungs
Patient is seated and disrobed to the waist for: Inspection, palpation, percussion, and auscultation of the posterior thorax Inspection and auscultation of the anterior The patient is supine for: Palpation and percussion of the anterior thorax T e ai t ams r cosda dlt for: h p t n r ae rs e s e n ied f Exam of the posterior thorax (at least for the examination of the triangles of auscultation)
Inspection (anterior & posterior)

1. Thoracic landmarks 2. Anterior to Posterior Diameter 3. Respiration 4. Symmetry of Thoracic Cage Movement 5. Inspect the ribs 6. Inspect the Intercostal Spaces (ICS) 7. Dyspnea 8. Flaring of the Alae 9. Breath odor 10. Accessory Muscle Use 11. Flushing of the Skin 12. Pallor 13. Cyanosis 14. Cicatrix 15. Skin Lesions 16. Vascular Abnormalities 17. Clubbing of the nails
Palpation (posterior)
1. 2. 3. 4. 5. 6. 7. Pain Tenderness Masses Sensations Further Assess Any Abnormalities Found Tactile Fremitus Respiratory Excursion (T8-T10 region, posterior)
Percussion (posterior)
1. Begin at the Lung Apices 2. Compare Side-to-Side 3. Determine Diaphragmatic Excursion
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Auscultation (posterior, then anterior)

1. Patient is Directed to Breath through their Mouth 2. Listen for These Characteristics: Pitch Intensity Duration 3. Listen for Normal Breath Sounds: Vesicular Bronchovesicular Bronchial 4. Listen for Adventitious Breath Sounds: Crackles Wheezes Rubs 5. Vocal resonance (doctor has the patient recite words) Bronchophony Whispered pectoriloquy Egophony
Palpation (anterior, with patient supine ALL of chest wall on male exclude breast area on female)
1. 2. 3. 4. 5. 6. 7. Pain Tenderness Masses Sensations Further Assess Any Abnormalities Found Trachael Position Lymph Nodes: Supraclavicular Infraclavicular Epitrochlear
Lateral axillary Medial axillary Anterior axillary Posterior axillary
8. Costochondritis 9. Possible Rib Fractures (can also use: 128 Hz tuning fork)
Percussion
(anterior, with patient supine)
1. Begin at Lung Apices 2. Compare Side-to-Side 3. Identify the Location of: Liver (2 marks) Gastric air bubble (1 mark) Spleen (1 mark)
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Chest and Lungs Explanation
Patient is seated and disrobed to the waist for: Inspection, palpation, percussion, and auscultation of the posterior thorax Inspection and auscultation of the anterior The patient is supine for: Palpation and percussion of the anterior thorax T e ai t ams r cosda dlt fr h p t n r ae rs e s e n ie o: fd Exam of the posterior thorax (at least for the examination of the triangles of auscultation)
Inspection (anterior and posterior)

1. Thoracic Landmarks Compare structures across the midsternal line for equality in: Size Shape Symmetry The chest is usually not absolutely symmetrical, but one side can compare to the other. 2. Anterior to Posterior Diameter: normal ratio is 1:2 Barrel Chest The ribs are more horizontal. The spine at least somewhat kyphotic and the sternal angle is more prominent. Note the A-P vs. lateral diameter (normal is 1:2, emphysema 1:1). Cause: compromised respiration as in chronic asthma or emphysema. Pectus Carinatum (pigeon breast) Prominent sternum Hepato-splenomegaly frequently occurs in rickets, the abdomen becomes distended and the lower ribs may be pushed anteriorly, causing a transverse groove just above the costal arch. This forward projection of the sternum is often asymmetrical. Cause: congenital problem or rickets. Pectus Excavatum (funnel chest) The lower part of the sternum is deeply depressed backward, producing an oval hollow in the lower sternum and upper epigastric regions. This does not appear to produce disturbances in vital functions. Prominent sternum Cause: congenital problem or rickets. Rickets A systemic disease of the infant and young child. It is the childhood equivalent of osteomalacia in the mature skeleton. The essential pathological alteration involves deficiencies of vitamin D, calcium or phosphate. The classic vitamin D deficiency presentation develops between 6 months and 1 year of age. Symptoms consist of muscle tetany, irritability, weakness, delayed development, and small statue and bone deformities. The most notable clinical finding is multiple costocardial bumps (rachitic rosary). Flail Chest Injury to the chest wall and loss of rigidity causes a condition call Paradoxical Breathing: in which the chest wall goes in on inspiration and out on expiration. Cause: Three or more broken ribs at the sternum or the separation of several contiguous costal cartilage resulting in abnormal movement of that chest wall.
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Rachitic Rosary Soft tissue swellings occurring around the growth plates due to hypertrophied cartilage at the anterior ribcage. Cause: Only exists during the active rickets and heals without a trace. Gibbus Deformity Angular kyphosis Extensive disintegration of discs and wedging of the involved vertebrae. Causes: Secondary tuberculosis: may develop a reversal of the height/width ratio of the vertebral bodies. Normally weight bearing lumbar vertebrae in the human is wider than they are tall. In long standing gibbus deformity tremendous biomechanical stress is placed upon the uninvolved vertebral body immediately caudal to the gibbus. This stress may alter the appearance of this vertebra whereby it becomes taller than it is broad. Kyphosis Abnormally increased convexity in the curvature of the thoracic spine as viewed from the side. Scoliosis Lateral curvature of the vertebral column. 3. Respiration Rate is the number per minute with a normal of 10-20. Rhythm is the pattern; steady, even, uneven or thready. Effort is breathing without apparent distress. 4. Symmetry of Thoracic Cage Movement Observe the muscles used for normal breathing: Diaphragm Intercostals Trapezius 5. Inspect the Ribs Slope: The slope of the ribs should be down to the floor almost perpendicular (900). In a barrel chest the ribs are almost parallel to the floor. Motion: The ribs should rise and fall at the same time during inspiration and expiration. If one side of the rib cage is not expanding at the same time or with the same volume as the other rib cage, this may be an indication of a phrenic nerve problem. Local lag: One side of the diaphragm will lag behind, usually a phrenic nerve problem. 6. Intercostal Spaces (ICS) Bulging: Noted on expiration Causes: Air outflow obstruction or compression by a tumor, aneurysm, or enlarged heart. Retraction Noted on inspiration Causes: Significant air inflow obstruction, asthma, and bronchiolitis.
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7. Dyspnea Difficult and labored breathing. Shortness of breath commonly found in pulmonary or cardiac compromise. Tachypnea is greater than 20 respirations per minute Bradypnea is less than 10 respirations per minute, which may be normal for athletes. 8. Flaring of the Alae Ptn s otlf r aet nsi l e i rs a . Occurs during inspiration Common sign of air hunger, particularly when the alveoli are considerably involved. 9. Breath Odor S e t ptn s r t frn o t fl wn im : m l h aet be h o ay fh o o i t s le i a e l ge Foul odor: tonsillar and dental infections. Acetone odor: diabetics and individuals in starvation acidosis. Musty odor: severe liver disease. Alcohol odor: ingestion of alcohol or drugs. 10. Accessory Muscle Use The following muscles are recruited to help in the breathing process. These muscles stabilize the upper thoracic cage so it is not pulled down. Platysma Scalenus Muscles Sternocleidomastoid (SCM) Causes: Possible COPD 11. Flushing of the Skin A red color to the skin or mucous membranes. Cause: increased blood flow to an area due to muscle activity. 12. Pallor A white color to the skin or mucous membranes. Causes: Edema Vasoconstriction Exposure to cold Severe pain Hemorrhage Shock and/or lack of breathing 13. Cyanosis A blue color of the lips, ears, nails of the hands and feet Cause: Hemoglobin that is not bound to oxygen Possible pulmonary or cardiac difficulty
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14. Skin lesions Macules Papules Nodules Vesicles Bullae Pustules Scales
Localized changes in skin color. They may be small or large and are not palpable. Are solid and elevated and are less than 5mm in diameter. Are solid and elevated and are greater than 5mm in diameter. They extend deeper into the dermis or subcutaneous tissue levels. Accumulation of fluid between the upper skin layers, which produces, and elevation covered by a translucent epithelium. Their diameter is less than 5 mm. Accumulation of fluid between the upper skin layers, which produces, and elevation covered by a translucent epithelium. Their diameter is greater than 5 mm. Tiny abscesses in the skin or pus filled vesicles or bullae. Thin sheets of dried cornified epithelium, which clings to the epidermis.
15. Cicatrix Large scars from burns, operations or lacerations. May cause difficulty in chest expansion due to lack of skin elasticity. 16. Vascular abnormalities Appear as distention of veins and/or arteries. 17. Clubbing of the Nails The angle of the nail bed approaches or exceeds 1800 (normal angle is 1600). The mechanism for the occurrence of clubbing of the nails is unknown. Causes: Pulmonary disease Cardiovascular disease Bronchiectasis Cyanotic congenital heart disease Emphysema Subacute bacterial endocarditis Tuberculosis Secondary polycythemia Lung cancers Not as common: Cirrhosis, Colitis, Thyroid disease
Palpation (posterior)
Patient is seated There should be bilateral symmetry and some elasticity of the rib cage. The sternum and xiphoid should be relatively inflexible and the thoracic spine rigid. Begin at the apex of the lungs (Chronus isthmus) and continue over the trap muscles. At the interscapular area patient should cross their arms (Scapula moves outward) so that the ICS can be felt without hindrance of the scapula. Below the scapula the patient uncrosses the arms and relaxes, continue to palpate out to the axillary area and down the slope of the ribs) 1. Pain Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was palpated. May be classified as: Burning Gradual or sudden onset Dull Aching Sharp Lancinating Cramping Throbbing Knifelike
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2. Masses Collection of cells clumped together. Note the size, shape, consistency, motility and pulsations. 3. Tenderness Unpleasant feeling when a specific area is touched. Not present unless area is palpated. 4. Sensations A feeling, impression, or awareness of a bodily state or condition that results from the stimulation of a sensory receptor site. 5. Further assess any abnormalities that were found on Inspection 6. Respiratory Excursion ( T8 to T10 area posterior) Take a tissue pull with the ball of the hand from axillary to mid-line and use thumbs as markers. Place thumbs along spinal processes at the level of 10th rib with palms lightly in contact with the posterolateral surface. Watch thumbs diverge during quiet and deep breathing. Ask patient to take a deep breath in and out through their mouth. Watch for symmetry of movement bilaterally. Repeat this process 3 times. Lag indicates an underlined lung problem on that side. 7. Tactile Fremitus Transmission of the spoken word through the lung and soft tissue being felt by the ball of the hand (most sensitive to fremitus). Using the ball of the hand have patient say a resonance sound (such as blue moon, toy boat, etc.) each t e o t c t ptn shr . i yuo hh aet t a m u e i ox Check for symmetry of vibration in the following areas: 1,2 Apices of lungs 3,4 It sau rr ( m c s dao T n r pl a aa s r s ,vi ps ec a e r oe d ) 5,6 Triangle of auscultation (arms crossed and elevated) 7,8 Medial base of lungs (Dr. should use ulnar surface of the hands) 9,10 Lateral base of lungs (Dr. should use ulnar surface of the hands) Note the fremitus level of the diaphragm bilaterally. The right side maybe slightly higher due to the density of the liver and there maybe a decrease in fremitus at the heart and aortic area. Fremitus is felt best parasternally at 2nd intercostal space at the level of bronchi bifurcation. Decreased or absent fremitus: Air in the lungs Emphysema Pleural thickening or effusion Massive pulmonary edema Bronchial obstruction Increased fremitus: Often coarser or rougher in feel Fluids or a solid mass within the lungs Lung consolidation Heavy but non-obstructive bronchial secretions Compressed lung or tumor
Percussion (posterior)
Patient seated Must have patient cross and lift arms for percussion of the intrascapular regions Percussion note will transmit into tissue to determine density. Depress as much soft tissue as possible. 1. Percuss the 10 primary areas (5 on each side) 1,2 Apices of lungs 3,4 It sau rr ( m c s dao T n r pl a aa s r s ,vi Ps ec a e r oe d ) 5,6 Triangle of auscultation (arms crossed and elevated) 7,8 Medial base of lungs 9,10 Lateral base of lungs 2. Begin at lung apices 3. Compare side to side 4. Diaphragmatic Excursion Ask patient to breathe deeply and hold. Percuss along the scapular line until a change in note from resonance to dullness is heard. This is the lower border of the diaphragm. (Breathe in allows the diaphragm to move down) Mark the point with a skin pencil at the scapular line. Allow the patient to breathe and then repeat the procedure on the other side. Ask the patient to take several breaths and then to exhale as much as possible and hold. Percuss up from marked point and make a mark at the change from dullness to resonance, bilateral. Remind the patient to start breathing. Measure and record the distance in centimeters between the marks on each side. Right side marks will be slightly higher due to the liver mass. Diaphragmatic excursion distance is usually 3 to 5 cm. Excursion limited by: Several types of lesions Pulmonary (emphysema) Abdominal (massive ascites) Superficial painful (fractured rib). The diaphragm is innervated by spinal nerves C3, C4, C5 and the phrenic nerve.
Auscultation (posterior, then anterior)
Patient is seated May have patient cross and lift arms (to listen to the triangles of auscultation) Check for normal and abnormal breath sounds. If abnormal sounds are heard ask patient to clear lungs by coughing. Posterior: Auscultate the 10 primary areas (5 on each side) 1,2 Apices of lungs 3,4 Interscapular area (arms crossed) 5,6 Triangle of Auscultation (arms crossed and elevated) 7,8 Medial base of lungs 9,10 Lateral axillary area Anterior: Auscultate the 8 primary areas (4 on each side) 1,2 Above the clavicles 3,4 Just above the breasts 5,6 Just below the breasts medially
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Just below the breasts laterally
1. Patient should breathe through mouth Helps accentuate breath sounds each time they are touched with stethoscope. 2. Listen for these characteristics: Pitch: Quality of tone or sound dependent on rapidity of vibrations. Intensity: The strength or depth of a sound. Duration: The length or continuance of a sound 3. Normal breath sounds: Vesicular: Heard over most of lung fields Low pitch Short expirations Listen for abnormal audible breath sounds. Bronchovesicular Heard over main bronchus area and over upper right posterior lung field Medium pitch Expiration equals inspiration. Bronchial Heard only over trachea High pitch Loud and long expirations 4. Adventitious breath sounds: Crackles n t e xl i s w i ocr hnpei s c sda w y oe sdel ao i pesr Mi a r ep s n h h cu w e r o l l e i as pn udn ,l wn r ue iu oo c v uy o r y l g s upstream and downstream to equalize. Early Crackles Conducted to the mouth and are not altered by coughing. They are caused by delayed elastic recoil that allows the airways to shut during expiration. Cause: chronic bronchitis, emphysema or asthma. Late Crackles Not conducted to the mouth, dependent on gravity and are found at the base of the lungs. Are heard when lung compliance is reduced and elastic recoil is augmented. Cause: sclerodema, congestive cardiac failure, and fibrosing alveolitis. Wheezes Partial obstruction of bronchioles (small airways). Heard almost everywhere. Whistling or high pitched sound as in asthma. Rubs Loss of lubricating fluid between pleura causing opposing surface rub together producing a sound similar to that from rubbing two dry pieces of leather together. May be constant, lasting for only a few respiratory movements, then disappearing for a while. 5. Vocal resonance (doctor has the patient recite words) Using the diaphragm of the stethoscope, & listening at any point on the thoracic cage Patient recites certain words or phrases, in a deep & resonant manner.
T p apr e,uh s y ot l m oe . yi lha ssc a:t ba ,b e on,t. c s o u c. Bronchophony T e ot cn erh ptn s o s l r t og t s t s p, h eh ptn sek h dc r a hat aet w r c a yh uh h th c ew i t aetpas o e i d el r e eo o l e i in a normal conversational tone and volume Whispered Pectoriloquy T e ot cn erh ptn s o s l r t og t s t s p, h eh ptn sek h dc r a hat aet w r c a yh uh h th c ew i t aetpas o e i d el r e eo o l e i in whispers. Egophony The patient speaks in a normal conversational tone and volume, and when they say t lt h ee E , e tr isud l eh lt hog t s t soe tonsi t ee A t uh h th cp. k e tr r e eo
Palpation (anterior)
Patient is supine Begin above the clavicles; work down below the clavicles into the ICS spaces, check the slope of the ribs, the axilla and finally the base of the lungs. 1. Masses Collection of cells clumped together. Note the size, shape, consistency, motility and pulsations. 2. Tenderness Unpleasant feeling when a specific area is touched. Not present unless area is palpated. 3. Pain Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was palpated. May be classified as: Burning Gradual or sudden onset Dull Aching Sharp Lancinating Cramping Throbbing Knifelike 4. Sensations A feeling, impression, or awareness of a bodily state or condition that results from the stimulation of a sensory receptor site. 5. Further assess any other abnormalities found on Inspection 6. Tracheal position The trachea should be centered with no deviation to the left or to the right. It should not have any evident pulsations. 7. Lymph Nodes The lymph nodes are normally present but are not felt. Infection within lymph nodes are soft, tender and easily moveable. Cancer within lymph nodes are hard, non-tender and non-moveable Supraclavicular Infraclavicular Epitrochlear Lateral axillary Medial axillary Anterior axillary
Posterior axillary 8. Costochondritis If patient complains of chest pain, use a knife-edge hand (hypothenar) and apply pressure. Checking for tenderness or any inflammation of the rib/cartilage junction. Other possible causes are rib or intercostal muscle strain or an anterior vertebra. 9. Rib Fractures Use a knife-edge hand and depress the sternum. Pain should radiate from the site. A 128 Hz tuning fork can also be used on the side of the suspected fractured rib.
Percussion (anterior)
1. 2. 3. Patient is supine Begin at the apices of the lungs Compare side-to-side Identify location of: Liver o ptn si ti at 6 ISm dl i l l e2 a s n aet r hs e th t C i a c a i ( m r ) i g d e h cv u rn k Gastric air bubble o ptn se side midclavicular line (1 mark) n aet l t i f Spleen o ptn se s e e en h 8 -10th ICS midaxillary line (1 mark) n aet l ti bt e t t i f d w e h
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LUNG SOUNDS
This tape contains recordings of breath sounds that you are likely to hear while examining the chest of the normal individuals and patients with pulmonary disease. To hear the sounds reproduced most realistically, you should listen to the tape through a stethoscope. * Be sure that the earpieces are pointing forward. Then hold the bell 2 to 3 inches from the speaker of your tape recorder. If you place the bell on the speaker, you will hear more noise than breath sounds. If you listen to the sounds without a stethoscope, they will sound unnaturally loud and booming. This phenomenon, known as the Fletcher-,Munson effect, is due to the frequency response characteristics of the human ear. On some of the sounds on this tape, you will hear a short beep just before or during inspiration. Listen now to normal vesicular breath sounds. . .. Note the relatively soft, low, pitched character of normal. vesicular breath sounds, sometimes described as a sighing or gentle rustling. These sounds are heard over most of the peripheral parts of the lung. The inspiratory phase is markedly longer than the expiratory phase. Expiration is much quieter than inspiration, and there is no pause between inspiration and expiration. The term vesicular is a misnomer; it arose from experiments perf0rmedinthe nineteenth century suggesting that these normal sounds originated in the alveoli, then called vesicles. In fact, modern engineering concepts make it more likely that the e sounds emanate from e the turbulent flow of air in the lobar and segmental bronchi, not the alveoli. Now listen again to normal vesicular breath sounds. . .. Listen to bronchial breath sounds.. .. These characteristically loud, high-pitched bronchial breath sounds resemble the sound of air blowing through a hollow pipe. Their expiratory phase is louder and longer than their inspiratory phase. They are present normally only over the manubrium, and there is a distinct pause between the inspiratory and expiratory phases. The appearance of bronchial breath sounds over the periphery of the lung may mean abnormal sound transmission because of consolidated lung tissue, as in pneumonia. Now listen to bronchial breath sounds over the chest of a patient with pneumonia. Note that the heart sounds are also audible.. .. These are bronchovesicular breath sounds. . .. Bronchovesicular breath sounds are a mixture of bronchial and vesicular sounds. Their inspiratory and expiratory phases are about equal in length. They are normally audible in two places: (1) anteriorly near the mainstem bronchi in the first and second intercostal spaces; and (2) posteriorly between the scapulae. They may be heard elsewhere in the presence of lung consolidation. Listen again to bronchovesicular breath sounds.. .. The following are tracheal breath sounds ...... Tracheal breath sounds, not usually auscultated, are present over the extrathoracic portion of the trachea. They are very loud, very high-pitched, and have a harsh, hollow quality, the expiratory phase being slightly longer than the inspiratory phase. Listen again to tracheal breath sounds. . . . *Note: While listening to this tape, you may find it helpful to stop the tape recorder, take off your stethoscope, and rest your ears periodically. Here are breath sounds over a cavity in the lung.. .. These sounds are also called amphorous breath sounds. Expiration is equal in length to inspiration but lower in pitch. There is a pause between inspiration and expiration, and the heart tones are audible. Now listen again to amphorous breath sounds....
Crackles are short, explosive, nonmusical sounds. They may be classified as high-or low pitched. High pitched crackles are also called fine crackles; low-pitched crackles are also called coarse crackles. Listen now to high-pitched crackles. . .. Now listen to low-pitched crackles. . .. Crackles are due to the sudden opening of very small airways. Listen again to high pitched crackles. . .. Listen again to low-pitched crackles. . .. Crackles may be classified as to position in the respiratory cycle. You will now hear early inspiratory crackles. . .. Early inspiratory crackles are characteristic of severe airway obstruction and appear to be produced in the proximal and larger airways. They are not silenced by cough or change of posture. Among the diseases associated with early inspiratory crackles are chronic bronchitis, asthma, and emphysema. Listen again to early inspiratory crackles ... The following are late inspiratory crackles. . .. Late inspiratory crackles appear to originate in peripheral airways and may occasionally be associated with an end-inspiratory wheeze. Late inspiratory crackles are characteristic of restrictive pulmonary disease and may be heard in interstitial fibrosis, asbestosis, pneumonia, pulmonary congestion of heart failure, pulmonary sarcoidosis, scleroderma, and rheilmatoid lung. Listen again to later inspiratory crackles. . .. Sometimes crackles are produced by the accumulation of secretions in the airway. When the secretions are profuse, the crackles can be heard over the mouth as well as over the chest wall, a sign known to. ancient physicians as the death rattle. You will now hear a death rattle in a dying patient, over the mouth. . .. Listen now to the sound of wheezing. ... A wheeze, sometimes called a rhonchus, is a musical pulmonary sound. The musical character is determined by the spectrum of frequencies that make up the sound. The lowest frequency, called the fundamental, sets the pitch of the wheeze. Wheezes may be described as high""pitched, in which case they are also called sibilant rhonchi, or low pitched, in which case they are also called sonorous rhonchi. Listen to a high pitched wheeze. . .. Now listen to a low-pitched wheeze. ... Wheezing is produced by a bronchus narrowed to the point of closure, whose opposite walls oscillate between the closed and barely open position. The sound made by a vibrating reed instrument, such as an oboe or the mouthpiece of a child's toy trumpet, is generated in the same manner as a wheeze. If the wheeze is made up of a single musical note, it is called a monophonic wheeze. Listen to the following example of a monophonic wheeze........ If a wheeze is composed of several dissonant notes starting and ending at the same time, it is called a polyphonic wheeze. All forms of obstructive lung disease may be associated with polyphonic wheezing. Listen to a polyphonic wheeze.... Stridor is a particularly loud musical sound of constant pitch. Listen to this example of stridor in a child with croup. . .. Although nothing except its intensity distinguishes stridor from a monophonic wheeze to the ear, stridor comes from obstruction of central airways such as the trachea or larynx. Wheezing is produced in more peripheral airways. Listen again to stridor. Listen to a pleural friction rub. . .. The smooth, moist layers of the normal pleura move easily and silently over one another. But when the surface is thickened by fibrin deposits or coarsened by inflammatory or neoplastic cells, the sliding motion is impeded by frictional resistance. The sound produced, the pleural friction rub, resembles the sound of leather sliding on leather. Listen again to a pleural friction rub. . ..
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The following sound is a squawk. . .. Many squawks are inspiratory, but this squawk is both inspiratory and expiratory, louder on inspiration and softer on expiration. The squawk is a musical sound found in some patients with diffuse pulmonary fibrosis, especially if associated with an allergic inflammation of the alveoli known as hypersensitivity pneumonitis. Here is the squawk again. . .. The presence of a bronchopleurocutaneous fistula may be accompanied by a bronchial leak squeak, which you will now hear. . .. The squeak is a high pitched sound over the affected chest area during a sustained Valsalva maneuver, the pitch being higher in smaller fistulas than in larger fistulas. This squeak was recorded without a stethoscope directly over a fistula. Listen again to a bronchial leak squeak.. . . Egophony, which is the Greek word for the voice of a goat, refers to the nasal or bleating quality of speech transmitted through consolidated lung tissue, as in pneumonia. Occasionally, egophony will be heard over a pleural effusion where there is collapse of the underlying lung. When egophony occurs, the patient says E, the letter will sound like A, because there is transmission of the higher frequencies, or formants. First you will hear the letter E spoken over the healthy side Now you will hear the letter E spoken over the area of consolidation Now you will hear the sounds of the microphone is moved from one side to the other, stating with the healthy side.... In the normal lung, whispered sounds are not transmitted because they lack the lower frequencies best transmitted by aerated lung tissue, and they are inaudible over the normal chest. However, through airless, consolidated lung tissue the high-'pitched whispered sounds above 200 cycles are transmitted, and whispering becomes audible. You will hear this phenomenon, whispered pectoriloquy, now. The patient will whisper the words "one, two, three," and you will hear the sound first over the normal lung...... Then over the consolidated lung ..... Listen now as we alternate between sides. Note that the heart sounds are clearly audible over the consolidated area.
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Heart Examination
Patient is Supine Patient is Disrobed to the Wa tuizt no gw s a b ue t poeth p t nmo et) i (ti i f o n cn e sd o rt te ai t s la o c e s ds y The Heart Examination Requires the Use of a Tangential Light Source
Inspection
1. 2. 3. 4. 5. 6. 7. Dyspnea Pulsations at the APETME areas Apical Impulse [aka: PMI (point of maximal intensity)] Precordial Heaves Abnormalities of the Fingernails Cyanosis Pitting Edema at the ankles
Palpation
1. Check (A.P.E.T.M.E.) Areas for Pulsations (using your finger pads) Aortic Pulmonic Ebs o t rpi n Tricuspid Mitral While at this location - Check for an Apical Impulse to include: Location Amplitude Epigastric Pulsations: Pulsations coming from superior to inferior to the finger pads May indicate: right ventricular enlargement Pulsations coming inferior to superior (actually P-A) to the finger pads May indicate: abdominal aortic aneurysm 2. Check the A.P.E.T.M.E. Areas for Thrills (using the ball of your hand) Thrills: turbulent blood flow, causing palpable vibrations Aortic Pulmonic Ebs o t rpi n Tricuspid Mitral
Percussion
1. Identify the Location and Size of the Heart 2. Percuss from Lateral to Medial The left 3rd, 4th, and 5th Intercostal Spaces (males) - Make 3 vertical marks The left 3rd and 5th Intercostal Spaces (females) - Make 2 vertical marks 3. Percuss down the right sternal border Dullness is heard at the 6th intercostal space indicating the superior border of the liver. Make 1 horizontal mark (males and females)
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Auscultation
1. Listen in the mitral area for S1 and palpate the carotid pulse check for pairing of the two 2. A t pl oia a r rpi using the diaphragm th u n r o Ebs o t e m c e n Check for: Rate Rhythm Identify Systole and Diastole At rates less than 100 bpm - Systole (time between S1 and S2), is shorter than diastole At rates less than 100 bpm - Diastole (time between S2 and S1), is longer then systole 3. Use the diaphragm 1st - auscultate the following areas for general cardiac sounds: Aortic Pulmonic Ebs o t rpi n Tricuspid Mitral Epigastric 4. Use the bell 2nd - auscultate the following areas for general cardiac sounds: Aortic Pulmonic Ebs o t rpi n Tricuspid Mitral Epigastric 5. Listen at the Apex to S1 S1 is louder at the apex 6. Listen at the Apex during Systole listen for splitting that is Accentuated Diminished: Other abnormal heart sounds Mitral murmurs 7. Listen at the Pulmonic area to S2 S2 is louder at the base 8. Listen at the Pulmonic area during Diastole listen for splitting that is Accentuated Diminished: Other abnormal heart sounds Pulmonic murmurs 9. Special Maneuver for Mitral Murmurs Patient is positioned in the left lateral recumbent position 10. Special Maneuver for Aortic Murmurs Patient in seated position
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Heart Explanation
Patient is supine Patient is disrobed to the waist (gowns can be utilized to protect patient modesty) The heart examination requires the use of a tangential light source All abnormalities should be described in terms of their location and timing in the cardiac cycle
Inspection
1. Dyspnea Difficult and labored breathing with shortness of breath. Commonly found with pulmonary or cardiac compromise. Tachypnea: 20 or more respirations per minute. Bradypnea: 10 or less respirations per minute (may be normal for athletes). Watch for bilateral symmetry of movement of the chest wall, during inspiration and expiration. 2. Pulsations in any of the following areas Pulsations are more exaggerated lifts and heaves of the chest and can provide clues to the size and symmetry of the heart. Aortic: Right side at 2nd ICS Pulmonic: Left side at 2nd ICS E bs o tLeft side 3rd ICS rP i : n Tricuspid: Left side 4th ICS Mitral: Left side 5th ICS, ~7-10 cm lateral of sternum Epigastric: Soft tissue inferior to tip of xyphoid process. 3. Check apical impulse aka PMI (point of maximal intensity or maximal impulse 4. Precordial heaves (dilated, failing heart) Visual inspection at the left heart side checking for thrusting up or down at each heart beat. Indicates: Severe ventricular dilatation or heart failure (congestive heart disease) 5. Abnormalities of the finger and toe nails Paronchia: Hang nail Clubbed nails: Respiratory or heart problems Spooned nails (Koilonchia): Iron deficiency anemia, fungal infection, hypothyroidism Pitted: Psoriasis Broad and flat: Secondary syphilis 6. Cyanosis Blue color of the lips, ears or nails (due to hemoglobin not bound to oxygen) Indicates possible pulmonary or cardiac difficulty.
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7. Edema (ankle edema) Excessive accumulation of interstitial fluid. Press index finger over the bony prominence of the tibia or medial malleolus for several seconds. A depression that does not rapidly fill and resume its original shape is evidence of orthostatic edema and is not usually accompanied by thickening or pigmentation of the overlying skin {Right sided heart failure}. Edema accompanied with thickening and ulceration of the skin is associated with: Deep venous obstruction Valvular incompetence Stasis dermatitis
Palpation
1. Check the A.P.E.T.M. areas for pulsations Using the pads of the fingers. Use gentle touch and let the movements rise to your fingers, because sensations will decrease as you increase pressure. 2. Check apical impulse for amplitude and location The visible, palpable, pushing force against the chest caused by left ventricular contractions. Usually synchronous with the carotid pulse and the first heart sound. Appears near the apex of the heart, its location is often a clue to cardiac size. It should be visible at the 5th left ICS about 7-9 cm from the midsternal line and can be easily obscured by obesity, large breasts and great muscularity. Normal size of 2.5 cm and usually only occupies one interspace. Absence, in addition to faint heart sounds, in the left lateral recumbent position: Intervening extracardiac problem Pleural or pericardial fluid Forceful and widely distributed, fills systole, or is displaced laterally and downward: Increased cardiac output Left ventricular hypertrophy. A lift along the left sternal border: May be caused by right ventricular hypertrophy. Displaced upward and to the left: Possibly due to pregnancy or a high left diaphragm. Amplitude is usually small and feels like a tapping sensation. 3. Check the epigastrium for pulsations Fingertips below and under apex of sternum pointing toward left shoulder. Instruct patient to inhale and hold breath while you palpate for pulsations. Pulsations coming from S to I to the fingertips may be right ventricular enlargement. Pulsations coming from I to S to the fingertips may be abdominal aortic aneurysm.
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4. Check the A.P.E.T.M. areas for Thrills Use the ball of the hand Thrills are best felt through bone. A thrill is a fine, palpable, rushing vibration resulting from: Aortic stenosis Mitral stenosis Patient ductus Arteriosclerosis Ventricular septal defect. This indicates a Grade III or better murmur.
Percussion
1. Identify the Location and Size of the Heart Note any dextrarotation or enlarged heart. 2. Percuss from Lateral to Medial The left 3rd, 4th, & 5th Intercostal Spaces (males) - 3 vertical marks The left 3rd & 5th Intercostal Spaces (females) - 2 vertical marks 3. Percuss down the right sternal border Dullness is heard at the 6th intercostal space indicating the superior border of the liver. Make (1) horizontal mark (males & females)
Auscultation
Use firm pressure with the diaphragm (high pitched sounds) Use light pressure with the bell (low pitched sounds). 1. Palpate the carotid pulse and pair with S1 at the Mitral Area Patient takes a deep breath in, exhales and holds 2. Listen for general cardiac sud (s pl oio e pi s onsue u n rr s o t m c b n) Rate Count the number of pulsations for 60 seconds The resting pulse rate is usually between 60 and 90 pulsations per minute. Rhythm The regularity of the heart pattern. An irregular heart pattern, which continues in a regular pattern, may indicate sinus arrhythmia. A patternless, unpredictable rhythm may indicate heart disease. 3. Auscultate the following areas: First with the diaphragm of the stethoscope Second with the bell of the stethoscope Aortic: Right side at 2nd ICS Pulmonic: Left side at 2nd ICS E bs o tLeft side 3rd ICS rP i : n Tricuspid: Left side 4th ICS Mitral: Left side 5th ICS, ~7-10 cm lateral of sternum Epigastric: Soft tissue inferior to tip of xyphoid process.
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4. Identify S1 and S2 (heard best with the diaphragm) Systole (S1 to S2), is shorter than diastole, at rates less than 100 bpm Period of ventricular contraction. Left ventricle pressure rises rapidly, levels off, and starts to fall when the blood is ejected from the left ventricle to the aorta and from the right ventricle into the pulmonary artery. Systole is indicated by the first heart sound, palpable apex beat and peripheral pulse Diastole (S2 to S1), is longer then systole, at rates less than 100 bpm Period of ventricular relaxation. Ventricular pressure falls almost to zero, and blood flows from atrium to the ventricle. Late in diastole, ventricle pressure rises slightly during atrial contraction. Ventricular diastole begins with the onset of the second heart sound and ends with the onset of the first heart sound. S1 is louder at the apex S1 sounds are comprised of the following: Contraction of ventricles. Increased intraventricular pressure Closure of the mitral and tricuspid valves with blood rebounding in the ventricles transmitting vibrations to the chest Opening of the aortic and pulmonic leaflets S2 is louder at the base S2 sounds are comprised of the following: Relaxation of the ventricles Decreased intraventricular pressure Aortic and pulmonic leaflets approximate with arterial back pressure completing closure Sudden stopping of the back flow set up the vibrations to the chest 5. Listen to S1 and evaluate for splitting: Not usually heard. If occurring it may be heard in the mitral area on deep inspiration. Accentuated Tachycardia High cardiac output states {exercise, anemia, hyperthyroidism}. In these conditions the mitral valve is still open wide at the onset of ventricular systole and then closes quickly. Diminished Bradycardia and first degree heart block {delayed conditions from atria to ventricles). The mitral valve has had time after atrial contraction to float back into an almost closed position before ventricular contraction shuts it. Diminishing also occurs by mitral valve calcification as in mitral regurgitation and in reduction of left ventricular contractility as in congestive heart failure or coronary heart disease.
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6. Listen During Systole for: Abnormal heart sounds The valves of the heart should close without noise, unless they are roughened, thickened, damaged or altered in some fashion as a result of a disease. If abnormal they produce clicks, gallops and/or snapping sounds. Listen for pericardial friction rubs. Abnormal heart murmurs Disruption of the flow of blood into, through or into out of the heart. Low pitched murmurs such as ventricular filling murmurs are produced by blood flowing under relatively low pressure High pitched murmurs such as aortic or mitral regurgitation is produced by blood flowing through narrow orifices under increased pressure. 7. Listen to S2 and evaluate for splitting: An expected event which is greatest at the peak of inspiration Accentuated Tachycardia High cardiac output states {exercise, anemia, hyperthyroidism}. In these conditions the mitral valve is still open wide at the onset of ventricular systole and then closes quickly. Diminished Bradycardia and first degree heart block {delayed conditions from atria to ventricles). The mitral valve has had time after atrial contraction to float back into an almost closed position before ventricular contraction shuts it. Diminishing also occurs by mitral valve calcification as in mitral regurgitation and in reduction of left ventricular contractility as in congestive heart failure or coronary heart disease. 8. Listen During Diastole for: Abnormal heart sounds The valves of the heart should close without noise, unless they are roughened, thickened, damaged or altered in some fashion as a result of a disease. If abnormal they produce clicks, gallops and/or snapping sounds. Listen for pericardial friction rubs. Abnormal heart murmurs Disruption of the flow of blood into, through or into out of the heart. Low pitched murmurs such as ventricular filling murmurs are produced by blood flowing under relatively low pressure High pitched murmurs such as aortic or mitral regurgitation are produced by blood flowing through narrow orifices under increased pressure. 9. Special Maneuver for Mitral Murmurs Patient in left lateral recumbent position Use bell (low pitched murmurs) at apical impulse area Ask patient to take in a deep breath and hold.
10. Special Maneuver for Aortic Murmurs Patient in seated position Ls n th l tt nl odrEbs o tfr et ersud ui t diaphragm (high pitched ie at e s rabre(rpi )o bsha ons s gh t e f e n t n e murmurs). Ask patient to take a deep breath in and lean forward while exhaling all the air.
REVISED - AUSCULTATION OF THE HEART 08 Sp

1. At the Mitral ,area, use the diaphragm and auscultate for S1 while palpating the carotid pulse to see if they are paired. Have the patient take in a deep breath, exhale, and hold. 2. Auscultate the APETME areas using the diaphragm for general cardiac sounds. 3. Auscultate the APETME areas using the bell for general cardiac sounds. 4. Identify S1 - While staying at the Mitral area, state that S1 is best heard at the apex. State that during systole you will be listening for splitting that is either accentuated or diminished. State that you are also listening during systole for murmurs or other abnormal heart sounds. 5. Identify S2 - Move to the Pulmonic area, state that S2 is best heard at the base of the heart. State that during diastole you will be listening for splitting that is either accentuated or diminished. State that you are also listening during diastole for murmurs or other abnormal heart sounds. 6. Move to Erb's point and listen for rate and rhythm. State that for rates less than 100 bpm, S1 to S2 is short and S2 to S1 is long.
S 1
S 2
S 1
S 2
LUB
DUB
LUB
DUB
7. Have the patient assume a left lateral recumbent position (about 45 degrees), place the bell at the Mitral area, take a deep breath and hold. Listen for mitral murmurs. 8. Have the patient assume a seated position. Place the diaphragm at the Aortic area or Erb's point. Have the patient breathe in and let it out in a slow sigh as they lean forward. Listen for Aortic murmurs. APETME = Aortic, Pulmonic, Erb's point, Tricuspid, Mitral, Epigastric
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HEART SOUNDS
This tape/CD is a supplement to the text Understanding Heart Sounds and Murmurs, With an Introduction to Lung Sounds by Tilkian and Conover. We recommend that you read the text and study the illustrations carefully before using the tape/CD. For best results, use either a quality home or a personal stereophonic/CD system. With the home unit, the quality of what you hear can be enhanced by lowering the volume and listening with the diaphragm of your stethoscope. Let us start with the normal first and second heart sounds, S1 and S2, as heard at the second left intercostal space. This the familiar lub dub, lub dub, with no additional sounds of murmurs. Concentrate on the second sound and notice its two components, A2 andP2, approximately 30msec apart. As you move the stethoscope to the apex in the normal person, P2 is not heard well and the second sound has one component, A2. These are the normal heart sounds at the apex with a single component of S2. Move back to the second left intercostal space to hear again the normal pulmonic component of the second heart sound. Several conditions (e.g., right bundle branch block) increase the interval between A2 and P2, causing a late or delayedP2 and thus producing a widely split second sound, which is best heard at the second left intercostal space. Note the wide splitting of the second sound at 50 msec and now at 70 msec apart. If there is associated pulmonary hypertension, then the wide splitting of S2 will be appreciated at the apex as well as the base of the heart.P2 will be accentuated. A frequently heard abnormal sound is the presystolic atrial gallop or the fourth heart sound, S4, coinciding with atrial contraction. This sound precedes the first heart sound by 40 to 110 msec and is frequently associated with a coronary artery disease or hypertension. Listen again to the normal heart sounds at the apex. Now listen for the S4 gallop preceding the first heart sound by 110 msec. For best results, you should use the bell of the stethoscope and listen at the apex, with the patient in the left lateral position. An S4 is frequently present with severe hypertension, and this may be accompanied by a loud second sound. Note the increased intensity of the second heart sound.
An S4 sound may be closer to the first heart sound, at 80 msec apart or only 40 msec apart. When an 84 is so close to the first heart sound, it may be difficult to distinguish it from the first component of the first heart sound. For review: Normal first and second heart sounds at the apex. 84 atrial gallop at 110 msec from 81, at 80 msecfrom 81, and at 40 msec from 8 1. An 84 gallop maybe associated with sinus tachycardia. Here is a presystolic 84 gallop at a heart rate of 100 beats/min. Another important heart sound is the ventricular gallop or the third heart sound, also called S3 gallop or protodiastolic gallop. When at the bedside, use the bell of the stethoscope pressed gently against the skin and listen at the apex with the patient in the left lateral position. Listen first to the normal heart sounds. Now you will hear a left ventricular S3 sound 15'0 msec after the second sound, Lub dub-ub, lub dub-ub, the "ub" timing with S3. S3 gallops can be faint and heard only with utmost concentration. 83 gallops are frequently heard in heart failure and are accompanied by fast heart rates. Here is an S3 gallop with sinus tachycardia of 1 a beats/min. 83 gallops produced in the right ventricle are best heard at the left lower sternal border and tend to increase with inspiration. Now that you have learned to recognize the third heart sound, we will add the previously learned fourth heart sound and thus you will hear 84-81..S2-S3, the so-called quadruple rhythm or gallop. Now the S3 gallop is removed and you hear only the presystolic 84 sound. Adding the third heart sound again. It may be difficult to distinguish four discrete sounds during fast heart rates. Listen now to both S3 and S4 gallop sounds at a heart rate of 110 beats/min. This is most reminiscent of the galloping of a horse. With rapid heart rates, the third and fourth heart sounds are sometimes perceived as a single middiastolic sound: the so-called summation gallop.
For best results, use the bell of the stethoscope applied lightly at the point of maximum impulse, with the patient in the left lateral position. For review: An atrial gallop, A left ventricular S3 gallop, And a summation gallop. If you are now familiar with the normal heart sounds and the frequently heard third and fourth heart sounds proceed to the next lesson. If in doubt, return to the beginning and review these sounds before proceeding further. Another common heart sound is the systolic ejection sound. Listen again to the familiar first and second heart sounds. And now listen to an early systolic ejection about 70 msec after the first sound. Such sounds are frequently produced by the aortic or pulmonic valves and should not be confused with S4 gallop sounds. When at the bedside, use the diaphragm of the stethoscope pressed firmly against the chest wall. Again, a systolic ejection sound. When these sounds appear later in systole they are called mid-systolic clicks, heard best at the apex. First, the normal heart sounds. And now, a mid-systolic click. Such clicks may be multiple and are frequently associated with mid-to late systolic murmurs. They reflect mitral valve prolapse with mitral regurgitation. Here is a mid-systolic click with a mid- to late systolic murmur. Another important abnormal heart sound it the opening snap of mitral stenosis: a sharp, high-pitched sound heard early in diastole 40 to 120 msec after the second heart sound. This accompanied by a loud first sound. Listen again to the first and second heart sounds at the fourth left intercostal space. Use the diaphragm of the stethoscope. Now listen for the opening snap 80 msec after the second heart sound. This must be distinguished from a widely split second heart sound, or a later occurring S3 gallop sound. The quality, location, and timing of these various sounds, as well as the respiratory variation, aid in their differentiation. For review: A split second sound, heard at the second left intercostal space.
the opening snap of mitral stenosis, heard at the fourth left intercostal space, and an S3 gallop, heard at the apex with the bell of the stethoscope. Now that you have acquired a basic familiarity with the commonly heard heart sounds, we will listen for some murmurs. A frequently heard systolic murmur is that of mitral regurgitation. It is heard best at the apex, occurs throughout systole, and has a high-pitched, blowing character. First, the normal heart sounds at the apex. And now, the murmur of mitral regurgitation. Frequently, a significant degree of mitral regurgitation is accompanied by a ventricular gallop or a third heart sound. Concentrate on mid-diastole to appreciate the accentuated third heart sound. Tricuspid regurgitation should not be confused with mitral regurgitation. This murmur is loudest at the left sternal border and subxiphoid area and is louder during inspiration and diminishes on expiration. Listen carefully to the respiratory variation of inspiration, and expiration. Tricuspid regurgitation may be accompanied by an S3 gallop, generated in the right ventricle. This sound, like the murmur of tricuspid regurgitation, will be' accentuated during inspiration. Listen to tricuspid regurgitation with right ventricular S3 gallop. Mitral regurgitation, when caused by rheumatic fever, is frequently accompanied by mitral stenosis. This is characterized by a loud first heart sound, a normal second heart sound, and a diastolic opening snap followed by a rumbling murmur. To start: the normal first and second heart sounds. Now, note the appearance of the opening snap and the accentuated first heart sound. Frequently, a diastolic rumble follows the opening snap. Listen with the bell of the stethoscope for the diastolic rumble of mitral stenosis. In combined mitral stenosis and mitral regurgitation, the systolic murmur of mitral regurgitation is also present. Again, here is the diastolic rumble of mitral stenosis. And now, the combined mitral stenosis and mitral regurgitation.
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Mitral stenosis is frequently accompanied by atrial fibrillation. Here, the heart rate is irregular and atrial contractions are absent. The diastolic mitral rumble persists, while the presystolic accentuation may be less pronounced. First, the normal heart sounds during atrial fibrillation. And now the opening snap of mitral stenosis with the diastolic rumble. Now, combined mitral stenosis and mitral regurgitation with atrial fibrillation. Let's turn our attention to the' aortic valve. Mild aortic stenosis is characterized by a mediumpitched, rough systolic murmur, peaking in early to mid-systole. Listen again to the first and second heart sounds at the aortic area. And now listen to the murmur of mild aortic stenosis, heard best with the diaphragm of the stethoscope applied firmly to the skin. Note that A2 is well preserved. With increasing degrees of aortic stenosis, A2 is diminished and the murmur is harsher and peaks later in systole.
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Examination of the Abdomen
Patient supine, and their bladder is empty Patient is exposed from the xiphoid to the pubis Ptn s r s rat is e,n t iha io sm fr o spot aet a a th ri sadh r ed s n o eom fupr i m e e d e
Inspection
1. 2. 3. 4. 5. Skin color Masses Vascular Abnormalities Contour Other Abnormalities
Auscultation
1. Bowel sounds (use diaphragm of stethoscope) Listen for frequency and character. Hyperactive (> 35/min) Normoactive (5-35/min) Hypoactive (1-4/min) Absent (0 bowel sounds, but you must listen for 5 continuous minutes) 2. Friction rubs (use diaphragm of stethoscope ) Liver Spleen 3. Major arteries for bruits (use bell of stethoscope ) Aorta Renals Common iliacs 4. Epigastrium for venous hums (use bell of stethoscope )
Percussion
1. 2. 3. 4. 5. Scan all (4) quadrants in a sequential manner Check for a distended bladder Check for liver size (2 marks) Check for dullness of the spleen (1 mark) Check fry a y fh s mah(k : gs ia b b l ) o tmp n o te t c a a at c i u be o r r
Palpation
1. Light palpation in all (4) quadrants for: Pain Tenderness Muscle guarding Masses 2. Deep palpation in all (4) quadrants for: Pain Tenderness Muscle guarding Masses Distinguish a superficial from a deep mass (by having patient lift their legs or sit-up)
3. Feel for liver edge Standard maneuver 4. Mup ys i rh s n g 5. Gallbladder 6. C niu t p lae o l eeg o t eo a tfri r d e n p v s Mi lom nue d e ns aevr dt Hooking maneuver 7. Check for spleen 8. Check around umbilicus 9. Check aorta 10. Kidney entrapment 11. Urinary bladder 12. Rebound Tenderness R vi Sg os gs i n n Bu brSg l e si m g n 13. Tests for Ascites Fluid Wave Shifting Dullness Puddle Sign 14. Pain Assessment 15. Psoas Sign 16. Obturator Sign 17. Mup ys u c rh P nh
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Abdomen Explanation
Patient is supine & their bladder is empty Patient is exposed from xiphoid to pubis Ptn s r s rat is e &t iha ir t g n o e upr aet a a th ri s h r ed se i o sm spot i m e e d e sn
Inspection
1. Skin Color Jaundice/Ictarus The yellowing of the skin and sclera due to the buildup of bilirubin in the blood. Cause: liver dysfunction. Cyanosis Blue color to the lips, ears or nails due to hemoglobin not bound to oxygen. Cause: Possible pulmonary or cardiac difficulty. C lns i ul Sg e n Bluing near umbilicus Cause: intra-abdominal bleeding. Ecchymosis of Flanks Bulges in lateral flanks of abdomen having a blue color Cause: acute hemorrhagic pancreatitis. Striae (blue or pink) Stretch marks. Cause: If deep blue or purple can be indicative of C si S nrm (Hyperadrenalism). uh gs ydo e n 2. Masses Hernias Protrusion of abdominal contents through abdominal muscles. Ss r r Jsp N d l ie May oehs o ue t s Enlarged lymph nodes around umbilicus. Cause: Possibly due to metastatic carcinoma. Organomegaly Enlarged organs usually the liver and spleen. 3. Vascular Abnormalities Caput Medusa Radiating veins around umbilicus. Cause: Portal hypertension, Liver/heart congestion. Distended Skin Veins Cause: Possibility of thrombosis, ascites or enlarged liver. Visible Pulsations Usually normal. Cause: Can be result of abdominal aortic aneurysm Aorta rising and falling could indicate blockage.
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4. Contour Bulging Flanks Cause: Intra-abdominal pressure or possible ascites. General Distention and Everted Umbilicus Cause: Sign of intra-abdominal pressure. Scaphoid Abdomen Concave stomach Cause: malnutrition, hernia. 5. Other Abnormalities Visible Peristalsis Obstruction causing visible movement. Hypermotility of G.I. tract. Diastasis Recti Separation of rectus abdominis at the linea alba. Seen with pregnancy. Scars/Keloids Scar: thin to thick fibrous tissue that replaces normal skin. Keloid: Irregular-shaped, elevated, progressively enlarging scar. Grows beyond wound boundaries. Caused by excessive collagen formation during healing. Post-surgical or healed wound.
Auscultation
1. Bowel Sounds (Diaphragm) Place diaphragm of stethoscope for 15 seconds in each of the 4 quadrants (one minute total) and hold it in place with very light pressure. Listen for bowel sounds and note their frequency and character. Usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per min. Auscultate to listen to bowel motility and discover vascular sounds. Hyperactive: Possible diarrhea (36 and higher per minute). Normoactive: Normal (5 to 35 per minute). Hypoactive: Constipation (1 to 4 per minute). Absent: Obstruction w/ possible blockage. Medical emergency (ZERO sounds for 5 min.). 2. Friction Rubs (Diaphragm) A high pitched sound associated with respiration (have patient take 3 deep breaths). If present will produce a sandpaper rubbing sound. Inflammation of peritoneal surface of an organ from infection or tumors. Liver: Between the 6th and 10th ICS midclavicular line on right. Spleen: Between the 6th and 10th ICS midaxillary line on left. 3. Major Arteries for Bruits (Bell) Aorta: One inch above and one inch to left of umbilicus. Renals: Two inches above and two inches lateral from umbilicus. Bilateral. Common Iliacs: Two inches down and two inches lateral from umbilicus. Bilateral.
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4. Epigastric Region for Venous Hums (Bell) Place the bell of the stethoscope below the tip of the xiphoid process and ask the patient to hold their breath. Common in children and it usually has no pathologic significance. When present it is a low-pitched continuous sound that is louder during diastole. Must not be confused with carotid bruit, patent ductus arteriosus or an aortic regurgitation. When found in adults it usually occurs with: Anemia Pregancy Thyrotoxicosis Intracranial arteriovenous malformation.
Percussion
To determine the size and shape of the organs and to detect the presence of fluid, air, or solid masses 1. Scan All 4 Quadrants in a sequential manner Percuss all quadrants or regions of the abdomen for a sense of overall tympany and dullness. Tympany is the predominate sound due to air pressure in the stomach and intestines. Dullness is heard over the organs and solid masses. 2. Check for Distended Bladder Percuss from ASIS to ASIS. If present, dullness in the suprapubic area will be evident. 3. Check for Liver Size and mark (2 marks) Begin liver percussion at the right midclavicular line over an area of tympany. [Always begin with an area of tympany and proceed to an area of dullness, because that sound change is easier to detect than the change from dullness to tympany]. Continue downward until the percussion tone changes to one of dullness, which is the upper border of the liver and mark. The upper border usually begins at the 5th to 7th intercostal spaces. An upper border below this may indicate downward displacement or liver atrophy. Percuss upward along the midclavicular line to determine the lower border of the liver and mark. The lower border us usually at the costal margin or slightly below it. A lower liver border that is more than 2 to 3 cm (3/4 to 1 in.) below the costal margin may indicate organ enlargement or downward displacement of the diaphragm because of emphysema or other pulmonary disease. The usual span of the liver is approximately 6 to 12 cm (21/2 to 4 1/2 in.). A span greater than this may indicate liver enlargement A lesser span suggests atrophy. Age and gender influence liver size. 4. Check for Dullness of Spleen (1 mark) The spleen is percussed just posterior to the midaxillary line on the left side. A small area of splenic dullness may be heard from the 6th to 10th ICS. 5. Check Tympany of Stomach Percuss down the midclavicular line on the left side. This is the predominate sound because of air in stomach and intestines.
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Palpation
Is used to assess the organs of the abdominal cavity and to detect muscle spasm, masses, fluid, and area of tenderness. The abdominal organs are evaluated for size, shape, mobility, consistency, and tension. 1. Light Palpation in all (4) quadrants for: No more than 1cm depth. Skin should feel smooth with consistent softness. Pain Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was palpated. May be classified as: mild, severe, chronic, acute, piercing, burning, dull or sharp. Tenderness Unpleasant feeling when a specific area is touched. Not present unless area is palpated. Muscle guarding Patient gasps for breath and/or the abdomen becomes tense (apprehensive). Masses Collection of cells clumped together. Note its size, shape, consistency, motility and/or pulsations. 2. Deep Palpation in all (4) quadrants for: (place the knees of the patient into flexion to relax the abdominal muscles). Delineation of organs and to detect less obvious masses. Use palmar surface of extended fingers, pressing deeply and evenly into the abdominal wall. Palpate all four quadrants, moving the fingers back and forth over the abdominal contents. Palpate about 1 to 2 inches deep or deeper if patient is obese. Tenderness not elicited with light or moderate palpation may become evident. Deep pressure may also evoke tenderness in the healthy person over the cecum, sigmoid colon, aorta and in the midline near the xiphoid process. Pain Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was palpated. May be classified as: mild, severe, chronic, acute, piercing, burning, dull or sharp. Tenderness Unpleasant feeling when a specific area is touched. Not present unless area is palpated. Muscle guarding Patient gasps for breath and/or the abdomen becomes tense (apprehensive). Masses Collection of cells clumped together. Note its size, shape, consistency, motility and/or pulsations. Distinguish if mass is superficial or deep Have patient do a half sit-up or leg raise with both feet several inches off the table. A superficial mass it will still be palpable or visible (superficial to abdominal muscles). A deep mass it will not be palpable or visible because the abdominal muscles will obscure the mass.
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3. P laeo tei rf lo tei r eg) a tfrh l e ( efrh l e d e p v e v s Usually not palpable. If the edge is felt it should be smooth, even and nontender. You are trying to feel for nodules, tenderness and irregularity. Standard Maneuver Doctor places their left hand under the patient at the 11th and 12th ribs pulling posterior-anterior and superior to elevate the liver toward the abdominal wall. Place your right hand on the abdomen, fingers pointing toward the head and extended so the tips rest on the right midclavicular line below the level of liver dullness. Have the patient breath normally a few times and then take a deep breath and hold. As the patient exhales push fingers gently but deeply in and up. Try to feel the liver edge as the diaphragm pushes it down to meet your fingertips. Usually it is not palpable. 4. Gallbladder Using finger pads push inferior to the liver at the 10 ICS. The healthy gallbladder may not be palpable. A tender palpable gallbladder may indicate cholecystitis. A nontender palpable gallbladder may indicate a common bile duct obstruction. 5 Mup ys i . rh Sg n Patient experiences pain and abruptly stops inspiration (reflex apnea, inspiratory arrest) upon application of any one of the three Feeling Liver Edge tests, or in palpation of the gallbladder. Cause: Inflamed gallbladder (aka cholecystitis). Mide ns n ee d l o Ma uvr t Have patient place their fist under ribs 11 and 12 on the right side. Place your right hand on the abdomen, fingers pointing toward the head and extended so the tips rest on the right midclavicular line below the level of liver dullness. Use same breathing instructions as above. Hooking Maneuver Hook your fingers over the right costal margin below the border of liver dullness. Sad nh ptn si ti f i h o hret t o t aet r h s ea n i r ef . n e i g d cg s e Press in and up toward the costal margin with your fingers. Use same breathing instructions as above. 6. Check for Spleen Wh e t d g nh ptn si ti ,ec arswt yu l t ad n p c ibna t i s ni o t aet r h s er h c s i ore hn ad l et eet h l a n e i g d a o h f a h e patient under the left costovertebral angle. Pull posterior-anterior to lift the spleen toward the abdominal wall. Paeh pl asr c o yu r hhn wt f gret dd n h ptn s bo e bl t l t a ruf e f ori tad i i e x ne o t aet adm n e w h c e m a g hn s e e i o e left costal margin. Press your fingertips anterior-posterior toward the spleen as you ask the patient to take a deep breath and hold. Try to feel the edge of the spleen as it moves downward toward your fingers. 7. Check around umbilicus Using finger pads palpate for tenderness, bulges or nodules. The umbilicus can be everted, but not protruded.
8. Check Abdominal Aorta Palpate deeply using your fingertips one inch to the left and one inch up from the umbilicus. If a bounding pulse is felt it could be indication of an aortic aneurysm. 9. Kidney Entrapment On the right side, place one hand under the paet r h f n adh o ehn at r hcs l tn si tl k n t t r ad th i tot i g a e h eg a margin. Ask the patient to take a deep breath. At the height of inspiration, press the fingers of your two hands together to capture the kidney between the fingers. Ask the patient to breathe out and hold the exhalation while you slowly release your fingers. If you have entrapped the kidney you may feel it slip beneath your fingers. Same procedures for the left kidney except doctor moves to the left side of patient. 10. Urinary bladder Using finger pads palpate in the suprapubic region. The bladder should not be felt unless it is distended. If distended it will feel like a smooth, round tense mass. 11. Rebound Tenderness Bu egs i lmbrSg n This is a maneuver to access all four quadrants. Patient supine, hold your hand at a 900 ag t ptn s bo e wtt f gret ddPes nl o aet adm n i h i e x ne. r e i h en s e s gently and deeply into the abdomen region. Rapidly withdraw your hand and fingers. The return to position (rebound) of the structures which were compressed by your fingers causes a sharp stabbing pain at the site of a problem. Indicates: peritonitis. Rovsing Sign R budedresetnh l el t udatn t ptnhs a oeMc unys o t eon t e s t i t o re qar ad h aeta pi vr B repi n n s e w f n e i n n (lower right quadrant, from the umbilicus to 2/3rd toward the ASIS). Indicates: appendicitis. 12. Tests for Ascites Fluid Wave This procedure requires three hands, so the patient will have to help the examiner. Patient supine, ask them to press the edge of their hand and forearm firmly along the vertical midline of the abdomen. This position helps stop transmission of a wave through adipose tissue. Place your hands on each side of the abdomen and strike one side sharply with your fingertips or perform a deep rebound tenderness test. Feel for the impulse of a fluid wave with the fingertips of your other hand. An easily detected fluid wave suggests as ascites, however the maneuver is not conclusive. A fluid wave can sometimes be felt in people without ascites and may not occur in people with early ascites. Shifting Dullness Puddle Sign
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13. Pain assessment There are 3 Rules for assessment: Does the patient give warning not to touch a certain area? Examiner palpates this area carefully w t i ptn sai epes n a h g aet f a xr i . c n i cl so Examiner asks patient if they are hungry. Patients with an organic cause (appendicitis, intrabdominal infection) are not hungry, usually nauseated. Examiner asks patient to point to site of pain. If pain is in a specific point then it has a greater significant importance. Some Qualities of Pain: Burning: Peptic ulcer Aching: Appendiceal irritation Gradual onset: Infection Sudden onset: Duodeneal ulcer, obstruction, acute pancreatitis Knifelike: Pancreatitis Cramping: Gastroenteritis 14. Psoas Sign Instruct:
Positive: Indicates:
Patient supine. Examiner places superior hand on right iliac crest and inferior hn o ptn si th hIsut aeto a e t i te o t right side ad n aet r h t g.nt cptn t r s sa hl nh i g i r i i rg g e against resistance. Increased pain. Appendicitis
15. Obturator Sign Instruct: Patient supine. Instruct patient to flex their hip to 90 degrees and their knee to 90 dgesE a i r l e spr r ad n aet r h ke adne o hn er . xm n p cs ue o hn o ptn si t ne n i r r ad e e a i i g fi a ud aet r h ak . aetn ray n et nl rte t ir h r n ptn si tnl Ptn i e l ad x ray o t h ri t o i g e i tn l e l as e g hip against resistance, given by the examiner. Positive: Increased pain. Indicates: Ruptured appendix or pelvic abscess 1. rh P nh 6 Mup ys u c Place palm of your hand over the right posterior costovertebral angle (Region should be from T10 to T12) and strike your hand with the ulnar surface or the fist of your other hand. Repeat this maneuver over the left costrovertebral angle. The patient should perceive the blow as a thud, but it should not cause tenderness or pain. Pain indicates: inflamed kidney (nephritis) due to a variety of disorders (kidney stones, infection, etc.)
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Orthopedic Diagnosis
Diagnosis 2730
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Orthopedic Clinical Assessment 2730 50 Point Final Examination Weeks 9 & 10

06 points 06 points 05 points 10 points Bony palpation Soft tissue palpation Range of motion Nerve Root Evaluation / Package (cervical or lumbar)
4 points (muscle test)
04 points 04 points 04 points 04 points 04 points 03 points 50 points
2 points (reflex test) 4 points (sensation test) Orthopedic test [all correct or no points] Orthopedic test [all correct or no points] Orthopedic test [all correct or no points] Orthopedic test [all correct or no points] Orthopedic test [all correct or no points] Doctor/patient interaction Total
Bony palpation = Each student will name (recite from memory) and palpate the structures of one joint on a patient. Soft tissue palpation = Each student will name (recite from memory) and palpate the structures of one joint on a patient. Range of motion = Each student will name the action for each motion (recite from memory), name the degrees for each motion (recite from memory) and demonstrate the motions of one joint on themselves. Nerve Root Evaluation / Package = Each student will talk their way through and perform either a cervical or lumbar nerve root evaluation on a patient. Orthopedic Tests = Each student will talk their way through and perform 5 tests on a patient. They will also explain the positive sign and the indication for each test. Each test is graded as an all or nothing item. If the test is performed wrong; the student gives the wrong positive sign and/or indicator then all points are forfeited for that test.
Doctor/patient interaction = Each student will be subjectively graded by the instructor on their skills. Doctor and student introduction must be given.
The Final Laboratory Examination may be administered by any Clinical Sciences Division Laboratory instructor, should your laboratory instructor be unable to test you.
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Essential Final Laboratory Examination Information

The final practical laboratory examination is worth 50 points [25%] of the total grade for the course. You MUST PASS the Final Lab exam (> 70) in order to pass the class. The student is responsible for adequate preparation for the final examination. There are no retakes/re-examinations if a student does not perform well. Students are responsible for all information presented in lecture and/or during lab instructions. Students are also responsible for all information coming from handouts and reference texts. All information for special tests are from the required textbook, Illustrated Orthopedic Physical Assessment, by Evans (E) and the lab packet. If a student does not take the final laboratory examination during his/her scheduled time and does not provide an acceptable excuse in accordance with the Student Handbook, then he/she will receive a ZERO (0) for their final laboratory examination grade. If a student does not take the final examination during his/her scheduled time and does provide an acceptable excuse according to the Student Handbook, then there is no forfeiture of points. The day the student returns back to school, the student must contact and reschedule with his/her instructor an acceptable time to take his/her final laboratory examination. Students in this lab are expected to be both Doctor and patient. The dress code for the final examination is as follows; males are to wear gym shorts, females are to wear gym shorts and either an aerobics top, jogging bra, or a bathing suit top. NOTE: There will be a 3 POINT DEDUCTION FROM the LAB PRACTICAL EXAM FOR NOT WEARING PROPER TESTING ATTIRE! There will be no deviation from the testing procedures on page 2 of this note booklet nor will any deletion of material occur for the final laboratory practical. The design of this lab is to be a hands-on experience. The Instructors should budget their time to achieve this goal.
Each student must have the proper equipment for the final lab examination and may not share their equipment. Each student has 12 minutes to complete the final laboratory examination.
Upon completion of each regional examination the student must check for any correlation between the positive findings and subluxations at the related spinal levels.
The Final Laboratory Examination may be administered by any Clinical Sciences Division Laboratory instructor, should your laboratory instructor be unable to test you.
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It is expected the student will greet the patient with the following standardized introduction. This will be included in the test format. Standard Introduction: Hello, I am (Student first name) I will be conducting a patient history/exam/chiropractic adjustment today. Anything we discuss during this visit will be completely confidential. Iy uh v a y u so s r o c rs ui td y a p i me t l s d n t f o a e n q e t n o c n en d r g o a p o t n p a e o o i n s n e hesitate to ask. If at any time you experience any discomfort or pain during the exam/adjustment please let me know.
Do I have your permission to proceed?
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SHOULDER EXAM INSPECTION 1) For any obvious unnatural movement or posture 2) For any topical abnormalities Scars/keloids Discoloration Abrasions Blebs Other apparent pathology 3) For any asymmetry of structure: Clavicle - dislocation or fracture Deltoid - atrophy, flaring or dislocation shape changes Scapular winging or congenital deformity PALPATION Bony Palpation 1) Sternoclavicular articulation 2) Clavicle 3) Coracoid process 4) Acromioclavicular articulation 5) Acromion 6) Greater tuberosity of the humerus 7) Bicipital groove 8) Less tuberosity of the humerus 9) Spine of the scapula 10) Body of scapula 11) Scapulothoracic articulation Soft Tissue Palpation 1) Rotator Cuff Muscles Supraspinatus Infraspinatus Teres minor Subscapularis Subacromial bursa Subdeltoid bursa Axillary borders Pectoralis major Serratus anterior Axillary lymph nodes Latissimus dorsi Bicipital tendon Prominent muscles of region Sternocleidomastoid Biceps Deltoid (palpate as a group and individually) Anterior portion Middle portion
2) 3) 4)
5)
Posterior portion Trapezius Rhomboid muscles (palpate as a unit and individually) Minor Major
RANGE OF MOTION Active and Passive Flexion (forward) 180 Extension 60 Abduction 180 Adduction 50 External rotation = (from horizontal abduction of arm) 90 Internal rotation = (from horizontal abduction of arm) 70 Scapular retraction (attention) Scapular protraction (reaching) Scapular elevation (shoulder shrug) Reflex Biceps Triceps Sensation (Covered under cervical spine packages)
SPECIAL TESTS 1) Dugas Test, pg. 224 E 2) Anterior Apprehension Test, pg. 202-205 E 3) Posterior Apprehension Test, pg. 202-205 E 4) C d n D o Am T s p . 1 -219 E o ma rp r e t g 2 4 s , 5) D w an T s p . 2 ,2 E a b r e t g 2 22 3 s , 6) Yergason Test, pg. 268-269 E (pg. 103 Cipriano) 7) Abbott-S u d r T s p . 8 -191 E a n e e t g 1 8 s , S e d T s p . 5 -255 E p e et g 2 4 s , A l S rt T s a aA l S rt T s p . 0 E p y cac e t k p y cac e t g 2 0 es h es h , Impingement Sign, pg. 236 E
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Shoulder Special Tests

Dugas Test Instruct: Patient seated, examiner instructs patient to place the hand of the affected side on the opposite shoulder and then bring the affected elbow to the chest. Positive: Inability to touch the opposite shoulder and/or inability of the elbow to touch the chest. Indicates: Acute dislocation of the shoulder (glenohumeral joint). Confirmation Tests: Apprehension Test, Radiography Anterior Apprehension Test Instruct: Patient seated, examiner abducts the patients shoulder, flexes the p t ne o a dte ga u l e tray oae t tep t n ai t l w n h n rd ay x n l rtts o h ai t e s b l e l e s shoulder. Positive: Patient will have a noticeable look of apprehension or alarm on their face with possible pain. Indicates: Chronic anterior dislocation of the shoulder (glenohumeral joint). Confirmation Tests: D g sT s R d ga h u a e t a i rp y , o Posterior Apprehension Test Instruct: Patient supine, examin rl e p t ns o l rf x s ai t e o e f x s ai t h u e,l e p t n l w e e s d e e s b a di en l rtts h p t ns o l r E a n r l e h /e h n o te n n ray oae te ai t h u e. x mi p c s ih r a d n h t l e s d e a s p t ne o a dga u l a pe i ra i p s r r rsue ai t l w n rd ay p lsn e s g o t i pe s r. e s b l i c n eo Positive: Patient will have a noticeable look of apprehension or alarm on their face with possible pain. Indicates: Chronic posterior dislocation of the shoulder (glenohumeral joint). Confirmation Tests: D g sT s R d ga h u a e t a i rp y , o D o A m T s / ... o ma D o A m T s rp r e t aka C d ns rp r e t Instruct: Patient seated, examiner passively abducts patients arm to slightly over 90 degrees and removes support, if patient can maintain arm, then instructs patient to slowly lower their arm. Positive: Patient will not be able to lower the arm slowly or the arm drops suddenly. Indicates: Rotator cuff tear, usually supraspinatus. Confirmation Tests: A l S rt ,mp g me t i p y cac I i e n Sg es h n n D w ansT sdeep palpation of shoulder elicits well-localized tender area, by a b r e t subacromial bursa Instruct: Patient seated, examiner applies pressure below the affected acromial process with his/her fingertips. Note for pain or tenderness. Examiner continues to apply pressure w i a d cn tep t nam past 90 degrees. he b u t g h ai t r l i e s Positive: Decrease in pain and/or tenderness. Indicates: Subacromial bursitis. Confirmation Tests: MRI
Y ra o T s ( ir n ) eg s ns e tCpi o a Instruct: P t n s ae , x mi rl e p t ne o t 9 d ge s E a n r tbi s ai t e td e a n f x s ai t l w o 0 e re . x mi s i e e e e e s b e al z p t ne o wt o eh n a de et sg t fr rrco .E a n r s s h i ai t l w i n a d n x r lh i ei t t n x mi u e te e s b h s i n o ai e r other hand and gras s lhla o ep t nw i. x mi r f r rs tn ew i p sg t b v ai t r tE a n of s e ia c he i y e s s e e s l patient is instructed to externally rotate his/her shoulder and slightly supinate. Positive: 1) Localized pain and/or tenderness at the bicipital groove. 2) Audible click or the biceps tendon subluxes or dislocates Indicates: 1) Tendinitis 2) Instability of the biceps tendon possibly associated with a torn transverse humeral ligament Confirmation Tests: A b t a n eT s S e d T s b o S u d r et p e et s , s Abbott-Saunders Test Instruct: Patient seated, x mi ruy b u t a de tray oae tep t n e a n fl a d c n x n l rtts h ai t e l s e l e s afc dam. x mi r l e h /e f g r o tep t nb itl f t r E a n p c s ih ri es n h ai t ip a ee e a s n e s ci go v a dte s wyo es h p t nafc dam t te s e ro e n h n l ll r te ai t f t r o h i i . o w e s ee rd Positive: Palpable and/or audible click. Indicates: Subluxation or dislocation of the biceps tendon. (Rupture of transverse ligament or tendon subluxation beneath subscapularis muscle belly) Confirmation Tests: S e d T s Y ra o T s p e e t eg s n e t s , s S e dsT s p e et Instruct: Patient seated with forearm supinated, and elbow flexed to 45 degrees. Examiner places his/her fingers on patients bicipital groove with their opposite hand on the patients forearm. Instruct the patient to flex his/her shoulder, maintain supination and completely extend the elbow as the doctor applies resistance. Positive: Pain and/or tenderness in the bicipital groove. Indicates: Bicipital tendinitis. Confirmation Tests: Abbott-S u d r T s Y ra o T s a n e e t eg s n e t s , s A lysT s pe e t Instruct: Patient seated. Have him/her place the affected hand behind the head and touch the o p ses p r r n l o tesa u =A l srt s p r r p o i u ei a g fh c p l t o e a p y cac u ei es h o Then patient is instructed to place the hand behind the back to touch inferior angle of sa u =A l srt i ei cp l a p y cac n r r es h fo Positive: Exacerbation of pain Indicates: Degenerative tendinitis of rotator cuff tendons (usually Supraspinatus.) Impingement Sign Instruct: P t n s ae wt ams t i , x mi r lhla d c p t nam (a ds o l ai t e td i r a s e e a n sg t b u t ai t r h n h u e h d e i y s e s d be pronated) and moves it fully through flexion (will jam greater tuberosity and anterior/inferior surface of the acromion) Positive: Pain in the shoulder Indicates: Overuse injury to the supraspinatus and possibly biceps tendon.
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ELBOW EXAM
INSPECTION 1) For any unnatural movement or posture 2) For any topical abnormalities Scars/ keloids Discoloration Abrasions Blebs Other apparent pathology 3) For any asymmetry of structure 4 C b u V l smoe a g h nten r l o1 ) u i s a u ( r L n l ta h oma 6 t 5) t g e 5) Cubitus Varus (gunstock deformity)
PALPATION Bony Palpation 1) Medial epicondyle 2) Medial supracondylar line of the humerus 3) Groove of the ulnar nerve 4) Trochlea 5) Olecranon 6) Olecranon fossa 7) Lateral epicondyle 8) Lateral supracondylar line of the humerus Radial head Soft Tissue Palpation 1) Ulnar nerve 2) Wrist flexor muscles (palpate as a unit and individually) Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris 3) Medial collateral ligament 4) Supracondylar lymph nodes 5) Brachial Artery 6) Triceps muscle 7) Lateral collateral ligament 8) Biceps 9) Olecranon bursa 10) Eb wFe os sl bew do tre (a aea au i n i id ay l o l r mu c s mo i a fhe p l t s n a d n v u l) x e l p t di l Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis
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RANGE OF MOTION Active and Passive Elbow flexion 150 Elbow extension 0 Forearm supination (radio-ulnar joint) 80 Forearm pronation 80 Reflex Biceps, Brachioradialis, & Triceps Sensation (Covered under cervical spine packages) SPECIAL TESTS 1) 2) 3) 4) 5) 6) Medial Collateral Ligament, pg. 314,315 E Lateral Collateral Ligament Test, pg. 314,315 E Tn l Eb wSg , g 3 8 i l es o i p . 1 -320 E n C z n T s p . 0 -310 E oe et g 3 0 s , Mis e tp . 1 -317 E l T s g36 l , G l r Eb wT s p . 0 -309 E o e l f s o et g 3 6 ,
Medial Collateral Ligament Test (Abduction Stress Test) Instruct: Patient seated, examiner stabilizes the lateral aspect of the arm and places an abduction (valgus) pressure on the medial forearm. Positive: Excessive gapping & pain. Indicates: Medial collateral ligament instability. Confirmation Test: MRI Lateral Collateral Ligament Test (Adduction Stress Test) Instruct: Patient seated, examiner stabilizes the medial aspect of the arm and p c s na d co (au ) rsueo tep t nl ea fram. l e a d u t n v rs pe s r n h ai t a rl e r a i e s t o Positive: Excessive gapping & pain. Indicates: Lateral collateral ligament instability. Confirmation Test: MRI Tn l Eb w Sg ie lo in s Instruct: Patient seated, with a Taylor reflex hammer, examiner taps over the groove between the medial epicondyle and the olecranon process. Positive: Pain and/or tenderness at the site being tapped and paresthesia in the ulnar nerve distribution area (fingers 4,5). Indicates: Neuroma of the ulnar nerve. Confirmation Test: Nerve Conduction Testing
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C z nsT s oe et Instruct: Patient seated, examiner instructs patient to make a fist and place wrist into extension. Examiner instructs patient to resist as examiner tries to push extended wrist into flexion. Positive: Pain over the lateral epicondyle. Indicates: Lateral epicondylitis (Tennis Elbow). Confirmation Test: Mis e t l Ts l Mi T s (maneuver) (Evans) ls e t l Instruct: Patient seated at rest with forearm supinated. In a smooth continuous motion the Dr. p si lma i l f x s h p t ne o ,h nw i a dte f g r.Whe as e v y x l l e te ai t l w te r t n h n i es may e e s b s n i l ma tin w i a df g rl i ,h D . a s e e tn s h p t ne o ( e i a i r t n i e f x n te rp si l x d te ai t l w t n ng s n eo vy e e s b h forearm is now pronated) Positive: Pain over the lateral epicondyle. Indicates: Lateral epicondylitis (Tennis Elbow). Confirmation Test: C zn T s oe et s G l r Eb w T s of lo e t es Instruct: Patient seated, examiner instructs patient to extend the elbow and supinate hand. Examiner instructs patient to flex the wrist against resistance. Positive: Pain over the medial epicondyle. Indicates: Medial Epicondylitis Confirmation Tests: C z n T s Mis e t oe et l T s s , l
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WRIST and HAND

INSPECTION
1) For any obvious unnatural movement or posture Is hand held in a protected position? Is hand held in a restricted manner? I tet u e o teh n n r l s h at d fh a d oma i t ? 2) For any topical abnormalities Scars/keloids Discoloration Abrasions Blebs Other apparent pathology 3) For any asymmetry of structure Any missing fingers? Any fingernail pathology? Any muscle atrophy or finger contractures?
PALPATION
Bony Palpation 1) Radial styloid process 2) Scaphoid (Navicular) 3) Lunate 4) L tr tb rl ( os l b rl ie u ec D ra t ec ) s s e u e 5) Triquetrium 6) Pisiform 7) Trapezium 8) Trapezoid 9) Capitate 10) Hook of hamate 11) Ulnar styloid process 12) Metacarpals 13) Phalanges Soft Tissue Palpation 1) Ulnar artery 2) Radial artery 3) Palmaris longus tendon 4) Carpal tunnel region 5) Thenar eminence 6) Hypothenar eminence 7) Palmar aponeurosis 8) Tissues surrounding proximal interphalangeal joints 9) Tissues surrounding distal interphalangeal joints 10) Distal tufts of fingers
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RANGE OF MOTION Active and Passive Wrist flexion 80 Wrist extension 70 Wrist ulnar deviation 30 Wrist radial deviation 20 Finger abduction Finger adduction Thumb flexion (MCP) Thumb extension (MCP) Finger flexion (MCP) Finger extension (MCP) Finger Opposition Reflex none Sensation (Covered under cervical spine packages) Peripheral Nerves Radial Nerve Dorsum of the hand on the radial side of the third metacarpal as well as the dorsal surfaces of the thumb, 2nd and 3rd digit as far as the DIP joints. Median Nerve The radial portion of the palm and the palmar surfaces of the thumb, 2nd and 3rd and lateral of the 4th digit. Ulnar Nerve The ulnar side of the dorsal and palmar surfaces and the 4th and 5th digit.
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SPECIAL TESTS Tn l Wr t i p . 9 -391 E i i Sg g 3 0 es s n P a n Sg ak . e es P a n Sg &Pa eSg , g3 0 h l i . a R v re h l i es n . e s n ry r i p .8 -383E s n Fn e tis e tp . 6 -369 E i le T s g 3 6 ks n , Bunnel -Littler Test, pg. 350-353 E Retinacular Test, pg. 390-391 E Al T s p . 4 -345 E ln e t g 3 2 es ,
Tn l Wr t in ie i Sg s s Instruct: Patient seated with wrist supinated, examiner taps over the palmar (volar) surface of the wrist. (flexor retinaculum). Positive: Reproduction of pain, tenderness and/or paresthesia in the median nerve distribution area (thumb, 2nd, 3rd, and the lateral of fourth finger). Indicates: Carpal Tunnel Syndrome Confirmation Tests: P a n T s R v reP a n T s N reC n u t nT sn h l e t e es h l e t ev o d co e t g es , es , i i
P ae Sg AND R v reP ae Sg aka P a e sg h lns in e es h lns in ... ry r in s Instruct: Patient seated, examiner instructs patient to flex both wrists to maximum degree and approximate until point of pain or 60 seconds. Prayer sign = maximally extend wrist (palms together), elbows same level as shoulders for 60 seconds. Positive: Reproduction of pain and/or paresthesia in the median nerve distribution area (thumb, 2nd , 3rd and the lateral side of the 4th digit). Indicates: Carpal Tunnel Syndrome Confirmation Tests: Tn l Sg , ev C n u t nT sn i i N re o d co e t g es n i i
Fn esensT s ik lti e t Instruct: Patient seated, examiner instructs patient to place his/her thumb across the palmar surface of the hand and make a fist. Have patient flex elbow and instruct patient to ulnar deviate his/her hand. Positive: Pain distal to the radial styloid process. Indicates: Stenosing tenosynovitis of the abductor pollicis longus and extensor p l ibe itn o s D Q ev is i a e. ois rv e d n ( e u ra Ds s ) l c s n e Confirmation Tests: Blood Testing, MRI
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Bunnel -Littler Test Instruct: Patient seated, examiner places metacarpophalangeal joint in extension and tries to flex the proximal interphalangeal joint. If no flexion is possible then there is either a joint capsule contracture or tight intrinsic muscles. To differentiate, examiner places the metacarpophalangeal joint in a few degrees of flexion and attempts to move the proximal interphalangeal joint into flexion. Positive: (1) Flexion of the proximal interphalangeal joint cannot be achieved. (2) Flexion of the proximal interphalangeal joint is achieved. Indicates: (1) Joint capsule contracture. (2) Tight intrinsic muscles. Confirmation Tests: Retinacular Test, Blood testing, Radiography
Retinacular Test Instruct: Patient seated, examiner places proximal interphalangeal joint in neutral and tries to flex the distal interphalangeal joint. If no flexion is possible then there is either a joint capsule contracture or tight retinacular ligaments. To differentiate, examiner places the proximal interphalangeal joint in a few degrees of flexion and attempts to move the distal interphalangeal joint into flexion. Positive: (1) Flexion of the distal interphalangeal joint cannot be achieved. (2) Flexion of the distal interphalangeal joint is achieved. Indicates: (1) Joint capsule contracture. (2) Tight retinacular ligament. Confirmation Tests: Retinacular Test, Blood testing, Radiography AlnsT s l et e Instruct: Patient seated, examiner instructs patient to raise his/her hand above the heart level of his/her head and to open and close his/her fist for 60 seconds. Examiner occludes both the radial and ulnar artery at the wrist and then lowers the patient's arm with the fist closed and allows the fist to rest on patient's thigh. Examiner instructs patient to open closed fist and releases digital pressure over one artery while keeping the other artery occluded. Record the filling time, while comparing color to the other hand. Then repeat procedure for other artery. Positive: A delay of more than 10 seconds (Evans 5 sec.) in returning a reddish color to the hand. Indicates: Radial or ulnar artery insufficiency. The artery held (occluded) by the examiner is not the artery being tested. Confirmation Tests: Vascular Assessment **A negative Allen's Test must be obtained before using the radial artery in neurovascular compression tests.**
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CERVICAL SPINE
INSPECTION
1) For any obvious unnatural movement or posture 2) For any topical abnormalities Scars/keloids Discoloration Abrasions Blebs Other apparent pathology 3) For any asymmetry of structure Muscle splinting Muscle atrophy Congenital deformity
PALPATION Bony Palpation Anterior Aspect 1) Hyoid Bone 2) Thyroid Cartilage 3) First Cricoid Ring 4) Mandible Posterior Aspect 1) Occiput 2) Inion (EOP) 3) Superior Nuchal Line 4) Mastoid Processes 5) Spinous Processes of Cervical Vertebrae 6) Facet Joints Soft Tissue Palpation 1) 2) 3) 4) 5) 6) 7) 8) 9) Sternocleidomastoid muscle Anterior lymph node chain Posterior lymph node chain Thyroid gland Carotid pulse Supraclavicular fossa Trapezius muscle Greater occipital nerves Superior nuchal ligament
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RANGE OF MOTION Active and Passive Flexion 60 Extension 75 Lateral bending left 45 Lateral bending right 45 Left rotation 80 Right rotation 80 Reflexes None Sensations (Covered under cervical spine packages) SPECIAL TESTS 1) Foraminal Compression Test, pg. 94-97 E 2) Cervical Distraction Test, pg. 88-93 E 3) Shoulder Depressor, pg.130-131 E 4) Valsalva Maneuver, pg. 148-151 E 5) Swallowing Test, pg. 142,143 E 6) Soto Hall Sign, pg. 132-135 E 7 K ris i , g 5 8 ) en Sg p . 3 -539 E g n 8) Spinal Percussion Test, pg. 136-137 9) O'Donoghue Maneuver, pg. 120-125 Foraminal Compression Test Instruct: Patient seated with examiner standing behind. Examiner clasps his/her hands over p t nh a a de et ga u l ce s gd w w r pe s r. x mi re e t ti ai t e d n x r rd a i ra i o n ad rsue E a n rp as h e s s n n e s po e uewt tep t nh a rttdr h a dte l t rc d r i h ai t e d oae i t n h n e . h e s g f Positive: 1) Exacerbation of localized cervical pain. 2) Exacerbation of cervical pain with a radicular component. Indicates: 1) Foraminal encroachment or facet pathology without nerve root compression. 2) Foraminal encroachment with nerve root compression or facet pathology (then evaluate the myotome, reflex & dermatome of the nerve root involved). Confirmation Tests: Shoulder Depression Test, Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI, Nerve Conduction Testing
Cervical Distraction Test Instruct: Patie t e td tee a n r rs s h p t nh a wt b t h n s n ga u l n s ae :h x mi ga p te ai t e d i oh a d a d rd ay e e s h l exerts upward pressure keeping hands off TMJ and ears. Positive: 1) Diminished or absence of pain. 2) Increase of cervical pain. Indicates: 1) Foraminal encroachment (local pain diminishes), nerve root compression (Radicular pain diminishes). 2) Muscular strain, ligamentous sprain, myospasm, facet capsulitis.
Confirmation Tests: Foraminal Compression Test, Shoulder Depression Test, Reflex and Sensory Testing, Radiography, MRI, Nerve Conduction Testing
Spinal Percussion Test Instruct: Patient seated with head in slight flexion, percuss each cervical spinous process(es) and the associated musculature with the pointed end of a reflex hammer. Positive: 1) Local pain 2) Radiating pain Indicates: 1) Possible fractured vertebrae, ligamentous involvement (spinous pain), muscular involvement (muscular pain). 2) Possible disc pathology.
Shoulder Depression Test Instruct: P t n s ae , x mi r tbi s ai t laterally flexed head while ai t e td e a n s i e p t n e e al z e s pushing down on shoulder. Positive: 1) Localized pain on the side being tested. 2) Pain on opposite side being tested. Indicates: 1) Localized Pain: Dural sleeve adhesion, and muscular adhesion/contracture, or spasm, or ligamentous injury. 2) Radicular Pain: On side being tested neurovascular bundle compression, dural sleeve adhesions, or Thoracic Outlet Syndrome On opposite side being tested foraminal encroachment with nerve root compression. Confirmation Tests: Cervical Distraction, Foraminal Compression Test, Sensory and Reflex Testing, and MRI
Valsalva Maneuver Instruct: Patient seated, examiner instructs patient to take a deep breath and hold, while bearing down as if having a bowel movement. Positive: Local or Radiating pain from site of lesion. Indicates: Space occupying lesion. Confirmation Tests: Swallowing Test, Shoulder Depression Test, Cervical Distraction, Foraminal Compression Test, Sensory and Reflex Testing, MRI
Swallowing Test Instruct: Patient seated: examiner instructs the patient to swallow. Positive: Difficulty in swallowing. Indicates: Space-occupying lesion at anterior portion of cervical spine. Possibly esophageal or pharyngeal Injury, anterior disc defect, muscle spasm or osteophytes etc. Confirmation Testing: V l l T s S n oy n R f x e t g MR a a a e t e s r a d el T sn , I svs , e i
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Soto Hall Sign Instruct: P t n s p e e a n rl e p t nh a tw r h /e c e t he ai t u i , x mi f x s ai t e d o ad ih r h s w i e n e e e s s l e et gd w w r pe s r o p t ns ru wt h p te a e n n eo i ei x rn o n ad rsue n ai t t n m i y oh n r mi c f fr r i e s e h e n o hand. Positive: Generalized pain in the cervical region, which may extend down to the level of T2. Indicates: Non-specific test for structural integrity of cervical region. Confirmation Tests: OD n g u T s S i l ec si T Swallowing Test, Valsalva Test, Sensory and Reflex o o h e e t p a P ru s n est, s , n o Testing, MRI K ri Sg engs in Instructs: Patient supine, examiner passively flexes patient h t 9 d ge s n tep t n i o 0 e re a d h ai t s p e s k e t 9 d ge s E a n r x n s ai t leg completely. n e o 0 e re . x mi e t d p t n e e e s Positive: Inability to fully extend the leg and/or pain (usually in the neck region.) Indicates: Meningeal irritation/ meningitis. Confirmation Tests: Bu z si Sg , u a T p rd i ks i L mb r a n n
O'Donoghue Maneuver (One of the best tests for Whiplash injury used by an examiner, can also be utilized on ANY joint in the body to determine sprain/strain injury ) Instruct: Patient is seated, examiner grasps the patient's head with both hands and passively takes the cervical region through a range of motion. The examiner then takes the cervical region through isometric contractions. Positive: 1) Pain during passive range of motion. 2) Pain during resisted range of motion. Indicates: 1) Ligamentous sprain. (Passive ROM stresses ligaments) 2) Muscle/tendon strain. (Active ROM stresses muscles and tendons)
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Evaluation of Nerve Root Lesions Involving the Upper Extremity

Always use the MRS system in the correct order, any deviation will result in a loss of points 1) Muscle test and name the muscle/s and nerve for each neurological package being tested 2) Reflex test and name the appropriate reflex being tested; if no reflex it must be stated. 3) Sensation ts tea po r t d r tmefrh n uo g a p ca ea di c r s o d g e th p rpi e emao a o te e rl i l a k g n t or p n i oc s e n dermatome above and below following the format enclosed from Hoppenfeld Evaluation is to be in this order: Muscle test (motor), Reflex, Sensation (dermatome) Testing individual nerve root C5 a) Disc Level C4 b) Muscle tests (2) Shoulder abduction: deltoid (axillary nerve) Forearm flexion: biceps (musculocutaneous nerve) c) Reflex Biceps d) Sensation Lateral arm Testing individual nerve root C6 a) Disc Level C5 b) Muscle test (1) Wrist extension: extensor carpi radialis longus & brevis, and extensor carpi ulnaris ( radial nerve) c) Reflex Brachioradialis d) Sensation Anterior lateral forearm, palm, thumb and 2nd digit Testing individual nerve root C7 a) Disc Level C6 b) Muscle tests (3) Elbow extension: triceps (Radial Nerve) Wrist flexion: flexor carpi radialis (Median Nerve), flexor carpi ulnaris (Ulnar Nerve) Finger extension: extensor digitorum communis, extensor indicis profundus, extensor digiti minimi (radial nerve) c) Reflex Triceps d) Sensation 3rd digit, middle of palm Testing individual nerve root C8 a) Disc Level C7 b) Muscle test (1) Finger flexion: flexor digitorum superficialis, flexor digitorum profundus, lumbricals (median and ulnar nerves) c) Reflex None d) Sensation 4th and 5th digits, antero-medial hand and forearm Testing individual nerve root T1 a) Disc Level b) Muscle tests (2) c) Reflex d) Sensation
T1 Finger abduction : dorsal interossei (ulnar nerve) Finger adduction : palmer interossei (ulnar nerve) None Antero-medial arm (distal aspect of arm to proximal aspect of forearm)
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Dermatomes of the Upper Extremity

Initial Examination Procedure
Example (Examination of C5 package dermatomes) Patient seated, anatomical position, eyes closed. Verbage = Can you feel this? AND does this feel like this? C4 of right side compared to C4 of left side (dermatome above) C5 of right side compared to C5 of left side (dermatome package) C6 of right side compared to C6 of left side (dermatome below)
Secondary Examination Procedure

Example (Examination of C5 package dermatomes) Patient seated, anatomical position, eyes closed. Verbage = Can you feel this? AND does this feel like this? First C4 of right side compared to C5 of right side C5 of right side compared to C6 of right side Second C4 of left side compared to C5 of left side C5 of left side compared to C6 of left side
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Evaluation of Nerve Root Lesions Involving the Upper Extremity (Examined As Follows)
Always use the MRS system in the correct order, any deviation will result in a loss of points Muscle test and name the muscle/s and nerve for each neurological package being tested Reflex test and name the appropriate reflex being tested; if no reflex it must be stated. Sensation ts tea po r t d r tmefrh n uo g a p ca ea di c r s o d g e th p rpi e emao o te e rl i l a k g n t or p n i a oc s e n dermatome above and below following the format enclosed from Hoppenfeld
Always use the MRS system in the correct order: Muscle Reflex Sensation Muscle (motor) Reflex Sensation (dermatome) Patient seated Anatomical position Eyes closed Always bilateral No hands on joints Skin on skin Gradual increase in pressure Always bilateral Always bilateral Pin to skin (verbiage used = does this feel like this), skin on skin Always bilateral Test sensation above and below
One hand above joint of Rapid flick of hammer motion for stability on tendon One hand used as short lever to test muscle No tension in muscles around tendon
For the evaluation of Nerve Root Lesions follow pages 22, 23, and 24 of this laboratory handout. Students are not to follow the Cipriano or Evans protocol for this section.
***** LECTURE MATERIAL ONLY *****

Evaluation of Nerve Root Lesions
Involving the Thoracic and Upper Lumbar Spine Regions

Testing individual nerve root levels T2-T12 a) Disc Level T2-T12 b) Muscle test (1) Rib elevation : intercostals [segmented innervated and difficult to evaluate individually], rectus abdominus c) Reflex: None (can perform superficial abdominal reflex) d) Sensation: T4 = nipple line T7 = xyphoid process T10 = umbilicus T12 = groin **There is sufficient overlap of these areas so that no anesthesia will occur if only one nerve root is involved.** Testing individual nerve roots L1, L2 and L3 pg. 234 a) Disc Level T12-L2 b) Muscle test (1) Primary hip flexor : iliopsoas (L1-L3) c) Reflex None d) Sensation Anterior thigh, obliquely from lateral to medial {L1 top of thigh, L2 middle of thigh, L3 lower thigh}
Testing individual nerve roots L2, L3 and L4 pg. 236 a) Disc Level L1-L3 b) Muscle tests (2) Primary knee extensors : Quadriceps Femoris, Vastus Medialis, Vastus Intermedius ( L2-L4, Femoral Nerve) Primary adductor : Adductor longus, Adductor Brevis, Adductor Magnus (L2-L4, Obturator Nerve) c) Reflex Patellar d) Sensation L2 middle of thigh, L3 lower thigh, L4 anteriomedial leg below the knee and medial side of the foot
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LUMBAR SPINE
INSPECTION 1) For any obvious unnatural movement or posture 2) For any topical abnormalities Scars/keloids Discoloration 3) Infection signs 4. Heating pad redness 5. Birthmarks 6. Cafe-au-lait spots 4) Abrasions 5) Blebs 6) Other apparent pathology Lipoma Hairy patches For any asymmetry of structure Shoulders level 5. Left vs. right symmetry 6. Listing to one side 7. Hyperlordosis vs. kyphosis
PALPATION
Bony Palpation 1) Lumbar spinous processes 2) Sacral tubercles 3) Iliac crest 4) PSIS Soft Tissue Palpation 1) Paraspinal muscles (palpate as a unit) superficial layer Spinalis Longissimus Iliocostalis 2) Sciatic nerve 3) Gluteus Maximus 4) Gluteus Medius 5) Hamstrings Biceps femoris Semitendinosus Semimembranosus 6) Anterior abdominal muscles
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RANGE OF MOTION
Active and Passive Flexion 25 Extension 30 Left lateral bending 25 Right lateral bending 25 Left rotation 30 Right rotation 30 Reflex Patellar and Achilles Sensation (Covered under lumbar spine packages)
SPECIAL TESTS
1) H o eSg , g 1 0 -1001 E o vr i p . 0 0 s n 2) Straight Leg Raiser (SLR), pg. 602-605 E 3) G l h a Sg , g 6 4 o tw i i p . 4 -645 E d t s n 4) Ba ad Sg , g 5 6 rg r i p . 0 -507 E s n 5) Buckling Sign pg. 209 C 6) Bowstring Sign, pg. 504-505 E 7) L sg e T sp . 4 E ae u et g 5 8 s 8) MirmT s p . 7 -575 E l a s et g 5 4 g , 9) Valsalva Maneuver, pg. 148-151 E 1 ) B c trws 0 e hee Test pg. 496-499 E 11) A tr rn o n t T s a aMa i P lc Maneuver, pg. 630 E nei In mi e e t k o a , zn ei os v (Advancement Sign) 12) Lewin Standing Test pg. 556-557 13) N r B wn T s ( ei Sg ) g 5 2 ei o i e tN r i p . 8 -583 ' s g n s 14) Heel Walk, pg. 526 E 15) Toe Walk, pg. 526 E 16) Ely's Heel to Buttock Test, pg. 518-519 (v nsc l ti Eyssg a a aka) E a al hs l in s n ... s H o e Sg o v r in s (Used to differentiate organic versus hysterical leg paralysis) Instructs: Patient supine, examiner instructs patient to lift the affected leg while the examiner places one hand under the heel of the non-affected leg (healthy side). Positive: Lack of counter-pressure on the healthy side Indicates: Lack of organic basis for paralysis (Malingering/hysteria). With organic hemiplegia, the patient will still exert downward pressure when attempting to raise paralyzed leg)
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Straight Leg Raiser (SLR) Instruct: P t n s p e e a n ra e p t nl s wy o9 0 or to the point ai t u i , x mi ri s ai t e l lt 0 e n e s e s g o of pain. Positive: Radiating pain and/or dull posterior thigh pain. Sciatic radiculopathy or tight hamstrings. Positive between 35 70 degrees = possible discogenic sciatic radiculopathy (Cipriano) Confirmation Tests: B c trws e tBa g rT s L s g e T s L wn Sa d gT s e hee T s rg ad e t a e u e t e is tn i e t , s , s , n Indicates: G ltw isSg odh at in Instruct: Patient supine examiner places the fingers of their superior hand under the interspinous spaces of the patient's lower lumbar vertebrae. Examiner then raises one of the patient's extended legs. Positive: Localized pain, low back or radiating pain down the leg. Indicates: Lumbo-sacral or sacroiliac pathology. Pain occurring after the lumbar spinouses move = possible lumbo-sacral problem. Pain occurring before the lumbars move = possible sacroiliac problem. Confirmation Tests: B l e tG e s n T s e T s a nl et t , as Bra adsSg g r in Instruct: Patient supine, examiner performs a (SLR) on the patient. Examiner lowers the raised leg (5 degrees) from the point of pain and sharply d ri x s ai t fo. osl e p t n o t f e e s Positive: Radiating pain in posterior thigh. Indicates: Sciatic radiculopathy Confirmation Tests: B c trws e tL s g e T s S RT s e hee T s a e u e t L e t , s , Buckling Sign (Cipriano) Instruct: Patient is supine, examiner performs a SLR on the patient. Positive: Pain in the posterior thigh with sudden knee flexion (buckle). Indicates: Sciatic radiculopathy. Confirmation Tests: B c trws e tBa g rT s L s g e T s L wn Sa d gT s e hee T s rg ad e t a e u e t e is tn i e t , s , s , n Bowstring Sign Instruct: P t n is p e e a n r l e p t nl o te s o l r n fs ai t u i , x mi p c s ai t e n h i h u e a d i t e s n e a e s g r d r applies pressure to the hamstring muscle if pain is not elicited then apply pressure to the popliteal fossa. Positive: Pain in the lumbar region or radiculopathy. Indicates: Sciatic nerve root compression, helps rule out tight hamstrings. Confirmation Tests: Heel Walk Test, Toe Walk Test, Milgra s e tN r B wn T s mT s ei o i e t , s g
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L s g esT s ae u et Instruct: Patient Supine. Hip and leg bent to 90 degrees. Slowly extend the knee (keeping hip at or close to 90 degrees). Positive: Reproduction of sciatic pain before 60 degrees Indicates: Sciatica Confirmation Tests: B c trws e tBa g rT s L wn Sa d gT s S RT s e hee T s rg ad e t e is tn i e t L e t , s , n , Mi rm T s l a s et g Instruct: P t n s p e e a n ra e b t o p t nl s -3 inches off the ai t u i , x mi ri s oh f ai t e 2 e n e s e s g table and instructs patient to hold legs off the table for 30 seconds. Positive: Inability to perform test and/or low back pain. Indicates: Weak abdominal muscles or space occupying lesion. Confirmation Tests: B w tn T s H e Wa T s T eWa T s K mp T s N r B wn T s o s i et e l l et o rg , k , l e t e e t ei o i e t k , s , s g
Valsalva Maneuver Instruct: Patient seated, examiner instructs patient to take a deep breath and hold while bearing down as if straining at a bowel movement. Positive: Radiating pain from site of lesion (usually positive in cervical or lumbar area of the spine). Indicates: Space occupying lesion (e.g. disc pathology). Confirmation Tests: Swallowing Test, Shoulder Depression Test, Cervical Distraction, Foraminal Compression Test, Sensory and Reflex Testing, MRI B c trw sT s e hee e t Instruct: Patient seated, examiner instructs patient to extend one knee at a time alternately, then both together. Positive: Reproduction of radicular pain or inability to perform correctly due to tripod sign. Indicates: Sciatic radiculopathy. Confirmation Tests: Ba ad T s L s g e T s L wn Sa d gT s Straight Leg Raising Test rg r e t a e u e t e is tn i e t s , s , n , Neri's Bowing Test ( ei Sg ) Nr i n s Instruct: Examiner instructs patient to bend forward from the waist. Positive: Pain accompanied by flexion of the knee on the affected side and body rotation away from the affected side. Indicates: Positive with a variety of low back pathologies. Hamstring tension on the pelvis may trigger the response. Confirmation Tests: B w tn Sg , e l lT s T eWa T s K mp T s MirmT s o s i i H e Wa e t o rg n k , l et e et l a s et k , s , g
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Anterior Innominate Test a.k.a. Ma insP l Maneuver (Advancement Sign) z evic o Instruct: The patient is standing. Examiner instructs patient to advance one leg forward approximately 2-3 feet. Patient is then instructed to bend forward from the waist and touch the advanced foot with both hands (advanced knee should be straight). Positive: The inability to bend at the waist more than 45 degrees, because of either/or (1) radiating pain along the sciatic nerve, either unilateral or bilateral (2) low back pain (lumbar or pelvic regions) Indicates: (1) sciatic neuralgia or radiculopathy, etc., possibly due to lumbar disc pathology (2) anterior (rotational) displacement of the ilium relative to the sacrum. Note: this test puts a strain on the sciatic nerve in a similar manner to the Straight Leg Raise, Lasegue, and Bechterew tests. If this test is positive (sciatica), those tests should b a o Ic n ie c o p si s n , l gwt ap t ni bi t s t e a t e l .n o s tn y f o i e i s a n i s s t v g o h ai t n iy o t e x cy e s al t a l when and where the pain occurs, may indicate malingering.
Lewin Standing Test Instruct: Examiner instructs patient to bend forward slightly at the waist with knees slightly flexed. Examiner first brings one knee into complete extension. Next the examiner brings the other knee into complete extension. Finally the examiner brings both knees into complete extension. Positive: Radiating pain down the leg causing flexion of the patient's knee or knees. Indicates: Gluteal, lumbosacral or sacroiliac pathologies. Confirmation Tests: B c trws e tBa ad ts L s g e T s S RTest e hee T s rg r e t a e u e t L , s , s ,
Heel Walk Instruct: Patient walks on heels. Positive: Inability to perform test. Indicates: L4-L5 disc problem (L5 nerve root). Confirmation Tests: B w tn T s K mp T s MirmT s N r B wn T s o s i e t e e t l a s e t ei o i e t rg , s , g , s g
Toe Walk Instruct: Patient walks on toes. Positive: Inability to perform test. Indicates: L5-S1 disc problem (S1 nerve root). Confirmation Tests: B w tn T s K mp T s MirmT s N r B wn T s o s i e t e e t l a s e t ei o i e t rg , s , g , s g
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Ely's Heel to Buttock Test (v n c l tiEy s na a ak .) E a as h ls i s n . a s l s g . Instruct: Patient prone, examiner flexes the knee of the patient's affected leg to 90 degrees. Examiner then approximates the heel of the affected leg to the contralateral buttock and hyperextends the thigh off the table. Positive: (1) Inability to raise the thigh. (2) Pain in the anterior thigh. (3) Pain in the lumbar region. Indicates: (1) Iliopsoas spasm. (2) Inflammation of lumbar nerve roots. (3) Lumbar nerve root adhesions. Confirmation Tests: Femoral Stretch Test
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Evaluation of Nerve Root Lesions

Involving the Lower Extremity and Lumbar Spine
Always use the MRS system in the correct order, any deviation will result in a loss of points Muscle test and name the muscle/s and nerve for each neurological package being tested Reflex test and name the appropriate reflex being tested; if there is no reflex it must be stated. Sensation ts tea po r t d r tmefrh n uo g a p ca ea di c r s o d g e th p rpi e emao a o te e rl i l a k g n t or p n i oc s e n dermatome above and below following the format enclosed from Hoppenfeld Evaluation is to be in this order: Muscle test (motor), Reflex, Sensation (dermatome) Testing individual nerve root L4 a) Disc Level L3 b) Muscle test (1) Foot dorsiflexion & inversion: tibialis anterior (deep peroneal nerve) c) Reflex Patellar Tendon d) Sensation Medial aspect of leg, medial foot, medial aspect of big toe
Testing individual nerve root L5 a) Disc Level L4 b) Muscle tests (4) Foot dorsiflexion Big toe dorsiflexion: extensor hallucis longus (deep peroneal nerve) Toes 2,3,4 dorsiflexion: extensor digitorum longus & brevis (deep peroneal nerve) Hip and Pelvis abduction: gluteus medius & minimus (superior gluteal nerve) c) Reflex None d) Sensation Lateral leg, dorsum of foot, and middle three toes
Testing individual nerve root S1 a) Disc Level L5 b) Muscle tests (3) Foot Plantarflexion: Gastrocnemius and Soleus (Tibial Nerve) Foot plantar flexion and eversion: peroneus longus & brevis (Superficial Peroneal Nerve). Hip extension: gluteus maximus (Inferior Gluteal Nerve). c) Reflex Achilles d) Sensation Posterior aspect of the leg, lateral aspect of foot, and lateral aspect of little toe. Testing individual nerve root S2 a) Disc Level S1 b) Sensation Posterior aspect of thigh over popliteal fossa onto posteromedial calf
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Dermatomes of the Lower Extremity

Initial Examination Procedure
Example (Examination of L5 package dermatomes) Patient seated, anatomical position, eyes closed. Verbage = Can you feel this? And does this feel like this? L4 of right side compared to L4 of left side (dermatome above) L5 of right side compared to L5 of left side (dermatome package) S1 of right side compared to S1 of left side (dermatome below)
Secondary Examination Procedure

Example (Examination of L5 package dermatomes) Patient seated, anatomical position, eyes closed. Verbage = Can you feel this? And does this feel like this? First L4 of right side compared to L5 of right side L5 of right side compared to S1 of right side Second L4 of left side compared to L5 of left side L5 of left side compared to S1 of left side
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Evaluation of Nerve Root Lesions Involving the Lower Extremity (Examined As Follows)
Always use the MRS system in the correct order, any deviation will result in a loss of points Muscle test and name the muscle/s and nerve for each neurological package being tested Reflex test and name the appropriate reflex being tested; if no reflex it must be stated. Sensation test the appropriate dermatome for the neurolo i l a k g a di c r s o d g g a p ca e n t or p n i c s e n dermatome above and below following the format enclosed from Hoppenfeld
Always use the MRS system in the correct order: Muscle Reflex Sensation Muscle (motor) Reflex Sensation (dermatome)
Patient seated Anatomical position Eyes closed Always bilateral No hands on joints
One hand above joint of Rapid flick of hammer motion for stability on tendon One hand used as short lever to test muscle No tension in muscles around tendon
Skin on skin
Gradual increase in pressure
Always bilateral
Always bilateral
Pin to skin (Verbiage used = does this feel like this) Skin on skin
Always bilateral
Test sensation above and below The evaluation of Nerve Root Lesions follow pages 32, 33, and 34 of this laboratory handout. Students are not to follow the Cipriano or Evans protocol for this section.
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HIP and PELVIS

INSPECTION 1) For any obvious unnatural movement or posture Gait Gluteus medius or maximus lurch 2) For any topical abnormalities Scars/keloids Discoloration Abrasions Blebs Other apparent pathology 3) For any asymmetry of structure Iliac Spines on same plane Hyperlordotic/Kyphotic lumbar spine Gluteal folds symmetry
PALPATION
Bony Palpation Anterior 1) ASIS 2) Iliac crest 3) Iliac tubercle 4) Greater trochanter Posterior 1) PSIS 2) Ischial tuberosity 3) Coccyx Soft Tissue Palpation 1) Femoral triangle borders Sartorius Adductor longus Inguinal ligament 1) Quadriceps muscles (palpate as a unit and individually) Vastus Lateralis Vastus Medialis Vastus Intermedius Rectus Femoris 3) Greater trochanteric bursa 4) Gluteus medius 5) Gluteus maximus 6) Sciatic nerve 7) Cluneal nerves 8) Hamstrings Biceps femoris Semitendinosus Semimembranosus
RANGE OF MOTION
Active and Passive Flexion 120 Extension 30 Abduction 45 Adduction 45 Internal rotation 45 External rotation 45 Flexion and Adduction Flexion, Abduction and External Rotation Reflex - None Sensation (Covered under lumbar spine packages)
SPECIAL TESTS
1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) Leg Length Discrepancy (true and apparent), pg. 696 E Al i , g 6 8E l Sg p . 9 i s n Thomas Test, pg. 736 E Anvil Test, pg. 702 E Patrick Test aka Faber Sign, pg. 728 E L g erT s p . 5 -655 a u r s et g 6 4 e , G e s n T s p . 4 -641 E a nl et g 6 0 es , L wnG e s n T s p . 5 E e i a nl et g 6 6 es , Hb T st, pg. 646 E i se b O eT s p . 2 E b r et g 7 6 s , Pelvic Rock Test aka Iliac Compression Test, pg. 648-651 E Te d l b rT s p . 3 E rn e n ug e t g 7 8 e s , Nachlas Test, pg. 578-579 E Yeoman's Test, pg. 670-671 Ey Sg (lT s , g346 Cipriano ls i Ey e t p n )
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Leg Length Discrepancy Instruct: Patient supine, (True) examiner takes a cloth measuring tape and measures from ASIS to the medial malleoli of the same leg. Examiner then measures from ASIS to the medial malleoli of the opposite leg. (Apparent) Examiner takes a cloth tape measure and measures from the umbilicus to the medial malleoli of one leg and then measures from the umbilicus to the medial malleoli of the opposite leg. Positive: Different measurements. Indicates: True = bony abnormality above or below level of trochanter difference. (anatomical short leg) Apparent = pelvic obliquity (Tilted pelvis). Confirmation Test: Radiography Al in ( a a zs i ) (e i r T s u e fr mo t t 2y as can also be ls Sg G l zi Sg = P d tc e t s d o 1 nh o e r-old i e n ai used in adults) Instruct: Patient is supine, examiner instructs patient to place both feet flat (approximate great toes and medial malleoli bilateral) on the bench while flexing both knees to 90 degrees. Positive: Difference in height and anteriority of the knees. Indicates: (1) If one knee is lower = ipsilateral congenital hip dislocation or tibial discrepancy (anatomical short leg) (2) If one knee is anterior = ipsilateral congenital hip dislocation or femoral discrepancy (anatomical short leg) Confirmation Test: Radiography
Thomas Test Instruct: Patient supine, examiner instructs patient to approximate each knee one at a time to his/her chest and hold. Positive: Lumbar spine maintains lordosis (should flatten) and opposite hip does not straighten. Indicates: Contracture of the hip flexors (iliopsoas). Confirmation Tests: O eT s Te d l b rT s b r e t rn e n eg e t s , e s
Anvil Test Instruct:
Patient supine, examiner elevates the affected leg while keeping the knee extended. The examiner then makes a fist and strikes teafc dl h f t es ee g inferior calcaneus. Positive: Localized pain in long bone or in hip joint Indicates: Possible fracture of long bones, or hip joint pathology. Confirmation Test: Radiography
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P tc T s ar ks e ta.k.a. FABERE sign i Instruct: Patient supine e a n rl e , b u t a de trayrttstep t ns h s ta , x mi f x s a d c n x n l oae h ai t i o h t e e s e l e p the ankle rests above or below the contralateral knee. Examiner then extends the hip by pushing just superior to the knee while stabilizing the contralateral ASIS. Positive: Pain in the hip region. Indicates: Hip joint pathology. Confirmation Tests: L g erT s R d ga h a u r s e t a i rp y e , o L g er T s a u r s et e Instruct: Patient is supine, examiner grasps the affected leg, flexes and externally rotates the hip and abducts the thigh (this test is similar to Patrick except the ankle of the affected leg is not resting on the contralateral knee). Examiner applies pressure to the end range of motion while stabilizing the contralateral ASIS (rest ankle on forearm and with other hand reach under arm to stabilize). Alternate Procedure (Cipriano): examiner exerts downward pressure on knee with superior hand, and exerts upward pressure on the ankle with the inferior hand. Positive: (1) Pain in the hip joint (2) Pain in the sacroiliac joint. Indicates: (1) Hip joint pathology (2) Mechanical problem of the sacroiliac joint Confirmation Test: P tcT s Hb T s ar k e t i s e t i s , b G e se T s a n lns e t Instruct: Patient in the supine position with the affected side of the sacroiliac joint as close to the edge of the table as is possible. The patient then grasps the unaffected leg just below the knee and approximates the knee to his chest. The examiner then places a downward pressure on the affected thigh until it is lower than the edge of the table. Positive: Pain on the affected SI joint stressed into extension. Indicates: General sacroiliac joint lesion, anterior sacroiliac ligament sprain, or inflammation of the SI joint. Confirmation Tests: B l e tG l h a T s Y o n T s e T s o tw i e t e ma e t t , d t s , s Lewin - G e se T s a n lns e t Instruct: Patient lying on his unaffected side, instruct patient to flex his inferior leg. Examiner grasps the superior leg and brings into extension while stabilizing the lumbosacral joint (extension of the leg stresses the sacroiliac joint and anterior joint ligaments on the side of leg extension). Positive: Pain on the side of extension. Indicates: General sacroiliac joint lesion, anterior sacroiliac ligament sprain, or inflammation of the SI joint. Confirmation Tests: G es n T s Y o n T a n l e t e ma est as , s
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Hb T s ibs e t Instruct: Patient prone, examiner stabilizes pelvis on near side while grasping the opposite ankle and flexing the knee to 90 degrees. The examiner maximally flexes the knee and then slowly internally rotates the thigh (pushing lateral on the leg). Compare bilateral. Positive: (1) Pain in the hip region. (2) Pain in the buttock/pelvic region. Indicates: (1) Hip joint pathology. (2) Sacroiliac joint lesion. Confirmation Test: L g erT s a u r s et e O e T s b r et s Instruct: Patient on his/her side, examiner flexes the affected while abducting and extending the hip. Perform bilaterally. Positive: Affected thigh remains in abduction. (Normal biomechanics, the thigh/hip will adduct.) Indicates: Contraction of the iliotibial band or tensor fascia lata, (usually secondary to synovitis of the hip, secondary to trauma of the gluteus medius and maximus) Confirmation Tests: T o sT s Te d l b rT s h ma e t rn e n eg e t , e s
Pelvic Rock Test aka Iliac Compression Test Instruct: Patient lies on their side. Examiner places both hands on the lateral portion o tep t ni m.E a n r u h s o n ad( trl me i) nte fh ai t l e si u x mi p s e d w w r l ea t e a o d lo h a p t ni m.T s baeay ai t l e si u e t itrl. l l Positive: Pain in either sacroiliac joint. Indicates: Sacroiliac joint lesion. Confirmation Test: Radiography
Nachlas Test Instruct: Patient prone, examiner takes the heel of the affected leg and approximates it to the ipsilateral buttock while stabilizing the pelvis to prevent hip flexion. Positive: Pain in the buttock and/or pain in the lumbar region. Indicates: Sacroiliac joint lesion, or Lumbar pathology. Confirmation Tests: L wn S p eT s Mi r Sg , p a P ru s nT s ( mb r e is u i e t n i S i l ec si e tl a) n , os n n o u
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Yeoman's Test Instruct: Patient prone, examiner flexes patient's leg to ipsilateral buttock and then extends thigh. Positive: Pain deep in the SI joint. Indicates: Strain/sprain of the anterior sacroiliac ligaments. Confirmation Tests: G e s n T s L wnG e s n T s a nl et e i a nl et as , as EysSg (l T s Cipriano), l in Ey e t Instruct: Patient prone, examiner passively flexes the patient's knee toward the ipsilateral buttock. Positive: Hip on side being tested will flex causing the buttock to raise off the table. Indicates: Rectus femoris or hip flexor contracture. Confirmation Tests: Femoral Stretch Test Ely's Heel to Buttock Test (v n c l tiEy s na a ak . E a as h ls i s n . a) s l s g . Instruct: Patient prone, examiner flexes the knee of the patient's affected leg to 90 degrees. Examiner then approximates the heel of the affected leg to the contralateral buttock and hyperextends the thigh off the table. Positive: (1) Inability to raise the thigh. (2) Pain in the anterior thigh. (3) Pain in the lumbar region. Indicates: (1) Iliopsoas spasm. (2) Inflammation of lumbar nerve roots. (3) Lumbar nerve root adhesions. Confirmation Tests: Femoral Stretch Test Te d ln ugsT s rn ee b r e t Instruct: Patient stands on foot of involved side of hip problem. Observe level of hips. Positive: High iliac crest on supported side and low crest on side of elevated leg. Indicates: Weak gluteus medius muscle on the supported side. Confirmation Tests: O eT s T o sT s b r e t h ma e t s ,
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KNEE
INSPECTION 1) For any obvious unnatural movement or posture Gait 2) For any topical abnormalities Scars/keloids Discoloration Abrasions Blebs Other apparent pathology 3) For any asymmetry of structure Swelling 1. Local - bursal swelling over patella and tibial tubercle 2. Diffuse - may obscure normal contour of knee 3. Knee slightly flexed (flexion houses greater volume) Atrophy - muscular area above knee Common knee deformities 1. Genu varum (bowed legs) 2. Genu valgum (knock knees) 3. Genu recurvatum (back knee)
PALPATION
Bony palpation 1) Patella 2) Medial tibial plateau 3) Tibial tubercle 4) Medial femoral condyle 5) Lateral tibial plateau 6) Lateral femoral condyle 7) Fibula head Soft Tissue Palpation Quadriceps muscles Quadriceps muscles (palpate as a unit and individually) Vastus Lateralis Vastus Medialis Vastus Intermedius Rectus Femoris 2) Infrapatellar tendon 3) Bursae Prepatellar Superficial infrapatellar 4) Medial meniscus 5) Lateral meniscus 6) Pes anserine area Sartorius Gracilis Semitendinosus 7) Popliteal fossa 8) Lateral collateral ligament 9) Medial collateral ligament 10) Gastrocnemius muscle
RANGE OF MOTION Active and Passive Flexion 135 Extension 0 Internal rotation External rotation Reflex Patellar Sensation (Covered under lumbar spine packages) SPECIAL TESTS 1) McMurray Sign, pg. 796 E 2) Medial Collateral Ligament Test aka Abduction Stress Test, pg. 760 E 3) Lateral Collateral Ligament Test aka Adduction Stress Test, pg. 762 E 4) Bounce Home Test, pg. 770 E 5 D a eT s p . 7 E ) rw r e t g 7 6 s , 6 L c ma T s p . 8 E ) ah n et g 7 6 s , 7) Apprehension Knee Test aka Apprehension Test for Patella, pg. 768E 8 P tl F moa G i i T s a aCak s n p . 7 E ) aea e rl r d g e t k l e i , g 7 4 l nn r s g 9) Patella Ballottment Test pg. 800 E 1 ) p y C mpe s nT s p . 6 E 0 A l o rsi e t g 7 4 es o , 1 ) p y Ds a t nT s p . 6 -767 E 1 A l irco e t g 7 4 es t i ,
McMurray Sign Instruct: P t n s p e e a n r l e p t n afc dh t 9 d ge sa dteafc d ai t u i , x mi f x s ai t f t i o 0 e re n h f t e n e e e s ee p ee knee to 90 degrees. Examiner grasps the heel of the affected leg and applies external rotation to the knee. Examiner places his/her hand on the lateral aspect of the affected knee and applies a valgus stress. Examiner maintains the external rotation and valgus stress on the knee and extends the affected leg slowly to the top of the table while palpating the medial knee joint line. (Occasional variance= repeat with internal rotation and varus stress) Positive: Clicking sound or pain by knee joint. Indicates: Tear of medial meniscus if positive on external rotation Tear of lateral meniscus if positive on internal rotation The higher the leg is raised when positive is elicited, the more posterior the meniscal injury. Confirmation Tests: B u c H meT s A l C mpe s nT s MR o ne o e t p y o rsi e t I , es o , Medial Collateral Ligament Test a.k.a. Abduction Stress Test a.k.a. Valgus Stress test Instruct: P t n s p e e a n rs bi s te l ea ti o te p t n afc d l . ai t u i , x mi e n e t i e h a rl h h f h ai t f t e al z t g e s ee g Examiner grasps just superior to the medial ankle of the affected leg and gradually pushes laterally (to open medial side of joint). Positive: Gapping and/or elicited pain above/at/or below joint line Indicates: Torn medial collateral ligament. Confirmation Tests: A l Ds a t nT s R d ga h , I p y irco e t a i rp y MR es t i , o
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Lateral Collateral Ligament Test a.k.a. Adduction Stress Test a.k.a. Varus Stress test Instruct: P t n s p e e a n r tbi s h me i ti o tep t n ai t u i , x mi s i e te d l g fh ai t e n e al z ahh e s affected leg. Examiner grasps just superior to the lateral ankle of the affected leg and gradually pushes medially (opening the lateral side of the joint). Positive: Gapping and/or elicited pain above/at/or below joint line Indicates: Torn lateral collateral ligament. Confirmation Tests: A l Ds a t nT s R d ga h , I p y irco e t a i rp y MR es t i , o
Bounce Home Test Instruct: P t n s p e e a n rn t c p t n t f x il , x mi r rs s h p t n ai t u i , x mi i r t ai to l h e e a n ga p te ai t e n e su s e e s g e e s heel and knee of the affected leg. Examiner pulls affected leg slowly into extension (passively). Positive: Knee does not go into full extension (slight flexion remains). Indicates: Diffuse swelling of the knee, accumulation of fluid, due to possible torn Meniscus. Confirmation Tests: A l C mpe s nT s Mc r y T s MR p y o rsi e t Mur e t I es o , as ,
Drawer Test Instruct: Patient supine, examiner flexes the hip and the knee of the pai t t n e s affected leg until the foot is flat on the table. Examiner sits on the foot of tep t nafc dl . x mi r rs s e i tep t nf x d h ai t f t e E a n ga p b h d h ai t l e e s ee g e n e se knee and exerts a pushing and pulling pressure into the affected knee. Positive: (1) Gapping > 6mm (tibia moves posterior) when the leg is pushed. (2) Gapping > 6mm (tibia moves anterior) when the leg is pulled. Indicates: (1) Torn posterior cruciate ligament. (2) Torn anterior cruciate ligament. Confirmation Test: L c ma T s ah n et s L c ma T st a h ns e Instruct: P t n s p e e a n r ustep t n k e a a3 0 angle of flexion and from this ai t u i , x mi p t h ai t n e t 0 e n e e s angle the examiner grasps both the proximal end of the tibia with one hand and the distal end of the femur with the other, and attempts to pull tibia forward in order the feel tejn p y (ai i o D a ests h o t l .v r t n f rw r t i a ao e) Positive: Gapping with the tibia moving away from the femur. Indicates: Anterior cruciate ligament or posterior oblique ligament instability. Confirmation Test: Drawer Test Apprehension Test for the Patella Instruct: Patient supine (or seated with quadriceps relaxed and resting over examiners leg at a 30 degree flexion), examiner pushes the patella laterally. Positive: Apprehension, distress of facial expression, contraction of quadriceps to bring patella back in line. Indicates: Chronic patella dislocation or pre-disposition to dislocation. Confirmation Test: MRI
Patella Femoral Grinding Test (. a Cak s n ak . l e i ) . r s g Instruct: Patient supine, affected knee extended examiner uses the web of the hand to move the patella to an inferior position. Examiner instructs patient to tighten the quadriceps muscles as the examiner continues to hold the patella in the inferior direction. Positive: Retropatellar pain and the patient is unable to hold the quadriceps contraction. Indicates: Degenerative changes of the patellar facets and /or within the trochlear groove (chondromalacia patella). Confirmation Test: Radiography Patella Ballottment Test Instruct: Patient supine with knee extended. Anterior to posterior pressure is applied over the patella. Positive: A floating sensation of the patella is a positive finding. Indicates: A large amount of swelling in the knee. Confirmation Tests: Radiography, MRI A lysC mpe so T s pe o rs in e t Instruct: Patient po e e a n rl e p t n afc dk e t 9 d ge s Sa i ep t n rn , x mi f x s ai t f t n e o 0 e re . tbi ai t e e e s ee l z e s ti wt y u k e , l ed w w r pe s r o tep t nh e w i i en l a d h h i o r n e Pa o n ad rsue n h ai t e l he n ray n g h c e s l t l e tray oai tep t nfo. x n l rtt g h ai t o t e l n e s Positive: Patient points to side of pain. Indicates: Pain on medial side is medial meniscus tear. Pain on the lateral side indicates lateral meniscus tear. Confirmation Tests: Mc r y T s B u c H meT s MR Mur e t o n e o as , et I , A lysDsrcinT s pe it t a o et Instruct: Patient prone, examiner flexes patient affected knee to 90 degrees. Examiner places h /e k e o p t n afc dti fr tbi t n E a n r rs step t n ih r n e n ai t f t h h o s i ai . x mi ga p h ai t s e s ee g al o z e e s foot and pulls the leg while internally and externally rotating the tibia. Positive: Patient will point to side of pain. Indicates: Pain on the medial side indicates medial collateral ligament tear. Pain on the lateral side indicates lateral collateral ligament tear. Confirmation Tests: Medial and Lateral Collateral Ligament Tests, Radiography, MRI
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FOOT and ANKLE

INSPECTION 1) For any obvious unnatural movement or posture 5. Check for external appearance of the shoe 2) Excessive medial or lateral wear 3) Scuffed toes 4) Holes, nails, torn stitching 5) For any topical abnormalities Scars/keloids Discoloration Abrasions Blebs Other apparent pathology 6) For any asymmetry of structure Count toes Toes flat and/or straight Toes proportional to each other Domed shaped medial longitudinal arch Color changes of foot from weight bearing to non-weight bearing Color changes of foot from non-weight bearing to weight bearing Thickness of skin Unilateral or bilateral swelling
PALPATION
Bony Palpation 1) Calcaneus 2) Sustentaculum tali 3) Medial malleolus 4) Lateral malleolus 5) Talus 6) Navicular 7) Cuboid 8) 3 Cuneiforms 9) 5 Metatarsals 10) Metatarsophalangeal joints Soft Tissue Palpation 1) Tibialis posterior tendon 2) Spring ligament 3) Tibialis anterior tendon 4) Deltoid ligament 5) Peroneus brevis 6) Achilles tendon 7) Plantar aponeurosis 8) Anterior talofibular ligament 9) Posterior tibial artery 10) Dorsal pedal artery
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RANGE OF MOTION Active and Passive Ankle Dorsiflexion 20 Ankle Plantarflexion 50 Subtalar Inversion 5 Subtalar Eversion 5 1st MTP Joint Flexion 1st MTP Joint Extension Reflex Achilles Sensation (Covered under lumbar spine packages)
SPECIAL TESTS 1) 2) 3) 4) 5) 6) Drawer Sign, pg. 842 E Ankle Dorsiflexion Test pg.345 C Rigid or Flat Feet Test (see lab packet) H ma sSg , g 8 8E o n i p . 6 n T o sn T s p . 8 E h mp o e t g 8 4 s , Motn T s p . 7 -875 r et g 8 4 os ,
Drawer Sign (Anterior Drawer Sign of the ankle) Instruct: Patient seated, examiner grasps just superior to the ankle with one hand and around the calcaneus of the affected foot with the other hand. Examiner pulls (draws) the calcaneus anteriorly and pushes the tibia posteriorly, the reverse procedure by pulling the ankle anterior and calcaneus posterior. Positive: Translation with the talus moving away from or toward the tibia. Indicates: 1) With tibia pushed/ foot pulled; a tear/instability of the anterior talofibular ligament. 2) With tibia pulled/foot pushed; a tear/instability of posterior talofibular ligament. Confirmation Test: MRI Ankle Dorsiflexion Test (Hoppenfeld) Patient experiences difficulty dorsiflexing the foot Instruct: With the patient seated, the examiner tries to dorsiflex foot of affected leg; first with the knee extended, then again with the knee flexed. Positive: (1) the foot cannot dorsiflex with knee extended, but is able to with knee flexed. (2) the foot cannot dorsiflex in either knee position Indicates: (1) contracture of the gastrocnemius muscle (2) contracture of the soleus muscle
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Rigid or Supple Flat Feet Test (Hoppenfeld) Instruct: P t n is ae a dte s n s e a n r b ev s ai t fe w i s ae a d ai t e td n h n t d , x mi o s re p t n e t he e td n e s a e e s l while standing. Positive: (1) Absence of medial longitudinal arch in both positions. (2) Presence of medial longitudinal arch while seated with a loss of medial longitudinal arch while standing. Indicates: (1) Rigid flat feet (2) Supple flat feet H ma s Sg o n in Instruct: Patient supine, examiner raises the extended affected leg about 12 " off the table or 45 and then forcibly dorsiflexes the foot of the affected leg. (Squeezing the calf is recommended by some sources, yet other sources feel it is contra-indicated, please note that this is a verbal component to be explained in examination.) Positive: Deep pain in the calf. Indicates: Deep vein thrombophlebitis. Confirmation Tests: Vascular Testing, Palpation T o s nsT s h mp o e t Instruct: Patient prone with leg flexed to 90 degrees by examiner. Examiner squeezes the belly of the calf muscle of the affected leg. Positive: Absence of foot plantarflexion motion. Indicates: Achilles tendon rupture. Confirmation Test: MRI Motn e t r sT s o Instruct: Patient supine, examiner grasps the affected forefoot with one hand and applies transverse pressure across the metatarsal heads. Positive: Sharp pain in the forefoot. Indicates: Metatarsalgia or neuroma (usually at the 3rd and 4th metatarsal interspace).
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MUSCLE GRADING CHART Oxford or Van Allens cl Sa e Muscle Gradations 5 Normal Descriptions Against gravity with full resistance, complete range of motion evident Against gravity with some resistance, complete range of motion evident Against gravity, complete range of motion evident Gravity eliminated, complete range of motion evident Slight contractility with no joint motion evident Contractility is not evident
Good
3 2 1 0
Fair Poor Trace Zero
REFLEX GRADING CHART- Wel Sa x r cl es e Reflexes are usually graded on a 0 to 5+ scale. 5+ 4+ 3+ 2+ 1+ 0 Highly increased response, sustained clonus, possibility of disease pathology exists Highly increased response, increased possibility disease pathology exists, hyperactive Slightly increased response, possibility of disease pathology exists Normal response Slightly diminished, lower than normal response, hypoactive No response
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Neurological Diagnosis
DIAG 2740
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1) Purpose of the Neurological Examination When there is no readily observable neurological deficiency or in the case of apparent neurological involvement, examination procedures are employed to assess the integrity of the nervous system, they are used to: A. Localize the level or site of involvement B. Identify the nature and/or extent of the lesion We will learn to evaluate the patients: Mental function Motor System Coordination and gait 2) Mandatory Lab Equipment and Materials
Sensory system Reflexes Cranial nerves
Neurological or percussion hammer Pinwheels Neurotips Tongue depressors Penlight 2 containers of aromatics
128 Hz tuning fork 512 Hz tuning fork Tape measure Sterile cotton swabs Cards with shapes, text, and colors Paperclips and toothpicks
3) Suggested Equipment Opthalmoscope (Mandatory for next quarter special senses lab) 4) Required Attire Dress casually for all labs. Pants, Sweatpants, or Shorts NOTE: 3 POINT DEDUCTION FROM LAB PRACTICAL EXAM FOR NOT WEARING PROPER TESTING ATTIRE! 5) Performing sensory and reflex tests (refer to topic outline for dressing requirements) Everyone should wear shorts Men should wear short sleeve shirts Women should wear aerobic or bathing suit tops (In cold weather, wear these items under an outer layer of clothing)
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Essential Final Laboratory Examination Information

The final practical laboratory examination is worth 50 points. You MUST PASS the Final Lab exam (> 70) in order to pass the class. The student is responsible for adequate preparation for the final examination. There are no retakes/reexaminations if a student does not perform well. The student MUST introduce him/herself to the patient in the following manner: "Hello I am ____, I will be performing a neurological exam on you today. Anything we discuss during this visit will be c mp tlc ni ni.Iy uh v a y u so s r o c rs ui td y a p i me tp a ed n t e i t t a k o l e o f e t l f o a e n q e t n o c n en d r g o a p o t n, l s o o h sae o s. e y d a i n s n e t If at any time you experience pain or discomfort during the exam please let me know. Do I have your permission to proceed?" Students are responsible for all information presented in lecture and/or lab instruction. Students are also responsible for all information coming from handouts and reference texts. If a student does not take the final laboratory examination during his/her scheduled time and does not provide an acceptable excuse in accordance with the Student Handbook, then he/she will receive a zero for their final laboratory examination grade. If a student does not take the final examination during his/her scheduled time and does provide an acceptable excuse according to the student Handbook, then there is no forfeiture of points. The day the student returns back to school, the student must contact and reschedule with his/her instructor an acceptable time to take his/her final laboratory examination. Each student must h v ad c r b g( l e u p d fr a hl a dfrh f a e a n t n T os d ns y a e o t a f l q i e )o e c a n o te i l x mi i . w t e t ma not os uy p b n ao u s aead c r b g E c s d n wl ee p c dt s o p ro a rs o s iy o h or her own equipment. hr o t a . a h t e t ib x e t o h w es n le p n il fr i os u l e bi t s Students in this lab are expected to be both doctor and patient. The dress code for the final examination is as follows; males are to wear gym shorts, females are to wear gym shorts and a tank top. NOTE: 3 POINT DEDUCTION FROM LAB PRACTICAL EXAM FOR NOT WEARING PROPER TESTING ATTIRE! Each student will have 12 minutes for the examination. Should your laboratory instructor be unable to test you, your examination may be administered by any Clinical Science faculty.
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Mental Status Evaluation

1) Orientation A k h p t nn me l ai , n d t s te ai t a , c t n a d ae e s o o 2) Level of alertness, attention, and cooperation Ask the patient to spell a word forward and backward Ask the patient to repeat a string of integers forward and backward Ask the patient to name the months forward and backward If the patient displays difficulty with Orientation or Attention higher level of evaluation is needed. 3) Memory Recent- recall three items after 5 minute delay Remote- recall certain historical c wti p t nme r ( ei ) f t i n ai t as h e s moy l t i me f eed y ug t h hsh o Wh r i o o o i c o l d g ? 4) Language Object naming Repetition of single words and sentences 5) Calculations Simple additions and subtractions, should be two or more steps 6) Apraxia Following a comp x tr o l moo c mma dlertn t c mby u h i o e n i pee d o o k or a r r rtn t bu hy u teh pee d o rs o re t 7) Sequencing tasks Ask the patent to tap the table with: fist, open palm, then side of open hand (rock, paper, scissors) perform as rapidly as possible 8) Abstraction A s a t ni epeai o apo ebo c lq ii h e r b dg t b t co n rrtt n f rv r r oo u lm T e al i es r i t o l as y r tew r h om
The Motor System Examination

Inspection 1 C e ki s n t n fra c u t n (a d , h u e, n ti ) ) hc l mb a d r k o fsi l i h n s s o l ra d h h, u c ao s d g involuntary movements or abnormal positions. 2) Look for atrophy/hypertrophy. 3) Observe posture Testing Muscle Strength 1) Passively move limbs through range of motion noting resistance and rigidity 2) Ask patient to hold arms straight out front palms up for 20 to 30 sec with eyes closed, look for drift to one side or pronator drift. 3) Test muscle strength at multiple joints and record.
O fr o V nAlnsS ae xod r a l c l e
Joint Lock Resistance Motion Against Gravity Motion Gravity Neutral Evidence of Contraction
5 4 3 2 1 0
X X
X X X
X X X X
X X X X X
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Coordination and Gait (mostly testing cerebellum)

1) Diadochokinesia Patting Test: Rapid rhythmic alternating movements. Have patient pat leg with each hand as fast as possible. 2) Diadochokinesia Supination Pronation Test: Have patient pronate and supinate palms as rapidly as possible. 3) Dysmetria- Have patient touch your index finger and then his/her nose alternately several times. (Note tremors or lack of coordination) 4) Dysmetria- Heel-Shin: Have patient run their heel from his/her knee to his/her foot. 6) Gait- observe patient walking toward and away, note posture, stability, foot elevation, trajectory of leg swing, balance, and arm motions. Tandem gait- ask the patient to walk heel toe. Forced gait testing- ask the patient to walk on heels and toes.
The Sensory System Examination

When performing a sensory examination: 1) Compare the stimulus bilateral 2) Scatter the stimuli through multiple dermatomes 3) Note the degree of perception of stimulus 4) Have patient close eyes Screening (Start on distal extremities work proximal) (EYES CLOSED) 1) Point Localization (Topognosis): The ability to recognize points being touched on the body. (use dull side of Neurotip on skin) 2) Pain (pinprick)- use sharp end of neurotip) stimuli on the hands and feet (spinothalamic). 3) Vibration Pallesthesia- Place the handle of a vibrating 128 Hz tuning fork on the bony prominances of the upper and lower extremities. Start distal work po i l A k c ny ufe v rt n a d h nd e i tp D . tp i. rx . s a o e li ai ? n w e o st o ? ( rSo st ma b o s ) 4) Light Touch- Gently stroke skin with a wisp of cotton or with a camel hair brush. 5) Joint Position Sense-Examiner moves patient's fingers and toes, he/she is asked to describe the digit position. 6) R mb r ts- ask the patient with eyes open, then closed, note any o egs e t swaying
Discriminatory Sensation (EYES CLOSED) 1) Sharp vs Dull discrimination- Alternate sharp and dull (use a neurotip) stimuli on the hands and feet (spinothalamic). 2) Stereognosis: The ability to recognize familiar objects by the sense of touch. 3) Graphesthesia: The ability to recognize numbers traced lightly on the skin. 4) Barognosis: The ability to distinguish between different weights. 5) Two Point discrimination: Determining the smallest area in which two points can be separately perceived. (use paperclip) 6) Double Simultaneous Stimulation Extinction- only one side is felt Displacement- one side is felt normally and the other displaced toward midline Synesthesia- one side is felt normally and the other is a vague burning
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Reflexes
Involuntary, stereotyped, motor responses to stimuli. They are extremely important in the diagnosis and localization of neurological lesions. Reflexes are divided into 4 groups: 1) Deep tendon a.k.a. myotactic reflexes 2) Visceral a.k.a. organic reflexes 3) Superficial reflexes Cutaneous Mucous membrane 4) Pathological reflexes When testing reflexes be aware that it involves: 1) A specific procedure 2) An afferent or sensory nerve 3) An integrating center 4) An efferent or motor nerve
Deep Tendon Reflexes reaction of a muscle to being passively stretched by percussion on the tendon
Have patient relax Mildly stretch muscle/tendon Strike tendon briskly Test bilaterally
Reflex Biceps
Response Elbow Flexion
Afferent/Efferent Musculocutaneous Nerve Radial Nerve Radial Nerve Femoral Nerve Tibial Nerve
Integrating Center C5 Spinal Cord C6 Spinal Cord C7 Spinal Cord L2, 3, 4 Spinal Cord S1, 2 Spinal Cord
Brachioradialis Slight Forearm Flexion Triceps Patellar Achilles Elbow Extension Knee Extension Foot Plantar Flexion
We th l sg sp a inabsence of any DTR (especially patellar; LMNL) s J n rs i ma e e da sks n uver AKA Reinforcement Test or Cortical Distraction Test A form of cortical distraction that brings out a reflex when hard to elicit Pt. hooks hands together by flexed fingers and pulls on the clenched hands at the moment the reflex is performed. Significance of Abnormal Deep Tendon Reflex Response Reflex responses are graded subjectively according to a classification scheme based on a scale of 0-5 called the Wexler Reflex Scale. Wexler Reflex Grading Chart Reflexes are usually graded on a 0 to 5+ scale. 5+ Highly increased response, increased possibility disease pathology exists, sustained clonus. 4+ Highly increased response, increased possibility disease pathology exists, hyperactive 3+ Slightly increased response, possibility of disease pathology exists 2+ Normal response 1+ Slightly diminished, lower than normal response, hypoactive 0 No response
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Decreased or absent reflex = Generally indicates a lower motor neuron lesion (can include peripheral nerve disease, posterior column involvement, cerebellar disease, hypothyroidism) Increased reflex = Generally indicates upper motor neuron lesion (can include motor cortex, pyramidal tract lesions, strychnine poisoning, hyperthyroidism)
Visceral Reflexes:
Reflex Direct Light Response
Ipsilateral pupillary constriction when light is shined in the eye Contralateral pupillary constriction when light is shined in the eye the eyes, pupillary constriction, Lens convexity when object is brought into near vision Reduction in heart rate when examiner presses the carotid sinus Reduction in heart rate When examiner presses the eye Pupillary dilation when examiner pinches the base of the neck at the cervical sympathetic chain
Afferent Optic Nerve II
Integrating Center Midbrain
Efferent Oculomotor Nerve III
Indirect Light
Optic Nerve II
Midbrain
Oculomotor Nerve III
Accommodation Convergence of
Optic Nerve II
Occipital Cortex
Oculomotor Nerve III
Carotid Sinus
Glossopharyngeal Medulla Nerve IX Trigeminal Nerve V Medulla
Vagus Nerve X
Oculocardiac
Vagus Nerve X
Ciliospinal
Cervical T1-T2 Spinal Cervical Sympathetic Chain Cord Sympathetic Chain
NOTE: Do not perform occulocardiac reflex while contact lenses are in place.
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Superficial Reflexes:
Reflex Corneal Response Blinking and tearing of the eye upon touching the cornea with a cotton wisp Gagging upon touching the back of the throat with a tongue depressor Raising of the uvula upon phonation, or touching with a tongue depressor Drawing inward of scapular when skin or interscapular space is irritated. Umbilicus deviation to the stroked side. Absence is normal only if bilateral Plantar flexion (curling) of toes upon stroking sole of foot Afferent Trigeminal Nerve V Integrating Center Pons Efferent Facial Nerve VII
Gag/Pharyngeal
Glossopharyngeal Nerve IX
Medulla
Vagus Nerve X
Uvular/Palateal
Glossopharyngeal Nerve IX
Medulla
Vagus Nerve X
Interscapular
T2-T7 Spinal Nerves
T2-T7 Spinal Cord
Dorsal scapular nerve
Abdominal
Upper T7-10 Lower T11-12
Spinal Cord T7T12
Upper T7-10 Lower T11-12
Plantar
Tibial Nerve
Spinal Cord S1-S2
Tibial Nerve
Significance of Abnormal Superficial Reflexes (+) is normal/present (-) is abnormal/diminished or absent Abnormal in both lower motor neuron and upper motor neuron lesion. When combined with exaggerated deep tendon reflexes and positive pathological reflexes are diagnostic Upper Motor Neuron Lesion (UMNL). NOTE: Do not perform the corneal reflex with contact lenses in place.
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Pathological Reflexes performed with STRONG stimulus

Head
Glabella aka Mc atys Cr h
Abnormal Response (Upper Motor Neuron Lesion)

Contraction of orbicularis occuli muscle upon percussion of supraorbital ridge (glabella)
Upper Extremity
H f ns of ma To e rmn r s

Clawing of the fingers and thumb (flexion and adduction of thumb with flexion of the fingers) upon flicking tip of index finger into extension Flexion of the fingers and thumb upon tapping palmar surface or tips of middle three fingers
Lower Extremity
Ankle Clonus Babinski

Continued involuntary contraction (flexion and extension) of foot upon quick forcible dorsiflexion of the foot Dorsiflexion of the big toe and fanning or splaying of other toes upon stimulation of the plantar surface of the foot (lateral to medial) Alternative ways to elicit babinskis sign: O p n em sg - application of pressure to anterior tibia stroking downward p e h i s in C a d c sg stroking down the lateral leg around the lateral malleolus h d o ks inG ro sg squeezing the calf od ns inS h ee c a fr ssign - squeezing the achilles tendon
Significance of Abnormal Pathological Reflexes (-) = Normal/absent (adults and children over 5 to 7 months) (+) = Abnormal/present (adults) Presence of these reflexes in corticospinal tract diseases (pyramidal tracts, lateral columns) indicates an UMNL Clinical Signs of Upper Motor Neuron 1) Spasticity of muscles with possible contractures 2) Decreased muscle strength, little or no atrophy 3) Presence of pathological reflexes 4) Altered superficial reflexes 5) Hyperactive deep tendon reflexes 6) No fasciculations (twitches) Clinical Signs of Lower Motor Neuron 1) Flaccidity of muscles 2) Loss of muscle strength and tone, noticeable muscle atrophy 3) Absence of pathological reflexes 4) Decreased or absent deep tendon reflexes 5) Altered superficial reflexes 6) Fasciculations (twitches)
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Examination of the Cranial Nerves

(I) Olfactory Nerve
Ask about disorders of sense of smell and of taste (will diminish with loss of smell) a) Using a penlight, make sure nostrils are not blocked. b) Occlude one nostril at a time (eyes should be closed) Have patient sniff familiar and non-irritating odors, use the milder scent first. Ask the patient: 1) Do you smell anything? 2) Can you identify the substance?
(II) Optic Nerve

a) Inspect external structures of eye b) Inspect the optic fundi with opthalmascope c) Test visual acuity Screen by reading print Screen with shapes and/or colors d) Test visual fields by confrontation (peripheral vision) a.k.a. Wiggling test Examine directly in front and level with patient's face Have patient cover one eye Bring object into view from eight different directions per eye e) Direct light reflex- ipsilateral pupillary constriction f) Indirect light reflex (consensual reflex)- contralateral pupillary constriction g) Accommodation reflex Test ability of the eyes to adapt for near vision Instruct patient to follow object inward from a distance Convergence of the eyes, constriction of the pupil, convexity of the lens
(III) Oculomotor, (IV) Trochlear, and (VI) Abducens Nerves

The following four tests are for CN III specifically: a. Direct light reflex b. Indirect light reflex c. Accommodation reflex d. Check for ptosis The following will test CN III, IV, and VI combined: a) Extraocular movements with six cardinal fid o g z .O s rep t n e s f a e b ev ai t l e s eyes for normal conjugate, or parallel movements of the eyes and nystagmus as you have him/her follow your finger or pencil while it makes a wide "H" in the air: Trochlear = down and in Abducens = lateral Oculomotor all other fields.
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(V) Trigeminal Nerve (Ophthalmic, Maxillary, and Mandibular)

a) b) c) d) e) Have patient clench teeth, palpate masseter and temporalis muscles Test pain discrimination (sharp-dull) on face bilateral Test for light touch to the face with wisp of cotton or brush Test corneal reflex with wisp of cotton, should see blinking and tearing Light touch to anterior 2/3 of tongue, inside cheeks, and hard palate with toothpick. (Use a penlight to view the inside of the mouth) f) Oculocardiac Reflex (Must ask patient if he/she wears contacts) Take pulse, a p pe s r o e tep t nc s de e p l rt s o l d ce s 2 beats p l rsue v rh ai t l e y , u e ae h u e ra e -3 y e s o s d per 15 sec.
(VII) Facial Nerve

a) Inspect face for asymmetry (at rest and during motion) Ask the patient to perform the following: Raise eyebrows Close eyes tightly Show teeth Puff out cheeks Smile Frown b) Ask the patient about changes in taste sensations sweet, salty, and sour on the anterior two thirds of the tongue.
(VIII) Vestibulo-Acoustic Nerve

Sensory-Cochlear Portion a) Screen tests include identifying hearing loss by: Finger Rub Test: Assess hearing by rubbing fingers together near the EAM, find maximal distance sound can be heard. Whisper Test Have patient close his eyes (to prevent lip-reading) and cover the ear on the side not being tested. Place your head/mouth 2 feet from the ear being tested and whisper words to the patient and ask patient to repeat the words. You can also ask questions to the patient and have him/her answer yes or no to each question. Repeat this procedure at varying (usually increasing) distances or with loud, medium and soft tones. b) Distinguish between perceptive and conductive hearing using 512 Hz tuning forks We e br sTest Procedure: Place the handle of the vibrating tuning fork on the midline of the skull and ask the patient to compare the intensity of the sound in the two ears. Indicates: (-) Normal: sound is equal in both ears. (+) Conductive deafness: sound lateralizes to the bad ear. (+) Sensorineural deafness: sound lateralizes to the good ear.
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Rn esTest in Procedure: Place the handle of the tuning fork against the mastoid process. Have the patient signal when the sound ceases, then hold the fork near the external ear without touching the patient, again have the patient indicate when the sound ceases. Indicates: (+) Normal: air conduction persists twice as long as bone conduction (-) Conduction deafness: air conduction is equal to bone conduction or air conduction is less than bone conduction. (-) Sensorineural deafness: air conduction and bone conduction are both radically decreased or absent. Vestibular Portion Labyrinthine Test for Positional Nystagmus Procedure: P t n s ae , x mi rn p c p t ne e fr p na e u ai t e td e a n i e t ai t y s o s o tn o s e e s s e s nystagmus. Then inspect for nystagmus for 30 seconds in each of the following positions: Patient supine Turn head to one side Turn head to the other side P t nh a h n i o tetb ai t e d a g g fh a l e s n e Patient returns to seated position Indicates: Normal: the fast component of the eye movement will be in the direction the patient is being moved. (Nystagmus is named for the fast component). Peripheral Lesion: the patient will exhibit nystagmus within 2-5 seconds, does not change direction if the patient is stationary, and disappears within 30 seconds. Medullary Lesion: Nystagmus begins immediately upon movement and may change direction while the patient is stationary (also patient does not have vertigo). B rn Whrn C ar e t aa ys iig h iT s l Procedure: Seated patient is spun in chair in one direction Indicates: Normal: fast component of nystagmus will be in the direction of the spin. Mittlemyer Instruct: Patient marches in place, eyes open then closed. Positive: A turning to one side Indicates: Side of vestibular lesion Vestibulo-ocular Reflex Procedure: D . o s ai t h a a di t c p t n t f v i o ted c r rh l p t n e d n n r t ai to i io n h o t d e s su s e x sn os fc .D .h ntrs ai t h a i ortt n l ea f x n a d a e rte un p t n e d n oai , trle i , n e s t o a l o flexion and extension. Indicates: Normal patient should maintain eye contact eyes moving at the same speed in the opposite direction of head movement. Abnormal findings are detailed in labyrinthine test above.
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(IX) Glossopharyngeal and (X) Vagus Nerve

a) Note any hoarseness of the voice. b) Uvula reflex = Patient says "ah." Watch for symmetrical rising of soft palate. Bilateral lesion of Vagus = Palate does not rise. Unilateral paralysis = One side of palate does not rise and uvula will deviates to the normal side. c) Gag reflex. d) Have patient swallow while you palpate thyroid cartilage. e) Carotid sinus reflex. f) Ask the patient about change in bitter taste sensation on the posterior third of the tongue.
(XI) Spinal Accessory Nerve

a) Trapezius Muscle Inspect Palpate Muscle test b) Sternomastoid Muscle Inspect Palpate Muscle test
(XII) Hypoglossal Nerve

a) Inspect tongue for: Atrophy Fasciculations b) Have patient stick out tongue and test bilateral with tongue depressor, or use the tongue in cheek method Unilateral paralysis = Protruded tongue deviates to involved side.
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CERVICAL and LUMBAR NERVE ROOT EVALUATION

1) Muscle test and name the muscle/s and nerve for each nerve root level being tested 2) Reflex test and name the appropriate reflex being tested; if no reflex it must be stated. 3) Sensation ts tea po r t d r tmefrh n uo g a p ca ea di e th p rpi e emao a o te e rl i l a k g n t oc s corresponding dermatome above and below following the format enclosed from Hoppenfeld
Muscle (motor)
One hand above joint of motion for stability One hand used as short lever to test muscle No hands on joints Gradual increase in pressure BILATERAL
Reflex
Rapid flick of hammer on tendon No tension in muscles around tendon
Sensation (dermatome)
Anatomical position Eyes closed Cover the entire dermatome Pin to skin (ask: does this feel like this?) Test dermatome above and below
BILATERAL
BILATERAL
Muscle Grading- Oxodo V nAlnsS ae(page 7) fr r a l c l e Reflex Grading- We lr S ae(page 10) xe c l s
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Evaluation of Cervical Nerve Roots

Neurological Level: C5 a) Disc Level b) Muscle tests (2) c) Reflex d) Sensation Neurological Level: C6 a) Disc Level b) Muscle test (1) c) Reflex d) Sensation Neurological Level: C7 a) Disc Level b) Muscle tests (3) C4 Shoulder abduction: deltoid (Axillary nerve) Forearm flexion: biceps (Musculocutaneous Nerve) Biceps Lateral arm and shoulder
C5 Wrist extension extensor carpi radialis longus & brevis, extensor carpi ulnaris (Radial Nerve) Brachioradialis Anterior lateral forearm, palm, thumb and index finger
c) Reflex d) Sensation Neurological Level: C8 a) Disc Level b) Muscle test (1) c) Reflex d) Sensation Neurological Level: T1 a) Disc Level b) Muscle tests (2) c) Reflex d) Sensation
C6 Elbow extension: triceps (Radial Nerve) Wrist flexion: flexor carpi radialis (Median Nerve), flexor carpi ulnaris (Ulnar Nerve) Finger extension: (Radial Nerve) Triceps Middle finger, middle of palm
C7 Finger flexion: (Median Nerve) None 4th and 5th phalanges, antero-medial hand and forearm
T1 Finger abduction: dorsal interossei (Ulnar Nerve) Finger adduction: palmer interossei (Ulnar Nerve) None Medial arm (distal aspect of arm to proximal forearm)
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Dermatomes of the Upper Extremity

Examination Procedure Example (Examination of C5 dermatome) Patient seated, anatomical position, eyes closed. 1. Bilateral Comparison Questioning = Does this feel like this? C4 of right side compared to C4 of left side (dermatome above) C5 of right side compared to C5 of left side (dermatome level) C6 of right side compared to C6 of left side (dermatome below) 3. Unilateral Comparison Questioning = Does this feel like this? First C4 of right side compared to C5, C5 compared to C6 of right side Second Repeat on the other side
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Evaluation of Nerve Root Lesions Involving the Thoracic Spine

Neurological Level: T2-T12 a) Disc Level T2-T12 b) Muscle test (1) Rib Elevation: Intercostals [segmentally innervated and difficult to evaluate individually], rectus abdominus. T7-T 2(1 B e oSg 1 L ) e vr i s n c) Reflex None (can do superficial abdominal reflex) d) Sensation T4: Nipple line T7: Xyphoid process T10: Umbilicus T12: Inguinal ligament There is sufficient overlap of these areas so that no anesthesia will occur if only one nerve root is involved.
Evaluation of Multiple Lumbar Nerve Roots

Neurological Levels: L1, L2 and L3 a) Disc Level T12-L2 b) Muscle test (1) Primary hip flexor: iliopsoas (L1-L3) c) Reflex None d) Sensation Anterior thigh, obliquely from lateral to medial. (L1 top of thigh, L2 middle of thigh, L3 lower thigh).
Neurological Level: L2, L3 and L4 a) Disc Level L1-L3 b) Muscle tests (2) Primary knee extensors: Quadriceps Femoris, Vastus Medialis, Vastus Intermedius (L2-L4, Femoral nerve). Primary adductor: Adductor longus, Adductor Brevi, Adductor Magnus (L2-L4, Obturator nerve). c) Reflex Patellar d) Sensation L2 middle of thigh, L3 lower thigh, L4 anteromedial leg below the knee and medial side of the foot.
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Evaluation of Individual Lumbar Nerve Roots

Neurological Level: L4 a) Disc Level b) Muscle test (1) c) Reflex d) Sensation L3 Foot inversion with slight dorsiflexion: tibialis anterior (Deep Peroneal/fibular Nerve) Patellar Tendon Medial aspect of leg, medial foot, medial aspect of big toe
Neurological Level: L5 a) Disc Level b) Muscle tests (4)
c) Reflex d) Sensation
L4 Foot dorsiflexion Big toe dorsiflexion: extensor hallucis longus (Deep Peroneal/fibular Nerve) Toes 2,3,4 dorsiflexion: extensor digitorum longus and brevis (Deep Peroneal/fibular Nerve) Hip/Thigh abduction: gluteus medius & minimus (Superior Gluteal nerve) None Lateral leg, dorsum of foot, middle three toes
Neurological Level: S1 a) Disc Level b) Muscle tests (3)
c) Reflex d) Sensation
L5 Foot Plantar flexion: Gastrocnemius and Soleus (Tibial Nerve) Foot plantar flexion and eversion: peroneus longus and brevis (Superficial Peroneal/fibular Nerve). Hip extension: gluteus maximus (Inferior Gluteal Nerve). Achilles Posterior aspect of the leg, lateral aspect of foot, lateral aspect of little toe.
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Dermatomes of the Lower Extremity

Examination Procedure Example (Examination of L4 dermatome) Patient seated, anatomical position, eyes closed. 1. Bilateral Comparison Questioning = Does this feel like this? L3 of right side compared to L3 of left side (dermatome above) L4 of right side compared to L4 of left side (dermatome level) L5 of right side compared to L5 of left side (dermatome below) Unilateral Comparison Questioning = Does this feel like this? First L3 of right side compared to L4, L4 compared to L5 of right side Second Repeat on the other side
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Spinal Cord and Meningeal Testing

LH r t Sg emies in t Procedure: Patient sitting or supine, patient flexes his/her head toward his/her chest o, e E a D . cv lf x s ai t h a tw r c e t rp r v n , ra te l e p t n e d o ad h s s i ye e s . Positive: Electric shock-like sensations down the spine and/or through extremities. Indicates: Dural irritation, severe spinal cord injury or degeneration, (MS patients exhibit a positive 30% of the time). Confirmation Tests: Soto Hall Test, Sensory and Reflex Testing, Nerve Conduction Testing, MRI K ri Sg engs in Procedure P t n s p e e a n r a s e f x s ai t h t 9 d ge s ai t u i , x mi p si l l e p t n i o 0 e re e n e vye e s p a dtep t nk e t 9 d ge s E a n r x n s ai t l n h ai t n e o 0 e re . x mi e t d p t n e e s e e e s g completely. Positive: Inability to fully extend the leg and/or pain (usually in the neck region). Indicates: Meningeal irritation/meningitis. Confirmation Tests: Bu z si Sg , u a T p rd i ks i L mb r a n n Brudzinski Sign Procedure: Patient supine, examiner flexes patient's head to the chest. Positive: Involuntary knee flexion. Indicates: Meningeal irritation or nerve root lesion (classic test for meningitis) Confirmation Tests: K ris i , u a T p en Sg L mb r a g n
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Cervical Spine and Nerve Root Testing

Soto Hall Sign Procedure: Patient supine, exami rl e p t nh a tw r h /e c e t n f x s ai t e d o ad ih r h s e e e s s w i s bin tep t ns ru wt h p te a o i ei h n . he t i i h ai t t n m i y oh n r f fr r a d l al g z e s e h n o Positive: Generalized pain in the cervical region which may extend down to the level of T2. Indicates: Nonspecific test for structural integrity of cervical region. Foraminal Compression Test Procedure: Patient seated with examiner standing behind. Examiner clasps his/her h n s v r ai t h a a de et i ra i d w w r pe s r. a d o e p t n e d n x r n e s g o n ad rsue e s s c n Examiner repeats this proced r wt tep t nh a rttdr h ue i h ai t e d oae i t h e s g and then left. Positive: 1) Exacerbation of localized cervical pain. 2) Exacerbation of cervical pain with a radicular component. Indicates: 1) Foraminal encroachment or facet pathology without nerve root compression. 2) Foraminal encroachment with nerve root compression (one would then want to evaluate the myotome, reflex and dermatome of the nerve root involved). Confirmatory Tests: Jackson Compression, Maximal Cervical Compresi T s B k d T s S o l r e rsi s n e t a o y e t h u e D pe s n o , s , d o Test, Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI, Nerve Conduction Testing Jackson Compression Procedure: Patient seated with examiner standing behind. Examiner laterally flexes the patient's head to one side and clasps his/her hands over patient's head and exerts increasing downward pressure. Perform bilaterally. Positive: 1) Exacerbation of localized cervical pain. 2) Exacerbation of cervical pain with a radicular component. Indicates: 1) Foraminal encroachment without nerve root pressure or facet pathology. 7) Foraminal encroachment with nerve root compression (one would 8) then want to evaluate the myotome, reflex and dermatome of the nerve root involved) Confirmatory Tests: F rmi l o rsi , x l ev a C mpe s nT s S ulg T s B k d T s oa n C mpe s n Ma i C ri l o rsi e t p r e t a o y e t a o ma c o , i s n , s , Shoulder Depression Test, Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI, Nerve Conduction Testing
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Maximal Cervical Compression Procedure: Patient seated with examiner standing behind. The examiner instructs the patient to rotate the head and hyperextend the neck. Perform bilaterally. Positive: 1) Pain on the concave side 2) Pain on the convex side Indicates: 1) Foraminal encroachment with or without nerve root compression (based on presence or absence of radicular component) 2) Muscular strain Confirmation Tests: F rmi l o rsi , a ko C mpe s nT s B k d Test, Shoulder Depression Test, oa n C mpe s n J cs n o rsi e t a o y a o s o , s Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI, Nerve Conduction Testing Valsalva Maneuver Procedure: Patient seated, examiner instructs patient to take a deep breath and hold while bearing down as if having a bowel movement. Positive: Radiating pain from site of lesion. Indicates: Space occupying lesion Confirmation Tests: D j i Ti , w lwn T s N f i r T s B k d Sg , x l ev a C mpe s n e r e r d S ao i e t afg e t a o y i Ma i C ri l o rsi , en s a l g , z es , n ma c o Shoulder Depression Test, C ri l irco , a ko C mpe s n F rmi l o rsi ev a Ds a t n J cs n o rsi , oa n C mpe s n c t i s o a o T s S ulg T s S n oy n R f x e t g MR e t p r e t e s r a d el T sn , I , i s n , e i Cervical Distraction Test Procedure: P t n s ae ,h e a n r rs s h p t nh a wt b t h n s ai t e td te x mi ga p te ai t e d i oh a d e e e s h and gradually exerts upward pressure keeping hands off TMJ and ears. Positive: 1) Diminished or absence of pain. 2) Increase of cervical pain. Indicates: 1) Foraminal encroachment (local pain diminishes), nerve root compression (Radicular pain diminishes). 2) Muscular strain, ligamentous sprain, myospasm, facet capsulitis. Confirmation Tests: F rmi l o rsi T s J cs nC mpe s n Ma i l ev a C mpe s nT s S ulg oa n C mpe s n e t a ko o rsi , x a o , o ma C ri l o rsi e t p r c o , i s n T s B k d T s S o l r e rsi T s R f x n S n oy e t g R d e t a o y e t h u e D pe s n e t el a d e s r T sn , a i , s , d o , e i ography, MRI, Nerve Conduction Testing Bakody Sign (Shoulder abduction Test) Procedure: Patient seated, examiner instructs patient to place the palm of the affected side flat on top of their head. Positive: Decrease or absence of radiating pain. Indicates: Cervical foraminal compression, nerve root entrapment (usually C5/C6 level because this motion elevates the subscapular nerve and puts traction on the lower brachial plexus). Confirmation Tests: Foraminal Compression, Maximal Compresi , a ko C mpe s nT s S ulg T s s n J cs n o rsi e t p r e t o s o , i s n , Shoulder Depression Test, Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI, Nerve Conduction Testing
Thoracic Spine and Nerve Root Testing

Adam's Sign (positions)
Instruct: Patient standing, with examiner standing behind patient, examiner looks for evidence of scoliosis. Examiner instructs patient to bend forward at the waist with fingers extended and hands together. Examiner observes for evidence of change in the scoliosis. 1 A rs s a e soo iio s re t s a he . ) c o h p d c ls s b ev d o t i tn i s rg 2 A rs s a e soo id e n t t i tn( o fri h mp g mu c l ) c o h p d c ls o s o s a he l k o r u i , su r i s rg o b n a imbalance, and asymmetry in hand length). 1) Negative: evidence of a functional scoliosis 2) Positive: evidence of a pathologic or structural scoliosis as well as trauma or subluxation.
Positive:
Indicates:
Confirmation Tests: Postural Analysis, Radiography
Schepelmann's Sign Procedure: Patient seated arms fully abducted and raised over head, examiner instructs patient to laterally flex thoracic spine to the left side and then to the right side. Positive: Pain on the concave or convex side. Indicates: Pain on the concave side indicates intercostal neuritis while pain on the convex side indicates fibrous inflammation of the pleura (or possible intercostal myofascitis). Beevor's Sign Procedure: Patient supine, examiner instructs patient cross his/her arms across the chest and perform a partial sit up. Positive: Superior movement of the umbilicus. Indicates: Superior movement of the umbilicus is indicative of a spinal cord lesion at the level of T10 or lower abdominal weakness. Inferior movement of the umbilicus is indicative of nerve root involvement T7 T10. Confirmation Tests: Sensory testing of thoracic nerve roots, MRI
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Upper Extremity Testing

R o et o s T s a.k.a. E.A.S.T (elevated arm stress test) Instruct: Patient standing, instruct patient to bring arms out in front of their body, bend the elbows to 90. The patient then externally rotates the arms and opens and closes their fists bilaterally at a moderate pace for up to 3 minutes. Positive: Ischemic pain, heaviness of the arms, or numbness and tingling of the hand. Indicates: Thoracic outlet syndrome on side involved (v n c n i r tits t b mo t E a o s es h e to e s s d s accurate for TOS evaluation) Confirmation Tests: R o T s H le dT s A s n T s Wr hT s S o l r e rsi T s E e T s o e t a ta e t d o e t i t e t h u e D pe s n e t d n e t s , s , s , g s , d o , s Adson's Test (Scalene Maneuver and Scalenus Anticus Test) Procedure: Patient seated with arms at side and elbows fully extended. Examiner finds radial pulse, slightly abducts affected arm and has patient take a deep breath and hold, then instruct patient to rotate head and elevate chin toward examiner while holding the breath. Note positive or negative findings, if negative then rotate head to the opposite side and repeat the procedure. Positive: Pain and/or paresthesia, decreased or absent pulse, pallor. Indicates: Scalenus anticus syndrome or cervical rib syndrome. (usually same side) Decrease or absence of radial pulse indicates compression of subclavian artery. Paresthesia/radiculopathy indicates compression of the brachial plexus at the neurovascular bundle by scalenius anticus or cervical rib.(usually opposite side) Confirmation Tests: H le dMa e v rS o l r e rsi T s Wr hT s E e T s a ta s n u e, h u e D pe s n e t i t e t d n e t d o , g s , s Halstead's Maneuver Instruct: Patient seated, examiner finds and monitors radial pulse in neutral position with one hand and with the othe h n t co tep t nam tw r tef o. x mi r r a d r t n h ai t r o ad h l rE a n ai e s o e instructs patient to elevate chin and hyperextend their neck. If the test is negative (the pulse does not disappear), then rotate the head to the opposite side and repeat. Positive: Pain and/or paresthesia, decreased or absent pulse, pallor. Indicates: Compression of the neurovascular bundle by scalenus anticus or cervical rib. Confirmation Tests: R o T s A s n T s S o l r e rsi T s o e t d o e t h u e D pe s n e t s , s , d o
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Costoclavicular Maneuver a.k.a. Eden's Test Procedure: Patient seated, examiner finds radial pulse and instructs patient to sit erects, force shoulders back, chest out and touch chin to chest. Positive: Pain and/or paresthesia, decreased or absent pulse, pallor. Indicates: Compression of the neurovascular bundle between the clavicle and 1st rib. Confirmation Tests: S o l r e rsi T s A s n T s H le dT s Wr hT s h u e D pe s n e t d o e t a ta e t i t e t d o , s , s , g s Hyperabduction Maneuver a.k.a. Wr h T s i t et g s Procedure: Patient seated, examiner finds radial pulse and hyperabducts the patient's arm. Positive: Pain and/or paresthesia, decreased or absent pulse, pallor. Indicates: Compression of the axillary artery by pectoralis minor or coracoid process. Thoracic outlet syndrome. Confirmation Tests: A s n T s H le dT s S o l r e rsi T s E e T s d o e t a ta e t h u e D pe s n e t d n e t s , s , d o , s Tn l Eb w Sg ie lo in s Procedure: Patient seated, examiner taps with the Taylor reflex hammer over the groove between the medial epicondyle and the olecranon process. Positive: Pain and/or tenderness at the site being tapped and paresthesia in the ulnar nerve distribution area (fingers 4,5). Indicates: Neuroma of the ulnar nerve. Confirmation Test: Nerve Conduction Testing Fo t P p r in rme a e Sg s Procedure: The patient is instructed to hold a piece of papaer between any two adducted fingers. The doctor tries to remove the paper. Positive: The patient is unable to maintain grip on the paper. Indication: Ulnar nerve paralysis. Comfirmation Tests: Nerve Conduction Testing PhalnsSg AND R v reP ae Sg aka P a e sg e in e es h lns in ... ry r in s Procedure: Patient seated, examiner instructs patient to flex both wrists to maximum degree and approximate until point of pain or 60 seconds. Prayer sign = maximally extend wrist (palms together), elbows same level as shoulders for 60 seconds. Positive: Reproduction of pain and/or paresthesia in the median nerve distribution (thumb, index finger, middle finger, and the thumb side of ring finger). Indicates: Carpal Tunnel Syndrome Confirmation Tests: Tn l Sg , ev C n u t nT sn i i N re o d co e t g es n i i
Tn l Wr t in ie i Sg s s Procedure: Patient seated with wrist supinated, examiner taps with the Taylor reflex hammer over the palmar (volar) surface of the wrist. (flexor retinculum). Positive: Reproduction of pain, tenderness and/or paresthesia in the median nerve distribution thumb, index finger, middle finger, and the lateral aspect of ring finger). Indicates: Carpal Tunnel Syndrome Confirmation Tests: P a n T s R v reP a n T s Nerve Conduction Testing h l e t e es h l e t, es , es
Lower Extremity Testing

Minor's Sign Instruct: Examiner instructs patient to stand. Observe for abnormal motion. Positive: Knee flexion of affected leg while supporting upper body weight (hand on back or thigh) on unaffected side. Indicates: Sciatica, lumbosacral or sacroiliac joint lesion Confirmation Tests: N c l e tS i l ec si T s S i i T s a h sT s p a P ru s n e t c ta e t a , n o , ac s B lT s (u p r dA a sT s, u p r dF r adB n igT s) et e tS p ot d m e tS p ot ow r e dn e t e e Procedure: Patient standing. Have patient bend forward and note for presence of low b c p i Wi p t n s n i , tbi p t ni c rs a dba e a k a . t ai t t d g s i e ai t l ce t n rc n h e a n al z e si a s h a a s p t ns cu H v p t n b n fr ada y u i g i t ai t a rm. a e ai t e d ow r s o p n e s e immobilize the pelvis. Positive: Low back pain Indicates: 1) Pain in during unsupported and supported bending = Lumbar involvement 2) Pain in during unsupported, no pain during supported bending = pelvic involvement Confirmation Tests: G e s n T s G l h a T s a n l e t o tw i e t as , d t s Mi rm T s l a s et g Instruct: P t n s p e e a n ra e b t o p t nl s -3 inches off the ai t u i , x mi ri s oh f ai t e 2 e n e s e s g table and instructs patient to hold legs off the table for 30 seconds. Positive: Inability to perform test and/or low back pain. Indicates: Weak abdominal muscles or space occupying lesion. Confirmation Tests: B w tn T s H e Wa T s T eWa T s K mp T s o s i et e l l et o rg , k , l et e et k , s
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Heel Walk Procedure: Positive: Indicates:
Patient walks on heels. Inability to perform test. L4-L5 disc problem (L5 nerve root)
Confirmation Tests: Bowstri T s K mp T s MirmT s N r B wn T s n e t e e t l a s e t ei o i e t g , s , g , s g Toe Walk Procedure: Positive: Indicates:
Patient walks on toes. Inability to perform test. L5-S1 disc problem (S1 nerve root).
Confirmation Tests: B w tn T s K mp T s MirmT s N r B wn T s o s i e t e e t l a s e t ei o i e t rg , s , g , s g K mpsT s e et Procedure: Patient either seated or standing with arms crossed in front of the chest. Examiner stands behind patient and stabilizes at the PSIS. With other hand examiner reaches around patient and grasps patient s o l r E a n r a s e bi s h u e b c h u e. x mi p si l r g s o l r a k s d e vy n d and obliquely pushes shoulder towards opposite PSIS. Positive: 1) Pain usually radicular, recreating existing sciatic pain 2) Pain - local Indicates: 1) Disc protrusion: nme i d c rt s n Kemps will be positive as the patient I d l i por i a s uo is leaning AWAY from the side of pain. nl ea d c rt s nK mp wl ep si a tep t n i I a rl i por i e s ib o i e s h ai t t s uo l t v e s leaning INTO the side of pain. 2) Localized pain may indicate lumbar spasm or facet capsulitis. Confirmation Tests: B w tn T s K mp T s MirmT s H e Wa T s T eWa T s F j stjs e t o s i et e et l a s et e l l et o rg , s , g , k , l e t a rz n T s k , e a' Lindner's Sign Instruct: Patient supine, examiner flexes patient's head toward the chest. Positive: Pain along sciatic distribution or sharp, diffuse pain (leg) Indicates: Sciatic radiculopathy Confirmation Tests: Ba g rSg , a rz js e tL s g e T s Sri t e R in T s rg ad i F j st n T s a e u e t t g L g a i e t s n e a , s , ah sg , Straight Leg Raiser (SLR) Procedure: P t n s p e e a n ra e p t nleg slowly to 90 or to ai t u i , x mi ri s ai t e n e s e s the point of pain. Positive: Radiating pain and/or dull posterior thigh pain. Indicates: Sciatic radiculopathy or tight hamstrings. Confirmation Tests: Ba g rT s F j stjs e tL s g e T s L d eT s rg ad e t a rz n T s a e u e t i n r e t s , e a , s ,n s
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Bragar Sg ds in Procedure: Patient supine, examiner performs a (SLR) on the patient. Examiner lowers the raised leg (5) from the point of pain and sharply d ri x s ai t fo. osl e p t n o t f e e s Positive: Radiating pain in posterior thigh. Indicates: Sciatica Confirmation Tests: F j stjs e tL s g e T s Sri t e R in T s a rz n T s a e u e t t g L g a i e t e a , s , ah sg Sicard's Sign Instruct: Examiner lowers raised leg (see SLR) 5 degrees from point of pain and dorsiflexes patient's big toe. Positive: Posterior thigh and leg pain. Indicates: Sciatic radiculopathy, usually from disc lesion Confirmation Tests: B c trws e tBa ad T s F j stjs e tL s g e T s L d eT s Sri t e e hee T s rg r e t a rz n T s a e u e t i n r e t t g L g , s , e a , s ,n s , ah R in T s T rn T s L wn Sa d gT s a i e t uy e t e is tn i e t sg , s , n Turyn's Sign Instruct: Patient supine, examiner dorsiflexes the big toe of the affected extremity. Positive: Pain in the gluteal region or radiating sciatic pain. Indicates: Sciatic radiculopathy. Confirmation Tests: B c trws e tBa ad T s F j stjs e tL s g e T s L d eT s Sri t e e hee T s rg r e t a rz n T s a e u e t i n r e t t g L g , s , e a , s ,n s , ah R in T s T rn T s L wn Sa d gT s Sc rT s a i e t uy e t e is tn i e t i d e t sg , s , n , a s Bonnet's Sign Procedure: Patient supine, examiner strongly internally rotates and adducts the affected leg across the midline and then performs a straight leg raiser test. Positive: Pain in posterior thigh or leg. Indicates: Sciatica (possibly piriformis syndrome) Confirmation Tests: Bragad T s F j stjs e tL s g e T s L d eT s Sri t e R in T s r e t a rz n T s a e u e t i n r e t t g L g a i e t s , e a , s , n s , ah sg Fajersztajn's Test a.k.a. Well-Leg-Raising Test of Fajersztajn a.k.a. Cross-over Sign Procedure: Patient is supine. Examiner performs a SLR on the patient's unaffected leg to 75 or until it produces pain down the affected leg. If no pain is produced, examiner dorsiflexes the foot. Positive: 1) Pain down affected leg.(Cross-Over Sign) 2) Decrease in pain down affected leg. Indicates: 1) Medial disc protrusion 2) Lateral disc protrusion. Confirmation Tests: Bragad T s L s g e T s L d eT s Sri t e r e t a e u e t i n r e t t g L gRaising Test s , s ,n s , ah
Femoral Stretch Test (Femoral Nerve Traction Test) Procedure: Patient lies on the unaffected leg side, hip and knee slightly flexed, patient straightens back and flexes neck. The affected leg is extended by the examiner at the hip approx. 15. The affected knee is flexed (stretching femoral nerve). Positive: Pain on the anterior portion of the thigh. Indicates: Traction on the femoral nerve indicating involvement of the 2nd, 3rd and 4th lumbar nerve roots. Confirmation Tests: Ey Sg ls i n Tn l F o Sg ie o t in s Procedure: Doctor taps the region of the medial plantar nerve, posterior to the medial malleolus Positive: Paresthesia radiating into the foot. Indication: Tarsal tunnel syndrome Confirmation Tests: D c e e s n n rve conduction study uh n i , e s g MotnsT s r et o Procedure: Doctor squeezes the metatarsal heads. Positive: Sharp pain in the forefoot. Indication: Metatarsalgia or neuroma Confirmation Tests: Srn ks n n rec n u t ns d t sy i , ev o d co t y u s g i u
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ADDITIONAL TESTS
Bracelet Test Instruct: Patient seated, examiner gives mild to moderate compressive pressure to d ru o p t nsw i ( u e c c s a i s eo w i, d x i e os m f ai t r tt mb n i l rd li f r ti e f g r e s h re a d s n n encircles ulnar side i.e. squeeze wrist) and then have patient attempt to make a fist. Perform bilaterally. Positive: Acute forearm, wrist and hand pain Indicates: Significant for Rheumatoid Arthritis. Confirm with diagnostic imaging and laboratory tests. Confirmation Tests: Blood testing, Radiography N f ie T s af g r e t z s Instruct: With the patient seated comfortably, the examiner occludes the jugular veins bilaterally for 30 40 seconds. The patient is then instructed to cough deeply. CONTRAINDICATED for geriatric patients. EXTREME CARE when performing on a patient with atherosclerosis. Positive: Radicular pain (typically in lumbars, possibly cervical or thoracic) Indicates: Space-occupying lesion Confirmation Tests: D j i Ti , a a a T s S ao i T s ( c ri lp e, etba Atr T sn ( e r e r d V l l e t w lwn e ti ev a s i )V r rl r y e t g i en s a svs , l g n c n e e i n cervical Spine) Forestier's Bowstring Sign Instruct: Patient is standing. Examiner instructs the patient to lateral bend to one side and then the other. Positive: Ipsilateral tightening and contracture of the paraspinal musculature (normally the contralateral musculature will contract) Indicates: Ankylosing Spondylitis (Marie Strumpell's Disease), further evaluate. Confirmation Tests: Mi r Sg , a h s e tS i l ec si , l dtsn , a i rp y n i N c l T s p a P ru s n Bo e t g R d ga h os n a , n o o i o
Chest Expansion Test Instruct: Patient is standing or sitting. Examiner measures the diameter of the thoracic cage at the level of the 4th intercostal space. The patient then maximally inhales, a measurement is taken. The patient relaxes and then maximally exhales, a measurement is taken. Positive: Males = less than two inches expansion Females = Less than 1 1/2 inches expansion Indicates: Thoracic fixation, commonly found with ankylosing conditions such as Ankylosing Spondylitis. Confirmation Tests: A sSg , orseB w tn , a g o Moi , l dtsn , Radiography mo s i F r t r o s i R n e f t n Bo e t g s n eis rg o o i
NON-ORGANIC EXAMS Based upon area of Chief Complaint Cervical: Lb nsSg ima in Instruct: Patient seated, examiner places a gradual increasing amount of pressure on the p t nma ti u ti e o s oi a lu c mfr b . o aebaeral. ai t e s s d nit c me n te b n o ot l C mp r it o lb c y ae l Positive: Response of pain. Indicates: I a i i tr fh p t np i trs o . a b u e d r gi epeai o s n n c o o te ai t a he h l C n e s d ui n rrtt n f da e s n d n t o palpation findings during rest of exam. Can be indicator for unusually low threshold to pain, possible malingerer. Confirmation Tests: Ma k pSg no f i s n Any Area, General: Ma n s nsT s g u o et Instruct: Patient standing or seated, examiner instructs patient to point to site of pain and examiner marks spot. Examiner distracts patient by performing some irrelevant test. Patient is instructed to point to site of pain again. Positive: Patient does not point to same site both times, significant difference in location of site of pain. Indicates: Lack of organic basis for LBP (Malingering). Patient with true pain will point to site of pain both times. Confirmation Tests: A i t n L a i , un B n hT s Fe e Hp Fi s n Tu k oai a T s x l u k o d g B r e c e t l d i l i , rn R tt n l e t ar n s , x , p g o Ma n o f Sg n k p in s Instruct: P t n s ae o s p e e a n r s bs e p t nrsn rd l u ert. ai t e td r u i , x mi e t lh s ai t e t g a i p l ae e n e ai e s i a s Without changing the pai t p si ,h e a n rrtts h p t nae o t n o i n te x mi ii e te ai t ra f e s t o e ra e s complaint while monitoring their pulse rate. Positive: An increase in pulse rate by 10 or more beats/min. is a positive (normal) sign. If no increase is noted or less than 10/min. = No organic reason for pain. Indicates: Positive is normal. Patient with true pain will experience an increase of 10 beats per minute, which is equal to approximately a 10 percent or more increase in their pulse rate. Confirmation Tests: L ma T s i n et b s
138
Low- Back, Patient on Table: B r B n hT s uns e c e t Instruct: Patient kneels on exam table and is instructed to touch the floor (have them bend from tew i) i te f g rp w i e a n r tbi s ai t l . h a twt h i i et s he x mi s i e p t n e s h rn i l e al z e s g Positive: Response of pain in low back area, inability or unwillingness to do test. Indicates: Lack of organic basis for LBP (Malingering). All stress is placed on posterior leg muscles. Confirmation Tests: A i Tu k o d g Fe e Hp Fi Sg , g u o Tu k oai T s x l rn L a i , l d i l i Ma n s n , rn R tt n e t a n x , p n s o Flexed-Hip Test Instruct: P t n s p e e a n r l e o eh n u d rh p t nl a s i wt ai t u i , x mi p c s n a d n e te ai t u e n e a e s mb r p e i n h fingertips touching the spinous processes (usually at L5/S1). Examiner passively flexes p t nk e t 9 d ge s n p t nh t 9 d ge s ai t n e o 0 e re a d ai t i o 0 e re . e s e s p Positive: Patient complains of pain in the lumbar region and/or leg pain. Indicates: Lack of organic basis for LBP (Malingering), if patient complains of pain in the lumbar region and/or leg before any spinous process separation is felt by the examiner. Confirmation Tests: A i Tu k o d g B rB n h Fi Sg , g u o T s Tu k oai T s x l rn L a i , un e c , l i Ma n s n e t rn R tt n e t a n s p n s , o Flip Sign Instruct:
Positive: Indicates:
Patient supine; the examiner performs a SLR and notes the degree of movement and location of pain. The patient is then asked to be seated, with legs hanging off the table edge, as the examiner tells the patient he/she is going to examine the knee joint. While doing the examination, a SLR is performed in the seated position. Patient does not complain of pain. Lack of organic basis for LBP (Malingering). The same degree of movement and location of pain should occur in either position.
Confirmation Tests: A i Tu k o d g B rB n h Fe e Hp Ma n s n T s Tu k oai T s x l rn L a i , un e c , l d i a n s x , g u o e t rn R tt n e t s , o
Low- Back, Patient Standing: Axial Trunk-Loading Test Instruct: Patient standing, examiner places downward pressure on the head with both hands w i n t iub gtep t npe e t gp s r. he o d tri h ai t rs ni o t e l s n e s n u Positive: Patient complains of pain in the lumbar region. Indicates: Lack of organic basis for LBP (Malingering). The axial loading may produce pain in the cervical region but should not produce pain in the lumbar region. Confirmation Tests: B rB n h Fi Sg , l e Hp Ma n s n T s Tu k oai T s un e c , l i Fe d i s p n x , g u o e t rn R tt n e t s , o
139
Trunk Rotational Test Instruct: P t n s n i wt ams rse a a s c e te a n r rs s ai t p ls ai t t d g i r co s d g i t h s x mi ga p p t n e i e a n h n , e e s v. Examiner instructs patient to rotate trunk to one side. Examiner simultaneously rotates p t np lsns med e t nta p t n rtts R p a po e ueto other side. ai t e ii a e s v i co h t ai toae . e e t rc d r r i e Positive: Patient complains of low back pain. Indicates: Lack of organic basis for pain (Malingering). In this test the whole spine is being moved as one unit, not in segments. Confirmation Tests: A i Tu k o d g B rB n h Fi Sg , g u o T s Fe e Hp x l rn L a i , un e c , l i Ma n s n e t l d i a n s p n s , x
140
SPECIAL SENSES
DIAG 3750
141
OPTHALMOSCOPY AND OTOSCOPY

Examining the patient Always perform an external examination of the eye before proceeding to use the ophthalmoscope Assess for: Bilateral symmetry Scars, abrasions other noticeable marks Discharge, alteration of sclera color Eye lids, eye brows Normal constriction, dilation, reflexes
The Ophthalmoscope
1) Viewing aperture 2) Focus wheel Black (green) # - spherical convex (positive) lenses, converge rays. For Hyperoptic eye Red # - spherical concave (negative) lenses, diverge rays. For myopic eye Lenses are necessary because different people have different refractive errors, the appropriate lens is necessary to focus on the retina. 3) Choosing the proper aperture (Shape or color of light beam) : Blue - fluorescein dye to evaluate cornea and circulatory system Green (red free), used to see if dark spots are pigment or dried blood, which is darker than the pigment spots Cross hatch - estimate size and distance of lesions for a landmark Slit - light bends over irregularities checking for retinal detachments for Polarizing filter (grayish aperture) use to cut glare The larger round white beam gives broadest view of the fundus when pupil is dilated. Use the small or medium beam for an undilated pupil Using the Ophthalmoscope 1. Use your right eye (hold ophthalmoscope in right hand) to view patients right eye, left for left. 2. Have patient maintain focus at a distant object. 3. Obtain a red light reflex - position ophthalmoscope 12 - 1 rm ptn ee n sgt t t s ed et 5f o aet y ad l h yo h i ,i c i s i l ed r beam into pupil. 4. At a 15 degree angle to the pupil, move close to patient, rest hand on cheek. 5. Start focus wheel on 0 (or focus ten feet away) and move back and forth until you have retinal vessel on focus , which is usually the ( d ) * s i e f gr n oui w el h e i i fnu. o 2 r 2. U en x i eo fcs g hew i v wn udsD nt e d n n l e g keep moving the light on and off of the pupil. This will cause it to constrict due to facilitation. 6. Follow the retinal vessel back towards the disc. Pivot around the pupil, you will need to tilt the ophthalmoscope in order to see the different fields of the fundus. 7. The disc lies slightly nasal to center of retina. Examining the Disc 1. Shape - round to oval 2. Margins - distinct, nasal margins being less so. 3. Pigment and/or scleral crescents, myelinated nerve fibers (all considered to be normal variants) 4. Color - normally orangish-pink, deeper color nasally. Too pale - optic atrophy Too red - hyperemia 5. Cup/disc ratio - less than a ratio of 1:2. Large cup or differences bilaterally, suspect Glaucoma.
Examination of the Vessels 1. Nasal vessels those that go from the disc towards nose are more horizontal. 2. Temporal vessels, those going towards ear, curve more. 1) Veins wider and darker than arteries are 2) Arteries narrower and brighter than veins, and taper towards the periphery. are 3) Note: Blood flow - obstructed or not. Look for arterial venous crossing (can change course of vein, vein will appear wider distal to the crossing, but crossings close to the disc cannot be judged accurately), Look for regularity of the blood column, multiple constrictions, focal constrictions. Caliber: size and width of the vessels, generalized narrowing, attenuated arteries, enlarged veins A:V ratio - should be 2:3 or 3:4, *if <1:2 they are not WNL 4) Central retinal artery occlusion (CRA) Lessened blood supply to retina, retinal edema Bloodless appearance, arteries narrowed or absent Macula - cherry red appearance (not involved) Sudden visual loss - *medical emergency 5) Central retinal vein occlusion (CRV) Hemorrhagic appearance Look for hemorrhages Vision will become obscured 6) Arterial light reflex Reflection of light by medial coat of retinal arterioles this is normal. Widening of the reflex - early sign of arteriolar sclerosis. Copper wiring - orange color of the reflex at later stage of sclerosis. Examination of the background Blood and choroidal plexus behind retina, the pigment cells in the choroid and pigment layer of the retina all contribute to general appearance of the background. 1. Normal pigment varies and usually corresponds to skin tones: lighter skin tone the individual the more light reflected and easier it is to see the choroidal vascular pattern. Tigroid - normal variation 2. Integrity of the fundus - the following are not normal: Hemorrhages - solid, flame shaped, linear, dot and blot Micro aneurysms-small, sharp point-like red spots Cotton wool areas - result from occlusion of terminal arterioles and resultant swelling of the axons occur along vessels and obscure the vessel Exudates - result from venous micro infarction and stasis. Yellowish, flat and do not completely obscure vessels posterior to them Retinal edema Drusen - small yellow dots, symmetrically distributed, seen in both eyes, they are a precursor of macular degeneration
143
Examination of the Macula 1. Area of highest concentration of cones and has the greatest visual acuity (Macula Lutea) 2. Fovea pit in center of macula, 2 disc diameters temporal and slightly lower to the disc is more pigmented a than rest of retina, has an avascular appearance. Vessels approach but do not cross the macula; it has a deeper blood supply for the choroid. 3. Have patient look at light of ophthalmoscope; this puts the macula in full view. Look for hemorrhages, exudates, edema Any pigment change is abnormal
The Otoscope
Speculum: Reusable - boil to clean or soak in alcohol. 4 sizes 2mm, 3mm, 4mm, 5mm Disposable - 2 sizes 2.5mm, 4mm In order to obtain the maximum field of view, choose the largest speculum which fits comfortably in the ptn s a aet er i . Examination the patient Always do an external examination first Hearing - Weber, Rinne, Bing, Schwabach Inspect bilaterally for shape, redness, scars, mastoiditis, discharge, lumps, cauliflower ear, wax (cerumen), foreign bodies etc. Palpate the pinna for any tenderness, nodules and granules. Using the Otoscope 1) Choose largest comfortable speculum, have patient tilt head away from you. 2) Straighten the outer ear canal Adults - up and back Children - down and back 3) Hold otoscope like a pencil (between thumb and forefinger) resting hand against patients cheek. Do not put pressure on the anterior wall with your speculum (it is VERY pain sensitive). 4) Be able to demonstrate recognition of anatomical landmarks of the tympanic membrane (T.M.): malleus Cone of light umbo pars flaccida short process pars tensa incus and stapes when visible 5) Be able to recognize normal from abnormal appearance of tympanic membrane 6) Normal: clarity varies with skin pigmentation from almost clear like Saran Wrap to Wax paper appearance. pale gray ovoid semi-transparent membrane situated obliquely at end of bony external auditory canal hnlo m lu et d dw ad ak ns th oe fi t ad f aes x ns o n n bc ed at cn o l h e l e e g the incus and its articulation with head of the stapes may be seen through a very clear membrane at the posterior superior quadrant. An abnormal membrane can be red or swollen or both, be retracted, demonstrate a loss of landmarks or malposition of landmarks due to abnormal tension on the membrane.
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Use speculum with a bright light Never use pressure on the sensitive septum Can view: Vestibules Middle meatus Mucosa Septum Inferior and middle turbinate bones Normal nasal mucosa has a red appearance Common cold - swollen erectile turbinates, bright red mucosa and discharge Allergic rhinitis - swollen erectile turbinates, polyps Atrophic rhinitis - turbinates are atrophic. Mucosa covered with crust and pus. Offensive odor ozena. Ethmoidal maxillary or frontal sinusitis associated with a history of chronic nasal discharge are (sinusitis can be unilateral or bilateral and involve any of the sinuses). Cystic fibrosis - presents with several edematous boggy, saccular masses in nasal passage called polyps. Polyps are more commonly associated with chronic allergies Polyps occur most frequently in the middle meatus. They are pale, non-tender and move freely on their stalk and are often confused with turbinates which are pink, tender and immobile.
Internal nasal examination
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Clinical Sciences Diagnosis Laboratory Manual July 2008

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CLINICAL DIAGNOSIS LABORATORY MANUAL

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

MO B G I ET S YS U D O PHYSICAL EXAMINATION (Seidel, Ball, Dains, Benedict)

Equipment for Course

CLINICAL SCIENCES DIVISION

Vital signs Explanation

Pr hr m aue et fn ni da s a i ac capacity. e pe l esr n o a i v ul cr o sular i a m di dv

Blood Pressure Explanation Palpatory Systolic

Place the blood pressure cuff so that:

Additional Blood Pressure Notes Technique

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

Head and Neck Examination

CLINICAL SCIENCES DIVISION

Head and Neck Examination Explanation Inspection

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

Patient is supine Patient is disrobed to the waist

CLINICAL SCIENCES DIVISION

Vascular Examination Explanation

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

Patient is supine Patient is disrobed to the waist

Signs of Vascular Abnormalities

Signs Common to Both Arterial Insufficiency and Venous Stasis

CLINICAL SCIENCES DIVISION

Signs of Vascular Abnormalities Explanation

Signs Common to both Arterial Insufficiency and Venous Stasis

CLINICAL SCIENCES DIVISION

Examination of the Chest and Lungs

Inspection (anterior & posterior)

CLINICAL SCIENCES DIVISION

Auscultation (posterior, then anterior)

Lateral axillary Medial axillary Anterior axillary Posterior axillary

(anterior, with patient supine)

CLINICAL SCIENCES DIVISION

Chest and Lungs Explanation

Inspection (anterior and posterior)

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

Auscultation (posterior, then anterior)

Just below the breasts laterally

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

REVISED - AUSCULTATION OF THE HEART 08 Sp

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

CLINICAL SCIENCES DIVISION

Examination of the Abdomen

CLINICAL SCIENCES DIVISION

* LECTURE MATERIAL ONLY *