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History & Physical Exam Special Tests

Blood Pressure – Auscultatory Gap

* Ask about caffeine use in the past 30 minutes
* Ask if patient has been sitting for 5 minutes
* Ask if patient has any restrictions to taking BP in either arm
* Align correctly sized cuff with brachial artery, palpate radial artery
* Inflate until radial artery not palpable, add 20mmHg as starting point for auscultation
* Orthostatic hypotension is defined as 20mmHg drop between patient positioning

Auditory Function – Rinne & Weber Tests

* Weber: Strike 512Hz and place handle on center of patient’s forehead
* Ask patient which ear the sound can be heard best in or if it is equal
* Rinne (said rin-na): Strike 512Hz and place handle on patient’s mastoid process
* Have patient tell you when the sound stops (bone conduction), then move the tines in
front of the ear (air conduction) and ask if they can hear the sound

Opthalmoscopic – Fundus Exam

* Dim room lights, use opthalmoscope with same eye as patient’s eye being examined
* Hold patient’s head with other hand to gauge your distance, adjust to 0 diopters
* Come toward patient’s eye at a 15-degree angle, looking for a vessel to cross
* Follow vessels to cup and disk, measure ratio to compare with other eye
* Examine for abnormalities (AV nicking, cotton wool spots, papillary edema)
* Have patient look into light briefly to examine macula and fovea
* Anterior chamber (perpendicular) lighting: crescent moon diming with glaucoma

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History & Physical Exam Special Tests

Otoscope – Ear Canal Exam

* Palpate tragus and pinna for pain and examine for exudate
* Retract pinna up, out, and back (adult) or down, out, and back (child)
* Insert otoscope with inverted hold using backhand method or extended 5th digit
* Examine canal (exudate, lesions, erythema, cerumen)
* Examine tympanic membrane (color, light reflex, boney structure)
* Insufflate for mobility of tympanic membrane

Neck – Auscultation & Thyroid

* Auscultate of carotid arteries and thyroid for bruits
* Hold thyroid from the back of the patient
* Have patient swallow (examine for nodules, thyroidmegaly)

Respiratory – Suspected Consolidation

* Bronchophony: sound transmitted louder at area of consolidation
* Egophony: patient says “e” and sounds like “a” at areas of consolidation
* Whispered pectoriloquy: whispered word sounds louder at area of consolidation

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History & Physical Exam Special Tests

Respiratory – Clinical Scenarios

Scenario Tactile fremitus Percussion
Pneumonia Increased Decreased resonance
Pneumothorax Decreased Increased resonance
Pleural effusion Decreased Decreased resonance

Meningitis – Brudzinski & Kernig Tests

* Brudzinski sign: Patient supine, passively flex patient’s neck
* Positive Brudzinski sign is pain or restricted flexion
* Kernig (K for Knee) sign: Patient supine, knees bend, extend lower leg
* Positive Kernig sign is pain

Cardiac – Heart Sounds

* S1: closure of the AV valves, marks onset of systole
* S2: closure of semilunar valves, aortic and pulmonic
* S2 split: right side slightly delayed with decreased pressures (A2>P2)
* Have patient exhale and hold to resolve physiologic split (not IHSS)
* Ejection click: early systole (diseased aortic valve)
* Opening snap: early diastole (mitral disease)
* S3: rapid deceleration of blood (decreased compliance in adults)
* S4: atrial kick against non-compliant ventricle
* Crescendo/decrescendo murmur: aortic stenosis
* Plateau murmur: mitral regurgitation, tricuspid regurgitation, septal defect
* Radiation to neck (aortic stenosis) or axilla (mitral regurgitation)

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History & Physical Exam Special Tests

Cardiac – Measuring Jugular Venous Pressure

Patient supine at 30-degree angle of recumbency
Measure height of jugular venous pulse from sternal angle
Upper limit for normal is 6cm at 30-degrees of elevation

Cardiac – Heart Sound Special Positioning

Left lateral decubitus: mistral stenosis, S3, S4
Sitting, learning forward, breath out and hold: aortic murmur
Standing, squatting, valsalva: MVP, aortic stenosis

Cardiac – Hepatojugular Reflex, Edema

Hepatojugular reflex: press on right costal margin, examine for jugular vein distension
Scale: 0 = none, 1 = ankle, 2 = tibia, 3 = femoral, 4 = sacrum

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History & Physical Exam Special Tests

Abdomen – Clinical: Ascites, Cholecystitis, Nephrolithiasis

Ascites: shifting dullness and fluid wave test
Shifting dullness: Patient on side, percuss for dullness, tympany is normal
Fluid wave: Patient’s hand mid-abdomen pressing down, tap on patient’s flank
Positive fluid wave test is detection of fluid “shock wave” by clinician
Cholecystitis: Murphy sign: push up under RCM and hold, have patient breath in deeply
Positive Murphy sign is sudden stop in inspiration
Nephrolithiasis, hydronephrosis, pyelonephritis: Costovertebral angle tenderness
Lloyds punch: costovertebral angle tenderness with percussion

Abdomen – Clinical: Acute Abdomen

* Assess for guarding, rigidity, rebound tenderness (push in then let go quickly)
* Ask patient what hurts more: pushing in, pushing in slowly/deep, or letting go quickly
* Rovsing sign: pain in RLQ with LLQ pressure
* Psoas sign: passively extend the thigh of patient with knees extended
* Positive psoas sign is pain in the abdomen
* Obturator sign: flex hip and externally rotate (painful)

Musculoskeletal – Arthritis
* Heberden nodes: distal interphalangeal joint (osteoarthritis)
* Bouchard nodes: proximal interphalangeal join (rheumatoid arthritis)

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History & Physical Exam Special Tests

Cardiac – Allen Test (Modified)

* Patient’s palm up, have them clench their fist
* Compress radial and ulnar artery
* Have patient relax hand, observe pale palm
* Release ulnar artery
* Normal is pink within 3-5 second, abnormal: repeat, release radial artery

Musculoskeletal – Clinical: Knee Injury

* Anterior drawer test: anterior cruciate ligament stability
* Varus and valgus stress test: collateral ligament stability
* Posterior drawer test: posterior cruciate ligament stability
* McMurray sign and Apley grind: meniscal tear
* Ballottement: fluid in joint space
* Patellar tracking: listen for crepitus

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History & Physical Exam Special Tests

Musculoskeletal – Clinical: Back Pain

* Straight leg raise: patient supine, provider’s hands under heal of patient
* Seated straight leg raise: is suspicious of factitious disorder (malingering)

Musculoskeletal – Clinical: Carpal Tunnel, Tenosynovitis

* Carpal Tunnel: Phalen sign, Tinel sign
* Phalen test: Wrists flexed and together for 90 seconds, mimics sensory deficits
* Tinel test: percussing on the carpal tunnel mimics sensory deficits
* Tenosynovitis: deQuervain test (thumb in fist, pain with ulnar deviation)

Neurological – Reflex Testing

* Scale +0/4 (lower motor neuron) to +4/4 (upper motor neuron), +2/4 is normal
* Biceps (C5-6), brachioradialis (C5-6), triceps (C6-7), patellar (L2-4), Achilles (S1-2)
* Babinski sign: stroke lateral plantar surface of foot and cross medially at the ball

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History & Physical Exam Special Tests

Neurological – Cerebellar Function

* Rapid alternating moments: have patient pronate and supinate their forearms
* Finger to nose: arms outstretched, eyes closed, patient touches nose alternating arms
* Pronator drift: arms forward, palms up, close eyes, watch for pronation and drifting
* Heel to shin: patient puts one heal on other shin and goes down with good tracking
* Tandem walk: heel walking (L5) and toe walking (S1)
* Romberg test: feet together, arms out in front, palms up, close eyes, patient is stable

Neurological – Dementia
* Perform mini mental status exam, have patient draw the face of a clock

Male Genital – Scrotal Mass, Hernia

* Scrotal mass: auscultate for bowel sounds, transilluminate scrotum
* Hernia detected on scrotal invagination: direct or indirect
* Taps on tip of finger: may indicate indirect inguinal hernia
* Taps on side of finger: may indicate direct inguinal hernia

Compiled by James Lamberg

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