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CPD Final Exam

Introduce yourself, get pt name, inform about procedure, 2 questions, wash hands !eport" who, what was done, what was found, what findings mean

'ead and (ec)

'air: distribution and te3ture $calp: scaliness, dandruff, swellin&s $)ull: palpation Face: symmetry, scars, swellin&s, colour chan&e, facial e3pression o 5yebrows: loss of lateral 1*3 indicated hypothyroidism *outh o 6ips: dryness, crackin&, sores, bleedin&. o 7eeth: 2 incisors, 1 canine, 2 premolars, 3 molars )per 8uadrant) Count all the teeth o 9uccal mucosa: inflammation, sores*ulcers, leukoplakia o 7on&ue: &lossitis, colour, swellin&, de.iation o :ums: bleedin&, swellin&, &um line, hyperplasia 4yperplasia of the &ums is commonly seen with some chronic dru& use. o 4ard and soft palate: swellin&, colour, leukoplakia, and con&enital anomalies. 7orus palatinus midline swellin& )not harmful) o 7onsils: swellin&, inflammation o %ali.ary ducts: swellin& and inflammation ;arotid duct opens on the buccal mucosa opposite the 2nd pre molar. o <.ula: ask patient to say ="aaaah>? mo.ement, de.iation +ymph (odes: palpate with 2 3 fin&ers in circular motion: %i,e, shape, consistency, tender*nontender, matted*discrete o @ccipital o ;re auricular o ;ost auricular o 7onsilar o %ubmandibular o %ubmental o %uperficial cer.ical o 2eep cer.ical o ;osterior cer.ical o %upracla.icular %hyroid o 1nspection: 6ocate anatomical landmarks 4yoid )hi&hest), thyroid cartila&e, cricoids, 7hyroid &land isthmus )lowest) 1nspect for any swellin&s, nodules, and make sure that it rises when swallowin&. o ;alpation: isthmus and lobes )3 fin&ers), for tenderness, swellin&, nodules "sk the person to swallow while palpatin&. 7o palpate the lateral lobes: 7ilt head towards the side of e3amination

#ital $igns
1. %emperature: dont actually check, but mention that you would. Check with the back of the hand 2. Pulse: radial, ulnar, brachial, carotid, femoral, popliteal, dorsalis pedis, posterior tibial 1) Rate count for a full minute 2) Rhythm 3) Radio femoral delay: ask if they want you to check it. !)"mplitude: #olume $ %tren&th %cale ' ! ! ( boundin& 3 ( full and increased )seen with aortic re&ur&itation) 2 ( normal 1 ( diminished, barely palpable )seen with heart failure) ' ( absent*not palpable +) Contour: character is often best characteri,ed in the right carotid artery -) %tate of .essel: ri&idity of the .essel is indicati.e of atherosclerosis. /) %ymmetry: Check both arms: ask tutor if they want you to check both arms. 3. &lood Pressure: check both arms and all 3 positions )sittin&, standin&, lyin& down). 0irst put cuff on and inflate while feelin& radial pulse. 1nflate until the radial pulse is no lon&er palpable 2eflate cuff Re inflate cuff appro3imately 2'mm4& past the point where radial pulse was lost. !. !espiratory !ate: pretend to take pulse while watchin& for breathin& mo.ement for 1 min.

;ush the %CA with one hand towards the side of e3amination Bith the other hand feel the lateral lobe of the thyroid. ;alpate superficial $ deep cer.ical lymph nodes. "uscultation: listen for bruits )may be si&n of 2isease)

Peripheral $igns o ,eneral: wei&ht chan&e o Eye signs: 6oss of lateral 1*3 of eye brow 6id la& 6id retraction 53ophthalmos Beakened e3traocular muscles o 'ands: tremors and sweatin&. o Cardiac signs: Rate: tachycardia*bradycardia Rhythm: atrial fibrillation #olume: increased .olume Aurmurs: systolic o +ower limbs: ;retibial my3edema 2elayed rela3ation of deep tendon refle3es Inspection" o 6ocate anatomical landmarks 4yoid )hi&hest), thyroid cartila&e, cricoids, 7hyroid &land isthmus )lowest) o 1nspect for any swellin&s, nodules, and make sure that it rises when swallowin&. Palpation: isthmus and lobes o "sk the person to swallow while palpatin&. o 7o palpate the lateral lobes: 7ilt head towards the side of e3amination ;ush the %CA with one hand towards the side of e3amination Bith the other hand feel the lateral lobe of the thyroid. o ;alpate superficial $ deep cer.ical lymph nodes. -uscultation: listen for bruits )may be si&n of 2isease)

Ear, (ose, . %hroat

Ears Inspection: e3ternal ear o "natomical landmarks: 4eli3, antiheli3, tra&us o 2ischar&e o 1nflammation o Con&enital abnormalities )pre auricular sinuses or appenda&es) Palpation: lymph nodes and tenderness o 6ymph Codes: pre auricular and post auricular o 7enderness: press tra&us and pull on ear lobes and heli3. ;ress on mastoid process if painful ( middle ear infection. $peculum Exam: use smaller attachment on otoscope o 53amine e3ternal auditory meatus o 53amine auditory canal and tympanic membrane 7ilt persons head away from you strai&hten the auditory canal by pullin& the ear upwards, backwards, and sli&htly away from head insert speculum into the ear canal downwards and towards the patients face. 3 maDor structures should be .isuali,ed on tympanic membrane: 'andle of the malleus /mbo where the eardrum meets the tip of the malleus. Cone of light from the umbo fannin& downwards and anteriorly. 'earing %ests: Bhisper 7est, Beber 7est, Rinne 7est o 0hisper %est: stand one foot away on one side of the patient, and their opposite ear then whisper a word and ask the patient to repeat it to you. o 0eber %est: strike the +12 4, tunin& fork and place it on the persons head in the midline ask the patient if they can hear it better or worse in one ear the other. 1f there is laterali,ation of sound, there are two possible reasons: Ipsilateral conductive hearing loss. Contralateral sensorineural hearing loss.

!inne %est )do on the side that Beber test laterali,ed to): strike tunin& fork and hold the base of it to the mastoid process ask patient when they can no lon&er hear the tunin& fork when patient indicates they cant hear it anymore, mo.e it so that the fork pron&s are .ibratin& towards and away from the ear ask patient to indicate when they can no lon&er hear it. 1n actual practice, would only do Rinne test if there is laterali,ation in the Beber test. 1n Rinne test, air conduction )"C) should be lon&er than 9one conduction )9C) "C ( 2 3 9C )appro3.) !inne1(egati2e 1f "C is not lon&er than 9C this would indicate conducti.e hearin& loss in this ear and the tunin& fork would not be heard when it was mo.ed to the e3ternal auditory meatus. !inne1 Positi2e Bhen ner.e deafness is present then the note is audible at the e3ternal meatus, as air and bone conduction are reduced e8ually, so that the air conduction is better )as is normal) than bone conduction.

(ose Inspection: symmetry, deformity, dischar&e Palpation: o ;atency of nostrils: block each nostril and ask patient to sniff. o %peculum e3am: use lar&er speculum on otoscope 1nsert &ently and obser.e for the followin&: Aucosa and septum normal colour and .asculature 7urbinates*concha if any are seen you will only see inferior concha on the lateral side. o 1nferior meatus drains: nasolacrimal duct o Aiddle meatus: ma3illary, frontal, anterior ethmoidal sinuses o %uperior meatus: posterior ethmoidal and sphenoid sinuses. o $inuses 6ook for swellin& or redness ma3illary or frontal sinuses. "pply &entle pressure the sinus and see if this causes any tenderness. 7ransillumination test: perform in dark room Aa3illary sinus E person has to open their mouth and li&ht should be applied to the nasolabial fold illumination will be seen inside mouth

0rontal sinus E use hand to form barrier for li&ht across the brow apply li&ht under the brow on the medial side of the eye socket illumination is seen abo.e hand.

Examination of Eye
Inspection: o %i,e, shape, symmetry, scars, swellin&s o "li&nment o Eye brows: loss of lateral 1*3 ( hypothyroid or leprosy o Eyelids: Ptosis 4orners, myasthenia &, dama&e to occulomotor ner.e 6id retraction, lid la& thyroid problems 3anthelasmata %li&htly raised, yellowish, well circumscribed pla8ues of cholesterol that appear alon& the nasal portions of one or both eyelids. $ty painful, tender red infection in a &land at the mar&in of the eyelid. Chala4ion subacute non tender and usually painless nodule a meibomian &land. Aay become acutely inflamed, but unlike sty usually points inside the lid rather than on lid mar&in. &lepharitis inflammation of the eyelid mar&ins. o Eyelashes: 5ctropion or entropion Ectropion mar&in of lower lid is turned outward, e3posin& the palpebral conDuncti.a )more common in the elderly). ;re.ents the eye from drainin& properly so tearin& occurs. Entropion inward turnin& of the lid mar&in which causes the lower lashes to irritate the conDuncti.a and the lower cornea. o Iris: colour, coloboma o Pupil: e8ual in both eyes o Con5uncti2a: 6aundice yellow sclera Pingueculum harmless yellow trian&ular nodule in the bulbar conDuncti.a on either side of iris. "ppears fre8uently with a&in&, first on nasal then temporal side. Pterygium trian&ular thickenin& of bulbar conDuncti.a that &rows across outer surface of cornea )usually from nasal side). Aay interfere with .ision as it encroaches onto pupil. o Cornea: 2irect li&htin& check to see htat reflections are symmetrical 6ateral li&htin& crescentic shadow. %ests o o

Corneal arcus thin &rayish white arc or circle not 8uite at ed&e of cornea. -nterior chamber: shine li&ht tan&entially into anterior chamber. 2epth 4yphema blood in the anterior chamber of the eye. 4ypopyon pus in the anterior chamber of the eye. +acrimal -pparatus: upper lateral orbital mar&in for any swellin& of lacrimal &land ;uncta on medial end of each upper and lower lid. Re&ur&itation or blocka&e of fluid ;ress on each side of the nose for e.idence of blocka&e or inflammation. Pupillary reaction: to li&ht )direct and consensual) Extraocular muscles '1test: patients ri&ht eye

Con2ergence: start from appro3imately 2 feet away and &et the person to follow a point as you mo.e it closer to the brid&e of their nose. o 7 components:, accommodation, pupillary constriction Co2er1unco2er test: patient should focus on an obDect at mid distance one eye is co.ered for appro3imately 2' seconds eye is unco.ered and any e3cursion of the eye is noted. o 7ests the restin& tone of the e3traocular muscles. #isual -cuity o %tand 2' feet from the %nellen chart and ask the patient to read the lar&est line if this is done then askt hem to read the ne3t smaller line and so on until they can identify less than +'F of the letters on a &i.en line the last line they can identify +'F of the letters is the last one to be counted. o Check first with one eye co.ered, then the ne3t eye, and finally with both eyes unco.ered. #isual Fields o <pper G 6ower: 7emporal fields: sit across from person and brin& hands towards yourself from far behind the persons head ask them to indicate to you when they can see your hands. Compare when each eye sees your hands. o Casal field: test by confrontation %ittin& across from the person you should act as the persons mirror ima&e.

Fundoscopy: in a dark room, hold the ophthalmoscope in the same hand as the eye that you wish to e3amine )ie. Ri&ht hand used to e3amine ri&ht eye of patient) and use the same side eye as the one youll be e3aminin& on the patient )ie. Hour ri&ht eye should be used to e3amine the patients ri&ht eye) use the other hand to hold the patients eyelid open sli&htly ask the patient to focus on somethin& far away approach the eye at a 1+ de&ree an&le obser.e red refle3 approach until .essel can be seen and is clear follow .essel to optic disc obser.e disc and cup as patient to look into the li&ht to obser.e macula and fo.ea.

;ulsations in mitral, tricuspid, 5rbs point, pulmonic and "ortic areas. Ceck and 5pi&astric area: aortic pulsations )if under costal cartila&e R# may be enlar&ed) o Palpation" )first palpate for tenderness) o 6ateral to sternal an&le is the 2nd intercostal space o Cardiac areas: "ortic ri&ht 2nd 1C% ;ulmonic left 2nd 1C% parasternal 5rbs ;oint left 3rd 1C% parasternal )$2 best heard here) Aitral left +th 1C% medial to midcla.icular 7ricuspid left +th 1C% parasternal o <se ball of hand to locate apical pulse in +th 1C%, then use fin&ertips to locali,e it )diameter, amplitude, duration) :i.e location o ;alpate all cardiac areas E ball of hand for thrills? fin&ertips for abnormal pulsations ).ibrations). o ri&ht .entricular hea.e or lift is best palpated at the left sternal border o left .entricular hea.e or lift is best palpated at the cardiac ape3 o ;alpate epi&astrium for abdominal aortic pulsation: from below )abdominal) or from below rib ca&e )R# hypertrophy) o <se ulnar surface of hand to check for parasternal hea2e R# hypertrophy o Ceck: ha.e patient in supine position 3' !+J 1nternal and e3ternal Du&ular .eins $ carotid pulsations. Aeasure I#;: normal ( 2 3 cm 4K2@ )C#; ( I#; G +cm 42@) o 4epato Du&ular refle3 supine at 3' !+J : apply pressure below R costal cartila&e, midcla.icular, for 1' 1+ seconds L I#; should rise L back to normal within a few seconds. )sustained rise ( ele.ated C#;. R#0) Percussion: o ;ercuss heart borders Ri&ht border: midcla.icular, 3,!,+ interspace 6eft border: ant a3illary line, 3, !, + -uscultation: o "uscultate all the cardiac areas: listen for %1 and %2 with bell and diaphra&m, left hand on carotid pulse $8 closin& of mitral and tricuspid )"# $2 closin& of aortic and pulmonic

Peripheral $igns" 0in&er nails: cyanosis )blue), splinter hemorrha&es )brown streaks in nail bed), clubbin& ;alms: Ianeway lesions )erythematous macular lesions). ;ulp of fin&er tips: @slers nodes )tender nodes in fin&ers and toes) 5yes: o ;allor in palpebral conDuncti.a anemia o 4emorrha&es in bulbar conDuncti.a $ sclera infecti.e endocarditis o Retina fundoscopy Chan&es seen with hypertensi2e retinopathy %ta&e 1: Copper $ wirin& %ta&e 2: " # nickin& %ta&e 3: 0lame shaped hemorrha&es $ Cotton wool e3udate %ta&e !: ;apilledema Roth %pots )infecti.e endocarditis) hemorrha&e in retina with central pallor. Chan&es seen with 1nfecti.e endocarditis: Ianeway lesions, @slers Codes, Roth spots, hemorrha&e of bulbar conDuncti.a and sclera. 0ace: malar flush )mitral stenosis) and central cyanosis )lips, ton&ue, buccal mucosa) "uscultate lun& bases )below scapula) for crepitations or rales. Check for pittin& edema + secs: le&s, dorsum of foot, behind medial malleoli Inspection: o %i,e, %hape, %ymmetry, scars, swellin&s, deformities of chest wall, sternum, spine o "pical impulse )+th intercostal space medial to left mid cla.icular line)

%3 rapid .entricular fillin& a&ainst .entricle with decreased compliance. 4eard between %2 and %1 )ri&ht after %2)

%! always patholo&ical )rapid fillin& a&ainst .entricle with decreased compliance) 4eard between %2 and %1 )Dust before %1) murmurs %pecial positions:

+eft +ateral Decubitus roll patient to left side and auscultate mitral area with bell of stethoscope best position to hear mitral stenosis murmur. Aitral %tenosis murmur mid1diastolic )decrescendo murmur) 4a.e patient sit and lean forward inhale and then e3hale and hold while you auscultate the aortic area and Erb9s point with diaphragm best position to hear -ortic regurgitation murmur. "ortic re&ur&itation murmur early diastolic murmur )decrescendo murmur)

le&s the side of the bed obser.e the feet for colour returnin& and .essels fillin& )colour should return in 1' seconds and .eins should fill in 1+ seconds). o -llen9s %est: palpate radial and ulnar pulses on patients arm ask patient to make a ti&ht fist occlude both pulses ask patient to open hand release one of the pulses colour should return to patients hand e.en with one still occluded. 7ests for arterial sufficiency to the hand "uscultation femoral for bruits, and any aa w* suspected bruits

-rterial $ystem
Inspection: upper and lower limbs o + %s o %kin: note dryness, atrophy, shiny appearance o Colour: pale colourM o 4air: loss of hair o Cails: thickness and rid&es o <lcers: classically on tips of toes and soles of feet o :an&rene o %i&ns of "rterial insufficiency: ;ain, paresthesia, poikilothermia, pallor, pulselessness. o 1ntermittent claudication, rest pain. Palpation: o 7emperature: use backs of hands o ;alpate pulses: radial, ulnar, brachial, femoral, popliteal, dorsalis pedis, posterior tibial. o :rade the pulses from ' !. $pecial %ests: o &uerger9s %est: patient lies in bed raise both le&s to appro3imately :; J for -'seconds and ha.e patient wi&&le toes to empty blood from the le&s ha.e patient sit up and swin&

+ymphatic $ystem Palpation o 5pitrochlear E near elbow o "3illary lymph nodes "nterior ;osterior 6ateral Aedial "pical o 1n&uinal lymph nodes: 4ori,ontal and .ertical &roups Characteristics of +ymph (odes (ormal Inflamed *alignant %mall 5nlar&ed 5nlar&ed Aobile %oft to firm 4ard Con tender 7ender Con tender 0irm 2iscrete 0i3ed to surroundin& tissue 2iscrete 5rythematous

#enous $ystem )only do lower limb) Inspection o + %s o Colour: cyanotic or brown pi&mentation o 1ncreased pi&mentation: brown*reddish o <lcers: primarily found alon& the path of the saphenous .ein )medial malleolus) o #aricosities Palpation o ;alpate for tenderness o ;alpate for temperature with back of hand )compare both sides) o ;alpate for cords o "ssess for pittin& edema o Aeasure the circumference of the calf and compare both le&s )tests for 2#7) $pecial %ests o %ests for D#% Pratt9s %est: apply &entle pressure to the calf to see if pain is caused

'oman9s %est: dorsifle3ion of the foot to see if pain is caused. %ests for assessing 2aricose 2eins *anual Compression %est: find .aricosity on lower limb place two fin&ers of each hand on the .ein at least 1' cm apart tap on the .essel with the lower fin&er and feel the transmission of a wa.e to the upper hand tap with upper fin&er to see if wa.e is transmitted )no wa.e should be transmitted, and if there is, there is .al.ular insufficiency) %rendelenberg %est: ha.e patient lie down raise one le& <; J your shoulder and ha.e patient wi&&le toes for -' secs apply a tourni8uet on the upper thi&h lower the le& and ha.e patient stand up. Immediate filling before tourniquet release ( incompetence of the of the communicating .eins? obser.e for 2' secs... Immediate filling after tourniquet release ( incompetence of the of the superficial .eins.

7rachea: should be midline

-nterior Chest Inspection supine o + %s o 2eformities, apparent dyspnea o ;osition of ribs E normally obli8ue o 1ntercostal muscles )obser.e mo.ements) o Cormal respiratory mo.ements. Palpation E e.erythin& starts abo.e cla.icle o ;alpate for tenderness o %actile Fremitus E use ulnar border of hand and ask patient to say =NN> a number of times. O - spots %hould feel .ibrations on chest wall and should compare both sides. o Chest Excursion E check e3pansion of chest by keepin& both hands on chest holdin& fold of skin btwn thumbs in midline. @bser.e symmetric e3pansion in 3 positions: costal mar&in, l.l of nipples, below cla.icle Aeasurement of "; lateral diameter 6ateral diameter ( distance from one anterior a3illary line to the other "; diameter ( distance from anterior a3illary line to posterior a3illary line 7he ";:lateral ratio should be 1:2 or +:/ Percussion o ;ercuss all areas startin& abo.e cla.icle and percussion in intercostal spaces down to the :th intercostal space )should hear resonance) -uscultation 1 diaphra&m o 6isten for breath sounds: #esicular breathing E inspiratory sounds are lon&er than e3piratory )heard most of the lun&) 9roncho .esicular breathin& E inspiratory sounds and e3piratory sounds are e8ual )heard at the an&le of 6ouis) 9ronchial breathin& E e3piratory sounds last lon&er than inspiratory )heard manubrium and sternum) 7racheal breathin& E inspiratory sounds and e3piratory sounds last about the same time )heard trachea in the neck) o "bnormal sounds: Crackles Bhee,in& Ronchi ;leural rub -dditional tests o 8= #ocal resonance: ask patient to say NN and listen for low pitched sounds in different lobes. o 2= Egophany: ask patient to say P5 and listen for muffled P5 sound. )5 to ") o

!espiratory $ystem
Peripheral $igns :eneral appearance: o Cache3ia )wastin&) o Respiratory distress: pursed lip breathin&, intercostal muscle retraction o Contraction of platysma and %CA @ral Ca.ity: o Cyanosis: bluish discolouration of mucous membranes and ton&ue o 4alitosis: foul smellin& breath o 4oarseness of .oice Cose: o ;atency of nostrils o %eptal de.iation o %eptal perforation o Colour of mucous membrane 5ye: o "nemia E pallor of palpebral conDuncti.a o 4orners syndrome: ptosis, constricted pupil Ceck: en&or&ement of .eins and palpation of supracla.icular 6Cs 4ands: o Clubbin& o ;i&mentation ( nicotine stain o "steri3is )flappin& tremor) E 1' 1+ secs 6e&s: edema E dorsum of foot, inf to med malleolus, shins

7= 0hispering pectoriloquy: ask patient to whisper PNN or P1 2 3 and listen for faint indistinct sounds.

Posterior Chest Inspection: patient should be sittin& with arms crossed in front of them. o #ertebral column o %capula o Respiratory mo.ements o ;osition of ribs o 1ntercostal muscles Palpation o ;alpate for tenderness o 7actile fremitus o Chest e3cursion: abo.e, between, and below scapula Percussion o Resonance o Diaphragmatic excursion )should be Q! -cm): ha.e person sittin& up with arms folded in front of them start percussion at le.el of tip of scapula )mark the le.el) ha.e patient take deep breath in and hold percuss downwards until resonance becomes dull )mark the le.el) return to tip of scapula and ha.e patient breath out and hold percuss upwards until dullness turns to resonance )mark this le.el). -uscultation: 9reath sounds, abnormal sounds, and additional tests )same as anterior chest)

-bdomen )inspection, auscultation, palpation, percussion)

Peripheral $igns 4ands: )62; 0CR) o Clubbin& o Roilonychia )fin&ernail spoonin&) iron deficiency anemia o 6eukonychia )white streaks or spots on the nails) o 2upuytrens contracture contracture of the palm which pre.ents the full openin& of the hand and makes the person unable to put their hand fully flat on a surface. o ;almar erythema o 0lappin& tremor )asteri3is) 0ace $ 5yes: o ;allor of the palpebral conDuncti.a "nemia o Hellow %clera Iaundice o Dehydration of the mucous membranes o Parotid enlar&ement Aouth: o 0etor hepatica o 6eukoplakia

o ;i&mentations o :lossitis o Candidiasis o <lcerations Chest: o :ynecomastia )males) o %pider an&ioma o 2ehydration E skin tur&or )see tentin& of skin on chest) :enitalia: %esticular atrophy 6imbs: peripheral edema 1nspection: nearly flat... Inspection )+ 0s of abdominal distension feces, flatus, fat, fetal, fluid) o + %s o %triae o Aasses o <mbilicus o Caput Aedusa o 4ernia E ask patient to raise their head and cough o @ther .enous distension o Colour )bruises, Cullens si&n, :rey 7urners si&n) Cullens periumbilical bruisin& )acute pancreatitis) :rey 7urners bruisin& of the flanks )acute pancreatitis) o 4air 2istribution o ;ulsations o Ao.ements )respiration, .isible peristalsis, pulsations, fetal mo.ements) -uscultation )diaphra&m) o "uscultate for bowel sounds )listen for 2 3 minutes if they arent heard ri&ht away). 1leocecal area o 9ruits: "orta, renal artery, iliac arteries, femoral arteries o 0riction rubs and spleen o #enous hum porta hepatis. Palpation o ;alpate li&htly for tenderness )watch for facial e3pression) o ;alpate more deeply for tenderness and masses )includin& for the si&moid colon) o -orta palpate sli&htly to the left of the midline o +i2er be&in palpation in ri&ht iliac fossa and ha.e patient breath deeply as you &radually mo.e up to the costal mar&in. o $pleen be&in palpation in ri&ht iliac fossa and mo.e dia&onally towards the left costal mar&in.

1f spleen isnt felt, ha.e patient roll on to ri&ht ride and palpate at costal mar&in a&ain to feel spleen. o >idneys with patient lyin& on back use one hand to press down and the other hand on the patients back at the costo .ertebral Dunction pressin& up? should feel the kidney between the two hands. Percussion o ;ercuss entire abdomen for tympany and dullness o +i2er percuss up from le.el of symphisis pubis and down from the le.el of the +th intercostal space to locate the upper and lower borders of the o $pleen percuss of the 8;th intercostal space in the anterior axillary line %hould be tympanic "sk patient to take deep breath and continue to percuss? if there is dullness splenic enlar&ement o /rinary bladder )person should ha.e .oided beforehand) percuss downwards from the umbilicus to the le.el of the pubic symphisis )should be tympanic). $pecial %ests o -scites Check for distension Fluid wa2e" Bith patient on their back ha.e them put one hand .ertically alon& the midline of their abdomen place one of your hands on one side of their abdomen flick the other side of the abdomen with your other hand and see if you can feel a wa.e transmitted to the hand placed on the other side of the patients hand. $hifting dullness" percuss across the abdomen from tympany to dullness laterally mark the line of dullness ha.e patient turn to their opposite side percuss the abdomen a&ain and check where the line of dullness is if it has mo.ed si&nificantly this means there is fluid in the abdomen. o -cute -ppendicitis !ebound tenderness: with patient lyin& on their back, apply pressure to Ac9urneys point )ri&ht iliac fossa) if this elicits pain when the pressure is remo.ed this is a positi.e si&n for appendicitis. !o2sing9s sign: apply pressure to the left iliac fossa and see if it elicits pain in the ri&ht iliac fossa. Psoas sign: ha.e patient try to raise their le& a&ainst resistance while lyin& flat.

?bturator $ign: ha.e patient try to brin& their knee to the opposite shoulder a&ainst resistance. Digital rectal exam -cute Cholecystitis *urphy9s $ign: insert the tips of your fin&er Dust below the costal mar&in on the ri&ht side at the midcla.icular line and ask the patient to take a deep breath if the patient suddenly stops breathin& in and has a look of pain on their face G.e si&n. &oa9s $ign: li&htly scratch the skin below the ri&ht scapula positi.e si&n is an uncomfortable sensation percei.ed by the patient. Pyelonephritis: place a hand at the costo .ertebral Dunction strike the dorsal surface of this hand with the other hand positi.e si&n would be pain.

*usculos)eletal $ystem @ I E-% %C

,eneral Inspection o @bser.e the patients &ait and posture o @bser.e for: 7ophi on the heli3 or anti heli3 of the ear and the &reat toe )&out) Rheumatoid nodules seen especially on e3tensor surface of the arms )Rheumatoid "rthritis) 4eberdens nodes E seen at 21; Doint )osteoarthritis) 9ouchards nodes E seen at ;1; Doint )osteoarthritis) ;soriasis on e3tensor surface of the elbows or knees, scalp, and on the nails. "ny eye inflammation Auscle wastin&

+ %s, wastin&, Dt swellin& 5rythema Doints 2eformity of the bones or Doints @bser.e acti2e ran&e of motion at each Doint: Fingers: 0le3ion, e3tension )ask patient to make fist and then open slowly), abduction, adduction, opposition 0rist: fle3ion, e3tension, lateral fle3ion Elbow: e3tension, fle3ion, supination $ pronation )ha.e elbow ri&ht up a&ainst the body and Doint at N' de&ree an&le). $houlder: fle3ion, e3tension, abduction, adduction, lateral $ medial rotation. Check motion of the cla2icular 5oints on inspection and palpation )sterno cla.icular, acromio cla.icular, and humero cla.icular Doints) Palpation o ;alpate each Doint for tenderness, crepitus, and heat. o 1f there is any deficiency of the acti.e ran&e of motion, check the passi.e ran&e of motion. $pecial %ests o Carpal %unnel $yndrome Phalen9s %est: ha.e patient place their hands back to back pointin& downwards with both wrists fle3ed and dorsum of both hands a&ainst the other positi.e phalens test would be pain or parasthesis elicited by this position. %inel9s test: percuss the anterior surface of the wrist at the le.el of the most distal skin crease positi.e 7inels test would be pain or parasthesia in the distribution of the median ner.e. o o o o

+ower +imb Inspection: look for same thin&s as upper limb @bser.e acti2e ran&e of motion at each Doint: %oes: fle3ion and e3tension Feet: in.ersion and e.ersion -n)le: dorsifle3ion, plantar fle3ion, medial $ lateral rotation. >nee: fle3ion, e3tention 'ip: fle3ion, e3tension, abduction, adduction, medial $ lateral rotation. Palpation o ;alpate each Doint for tenderness, crepitus, and heat. o

/pper +imb E ha.e patient sittin& with upper limbs fully e3posed Inspection

1f there is any deficiency of the acti.e ran&e of motion, check the passi.e ran&e of motion. $pecial %ests o Chec) >nee for 5oint effusion &ulge $ign: use one hand to compress the suprapatellar pouch massa&e the Doint from the medial side upwards and laterally to empty any fluid from the medial side poke the lateral side of the Doint and obser.e any bul&e on the medial side )positi.e bul&e si&n). &allotment $ign: compress the suprapatellar pouch with one hand press the patella backwards and up with the other hand if there is e3cess fluid in the Doint the patella will be pushed throu&h it slowly and collide with the femur as a palpable tap )positi.e ballotment si&n) o Chec) )nee for integrity of ligaments -C+ : ha.e patient fle3 their knee while lyin& down to brin& it to a N' de&ree an&le %it on the persons foot &rip the persons le& Dust below the knee with the thumbs on tibial prominence pull the le& forward and obser.e the mobility of the Doint. PC+: same as "C6, e3cept push the le& backwards. *C+: with patient lyin& down, bend their knee to a 1+ de&ree an&le hold foot in one hand and the thi&h in the other hand forcibly push knee into lateral fle3ion look for e3cess mo.ement of the Doint. +ateral +igament: same as AC6, e3cept push le& towards medial fle3ion. o Chec) )nee for meniscus in5ury *edial meniscus: le& should be at 1+ de&rees with the palm of your hand on the instep of the patients foot and the other foot on the patients knee, rotate the foot laterally &ently laterally fle3 the le& at the Doint &radually strai&hten the knee. +ateral meniscus: same as medial e3cept hand should be on the outside of the patients foot and rotate the foot and the le& in the opposite directions. "ny clickin& or pain may indicate a problem with the Doint. o Chec) the hip %homas9 test: with patient lyin& on their back, ha.e them brin& one le& to their chest by fully fle3in& their hip o

if the opposite le& cannot continue to lie flat on the bad there is a fi3ed fle3ion contracture. -xial $)eleton %emporomandibular 5oint o Inspection: open and close mouth widely? ensure both side of Daw mo.e symmetrically. o Palpation: for crepitus, heat, or tenderness. $pinal Column E patient should be standin& with feet to&ether and with spine e3posed. o Inspection: ali&nement, asymmetry and lateral bendin& )scoliosis), spinal cur.atures. Cer2ical spine: inspect for erythema or deformity of the Doints. -cti2e range of motion: fle3ion )noddin&), e3tension, lateral fle3ion, rotation. +umbar spine: inspect for erythema or deformity of the Doints. -cti2e range of motion: fle3ion, e3tension, lateral fle3ion, rotation )should hold patients hips when rotatin&). o Palpate: for tenderness, crepitus, heat. 1f there is any restriction of mo.ement then perform passi.e mo.ement of the Doints. $pecial %ests o Chec) for $ciatic ner2e root irritation +asegue9sA$traight leg test: with patient lyin& down raise one le& passi.ely to Q-' de&rees ner.e root irritation will cause pain in lumbar spine and*or down the lower limb. &owstring manoeu2re: lower the foot until the pain subsides and then dorsifle3 the foot passi.ely will a&ain elicit pain. o Chec) for tenderness of sacroiliac 5oint 6oint $tress *anoeu2re: ha.e patient lyin& supine .ery close to the ed&e of the bed ha.e them fle3 their hip to their chest and hold their le& in that position ha.e them dan&le the other foot off the ed&e of the bed put pressure on the thi&h of the le& han&in& off the bed if sacroiliac Doint is inflamed or painful this will cause pain.

C($ I
*ental $tatus Exam o ,eneral appearance o ,ait o $peech E tone, .olume, 8uantity, dysarthrias, aphasias, aphonias. o -ffect E appropriate for inter.iew o +e2el of consciousness E alert, drowsy, coma o ?rientation Eperson, place, time o *emory 1mmediate recall E immediate repetition of three words.

%hort term memory E repeat same three words at the end of the inter.iew 6on& term memory E ask patient to recall a past e.ent. o -bstract thin)ing E interpret a pro.erb o 6udgement E =Hou find a stamped letter in front of a mailbo3, what do you do with itM> o 'igher functions E serial /s, spell PB@R62> forwards and backwards. Examination of Cranial (er2es C( I @ ?lfactory o ;atency of each nostril o "sk patient to identify a familiar scent C( II @ ?ptic o 7est .isual acuity: %nellen and Rosenbaum charts. o ;eripheral .isual fields by confrontation. o 2irect and consensual reaction to li&ht o Cear reaction to pupils. o 0unduscopy E check optic disc C( III @ ?cculomotor, I# @ %rochlear, #I @ -bduscens o %ymmetric corneal reflection o 4 test o o test C( # @ %rigeminal )@phthalmic, ma3illary, and mandibular di.isions) o $ensory component 7est sensation bilaterally in the distributions of the three branches of CC #. Pain . crude touch )1st show pt) use opened paper clip with point bein& pain and the cur.ed part as crude touch with the patients eyes closed touch them in the three di.isions of the face and ask them to distin&uish between sharp and dull. +ight touch: use a wisp of cotton and do the same thin& as pain $ crude touch o *otor component %emporalis: ask patient to clench teeth while you palpate the muscle )palpate both sides simultaneously and compare) *asseters: ask patient to clench teeth while you palpate the muscle )palpate both sides simultaneously and compare) Pterygoids: ask patient to mo.e Daw from side to side and oppose the mo.ement with your hand.

!eflexes Corneal reflex: ask patient to look away and usin& a thin wisp of cotton approach from the side and touch the cornea with cotton patient will blink eye is there is intact sensory )CC #) and motor )CC #11). 6aw 6er) reflex: ask patient to rela3 Daw with mouth sli&htly open place fin&er on the chin Dust below the lower lip tap your fin&er with your refle3 hammer Daw should Derk up sli&htly but if it is e3a&&erated it would indicate an upper motor neuron lesion of CC #. C( #II @ Facial o *otor component: 7est for action of facial muscles by askin& patient to... Close eyes and not let you open them. %how their teeth. )"ttempt to) whistle 9low or puff out cheeks Brinkle their forehead E intact w* <AC lesion o $ensory component: )not done) taste to anterior 2*3 of the ton&ue. o !eflexes: motor component of corneal refle3. C( #III @ #estibulocochlear o 0hisper test o 0eber9s %est o !inne9s %est C( I3 @ ,lossopharyngeal . 3 @ #agus o *o2ement of the soft palate: ask patient to say ="ahhh> while for symmetrical mo.ement of u.ula. o ,ag reflex: sensory component )CC 1O) and motor component )CC O). C( 3I @ $pinal -ccessory o %rape4ius *uscle: ha.e patient shru& shoulders a&ainst resistance. o $C*: ask patient to mo.e head laterally a&ainst resistance in both directions while you feel the muscle as it contracts. C( 3II @ 'ypoglossal o 53amine ton&ue for atrophy or fasciculations. o %ongue protrusion: check for de.iation. o

1s not considered as nuchal ri&idity if mo.ement is painful but patient still has full ran&e of motion. o &rud4ins)i9s (ec) $ign: 0le3in& the patients neck causes fle3ion of their hips and knees positi.e response. o >ernig9s $ign: 0le3in& patients hip to N' de&rees and then e3tendin& their knee causes pain positi.e response. %ests for 'ypocalcemia o Ch2oste)9s $ign: Elicitation: tap on face at a point Dust anterior to the ear and Dust below the ,y&omatic bone. Positi2e !esponse: twitchin& of ipsilateral facial muscles )neuromuscular e3citability caused by hypocalcemia). o %rousseau9s $ign: Elicitation: inflate 9; cuff on patients arm past the systolic 9; for se.eral minutes. Positi2e !esponse )carpopedal spasm): muscular contraction includin& fle3ion of the wrist and AC; Doints, hypere3tension of the fin&ers, and fle3ion of the thumb on the palm neuromuscular e3citability caused by hypocalcemia))carpopedal spasm).

$pecial %ests %ests for meningeal irritation o (ec)A(uchal rigidity: patient is unable to fle3 head forward due to ri&idity of the neck muscles.

C($ II
%tart with mini1mental status examination )see CC% 1) $ensory $ystem $pinothalamic %ract

Pain and Crude %ouch: use paperclip much like it was used when testin& CC # and poke patient with it on their upper and lower limbs, askin& the patient to distin&uish between pain and crude touch. %ystematically e& C! 71 in upper limb, 61 %1 lower limb o %emperature )not tested in lab) Dorsal Column %ract o Fine %ouch: same as pain and crude touch, e3cept a wisp of cotton is used instead of paperclip. )donSt dra& cotton on skin, Dust touch) o Proprioception: stabili,e the patientSs fin&er or toe by holdin& at the sides of the interphalan&eal Doint with the patients eyes closed, position the di&it pointin& up or down and ask the patient to identify which way it is pointin&. o #ibration $ense: usin& the 12T 4U tunin& fork, demonstrate to the patient what the .ibratin& fork feels like on a bony prominence )sternum) with the patients eyes closed place it a number of bony prominences on the body while askin& the patient if they can feel it randomly stop the .ibration and ask patient if they can still feel it. )<sually .ibration sensation is lost distal to pro3imal, so wouldnt ha.e to continue pro3imally if distal location is intact). o !omberg %est: with patient standin& with feet to&ether, ask them to close their eyes and obser.e if they are able to maintain balance. )ready to catch) Parietal Cortex o $tereognosis: with the patients eyes closed, ask them to identify a familiar obDect placed in their hand. o ,raphesthesia: with patients eyes closed, draw a number on the patients palm and ask the patient to identify the number. o 21Point Discrimination: with patients eyes close, use an open paperclip to determine what distance between 2 points that the patient is able to discriminate. 0in&ertips, hands, forearms. o Point +ocali4ation: with the patients eyes closed, touch them in a number of spots and ask them to point to where you touched them. 7ouch left and ri&ht randomly. o Extinction )in parietal corte3 lesions, may not feel contralateral stimulus): with patients eyes closed, touch them on two areas of the body simultaneously and ask them to point to where you touched them. %ometimes touch only one area. *otor $ystem Inspection: Auscle atrophy and asymmetry, fasciculations, tremors, tics, twitches. Palpation: o

%one: with patient rela3in& muscles, passi.ely mo.e each limb at se.eral Doints to &et a feelin& for any resistance or ri&idity. B 7one ( 6AC lesion C 7one ( <AC lesion Power: test stren&th of each muscle &roup systematically a&ainst resistance. 'ands . Fingers: "sk patient to s8uee,e your fin&ers in their hand. "sk patients to spread fin&ers a&ainst resistance. "sk patient to hold piece of paper by adductin& fin&ers while you pull the paper out. @ppose thumb a&ainst resistance. 0rists: ask patient to fle3 and e3tend wrist a&ainst resistance. &iceps . %riceps: fle3 and e3tend arm $houlder: fle3, e3tend, abduct, adduct. 2o the same for the lower limb ,raded on scale from ; to D ' ( absent contraction 1 ( muscle flicker or contraction without mo.ement. 2 ( mo.ement possible, but not a&ainst &ra.ity. )test in hori,ontal plane) 3 ( mo.ement possible a&ainst &ra.ity but not a&ainst resistance by you. ! ( mo.ement possible a&ainst some resistance. + ( Cormal stren&th or power

!eflexes -bdominal !eflex )7T,N,1' E abo.e umbilicus? 71',11,12 E below umbilicus): Bith patient lyin& flat, use a blunt obDect to stroke the abdomen li&htly on each side medially obser.e contraction of the abdominal muscles and de.iation of umbilicus towards side of stimulus. Plantar !esponse )%1): on the sole of the foot, startin& from the heel dra& a pointed obDect upwards and then medially across the ball of the foot obser.e plantar fle3ion of all the toes. Cremasteric !espone )61,2): stroke upper medial aspect of thi&h in downward direction obser.e refle3 contraction of cremaster muscle. -nal !eflex )%3,!,+): stroke the perianal area with a pointed obDect obser.e the refle3 contraction of the e3ternal sphincter )anal wink). Deep %endon !eflexes: limbs should be in rela3ed and symmetric position.

&iceps )C+,-) %riceps )C-,/) &rachioradialis )C+,-) >nee )62,3,!) -n)le )%1,2) 2eep tendon refle3es are rated from ' to !. o ' ( absent refle3 o 1G ( diminished response o 2G ( normal o 3G ( increased response )without clonus) o !G ( hyperrefle3ia o 2eep tendon refle3es are normal if they are 1G, 2G, or 3G as lon& as they are symmetric. -bnormal !eflexes 'offmann9s $ign: by holdin& patients middle fin&er loosely and flickin& the fin&ernail downward. o (ormal: fin&er rebounds sli&htly into e3tension. o -bnormal: thumb fle3es and adducts ,rasp !eflex: stroke patients palm with your fin&er. o (ormal: no response o -bnormal: refle3 &raspin& of fin&er. Clonus: support Doint and apply a sudden muscle $ tendon stretch )an)le, )nee, wrist clonus). o (ormal: no response sli&ht rebound motion. o -bsnormal: repetiti.e .ibratory contraction of the muscle. &abins)i9s $ign: on the sole of the foot, startin& from the heel dra& a pointed obDect upwards and then medially across the ball of the foot o (ormal: plantar fle3ion of all the toes. o -bnormal: fle3ion of the bi& toe and fannin& and e3tension of the rest of the toes. 6aw 6er): ask patient to rela3 Daw with mouth sli&htly open place fin&er on the chin Dust below the lower lip tap your fin&er with your refle3 hammer o (ormal: Daw should Derk up sli&htly o -bnormal: e3a&&erated snappin& shut of the mouth would indicate an upper motor neuron lesion of CC #. Cerebellar Function )cerebellar si&ns are always ipsilateral) $peech ,ait: ask patient to walk in a strai&ht line, heel 2 toe &alance: ask patient to walk on heels, on toes, or hop on one foot. Finger to nose test: ask patient to touch their nose and then touch your fin&er as you mo.e your fin&er to different positions.

Diadocho)inesia: ask patient to perform rapid alternatin& mo.ements )e&. Rapidly alternatin& clappin& on dorsal and palmar sides of the hand. Coordination: ask patient to perform rapid foot taps 'eel1)nee1shin test: ask patient to brin& heel to opposite knee and then dra& heel down their shin. 'ori4ontal nystagmus: ask patient to focus on an obDect and track itSs mo.ement without their head nysta&mus may be seen when obDect is brou&ht far laterally.