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History of Present Illness (HPI

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Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially in the coming years as you gain a greater understanding of the pathophysiology of disease through increased exposure to patients and illness. However, you are already in possession of the tools that will enable you to obtain a good history. That is, an ability to listen and ask common-sense questions that help define the nature of a particular problem. It does not take a vast, sophisticated fund of knowledge to successfully interview a patient. In fact seasoned physicians often lose site of this important point, placing too much emphasis on the use of testing while failing to take the time to listen to their patients. Successful interviewing is for the most part dependent upon your already well developed communication skills. What follows is a framework for approaching patient complaints in a problem oriented fashion. The patient initiates this process by describing a symptom. It falls to you to take that information and use it as a springboard for additional questioning that will help to identify the root cause of the problem. Note that this is different from trying to identify disease states which might exist yet do not generate overt symptoms. To uncover these issues requires an extensive "Review Of Systems" (a.k.a. ROS). Generally, this consists of a list of questions grouped according to organ system and designed to identify disease within that area. For example, a review of systems for respiratory illnesses would include: Do you have a cough? If so, is it productive of sputum? Do you feel short of breath when you walk? etc. In a practical sense, it is not necessary to memorize an extensive ROS question list. Rather, you will have an opportunity to learn the relevant questions that uncover organ dysfunction when you review the physical exam for each system individually. In this way, the ROS will be given some context, increasing the likelihood that you will actually remember the relevant questions. The patient's reason for presenting to the clinician is usually referred to as the "Chief Complaint." Perhaps a less pejorative/more accurate nomenclature would be to identify this as their area of "Chief Concern." Getting Started: Always introduce yourself to the patient. Then try to make the environment as private and free of distractions as possible. This may be difficult depending on where the interview is taking place. The emergency room or a non-private patient room are notoriously difficult spots. Do the best that you can and feel free to be creative. If the room is crowded, it's OK to try and find alternate sites for the interview. It's also acceptable to politely ask visitors to leave so that you can have some privacy. If possible, sit down next to the patient while conducting the interview. Remove any physical barriers that stand between yourself and the interviewee (e.g. put down the side rail so that your view of one another is unimpeded... though make sure to put it back up at the conclusion of the interview). These simple maneuvers help to put you and the patient

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on equal footing. Furthermore, they enhance the notion that you are completely focused on them. You can either disarm or build walls through the speech, posture and body languarge that you adopt. Recognize the power of these cues and the impact that they can have on the interview. While there is no way of creating instant intimacy and rapport, paying attention to what may seem like rather small details as well as always showing kindness and respect can go a long way towards creating an environment that will facilitate the exchange of useful information. If the interview is being conducted in an outpatient setting, it is probably better to allow the patient to wear their own clothing while you chat with them. At the conclusion of your discussion, provide them with a gown and leave the room while they undress in preparation for the physical exam. Initial Question(s): Ideally, you would like to hear the patient describe the problem in their own words. Open ended questions are a good way to get the ball rolling. These include: "What brings your here? How can I help you? What seems to be the problem?" Push them to be as descriptive as possible. While it's simplest to focus on a single, dominant problem, patients occasionally identify more then one issue that they wish to address. When this occurs, explore each one individually using the strategy described below. Follow-up Questions: There is no single best way to question a patient. Successful interviewing requires that you avoid medical terminology and make use of a descriptive language that is familiar to them. There are several broad questions which are applicable to any complaint. These include: 1. Duration: How long has this condition lasted? Is it similar to a past problem? If so, what was done at that time? 2. Severity/Character: How bothersome is this problem? Does it interfere with your daily activities? Does it keep you up at night? Try to have them objectively rate the problem. If they are describing pain, ask them to rate it from 1 to 10 with 10 being the worse pain of their life, though first find out what that was so you know what they are using for comparison (e.g. childbirth, a broken limb, etc.). Furthermore, ask them to describe the symptom in terms with which they are already familiar. When describing pain, ask if it's like anything else that they've felt in the past. Knife-like? A sensation of pressure? A toothache? If it affects their activity level, determine to what degree this occurs. For example, if they complain of shortness of breath with walking, how many blocks can they walk? How does this compare with 6 months ago? 3. Location/Radiation: Is the symptom (e.g. pain) located in a specific place? Has this changed over time? If the symptom is not focal, does it radiate to a specific area of the body? 4. Have they tried any therapeutic maneuvers?: If so, what's made it better (or worse)? 5. Pace of illness: Is the problem getting better, worse, or staying the same? If it is changing, what has been the rate of change?

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6. Are there any associated symptoms? Often times the patient notices other things that have popped up around the same time as the dominant problem. These tend to be related. 7. What do they think the problem is and/or what are they worried it might be? 8. Why today?: This is particularly relevant when a patient chooses to make mention of symptoms/complaints that appear to be long standing. Is there something new/different today as opposed to every other day when this problem has been present? Does this relate to a gradual worsening of the symptom itself? Has the patient developed a new perception of its relative importance (e.g. a friend told them they should get it checked out)? Do they have a specific agenda for the patient-provider encounter? The content of subsequent questions will depend both on what you uncover and your knowledge base/understanding of patients and their illnesses. If, for example, the patient's initial complaint was chest pain you might have uncovered the following by using the above questions: The pain began 1 month ago and only occurs with activity. It rapidly goes away with rest. When it does occur, it is a steady pressure focused on the center of the chest that is roughly a 5 (on a scale of 1 to 10). Over the last week, it has happened 6 times while in the first week it happened only once. The patient has never experienced anything like this previously and has not mentioned this problem to anyone else prior to meeting with you. As yet, they have employed no specific therapy. This is quite a lot of information. However, if you were not aware that coronary-based ischemia causes a symptom complex identical to what the patient is describing, you would have no idea what further questions to ask. That's OK. With additional experience, exposure, and knowledge you will learn the appropriate settings for particular lines of questioning. When clinicians obtain a history, they are continually generating differential diagnoses in their minds, allowing the patient's answers to direct the logical use of additional questions. With each step, the list of probable diagnoses is pared down until a few likely choices are left from what was once a long list of possibilities. Perhaps an easy way to understand this would be to think of the patient problem as a Windows-Based computer program. The patient tells you a symptom. You click on this symptom and a list of general questions appears. The patient then responds to these questions. You click on these responses and... blank screen. No problem. As yet, you do not have the clinical knowledge base to know what questions to ask next. With time and experience you will be able to click on the patient's response and generate a list of additional appropriate questions. In the previous patient with chest pain, you will learn that this patient's story is very consistent with significant, symptomatic coronary artery disease. As such, you would ask follow-up questions that help to define a cardiac basis for this complaint (e.g. history of past myocardial infarctions, risk factors for coronary disease, etc.). You'd also be aware that other disease states (e.g. emphysema) might cause similar symptoms and would therefore ask questions that could lend support to these possible diagnoses (e.g. history of smoking or wheezing). At the completion of the HPI, you should have a pretty good idea as to the likely cause of a patient's problem. You may then focus your exam on the search for physical signs that would lend support to your working diagnosis and help direct you in the rational use of adjuvant testing.

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Recognizing symptoms/responses that demand an urgent assessment (e.g. crushing chest pain) vs. those that can be handled in a more leisurely fashion (e.g. fatigue) will come with time and experience. All patient complaints merit careful consideration. Some, however, require time to play out, allowing them to either become "a something" (a recognizable clinical entity) or "a nothing," and simply fade away. Clinicians are constantly on the look-out for markers of underlying illness, historical points which might increase their suspicion for the existence of an underlying disease process. For example, a patient who does not usually seek medical attention yet presents with a new, specific complaint merits a particularly careful evaluation. More often, however, the challenge lies in having the discipline to continually re-consider the diagnostic possibilities in a patient with multiple, chronic complaints who presents with a variation of his/her "usual" symptom complex. You will undoubtedly forget to ask certain questions, requiring a return visit to the patient's bedside to ask, "Just one more thing." Don't worry, this happens to everyone! You'll get more efficient with practice. Dealing With Your Own Discomfort: Many of you will feel uncomfortable with the patient interview. This process is, by its very nature, highly intrusive. The patient has been stripped, both literally and figuratively, of the layers that protect them from the physical and psychological probes of the outside world. Furthermore, in order to be successful, you must ask in-depth, intimate questions of a person with whom you essentially have no relationship. This is completely at odds with your normal day to day interactions. There is no way to proceed without asking questions, peering into the life of an otherwise complete stranger. This can, however, be done in a way that maintains respect for the patient's dignity and privacy. In fact, at this stage of your careers, you perhaps have an advantage over more experienced providers as you are hyper-aware that this is not a natural environment. Many physicians become immune to the sense that they are violating a patient's personal space and can thoughtlessly over step boundaries. Avoiding this is not an easy task. Listen and respond appropriately to the internal warnings that help to sculpt your normal interactions.

The Rest Of The History
The remainder of the history is obtained after completing the HPI. As such, the previously discussed techniques for facilitating the exchange of information still apply. Past Medical History: Start by asking the patient if they have any medical problems. If you receive little/no response, the following questions can help uncover important past events: Have they ever received medical care? If so, what problems/issues were addressed? Was the care continuous (i.e. provided on a regular basis by a single person) or episodic? Have they ever undergone any procedures, X-Rays, CAT scans, MRIs or other special testing? Ever been hospitalized? If so, for what? It's quite amazing how many patients forget what would seem to be important medical events. You will all encounter the patient who reports little past history during your interview yet reveals a complex series of illnesses to your resident or attending! These patients are generally not

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is a life threatening reaction and an absolute contraindication to re-exposure to the drug. how much do they consume over a week or month? Other Drug Use: Any drug use. One drink may mean a beer or a 12 oz glass of whiskey. How much are they taking and what are they treating? Has it been effective? Are these medicines being prescribed by a practitioner? Self administered? * You'll be surprised to learn how many patients don't know the answers to these questions. a widely accepted method for smoking quantification. does not raise the same level of concern. try to at least determine why it was performed. patients older. Medications: Do they take any prescription medicines? If so. Identifying these situations requires some tact. particularly if the agent in question is clearly the treatment of choice. Get in the habit of asking all your patients these questions as it can be surprisingly difficult to accurately determine who is at risk strictly on the basis of appearance.purposefully concealing information. particularly when regimens are complex. A rash. even as a child? What year did this occur? Were there any complications? If they don't know the name of the operation. missing doses or not taking medications altogether. Remind them that these 5 . how many packs per day and for how many years? If they quit. It helps to clearly explain that without this information your ability to assess treatment efficacy and make therapeutic adjustments becomes difficult/potentially dangerous. cigar and chewing tobacco use should also be noted. each with different implications. This can provide critical information as frequently what appears to be a failure to respond to a particular therapy is actually non-compliance with a prescribed regimen. a reasonable fear that can be addressed. if they are in-patients. It's important to ascertain if they are actually taking the medication as prescribed. or a more acceptable substitute regimen which might be implemented. They simply need to be prompted by the right questions! Past Surgical History: Were they ever operated on. past or present. ask them why this is happening. Encourage them to keep an up to date medication list and/or write one out for them. ask the patient to bring their meds with them when they return or. If patients are. however. as you'd like to encourage honesty without sounding accusatory. Anaphylaxis. cognitively impaired or simply disinterested. should be noted. Allergies/Reactions: Have they experienced any adverse reactions to medications? The exact nature of the reaction should be clearly identified as it can have important clinical implications. Perhaps there is an important side effect that they are experiencing. how much per day and what type of drink? Encourage them to be as specific as possible. If they don't drink on a daily basis. what is the dose and frequency? Do they know why they are being treated?* Medication noncompliance/confusion is a major clinical problem. Alcohol: Do they drink alcohol? If so. Smoking History: Have they ever smoked cigarettes? If so. Encourage them to be as specific as possible. for example. when did this occur? The packs per day multiplied by the number of years gives the pack-years. Don't forget to ask about over the counter or "non-traditional" medications. When all else fails. in fact. Pipe. see if a family member/friend can do so for them.

it can provide important information and should be pursued. If. what do they do to stay busy? Any hobbies? Participation in sports or other physical activity? Where are they from originally? These questions do not necessarily reveal information directly related to the patient's health. Also ask about any unusual illnesses among relatives.g. the process will become less awkward.questions are not meant to judge but rather to assist you in identifying risk factors for particular illnesses (e. you are searching for heritable illnesses among first or second degree relatives. diabetes and certain malignancies. coronary artery disease and congenital abnormalities. Obstetric (where appropriate): Have they ever been pregnant? If so." for example. As with questions about substance abuse. if at any time you uncover information relevant to the chief complaint don't be afraid to revisit the HPI. Find out the age of onset of the illnesses. perhaps revealing evidence for rare genetic conditions. full term delivery. a patient will clearly indicate that they do not wish to discuss these issues. In recounting their history. In some cases. for example. This may help improve the patient-physician bond and relay the sense that you care about them as a person. spontaneous abortion. hepatitis). It also gives you something to refer back to during later visits. Patients should be as specific as possible. By asking all of your patients these questions. it is nice to know something non-medical about them. therapeutic abortion). Work/Hobbies/Other: What sort of work does the patient do? Have they always done the same thing? Do they enjoy it? If retired. however. Most common. However. are coronary artery disease. HIV. "Heart disease. patient's frequently drop clues that suggest issues meriting further exploration. Respect their right to privacy and move on. includes valvular disorders. Sexual Activity: This is an uncomfortable line of questioning for many practitioners. letting the patient know that you paid attention and really remember them. of which only coronary disease has genetic implications. are they healthy? Do they live with the patient? Family History: In particular. Perhaps they will be more forthcoming at a later date. at least in America. as this has prognostic importance for the patient. additional history taking would be in order. Do they participate in intercourse? With persons of the same or opposite sex? Are they involved in a stable relationship? Do they use condoms or other means of birth control? Married? Health of spouse? Divorced? Past sexually transmitted diseases? Do they have children? If so. However. your ability to determine on sight who is sexually active (and in what type of activity) is rather limited. they are taking anti-hypertensive or anti-anginal medications yet made no mention of cardiac disease.g. how many times? What was the outcome of each pregnancy (e. For example. 6 . Furthermore. a father who had an MI at age 70 is not a marker of genetic predisposition while one who had a similar event at age 40 certainly would be.

if possible. "Johnny") and leave the room (or draw a separating curtain) while they change. respiratory rate. hypertension is defined as chronically elevated blood pressure). pulse. upset? What about their dress and hygiene? Remember. Does the patient seem anxious. Can identify the existence of an acute medical problem. All measurements are made while the patient is seated. However. capes or in other creative ways. Observation: Before diving in. Most patients will have had their vital signs measured by an RN or health care assistant before you have a chance to see them. there is significant potential for measurement error. 2. of course. making your observations. The more deranged the vitals. provide them with a gown (a. Rectal temperatures. are approximately 1 degree F higher than those obtained orally. Occasionally. particularly if you are going to use these values as the basis for management decisions. the exam begins as soon as you lay eyes on the patient. As noted below. so repeat determinations can provide critical information. Depending on the bias of a particular institution.5 F. warm and well lit. with a fever defined as greater than 38-38. they: 1.5 C or 101-101. blood pressure and. Instruct them to remove all of their clothing (except for briefs) and put on the gown so that the opening is in the rear. Are a means of rapidly quantifying the magnitude of an illness and how well the body is coping with the resultant physiologic stress. patient's will end up using them as ponchos. in pain. take a minute or so to look at the patient in their entirety. As most exam rooms do not have thermometers. which most closely reflect internal or core values.g. from an out-of-the way perch. they feel hot but reportedly have no fever or vice versa). Getting Started: The examination room should be quiet. temperature is measured in either Celcius or Farenheit.g. blood oxygen saturation. This not only allows you to practice obtaining vital signs but provides an opportunity to verify their accuracy. Are a marker of chronic disease states (e. While this may make for a more attractive ensemble it will also. the recorded value seems discordant with the patient's clinical condition (e. In particular. These numbers provide critical information (hence the name "vital") about a patient's state of health. Temperature: This is generally obtained using an oral thermometer that provides a digital reading when the sensor is placed under the patient's tongue. the patient should have had the opportunity to sit for approximately five minutes so that the values are not affected by the exertion required to walk to the exam room. interfere with your ability to perform an examination! Prior to measuring vital signs. it is not necessary to repeat this measurement unless. the sicker the patient. where appropriate.k. 3.a. these values are of such great importance that you should get in the habit of repeating them yourself. unfortunately.Vital Signs Vital signs include the measurement of: temperature. 7 . After you have finished interviewing the patient.

8 . You may find it helpful to feel both radial arteries simultaneously.g. femoral.Respiratory Rate: Respirations are recorded as breaths per minute. doubling the sensory input and helping to insure the accuracy of your measurements. this measurement offers no relevant information for the routine examination. Pulse: This can be measured at any place where there is a large artery (e. Normal is between 12 and 20. Place the tips of your index and middle fingers just proximal to the patients wrist on the thumb side. However. orienting them so that they are both over the length of the vessel. or simply by listening over the heart). though for the sake of convenience it is generally done by palpating the radial impulse. Technique for Measuring the Radial Pulse The pictures below demonstrate the location of the radial artery (surface anatomy on the left. gross anatomy on the right). They should be counted for at least 30 seconds as the total number of breaths in a 15 second period is rather small and any miscounting can result in rather large errors when multiplied by 4. it can be a very reliable marker of disease activity. This can be done by observing the rise and fall of the patient's hospital gown while you appear to be taking their pulse. carotid. particularly in the setting of cardio-pulmonary illness. Try to do this as surreptitiously as possible so that the patient does not consciously alter their rate of breathing. In general.

If you push too hard. Count for 30 seconds and multiply by 2 (or 15 seconds x 4). you might occlude the vessel and mistake your own pulse for that of the patient. so the radial artery should be readily palpable in most patients.Frequently. Push lightly at first. Upper extremity peripheral vascular disease is relatively uncommon. If the rate is particularly slow 9 . adding pressure if there is a lot of subcutaneous fat or you are unable to detect a pulse. Quantity: Measure the rate of the pulse (recorded in beats per minute). During palpation. note the following: 1. you can see transmitted pulsations on careful visual inspection of this region. which may help in locating this artery.

it's a good idea to verify the rate by listening over the heart (see cardiac exam section). in which case the rhythm is described as regularly irregular. In the setting of hypovolemia. the readings will be artificially elevated. for example. it is referred to as irregularly irregular and likely represents atrial fibrillation. with readings reported in millimeters of mercury (mm Hg). are quite common. Blood Pressure: Blood pressure (BP) is measured using mercury based manometers. occurring occasionally with systolic heart failure. should reach roughly 80% around the circumference of the arm while its width should cover roughly 40%. Normal is between 60 and 100. The resultant systole may generate a rather small stroke volume whose impulse is not palpable in the periphery. when impulses originating from the ventricle are interposed at regular junctures on the normal rhythm. There may even be beat to beat variation in the volume. Blood Pressure Cuffs 10 . The inflatable bladder. The opposite occurs if the cuff is too large. This is because certain rhythm disturbances do not allow adequate ventricular filling with each beat. This may occur. Regularity: Is the time between beats constant? In the normal setting. normal and large. 2. Irregular rhythms. the subjective sense of fullness) feel normal? This reflects changes in stroke volume. If the pattern is entirely chaotic with no discernable pattern. Clinics should have at least 2 cuff sizes available.or fast.e. recognizing that there will rarely be a perfect fit. If it is too small. it is probably best to measure for a full 60 seconds in order to minimize the impact of any error in recording over shorter periods of time. Volume: Does the pulse volume (i. If the pulse is irregular. Extra beats can also be added into the normal pattern. Try to use the one that is most appropriate. 3. which can be felt through the vinyl covering of the cuff. the heart rate should appear metronomic. The size of the BP cuff will affect the accuracy of these readings. for example. the pulse volume is relatively low (aka weak or thready). however.

gross anatomy on the right). The placement does not have to be exact nor do you actually need to identify this artery by palpation. 11 .In order to measure the BP.e. proceed as follows: 1. Wrap the cuff around the patient's upper arm so that the line marked "artery" is roughly over the brachial artery. Antecubital Fossa The pictures below demonstrate the antecubital fossa anatomy (surface anatomy on the left. the crook on the inside of their elbow). located towards the medial aspect of the antecubital fossa (i.

Experiment with both and see if this makes a difference. If the arm is held too high. Twist the head piece so that the diaphragm is engaged. Note that although the needle may oscillate prior to this time. You can provide additional support by gently trapping their hand and forearm between your body and right elbow. This is the position which allows air to enter and remain in the bladder. These are known as the Sounds of Koratkoff. Then listen.e. it is the sound of blood flow that indicates the SBP. 3. Read the instruction manual accompanying your stethoscope in order to determine how your device works. If you immediately hear sound. Use your right hand to pump the bulb until you have generated 150 mmHg on the manometer. you have underestimated the SBP. 5. This is a bit above the top end of normal for systolic blood pressure (SBP). The first sound that you hear reflects the flow of blood through the no longer completely occluded brachial artery.2. 6. allowing the free flow of blood without turbulence and thus no audible sound. Put on your stethescope so that the ear pieces are angled away from your head. The diastolic blood pressure (DBP) is measured when the sound completely disappears. Pump up an additional 20 mmHg and repeat. The arm should remain somewhat bent and completely relaxed. This can be verified by gently tapping on the end. which should produce a sound. and vice versa. While most practitioners use the diaphragm of the stethescope. each with its own variation on the structure of the diaphragm and bell. The value on the manometer at this moment is the SBP. a few mm Hg per second) by turning the valve in a counter-clockwise direction while listening over the brachial artery and watching the pressure gauge. Now slowly deflate the blood pressure cuff (i. Grasp the patient's right elbow with your right hand and raise their arm so that the brachial artery is roughly at the same height as the heart. 4. Continue listening while you slowly deflate the cuff. This is the point when the pressure within the vessel is greater then that supplied by the cuff. It's worth mentioning that a number of different models of stethescops are available on the market. the bell may actually be superior for picking up the low pitched sounds used for measuring BP. the reading will be artifactually lowered. Hold the diaphragm in place with your left hand. place the diaphragm over the area of the brachial artery. With your left hand. Technique for Measuring Blood Pressure 12 . Turn the valve on the pumping bulb clockwise (may be counter clockwise in some cuffs) until it no longer moves.

and thus the position of the brachial artery relative to the heart. position the patient's right arm as described above.7. At the other end of the spectrum. Do not place the blood pressure cuff over a patients clothing or roll a tight fitting sleeve above their biceps when determining blood pressure as either can cause elevated readings. obtain measurements 13 . Repeat the measurement on the patient's other arm. Slowly deflate the cuff until you can again detect a radial pulse and note the reading on the manometer. relatively deconditioned) will develop an elevation in both their SBP and DBP. though in a slow and relatively silent fashion. interpretation of low values must take into account the clinical situation. Also. Therefore. Patients who are not too physically active (i. Then repeat after they've walked briskly in place for several minutes. In order to limit their impact. has on BP. can adjust to a chronically low SBP (e. 10. used to higher baseline values. Inflate the cuff until you can no longer feel the pulse. Place the index and middle fingers of your right hand over the radial artery. However others. That is. the minimal SBP required to maintain perfusion varies with the individual. which most frequently occurs in the setting of subclavian artery atherosclerosis. Occasionally you will be unsure as to the point where systole or diastole occurred and wish to repeat the measurement. Take a patient's BP after they've rested. 8. reversing the position of your hands. Ideally. emergencies resulting from extremely high values and subsequent acute end organ dysfunction are quite rare. permit any venous congestion in the arm to resolve (which otherwise may lead to inaccurate measurements). The two readings should be within 10-15 mm Hg of each other. Rather. Furthermore. It is important to recognize that blood pressure is rarely elevated to a level that causes acute symptoms. or simply to a value 10 points above the SBP as determined by auscultation. To do this. see what effect raising or lowering the arm. might become quite ill if their SBPs were suddenly decreased to these same levels. 9. If you have a chance. 80-90) and live without symptoms of hypoperfusion. Try the following experiment to assess the impact that this can have. repeated measurement can be uncomfortable for the patient. Make sure the patient has had an opportunity to rest before measuring their BP. for example. Normal is between 100/60 and 140/90.e. Hypertension is thus defined as either SBP greater then 140 or DBP greater than 90. you should allow the cuff to completely deflate. This is the SBP and should be the same as the value determined with the use of your stethescope. and then repeat a minute or so later. while no one has ever lost a limb secondary to BP cuff induced ischemia. Those with poorly functioning hearts.g. Many things can alter the accuracy of your readings. remember the following: 1. Differences greater then this imply that there is differential blood flow to each arm. 2. while hypertension in general is common. it is the chronically elevated values which lead to target organ damage. another good reason for giving the arm a break. You can verify the SBP by palpation. Avoid moving your hands or the head of the stethescope while you are taking readings as this may produce noise that can obscure the Sounds of Koratkoff.

a greater then 20 point drop may be seen.g. on the same patient with both a large and small cuff. The 20 point value is a rough guideline. If the reading is surprisingly high or low. SBP does not vary by more then 20 points when a patient moves from lying to standing. it can help quantify the degree of impairment. In the setting of significant volume depletion. If possible. Orthostatic measurements may also be used to determine if postural dizziness. postural) measurements of pulse and blood pressure are part of the assessment for hypovolemia. For example. Normally. 4. While imperfect. In general. These exercises should give you an appreciation for the magnitude of error that can be introduced when improper technique is utilized.k. This results in postural vital sign changes and symptoms. this non-invasive measurement of gas exchange and red blood cell oxygen carrying capacity has become available in all hospitals and many clinics. In the setting of GI bleeding. it can provide important information about cardio-pulmonary dysfunction and is considered by many to be a fifth vital sign. Orthostatic (a. for example. In particular. the more likely it is to cause symptoms and be of clinical relevance. smoking or any other unprescribed drug with sympathomimetic activity on the day of the measurement. measure the blood pressure of a patient who has an indwelling arterial catheter (these patients can be found in the ICU with the help of a preceptor). which allows for equilibration. 5. Heart rate should increase by more then 20 points in a normal physiologic attempt to augment cardiac output by providing chronotropic compensation. This requires first measuring these values when the patient is supine and then repeating them after they have stood for 2 minutes. Oxygen Saturation: Over the past decade.a. Instruct your patients to avoid coffee. for those suffering from either acute or chronic cardio-pulmonary disorders.. light headedness). 6.3. repeat the measurement towards the end of your exam. patients who suffer from diabetes frequently have autonomic nervous system dysfunction and cannot generate appropriate arteriolar vaosconstriction when changing positions. 14 . is the result of a fall in blood pressure. a drop in blood pressure and/or rise in heart rate after this maneuver is a marker of significant blood loss and has important prognostic implications. Arterial transducers are an extremely accurate tool for assessing blood pressure and therefore provide a method for checking your non-invasive technique. the greater the change. a common complaint with multiple possible explanations. This is frequently associated with symptoms of cerebral hypoperfusion (e. Changes of lesser magnitude occur when moving from lying to sitting or sitting to standing.

walking your fingers down the area in question while applying steady. 5.Head and Neck Exam Lymph Nodes: The major lymph node groups are located along the anterior and posterior aspects of the neck and on the underside of the jaw. Drainage: Part of the throacic cavity. mononucleosis). Posterior Cervical: Extend in a line posterior to the SCMs but in front of the trapezius. Sub-Mental: Just below the chin.g. particularly if the enlargement is asymmetric (i. the preauricular nodes. Drainage: The structures in the floor of the mouth. you may be able to see them bulging under the skin.g. This muscle allows the head to turn to the right and left. are listed below. gentle pressure. The description of drainage pathways are rough approximations as there is frequently a fair amount of variability and overlap. located in front of the ears. Drainage: The teeth and intra-oral cavity. A number of other lymph node groups exist. Anterior Cervical (both superficial and Nodes deep): Nodes that lie both on top of and beneath the sternocleidomastoid muscles (SCM) on either side of the neck. abdomen. tonsils. just lateral to where it joins the sternum. Drainage: The skin on the back of the head. Lymph nodes of the head and neck 15 . To palpate. 6. 4. from the angle of the jaw to the top of the clavicle. may become inflamed during infections of the external canal of the ear). it will be more obvious if one side is larger then the other).e. Sub-Mandibular: Along the underside of the jaw on either side. The major groups of lymph nodes as well as the structures that they drain. 3. Also frequently enlarged during upper respiratory infections (e. Nodes are generally examined in the following order: Palpating Anterior Cervical Lymph 1. If the nodes are quite big. Examine both sides of the head simultaneously. Supra-clavicular: In the hollow above the clavicle. use the pads of all four fingertips as these are the most sensitive parts of your hands. Drainage: The internal structures of the throat as well as part of the posterior pharynx. However. Tonsillar: Located just below the angle of the mandible. from the level of the mastoid bone to the clavicle. 2. and thyroid gland. palpation of these areas is limited to those situations when a problem is identified in that specific region (e. The right SCM turns the head to the left and vice versa. Drainage: The tonsilar and posterior pharyngeal regions. They can be easily identified by asking the patient to turn their head into your hand while you provide resistance.

lymphoma) or as a site of metastasis. for example. these nodes are generally: 16 . Malignancies may also involve the lymph nodes. Infected lymph nodes tend to be: • Firm. lymph nodes occasionally remain permanently enlarged. enlarged and warm. the center of the node may become necrotic.g. Inflammation can spread to the overlying skin. the preauricular nodes. though they should be nontender. fluctuance). either primarily (e. resulting in the accumulation of fluid and debris within the structure. to find small. palpable nodes in the submandibular/tonsilar region of otherwise healthy individuals. However. In either case. If an infection remains untreated. palpation of these areas is limited to those situations when a problem is identified in that specific region (e. This is known as an abscess and feels a bit like a tensely filled balloon or grape (a. tender. located in front of the ears. small (less the 1 cm). Following infection. have a rubbery consistency and none of the characteristics described above or below. they are most readily palpable when fighting infections.k. may become inflamed during infections of the external canal of the ear). It is common.g. Knowledge of which nodes drain specific areas will help you search efficiently.a. As such. What are you feeling for? Lymph nodes are part of the immune system.A number of other lymph node groups exist. referred to as lymphadenitis. causing it to appear reddened. Infections can either originate from the organs that they drain or primarily within the lymph node itself. This likely represents sequelae of past pharyngitis or dental infections.

for example. Furthermore.g. matted (i. frequently associated with an intra-oral primary cancer.g basal cell. systemic infections (e. for example. try to identify its precise location. stuck to each other).e. paying particular attention to any skin changes suggestive of cancer (e. squamous cell). The location of the lymph node may help to determine the site of malignancy. If the patient has pain. Cervical Adenopathy: Right anterior cervical adenopathy secondary to metastatic cancer. lymph node enlargement). lymphoma) while those limited to a specific anatomic region are more likely associated with a local problem. would be consistent with a squamous cell carcinoma. it may take serial examinations over the course of weeks to determine whether a node is truly enlarging. sarcoidosis) can also cause lymphadenopathy (i. Cervical Adenopathy: Massive right side cervical adenopathy secondary to metastatic squamous cell cancer originating from this patient's oropharynx.g. non-tender.e. melanoma. not freely mobile but rather stuck down to underlying tissue). This can be either symmetric or asymmetric. mononucleosis). suggestive of malignancy.g. bilateral involvement suggests a systemic malignancy (e. Infection within the external canal. Enlargement of nodes located only on the right side of the neck in the anterior cervical chain. and increase in size over time.g. fixed (i. a common asymptomatic abnormality affecting this sun exposed area. Diffuse. The Ear External structures: Briefly examine the outer structures. as might occur with other inflammatory processes. or responding to therapy/the passage of time and regressing in size.e.• Firm. Diffuse upper airway infections (e. 17 . Historical information as well findings elsewhere in the body are critical to making these diagnoses. tuberculosis) and inflammatory processes (e.

Either technique is acceptable. The scope should be in your right hand if you are examining the right ear. In the setting of infection. not while looking through the scope). This straightens out the canal. Slowly advance the scope. Put the otoscopic head on your oto-opthalmoscopic. Turn on the light source. which has a stabilizing effect. I find it helpful to extend the pinky and fourth fingers of my right hand and place them on the side of the patient's head. Try not to wiggle the scope too much as the external canal is quite sensitive. obscures your view. Move in small increments. Otoscope Otoscopy: The otoscope allows you to examine the external canal. Proceed as follows: 1. 2. Grasp the scope so that the handle is either pointed directly downward or angled up and towards the patient's forehead. stop and go to the other side. swollen and may not accommodate the speculum. Look through the viewing window with either eye. Do this under direct vision (i. It should easily twist into position.may cause discharge from the ear as well as pain on manipulation of any of the external structures. Do not try to extract it until/unless you have had 18 . the structure that connects the outside world with the middle ear. Gently grasp the top of the left ear with your left hand and pull up and backwards. Place the tip of the specula in the opening of the external canal. 3. called otitis externa. 5. 4. allowing easier passage of the scope. 6. heading a bit towards the patient's nose but without any up or down angle. 7. pay attention to the appearance of the external canal. Place one of the disposable specula on the end of the scope. which appears brownish. If wax. the walls becomes red.e. as well as the ear drum and a few inner ear structures. As you advance. irregular and mushy. In the normal state there should be plenty of room.

This is called a middle ear effusion and can cause the drum to bulge outwards. The malleous also appears less prominent and you may be able to see a line caused by fluid collecting behind the drum.k. the most common pathologic process affecting this area). which may then be easily irrigated from the canal. b. making a triangle that is visible below the malleous. Picture on left is of normal ear for comparison. d.a. you can squirt small puffs of air 19 . There is a valve on your scope that allows the attachment of a small. The structures behind it: The malleous. compressible bulb. In the setting of infection within the middle ear (known as otitis media. c. e. After moving ahead a few centimeters. Otitis Externa: Swelling due to infection in the external canal of the left ear (picture on right) limits the space around the Q-Tip. one of the bones of the middle ear. you should see the tympanic membrane (a. The drum is draped over this bone. Pay particular attention to: Otoscopic Examination a. and is generally most prominent. the drum becomes diffusely red and the light reflex is lost. The tip at the bottommost aspect is the umbo. The part that is closest to the top of the drum is called the lateral process. touches the drum. The light reflex: Light originating from your scope will be reflected off the surface of the drum.specific training in this area! There are pharmacologic means of softening wax. The color: When healthy. Place the bulb in the palm of the hand which is not holding the scope. which is visible through its top half. angled down and backwards. With this device. it has a grayish. translucent appearance. ear drum).

g. Rub the finger tips of first one hand and then the other. the Weber test is said to be mid-line. the following tests are performed: Weber: Grasp the 512 Hz tuning fork by its stem and get it to vibrate by either striking the tines against your hand or by "snapping" the ends between your thumb and middle finger. If sound is heard better in one ear it is described as lateralizing to that side. Hand position is reversed. Are they able to repeat the phrases back correctly? Does this seem to be equal on either side? These tests obviously are not very objective. Hearing loss can occur at either level. Sensorineural Deficits: As with acuity. the sound will be best heard in the normal ear. 20 . Precise quantification requires sensitive equipment and is usually done by a trained audiologist. Auditory Acuity: If the patient does not complain of hearing loss. 8. Make note of any obvious differences in hearing. Move to the other side of the body and examine the left ear. you can stand behind the patient and whisper a few words in first one ear and then the other. wax in the external canal). Sound transmitted from the tuning fork will then be heard louder on that side. The bones of the skull will transmit this sound to the 8th nerve. Remind the patient that they are trying to detect sound. Ask an experienced examiner to demonstrate as this is quite awkward at first and it's difficult to appreciate the movement. Otherwise. The normal membrane moves. these tests would only be performed if the patient complained of hearing loss. which should then be appreciated in both ears equally. This includes transmission of sound through the external canal and middle ears. Conduction: The passage of sound from outside to the level of the 8th cranial nerve. If there is a conductive deficit (e. on an imaginary line equidistant from either ear. this part of the exam is omitted. Sensorineural: The transmission of sound through the 8th nerve to the brain. To determine which is affected. In the setting of a sensorineural abnormality (e. not the buzzing vibratory sensation from the fork. This is because impaired conduction has prevented any competing sounds from entering the ear via the normal route. which can be appreciated by the examiner. the sound will be heard better in that ear. Detecting Conductive v. Then place the stem towards the back of the patient's head.(known as pneumatic otoscopy) at the tympanic membrane. Alternatively.g. You can create a transient conductive hearing loss by putting a finger in one ear. 2. Effusions prevent this from occurring. A crude assessment can be performed by asking the patient to close their eyes while you place your fingers a few centimeters from either ear. an acoustic neuroma. a tumor arising from the 8th CN). Transmission of sound can be broken into two components: 1.

Weber Test Rinne: Strike the same tuning fork and place the stem on the mastoid bone. medication induced toxicity to the 8th CN). fluid associated with an infection in the middle ear). which causes bone conduction to be greater then or equal to air. Instruct the patient to let you know as soon as they can no longer hear the sound. Then place the tines of the still vibrating fork right next to. This will not be the case if there is a conductive hearing loss (e.g. air conduction should still be better then bone as they will both be equally affected by the deficit. a bony prominence located just behind and below the ear. the external canal. They should again be able to hear the sound. but not touching. transmission of sound through air is always better then through bone. Rinne Test 21 . Bone conduction will allow the sound to be transmitted and appreciated.g. If there is a sensorineural abnormality (e. when everything is functioning normally. This is because.

To look in the nose. Occlude one nostril and then present an alcohol pad to the other side. c. olfaction can be crudely assessed using an alcohol pad sniff test as follows: a. Any polypoid growths. though often undiagnosed. First check to see if the patient is able to breathe through either nostril effectively. The color of the mucosa. Then repeat on the other side. The presence of any discharge as well as its color (clear with allergic reactions. this exam is generally omitted. Push up slightly on the tip of the nose with the thumb of your left hand. Air should move equally well through each nares. making sure that they can move air adequately thru both. b. yellowish with infection). The middle and inferior turbinates. which may be associated with allergies and obstructive symptoms? 4. noting: 1. have the patient tilt their head back.The Nose In the absence of symptoms. coffee grounds. Push on one nostril until it is occluded and have them inhale. wintergreen oil. which are shelf-like projections along the lateral wall. The other nostril is examined in a similar manner. 2. etc). A patient should be able to detect the odor of the alcohol pad at a distance of 10 cm. Now look through the viewing window. Occlude each nostril seqeuentially. It can become quite reddened in the setting of infection. 3. Place the end of the speculum (it's OK to use the same one from the ear exam) into the nares under direct vision. asking the patient to inform you when they are able to detect its smell. In patients who make mention of this problem. Ask the patient to close their eyes so that they don't get any visual cues. 5. Alcohol is used for convenience.g. as most exam rooms have these pads. Loss of smell (anosmia) is a relatively common problem. 22 . More sophisticated testing can be done using vials containing very distinctive odors (e.

these sinuses cannot be appreciated on examination and cause no symptoms. Inflammatory states. They function to warm and cleanse air before it travels down to the lungs. They may also help to reduce the total weight of the skull.Alcohol Pad Smell Test Evaluation of Frontal and Maxillary Sinuses Maxillary and Frontal Sinuses The head and face contain a number of sinuses. open cavities that communicate with the upper airway. in particular those caused by allergy or infection. In normal health. produce symptoms and findings that may 23 .

4. but are not readily available. The Oro-Pharynx Exposure and good lighting are critical. Symptoms associated with sinusitis include: nasal congestion. Pain suggests underlying inflammation. Ask the patient to open their mouth and look for light glowing through the mucosa of the upper mouth. This is due to the fact that the maxillary sinuses drain into the nose via a passageway located under the middle turbinate. Directly palpate and percuss the skin overlying the frontal and maxillary sinuses. fever. 3. A tongue depressor assists with the exploration. however. Examination of the nasal mucosa for colored discharge as described above. Head and Neck specialists have head lamps that provide excellent illumination and allow them to use both hands to explore the oral cavity. 2. the maxillary sinus becomes fluid filled and will not allow this transillumination. facial pain.be detected during examination. Place the lighted otoscope directly on the infraorbital rim (bone just below the eye). In the setting of inflammation. The frontal and maxillary sinuses are the two that can be indirectly examined. Most other physicians. Transillumination of the right maxillary sinus 5. Examination for sinusitis should include the following: 1. Using a tongue depessor. This may cause discomfort if the sinus is inflamed. tap on the teeth which sit in the floor of the maxillary sinus. use an otoscope or flashlight for illumination. There are specially designed transilluminators that may work better for this task. The exam should be performed in an orderly fashion as follows: 24 . and pain on palpation of the maxillary teeth. Dim the room lights. nasal discharge.

It is not necessary to do this during your routine exam as it can be quite noxious! 2. Note that the uvula hangs down from the roof of the mouth. place the tongue blade ½ way back on the tongue and press down while the patient again says "Ah. This is done by touching a q-tip against the posterior pharynx. If you are still unable to see. giving you a better view. or to determine if a patient with depressed level of consciousness is able to protect their airway from aspiration).g. after a stroke that impairs CNs 9 or 10.e. the back of the throat). Ask the patient to say "Ah". which elevates the soft palate." the uvula rises up.1. Have the patient stick out their tongue so that you can examine the posterior pharynx (i. This causes some people to gag. particularly when the blade is pushed onto the more proximal aspects of the tongue." hopefully improving your view. 25 . Deviation to one side may be caused by CN 9 palsy (the uvula deviates away from the affected side). It may occasionally be important to determine whether the gag reflex is functional (e. directly in the midline. With an "Ah. uvula or tongue. a tumor or an infection.

frequently covered with a yellow or white exudate (e. Left Peritonsilar Abscess.Cranial Nerve 9 Dysfunction: Patient has suffered stroke. it can become quite red. The tonsils lie in an alcove created by arches on either side of the mouth. Normal tonsils range from barely apparent to quite prominent. In the setting of a peritonsilar abscess.g. When this occurs. the tonsils appear asymmetric and the uvula may be pushed away from the affected side. The normal pharynx has a dull red color. they become red. The apex of these arches are located lateral to and on a line with the uvula. making breathing quite difficult. the tonsil may actually compromise the size of the oral cavity. In the setting of infection. with Strep. causing loss of function of left CN 9. Note deveiation of uvula towards right. When infected. 26 . 4. As a result. Throat or other types of pharyngitis). uvula is pulled towards the normally functioning (ie right) side. 3. are frequently covered by whitish/yellow discharge.

7. particularly if the patient has a dental complaint. which allows evaluation of CN 12. Associated inflammation of left face can clearly be seen. If there is nerve impairment.5. Examine the teeth to get a sense of general dentition. Any obvious growths or abnormalities? Ask them to flip their tongue up so that you can look at the underside. If you see something abnormal. the tongue will deviate towards the affected side. grasp the tongue with gauze so that you can get a better look. Have the patient stick their tongue outside their mouth. 6. Tooth Abscess: Tooth abscess involving left molar region. which can appear quite dry if the patient is dehydrated. Look carefully along the upper and lower gum lines and at the mucosa in general. 27 . Pain produced by tapping on a tooth is commonly caused by a root abscess.

The Thyroid Exam Prior to palpation. Tongue therefore deviates to the left. you may be able to express pus from the ducts by gently palpating the gland. look at the thyroid region. The parotid glands are located in either cheek. Make note of any growths along the cheeks. which can be confirmed on palpation. In particular. What do they feel like? Are they hard? To what extent does a growth involve deeper structures? If the patient feels something that you cannot see. Note enlargement on right compared with left. hard palate (the roof of the mouth between the teeth). soft palate. Put on a pair of gloves to better explore these regions. you may 28 . 8. The ducts which drain the parotids enter the mouth in line with the lower molars and are readily visible. try to get someone else to hold the light source. When infected. Any areas which are painful or appear abnormal should also be palpated. patients who smoke or chew tobacco are at risk for oral squamous cell cancer. 9. freeing both your hands to explore the oral cavity with two tongue depressors. Infection will cause pain and swelling in this area. If the gland is quite enlarged.Left CN 12 Dysfunction: Stroke has resulted in L CN 12 Palsy. Right parotid mass. or anywhere else.

Thyroid tissue. along with the trachea. it may be helpful to practice in front of a mirror. As you cannot actually see the area that you're examining. Make sure that you tell your patients what you're doing so they know you're not trying to choke them! The cartilage has a small notch in its top and is approximately 1. will move up and down with swallowing. For example.k. The normal thyroid is not visible. sits atop the tracheal rings. You can also try to identify and feel the 29 . just below the chin. To find the thyroid gland. Deviation to one side or the other is usually associated with intra-thoracic pathology. Exam from behind the patient is described below: 1. the first firm structure with which you come into contact. This deviation may be visible on inspection and can be accentuated by gently placing your finger in the top of the thyroid cartilage and noting its position relative to the midline. The thyroid gland lies approximately 2-3 cm below the thyroid cartilage. If you're unsure. to be pushed towards the opposite chest. Location of the Thyroid Palpation: The thyroid can be examined while you stand in front of or behind the patient. and can be seen best when the patient tilts their head backwards. Stand behind the patient and place the middle three fingers of either hand along the mid-line of the neck. air trapped in one pleural space (known as a pneumothorax) can generate enough pressure so that it collapses the lung on that side. which is a mid-line bulge towards the top of the anterior surface of the neck. first locate the thyroid cartilage (a.a the Adams Apple). on either side of the tracheal rings.5-2 cm in length. Gently walk them down until you reach the top of the thyroid cartilage. Use gentle pressure. otherwise this can be uncomfortable. so it's not worth going through this swallowing exercise if you don't see anything on gross inspection. along with all of the adjacent structures. It's particularly prominent in thin males. causing mediastinal structures.actually notice it protruding underneath the skin. give the patient a glass of water and have them swallow as you watch this region. which may or may not be apparent on visual inspection.

e. The gland should slide beneath your fingers while it moves upward along with the cartilagenous rings. moves up and down with swallowing)? If there is concern re: malignancy. The two main lobes are connected by a small isthmus that reaches across mid-line and is almost never palpable. fixed to underlying tissue. experienced touch in order to actually feel this structure. This is the cricothyroid membrane. consistent with malignancy) or freely mobile (i. is it attached to the adjacent structures (i. Walk down the thyroid cartilage with your fingers until you come to the horizontal groove which separates it from the cricoid cartilage (the first tracheal ring). have the patient drink water as you palpate. Now slide the three fingers of both hands to either side of the rings. the site for emergent tracheal access in the event of upper airway obstruction. Apply very gentle pressure when you palpate as the normal thyroid tissue is not very prominent and easily compressible. Thyroid Examination 4.e. It takes a very soft. You should be able to feel a small indentation (it barely accepts the tip of your finger) between these 2 structures. so don't be disappointed if you can't identify anything. 3. Pay attention to several things as you try to identify the thyroid: If enlarged (and this is a subjective sense that you will develop after many exams). Continue walking down until you reach the next well defined tracheal ring. If you're unsure or wish confirmation. bilateral? Are there discrete nodules within either lobe? If the gland feels firm.structures from the front while looking at the area in question before performing the exam from behind.. 2. The thyroid gland extends from this point downwards for approximately 2-3 cm along each side. a careful lymph node exam (described above) is important as this is the most common site of spread 30 . is it symmetrically so? Unilateral vs. directly in the mid-line.

are discussed elsewhere. blue is bad! Cyanosis of nail beds 4. Pay particular attention to: 1. sternocleidomastoids). Use of accessory muscles of breathing (e. palpation. Vital signs. 3. General comfort and breathing pattern of the patient. Obviously.The Lung Exam The 4 major components of the lung exam (inspection. The position of the patient.g. Color of the patient. Inspection/Observation: A great deal of information can be gathered from simply watching a patient breathe. they will lean forward. labored? Are the breaths regular and deep? 2. Patient with emphysema bending over in Tri-Pod Position 31 . scalenes. Do they appear distressed. percussion and auscultation) are also used to examine the heart and abdomen. Those with extreme pulmonary dysfunction will often sit up-right. resting their hands on their knees in what is known as the tri-pod position. an important source of information. In cases of real distress. diaphoretic. Their use signifies some element of respiratory difficulty. Learning the appropriate techniques at this juncture will therefore enhance your ability to perform these other examinations as well. in particular around the lips and nail beds.

Any obvious chest or spine deformities. often seen in cases of emphysema. The direction of abdominal wall movement during inspiration.5. occur congenitally. referred to as paradoxical breathing. they can impair a patient's ability to breathe normally. the descent of the diaphragm pushes intra-abdominal contents down and the wall outward. the abdominal wall may move inward during inspiration. place your hand on the patient's abdomen as they breathe. The x-ray shows a subtle concave appearance of the lower sternum. wheezing or the gurgling caused by secretions in large airways are audible to the "naked" ear. Normally. Any audible noises associated with breathing as occasionally. A few common variants include: o Pectus excavatum: Congenital posterior displacement of lower aspect of sternum. 7. Ability to speak.g. 9. emphysema) or paralysis. Breathing through pursed lips. If this occurs. 32 . If you suspect this to be the case. respiratory rates can be so high and/or work of breathing so great that patients are unable to speak in complete sentences. which should accentuate its movement. emphysema). In any case. or be otherwise acquired. These may arise as a result of chronic lung disease (e.e. In cases of severe diaphragmatic flattening (e.g. note how many words they can speak (i. This gives the chest a somewhat "hollowed-out" appearance. 8. the fewer words per breath. At times. the worse the problem!). 6.

o Barrel chest: Associated with emphysema and lung hyperinflation. 33 . Accompanying xray also demonstrates increased anterior-posterior diameter as well as diaphragmatic flattening.

34 .  Scoliosis: Condition where the spine is curved to either the left or right. In the pictures below. Accompanying X-Ray of same patient clearly demonstrates extreme curvature of the spine.o Spine abnormalities:  Kyphosis: Causes the patient to be bent forward. Curvature is more pronounced on x-ray. scoliosis of the spine causes right shoulder area to appear somewhat higher than the left.

the skeleton. Nevertheless. and the main lobes of the lung.Review of Lung Anatomy: Understanding the pulmonary exam is greatly enhanced by recognizing the relationships between surface structures. The pictures below demonstrate these relationships. surface markers will give you a rough guide to what lies beneath the skin. The multi-colored areas of the lung 35 . Realize that this can be difficult as some surface landmarks (eg nipples of the breast) do not always maintain their precise relationship to underlying structures.

The following abbreviations are used: RUL = Right Upper Lobe.model identify precise anatomic segments of the various lobes. which cannot be appreciated on examination. Anterior View 36 . RLL = Right Lower Lobe. RML = Right Middle Lobe. Main lobes are outlined in black. LUL = Left Upper Lobe. LLL = Left Lower Lobe.

Posterior View

37

Right Lateral View

38

Left Lateral View

39

Palpation: Palpation plays a relatively minor role in the examination of the normal chest as the structure of interest (the lung) is covered by the ribs and therefore not palpable. Specific situations where it may be helpful include: 1. Accentuating normal chest excursion: Place your hands on the patient's back with thumbs pointed towards the spine. Remember to first rub your hands together so that they are not too cold prior to touching the patient. Your hands should lift symmetrically outward when the patient takes a deep breath. Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree. There has to be a lot of plerual disease before this asymmetry can be identified on exam. Detecting Chest Excursion

40

If a large enough segment of parenchyma is involved. This is referred to as fremitus and can be detected by placing the ulnar aspects of both hands firmly against either side of the chest while the patient says the words "Ninety-Nine. Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall. In general. it can alter the transmission of air and sound.2. known as a pleural effusion. 41 . fremitus is a pretty subtle finding and should not be thought of as the primary means of identifying either consolidation or pleural fluid. lend supporting evidence if other findings (see below) suggest the presence of either of these processes. Pleural fluid: Fluid. displacing the lung upwards. Fremitus over an effusion will be decreased." This maneuver is repeated until the entire posterior thorax is covered. It can. can collect in the potential space that exists between the lung and the chest wall. The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations. In the presence of consolidation. In particular: A. Lung consolidation: Consolidation occurs when the normally air filled lung parenchyma becomes engorged with fluid or tissue. most commonly in the setting of pneumonia. Assessing Fremitus Pathologic conditions will alter fremitus. however. B. fremitus becomes more pronounced.

3. Investigating painful areas: If the patient complains of pain at a particular site it is obviously important to carefully palpate around that area. trauma) mandate careful palpation to look for evidence of rib 42 .g. an infiltrate is depicted by the blue coloration that has invaded the sponge itself (sponge on left). In addition. special situations (e.Effusions and infiltrates can perhaps be more easily understood using a sponge to represent the lung. An effusion is depicted by the blue fluid upon which the lung is floating (sponge on right). In this model.

Allow your hand to swing freely at the wrist. more drum-like) notes on percussion. If you're percussing with your right hand. Initially.g. grasping the opposite shoulder with each hand. you will find that this skill is a bit awkward to perform. A stiff wrist forces you to push your finger into the target which will not elicit the correct sound. Percussion: This technique makes use of the fact that striking a surface which covers an air-filled structure (e. The impact should be crisp so you may want to cut your nails to keep blood-letting to a minimum! 43 . In addition. pneumonia). 4.g.g. Try to focus on striking the distal inter-phalangeal joint (i. Work down the "alley" that exists between the scapula and vertebral column. will produce hyperresonant (i. stand a bit to the left side of the patient's back. This will help to pull the scapulae laterally. emphysema) or acute (e. pneumothorax) air trapping in the lung or pleural space. normal lung) will produce a resonant note while repeating the same maneuver over a fluid or tissue filled cavity generates a relatively dull sound. which should help you avoid percussing over bone. 2. etc. subcutaneous air (feels like your pushing on Rice Krispies or bubble paper). away from the percussion field.fracture.g. air-filled tissue has been displaced by fluid (e. A few things to remember: 1. it takes a while to develop an ear for what is resonant and what is not. respectively. pleural effusion) or infiltrated with white cells and bacteria (e. 3.e. If the normal.g. hammering your finger onto the target at the bottom of the down stroke.e. percussion will generate a deadened tone. processes that lead to chronic (e. Alternatively. the last joint) of your left middle finger with the tip of the right middle finger. Ask the patient to cross their hands in front of their chest.

percussion is limited to the posterior lung fields. Percussion Technique 11. stand a bit to the left side of the patient's back. it's a good idea to slide your hands across to the other for comparison. 10. though feel free to do more if you'd like. the quality of the sound changes.5. If you're percussing with your right hand. in order to minimize any dampening of the perucssion notes. away from the percussion field. one thorax serves as a control for the other. which should help you avoid percussing over bone. Then move your hand down several inter-spaces and repeat the maneuver. After you have percussed the left chest. percussion in 5 or so different locations should cover one hemi-thorax. Work down the "alley" that exists between the scapula and vertebral column. When percussing any one spot. This normally occurs when you leave 44 . 8. the last joint) of your left middle finger with the tip of the right middle finger. percussion over these areas can help identify its cause. The impact should be crisp so you may want to cut your nails to keep blood-letting to a minimum! 9. In general. grasping the opposite shoulder with each hand. This will help to pull the scapulae laterally. or rest only the tips on them if this is otherwise too awkward. 7. 6. However. If you detect any abnormality on one side. if auscultation (see below) reveals an abnormality in the anterior or lateral fields. 2 or 3 sharp taps should suffice. The goal is to recognize that at some point as you move down towards the base of the lungs. Try to focus on striking the distal inter-phalangeal joint (i. Ask the patient to cross their hands in front of their chest. Try to keep the remainder of your fingers from touching the patient. The last 2 phalanges of your left middle finger should rest firmly on the patient's back.e. move yours hands across and repeat the same procedure on the right side. In this way. In general.

12. the nonpercussing) hand at a constant rate down the patient's back.e. Practice percussion! Try finding your own stomach bubble. This tends to make the point of inflection (i. Ultimately. Many disease processes (e.e. which should be around the left costal margin. producing abnormal findings in multiple fields. During this technique. remind yourself which lobe of the lung is heard best in that region: lower lobes occupy the bottom 3/4 of the posterior fields. Adjust the head of the scope so that the diaphragm is engaged. lingula in left axilla. tapping over your left chest will produce a different sound then when performed over your right. pneumonia). right middle lobe heard in right axilla. This can be quite helpful in trying to pin down the location of pathologic processes that may be restricted by anatomic boundaries (e. If you're not sure. The exact vertebral level at which this occurs is not really relevant. Auscultation: Prior to listening over any one area of the chest. Percuss your walls (if they're sheet rock) and try to locate the studs. change from resonant to dull) more pronounced. Tap on tupperware filled with various amounts of water. Put on your stethoscope so that the ear pieces are directed away from you. all the better.g. the examiner moves their left (i. Note that due to the location of the heart. It is not particularly important to identify the exact location of the diaphragm. scratch lightly on the diaphragm.the thorax. 1. This not only helps you develop a sense of the different tones that may be produced but also allows you to practice the technique. "Speed percussion" may help to accentuate the difference between dull and resonant areas.g. tapping on it continuously as it progresses towards the bottom of the thorax. pulmonary edema. twist the head and 45 . though if you are able to note a difference in level between maximum inspiration and expiration. bronchoconstriction) are diffuse. you will develop a sense of where the normal lung should end by simply looking at the chest. If not. upper lobes in the anterior chest and at the top 1/4 of the posterior fields. which should produce a noise.

4. move around to the front and listen to the anterior fields in the same fashion. Don't get in the habit of performing auscultation through clothing. if you hear something abnormal. Of course.g. Get help if the patient is unable to move on their own. The upper aspect of the posterior fields (i. Gently rub the head of the stethoscope on your shirt so that it is not too cold prior to placing it on the patient's skin. Sometimes it's helpful to have the patient cough a few times prior to beginning auscultation. collapsed) areas at the lung bases. This forces the patient to move greater volumes of air with each breath. This again makes use of one lung as a source of comparison for the other. which may make this part of the examination easier.e. Ask the patient to take slow. 2. The lingula and right middle lobes can be examined while you are still standing behind the patient. This is generally done while the patient is still sitting upright. If the patient cannot sit up (e. and thus detectability of any abnormal breath sounds that might be present. In cases where even this 46 . 1. intensity. Then. 3.e. Asking female patients to lie down will allow their breasts to fall away laterally. in cases of neurologic disease.try again. Lung Auscultation 3. auscultation can be performed while the patient is lying on their side. A few additional things worth noting. 4. Listen over one spot and then move the stethoscope to the same position on the opposite side and repeat. towards the top of the patient's back) are examined first. 2. This clears airway secretions and opens small atelectatic (i. deep breaths through their mouths while you are performing your exam.). etc. increasing the duration. you'll need to listen in more places. The entire posterior chest can be covered by listening in roughly 4 places on each side. post-operative states.

wheezing) that might not be heard when they are breathing at normal flow rates. Requesting that the patient exhale forcibly will occasionally help to accentuate abnormal breath sounds (in particular. In cases of significant bronchoconstriction. As this most commonly occurs in association with diffuse processes that affect all lobes of the lung (e. Wheezes are whistling-type noises produced during expiration (and sometimes inspiration) when air is forced through airways narrowed by bronchoconstriction. and results in symmetric findings. These 'eee' to 'aaa' changes are referred to as egophony. and therefore produce crackles restricted to a specific region of the lung. with little noise produced on expiration. The sound is similar to that produced by rubbing strands of hair together close to your ear. results in the transmission of large airway noises (i.cannot be accomplished. expiration twice as long as inspiration) though actual timed measurements are neither practical nor reliable.k. Occasionally. the expiratory phase of respiration (relative to inspiration) becomes noticeably prolonged. as can occur with pneumonia. and/or associated mucosal edema. This tends to occur first in the most dependent portions of the lower lobes and extend from the bases towards the apices as disease progresses. Rales (a. transferring central sounds directly to the edges. diffuse. as might occur with an obstructing tumor or bronchoconstriction induced by pneumonia. Pneumonia. focal wheezing can occur when airway narrowing if restricted to a single anatomic area. a minimal examination can be performed by listening laterally/posteriorly as the patient remains supine. The greater the difference. the worse the obstruction. you'll think that the patient is actually 47 . A healthy individual breathing through their mouth at normal tidal volumes produces a soft inspiratory sound as air rushes into the lungs. The first time you detect it. are caused by pulmonary fibrosis. if you direct the patient to say the letter 'eee' it is detected during auscultation over the involved lobe as a nasal-sounding 'aaa'. These are referred to as vessicular breath sounds. It's very similar to the noise produced when breathing through a snorkel. dry-sounding crackles. This may be best appreciated by placing your stethescope directly on top of the trachea. Very distinct.g. at least in the older adult population.e. the consolidated lung acts as a terrific conducting medium. can result in discrete areas of alveolar filling. Dense consolidation of the lung parenchyma. 3. 4. 2. similar to the noise produced when separating pieces of velcro. Pulmonary edema is probably the most common cause. Wheezing heard only on inspiration is referred to as stridor and is associated with mechanical obstruction at the level of the trachea/upper airway. a relatively uncommon condition. asthma and emphysema) it is frequently audible in all fields.e. noting whether E seems >> I. Normal is approximatley 1:2 (i. on the other hand.a. What can you expect to hear? A few basic sounds to listen for: 1. Clinicians refer to this as an increased I to E ratio. crackles) are scratchy sounds that occur in association with processes that cause fluid to accumulate within the alveolar and interstitial spaces. Focus instead on simple observation. secretions. those normally heard on auscultation over the trachea… known as tubular or bronchial breath sounds) to the periphery.. In this setting. Furthermore.

Most of the above techniques are complimentary. it may be necessary to repeat certain aspects of the exam. Few findings are pathognomonic. resulting in their breathing at small tidal volumes that generate almost no noise. 7. as consolidation generates bronchial breath sounds while an effusion is associated with a relative absence of sound. These patients suffer from significant lung destruction and air trapping. Wheezing occurs when there is a superimposed acute inflammatory process (see above). can produce a gurgling-type noise. you listen carefully to the region on top of the effusion. originating from lung which is compressed by the fluid pushing up from below. Auscultation over the same region should help to distinguish between these possibilities. fremitus will be increased over consolidation and decreased over an effusion. for example. They have their greatest meaning when used together to paint the most informative picture. These noises are referred to as ronchi.saying 'aaa'… have them repeat it several times to assure yourself that they are really following your directions! 5. Dullness detected on percussion. The Dynamic Lung Exam: Pulse Oxymeter 48 . however. 6. Auscultation over a pleural effusion will produce a very muffled sound. may represent either lung consolidation or a pleural effusion. as might occur with bronchitis or other mucous creating process. stable emphysema will produce very little sound. Auscultation of patients with severe. As such. you may hear sounds suggestive of consolidation. Asymmetric effusions are probably easier to detect as they will produce different findings on examination of either side of the chest. similar to the sound produced when you suck the last bits of a milk shake through a straw. If. Similarly. Secretions that form/collect in larger airways. using one finding to confirm the significance of another.

if available) as a dynamic extension of the cardiac and pulmonary examinations. Remember that although assessment of pulse and blood pressure are discussed in the vital signs section they are actually important elements of the cardiac exam. palpation and. can be a marker of significant cardiac or pulmonary dysfunction. auscultation (percussion is omitted). a device that continuously measures heart rate and oxygen saturation. helping to create a list of possible diagnoses and assisting you in the rational use of additional tests to further delineate the nature of the problem. It will also generate a measurement that you can refer back to during subsequent evaluations in order to determine if there has been any real change in functional status. This in turn is an important marker of intravascular volume status and related cardiac function. c and v waves that make up the jugular venous pulsations can be found elsewhere. use 2 or 3 pillows. Pay particular attention to the rate at which the patient walks. which can provide quite a bit of cover. Observation: Assessment for distention of the right Internal Jugular vein (IJ) is a difficult skill. ability to talk during exercise and anything else that the patient identifies as limiting their activity. Quantifying a patient's exercise tolerance in terms of distance and/or time walked can provide information critical to the assessment of activity induced symptoms. establishing adequate exposure and a quiet environment are critical. As with all other areas of the physical exam.Oftentimes. one such example. The objective data derived from this low tech test can aid you in determining disease and symptom severity. a patient will complain of a symptom that is induced by activity or movement. The initial examination may be relatively unrevealing. These are quite difficult to detect for even the most seasoned physician. the patient should rest supine with the upper body elevated 30 to 45 degrees. This can be particularly helpful in providing objective information when symptoms seem out of proportion to findings. consider observed ambulation (with the use of a pulse oxymeter. development of dyspnea. duration of activity. Exam of the Heart The major elements of the cardiac exam include observation. Most exam tables have an adjustable top. Additionally. In such cases. distance covered. Its importance lies in the fact that the IJ is in straight-line communication with the right atrium. The IJ can therefore function as a manometer. Initially. Shortness of breath on exertion. It may also help unmask illness that would be inapparent unless the patient was asked to perform a task that challenged their impaired reserves. The focus here is on simply determining whether or not Jugular Venous Distention (JVD) is present. Why is JVD so hard to assess? The IJ lies deep to skin and soft tissues. with distention indicating elevation of Central Venous Pressure (CVP). A discussion of the a. this blood vessel is under much lower pressure 49 . most importantly. changes in heart rate and oxygen saturation. Or when patients report few complaints yet seem to have a cosiderable amount of disease. If not.

then the adjacent, pulsating carotid artery. It therefore takes a sharp eye to identify the relatively weak, transmitted venous impulses. A few things to remember: 1. Think anatomically. The right IJ runs between the two heads (sternal and clavicular) of the sternocleidomastoid muscle (SCM) and up in front of the ear. This muscle can be identified by asking the patient to turn their head to the left and into your hand while you provide resistance to the movement. The two heads form the sides of a small triangle, with the clavicle making up the bottom edge. You should be able to feel a shallow defect formed by the borders of these landmarks. Note, you are trying to identify impulses originating from the IJ and transmitted to the overlying skin in this area. You can't actually see the IJ. The External Jugular (EJ) runs in an oblique direction across the sternocleidomastoid and, in contrast to the IJ, can usually be directly visualized. If the EJ is not readily apparent, have the patient look to the left and valsalva. This usually makes it quite obvious. EJ distention is not always a reliable indicator of elevated CVP as valves, designed to prevent the retrograde flow of blood, can exist within this vessel causing it to appear engorged even when CVP is normal. It also makes several turns prior to connecting with the central venous system and is thus not in a direct line with the right atrium.

2. Take your time. Look at the area in question for several minutes while the patient's head is turned to the left. The carotid artery is adjacent to the IJ, lying just medial to it. If you are unsure whether a pulsation is caused by the carotid or the IJ, place your hand on the patient's radial artery and use this as a reference. The carotid impulse coincides with the palpated radial artery pulsation and is characterized by a single upstroke timed with systole. The venous impulse (at

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3.

4. 5.

6.

least when the patient is in sinus rhythm and there is no tricuspid regurgitation) has three components, each associated with the aforementioned a, c and v waves. When these are transmitted to the skin, they create a series of flickers that are visible diffusely within the overlying skin. In contrast, the carotid causes a single up and down pulsation. Furthermore, the carotid is palpable. The IJ is not and can, in fact, be obliterated by applying pressure in the area where it emerges above the clavicle. Search along the entire projected course of the IJ as the top of the pressure wave (which is the point that you are trying to identify) may be higher then where you are looking. In fact, if the patient's CVP is markedly elevated, you may not be able to identify the top of the wave unless they are positioned with their trunk elevated at 45 degrees or more (else their will be no identifiable "top" of the column as the entire IJ will be engorged). After you've found the top of the wave, see what effect sitting straight up and lying down flat have on the height of the column. Sitting should cause it to appear at a lower point in the neck, while lying has the opposite effect. Realize that these maneuvers do not change the actual value of the central venous pressure. They simply alter the position of the top of the pulsations in relation to other structures in the neck and chest. Shine a pen light tangentially across the neck. This sometimes helps to accentuate the pulsations. If you are still uncertain, apply gentle pressure to the right upper quadrant of the abdomen for 5 to 10 seconds. This elicits Hepato-Jugular Reflux which, in pathologic states, will cause blood that has pooled in the liver to flow in a retrograde fashion and fill out the IJ, making the transmitted pulsations more apparent. Make sure that you are looking in the right area when you push as the best time to detect any change in the height of this column of blood is immediately after you apply hepatic pressure. Once you identify JVD, try to estimate how high in cm the top of the column is above the Angle of Louis. The angle is the site of the joint which connects the manubrium with the rest of the sternum. First identify the supra-sternal notch, a concavity at the top of the manubrium. Then walk your fingers downward until you detect a subtle change in the angle of the bone, which is approximately 4 to 5 cm below the notch. This is roughly at the level of the 2nd intercostal space. The vertical distance from the top of the column to this angle is added to 5cm, the rough vertical distance from the angle to the right atrium with the patient lying at a 45 degree angle. The sum is an estimate of the CVP. However, if you can simply determine with some accuracy whether JVD is present or not, you will be way ahead of he game! Normal is 7-9 cm.

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Bony Structures of the Chest

Finding the Angle of Louis:The wooden Q-tips highlight the different slopes of the sternum and manubrium. The point at which the Q-tips cross is the Angle of Louis.

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Determining the CVP Take some time to look across the left chest and try to identify the transmitted impulse caused by ventricular contraction, which may be apparent when contractions are particularly vigorous. Palpation: The palm of your right hand is placed across the patient's left chest so that it covers the area over the heart. The heel should rest along the sternal border with the extended fingers lying below the left nipple. Focus on several things: Palpation of the Precordium to Determine the Location of the PMI

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g.g. The quantity of subcutaneous fat will dictate how firmly you need to push. If the ventricle becomes dilated. However. aortic stenosis. Do you feel a thrill. 4. or severely impaired ventricular 54 . partially obstructing the flow of water. Can you feel a Point of Maximum Impulse (PMI) related to contraction at the apex of the underlying left ventricle? If so. Diminution may be caused by atherosclerosis. They can exist separately or in conjunction with one another. a vibratory sensation produced by turbulent blood flow that is usually secondary to valvular abnormalities? The feeling is similar to that produced when you squeeze on a garden hose. you may then go back and reassess for the presence of a thrill. thrills caused by aortic stenosis are best felt toward the right upper sternal border). compensated mitral regurgitation or aortic insufficiency that result in exceptionally large stroke volumes) generate an impulse of unusual vigor. Remember that with age tissue turgor often declines. try to pin down the precise location with the tip of your index finger. The pulsations should be easily palpable. roughly at the 5th intercostal space. The carotid pulsation is palpable just lateral to the groove formed by the trachea and the surrounding soft tissue. 2.1. 3. Make sure that you tell that patient what you are about to do (and why) before actually performing this maneuver. which does not necessarily indicate ventricular enlargement or dysfunction. causing the breasts to hang below the level of the heart. where is it located? After identifying the rough position with the palm of your hand. most commonly as the result of past infarcts and always associated with ventricular dysfunction. 5. *Palpation of the precordium of a female patient is best done by placing the palm of your right hand directly beneath the patient's left breast such that the edge of your index finger rests against the inferior surface of the breast. the PMI is displaced laterally. In cases of significant enlargement.e.e. How vigorous is the transmitted impulse? Processes associated with ventricular hypercontractility (e. adams apple). Note that hypertrophy and dilatation are not synonymous. The normal sized and functioning ventricle will generate a penny sized impulse that is best felt in the mid-clavicular line. In general. What is the duration of the impulse? In the setting of hypertension or any other state of chronic pressure overload. thrills are an uncommon finding. Carotid Artery Palpation: This is of greatest value during the assessment of aortic valvular and out flow tract disease (see below) and should thus be performed after auscultation so that you know whether or not these problems exist prior to palpation. the ventricle hypertrophies and the PMI becomes sustained (i. The location of the thrill will depend on the involved valve (e. If a loud murmur is detected during auscultation. This is actually pretty subjective and can be tough to detect. for the sake of completeness it will be described here. The carotids can be located by sliding the second and third finger of either hand along the side of the trachea at the level of the thyroid cartilage (i. the PMI will be located near the axilla. Occasionally. you feel the impulse for a longer period of time). Obesity and COPD may also limit your ability to identify its precise location. the PMI will not localize to any one area. Palpating while the patient is in the left lateral decubitus position can make the PMI more obvious.

performance. 55 . Do not push on both sides simultaneously as this may compromise cerebral blood flow. Auscultation: The following anatomic pictures will aid you in understanding the principles of cardiac auscultation.

1. and newborn sizes also exist. each of which incorporates its own version of a bell (low pitched sounds) and diaphragm (higher pitched sounds). And some combine adult and pediatric scopes into a single unit. It's worth mentioning that almost any commercially available scope will do the job. Others have the bell and diaprhragm built into a single side. pediatric. Take the time to read the instructions for your particular model so that you are familiar with how to use it correctly. 56 . The most important "part" is what sits betwen the ear pieces! Adult Stethoscope Adult Stethoscope: Diaphragm and Bell Incorporated Into Single Side. Several sample stethescopes are pictured below. Adult. Become comfortable with your stethescope. Some have the diaphragm and bell on opposite sides of the head piece. There are multiple brands on the market. with the bell engaged by applying light pressure and the diaphragm engaged by pushing more firmly.

Compare the relative intensities of S1 and S2 in these different areas. In each area. Note that the time between S1 and S2 is shorter then that between S2 and S1. These locations are rough approximations and are generally determined by visual estimation. the location of the pulmonic valve. Engage the diaphragm of your stethescope and place it firmly over the 2nd right intercostal space. listen specifically for S1 and then S2. And finally.Combination Adult & Pediatric Stethoscope Newborn Stethoscope 2. left midclavicular line to examine the mitral area. position the diaphragm over the 4th intercostal space. This should help you to decide which sound is produced by the closure of the mitral/tricuspid and which by the aortic/pulmonic valves and therefore when systole and diastole occur. S1 will be loudest over the left 4th intercostal space (mitral/tricuspid valve areas) and S2 along the 2nd R and L intercostal spaces (aortic/pulomonic valve regions). Move down along the sternum and listen over the left 4th intercostal space. Then move it to the other side of the sternum and listen in the 2nd left intercostal space. the region of the aortic valve. Auscultation of the Heart 57 . the region of the tricuspid valve.

4.a. allowing you to hear first A2 and then P2.e. An S3 is most commonly associated with left ventricular failure and is caused by blood from the left atrium slamming into an already overfilled ventricle during early diastolic filling. they represent pathology in older patients. you should also be able to detect physiologic splitting of S2. aortic (A2) and pulmonic (P2) valve closure. Either sound can be detected by gently laying the bell of the stethoscope over the apex of the left ventricle (roughly at the 4th intercostal space. 5.k. it may actually make more sense to begin laterally (i. You may find it helpful to tap out S1 and S2 with your fingers as you listen. On expiration. venous return to the heart is augmented and pulmonic valve closure is delayed. mid-clavicular line) and 58 . gallops). While most clinicians begin asucultation in the aortic area and then move across the precordium. the two sounds occur closer together and are detected as a single S2. It's most frequently associated with left ventricular hypertrophy that is the result of long standing hypertension. On inspiration. giving you a bit more time to identify this phenomenon. in the mitral area) and then progress towards the right and up as this follows the direction of blood flow.3. S2 is made up of 2 components. Listen for extra heart sounds (a. non-compliant left ventricle during atrial contraction. Try both ways and see which feels more comfortable. That is. accentuating the location of systole and diastole and lending a visual component to this exercise. While present in normal subjects up to the ages of 20-30. The S4 is a sound created by blood trying to enter a stiff. The two components of S1 (mitral and tricuspid valve closure) occur so close together that splitting is not appreciated. Ask the patient to take a deep breath and hold it. In younger patients.

Listening for Extra Heart Sounds 6. Positioning the patient on their left side while you listen may improve the yield of this exam. an S3) or precede S1 (i. students are taught that auscultation is 59 . Traditionally. Murmurs: These are sounds that occur during systole or diastole as a result of turbulent blood flow.listening for low pitched "extra sounds" that either follow S2 (i. The presence of both an S3 and S4 simultaneously is referred to as a summation gallop.e. an S4).e. These sounds are quite soft. so it may take a while before you're able to detect them.

listening in 8 or 10 places along the chest wall) you will be more likely to detect changes in the character of a particular murmur and thus have a better chance of determining which valve is affected and by what type of lesion. 7. This is actually of clinical importance because recent data suggest that it may be 60 . it is actually quite helpful to listen in many more when any abnormal sounds are detected. So. It's helpful if the patient can hold their breath as you listen so that you are not distracted by transmitted tracheal sounds. you can listen for carotid bruits (sounds created by turbulent flow within the blood vessel) at this point in the exam. If you hear a murmur.e. What is the quantity of the sound? The rating system for murmurs is as follows:  1/6… Can only be heard with careful listening  2/6… Readily audible as soon as the stethescope is applied to the chest  3/6… Louder then 2/6  4/6… As loud as 3/6 but accompanied by a thrill  5/6… Audible even when only the edge of the stethescope touches the chest  6/6… Audible to the naked ear Most murmurs are between 1/6 and 3/6. while it might be OK to listen in only 4 places when conducting the normal exam. This leads to some misperceptions.e. does it maintain the same intensity throughout. Does it occur during systole or diastole? b. high pitched "shshing" sound. pulmonic valve area ='s the 2nd LICS.e. a number of studies provide evidence that atherosclerotic disease is frequently absent when a bruit is present as well as the reverse situation. aortic valve area ='s the 2nd Right Intercostal Space. and mitral valve area ='s 4th LICS in the midclavicular line). when does it start and stop)? e. Valves are not strictly located in these areas nor are the sounds created by valvular pathology restricted to those spaces. However. Place the diaphragm gently over each carotid and listen for a soft. I was taught that bruits represented turbulent flow associated with intrinsic atherosclerotic disease… and that the disappearance of a bruit which was previously present was a sign that the lesion was progressing (i. What happens when you march your stethescope from the 2nd RICS (the aortic area) out towards the axilla (the mitral area)? Where is it loudest and in what directions does it radiate? By moving in small increments (i. The meaning of a bruit remains somewhat controversial. Louder generally (but not always) indicates greater pathology. Auscultation over the carotid arteries (see under aortic stenosis for additional information): In the absence of murmurs suggestive of aortic valvular disease. ask yourself: a. does it start loud and become soft)? It sometimes helps to draw a pictoral representation of the sound. What is the quality of the sound (i. further encroachment on the lumen of the vessel). does it get louder and then softer. c. tricuspid valve area ='s 4th LICS.e. d.performed over the 4 areas of the precordium that roughly correspond to the "location" of the 4 valves of the heart (i.e. What is the relationship of the murmur to S1 and S2 (i.

Transient ischemic attacks or strokes.. these generally represent either aortic stenosis or mitral regurgitation. its peak intensity) occurs later in systole. and carotid auscultation may.. Surgery in these settings has already proven to be beneficial).beneficial to surgically repair carotid disease in patients who have significant stenosis yet have not experienced any symptoms (e. a phenomenon referred to at the Gallavardin Effect which can cause murmurs of AS to sound as loud towards the axilla as they do over the aortic region. a loud transmitted murmur associated with a valvular lesion may overwhelm any sound caused by intrinsic carotid disease. the shape of the sound should be similar in both regions. remember the following: 10. Are heard in the carotid arteries and over the right clavicle. Also. carotid bruits are softer. however. b. systolic ejection. Have a growling. They can be affected by aortic stenosis and must be assessed whenever you hear a murmur that could be consistent with AS. also referred to as a crescendo decrescendo. When this occurs.e. To distinguish between them. Identifying the Most Common Murmurs: 9. get louder and then softer. towards the chest. In settings where carotid pathology coexists with aortic stenosis. or diamond shaped murmur). c. as it takes longer to generate the higher ventricular pressure required to push blood through the tight orifice. murmurs associated with aortic pathology should be audible in both carotids and get louder as you move down the vessel. Murmurs of Aortic Stenosis (AS): a. Tend to be loudest along the upper sternal borders and get softer as you move down and out towards the axilla. helping you to distinguish it from MR (see below). masking it completely. Carotid bruits can be confused with the radiating murmur of aortic stenosis. have the patient hold their breath while you listen over each artery using the diaphragm of your stethescope. This is done by placing your fingers on the carotid artery as 61 .e. Carotid upstrokes refer to the quantity and timing of blood flow into the carotids from the left ventricle. in fact. There is. the point at which the murmur is loudest (i.. When the stenosis becomes more severe. 1. Are better heard when the patient sits up and exhales. d. Thus. Radiation to the clavicle can be appreciated by simply resting the diaphragm on the right clavicle. In general. it is becoming increasingly important to determine the best way of identifying asymptomatic carotid artery disease. To assess for transmission to the carotids. e. not be the mechanism of choice! 8.g. harsh quality (i. Systolic Murmurs: In the adult population.

This decreases venous return and makes the murmur louder (and will have the opposite effect on a murmur of AS). decreasing the amount of obstruction. and when you feel the pulsation in the carotid. Mild or moderate stenosis does not alter the character of carotid in-flow.e. This makes anatomic sense as the obstruction is located near this region. This maneuver increases venous return. It causes a crescendo-decrescendo murmur that sounds just like aortic stenosis. 62 . Will get even louder if you roll the patient onto their left side while keeping your stethescope over the mitral area of the chest wall and listening as they move. It also does not radiate loudly to the carotids as the point of obstruction is further from these vessels in comparison with the aortic valve. the murmur is louder along the left lower sternal border and out towards the apex. Get louder as you move your stethescope towards the axilla. the left atrium. parvus et tardus). as opposed to the full and prompt inflow which occurs in the absence of disease. Conversely. accentuating the murmur. again while listening. This maneuver brings the chamber receiving the regurgitant volume. j. Sound the same throughout systole. squat down with the patient. In aortic stenosis. it gets louder if filling is decreased. they sound a bit like the "shshing" noise produced when you pucker your lips and blow through clenched teeth. As opposed to AS. Standing will cause the opposite to occur. This phenomenon can actually be detected on physical exam and is a useful way of distinguishing between AS and sub-aortic obstruction. small amounts of blood will be ejected into the carotid and there will be a lag between when you hear the murmur and feel the impulse. however. closer to your stethescope. You need to listen for 20 seconds or so after each change in position to really appreciate any difference. sub-aortic stenosis is referred to as a dynamic outflow tract obstruction.k. very severe) aortic stenosis. Ask the patient to valsalva while you listen. Generally do not have the harsh quality associated with aortic stenosis.described above while you simultaneously listen over the chest. There should be no delay between the onset of the murmur. the murmur will get softer if the ventricle is filled with more blood as filling pushes the abnormal septum away from the opposite wall. In fact. This is referred to as diminished and delayed upstrokes (a. Furthermore. Sub-Aortic stenosis is a relatively rare condition where the obstruction of flow from the left ventricle into the aorta is caused by an in-growth of septal tissue in the region below the aortic valve known as the aortic outflow tract.a. Because the degree of obstruction can vary with ventricular filling. Murmurs of Mitral Regurgitation (MR): g. causing the murmur to become softer. You may also be able to palpate a bisferiens pulse in the carotid artery (see under aortic insufficiency). h. the degree of obstruction that exists at any given point in time is fixed. i. f. In the setting of critical (i. Then. which marks the beginning of systole.

Sometimes murmurs of aortic stenosis and mitral regurgitation co-exist. Squatting increases venous return. Get louder if afterload is suddenly increased. you will probably not be able to detect diastolic murmurs on your own until you have had them pointed out by a more experienced examiner. which can be difficult to sort out on exam. Standing decreases venous return. MR is also affected by the volume of blood returning to the heart. consistent with a one valve problem). Moving your stethescope back and forth between the mitral and aortic areas will allow for direct comparison.k. Aortic Insufficiency (AI): 63 . 2. This makes physiologic sense as diastolic murmurs are not generated by high pressure ventricular contractions. a.a.k. Aortic Regurgitation (AR). which may help you decide if more then one type of lesion is present or if the quality of the murmur is the same in both locations. changing only in intensity (i. While systolic murmurs are often obvious.e. In adults they may represent either aortic regurgitation or mitral stenosis. neither of which is too common. causing a louder sound. thereby diminishing the intensity of the murmur. which can be accomplished by having the patient close their hands tightly. Diastolic Murmurs: Tend to be softer and therefore much more difficult to hear then those occurring during systole.

Heard best towards the axilla r. you can build a case in your mind for a particular lesion.a. n. so listen carefully for regurgitation in patients with AS. however. By linking auscultatory findings with physiology. resulting in ejection of an augmented stroke volume.l. Will cause the carotid upstrokes to feel extraordinarily full as significant regurgitation increases ventricular pre-load. how loud is it? What is its character? Where does it radiate? Are there any maneuvers which affect its intensity? Remember that these sounds are created by mechanical events in the heart. Mitral Stenosis (MS): q. an ordered approach: Try to focus on each sound individually and in a systematic fashion. It may also be present with sub-aortic stenosis (see above). lean forward and exhale while you listen. Associated with a soft. an S4 or S3)? Is there a murmur during systole? Is there a murmur during diastole? If a murmur is present.k. As you listen. Can be accentuated by having the patient sit up. Becomes softer towards the end of diastole (a. m. AI can also produce a double peaked pulsation in the carotids known as a bisferiens pulse. called the opening snap. Is best heard along the left para-sternal border. remind yourself what is happening to produce each of them. p.e. decrescendo). Can be accentuated by having the patient role onto their left side while you listen with the bell of your sthethescope. Occasionally accompanies aortic stenosis. Feeling your own carotid impulse at the same time that you're palpating the patient's may accentuate this finding. a bisferiens pulse suggests that the AI is the dominant problem. Ask yourself: Do I hear S1? Do I hear S2? What is their relative intensities in each of the major valvular areas? Is S2 split physiologically? Are there extra sounds before S1or after S2 (i. It can. be pretty hard to detect. o. low pitched sound preceding the murmur. s. as this is the direction of the regurgitant flow. Auscultation. which is quite difficult to appreciate. In cases of co-existent AS and AI. This is the noise caused by the calcified valve "snapping" open. Interrelationship of Cardiac Events & Sounds 64 . helping to distinguish it from AS.

Tricuspid regurgitation (TR) is relatively common. It can therefore be difficult to sort out if there is co-existent TR when MR is present. 2. Try to listen along both the low left and right sternal borders (areas where the 65 . Wilbur Lew. Department of Medicine. even when present. A few final comments about auscultation: 1. most frequently associated with elevated left sided pressures which are then transmitted to the right side of the heart (though a number of other processes can cause TR as well). are difficult to hear due to the relatively low pressures generated by the right side of the heart. In this setting. San Diego VA Medical Center. The murmur of MR is generally louder then that of TR. both mitral and tricuspid regurgitation often co-exist. Pulmonic valve murmurs are rare in the adult population and. again due to the higher pressures on the left side of the heart.This diagram courtesy of Dr.

1. Move your stethoscope slowly across the precordium and note if there is any change in the character/intensity of the murmur. murmurs. heart sounds can be accentuated by having the patient lean forward and fully exhale prior to listening. 6. Make sure the room is quiet. it may be helpful to ask them to hold their breath (if they're able) while you examine the heart. ventricular contraction. associated with atrial contraction. leans forward and exhales. A number of the more subtle findings (e. The goal is to have a "bag of skills" at your disposal that you can reach into and employ to better define abnormalities when they present themselves. Ask for help frequently. bringing the two layers in closer communication. In reality. If the exam is normal. generating a creaky-scratchy noise as they rub together. I feel compelled to mention this finding only because a common short hand for reporting the results of the cardiac exam comments on the absence of "Gallops. Air trapping and subsequent lung hyperinflation results in a posterior-inferior rotation of the heart away from the chest wall and causes the interposition of lung between the chest wall and heart.3. tricuspid valve is best assessed) and compare this to the mitral area. If a patient has an abnormal heart sound due to a structural defect that has been quantified by echocardiography. Re-examination after the patient has made clinical improvement may be more revealing. The classic rub is actually made up of three sounds. 2 are apparent). 5. its rare to hear all 3 components (more commonly. Furthermore. This is a great way of learning! Don't get frustrated! Auscultation is a difficult skill to "master" and we are all continually refining our techniques. Take your time." implying (incorrectly) that rubs are a frequent finding. to identify when the patient is tachycardic.g. In general. They can be accentuated by listening when the patient sits up. Patients with COPD (emphysema) often have very soft heart sounds. TR murmurs are also accentuated by inhalation. and ventricular filling. In this setting. it would be neither efficient nor revealing to put a patient through all of these maneuvers. many of the above techniques are not used when examining every patient. 66 . make sure that you compare your findings to those identified during the study. Read about particular murmurs and their pathophysiology when you encounter them. a not uncommon scenario as this is one of the compensatory mechanisms for dealing with the dysfunction that has generated these findings in the first place. Be patient. in any patient with particularly "noisy" breath sounds. or rubs. an S3 or S4) can be very difficult 2. 4. which increases venous return and therefore flow across the valve. Rubs: These are uncommon sounds produced when the parietal and visceral pericardium become inflamed.

they are performed here in a slightly different order (i. While these are the same elements which make up the pulmonary and cardiac exams. Topical Anatomy of the Abdomen Quadrants of the Abdomen 67 . Pelvic. feeling and percussing imagine what organs live in the area that you are examining. auscultation before percussion) and carry different degrees of importance. By thinking in anatomic terms. are discussed elsewhere.Exam of the Abdomen The major components of the abdominal exam include: observation. right lower. The abdomen is roughly divided into four quadrants: right upper. percussion.e. left upper and left lower. auscultation. Think Anatomically: When looking. all part of the abdominal evaluation. you will remind yourself of what resides in a particular quadrant and therefore what might be identifiable during both normal and pathologic states. listening. genital. and palpation. and rectal exams.

underwear. 3. Keep the room as warm as possible and make sure that the lighting is adequate. Allowing the patient to bend their knees so that the soles of their feet rest on the table will also relax the abdomen. At this point. the abdominal musculature becomes tensed and the examination made more difficult. the abdominal musculature becomes tensed and the examination made more difficult.By convention. If the head is flexed. If the head is flexed. Take a spare bed sheet and drape it over their lower body such that it just covers the upper edge of their underwear (or so that it crosses the top of the pubic region if they are completely undressed). the patient should be dressed in a gown and. 2. This will allow you to fully expose the abdomen while at the same time permitting the patient to remain somewhat covered. The patient's hands should remain at their sides with their heads resting on a pillow. the abdominal exam is performed with the provider standing on the patient's right side. you create an environment that gives you the best possible chance of performing an accurate examination. By paying attention to these seemingly small details. 5. if they wish. The gown can then be withdrawn so that the area extending from just below the breasts to the pelvic brim is entirely uncovered. This is particularly important early in your careers. This requires complete exposure of the region in question. when your skills are relatively 68 . remembering that the superior margin of the abdomen extends beneath the rib cage. Observation: Much information can be gathered from simply watching the patient and looking at the abdomen. Allowing the patient to bend their knees so that the soles of their feet rest on the table will also relax the abdomen. The patient's hands should remain at their sides with their heads resting on a pillow. which is accomplished as follows: 1. Ask the patient to lie on a level examination table that is at a comfortable height for both of you. Draping the Abdomen 4.

through which omentum/intestines/peritoneal fluid can pass when intra-abdominal pressure is increased. anxious. or fat. Those with peritonitis (e. 2. does this appear symmetric or are there distinct protrusions. fluid. 3. These are points of weakening in the abdominal wall. pay particular attention to: 1. Global abdominal enlargement is usually caused by air.g. distressed or otherwise challenging patients. Patient's movement (or lack thereof). perhaps linked to underlying organomegaly? The contours of the abdomen can be best appreciated by standing at the foot of the table and looking up towards the patient's head. unable to find a comfortable position. It is frequently impossible to distinguish between these entities on the basis of observation alone (see below for helpful maneuvers). Presence of surgical scars or other skin abnormalities.unrefined. patients with kidney stones will frequently writhe on the examination table. Appearance of the abdomen. While observing the patient. Presence of surgical scars or other skin abnormalities. Is it flat? Distended? If enlarged. Areas which become more pronounced when the patient valsalvas are often associated with ventral hernias. Various Causes of Abdominal Distension Obese abdomen Hepatomegaly 69 . 4. frequently due to previous surgery. Contrary to this. appendicitis) prefer to lie very still as any motion causes further peritoneal irritation and pain. it will also stand you in good stead when examining obese. However.

" Abdominal Auscultation 70 . The stethoscope can be placed over any area of the abdomen as there is no true compartmentalization and sounds produced in one area can probably be heard throughout. There is no magic time frame. Those with peritonitis (e. 5. perhaps artificially altering their activity and thus bowel sounds. Presence of surgical scars or other skin abnormalities. unable to find a comfortable position.Ascites Markedly enlarged gall bladder (labeled "GB") Umbilical Hernia Same umbilical hernia while patient performs valsalva maneuver. It is performed before percussion or palpation as vigorously touching the abdomen may disturb the intestines. At this stage. patients with kidney stones will frequently writhe on the examination table. Patient's movement (or lack thereof). Auscultation: Compared to the cardiac and pulmonary exams. practice listening in each of the four quadrants and see if you can detect any "regional variations. 6. How many places should you listen in? Again. there is no magic answer.g. auscultation of the abdomen has a relatively minor role. Contrary to this. appendicitis) prefer to lie very still as any motion causes further peritoneal irritation and pain. Exam is made by gently placing the pre-warmed (accomplished by rubbing the stethoscope against the front of your shirt) diaphragm on the abdomen and listening for 15 or 20 seconds.

In general.e. They lend supporting information to other findings but are not in and of themselves pathognomonic for any particular process. Bowel sounds can. Are bowel sounds present? 2. most physicians will omit abdominal auscultation unless there is a symptom or finding suggestive of abdominal pathology. the insides of the intestine.e.e.What exactly are you listening for and what is its significance? Three things should be noted: 1. quality)? As food and liquid course through the intestines by means of peristalsis noise. If present. called "tinkles." and then silence.as with peritonitis) will cause the abdomen to be quiet (i. Processes which lead to intestinal obstruction initially cause frequent bowel sounds. add important supporting information in the right clinical setting. the presence or absence of bowel sounds is essentially irrelevant (i. the reappearance of bowel sounds heralds the return of normal gut function following an injury. inflammatory processes of the serosa (i. any of the surfaces which cover the abdominal organs.e. however. you should still practice listening to all the patients that you examine so that you develop a sense of what constitutes the range of normal.. whatever pattern they have will be normal for them). bowel sounds will be infrequent or altogether absent). on the order of every 2 to 5 seconds. That is. Bowel sounds. must be interpreted within the context of the particular clinical situation." Think of this as the intestines trying to force their contents through a tight opening. In fact. After abdominal surgery. is generated. What is the nature of the sounds (i.. are they frequent or sparse (i. for example. although there is a lot of variability. there is a period of several days when the intestines lie dormant.. Bowel sounds in and of themselves do not carry great significance. However. in the normal person who has no complaints and an otherwise normal exam. an important phase of the patient's recovery. These sounds occur quite frequently. Alternatively.e. quantity)? 3. referred to as bowel sounds. Inflammation of the intestinal mucosa (i. then. referred to as "rushes. 71 . The appearance of bowel sounds marks the return of intestinal activity. This is followed by decreased sound.e. as might occur with infections that cause diarrhea) will cause hyperactive bowel sounds.

in the right clinical setting (e. Thus. 2. *Special note should be made if percussion produces pain.g. as in peritonitis. Dull sounds that occur when a solid structure (e. you will need to press down quite firmly as the renal arteries are retroperitoneal structures. place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. This would certainly be supported by other historical and exam findings. at the take off of the Iliac Arteries) can also generate bruits. using the previously described floppy wrist action (see under lung exam).After you have finished noting bowel sounds. However. along the lateral edge of either rectus muscles. difficult to control hypertension and known vascular disease). There are two basic sounds which can be elicited: 1. Abdominal Percussion 72 .g. The place to listen is a few cm above the umbilicus. auscultation over this structure is not a good screening test for the presence of aneurysmal dilatation.e. a high pitched sound (analogous to a murmur) caused by turbulent blood flow through a vessel narrowed by atherosclerosis. Most providers will not routinely check for bruits. Tympanitic (drum-like) sounds produced by percussing over air filled structures. remember to rub your hands together and warm them up before placing them on the patient. a patient with some combination of renal insufficiency. which may occur if there is underlying inflammation. Then. Blood flow through the aorta itself does not generate any appreciable sound. First. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger.g. Atherosclerosis distal to the aorta (i. ascites) lies beneath the region being examined. use the diaphragm of your stethoscope to check for renal artery bruits. liver) or fluid (e. Percussion: The technique for percussion is the same as that used for the lung exam. the presence of a bruit would lend supporting evidence for the existence of renal artery stenosis. When listening for bruits.

for the most part. Proceed as follows: 1. This maneuver helps to accentuate different percussion notes. The total span of the normal liver is quite variable. Percussion in this area should produce a relatively resonant note. The remainder of the normal abdomen is. dull or some combination of the above. you will be over the liver. Percuss as you move the hand at a slow and steady rate from the region of the right chest. The spleen is smaller and is entirely protected by the ribs. Speed percussion. At this point. The resonant tone produced by percussion over the anterior chest wall will be somewhat less drum like then that generated over the intestines. While they are both caused by tapping over air filled structures. you will reach a point where 73 . ascites) and gas. In most cases. assessment for shifting dullness is perhaps the most reliable and reproducible. particularly if there is a lot of subcutaneous fat. down over the liver and towards the pelvis. Move your hand down a few centimeters and repeat. resting in a hollow created by the left ribs. proceed as follows: 1. percussion in the left upper quadrant will produce a dull tone. This method depends on the fact that air filled intestines will float on top of any fluid that is present. the ribs and pectoralis muscle tend to dampen the sound. filled with the small and large intestines. Splenomegaly suggested by percussion should then be verified by palpation (see below). depending on the size of the patient (between 6 and 12 cm). Continue your march downward until the sound changes once again. 4.a. Don't get discouraged if you have a hard time picking up the different sounds as the changes can be quite subtle. Try percussing each of the four quadrants to get a sense of the normal variations in sound that are produced.What can you really expect to hear when percussing the normal abdomen? The two solid organs which are percussable in the normal patient are the liver and spleen.k. begin percussion at the level of the umbilicus and proceed down laterally. Of the techniques used to detect ascites. perhaps making the identification of the liver's borders a bit more obvious. particularly in distinguishing between fluid (a. These will be variably tympanitic. depending on whether the underlying intestines are gas or liquid filled. you will have reached the inferior margin of the liver. an edge may protrude a centimeter or two below the costal margin. When significantly enlarged. After doing this several times. To determine the size of the liver. 3. a point that you are reasonably certain is over the lungs. In the presence of ascites. the liver will be entirely covered by the ribs. Occasionally. may also be useful. Orient your left hand so that the fingers are pointing towards the patients head. as described in the pulmonary section. Percussion can be quite helpful in determining the cause of abdominal distention. The stomach "bubble" should produce a very tympanitic sound upon percussion over the left lower rib cage. 5. With the patient supine. This may occur while you are still over the ribs or perhaps just as you pass over the costal margin. Percussion of the spleen is more difficult as this structure is smaller and lies quite laterally. close to the sternum. 2. which will produce a duller sounding tone. Start just below the right breast in a line with the middle of the clavicle.

the sound changes from tympanitic to dull. It should also cause a symmetric bulging of the patient's flanks.g. If there is ascites. 2. beginning at the top of the patient's now up-turned side and moving down towards the umbilicus. If the distention is not caused by fluid (e. no shifting will be identifiable. distributing evenly across the posterior aspect of the abdomen. 3. Repeat percussion. Mark this point on both the right and left sides of the abdomen and then have the patient roll into a lateral decubitus position (i. With the "patient" lying flat on their back balloons (representing the intestines) float on the water (representing ascites). When the "patient" turns on their right side. This is the intestine-fluid interface and should be roughly equidistant from the umbillicus on the right and left sides as the fluid layers out in a gravity-dependent fashion. onto either their right or left sides). Shifting Dullness (real patient) 74 . The place at which sound changes from tympanitic to dull will therefore have shifted upwards (towards the umbillicus) and be above the line which you drew previously.e. a new air fluid level is established. secondary to obesity or gas alone). fluid will flow to the most dependent portion of the abdomen. The models below should help to clarify the concept of shifting dullness. Speed percussion (described above) may also be used to identify the location of the air-fluid interface.

avoiding any rapid/sharp movements that are likely to startle the patient or cause discomfort.Realize that there has to be a lot of ascites present for this method to be successful as the abdomen and pelvis can hide several hundred cc's of fluid that would be undetectable on physical exam. Advance your hands a few cm cephelad and repeat until ultimately you are at the bottom margin of the ribs. This should insure that you are below the liver edge. it is easier to detect abnormal if you start in an area that you're sure is normal. Also. imagining what structures lie beneath your hands and what you might expect to feel. with the left resting on top of the right. this may not be a very useful technique. Start in the right upper quadrant. Palpation can also be used to check for ascites (see below). allowing the greatest number of fingers to be involved in the exam as you try to feel the edge of the liver. The pads and tips (the most sensitive areas) of the index. in cases of prior surgery or infection with resultant adhesion formation. shifting dullness is based on the assumption that fluid can flow freely throughout the abdomen. Apply slow. In general. steady pressure. 1. Examine each quadrant separately. You may use either your right hand alone or both hands. middle. 10 centimeters below the rib margin in the midclavicular line. Palpation: First warm your hands by rubbing them together before placing them on the patient. Initial palpation is done lightly. Thus. and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures. Abdominal Palpation 75 . Gently push down (posterior) and towards the patient's head with your hand oriented roughly parallel to the rectus muscle.

3. Pushing up and in while the patient takes a deep breath may make it easier to feel the liver edge as the downward movement of the diaphragm will bring the liver towards your hand.2. repeat the examination of the same region but push a bit more firmly so that you are interrogating the deeper aspects of the right upper quadrant. You can also try to "hook" the edge of the liver with your fingers. To utilize this technique.e. in the mid-line where the right and left sides meet). the bony structure at the bottom end of the sternum. flex the tips of the fingers of your right hand (claw-like). may be directed outward or inward and can be mistaken for an abdominal mass. You should be able to distinguish it by noting its location relative to the rib cage (i. The tip of the xyphoid process. Following this. particularly if the patient has a lot of subcutaneous fat. Then push down in the right upper quadrant and pull upwards (towards the patient's head) as you try to rake-up on the edge of the liver. This is a nice way of confirming the presence of a palpable liver edge felt during conventional examination Rib Cage 76 .

Examine superficially and then more deeply. is soft. However. on the other hand. flex the tips of the fingers of your right hand (claw-like). The spleen. Hooking Edge of the Liver 5. examine in a slow. you will be able to feel enlargement in either direction. So. you may even be able to "bounce" it back and forth between your hands. This is a nice way of confirming the presence of a palpable liver edge felt during conventional examination. When enlarged. and rather superficial. which will drop the spleen down towards your examining hand. directing an enlarged spleen towards your right hand. If the right kidney is massively enlarged. rounded. is not so definitively bordered and thus has a tendency to float away from you as you palpate. can be elicited on direct examination if the entire structure becomes palpable as a result of associated edema. when palpable. Now examine the left upper quadrant.4. You can use your left hand to push in from the patient's left flank. Splenomegaly is probably more difficult to appreciate then hepatomegaly. 6. You can also try to "hook" the edge of the liver with your fingers. Repeat the exam with the patient turned onto their right side. This is generally not the case. In this way. If the spleen is very big. Place your right hand at the inferior and lateral border of the ribs. Kidney pain. you may be able to feel it between your hands. The liver is bordered by the diaphragm and can't move away from an examining hand.e. Then start 8-10 cm below the rib margin and move upwards. The normal spleen in not palpable. To utilize this technique. both down and across). gentle fashion. it tends to grow towards the pelvis and the umbilicus (i. 7. as the kidney lies in 77 . The edge. Then push down in the right upper quadrant and pull upwards (towards the patient's head) as you try to rake-up on the edge of the liver. most commonly associated with infection. Begin palpating near the belly button and move slowly towards the ribs. pushing down as you push up from behind with your left hand. Exploration for the left kidney is performed in the same fashion as described for the right.

g. where the bottom-most ribs articulate with the vertebral column) will cause pain if the underlying kidney is inflamed.the retroperitoneum. Known as costovertebral angle tenderness (CVAT). pounding gently with the bottom of your fist on the costovertebral angle (i. it should be pursued when the patient's history is suggestive of a kidney infection (e.e. back pain and urinary tract symptoms). fever. Posterior View: Location of the Kidneys Gross Retroperitoneum Anatomy 78 .

However. during pathologic states that these organs become identifiable to the careful examiner. for the most part. Examine the left and right lower quadrants. First push down with a single hand in the area just above the umbillicus. 9.8. so that both are equidistant from the umbillicus. etc. you will not be able to recognize abnormal until you become comfortable identifying variants of normal. It is. palpating first superficially and then deeper. If there is a lot of ascites present. firmly tap on the abdomen with your right hand while your left remains against the abdominal wall. orient your hands so that the thumbs are pointed towards the patient's head.). most commonly the pregnant uterus. don't be discouraged if you are unable to identify anything. 79 . The smooth dome of the bladder may rise above the pelvic brim and become palpable in the mid-line. Remember also that the aorta is a retorperitoneal structure and can be very hard to appreciate in obese patients. Place your right hand on the left side of the abdomen and your left hand opposite. If you are able to identify this pulsating structure with one hand. admittedly. Then push deeply and try to position them so that they are on either side of the blood vessel. Now. Estimate the distance between the palms (it should be no greater then roughly 3 cm). try to feel the abdominal aorta. This test is quite subjective and it can be difficult to say with assurance whether you have truly felt a wave-like impulse.g. They should press firmly so that the subcutaneous tissue and fat do not jiggle. There have been no reports of anyone actually causing the aorta to rupture using this maneuver. It's also quite easy to miss abnormalities if you rush or push too vigorously. What can you expect to feel? In general. To do this. a crude technique. so don't be afraid to push vigorously. Ask the patient or an observer to place their hand so that it is oriented longitudinally over the center of the abdomen. which is a firm structure that grows up and towards the umbillicus. Finally. so take your time and focus on the tips/pads of your fingers. Remember that the body is designed to protect critically important organs (e. palpation can be used as a confirmatory test. Examining for a fluid wave: When observation and/or percussion are suggestive of ascites. It is therefore important to practice all of these maneuvers on every patient that you examine. though it needs to be quite full of urine for this to occur. A stool filled sigmoid colon or cecum are the most commonly identified structures on the left and right side respectively. liver and spleen beneath the ribs. try to estimate its size. you may be able to feel a fluid wave (generated in the ascites by the tapping maneuver) strike against the abdominal wall under your left hand. Other pelvic organs can also occasionally be identified. The ovaries and fallopian tubes are not identifiable unless pathologically enlarged. a theme common to the examination of any part of the body. kidneys and pancreas deep in the retroperitoneum. This is.

In the event that a patient presents complaining of pain in any region of the abdomen. this is referred to as Cirrhosis. This can be particularly revealing when evaluating otherwise stoic individuals (i. superficial muscle tightening which protects intra-abdominal organs from being poked). if possible with a single finger. Go back and repeat maneuvers to either confirm or refute your suspicions. hear. is to obtain relevant information while generating a minimal amount of discomfort. Every maneuver has a purpose. the liver may become unable to perform some or all of its normal functions. It's important to realize that a cirrhotic liver can be markedly enlarged (in which case it may be palpable) or shrunken and fibrotic (non-palpable). viral hepatitis (B or C) or hemachromatosis (the complete list is much longer). examine each of the other abdominal quadrants first before turning your attention to the area in question. or feel.e. is not done randomly. If. pointing you towards the cause of the problem. This should help to keep the patient as relaxed as possible and limit voluntary and involuntary guarding (i. of course. The goal. Findings Commonly Associated With Advanced Liver Disease: Chronic liver disease usually results from years of inflamation. most commonly chronic alcohol use. in the 80 .e. Then. Histologically. Think about what you're expecting to see. While none are pathonomonic for liver disease. After many years (generally greater then 20) of chronic insult. even these patients will grimace if the area is painful to the touch).Assessing for a fluid wave The abdominal examination. allowing you to gather the greatest amount of clinical data. which ultimately leads to fibrosis and decline in function. have them first localize the affected area. Make sure you glance at the patient's face while examining a suspected tender area. like all other aspects of the physical. Use information that you've gathered during earlier parts of the exam and apply it in a rational fashion to the rest of your evaluation. This can be driven by a number of different processes. There are several clinical manifestations of this dysfunction. for example. a certain area of the abdomen was tympanitic during percussion. feel the same region and assure yourself that there is nothing solid in this location.

accumulation of fluid in the peritoneal cavity. blood "finds" alternative pathways back to the heart that do not pass through the liver.Yellow discoloration of the skin. though these are not apparent on physical examination. The most common is via the splenic and short gastric veins. Bilirubinuria . Increased Systemic Estrogen Levels: The liver may become unable to process particular hormones. b. Hyperbilirubinemia: The diseased liver may be unable to conjugate or secrete bilirubin appropriately. 2. Varices: In the setting of portal hypertension. Jaundice . Some of the most common findings are described and/or pictured below. Icterus 81 . c. Testicular atrophy. b. 3.Golden-brown coloration of the urine.Yellow discoloration of the sclera. This can lead to a. This causes esophageal varices which can bleed profoundly. 4. c. This is particularly evident in the lower extremities. A much less common path utilizes the recanalized umbilical vein.right historical context they are very suggestive of underlying pathology. High levels promote: a. which pass through the esophageal venous plexus enroute to the SVC. This can lead to ascites. Spider Angiomata . Breast development (gynecomastia). Ascites: Portal vein hypertension results from increased resistance to blood flow through an inflamed and fibrotic liver. 5.dilated arterioles most often visible on the skin of the upper chest. leading to their peripheral conversion into estrogen. which directs blood through dilated superficial veins in the abdominal wall. 1. Lower Extremity Edema: Impaired synthesis of the protein alburmin leads to lower intravascular oncotic pressure and resultant leakage of fluid into soft tissues. These are visible on inspection of the abdomen and are known as Caput Medusae. Icterus .

Caput Medusae Ascites Jaundice Edema 82 .

e. c. it rarely occurs in the arms or hands. Delay implies under perfusion. causing the underlying skin to whiten. Tissue death (i. occurs most frequently in women after exposure to cool temperatures. Thus. Press the nail bed or tip of any finger for several seconds. while atherosclerotic vascular disease is a common cause of arterial insufficiency in the lower extremity. Pay particular attention to the following: The Hands: a. Onycholysis: Onychomycosis: Separation of Nail Paronychia: Nicotine Staining Fungal Infection of from Underlying Infection of skin the Nail Bed. gangrene) Peripheral Vascular Disease. often due to adjacent to nail of onychomycosis.The Upper Extremities Exam of the hands and arms is usually quite brief in the asymptomatic patient. After releasing pressure. delayed capillary refill in the hands more likely reflects vasospasm or hypovolemia then it does intraluminal arterial obstruction. the normal pink color should return in 2-3 seconds. Capillary refill: This is a mechanism for gauging arterial perfusion. Nail shape and color (see below for discussion of cyanosis): Several examples of common nail pathology are shown below. causing both hands to become white and painful. Hand of the fingers secondary to severe peripheral vascular disease. Appearance of hand and fingers: Any obvious deformity or discoloration? Do they appear relatively red and well perfused or white/mottled? b. Severe vasospasm. referred to as Raynaud's Phenomenon. middle finger. Interestingly. 83 .

however. vasospasm. An isolated abnormality of a single. Joint deformities secondary to rheumatoid arthritis And a few words about uncommonly encountered abnormalities… The presence or absence of these findings are frequently mentioned in clinical medicine. deformity of the metacarpal-phalyngeal joints on every finger of both hands is consistent with a systemic inflammatory process like Rheumatoid Arthritis. giving 84 . or hypovolemia. this can also reflect vascular insufficiency. Temperature: Cool hands occur most commonly as a result of exposure to a cold environment. noting particularly if there is a specific pattern or distribution. However. For example. distal joint.d. e. is more likely secondary to local trauma or degenerative arthritis. Obvious joint abnormalities.

d. as most hypoxic patients do not have clubbing. though it is also associated with a number of other conditions. As with clubbing. This is most commonly associated with conditions that cause chronic hypoxemia (e. a.g. This is more myth then fact as most patients with the disease states in question do not have these findings. c. it is not at all sensitive for either of these conditions.the impression that they are common and/or of great importance. in general it is neither common nor particularly sensitive for hypoxia. usually occurs focally over an area of local 85 . when present. This is because the lower extremities are exposed to greater hydrostatic pressure due to their dependent position. thin. However. b. Splinter Hemmorrhages: Short. Their clinical utility tends to be over emphasized. Cyanosis: A bluish discoloration visible at the nail bases in select patient with severe hypoxemia or hypoperfusion. Clubbing: Bulbous appearance of the distal phalanges of all fingers along with concurrent loss of the normal angle between the nail base and adjacent skin. severe emphysema). it rarely occurs in the arms and hands. brown. linear streaks in the nails of some patients (the minority) with endocarditis. Upper extremity edema. Edema: While edema is a relatively common finding in the lower extremity.

g. Right upper extremity DVT. 86 . For example.inflammation (e. the affected area should be examined in greater detail. Upper extremity venous obstruction can also cause edema. Edema in this case is due to lymphatic obstruction. though blood clots in this region are much less common then in the lower extremity. cellulitis). Diffuse arm edema can occur if drainage is compromised. In the setting of injury or infection. Note divit left (pitting) after application of pressure. as when the lymphatics are disrupted following axillary lymph node surgery for staging and treatment of breast cancer. acute inflammation secondary to cellulitis of the upper extremity is demonstrated in the image below. Note diffuse swelling.

If there is clinical evidence of an infection distal to the elbow. the nodes become large and tender. Infection: o systemic (e. cup the patient's elbow in your hand (left elbow with right hand and vice versa) and palpate just above the elbow. To examine. TB. When inflamed. HIV) 87 . it makes sense to feel for these nodes as they are part of the drainage pathway. Palpation of Epitrochlear Lymph Nodes Axillary Nodes: Pathologic enlargement occurs most commonly in the following settings: a.Lymph Nodes of the Upper Extremity: Epitrochlear Nodes: Found on the inside of the upper arm.g. These are rarely the site of pathology and thus not routinely examined. just above the elbow. along the inside of the upper arm.

as would be done if you were to couple it with the female breast exam. This technique permits the patient's arm to remain completely relaxed. When examining the left axilla. though hand positioning is reversed. You can do this through the patients gown if you don't want to place your fingers in direct contact with the axilla. the more likely true pathology exists Pain: Often associated with inflammation (e. If you are able to feel adenopathy. ask the patient to lift both arms away from the sides of their body. both axilla can be examined simultaneously. The right axilla is examined in a similar fashion. grasp the patient's left wrist or elbow with your left hand and lift their arm up and out laterally. in particular breast. cellulitis of the hand/arm) b. Then use your right hand to examine the axillary region as described above. This allows you to explore the axillary regions in their entirety.o local (e. where the malignacy is based in lymph nodes o metastases. minimizing tension in the surrounding tissues that can mask otherwise enlarged lymph nodes. Other: o various systemic inflammatory illnesses (e. This examination may also be performed while the patient is supine.g. repeat the exam of each axilla separately. though could be from any site c. infection) 88 .g sarcoidosis) When examining healthy individuals. Most patients do not have palpable axillary nodes. To do this. Now press your hands towards the patient's body and move them slowly down the lateral chest wall. Palpation of the Axilla If you feel any abnormalities.g. Then extend the fingers of both your hands and gently direct them towards the apices of the arm pits. make note of the following characteristics: • • • • Size: Pathologic nodes are generally greater than 1 cm Firmness: Malignancy makes nodes feel harder Quantity: The greater the number of nodes. Malignancy: o lymphoma.

Left Axillary Adenopathy Exam of the Lower Extremities The discussion which follows focuses on the search for evidence of arterial and venous insufficiency as well as edema. Make note of any discrete swellings. Palpate the area. Joint and neurologic examinations are covered elsewhere..• • Relation to other nodes and surrounding tissue: Nodes fixed to each other or adjacent structures are worrisome for malignancy Changes over time: Nodes which regress spontaneously are obviously of less concern then those that increase in size. If you feel any lymph nodes. feeling carefully for the femoral pulses as well as for inguinal/femoral adenopathy (nodes which surround the femoral artery and vein. 89 . note if they are firm or soft. 1. Begin by simply looking at the area in question. Making these determinations requires multiple evaluations over time. pants and skirts should all be removed. exposure is key. Socks.. firm nodes are more worrisome for pathologic states). The Femoral Region: As with examination of any other area of the body. up to one cm in size are considered non-pathologic).. which might represent adenopathy or a femoral hernia. stockings. These are the most common serious ailments which affect the lower extremities and therefore merit the greatest attention. number. fixed in position or freely mobile (fixed. or appear to be growing in new locations. which is on either side of the crease separating the leg from the groin region. 2.

A femoral hernia. investigation should include observation as well as palpation while the patient performs a valsalva maneuver. the patient reports its presence yet you find nothing on examination). medial to the femoral artery. is located on the anterior thigh. The Popliteal Region: 90 .3. 4. which may make a hernia more prominent. 3rd and 4th fingers. As it can be transient (i.e. If there is a lot of subcutaneous fat. you will need to push firmly. The femoral pulse should be easily identifiable. if present. Use the tips of your 2nd. located along the crease midway between the pubic bone and the anterior iliac crest.

First. Note whether it feels simply pulsatile (normal) or enlarged and aneurysmal (uncommon). it may not be palpable. Acute Arterial Insufficiency: Note Mottled Appearance of Skin Chronic Arterial Insufficiency with Ulcers 91 . In cases of severe ischemia. This occurs as a result of gravity working against an already ineffective blood return system. When their legs are placed in a dependent position. gravity enhances arterial inflow and the skin may become more red as maximally dilated arterioles attempt to bring blood to otherwise starved tissues. Cellulitis (infection in the skin) will cause the skin to appear bright red. long standing stasis of blood leads to the deposition of hemosiderin. turn your attention to the lower leg (i. These changes can be difficult to detect in people of color. Over time.k. paying attention to: 1. which is not clinically important if you can still identify the more distal pulses (see below). on the other hand. so you may need to push pretty hard. This artery is covered by a lot of tissue and can be difficult to identify. Dead tissue turns black (a. Even then. Below The Knee: Now. the affected areas (usually involving the most distal aspect of the foot). If the leg is placed in a dependent position. 2.e. Move down to the level of the knee allowing it to remain slightly bent. from the knee to the foot). gangrene). Place your hands around the knee and push the tips of your fingers into the popliteal fossa in an effort to feel the popliteal pulse. can appear whitish or mottled. may have relatively pale skin as a result of under perfusion. further suggestive of venous insufficiency. Color: Venous insufficiency is characterized by a dark bluish/purple discoloration. the bluish/purple discoloration may darken dramatically.a. giving the leg a marbleized appearance. examine with your eyes. Patients with severe arterial insufficiency.1. giving the skin a dark. speckled appearance.

e.Gangrene of Toes Venous Insufficiency 3. 2. is it symmetric? To what level does the swelling exist (i. Cellulitis 4. ankle. Obvious swelling of the leg: If present. knee etc.)? 92 . calf.

Skin: Any obvious growths? Shiny. Onychomycosis 4. 3. Swelling secondary to Deep Venous Thrombosis in Right Leg. hairless appearance (seen with arterial insufficiency)? Dilated or varicose superficial veins? Ulceration of the skin can occur in the setting of either venous or arterial disease.Assymetric Leg. Venous Stasis Ulcer 93 . also with fungal infections. Nail growth: Nail thickening and deformity often occurs with arterial insufficicency.

arterial insufficiency. This can be explored with the use of a Q-tip. Probing the depth of an ulcer: Ulcers can extend rather deeply. 94 . or both." particularly in patients with diabetes who are predisposed as a result of sensory impairment. The bottom of the foot and between the toes: These are common "problem areas. If the bone is visible or can be reached with the Q-tip. This is referred to as clinical osteomyelitis. the infection is assumed to involve the underlying structure. then the act of probing does not cause pain because the area is insensate. It's worth noting that if the ulcer developes in a patient with neuropathy (as is the case here). Neuropathic Ulcer in Patient with Diabetic Neuropathy 6.5.

which makes perfect sense as the problem lies in the delivery of blood to the extremity. This is related to some perturbation in the Startling forces. retroperitoneal adenopathy secondary to malignancy). causes hyperemia and relative warmth. the conditions may coexist. On occasion. on the other hand. local venous insufficiency (e. 2. impaired inflow of blood may generate less warmth (and also less redness) then might otherwise be expected. face) as a reference point. a blood return problem. rarely causes edema. The back of your hand may be the most sensitive surface for detecting subtle temperature difference. Compare one leg to the other. Edema: Fluid frequently collects in the feet and ankles due to the effects of gravity. Increased hydrostatic pressure: Transmitted back from the level of the heart (right heart failure). It's also OK to use your own skin (e.g. it's usually the result of: Low oncotic pressure: Either failure to synthesize albumin (as with malnutrition or liver disease) or increased loss of albumin (via the kidney or local leakage due to altered capillary permeability).g. Temperature: Arterial insufficiency will often cause the skin to feel cool. Infection. Feel the skin.Clinical Osteomyelitis: Deep ulcer which permits passage of Q-tip to underlying level of bone. The fluid builds up preferentially in the most distal aspects of the leg and progress up towards the knee as the process worsens. not the return from it.g. towards the end of the day if the patient has been standinag for long periods of time). 95 . on the other hand. Thinking in broad strokes. noting in particular: 1. Disorders of blood inflow (arterial) and outflow (venous) have different associated signs and symptoms based on their varying pathophysiology (see above). venous valvular incomepetence with impaired flow of blood back to the heart from the legs). Realize that all "circulation" problems are not the same. This disorder tends to get worse when the legs are allowed to dangle for prolonged periods below the level of the heart (e. lymphatic obstruction (e. or obesity (which may impair both venous and lymphatic drainage). Arterial insufficiency. Note that in cases where arterial insufficiency and infection occur simultaneously (which is quite common).g. Edema is commonly associated with venous insufficiency. liver (portal hypertension).

There is a very subjective scale for rating edema which ranges from "trace at the ankles" to "4+ to the level of the knees. causing them to appear less defined. the area of edema can be quite focal. release. however. Edema may either be diffuse. Much is said about pitting edema being associated with some disease states and non-pitting with others. Look around the malleoli. Note: Remaining imprint of fingers. involving all of the surrounding tissue symmetrically. as is frequently the case in disorders of low oncotic or elevated hydrostatic pressure. however. you'll develop a sense of what is a lot and what is not. Edema of Right Foot. Also note the proximal extent of the edema and if it is present to the same degree in both legs." referred to as pitting.It may be difficult to detect small amounts of fluid. If. Note Loss of Distinct Edges of Malleolous and Extensor Tendons on Top of Foot Massive edema. the actual importance of this distinction is probably over stated. fluid will tend to "fill in" the spaces between the extensor tendons on the top of the foot. there is a local inflammatory process. Similarly. as might occur with cellulitis. and then gently rub your finger over that same spot. as fluid will cause a loss of the normally distinct appearing edges of the bone. push on the area for several seconds. 96 ." After examining many patients. feeling for the presence of a "divot. If you're not sure whether fluid is present.

Pain: Cellulitic skin. a reflection of blood inflow to the distal aspect of the lower extremity. Remember that certain disease states (diabetes in particular) cause a peripheral neuropathy that predisposes these patients to the development of skin breakdown and subsequent infection precisely because they have abnormal sensation in their distal extremities. then. Left Leg 3. for example. Then release and note how long it takes for the red color to return. This can be helpful as it will occasionally be difficult to determine if infection and venous insufficiency are both present. Skin that is discolored from venous insufficiency blanches when pushed and it generally takes more then a few seconds for the bluish hue to return. infection may occur in the absence of pain. 5. Refill may also be delayed in the setting of significant hypovolemia. blanch and then very rapidly return to their bright red coloration. Note: Swelling and redness along lateral edge of nail. Capillary Refill: Push on the tip of the great toe or the nail bed until blanching occurs. 4.Lymphedema. however. Longer then 2-3 seconds is considered abnormal and consistent with arterial insufficiency. is often tender when touched. 97 . as decreased blood volume available for perfusion is shunted away from the extremities to feed more vital organs. In these cases. Cellulitic areas. Paronychia Great Toe.

Gently place the tips of your 2nd. 1.6. more distal blood vessels). 3rd and 4th fingers adjacent to the tendon and try to feel the pulse. Palpating the patients radial artery or your own carotid simultaneously with your free hand can help sort this out.g. A history of pain/cramps with activity suggestive of arterial insufficiency is also of great importance. may be affecting predominantly smaller. In general. however. for example. If you can't feel it. Note the character of any swollen area: Does it feel full of edema fluid? Is there a suggestion of a solid mass (uncommon)? Is there focal fluctuance. Aorto-iliac disease. the less prominent the pulses. The location of the blockage(s) will dictate the symptoms and findings. try moving your hand either proximally/distally or more laterally and repeat. This is not a perfect correlation. will cause symptoms in the hips/buttocks and a loss of the femoral pulse while disease affecting the more distal vessels will cause symptoms in the calves and feet. as would occur in an abscess? The Distal Pulses: Pulses are assessed to identify the presence of arterial vascular disease. as pulses may be palpable even when significant disease is present (e. which can be identified by asking the patient to flex their toe while you provide resistance to this movement. the greater the chance that there is occlusive arterial disease. The Dorsalis Pedis (DP) Artery: Located just lateral to the extensor tendon of the big toe. Common pitfalls include pushing too hard and/or mistaking your own pulse for that of the patient. Location of Dorsalis Pedis Artery The pictures below demonstrate the location of the dorsalis pedis artery in relation to surrounding structures 98 .

In either case. you are attempting to locate the artery using the tips of your fingers.Palpating Dorsalis Pedis Artery 2. The Posterior Tibial (PT) Artery: Located just behind the medial malleolous. Location of Posterior Tibial Artery The pictures below demonstrate the location of the posterior tibial artery in relation to surrounding structures (surface anatomy on left. you can reach your fingers over the top of the medial malleolous and approach the artery from this direction. Alternatively. gross anatomy on right). Pitfalls mentioned with the DP also apply here. It can be palpated by scooping the patient's heel in your hand and wrapping your fingers around so that the tips come to rest on the appropriate area. Palpating Posterior Tibial Artery 99 .

Mark the place with a pen and then go back and again try to feel it with your fingers. which should be present on any inpatient floor or ER. In the event that the pulse is not palpable. 100 . and use it to identify the location of the artery.Palpating Posterior Tibial Artery 3. the doppler signal generated is also rated. you will be able to determine if the vessel was not palpable on the basis of limited blood flow or if you are simply having a "technical" problem. If there is a lot of edema. In this way. As with edema. 4. this is very subjective and it will take you a while to develop a sense of relative values.Pulses are rated on a scale ranging from 0 (not palpable) to 2+ (normal). If you are unable to palpate a pulse. ranging again from 0 to 2+. Using Doppler Device to Identify Posterior Tibial Artery 5. find a doppler machine. you will have to push your way through the fluid-filled tissue to get down to the level of the artery.

Strength. you'll be able to "logic" your way thru the exam. both active (patient moves it) and passive (you move it) if active is limited/causes pain. Is there warmth? Point tenderness? If so. This is not meant to be an all-inclusive list. redness. and understanding anatomy and physiology of both normal function and pathologic conditions is critically important when evaluating the symptomatic patient.Musculo-Skeletal Examination Detailed examination of the joints is usually not included in the routine medical examination. etc covering either side gowns come in handy Carefully inspect the joint(s) in question. warmth)? Deformity? As many joints are symmetric. neuro-vascular assessment. what was the mechanism of injury? Palpate the joint in question. joint related complaints are rather common. and common disorders are described for most of the other major joints. In addition. pants. over what anatomic strucutres? Assess the range of motion.what does this joint normally do? Observe the joint while patient attempts to perform normal activity . trauma) that caused this? If so. a review of relevant anatomy. 101 . it's often very difficult to assess a joint as patient "protects" the affected area. Specific provocative maneuvers related to pathology occurring in that joint (see descriptions under each joint). Are there signs of inflammation or injury (swelling. compare with the opposite side Must understand normal functional anatomy . function.no shirts. However.g. even if you can't remember the eponym attached to each specific test! I have included detailed descriptions of the shoulder. knee. It helps to examine the unaffected side first (gain patient's confidence. By gaining an appreciation for the basic structures and functioning of the joint. In the setting of acute injury and pain. develop sense of their normal). A few general comments about the musculoskeletal exam Historical clues when evaluating any joint related complaint: • • • • • • What is the functional limitation? Symptoms within a single region or affecting multiple joints? Acute or slowly progressive? If injury.what can't they do? What specifically limits them? Was there a discrete event (e. limiting movement and thus your examination. what was the mechanism? Prior problems with the affected area? Systemic symptoms? Common approach to the examination of all joints: • • • • • • • • • Make sure the area is well exposed . and low back examinations as these are the most commonly affected areas.

as in degenerative joint disease. Do they limp or appear to be in pain? When standing.The Knee Exam Observation: 1. Is there evidence of atrophy of the quadriceps. leading to wasting of the muscles. more marked on the left leg. Chronic/progressive damage. Verus Knee Deformity. Make sure that both knees are fully exposed. Rolled up pant legs do not provide good exposure! 2. Make note of any scars or asymmetry. Is there obvious swelling as would occur in an effusion? Redness suggesting inflammation? 4. Watch the patient walk. 3. a common cause of bowing. hamstring. The patient should be in either a gown or shorts. 102 . or calf muscle groups? Knee problems/pain can limit the use of the affected leg. may lead to abnormal contours and appearance. is there evidence of bowing (verus) or knock-kneed (valgus) deformity? There is a predilection for degenerative joint disease to affect the medical aspect of the knee.

Tibial tuberosity 103 . Patellar tendon c. Quadriceps/Hamstring/Calf muscles d. e. the left calf and hamstring are bulkier than the right. Femur and Tibia f. noting structures above and below the knee itself: a. Medial and lateral joint lines. 5.While both legs have well developed musculature. Look at the external anatomy. Patella b.

Note any warmth. 2. and lateral. DJD is suggested by the presence of pain with activity that gets progressively more limiting over time. Place one hand on the patella. tibia. referred to as its passive range of motion. would suggest inflammation. If the knee is injured. full flexion ~ 140. The precise location of the DJD can be hard to determine on examination and is more accurately defined via x-rays. of degenerative joint disease (DJD). If present. start by examining the unaffected side. but not diagnostic. and patella). DJD can occur in any or all regions. which if present. using the hand on the patella. Knee Flexion (Left) and Extension (Right) 4. There may be a history of antecedent injury. Note the extent to which you can flex and extend the knee. 104 . feel for crepitus. Full extension is 0 degrees. it's suggestive. Also. the knee is broken into 3 compartments: Medial. gauging whether they can fully extend and flex. This is a crackling/grinding sensation that occurs with movement. This allows for comparison and relaxes the patient as you are not performing maneuvers that cause discomfort from the outset. Grasp the ankle or calf with your other hand and gently flex the knee. 3.Palpation and Examination for Degenerative Joint Disease: 1. This is referred to as their active range of motion. And coexistent damage to ligaments or menisci may also be present (see below). central. Ask the patient to bend the knee. It reflects a loss of the normal smooth movement between the articulating structures (femur. which caused the inciting damage to the articulating surface. When defining the extent of DJD.

Effusions resulting from inflammatory arthritis (e. redness. Tests for an effusion: An effusion is the accumulation of fluid within the joint space. popping. pain or functional limitation are the subjective complaints which carry clinical relevance. rheumatoid arthritis) are associated with other signs of inflammation. If there is a large collection. If any of the above maneuvers elicits pain. The vast majority of these sounds are not clinically significant. cracking) associated with joint movement.5.. It's important to note that many patients report noises (e. the knee will look swollen. Rather. Patient's symptoms are often related to whatever caused the fluid to accumulate in the first place. gout. including: warmth. infection. pain with any movement.g. The effusion itself makes the knee feel as if it's somewhat unstable or floating and may limit range of motion. 7. X-Ray of Normal Knee (Left) and Knee With DJD (Right) 6.g. creaking. Lesser amounts of fluid can be a bit more subtle. stop and note at what point in the range of motion this occurs. 105 .

Slightly flex the knee which is to be examined. causing the medial skin to bulge out slightly. forcing any fluid to accumulate in the central part of the joint. Ballotment (helpful if the effusion is large) 1. Identifying the precise cause of IA is critical as it directs the clinician towards the best treatment. Right Knee. Milking (helpful for detecting small effusions) 1. This usually requires 106 . Gently push down on the patella with your thumb.Large Effusion. Gently push on the lateral aspect of the joint. gout. Gently push down and towards the patella. 4. which is above the patella and communicates with the joint space. there is significant pain with any active or passive movement. Gently stroke upwards along the medial aspect of the patella. The more intense the inflammation. the patella will feel as if it's floating and "bounce" back up when pushed down. In addition. Inflammatory Arthritis and Effusions: Intense inflammatory processes within the joint space can also cause an effusion. the more severe the pain and the more limited the range of motion. Balloting the Left Knee. pushing fluid towards the top and lateral aspects of the joint. Infection. Place one hand on the supra-pateallar pouch. and rheumatoid arthritis are a few of the conditions that can lead to an inflammatory arthritis (IA) and effusion. If there is a sizable effusion. 2. limiting permanent damage to the joint. 3. If there's a small effusion. the fluid which was milked to the lateral aspect will be pushed back towards the medial area of the joint. 2. The joint and overlying skin is usually warm and red.

Additionally. Fluid from those with degenerative effusions has relatively few white cells.g. ulnar deviation of the hands in RA). DJD is usually slowly progressive while those with IA more often have an acute presentation. damage can occur to the underlying bone. 107 . those with IA may have characteristic patterns of recurrence (e. great toe MTP in gout. If the meniscus has been injured and no longer adequately covers the tibia. and particular radiographic changes. Left Great Toe Specific Maneuvers for the Knee Exam Tests for Meniscal Injury Normal anatomy and function: The menisci sit on top of the tibia and provide a cushioned articulating surface between the femur and tibia. suggestive joint deformities (e. can result from joint damage that occurred secondary to past episodes of gout or infection. Gouty Inflammation of Metatarsal-Phalangeal Joint. infection --> bacteria on gram stain and culture. Symptoms occur when a torn piece interrupts normal smooth movement of the joint. patients with DJD have few signs of inflammation and some degree of preserved range of motion (ROM). for example. DJD.g. systemic symptoms. Of course.aspiration and examination of the joint fluid. gout --> crystals on microscopy. instability ("giving out") or locking in position.g. MCPs of hands in RA). Clinically. This can cause a sensation of pain. Injury may also cause swelling. Historical information also helps distinguish DJD from IA. etc). it's possible to have element of both IA and DJD. Inflammatory fluid has a high white cell count and should contain other clues as to its origin (e. leading to degenerative arthritis.

Gently palpate along first the medial and then the lateral margins. Right Knee (patella has been removed). Have the patient slightly flex their knee. Define the joint space along its lateral and medial margins. Osteoarthritis can also cause joint line tenderness 108 . The joint line is perpendicular to the long axis of the tibia. 3.Anatomy of Menisci. This positions the joint such that other stabilizing elements do not interfere with the structure that is being tested. Joint Line Tenderness: 1. 2. Pain suggests that the underlying meniscus is damaged. The knee is slightly flexed when performing all of the functional tests that are described below.

and ring fingers are aligned along the medial joint line. you will feel a "click" with the hand on the knee as it is extended. Gently turn the ankle so that the foot is pointed outward (everted). If there is medial meniscal injury. 4. While holding the foot in this everted position. 3. Then direct the knee so that it is pointed outward as well (valgus stress). Palpation Along Lateral (picture on left) and Medial (picture on right) Joint Lines. place your left hand so that your middle. The remainder of the meniscus cannot be assessed with this technique. The Joint Line is Marked by Purple Line. 6. When examining the right knee. gently extend and flex the knee. index. Grasp the foot with your right hand and fully flex the knee.4. McMurray's Test 1. Simulated McMurray's Test With Foot Everted (picture on left). This may also elicit pain. Close-up (picture on right) Reveals How This Maneuver Streeses The Medial Meniscus. 109 . Note that only a portion of the meniscus lies near the joint line. 5. 5. 2.

and turn the foot inwards (inversion). 3. Injury usually requires significant force. Appley Grind Test 1. swelling and the injured person will often report hearing a "pop" (the sound of the ligament tearing). Hold the patients leg down by gently placing your leg over the back of their thigh. If the lateral meniscus has been injured. they assure stability and correct alignment. Test the opposite leg in the same fashion. You may also elicit pain. Lateral Meniscus In Picture On Right. Following a ligamentous injury. return the knee to the fully flexed position. In the knee. Then direct the knee so that it is pointed inward as well (varus stress). there is generally acute pain. 2. lateral collateral (LCL). The cruciate ligaments limit anterior and posterior movement of the femur on the tibia and limit the degree to which the knee can rotate. you may feel a "click" with the hand palpating the joint line. 10. Push down gently while rotating the ankle back and forth. This maneuver places direct pressure on the menisci. middle. anterior cruciate (ACL) and posterior cruciate (PCL). Place the index. Now.7. Gently extend and flex the knee. the patient may report pain and instability 110 . Tests for Injury to the Ligaments Normal anatomy and function The ligaments are very strong tissues that connect bone to bone. After the acute swelling and pain have dissipated. The medial and lateral ligaments provide stability in response to medial and lateral joint stress. 5. it will cause pain. If injured. 9. 8. Appley Grind Test 4. There are 4 main ligaments in the knee: Medial collateral (MCL). McMurray's Test: Assessment Of Medial Meniscus Demonstrated In Picture On Left. Have the patient lie on their stomach. Grasp one ankle and foot with both of your hands and gently flex the knee to ninety degrees. 6. and ring fingers of your left hand along the lateral joint line.

PCL: Much less commonly injured then the ACL. If you're unsure as to whether there is really an abnormality. Given the forces required to tear a ligament. 3. 2. By working on their unaffected side. The ACL may also be injured from a direct force on the lateral knee while the foot is planted. ACL: Most commonly injured when the foot is planted while extreme rotational force is applied (e. menisci are often damaged at the same time. check back and forth between the normal and abnormal sides. Always begin your exam with the asymptomatic knee.(sensation of the knee giving out) during any maneuver that would expose the deficiency created by the damaged ligament (e. rotation. LCL: Direct force on the medial aspect of the knee while the foot is planted. MCL: Direct force on the lateral aspect of the knee while the foot is planted. The following are common mechanisms of injury for each of the major ligaments: 1. Right Knee (Patella Has Been Removed).g. 2. the "tightness" of everyone's ligaments varies somewhat. 4.g.g. When testing any ligament. during which there is nothing to "check" the movement of the femur on the tibia). you will define "normal. Anatomy of Ligaments. the tibia striking against the dashboard in a motor vehicle accident) can lead to disruption. remember the following: 1. This gives you some sense of the individual normal degree of laxity. This will enhance your ability to identify differences. a cleated foot caught in the turf while an athlete attempts to rotate towards that side). That is. Posterior force on the tibia (e. 111 . It is also possible to tear more then one ligament at once." It also helps to generate a sense of trust between you and the patient.

anti-inflammatory medications. Place your right hand on the ankle or calf. and time) before being able to perform an accurate exam. Specifics of Ligament Testing Medial Collateral Ligament 1. Place your left hand along the lateral aspect of the knee. The patient is understandably apprehensive and will use surrounding muscles to prevent movement. elevation. Stressing the MCL 6. 112 . If the MCL is completely torn. Movement often causes significant pain. This inability to relax is a normal response and may limit the extent of your exam. particularly if you have small hands! 4. 2. Push steadily inward with your left hand while supplying an opposite force with the right. It can be extremely difficult to examine the acutely injured knee. 5.3. 5. It may be necessary to simply wait until the acute inflammation resolves (with rest. 4. It can be difficult to examine patients with large joints. the joint will "open up" along the medial aspect. Detecting subtle abnormalities takes lots of practice. particularly if you don't have a great sense for the range of normal. 3. Slightly flex the right knee (~30 degrees).

Push steadily outward with your right hand while supplying an opposite force with the left. 8. If the LCL is completely torn. 2. Stressing the LCL 6. 3. palpation along the course of the ligament may also elicit pain if it has been injured. Lateral Collateral Ligament 1. the joint will "open up" along the lateral aspect. Slightly flex the right knee (~30 degrees). 5.Simmulated Torn MCL--Note How Joint Line Opens Up Along Medial Aspect 7. Additionally. Place your left hand on the ankle or calf. Reverse hand position to assess the left knee. 113 . 4. Place your right hand along the medial aspect of the knee.

Alternative method for stressing the medial lateral collateral ligaments: 1. Reverse hand position to assess the left knee. Using your body and index fingers.Simmulated Torn LCL--Note How Joint Line Opens Up Along Lateral Aspect 7. 3. Extend the patient's knee and cradle the heel between your arm and body. Stressing the MCL and LCL 114 . gently provide first medial and then lateral stress to the joint. palpation along the course of the ligament may also elicit pain if it has been injured. Place your index fingers across the medial and lateral joint lines. The knee should be slightly flexed. Additionally. 2. 8.

It may also help to further stabilize the leg by holding their ankle between your legs. 4. Variation On Lachman's Test For Patients With Large Legs. 8. 3. If they cant. Compare this to the other leg. 115 . reversing your hand position. making it very difficult to assess the integrity of the ACL. If the ACL is completely torn. The intact ACL is described as providing a firm end point during Lachman testing. then compensatory muscles will limit the degree of motion.Anterior Cruciate Ligament Lachman's Test 1. 6. 2. Flex the knee slightly. grasp the femur just above the knee with your left hand and the tibia with your right. The patient must be able to relax their leg for this test to work. Stressing the ACL 5. The intact ACL will limit the amount of distraction that you can achieve. If the thigh is too big in circumference (or your hand too small) to stabilize. Pull up sharply (towards your belly button) with your right hand while stabilizing the femur with the left. For testing the right leg. you can perform the Lachman's test with the leg hanging off the side of the table (see picture below). 7. the tibia will feel unrestrained in the degree to which it can move forward (see above for image of simulated ACL tear).

The ACL.Anterior Drawer Test (Note: This test has largely fallen out of favor. Grasp below the knee with both hands. 3. with your thumbs meeting along the front of the tibia. 4. the tibia will feel unrestrained in the degree to which it can move forward. 2. if intact. If the ACL is completely torn. with the right knee flexed such that their foot is flat on the table. Simmulated Torn ACL--Note How Far The Tibia Is Distracted Relative To The Femur 116 . gauging how much the tibia moves forward in relation to the femur. 1. Gently pull forward. Gently sit on the foot. It is included for the sake of completeness). Stressing the ACL 5. Have the patient lie down. will provide a discrete end point.

gauging how much the tibia moves in that direction in relation to the femur. Have the patient lie down. with your thumbs meeting along the front of the tibia. Compare this to the other side by simply shifting your hands to the same position on the opposite leg and repeating. If the PCL is completely torn.6. the right knee flexed to 90 degrees. 3. foot flat on the table. The Actual Ligament Cannot Be Seen In Picture On Right) 5. 6. 4. The intact PCL will give a discrete end point. Compare this to the other side by simply shifting your hands to the same position on the opposite leg and repeating. 2. Simmulated Torn PCL--Note How Far Back The Tibia Moves Relative To The Femur 117 . Stressing the PCL (Because Of Its Posterior Location. Grasp below the knee with both hands. Posterior Cruciate (PCL) Posterior Drawer Test 1. Gently sit on the foot. the tibia will feel unrestrained in the degree to which it moves backwards. Gently push backward.

Several ways of assessing for this condition are described below: 1. 3. Known as Chondromalacia. Their presence allows the tendons to move without generating a lot of friction. eliciting pain in the setting of Chondromalacia. gently move the patella from side to side and try to palpate its undersurface. another cause of bursitis. Have the patient slightly flex the leg to be tested. Inflammation of the bursa. This will force the inferior surface of the patella onto the femur. and redness may be prominent if there is concurrent infection. most commonly due to overuse of the tendon or direct trauma. 4. Hold the patella in place with your hand and ask the patient to contract their quadriceps muscle. Assorted Other Testing Patello-Femoral Syndrome: A problem with the way in which the patellar articulates with the femur and moves (tracks) during flexion and extension. Examination of the affected area reveals focal pain. Gently push down on the patella with both thumbs. Assessing For Chondromalacia Bursitis Bursa are small pouches of fluid that lie between bony prominences and the tendons that surround joints. This may elicit pain in the setting of Chondromalacia. cartilage lining the undersurface of the patella becomes irritated and worn down. 2. Swelling. 5. Now. The major bursa surrounding the knee include: 118 . which may elicit pain in the setting of Chondromalacia. If the PCL is completely torn. As a result.7. The bursa do not communicate with the joint space itself. can cause pain and swelling. this process causes anterior knee pain with activity and often after prolonged sitting. Bursitis can be distinguished from an intra-articular process because of the location of the pain and the fact that movement of the joint itself does not cause discomfort. warmth. the tibia may appear to "sag" backwards even before you apply any force.

Location Of Bursa Is Shown On Model (Top). 2. Left Knee Shoulder Exam 119 . Picture On Right Demonstrates Septic Prepatellar Bursitis Of The Left Knee. carpet layers. Picture on Left Demonstrates Septic Infrapatellar Bursitis. Most frequently affected due to direct trauma. as may occur with people who spend a lot of time on their knees (e.k.1. anserine): Below the knee.a. Infrapatella (a. Pre-patella: Located directly on top of the patella.g. Also affected by direct trauma. as with the prepatella bursa. carepenters).

6. 5. In terms of functionality. 3. humerus and clavicle. 4. 7. Acromion Clavicle Scapula Deltoid muscle Supraspinatus Infraspinatus Teres Minor Anterior View On Left.I think that the most daunting aspect of the shoulder exam is appreciating the functional anatomy of this incredibly mobile joint. Posterior On Right. Observation The shoulder joint is created by the confluence of 3 bony structures: the scapula. Critical external landmarks include the following: 1. These are held together by ligaments and an intricate web of muscles. 120 . 2. The primary benefit of the ball and socket arrangement is that it allows the hand to be positioned precisely in space. maximizing our ability to function. the shoulder might be best described as having a golf ball-on-a-tee design.

Normal range is from 0 to 180 degrees. Abduction: Determine the extent to which the patient can abduct their arm. swelling. obvious asymmetry. test both sides simultaneously. start with the normal side. touching each of the landmarks noted above. Make note of pain. Otherwise. Start by looking at the normal (or more normal) side. Palpation Gently palpate around the shoulder. 121 . Range of Motion (ROM) If there are no symptoms. Active ROM: 1. or muscle asymmetry. The patient should be able to lift their arm in a smooth.Location Of The Muscle Groups Is Approximated In The Pictures Above. painless arc to a position with hand above their head. discoloration. Note any scars.

Adduction and Internal rotation (Appley Scratch Test): Ask the patient to place their hand behind their back.2. Note the extent of their reach in relation to the scapula or thoracic spine. and instruct them to reach as high up their spine as possible. Abduction and External rotation: Ask the patient to place their hand behind their head and instruct them to reach as far down their spine as possible. 3. Note the extent of their reach in relation to the cervical spine. 122 . They should be able to reach the lower border of the scapula (~ T 7 level). with most being able to reach ~C 7 level.

123 .4. They should be able to position their hand behind their back. Forward flexion: Ask the patient to trace out an arc while reaching forward (elbow straight). 5. Normal range is 0 to 180 degrees. They should be able to move their hand to a position over their head. Extension: Ask the patient to reverse direction and trace an arc backwards (elbow straight).

g. The space between the acromion/coracoacromial ligament and the tendons (in particular. Note if there is pain. as they are firing with active ROM but not passive. the growth of an oteophyte on the under surface of the bone). Also note if you feel crepitus with the hand resting on the shoulder. Gently grasp the humerus in your other hand and move the shoulder through the range of motions described above. particularly when raising the arm over 124 . Limitations in movement in any of the directions should be noted. The net result is shoulder pain. Pain/limitation on active ROM but not present with passive suggests a structural problem with the muscles/tendons. The 4 tendons of the rotator cuff all pass underneath the acromion en route to their insertions on the humerus." The resulting friction inflames the tendons as well as the subacromial bursa. and if so which movement(s) precipitates it. Impingement. which lies between the tendons and the acromion. This causes the tendons to become "impinged upon. though realize that there is often a significant amount of overlap between several conditions. Crepitus suggests DJD. the supraspinatus) can become relatively narrowed for any number of reasons (e. with impingement as the root cause in a large number of cases. Shoulder pain in general is very common. Where exactly in the arc does this occur? Is it due to pain or weakness? How does it compare with the other side? Determining the precise etiology can be defined using the tests below.Passive ROM If there is pain with active ROM. Impingement is a dynamic condition that can lead to tendonitis and bursitis. Rotator Cuff Tendonitis and Sub-Acromial Bursitis Anatomy and Function: I have placed these processes under one heading as they are all linked. assess the same movements with passive ROM. Have the patient relax and place one of your hands on their shoulder.

and even complete disruption. Palpation may cause pain if the tendons/bursa are inflamed. tears. Then gently palpate in the region of the sub-acromial space (see picture below). 125 . swimming. chronic irritation to the tendons can lead to fraying. arm positioning during sleep). reaching for something on a top shelf. Right Shoulder Anatomy (anterior view) Several tests can be done to localize the problem: Sub-acromial Palpation: First.g. which is the acromium. Over time. identify the acromium by walking your fingers along the spine of the scapula until you reach its lateral endpoint.head (e.

Gently foreard flex the arm. Pain suggests impingement. Hawkin's (for more subtle impingement) 1. Hawkins Test For Impingement 126 . Neers Test: 1. Raise the patient's arm to 90 degrees forward flexion. This places the greater tubercle of the humerus in a position to further compromise the space beneath the acromion. Pain with this maneuver suggests impingement. generating symptoms related to impingement if it is in fact present. 3. 2.e. thumb pointed down). The arm should be internally rotated such that the thumb is pointing downward. 2. Place one of your hands on the patient's scapula.The following two tests passively maneuver the tendons so that they are most likely to rub against the acromion. positioning the hand over the head. and grasp their forearm with your other. Then rotate it internally (i.

127 . Evaluation of the Muscles of the Rotator Cuff Anterior View On Left. this will have little effect. MRI can also be extremely helpful in defining the precise nature of the pathology. tendonitis or even partial rotator cuff tears) can be difficult to make on clinical grounds. bursitis. Local anesthetic and steroids are injected into the bursa. One helpful adjunct is the diagnostic subacromial bursa injection.It's worth noting that defining the precise location of the problem (ie. If the symptoms are due to bursitis. Posterior On Right. if the symptoms are predominantly caused by tendonitis or a partial rotator cuff tear. this provides significant relief. However.

Have the patient abduct their shoulder to 90 degrees. 3.e. This is the most commonly damaged of the rotator cuff muscles. Testing (aka "empty can test): 1. 2. Contraction allows the shoulder to abduct. with 30 degrees forward flexion and full internal rotation (i. without resistance. Each of the 4 muscles can be tested individually as follows: Supraspinatus: Connects the top of the scapula to the humerus. symptoms caused by rotator cuff tears or tendonitis are often related to impingement. Supraspinatus (Empty Can)Test 128 . Acute shoulder trauma can also result in injury. As mentioned above. turned so that the thumb is pointing downward). Repeat while you offer resistance. Direct them to forward flex the shoulder.Anatomy and Function: There are 4 major muscles that allow shoulder movement.

Interpretation: If there is a partial tear of the muscle or tendon. with the palm facing out. Interpretation: Tears in the muscle will cause weakness and/or pain. Subscapularis: Connects the scapula to the humerus. Have the patient place their hand behind their back. Have the patient slightly abduct (20-30 degrees) their shoulders. 2.e. Provides the same function as the infraspinatus (external rotation). Direct them to lift their hand away from their back. keeping both elbows bent at 90 degrees. Testing is done as described for the Infraspinatus. movement will be limited or cause pain. Complete disruption of the muscle will prevent the patient from achieving any forward flexion. Complete tears will prevent movement in this direction entirely. Infraspinatus: Connects the scapula to the humerus. 129 . and instead try to "shrug" it up using their deltoids to compensate. on the side opposite the origin of the other 3 muscles of the RC). Specifics of testing: 1. Function can be tested using "Gerber's lift off test:" 1. Direct them to push their arms outward (externally rotate) while you resist. though the origin is on the anterior surface of the scapula (i. These patients will also be unable to abduct their arm. Testing Infraspinatus And Teres Minor (External Rotators) Teres Minor: Connects the scapula to the humerus. Contraction allows the arm to rotate externally. 2. the patient will experience pain and perhaps some element of weakness with the above maneuver. 3. Place your hands on the outside of their forearms. Contraction causes internal rotation. If the muscle is partially torn.

The supraspinatus is responsible for the early component of abduction. Fully abduct the patient's arm. Specifics of Testing: 130 . This is lost if the rotator cuff as been torn. allowing for smooth movement. at ~ 90 degrees the arm will seem to suddenly drop towards the body. However. Now ask them to slowly lower it to their side. This is because the torn muscle cant adequately support movement thru the remainder of the arc of adduction. but important for the later aspects of abduction and flexion. The deltoid is readily visible on exam and not commonly injured. inflammation and degeneration can occur. so that their hand is over their head. 2. causing pain. 3. When all is working normally. Specifics of testing: 1. If the suprapinatus is torn.Gerbers Liftoff Test (Subscapularis) Drop Arm Test for Supraspinatus Tears: Adducting the arm depends upon both the deltoid and supraspinatus muscles. Acromioclaviular Arthritis Anatomy and Function: The A-C joint is minimally mobile. there is a seamless transition of function as the shoulder is lowered. Deltoid: Not a muscle of the rotator cuff.

also known as AC separation. the area will appear swollen and deformed compared with the other side. 131 . The patient will avoid movement. AC Disruption: Trauma can cause disruption of the ac joint. Identify by palpation the point at which the end of the clavicle articulates with the acromion. Look at the area in question.1. 3. as this causes pain. 2. If there has been significant disruption (or a fracture to the clavicle itself). Ask the patient to move their arm across their chest. This stresses the a-c joint and will cause pain in the setting of DJD. Specifics of testing: 1. noting if it causes pain similar to what the patient was describing. Gently push on the area.

which is formed by the greater and lesser tubercles of the humeral head. 2. It helps to have the patient externally rotate their shoulder. in this case caused by trauma. The biceps muscle flexes and supinates the forearm and assists with forward flexion of the shoulder. Gently have the patient move their arm across their chest while you palpate in the AC region.Acromio-clavicular Joint Separation: Disruption of the right A-C joint. which should cause it to move. Palpate the biceps tendon where it sits in the bicipital groove. Biceps Tendonitis: The long head of the biceps tendon inserts on the top of the glenoid. Pain suggests tendonitis. You can confirm the location of the tendon by asking the patient to flex and supinate their forearm while you palpate. Specifics of testing: 1. 132 . Inflammation can therefore cause pain in the anterior shoulder area with any of these movements. This will cause pain specifically at the AC joint if there is separation.

the long head of the biceps may rupture. Ask the patients to position the affected arm such that the elbow is flexed to ~30 degrees and the forearm supinated (palm up). this will produce pain. Direct the patient to flex their arm as you provide resistance. arm against body). When this occurs. Resisted Supination (Yergason's Test) Speed's Maneuver for Bicipital Tendonitis: 1.Biceps Tendon Palpation Resisted Supination (Yergason's Test): 1. Balled Up Biceps Secondary to Tendon Rupture 133 . 2. Pain suggests tendonitis of the biceps. In the setting of tendonitis. 2. Grasp the patient's hand and direct them to try and rotate their arm such that the hand is palm up (supinate) while you provide resistance. Elbow should be flexed to 90 degrees. the biceps muscle appears as a ball of tissue and there is a loss of function. shoulder adducted (ie elbow bent at right angle. Biceps Tendon Rupture: As a result of chronic tendonitis or truama.

The cavity is lined by the labrum. Palpation of the joint with a hand placed on the shoulder during movement may reveal crepitus. leading to DJD. The joint is held together by the muscles of the rotator cuff as well as a tough capsule that surrounds the muscles. Glenohumeral Instability: The rotator cuff. Over time. 2. Together. Perform active ROM maneuvers as described previously. stabilize the joint. noting degree to which movement is limited. instability. Tears of the capsule or labrum can generate feelings of pain.e. The patient may have a history of trauma or recurrent dislocation. Assessment is done as follows: 1. Glenohumeral Joint Anatomy-Humerus has been removed from its normal position of articulation. Specifics of testing (The Apprehension Test): 134 . where the humerus actually pops out of joint. Perform passive ROM. Glenohumeral DJD: DJD usually results from an injury that has disrupted the normal articulating surfaces. The rotator cuff and capsule surround the outside of the joint. where the ball meets the socket). Patients experience pain and gradual limitation in movement. along with the outer joint capsule and the labrum. movement of the shoulder causes additional wear and tear. You may feel crepitus by placing your hand on the patient's shoulder during passive ROM. assuring smooth/cushioned contact between the bones. The labrum is a tough tissue that lines the cup formed by the scapular component of the glenohumeral joint. This is particularly noticeable on external rotation and abduction. again noting limitations and degree of pain. or a "dead arm" sensation. they allow the humerus enough freedom so that the shoulder maintains its full range of motion and function.The Glenohumeral Joint Anatomy and Function: This joint is the actual place where the humerus articulates with the scapula (i. which functions like the menisci of the knee. 3.

g RA). Acute Inflammatory Arthritis: Inflammatory processes within the joint can be caused by a number of processes.1. 2. 2. 135 . This maneuver should relieve any feeling of pain and/or sense that the shoulder is going to dislocate. 3. Gently externally rotate their arm while pushing anteriorly on the head of the humerus with your other hand. red. 3. this technique is essentially the opposite of that used for the aprehension test. and will be painful to the touch. Push on the humerus in posterior direction while externally rotating the arm. Patient supine. 4. When this occurs. the shoulder may appear swollen. Any movement will be limited by pain. Sampling of fluid from within the joint space allows definitive diagnosis. Note. including infection (septic) or autoimmune (e. Instability will give the sense that the arm is about to pop out of joint. Testing Glenohumeral Stability Relocation Test (to be done if + apprehension test) 1. Grasp their elbow in your hand and abduct the humerus to 90 degrees. Have the patient lie on their back with the arm hanging off the bed.

in particular C5 and C6.Septic Shoulder: Intense Inflammation Over Shoulder Area As Seen In Picture On Left. this is caused by idiopathic inflammation of the capspule around the shoulder. Examination and history would suggest that the pathology lies outside the shoulder. and oftentimes when the shoulder is at rest. can generate pain that radiates to the shoulder. This causes a burning or tingling type pain to be referred to the deltoid area. Intra-abdominal inflammation can cause pain to be referred to the shoulder. The net result is severe limitation of motion in any direction (active or passive). A few sites that can cause referred symptoms: 1. Referred Pain to the Shoulder Area It's important to recognize that not all shoulder pain is cause by shoulder pathology. H&P should be revealing. splenic abscess) may be referred to the shoulder. In particular. Intrathoracic processes can also cause referred symptoms. Appropriately directed history and neuro examinations help to pin down the cervical spine as the location of the pathology. 136 . The etiology is unclear and it can be difficult to distinguish from a number of the above conditions. 3. inflammation that takes place just below the diaphragm (e. Due To Intra-Articular Infection. for example. Adhesive Capsulitis: Also called a frozen shoulder. Cervical spine pathology can cause irritation of the cervical nerve roots. Pain is present with movement.g. MI. 2. As above. Picture On Right Is Normal For Comparison.

there may be loss of motor strength of the thumb (see below). A cursory review of this area is included in the Upper Extremity Examination. this space becomes inadequate to accommodate the nerve. pain can be present at all times during the day. presumably due to tendency to flex wrist during sleep. placing it under increased pressure.Hand and Wrist Normal function of the hand and wrist is obviously of great importance. It may also occasionally be reproducible if the wrist is held in forced flexion x 1 minute (Phelan's sign). Patients will often try to "shake out" their hands in an effort to reduce pain and "increase blood flow" (based on the patient's assumption that decreased perfusion caused the symptoms). The precise reason why this occurs is not clear. Tinnel's Test Phelan's Test 137 . 1. With increased severity. In severe cases. index. Carpal Tunnel Syndrome Presentation and Anatomy: The median nerve travels through a narrow space when it crosses the wrist en route to the hand. Flexing puts additional pressure on the nerve. Occasionally. What follows is a description of commonly occurring pain syndromes and pathologic processes involving this region. Neither of these signs is particularly sensitive. middle and lateral ½ of ring finger) Symptoms are often worse at night. Examination: o o The hand and wrist usually appear normal Pain may some times be reproducible by tapping over the nerve (Tinnel's sign). Patients usually report some combination of the following: o o o o o Numbness and tingling (ie neuropathic pain symptoms) in the distribution of the median nerve (thumb.

The Abductor Pollicis Brevis (APB) muscle receives sole innervation from the median nerve. Resistance to movement of APB o Prolonged compression will lead to impaired 2 point discrimination on sensory testing. A normal appearing Thenar Eminence is demonstrated on left. 2. severe compression of the median nerve within the carpal tunnel has led to atrophy of the Thenar muscles (hand on right). That is. there may be atrophy of the thenar eminence (due to denervation of the muscle as well as disuse atrophy) and associated decrease in motor strength. 138 . The cyst is painless and usually located on the dorsal aspect of the wrist.o In advanced carpal tunnel. Carpal Tunnel Induced Atrophy: Chronic. spontaneous protrusion of joint fluid outside of the articular space. Ganglion Cyst Presentation and Anatomy: Idiopathic. Function can be tested by providing resistance to abduction up and away from the plane of the palm. the patient can't discern whether being touched with one object or 2 when separated by 5mm (can check using a bent paper clip).

If pronounced. the structure has a fluid filled consistency and is non-tender. 3. The structure should trans-illuminate when a light is placed upon it (as it's fluid filled). There is usually no associated pain or inflammation. On palpation. On palpation. it may prevent the hand from being able to fully open. Dupuytren's Contracture Presentation and Anatomy: Thickening of the palmar fascia. feels tough and thick. May interfere with ability to fully open hand Dupuytren's Contracture 139 . though non-tender and without signs of inflammation. which is usually painless and develops slowly over time.Examination: o o o o Patients often present noting the abrupt development of a focally swollen area. Examination: o o o Obvious focal thickening on palmar aspect hand.

Patients note difficulty flexing and extending the affected finger and lack of smooth movement. May affect many joints or only a few. 140 . Heberden's Nodes Presentation and Anatomy: Bony excresences that cause deformity at the DIP joints of the fingers. the movement will be impaired. There is usually no associated pain or inflammation. they pull on the tendons. It's worth noting that sometimes the triggering does not occur with every movement. Similar protrusions at the PIP joints are called Bouchard's nodes. causing the fingers to flex. When the muscles shorten. The affected tendon is not visible. Occurs slowly over time and is associated with Osteoarthritis. though not usually symmetric. Ask the patient to fully flex the affected finger. This is associated with a sensation of sudden freeing of the tendon ("triggering") when the irregularity slips through the pulley. Trigger Finger Presentation and Anatomy: Flexor tendons connect muscles proximal to the wrist to the fingers. When they attempt to extend and flex it.4. Examination: o o o The palm and fingers usually appear normal. If you place one of your fingers over the affected tendon. you may feel the "pop" when it finally pulls thru. nodules/irregularities develop along the tendons. Examination: o o o Obvious bony protrusions at DIP joints Non-tender on palpation with an absence of inflammation Some times interfere with joint movement and function Heberden's Nodes 5. which then interfere with their smooth movement thru "pulleys" on the palm. Occasionally.

k. Tenosynovitis of the Thumb (DeQuervain's type) Presentation and Anatomy: Repetitive abduction and adduction of the thumb can irritate the tendons of the extensor policis brevis and abductor policis longus muscles. any movement of the thumb (in particular.6. Examination: o o The thumb usually appears normal. Finklestein Test): 141 . Tenderness at the point where the tendons of the extensor pollicis brevis and longus cross the radial styloid (distal end of the radius) o Pain with passive stretching of the tendons (a. In cases of severe tendonitis.a. gripping) may cause pain at its base. When this occurs. there may be swelling overlying the tendons.

Gently deviate the wrist towards the ulna. b. Boxer's Fracture Presentation: When a closed fist strikes a solid surface.a. Have them cover the thumb with the fingers of the same hand. reproducing the patient's pain. Finkelstein's Test Selected Traumatic Injuries To The Hand (not in any way inclusive!) 1. Direct the patient to place the thumb in their palm. forming a fist. Examination: o Pain and swelling over the 5th metacarpal 142 . c. the force may cause a break in the 5th metacarpal. This stretches the inflamed tendons over the radial styloid.

Ulnar Collateral Ligament Disruption (Gamekeeper's Thumb) Ulnar Collateral Ligament Anatomy Gamekeeper Technique That Lead To UCL Injury (Don't Worry. who damaged the ligament as a result of the manner in which they killed rabbits. Injury to this structure was first described in Scottish Gamekeepers. usually associated with striking an object with a closed fist. Bunny Used In Photo Is Not Real!) The ulnar collateral ligament (UCL) is a strong band of tissue that connects the first phalanx of the thumb to the metacarpal bone along the ulnar side. X-ray demonstrates fracture of distal right metacarpal. Note swelling over dorsal aspect of right hand. 2.o Boxer's Fracture. It is the result of a fracture to the fifth metacarpal (bone below small finger). most pronounced below the small finger. The head of the rabbit was grasped between thumb 143 .

Patient's are usually immediately aware that something is wrong. This force chronically stressed the UCL. it was quickly recognized that the ligament could be torn by any strong force that acutely abducts the extended thumb. The key maneuver assesses the degree of laxity at the joint. Place the thumb in extension (see picture below for positioning). Gently grasp the end of the thumb and apply an abducting force. Mechanism Of UCL Injury In Skiers Examination is remarkable for swelling and pain at the MCP. 144 . pain and instability at the metacarpal-phalangeal (MCP) joint . It has become a relatively common ski injury. leading to weakening or frank rupture. After its initial description. developing swelling. If the UCL has been disrupted. occurring when a person falls on a hand that has a ski pole gripped between the thumb and forefinger. you will be able to distract the thumb to a much larger degree then when compared to the normal side.and first finger of one hand while they pulled on the rabbit's hind quarters with their other.

Elbow Function and Anatomy: Hinge type joint formed by the articulation of the Ulna and Radius (bones of the forearm). 145 . pulling away a small piece of bone that can be seen on x-ray. Picture On The Right Demonstrates Markedly Increased Laxity Resulting From Disrupted UCL. The ligament may become disrupted at it's insertion on the proximal phalanx. Full extension is equal to 0 degrees. X-Ray Demonstrating Gamekeeper's Fracture (Fragment At Proximal End Phalnax). full flexion to ~ 150 degrees. and Humerus (upper arm). Maximum supination (turning hand palm up so that it can hold a bowl of "soup") and pronation (palm down) are both 90 degrees.Picture on Left Demonstrates Normal Degree Of Laxity At The MCP Joint.

Click on Case 5 3. Repetitive extension (e. 146 . Repetitive flexion of the wrist can cause inflammation and pain around this bony prominence. University of Washington. Anatomy of wrist extensors. Lateral Epicondylitis (tennis elbow): Presentation and Anatomy: Extensors and supinators of the wrist insert on the lateral epicondyle of the humerus. Medial Epicondylitis (golfer's elbow): Presentation: Flexors and pronators of the wrist insert on the medial epicondyle. or other findings of acute inflammation. Palpation of lateral epicondyle Resisted Wrist Extension 2. erythema. or other findings of acute inflammation. o Absence of warmth. o Reproducibility of pain with resisted wrist flexion. University of Washington Lateral Epicondylitis. Examination is usually remarkable for: o Pain on palpation around the lateral epicondyle. o Reproducibility of pain with resisted wrist extension and supination. Examination is usually remarkable for: o Pain on palpation around the medial epicondyle.Elbow Pain and Symptom Syndromes 1. though could be any activity with similar movement) of the wrist can cause inflammation and pain around this bony prominence. back hand motion in tennis.g. erythema. o Absence of warmth.

 Absence of pain. redness or warmth. painless range of motion of the elbow. excess fluid can develop within the bursa. It provides a lubricating pad that minimizes direct trauma to the underlying bone during usual activity. persistent leaning on elbows). It will become clear that your extensors attach laterally and flexors medially. as there is usually a minimum of inflammation.g. University of Washington Anatomy Flexors 1 University of Washington Anatomy Flexors 2 5. There are several situations when it becomes clinically prominent: A. Olecranon Bursitis Anatomy: The olecranon process is formed by the proximal aspect of the Ulna and is the bony prominence that forms the tip of the elbow. Non-Inflammatory Bursitis Presentation: As a result of repeated trauma (e.  Full. extend and flex your own wrist while palpating both epicondyles with the other hand. 6. Helpful Hint: If you forget where the flexors and extensor insert. Examination is remarkable for:  Obvious swelling at the tip of the elbow. causing it to become very apparent on direct observation. the bursa is not apparent on examination. 147 . Normally.Palpation Medial Epicondyle Resisted Wrist Flexion 4. The olecranon bursa is a fluid filled pouch that is located directly on top of the olecranon process.

redness. making it difficult to distinguish these entities from intra-articular inflammation.Normal Elbow B. the bursa can become very inflamed.g. This is one way of distinguishing inflammatory bursitis from inflammatory arthritis. the elbow area is diffusely swollen (ie not limited to the area of the bursa) and there is pain with any flexion or extension of the elbow. Examination in this case is remarkable for: 1 1 1 1 Obvious swelling at the tip of the elbow Marked warmth. When it occurs. Range of motion of the elbow is usually preserved. bursitis and/or cellulitis can be so severe that ROM is compromised. Minimally Inflammatory Olecranon Bursit Inflammatory Bursitis Presentation and Anatomy: As a result of infection (via abrasion to overlying skin) or any other intensely inflammatory process (e. and pain on palpation of the bursa. 1 1 Normal Elbow Septic Olecranon Bursitis 148 . rheumatoid arthritis). gout. Rarely. Infection within the elbow joint (inflammatory arthritis) is rather rare.

from elbow down to the hand. When this occurs. May be compromised if nerve compression is severe and of long duration. Examination in the setting of ulnar entrapment: o o o o Normal external appearance Usually normal motor strength: wrist flexion. referred to as ulnar Tinnel's sign. It also provides motor function that allows wrist flexion (along with the median nerve). finger adduction and finger abduction. Ulnar Nerve Entrapment Presentation and Anatomy: The ulnar nerve runs in the groove between the medial epicondyle and olecranon process.e. pressure can develop on the nerve due to entrapment as it travels around the elbow through Guyon's canal. sometimes also migrating proximal to the elbow). finger flexion (grip). it causes the "funny bone" sensation of pins and needles/electric shock traveling down towards your hand.Elbow Effusion Cause articularInflammator 4. Usually normal sensation in the pinky and medial half of the ring finger (assess by checking 2 point discrimination). When inadvertently struck. Pain reproducible with tapping over nerve. patients report neuropathic type pain (pins and needles. finger adduction/abdution. electric shock) along the nerve's distribution (i. Occasionally. finger flexion (grip). The ulnar nerve provides sensation to the pinky and medial half of the ring finger. Ulnar Tinnel Test 149 .

Hip Function and Anatomy: The hip is a ball and socket type joint. pathology outside of the hip can be referred to this region. History and exam obviously help in making these distinctions. Additionally. 150 . internal and external rotation. flexion 135 degrees. though frequently pain is anterior and radiates to the groin region. formed by the articulation of the head of the femur with the pelvis. Normal range of motion includes: abduction 45 degrees. adduction 20-30 degrees. extension 30 degrees. Hip pathology can cause symptoms anywhere around the joint.

Degenerative Joint Disease and Osteoarthritis Presentation and anatomy: Patients usually report pain with weight bearing and ambulation.A few common problems are described below: 1. 151 . Obesity. "setting it up" for degenerative changes over time. This tends to occur in patients > 50. as age increases the risk of wear and tear on the joint. is a major risk factor. Symptoms progress slowly over time (ie years) with pain precipitated by less activity (ie shorter distances walked) as the disease worsens. which chronically increases the load and stress that the joint must bear. There may also be a history of significant antecedent trauma that damaged the joint.

nerve roots (known as the cauda equine) drape down and fill the lower aspect of the spinal canal. perhaps even with limping. The vertebrae are separated by discs. Symptoms tend to get worse with walking.Examination: o o Pain with walking. Powerful ligaments connect the verterbrae to each other along their anterior and posterior aspects. Examination: o o o Range of motion is generally preserved Pain on direct palpation over the bursa Pain with resisted abduction. The vertebral column has regularly spaced lateral openings known as neuroforamina. When it becomes inflamed. Function and Anatomy: The lumbar spine must support a tremendous amount of weight. which is innervated and thus generates pain if inflamed (see below). focused on the lateral area of the joint.g L5-S1 neuro foramen sits between the L5 and 152 . The outer aspect of the disc is made of a tough fibrous tissue called the annulus fibrosis. The actual cord ends at about the L1 level. Below this point. The bones are covered by periosteum. Low Back Pain Low back pain is a very common condition. Each vertebrae articulates with the one above and below it in a precise fashion that helps to maximize function. protect the spinal cord and yet still maintain flexibility that maintains range of motion. Trochanteric Bursitis: Anatomy and function: The troachanteric bursa overlies the greater trochanter of the femur. characterized by trying to minimize the amount of time spent with weight bearing on the affected joint. which allow for smooth. while the inner aspect is gelatinous and known as the nucleus propulsus. just posterior to the main body of the vertebrae. Early on. The neuro formaina are identified by the vertebrae that are above and below it (e. cushioned articulation. internal rotation may elicit more pain then movement in other directions. Range of motion reduced as degeneration progresses. This space is well designed to protect the delicate nervous tissue of the cord. This can be assessed by having patient lie on unaffected side and asking them to abduct the affected hip as you provide resistance. Patient's may develop an Antalgic gait. 2. patient's report vague hip pain. Examination and history provide important clues as to its etiology. The spinal cord runs in a bony canal. The low back is formed by 5 lumbar vertebrae and the sacrum. through which nerve roots exit and travel to the target organs which they innervate.

continuing along the backs of both legs. patient's report a burning/electric shock type pain that starts in the low back. spinal cord." this is a pain syndrome caused by irritation of one of the nerve roots as it exits the spinal column. In terms of surface landmarks. This is caused by spinal stenosis. The rest of the structures (e. 3. However. Sometimes. There may or may not be a clear history of antecedent over use or increased activity. In any case. bony osteophyte that limits size of the opening) or a herniated disc (the fibrosis tears.g.S1 vertebrae). Symptoms are usually worse with walking and improve when the patient bends forward. it's helpful to identify the posterior superior iliac crest. and improves with rest. nerve roots) are not palpable. allowing the propulsus to squeeze out and push on the adjacent root). The pain is presumably caused by irritation of the paraspinal muscles. it's not precisely clear what has lead to the irritation. The most commonly affected nerve roots are L5 and S1. discs. The root can become inflamed as a result of a compromised neuroforamina (e. a precise etiology is difficulty to identify. traveling down the buttocks and along the back of the leg. This point is roughly on line with the L4-5 intervertebral space. a narrowing of the 153 . Spinous processes make up the most posterior aspect of the spinal column and are palpable on exam.g. Patients present with lumbar area pain that does not radiate. Patient's may describe that they relieve symptoms by leaning forward on their shopping carts when walking in a super market. is worse with activity. ligaments or vertebral body articulations. Overview of Spine Representative Segment of Spinal Column (Lateral View) Common Benign Pain Syndromes--Symptoms and Etiology: 1. radiating below the knee. Spinal Stenosis: Pain starts in the low back and radiates down the buttocks bilaterally. Non-specific musculoskeletal pain: This is the most common cause of back pain. Radicular Symptoms: Often referred to as "sciatica. 2.

limited by pain? 3. Pain that doesn't get better when lying down/resting. Known history of cancer. pain may be reflected by increase pulse. 4. 2. 3. posterior duodenal ulcer. chills). causing elements of more then one symptom syndrome to co-exist. which increases risk of compression fracture (vertebrae collapsing under the weight they must bear). 4. peripheral pulses should be normal. 7. bowel or bladder incontinence. Any skin abnormalities suggesting underlying inflammation? Normal curvature is as follows: Cervical spine sweeps anteriorly. More common as people age. pancreatitis. Red Flags: There are a variety of ominous processes that cause low back pain. more then one process may co-exist. Careful history taking and examination can help distinguish these problems. Vital signs. Mixed symptoms: In some patients. particularly if of substantial force. temperature if concern re an infectious process. in particular malignancies that metastasize to bone (e. and lumbro-sacral spine sweeps anteriorly. lung). IV drug users. Is it slow. As opposed to true claudication (pain in calfs/lower legs due to arterial insufficiency). in particular in those at risk for systemic infection that could seed the spinal area (e. These problems carry significant morbidity and mortality and mandate a focused and rapid evaluation (including lab and imaging studies) different from what is required for the relatively benign processes described above. 4. In particular. Look at the lumbar spine area. implying diffuse sacral root dysfunction. Range of motion testing should include forward flexion. Observe gait. fever. 154 . prostate. BP or pain score (if asked). 2. Spinal stenosis can be congenital or develop over years as a result of djd of the spine. lateral flexion. causing the symptoms (referred to as neurogenic claudication). weakness in legs suggesting motor dysfunction. Examination Keys: 1. thoracic spine sweeps posteriorly. Also. Trauma. Also.g. particularly in older patients (> 50). Note: it can sometimes be difficult to distinguish true weakness from motor limitation caused by pain. Osteoporosis. 5. 6.g. breast. hyperextension.central canal that holds the spinal cord. Also. The limited amount of space puts pressure on the nerve roots when the patient walks. Historical keys include: 1. and rotation. intra-abdominal or retroperitoneal processes). women > men. pain resolves very quickly when person stops walking and assumes upright position. Pain associated by systemic symptoms of inflammation (e. leaking/rupturing abdominal aortic aneurysm.g. In particular. Pain referred to the back from other areas of the body (e.g. etc. Could include: Pyelonephritis. patients with bacteremia). Anything suggesting neurological compromise.

g. osteomyelitis. Spine Percussion 155 . Processes that inflame the bone (e. compression fracture. Can the patient point to the precise area of the pain? Is it along the vertebral column? Para-spinal. as might occur with spasm? Radiating down the legs as would occur with nerve root irritation? 6. metastatic disease) will generate pain when the affected vertebrae is palpated or percussed. Palpate the spine.5.

b. if it does not reproduce pain. Sensitive (75-90%). Ask the patient to lie down on their back. This is referred to at the "straight leg raise test" and is sensitive for identifying root pathology (i. proceed as follows: a. percussion over this area will cause pain. If the patient's complains of a radiating type pain down one leg. Therefore. positive test makes root irritation the likely etiology of the symptoms. Have the patient completely relax the affected leg. d. 8. but not specific. 156 . Therefore. Is the pain in the costo-vertebral angle area. This is called the crossed straight leg raised test and is 85-95% specific for root irritation. Cup the heel of their foot and gently raise the leg. In the setting of kidney infection (pyelonephritis). c. negative test helps rule out nerve root irritation as cause of pain.7. suggestive of nerve root irritation. but not sensitive.e. repeat the same test on the opposite leg. suggestive of a kidney infection? Location of kidneys drawn on back. the patient will experience their typical pain when the leg is elevated between 30 and 60 degrees. If the straight leg test is positive. root irritation unlikely). If there is nerve root irritation.

paying attention to the L5 and S1 d 157 .Leg Raise Test 9. in particular the Achilles. which is a function of the S1 root. Reflexes. 11. as plantar flexion is mediated by the S1 root. In particular. Resisted great toe extension (extensor hallicis longus). 10. if concern that nerve root pathology has lead to motor dysfunction (quite uncommon) check the following: a. b. mediated by the L5 nerve root. Assess bilateral lower extremity strength. Walking on toes. Distal sensation.

this may be compromised. it is important is this setting. c. causing further compression of the underlying nerve. genitalia and inner thighs. If patient's note any bowel or bladder symptoms. assess sacral nerve root function as follows: a. Patients should be able to easily distinguish light touch and pin prick. 13.12. Post Void Residual: Patient's should normally be able to completely empty their bladders. Check pulses in feet to assure that symptoms not related to peripheral vascular disease. 14. Saddle area anesthesia: This is the region around the rectum. In acute sacral root dysfunction. This can be assessed by using either a bedside bladder scan or placement of a foley catheter. Straight and crossed leg raising will not reproduce symptoms. Detailed review of lower extremity examination. This should reproduce the patient's symptoms. In pyriformis syndrome internal rotation will stretch an already tight external rotator. While not part of the typical exam. b. Rectal tone: Patient should be able to contract anal sphincter around examining finger when directed to do so. 158 . Gently internally and externally rotate the hip.

This review provides an opportunity to consciously think of the elements contained within the MSE. First and foremost. etc. Level of alertness: Is the patient conscious? If not. Appearance: How does the patient look? Neatly dressed with clear attention to detail? Well groomed? 2. if concern that back pain is a manifestation of systemic illness. altered capacity for memory. The components of the MSE are as follows: 1. intoxication) will preclude a complete. the final step in this process is. even if you had the experience and knowledge to generate diagnoses. ordered evaluation of mental status. volume and quantity? 4. Speech: Is it normal in tone. The Mental Status Exam (MSE) In actual practice. appropriate detailed general exam should be performed. Also. also referred to as orientation: Do they know where they are and what they are doing here? Do they know who you are? Can they tell you the day. the goal is to be able to note when these abnormalities exist (you'd be surprised at how frequently they can be missed) and then to categorize them as specifically as possible. this still may not be possible after a single patient encounter. Behavior: Pleasant? Cooperative? Agitated? Appropriate for the particular situation? 5.g. If any concern that symptoms are referred from the abdomen. Frequently. In the day to day practice of medicine (and. confused or not quite right" what do we mean by this? What about their behavior. for the most part. a detailed exam of this area is performed. markedly depressed level of consciousness. can they be aroused? Can they remain focused on your questions and conversation? What is their attention span? 3. Awareness of environment. most of the information relevant to this assessment is obtained indirectly. in fact. providers (with the exception of a psychiatrist or neurologist) do not regularly perform an examination explicitly designed to assess a patient's mental status. The interview provides a "snap shot" of the patient. speech. so flexibility is important. In fact. has lead us to these conclusions? In some instances. a picture of them as they exist at one point in time. throughout all of our interactions) we continually come into contact with persons who have significantly impaired cognitive abilities. date and year? 159 . If a person seems "odd. and this applies to the physical examination as well. Knowing when to "cut your losses" and abandon a more detailed examination obviously takes a bit of experience! The formulation of actual diagnoses. several interactions are required along with information about the patient's usual level of function before you can come to any meaningful conclusions about their current condition. During the course of the normal interview. disordered thought processes and otherwise abnormal mental status. beyond the scope of this discussion (I've included two of the most commonly encountered ones at the end of this section as examples). the patient's condition (e.15. appearance.

g. Patients may appear quite ill. Is it appropriate for their current situation? 7. excitable. liver or kidney failure). the patient should be asked this directly. For example. about what.g. 8. Mood: How do they feel? You may ask this directly (e. global change in mental status that can be the result of physiologic derangement anywhere within the body. multiplication? Are the responses appropriate for their level of education? Have they noticed any problems balancing their check books or calculating correct change when making purchases? This is also a test of the patient's attention span/ability to focus on a task. and then checking recall at 5 minutes. Are they paranoid? Delusional (i. Thought Content: A description of what the patient is thinking about. "Don't judge others"). 160 . hypotension. you may ask them the meaning of the phrase. depressed. "People in glass houses should not throw stones. Acute Confusional State. toxic ingestion. Causes include: infection. Note: These questions have never been shown to plant the seeds for an otherwise unplanned event and may provide critical information. Judgment: Provide a common scenario and ask what they would do (e. about what? Phobic? Hallucinating (you need to ask if they see or hear things that others do not)? Fixated on a single idea? If so. family history.g.e. abstract (e. Higher cortical functioning and reasoning: Involves interpretation of complex ideas.g. Is the thought content consistent with their affect? If there is any concern regarding possible interest in committing suicide or homicide. ranging from unarousable to extremely agitated. or Toxic Metabolic State. etc. hypoxia. 13. infection). 11. impaired ability of the body to handle endogenously produced toxins (e.g. including a search for details (e. 12.g. "If you found a letter on the ground in front of a mailbox." A few common interpretations include: concrete (e. hold beliefs that are untrue)? If so. what would you do with it?"). Do they make eye contact? Are they excitable? Does the tone of their voice change? Common assessments include: flat (unchanging throughout). where they were born and raised. "Are you happy. Thought Process: This is a description of the way in which they think. appropriate. specific plan.). asking the patient to repeat them to you to insure that they were heard correctly. Diagnoses are made on the basis of a pattern of responses to the above evaluation. or bizarre. Ability to perform calculations: Can they perform simple addition.6. Affect: How do they appear to you? This interpretation is based on your observation of their interactions during the interview. time etc. sad. This is a very common condition (particularly among hospitalized patients) notable for an acute. etc. how off base are they? Do they tend to stray quickly to related topics? Are their thoughts appropriately linked or simply all over the map? 9. Two commonly occurring disorders are described below: 1. Are their comments logical and presented in an organized fashion? If not.g. so they should be asked! 10. Delirium: Also referred to as Altered Mental Status. with markedly abnormal vital signs that in themselves can suggest the cause of the delirium (e. Delta MS. There is a wide spectrum of presentations. "Don't throw stones because it will break the glass"). Memory: Short term memory is assessed by listing three objects. Long term memory can be evaluated by asking about the patients job history. angry?").

2. thorough examination. presentation will depend on the level of advancement.) it is also important to recognize that our observation and interpretation of patient behavior and responses is colored by our own life experiences. The elderly as well as those with multiple medical problems (conditions which frequently coexist) are at the highest risk for developing this condition. This can only be sorted out with time and appropriate testing. alert and cooperative to agitated. As this is a progressive disease. M. progressive nature. etc.. Initial presentation of psychotic disorders as well as dementia can be mistaken for delirium (and vice versa). 161 . While quite uncommon under 50. and may or may not be appropriate for the given situation.g. Formal evaluation of mood. and DANIEL SWAGERTY. the year. SANTACRUZ. review of medications. affect.P." Proverbs. the purpose of their visit to the hospital.They are frequently confused. Realize that there is a major distinction between "different" and "abnormal. Patient's appearance and behavior vary with the extent of involvement. Thought process is disordered and content notable for delusions.D. a "failure" to provide a correct interpretation may in fact have nothing to do with an individual's intellectual function but rather may simply reflect a different upbringing or background. unable to care for themselves and incapable of answering even simple questions. Treatment is dictated by the underlying insult. Thought process and content have similar variability. are not necessarily a part of any communal experience. M. educational level.e. These situations are unavoidable in the extremely diverse community in which we live. tests of memory which require the subject to recite past U. Dementia: A final common pathway for multiple disorders characterized by its slow. and appropriate use of lab and radiologic testing.. language skills. paranoia and hallucinations. judgment or insight can be hopeless. though these distinctions are extremely important. University of Kansas Medical Center. Contributions from other acute. This ranges from well groomed. Kansas provides a copy of this test along with assorted supporting information. While it is reasonable to expect that people be aware of certain basic facts (e. MMSE can also be accessed via Alzheimer's Society. UK. Similarly. memory. There is tremendous potential for our own cultural exposure and background to color these assessments. their name. the incidence increases markedly with age. Memory. Kansas City. examination and laboratory testing. for example. Thus. The Mini Mental Status Examination (MMSE) is a brief bedside test that is an excellent means of quantifying cognitive function and decline.S. Quantifying and defining the nature of a specific abnormality is an important part of the practice of medicine. M. reversible medical problems must be ruled out on the basis of history. judgment and higher cortical function deteriorate with time.H. Presidents may not be an appropriate measuring tool depending on a person's country of origin.D. etc. by KAREN S. the diagnosis is suggested by the time course of the illness (i. Delirium in this patient sub-set can be provoked by seemingly minor precipitants. the change is acute). Many aspects of the MSE are extremely subjective. which can generally be determined after a detailed history (usually with the help of others who are familiar with the patient). The following article from The American Journal of Family Practice. Mood and affect can range widely. disoriented. In general. taking months to years to develop.Early Diagnosis of Dementia. agitated and uncooperative.

motor.) it is also important to recognize that our observation and interpretation of patient behavior and responses is colored by our own life experiences. on the basis of an organized and thorough examination.Many aspects of the MSE are extremely subjective.g. educational level. brain and spinal cord imaging) then applied in an orderly and logical fashion. tests of memory which require the subject to recite past U. 2. There is tremendous potential for our own cultural exposure and background to color these assessments. If possible. These situations are unavoidable in the extremely diverse community in which we live. Identify which component(s) of the neurological system are affected (e. c. Presidents may not be an appropriate measuring tool depending on a person's country of origin. For patients presenting with symptoms suggestive of a neurological problem.S. sensory. are not necessarily a part of any communal experience. for example. the year. determine the precise location of the problem (e. for example (particularly those with long standing poor control). etc. Screening for the presence of discrete abnormalities in patients at risk for the development of neurological disorders.g. cranial nerves. Determine.g. Unlikely diagnoses can be excluded and appropriate testing (e. peripheral v central nervous system. etc. region and side of the brain affected etc. b. Similarly. generate a list of possible etiologies. whether in fact neurological dysfunction exists. Thus.g. or possibly several systems simultaneously). The Neurological Examination Cranial Sensory and Motor Nerves Examinations Introduction The goals of the neurological examination are several: 1. language skills. While it is reasonable to expect that people be aware of certain basic facts (e. the purpose of their visit to the hospital. the examination should: a. Realize that there is a major distinction between "different" and "abnormal. d." Proverbs. This is appropriate for individuals who have no particular subjective symptoms suggestive of a neurological problem.). a "failure" to provide a correct interpretation may in fact have nothing to do with an individual's intellectual function but rather may simply reflect a different upbringing or background. may develop peripheral nerve dysfunction. Quantifying and defining the nature of a specific abnormality is an important part of the practice of medicine. This may only be detected Reflex Testing Cerebellar Gait Testing Testing Making Sense of Neurological Findings 162 . their name. Diabetic patients. On the basis of these findings. yet have systemic illnesses that might put them at risk for subtle dysfunction.

6. 3. 2. 4. Simply observing the patient during the course of the usual H&P (i. which would have important clinical implications. even if it is not seen on a particular radiological study (i. There is an over reliance on the utility of neuro-imaging (e. 3. get up and down from the exam table. in turn. probably translates into poor performance later in their careers. nor in the accuracy of their findings.e. Cursory screening/documentation of baseline function for those who are otherwise healthy. Thus. watching them walk. particularly when the examiner does not have confidence in their abilities (see above). This. I suspect that this situation exists for several reasons: 1. Many examiners incorporate some aspects of the neuro exam into their standard evaluations. Careful examination may make imaging unnecessary. for example. CT. 163 . MRI). there are limits to what can be seen on even the most high tech imaging). tone and bulk Reflexes Cerbellar Function Sensory Function Gait Real and imagined problems with the neurological examination: The neurological examination is one of the least popular and (perhaps) most poorly performed aspects of the complete physical. As many clinicians do not see a large number of patients with neurological disorders. 7. Exam findings are often quite subjective. In patients with neither signs nor risk factors for neurological disease. interpretation of the results can be problematic. covering the most testable components of the neurological system. include: 1. These studies provide an evaluation of anatomy but not function. 5.Thus. This exam is perceived as being time and labor intensive. etc.) may well suffice. The major areas of the exam. it’s unlikely that the detailed exam would uncover occult problems.e. exam findings can make a strong case for the presence of a pathologic process. Mental status testing (covered in a separate section of this web site) Cranial Nerves Muscle strength. Understanding/Interpretation of some neurological findings requires an in depth understanding of neuroanatomy and pathophysiology. can be easily blended into the Head and Neck evaluation. Deciding what other aspects to routinely include is based on judgment and experience. they likely maintain a limited working understanding of this information. Also. 2.through careful sensory testing (see below under Sensory Testing). while extremely helpful. 3. 5. Students and house staff never develop an adequate level of confidence in their ability to perform the exam. they must be interpreted within the context of exam findings. Cranial Nerve testing. 4.g.

both right and left sides must be checked independently. a patient’s severe degenerative hip disease will prevent them from walking. watch them perform their exam. provided that it is done carefully and accurately. When possible. and give you confidence in the meaning of findings identified when evaluating other patients. As each half of the body has its own cranial nerve. of course. 3. the neurological assessment has limits. 5 CN6 CN7 CN8 CN9. increase the accuracy of the results generated. If it is to be tested: 164 .e. It is sometimes appropriate to perform only certain parts of the neurological examination (e.The above are not meant to lower expectations with regards to how well a physician should be expected to learn and perform the neurological examination. otherwise healthy people as the yield (i. Then go back alone and verify the findings. or only motor testing)These situations will become apparent with experience. provide you with a better sense of the range of normal. of course. but can be found in other references. predicated on learning how to do it correctly. Cranial Nerve 1 (Olfactory): Formal assessment of ability to smell is generally omitted. the neurological examination is not applied in its entirety to asymptomatic. 4. A detailed description of the CN assessment is provided below. There are many additional aspects of the exam that should be applied in specific settings. just cranial nerves.This is. however. for example. The interpretation of “findings” must therefore take these things into account. 4. Testing of one system is often predicated on the normal function of other organ systems. Doing this. Cranial Nerve (CN) Testing CN2 CN3. It is.This will improve the facility with which you perform the exam. Like any other aspect of the exam. a part of the assessment of cerebellar function (see below). making that aspect of the exam impossible to assess. Like all other aspects of the physical exam. Take advantage of those opportunities when a more experienced clinician examines one of your patients. takes practice and experience. Rather. Or. They are beyond the scope of this text. likelihood of identifying occult disease) would be quite low. unless there is a specific complaint. I mention these points to highlight some of the real and imagined obstacles to clinical performance. they may not be able to perform finger to nose testing. there is a wealth of information that can be obtained from the neurological examination. even when working with normal patients. a good idea to practice the exam early in your careers. 2. In general. a patient is visually impaired. 10 CN11 CN12 Many practitioners incorporate cranial nerve testing with their complete examination of the head and neck (see the Head and Neck section of this web site for details). Only in this way can you generate an accurate picture. A few practical considerations/suggestions: 1. If.g. The testing described below is still rather basic.

Acuity: a. Each line has a fraction written next to it. The patient should be able to correctly identify the smell. Patients should be able to identify its distinctive odor from approximately 10 cm . common odor (e. Alcohol Pad Sniff Test For more information about CN1. b. If you wish to test olfaction and don’t have any “substance filled tubes” use an alcohol pad as a screening test. 3. Patients are asked to read the letters or numbers on successively lower lines (each with smaller images) until you identify the last line which can be read with 100% accuracy. A Snellen Chart is the standard. wall mounted device used for this assessment.g.1. Each nostril should be checked separately. see the following links: Cranial Nerve 2 (Optic): This nerve carries visual impulses from the eye to the optical cortex of the brain by means of the optic tracts. ground coffee) to the open nostril. Push on the outside of the nares. they should be permitted to wear them (referred to as best corrected vision). Present a small test tube filled with something that has a distinct. occluding the side that is not to be tested. In other words. Make sure that the patient is able to inhale and exhale through the open nostril. Have the patient close their eyes. 165 . If the patient uses glasses to view distant objects. the worse the vision. Each eye is tested separately. the larger the denominator. 20/400 means that the patient's vision 20 feet from an object is equivalent to that of a normal person viewing the same object from 400 feet. 20/20 indicates normal vision. Testing involves 3 phases (also covered in the section of this site dedicated to the Eye Exam): 1. 2.

There are hand held cards that look like Snellen Charts but are positioned 14 inches from the patient. Testing and interpretation are as described for the Snellen.Snellen chart for measuring visual acuity c. Hand held visual acuity card 166 . These are used simply for convenience.

These nerves carry the impulse generated by the light back towards the brain. the examiner must understand the normal pathways by which visual impulses travel from the eye to the brain. 2. b. along an imaginary line drawn between the two persons. The wiggling finger is moved towards the open eyes. Prior to interpreting abnormal findings. The examiner should move their hand out towards the periphery of his/her visual field on the side where the eyes are open. Testing is then done starting at a point in front of the closed eyes. see the following links: 3. The examiner closes one eye and the patient closes the one opposite. If neither chart is available and the patient has visual complaints. Pupils: The pupil has afferent (sensory) nerves that travel with CN2. Each eye is checked separately. They function in concert with efferent (motor) nerves that travel with CN 3 and cause pupillary constriction. The examiner should be nose to nose with the patient. Holes in vision (referred to as visual field cuts) are caused by a disruption along any point in the path from the eyeball to the visual cortex of the brain. For more information about visual field testing. If the examiner cannot seem to move their finger to a point that is outside the patient’s field don’t worry. This is a critically important reference point. c. Meaningful interpretation is predicated upon the examiner having normal fields. and it is quite possible to have small visual field defects that would not be apparent on this type of testing. The open eyes should then be staring directly at one another. particularly when trying to communicate the magnitude of a visual disturbance to a consulting physician. as it simply means that their fields are normal. The finger should be equidistant from both persons. 167 . The finger is then moved out to the diagonal corners of the field and moved inwards from each of these directions. This information is carried to the brain along well defined anatomic pathways. separated by approximately 8 to 12 inches. f. The other eye is then tested. some attempt should be made to objectively measure visual acuity. Visual Field Testing: Specific areas of the retina receive input from precise areas of the visual field. Seen under CN 3 for specifics of testing. Can the patient read news print? The headline of a newspaper? Distinguish fingers or hand movement in front of their face? Detect light? Failure at each level correlates with a more severe problem. as they are using themselves for comparison. The examiner should then move the wiggling finger in towards them. Visual fields can be crudely assessed as follows: a. e.d. d.The patient and examiner should detect the finger at more or less the same time. Interpretation: This test is rather crude.

For more information about CN 2, see the following links: CN 3 (Occulomotor): This nerve is responsible for most of the eyeball’s mobility, referred to as extra-occular movement. CN 3 function is assessed in concert with CNs 4 and 6, the other nerves responsible for controlling eyeball movement. CN 4 controls the Superior Oblique muscle, which allows each eye to look down and medially. CN 6 controls the Lateral Rectus muscle, which allows each eye to move laterally. CN 3 controls the muscles which allow motion in all other directions. The pneumonic “S O 4 – L R 6 – All The Rest 3” may help remind you which CN does what (Superior Oblique CN 4 – LateralRectus CN 6 – All The Rest of the muscles innervated by CN 3). Testing is done as follows: 1. Ask the patient to keep their head in one place. Then direct them to follow your finger while moving only their eyes. 2. Move your finger out laterally, then up and down. 3. Then move your finger across the patient’s face to the other side of their head. When it is out laterally, move it again up and down. You will roughly trace out the letter “H”, which takes both eyeballs through the complete range of movements. At the end, bring your finger directly in towards the patient's nose. This will cause the patient to look cross-eyed and the pupils should constrict, a response referred to as accommodation.

CN 3 also innervates the muscle which raises the upper eye lid. This can first be assessed by simply looking at the patient. If there is CN 3 dysfuntion, the eyelid on that side will cover more of the iris and pupil compared with the other eye. This is referred to as ptosis.

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Right CN3 Lesion: Note patient's right eye is deviated laterally and there is ptosis of the lid (picture on left), and the right pupil (middle picture) is more dilated than the left pupil (picture on far right).

CN6 Palsy: This patient is unable to move left eye lateral of midline due to left CN6 lesion. It’s also worth noting that disorders of the extra ocular muscles themselves (and not the CN which innervate them) can also lead to impaired eye movement. For example, pictured below is a patient who has suffered a traumatic left orbital injury. The inferior rectus muscle has become entrapped within the resulting fracture, preventing the left eye from being able to look downward.

Entrapment of Left Inferior Rectus Muscle The response of pupils to light is controlled by afferent (sensory) nerves that travel with CN 2 and efferent (motor) nerves that travel with CN 3. These innervate the ciliary muscle, which controls the size of the pupil. Testing is performed as follows: 1. It helps if the room is a bit dim, as this will cause the pupil to become more dilated. 2. Using any light source (flashlight, oto-ophtahlmoscope, etc), shine the light into one eye. This will cause that pupil to constrict, referred to as the direct response. 3. Remove the light and then re-expose it to the same eye, though this time observe the other pupil. It should also constrict, referred to as the consensual response.

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This occurs because afferent impulses from one eye generate an efferent response (i.e. signal to constrict) that is sent to both pupils. 4. If the patient’s pupils are small at baseline or you are otherwise having difficulty seeing the changes, take your free hand and place it above the eyes so as to provide some shade. This should cause the pupils to dilate additionally, making the change when they are exposed to light more dramatic. If you are still unable to appreciate a response, ask the patient to close their eye, generating maximum darkness and thus dilatation. Then ask the patient to open the eye and immediately expose it to the light. This will (hopefully) make the change from dilated to constricted very apparent. Interpretation: 1. Under normal conditions, both pupils will appear symmetric. Direct and consensual response should be equal for both. 2. Asymmetry of the pupils is referred to as aniosocoria. Some people with anisocoria have no underlying neuropathology. In this setting, the asymmetry will have been present for a long time without change and the patient will have no other neurological signs or symptoms. The direct and consensual responses should be preserved. 3. A number of conditions can also affect the size of the pupils. Medications/intoxications which cause generalized sympathetic activation will result in dilatation of both pupils. Other drugs (e.g. narcotics) cause symmetric constrictionof the pupils. These findings can provide important clues when dealing with an agitated or comatose patient suffering from medication overdose. Eye drops known as mydriatic agents are used to paralyze the muscles, resulting marked dilatation of the pupils. They are used during a detailed eye examination, allowing a clear view of the retina. Addiitonally, any process which causes increased intracranial pressure can result in a dilated pupil that does not respond to light. 4. If the afferent nerve is not working, neither pupil will respond when light is shined in the affected eye. Light shined in the normal eye, however, will cause the affected pupil to constrict. That’s because the efferent (signal to constrict) response in this case is generated by the afferent impulse received by the normally functioning eye. This is referred to as an afferent pupil defect. 5. If the efferent nerve is not working, the pupil will appear dilated at baseline and will have neither direct nor consensual pupillary responses. For more information about pupillary response and CN 3, see the following links: CN 4 (Trochlear): Seen under CN 3. CN 5 (Trigeminal): This nerve has both motor and sensory components. Assessment of CN 5 Sensory Function: The sensory limb has 3 major branches, each covering roughly 1/3 of the face. They are: the Ophthlamic, Maxillary, and Mandibular. Assessment is performed as follows:

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1. Use a sharp implement (e.g. broken wooden handle of a cotton tipped applicator). 2. Ask the patient to close their eyes so that they receive no visual cues. 3. Touch the sharp tip of the stick to the right and left side of the forehead, assessing the Ophthalmic branch. 4. Touch the tip to the right and left side of the cheek area, assessing the Maxillary branch. 5. Touch the tip to the right and left side of the jaw area, assessing the Mandibular branch. The patient should be able to clearly identify when the sharp end touches their face. Of course, make sure that you do not push too hard as the face is normally quite sensitive. The Ophthalmic branch of CN 5 also receives sensory input from the surface of the eye. To assess this component:

1. Pull out a wisp of cotton. 2. While the patient is looking straight ahead, gently brush the wisp against the lateral aspect of the sclera (outer white area of the eye ball). 3. This should cause the patient to blink. Blinking also requires that CN 7 function normally, as it controls eye lid closure. Assessment of CN 5 Motor Function: The motor limb of CN 5 innervates the Temporalis and Masseter muscles, both important for closing the jaw. Assessment is performed as follows: 1. Place your hand on both Temporalis muscles, located on the lateral aspects of the forehead. 2. Ask the patient to tightly close their jaw, causing the muscles beneath your fingers to become taught. 3. Then place your hands on both Masseter muscles, located just in from of the Tempero-Mandibular joints (point where lower jaw articulates with skull). 4. Ask the patient to tightly close their jaw, which should again cause the muscles beneath your fingers to become taught. Then ask them to move their jaw from side to side, another function of the Massester.

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CN6 (Abducens): See under CN 3. The nasolabial folds (lines coming down from either side of the nose towards the corners of the mouth) should be equal c. ask the patient for a picture (often found on a driver’s license) for comparison. 2. There should be the same amount of wrinkles apparent on either side of the forehead… barring asymmetric Bo-Tox injection! b. CN 7 controls the muscles that close the eye lids (as opposed to CN 3. You should not be able to open the patient’s eyelids with the application of gentle upwards pressure. Interpretation: CN 7 has a precise pattern of inervation. Ask the patient to wrinkle their eyebrows and then close their eyes tightly. Assessment is performed as follows: 1. It should appear symmetric. 4. which has important clinical implications. The right and left upper motor neurons (UMNs) each innervate both the right and left lower motor neurons (LMNs) that allow the forehead to move up and down. That is: a. 172 . CN7 (Facial): This nerve innervates many of the muscles of facial expression. Ask the patient to puff out their cheeks. First look at the patient’s face. 3. The corners of the mouth should be at the same height If there is any question as to whether an apparent asymmetry if new or old. which controls the muscles which open the lid). Ask the patient to smile. Both sides should puff equally and air should not leak from the mouth. The corners of the mouth should rise to the same height and equal amounts of teeth should be visible on either side.

However.Facial Nerve Precise Pattern of Innervation Thus. the patient would be able to wrinkle their forehead on both sides of their face. CN7 . 173 . the patient would be unable to effectively close their left eye or raise the left corner of their mouth. UMN dysfunction: This might occur with a central nervous system event. as the left CN 7 UMN cross innervates the R CN 7 LMN that controls this movement. the pattern of weakness or paralysis observed will differ depending on whether the UMN or LMN is affected. Specifically: 1. in the setting of CN 7 dysfunction. the LMNs that control the muscles of the lower face are only innervated by the UMN from the opposite side of the face. such as a stroke.However. In the setting of R UMN CN 7 dysfunction.

LMN) dysfunction. ability to close eye. Left peripheral CN7 dysfunction: Note loss of forehead wrinkle. ability to raise corner of mouth. LMN dysfunction: This occurs most commonly in the setting of Bell’s Palsy. This clinical distinction is very important. neuroimaging to determine etiology). an idiopathic. however. Assessment of acute central (UMN) CN 7 dysfunction would require quite a different approach (e. Left naso-labial fold is slightly less pronounced compared with right. and decreased naso-labial fold prominence on left.e. Left sided function would be normal. Bell’s Palsy (peripheral CN 7 dysfunction)tends to happen in patient’s over 50 and often responds to treatment with Acyclovir (an anti-viral agent) and Prednisone (a corticosteroid). the sound must first traverse the external canal and middle ear. In the setting of R CN 7 peripheral (i. the patient would not be able to wrinkle their forehead. 2. However as this is rarely of clinical import. Auditory acuity can be assessed very crudely on physical exam as follows: 1.g. CN8 (Acoustic): CN 8 carries sound impulses from the cochlea to the brain. close their eye or raise the corner of their mouth on the right side. 174 . is slightly lower than right. Prior to reaching the cochlea.Right central CN7 dysfunction: Note preserved abiltiy to wrinkle forehead. acute CN 7 peripheral nerve palsy. Stand behind the patient and ask them to close their eyes. Over the course of weeks or months there is usually improvement and often complete resolution of symptoms. Left corner of mouth. further discussion is not included. as central vs peripheral dysfunction carry different prognostic and treatment implications. CN 7 is also responsible for carrying taste sensations from the anterior 2/3 of the tongue.

The bones of the skull will carry the sound equally to both the right and left CN 8. 512 Hz Tuning Fork 2. Both CN 8s. Alternatively. Grasp the 512 Hz tuning fork by the stem and strike it against the bony edge of your palm. Then perform the same test for the other ear. Identification of conductive (a much more common problem in the general population) defects is determined as follows: Weber Test: 1. Alternatively you can get the fork to vibrate by "snapping" the ends between your thumb and index finger. place your fingers approximately 5 cm from one ear and rub them together. 3. 3. These tests are rather crude. Hold the stem against the patient’s skull. The patient should report whether the sound was heard equally in both ears or better on one side then the other (referred to as lateralizing to a side). The patient should be able to hear the sound generated. The conductive phase refers to the passage of sound from the outside to the level of CN 8. Hearing is broken into 2 phases: conductive and sensorineural. requires special equipment and training. The cause of subjective hearing loss can be assessed with bedside testing. in turn. 4. Sensorineural refers to the transmission of sound via CN 8 to the brain.2. along an imaginary line that is equidistant from either ear. Repeat for the other ear. This includes the transmission of sound through the external canal and middle ear. will transmit the impulse to the brain. Precise quantification. 175 . The patient should be able to repeat these back accurately. generating a continuous tone. Whisper a few words from just behind one ear. generally necessary whenever there is a subjective decline in acuity.

on the basis of history. 3. there should be a complaint of hearing decline in one or both ears. the patient should be able to again hear the sound. 2. The above testing is reserved for those instances when a patient complains of a deficit in hearing. 4. the bony prominence located immediately behind the lower part of the ear.Weber Test Rinne Test: 1. Rinne Test Interpretation: 1. When this occurs. 176 . The vibrations travel via the bones of the skull to CN 8. Ask the patient to inform you when they can no longer appreciate the sound. Place the stem of the tuning fork on the mastoid bone. At this point. move the tuning fork such that the tines are placed right next to (but not touching) the opening of the ear. generating a continuous tone. allowing the patient to hear the sound. This is because air is a better conducting medium then bone. Thus. Grasp the 512 Hz tuning fork by the stem and strike it against the bony edge of your palm.

If there is a conductive hearing deficit. sound generated by the vibrating tuning fork and traveling to CN 8 by means of bony conduction is better heard as it has no outside “competition. the sound will be heard on that side. a protective mechanism which prevents food or liquid from traveling into the lungs As both CNs contribute to these functions. Thus. there will still be a marked hearing decrement in the affected ear. If there is a sensorineural deficit. the Webber test will lateralize (i. This is because the problem is at the level of CN 8. the Webber will lateralize to the affected ear. 5. Thus.g. BC will be greater then or equal to AC in the affected ear. In the setting of conductive hearing loss. 3. it cannot then be carried to the brain due to the underlying nerve dysfunction. air conduction will still be better then bone conduction (i. regardless of the means (bone or air) by which the impulse gets to CN 8. a tumor of CN 8).e. In the setting of a sensorineural hearing loss. this will still be the case.2. 2. If you do this while performing the Webber test. the patient will note BC to be better then or equal to AC in the ear with the subjective decline in hearing. sound will be heard better)in the ear that has the subjective decline in hearing. If there is a blockage in the passageway (e. the normal pattern will be retained). If there is a sensorineural hearing deficit. even though the bones of the skull will successfully transmit the sound to CN 8. 4. Perform the Rinne test. For more information about CN 8. this data is interpreted as follows: 1. wax) that carries sound from the outside to CN 8. This is because when there is a problem with conduction. If there is a conductive hearing deficit. wax in the external canal). This is because CN 8 is the final pathway through which sound is carried to the brain. Summary: Identifying conductive v sensorineural hearing deficits requires historical information as well as the results of Webber and Rinne testing. bone conduction (BC) will be better then air conduction (AC) when assessed by the Rinne Test. then sound will be better heard when it travels via the bones of the skull. Thus. they are tested together. First determine by history and crude acuity testing which ear has the hearing problem. In the setting of a sensorineural hearing loss (e. the Webber test will lateralize to the ear which does not have the subjective decline in hearing. the Webber will lateralize to the normal ear. 177 . Perform the Webber test. see the following links: CN9 (Glosopharyngeal) and CN 10 (Vagus): These nerves are responsible for raising the soft palate of the mouth and the gag reflex. In the setting of a conductive hearing loss (e.g.” You can transiently create a conductive hearing loss by putting the tip of your index finger in the external canal of one ear.e. In summary.g. 3. AC will be greater then BC in the affected ear. As AC is normally better then BC. competing sounds from the outside cannot reach CN 8 via the external canal. Thus.

Testing Elevation of the soft palate: 1.e. 178 . 2. a midline structure hanging down from the palate. “ahhhh. Be aware that other processes can cause deviation of the uvula. Uvula therefore pulled over towards right. the uvula will be pulled to the left. Left CN9 Dysfunction: Patient status post stroke affecting left CN9.g.” causing the soft palate to rise upward. for example. will push the uvula towards the opposite (i. in the setting of a stroke). normal) tonsil. Ask the patient to open their mouth and say. Look at the uvula. take a tongue depressor and gently push it down and out of the way. 3. The Uvula should rise up straight and in the midline. The opposite occurs in the setting of left CN 9 dysfunction. If the tongue obscures your view.A peritonsilar abscess. Normal Oropharynx Interpretation: If CN 9 on the right is not functioning (e.

Left peritonsillar abscess: infection within left tonsil has pushed uvula towards the right. Testing the Gag Reflex: 1. Ask the patient to widely open their mouth. If you are unable to see the posterior pharynx (i.e. the back of their throat), gently push down with a tongue depressor. 2. In some patients, the tongue depressor alone will elicit a gag. In most others, additional stimulation is required. Take a cotton tipped applicator and gently brush it against the posterior pharynx or uvula. This should generate a gag in most patients. 3. A small but measurable percent of the normal population has either a minimal or non-existent gag reflex. Presumably, they make use of other mechanisms to prevent aspiration. Gag testing is rather noxious. Some people are particularly sensitive to even minimal stimulation. As such, I would suggest that you only perform this test when there is reasonable suspicion that pathology exists. This would include two major clinical situations: 1. If you suspect that the patient has suffered acute dysfunction, most commonly in the setting of a stroke. These patients may complain of/be noted to cough when they swallow. Or, they may suffer from recurrent pneumonia. Both of these events are signs of aspiration of food contents into the passageways of the lungs. These patients may also have other cranial nerve abnormalities as lesions affecting CN 9 and 10 often affect CNs 11 and 12, which are anatomically nearby. 2. Patient’s suffering from sudden decreased level of consciousness. In this setting, the absence of a gag might indicate that the patient is no longer able to reflexively protect their airway from aspiration. Strong consideration should be given to intubating the patient, providing them with a secure mechanical airway until their general condition improves. CN 9 is also responsible for taste originating on the posterior 1/3 of the tongue. As this is rarely a clinically important problem, further discussion is not included.

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CN 10 also provides parasympathetic innervation to the heart, though this cannot be easily tested on physical examination. CN11 (Spinal Accessory): CN 11 innervates the muscles which permit shrugging of the shoulders (Trapezius) and turning the head laterally (Sternocleidomastoid). 1. Place your hands on top of either shoulder and ask the patient to shrug while you provide resistance. Dysfunction will cause weakness/absence of movement on the affected side.

2. Place your open left hand against the patient’s right cheek and ask them to turn into your hand while you provide resistance. Then repeat on the other side. The right Sternocleidomasoid muscle (and thus right CN 11) causes the head to turn to the left, and vice versa.

CN12 (Hypoglossal): CN 12 is responsible for tongue movement. Each CN 12 innervates one-half of the tongue. Testing: 1. Ask the patient to stick their tongue straight out of their mouth.

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2. If there is any suggestion of deviation to one side/weakness, direct them to push the tip of their tongue into either cheek while you provide counter pressure from the outside.

Interpretation: If the right CN 12 is dysfunctional, the tongue will deviate to the right. This is because the normally functioning left half will dominate as it no longer has opposition from the right. Similarly, the tongue would have limited or absent ability to resist against pressure applied from outside the left cheek.

Left CN 12 Dysfunction: Stroke has resulted in L CN 12 Palsy. Tongue therefore deviates to the left. Sensory and Motor Examinations – A Brief Review of Anatomy and Physiology: Testing of motor and sensory function requires a basic understanding of normal anatomy and physiology. In brief: 1. Voluntary movement begins with an impulse generated by cell bodies located in the brain.

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2. Signals travel from these cells down their respective axons, forming the Cortiospinal (a.k.a. Pyramidal) tract. At the level of the brain stem, this motor pathway crosses over to the opposite side of the body and continue downward on that side of the spinal cord. The nerves which comprise this motor pathway are collectively referred to as Upper Motor Neurons (UMNs). It’s important to note that there are other motor pathways that carry impulses from the brain to the periphery and help modulate movement. A discussion of these tracts can be found in other Neurology reference texts. 3. At a specific point in the spinal cord the axon synapses with a 2nd nerve, referred to as a Lower Motor Neuron (LMN). The precise location of the synapse depends upon where the lower motor neuron is destined to travel. If, for example, the LMN terminates in the hand, the synapse occurs in the cervical spine (i.e. neck area). However, if it’s headed for the foot, the synapse occurs in the lumbar spine (i.e. lower back). 4. The UMNs are part of the Central Nervous System (CNS), which is composed of neurons whose cell bodies are located in the brain or spinal cord. The LMNs are part of the Peripheral Nervous System (PNS), made up of motor and sensory neurons with cell bodies located outside of the brain and spinal cord. The axons of the PNS travel to and from the periphery, connecting the organs of action (e.g. muscles, sensory receptors) with the CNS. 5. Nerves which carry impulses away from the CNS are referred to Efferents (i.e. motor) while those that bring signals back are called Afferents (i.e. sensory). 6. Axons that exit and enter the spine at any given level generally connect to the same distal anatomic area. These bundles of axons, referred to as spinal nerve roots, contain both afferent and efferent nerves. The roots exit/enter the spinal cord through neruoforamina in the spine, paired openings that allow for their passage out of the bony protection provided by the vertebral column. 7. As the efferent neurons travels peripherally, components from different roots commingle and branch, following a highly programmed pattern. Ultimately, contributions from several roots may combine to form a named peripheral nerve, which then follows a precise anatomic route on its way to innervating a specific muscle. The Radial Nerve, for example, travels around the Humerus (bone of the upper arm), contains contributions from Cervical Nerve Roots 6, 7 and 8 and innervates muscles that extend the wrist and supinate the forearm. It may help to think of a nerve root as an electrical cable composed of many different colored wires, each wire representing an axon. As the cable moves away from the spinal cord, wires split off and head to different destinations. Prior to reaching their targets, they combine with wires originating from other cables. The group of wires that ultimately ends at a target muscle group may therefore have contributions from several different roots. For more information about radial nerve anatomy and function, see below. 8. Afferents carry impulses in the opposite direction of the motor nerves. That is, they bring information from the periphery to the spinal cord and brain. 9. Sensory nerves begin in the periphery, receiving input from specialized receptor organs. The axons then move proximally, joining in a precise fashion with other axons to form the afferent component of a named peripheral nerve. The Radial 182

For more information about sensory pathways. on the other hand. identifying which root(s) is dysfunctional. Understanding the above neruo-anatomic relationships and patterns of innervation has important clinical implications when trying to determine the precise site of neurological dysfunction. crossing over only when they reach the brain stem (see following sections for detailed descriptions). not only has a motor function (described previously) but also carries sensory information from discrete parts of the hand and forearm. where the impulses are integrated and perception occurs. leading to partial motor or sensory deficits. Each root carries sensory information from a discrete area of the body. Also. Sensory Testing Sensory testing of the face is discussed in the section on Cranial Nerves. and travel up to the brain on that side of the cord. They travel from the periphery. Sensory input travels up through the spinal cord along specific paths. Injury at the spinal nerve root level. see the following link: 11. This will differ from that caused by a problem at the level of the peripheral nerve. view a dermatomal map. temperature and crude touch. Testing of the extremities focuses on the two main afferent pathways: Spinothalamics and Dorsal Columns. cross to the opposite side of the spinal cord soon after entering. The area of skin innervated by a particular nerve root is referred to as a dermatome. As the sensory neurons approach the spinal cord. An approach to localizing lesions on the basis of motor and sensory findings is described in the sections which follow. This can be mapped out during a careful exam (see below). the specific area supplied by that root will be affected. for example. Spinothalamics: These nerves detect pain.Nerve. Realize that there is a fair amount of inter-individual variation with regards to the specifics of innervation. 1. 183 . In the setting of nerve root dysfunction. the patterns of loss are rarely as “pure” as might be suggested by the precise descriptions of nerves and their innervations. Dermatome maps describe the precise areas of the body innervated by each nerve root. will produce a characteristic loss of sensory and motor function. which is clinically important. 10. the sensory nerves terminate in the brain. for example. enter the cord and travel up the same side. for example. they join specific spinal nerve roots. enter the spinal cord and then cross to the other side of the cord within one or two vertebral levels of their entry point They then continue up that side to the brain. Ultimately. recognize that often only parts of nerves may become dysfunctional. These distributions are more or less the same for all people. Nerves carrying pain impulses. As such. Vibratory sensations. with the precise route defined by the type of sensation being transmitted. terminating in the cerebral hemisphere on the opposite side of the body from where they began.

Ask the patient to close their eyes so that they are not able to get visual clues. vibratory sensation and light touch. They travel from the periphery. If they give accurate responses.2. Upon reaching the brain stem they cross to the opposite side. such that you create a sharp. 5. the soft end of a q-tip). entering the spinal cord and then moving up to the base of the brain on the same side of the cord as where they started. I would discourage the use of the pointy. Start at the top of the foot. Alternatively.k. it’s possible (if the tip were not well cleaned) to transmit blood borne infections from one patient to another. This clarifies for the patient what you are defining as sharp and dull. break a Q-tip or tongue depressor in half. 184 . pointy end. though this would only be of utility if the patient complained of numbness/impaired sensation in that area. The same test can be repeated for the upper extremities (i. A screening evaluation of these pathways can be performed as follows: Spinothalamics 1. The patient's ability to perceive the touch of a sharp object is used to assess the pain pathway of the Spinothalamics. If. Move medially across the top of the foot.g. do the same on the other foot. asking them to report their response. Dorsal Columns: These nerves detect position (a. 4. 2. for example. Orient the patient by informing them that you are going to first touch them with the sharp implement. To do this. noting their response to each touch. Better to use a disposable implement. Then do the same with a nonsharp object (e. metal spikes that accompany some reflex hammers. you can use a disposable needle as the sharp-ended probe. Now. touch the lateral aspect of the foot with either the sharp or dull tool.a.e. proprioception). on the hand). 3. terminating in the cerebral hemisphere on the opposite side of the body from where they began. you used this and caused bleeding.

185 .g. Grasp either side of the great toe. Orient the patient as to up and down. If the patient is unable to correctly identify the movement/direction. They should be able to correctly identify the movement and direction. Similar testing can be done on the fingers. Testing Proprioception 3. 5. Flex the toe (pull it upwards) while telling the patient what you are doing. This is usually reserved for those settings when patients have distal findings and/or symptoms in the upper extremities. the hands). Then extend the toe (pull it downwards) while again informing them of which direction you are moving it. Thus.g. 4. Technique: 1.Dorsal Columns Proprioception: This refers to the body’s ability to know where it is in space. disorders which affect this system tend to first occur at the most distal aspects of the body. the findings generated from testing this system should corroborate those of proprioception (see above). If normal. Vibratory Sensation: Vibratory sensation travels to the brain via the dorsal columns. Alternately deflect the toe up or down without telling the patient in which direction you are moving it. no further testing need be done in the screening exam. if abnormal. Ask the patient to close their eyes so that they do not receive any visual cues. test whether they can determine whether the foot is moved up or down at the ankle). more proximally (e.g. As such. to the ankle joint) and repeat (e. Similar to the Spinothalamic tracts. proprioception is checked first in the feet and then. move more proximally (e. it contributes to balance. 2. Thus. Both great toes should be checked in the same fashion.

The patient should be able to determine when the vibration stops. You will need a 128 hz tuning fork. 3. 6. If you want to move 186 . Grasp the tuning fork by the stem and strike the forked ends against the heel of your hand. Testing vibratory sensation 5. Place the stem on top of the interphalangeal joint of the great toe. 4. causing it to vibrate. Start at the toes with the patient seated.Technique: 1. Put a few fingers of your other hand on the bottom-side of this joint. Ask the patient if they can feel the vibration. which will correlate with when you are no longer able to feel it transmitted through the joint. It sometimes takes a while before the fork stops vibrating. Ask the patient to close their eyes so that they do not receive any visual cues. 128 Hz tuning fork 2. You should be able to feel the same sensation with your fingers on the bottom side of the joint.

injury to the radial nerve). Technique: 1. While not checked routinely. Small wounds can become large and infected. Sensory testing as described above can detect this type of problem. Testing can be done with a paperclip. it is useful test if a discrete peripheral neruropathy is suspected (e. 2.things along. Repeat testing on the other foot. The patient should be able to correctly identify whether you are touching them with one or both ends simultaneously. along the entire distribution of the specific nerve which is being assessed. Monofiliment 187 . unbeknownst to the insensate patient. anyone with Diabetes). Loss of sensation in this area can be particularly problematic as the feet are a difficult area for the patient to evaluate on their own.g. Additional/Special Testing for Dorsal Column Dysfunction Testing Two Point Discrimination: Patients should normally be able to distinguish simultaneous touch with 2 objects which are separated by at least 5mm.g. These stimuli are carried via the Dorsal Columns. opened such that the ends are 5mm apart. Disposable monofilaments (known as the Semmes-Weinstein Aethesiometer) are specially designed for a screening evaluation. rapidly dampening the vibration. Special Testing for Early Diabetic Neuropathy: A careful foot examination should be performed on all patients with symptoms suggestive of sensory neuropathy or at particular risk for this disorder (e. rub the index finger of the hand holding the fork along the tines. These small nylon fibers are designed such that the normal patient should be able to feel the ends when they are gently pressed against the soles of their feet.

then sensation is impaired. Interpretation: If the examiner has to supply enough pressure such that the filament bends prior to the patient being able to detect it. 3. Avoid calluses. Monofiliment testing: Patients with normal sensation should be able to detect the monofiliment when it is lightly applied (picture on left). they likely suffer from sensory neuropathy. Patient’s with distal sensory neuropathy should carefully examine their feet and wear good fitting shoes to assure that skin breakdown and infections don’t develop. Efforts should also be made to closely control their diabetes so that the neuropathy does not progress. Touch the monofilament to 5-7 areas on the bottom of the patient's foot. Pick locations so that all of the major areas of the sole are assessed. which are relatively insensate. 188 . If the force required to provoke a sensory response is strong enough to bend the monofiliment (picture on right). The patient should be able to detect the filament when the tip is lightly applied to the skin. 2.Technique: 1. Testing should be done in multiple spots to verify the results. Have the patient close their eyes so that they do not receive any visual cues.

As the examiner tests more proximally. the feet are the first area to be affected. In this setting. As it is a systemic disease. for example. at least in Western countries. indicating normal function of the spinothalamic pathway. This might. Patients should be able to correctly distinguish sharp sensation. as the area involved covers an entire distal region. Mapping out regions of impaired sensation: The examination described above is a screening evaluation for evidence of sensory loss. Thus. occur as the result of trauma or infarction (another complication of diabetes). the sensory nerves become dysfunctional. you can simultaneously consult a reference book to see if the mapped territory matches a specific nerve distribution. Motor function would also be affected (see under motor exam). When this occurs. the sensory loss does not follow a dermatomal (i. This is perfectly adequate in most clinical settings. When control has been poor over many years. Radial nerve palsy. there will be a pattern of sensory impairment that follows the distribution of the nerve. he/she will ultimately reach a point where sensation is again normal.Neuropathic Ulcer: Large ulcer has developed in this patient with severe diabetic neuropathy. spinal nerve root) or peripheral nerve distribution. Such deficits may be associated with neuropathic pain. though much less commonly then feet as the nerves traveling to the legs are longer and thus at much greater risk. Interpreting Results of Sensory Testing Patterns of Impairment for the Spinothalamic Tracts: 1. is Diabetes. Thus. Peripheral Nerve Distribution: A specific peripheral nerve can become dysfunctional. 2. On a practical level. a continuous burning sensation affecting the distal extremity. using careful pin testing to define the medial/lateral and proximal/distal boundaries of the affected region. the higher up the leg this will occur. most clinicians don’t commit 189 . This type of mapping is somewhat tedious and should only be done in appropriate situations. it occurs simultaneously in both limbs. Exam reveals loss of ability to detect the sharp stimulus across the entire foot. 3. Hands can be affected. The resultant sensory loss would involve the back of the hand and forearm. Pinning down the culprit nerve requires knowledge of nerve anatomy and innervation. it is important to try and map out the territory involved.e. the normal means by which we prevent nerves from being exposed to constant direct pressure. can occur if an intoxicated person falls asleep in a position that puts pressure on the nerve as it travels around the Humerus (bone of the upper arm). much as a sock or glove would cover a foot or hand. the history or screening examination will suggest a discrete anatomic region that has sensory impairment. This pattern of loss is referred to as a Stocking or Glove distribution impairment. 4. Intoxication induced loss of consciousness then prevents the patient from reflexively changing position. Diffuse Distal Sensory Loss: A number of chronic systemic diseases affect nerve function. Occasionally. This first affects the most distal aspects of the nerves and then moves proximally. The more advanced the disease. You may even make pen marks on the skin to clearly identify where the changes occur. The most commonly occurring of these. As most clinicians have not memorized the distributions of all peripheral nerves or spinal nerve roots. for example.

this to memory. multiple sacral and lumbar roots become compressed bilaterally (e. Patients should be able to detect the initial vibration and accurately determine when it has stopped. and then look it up in a reference book. they gather a history suggestive of a discrete nerve deficit. dorsal column dysfunction tends to first affect the most distal aspects of the system. Rather. Ability to detect pin pricks in the perineal area (a. most clinicians do not memorize the dermatomes related to each nerve root. As mentioned under peripheral nerve dysfunction. In the setting of Dorsal Column dysfunction (a common complication of diabetes. 6.g. This would cause sensory loss along the lateral aspect of the lower leg and the bottom of the foot. serving the anus and rectum. Only the leg on the affected side would have this deficit. Nerve Root Impairment: A nerve root (or roots) can be damaged as it leaves the cord. inability to defecate/urinate. which can be appreciated on rectal exam. Patterns of Impairment for Dorsal Column Dysfunction: Proprioception: Patients should be able to correctly identify the motion and direction of the toe. verify a dermatomal distribution of loss on exam. which can in turn be identified on examination. can be compressed by herniated disc material in the lumbar spine. and then look it up in a reference book. for example). verify the territory of loss on exam. for example. etc) this is omitted in the screening exam. as the lower motor neurons carried in these sacral nerve roots no longer function.k. Thus there is no way to send an impulse to the bladder instructing it to contract. For practical reasons (i. Rather. This is similar to the pattern of injury which affects the Spinothalamic tracts described above. distal testing will be abnormal. In the setting of Cauda Equina syndrome. 5. The information from sharp stimulus testing as described above should suffice. This will result in a sensory deficit along its specific distribution. fill them with the requisite temperature water. Nor will they be aware that there bladders are full. for example. The S1 nerve root. the patient is unable to urinate. or there is otherwise reason to suspect that these roots may be compromised. by posteriorly herniated disc material or a tumor). the patient is either unable to detect the vibration or they perceive that the sensation 190 . Testing of the sacral nerve roots. 7.e. The Spinothalamics are also responsible for temperature discrimination. 2. When this occurs. Vibratory Sensation: 1.a. When this occurs. As described under testing of proprioception. Temperature discrimination could be assessed as a means of verifying any abnormality detected on sharp/dull testing. There will also be loss of anal spincter tone. they gather a history suggestive of a discrete nerve deficit. it’s often hard to find test tubes. is important if patients complain of incontinence. saddle distribution) is also diminished.

extinguishes too early (i. you will get a sense of the normal range for given age groups. Muscle groups should appear symmetrically developed when compared with their counterparts on the other side of the body. The patient should be in a gown so that the areas of interest are exposed. 191 . Palpation of the muscles will give you a sense of underlying mass. The largest and most powerful groups are those of the quadriceps and hamstrings of the upper leg (i. for example. sex. factoring in their particular activity levels and overall states of health. after making allowances for the patient’s age. they stop feeling it even though you can still appreciate the sensation with your fingers on the underside of the joint). sex and the activity/fitness level of the individual. Normal motor function depends on intact upper and lower motor neurons. sensory pathways and input from a number of other neurological systems. Things to look for: 1. 2. A frail elderly person. Motor Testing The muscle is the unit of action that causes movement. as both sensations travel via the same pathway. front and back of the thighs).e. and activity level. 3. They should also be appropriately developed. The findings on vibratory testing should parallel those obtained when assessing proprioception. will have less muscle bulk then a 25 year old body builder. Muscle Bulk and Appearance: This assessment is somewhat subjective and quite dependent on the age. Disorders of movement can be caused by problems at any point within this interconnected system. carefully examine the major muscle groups of the upper and lower extremities.e. With experience. Using your eyes and hands.

g. Does the asymmetry follow a particular nerve distribution. 3. If there is asymmetry. However. easily distinguishing it from PD. myositis (a rare condition characterized by idiopathic muscle inflammation) causes the patient to experience weakness but not pain. Remember that some allowance must be made for handedness (i. 4. for example. deltoids. mobility. muscles which lose their LMN inervation become very atrophic. involuntary muscle activity that results in limb movement. There should be no muscle movement when the limb is at rest. This causes twitching of the fibers known as fasciculations. etc. 7. The major muscle groups to be palpated include: biceps. Amyotrophic Lateral Sclerosis) result in death of the lower motor neuron and subsequent denervation of the muscle. Interestingly. 192 . Parkinson’s Disease (PD). Palpation should not elicit pain. For more information about Parkinson's Disease. Rare disorders (e.Muscle Assymetry While both legs have well developed musculature. quadriceps and hamstrings. triceps. persists throughout movement and is not associated with any other neurological findings. NIH Sponsored Site About Parkinson's Disease 6.e. Is there another process (suggested by history or other aspects of the exam) that has resulted in limited movement of a particular limb? For example. a broken leg that has recently been liberated from a cast will appear markedly atrophic. see the following link: 5. Is the bulk in the upper and lower extremities similar? Spinal cord transection at the Thoracic level will cause upper extremity muscle bulk to be normal or even increased due to increased dependence on arms for activity. the muscles of the lower extremity will atrophy due to loss of innervation and subsequent disuse. right v left hand dominance). Benign Essential Tremor. suggesting a peripheral motor neuron injury? For example. can cause a very characteristic resting tremor of the hand (the head and other body parts can also be affected) that diminishes when the patient voluntarily moves the affected limb. the left has greater bulk. Tremors are a specific type of continuous. note if it follows a particular pattern.which can be seen on gross inspection of affected muscles. on the other hand.

generating a ratchet-like sensation (known as cog wheeling) when the affected limbs are passively moved by the examiner. The EPS normally contributes to initiation and smoothness of movement. The quadriceps group. 2. 4. it is reasonable to limit this assessment to only the major joints. 2. Strength: As with muscle bulk (described above). Carefully move the limb through its normal range of motion. Degenerative joint disease of the knee. strength testing must take into account the age. compare left and right thenar eminences. PD causes increased tone. sex and fitness level of the patient. In this setting. a frail. If the patient has recently injured the area or are in pain. A number of disease states may alter this sensation. which occurs when the upper motor neuron no longer functions. hips and knees. which results in the death of the upper motor neuron cell body in the brain. elbow. 193 . After performing this exam on a number of patients. Disorders that do not directly affect the muscles. Flaccidness is the complete absence of tone. Increased tone (hypertonicity) results from muscle contraction. In particular. upper or lower motor neurons can still alter tone. Tone: When a muscle group is relaxed. Interpretation must also consider the expected strength of the muscle group being tested. For example. the affected limb is held in a flexed position and the examiner may be unable to move the joint. At the extreme end is spasticity. for example. particularly the elderly. being careful not to maneuver it in any way that is uncomfortable or generates pain. the examiner should be able to easily manipulate the joint through its normal range of motion. might cause limited range of motion. This occurs when the lower motor neuron is cut off from the muscles that it normally innervates. This is a disorder of the Extra Pyramidal System (EPS). This is seen most commonly following a stroke. often have other medical conditions that limit joint movement. for example.Diffuse Muscle Wasting: Note loss muscle bulk in left hand due to peripheral denervation. 3. Normal muscle generates some resistance to movement when a limb is moved passively by an examiner. For the screening examination. Perhaps the most common of these is Parkinson’s Disease (PD). shoulder. Be aware that many patients. Technique: 1. though tone should still be normal. 3. do not perform this aspect of the exam. should be much more powerful then the Biceps. bed bound patient may have muscle weakness due to severe deconditioning and not to intrinsic neurological disease. elderly. Ask the patient to relax the joint that is to be tested. This movement should feel fluid. including: wrist.you’ll develop an appreciation for the range of normal tone. Things to look for: 1.

along with their precise innervations can be found in a Neurology reference text.There is a 0 to 5 rating scale for muscle strength: 0/5 1/5 2/5 No movement Barest flicker of movement of the muscle. More detailed testing can be performed in the setting of discrete/unexplained weakness. Voluntary movement capable of overcoming gravity.. Intrinsic muscles of the hand (C 8. 194 . innervated by the Ulnar Nerve. with your fingers placed in between each of their digits (adduction). but not any applied resistance. The names of the major muscles/muscle groups along with the spinal roots and peripheral nerves that provide their innervation are provided below. it is reasonable to check only the major muscles/muscle groups. allowing for internal consistency and interpretability of serial measurements. Thus. Voluntary movement which is not sufficient to overcome the force of gravity. Ultimately. Test each hand separately. Nerve roots providing the greatest contribution are printed in bold. The muscles which control adduction and abduction of the fingers are called the Interossei. 1. but not if any additional resistance were applied. though not enough to move the structure to which it’s attached. the patient would be able to slide their hand across a table but not lift it from the surface. T 1): Ask the patient to spread their fingers apart against resistance (abduction). with a fair amount of variability amongst clinicians. Voluntary movement capable of overcoming “some” resistance Normal strength 3/5 4/5 5/5 ‘+’ and ‘-‘ can be added to these values.Major Muscle Groups: In the screening examination. Then squeeze them together. More extensive descriptions of individual muscles and their functions. For example. Specifics of Strength Testing . it’s most important that you develop your own sense of what these gradations mean. For example. providing further gradations of strength. the patient could raise their hand off a table. a patient who can overcome “moderate but not full resistance” might be graded 4+ or 5. This is quite subjective.

The muscle groups which control flexion are innervated by the Median and Ulnar Nerves. Test each hand separately. 6.edu/atlas/abddigminimi. are toti muschii) Wrist extension (C 6. 3. 8. If the grip is normal. Test each hand separately. Wrist flexion (C 7. T 1): Have the patient try to flex their wrist as you provide resistance. For more information about finger abductors and adductors. T1): Ask the patient to make a fist. The Flexor Digitorum Profundus controls finger flexion and is innervated by the Median (radial ½) and Ulnar (medial ½) Nerves.html (important. Anatomy of finger abductors and adductors 5. University of Washington.washington. squeezing their hand around two of your fingers. see the following link: 4. 7. For more information about wrist flexors. The Extensor Radialis muscles 195 . 8.2. you will not be able to pull your fingers out. 8): Have the patient try to extend their wrist as you provide resistance. see the following links: http://www. Test each hand separately. Flexors of the fingers (C 7.rad.

control extension and are innervated by the Radial Nerve. 196 . Elbow Flexion (C 5. The Triceps is innervated by the Radial Nerve. Have the patient extend their elbow against resistance while the arm is held out (abducted at the shoulder) from the body at ninety degrees. These muscles are innervated by the Musculocutaneous Nerve. Clinical Correlate: Damage to the radial nerve results in wrist drop (loss of ability to extend the hand at the wrist). Elbow Extension (C 7. For example. Test each arm separately. This can occur via any one of a number of mechanisms. Test each arm separately. Then direct them to flex their forearm while you provide resistance. 8. the nerve can be compressed against the humerus for a prolonged period of time when an intoxicated person loses consciousness with the inside aspect of the upper arm resting against a solid object (known as a “Saturday Night Palsy”). 7. 8): The main extensor of the forearm is the triceps muscle. Have the patient bend their elbow to ninety degrees while keeping their palm directed upwards. 6): The main flexor (and supinator) of the forearm is the Brachialis Muscle (along with the Biceps Muscle).

Test each shoulder separately. 197 . Shoulder Abduction (C 5. though the Latissiumus and others contribute as well. Then provide resistance as they try to further adduct at the shoulder. 6): The deltoid muscle. is the main muscle of abduction. innervated by the axillary nerve.9. 10. Then provide resistance as they try to further abduct at the shoulder. Have the patient flex at the elbow while the arm is held out from the body at forty-five degrees. Shoulder Adduction (C 5 thru T1): The main muscle of adduction is the Pectoralis Major. Test each shoulder separately. Have the patient flex at the elbow while the arms is held out from the body at forty-five degress.

5. This movement is mediated by a number of muscles. Hip Flexion (L 2. The main hip flexor is the Iliopsoas muscle. Hip Abduction (L 4. place your hand on top of one thigh and instruct the patient to lift the leg up from the table. S1): Place your hands on the outside of either thigh and direct the patient to separate their legs against resistance. 198 . S1): With the patient lying prone. 13. The main hip extensor is the gluteus maximus.11. 3. 12. direct the patient to lift their leg off the table against resistance. Test each leg separately. 4): With the patient seated. Hip Extension (L5. innervated by inferior gluteal nerve. innervated by the femoral nerve.

4): Place your hands on the inner aspects of the thighs and repeat the maneuver. 16. 15. 2): Have the patient rest prone. Knee Extension (L 2. Flexion is mediated by the hamstring muscle group. which is innervated by the femoral nerve. 3. Test each leg separately. Extension is mediated by the quadriceps muscle group. 3.14. 199 . Knee flexion (L 5. A number of muscles are responsible for adduction. via branches of the sciatic nerve. 4): Have the seated patient steadily press their lower extremity into your hand against resistance. Hip Adduction (L 2. Then have them pull their heel up and off the table against resistance. They are innervated by the obturator nerve. S 1. Each leg is tested separately.

the patient develops “Foot Drop. make note of differences between: 1. 4. as they should more or less be equivalent (taking into account the handedness of the patient). Ankle Plantar Flexion (S 1. Right v Left Proximal muscles v distal Upper extremities v lower Or is the weakness generalized. Test each foot separately. 5): Direct the patient to pull their toes upwards while you provide resistance with your hand. The gastrocnemius and soleus. In particular.” an inability to dorsiflex the foot. below the knee). 2. Ankle Dorsiflexion (L 4. which might provide a clue as to the etiology of the observed decrease in strength. If there is weakness. suggestive of a systemic neurological disorder or global deconditioning 200 . 3. are innervated by a branch of the sciatic nerve.17. Plantar flexion and dorsiflexion can also be assessed by asking the patient to walk on their toes (plantar flexion) and heels (dorsiflexion). the muscles which mediate this movement. try to identify a pattern. The muscles which mediate dorsiflexion are innervated by the deep peroneal nerve. It is generally quite helpful to directly compare right v left sided strength. 18. If injured. Clinical Correlate: The peroneal nerve is susceptible to injury at the point where it crosses the head of the fibula (laterally. Have the patient “step on the gas” while providing resistance with your hand. Each foot is tested separately. S 2).

Compression at carpal tunnel causes carpal tunnel syndrome Lateral Cutaneous Nerve of Thigh Lateral aspect thigh L1. the arm will rotate slightly inward and down). Peripheral Sensory Nerve Innervation Back of thumb. middle. known as "Saturday Night Palsy" At risk for injury with elbow fracture. back of forearm Motor Innervation Contributing Spinal Nerve Roots Clinical Radial Nerve Wrist extension and abduction of thumb in palmer plane C6. palm below these fingers. 8 and T1 Median Nerve Palmar aspect of the thumb.e. Can get transient symptoms when inside of elbow is struck ("funny bone" distribution) Ulnar Nerve Palmar and dorsal aspects of pinky and ½ of ring finger Abduction of fingers (intrinsic muscles of hand) C7. get up and down from a seated position. Subtle weakness in either arm will cause slight downward drift and pronation of that limb (i. palms directed upward. territories of innervation. 8 At risk for compression at humerus. uses and holds their arms and hands as they enter the room. and clinical correlates. middle and ½ ring finger. and ½ ring finger. 2 Can become compressed in obese patients. index.Special Testing for subtle weakness: Subtle weakness can be hard to detect. 7. move onto the examination table. Pay attention to how the patient walks. Pronator drift is a test for slight weakness of the upper extremities. The patient should sit with both arms extended. etc. Common peripheral nerves. T1 to palm (thenar muscles). index. causing numbness over its distribution 201 . Abduction of thumb perpendicular C8.

Carpal Tunnel Induced Atrophy: Chronic. That is.. In the setting of peripheral nerve dysfunction. Physiology of Reflexes 202 . A normal appearing Thenar Eminence is demonstrated on left. Last updated 8/30/2006 . Video of findings in advanced carpal tunnel syndrome. proximal insults will cause the entire nerve distribution to be affected while more distal lesions will only impact function beyond the site of the injury. the level of the lesion will determine the extent of the deficit. The Regents of the University of California. All rights reserved. Cranial Sensory and Motor Nerves Examinations Reflex Testing Cerebellar Gait Testing Testing Making Sense of Neurological Findings home | Clinical Images | Curricular Resources | For Our Students | BioMed Library | Web Resources | SOM 201 (ICM) Course | Next Copyright ©2005. S1 anterior muscle) Can be injured with proximal fibula fracture.Peroneal Dorsiflexion of Lateral leg. leading to foot drop (inability to dorsiflex foot) This table provides information about usual patterns of innervations. Reflex Testing Reflex testing incorporates an assessment of the function and interplay of both sensory and motor pathways. top foot (tibialis of foot L4. 5. More on carpal tunnel syndrome.. There is occasionally interindividual variation. It is simple yet informative and can give important insights into the integrity of the nervous system at many different levels. severe compression of the median nerve within the carpal tunnel has led to atrophy of the Thenar muscles (hand on right).

causing pain along its entire distribution (i. 4. but still present (hypo-reflexic) Normal Super-normal (hyper-reflexic) Clonus: Repetitive shortening of the muscle after a single stimulation For more information about anatomy and physiology of reflexes. If enough pressure if placed on the nerve. When the muscle contracts. A normal response generates an easily observed shortening of the muscle. Pathologic processes affecting discrete roots or named peripheral nerves will cause the reflex to be diminished or absent. 3. the lateral aspect of the lower leg). the message is transmitted across a synapse to an appropriate lower motor neuron. Herniated disc material (a relatively common process) can put pressure on the S1 nerve root. The signal then travels down the lower motor neuron to the target muscle. usually crossing a joint.Assessment of reflexes is based on a clear understanding of the following principles and relationships: 1. whose cell body resides in the brain. The sensory and motor signals that comprise a reflex arc travel over anatomically well characterized pathways. in turn.e. At this juncture. stretch receptors contained within it generate an impulse that is carried via sensory nerves to the spinal cord. 6. causes the attached structure to move. it may no longer function. 2. The specific nerve roots that comprise the arcs are listed for each of the major reflexes described below. the tendon pulls on the bone. they will 203 . causing the attached structure to move. the patient may develop weakness or even complete loss of function of the muscles innervated by the nerve root. The Achilles Reflex (see below) is dependent on the S1 and S2 nerve roots. Regardless of the hammer type. proper technique is critical. The larger hammers have weighted heads. such that if you raise them approximately 10 cm from the target and then release. This. also provides input to this synapse. 5. causing a loss of the Achilles reflex. see the following link: Technique The Reflex Hammer You will need to use a reflex hammer when performing this aspect of the exam. Tendons connect muscles to bones. An upper motor neuron. a medical emergency mandating surgical decompression. In extreme cases. This can obviously be of great clinical significance. The vigor of contraction is graded on the following scale: 0 1+ 2+ 3+ 4+ No evidence of contraction Decreased. A number of the most commonly used models are pictured below. When the tendon is struck by the reflex hammer.

You will probably need to support the bottom of the foot with your hand. While this is done firmly. S2 – Sciatic Nerve): 1. Simply move on to another aspect of the exam. neither stretched nor contracted). for example. Identify the Achilles tendon. 204 . stroke. arrange the legs in a frog-type position. due to other medical problems (e. “step on the gas”). confirming its precise location.e. you should be able to both see and feel the cord like tendon. 3. ask the patient to plantar flex (i. Or. crossing one leg over the other in a figure 4. contract their Biceps muscle) while you simultaneously palpate the fossa. 4.e. If this occurs. Strike the tendon with a single. Technique: 1. have some difficulty identifying the Biceps tendon within the Antecubital Fossa. failing that. Ask the patient to flex their forearm (i. This grading system is rather subjective. ask the patient to contract the muscle to which it is attached. You may. feet dangling over the edge of the exam table.g. This is most easily done with the patient seated. If you are having trouble locating the tendon. Specifics of Reflex Testing – The peripheral nerves and contributing spinal nerve roots that form each reflex arc are listed in parentheses: Achilles (S1. discrete. you’ll have a greater sense of how to arrange your own scale. Occasionally.swing into the tendon with adequate force. cord-like structure running from the heel to the muscles of the calf. it should not elicit pain. When the muscle shortens. As you gain more experience. The muscle group to be tested must be in a neutral position (i. The extremity should be positioned such that the tendon can be easily struck with the reflex hammer. severe arthritis). The Biceps tendon should become taut and thus readily apparent. brisk. The tendon attached to the muscle(s) which is/are to be tested must be clearly identified. 3. Additional levels of response can be included by omitting the ‘+’ or adding a ‘-‘ to any of the numbers. Achilles Tendon:Tendon is outlined in pen on left. 2. If they cannot maintain this position. Position the foot so that it forms a right angle with the rest of the lower leg. 2.e. you will not be able to position the patient’s arm in such a way that you are able to strike the tendon. If you are unsure. which will cause the calf to contract and the Achilles to become taut. grasped by forceps (gross dissection) on right. The smaller hammers should be swung loosely between thumb and forefinger. do not cause the patient discomfort. have them lie supine. a taut.

Positions for Checking Achilles Reflex Patellar (L3. Strike the tendon directly with your reflex hammer. Be sure that the calf if exposed so that you can see the muscle contract. move into your supporting hand). L4 – Femoral Nerve): 205 .e.4. A normal reflex will cause the foot to plantar flex (i.

(gross dissection)on right. Patellar Tendon: Outlined in pen on left. Identify the patellar tendon.g. This is most easily done with the patient seated. place your index finger firmly on top of it.e. ask the patient to extend their knee. 2. which should then transmit the impulse. If they cannot maintain this position. broad band of tissue extending down from the lower aspect of the patella (knee cap). This causes the quadriceps (thigh muscles) to contract and makes the attached tendon more apparent.1. if there is a lot of subcutaneous fat). 3. seated patient 206 . feet dangling over the edge the exam table. Patellar Reflex Testing. a thick. If you are not certain where it’s located. Strike your finger. If you are having trouble identifying the exact location of the tendon (e. on their backs). have them lie supine (i. Strike the tendon directly with your reflex hammer.

Then strike the tendon as described above. This is most easily done with the patient seated. support the back of their thigh with your hands such that the knee is flexed and the quadriceps muscles relaxed. The tendon will look and feel like a thick cord. To do this. C6 – Musculocutaneous Nerve): 1. have the patient flex at the elbow while you observe and palpate the antecubital fossa. Biceps (C5. the lower leg will extend at the knee. Identify the location of the biceps tendon. Biceps Tendon:Tendon is outlined in pen on left. Patellar Reflex. For the supine patient. grasped by forceps (gross dissection) on right. 207 . In the normal reflex. Make sure that the quadriceps are exposed so that you can see muscle contraction. 2. supine patient 5.4.

Biceps Reflex Testing. Biceps Reflex Testing b.arm supported 4. 6. Make sure that the patient’s sleeve is rolled up so that you can directly observe the muscle as well as watch the lower arm for movement. The patient’s arm can be positioned in one of two ways: a. and vice versa). Allow the arm to rest in the patient’s lap. such that your thumb is resting directly over the biceps tendon (hold their right arm with your right. It may be difficult to direct your hammer strike such that the force is transmitted directly on to the biceps tendon. place your thumb on the tendon and strike this digit. Make sure that the biceps muscle is completely relaxed. Support the arm in yours. 208 .3. place your index or middle fingers firmly against the tendon and strike them with the hammer. If the arm is unsupported. A normal response will cause the biceps to contract. If you are supporting the patient’s arm. and not dissipated amongst the rest of the soft tissue in the area. 5. forming an angle of slightly more then 90 degrees at the elbow. drawing the lower arm upwards.

C6 – Radial Nerve): 1. The lower arm should be resting loosely on the patient’s lap. 2. 3. Brachioradialis Reflex 209 . hitting anywhere in the right vicinity will generate the reflex. This is most easily done with the patient seated. grasped by forceps (gross dissection) on right. Strike this area with your reflex hammer. Usually. The tendon crosses the radius (thumb side of the lower arm) approximately 10 cm proximal to the wrist. which makes this reflex a bit tricky to elicit. Brachioradialis Tendon: Tendon is outlined in pen on left. The tendon of the Brachioradialis muscle cannot be seen or well palpated.Brachioradialis (C5.

located on the back of the upper arm. ask the patient to extend their lower arm at the elbow while you observe and palpate in the appropriate region. Gently pull the arm out from the patient’s body. Identify the triceps tendon. The lower arm should dangle directly downward at the elbow. Triceps Reflex. (gross dissection) on right. Triceps Tendon:Tendon is outlined in pen on left. 3. The arm can be placed in either of 2 positions: a. arm supported 210 . A normal reflex will cause the lower arm to flex at the elbow and the hand to supinate (turn palm upward). Triceps (C7. Observe the lower arm and body of the Brachioradialis for a response. This is most easily done with the patient seated. 2. broad structure that can be palpated (and often seen) as it extends across the elbow to the body of the muscle. such that it roughly forms a right angle at the shoulder. If you are having trouble clearly identifying the tendon. a discrete.4. C8 – Radial Nerve): 1.

6. The normal reflex will cause the lower arm to extend at the elbow and swing away from the body. the reflexes are actually diminished. resulting in hyperactive reflexes. for example.b. Making Clinical Sense of Reflexes: Normal reflexes require that every aspect of the system function normally. the arm will not move but the muscle should shorten vigorously . the reflex dependent on this nerve will be absent. Have the patient place their hands on their hips. Either of these techniques will allow the triceps to completely relax. place your index or middle finger firmly against the structure. Make sure that the triceps is uncovered. a peripheral motor neuron is transected as a result of trauma. Disorders in the sensory limb will prevent or delay the transmission of the impulse to the spinal cord. strike this area directly with your hammer. A similar pattern is seen with the death of the cell 211 . Triceps Reflex. is a relatively common reason for loss of reflexes. Breakdowns cause specific patterns of dysfunction. 3. Abnormal lower motor neuron (LMN) function will result in decreased or absent reflexes. Diabetes induced peripheral neuropathy (the most common sensory neuropathy seen in developed countries). 5. the arc receiving input from this nerve becomes disinhibited. with hyper-reflexia developing several weeks later. These are interpreted as follows: 1. If the upper motor neuron (UMN)is completely transected. If the target is not clearly apparent or the tendon is surrounded by an excessive amount of subcutaneous fat (which might dissipate the force of your strike). as might occur in traumatic spinal cord injury. arm unsupported 4. immediately following such an injury. If. 2. If the patient’s hands are on their hips. Of note. for example. This causes the resulting reflex to be diminished or completely absent. If you are certain as to the precise location of the tendon. Then strike your finger. so that you can observe the response.

nor what might be causing the dysfunction. which can inhibit the reflex even when all is neurologically intact. Poorly controlled diabetes. If you are unable to elicit a reflex. etc. while you simultaneously strike the tendon. Trouble Shooting 1. pattern of distribution (bilateral v unilateral. This is most commonly due to a patient's inability to relax. stop and consider the following: a. and hypothyroidism with hyporeflexia. Only by considering all of the findings. though the precise mechanisms through which this occurs are not clear. Detection of abnormal reflexes (either increased or decreased) does not necessarily tell you which limb of the system is broken.) and other medical conditions can the clinician make educated diagnostic inferences about the results generated during reflex testing. Some have their impact through direct toxicity to a specific limb of the system. Hyperthyroidisim is associated with hyperreflexia. as occurs with a stroke affecting the motor cortex of the brain. Occasionally. even when no neurological disease exists. used appropriate examination techniques. and otherwise identified no evidence of disease.body of the UMN (located in the brain). d. Primary disease of the neuro-muscular junction or the muscle itself will result in a loss of reflexes. place a finger firmly on the correct tendon and use that as your target. This assumes that you were otherwise thorough in your history taking. If there is a lot of surrounding soft tissue that could dampen the force of the strike. 4. making the attached tendon more apparent. If this occurs during your assessment of lower extremity reflexes. b. as disease at the target organ (i. can result in a peripheral sensory neuropathy. Sometimes the patient is unable to relax. In these settings. it will not be possible to elicit reflexes. 2. Decreased reflexes could be due to impaired sensory input or abnormal motor nerve function.e. the absence of reflexes are of no clinical consequence. This sometimes provides enough distraction so that the reflex arc is no longer inhibited. Babinski Response 212 . the muscle) precludes movement. 6. together with their rate of progression. Make sure that the muscle is uncovered so that you can see any contraction (occasionally the force of the reflex will not be sufficient to cause the limb to move). Make sure that your hammer strike is falling directly on the appropriate tendon. ask the patient to interlock their hands and direct them to pull. 5. Are you striking in the correct place? Confirm the location of the tendon by observing and palpating the appropriate region while asking the patient to perform an activity that causes the muscle to shorten. c. A number of systemic disease states can affect reflexes. as described above. Extremes of thyroid disorder can also affect reflexes.

2. The patient may either sit or lie supine. 4. spinal cord injury. Sometimes you will be unable to generate any response. it is recorded as absent. then the great toe will dorsiflex and the remainder of the other toes will fan out. Withdrawal of the entire foot (due to unpleasant stimulation). For reasons of semantics. screening exam of the normal patient) and they are quite averse. Some patients find this test to be particularly noxious/uncomfortable. move medially.g. Use the handle end of your reflex hammer. plantar flexion). If the great toe flexes and the other toes flair. the first movement of the great toe should be downwards (i. Interpretation: In the normal patient. near the heel. the Babinski is not recorded as ‘+’ or ‘-‘. If there is an upper motor neuron injury (e. It usually goes away after about 6 months. Then test the other foot. even in the absence of disease. Start at the lateral aspect of the foot. the Babinski Response is said to be present. If it’s unlikely to contribute important information (e. When you reach the ball of the foot.g. Tell them what you are going to do and why.e. Apply steady pressure with the end of the hammer as you move up towards the ball (area of the metatarsal heads) of the foot. 6. 2. stroke).e. 3. Newborns normally have a positive Babinksi. is not interpreted as a positive response. normal). 4. 5. 3. Responses must therefore be interpreted in the context of the rest of the exam. A few additional things to remember: Babinski Response Present 1. simply skip it. which is solid and comes to a point. If not (i.The Babinski response is a test used to assess upper motor neuron dysfunction and is performed as follows: 1. 213 . stroking across this area.

an important part of the cerebellar exam. Interpretation: The movement should be fluid and accurate. c. 214 . Interpretation: The patient should be able to do this at a reasonable rate of speed. Dysfunction results in a loss of coordination and problems with gait. using one modality will suffice. trace a straight path. Rapid Alternating Hand Movements: a. If an abnormality is suspected or identified. d. Heel to Shin Testing: a. Then test the other hand. Rapid Alternating Finger Movements: a. Direct the patient to move the heel of one foot up and down along the top of the other shin. Reposition your finger after each touch. Instruct the patient to move their index finger between your finger and their nose. Gait testing. may be indicative of cerebellar disease. Inability to do this. known as dysdiadokinesia. Interpretation: The movement should be performed with speed and accuracy. Missing the mark. multiple tests should be done to determine whether the finding is durable. 3. Then test the other hand.Cerebellar Testing The cerebellum fine tunes motor activity and assists with balance. The left cerebellar hemisphere controls the left side of the body and vice versa. Test both hands. b. Intepretation: The movement should trace a straight line along the top of the shin and be done with reasonable speed. 1. position your index finger at a point in space in front of the patient. if the abnormality on one test is truly due to cerebellar dysfunction. Inability to do this. b. other tests should identify the same problem. b. Then test the other foot. Specifics of Testing: There are several ways of testing cerebellar function. That is. Ask the patient to touch the tips of each finger to the thumb of the same hand. known as dysdiadokinesia. 2. For the screening exam. is discussed separately (see next section). Finger to nose testing: a. 4. known as dysmetria. With the patient seated. Direct the patient to touch first the palm and then the dorsal side of one hand repeatedly against their thigh. may be indicative of cerebellar disease. may be indicative of disease. b. and hit the end points accurately.

they may not be able to see the target during finger to nose pointing. No test result is worth a broken hip! 2. simply observing while the patient walks into your office and gets up and down from the exam table will provide all of the relevant information. other exam findings. In each case. Pay particular attention to: a. observation of gait) then more detailed testing should be performed. Gait Testing Ability to stand and walk normally is dependent on input from several systems. skip this area of testing. Alternatively. Balance: Do they veer off to one side or the other as might occur with cerebellar dysfunction? Disorders affecting the left cerebellar hemisphere (as might occur with a stroke or tumor) will cause patient’s to fall to the left. the patient is visually impaired. for example. As mentioned above. have them close their eyes. 3. motor. or difficulty initiating movements. For the screening exam. cerebellar. On the other hand. A lot of information about neurological (and other) disorders can be gained from simply watching a patient stand and then walk. including: visual. Difficulty getting up from a chair: Can the patient easily arise from a sitting position? Problems with this activity might suggest proximal muscle weakness. If they are very weak or unsteady. This is referred to as the Romberg test. cerebellar. This is a test of balance. Loss of balance suggests impaired proprioception. turn. Have the patient stand in one place. incorporating input from the visual. proprioceptive. and vestibular systems. Thus. Ask the patient to stand. If you are still unsure as to whether standing/walking can be performed safely. walk across the room. Right sided lesions will cause the patient to fall to the right. Proceed as follows: 1. a balance problem. as it is this pathway which should provide input that allows the patient to remain stably upright. 215 . If there is suspicion of neurological disease (based on history. Enlist the help of a colleague if you need an extra pair of hands. and come back towards you. Difficulty getting out a chair and initiating movement. b. vestibular. finding elsewhere in the exam should help point you in the right direction. lack of balance and a wide based gait would suggest a cerebellar disorder. and sensory. Ask the patient to stand from a chair. would be consistent with Parkinson’s Disease. weakness due to a primary muscle disorder might limit the patient’s ability to move a limb in the fashion required for some of the above testing. The precise cause(s) of the dysfunction can be determined by identifying which aspect of gait is abnormal and incorporating this information with that obtained during the rest of the exam. If they are able to do this. for example. make sure that you are in a position and capable of catching and supporting them if they fall. make sure that you are capable/in position to catch and support them if they fall. If.Realize that other organ system problems can affect performance of any of these tests. other medical and neurological conditions must be taken into account when interpreting cerebellar test results. Diffuse disease affecting both cerebellar hemispheres will cause a generalized loss of balance. removing visual input.

b. of course. does this appear to occur at the level of the spinal cord or the brain? Complete cord lesions will affect both sides of the body. Heel to Toe Walking: Ask the patient to walk in a straight line. for example. is it at the level of a Spinal nerve root? Or more distally. as might occur with Parkinson’s Disease)? Are they simply slow moving secondary to pain/limited range of motion in their joints. Making Sense of Neurological Findings While compiling information generated from the motor and sensory examinations. as would occur with a peripheral nerve problem? 8.g. 6.c.g. spinothalamic and dorsal columns) affected equally. the clinician tries to identify patterns of dysfunction that will allow him/her to determine the location of the lesion(s). putting the heel of one foot directly in front of the toe of the other. possible for a lesion to affect only part of the cord. perhaps losing control of their balance or speed (e. Do the findings on Babinski testing (assuming the symptoms involve the lower extremities) support the presence of a UMN lesion? 5. weakness with flaccidity)? Does the weakness follow a specific distribution (e. What follows is one way of making clinical sense of neurological findings. as might occur with diffuse/systemic disease? 7. following a spinal nerve root or peripheral nerve distribution)? Bilateral? Distal? 3. as might occur with degenerative joint disease? etc.g. Does the loss in sensation follow a pattern suggestive of dysfunction at a specific anatomic level? For example. would lead to characteristic motor and sensory findings.g. under description of Brown Sequard lesion).g. as might occur after a stroke)? 4. Is there evidence of motor dysfunction (e. Atttitude of Arms and Legs: How do they hold their arms and legs? Is there loss of movement and evidence of contractures (e. Rate of walking: Do they start off slow and then accelerate. hyporeflexic in LMN disorders)? 4. assuming one is present? Radial nerve compression. weakness with spasticity). If so. 216 . Does the distribution of the sensory deficit correlate with the “correct” motor deficit. d. Is there impaired sensation? Some disorders. sparing sensation. does the pattern follow an upper motor neuron or lower motor neuron pattern? a. Brain level problems tend to affect one side or the other.g. Is it consistent with an LMN process (e. weakness.g. leading to findings that lateralize to one side (see below. Realize that this may be difficult for older patients (due to the frequent coexistence of other medical conditions) even in the absence of neurological disease. Which aspects of sensation are impaired? Are all of the ascending pathways (e. affect only the Upper or Lower motor pathways. 1. for example. hyper-reflexic in UMN disorders. spasticity. This is referred to as tandem gait and is a test of balance. Do the findings on reflex examination support a UMN or LMN process (e. If it’s consistent with a UMN process (e. tremor)? 2.g. It is.

decreased in the right leg. vibration or propriocetion below the level of the umbilicus. absent Achilles and Patellar reflexes. Vibratory sensation would be impaired on the right side of the body below the level of the injury. Initially. Babinski response will be present). painting the best picture of where the level of dysfunction is likely to exist. A few examples of injuries resulting in characteristic patterns of motor and sensory loss are described below: Example 1 In the setting of a suspected acute spinal cord injury at the T 10 vertebral level. these will become hyperreflexic and demonstrate clonus. might damage only the right half of the cord at the T 10 level. Over weeks.g. The patient would be unable to move their right leg. This would result in the following findings on detailed exam: The patient would be unable to identify the pin stimulus on the left side of his body (remember that the spinothalamacs cross soon after entering the cord) below the level of the injury. Reflexes: Babinksi Example 2 Partial Cord Transection . After a few weeks. for example. absent at the right Patellar and Achilles.Information from the sensory.The Brown-Sequard Lesion: A knife injury. as these paths do not cross over until they reach the base of the brain. Sensation: Strength: Tone: Reflexes: 217 . Initially. Over weeks. motor and reflex examinations should correlate with one another. Initially. the following might be identified on detailed neurological examination: Sensation: Strength: Tone: Absence of ability to sense pin prick. No movement of the lower extremities (e. Toes will be up-going bilaterally (i.e. decreased. for example. with progression to spasticity. After a few weeks becoming hyper-reflexic. Initially. paralysis). tone increases. tone increases with progression to spasticity and contractures of the lower extremities.

I encourage you to experiment while choreographing your own moves. In contrast. Additionally. makes sense and yet is not awkward or prolonged? Is it OK to mix together different areas of the exam or should each system be explored as a block? As I am sure you've already recognized. It makes sense.e. toxin induced damage to the cerebellum can result in profound atrophy of this region of the brain. Patient presentation will also be affected by the size and location of the lesion. exam findings can remain relatively minimal.). allowing you to perform the exam the same way all the time. patients with pre-existing medical or neurological dysfunction may well tolerate new lesions poorly. to integrate the cranial nerve and head and neck examinations as both involve the same region of the body. 2.e. however. Putting It All Together How do you perform the examination in a way that is complete. allowing the patient no time to develop compensatory mechanisms. It may take a fair amount of time. quite challenging. While imaging may reveal significant volumetric loss. disorders which occur more slowly tend to cause relatively subtle symptoms. in fact. The goal is to generate a method that works for you. minimize the number of times that you pick up and put down instruments. should: 1. Keep patient gymnastics to a minimum (i. There is no single right way to perform a complete physical. Any technique. Be readily reproducible. Putting together a smooth exam is. 3. For example. limit the number of times that the patient has to get up and down). Cover all aspects of the examination such that you have a reasonable chance of identifying any pathology that might in fact be present. 5. for example. Allow you to be efficient and perform the exam with an economy of movement (i. thought and practice before you come up with a system that works for you. 4. Link together sections which. move from one side of the patient to the other. These same principles apply to most other aspects of the physical examination. etc. Larger lesions or those affecting critical areas of function tend to generate more overt problems. are connected spatially. 218 . Acute dysfunction (as might occur with a stroke) generally causes obvious symptoms as the loss of function is abrupt.Babinksi Up-going toe on the right A few final comments about diagnosing neurologic disorders: It is also important to note that the pace at which a particular disorder develops will have a dramatic effect on symptoms and exam findings. these and many other related questions are not easy to answer. although disconnected physiologically.

. Palpate the carotids. ask the patient to lie down. 4. and Rinne (CN 8) if appropriate. check pupillary response to light (direct and indirect). Feel for lymph nodes in the head and neck. Wash your hands. 27. (CN 9. examine the oral cavity. and listen to the anterior lung fields. Examine the scalp and head for any superficial abnormalities. If possible. 13. wrinkle forehead. Listen over the carotids. 10. Check sensation to touch on face. Examine external structures of the eye. Examine the nose. 8. Examine the outer and inner ears. Have the patient turn their head to the left and assess for jugular venous distention. Check visual fields and acuity (CN 2) if appropriate. 6. 19. Check hearing acuity. palpate. percuss and palpate the abdomen. 25. Have the patient change into a hospital gown and take a seat at the end of the examining table.. 24. 1. 10. Then feel for the point of maximal cardiac impulse. Feel for axillary lymph nodes. 17. Perform fundoscopy. Determine the blood pressure in both arms. Palpate the spine. Following this. Observe.Steps 19 thru 25 can be performed without ever removing your stethoscope from your ears. Walk around to the front. Measure this at both radial arteries simultaneously. *Note. 12). You will again have to walk to the left side of the body to look at the left ear. 26. When examining the left eye you will have to walk to the left side of the body. auscultate.. Look at the cardiac area of the chest. Using ophthalmoscope. 219 . 7. 9. 20. 15. Count the pulse. Look for red reflex. 12. Ask the patient to show their teeth and stick out their tongue. close their eyes and smile (CN 7).What follows is not an in-depth review detailing the specifics of each area of the exam. 23. 4. Using the otoscope. Auscultate the heart. 22. spend a few minutes simply watching them. 14. Have the patient shrug their shoulders and turn their head from side to side (CN 11). 21. & 6). percuss and auscultate the posterior lung fields as well the right middle lobe and the lingula. 5. Respiratory rate is noted while counting the pulse. 2. 11. Rather. Temperature is measured at the same time. 16. 3. Weber. Assess extra occular movements (cranial nerves 3. Have patient raise eyebrows. Observe. 18. it is simply an outline of the "mechanical events" that make up a complete physical. examine the hands and fingers. Walk behind the patient and feel the thyroid gland. Feel temporal and masseter muscles when jaw clenched (CN 5).

this can be done in concert with assessment of extremity strength towards the end of the exam. 36. Feel for inguinal adenopathy and asses femoral and then popliteal pulses. 30. thorough and efficient. 40. Check biceps. 38. Wash your hands. tone and strength in lower extremities. 39. limits the frequency with which the patient has to get up and down. Assess for Babinski. Check for Romberg's Sign. perform genital and rectal exam while they are standing. perform pelvic exam. and position sense in feet and lower extremities if appropriate. etc. 32. I have omitted the formal joint examination. etc.28. These include: 220 . as described for lower extremities. This must be done in such a way that it tells the patient's story in a logical. if appropriate. Examine the feet. 31. Observe gait. tone and strength in upper extremities. 35. triceps and brachioradialis reflexes. with emphasis placed on reviewing new facts and data (e. looking for edema. For female patients. For male patients. The second example calls for a much more detailed discussion. Assess muscle bulk. There is a lot of room for flexibility. are not the same as those given at formal patient management conferences. 29.g. vital signs. Have patient stand and then walk. Ask patient to sit up. This approach keeps the movement of the examiner to a minimum. presentations given during morning work rounds (the time when the medical team briefly visits with each patient to review their clinical course and determine the plan for the day). light touch. Assess muscle bulk. Check achilles and patellar reflexes. changes in clinical course. Check sensation in upper extremities. The Oral Presentation The purpose of the oral presentation is to provide other clinicians with patient information. ulcers. The presenter. Check sensation to pin prick. must take into account the "environmental" factors which determine the type of presentation that is required. test results. Check for dorsalis pedis and posterior tibial pulses. For example.) and outlining the care plan. discoloration. 33. 34. The first situation requires a focused presentation. vibration. then. Assess cerebellar function with finger to nose and heel to shin testing. and is reasonably logical. allows exploration of neighboring areas of the body even if they are part of different organ systems. If indicated. It is a difficult skill to master and is made more complicated by the fact that different clinical situations demand different types of presentations. clear and complete fashion yet is neither cumbersome nor too long. 37.

and Indinavir. clinic etc. H has been HIV + since 1987.000. He currently takes 3TC. are going to be most interested in the cardiac history. AZT. 4. It should not be too inclusive. For the above patient. for example. The longest. this might be quite limited. At the current time. A group of cardiologists. For the purposes of this discussion. He has never used intravenous drugs. his CD4 count in June of '97was 150 and viral load approximately 50. Time available to give the presentation. the presenter may try to link them together when appropriate." This information is not. we will focus on the formal/complete presentation as it is probably the form which is most complicated and intimidating. The purpose of the presentation (e. "Mr.e. all of which he has been receiving for approximately one year. The audience to which you are presenting. and Kaposi's Sarcoma first noted on his skin 1/96. chills and a cough over the past 3 days. 2. If there is more then one problem. the dominant problem/complaint serves as the centerpiece of the history. however. illustrative examples are frequently included and have been set off from the text by means of quotation marks and italics. is it for work rounds.1. most complete presentation should take no longer then 5-7 minutes while shortened versions can be given in as little as 15 to 30 seconds. He is homosexual though he is currently not sexually active. Past opportunistic infections have included: PCP pneumonia 12/95. This requires that the presenter go back far enough in time to cover any historical data that is relevant to the patient's main complaint. Tips for presenting during work rounds are provided in the "Inpatient Medicine" section of the Clinical Guide. However. the Chief Complaint). that once you grasp the logic and organization of this process and have an opportunity to practice. a thorough description would include: "Mr. it providescritical information that will have a direct bearing on the listener's interpretation 221 . Information related to this main theme is presented in chronological order. in a strict sense. CMV retinitis 1/96. H is a 50 year old male with AIDS who presents for the evaluation of fever." History of Present Illness (HPI): The HPI is presented in both a problem based and chronological fashion. You will find. part of the present illness. In the discussion that follows. That is. Your familiarity with the case as well as associated pathophysiology. Your ability as a presenter to know which past information is important and which superfluous will be based on both your clinical experience and understanding of pathophysiology. The Formal Presentation Chief Complaint/Chief Concern: The presentation begins with a one sentence description of the patient and the reason prompting their evaluation (i. He claims to be 100% compliant with all of his medication. teaching conference.g. along with Fluconazole troches PRN for thrush. He also takes Bactrim Single Strength tablets on a daily basis.?). 3. your presentations will become both more effective and less anxiety provoking. This is a teaser that sets the tone for the information to follow.

If a patient is a poor historian. friends. There is no know history of asthma. abdominal pain. stiff neck. It concludes with a list of "pertinent negatives" that are meant to exclude. on the basis of history. photophobia.of this patient's active problem. other possible diagnoses that are known to have a similar symptom complex. He has spent most of the last 24 hours in bed. COPD or chronic pulmonary condition. Your ability to determine which background to incorporate into your HPI will improve with time and exposure. There was associated nausea but no vomiting. When the problems are completely unrelated. he began to feel dyspneic with moderate activity. make sure that you note the source. These questions are designed to uncover illnesses which might "travel with" the main problem and attempt to identify commonly occurring complications (e. Review of Systems: The critical positive and negative findings discovered during a review of systems are generally incorporated at the end of the patient's history. for example. H had been quite active. He denies head ache. If. allowing the listener to gain some sense of the degree of impairment caused by the acute medical problem. In a patient with an HIV related illness. he began to develop subjective fevers and chills along with a cough productive of rust-colored sputum.g. it is generally acceptable to simply state. this review might actually be much more extensive than that provided above due to the diffuse. 1 day ago." This section documents the course of the patient's most active problem. diarrhea or other complaints. Note that the patient's baseline functional status is described. Mr. hemoptysis can be a sequelae of pulmonary infection). walking up to 2 miles a day without feeling short of breath. they may well be secondary to a single underlying process such as myocardial ischemia resulting in heart failure. Those items mentioned above are not repeated. followed by a discussion of the secondary complaint. multi-organ system involvement that occurs with this disease." Past Medical History: Note is made of any other past medical problems which the patient has that are not related to the current complaint. This can get quite complicated when multiple problems exist in parallel. etc. confused or simply unaware of all the details related to their illness. state this and move on. a patient complains of both chest pain and shortness of breath. Historical information can be obtained from family. The details of the patient's acute problem are then presented: "Until 1 week ago. as was done above. the "dominant issue" (as determined by the presenter) is treated first. "The patient's past medical history includes: 222 . If this is the case. hemoptysis. His current problem seems different to him then his past episode of PCP. 3 days ago. focal weakness. he was breathless after walking up a single flight of stairs. If it is completely negative. "ROS negative. Approximately 1 week ago. Any positive responses to a more inclusive ROS that covers all of the other various organ systems are then noted. chest pain. The extent to which this is repeated is left to the discretion of the presenter. This progressed to the point that. The listener needs this information to help them put the remainder of the history in appropriate perspective.

the presenter might mention that rales. BID Indinavir 750 mg. 223 .) should also be mentioned. etc. He denies any other drug use. H works as an accountant for a large firm in Boston. etc. There is no family history of heart disease or cancer. 2 PO. Status Post Cholycystectomy 1990 2.1. TID 3TC 150 mg. He drinks approximately 1 glass of wine per week. 1 PO. route and frequency) are mentioned: "The patient takes the following medications: AZT 300 mg. who are also healthy. diabetes. elevated jugular venous pressure and an S3 were not present. Sexual history. PO. indicating that congestive heart failure is an unlikely diagnosis. 1 PO TID PRN Naprosyn 250 mg. if relevant to the oral presentation would also be presented here. Status Post open repair and internal fixation of left femur fracture. He has 2 brothers. cocaine use. a patient has shortness of breath secondary to asthma. Any unusual work-related exposures should be noted. 1 PO. Gastro-Esophageal Reflux Disease 3. If. BID Lopressor 50 mg. It is also reasonable to mention the absence of certain things that the listener will find helpful in excluding particular diagnoses." Physical Exam: This begins with a one sentence description of the patient's appearance along with their vital signs." Social/Work History: This includes a brief description of the patient's work and home environments. "Past surgical history is remarkable for: 1. This would include: history of coronary artery disease. intravenous drugs. Status Post Appendectomy 1985 3. 1-2. certain neoplasms. 1 PO. 2 PO. BID Clotrimazole Troches 100 mg. "Mr. 1983" Medications/Allergies: All current medications (along with dose. He lives alone in an apartment in the city. Any additional substance abuse (e. BID Lansoprazole 20 mg. "Mr. only '+' findings are noted. one 45 and the other 55. Degenerative Joint Disease of the Right Knee" Past Surgical History: Any prior surgeries (along with the year in which they occurred) are noted. Hypertension x 10 years 2. H smokes 1 pack of cigarettes per day and has done so for 20 years. for example.g. "Both of the patient's parents are alive and well (his mother is 78 and father 80). BID PRN He has no allergies" Smoking and Alcohol (and any other substance abuse): Cigarettes and alcohol are highlighted because their use is so widespread and the deleterious effects associated with prolonged exposure well documented. In general." Family History: Emphasis is placed on the identification of illnesses within the family (particularly among first degree relatives) that are known to be genetically based and therefore potentially inherited by the patient.

There was no appreciable adenopathy. purplish. negative Romberg. breathing comfortably through a face mask oxygen delivery system. However. prostate small. Cerebellar: Finger to nose well done. Breathing was unlabored and accessory muscles were not in use. Abdomen: Symmetric appearing. "Mr. Dorsalis Pedis and Posterior Tibial pulses 2+ and equal bilaterally. only lab values which are abnormal are mentioned. No thrush was noted. Cranial Nerves: 2 thru 12 tested and intact." Lab results. vibration normal. CXR showed a dense right lower lobe infiltrate without effusion." 224 . Mucosa was dry and without lesions. Extremities: No evidence of clubbing.Some listeners expect the entire physical examination to be recounted. non-blanching area noted on left mid-shin. biceps and triceps Sensation: Intact to light touch and pin prick bilaterally. no masses. Radiological Studies. E to A changes present. No wheezing or other abnormal sounds noted over any other area of the lung. Normal Chem 7 and LFTs. well healed Right upper and lower quadrant incisions at sites of prior apppendectomy and cholycystectomy. JVP was less then 5 cm. no masses. Eyes. it should give you an idea of how abnormalities as well as "normal findings" are reported. no palpable masses. round and reactive to light. Throat: Pupils equal. including "normal findings. Neurologic Exam: Mental Status: Awake.45/ PO2 of 55/PCO2 of 30. Sclera anicteric. appropriate and completely oriented. non-tender. Dullness to percussion and increased fremitus was also appreciated at the right base. flat. Room air blood gas: pH of 7. • • • • • • • • • • Vital signs were: Temp 102 Pulse 90 BP 150/90 Respiratory Rate 20 O2 Sat (on 40% Face Mask) 95% Head. Thyroid non-palpable. Rectal Exam: Brown stool in rectal vault. Ears. Ambulation: Normal gait. no hernia. if the interpretation of radiological studies and EKGs are directly relevant to the case. Skin: a 2x3 cm raised. Motor: Strength 5/5 all extremities. soft. Tympanic membranes pearly gray with cone of light well seen. knees. EKGs: In general. proprioception normal. Reflexes: 2+ at ankles. "Mr. Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci. No murmurs or extra heart sounds noted. H's lab work was remarkable for: White count of 18 thousand with 10% bands. H was seated on a gurney in the ER. smooth and non-tender. non-tender. The following exam is listed in more detail then is necessary. Similarly. alert. Cardiac: Rhythm was Regular. they are discussed. Lungs: Crackles and Bronchial breath sounds noted at right base. guiac negative. penis without lesions. Normal S1 and S2. Nose. cyanosis or edema. no other skin abnormalities identified. GU: Testes descended bilaterally." particularly if the presenter is a student.

along with the sputum gram stain suggest a bacterial infection. in particular Streptococcal pneumonia. Legionella. compliance with PCP prophylaxis and statement that his current illness seems different then past PCP infection would argue against this as the etiologic agent. less commonly.with goal to keep sats greater then 92% IV fluid replacement with Normal Saline at 125cc/H for next 24 hours to correct mild hypovolemia. If patient does not show improvement (or worsens) and cultures are unrevealing. 4. While he is certainly at risk for PCP. focality of findings on lung exam and radiography. The Current plan then is: 1. Hold off on empiric treatment for PCP. H is an HIV + male with a low CD 4 count and high viral load who presents with an acute pulmonary process. Continue O2. 5. Furthermore. Obtain sputum for silver staining to r/o PCP Begin treatment with IV cefuroxime. "Mr. Follow up on cultures of sputum and blood.Impression and Plan: This is your opportunity to summarize the important aspects of the history. 2. with plan to reassess volume status at that time 6. consider bronchoscopy as a means of making more definitive diagnosis. the data does not support the existence of either a primary cardiac or noninfectious pulmonary process. Mycobacterial infection also seems unlikely. his presentation. physical exam and supporting lab tests and formulate a differential diagnosis as well as a plan of action that addresses both the diagnostic and therapeutic approach to the patient's problems. Viral infections and neoplastic processes like CMV or Kaposi's Sarcoma of the lung do not generally give this clinical presentation. 3." 225 . Other pathogens to consider include H Flu and. The rapid progression.