Communication Skills and History Taking

Communication skills toolbox

Skill Definition Example

Rapport building Establishing a good relationship “Chit-chat”, get to know the patient
Finding out EVERYTHING the patient wants to attend “I would like to discuss your pain more, but first is
Setting the agenda to while getting chief complaint there anything else that is bothering you besides the
pain?”
Closely attend to what the patient is communicating –
Active listening
verbally and non-verbally
Open-ended Allows patient to give more info in his/her own words, “Tell me more about your pain”, “Can you describe
questions can be focus open-ended, or open open-ended what’s happened with your pain since it started?”
Close-ended Can be answered with a specific and simple answer, “When did the pain start?
questions use to fill in the gaps
Used throughout interview to confirm what you
Recap believe you heard – allows for understanding,
corrections
Technique of eliciting info without providing direction “Go-on”, “Tell me more”, nod head
Continuers
or topic
Form of continuer, repetition of patient’s last couple of “Chest pain?”
Echoing
words – gets them to elaborate more
Aka Normalization, to put a patient at ease from “Many people in this situation would have the same
Displacement
discussing a sensitive topic feelings”
Acknowledgement that the patient’s opinions and “It is quite natural to feel that way”
Validation
emotions are justified, whether or not you agree
Matching the patients tone of voice/posture to make Speaking quietly if patient is sad, nervous
Mirroring
them feel more comfortable
To make it known that you are not singling out the “I ask these questions of all my patients, routinely”
Ubiquity
patient on sensitive topics (sexual history, drug abuse)
Transitioning – Verbal road map – from one line of question to “Now, I am going to ask you about your social
segue another history”
To let the patient know info said will be kept between
Confidentiality
the physician and staff
Make it known you desire to work with the patient in “Let’s work on this together”
Partnering
solving the issues brought up
Hypothesis Making an assumption from non-verbal clues given “I suspect you must be very angry about that – Am I
formulation by the patient right?”
Summary of ALL data collected at end of interview, to
Summarization
confirm, close the interview

History taking

1. INTRODUCTION, BIODATA
• “Hello, my name is _________. I am a medical student here at SGU. What is your name?
• “Nice to meet you Mr/Ms. ______” *REPEAT NAME
• “Since this is our first time meeting, I would like to get to know you a little better, can you tell me about your self?”
• Get AGE, WHERE THEY LIVE, WHO THEY LIVE WITH (MARITAL STATUS), WHERE THEY WORK
• Use rapport building and active listening
2. CHIEF COMPLAINT
• “Alright, thanks for telling me about yourself. I really appreciate it. So can you now tell me what brought you in today?”
• SET THE AGENDA  “We are going to talk more about that, but first is there anything else you would like to discuss
today?”
• If there is more than one chief complaint – determine chronological order and start from there
• Beware of premature diving – patient may spontaneously leap into detailed descriptions
• Use empathy and do not interrupt
3. HISTORY PRESENTING ILLNESS
• “OK – could you now tell me more about the ______”
• Use open ended questions and continuers
• TIMING, FREQUENCY, LOCATION (have them point it out), WHEN IT GETS BETTER OR WORSE, SETTING,
CHARACTERISTICS, RELATED MANIFESTATIONS – “Have you noticed any other changes in your body that may have
to do with this?”
4. PAST MEDICAL HISTORY
 • Use empathy and a segue here – “I can understand this must be really hard for you. We are going to work together to
figure out what is going on and help you get better. I would like to ask you a few questions about your past medical
history, which will help me get the bigger picture.”
• “Have you had any past illnesses?” What about as a child?”
• “Have you ever been hospitalized?”
• “How are your immunizations?”
• “Do you have any allergies?”
• “Are you currently on any medications, supplements?”
• “Have you ever been diagnosed with high blood pressure or hypertension? What about high blood sugar or diabetes?”
5. FAMILY HISTORY
• “Could you tell me about the health of your family?”
• Get PARENTS, CHILDREN, SIBLINGS
6. SOCIAL HISTORY
• “I would now like to ask you a few questions about your PERSONAL life. I want to assure you that everything you tell
me is kept confidential and I ask these questions of all my patients. Can you start by telling me some of your daily
activities?”
• Get DIET, EXERCISE, SMOKE (how often), DRINK (how often), RECREATIONAL DRUGS
7. OBGYN/SEXUAL HISTORY
• “Now I am going to ask you a few sensitive questions about your sexual history. I want to assure you again that these are
routine questions I ask of all my patients and whatever you tell me will be kept confidential, so please feel comfortable.”
• OBGYN first if female – MENSTRUAL PERIOD? PAP SMEAR? BREAST EXAM?
• “At any point in your life have you been sexual active?” – “What about now?”
• “At any point in your life have you had more than one sexual partner?” – “What about now?”
• “Do you use condoms?”
• “Have you ever been tested for sexually transmitted infections?” – “What tests?” “What were the results?”
• Important to educate the patient at this step – safe sex = condoms
8. REVIEW OF SYSTEMS
• “Finally I would like to ask you some questions about your general health. These questions are just going to help me get
the bigger picture and figure out what may be going on.”
• Skin changes? • Breathing difficulties?
• Headache? • Chest pain?
• Dizziness? • Numbness?
• Vision changes? • Joint pain?
• Hearing loss? • Appetite?
• Sense of smell? • Digestion?
• Sense of taste? • Change in urination?
• Enlarged lymph nodes? • Mood changes?
9. CLOSING THE INTERVIEW
• “Thank you so much for answering all my questions today.”
• Give SUMMARY
• Discuss diagnosis and treatment options
• Use partnering
• Elicit patient full understanding of the discussion
• Agenda check – “Is there any other issue you would like to discuss?”
• “Any other questions?”
Physical Diagnosis
Wash hands Explain the nature and purpose of the examination
Introduce yourself Expose the area to be examined
Identify the patient Position the patient as required * remember to stand on right
Permission to examine side of patient

Section 1 - Vital signs

Vital signs are measurements made to reflect the body’s basic functions, all patients get vital signs

VITAL&SIGNS&
WIIPEEP%
“Today%I%am%going%to%be%getting%your%vitals%–%pulses,%respiration%rate,%&%blood%pressure.%That%is%going%to%involve%me%feeling%your%wrists%and%neck%
as%well%as%placing%a%blood%pressure%cuff%tightly%around%your%arm,%increasing%the%pressure%and%listening%with%stethoscope.%Is%that%okay%with%
you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
First%I%would%like%to%ask%you,%
“Have%you%been%experiencing%any%chest%pain?”%
“Do%you%ever%have%trouble%breathing?”%
1.&PULSE&
Radial%pulse%–%used%to%evaluate%rate,%rhythm,%&%volume%
• Palpate%radial%pulse%1K2%finger%breaths%above%the%volar%crease%of%the%wrist%near%the%radial%styloid,%using%finger%pads,%with%middle%
finger%closer%to%wrist%crease%
• Rate%–%for%full%60%seconds%–%report&count&“pulse&was&70&beats&per&minute&with&regular&rhythm”%
• Rhythm%–%report&“regular”%(if%irregular%may%need%to%use%EKG)%
• Volume%–%report&“symmetrical&in&volume&on&both&sides,&+2”%
Carotid%pulse%–%used%to%determine%contour%
• Palpate%right&carotid%artery%pulse%by%asking%patient%to%look%to%the%side,%then%place%2%finger%pads%between%SCM%and%trachea%about%1/3%
up%the%neck%
• Contour&(shape)%–%report&“smooth,&rapid&upstroke,&brief&plateau,&and&slower&downstroke”&
2.&RESPIRATION&
Count%respiration%rate%in%full%60%seconds%right%after%getting%radial%pulse%(this%allows%for%patient%to%be%distracted)%
• Report&“Respiration&was&17&breaths&per&minute,&regular&rhythm,&normal&depth,&quiet&and&effortless&without&use&of&accessory&
muscles&and&no&other&signs&of&respiratory&distress”&
3.&BLOOD&PRESSURE&
Position%arm%at%the%level%of%the%patient’s%heart%
• Wrap%cuff%around%tightly%leaving%enough%room%to%palpate%brachial%artery%(2cm%above%the%antecubital%fossa)%
Palpate%radial%pulse%
• Fill%cuff%until%get%to%high%enough%pressure%that%occludes%the%artery%and%radial%pulse%can%no%longer%be%palpated&
• This%is%the%estimated%systolic%pressure&–&report&“Systolic&pressure&on&palpation&125,&Osler&sign&negative”&
• Deflate%and%wait&a&few&seconds%(normally&–&30&seconds),%add%20K30%mmHg%to%this%reading&
Place%stethoscope%(diaphragm)%over%brachial%artery%and%inflate%to%the%higher%level%
• Deflate%the%cuff%2K3mm/sec%until%hear%first%2%consecutive%beats%=%systolic%BP%then%continue%deflating%until%sounds%disappear%=%
diastolic%BP%–%report&BP&measured&
4.&TEMPERATURE&
• &“I&would&normally&like&to&also&get&the&pulse&&&BP&bilaterally&and&on&upper&and&lower&limb,&and&in&the&standing&&&lying&down&
positions.&I&would&also&get&the&patient’s&temperature.”&
5.&PAIN%–%scaled%from%1K10%
Section 2 – Global assessment

1.&GENERAL&SURVEY&
Listen'for:'foot'slapping,'noisy'breathing,'stridor'
Observe:'stance'&'swing'of'the'patient’s'walk'
State%of%health%–%healthy,%acutely%ill%or%chronically%ill%
Height,%weight,%and%build%–%obese,%edematous,%scoliosis,%kyphosis%%
Posture%–%noting%for%decorticate%rigidity,%hemiplegia%spasticity,%decerebrate%rigidity,%motor%activity,%involuntary%movements%
Gait%K%Spastic%hemipareisis,%steppage,%scissors,%Parkinsonian,%cerebellar%ataxia,%sensory%ataxia%
Appearance%–%eye%contact,%grooming,%personal%hygiene,%odors%
Facial%expression%&%facies%–%Parkinson’s,%Down%syndrome,%facial%nerve%palsey,%hyperthyroidism%
Speaking%–%aphonia,%dysphonia,%dysarthria,%aphasia%
State%of%awareness/level%of%consciousness%–%alertness,%lethargy,%obtundation,%stupor,%or%coma%
2.&INSPECTION&
Head%and%neck:% Extremities:% Trunk:%
• Size%and%shape%of%the%head%in%relation%to%the% • Skin%color% • Movement%of%the%
torso% • Scars% chest%wall%
• Presence%and%symmetry%of%a%pair%of%eyes,% • Swellings/edema% • Involuntary%
nostrils%and%ears% • Symmetry%of%appearance% movements%
• Relative%position%of%the%ears% • Muscle%bulk% • Scars%
• Color%of%skin%–%normal%for%race% • Involuntary%movements§%Range%of% • Swellings%
• Conjunctival%mucosa%for%pallor%or%icterus% motion%of%the%joints% • Venous%distension%
• Hair%of%the%scalp%–%presence%and%distribution& • Contractures% • Dilated%arterioles%
• Presence%of%congenital%deformities%such%as% • Deformities%and%misalignment%
cleft%lip/palate% • Examine%the%palms%of%the%hands%and%
• Swellings%and%scars%about%the%head%and%neck% fingers%for%nodules%
• Facies%and%facial%expression% • Examine%the%fingers%for%clubbing%
• Distended%neck%veins% • Examine%the%nails%for%lines,%ridges,%
• Neck%held%in%abnormal%position% thickening,%splitting,%splinter%
• Involuntary%movements% hemorrhage,%separation%of%nail%plate%
• Flapping%tremor% from%the%nail%bed%
• Tracheal%deviation& • Bruises,%ecchymoses,%petechiae%
3.&PALPATION&
With%the%patient%sitting%on%the%examination%table,%palpate%the%head%and%neck%areas%followed%by%the%extremities%and%note%the%following:&
• Areas%of%tenderness%
• Swellings/massesK%determine%size,%shape,%consistency,%texture,%surface%characteristics%and%mobility%
• Perform%passive%range%of%motion%the%joints%of%the%extremities%and%determine%the%presence%of%crepitus%or%clicks%
• Abnormal%pulsations%
• Tracheal%deviation%
• Palpate%for%muscle%tone%and%strength.%Grade%strength%0%to%5%
• Test%the%following%reflexesK%biceps,%triceps,%patella%and%ankle.%
With%the%patient%standing,%make%note%of%the%following:%
• Palpate%the%spinous%processes%of%the%spine%to%determine%any%deviation%from%the%midline.%Note%any%scoliosis%or%anterior%curvature%
• Spasm%of%muscles%of%the%neck%and%back%
With%the%patient%lying,%examiner%standing%on%the%right%side%of%the%patient%and%the%chest%exposed,%palpate%for:%
• Tenderness%
• Thrills%
• Heaves%
• Pulsations%
• Dilated%veins%and%arterioles%
With%the%patient%lying,%examiner%standing%on%the%right%side%of%the%patient,%and%abdomen%exposed,%palpate%for:%
• Tenderness%
• Swellings/masses%
• Dilated%veins&
4.&PERCUSSION&
Examine%the%chest%and%abdomen%simultaneously%with%the%shirt%off%and%the%abdomen%exposed%to%the%iliac%crest%
5.&AUSCULTATION&
Lungs%%for%breath%sounds%and%adventitious%sounds%–%have%the%patient%take%deep%breaths%through%the%mouth%
Apex%beat&&of%the%heart%for%heart%sounds%1%and%2%K%with%the%diaphragm%and%bell&
Anterior%abdominal%wall&&for%bowel%sounds&
Section 3 – Head & Neck

SKULL,&SCALP,&HAIR&&&FACE&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%your%head,%hair%and%face,%is%that%okay%with%you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
First%I%would%like%to%ask%you,%
%“Have%you%experienced%any%pain%on%your%head%&%face?”%
“Have%you%noticed%any%loss%of%hair?%
1.&SKULL&
Inspection% Palpation%
Size%&%shape%–%observe%from%front,%sides,%&% Bulging%or%sunken%fontanels%(in%children%only)%
back% Fractures%
Symmetry% Swellings%(bony%if%originates%from%skull)%
Deformities%
Swellings%&%masses%
&
2.&HAIR&&&SCALP&
Inspection% Palpation%
Skin%lesions,%rashes,%scars% Hair%texture%
Swelling,%nodules% Size%&%consistency%of%any%swellings%(hard%=%skull,%cystic%=%cyst%or%abscess,%soft%&%boggy%=%
Scaliness% hematoma)%
Dandruff% Tenderness&
Pigmentation%(vitilgo,%erthyema)% Temporal&arteries%(for%thickening,%tenderness,%or%absent%pulses%=%temporal%arteritis)%
Hair%distribution%
Alopecia%
Lice%&%nits%
3.&FACE&–&INSPECTION&only&
Symmetry%(asymmetry%can%indicate%facial%paralysis)%
Scars,%swellings,%masses,%patches,%leukoplakia%
Color%(pigmentation)%
Infections%–%such%as%pustule%of%the%lip%(danger%triangle),%lacerations%(with%swelling)%
Facial%expressions%(facial%nerve%palsy)%&%facies%(e.g.%maskKlike%in%Parkinson’s)%
Involuntary%movements%
Congenital%abnormalities%–%cleft%lip%is%the%most%common&

ORAL&CAVITY,&PHARYNX,&&&SALIVARY&GLANDS&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%the%inside%your%mouth,%is%that%okay%with%you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
First%I%would%like%to%ask%you,%
“Have%you%ever%had%any%ulcers%or%canker%sores?%How%long%did%they%last?”%
“Do%you%have%any%pain%in%the%teeth%or%mouth?”&
2.&INSPECTION&OF&THE&LIPS&
• Swellings,%masses,%indurations%
• Ulceration,%blisters,%vesicles%(herpes)%
• Actinic%damage%(atrophy%with%erythema%or%leukoplakia)%
• Angular%chelitis%(cracking%in%corners%of%mouth)%
• Cleft%lip%
• Ask%the%patient%to%close%mouth%and%smile%–%detect%CN%VII%deficits%
3.&PALPATION&OF&THE&LIPS%–%with%gloved%hands%
Look%for%any%surface%irregularities%not%visible%to%the%eye,%submucosal%nodules,%or%areas%of%redness/induration/growth%
4.&INSPECTION&OF&THE&LABIAL&MUCOSA%–%with%gloved%hands%
Hold%the%lip%at%the%corners%&%evert%(do%for%top%&%bottom)%%
• Mucosa%should%be%soft,%smooth%and%well%lubricated%
• Inspect%for%color,%nodules,%ulcerations,%thickening,%or%mucocele%(due%to%trauma%to%salivary%glands)&
5.&PALPATION&OF&THE&LABIAL&MUCOSA%–%with%gloved%hands%%
Palpate%upper%&%lower%lips%with%two%fingers%from%commissure%to%commissure%
• Submucosal%lesions%–%nodules%&%thickenings%
• Consistency%of%any%abnormalities%observed%
6.&INSPECTION&OF&THE&BUCCAL&MUCOSA%–%with%gloved%hands,%use%of%tongue%depressor,%and%penlight%
Retract%each%side%of%the%mouth%to%inspect%the%buccal%mucosa%and%use%pen%light%
• Color,%inflammation,%redness,%moisture%(dryness%may%indicate%obstruction%of%Stenson’s%duct)&
• Koplik%spots,%leukoplakia,%patches,%vesiculoKerosive%disease&
• Ulcerations,%surface%nodules&
• Ectopic%sebaceous%glands%=%Foryce%granules%(appear%whitishKyellow%papules)&
• Orifice&of&Stenson’s&duct&opposite&the&second&molar&tooth&
7.&INSPECTION&OF&SALIVA%
Palpate%the%parotid%gland%on%both%sides%
• Ask%for%tenderness&
• Massage%then%inspect%inside%the%mouth%for%amount,%consistency%&%color%
8.&INSPECTION&OF&THE&GINGIVAE&&&TEETH%–%with%gloved%hands%and%use%of%tongue%depressor%
Gingiva:%best%done%with%mouth%partially%closed%and%lips%retracted%
• Color,%erythema,%bleeding,%ulcerations,%infection%(gingivitis)&
• Hypertrophy%(may%be%secondary%to%drugs)%or%atrophy&
• Periodontitis%–%swelling,%inflammation,%bleeding,%&%pus%–%pyorrhea&
• Gingival%recession&
• MucoKcutaneous%disease&
Teeth:%#%and%position%–%2%incisors,%1%canine,%2%premolars,%and%3%molars%
• Anodontia%(missing%teeth),%supernumery%teeth%(garner%syndrome),%transverse%ridges&
• Congenital%abnormalities%in%teeth%–%Hutchinson’s%incisors%(congenital%syphilis)&
• Dental%plaques,%calculus,%discoloration,%infection,%or%decay&
• MalKocclusion&
9.&PALPATION&OF&THE&GINGIVAE&&&TEETH%–%with%gloved%hands%
Gums:&areas%of%enlargement%–%may%be%due%to%edema,%bony%or%fibrous%processes&
Teeth:%tenderness%and/or%looseness%
10.&INSPECTION&OF&THE&TONGUE%–%with%gloved%hands%
Inquire%first:%
• “Have%you%felt%any%soreness%of%the%tongue?”&
• “Have%you%had%any%loss%of%taste?”&
• “Have%you%noticed%any%swelling,%patches,%or%lumps%on%the%tongue?”&
Examine%the%dorsum%by%having%the%patient%protrude%the%tongue%and%attempt%to%touch%the%chin%
• Identify%the%terminal&sulcus,&medial&sulcus&&&foramen&cecum%
• Inspect%the%papillae%–%filiform,%fungiform,%&%circumvallate,%hairy%tongue%(elongation%of%the%filiform%papillae)%
• Inspect%texture,%color,%atrophy,%masses,%ulceration,%plaques%
• Fasiculations,%coating,%furrowing,%movement,%deviation%
Observe%the%lateral%borders%by%holding%the%tip%of%the%tongue%with%a%gauze&
Examine%the%ventral%surface%by%having%the%patient%touch%the%tip%of%the%tongue%against%the%roof%of%the%mouth%
• Identify%the%lingual&frenulum,&sublingual&vasculature%
• Inspect%for%mucosal%color,%any%masses%
• Locate%the%ostia&of&Wharton&ducts%(seen%as%2%bilateral%punctuate%structure%on%either%side%of%the%base%of%the%frenulum)%
Common%site%for%intraoral%squamous%cell%carcinoma%–%palpate&any&suspicious&masses%
11.&INPECTION&OF&THE&HARD&PALATE%–%using%pen%light%
• Color,%redness%(inflammation),%leukoplakia&
• Congenital%abnormalities%such%as%cleft%palate&
• Incisive%papilla%(small%firm%nodule,%covering%incisive%foramen)&
• Any%swellings%(torus%palatinus%=%midline%bony%swelling%of%the%hard%palate),%vesicles,%ulcerations,%exudates%or%petechiae&
12.&PALPATION&OF&THE&HARD&PALATE%–%with%gloved%hands%
• Submucosal%nodules&
• Visible%swellings&
• Areas%of%induration&
13.&INSPECTION&OF&THE&POSTERIOR&ORAL&CAVITY,&TONSILS,&AND&POSTERIOR&WALL&OF&OROPHARYNX&
Depress%the%dorsum%of%the%posterior%tongue%(tongue%inside%mouth)%and%have%the%patient%say%“AHH”%
• Color%(should%be%salmon%pink)%
• Movement%of%the%uvula%(should%be%midline)%–%deviation%(may%indicate%neurological%deficit%in%CN%IX%&%X)%
• Paralysis%of%the%soft%palate%(may%indicate%diphtheria%neurotoxin)%
• Bifid%uvula%(may%indicate%cleft%palate)%
Depress%the%tongue%laterally%on%both%side%to%visualize%the%tonsils%&%tonsillar&crypts%
• Presence%or%absence%of%tonsils&
• Erythema,%exudates,%asymmetric%swelling&
• Accumulation%of%desquamated%cells,%food,%&%debri%(can%indicate%tonsillar%stones)&
Observe%posterior%wall%of%oropharynx%
• Accessory%lymphoid%tissue%(adenoids)%
 • Bulging%(may%indicate%retropharyngeal%abscess)&
14.&INSPECTION&&&PALPATION&OF&THE&SALIVARY&GLANDS%–%take%off%one%glove%&%use%penlight%
First%inquire:%
• “Have%you%had%any%dryness%of%your%mouth?”&
• “Have%you%had%any%abnormal%discharges%into%the%mouth%with%a%bad%taste?”&
• “Have%you%had%any%pain%or%swelling%around%the%jaw?”&
Inspection%
Exterior%swellings,%skin%changes,%scarring%
Retract%the%lateral%cheeks%to%expose%buccal%mucosa,%use%a%pen%light%
nd
• Inspect%for%Stenson’s%duct%opening%into%the%buccal%mucosa%opposite%to%the%upper%2 %molar%tooth%–%one%each%side%
• Use%other%hand%to%massage%the%gland%and%observe%saliva%for%amount,%consistency,%&%color%
Palpation%
• Course%of%the%parotid%duct%–%place%finger%@%lower%border%of%zygotmatic%arch%pointing%toward%the%upper%lip%
• Ask%patient%to%clench%teeth%%palpate%anterior%to%the%masseter%muscle%just%below%the%zygomatic%arch%
• Palpate%the%parotid%gland%(from&behind)%–%anterior%to%the%tragus%&%below%the%lobule%of%the%ear%on%both%sides%
• For%tenderness,%swellings,%or%stones&
• *In%assessing%a%parotid%gland%swelling,%always%test%integrity%of%CN%VII*&
Bimanual%palpation%of%the%submandibular&gland%with%gloved%hand&
• First%locate%&%inspect%the%duct%on%either%side%of%the%frenulum%for%swellings,%skin%changes,%color%@%orifices,%&%secretions&
• Right%index%finger%placed%under%the%tongue%&%middle%finger%under%the%mandible&
• Left%thumb%&%index%finger%pushing%cheeks%inwards%(to%prevent%biting)&
• Palpate%the%duct%on%both%sides%of%the%frenulum&
• For%tenderness,%swellings,%or%stones&

NECK&&&LYMPH&NODES&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%your%neck,%&%using%this%to%listen%to%your%vessels%in%your%neck.%Is%that%okay%with%you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
“First%I%would%like%to%ask%you,”%
“Have%you%felt%any%neck%stiffness%or%pain?”%
“Have%you%noticed%any%abnormal%lumps%in%your%neck?”&
1.&INSPECTION&of&neck%–%ask%patient%to%look%up%
Examine%anterior%triangles&&%borders%from&behind%on%both%sides&
• Trace%out%SCM,%mandible,%midline%
Examine%posterior%triangles%&%borders%from&the&front%
• Trace%out%SCM,%trapezius,%clavicle&
Observe%%
• Downward&tugging&of&the&trachea%–%may%suggest%aortic%aneurysm%
• Symmetry%of%muscles%
• Swellings,%masses,%scars,%lesions%
• Fullness,%shortness?%
• Webbing,%excess%skin%folds%
• Any%distension%of%jugular%veins%or%prominent%carotid%pulsations&
2.&PALPATION&&&AUSCULTATION&of%the%neck%(with%head%still%looking%up)%
• Palpate&tracheal&alignment%with%middle%finger%along%trachea%&%two%side%fingers%on%sternoclavicular%joint&
• Palpate%for%any%tenderness,&lesions,%swellings%or%masses%noted&
• Palpate%the%carotid%pulse&
• Auscultate&for&bruit%in%area%of%carotid&
3.&INSPECTION&of&lymph&nodes&
Swelling%and%redness%
4.&PALPATION&of&lymph&nodes&
With%pads%of%two%fingers%in%a%circular%motion,%BILATERALLY%at%the%same%time!%
• Submental%%in%submental%triangle&
• Submandibular%%along%inferior%border%of%mandible%–%using%thumb%&%4%finger%tips&
• Preauricular/parotid&
• Postauricular&
• Occipital%%near%attachment%of%trapezius&
• Posterior%cervical%%in%posterior%triangle%with%3%fingers,%starting%from%apex%going%to%base&
• JuguloKdigastric%(tonsillar)%%@%the%angle%of%the%mandible&
• Superficial%anterior%cervical%%over%the%SCM%–%with%3%fingers&
• Deep%anterior%cervical%%inform%the%patient%it%may%be%uncomfortable,%hook%finger%under%anterior%border%of%SCM%and%move%the%
 muscle%laterally%to%palpate%for%the%deep%nodes&
• Supraclavicular%%have%patient%perform%valsalva%maneuver%&%dig%into%the%hollow%behind%the%clavicle&
Compare%both%sides%for%
• Warmth%&%tenderness&
• Size%(<1cm)&
• Consistency&
• Discreteness&
• Mobility&
Compression%of%surrounding%structures&

THYROID&GLAND&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%your%hands%and%skin,%checking%your%eyes%and,%then%I%will%be%looking%at%and%feeling%your%thyroid%
gland%in%your%neck%while%you%take%sips%of%water%and%I%will%be%listening%with%my%stethoscope%in%your%neck%region,%is%that%okay%with%you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
First%I%would%like%to%ask%you,%
%“Have%you%noticed%any%heat%or%cold%intolerence?”%
“What%about%any%abnormal%weight%loss%or%gain?”&
1.&PERIPHERAL&SIGNS&OF&HYPERTHYROIDISM&
Global%signs%%restlessness,%agitation,%weight%loss%
Eyes%
• Lid%lag%(ask%patient%to%follow%tip%of%pen%light%in%downward%direction)%
• Chemosis%
• Look%from&side&and&from&above%to%check%for%exophthalmos%or%proptosis%
• 4%tests%for%extraocular%muscles%
o Corneal%reflection%test%to%assess%the%alignment%of%the%eyes%
o H%test%&%convergence%to%assess%for%opthalmoplegia%
o Cover%–%uncover%test%(ask%patient%to%look%into%the%distance%&%wait%20%seconds)%to%assess%for%deviation%of%any%of%the%
extraocular%muscles%
Hands%&%skin%
• Vitiligo%
• Oncycholysis%(separation%of%nails%from%nailbed)%
• Palpate%temperature%(should%be%increased)%
• Inspect%for%erythema,%sweating%
• Thyroid%acropachy%–%soft%tissue%swelling%of%fingers%&%toes%(usually%presents%as%pretibial%myxedema)%
• Tremor%–%ask%patient%to%hold%hands%out%&%place%piece%of%paper%on%them%
• Bilateral%pulse%–%tachycardia%
Pretibial%myxedema%(deposition%of%mucin%in%the%dermis)%–%bilateral,%asymmetric%plaques%or%nodules%on%lateral%&%anterior%aspects%of%legs%
%“I%would%normally%also%check%full%pulse%and%BP%to%check%for%tachycardia%&%systolic%hypertension.%I%would%also%test%for%muscle%weakness.”&
2.&PERIPHERAL&SIGNS&OF&HYPOTHYROIDISM&
Global%signs%&immobility,%uninterest,%weight%gain%
Eyes%
• Periorbital%edema&
• Thinning%of%lateral%1/3%of%eyebrow&
Hands%&%skin%
• Pulse%–%bradycardia&
• Temperature%(should%be%decreased)&
• Oncycholysis&
• Course,%dry%skin&
• Myxedematous%changes&
• Yellow%discoloration%(hypercarotenmia)&
• Pallor%(anemia)&
Deep%tendon%reflexes%–%assess%knee%jerk%for%delayed&relaxation&phase&
3.&INSPECTION&&&PALPATION&OF&THYROID&GLAND&
Inspection:%have%patient%extend%neck%&%observe:%
• Scars%(previous%surgery)%
• Fullness%
• Outline%of%the%gland%–%enlargement,%contour%&%symmetry%
• Any%masses%or%abnormal%pulsations%
• Have%the%patient%take%a%sip%of%water%and%observe%the%mobility%of%the%thyroid%gland%and%any%substernal%component%or%thyroglossal%
cyst%%
Locate%the%thyroid&cartilage%(most%superior,%largest),%then%the%thyrocricoid&membrane,%then%the%cricoid&cartilage%–%marks%the%superior%border%
of%the%isthmus%of%the%thyroid%gland%
Palpate%for%presence%of%tracheal&deviation%
Palpation%of%the%thyroid%from%behind%
Isthmus%%2%fingers%of%each%hand%on%either%side%of%the%trachea%just%below%the%cricoid%cartilage%
• Ask%the%patient%to%take%a%sip%of%water%&%swallow%–%feel%for%movement%of%gland%
• Noticing%size,%surface,%consistency,%tenderness,%&%mobility&
• “Can%you%let%me%know%if%you%feel%any%pain%while%I%am%doing%this?”&
Right%lateral%lobe%%2%fingers%of%left%hand%on%right%side%of%trachea%&%2%fingers%of%the%right%hand%just%posterior%to%the%right%SCM%
• Ask%the%patient%to%take%a%sip%of%water%&%swallow%
• Noticing%size,%surface,%consistency,%tenderness,%&%mobility%
Left%lateral%lobe%%2%fingers%of%right%hand%on%left%side%of%trachea%&%2%fingers%of%the%left%hand%just%posterior%to%the%left%SCM%
• Ask%the%patient%to%take%a%sip%of%water%&%swallow%–%feel%for%movement%of%gland%
• Noticing%size,%surface,%consistency,%tenderness,%&%mobility&
• Also%comparing%symmetry%to%the%right%side&
4.&PALPATION&OF&THE&CERVICAL&LYMPH&NODES&
• Deep%cervical%
• Supraclavicular&
5.&AUSCULTATION&OF&THE&THYROID&GLAND&
Auscultate%over%both%lobes%of%the%gland%with&the&bell%of%the%stethoscope%listening%for%any&bruit&&&increasing&blood&flow%
6.&PERCUSSION&OF&RETROSTERNAL&THYROID&
Start%at%the%sternal%notch%and%move%down%–%any&dullness%may%indicate%retrosternal%thyroid%

JAW&AND&TEMPEROMANDIBULAR&JOINT&
WIIPEEP%
“Today%I%am%going%to%be%feeling%for%and%checking%the%movement%of%your%jaw,%is%that%okay%with%you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
“First%I%would%like%to%ask%you,”%
“Have%you%had%any%trauma%or%injury%in%the%past%to%the%jaw?”%
“Do%you%ever%experience%clicking%or%crunching%sound%when%opening%the%mouth?”&
1.&PALPATION&
Place%the%tips%of%the%fingers%over%the%joint%in%front%of%the%tragus%or%the%tip%of%the%little%finger%in%the%auditory%canal%pressing%again%the%anterior%
wall%
Ask%the%patient%to%open%&%close%the%mouth,%checking%for%
• Crepitations,%clicking,%popping&
• Decreased%range%of%motion&
• Tenderness&
• Swelling&
• Ask%patient%to%bite%down%on%wooden%tongue%blade%and%check%for%pain&
Section 4 – Ear, Nose, & Sinus

EAR&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%your%external%ear%area,%then%I%am%going%to%be%using%this%instrument%to%look%into%your%ear,%and%
finally%I%will%be%performing%some%simple%tests%to%test%your%hearing%&%balance,%Is%that%okay%with%you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
“First%I%would%like%to%ask%you,”%
“Have%you%had%any%problems%hearing?”%
“Have%you%noticed%any%discharge%from%your%ears?”%
1.&INSPECTION%
Identify%%pinna,%external%acoustic%meatus,%tragus,%antitragus,%helix,%antihelix,%&%lobule%
• Size,%shape,%position%(draw%line%from%eye%–%should%touch%top%or%auricle%&%another%line%perpendicular%–%should%be%in%verticle%plane),%
symmetry%
• Microtia%
• Color,%swellings,%lesions,%lifting%of%the%ear%
• Tophi,%cauliflower,%keloids,%sebaceous%cysts,%preauricular%tags%or%pits%
External%auditory%canal%
• Discharge%&%odor%
• Patency%&%any%blockage%due%to%wax,%foreign%body,%or%swelling%
• Color%–%redness%can%signify%infection%or%trauma%
• Dry%&%scaley%–%may%indicate%eczema%
2.&PALPATION&
• Masses,%swellings,%nodules&
• PreKauricular%and%postKauricular%areas%for%lymph%nodes%(simultaneously%both%hands%in%rotating%motion)&
• Tenderness&
o Press%tragus%against%external%ear&
o Pull%the%external%ear%up%(on%helix)%&%down%(on%tragus)&
o Press%over%the%mastoid%process%(can%signify%mastoiditis%&%middle%ear%infection)&
3.&OTOSCOPE&INSPECTION%
First&teach&the&patient&how&to&do&the&Valsava&maneuver%–%take%a%deep%breath%in,%then%with%lips%together%and%nares%closed%by%pinching%with%
fingers,%attempt%to%breath%out%forcefully%
Positioning%–%attach%a%disposable%speculum%(make%sure%on%tight),%tilt%head%to%opposite%shoulder,%pull%ear%back%to%straighten%auditory%canal,%hold%
otoscope%like%a%pen%and%rest%fingers%on%the%patient’s%face,%then%bring%eye%to%otoscope%to%visualize%
Auditory%canal%
• Dryness,%flaky%skin&
• Redness,%swellings,%masses&
• Wax,%foreign%body&
• Discharge&
Tympanic%membrane%%should%be%ovioid,%semitransparent%and%pearly%grey%
• Landmarks%–%handle%of%malleus,%umbo,%cone%of%light,%pars%tensa,%pars%flaccida%(noticing%any%distortion)&
• Color,%blurring,%dullness&
• Contour,%fluid%levels&
• Perforations,%lesions&
• Ask%patient%to%perform%Valsava%maneuver%and%visualize%mobility%of%the%membrane&
4.&HEARING&TESTS&
Whisper%test%
• Explain%–%“I%am%going%to%be%whispering%a%word%while%I%cover%one%of%your%ears,%then%please%repeat%the%word%I%say%if%you%can%hear%it.”%
• Block%one%of%patient’s%ears%(left)%by%pressing%the%tragus,%place%other%hand%between%mouth%and%patient’s%field%of%vision%to%test%other%
ear%(right)%
• About%one%foot%away,%whisper%a%“Grenada”%
• Repeat%for%other%ear%using%a%different'word'“Flower”&
• Report%“Hearing%seems%to%be%intact%on%both%sides”&
Weber%test%
• Explain%–%“I%am%going%to%be%using%this%tuning%fork%to%test%your%hearing.%I%will%be%placing%it%on%your%head%then%can%you%please%let%me%
know%where%you%hear%the%sound%more%–%the%right,%the%left,%or%both%sides?”%
• Put%vibrating%512%Hz%tuning%fork%on%midline%of%patient’s%forehead%then%ask%the%patient%where%they%hear%the%vibrations%
• Report%“No%lateralization%to%either%side”%
Lateralization'to'side'of'hearing'defect'='conductive'hearing'loss,'lateralization'to'the'normal'ear'='sensorineural'hearing'loss'
Rinne%test%
• Explain%–%“I%am%going%to%use%this%tuning%fork%again%now%on%either%side,%first%I%am%going%to%place%it%on%your%head%behind%your%ear%and%
you’re%going%to%tell%me%when%you%stop%hearing%the%sound.%Then%I%will%pull%it%away%from%your%ear,%you%should%hear%the%sound%again,%
 and%then%again%tell%me%when%it%stops”&
• Put%vibrating%512%Hz%tuning%fork%on%mastoid%process%and%watch&the&clock&to&measure&length&of&BC&time&
• Then%pull%the%tuning%fork%next%to%the%ear%(@%right%angle%to%the%ear)%and%watch%the%clock%to%measure%length%of%AC%time&
• Repeat%on%other%side&
• Report%“AC%was%greater%than%BC%in%both%ears.”&
Romberg%test%–%test%for%balance%
• Ask%the%patient%to%stand%upright%with%feet%parallel%and%close%together%and%eyes%closed%with%arms%folding%across%chest&
• Have%the%patient%walk%in%a%straight%line&
• Report%“I%do%not%notice%any%swaying”&

NOSE&
WIIPEEP%
“Today%I%am%going%to%be%looking%and%feeling%your%nose%then%looking%inside%your%nose%using%this%instrument,%Is%that%okay%with%you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
“First%I%would%like%to%ask%you,”%
“Do%you%have%any%nasal%congestion?”%
“Do%you%experience%nose%bleeds%often?”%
1.&INSPECTION%from%front%&%sides%
• Color,%width,%length,%distortions%
• Deformities%like%clefts,%pits,%sinuses,%humps,%depression,%deviations,%drooping%tip%
• Scars,%swelling,%ulcerations%
• Dilated%vessels%
2.&PALPATION%with%head%tilted%slightly%up%
• Tenderness%–%over%nasal%bones,%tip,%and%dorsum&
• Depressions,%deformities,%deviations&
• Crepitus&
• Presence%of%cartilage%at%tip%of%nose&
3.&INSPECTION&OF&NASAL&CAVITY%–%using%pen%light%&%otoscope%
Using%a%penlight,%first%(bend%head%back%slightly%&%elevate%nose%with%thumb%
• Swellings,%ulcerations&
• Deviation&
• Foreign%body&
• Excoriation%of%skin%–%due%to%persistent%nasal%discharge&
Test%patency%%ask%patient%to%hold%one%nostril%closed%and%breath%through%other%
Using%otoscope%–%hold'upside'down,'use'left'hand'to'examine'right'nostril'and'vice'versa,'hold'like'a'pen,'with'remaining'fingers'against'
patient’s'face%
Medal%wall/septum%–%bend'patient’s'head'slightly'forward'to'observe'anterior'&'inferior'parts,'bend'slightly'backward'to'observe'posterior'&'
superior'parts%
• Vascularity%&%vessel%fragility&
• Bleeding&
• Spurs,%deviations,%perforations&
Lateral%wall%
• Color,%size,%quality%of%mucosal%lining&
• Discharge%from%inferior%&%middle%meatus%(amount,%color,%and%consistency)&
• Presence%of%polyps%or%neoplasm%
• Chonchae%%inferior%choncha%can%easily%be%seen,%tilt%patient’s%head%up%&%back%(45degrees)%to%visualize%middle%choncha,%cannot'
visualize'superior'choncha'&'meatus&
SINUSES&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%your%sinuses%then%using%my%pen%light%against%your%skin%to%observe%the%sinuses,%Is%that%okay%with%
you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
“First%I%would%like%to%ask%you,”%
“Do%you%ever%experience%any%pain%over%your%sinuses?”%
“Do%you%notice%any%unusual%discharge%into%your%nose?”%
1.&INSPECTION%
• Swelling,%redness%
• Signs%of%nasal%congestion%or%rhinorrhea%
2.&PALPATION&for%tenderness%using%thumb%pressure%simultaneously%on%both%sides&
• Frontal&sinus%%medial%supraorbital%ridge&
• Maxillary&sinus%%canine%fossa&
 • Anterior&ethmoid&sinus%%inner%wall%of%the%orbit%in%proximity%with%the%nose&
3.&TRANSILLUMINATION&TEST%–%using%pen%light,%in%dark%room%
• Explain%–%“I%am%now%going%to%be%using%my%penlight%to%observe%the%sinuses.%I%would%normally%do%this%in%a%dark%room.”&
• Maxillary&sinus%%ask%patient%to%tilt%head%back,%close%eyes,%and%open%mouth,%place%pen%light%above%upper%end%of%nasolabial%fold%
against%bone,%directing%light%downward,%observe%glow%through%mucosa%of%the%hard%palate&
o Do%other%side&
• Frontal&sinus%%ask%patient%to%close%eyes,%place%light%inside%area%of%medial%part%of%supraorbital%ridge%while%placing%border%of%one%
hand%across%the%forehead%against%the%bone,%and%observe%the%light%glowing%into%the%forehead%above%the%your%hand&
o Do%other%side&
Section 5 – Eye

EYE&
WIIPEEP%
“Today%I%am%going%to%be%touching%your%face%to%examine%your%eye%and%then%I%am%going%to%use%this%instrument%to%look%inside%your%eye,%is%that%
okay%with%you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
“First%I%would%like%to%ask%you,”%
“Do%you%experience%any%blurry%vision?”%
“Do%you%experience%any%itching%in%or%around%the%eye?”&
1.&INSPECTION%of%outer%eye,%conjunctiva%&%sclera%
Eye%&%bony%orbits% • Discoloration%–%raccoon&eyes'
• Symmetry%–%of%orbits,%eyebrows,%eyelids,%and%eyeball% • Lid&lag%–%have%the%patient%follow%an%object%without%moving%
including%iris%&%pupil% head%–%moving%slowly%from%top%to%bottom%and%take%notice%to%
• Scarring% any%exposure%of%the%superior%sclera'
• Bulging% Conjuctiva%–%to%visualize%the%conjunctiva%by%pulling%down%the%lower%
• Eyebrow%–%hair%distribution% eyelids%(both%sides,%simultaneously)%and%having%the%patient%look%up,%
Lacrimal%apparatus% then%pull%open%the%upper%eyelid%while%the%patient%looks%down%
• Upper/outer%margin%for%swelling%of%lacrimal%gland% • Color%–%pallor,%yellow%or%red%
• Puncta%on%medial%end%of%each%upper%and%lower%eye%lid%for% • Swellings%(chemosis%–%fluid%in%the%episcleral%space)%
inflammation%or%regurgitation%of%fluid% • Pinguecula,%pterygium%
• Compress%the%lacrimal%sac%gently%(inner%lower%orbital%rim% • Collagen%defects%
on%the%side%of%the%nose)%and%notice%inflammation%or% • Foreign%bodies%or%exudates%%
regurgitation% Sclera%–%to%visualize%the%sclera,%separate%the%upper%&%lower%eyelids%with%
Eyelids% index%&%thumb%(one%eye%at%a%time)%
• Position%–%ptosis,%lid%retraction%(visible%superior%sclera),% • Color%%yellowish%or%bluish%
ectropion,%entropion! • Vascularity%&%nodularity&
• Margin%–%mucus,%pus%discharge,%redness,%scales,%
swellings,%specifically%for%stye,%chalazion,%xanthelasma'
2.&INSPECTION&of%anterior%segment%of%the%eye%
Anterior%segment%of%the%eye%=%cornea,%anterior%chamber,%iris,%pupil,% Iris%
lens%&%posterior%chamber% • Shape,%well%circumscribed%
Cornea%–%to%visualize%the%cornea,%use%tangential&lighting&using& • Color%
penlight%and%examine%from%the%side%&%front% • Vascularity%&%nodularity%
• Shape& Pupil%–%have%patient%look%at%distant%object%&%shine%light%from%below%
• Rings,%color& • Size,%shape%&%symmetry%(anisocoria)%
• Ulcerations& • Notice%any%reflected%light%
• Opacities& Lens%–%using%oblique%lighting%(at%angle%from%in%front%of%ear%lobe)%
Anterior%chamber%–%to%visualize%the%cornea,%use%tangential&lighting& • Opacification%
using&penlight%and%examine%from%the%front% • Position,%dislocaton%
• Clarity%
• Depth,%noticing%any%shadows%on%the%medial%side&
3.&PUPILLARY&REACTIONS&–%using%pen%light%
Light%reaction%–%perform'in'darkened'room'
• Have%patient%look%at%distant%object&
• Direct%light%source%at%an%angle%toward%patient’s%pupils&
• Hold%other%hand%midway%between%eyes%on%bridge%of%nose%(tightly)&
• Observe%direct%response%(pull%penlight%away)%then%observe%consensual%response&
• Do%the%same%with%the%other%eye&
Near%reaction%–%performed'in'a'normally'light'room%
• Hold%finger%about%10%cm%from%patient’s%nose%and%ask%the%patient%to%look%at%distant%object%then%at%the%finger&
• Observe%pupillary%constriction%as%the%eyes%converge%on%the%finger&
• Be%sure%to%observe%both%eyes&
4.&EXTRAOCULAR&MUSCLES&
Corneal%light%reflection%–%assess%symmetry%of%reflection%both%eyes%(asymmetry%suggests%deviation)%
• Instruct%the%patient%to%look%directly%into%the%light,%immobilze%the%patient’s%head%with%your%hand%and%ask%the%patient%to%follow%the%light%
with%their%eyes&
• Shine%penlight%into%patient’s%pupils%from%about%18K24%inches%away%and%move%wrist%in%cross'motion%while%keeping%reflection%in%pupils&
Convergence%–%assess%for%symmetrical%convergence%&%pupillary%constriction%
• Hold%a%pencil%about%12%inches%from%eyes%in%the%midline,%ask%patient%to%follow%the%object%without%moving%his%head%
• Move%object%toward%nose%
HKtest%–%full%movement%of%eyes%in%all%directions%to%assess%muscle%paresis%
• Instruct%patient%to%follow%finger%or%object%without%moving%his%head&
 • Form%a%“H”%with%finger%or%object&
Cover/Uncover%test%–%to%assess%latent%ocular%deviation%
• Have%patient%look%at%distant%object&
• Cover%one%eye%for%20&seconds,%remove%cover%and%notice%any%deviation&
• Repeat%with%other%eye&
5.&VISUAL&ACUITY&
• Hold%eye%chart%14%inches%away,%instruct%the%patient%to%cover&one&eye%then%read%the%lowest%line%they%can&
• Do%other%eye&
• Then%both%eyes%together&
• If%patient%cannot%read%any%of%the%lines%then%assess%ability%to%count%fingers%or%perceive%light&
6.&VISUAL&FIELD&TESTING%by%confrontational%testing%
• Explain%–%“Ok,%now%I%am%going%to%be%testing%your%visual%fields.%I%am%going%to%wiggling%my%fingers%and%you%let%me%know%when%you%can%
see%my%finger%in%your%field%of%vision.%Look%at%my%nose%and%don’t%move%your%head.”%(Examiner%and%patient%should%be%at%the%same%eye%
level)&
• First%assess%temporal%fields%simultaneously,%move%fingers%from%behind%patient%n%all%6%areas&
• Ask%patient%to%cover%one%eye%and%you%cover%opposite%(with%opposite%hand)%and%assess%nasal%fields%for%each%eye&
7.&RETINAL&EXAMINATION&–%using%ophthalmoscope,%ambient%lighting%
1. Turn%light%on%and%switch%to%small%aperture,%ask&patient&to&focus&on&distant&object%
2. Turn%light%intensity%down%as%far%as%compatible%with%seeing%red&reflex%from&distance&of&2&feet%
3. Place%instrument%in%front%of%right%eye%with%right%hand%to%examine%the&patients&right&eye,%rest%index%finger%on%the%lens%wheel%(to%
change%diopter)%
4. Approach%eye%at%angle%of%15%degrees%lateral%form%center,%while%using%left%hand%to%elevate%eyebrow,%rest%right%hand%on%patient’s%cheek%
5. Adjust%diopter%if%needed%
6. Find%blood%vessels,%follow%to%optic%disc%by%moving%head%&%ophthalmoscope%as%unit%
7. Report%“I%can%see%the%blood%vessels,%I%am%following%vessels%to%the%optic%disc.%Now%I%am%at%the%optic%disc.%Can%you%look%into%the%light?%
Now%I%can%observe%the%macula%and%fovea.”%(optic%disc%is%MEDIAL%(NASAL)%to%macula)%
8. Repeat%with%other%eye%
Section 6 – Cardiovascular System

PERIPHERAL&SIGNS&OF&CVS&DISEASE&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%your%hands,%feet%&%inside%your%mouth,%then%using%this%instrument%to%look%into%your%eye,%and%my%stethoscope%
to%listen%to%your%neck%&%lungs.%Is%that%okay%with%you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
“First%I%would%like%to%ask%you,”%
“Do%you%have%any%chest%pain?”%
“Do%you%have%any%shortness%of%breath?”%
1.&INSPECTION&&&PALPATION&of&hands%
• Nails%–%cyanosis,%clubbing,%splinter%hemorrhages%
• Palms%–%Janeway%lesions%(nonKtender)%
• Palpate%finger%tips%–%Osler’s%nodes%(tender)%
2.&EXAMINATION&OF&THE&EYE&
• Inspect%for%–%pallor,%hemorrhage&
• Use%ophthalmoscope%–%Roth%spots%(infective%endocarditis)&
3.&INSPECTION&of&the&face/mouth%
• Malar%flush%(mitral%stenosis)&
• Cyanosis%of%skin/lips&
• Cyanosis%of%tongue/buccual%mucosa&
4.&PALPATION&&&AUSCULTATION&in&neck&
• Assess%amplitude%&%waveform%of%carotid%pulse%bilaterally%(but%not%at%the%same%time)&
• Listen%to%carotid%pulse%bilaterally%for%thrills%or%bruit&
• Palpate%for%tracheal%shift&
5.&&AUSCULTATION&of%lung%bases&
• “In%order%for%me%to%listen%to%lungs%I%am%going%to%open%up%the%back%of%your%gown.%Is%that%okay?”&
• “Can%you%please%cross%your%arms%in%front%of%your%chest%and%hunch%forward?”&
• First%locate%the%angle%of%the%scapula%and%place%stethoscope%below%it&
• “Can%you%take%a%deep%breath%then%exhale%please?”%“Again.”&
• Listen%to%both%sides%for%crepitations%or%rales&
6.&PALPATION&of%the%lower%limbs%
• Apply%pressure%on%5%seconds,%release%&%inspect%for%depression%or%pitting&
o Dorsum%of%feet%
o Inferior%to%medial%malleoli%
o Over%the%shins%
o (in%bed%bound%patient%also%check%over%sacrum)%

EXAMINATION&OF&THE&HEART&
WIIPEEP%
“Today%I%am%going%to%be%looking%&%feeling%your%neck,%chest,%and%abdomen%to%examine%your%heart%&%blood%vessels.%Then%I%will%be%using%my%
stethoscope%to%listen%to%your%heart.%This%will%involve%you%lying%down%and%exposing%your%chest%and%abdomen.%Is%that%okay%with%you?%%
DRAPE%UP%TO%WAIST,%then%expose%chest%and%abdomen%
“First%I%would%like%to%ask%you,”%
“Do%you%have%any%chest%pain?”%
“Do%you%have%any%shortness%of%breath?”%
1.&JUGULAR&VENOUS&PRESSURE%
• Make%sure%patient’s%head,%neck%&%thorax%is%elevated%30K45d%
• Turn%patient’s%head%to%left%
• Use%tangential%light%to%first%INSPECT%the%pulsation%of%the%right%internal%jugular%vein%
• Measure%the%HEIGHT%of%the%internal%jugular%pulsation:%
o Locate%the%sternal%angle%4%cm%below%suprasternal%notch%–%place%ruler%upright%
o Use%straight%edge%just%above%the%highest%level%(meniscus)%of%the%pulsations%=%jugular&venous&pressure%(normal%is%2K3%cm%
H20)%
o Add%5%cm%=%central&venous&pressure%
2.&HEPATOJUGULAR&REFLEX&
• Explain%–%“I%am%going%to%be%pushing%into%your%abdomen%now%with%some%pressure,%is%that%okay?”&
• Apply%firm%pressure%with%fingers%below%right%costal%margin%in%midKclavicular%line%for%15&seconds%while%examining%the%right%internal%
jugular%pulsations&
• Pulsations%should%increase%but%not%sustained%more%than%10%seconds&
• Abnormal%if%JVP%is%>%3%cm%and%sustained%for%>%10K15%sec%(RV%failure)&
3.&INSPECTION&of&the&thorax&*from'foot'of'the'bed*%
• Size&
• Shape%(barrel)&
• Scars&
• Symmetry&
4.&INSPECTION&of&the&heart&pulsations%*with'use'of'tangential'lighting*%
th
• Apical%impulse/mitral%area%–%left%5 %IC%midKclavicular&
th
• Tricuspid%–%left%5 %IC%parasternal&
rd
• Erb’s%point%–%left%3 %IC%parasternal&
nd
• Pulmonic%–%left%2 %IC%parasternal&
nd
• Aortic%–%right%2 %IC%parasternal&
• Jugular%&%carotid%pulsations&
• Epigastric%–%aortic%pulsations&
5.&&PALPATION&of%thorax&
First%assess%for%TENDERNESS%–%ask%patient%if%there%is%any%pain%then%palpate%(painful%area%last)%
Apex%beat%
th th th
• Place%palmar%surface%of%your%right%hand%over%the%area%(midclaviular%line%to%anterior%axillary%in%4 ,%5 ,%&%6 %IC%spaces&
• Ask%patient%to%take%a%deep%breath%and%exhale&
• If%can’t%feel%have%patient%roll%over%to%left%side%keeping%palm%over%apex%beat%then%turn%back&
• Try%to%localize%with%one%finger%–%note%diameter,&amplitude,&and&duration&of&the&apex&beat%(less%than%1%inch)&
th
• Document%the%location,%count%with%left%hand%–%e.g.%“Apex%beat%is%in%the%5 %IC%space%1%cm%lateral%to%midclavicular%line”&
Palpate%each%of%the%cardiac%areas%
• For%pulsation%(with%two%fingers)%and%thrills%(with%palmar%surface%=%palpable%murmurs)&
• Aortic&
• Pulmonic&
• Erb’s%Point&
• Tricuspid&
• Mitral&
Right%ventricular%heave%–%place%ulnar%surface%of%hand%along%left%parasternal%border%
Abdominal%aortic%or%right%ventricular%pulsations%–%place%palmar%surface%flat%in%the%epigastric%area%(finger%tips%up)%
6.&PERCUSSION%to%determine%heart%borders%
rd th th
• Left%border%K%start%anterior%axillary%line%on%the%left,%3 %IC%space,%percuss%medially%until%feel%dullness%then%repeat%in%4 %&%5 %IC%space&
rd th th
• Right%border%–%start%midKclavicular%line%on%the%right,%3 %IC%space,%percuss%medially%until%feel%dullness%then%repeat%in%4 %&%5 %IC%space%
(normally%at%the%sternum)&
7.&AUSCULTATION&
First%verify%function%by%tapping%on%diaphragm%and%listening%for%sound%
• Identification%of%S1%@%the%cardiac%apex%with%the%diaphragm,%while%using%left%hand%to%palpate%carotid%pulse%(should%be%simultaneous)&
o S1S2%=%ventricular%systole&
o S2S1%=%ventricular%diastole&
• Continue,%using%diaphragm,%to%listen%to%all%heart%areas&
• Next,%use%the%bell%on%all%cardiac%areas%to%auscultate%any%murmurs&
Special%positions%
• Auscultate%mitral&area&with&the&bell%&%ask%patient%to%roll%to%left%side%(to%hear%mitral%stenosis%murmur%or%S3/S4)&
• Have%patient%sit&up&and&lean&forward%–%place%diaphragm%over%the%aortic%area%and%ask%the%patient%to%inhale%then%exhale%and%hold%
breath%in%expiration%(to%hear%accentuation%of%the%diastolic%murmur%of%aortic%regurgitation),%also%at%erbs%point%(to%hear%S2)&
Section 7 – Peripheral Vascular System

UPPER&LIMB&h&ARTERIAL&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%your%hands%&%arms%to%examine%the%integrity%of%your%blood%vessels.%Is%that%okay%with%you?”%
“You%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
“First%I%would%like%to%ask%you,”%
“Do%you%experience%pain%in%your%arms%or%legs?”%
“Do%you%feel%numbness%or%tingling%in%your%arms%or%legs?”%
1.&INSPECTION%
• Dorsum%of%hands%–%hair%loss,%thickening%&%ridging%of%the%nails%
• Palms%–%changes%in%color%(like%pallor,%hyperemia,%any%black,%blue,%or%yellow%discoloration),%and%texture%(thin%&%shiny)%
• Ulcerations%@%the%tips%of%the%digits%or%over%bony%prominences%
• Scars,%muscle%atrophy,%swelling,%missing%parts%
2.&PALPATION&
• Temperature%(using%backs%of%hands),%both%limbs%simultaneously%for%comparison%–%also%medially%&%laterally&
• Pulses%%brachial,%radial,%&%ulnar%–%noting%amplitude%(+2)&
• Tenderness%–%ask%about%pain%then%palpate%the%painful%area%last&
3.&SPECIAL&TESTS%
Allen%test%=%to%test%for%arterial%insufficiency%or%for%patency%of%the%radial%&%ulnar%arteries%
• Cover%radial%&%ulnar%pulses%with%the%thumb%of%each%hand&
• Ask%the%patient%to%make%a%tight%fist%and%occlude%for%10%seconds&
• Have%the%patient%open%the%hand%(should%be%pale),%uncover%the%radial%artery%while%maintaining%the%ulnar%and%observe%return%of%color&
• Repeat%then%uncover%ulnar%&%observe%for%return%of%color&
• Repeat%on%other%hand&
Capillary%refill%=%to%test%integrity%of%small%vessels%
• Apply%pressure%on%tip%of%nail%for%5%sec,%nail%bed%should%become%pale%&%pink%color%should%return%upon%release%in%<%2%sec&

LOWER&LIMB&h&ARTERIAL%
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%your%legs%&%feet%to%examine%the%integrity%of%your%blood%vessels.%That%will%involve%me%lifting%your%
leg%to%various%positions.%I%will%also%look%at%&%listen%to%your%abdominal%area%with%my%stethoscope%–%that%will%also%involve%me%exposing%the%area.%Is%
that%okay%with%you?”%
“If%I%could%please%have%you%lie%down.”%
“First%I%would%like%to%ask%you,”%
“Do%you%experience%pain%in%your%arms%or%legs?”%
“Do%you%feel%numbness%or%tingling%in%your%arms%or%legs?”&
1.&INSPECTION&
• Dorsum%of%feet%–%hair%loss,%thickening%&%ridging%of%the%nails%
• Soles%of%feet%–%changes%in%color%(pallor,%hyperemia,%any%black,%blue,%or%yellow%discoloration),%and%texture%(thin%&%shiny)%
• Ulcerations%@%the%tips%of%the%toes,%between%toes,%plantar%surface%(neuropathic),%on%the%heal%
• Scars,%muscle%atrophy,%swelling,%missing%parts%
• Epigastric%area%–%pulsations%of%aortic%aneurysm&
• Popliteal%fossa%–%abnormal%pulsations&
2.&PALPATION&
• Tenderness%–%ask%about%pain%first%then%palpate%the%painful%area%last&
• Temperature%(using%backs%of%hands),%both%limbs%simultaneously%for%comparison%–%also%medially%&%laterally&
• Pulses%%popliteal,%dorsalis%pedis,%&%posterior%tibial%–%noting%amplitude%(+2)&
o Epigastric%area%for%aorta&
o Carotid%arteries&
o Mass%may%indicate%aneurysm%–%aorta%or%popliteal&
o Auscultation&over&abdominal&aorta&&&popliteal&
3.&SPECIAL&TESTS&
Burger’s%test%=%to%assess%arterial%insufficiency%
• Have%the%patient%lie%on%the%bed,%face%up&
• Raise%both%legs%(can%use%shoulder%for%support)%to%60%degrees,%hold%for%60%seconds%while%the%patient%wiggles%his%toes&
• Observe%the%soles%of%the%feet%–%should%appear%pale&
• Ask%patient%to%sit%up%&%swing%his%feet%around%the%side%of%the%bed,%allowing%to%dangle&
• Observe%color%return%(capillary%refill)%within%10%seconds%&%filling%of%veins%within%15%seconds&
Capillary%refill%=%to%test%integrity%of%small%vessels%
• Apply%pressure%on%tip%of%nail%for%5%sec,%nail%bed%should%become%pale%&%pink%color%should%return%upon%release%in%<%2%sec%
 LOWER&LIMB&h&VENOUS%
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%your%legs%&%feet%to%assess%your%veins.%That%will%also%involve%me%lifting%your%leg%to%various%
positions%&%tying%this%(tournique)%around%your%thigh.%Is%that%okay%with%you?”
“You%are%already%in%the%standing%position%and%the%area%to%be%examined%is%exposed,%so%we%can%go%ahead%and%get%started.”%
“First%I%would%like%to%ask%you,”%
“Have%you%noticed%any%swelling%in%your%feet%or%legs?”%
“Do%you%experience%pain%in%your%calf%area%while%walking?”&
1.&INSPECTION&
• Venous%enlargement,%toruosity,%varicose%veins,%reticular%veins,%telangiectasis%
• Size,%shape,%&%symmetry%of%the%limbs,%edema%
• Texture%–%thickening,%hyperpigmentation,%scaliness&
• Ulceration%above%&%anterior%to%the%medial%malleolus&
2.&PALPATION&
• Tenderness%–%superficially%(cellulitis),%deep%(DVT)&
• Temperature%(using%backs%of%hands),%both%limbs%simultaneously%for%comparison%–%also%medially%&%laterally&
• Superficial%abnormalities%–%cords%(thrombosed%superficial%veins),%varicose%veins,%reticular%veins,%&%telangiectasis,%skin%thickening%
• Edema%–%apply%pressure%for%5%seconds,%release%&%inspect%for%depression%or%pitting&
o Dorsum%of%feet%
o Posterior%to%medial%malleoli%
o Over%the%shins%
3.&SPECIAL&TESTS&
Measurement%of%the%calf%=%from%tibial%tuberosity%to%widest%point%then%around&
Pratt’s%test%%to%assess%pain%&%DVT%
• Have%the%patient%lie%down%with%knee%flexed&
• Place%hands%around%calf%with%thumbs%along%the%anterior%tibia&
• Gently%apply%pressure%(squeeze)%&%watch%for%signs%of%pain%the%patients%face&
Homan’s%test%%test%for%DVT%
• With%patient%lying%down%&%knee%flexed&
• Forcibly%dorsiflex%the%foot%at%the%ankle&
• Note%any%resistance%=%positive%Homan’s%sign&
Manual%compression%test%%to%asses%valves%
• With&patient&standing&
• Map%a%segment%of%the%greater%saphenous%vein%%place%2%finger%of%right%hand%above%&%2%fingers%of%left%hand%below&
• First%block%upper%portion%&%feel%for%distension%in%lower%hand&
• Tap%lower%%should%feel%wave%move%up&
• Tap%upper%%should%not%feel%wave%@%lower&
Trendelenburg%test%%to%assess%valves%
• With%patient%lying%down,%raise%one%leg%at%a%time%to%90%degrees%&%have%patient%wiggle%toes%for%60%seconds&
• Tie%tourniquet%around%thigh%then%have%patient%stand&
• Observe%filling%of%superficial%veins%within%35%seconds%(rapid%filling%suggests%incompetent%valves%of%the%perforators)&
• Observe%the%leg%for%20%seconds%then%release%the%tourniquet%&%observe%the%superficial%veins%–%there%should%be%no%further%distention%
(continued%filling%on%release%indicates%incompetent%of%the%valves%of%the%saphenous%system)&
• NegativeKnegative%means%all%valves%are%competent&
• PositiveKnegative%(for%example)%indicates%valves%of%the%perforators%are%incompetent%&%valves%of%the%saphenous%system%are%competent&
 LYMPHATIC&SYSTEM&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%your%arms%and%in%your%armpits%for%lymph%nodes.%That%would%involve%me%just%exposing%your%full%
arm.%Is%that%ok%with%you?”%
“If%you%could%stand%up%please.”%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Have%you%had%any%recent%infections?”%
“Have%you%noticed%any%painful%or%swollen%areas%in%and%under%your%arms?”%
1.&INSPECTION%
Obvious%swellings%in%the%neck,%axilla,%or%elbow%area%(groin%is%not%examined)%
(Examination'of'cervical'lymph'nodes'done'in'head'&'neck)'
2.&PALPATION%examine'patient’s'right'arm'
• Epitrochlear%lymph%nodes%%with%right%hand%(2%fingers%in%circular%fashion),%3%cm%above%medial%epicondyle,%lateral%to%biceps%tendon&
• Anterior%axillary%lymph%nodes%%with%left%hand,%using%right%hand%to%support%arm&
• Medial%axillary%lymph%nodes%%with%left%hand,%using%right%hand%to%support%arm&
• Posterior%axillary%lymph%nodes%%with%left%hand,%using%right%hand%to%support%arm&
• Lateral%axillary%lymph%nodes%%with%left%hand,%using%right%hand%to%support%arm&
• Apical%axillary%lymph%nodes%%bring%patietn’s%arm%down%and%go%high%up%with%left%hand&
Section 8 – Respiratory System

PERIPHERAL&SIGNS&OF&RESPIRATORY&DISEASE&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%different%parts%of%your%body%to%assess%the%function%of%your%lungs.%We%can%start%with%you%sitting%
but%then%I%will%have%you%lie%down%at%some%point%and%expose%your%abdomen.%Is%that%okay%with%you?”%
“Before%we%start,%I%would%like%to%ask%you%a%couple%of%questions,”%
“Do%you%have%any%trouble%breathing?”%
“Do%you%have%any%pain%in%your%chest?”%
1.&INSPECTION&&&PALPATION%
General%appearance%%weight%loss,%evidence%of%pyrexia,%level%of% • Abnormal%pigmentation%
consciousness,%respiratory%distress%(dyspnea,%rapid,%shallow%or%deep% • Flapping%tremor%(asterixis)%*%have%patient%extend%
breathing,%prolonged%inspiration%or%expiration,%use%of%accessory%muscles)% arms%and%dorsiflex%wrist%with%fingers%spread%apart%
Voice%changes%–%hoarseness% &%observe%for%flapping%motion%
Face%&%eyes% Check%radial%pulse%–%bounding%may%indicate%CO2%retention%
• Pallor%of%conjuctiva& Check%blood%pressure%
• Polycythemic%facies% Neck%
• Pupillary%constriction,%ptosis,%anhydrosis%(Horner’s)% • Engorgement%of%veins%
Nose%&%sinuses% • Palpable%supraclavicular%nodes%
• Patency%–%septal%deviation,%foreign%body,%mucosal%edema,% • Tracheal%deviation%
inspissated%mucus%(ask%patient%to%hold%one%nostril%&%breath,%then% • Tracheal%tug%
use%penlight)& Have%patient%lay%down%at%this%point%
• Sinuses%–%evidence%of%sinusitis& Legs%
Oral%cavity% • Bilateral%pitting%edema%*%check%dorsum,%medial%
• Pallor%or%cyanosis%of%tongue,%labial%&%buccal%mucosa& malleolus,%shin%
• Halitosis& • Swollen%calf%
• Teeth%for%partial%dentures%(may%be%aspirated)& • Peripheral%cyanosis%
Hands% • Toe%clubbing%
• Clubbing%(shamrock%test)& Elevated%jugular%venous%pulsation%
• Nicotine%staining& Palpate%abdomen%for%hepatomegaly&
• Peripheral%cyanosis& &
• Wrist%tenderness%

THORAX&AND&LUNGS&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%around%your%chest%&%back%to%assess%the%function%of%your%lungs.%I%will%also%be%using%my%
stethoscope%to%listen%to%your%breathing.%This%will%involve%you%exposing%your%chest%&%back%areas.%Is%that%ok%with%you?”%
“We%will%start%with%you%laying%down%then%later%on%I%will%have%you%sit%up%on%the%bed.”%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Do%you%have%any%trouble%breathing?”%
“Do%you%ever%experience%any%pain%in%your%chest?”%
1.&INSPECTION%
The%major%characteristic%of%normal%respiratory%function%is%symmetry%
General%inspection%–%skin%&%underlying%tissue%of%chest%for%spider&nevi,%use%of%accessory%muscles,%cough,%audible%wheeze,%stridor%
START%AT%FOOT%OF%THE%BED%
• AP/transverse%diameter%(normal%=%1:2%or%5:7),%signs%of%barrel%chest,%pectus%excavatum%(funnel%chest),%pectus%carinatum%(pigeon%
breast)%
• Chest%symmetry%&%movement%%
• Have%patient%sit%up%to%look%for%kyphosis,%scoliosis%and%observation%of%chest%symmetry%&%movement%(observe%sides%from%behind%the%
patient)%
• Scars,%visible%masses%
• Intercostal%retraction%(can%be%unilateral,%generalized,%or%focal)%
• Suprasternal/substernal%retraction%
• Bulging%interspace%during%inspiration%
• Unilateral%bulging%apex%in%supraclavicular%space%
• Slope%of%the%ribs%(elevation%with%loss%of%normal%slope%in%COPD)%
• Movement%of%intercostal%spaces%during%inspiration%
• Pattern%of%respiration%–%use%of%diaphragm,%use%of%intercostal%muscles%(thoracic)%
• Rate,&depth,&rhythm,&and&type&of&breathing&
2.&PALPATION&of'anterior'chest%
• Tenderness%–%first%ask%the%patient%if%they%have%any%pain,%palpate%that%area%last,%observe%patient’s%face%for%grimace&
• Subcutaneous%emphysema%–%depress%and%lift%lingers%over%different%areas,%feeling%for%crackling'sensation&
 • Tracheal%deviation&
• Tracheal%tug&
• Cardiac%apex%beat&
Tactile%fremitus%
• Use%ulnar%side%of%hand%in%rib%space%and%feel%for%vibrations%as%the%patient%says%“99”%over%all%
lung%fields&
nd
• Upper%lobe%%2 %intercostal,%midclavicular&
th
• Middle%lobe%on%right%%4 %intercostal,%midclavicular&
th
• Anterior%basal%segment%of%lower%lobe%%5 %intercostal,%anterior%axillary&
Thoracic%expansion%–%Respiratory%excursion%
• Place%hands%on%chest%wall%with%thumbs%pointing%up%in%midline%with%fold%of%skin%between%(3K5%
cm%apart)&
• Observe%movement%on%quiet%breathing%then%ask%patient%to%take%deep%breath%slowly%&%exhale&
• (1)%infraclavicular%(2)%nipple%line%(3)%costal%margins&
Measurement%of%chest%(normal%is%1:2%or%5:7)%
• AP%diameter%%distance%between%anterior%&%posterior%axillary%lines&
• Lateral%diameter%%distance%between%both%anterior%axillary%line%along%front%of%chest&
3.&PERCUSSION&AND&AUSCULTATION&of'the'anterior'chest'
Areas%of%percussion%&%auscultation%(6x2)%–%snakeElike'pattern'to'compare'sides%
• Apical%segment%of%upper%lobe%%supraclavicular%and%first%intercostal,%midclavicular%line %
nd
• Anterior%segment%of%upper%lobe%%2 %intercostal%space,%midclavicular%line%
rd
• Anterior%segment%of%upper%lobe%%3 %intercostal%space,%midclavicular%line%
th
• Middle%lobe%on%right,%lingual%area%of%upper%lobe%on%left%%4 %intercostal%space,%midclavicular%
line%
th
• Middle%lobe%of%right,%lingual%area%of%upper%lobe%on%left%%4 %intercostal%space,%anterior%axillary%
line%
th
• Anterior%basal%segment%of%lower%lobe%%6 %intercostal%space,%anterior%axillary%line&
General%percussion%–%in%areas%as%above,%listen%for%normal%resonance%
Auscultation%–%have%patient%take%deep%breaths%in%&%out%
• Listen%for%quality%&%intensity%of%breath%sounds&
• Crackles,%wheezes,%rhonchi,%stridor,%pleural%rub&
• Vocal&fremitus%=%ask%patient%to%say%“99”%&%listen%over%all%lung%fields%for%low%pitched%sounds&
• Egophony%=%ask%patient%to%say%“ee”%&%listen%over%all%lung%fields&
• Whispered&pectoriloquy%=%ask%patient%to%whisper%“1,2,3”%over%all%lung%fields%–%should%be%fate%and%indistinct&
4.&PALPATION&of'posterior'chest&
Palpate&for&sacral&edema&
Tactile%fremitus%ask'patient'to'hug'their'chest%
• Always%2.5%lateral%to%spinous%process%unless%otherwise%stated&
nd
• Apical%segment%of%upper%lobe%%2 %interspace&
th
• Superior%segment%of%lower%lobe%%4 %interspace&
th
• Posterior%basal%segment%of%lower%lobe%%7 %interspace&
th
• Lateral%basal%segment%of%lower%lobe%%8 %interspace%in%posterior%axillary%line&
Thoracic%excursion%
• Done%(1)%suprascaular,%(2)%between%the%scapula%(below%superior%angle),%(3)%below%the%
scapula%(just%distal%to%inferior%angle)&
Level%of%diaphragm%using%tactile%fremitus%
• Start%from%inferior%angle%of%scapula%moving%inferiorly%as%the%patient%says%“99”&
• Palpate%until%fremitus%is%absent%*%this%point%marks%the%level%of%the%diaphragm&
Compare%both%sides%(usually%slightly%higher%on%the%right)&
5.&PERCUSSION&AND&AUSCULTATION&of'the'posterior'chest%
Areas%of%percussion%&%auscultation%(7x2)%–%snakeElike'pattern'to'compare'sides'
nd
• Apical%&%posterior%segment%%suprascapular%–%2 %intercostal%space,%lateral%to%spinous%process&
th
• Superior%segment%of%lower%lobe%%4 %intercostal%space,%lateral%to%spinous%process&
th
• Superior%segment%of%lower%lobe%%6 %intercostal%space,%lateral%to%spinous%process&
th
• Posterior%basal%segment%of%lower%lobe%%7 %intercostal%space,%lateral%to%spinous%process&
th
• Lateral%basal%segment%of%lower%lobe%%7 %intercostal%space,%posterior%axillary%line&
th
• Posterior%basal%segment%of%lower%lobe%%8 %intercostal%space,%lateral%to%spinous%process&
th
• Lateral%basal%segment%of%lower%lobe%%8 %intercostal%space,%posterior%axillary%line&
General%percussion%–%in%areas%as%above,%have%patient%fold%his/her%arms%in%front%of%chest,%should%stand%
to%side%of%patient%
Diaphragmatic%excursion%(normally%4K6%cm)%*%repeat%on%both%sides%for%comparison%
• Start%percussion%at%the%level%of%inferior%angle%of%scapula&
• Have%patient%take%deep%breath%in%with%mouth%open%and%hold%in%expiration&
• Percuss%moving%down%until%dullness%is%heard%*%mark%this%point&
• Tell%patient%to%breath&
• Then%ask%the%patient%to%take%another%deep%breath%when%they%are%ready%and%hold%in%inspiration&
• Start%percussion%from%previous%mark,%go%downwards%until%dullness%is%heard%*%mark%this%point&
Auscultation%–%have%patient%take%deep%breaths%in%&%out%
• Listen%for%quality%&%intensity%of%breath%sounds&
• Crackles,%wheezes,%rhonchi,%stridor,%pleural%rub&
• Vocal&fremitus%=%ask%patient%to%say%“99”%&%listen%over%all%lung%fields%for%low%pitched%sounds&
• Egophony%=%ask%patient%to%say%“ee”%&%listen%over%all%lung%fields&
• Whispered&pectoriloquy%=%ask%patient%to%whisper%“1,2,3”%over%all%lung%fields%–%should%be%fate%and%indistinct&
Section 9 – Abdomen

PERIPHERAL&SIGNS&OF&ABDOMINAL&DISEASE&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%different%parts%of%your%body.%This%will%involve%me%looking%at%your%chest%so%I%would%need%to%expose%that%area.%
Is%that%ok%with%you?”%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Have%you%noticed%any%weight%changes?”%
“Do%you%have%any%pain%in%your%abdomen?”%
1.&INSPECTION%
General%inspection%%mental%status,%alertness% Mouth%
Constitutional%signs%%fever,%weight%loss,%dehydration,%state%of%nutrition% • Fetor%hepaticus%(sweet%fecal%smell)%K%liver%disease%
Hands% • Atrophic%glossitis%–%Vitamin%B12%and%iron%def%
• Clubbing% • Furring%of%the%tongue%
• Koilonychia%(spooning%–%iron%def)% • Candidiasis%
• Leukonychia%(white%lines/spots%–%albumin%def)% • Ulcerations%
• Dupuytren’s%contracture% • Mucosal%pigmentation%–%Peutz%Jegher’s%syndrome%
• Palmar%erythema% • Leukoplakia%
• Palmar%crease%pigmentation%(Addison’s)% • Angular%stomatitis%
• Flapping%tremor%–%Asterixis%(ask%patient%to%extend%both%arms% • Gingivitis%
with%wrists%extended%&%fingers%spread%apart)% • Bleeding%gums%
Arms% • Gum%hypertrophy%
• Muscle%wasting% Neck%%supraclavicular%lymphadenopathy%
• Bruises% Chest%*%expose%the%chest%
• Scratch%marks%(indicated%pruritis%due%to%jaundice)& • Gynaecomastia%–%liver%failure,%high%circulating%estrogens%
Face%&%eyes% • Spider%naevi%
• Conjunctival%pallor%–%anemia% • Loss%of%hair%in%patients%with%hair%on%the%chest%
• Jaundice%and%icterus% • Reduced%skin%turgor%(elasticity)%–%dehydration%
• Dehydration%–%dry%mucous%membranes%and%sunken%eyes% Testicular'atrophy'
• Parotid%enlargement%–%chronic%alcoholic% Lower%limbs%%peripheral%edema%
• Xanthelasma%–%primary%biliary%cirrhosis% Cardiovascular%%blood%pressure,%pulse%(may%be%rapid%&%weak%due%
• Kaiser%Fleischer%rings%–%Wilson’s%disease& to%hypovolemia)%

ABDOMEN&PROPER&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%and%feeling%your%abdomen,%as%well%as%listening%with%my%stethoscope.%This%will%involve%you%lying%on%the%
examination%table%and%exposing%your%abdomen.%Is%that%okay%with%you?%
“Ok,%you%can%go%ahead%and%lie%down.”%*Drape'patient'up'to'waist,'if'woman'only'expose'belly,'covering'chest%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Do%you%have%any%pain%in%your%abdomen?”%
“Do%you%have%any%problems%with%digestion?”%
1.&INSPECTION%
START%FROM%FOOT%OF%BED%to%get%a%full%look%then%move%to%the%right%side%of%the%bed%
Examination'table'should'be'flat'for'everything'except'CVS'
• Body%posture%&%position%–%any%signs%of%pain/discomfort&
• Size,%shape,%scars&
• Any%protuberance%or%distension%(9%F’s)&
• Symmetry%of%movement,%exaggerated%respiratory%movements,%paradoxical%abdominal%movements,%or%absent%movement&
• Skin%changes%–%jaundice,%striae,%ecchymosis%–%Cullen’s%sign%(blue%discoloration%of%umbilicus),%Grey%Turner’s%sign%(blue%discoloration%of%
flanks)&
• Engorged%veins,%spider%andiomas,%caput%medusa&
• *%Have%patient%contract%abdomen%to%look%for%any%masses&
• Visible%pulsations%in%epigastrium%(normal%in%thin%or%aortic%aneurysm)%–%use%tangential%lighting&
• Visible%peristalsis%(hypertrophic%pyloric%stenosis%in%infants,%intestinal%obstruction%in%adults)&
• Shape%of%navel%–%inverted%or%everted%(may%indicate%umbilical%hernia%or%increased%intrabdominal%pressure)&
2.&AUSCULTATION%
Using'diaphragm'of'stethoscope%
Start%at%McBurney’s%point%to%listen%for%nature&of&bowel&sounds&–%consider%character%and%frequency%(need%to%listen%for%atleast%3%minutes%to%be%
considered%absent)%
Listen%for%presence&of&bruit%(with%bell)%
• Aorta%(midline%epigastrium)&
• Left%&%right%renal%arteries%(right%&%left%upper%quadrants,%just%inferior%to%area%of%aorta%@%outer%border%of%rectus%abdominis)&
 • Left%&%right%iliacs%(just%inferior%to%the%navel%at%outer%border%of%rectus%abdominis%on%either%side%–%½'way'between'ACIS'and'umbilicus)&
Listen%for%abdominal&friction&rubs%over%liver%&%spleen%
Listen%for%venous&hum%over%hepatic%vein%(over%liver%region)%
3.&GENERAL&PALPATION%
First'ask'for'any'pain,'palpate'tender'area'last'
Superficial%palpation%–%to'assess'tenderness,'rigidity,'and'guarding%
• RUQ%%LUQ%%LLQ%%RLQ&
• Ask%the%patient%if%they%feel%any%pain&
Deep%palpation%–%to'assess'organ'size'and'presence'of'abnormal'masses'
• Can%be%done%with%1%or%2%hands%(left%hand%on%top%of%right)&
• Keep%hand%&%forearm%in%horizontal%plane,%fingers%together,%and%placed%FLAT%on%abdominal%wall&
• Ask%patients%to%breath%normally%and%palpate%during%expiration&
• Bend%fingers%at%MCP%joints,%move%smoothly%from%place%to%place%only%slightly%lifting%the%hand&
• RUQ%%LUQ%%LLQ%%RLQ&
4.&GENERAL&PERCUSSION'
Percuss%from&midline&to&the&flanks%(areas%of%tympany%to%areas%of%dullness)%
5.&PALPATION&&&PERCUSSION&of&the&liver%
th th
Start%palpation%in%RLQ,%right%hand%lateral%to%rectus%muscle%pointing%up,%left%hand%parallel%to%&%supporting%right%11 %&%12 %ribs%
• Ask'patient'to'take'deep'breaths'with'mouth'open,'palpate'on%expiration%
• Move%superiorly%until%reach%lower%edge%of%liver%(normally%at%subcostal%area)%
• Should%be%soft,%sharp,%and%regular%with%smooth%surface&
Percussion%to%outline'the'liver'span%
• Right%lobe%%in%midclavicular%line%on%right,%start%from%below%at%iliac%spine%(area%of%tympany)%and%percuss%up%to%area%of%dullness,%then%
start%from%top%at%nipple%and%percuss%down%to%area%of%dullness,%measure%that%area%(normal%6K12%cm)&
• Left%lobe%%along%midsternal%line,%start%at%umbilicus%and%percuss%up%to%area%of%dullness,%measure%from%xiphoid%process%(normal%4K8%
cm)&
6.&PALPATION&&&PERCUSSION&of&the&spleen&
th th
Start%palpation%in%RLQ,%right%hand%&%fingers%pointed%towards%left%shoulder,%left%hand%behind%&%supporting%left%9 K11 %ribs%
• Ask'patient'to'take'deep'breaths'with'mouth'open,%palpate%on%expiration&
• Normally%should%not%be%palpable&
Percussion%is%done%to%assess%for%splenomegaly%–%should'remain'tympanic'during'deep'breath'in'absence'of'splenomegaly%
th
• Percuss%lowest%interspace%in%the%anterior%axillary%line%(10 %interspace)&
• Ask%patient%to%take%deep%breath%and%percuss&during&inspiration&
7.&PALPATION&of&the&kidney&
Usually%not%palpable%
Right%kidney%
• Stand%on%right%side,%with%left%hand%over%the%right%flank%between%costal%margin%&%iliac%crest,%right%hand%just%below%right%costal%margin,%
lateral%&%parallel%to%rectus%muscle%
• Lift%left%hand,%ask%patient%to%take%deep%breath,%palpate%deeply%–%peak%of%inspiration%may%be%able%to%capture%lower%pole%between%two%
hands%
Repeat'for'left'kidney'by'standing'on'left'side'of'patient%%
8.&PERCUSSION&of&the&bladder&
First%ask%if%patient%has%voided%in%the%last%hour%(if%not%will%be%abnormally%tympanic?)%
Percuss%in%midline%from%suprapubic%area%to%assess%for%a%distended,%enlarged%bladder%
9.&PALPATION&of&the&aorta&
Only'done'on'completion'of'palpation'&'percussion'of'solid'organs%
• Press%firmly%in%the%epigastrium%to%determine%presence%of%aortic%pulsation%(normally%slightly%left%to%midline)&
• Estimate%width%by%pressing%down%deeply%on%both%side%of%the%pulsation%with%2%hands%(normally%less%than%2.5%cm)&
Would!normally!also!do!a!digital!rectal!examination!to!be!complete&
10.&SPECIAL&TESTS&
Signs%of%peritonitis%
• Assess%for%direct&tenderness,&guarding,&and&rigidity%in%all%4%quadrants%–%using%skill%of%light&palpation,%observe%patient’s%face%for%pain,%
look%for%any%reaction%guarding,%and%look%for%involuntary%contraction%of%the%muscles&
• Rebound&tenderness%–%place%flat%hand,%fingers%together%on%abdomen,%using%pads%of%fingers%exert%steady,%gentle,%deep%pressure%for%5K
10%sec,%if%rebound%tenderness%exists%patient%with%experience%increase%in%pain%upon%release%(QUICK%RELEASE)&
Test%for%ascites%
• Inspection%for%bulging&at&the&flanks&
• Palpation%for%fluid&wave&–%have%patient%indent%the%anterior%abdominal%wall%in%midline%around%the%navel%with%ulnar%border%of%his/her%
hand,%place%your%hand%against%right%flank%and%tap%the%other%flank%with%other%hand&
• Percussion%for%shifting&dullness%–%percuss%from%midline%to%the%flanks%&%from%xiphoid%to%symphysis,%mark%areas%where%dullness%&%
tympany%meet,%have%patient%turn%onto%one%side,%percuss%from%upper%to%lower%part%&%determine%new%division%between%dullness%&%
tympany%(if%ascites%is%present,%line%of%dullness%shifts%towards%the%umbilicus)&
Signs%of%acute%appendicitis%
• Signs%of%peritonitis%–%direct%tenderness,%rebound%tenderness,%and%localized%guarding%in%the%right%lower%quadrant&
• Rovsing’s&sign%–%apply%deep'pressure%over%LLQ;%referred%pain%to%RLQ%=%positive%Rovsing’s%sign&
• Psoas&sign%–%ask%patient%to%raise%right%thigh,%apply'resistance%to%this%motion%just%above%the%knee;%pain%felt%in%RLQ%upon%this%maneuver%
=%positive%psoas%sign&
• Obturator&sign%–%ask%patient%to%bend%the%right%knee,%pull%thigh%toward%chest,%pointing%knee%toward%left%shoulder,%apply'resistance%to%
movement%at%the%hip%(trying%to%keep%patient%from%flexing%at%the%hip);%pain%in%the%RLQ%during%this%maneuver%=%positive%Obturator%sign&
• Never'complete'without'DRE&
Signs%of%acute%cholecystitis%
• Murphy’s&sign%–%place%right%hand%in%RUQ,%fingers%together%pointing%toward%right%costal%margin,%ask%patient%to%take%deep%breaths,%
palpate%in%midclavicular%line%in%small%increments%moving%superiorly;%inspiration%cut%short%=%positive%Murphy’s%sign&
• Boa’s&sign%–%scratch%skin%below%inferior%angle%of%right%scapula;%uncomfortable%sensation%=%positive%Boa’s%sign&
Tests%for%pyelonephritis%
• Fist&percussion%–%place%left%hand%over%right%costoKvertebral%angle%on%back,%with%right%fist%gently%thump%left%hand;%pain%during%this%
maneuver%=%positive,%repeat&on&opposite&side&
Section 10 – Musculoskeletal System

EXTRAhARTICULAR&MANIFESTATIONS&OF&MUSCULOSKELETAL&DISORDERS&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%your%skin%&%eyes,%as%well%as%listening%to%your%lungs%and%heart%with%my%stethoscope.%This%will%involve%you%
exposing%your%back%&%chest%and%laying%down%on%the%examination%table%at%a%later%point.%Is%that%okay%with%you?%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Do%you%have%any%pain%in%your%joints?”%
“Have%noticed%the%presence%of%a%fever,%night%sweats,%weight%loss%or%tiredness?”%
1.&INSPECTION%
• Rash%–%psoriasis,%malar%rash%(SLE)%
• Nodules%–%tophi%on%the%helix%&%antihelix%of%the%ear%(gout),%extensor%surface%of%forearm%(RA)&
• Eye%inflammation%–%conjunctivitis,%uveitis,%scleritis,%episcleritis%(reactive%arthritis)&
• Mucocutaneous%ulcers%(SLE,%reactive%arthritis)&
Have'patient'lie'down'at'this'point'–'expose'chest'
• Examine%breathing%–%decreased%chest%expansion%(ankylosing%spondylitis)&
• Check%for%sensation%with%paperclip%–%sharp'or'dull%in'area'of'median'&'ulnar'nerve'in'hand'(neuropathy%of%polyarthritis%nodosa%&%
vasculitis,%lost%in%distal%extremities%first?)&
2.&AUSCULTATION&OF&THE&HEART&&&LUNGS%
Lungs%%listen'at'auculatory'triangle,'have'patient'hug'arms'and'lean'forward,'breath'in'and!out%
• Listen%for%pulmonary%nodules,%infiltrate,%and%pleural%effusion%
Heart%%listen'over'all'cardiac'areas%
• Murmurs%or%pericardial%effusion%

AXIAL&SKELETON&
WIIPEEP%
“Today%I%am%going%to%be%looking%at%your%jaw%and%spine%and%having%you%perform%some%movements.%This%will%involve%you%taking%your%gown%off%to%
expose%your%upper%body%and%limbs.%Is%that%okay%with%you?%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Do%you%have%any%pain%or%stiffness%in%back?”%
“Do%you%experience%any%difficulty%doing%normal%daily%activities%like%dressing%or%feeding?”%
1.&GENERAL&OBSERVATION%
Have%patient%stand%at%this%point,%observe:%
Ability%to%ambulate%
Posture&–&observe'front,'back'&'sides%'normal%spinal%curvatures,%spinal%alignment,%level%of%ilac%crest,%any%pelvic%tilt,%limb%length,%contractures,%
deformities%&%angulations&
• Types%of%postures%–%head%tilt,%forward%head%posture,%posterior%pelvic%tilt,%winged%scapula,%kyphosis,%scoliosis,%lordosis&
Gait%–%ask'patient'to'take'a'few'steps,'turn'&'walk'back%–%note%symmetry,%smoothness%of%movement,%length%of%stride,%ability%to%turn%smoothly,%
and%stability%
• Abnormal%gaits%–%trendelenberg,%waddling,%steppage,%scissors,%spastic&
2.&TEMPEROMANDIBULAR&JOINT%
LOOK%and%MOVE%–%ask'patient'to'open'mouth'as'wide'as'possible,' FEEL%–%repeat'movements'while'placing'finger'over'joint%
move'lower'jaw'to'right/left'and'forward/backward' • Feel%mandibular%condyle%
• Deformity%at%rest& • Feel%depression%with%mouth%open%wide%
• Smoothness%and%symmetry%of%motion& • Note%–%tone,%crepitus%or%palpable%click%
• Deviations%
• Restriction%of%movement&
• Audible%clicks&
• Ask'if'the'patient'feels'any'pain%
3.&SPINAL&COLUMN%
LOOK%–%done'with'patient'standing'with'feet'together,'observe'from' FEEL%–%from'base'of'skull'to'lowest'lumbar'vertebra'
posterior'position'&'from'sides' • Spinal%processes%(C2%=%first,%C7%=%most%prominent)%
• Symmetry% • Warmth%with'back'of'hand%
• Muscle%wasting& • Tenderness%–%over%paraspinal%muscles,%vertebrae%
• Erythema% (intervertebral%discs)%&%sacroiliac%joint%–%if%absent,%fist%
• Ask%patient%to%bend%forward%–%observe%alignment,%any% percussion%can%be%used%over%spinal%column%
abnormal%prominence% • Crepitus%–%nod'patient’s'head'up'&'down'(passive'motion)'
• From%side%observe%normal%curvatures%–%cervical%&%lumbar% while'palpating'cervical'spinous'processes%
lordosis,%thoracic%kyphosis&
MOVE%–%cervical&spine% MOVE%–%lumbar&spine%
• Head%nodding%–%say'‘yes’%(atlantooccipital%joint)& • Flexion%&%extension%–%place'two'fingers'over'lumbar'spine'
 • Head%turning%–%say'‘no’'(atlantoaxial%joint)& (10E15'cm'apart)'then'ask'patient'to'bend'forward'to'touch'
• Forward%flexion,%extension%&%hyperextension%–'chin'to'chest' toes%
and'then'look'up'at'ceiling& • Lateral%flexion%–%bend'to'side,'walking'fingers'down'side'of'
• Lateral%flexion%–'bring'ear'to'shoulder'on'both'sides& leg,'repeat'on'other'side%
• Rotation%–%look'over'shoulder'to'both'sides& • Rotation%–%sit'at'edge'of'bed,'cross'forearms,'turn'trunk'as'
far'as'possible,'repeat'to'other'side%(examiner%place%hands%
on%patient’s%shoulder%to%guide%the%trunk)%
SPECIAL%TESTS%
Sciatic%nerve%root%irritation%or%entrapment%
• Straight&leg&raising&(Lasegue’s)&test%–%patient%lying%supine,%holding%at%ankle,%raise%each%leg%(one%at%a%time)%to%60°%(will%experience%
sharp%pain)&
• Bowstring&maneuver%–%if%patient%experiences%pain%during%straight%leg%raising%test,%lower%the%leg%until%the%pain%is%just%relieved%then%
dorsiflex%the%foot%(pain%will%recur)&
Sacroiliac%joint%stress%maneuver%
• Patient%lying%supine%very%close%to%the%edge%of%the%couch,%examiner%position%to%prevent%patient%from%falling%off&
• Ask%patient%to%fully%flex%further%knee%&%hip%bringing%to%chest,%slide%other%limb%off%the%couch%&%push%firmly%down%on%the%knee%
(hyperextension%at%the%hip)&
• Repeat%on%the%other%side&

UPPER&LIMB&
WIIPEEP%
“Today%I%am%going%to%be%examining%the%muscles%&%joints%in%your%upper%limbs.%This%will%involve%me%feeling%your%joints%as%you%perform%different%
movements.%We%will%need%to%expose%your%entire%arm.%Is%that%okay%with%you?%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Do%you%have%any%pain%or%tingling%in%your%hands?”%
“Do%you%experience%any%difficulty%doing%normal%daily%activities%like%dressing%or%feeding?”%
1.&SHOULDER&JOINT%
LOOK%–%from'front,'back'and'sides' FEEL%
• Appearance%(normally%rounded),%winged%scapula! • Warmth'
• Posture' • Bony%landmarks%–%sternoclavicular%joint,%clavicle,%
• Swelling,%symmetry,%scars! acromioclavicular%joint,%acromion,%coracoid,%greater%
• Muscular%wasting! tubercle%of%humerus,%spine%of%scapula'
• Fasciculations' • Biceps%tendon%K%in'the'intertubercular'groove'
• Tenderness%over%long%head%of%biceps,%tip%of%the%shoulder,%
subacromial%bursa'
• Joint%line%–%anterior'&'posterior'aspects'of'joint'for'
fullness'&'tenderness'
• Muscle%bulk'
• Swellings,%masses'
MOVE%–%always'look'at'patient’s'facial'expression'for'pain,'stand'in'front' SPECIAL%TESTS%
of'the'patient'–'active!then!passive' • Rotator%cuff%tear%–%shoulder&drop&test%=%ask'patient'to'
• Flexion%–%brings'arms'out'in'front,'palms'up,'parallel'to'floor& slowly'adduct'shoulder'from'fully'abducted'position,'at'
• Extension%–%push'arms'back,'palms'back,'as'far'as'possible& 30E90°'arm'will'suddenly'fall'to'side%
• Abduction&&&adduction%–%(stand%behind%patient%to%assess% • Rotator&cuff&tendinitis&test%=%ask'patient'to'extend'elbow'
scapula)%palms'facing'down'lift'arms'at'sides'45°' while'you'forcibly'flex'the'patients'arm%
(supraspinatus),'beyond'this'(deltoid),'beyond'90°'with'palms' • Bicipital&tendinitis&test%=%resistance'to'forearm'
facing'up,'return'arms'back'to'sides% supination%
• Internal&&&external&rotation%–%arms'at'sides,'forearms'flexed'
90°'&'supinated,'elbow'against'trunk'point'forearms'outward'
then'inward&
• Ask'patient'to'put'his'hands!behind!his!head%–%to%assess%
abduction,%external%rotation,%and%elbow%flexion&
• Ask'patient'to'walk!hands!up!the!back'noting'how'far'they'
can'reach%
2.&ELBOW&JOINT%
LOOK%–%with'upper'limb'in'anatomical'position% FEEL%
• Carrying%angle%–%observe'from'front& • Warmth%
• Flexion%deformity%–%observe'from'side& • Tenderness%over%medial%&%lateral%epicondyles,%olecranon%
• Muscle%bulk,%wasting& • Swelling%–%place'elbow'in'90°'flexion,'support'with'one'
• Symmetry,%scars,%skin%changes%(rashes,%psoriatic%plaques%over% hand'&'palpate'with'thumb'of'same'hand'–'head'of'
extensor%surface%of%elbow),%nodules,%swellings& radius,'posterolateral'joint'line,'palpate'with'fingers'of'
 same'hand'–'posteromedial'joint'line%
• Nodules%
• Crepitus%during%passive%range%of%motion%
MOVE%–%active'&'passive% SPECIAL%TESTS%
• Flexion&&&extension%–%start'in'anatomical'position,'bend' Lateral%epicondylitis%–%tennis'elbow%
elbows'bringing'fingers'to'touch'shoulders,'and'return'to' 1. Cozen’s&test%–%flex'patient’s'elbow'to'90°,'place'thumb'
straightened'position& over'lateral'epicondyle'and'have'patient'radially'deviate'
• Pronation&&&supination%–%flex'elbows'to'90°,'face'palms'down' &'dorsiflex'(extend)'wrist'against'resistance%
(pronation),'then'face'palms'up'(supination)& Medial%epicondylitis%–%golfer’s'elbow'
1. Tenderness%–%palpate'medial'epicondyle,'asking'patient'
for'pain%
2. Wrist%flexion%against%resistance%OR%
3. Forearm%pronation%against%resistance?%
4. Tap%over%ulnar%nerve%at%elbow%
3.&HAND&&&WRIST%
LOOK%–%hands'should'be'resting'on'table'or'patient’s'thighs,'always' FEEL'
compare'one'side'to'other' With&palms&up%
With&palms&down& • Warmth%–%compare'to'wrist'&'forearm%
• Posture& • Tenderness%along%flexor%tendon%sheaths,%at%joints%
• Deformity,%deviation%–%ulnar'drift%(RA)& • Tendon%thickening,%nodules%(trigger'finger)%
• Muscle%wasting/atrophy& • Muscle%bulk%of%thenar%&%hypothenar%eminences%
• Joint%symmetry,%swellings,%nodules& • Pulses%at%the%wrist%(2+)%
• Skin%changes%–%erythema,'scars,'thinning,'bruising& • Touch&sensation%(using%paperclip)%–%touch'little'finger'&'
• Nails%–%pitting%&%onycholysis%(psoriasis)& hypothenar'eminence'(ulnar'nerve),'touch'index'finger'
With&palms&up%–%note'any'difficulty'in'supination'at'proximal'radioulnar' and'thenar'eminence'(median'nerve)%
joint% With&palms&down%
• Muscle%wasting/atrophy& • Warmth%–%MCP'joints,'wrist,'&'distal'forearm%
• Contractures%–%Dupuytren’s& • Tenderness%of%joints%(bimanual%palpation%of%any%joints%
• Deformity%–%clawing'of'the'fingers& that%are%swollen%or%tender)%
• Palmar%erythema& • Squeeze&row&of&MCPs%between%thumb%and%index%finger%
• Scars& observing%patient’s%face%for%pain%
• Swellings%–%bony,%soft,%superficial,%deep?%
• Touch&sensation%–%over'dorsum'of'first'web'space'(radial'
nerve)%
MOVE%–'always'look'at'patient’s'face'on'movement'
Wrist%–%active'only'
• Flexion&&&extension%–%rest'flexed'elbow'on'bed'or'table,'palms'down,'bend'wrist'toward'floor'then'return'to'neutral,'then'bend'
backward'toward'the'body&
• Abduction&&&adduction%–%forearm'in'supination'against'trunk,'bends'hands'inward,'to'neutral'position,'then'outward&
• Pronation&&&supination%–%same%motion%as%with%elbow%joint,%using%the%proximal%radioulnar%joint&
Thumb%–%active'&'passive'
• Adduction&&&abduction%–%palms'flat'on'table,'move'thumb'toward'index'finger'then'away&
nd rd
• Flexion&&&extension%–%palms'up,'bring'thumb'to'2 'and'3 'metacarpals'(with'flexion'at'MCP'and'IP),'then'back&
• Opposition&&&reposition%–%bring'tip'of'thumb'to'distal'phalanx'of'pinky'and'then'back'to'neutral&
Fingers%–%active'&'passive%
• First%test%all%digits%by%having%patient%make%a%fist&
• Flexion&&&extension&@&DIP%–%immobilize'top'&'bottom'of'PIP'for'each'finger&
• Flexion&&&extension&@&PIP%–%push'all'other'fingers'into'extension'to'isolate'single'PIP,'ask'patient'to'bend'finger'forward'&'back&
• Flexion&&&extension&@&MP%–%extend'all'fingers'then'flex'and'roll'in'to'touch'finger'tips'to'midpalm'level'(byeEbye'motion)&
• Abduction&&&adduction&@&MP%–%palm'down'on'flat'surface,'spread'fingers'apart'then'bring'them'together&
SPECIAL%TESTS%
Carpal%tunnel%syndrome%
• Phalen’s&test%–%reverse'prayer'for'60'seconds%
• Tinel’s&test%–%tap'over'anterior'wrist'at'distal'skin'crease'lateral'to'palmaris'longus'tendon%
Power%
• Tight%fist%–%grip'two'of'your'fingers%
• Extension%&%flexion%of%MCP%joints%against%resistance%
• Pincer%grip%K%pinch'skin,'pick'something'up'between'thumb'&'index'finger%
• Adduction%–%paper'pull%
• Abduction%–%spread'fingers'apart'against'resistance'(this%tests%ulnar%nerve)%
• Thumb%(tests%median%nerve)%–%abduct'against'resistance%
 LOWER&LIMB&
WIIPEEP%
“Today%I%am%going%to%be%examining%the%muscles%&%joints%in%your%lower%limbs.%This%will%involve%me%feeling%your%joints%as%you%perform%different%
movements.%We%will%need%to%expose%your%entire%leg%and%we%can%start%standing%then%move%to%lying%down%in%a%couple%of%minutes.%Is%that%okay%
with%you?%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Do%you%have%any%pain%or%stiffness%in%your%joints%of%your%legs?”%
“Do%you%experience%any%difficulty%walking?”%
1.&HIP&JOINT%
LOOK%–%with'patient'in'standing'position' FEEL%
• Muscle%wasting%–%esp.'gluteal'muscles' • Temperature%over%lateral%hip%&%surrounding%areas'
• Pelvic%tilt%&%position%of%lower%gluteal%fold' • Tenderness%over%greater%trochanter'
Now&patient&lying&down&
• Size,%symmetry,%swelling,%scars,%skin%changes&
• Leg%length%–%if'there'is'an'appearance'of'differences'in'length'
then'measure'from'ASIS'to'medial'malleolus&
• Deformity%–%fixed'flexion'contracture&
• Abnormal%posture&
MOVE%–%active'&'passive&
With&patient&lying&down&(or%standing%*%easier%to%do%all%motions%standing%by%showing%patient%movements,%then%lay%down%for%passive%motion)%
• Flexion&&&extension%–%knee'90°'flexion,'hug'to'chest,'then'return&
• Hyperextension%–%lay'on'one'side'and'move'upper'straight'leg'as'far'back'as'possible&
• Internal&&&external&rotation%–%with'knee'&'hip'flexed'90°,'rotate'hip'inwards'by'pulling'knee'toward'other'hip,'then'outward'away'
from'midline&
• Abduction&&&adduction%–%with'lower'leg'straight'slide'heels'outward'in'line'with'gravity'as'far'as'possible'then'inwards&
With&patient&standing%
• Circular&rotation%–%standing'on'one'limb,'rotate'other'with'leg'straight'in'circular'motion,'repeat'on'other'side&
SPECIAL%TESTS%
• Trendelenburg&sign%–%place'finger'on'left'ASIS'and'have'patient'lift'left'leg'off'the'ground'and'observe'level'of'pelvis%
• Observe%gait%
• Thomas’&test&for%fixed%flexion%contracture&–&place'one'hand'under'patient’s'back,'fully'flex'right'hip'bringing'thigh'to'chest,'check'
that'the'left'pelvis'tilts'and'left'knee'remains'on'couch,'repeat'on'other'side%
2.&KNEE&JOINT%
LOOK%–%with'patient'lying'on'bed,'lower'limbs'straight,'examiner' FEEL%
standing'at'foot'of'bed% • Warmth%–%compare'knee'to'lower'leg%
• Size,%swelling,%scars,%symmetry,%skin%changes%(erythema,% • Tenderness%–%along'borders'of'patella'with'knee'extended,'
psoriasis%on%ant.%aspect%of%knee)& with'knee'flexed,'palpate'joint'line'from'femoral'condyles'
• Alignment& to'tibial'plateau%
• Posture%–%valgus'or'varus'deformities& • Palpate%along%patellar%tendon%for%tenderness%and%
• Deformity& discontinuity%
• Muscle%wasting& • Swelling%
• Palpate%behind%the%knee%–%effusion'or'Baker’s'cysts'(filled'
with'synovial'fluid),'pulsatile'swelling'(popliteal'aneurysm)%
MOVE%
Start'with'patient'lying'on'side'
• Flexion&&&extension%–'upper'leg'straight'then'bend'knee,'brining'heel'to'butt,'return'to'straight'position&
• Passive&range&of&motion&–%one'hand'over'knee,'other'moving'leg,'feel'for'crepitus,'excessive'give,'excessive'joint'mobility,'clicking'or'
locking&
• Repeat%other%side&
SPECIAL%TESTS%
Joint%effusion%
• Bulge&sign%–%compress'lower'1/3'of'patient’s'thigh'with'left'hand,'slide'hand'down'to'upper'border'of'patella,'stroke'medial'side'
upwards'(emptying'compartment)'then'lateral'side'downward'with'right'hand'E'check'for'refilling'(bulge)'in'the'medial'compartment%
• Ballotment&sign&(patellar&tap)%–%empty'subpatellar'pouch'as'above,'push'patella'gently'backward'with'two'fingers'(feel'for'tap'
against'femoral'condyles)%
Ligament%integrity%
• Medial&ligament%–%flex'knee'15°,'apply'pressure'to'lateral'knee'(valgus!stress)'&'pull'lower'leg'lateral'*'PUSH'&'PULL%
• Lateral&ligament%–%flex'knee'15°,'apply'pressure'to'medial'knee'(varus!stress)'and'pull'lower'leg'medial'*'PUSH'&'PULL%
• Anterior&cruciate&ligament&(anterior%draw%sign)%–%flex'knee'with'foot'flat'on'couch,'sit'on'dorsum'of'foot,'place'both'hands'around'
upper'tibia'with'thumbs'on'tibial'tuberosity'&'index'fingers'behind'the'hamstrings'–'forcibly'pull'tibia'forward%
• Posterior&cruciate&ligament&(posterior%draw%sign)%–%*%before%test%look%at%knee%from%side%to%check%fro%posterior%sag%then%same'as'
 above'but'push'tibia'backward%
Menisci%injury%
• Medial&meniscus&–&hold'flexed'knee'with'left'hand'on'joint'line,'grip'sole'of'foot'with'right'hand'–'externally!rotate'the'leg'then'
slowly'straighten'leg'while'pushing'on'medial'knee,'repeat'on'opposite'side%
• Lateral&meniscus&–&hold'flexed'knee'with'left'hand'on'joint'line,'grip'sole'of'foot'with'right'hand'–'internally!rotate'the'leg'then'
slowly'straighten'leg'while'pushing'on'lateral'knee,'repeat'on'opposite'side%
3.&ANKLE&&&FOOT%
LOOK%% FEEL%–%with'patient'sitting,'legs'hanging'
With&patient&seated&&&legs&hanging& • Pulses%–%dorsalis'pedis'&'posterior'tibial%
• Skin%changes%(psoriasis,%erythema,%callus%formation,% • Warmth%over%ankle%and%foot%
ecchymosis),%swellings,%symmetry! • Tenderness%over%dorsum%–%tarsal'joints,'talonavicular'&'
• Nails%–%pitting%&%onycholysis! calcaneotalar'joints,'anterior'&'lateral'ankle'joint%
• Alignment,%deformity%of%toes%–%hallux'valgus,'clawing! • Squeeze%across%MP%joints%
With&patient&standing& • Swelling%–%edema,'soft'tissue,'nodules%
• Alignment,%deformity%of%ankle%&%subtalar%region%–%look'from'
front'&'behind'for'varus'or'valgus&
• Arch%–%look'from'side'then'have'patient'stand'on'toes&
• Achilles%tendon%–%for%swelling%or%thickening&
MOVE%–%both'active'&'passive'should'be'done% SPECIAL%TESTS%–%%
• Dorsiflexion&&&plantar&flexion%@%the%ankle%joint%–%move'foot' Power%–%same'movements'against'resistance'
toward'trunk'then'point'toes'toward'floor& Observe%gait%–%observe'components'of'the'cycle'–'swing'&'heel'
• Inversion&&&eversion&@%subtalar%joints%–%face'soles'of'feet' strike,'stance'&'toeEoff%
toward'eachother'then'away'from'eachother&
• Abduction&&&adduction&@%subtalar%joints%–%sighting'on'chair'
with'feet'lightly'touching'ground,'move'foot'away'from'
midline'along'plane'of'the'floor'and'then'toward'midline&
• Inversion&&&eversion&@%midtarsal%joints%–%passive'movement'
–'hold'the'heel'and'passively'invert'&'evert'the'foot&
• Dorsiflexion&&&plantar&flexion&of&the&big&toe%–%bend'big'toe'
toward'floor'then'bend'up&
Section 11 – Central Nervous System

MINI&MENTAL&STATUS&EXAM&
WIIPEEP%
1.&OBSERVATION%
• General%appearance%–%hygiene,%dress,%etc&
• Gait&
• Speech%–%tone,%volume,%quantity%&%quality&
• Affect%–%expansive%or%flat%(at%any%given%moment)&
• Mood%–%sustained%emotion&
• Level%of%consciousness%–%alert,%drowsy%(lethargic),%comatose,%etc&
2.&INTERVIEW%
Orientation%to%time,%person,%place%
• “Can%you%tell%me%who%you%are%–%your%name%&%how%old%you%are?”%
• “What%day%is%it?”%
• “Where%are%we?”%
Memory%
• Immediate%recall%–%“Can%you%repeat%the%following%3%words?%Cat,%house,%chocolate.”&
• Short%term%memory%–%“I%am%going%to%ask%you%repeat%those%same%3%words%at%the%end%of%the%interview.”&
• Long%term%memory%–%“In%what%year%did%hurricane%Ivan%hit%Grenada?”&
Abstract%thinking/reasoning%
• “What%do%I%mean%when%I%say,%don’t%cry%over%spilled%milk?”&
Judgement%
• “If%you%found%a%stamped%envelope%on%the%floor%in%front%of%a%mailbox%what%would%you%do%with%it?”&
Higher%functioning%
• “Can%you%spell%the%word%WORLD%backwards?”&
DO&NOT&FORGET&TO&ASK&ABOUT&3&WORDS&FROM&EARLIER&

CRANIAL&NERVES&+&
WIIPEEP%
“Today%I%am%going%to%be%checking%your%sensations,%using%this%instrument%to%look%into%your%eyes,%looking%into%your%mouth%and%having%you%do%
some%simple%movements.%Is%that%okay%with%you?%
“Ok,%you%are%already%in%the%seated%position%and%the%area%to%be%examined%is%exposed.”%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Have%you%noticed%any%loss%of%sensation%in%your%face%or%mouth?”%
“Are%you%having%any%visual%difficulties,%such%as%double%vision?”%
1.&CN&I&–&OLFACTORY&NERVE%
• First%check&patency%of%the%nostrils,%ask%patient%to%breath%though%holding%opposite%nostril,%also%use%penlight%and%tilt%head%back%to%look%
up%
• Test%two%different%smells%in%each%nostril%with%patient’s&eyes&closed&
2.&CN&II&–&OPTIC&NERVE%
Pupillary%reflexes%
• Light&reflex%–%direct'&'consensual&
• Accommodation/near&reaction%–%ask'patient'to'look'to'distance'then'at'finger&
Retinal%function%
• Central&vision%–%visual'acuity'charts,'14'inches,'both'eyes'together'then'each'eye'separately&
• Peripheral&visual&fields%–%confrontation,'1'meter,'fixed'sight'on'examiner’s'nose,'temporal'fields'of'both'eyes,'then'nasal'fields'of'
each'eye'separately&
• Fundoscopy%–%turn'down'light,'start'from'2'ft'to'visualize'red'reflex,'move'in'and'use'other'hand'to'lift'patient’s'eyebrow,'find'vessels'
then'follow'to'optic'disc,'then'ask'patient'to'look'into'light'and'visualize'macula'&'fovea&
3.&CN&III,&IV,&&&VI&–&OCULOMOTOR,&TROCHLEAR,&AND&ABDUCENS&NERVES%
Motor%functions%
• Symmetrical%corneal%light%reflection%test%–%for'alignment'of'eyes%
• HKtest%–%note!nystagmus%
• Near%reaction%(combination%of%convergence,%pupillary%constriction,%and%accommodation%–%testing%CN%II%and%III)%
• CoverKuncover%test%–%for'strabismus,'muscle'tone%
Pupillary%light%reflex%–%PS%fibers%of%CN%III%
5. CN&V&–&TRIGEMINAL&NERVE&
Sensation%
• Pain%&%crude%touch%using%paperclip%–%first'demonstrate'on'area'not'being'tested'with'eyes'open%
o Close%eyes%–%test%bilaterally%in%ophthalmic,%maxillary%&%mandibular%divisions%
Motor%functions%
• First%observe%for%atrophy&
• Palpate%temporalis%&%masseter%muscles%for%symmetry%of%bulk&
• Strength%testing&
o Temporalis%–%ask%patient%to%clench%teeth,%while%palpating%both%muscles%simultaneously&
o Masseters%–%ask%patient%to%clench%teeth,%while%palpating%both%muscles%simultaneously&
o Lateral&pterygoid%–%ask%patient%to%open%jaw%against%resistance&
Corneal%reflex%–%not'done'in'lab'
Jaw&jerk&reflex%–%open'mouth'partially,'place'finger'of'left'hand'over'lower'jaw'and'strike'over'finger'in'a'downward'direction!
5.&CN&VII&–&FACIAL&NERVE%
Motor%functions%
• Inspect%for%drooping,%asymmetry%@%rest,%and%during%spontaneous%facial%expression,%observe%for%presence%of%nasolabial%folds&
• Squeeze%eyes%shut,%and%try%to%open%with%index%finger%on%supraorbital%ridge%and%thumb%on%lower%lid&
• Wrinkle%forehead,%raise%eyebrow&
• Smile&
• Puff%out%cheeks%against%resistance&
Sensory%functions%–%anterior%2/3%of%tongue%–%not'done'in'lab'
Corneal%reflex%–%not'done'in'lab%
6.&CN&VIII&–&VESTIBULOCOCHLEAR&NERVE&
Vestibular%branch%
• Doll’s%eye%maneuver%&%ice%water%calorics%–%not'done'in'lab%
• Nystagmus%K%put%one%finger%in%each%of%patient’s%peripheral%fields%and%ask%patient%to%look%to%one%finger%then%other%without%moving%
neck,%repeat%several%times%
• Gait%
• Balance%
Cochlear%portion%
• Whisper%test&
• Weber%test&
• Rinne’s%test&
7.&CN&IX&&&X–&GLOSSOPHARYNGEAL&&&VAGUS&NERVES&
• Check%for%deviation%of%the%uvula,%movement%of%soft%palate%–%ask%patient%to%as%“Ahh”&
• Gag%reflex%–%not'done'in'lab&
8.&CN&XI&–&SPINAL&ACCESSORY&NERVE&
Motor%functions%
• Shrug%shoulders%against%resistance%–%from'behind'patient&
• Turn%head%against%resistance%–%right'hand'on'patient’s'left'cheek'to'test'right'SCM,'feel!the!right!SCM!as!it!contracts&
• Pick%head%up%against%resistance%–%while'patient'is'lying'down,'hold'patient’s'head'back'with'palm'on'forehead&
9.&CN&XII&–&HYPOGLOSSAL&NERVE&
• Speech:%ask%patient%to%repeat%words%–%“like%the%red%dog%nose”%
• Inspection:%tongue%in%mouth%at%rest%for%atrophy,%fasciculations,%size%
• Ask%patient%to%protrude%tongue%as%far%as%possible%–%look%for%deviation%
• Ask%patient%to%push%toward%his%cheek%against'resistance,%repeat%on%other%side&
10.&TESTS&FOR&MENIGEAL&IRRITATION&
With%patient%lying%down%
• Nuccal&rigidity%–%ask%patient%to%lift%head%up,%flexion%of%neck&
• Brudzinski’s&sign&–&passive%flexion%of%the%patient’s%neck%and%observe%for%involuntary%flexion%of%the%hips%&%knees&
• Kernigs’&sign%–%flexion%of%the%hip%to%90°%and%extension%of%knee,%will%cause%pain&
11.&TESTS&FOR&HYPOCALCEMIA/TETANY&
With%patient%seated%
• Chvostek’s&sign%–%tap%anterior%to%tragus,%below%zygomatic%over%facial%nerve,%observe%for%twitching%of%the%ipsilateral%facial%muscle&
• Trosseau’s&sign%–%inflate%BP%cuff%above%systolic%BP%&%observe%for%carpopedal'spasm&
 SENSORY&CNS&
WIIPEEP%
“Today%I%am%going%to%be%checking%your%sensation%at%different%areas%of%your%body%and%having%you%do%some%simple%tests.%This%will%involve%you%
lying%down%for%right%now%and%exposing%your%abdomen.%Is%that%ok%with%you?%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Have%you%noticed%any%loss%of%sensation%or%tingling%in%your%limbs?”%
“Do%you%ever%feel%unstable%when%you%close%your%eyes?”%
1.&SPINOTHALAMIC&TRACT&(anterolateral%system)%
With'patient'lying'down% • T5%–%nipple%line%
Pain&&&crude&touch& • T10%–%umbilical%line%
• C4%–%posterior%aspect%of%shoulder& • L2%–%upper%thigh%
• C5%–%lateral%aspect%of%upper%arm& • L3%–%medial%lower%thigh%
• C6%–%thumb% • L4%–%medial%lower%leg%
• C7%–%middle%finger& • L5%–%lateral%lower%leg%
• C8%–%little%finger& • S1%–%sole%of%foot%
• T1%–%medial%aspect%of%lower%arm& Temperature%–%not'being'tested'in'lab%
2.&DORSAL&COLUMNS%(posterior%colums)%
Proprioception%–%joint'position'sense,%first%demonstrate%to%patient%what%“up”%is%an%what%“down”%is,%then%close%eyes%
• Big%toe,%both%sides%%use%left%hand%to%separate%other%toes,%use%right%hand%to%move%big%toe,%holding%it%on%its%sides%at%IP%joint!
• Index%finger,%both%sides%use%left%hand%to%separate%other%fingers,%use%right%hand%to%move%finger,%holding%it%on%its%sides%at%PIP%joint!
Vibration%–%using'128'Hz'tuning'fork,%first%demonstrate%in%an%area%not%being%tested,%show%vibration%then%stop%so%they%know%the%difference%
• Start%at%distal%phalynx%of%index%finger,%ask%“what%do%you%feel?”%then%stop%vibration%&%again%ask&
• If%present%distally%no%need%to%move%proximally,%but%SHOW%THAT%YOU%WOULD%MOVE%PROXIMALLY&
Romberg&test%–%be'ready'to'catch'patient'just'in'case'
• Ask%the%patient%to%stand%still%with%feet%together%&%eyes%open,%note%any%instability%(deficit%in%cerebellum)%
• Then%ask%patient%to%close%eyes,%note%any%instability%(deficit%in%dorsal%column)%
3.&PARIETAL&CORTEX%
Stereognosis&–&ask'patient'to'identify'a'small'object'in'hand'with'closed'eyes,'use'different'object'for'opposite'hand'
Graphesthesia%–%ask'patient'to'identify'number'drawn'in'palm'of'hand'(3,6,7)'with'eyes'closed'
2hpoint&discrimination%–%first'demonstrate'what'2'points'feel'like'and'what'one'point'feels'like,'then'ask'patient'to'close'eyes'
• Start%30K40%mm%apart,%10%mm%apart%for%finger,%decrease%5%mm%each%time%until%2%points%can%no%longer%be%perceived!
• Check%on%volar%aspects%the%tip%of%the%index%finger%and%forearm%
Point&localization%–%ask'patient'to'close'eyes'&'point'to'a'place'you'have'touched'them'on'right'&'left'sides'of'body,%randomly%
Extinction%–%aka'double'simultaneous'stimuli%
• Tactile%–%first%demonstrate%that%you%will%tough%the%left%side,%right%side,%then%both%sides,%ask%patient%to%close%eyes%&%to%tell%you%if%they%
were%feeling%“right,%left%or%both”,%then%touch%random%parts%of%body%simultaneously%alternating%with%just%touching%one%side&
• Visual%–%patient%looking%straight%ahead,%wiggle%finger%in%left%&%right%temporal%fields%simultaneously%and%ask%patient%to%report%where%
objects/what%objects%were%seen&
• Hearing%–%with%patient’s%eyes%closed,%snaps%both%fingers%on%left%&%right%simultaneously,%ask%patient%if%sound%is%hear%on%left,%right,%or%
both&

MOTOR&CNS&
WIIPEEP%
“Today%I%am%going%to%be%checking%your%movement%in%different%areas%of%your%body%and%checking%for%your%reflexes.%This%will%involve%me%touching%
your%muscles%and%joints%for%right%now,%then%I%will%have%you%lay%down%and%expose%your%abdomen%in%a%few%moments.%Is%that%ok%with%you?%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Do%you%have%any%weakness%in%your%limbs?”%
“Have%you%had%any%trouble%walking%or%doing%normal%daily%activities?”&
1.&INSPECTION'
• Muscle%bulk&
• Involuntary%movements%–%fasiculations,'tremors,'chorea,'athetosis,'hemiballism,'dystonia&
• Station%–%ask'to'stand'up'with'feet'together,'first'with'eyes'open'then'eyes'closed%–%observe%for%excessive%sway,%falling%to%one%side&
• Gait%K%length%of%stride%when%walking%at%a%normal%pace,%symmetry%of%gait,%ability%to%walk%with%a%narrow%base,%ability%to%turn%with%
minimal%steps%and%without%being%unsteady&
2.&PALPATION&
• Tone%–%stabilize'limb'proximal'to'joint'being'tested'with'left'right'and'passively!move!limb!with'right'hand,'feel'for'rigidity'or'
spasticity,'compare'both'sides&
• Power%–%test'by'applying'resistance'to'movement'at'specific'muscles,%simultaneously'if'possible,%grade'0E5&
o Hands%K%gripping%of%the%fingers%&%attempt'to'remove,'abduction%of%fingers,%opposition%&%attempt'to'pull'apart%
o Wrists%–%make%fist%&%flex/extend%
o Biceps%–%flexion%at%elbow%
 o Triceps%–%extension%at%elbow%
o Shoulder%–%abduct/adduct%&%flex/extend,%raise%arms%in%front%
o Pronator&drift%–%ask'patient'to'raise'arms'in'front,'palms'up,'patient'closes'eyes'&'counts'to'10,'trying'to'maintain'posture,'
observe'for'tremors,'drifting'downwards'&'going'to'pronation%
o Hip,%knee,%ankle%
3.&REFLEXES%
Deep&tendon&reflexes% Superficial&reflexes& Pathological&reflexes&
• Biceps%–%C5,'C6& • Abdominal%–%T10,'T11,'T12% • Clonus%–%feel'for'rhythmic'oscillations&
• Triceps%–%C6,'C7& • Plantar%response%–%L5,'S1% o Ankle%–%rapidly%dorsiflex%foot,%while%
• Brachioradialis%–%C5,'C6& • Cremasteric%–%L1,'L2% supporting%knee&
• Knee%–%L2,'L3,'L4& • Anal%wink%–%S3,'S4,'S5& o Knee%–%grasp%just%above%patella%&%push%
• Ankle%–%S1,'S2% downward&
o Wrist%–%forearm%in%extension,%rapidly%
dorsiflex%hand%at%wrist&
• Babinski&sign%–%abnormal%plantar%response%
(dorsiflexion%&%splaying%of%toes)&
• Grasp&reflex%–%stroke'patient’s'palm'&'look'for'
abnormal'grasping&
• Jaw&jerk&–&UMN%lesion%of%CN%V&
• Hoffman’s&sign%–%hold'patient’s'middle'finger'&'flick'
the'fingernail'downward,'flexion'of'terminal'phalanx'
of'thumb'is'positive&

CEREBELLUM&
WIIPEEP%
“Today%I%am%going%to%be%performing%some%tests%to%assess%your%brain%function.%This%will%involve%you%doing%some%movements%with%your%arms%&%
legs%as%well%as%walking,%&%lying%down%in%a%few%moments.%Is%that%ok%with%you?%
“Before%we%get%started,%I%would%like%to%ask%you%a%couple%questions.”%
“Do%you%have%any%weakness%in%your%limbs?”%
“Have%you%had%any%trouble%walking%or%doing%normal%daily%activities?”%
1.&TEST&FOR&NYSTAGMUS&&&DYSARTHRIA&
• Nystagmus&h&put%one%finger%in%each%of%patient’s%peripheral%fields%and%ask%patient%to%look%to%one%finger%then%other%without%moving%
neck,%repeat%several%times%
• Dysarthria%–%ask%the%patient%to%say%“baby%hippopotamus”%
2.&TEST&FOR&ATAXIA&
Lower%limb%ataxia%
• Posture%–%ask'patient'to'stand'with'feet'together'with'eyes'open,'be'prepared'to'support'the'patient&
• Tandem&walking%–%ask'patient'to'walk'in'a'straight'line,'observe'for'reeling'gait&
• Heel&to&toe&walking%–%ask'patient'to'walk'in'a'straight'line,'heel'to'toe&
• Heel&to&kneehshin%–%with!patient!lying!down,'ask'patient'to'place'on'heel'on'opposite'knee'&'hold'steady'for'few'seconds'then'move'
the'heel'down'to'shin,%repeat'on'other'side&
• Heel&tapping%–%ask'patient'to'tap'heel'on'opposite'shin'rapidly'several'times&
Upper%limb%ataxia%
• Postural&tremor%–%ask'patient'to'hold'arms'straight'out,'observe'for'unsteadiness%
• Finger&to&nose%–%ask'patient'to'touch'tip'of'his'nose'then'examiners'finger'(2'ft'away'in'midline),'start'slowly'then'increase'rate,'
repeat'on'other'limb%
• Dysdiadokinesia%–%demonstrate'first,'slap'knee'alternating'palm'to'back'of'hand'as'fast'as'possible,'both'hands'separately'then'
together%
• Overshooting&(rebound&phenomenon)&&&checking&test%–%patient!stands,'eyes'closed'and'arms'outstretched,'palms'down,'“I'will'be'
tapping'your'wrists,'can'you'please'try'to'keep'your'arms'steady.”'–'test'each'arm'separately%
Truncal%ataxia%
• Sit%up%with%forearms%crossed,%observe%for%falling%or%jerking%of%the%head%and%trunk&
• Ataxia%of%stance%–%stand'with'feet'together'and'eyes'open,'be'prepared'to'support'the'patient&
3.&TEST&FOR&BALANCE&
• Walk%on%heels%&%toes&
• Hop%in%one%place&
4.&TEST&FOR&HYPOTONIA&
• Inspection%of%posture%at%rest%and%walking%
• Stretch%reflex%of%quadriceps%–%observe%for%pendulum%like%swinging%