CD I|na| Lxam

A|ways approach pat|ent and |ntroduce yourse|f. 1e|| them about what you're
go|ng to be do|ng. Ask 1-2 pert|nent quest|ons. Wash hands before beg|nn|ng.

V|ta| S|gns
1. 1emperature: don'L acLually check, buL menLlon LhaL you would.
Check wlLh Lhe back of Lhe hand
2. u|se: radlal, ulnar, brachlal, caroLld, femoral, popllLeal, dorsalls pedls,
posLerlor Llblal
8aLe ! counL for a full mlnuLe
8hyLhm
AmpllLude: volume & SLrengLh
Scale 0-4
4 = boundlng
3 = full and lncreased (seen wlLh aorLlc regurglLaLlon)
2 = normal
1 = dlmlnlshed, barely palpable (seen wlLh hearL
fallure)
0 = absenL/noL palpable
CharacLer: characLer ls ofLen besL characLerlzed ln Lhe r|ght carot|d
artery
SLaLe of vessel: rlgldlLy of Lhe vessel ls lndlcaLlve of aLherosclerosls.
Check boLh arms: ask LuLor lf Lhey wanL you Lo check boLh arms.
8adlo-femoral delay: ask lf Lhey wanL you Lo check lL.
3. 8|ood ressure: check boLh arms and all 3 poslLlons (slLLlng, sLandlng, lylng
down).
llrsL puL cuff on and lnflaLe whlle feellng radlal pulse.
lnflaLe unLll Lhe radlal pulse ls no longer palpable
ueflaLe cuff
8e-lnflaLe cuff approxlmaLely 20mmPg pasL Lhe polnL where radlal
pulse was losL.
4. kesp|ratory kate: preLend Lo Lake pulse whlle waLchlng for breaLhlng
movemenL for 1 mln.








nead and Neck
na|r: dlsLrlbuLlon and LexLure
Sca|p: scallness, dandruff, swelllngs
Sku||: palpaLlon
Iace: symmeLry, scars, swelllngs, colour change, faclal expresslon
o Lyebrows: loss of laLeral 1/3 lndlcaLed hypoLhyroldlsm
Mouth
o Llps: dryness, cracklng, sores, bleedlng.
o 1eeLh: 2 lnclsors, 1 canlne, 2 premolars, 3 molars (per quadranL)
" CounL all Lhe LeeLh
o 8uccal mucosa: lnflammaLlon, sores/ulcers, leukoplakla
o 1ongue: glosslLls, colour, swelllng, devlaLlon
o Cums: bleedlng, swelllng, gum llne, hyperplasla
" Pyperplasla of Lhe gums ls commonly seen wlLh some chronlc
drug use.
o Pard and sofL palaLe: swelllng, colour, leukoplakla, and congenlLal
anomalles.
" 1orus palaLlnus ! mldllne swelllng (noL harmful)
o 1onslls: swelllng, lnflammaLlon

o Sallvary ducLs: swelllng and lnflammaLlon
" aroLld ducL opens on Lhe buccal mucosa opposlLe Lhe 2
nd

pre-molar.
o uvula: movemenL, devlaLlon
o harynx: ask paLlenL Lo say Aaaaah"
Lymph Nodes: palpaLe wlLh 2-3 flngers ln clrcular moLlon
o CcclplLal
o re-aurlcular
o osL-aurlcular
o 1onsllar
o Submandlbular
o SubmenLal
o Superflclal cervlcal
o ueep cervlcal
o osLerlor cervlcal
o Supraclavlcular








1hyro|d
er|phera| S|gns
o Genera|: welghL change
o Lye s|gns:
" Loss of laLeral 1/3 of eye brow
" Lld lag
" Lld reLracLlon
" LxophLhalmos
" Weakened exLraocular muscles
o nands: Lremors and sweaLlng.
o Card|ac s|gns:
" 8aLe: Lachycardla/bradycardla
" 8hyLhm: aLrlal flbrlllaLlon
" volume: lncreased volume
" Murmurs: sysLollc
o Lower ||mbs:
" reLlblal myxedema
" uelayed relaxaLlon of deep Lendon reflexes
Inspect|on:
o LocaLe anaLomlcal landmarks
" Pyold (hlghesL), Lhyrold carLllage, crlcolds, 1hyrold gland
lsLhmus (lowesL)
o lnspecL for any swelllngs, nodules, and make sure LhaL lL rlses when
swallowlng.
a|pat|on: lsLhmus and lobes
o Ask Lhe person Lo swallow whlle palpaLlng.
o 1o palpaLe Lhe laLeral lobes:
" 1llL head Lowards Lhe slde of examlnaLlon
" ush Lhe SCM wlLh one hand Lowards Lhe slde of examlnaLlon
" WlLh Lhe oLher hand feel Lhe laLeral lobe of Lhe Lhyrold.
o alpaLe superflclal & deep cervlcal lymph nodes.
Auscu|tat|on: llsLen for brulLs (may be slgn of Crave's ulsease)























































Lar, Nose, & 1hroat
Lars
Inspect|on: exLernal ear
o AnaLomlcal landmarks: Pellx, anLlhellx, Lragus
o ulscharge
o lnflammaLlon
o CongenlLal abnormallLles (pre-aurlcular slnuses or appendages)
a|pat|on: lymph nodes and Lenderness
o Lymph nodes: pre-aurlcular and posL-aurlcular
o 1enderness: press Lragus and pull on ear lobes and hellx.
" ress on masLold process ! lf palnful = mlddle ear lnfecLlon.
Specu|um Lxam: use smaller aLLachmenL on oLoscope
o Lxamlne exLernal audlLory meaLus
o Lxamlne audlLory canal and Lympanlc membrane
" 1llL persons head away from you ! sLralghLen Lhe audlLory
canal by pulllng Lhe ear upwards, backwards, and sllghLly
away from head ! lnserL speculum lnLo Lhe ear canal curvlng
downwards and Lowards Lhe paLlenL's face.
" 3 ma[or sLrucLures should be vlsuallzed on Lympanlc
membrane:
nand|e of the ma||eus
Umbo ! where Lhe eardrum meeLs Lhe Llp of Lhe
malleus.
Cone of ||ght ! from Lhe umbo fannlng downwards
and anLerlorly.
near|ng 1ests: Whlsper 1esL, Weber 1esL, 8lnne 1esL
o Wh|sper 1est: sLand one fooL away on one slde of Lhe paLlenL, and
cover Lhelr opposlLe ear ! Lhen whlsper a word and ask Lhe paLlenL Lo
repeaL lL Lo you.
o Weber 1est: sLrlke Lhe 312 Pz Lunlng fork and place lL on Lhe person's
head ln Lhe mldllne ! ask Lhe paLlenL lf Lhey can hear lL beLLer or
worse ln one ear over Lhe oLher.
" lf Lhere ls laLerallzaLlon of sound, Lhere are Lwo posslble
reasons:
!"#$%&'()&% +,-./+'$0( 1(&)$-2 %,##3
4,-')&%&'()&% #(-#,)$-(/)&% 1(&)$-2 %,##3
o k|nne 1est (do on Lhe slde LhaL Weber LesL laLerallzed Lo): sLrlke Lunlng
fork and hold Lhe base of lL Lo Lhe masLold process ! ask paLlenL
when Lhey can no longer hear Lhe Lunlng fork ! when paLlenL
lndlcaLes Lhey can'L hear lL anymore, move lL so LhaL Lhe fork prongs
are vlbraLlng Lowards and away from Lhe ear ! ask paLlenL Lo lndlcaLe
when Lhey can no longer hear lL.
" ln acLual pracLlce, would only do 8lnne LesL lf Lhere ls
laLerallzaLlon ln Lhe Weber LesL.
" ln 8lnne LesL, alr conducLlon (AC) should be longer Lhan 8one
conducLlon (8C) ! AC = 2 x 8C (approx.)
" k|nne-Negat|ve ! lf AC ls noL longer Lhan 8C Lhls would
lndlcaLe conducLlve hearlng loss ln Lhls ear and Lhe Lunlng
fork would noL be heard when lL was moved Lo Lhe exLernal
audlLory meaLus.
" k|nne- os|t|ve !When nerve deafness ls presenL Lhen Lhe
noLe ls audlble aL Lhe exLernal meaLus, as alr and bone
conducLlon are reduced equally, so LhaL Lhe alr conducLlon ls
beLLer (as ls normal) Lhan bone conducLlon.

Nose
Inspect|on: symmeLry, deformlLy, dlscharge
a|pat|on:
o aLency of nosLrlls: block each nosLrll and ask paLlenL Lo snlff.
o Speculum exam: use larger speculum on oLoscope
" lnserL genLly and observe for Lhe followlng:
Mucosa and sepLum ! normal colour and
vasculaLure
1urblnaLes/concha ! lf any are seen you wlll only
see lnferlor concha on Lhe laLeral slde.
o lnferlor meaLus dralns: nasolacrlmal ducL
o Mlddle meaLus: maxlllary, fronLal, anLerlor
eLhmoldal slnuses
o Superlor meaLus: posLerlor eLhmoldal and
sphenold slnuses.
o S|nuses
" Look for swelllng or redness over maxlllary or fronLal slnuses.
" Apply genLle pressure over Lhe slnus and see lf Lhls causes any
Lenderness.
" 1ranslllumlnaLlon LesL: perform ln dark room
Maxlllary slnus - person has Lo open Lhelr mouLh
and llghL should be applled Lo Lhe nasolablal fold !
lllumlnaLlon wlll be seen lnslde mouLh
lronLal slnus - use hand Lo form barrler for llghL
across Lhe brow ! apply llghL under Lhe brow on Lhe
medlal slde of Lhe eye sockeL ! lllumlnaLlon ls seen
above hand.




Lxam|nat|on of Lye
Inspect|on:
o Slze, shape, symmeLry, scars, swelllngs
o AllgnmenL
o Lye brows: loss of laLeral 1/3 = hypoLhyrold or leprosy
o Lye||ds:
" tos|s ! Porner's, myasLhenla gravls, damage Lo occulomoLor nerve
" Lld reLracLlon, lld lag ! Lhyrold problems
" kanthe|asmata ! SllghLly ralsed, yellowlsh, well clrcumscrlbed
plaques of cholesLerol LhaL appear along Lhe nasal porLlons of one or
boLh eyellds.
" Sty ! palnful, Lender red lnfecLlon ln a gland aL Lhe margln of Lhe
eyelld.
" Cha|az|on ! subacuLe non-Lender and usually palnless nodule
lnvolvlng a melbomlan gland.
May become acuLely lnflamed, buL unllke sLy usually
polnLs lnslde Lhe lld raLher Lhan on lld margln.
" 8|ephar|t|s ! lnflammaLlon of Lhe eyelld marglns.
o Lye|ashes: LcLroplon or enLroplon
" Lctrop|on ! margln of lower lld ls Lurned ouLward, exposlng Lhe
palpebral con[uncLlva (more common ln Lhe elderly).
revenLs Lhe eye from dralnlng properly so Learlng occurs.
" Lntrop|on ! lnward Lurnlng of Lhe lld margln whlch causes Lhe
lower lashes Lo lrrlLaLe Lhe con[uncLlva and Lhe lower cornea.
o Ir|s: colour, coloboma
o up||: equal ln boLh eyes
o Con[unct|va:
" Iaund|ce ! yellow sclera
" |nguecu|um ! harmless yellow Lrlangular nodule ln Lhe bulbar
con[uncLlva on elLher slde of lrls.
Appears frequenLly wlLh aglng, flrsL on nasal Lhen Lemporal
slde.
" teryg|um ! Lrlangular Lhlckenlng of bulbar con[uncLlva LhaL grows
across ouLer surface of cornea (usually from nasal slde).
May lnLerfere wlLh vlslon as lL encroaches onLo pupll.
o Cornea:
" ulrecL llghLlng ! check Lo see hLaL reflecLlons are symmeLrlcal
" LaLeral llghLlng ! crescenLlc shadow.
" Corneal arcus ! Lhln graylsh whlLe arc or clrcle noL qulLe aL edge of
cornea.
o Anter|or chamber: shlne llghL LangenLlally lnLo anLerlor chamber.
" uepLh
" Pyphema ! blood ln Lhe anLerlor chamber of Lhe eye.
" Pypopyon ! pus ln Lhe anLerlor chamber of Lhe eye.
o Lacr|ma| Apparatus: upper laLeral orblLal margln for any swelllng of lacrlmal
gland
" uncLa on medlal end of each upper and lower lld.
" 8egurglLaLlon or blockage of fluld
" ress on each slde of Lhe nose for evldence of blockage or
lnflammaLlon.
1ests
o up|||ary react|on: Lo llghL (dlrecL and consensual)
o Lxtraocu|ar musc|es
" n-test: paLlenL's rlghL eye

Convergence: sLarL from approxlmaLely 2 feeL away and geL Lhe
person Lo follow a polnL as you move lL closer Lo Lhe brldge of Lhelr
nose.
o 3 components: convergence, accommodaLlon, puplllary
consLrlcLlon.
Cover-uncover test: paLlenL should focus on an ob[ecL aL mld-
dlsLance ! one eye ls covered for approxlmaLely 20 seconds ! eye
ls uncovered and any excurslon of Lhe eye ls noLed.
o 1esLs Lhe resLlng Lone of Lhe exLraocular muscles.
V|sua| Acu|ty
o SLand 20 feeL from Lhe Snellen charL and ask Lhe paLlenL Lo read Lhe
largesL llne ! lf Lhls ls done Lhen askL hem Lo read Lhe nexL smaller
llne and so on unLll Lhey can ldenLlfy less Lhan 30 of Lhe leLLers on a
glven llne ! Lhe lasL llne Lhey can ldenLlfy 30 of Lhe leLLers ls Lhe
lasL one Lo be counLed.
o Check flrsL wlLh one eye covered, Lhen Lhe nexL eye, and flnally wlLh
boLh eyes uncovered.
V|sua| I|e|ds
o 1emporal flelds: slL across from person and brlng hands Lowards
yourself from far behlnd Lhe person's head ! ask Lhem Lo lndlcaLe
Lo you when Lhey can see your hands.
" Compare when each eye sees your hands.
o nasal fleld: LesL by confronLaLlon
" SlLLlng across from Lhe person you should acL as Lhe
person's mlrror lmage.
Iundoscopy: ln a dark room, hold Lhe ophLhalmoscope ln Lhe same hand as
Lhe eye LhaL you wlsh Lo examlne (le. 8lghL hand used Lo examlne rlghL eye of
paLlenL) and use Lhe same slde eye as Lhe one you'll be examlnlng on Lhe
paLlenL (le. ?our rlghL eye should be used Lo examlne Lhe paLlenL's rlghL eye)
! use Lhe oLher hand Lo hold Lhe paLlenL's eyelld open sllghLly ! ask Lhe
paLlenL Lo focus on someLhlng far away ! approach Lhe eye aL a 13 degree
angle ! observe red reflex ! approach unLll vessel can be seen and ls clear
! follow vessel Lo opLlc dlsc ! observe dlsc and cup ! as paLlenL Lo look lnLo
Lhe llghL Lo observe macula and fovea.


neart
er|phera| S|gns:
llnger nalls: cyanosls (blue), spllnLer hemorrhages (brown sLreaks ln nall bed),
clubblng
alms: !aneway leslons (eryLhemaLous macular leslons).
ulp of flnger Llps: Csler's nodes (Lender nodes ln flngers and Loes)
Lyes:
o allor ln palpebral con[uncLlva ! anemla
o Pemorrhages ln bulbar con[uncLlva & sclera ! lnfecLlve endocardlLls
o 8eLlna ! fundoscopy
" Changes seen wlLh hypertens|ve ret|nopathy
SLage 1: Copper & sllver wlrlng
SLage 2: A-v nlcklng
SLage 3: llame shaped hemorrhages & CoLLon wool
exudaLe
SLage 4: apllledema
" 8oLh SpoLs (lnfecLlve endocardlLls) ! hemorrhage ln reLlna
wlLh cenLral pallor.
Changes seen wlLh lnfecLlve endocardlLls: !aneway leslons, Csler's nodes, 8oLh
spoLs, hemorrhage of bulbar con[uncLlva and sclera.
lace: malar flush (mlLral sLenosls) and cenLral cyanosls (llps, Longue, buccal
mucosa)
neck: have paLlenL ln suplne poslLlon
o lnLernal and exLernal [ugular venous pulsaLlons & caroLld pulsaLlons.
o Measure !v: normal = 2-3 cm P
2
C (Cv = !v + 3cm P
2
C)
PepaLo-[ugular reflex: apply pressure below cosLal carLllage for 10-13 seconds
! !v should rlse ! back Lo normal wlLhln a few seconds. (susLalned rlse =
elevaLed Cv)
AusculLaLe lung bases for creplLaLlons or rales.
Check for plLLlng edema: legs, dorsum of fooL, behlnd medlal malleoll

Inspect|on:
o SymmeLry, shape, deformlLles
o Aplcal lmpulse (3
Lh
lnLercosLal space medlal Lo lefL mld-clavlcular llne)
o ulsaLlons ln mlLral Lrlcuspld, Lrb's polnL, pulmonlc and AorLlc areas.
o LplgasLrlc area: aorLlc pulsaLlons (lf under cosLal carLllage ! 8v may
be enlarged)
a|pat|on:
o LaLeral Lo sLerna angle ls Lhe 2
nd
lnLercosLal space
o Cardlac areas:
" AorLlc ! rlghL 2
nd
lCS
" ulmonlc ! lefL 2
nd
lCS parasLernal
" Lrb's olnL ! lefL 3
rd
lCS parasLernal
" MlLral ! lefL 3
Lh
lCS medlal Lo mldclavlcular
" 1rlcuspld ! lefL 3
Lh
lCS parasLernal
o use ball of hand Lo locaLe aplcal pulse ln 3
Lh
lCS, Lhen use flngerLlps Lo
locallze lL (dlameLer, ampllLude, duraLlon)
o alpaLe all cardlac areas - ball of hand for Lhrllls, flngerLlps for
abnormal pulsaLlons (vlbraLlons).
o alpaLe abdomlnal aorLlc pulsaLlon: from below (abdomlnal) or from
below rlb cage (8v hyperLrophy)
o use ulnar surface of hand Lo check for parasLernal heave ! 8v
hyperLrophy
ercuss|on:
o ercuss hearL borders
" 8lghL border: aL Lhe sLernum
" LefL border: on an angle
Auscu|tat|on:
o AusculLaLe all Lhe cardlac areas: llsLen for S1 and S2 wlLh bell and
dlaphragm
" S1 ! closlng of mlLral and Lrlcuspld valves (Av valves)
" S2 ! closlng of aorLlc and pulmonlc valves
" S3 ! rapld venLrlcular fllllng agalnsL venLrlcle wlLh decreased
compllance.
Peard beLween S2 and S1 (rlghL afLer S2)
" S4 ! always paLhologlcal (rapld fllllng agalnsL venLrlcle wlLh
decreased compllance)
Peard beLween S2 and S1 ([usL before S1)
o Speclal poslLlons:
" LefL LaLeral uecublLus ! roll paLlenL Lo lefL slde and
ausculLaLe mlLral area wlLh bell of sLeLhoscope ! besL
poslLlon Lo hear mlLral sLenosls murmur.
MlLral SLenosls murmur ! presysLollc murmur
(crescendo murmur)
" Pave paLlenL slL and lean forward ! lnhale and Lhen exhale
and hold whlle you ausculLaLe Lhe aorLlc area and Lrb's polnL
! besL poslLlon Lo hear AorLlc regurglLaLlon murmur.
AorLlc regurglLaLlon murmur ! dlasLollc murmur
(decrescendo murmur)







Arter|a| System
Inspect|on: upper and lower llmbs
o 3 S's
o Skln: noLe dryness, aLrophy, shlny appearance
o Colour: pale colour?
o Palr: loss of halr
o nalls: Lhlckness and rldges
o ulcers: classlcally on Llps of Loes and soles of feeL
o Cangrene
o Slgns of ArLerlal lnsufflclency: aln, parasLhesla, perlshlngly cold,
pallor, pulselessness.
o lnLermlLLenL claudlcaLlon, resL paln.
a|pat|on:
o 1emperaLure: use backs of hands
o alpaLe pulses: radlal, ulnar, brachlal, femoral, popllLeal, dorsalls
pedls, posLerlor Llblal.
o Crade Lhe pulses from 0-4.
Spec|a| 1ests:
o 8uerger's 1est: paLlenL lles ln bed ! ralse boLh legs Lo approxlmaLely
60 degrees for 1 mlnuLe and have paLlenL wlggle Loes Lo empLy blood
from Lhe legs ! have paLlenL slL up and swlng legs over Lhe slde of Lhe
bed ! observe Lhe feeL for colour reLurnlng and vessels fllllng (colour
should reLurn ln 10 seconds and velns should flll ln 13 seconds).
o A||en's 1est: palpaLe radlal and ulnar pulses on paLlenL's arm ! ask
paLlenL Lo make a LlghL flsL ! occlude boLh pulses ! ask paLlenL Lo
open hand ! release one of Lhe pulses ! colour should reLurn Lo
paLlenLs hand even wlLh one sLlll occluded.
" 1esLs for arLerlal sufflclency Lo Lhe hand
Lymphat|c System
a|pat|on
o LplLrochlear - near elbow
o Axlllary lymph nodes
" AnLerlor
" osLerlor
" LaLeral
" Medlal
" Aplcal
o lngulnal lymph nodes: PorlzonLal and verLlcal groups
Character|st|cs of Lymph Nodes
Norma| Inf|amed Ma||gnant
Small
Moblle
non-Lender
llrm
ulscreLe
Lnlarged
SofL Lo flrm
1ender
ulscreLe
LryLhemaLous
Lnlarged
Pard
non-Lender
llxed Lo surroundlng
Llssue
Venous System (only do lower llmb)
Inspect|on
o 3 S's
o Colour: cyanoLlc or brown plgmenLaLlon
o lncreased plgmenLaLlon: brown/reddlsh
o ulcers: prlmarlly found along Lhe paLh of Lhe saphenous veln (medlal
malleolus)
o varlcoslLles
a|pat|on
o alpaLe for Lenderness
o alpaLe for LemperaLure wlLh back of hand (compare boLh sldes)
o alpaLe for cords
o Assess for plLLlng edema
o Measure Lhe clrcumference of Lhe calf and compare boLh legs (LesLs
for uv1)
Spec|a| 1ests
o 1ests for DV1
" ratt's 1est: apply genLle pressure Lo Lhe calf Lo see lf paln ls
caused
" noman's 1est: dorslflexlon of Lhe fooL Lo see lf paln ls caused.
o 1ests for assess|ng var|cose ve|ns
" Manua| Compress|on 1est: flnd varlcoslLy on lower llmb !
place Lwo flngers of each hand on Lhe veln aL leasL 10 cm
aparL ! Lap on Lhe vessel wlLh Lhe lower flnger and feel Lhe
Lransmlsslon of a wave Lo Lhe upper hand ! Lap wlLh upper
flnger Lo see lf wave ls LransmlLLed (no wave should be
LransmlLLed, and lf Lhere ls, Lhere ls valvular lnsufflclency)
" 1rende|enberg 1est: have paLlenL lle down ! ralse one leg
over your shoulder and have paLlenL wlggle Loes for 1 mlnuLe
! apply a LournlqueL on Lhe upper Lhlgh ! lower Lhe leg and
have paLlenL sLand up.
Immed|ate f||||ng before tourn|quet re|ease =
lncompeLence of Lhe valves of Lhe communlcaLlng
velns
Immed|ate f||||ng after tourn|quet re|ease =
lncompeLence of Lhe valves of Lhe superflclal velns.








kesp|ratory System
er|phera| S|gns
Ceneral appearance:
o Cachexla (wasLlng)
o 8esplraLory dlsLress: pursed llp breaLhlng, lnLercosLal muscle reLracLlon
o ConLracLlon of plaLysma and SCM
Cral CavlLy:
o Cyanosls: blulsh dlscolouraLlon of mucous membranes and Longue
o PallLosls: foul smelllng breaLh
o Poarseness of volce
nose:
o aLency of nosLrlls
o SepLal devlaLlon
o SepLal perforaLlon
o Colour of mucous membrane
Lye:
o Anemla - pallor of palpebral con[uncLlva
o Porner's syndrome: pLosls, consLrlcLed pupll
neck: engorgemenL of velns and palpaLlon of lymph nodes
Pands:
o Clubblng
o lgmenLaLlon
o AsLerlxls (flapplng Lremor)
Legs: edema
1rachea: should be mldllne

Anter|or Chest
Inspect|on
o 3 S's
o ueformlLles
o oslLlon of rlbs
o lnLercosLal muscles (observe movemenLs)
o normal resplraLory movemenLs.
a|pat|on
o alpaLe for Lenderness
o 1acLlle lremlLus - use ulnar border of hand and ask paLlenL Lo say 99" a
number of Llmes.
" Should feel vlbraLlons on chesL wall and should compare boLh sldes.
o ChesL Lxcurslon - hands should be placed genLly on Lhe chesL and space
beLween flngers should be observed upon lnsplraLlon Lo see lf boLh sldes are
expandlng equally.

o MeasuremenL of A-laLeral dlameLer
" LaLeral dlameLer = dlsLance from one anLerlor axlllary llne Lo Lhe
oLher
" A dlameLer = dlsLance from anLerlor axlllary llne Lo posLerlor
axlllary llne
" 1he A:laLeral raLlo should be 1:2 or 3:7
ercuss|on
o ercuss all areas sLarLlng above clavlcle and percusslon ln lnLercosLal spaces
down Lo Lhe 6
Lh
lnLercosLal space (should hear resonance)
Auscu|tat|on
o LlsLen for breaLh sounds:
" Ves|cu|ar breath|ng - lnsplraLory sounds are longer Lhan explraLory
(heard over mosL of Lhe lung)
" 8roncho-veslcular breaLhlng - lnsplraLory sounds and explraLory
sounds are equal (heard aL Lhe angle of Louls)
" 8ronchlal breaLhlng - explraLory sounds lasL longer Lhan lnsplraLory
(heard over manubrlum and sLernum)
" 1racheal breaLhlng - lnsplraLory sounds and explraLory sounds lasL
abouL Lhe same Llme (heard over Lrachea ln Lhe neck)
o Abnormal sounds:
" Crackles
" Wheezlng
" 8onchl
" leural rub
Add|t|ona| tests
o Voca| resonance: ask paLlenL Lo say 99 and llsLen for low plLched sounds ln
dlfferenL lobes.
o Lgophany: ask paLlenL Lo say 'L' and llsLen for muffled 'L' sound.
o Wh|sper|ng pector||oquy: ask paLlenL Lo whlsper '99' or '1-2-3' and llsLen for
falnL lndlsLlncL sounds.

oster|or Chest
Inspect|on: paLlenL should be slLLlng wlLh arms crossed ln fronL of Lhem.
o verLebral column
o Scapula
o 8esplraLory movemenLs
o oslLlon of rlbs
o lnLercosLal muscles
a|pat|on
o alpaLe for Lenderness
o 1acLlle fremlLus
o ChesL excurslon: above, beLween, and below scapula
ercuss|on
o 8esonance
o D|aphragmat|c excurs|on (should be ~4-6cm): have person slLLlng up wlLh
arms folded ln fronL of Lhem ! sLarL percusslon aL level of Llp of scapula (mark
Lhe level) ! have paLlenL Lake deep breaLh ln and hold ! percuss downwards
unLll resonance becomes dull (mark Lhe level) ! reLurn Lo Llp of scapula and
have paLlenL breaLh ouL and hold ! percuss upwards unLll dullness Lurns Lo
resonance (mark Lhls level).
Auscu|tat|on: 8reaLh sounds, abnormal sounds, and addlLlonal LesLs (same as anLerlor
chesL)


























































































Abdomen (lnspecLlon, ausculLaLlon, palpaLlon, percusslon)
er|phera| S|gns
Pands:
o Clubblng
o kollonychla (flngernall spoonlng) ! lron deflclency anemla
o Leukonychla (whlLe sLreaks or spoLs on Lhe nalls)
o uupuyLren's conLracLure ! conLracLure of Lhe palm whlch prevenLs
Lhe full openlng of Lhe hand and makes Lhe person unable Lo puL Lhelr
hand fully flaL on a surface.
o almar eryLhema
o llapplng Lremor (asLerlxls)
lace & Lyes:
o allor of Lhe palpebral con[uncLlva ! Anemla
o ?ellow Sclera ! !aundlce
o uehydraLlon of Lhe mucous membranes
o aroLld enlargemenL
MouLh:
o leLor hepaLlca
o Leukoplakla
o lgmenLaLlons
o ClosslLls
o Candldlasls
o ulceraLlons
ChesL:
o CynecomasLla (males)
o Splder angloma
o uehydraLlon - skln Lurgor (see LenLlng of skln on chesL)
CenlLalla: 1esLlcular aLrophy
Llmbs: perlpheral edema

Inspect|on (3 l's of abdomlnal dlsLenslon ! feces, flaLus, faL, feLal, fluld)
o 3 S's
o SLrlae
o Masses
o umblllcus
o CapuL Medusa
o Pernla - ask paLlenL Lo ralse Lhelr head and cough
o CLher venous dlsLenslon
o Colour (brulses, Cullen's slgn, Crey 1urner's slgn)
" Cullen's ! perlumblllcal brulslng (acuLe pancreaLlLls)
" Crey 1urner's ! brulslng of Lhe flanks (acuLe pancreaLlLls)
o Palr ulsLrlbuLlon
o ulsaLlons
o MovemenLs (resplraLlon, vlslble perlsLalsls, pulsaLlons, feLal
movemenLs)
Auscu|tat|on
o AusculLaLe for bowel sounds (llsLen for 2-3 mlnuLes lf Lhey aren'L
heard rlghL away).
o 8rulLs: AorLa, renal arLery, lllac arLerles, femoral arLerles
o lrlcLlon rubs over llver and spleen
o venous hum over porLa hepaLls.
a|pat|on
o alpaLe llghLly for Lenderness (waLch for faclal expresslon)
o alpaLe more deeply for Lenderness and masses (lncludlng for Lhe
slgmold colon)
o Aorta ! palpaLe sllghLly Lo Lhe lefL of Lhe mldllne
o L|ver ! begln palpaLlon ln rlghL lllac fossa and have paLlenL breaLh
deeply as you gradually move up Lo Lhe cosLal margln.
o Sp|een ! begln palpaLlon ln rlghL lllac fossa and move dlagonally
Lowards Lhe lefL cosLal margln.
" lf spleen lsn'L felL, have paLlenL roll on Lo rlghL rlde and
palpaLe aL cosLal margln agaln Lo feel spleen.
o k|dneys ! wlLh paLlenL lylng on back use one hand Lo press down and
Lhe oLher hand on Lhe paLlenLs back aL Lhe cosLo-verLebral [uncLlon
presslng up, should feel Lhe kldney beLween Lhe Lwo hands.
ercuss|on
o ercuss enLlre abdomen for Lympany and dullness
o L|ver ! percuss up from level of symphlsls publs and down from Lhe
level of Lhe 3
Lh
lnLercosLal space Lo locaLe Lhe upper and lower borders
of Lhe llver.
o Sp|een ! percuss of Lhe 10
Lh
lnLercosLal space ln Lhe anLerlor axlllary
llne
" Should be Lympanlc
" Ask paLlenL Lo Lake deep breaLh and conLlnue Lo percuss, lf
Lhere ls dullness ! splenlc enlargemenL
o Ur|nary b|adder (person should have volded beforehand) ! percuss
downwards from Lhe umblllcus Lo Lhe level of Lhe publc symphlsls
(should be Lympanlc).
Spec|a| 1ests
o Asc|tes
" Check for dlsLenslon
" I|u|d wave: WlLh paLlenL on Lhelr back have Lhem puL one
hand verLlcally along Lhe mldllne of Lhelr abdomen ! place
one of your hands on one slde of Lhelr abdomen ! fllck Lhe
oLher slde of Lhe abdomen wlLh your oLher hand and see lf
you can feel a wave LransmlLLed Lo Lhe hand placed on Lhe
oLher slde of Lhe paLlenL's hand.
" Sh|ft|ng du||ness: percuss across Lhe abdomen from Lympany
Lo dullness laLerally ! mark Lhe llne of dullness ! have
paLlenL Lurn Lo Lhelr opposlLe slde ! percuss Lhe abdomen
agaln and check where Lhe llne of dullness ls ! lf lL has
moved slgnlflcanLly Lhls means Lhere ls fluld ln Lhe abdomen.
o Acute Append|c|t|s
" kebound tenderness: wlLh paLlenL lylng on Lhelr back, apply
pressure Lo Mc8urney's polnL (rlghL lllac fossa) ! lf Lhls ellclLs
paln when Lhe pressure ls removed Lhls ls a poslLlve slgn for
appendlclLls.
" kovs|ng's s|gn: apply pressure Lo Lhe lefL lllac fossa and see lf
lL ellclLs paln ln Lhe rlghL lllac fossa.
" soas s|gn: have paLlenL Lry Lo ralse Lhelr leg agalnsL
reslsLance whlle lylng flaL.
" Cbturator S|gn: have paLlenL Lry Lo brlng Lhelr knee Lo Lhe
opposlLe shoulder agalnsL reslsLance.
" D|g|ta| recta| exam
o Acute Cho|ecyst|t|s
" Murphy's S|gn: lnserL Lhe Llps of your flnger [usL below Lhe
cosLal margln on Lhe rlghL slde aL Lhe mldclavlcular llne and
ask Lhe paLlenL Lo Lake a deep breaLh ! lf Lhe paLlenL
suddenly sLops breaLhlng ln and has a look of paln on Lhelr
face ! +'ve slgn.
" 8oa's S|gn: llghLly scraLch Lhe skln below Lhe rlghL scapula !
poslLlve slgn ls an uncomforLable sensaLlon percelved by Lhe
paLlenL.
o ye|onephr|t|s: place a hand aL Lhe cosLo-verLebral [uncLlon ! sLrlke
Lhe dorsal surface of Lhls hand wlLh Lhe oLher hand ! poslLlve slgn
would be paln.



























































Muscu|oske|eta| System
Genera| Inspect|on
o Cbserve Lhe paLlenL's galL and posLure
o Cbserve for:
" 1ophl on Lhe hellx or anLl-hellx of Lhe ear and Lhe greaL Loe
(gouL)
" 8heumaLold nodules - seen especlally on exLensor surface of
Lhe arms (8heumaLold ArLhrlLls)
" Peberden's nodes - seen aL ul [olnL (osLeoarLhrlLls)
" 8ouchard's nodes - seen aL l [olnL (osLeoarLhrlLls)
" sorlasls on exLensor surface of Lhe elbows or knees, scalp,
and on Lhe nalls.
" Any eye lnflammaLlon
" Muscle wasLlng

Upper L|mb - have paLlenL slLLlng wlLh upper llmbs fully exposed
Inspect|on
o 3 S's
o LryLhema over [olnLs
o ueformlLy of Lhe bones or [olnLs
o Cbserve act|ve range of moLlon aL each [olnL:
" I|ngers: llexlon, exLenslon (ask paLlenL Lo make flsL and Lhen
open slowly), abducLlon, adducLlon, opposlLlon
" Wr|st: flexlon, exLenslon, laLeral flexlon
" L|bow: exLenslon, flexlon, suplnaLlon & pronaLlon (have
elbow rlghL up agalnsL Lhe body and [olnL aL 90 degree angle).
" Shou|der: flexlon, exLenslon, abducLlon, adducLlon, laLeral &
medlal roLaLlon.
Check moLlon of Lhe clavlcular [olnLs on lnspecLlon
and palpaLlon (sLerno-clavlcular, acromlo-clavlcular,
and humero-clavlcular [olnLs)
a|pat|on
o alpaLe each [olnL for Lenderness, creplLus, and heaL.
o lf Lhere ls any deflclency of Lhe acLlve range of moLlon, check Lhe
passlve range of moLlon.
Spec|a| 1ests
o Carpa| 1unne| Syndrome
" ha|en's 1est: have paLlenL place Lhelr hands back Lo back
polnLlng downwards wlLh boLh wrlsLs flexed and dorsum of
boLh hands agalnsL Lhe oLher ! poslLlve phalen's LesL would
be paln or parasLhesls ellclLed by Lhls poslLlon.
" 1|ne|'s test: percuss over Lhe anLerlor surface of Lhe wrlsL aL
Lhe level of Lhe mosL dlsLal skln crease ! poslLlve 1lnel's LesL
would be paln or parasLhesla ln Lhe dlsLrlbuLlon of Lhe medlan
nerve.

Lower L|mb
Inspect|on: look for same Lhlngs as upper llmb

o Cbserve act|ve range of moLlon aL each [olnL:
" 1oes: flexlon and exLenslon
" Ieet: lnverslon and everslon
" Ank|e: dorslflexlon, planLar flexlon, medlal & laLeral roLaLlon.
" knee: flexlon, exLenLlon
" n|p: flexlon, exLenslon, abducLlon, adducLlon, medlal & laLeral
roLaLlon.
a|pat|on
o alpaLe each [olnL for Lenderness, creplLus, and heaL.
o lf Lhere ls any deflclency of Lhe acLlve range of moLlon, check Lhe
passlve range of moLlon.
Spec|a| 1ests
o Check knee for [o|nt effus|on
" 8u|ge S|gn: use one hand Lo compress Lhe suprapaLellar
pouch ! massage Lhe [olnL from Lhe medlal slde upwards
and laLerally Lo empLy any fluld from Lhe medlal slde ! poke
Lhe laLeral slde of Lhe [olnL and observe any bulge on Lhe
medlal slde (poslLlve bulge slgn).
" 8a||otment S|gn: compress Lhe suprapaLellar pouch wlLh one
hand ! press Lhe paLella backwards and up wlLh Lhe oLher
hand ! lf Lhere ls excess fluld ln Lhe [olnL Lhe paLella wlll be
pushed Lhrough lL slowly and colllde wlLh Lhe femur as a
palpable Lap (poslLlve balloLmenL slgn)
o Check knee for |ntegr|ty of ||gaments
" ACL: have paLlenL flex Lhelr knee whlle lylng down Lo brlng lL
Lo a 90 degree angle ! SlL on Lhe person's fooL ! grlp Lhe
person's leg [usL below Lhe knee wlLh Lhe Lhumbs on Llblal
promlnence ! pull Lhe leg forward and observe Lhe moblllLy
of Lhe [olnL.
" CL: same as ACL, excepL push Lhe leg backwards.
" MCL: wlLh paLlenL lylng down, bend Lhelr knee Lo a 13 degree
angle ! hold fooL ln one hand and Lhe Lhlgh ln Lhe oLher
hand ! forclbly push knee lnLo laLeral flexlon ! look for
excess movemenL of Lhe [olnL.
" Latera| L|gament: same as MCL, excepL push leg Lowards
medlal flexlon.
o Check knee for men|scus |n[ury
" Med|a| men|scus: leg should be aL 13 degrees ! wlLh Lhe
palm of your hand on Lhe lnsLep of Lhe paLlenL's fooL and Lhe
oLher fooL on Lhe paLlenL's knee, roLaLe Lhe fooL laLerally !
genLly laLerally flex Lhe leg aL Lhe [olnL ! gradually sLralghLen
Lhe knee.
" Latera| men|scus: same as medlal excepL hand should be on
Lhe ouLslde of Lhe paLlenL's fooL and roLaLe Lhe fooL and Lhe
leg ln Lhe opposlLe dlrecLlons.
" Any cllcklng or paln may lndlcaLe a problem wlLh Lhe [olnL.
o Check the h|p
" 1homas' test: wlLh paLlenL lylng on Lhelr back, have Lhem
brlng one leg Lo Lhelr chesL by fully flexlng Lhelr hlp ! lf Lhe
opposlLe leg cannoL conLlnue Lo lle flaL on Lhe bad Lhere ls a
flxed flexlon conLracLure.

Ax|a| Ske|eton
1emporomand|bu|ar [o|nt
o Inspect|on: open and close mouLh wldely, ensure boLh slde of [aw
move symmeLrlcally.
o a|pat|on: for creplLus, heaL, or Lenderness.
Sp|na| Co|umn - paLlenL should be sLandlng wlLh feeL LogeLher and wlLh splne
exposed.
o Inspect|on: allgnemenL, asymmeLry and laLeral bendlng (scollosls),
splnal curvaLures.
" Cerv|ca| sp|ne: lnspecL for eryLhema or deformlLy of Lhe
[olnLs.
Act|ve range of mot|on: flexlon (noddlng), exLenslon,
laLeral flexlon, roLaLlon.
" Lumbar sp|ne: lnspecL for eryLhema or deformlLy of Lhe
[olnLs.
Act|ve range of mot|on: flexlon, exLenslon, laLeral
flexlon, roLaLlon (should hold paLlenL's hlps when
roLaLlng).
o a|pate: for Lenderness, creplLus, heaL.
" lf Lhere ls any resLrlcLlon of movemenL Lhen perform passlve
movemenL of Lhe [olnLs.
Spec|a| 1ests
o Check for Sc|at|c nerve root |rr|tat|on
" Lasegue's]Stra|ght |eg test: wlLh paLlenL lylng down ralse one
leg passlvely Lo ~60 degrees ! nerve rooL lrrlLaLlon wlll cause
paln ln lumbar splne and/or down Lhe lower llmb.
" 8owstr|ng manoeuvre: lower Lhe fooL unLll Lhe paln subsldes
and Lhen dorslflex Lhe fooL passlvely ! wlll agaln ellclL paln.
o Check for tenderness of sacro|||ac [o|nt
" Io|nt Stress Manoeuvre: have paLlenL lylng suplne very close
Lo Lhe edge of Lhe bed ! have Lhem flex Lhelr hlp Lo Lhelr
chesL and hold Lhelr leg ln LhaL poslLlon ! have Lhem dangle
Lhe oLher fooL off Lhe edge of Lhe bed ! puL pressure on Lhe
Lhlgh of Lhe leg hanglng off Lhe bed ! lf sacrolllac [olnL ls
lnflamed or palnful Lhls wlll cause paln.






































CNS I
Menta| Status Lxam
o Genera| appearance
o Ga|t
o Speech - Lone, volume, quanLlLy, dysarLhrlas, aphaslas, aphonlas.
o Affect - approprlaLe for lnLervlew
o Leve| of consc|ousness - alerL, drowsy, coma
o Cr|entat|on - Llme, person, place
o Memory
" lmmedlaLe recall - lmmedlaLe repeLlLlon of Lhree words.
" ShorL Lerm memory - repeaL same Lhree words aL Lhe end of
Lhe lnLervlew
" Long Lerm memory - ask paLlenL Lo recall a pasL evenL.
o Abstract th|nk|ng - lnLerpreL a proverb
" Pow are oranges and apples slmllar?"
o Iudgement - ?ou flnd a sLamped leLLer ln fronL of a mallbox, whaL do
you do wlLh lL?"
o n|gher funct|ons - serlal 7's, spell 'WC8Lu" forwards and backwards.
Lxam|nat|on of Cran|a| Nerves
CN I - C|factory
o aLency of each nosLrll
o Ask paLlenL Lo ldenLlfy a famlllar scenL
CN II - Cpt|c
o 1esL vlsual aculLy: Snellen and 8osenbaum charLs.
o erlpheral vlsual flelds by confronLaLlon.
o ulrecL and consensual reacLlon Lo llghL
o near reacLlon Lo puplls.
o lundoscopy - check opLlc dlsc
CN III - Cccu|omotor, IV - 1roch|ear,
VI - Abduscens
o SymmeLrlc corneal reflecLlon
o P-LesL
o Convergence
o Cover-uncover LesL
CN V - 1r|gem|na| (CphLhalmlc, maxlllary, and mandlbular dlvlslons)
o Sensory component
" 1esL sensaLlon bllaLerally ln Lhe dlsLrlbuLlons of Lhe Lhree
branches of Cn v.
" a|n & crude touch: use opened paper cllp wlLh polnL belng
paln and Lhe curved parL as crude Louch ! wlLh Lhe paLlenL's
eyes closed Louch Lhem ln Lhe Lhree dlvlslons of Lhe face and
ask Lhem Lo dlsLlngulsh beLween sharp and dull.
" L|ght touch: use a wlsp of coLLon and do Lhe same Lhlng as
paln & crude Louch
o Motor component
" 1empora||s: ask paLlenL Lo clench LeeLh whlle you palpaLe Lhe
muscle (palpaLe boLh sldes slmulLaneously and compare)
" Masseters: ask paLlenL Lo clench LeeLh whlle you palpaLe Lhe
muscle (palpaLe boLh sldes slmulLaneously and compare)
" terygo|ds: ask paLlenL Lo move [aw from slde Lo slde and
oppose Lhe movemenL wlLh your hand.
o kef|exes
" Cornea| ref|ex: ask paLlenL Lo look away and uslng a Lhln wlsp
of coLLon approach from Lhe slde and Louch Lhe cornea wlLh
coLLon ! paLlenL wlll bllnk eye ls Lhere ls lnLacL sensory (Cn
v) and moLor (Cn vll).
" Iaw Ierk ref|ex: ask paLlenL Lo relax [aw wlLh mouLh sllghLly
open ! place flnger on Lhe chln [usL below Lhe lower llp !
Lap your flnger wlLh your reflex hammer ! [aw should [erk up
sllghLly buL lf lL ls over exaggeraLed lL would lndlcaLe an upper
moLor neuron leslon of Cn v.
CN VII - Iac|a|
o Motor component: 1esL for acLlon of faclal muscles by asklng paLlenL
Lo...
" Close eyes and noL leL you open Lhem.
" Show Lhelr LeeLh.
" ALLempL Lo whlsLle
" 8low or puff ouL cheeks
" Wrlnkle Lhelr forehead
o Sensory component: LasLe sensaLlon Lo Lhe anLerlor 2/3 of Lhe Longue.
o kef|exes: moLor componenL of corneal reflex.
CN VIII - Vest|bu|ococh|ear
o Wh|sper test
o Weber's 1est
o k|nne's 1est
CN Ik - G|ossopharyngea| & k - Vagus
o Movement of the soft pa|ate: ask paLlenL Lo say Aahhh" whlle
observlng for symmeLrlcal movemenL of uvula.
o Gag ref|ex: sensory componenL (Cn lx) and moLor componenL (Cn x).
CN kI - Sp|na| Accessory
o 1rapez|us Musc|e: have paLlenL shrug shoulders agalnsL reslsLance.
o SCM: ask paLlenL Lo move head laLerally agalnsL reslsLance ln boLh
dlrecLlons whlle you feel Lhe muscle as lL conLracLs.
CN kII - nypog|ossa|
o Lxamlne Longue for aLrophy or fasclculaLlons.
o 1ongue protrus|on: check for devlaLlon.

Spec|a| 1ests
1ests for men|ngea| |rr|tat|on
o Neck]Nucha| r|g|d|ty: paLlenL ls unable Lo flex head forward due Lo
rlgldlLy of Lhe neck muscles.
" ls noL consldered as nuchal rlgldlLy lf movemenL ls palnful buL
paLlenL sLlll has full range of moLlon.
o 8rudz|nsk|'s Neck S|gn: llexlng Lhe paLlenL's neck causes flexlon of
Lhelr hlps and knees ! poslLlve response.
o kern|g's S|gn: llexlng paLlenL's hlp Lo 90 degrees and Lhen exLendlng
Lhelr knee causes paln ! poslLlve response.
1ests for nypoca|cem|a
o Chvostek's S|gn:
" L||c|tat|on: Lap on face aL a polnL [usL anLerlor Lo Lhe ear and
[usL below Lhe zygomaLlc bone.
" os|t|ve kesponse: LwlLchlng of lpsllaLeral faclal muscles
(neuromuscular exclLablllLy caused by hypocalcemla).

o 1rousseau's S|gn:
" L||c|tat|on: lnflaLe 8 cuff on paLlenL's arm pasL Lhe sysLollc
8 for several mlnuLes.
" os|t|ve kesponse (carpopedal spasm): muscular conLracLlon
lncludlng flexlon of Lhe wrlsL and MC [olnLs, hyperexLenslon
of Lhe flngers, and flexlon of Lhe Lhumb on Lhe palm.


































































CNS II
SLarL wlLh m|n|-menta| status exam|nat|on (see CnS l)

Sensory System
Sp|notha|am|c 1ract
o a|n and Crude 1ouch: use papercllp much llke lL was used when
LesLlng Cn v and poke paLlenL wlLh lL on Lhelr upper and lower llmbs,
asklng Lhe paLlenL Lo dlsLlngulsh beLween paln and crude Louch.
o 1emperature (noL LesLed ln lab)
Dorsa| Co|umn 1ract
o I|ne 1ouch: same as paln and crude Louch, excepL a wlsp of coLLon ls
used lnsLead of papercllp. (don`L drag coLLon on skln, [usL Louch)
o ropr|ocept|on: sLablllze Lhe paLlenL`s flnger or Loe by holdlng aL Lhe
sldes of Lhe lnLerphalangeal [olnL ! wlLh Lhe paLlenL's eyes closed,
poslLlon Lhe dlglL polnLlng up or down and ask Lhe paLlenL Lo ldenLlfy
whlch way lL ls polnLlng.
o V|brat|on Sense: uslng Lhe 128 PZ Lunlng fork, demonsLraLe Lo Lhe
paLlenL whaL Lhe vlbraLlng fork feels llke on a bony promlnence
(sLernum) ! wlLh Lhe paLlenL's eyes closed place lL over a number of
bony promlnences on Lhe body whlle asklng Lhe paLlenL lf Lhey can feel
lL ! randomly sLop Lhe vlbraLlon and ask paLlenL lf Lhey can sLlll feel lL.
(usually vlbraLlon sensaLlon ls losL dlsLal Lo proxlmal, so wouldn'L have
Lo conLlnue movlng proxlmally lf dlsLal locaLlon ls lnLacL).
o komberg 1est: wlLh paLlenL sLandlng wlLh feeL LogeLher, ask Lhem Lo
close Lhelr eyes and observe lf Lhey are able Lo malnLaln balance.
ar|eta| Cortex
o Stereognos|s: wlLh Lhe paLlenL's eyes closed, ask Lhem Lo ldenLlfy a
famlllar ob[ecL placed ln Lhelr hand.
o Graphesthes|a: wlLh paLlenL's eyes closed, draw a number on Lhe
paLlenL's palm and ask Lhe paLlenL Lo ldenLlfy Lhe number.
o 2-o|nt D|scr|m|nat|on: wlLh paLlenL's eyes close, use an open
papercllp Lo deLermlne whaL dlsLance beLween 2 polnLs LhaL Lhe
paLlenL ls able Lo dlscrlmlnaLe.
o o|nt Loca||zat|on: wlLh Lhe paLlenL's eyes closed, Louch Lhem ln a
number of spoLs and ask Lhem Lo polnL Lo where you Louched Lhem.
o Lxt|nct|on (ln parleLal corLex leslons, may noL feel conLralaLeral
sLlmulus): wlLh paLlenL's eyes closed, Louch Lhem on Lwo areas of Lhe
body slmulLaneously and ask Lhem Lo polnL Lo where you Louched
Lhem.
Motor System
Inspect|on: Muscle aLrophy and asymmeLry, fasclculaLlons, Lremors, Llcs,
LwlLches.
a|pat|on:
o 1one: wlLh paLlenL relaxlng muscles, passlvely move each llmb aL
several [olnLs Lo geL a feellng for any reslsLance or rlgldlLy.
" 1one = LMn leslon
" ^ 1one = uMn leslon
o ower: LesL sLrengLh of each muscle group sysLemaLlcally agalnsL
reslsLance.
" nands & I|ngers:
Ask paLlenL Lo squeeze your flngers ln Lhelr hand.
Ask paLlenLs Lo spread flngers agalnsL reslsLance.
Ask paLlenL Lo hold plece of paper by adducLlng
flngers whlle you pull Lhe paper ouL.
Cppose Lhumb agalnsL reslsLance.
" Wr|sts: ask paLlenL Lo flex and exLend wrlsL agalnsL reslsLance.
" 8|ceps & 1r|ceps: flex and exLend arm
" Shou|der: flex, exLend, abducL, adducL.
" uo Lhe same for Lhe lower llmb
" Graded on sca|e from 0 to S.
0 = absenL conLracLlon
1 = muscle fllcker or conLracLlon wlLhouL movemenL.
2 = movemenL posslble, buL noL agalnsL gravlLy.
3 = movemenL posslble agalnsL gravlLy buL noL
agalnsL reslsLance by you.
4 = movemenL posslble agalnsL some reslsLance.
3 = normal sLrengLh or power
kef|exes
Abdom|na| kef|ex (18,9,10 - above umblllcus, 110,11,12 - below umblllcus):
WlLh paLlenL lylng flaL, use a blunL ob[ecL Lo sLroke Lhe abdomen llghLly on each
slde medlally ! observe conLracLlon of Lhe abdomlnal muscles and devlaLlon of
umblllcus Lowards slde of sLlmulus.
|antar kesponse (S1): on Lhe sole of Lhe fooL, sLarLlng from Lhe heel drag a
polnLed ob[ecL upwards and Lhen medlally across Lhe ball of Lhe fooL !
observe planLar flexlon of all Lhe Loes.
Cremaster|c kespone (L1,2): sLroke upper medlal aspecL of Lhlgh ln downward
dlrecLlon ! observe reflex conLracLlon of cremasLer muscle.
Ana| kef|ex (S3,4,3): sLroke Lhe perlanal area wlLh a polnLed ob[ecL ! observe
Lhe reflex conLracLlon of Lhe exLernal sphlncLer (anal wlnk).

Deep 1endon kef|exes: llmbs should be ln relaxed and symmeLrlc poslLlon.
8|ceps (C3,6)
1r|ceps (C6,7)
8rach|orad|a||s (C3,6)
knee (L2,3,4)
Ank|e (S1,2)
ueep Lendon reflexes are raLed from 0 Lo 4.
o 0 = absenL reflex
o 1+ = dlmlnlshed response
o 2+ = normal
o 3+ = lncreased response (wlLhouL clonus)
o 4+ = hyperreflexla
o ueep Lendon reflexes are normal lf Lhey are 1+, 2+, or 3+ as long as
Lhey are symmeLrlc.
Abnorma| kef|exes
noffmann's S|gn: by holdlng paLlenL's mlddle flnger loosely and fllcklng Lhe
flngernall downward.
o Norma|: flnger rebounds sllghLly lnLo exLenslon.
o Abnorma|: Lhumb flexes and adducLs
Grasp kef|ex: sLroke paLlenL's palm wlLh your flnger.
o Norma|: no response
o Abnorma|: reflex grasplng of flnger.
C|onus: supporL [olnL and apply a sudden muscle & Lendon sLreLch (ank|e,
knee, wr|st c|onus).
o Norma|: no response ! sllghL rebound moLlon.
o Absnorma|: repeLlLlve vlbraLory conLracLlon of Lhe muscle.
8ab|nsk|'s S|gn: on Lhe sole of Lhe fooL, sLarLlng from Lhe heel drag a polnLed
ob[ecL upwards and Lhen medlally across Lhe ball of Lhe fooL
o Norma|: planLar flexlon of all Lhe Loes.
o Abnorma|: flexlon of Lhe blg Loe and fannlng and exLenslon of Lhe resL
of Lhe Loes.
Iaw Ierk: ask paLlenL Lo relax [aw wlLh mouLh sllghLly open ! place flnger on
Lhe chln [usL below Lhe lower llp ! Lap your flnger wlLh your reflex hammer
o Norma|: [aw should [erk up sllghLly
o Abnorma|: over exaggeraLed snapplng shuL of Lhe mouLh would
lndlcaLe an upper moLor neuron leslon of Cn v.

Cerebe||ar Iunct|on (cerebellar slgns are always lpsllaLeral)
Speech
Ga|t: ask paLlenL Lo walk ln a sLralghL llne, heel-2-Loe
8a|ance: ask paLlenL Lo walk on heels, on Loes, or hop on one fooL.
I|nger to nose test: ask paLlenL Lo Louch Lhelr nose and Lhen Louch your flnger
as you move your flnger Lo dlfferenL poslLlons.
D|adochok|nes|a: ask paLlenL Lo perform rapld alLernaLlng movemenLs (eg.
8apldly alLernaLlng clapplng on dorsal and palmar sldes of Lhe hand.
Coord|nat|on: ask paLlenL Lo perform rapld fooL Laps
nee|-knee-sh|n test: ask paLlenL Lo brlng heel Lo opposlLe knee and Lhen drag
heel down Lhelr shln.
nor|zonta| nystagmus: ask paLlenL Lo focus on an ob[ecL and Lrack lL`s
movemenL wlLhouL movlng Lhelr head ! nysLagmus may be seen when ob[ecL
ls broughL far laLerally.