Scott - S ICM

Ultra High Yield ICM-2004 Page 1 oI 29
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CARDIOVASCULAR EXAM

1. General Exam
General inspection
-age, sex, appearance, any signs oI distress
Head
- temperature
- sclera for jaundice
-yellowish discoloration oI the skin and sclera with bilirubin levels greater than
2.5 mg/dL
-conjunctiva for anemia
-blood loss
-iron deIiciency
-Iolate/B12
-hemolysis
-inIection
-sickle cell
-thalassemia
-DIC
- tongue for glossitis
-B12, Iolate, niacin, B6 or riboIlavin (B2) deIiciency
- underneath tongue for central cyanosis
-having central cyanosis implies peripheral cyanosis, but peripheral cyanosis
can exist without central
cyanosis - bluish discoloration oI the skin with reduced Hb in blood greater than
5 gm/100 ml
a. CO anemia
b. Right to LeIt shunts
c. vasoconstriction
d. polycythemia
e. pulmonary problems

Palms
-temperature
-moisture
-pallor
-jaundice
-xanthomas
-lesions
Nails
- clubbing
nail to nail bed angle is ~ than 180
a. Right to LeIt shunts
b. inIective endocarditis
c. bronchogenic carcinoma
d. Crohn`s disease and Ulcerative Collitis
e. liver disease
-capillary refill (normal 1-2sec)
problems with peripheral vasculature
a. Diabetes Mellitis
b. vasculitis
-splinter hemorrhages (subacute bacterial endocarditis)

General Exam (cont.)

Legs
Pitting edema (look at patient Ior signs oI pain)
a. CHF
b. liver disease
c. Nephrotic syndrome
d. IVC obstruction

2. Arterial

Radial pulse: Time Ior 60 seconds or 15 seconds and x 4 (60 brady; ~100 tachy)
Report
Rate - beats per minute
Rhythm - regular, regularly irregular (heart block), irregularly irregular (atrial
Iibrillation)
Volume - low, normal, increased, increased collapsing ( Water- hammer)
Water- hammer pulse
a. Iever
b. anemia
c. hyperthyroidism
d. aortic regurge
e. AV Iistula
Character - normal
BisIerens- Aortic Regurge, Aortic Regurge & Aortic Stenosis
Pulsus Alterans - LeIt ventricular Iailure
Bigeminal - Premature ventricular contraction
Plateau - Aortic Stenosis
Parodoxical - cardiac temponade, constrictive pericarditis,
obstructive lung disease
Vessel Tone - non-palpable, palpable (atherosclerosis)

Peripheral Pulses
Report - presence, symmetry, character
Radial
Brachial
Carotid
Femoral
Popliteal
Dorsalis Pedis
Posterior tibial
Allen`s Test - check Ior patency oI ulnar and radial arteries

Radial - Femoral Delay
Report - not present or present indicating coarctation oI the aorta

Blood Pressure - check Ior lymphedema, scars (brachial cutdown), AV Iistula
Measure cuff size( loose cuII & a short cuII give a high reading)
Confirm the brachial pulse
Position arm; antecubital crease at heart level
Determine target level for inflation (pulse occlusion plus 30)
Take blood pressure twice and repeat in left arm
Hypertension- BP ~ than 140/90
a. essential hypertension
b. Renin/Angiotensin problem
c. Coarctation oI Aorta
d. Pheochromocytoma
e. Cushing`s
I. Conn`s Syndrome

3. Venous System
Check Ior varicose veins and caput medusa oI abdomen

1ugular Venous Pressure
Determination oI Right Atrial pressure
-Position patient
a. patient`s head and torso elevated - 30
b. turn pt`s. head slightly away Irom you
-Locate internal jugular or external jugular vein
use tangential lighting and valsalva maneuver iI necessary
-Confirm vessel is the jugular and not the carotid
a. int. jugular is not palpable
b. vein has 2 beats
c. vein`s pulsations are eliminated by pressure
-Measure highest point of pulsation from the sternal angle
a. sternal angle is 5 cm above right atrium
b. normal jugular measurement is 4cm Irom sternal angle
c. iI ~ than 4cm than right atrial pressure is increased

-Execute Hepato-jugular Reflux

Kussmaul sign- upon inspiration the JVP rises as opposed to decreasing in a normal
individual

4. Precordium

Inspection
Irom the Ioot oI the bed
Report
a. signs of distress
b. symmetry
c. scars
d. visibility of apex beat
Palpation
-check for dextrocardia
-check for thrills (palpable murmurs) over all 4 valve areas
-localize apex beat and describe it (know diIIerence between this and the PMI)
-use leIt lateral decubitus position iI having problems Iinding the apical beat
a. location
b. amplitude (normal, hyperkinetic, hypokinetic)
c. diameter
d. duration (auscultate- normal, sustained)
-parasternal heave (right ventricular hypertrophy)

Auscultation
Listen for heart sounds, murmurs and rubs (pericarditis)
a. listen to all 4 heart areas with both diaphragm and bell
b. listen Ior Mitral valve stenosis and regurge with the pt in the leIt lateral
decubitus position and using the bell
c. listen Ior Aortic regurge with the pt. sitting up, leaning Iorward and holding
their breath aIter completely exhaling - use the diaphragm

Reporting of murmurs
location
timing (systolic, diastolic / crescendo, decrescendo)
intensity (1 - 6)
radiation
character (harsh, blowing)
pitch (low, high)

Austin Flint murmur : murmur oI Mitral Regurge due to a chronic Aortic Regurge

Graham- Steele murmur : murmur caused by pulmonary hypertension

Diastolic murmurs: Mitral Stenosis, Aortic Regurge, Tricuspid Stenosis, Pulmonary Regurge

Systolic murmurs: Mitral Regurge, Aortic Stenosis, Tricuspid Regurge, Pulmonary Stenosis

Hypokinetic Apical Beat : Dilated Cardiomyopathy

Hyperkinetic Apical Beat : Anemia, Hyperthyroidism, Aortic Stenosis, Mitral Regurge, Anxiety

Causes of Murmurs
Congenital
Ruptured papillary muscle
Dilated ring valve
Rheumatic Heart Disease

Head & Neck Exam

A. Head
inspection /palpation - examine the pt`s hair (quality, distribution, texture, loss oI)
(Iine hair- hyperthyroidism ; coarse hair- hypothyroidism)
-examine the skull Ior deIormities (lumps or lesions)
-look Ior Iacial asymmetry, involuntary movements, edema or masses
-look at the skin (coloration, texture, thickness, hair distribution, lesions)
B. Eyes
inspection-
(1) test visual acuity using a Snellen Eye Chart (use any available print iI eye chart is
not available)
presbyopia- impaired near vision Iound in middle & old age
(2) screen visual Iields by conIrontation (repeat pattern in upper, middle & lower
temporal quadrants)
-have pt look into your eyes
-place your hands about 2 It apart and lateral to pt`s ears
-slowly wiggle Iingers as you bring them into pt`s visual Iield
-tell pt to point to your Iingers when they appear
*** iI deIect exists then examine one eye at a time (Bates p170)
(3) assess eye position & alignment (eyes protrude in Grave`s disease & ocular tumors)
(4) eyebrows (lateral borders thin in Hypothyroidism)
(5) eyelids
-width oI palpebral Iissure
-periorbital edema (nephrotic syn., myxedema)
-color oI lids (inIlammation)
-lesions (chalazion, sty, xanthelasma)
-direction eyelashes point (entropion or ectropion)
-eyelid closure
(6) lacrimal apparatus (examine Ior inIlammation, dryness, obstructed duct)
(7) conjunctiva & sclera (jaundice, episcleritis, corneal arcus, pterygium)
(8) cornea & lens (use oblique lighting to inspect Ior opacities in lens such as cataracts)
(9) iris
-shine light Irom temporal side Ior crescentic shadowing (narrow angle
glaucoma; open angle glaucoma has no shadowing )
(10) pupils (size, shape, symmetry)
anisocoria- pupillary inequality oI less than 0.5mm (benign)
miosis- constriction oI the pupils
mydriasis- dilation oI the pupils
test pupillary light reaction (darken room)
-ask pt to look into the distance
-shine light obliquely in each pupil checking direct & consensual rxns
direct reaction- pupillary constriction oI the same eye
consensual reaction- pupillary constriction in the opposite eye
test pupillary near reaction (normal room light)
-hold pen about 10cm Irom pt`s eye
-ask pt to look at it and into the distance directly behind it
-look Ior pupillary constriction with near eIIort
(11) extraocular muscles
-complete an 'H test (look Ior nystagmus)
-check the corneal reIlection (pt looks into your light)
(normal is slightly nasal to pupil center)
-test Ior lid lag & convergence (lid lag and poor convergence iI Hyperthyroid)
Ophthalmoscopic Exam (darken room and crack open exam room door)
(1) use right hand & right eye to examine pt`s right eye & leIt hand & leIt eye to
examine pt`s leIt eye (keep a Iinger on the Iocus dial at all times)
(2) start by examining the pt`s right eye & then repeat all steps Ior the leIt
(3) have the patient Iocus on a point in the distance and Iind the red reIlex by standing
about 15 inches away Irom the pt and about 15 lateral to his/her line oI vision (red
reIlex is absent in cataracts, Retinoblastomas & detached retinas)
(4) move close enough to the pt until your ophthalmoscope is almost touching the pt`s
eyelashes
(5) support yourselI by placing the thumb oI your Iree hand on the pt`s eyebrow
(6) locate the optic disc and bring it into Iocus
(7) Iollow the vessels outward in the 5 positions shown in Bates p178
(8) describe the disc & retina
-clarity oI disc
-color (normal is yellowish orange to creamy pink)
-size oI central physiologic cup (normally white & diameter oI disc)
-character & size oI arteries & veins (check A-V crossings)
(7) inspect the Iovea & macula
Hypertensive findings in the retina
(1) silver wiring- narrowed artery becomes completely opaque
(2) copper wiring- artery becomes tortuous & light reIlex giving a 'copper appearance
A-V crossings
tapering- vein appears to taper down on either side oI the artery
nicking- vein appears to stop abruptly on either side oI the artery
banking- vein twists on the distal side oI the artery and Iorms a dark, wide end
(3) Superficial hemorrhages- small, linear, Ilame-shaped red streaks in the Iundus
(seen in severe hypertension, papilledema & occlusion oI the retinal vein)
(4) Cotton Wool Patches- white or grayish, ovoid lesions with irregular borders that MC result
Irom inIarcted nerve Iibers
(5) Hard Exudates- small, round yellow lesions with well deIined borders that are oIten in
clusters or circular, linear patterns (also seen in Diabetic Retinopathy)
Diabetic Retinopathy
(1) Deep Retinal Hemorrhages- small, rounded irregular red spots that occur deep in the retina
(2) Microaneurysms- tiny, round, red spots seen MC around the macular region. Consist oI
minute dilatations oI very small retinal bl. vessels
(3) Neovascularization- Iormation oI new blood vessels that are more numerous, tortuous &
narrower than the other vessels. MC seen in late stage Diabetes
(4) Proliferative Diabetic Retinopathy- bands oI white Iibrous tissue that develops in late
stages oI Diabetic Retinopathy

C. Ear
inspection- examine the auricle & surrounding tissues Ior deIormities or lesions
palpate- press on the tragus and gently pull on the auricle to check Ior otitis externa
-press on the mastoid process to check Ior possible otitis interna
Otoscope exam (pull pt`s auricle upward, backward & slightly away Irom the head gently)
(1) insert the ear speculum gently into the ear canal & inspect the canal (discharge,
Ioreign bodies, inIlammation, cerumen)
(2) inspect the ear drum (color, contour)
-identiIy the cone oI light (usually anterior-inIerior to handle oI the malleus)
-identiIy the malleus, incus & stapes
-describe the tympanic membrane (normal is pale gray in color)

Auditory Acuity
(1) while occluding one oI the pt`s ears, rub Iingers together next to the unoccluded ear
(2) repeat Ior other ear
*** iI hearing is diminished, try to distinguish between conductive & sensorineural
hearing loss
-use a tuning Iork with 512 Hz or 1024 Hz
Weber Test (lateralization)
(1) tap the tuning Iork against a hard surIace so that it begins to vibrate and then place the Iork
Iirmly on top oI the pt`s head
(2) ask the pt iI the sound is heard in one or both ears (in unilateral sensorineural hearing loss,
sound is heard in the good ear whereas in conductive hearing loss, sound is heard in the
impaired ear)
(3) repeat test iI no sound is heard (normally sound is heard equally in both ears)
Rhine Test (air & bone conduction)
(1) place the vibrating tuning Iork on the mastoid bone behind the ear & level with the ear canal
(2) when the sound can no longer be heard by the pt, place the Iork close to the ear canal & ask
the pt iI the sound is still audible
(3) the 'U oI the Iork should be Iacing Iorward to maximize the vibration
(4) in conductive hearing loss, sound is heard through bone as long or longer than it is through
air whereas in sensorineural hearing loss, sound is heard longer through air
Causes of Conductive hearing loss- obstruction oI the ear canal (Ioreign body, cerumen), otitis
media, perIoration, otosclerosis
Causes of Sensorineural hearing loss- sustained exposure to loud noise, drugs (ototoxicity),
inner ear inIections, trauma, tumors, congenital disorders, aging (presbycusis)

D. Nose & Paranasal Sinuses
inspection- examine the anterior & inIerior surIaces oI the pt`s nose
(1) gently press on the tip oI the nose with your thumb to widen the pt`s nostrils
(2) with the aid oI a pen light note any deIormities or asymmetries (test Ior nasal
obstruction iI indicated by occluding one nare at a time and asking the pt to breathe
through the nostril that is patent
-examine the inside oI the nose with an Otoscope using the largest speculum available
(1) locate the middle and inIerior conchae and the narrow nasal passage between them
a. note the color oI the nasal mucosa and any abnormalities (swelling,
bleeding exudate)
b. note any deviation oI the nasal septum (inIlammation, perIoration)
c. note any remaining abnormalities (polyps, ulcers)
-palpate the Irontal and maxillary sinuses by applying pressure with your thumbs over
each sinus region and noting any tenderness (possible acute sinusitis)

E. Mouth & Pharynx
Lips- color (cyanosis), lesions, ulcers (herpes), cracking (angular cheilitis) or scaliness
Oral Mucosa- examine the pt`s mouth with your pen light & a tongue depressor
(1) look Ior ulcers, white patches (leukoplakia), chancres
Gums & Teeth-
(1) examine the gums (color, signs oI gingivitis, Pb poisoning (lead lines))
(2) inspect the teeth (any missing, color)
Tongue & Floor of mouth-
(1) check the tongue Ior glossitis, carcinoma oI the tongue, XII nerve lesion (deviated
tongue on protrusion)
(2) check the Iloor oI the mouth Ior lesions & abnormalities (Carcinoma)
Pharynx- inspect the soIt palate, anterior & posterior pillars, uvula, tonsils & pharynx
(1) note the color, symmetry, inIlammation, ulcers, lesions & any other abnormalities
F. Neck
inspection- examine the pt`s neck Ior symmetry, any masses, scars or lesions
(1) examine the salivary glands Ior enlargement (Parotid & Submandibular)
(2) inspect the pt`s lymph nodes and palpate each one using the pads oI your index and
middle Iingers
(3) pt should be relaxed with his/her neck Ilexed slightly Iorward
-Preauricular
-Posterior Auricular
-Occipital
-Tonsillar
-Submandibular
-Submental
-SuperIicial Cervical
-Posterior Cervical
-Deep Cervical Chain
-Supraclavicular
(4) note the shape, size, delimitation, mobility, consistency, and any tenderness iI they
are palpable (tender nodes suggest inIlammation; hard nodes suggest malignancy)

G. Thyroid Gland
inspection-
(1) with the pt`s neck slightly extended, use tangential lighting directed downward Irom
the tip oI the pt`s chin
(2) inspect the region below the cricoid cartilage Ior the gland
(3) have the pt swallow (water is helpIul)
(4) watch the movement oI the gland, noting the contour & symmetry
(5) thyroid cartilage, cricoid cartilage, and thyroid gland all should elevate upon
swallowing & then Iall to their resting positions
palpation-
(1) position yourselI behind the pt
(2) place your Iingers (use both hands) on the pt`s neck just below the cricoid cartilage
(3) have the pt swallow again and Ieel Ior the gland rising under your Iingers
(4) note the size, shape & consistency (nodules or tenderness)
(5) iI the gland is enlarged listen Ior a bruit with the bell oI your stethoscope
Goiter- compensatory hyperplasia oI Iollicular epithelium 2 to impaired production oI thyroid
hormones that leads to elevated TSH levels; goiters are seen in Hashimoto`s Thyroiditis, Grave`s
Disease and Iodine deIiciency.
Hashimoto`s Thyroiditis- goitrous hypothyroidism due to deIective Iunction oI thyroid speciIic
CD-8 T cells, resulting in the emergence oI CD-4 T cells directed at thyroid and auto-Abs to
various components oI thyroid such as thyroid peroxidase, TSH receptors and thyroglobulin.
Grave`s Disease- goitrous hyperthyroidism due to a deIect in thyroid speciIic CD-8 T cells
which lead to the production oI TSH Ab (thyroid stimulating immunoglobulins) and thyrotropin
binding inhibitor immunoglobulins that cause increase activity oI thyroid epithelial cells

ABDOMINAL EXAM

1. Inspection (Irom the Ioot oI the bed)
(! #$ #% #& #& #&)
Contour (Ilat, round, protuberant, scaphoid)
Umbilicus (Inverted, Everted)
Pulsations / Peristaltic waves
Symmetry
SigniIicant scars and striae (purple striae Cushing`s Syndrome)
SuperIicial veins (Caput Medusa)
also look Ior Masses, Bulges and Lesions

Increased Abdominal Pulsations - Abdominal Aortic aneurysm , increased pulse pressure
Cullen`s Sign -Periumbilical darkening oI skin Irom blood, a sign oI intraperitoneal
hemorrhaging ( ruptured ectopic pregnancy )
Turner`s Sign -Darkening oI skin Irom blood in the Ilanks, a sign oI retroperitoneal
hemorrhaging

2. Auscultation (Done beIore palpation/ percussion because they may alter bowel sounds)
Listen for bowel sounds - wait at least 2 min. beIore saying absent
-listen in all Iour quadrants or just in the lower right quadrant
Report : Present or Absent
Frequency (normal is 5 -34 bowel sounds/ minute)
Pitch ( high or low)

Increased Bowel Sounds - Diarrhea , early intestinal obstruction
Decreased Bowel Sounds - Adynamic ileus, Peritonitis, late intestinal obstruction
Borborygmi - loud, prolonged gurgle oI hyperperistalsis

Listen for arterial bruits - (turbulent blood Ilowing through a vessel), use bell
- Abdominal Aorta
- Renal Arteries ( Renal Artery Stenosis is a common cause oI hypertension)
- Iliac Arteries
- Femoral Arteries
Listen for friction rubs - InIlammation oI Liver capsule
Listen for a Venous Hum - soIt humming noise heard during both systolic and diastolic,
indicating increased collateral circulation between portal system and systemic ( Liver
Cirrhosis is MCC)

3. Percussion
- Percuss all 4 or 9 quadrants ( report either tympanic or dull sounds)
- Check Abdomen for Ascites
a. ShiIting Dullness
b. Fluid Wave Transmission
c. Puddle Sign ()
- Percuss organs with palpation of each organ

Ascites - Accumulation oI serous Iluid in the peritoneal cavity
1. Alcoholic Cirrhosis
2. Congestive Heart Failure
3. Hepatic Vein obstruction (Budd- Chiari Syn.)
4. Nephrotic Syndrome

4. Palpation
Light Palpation (ask pt Ior any pain present beIore touching them)
- You must sit during Light Palpation
- LOOK AT THE PATIENT`S FACE
- Palpate all 4 or 9 quadrants
report presence oI masses, guarding or tenderness

Deep Palpation
- You must STAND during deep palpation
- LOOK AT THE PATIENT`S FACE
- Palpate all 4 quadrants and report presence oI organs, masses or tenderness
- Test Ior Rebound Tenderness and a () Rovsing`s Sign

Appendicitis Signs
1. Pain on Cough in lower right quadrant
2. Cutaneous Hyperesthesia
3. Rebound Tenderness
4. Rovsing`s Sign
5. Psoas Test
6. Obturator Test

Organ Palpation
Liver - sit down and LOOK at the pt`s Iace
- Start with percussing for the Liver Span
a. percuss up Irom the lower right quadrant in the mid-clavicular line until
dullness heard
b. percuss down the mid-clavicular line starting at the 2-3 intercostal space
until dullness is heard, indicating the upper border oI the liver
c. measure span oI dullness
d. 6 - 12 cm is normal in the mid-clavicular line
e. measured Irom the mid- sternal line 4 - 8 cm is normal
- dullness displaced inIeriorly can be caused by COPD
- Ialse increase in Liver span dullness may be due to a Pleural EIIussion or Consolidation
- Ialse decrease in Liver span may be due to gas in the Abdomen Irom a ruptured bowel
- Palpate for the Liver starting at the right Anterior Superior Iliac Spine
a. have pt take a deep breath while palpating costal margin
b. Ieel Ior the Liver`s edge as it shiIts position
c. can also use the 'hooking technique
(Normal Liver is Smooth, Large and Non -Tender)

Large, Irregular Liver - Cirrhosis, Malignancy
Large, Smooth and Tender - Hepatitis, Venous Congestion (CHF, Budd- Chiari)

Causes oI Hepatomegaly
1. CHF
2. Hepatitis
3. Early Cirrhosis
4. Hepatocellular CA

- Attempt to elicit Murphy`s sign for acute cholecystitis
a. hook Iingers or thumb oI right hand under costal margin at border oI
Lateral Rectus and costal margin (9
th
intercostal space)
b. have pt take a deep breath
c. iI sudden stop oI inspiration and pain occurs then () Murphy sign
Spleen - Sit and LOOK at the patient
- first check for a Splenic Percussion Sign (Splenomegaly)
a. percuss along Traube`s Space ( area oI tympany below lung resonance
along costal margin )
b. percuss lowest interspace in LeIt Anterior Axillary Line - should be tympanic
c. ask pt to take a deep breath and hold ; percuss again and iI dullness is heard
then Splenomegaly is present ( Splenic Percussion Sign)
-palpation
-start at the ASIS and progress to LeIt Costal Margin
a. ask pt to take deep breaths as you approach the LeIt Costal Margin
b. Ieel Ior the Spleen`s edge as it shiIts position
c. roll pt onto their right side and repeat palpation

Enlarged Spleen vs. Kidney
Spleen - a. medial border notch Kidney - a. tympanic upon percussion
b. extends beyond midline b. Iingers can get between Kidney
c. dullness upon percussion and costal margin
d. Iingers cannot get between Spleen and
costal margin

Causes oI Splenomegaly
1. CHF
2. Portal Hypertension
3. Early Sickle Cell Anemia
4. Leukemia (Hairy Cell Leukemia, CML)

Kidney - Stand and LOOK at the patient
- attempt to trap the kidney between your hands at the peak oI the pt`s inspiration
report
a. Enlargement ( hydronephrosis, pyelonephrosis, Renal Cell CA, Polycystic
Kidney Disease)
b. Masses or Lumps ( CA, Cysts)
c. Costovertebral Angle tenderness ( Musculoskeletal Problem,
pyelonephrosis, kidney inIarcts)
Right kidney is more likely too be palpable due to its lower location whereas the LeIt
kidney is rarely palpable

Causes oI a Small Kidney
1. Congenital Hypoplasia
2. Chronic Pyelonephritis
3. Benign & Malignant Hypertension

- Assess Kidney Tenderness (Murphy`s Punch)
a. pt is sitting
b. place your palm over the pt`s kidney ( Costovertebral Margin between 11
th
&12
th

intercostal space on Posterior Chest)
c. strike the back oI your hand Iirmly with a closed Iist
d. report any tenderness

5. Rectal & Genital
These exams will not be perIormed with your Abdominal exam but you should let your Preceptor
know that you are aware that they should be included in a complete Abdominal exam.

PELVIC, RECTAL & BREAST EXAM

1. Pelvic Exam
External Examination
- inspect the mons pubis, labia, and perineum
Lesions oI the Vulva
1. Genital Herpes (MCC by HSV2)
2. Syphilitic Chancre (1syphilis)
3. Condyloma Latum (2syphilis)
4. Condyloma Acuminatum (MCC by HPV type 6&11)
5. Extramammary Paget`s Disease
6. Vulvar Dystrophy (Lichen Sclerosus & Squamous Hyperplasia)
- separate the labia and inspect
a. labia minora
b. clitoris (enlarged in masculinizing conditions)
c. urethral meatus (urethral caruncle benign lesion)
d. vaginal opening
- inspect Bartholin`s gland ( Bartholin`s cyst)
a. insert index Iinger into vagina near the posterior end oI the
introitus and place your thumb outside the posterior part oI the labium majus.
b. palpate between your thumb & Iinger Ior swelling or tenderness
c. note any discharge Irom opening oI duct (culture it iI present)
- inspect Paraurethral glands (Skene`s gland)
a. iI you suspect urethritis or inIlammation, insert index Iinger into the vagina
and milk the urethra gently Irom inside outward
b. note any discharge Irom opening oI duct (culture it iI present)
MCC oI Urethritis - Neisseria gonorrhea & Chlamydia trachomatis

Internal Examination
- locate the position of the cervix manually with your 2
nd
and 3
rd
finger
(iI lubrication is needed, use water only)
- assess the support of the vaginal walls
a. separate the labia with your middle and index Iingers
b. ask the pt to strain down ( note any bulging oI the vaginal walls)
Cystocele- bladder bulges into vaginal canal due to weak vaginal musculature
Rectocele- rectum bulges into vaginal canal due to weak vaginal musculature
Cystourethrocele- both bladder & urethra bulge into vaginal wall

Speculum Examination would be done at this time

Bimanual Examination (done Irom a standing position)
- lubricate the index Iinger and middle Iinger oI one gloved hand
- insert fingers into vagina (keep thumb abducted & 4
th
,5
th
digits Ilexed into palm)
- palpate cervix ( position, shape, consistency, mobility & tenderness)
- an immobile and tender cervix may be signs oI Pelvic InIlammatory Disease
Lesions oI the Cervix
1. Carcinoma oI the cervix (MC Squamous Cell CA)
2. Cervical Polyp (benign but may bleed)
3. Cervicitis ( MCC by N. gonorrhea, C. trachomatis )
- palpate all 4 fornices around the cervix

- palpate the uterus
a. place your other hand on the pt`s abdomen about midway between the
umbilicus and the symphysis pubis
b. while you push on the cervix with your pelvic hand, press your abdominal
hand in and down, trying to Ieel the uterus between your two hands
c. note shape, consistency, mobility, masses (Iibroids) & tenderness
d. place pelvic hand into ant. Iornix and palpate the body oI the uterus
between your hands (pelvic hand will Ieel the ant. uterine surIace while the
abdominal hand will Ieel the post. uterine surIace)
- iI the uterus is non-palpable it may be retrodisplaced (retroverted &
retroIlexed) ; iI this is the case then place pelvic hand into the post. Iornix and
Ieel Ior the uterus pushing against your Iingertips

- palpate the ovaries (normal ovaries are somewhat tender)
a. place the abdominal hand over the LRQ and the pelvic hand in the right
lateral Iornix
b. press the abdominal hand in & down trying to push the adnexal structures
toward your pelvic hand
c. identiIy the right ovary or any adnexal masses (size, shape, consistency,
mobility & tenderness)
d. repeat the procedure in the LLQ Ior the leIt ovary

- assess strength of the pelvic muscles
a. withdraw your two Iingers slightly, just clear oI the cervix and spread them
to touch the sides oI the vaginal wall
b. ask pt to squeeze her muscles around your Iingers as hard and as long as
she can ( Iull strength lasts ~3 seconds and compresses Iingers snugly )

Pelvic Inflammatory Disease (PID)- MCC by N. gonorrhea & C. trachomatis;
salpingitis or salpingo-oophoritis that causes extreme tenderness and pain oI pelvic
region; resolves leaving tubal adhesions that may cause inIertility or an ectopic
pregnancy

Ectopic Tubal Pregnancy - Iertilized egg implants in the Iallopian tube rather than
the uterine wall (MC in the ampulla). II the tube ruptures pt will present with
a. Iaintness
b. syncope
c. nausea & vomiting
d. tachycardia
e. shock due to severe hemorrhage

MALE RECTAL EXAM

Inspection
a. position the pt on his leIt side with his buttocks close to the edge oI the examining
table near you
b. Ilex the pt`s hips & knees with the top leg slightly ahead oI the bottom leg
c. put on gloves and spread the buttocks apart
- inspect the sacrococcygeal & perianal areas
look Ior lumps, ulcers, inIlammation and rashes
Anal / Perianal Lesions
hemorrhoids carcinoma
venereal warts syphilitic chancre
Herpes (MC HSV2)
- inspect the anus and rectum
a. lubricate your gloved index Iinger and explain to the pt what you are going
to do
b. tell him that he may Ieel as iI he were moving his bowels but he won`t do so
c. ask the pt to strain down and inspect the anus as he does so noting any
lesions (hemorrhoids, rectal prolapse)
- palpation
a. as the patient strains down , place your lubricated and gloved index Iinger
over the anus and as the sphincter relaxes, gently insert your Iingertip into
the anal canal in the direction oI the umbilicus
(a tight sphincter may be due to anxiety, inIlammation, scarring whereas a
loose sphincter may be due to neurological disease)
b. palpate the posterior rectal wall Ior any masses, tenderness or induration
(induration may be due to inIlammation, scarring or malignancy)
c. with your Iinger inserted as Iar as possible, rotate your hand clockwise to
palpate as much oI the rectal surIace as possible on the pt`s right side, then
counterclockwise to palpate the surIace posteriorly and on the pt`s leIt side
d. note any nodules, irregularities, or induration (CA has irregular borders)
e. examine the anterior surIace oI the prostate gland; tell the pt that he may
Ieel as iI he will urinate but that he won`t do so
I. Ieel over the lateral lobes and the median sulcus between them noting size,
shape & consistency oI the prostate
(Normal prostate is rubbery and non-tender)
*** Gently withdraw your Iinger and observe it Ior occult blood or Iecal matter;
wipe Iinger over a slide and stain Ior histology

Anal Fissure - a very painIul oval ulceration oI the anal canal, Iound MC in the midline
posteriorly. Inspection may show a 'sentinel skin tag just below the anal opening. The
sphincter is spastic and the examination is painIul
Rectal ShelI - peritoneal metastases that develop in the area oI the peritoneal reIlection
anterior to the rectum

Abnormalities oI the Prostate
CA of the Prostate- hardened, irregular, enlarged gland in which the median sulcus
may be obscured ; Metastatic Prostatic cancer is osteoblastic.
Prostatitis- Acute Prostatitis is an acute, Iebrile condition caused by a bacterial inIection
where the gland is very tender, swollen, Iirm and warm. Chronic Prostatitis does not produce
consistent physical Iindings and may not be tender or warm to the touch.
Benign Prostatic Hypertrophy- MC ~ 50yrs; gland Ieels symmetrically enlarged,
smooth and Iirm though slightly elastic. Median Sulcus may be absent to palpation and
the enlarged gland may obstruct urinary outIlow.

FEMALE BREAST EXAM

Inspection
- inspect the breasts ( pt should be sitting at the edge oI the bed)
a. size ( some diIIerence in size is normal)
b. symmetry
c. contour ( dimpling or Ilattening oI the breast suggests CA)
d. color (redness Irom inIection or inIlammatory CA)
- inspect the nipples (size, shape, color, discharge)
a. inverted nipple - iI it has been inverted since birth or childhood then it is a normal
variant but iI it is a recent occurrence then there may be an underlining CA
b. nipples should point outward and downward (nipples pointing in alternate directions
suggests CA)
c. rashes or ulcerations suggest Pagets disease of the breast which almost always
carries an underlying CA
d. look Ior discharge ( bloody discharge may be Irom a benign intraductal papilloma;
nonmilky unilateral discharge suggests local breast disease)

ask the pt to raise her arms over her head and then to press her hands against her hips
a. dimpling or retraction oI the breasts in either oI these positions suggests CA but
could also be Irom trauma causing Iatty necrosis
b. Ior cases oI large breasts ask the pt to stand up and place hands at the edge oI the
table while leaning Iorward

palpation (pt should be lying down with a pillow under the shoulder oI the opposite side being
examined)
a. examine each breast with the 2
nd
to 5
th
digit oI one hand compressing the tissues
gently in a rotary motion against the chest wall
b. start in one quadrant and move in a systematic Iashion until the entire breast is
examined including the tail oI the breast but leaving the nipple and areola Ior last
c. note the consistency, tenderness, & any nodules present
d. iI a mass is Iound describe its
-location (quadrant, cm Irom the nipple)
-size (measured in cm)
-shape (round, regular, irregular)
-consistency (soIt, hard, Iirm)
-delimitation (well circumscribed or not)
-mobility (Ireely mobile or Iixed to chest wall)

examine the axilla
a. cup hand and palpate each axilla oI the pt Ior enlarged lymph nodes
b. Ieel Ior the central, axillary, pectoral, lateral, subscapular, supraclavicular &
inIraclavicular nodes

Paget`s disease of the breast - dermatitis oI the areola and nipple (eczemalike lesion) with an
underlying CA oI the breast ( in situ or invasive)
Fibroadenoma- benign, solitary, Ireely movable, rubbery to soIt lump Iound in the breast

RESPIRATORY EXAMINATION

1. Inspection (done at the Ioot oI the bed)
-respiration rate ( breaths/min; rhythm, easy or diIIicult)
which muscles are being used (accessory muscles?)
a. Cheyne-Stokes Breathing - Hyperpnea with apnea
b. Biot`s Breathing - unpredictable irregularity (shallow or deep breaths with short periods
oI apnea)
-chest shape
check symmetry, AP diameter, extent oI expansion
a. Iunnel chest - assoc. with possible murmurs
b. pigeon chest- increased AP diameter
c. thoracic kyphoscoliosis - abnormal spinal curvatures and vertebral rotation deIorm the
chest
-check for chest scars
-inspect for cyanosis (tongue, lips and nail beds)
-check for clubbing

2. Palpation
trachea midline
a. atelectasis deviates trachea toward same side
b. pleural eIIussion deviates trachea to opposite side
c. pneumothorax deviates trachea to opposite side
d. consolidation has no trachea deviation
chest expansion ( symmetry and extent)
check expansion 2 places on anterior chest and 3 places on posterior chest
non symmetrical chest expansion
-broken ribs
-musculoskeletal problems
-collapsed lung
-pneumothorax
-pleural Iibrosis
tactile vocal fremitus (see Bates pg. 24O & 249)
-checking Ior symmetry and presence
-ask pt to say '99 as you palpate with bony surIace oI hand
Anterior Chest- palpate 3 places symmetrically
Posterior Chest- palpate 4 places symmetrically

Decreased Fremitus Increased Fremitus No Fremitus
-asthma -consolidation -atelectasis
-emphysema
-pleural eIIussion
-pneumothorax

3. Percussion
- percuss both sides oI the chest symmetrically, one side at a time

Anterior Chest- start above clavicles and percuss down midclavicular line 4 places and 2
more moving laterally and down anterior axillary line Ior a total oI 6 sites Ior percussion
(Bates pg 249)
Posterior Chest- pt should cross arms; percuss 5 places down just medial to scapula and 2
more moving laterally to cover lower lobes Ior a total oI 7 sites Ior percussion (Bates pg
243)
Percussion sounds
Dullness (Lobar pneumonia, Empyema, Hemothorax,Hydrothorax )
Resonance (Normal, Chronic Bronchitis, Asthma)
Hyperresonance (Emphysema, Pneumothorax, Asthma)
Tympanic (Large Pneumothorax)
Stony Dull or Flat (Pleural EIIussion)

4. Auscultation (ask pt to breathe quietly and deeply through an open mouth )
Anterior Chest - start above the clavicles using the bell, switch to diaphragm and listen to 5 more
lung Iields moving down the mid clavicular line and out to lower lobes as shown in Bates on pg
249. Listen to symmetrical Iields as you move downward
Posterior Chest - have pt cross their arms; listen to 7 lung Iields in a symmetrical pattern as shown
in Bates pg 243

Lung Sounds
Vesicular - inspiratory sounds last longer than expiratory; normal
Broncho-vesicular - inspiratory and expiratory sounds are equal; may be heard with
consolidation
Bronchial - expiratory sounds last longer than inspiratory ones ( gap exists between sounds);
most oIten heard in consolidation
Tracheal - inspiratory and expiratory sounds are equal (gap exists between sounds)

Adventitious Lung Sounds
Discontinuous sounds - Iine crackles & course crackles which are both intermittent, nonmusical,
and brieI
fine crackles - soIt, high pitched and very brieI (5 - 10 msec.)
coarse crackles - louder, lower pitched and longer in duration (20 -30 msec.)
- both can be due to abnormalities oI the lungs as seen with pneumonia, fibrosis or
early CHF
- or due to abnormalities oI the lung airways as seen with bronchiectasis or bronchitis

Continuous sounds - ~ 250 msec. but do not usually span entire length oI resp. cycle; are musical
wheezes - high pitched with a hissing or shrill quality (suggest narrowed airways as in
asthma, COPD or bronchitis)
rhonchi - low pitched with a snoring quality (suggest secretions in lrg. airways)

-Alternate tests for located broncho-vesicular or bronchial breath sounds
a. Bronchophony
b. Egophony ( 'ee is heard as 'ay)
c. Whispered Pectoriloquy

Stridor - wheeze that is entirely inspiratory ; heard loudest over the neck and indicates
partial obstruction oI the larynx or trachea and is a medical emergency
MCC by croup in children or a Ioreign body obstruction

Hamman`s Sign - a mediastinal crunch heard synchronous with the beat oI the heart and
not with respiration. MC due to mediastinal emphysema (pneumomediastinum) and is a
medical emergency

Tension Pneumothorax - air enters the pleural cavity and gets trapped upon expiration.
The intra-thoracic pressure increases and compresses the mediastinum and causes torsion
oI the Great Vessels leading to sudden death.

MUSCULOSKELETAL SYSTEM
(Look - Feel - Move)

A. Head and Neck (pt should be sitting up)
Temporomandibular 1oint
inspection- look Ior masses, lesions, scars, inIlammation and abnormalities
feel- place the tips oI your Iingers (2
nd
& 3
rd
) over the pt`s Temporomandibular Joint
move- ask the pt to open and close his mouth while you Ieel Ior
-tenderness
-swelling
-decreased range oI motion
( these 3 are present in arthritis )
** some crepitus is normal
Neck
inspection- look Ior deIormities / abnormal posture (ankylosing spondylitis, kyphosis)
feel- palpate the cervical spinous processes and surrounding musculature Ior tenderness
move- ask the pt to - flex: touch his chin to his chest
rotate: touch his chin to each shoulder
lateral bending: touch his ear to each shoulder
extension: look at the ceiling

B. Shoulders
inspection- look Ior any swelling, deIormities, or muscular atrophy oI the shoulder and shoulder
girdle both anteriorly and posteriorly
feel- palpate the Iollowing regions
-sternoclavicular joint
-acromioclavicular joint
-subacromial joint
-bicipital groove
move- ask the pt to (1) raise both arms over his head
(2) place both hands behind his neck with his elbows out to the side
(external rotation and abduction)
(3) place both hands behind his back (internal rotation)
cup your hands over the pt`s shoulder joints as he makes these movements and note any
crepitations, pain or decreased range oI motion
Rotator Cuff Muscles- S-I-T-S- Supraspinitus, InIraspinitus, Teres Minor & Subscapularis
(all insert onto the Greater Tubercle oI the Humerus except the Subscapularis which inserts onto
the Lesser Tubercle)
Rotator Cuff Tendinitus (impingement Syndrome)- MCC oI pain in the shoulder which oIten
involves the Supraspinitus tendon. Results in acute, recurrent, or chronic pain with underlying
edema, hemorrhage and Iibrosis.
Dislocation of the shoulder- direction oI the dislocation is Anterior to the joint but it gets to this
position by an InIerior Anterior Superior route

C. Elbows
inspection- examine the elbow, olecranon process and ulnar extensor surIace
-swelling
-nodules (Rheumatoid)
-inIlammation
feel- palpate the olecranon process and the grooves between the epicondyles and the olecranon
-tenderness (Epicondylitis, Arthritis)
-thickening
-swelling (Epicondylitis, Arthritis)
move- ask the pt to Ilex, extend, supinate, and pronate their arms
Rheumatoid Nodules- Subcutaneous nodules that are Iirm, non-tender and not attached to the
overlying skin. Occur MC with Rheumatoid Arthritis and Rheumatic Fever along the extensor
surIaces oI the ulna
Epicondylitis- Lateral (tennis elbow) epicondylitis occurs aIter repetitive extension oI the wrist or
pronation - supination oI the Iorearm and results in pain when the pt extends the wrist. Medial
(golIer`s elbow) epicondylitis occurs aIter repetitive Ilexion oI the wrist and results in wrist pain
upon Ilexion

D. Hands & Wrists
inspection- look Ior any swelling, inIlammation, nodules, deIormities or muscular atrophy
feel- palpate the wrist joint with your thumbs on the dorsum oI the wrist and Iingers beneath it
-swelling, tenderness or bogginess (Rheumatoid Arthritis presents bilaterally with all 3)
-palpate the distal interphalangeal (DIPS), proximal interphalangeal (PIPS) and metacarpo-
interphalangeal (MIPS) joints between your thumb and index Iinger
-Heberden`s nodes (DIPS) and Bouchard`s nodes (PIPS) present as hard, painless
joints with decreased or no range oI motion due to osteoarthritis.
-Iinally, squeeze the pt`s hand (not too Iirmly) to check Ior a tenosynovitis that presents with
extreme pain on compression
move- ask pt to (1) make a Iist
(2) Ilex and extend the wrist
(3) ulnar and radial deviation
Gonococcal Arthritis- N. Gonorrhea commonly inIects the wrist joint or tendon sheath and
presents with pain, tenderness and decreased range oI motion.
Osteoarthritis- progressive deterioration and breakdown oI articular cartilage, mainly in
weightbearing joints, leading to subchondral bony thickening and bony overgrowths (osteophytes)
about the joint margins.
Rheumatoid Arthritis- a chronic, severe synovitis that leads to destruction and ankylosis oI
aIIected joints while also aIIecting blood vessels, heart, eyes, nerves, skin and lungs. Pannus
Iormation oI the joint is characteristic in RA and leads to the bony ankylosis. Boutonniere and
Swan Neck deIormities can be seen with Chronic RA whereas rheumatoid nodules are seen in
both Acute and Chronic RA.
Dupuytren`s Contracture- Ilexion contracture oI the Iingers due to thickening oI the Ilexor
tendon oI the ring Iinger or 5
th
digit at the level oI the distal palmar crease
Carpal Tunnel Syndrome- MCC oI thenar atrophy due to compression oI the Median nerve at
the level oI the wrist due to edema and inIlammation within the Ilexor retinaculum. Both Phalen`s
Test and Tinel`s Sign can be done to test Ior Carpal Tunnel Syndrome.

E. Hips (pt should be laying down)
inspection- look Ior any deIormities, muscle atrophy or scars
feel- palpate the
(1) hip joint and overlying iliopectineal bursa
(2) greater trochanter and trochanteric bursa
(3) ischial tuberosity and ischial bursa
-note any tenderness or inIlammation (bursitis, synovitis)
move- the pt should be lying Ilat on the exam table
(1) bend each knee to his chest
(2) bring the thigh up and Ilex the leg to 90; as you then stabilize the thigh, internally
and externally rotate the leg
(3) stabilize the pelvis by pressing down on the opposite ASIS with one hand and
abducting the other leg with your other hand until you Ieel the iliac spine move
(hip disease oIten restricts abduction); then adduct the leg back past the pt`s midline
Ior complete range oI motion.

F. Knees
inspection- look Ior any swelling, scars, normal hollows, inIlammation, deIormities or atrophy
feel- palpate the tibial tuberosity, patella, patellar Iat pad & patellar tendon, tibial condyles, lateral
& medial collateral lig., and Iemoral epicondyles ( the pt`s knees should be at 90 with Ieet Ilat on
the examining table)
-note any tenderness, bogginess, warmth or swelling (bony ridges Ielt along the joint margins may
be signs oI osteoarthritis, a painIul tibial tuberosity in a child may be Osgood-Schlatter Disease)
move- Ilex and extend the pt`s knee noting any pain, decreased range oI motion or crepitations
(patelloIemoral disorders present with pain & crepitations along with a Hx oI knee pain)

Bulge Sign- with the palm oI your hand, milk the medial aspect oI the knee Iirmly upward 2-3
times to displace any Iluid. Tap the knee lateral to the patellar margin (Bates pg 471). Watch Ior
any return oI Iluid into the knee hollow medial to the patella. This test will identiIy small
eIIusions oI the knee. (non-tender eIIusions are common in osteoarthritis)
Balloon Sign- Place the thumb and index Iinger oI your right hand on each side oI the pt`s patella
(inIerior to the patella) and with your leIt hand, milk the suprapatellar pouch down towards the
patella 2-3 times with the last stroke holding the knee Iirmly just above the patella compressing
the suprapatellar pouch against the Iemur. Feel Ior any Iluid entering into the spaces next to the
patella with your right thumb and Iinger. II any Iluid is present, the patella should 'balloon
outward. II Iluid is seen Iilling the joint space, then with your right index Iinger, press the patella
backward against the Iemur to conIirm the presence oI a possibly large eIIusion.
Drawer Test- with the pt`s knee Ilexed to 90 and the Ioot Ilat on the examining table, grab hold
oI the leg just below the knee joint. To test Ior a competent Anterior Cruciate Lig., pull the leg
towards you and push back on the leg to test the Posterior Cruciate Lig. II the leg moves more
than what is considered 'normal then the respective cruciate ligament is torn and gives a positive
drawer sign Ior that ligament.

Osgood-Schlatter Disease- epiphysial aseptic necrosis oI the tibial tubercle MC seen in children
Baker`s Cyst- herniation oI knee-joint capsule & synovium into the Popliteal space due to
increased intra-articular Iluid exudate as seen with Rheumatoid Arthritis

G. Ankles & Feet
inspection- look Ior signs oI swelling, inIlammation, scars, lesions, warts, calluses, corns or
deIormities
feel-
(1) palpate the Achilles Tendon Ior Rheumatoid nodules (a tender tendon may be a
tendinitis or bursitis)
(2) palpate the anterior & posterior aspects oI the ankle joint and each metatarsophalangeal
joint oI the Ioot (an enlarged painIul 1
st
digit may be Gout)
(3) Ieel the plantar surIace Ior tenderness
move-
(1) dorsal & plantar Ilex the pt`s ankle (Tibiotalar joint)
(2) invert & evert the Subtalar joint
(3) with the heel stabilized, invert & evert the Transverse Tarsal joint
(4) ask the pt to wiggle his toes (Metatarsophalangeal joints)
Gout- recurrent attacks oI acute arthritis due to deposition oI urate crystals in joints which MC
ends in a chronic arthritis. Occurs when the blood concentration oI uric acid is ~ 7 mg/dl and MC
occurs in the big toe (50), ankle and knee
Pseudogout- similar to Gout but any joint can be aIIected (MC the knee & intervertebral discs). It
is due to the deposition oI Calcium Pyrophosphate Crystals and no Tx exists to date.

H. Spine
(the patient is standing)
inspection- look at the cervical, thoracic and lumbar curvatures (Scoliosis, Kyphosis, Lordosis &
List) ; look Ior diIIerences in height oI the shoulders, iliac crests and skin creases below the
buttocks
feel- palpate the spinous processes (Irom a sitting position) with your thumb and the paravertebral
muscles Ior tenderness or spasm.
move- ask the pt to
(1) touch his toes (Ilexion) -lumbar curvature should Ilatten out
(2) bend sideways (lateral bending) while you support his waist
(3) bend back towards you (extension)
(4) twist the shoulders in both directions (rotation)
Gibbus- angular deIormity oI a collapsed vertebra due to a metastatic cancer (osteoclastic cancer)
or Irom tuberculosis oI the spine (Pott`s Disease)
List- lateral tilt oI the spine due MC to a herniated disc or paravertebral muscle spasms.


Neurological Exam

Cranial Nerves
CN I -check sense oI smell with Iamiliar odors (pt`s eyes are closed)
-do one nostril at a time
CN II -visual acuity using a Snellen Eye Chart (one eye at a time)
-examine visual Iields -reIer to head and neck exam
-examine the optic disc (use your right hand & right eye Ior pt`s right eye & leIt hand,
leIt eye Ior pt`s leIt eye)-reIer to head and neck exam
(1) locate the red reIlex
(2) examine the optic disc, macula & Iovea
CN II/III
-check pupillary light reIlex (direct & consensual)
-check near reaction (accommodation)
Argyll Robertson pupil- absence oI a miotic rxn to light, both direct & consensual, with
the preservation oI a miotic rxn to near stimulus (pt can accommodate but not react). This
can be seen in both Diabetes Mellitus and Syphilis.
CN III/ IV/VI
-examine the pt`s extraocular muscles with the 'H test
-check Ior convergence & lid lag (lid lag is present & convergence is impaired with
hyperthyroidism)
CN V
-motor: test the strength oI the Temporalis, Masseter & Pterygoid Muscles
(1) have the pt clench his/her teeth while palpating the Masseter & Temporalis
(2) place your hand on the side oI the pt`s chin and resist lateral motion oI the
Pterygoid Muscle oI that same side (repeat Ior opposite side)
-sensory: test the Iorehead, cheeks & jaw on each side Ior pain, temperature & light
touch sensations (use a cotton swab Ior light touch)
-test Ior the corneal reIlex using a Iine wisp oI cotton
(1) touch the pt`s cornea with the cotton tip making sure not to touch the pt`s
eyelash
(2) CN V is the aIIerent branch whereas CN VII is the eIIerent branch in this
reIlex
CN VII
-inspection- look Ior Iacial symmetry (nasal labial Iolds present & symmetrical), masses,
scars, lesions or any involuntary movements (Tics, Tardive Dyskinesias)
-ask the pt to make the Iollowing Iacial expressions
(1) raise both eyebrows
(2) Irown
(3) close eyes tightly (as you try to open them)
(4) show teeth
(5) smile
(6) blow out cheeks
**note any weakness or asymmetry
-check corneal reIlex Ior this nerve too
CN VIII- examine the pt`s hearing
(1) occlude one ear at a time and test acuity by rubbing Iingers together next to
the patent ear
(2) iI impairment exists do the Weber & Rhine Test to determine whether the
loss is conductive or sensorineural
(3) check Ior nystagmus (Vestibular Iunction oI CN VIII)


CN IX/X- (1) have the pt speak and listen Ior hoarseness
(2) check Ior dysphagia
(3) examine the pt`s soIt palate & pharynx (uvula deviates to opposite side in
Xth nerve lesion)
(4) test the gag reIlex (IX nerve is the aIIerent branch whereas X nerve is the
eIIerent branch oI this reIlex)
CN XI- inspection- look Ior signs oI atrophy or Iasciculations oI the musculature
- ask the pt to shrug their shoulders & turn their head against your resistance
(note any weakness or asymmetry)
CN XII- (1) listen to the articulation oI the pt`s words (normal or impaired)
(2) examine the pt`s tongue (atrophy, Iasciculations, asymmetry or deviation)
**tongue deviates to same side as lesion oI XII nerve
(3) ask the pt to move tongue side to side
(4) test the tongue strength by having the pt push his/her tongue against the
inside oI their cheek while you resist against the outside oI the cheek

Motor System
inspection
examine -the pt`s body position
-involuntary movements (chorea, hemiballism)
-muscle bulk/atrophy (diabetic neuropathy, Duchenne Muscular Dystrophy)
(1) examine the pt`s muscle tone
-upper limb(at wrist, elbow & shoulder)
-lower limb(at knee & ankle)
-note signs oI spasticity or Iloppiness (possible cerebellar disease with
Iloppiness)
(2) examine the pt`s muscle strength (grade on 0-5 scale with 5 being normal)
-ask the pt to move against your resistance (test symmetrically whenever
possible)
0-no muscular contraction detected
1-barely detectable Ilicker or trace oI contraction
2-active movement with gravity eliminated
3-active movement vs. gravity
4-active movement vs. gravity & some resistance
5-active movement vs. Iull resistance (normal)
-upper limb
(1) shoulder (shrug up/down, abduct & adduct)
(2) elbow (Ilexion & extension) -C5,C6 biceps-C6,C7,C8 triceps
(3) wrist (extension)-C6,C7,C8 wrist
(4) grip (cross Iingers, middle on top oI index, as pt squeezes)-
C7,C8,T1
(5) Iingers (abduction)-C8,T1 finger abduction
(6) thumb & 5
th
digit (opposition)-C8,T1 opposition
-lower limb
(1) hip (Ilexion, extension, abduction & adduction)-L2,L3,L4 hip
flexion,adduction-L4,L5,S1 abduction- S1 extension
(2) knee (Ilexion & extension)-L2,L3,L4 extension -L4,L5,S1,S2
flexion
(3) ankle (dorsi-Ilexion & plantar-Ilexion) -L4,L5


Upper Motor Neuron Lesion Lower Motor Neuron Lesion
Acute Stage Lesion Chronic Stage Lesions -Ilaccid paralysis
-Ilaccid paralysis -spastic paresis -areIlexia
-areIlexia -hypertonia -muscle atrophy
-hypotonia - or loss oI superIicial -Iasciculations
abdominal & cremasteric reIlexes
-Babinski`s sign
-Clonus

(3) examine the pt`s coordination (do each side separately)
-test Ior rapidly alternating movements (dysdiadochokinesis in cerebellar
disease)
-test point to point movements (overshooting in dysmetria)
a. Iinger to nose test
b. heel to shin test
-examine the pt`s gait (instability in ataxia)
a. have pt walk across room (normal heel to toe, on toes, on heels)
(inability to heel walk may be an upper motor neuron lesion)
b. have pt hop in place/ do a shallow knee bend
c. ask pt to rise Irom a sitting position without arm support
-examine the pt`s stance with the Romberg Test
a. have pt stand with Ieet together & eyes open
b. repeat with eyes closed Ior 20-30 seconds-hold out your arms in
case the pt. starts to Iall
(diIIiculty in both a & b is seen with cerebellar ataxia)
c. test Ior Pronator DriIt (positive test in corticospinal lesion oI
opposite side)
d. ask the pt to keep their arms up & eyes shut as you tap the arms
downward (normal return to horizontal position is lost iI pt has
lack oI position sense)
Sensory System
-compare symmetrical sides and begin distally in upper & lower extremities
(1) Light touch- test in a dermatomal and major peripheral nerve pattern using
a cotton swab (touch lightly & do not drag cotton across skin)
(2) Pain- test sharp vs. dull in the same dermatomes as in light touch
(3) Temperature- test cold vs. warm
(4) Position- test at interphalangeal joint in thumb & big toe (iI impairment
exists then examine proximal joints)
(5) Vibration- use a tuning Iork with 128Hz or 256Hz and test at bony
prominences on both upper & lower limbs starting distally and moving
proximally
(6) Discrimination-
-stereognosis
-graphesthesia
-2 point discrimination
-point localization
-extinction
~glove & stocking sensory loss- symmetrical distal sensory loss oI a polyneuropathy
seen in alcoholism & diabetes
Loss of Vibration Sense- MC the 1
st
sensation lost in the polyneuropathies oI
alcoholism & diabetes but also seen with posterior column disease in 3 syphilis &
vitamin B12 deIiciency


Reflexes
-compare one side to the other on a 0-4 scale with 2 being normal
(iI diIIiculty in eliciting a reIlex exists, use reinIorcement techniques)
upper limbs
-biceps (C5,C6)
-triceps (C6,C7)
-brachioradialis (C5,C6)
-HoIIman`s
lower limbs
-knee (L2,L3,L4)
-ankle (S1)
-plantar response (L5,S1)
- Babinski sign (present in upper motor neuron lesions & prior to 2 yrs
oI age in inIants due to lack oI myelination)
-check Ior clonus (present with upper motor neuron lesions)
iI you are asked to perIorm an exam oI the motor system, you will need to include reIlexes

Spinal Cord Tracts
Posterior Column- carries Iibers Ior tactile discrimination, vibration sensation, Iorm
recognition, and joint and muscle sensation (proprioception)
Spinothalamic- carries Iibers Ior pain & temperature sensation
Corticospinal- carries Iibers Ior voluntary skilled motor activity

Bell`s Palsy- peripheral Iacial paralysis caused by trauma or inIection that involves the
upper and lower Iace; this diIIers Irom a cortical lesion where the lower halI oI the Iace
is paralyzed but the upper Iace is not. This is due to the lower part oI the Iace being
controlled by upper motor neurons on only one side oI the cortex (the opposite side) and
the upper halI oI the Iace being controlled by neurons Irom both sides oI the cortex.

ICM PRACTICAL EXAM

To the examiner:

We are looking for COMPETENCE & CONFDENCE and should not be worried about
minor variations in technique that may vary between specialties and physicians.

Mark each student independently out of 20 on a basis of 14 = pass, 16 = B, 18 = A

Please follow the same routine for each student in a session and ask the same
questions. For honors students you may ask additional questions if there is time.

Please maintain the six-minute time limit.

Self presentation: 2pts
Appropriately dressed, greets patient and introduces self. Professional manner.

Practical: 14pts
"PIease take the patient's bIood pressure.

Explains & positions patient, (sitting is easier): 2
Checks cuff size, applies cuff correctly, knows how to assemble machine: 4
Checks systole by palpation. Deflates cuff completely: 2
nflates 2
nd
time to 30mm Hg above systolic pressure by palpation: 4
Gives reading to 2mm (does not say "BP is about): 2

Follow up questions: 2 pts
What can cause a BP to be low?

Bonus: 2 pts
Example: Ask to check BP in other arm

ICM PRACTICAL EXAM

To the examiner:






Practical: 14pts
"Imagine that you are seeing the patient for the first time. PIease show how you
wouId start a generaI physicaI exam and report your findings."

Describe initial observations
(e.g. - age, gender, build, grooming, distress, slurred speech): 4
Examine eyes for jaundice and pallor: 2
Examine mouth for pallor, cyanosis, hydration, teeth: 3
Examines hands for clubbing and color (note pigmentation) : 3
Examine for edema: 2

FoIIow up questions: 2pts
Why might a patient have slurred speech?
What is the difference between dysphagia, dysarthria and dysphonia?

Bonus 2 pts

ICM PRACTICAL EXAM

To the examiner:






Practical: 14pts
"PIease examine this patient's JVP."

Explain actions correctly: 1
Positions patient correctly: 2
nspects neck and identifies internal and external venous pulse: 3
Demonstrates why it a venous pulse (4 reasons): 2
Measures sternal angle with a right triangle: 4
Gives pressure in cms from right atrium: 2

FoIIow up questions: 2pts

Give two clinical conditions in which measuring the JVP would be helpful.
(e.g. - CCF, hypovolemia, cardiac tamponade, SOB, arrythmia, etc.)

Bonus 2 pts

ICM PRACTICAL EXAM

To the examiner:






Practical: 14pts
"PIease examine the patient's precordium."

Explains actions correctly: 1
nspection (from the foot of the bed) 2
Palpates and identifies apex: 2
Describes position and character (counts rib spaces from AOL) 5
Feels for palpable sounds and thrills 2
Feels for RVH (parasternal heave) 2

'())(* +, -+./01(2/ 2pts
What might you find in a patient with long-standing hypertension?
(e.g. hyperdynamic, well-localized apex, sustained, displaced; late sign of failure)

Bonus 2 pts

Scott - S ICM

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