Medical Skills Physical Exam

Physical Exam
Sub-Unit of the Medical Skills Program

MDCN 320 & MDCN 420
UNDERGRADUATE MEDICAL EDUCATION

CORE DOCUMENT
Class of 2017 & 2016
2014-2015 Academic Year
2014
1
Contents
The Physical Exam Course .....................................................................................................................3
Purpose ............................................................................................................................................3
Overview .........................................................................................................................................3
Responsibilities and Expectations...................................................................................................4
Scheduling.......................................................................................................................................4
Reference Material ..........................................................................................................................5
Evaluation .......................................................................................................................................5
Written Medical Record..................................................................................................................5
General Objectives ..........................................................................................................................6
Written Medical Record..................................................................................................................7
Written Medical Record Sample ...................................................................................................11
General Schedules .................................................................................................................................15
Year 1 Class of 2017 ..................................................................................................................15
Year 2 Class of 2016 ..................................................................................................................16
Sessions for Year 1 ...............................................................................................................................17
General Inspection, Vital Signs and Draping ...............................................................................17
Lymph Nodes Exam .....................................................................................................................24
General Abdominal Exam.............................................................................................................27
Liver and Spleen Exams ...............................................................................................................34
Hand and Wrist Exams .................................................................................................................42
Cervical Spine and Shoulder Exams .............................................................................................50
Ankle, Foot, and Knee Exams ......................................................................................................58
Hip and Thoracolumbar Spine Exams ..........................................................................................68
Jugular Venous Pulse Exam..........................................................................................................79
Respiratory Exam..........................................................................................................................83
Precordial Exam ............................................................................................................................92
Peripheral Vascular Exam.............................................................................................................98
Sessions for year 2 ..............................................................................................................................105
Head and Neck Exam..................................................................................................................105
Endocrine System .......................................................................................................................115
Cranial Nerves Exam ..................................................................................................................120
Mini-Mental Status Exam (MMSE)............................................................................................129
Peripheral Neurological Exam ....................................................................................................134
References ...........................................................................................................................................147
The Physical Exam Course

Dr. Luc Berthiaume
Co-chair
Phone: 403-943-4467
Luc.Berthiaume@albertahealthservices.ca
Dr. Florence Obianyor

Co-chair
fnobiany@ucalgary.ca
Kerri Martin
Program Coordinator
Phone: 403-220-6879
medskil2@ucalgary.ca
The unit co-chairs would like to acknowledge the unbelievably generous contribution of Dr.
Heather Baxter in reviewing this core document. Any mistakes that remain are entirely our
own.
Purpose
The purpose of the Physical Examination course is to develop the technical skills
required to perform a physical examination, including:
o Mastering the examination techniques within individual body regions or
systems;
o Use of instruments required during a physical examination;
o Integration of these skills into a focused assessment.
These skills will be integrated with other courses in the Medical Skills program.
Overview
The Physical Examination course runs over two years.

o The expected time commitment for scheduled physical exam skills sessions is
approximately 28 hours in the first year, and 24hours in the second year.
In your first year, you will attend small group sessions where:
o You will learn the proper techniques to examine major body regions or
systems.
Excludes the examination of the endocrine, head/ear/eye/nose/throat (HEENT) and
neurological systems.
In your second year, you will attend small group sessions where:
o You will learn the proper techniques to examine the endocrine,
head/ear/eye/nose/throat (HEENT) and neurological systems.
o You will participate in case-based session where you will use clinical
reasoning and evidence-based medicine to develop a differential diagnosis
and perform physical examination focusing around common presenting
complaints.
o You will participate in the Well Woman sub-course.
You will learn an approach to and practice the examination of the
female breast and female genitalia.
o You will participate in the Well Man sub-course.
You will learn an approach to and practice the examination of the male
breast, the male genitalia, and the ano-rectum.
Responsibilities and Expectations
Student will be assigned to clinical small groups.

o The groups will remain the same for two years.
o Each group will need to assign a student leader.
It is the responsibility of the student leader to ensure that a laptop or
iPad is available for use during the physical exam session.
o Each group will be assigned one or more clinical skills preceptors for the year.
Preceptors will lead the physical exam sessions.
Attendance is 100% mandatory.
o It is expected that students will attend all small group sessions in the physical
exam course except under exceptional circumstances.
Come prepared.
o Prior to the small group sessions, review the pertinent physical exam
techniques from the core document.
Supplement this with a review of a standard physical exam textbook.
Rules around physical examination:
o Medical students cannot examine a standardized patient without the preceptor
being physically in the same room as the student and the patient.
o Medical students may not examine each other or the preceptor during a
Physical Examination session.
This course requires both small group attendance and independent study.
o Small groups will focus on the techniques for physical examination, and
normal physical findings.
o Independent study should focus on:
Practice/review of physical exam skills and techniques.
Exploration of related topics such as normal physiology, surface
anatomy, expected normals, and differential diagnoses for abnormal
findings.
Students will use the course objectives as outlined in this core document as a guide
for appropriate study topics.
Scheduling
Physical examination sessions will occur at pre-arranged times, as per the published
timetable (refer to Osler).
o Year-long individualized schedules will be sent to each group at the beginning
of the school year.
Members of small groups may consider meeting as a group, in the Medical Skills
Centre, during their IST to work on physical exam skills, room availability permitting.
o Space for practice may be booked.
o Standardized patients are not available for these practice sessions if a
preceptor is not in attendance, due to liability reasons.
As part of each systems course, the students will participate in Clinical Correlations
(core.)
o The physical exam course is meant to teach fundamental skills of the physical
exam and introduce the student to expected normals.
o The core sessions are meant to introduce the student to the presentation of
common clinical conditions.
For ease of scheduling, the small groups will be the same as for physical exam.
Reference Material
This core document should be considered as a general guide.

o It is not a comprehensive resource for physical exam skills.
o It is strongly suggested that you purchase a general textbook on
physical/clinical exam skills.
These resources below are recommended as aids to learning physical exam.
o Bickley, L.S. Bates Guide to Physical Examination and History Taking. 10th
Edition. Lippincott.
o LeBlond, R.F. DeGowins Diagnostic Examination. 9th Edition. McGraw-Hill
Medical.
o McGee, S.R. Evidence-Based Physical Diagnosis. 2nd Edition.
Saunders/Elsevier.
o Orient, J.M. Sapiras The Art and Science of Bedside Diagnosis. 3rd Edition.
Lippincott Williams &Wilkins.
o Seidel, H.M. Mosby's Guide to Physical Examination. 5th Edition. Mosby.
o Talley, N.J. Clinical Examination: A Systematic Guide to Physical Diagnosis.
6th Edition. Elsevier Churchill Livingstone.
o Walker, H.K. Clinical Methods: The History, Physical, and Laboratory
Examinations. 3rd Edition. Butterworths.
Additional PE Video Clips and Interactive Websites:
www.prep4usmle.com/resources/72
www.conntutorials.com/
www.med.ucla.edu/wilkes/inex.htm
The U of T-developed The Art and Science of Clinical Medicine is available
via OSLER.
Evaluation
This course will be primarily evaluated through OSCE-style assessments.

o The OSCE stations will be based entirely on the contents of the core
document (i.e., if it is in the core document, unless specified otherwise, you
are expected to know it and can be evaluated on it).
o Both years will have a formative and a summative OSCE experience.
In second year, a written medical record detailing a physical examination is required.
o Will be done during a case-based physical exam session.
o Will be written in a style similar to a hospital or clinic record.
o Completion of the written medical record is mandatory.
The absence of a completed record will result in an incomplete grade.
Written Medical Record
Further information will be provided at the beginning of the 2nd year case based
sessions.
General Objectives
Year 1 and first half of Year 2
Develop the technical skills and use of medical instruments required to complete a
physical examination.
Perform the physical examination for each of the major body regions or systems.
Recognize expected normals.
Identify when a finding is normal.
Begin to develop an understanding of the pathophysiology of abnormal clinical
findings.
Second half of Year 2
Develop a structure for a focused history as pertinent to the patients complaint.
Demonstrate the synthesis of information into a list of possible diagnoses for the
presenting problem.
Demonstrate an approach to a detailed, limited physical examination for common
presenting complaints or medical problems.
Develop a focused physical examination so as to include or exclude items from the
possible diagnoses for the presenting problem list.
Demonstrate the incorporation of clinical reasoning and evidence-based medicine in
the development of a differential diagnosis and during physical examination.
Written Medical Record

In general, such records usually include information on:
Chief complaint.
Past medical history.
History of present illness.
Drug and allergy history.
Family history.
Social history.
Review of systems.
Physical examinations performed and findings.
Differential diagnosis list.
Management plan/recommendations.
o Further investigations.
o Possible treatments.
Plan of action negotiated/agreed upon with patient.
It is our hope that this exercise and the feedback that will be provided will help you
understand how to write good notes in your patients charts once you enter clerkship. What
you put into this exercise, is what you will get out of it!
The following is a key to the accompanying case write up example.
ID: identity/identifying features. Usually short e.g. 1 sentence that summarizes the patients
demographics
iAge: years old is often abbreviated y/o
iiSex: Male vs. female. Would avoid adding editorial details such as gentleman in
favor of man or woman
iiiState if patient has (or lives) with partner/significant other, spouse
ivState if patient has children
vOccupation (be brief)
CC: chief complaint. The key is brevity, one (or two) symptoms. Can list duration of
symptoms.
Profile/Past Med Hx (past medical history): can list this before or after the history of present
illness (HPI). The key is listing the diagnoses in addition to relevant features that pertain to
individual diagnoses
e.g. Type 2 diabetes history of retinopathy (no photocoagulation), nephropathy (baseline
creatinine 111); no neuropathy, stroke, coronary artery disease.
Meds (medications): can list this before or after the history of present illness (HPI). For each
medication, the following should be listed:
iDrug name (generic as opposed to trade names)
iiDose with appropriate units (units, g, mg, micrograms)
iiiRoute: Oral-PO, Via feeding tube nasogastric (NG) vs. nasojejunal (NJ) vs.
Gastrostomy (G-tube) Intravenous (IV), inhalation (inh)
ivFrequency: once daily (OD), twice daily (BID), three times daily (TID), Four times
daily (QID), specific hourly intervals Q?H where? represents the number of hours
between doses. Should also add if medication is taken on a as needed basisPRN
e.g.
1- Metoprolol 25 mg PO BID
2- Acetaminophen 325 mg PO TID PRN
Alls (allergies): Can list this before or after the history of present illness (HPI). If no drug
allergies, can state Nil or NKDA, where the latter stands for no known drug allergies. If there
are allergies, state the medication and the reaction to the medication e.g. penicillin-nausea
and vomiting. The reaction description is very important not only to prevent adverse events
but also to ensure that lifesaving medications are not withheld in the event of life-threatening
diseases e.g. documented allergy to ceftriaxone (nausea/vomiting no rash or anaphylaxis)
in a patient with bacterial meningitis.
HPI (history of present illness): This section is the most important as it is your opportunity to
tell the story. It is probably easiest to have it point form. In the first part, the reader should
be able to ascertain what is the writers suspected diagnosis. In the second part, the reader
should be able to exclude other pathologies on the differential diagnosis. When you are
starting, it is worthwhile to refer to your blackbook as soon as you hear the chief complaint
(or reason for referral) as this will remind you of the relevant questions to ask for a given
presentation. It is also important to note that the HPI may contain elements from other
sections (past history/profile and review of systems) if they are relevant to the case. In the
case write up example provided, there are elements of past history (risk factors for coronary
disease) and review of systems (GI symptoms). It is also noteworthy that pertinent
negatives are as relevant as pertinent positives. If not explicitly stated, the question(s) did
not get asked. At the end of this section, the reader should know the diagnosis or narrow
differential diagnosis as well as which diagnoses from the differential are unlikely.
SocHx (social history): There are multiple components to this section:

iState if the patient has and/or lives with a partner, spouse, roommate, friend
iiList the patients people of significance/next of kin in addition to that stated abovechildren, siblings, other family members, friends
iiiCigarette smoking: pack per day x years of smoking= pack years
ivAlcohol use: how much per day
vDrug use: injection, recreational drugs, prescription drugs
viEmployment: state the patients current occupation. This section should be
extensive if thinking about occupational diseases- for example, a detailed list of
each job, direct/indirect exposures for each job.
FamHx (family history): List diagnoses in first order relatives. Can build family tree if thinking
of congenital diseases.
ROS (review of systems or functional inquiry): List symptoms by organ system if it was not
done in HPI.
Exam: Should open with a general statement- well groomed vs. unkempt, well vs. unwell,
stated vs. younger or older than stated age. Some preceptors would say that this statement
should enable the reader to find the patient in question in a busy waiting room.
Vital Signs: BP, HR, RR, Temp and most include SpO2.
For all other organ systems, list all the pertinent negatives and positives in an organized
fashion- probably best to list according to IPPA. Remember if it is not reported in your write
up, it did not happen.
Investigations: The approach to listing investigations varies according to the situation
and/or preceptor. You should list all the investigations in the following circumstances: 1hospital admission note 2- initial consult note 3- initial clinic visit. For daily hospital progress
notes and repeat clinic visits, it is sufficient to list relevant investigations.
Assessment/Impression: This statement should be limited to one or two sentences. Ideally,
it should include up to 10 (but no more) salient findings from the history, physical exam and
investigations. This statement should have stand alone value in so far as disclosing the
diagnosis or narrow differential diagnosis.
Issues/Plan: The format is a problem list. It is key to list the problems in order of importance
as this demonstrates the writers ability to prioritize and problem formulate. For each
problem, the diagnosis should be listed or alternatively, the narrow differential diagnosis.
Investigations and treatment plans for that problem should also be described, including,
where necessary, the rationale for selecting a particular diagnostic test/approach and/or
treatment strategy.
Additional information regarding case write ups: The sample write up and write up
information provided to you is an example of a hospital admission write-up for a medical
patient. Hospital admission notes will vary according to the medical service. As well,
progress notes are framed very differently, commonly using the SOAP format where each
letter stands for Subjective (patients symptoms), Objective (your observations),
Assessment (problem list) and Plan. Clinic notes will also have a different format depending
on the environment where you are working.
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For example, the documentation in a family medicine may have a similar format as
presented above in so far as the creation of a problem list. However, the plan for each
problem could be broken down to:
1- over the counter remedies (OTC) meaning interventions that the patient can do for
themselves such as ice elevation, ice and acetaminophen for a swollen joint,
2- prescription remedies such as NSAIDS
3- investigations such as x-rays, blood work, ECGs, echo
4- Other health care professionals such as referrals to a specialist, physiotherapist,
dietician.
5- Red flags- symptoms that should prompt follow up to the family physicians office
and/or to the emergency room.
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Written Medical Record Sample

ID: 56 year old man, married with 2 children, car salesman
CC: chest pain x 24 hours
Profile/Past hx:
1- LUL lobectomy for NSCLC 2 year ago
2- COPD- no home oxygen, no cor pulmonale, ex-smoker, MRC class 1
3- Hypertension
4- Dyslipidemia
5- Appendectomy Age 16
Meds:
1- Tiotropium 18 g 1 inh daily
2- Salbutamol 100 g 2 puffs qid prn
3- Hydrochlorothiazide 25 mg PO daily
4- Ramipril 10 mg PO daily
5- Simvastatin 40 mg PO daily
Alls: NKDA
HPI:
-
chest pain on and off x 24 hours; left sided (no radiation); sharp; worse with
inspiration; no relieving factors; not precipitated by exercise
dyspnea x 72 hours (over weekend), usually dyspnea with vigorous exercise, now
dyspnea with < 1 flight of stairs or < 1 block if ground level
+ swelling of ankles bilaterally
no cough, no hemoptysis
cardiac risk factors as noted above (no DM, no famHx); no hx of MI or angina
no orthopnea or PND
no fevers/sweats/chills/anorexia/malaise; pneumovax 2 years ago, yearly flu shot
no wheezing, no improvement in symptoms with increased ventolin, no prior hospital
lost to follow up post lobectomy; unknown cancer status; weight stable recently
no hx GERD, no hx biliary colic, no jaundice
SocHx:
- married x 32 years; lives with wife
- 2 adult children
- car sales x many years
- ex smoker- quit 2 years ago (with dx of lung ca)
- EtOH- socially
- No drug use (injection or otherwise)
FamHx:
- Father: hypertension, alive and well
- Mother: died ovarian ca 10 years ago
- Brother: Hypertension
- Children: healthy
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ROS:
-neuro: no headache, diplopia, weakness, numbness or tingling
-GI: no diarrhea, abdo pain
-Skin: no rashes
-MSK: no arthralgias, stiffness
Exam:
General: obese middle aged man, looks stated age, mild respiratory distress
VS: BP 150/92 (equal both arms) HR 119 regularly regular RR 26 T 37.3 SpO2
82% R/A, now 95% on 8 LPM np
HEENT: no jaundice, MMM- no oral lesions, TMs- normal, no lymphadenopathy,
no thyromegaly
Resp: + thoracotomy scar, + accessory muscle use, trachea midline-no tug,
normal percussion, normal tactile fremitus, breath sounds vesicular- no
wheeze or bbs, ? pleural friction rub left
CVS: JVP 7 cm ASA, + kussmauls, bilateral lower extremity pitting edema, cool
extremities- no mottling, PPP-no bruits, PMI 5th ICS/MCL- no heaves or
thrills, S1S2 +S3 (increases with inspiration) no S4 no murmur no rub
Abdo: appendectomy scar, BS+, obese abdo, no stigmata CLDZ, soft, nontender,
no organomegaly, no masses
Skin: no lesions, ? right axillary lymphadenopathy
MSK: no active joints
Neuro: not performed
Investigations:
ABG (on 8LPM): 7.37/41/67/25 Lactate 1.2
Hb 142 WBC 11.9 Neuts 9.2 no left shift Plts 219
Na 141 K 3.9 Cl 101 Cr 87 Urea 5.2
INR 1.2 aPTT 37
AST 32 ALT 24 ALP 103 Bili 12 GGT 109
ECG: sinus tach, right axis deviation, no ischemic changes
CXR: RLL mass, right hilar adenopathy, surgical clips left hila, left
hemidiaphragm elevations
d-dimer: 14
tnt: 0.05
Impression:
56 year old man, with hx NSCLC presents with chest pain, dyspnea, elevated JVP with
kussmauls, right sided S3, hypoxemia, positive d-dimer and right lower lobe mass/right hilar
adenopathy on CXR. Findings are most suspicious for acute PE and lung cancer
recurrence.
Issues/Plan:
1- Chest pain/dyspnea: as above most suspicious for PE. + TnT likely represents
strain from PE- doubt acute coronary syndrome or dissection. PE likely
hemodynamically significant (JVP, kussmauls, TnT)Do not suspect
AECOPD as no signs of airflow obstruction on exam + alternative
12
Plan:
iCT PE protocol- favor this above V/Q given abnormal CXR + suspicion of cancer
(CT will also provide more detail regarding RLL mass/right hilar adenopathy)
iiDoppler legs: suspect residual DVT given bilateral leg edema
iiiTTE: need to characterize RV performance given exam/ + tnt suggest impaired
performance.
ivAnticoagulation: LMWH should be ok given no indications for thrombolysis
currently despite suspicion of hemodynamically significant PE(normal Cr,
mentation, lactate normal). Tinzaparin 175 u/kg.
v+/- temporary IVC filter depending on Doppler legs- suspect limited
cardiopulmonary reserve
viWill admit to MTU with telemetry given suspect large PE
viiPulmonary consult re: PE + possible recurrent lung ca
viiiICU consult if deteriorates
ixFor now, work up for recurrent lung ca as cause of hypercoagulability. No
indication for hypercoagulability screen.
2- ? Lung cancer recurrence re: RLL mass/right hilar adenopathy/query right
axillary lymphadenopathy/suspicion of large PE, thus suspicion of recurrent
ca as reason for hypercoagulability
Plan:
iiiiiiiv-
v-
CT PE protocol- should give further characterization of RLL mass/right hilar

lymphadenopathy. Will speak with radiologist re: upper abdominal cuts to look at
liver/adrenals
CT head: no neuro symptoms but suspect extensive cancer + starting on
anticoagulation- r/o brain mets
Consider bone scan to look for mets
Will need tissue diagnosis- at this point, too ill to consider bronchoscopy. Will ask
Pulmonary as to timing of bronchoscopy. Could consider right axillary LN biopsy
(?size on CT) as might be least invasive. CT will also potentially reveal other sites
for biopsy/tissue diagnosis.
Notify Thoracic Surgeon that performed lobectomy of admission + obtain surgeons
records.
3- COPD
Plan:
i-
No evidence active airflow obstruction. Not known to be CO2 retainer, so target

sats> 92%. Continue bronchodilators (tiotropium/slabutamol)
4- Hypertension
Plan:
i-
Will hold antihypertensives for now given suspect large PE. Restarting will depend
on clinical evolution/ echo results.
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5- Dysplidemia
Plan:
i-
Continue Simvastatin.
6- Goals of Care
Plan:
i-
Discussion with patient and wife. Outlined above + potential for deterioration.
Wishes for R1 GOC in short term. Will review as more details come to light.
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General Schedules
Year 1 Class of 2017
Introductory lecture on August 19, 2014 (0830-0920).
Session 1 course 1
(draping/general techniques )
Session 2 course 1
(lymph nodes exam)
Session 3 course 1
(general abdominal exam)
Session 4 course 1
(liver & spleen exams)
Session 5 course 2
(hand/wrist exams)
Session 6 course 2
(shoulder/cervical spine
exams)
Session 7 course 2
(ankle/foot/knee exams)
Session 8 course 2
(hip/L-spine exams)
Session 9 course 3
(BP & JVP exams)
Session 10 course 3
(chest exam)
Session 11 course 3
(precordium exam)
Session 12 course 3
(peripheral vascular exam)
Session 13
(review)
Session 14
(practice OSCE)
Tuesday - AM
(1030-1220)
Wednesday PM
(1330-1520)
Wednesday - PM
(1530-1720)
August 19
August 20
August 20
August 26
August 27
August 27
September 2
September 3
September 3
September 9
September 10
September 10
November 18
November 12
November 12
Thursday
November 20
November 19
November 19
November 25
November 26
November 26
December 2
December 3
December 3
January 13, 2015
January 14, 2015
January 14, 2015
January 20, 2015
January 21, 2015
January 21, 2015
January 27, 2015
Wednesday
January 28, 2015 (0830)
Wednesday
January 28, 2015 (1030)
February 17, 2015
February 18, 2015
February 18, 2015
February 24, 2015
February 25, 2015
February 25, 2015
Thursday
February 26, 2015 (1030)
Tuesday
March 3, 2015 (1030)
Thursday
March 5, 2015 (1030)
15
Year 2 Class of 2016

Well Woman introductory lecture October 20 (0830-1020) for entire class
Supplementary lecture October 20 (1030 1220) for entire class
Monday - AM
(0830-1020)
Session 1 course 5
(visual fields/cranial nerve
exams)
Session 2 course 5
(MMSE)
Session 3 course 5
(peripheral neuro exam)
Session 4
(case based*)
Session 5
(case based*)
Session 6
(case based*)
Session 7
(case based*)
Session 8
(case based*)
Thursday - PM
(1330-1520)
Thursday - PM
(1530-1720)
August 14
August 14
August 18
August 21
August 21
August 25
August 28
August 28
November 3
November 6
November 6
November 17
November 20
November 20
November 24
November 27
November 27
December 1
December 4
December 4
December 8
December 11
December 11
August 11
Well Woman Sub-Unit
* Patient write-up (medical written record) must be handed to the Program Coordinator,
Kerri Martin as a demonstration of completion of this assignment. Deadline to hand in
completed patient write-ups is November 29, 2013??.
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Sessions for Year 1

General Inspection, Vital Signs and Draping
Session 1- Course 1
OBJECTIVES for GENERAL INSPECTION, VITAL SIGNS and DRAPING
Cleanse hands prior to examining a patient.
Demonstrate proper draping techniques.
Identify by inspection common general markers of chronic illness:
Cachexia.
Wasting.
Obesity.
Stated age.
Disheveled state.
Odor.
Identify by inspection common general markers of acute illness:
Position in bed (sitting, upright, reclining).
Diaphoresis.
Odor.
Rash.
Identify common measures of general health status including:
Height.
Weight.
Vital signs.
Pulse.
Blood pressure.
Respiratory rate.
Temperature.
Oxygen saturation.
Identify and describe the features of an arterial pulse:
Rate.
Rhythm.
Contour.
Amplitude.
Demonstrate the correct technique for the evaluation of:
The peripheral palpable blood pressure.
The auscultatory blood pressure.
Identify and demonstrate conditions needed to take a blood pressure:
Relaxation.
Support for feet.
Arm at heart level.
Appropriate cuff size.
Appropriate cuff placement.
Identify location of brachial artery in antecubital fossa.
Demonstrate and explain the technique for identifying pulsus paradoxus.
17
COMMON MARKERS OF ILLNESS

Upon entering a room, you should be able to make a quick assessment of a patients
condition, noticing certain common general markers of illness.
o Chronic illness:
Cachexia.
A catabolic state that induces weight loss, including loss of both fat
and some fat-free mass.
Wasting.
State of emaciation and weakness, caused by loss of fat-free mass.
Obesity.
Stated age.
Disheveled state.
Odor.
o Acute illness:
Position in bed.
Sitting, upright, reclining.
Diaphoresis (sweating).
Odor.
Rash.
COMMON MEASURES OF GENERAL HEALTH STATUS
Important basic physiological information is provided by the following measurements:
o Height.
o Weight.
o Vital signs.
Pulse.
Blood pressure.
Respiratory rate.
Temperature.
Oxygen saturation.
PULSE
Rate.
o The radial pulse is typically used to determine the
rate.
It can be felt just medial to the radius,
usually using the tips or pads of your index
and middle fingers.
Less often the rate is determined by
listening to the heart (apical rate).
o How you determine the rate depends on whether the pulse is regular or irregular.
If the pulse is regular, the rate can be counted for 15 seconds and
multiplied by four to establish beats per minute.
If the pulse is irregular, the rate can be counted for 30 seconds and
multiplied by two or can be counted for 60 seconds to establish beats per
minute.
18
o Normal rate is 60 to 100 beats per minute for adults.

Athletes will often have normal rates below 60.
A rate below 60 is by definition called bradycardia.
A rate above 100 is by definition called tachycardia.
Rhythm.
o Can be regular, regularly irregular or irregularly
irregular.
Contour.
o A normal pulse has a smooth and rapid upstroke
and a more gradual down-stroke.
o The diagram on the side shows a few different
types of abnormal pulse contours (this is
not an exhaustive list).
o If you think that the contour or amplitude
of the arterial pulse may be abnormal,
check the carotid (see Year 1, sessions 11
and 12).
Amplitude.
o Can be quantified as:
Thready or weak (easy to
obliterate).
Normal (obliterates with moderate
pressure).
Bounding (unable to obliterate or
requires very firm pressure).
o If you think that the contour or amplitude
of the arterial pulse may be abnormal,
check the carotid (see Year 1, sessions 11
and 12).
RESPIRATORY RATE
The respiratory rate is typically measured while
appearing to be doing something else (e.g. taking
the pulse) so the patient is unaware that it is
being measured.
o This is because respiratory rate is the only vital sign which in under voluntary
control.
o Tip: if you place the patients arm across the chest while palpating pulse, you can
also count respirations. Just keep your fingers on the pulse even after you have
finished taking it.
Count for at least 30 seconds and multiply by two to determine breaths per minute.
Normal rate averages about 12-16 breaths per minute.
Also pay attention to the quality of the breaths: shallow, unequal, very deep, etc.
19
BLOOD PRESSURE
Inspection:
Identify the brachial artery in the antecubital fossa.
Place the blood pressure cuff around the arm.
o Make sure that the cuff size is appropriate.
The bladder is the inflatable bag part of the cuff.
The width of the bladder should be equal to 40%
of the circumference of the limb.
The length of the bladder should be equal to 80% of
the circumference of the limb.
A cuff bladder that is too small can make the blood
pressure reading artificially high.
A cuff bladder that is too big can make the blood
pressure reading artificially low.
If the cuff size is borderline, err on the side of using
the larger size cuff.
o Make sure the cuff is placed over the brachial artery.
There are usually markings on the cuff that show how
it should be placed.
Place the arm in such a way that it is located at heart level.
o If the arm is placed higher, the blood pressure reading will be
artificially low.
o If the arm is below the level of the heart, the blood
pressure reading will be artificially high.
o If the patient is sitting on a chair, you can usually have
them rest their arm on a table.
o If the patient is sitting on the exam bed, you can
usually have their arm rest on a rolled up pillow or you
can support it with your own arm.
Palpation:
While having your fingers on the radial pulse of the arm in
which you are measuring the blood pressure, rapidly inflate
the cuff to about 30 mmHg above the level at which the arterial pulsation disappears.
Slowly deflate the cuff while palpating the arterial pulse.
o Deflate at approximately 2-4 mmHg per second.
Estimate the palpable systolic pressure (i.e., number at which you can you feel the pulse
again).
Deflate the cuff totally.
Auscultation:
Place the diaphragm of your stethoscope over the brachial artery.
Inflate the cuff approximately 20-30 mmHg above the palpable systolic pressure (as
obtained in the Palpation step above.
Slowly deflate the cuff.
o Deflate at approximately 2-4 mmHg per second.
Identify the systolic and diastolic blood pressures.
o The number at which you hear two consecutive heart sounds is the systolic
pressure.
o The number at which the sound disappears is the diastolic pressure.
20
Pulsus Paradoxus:
Normally, during inspiration the systolic and diastolic blood pressures decrease.
o When the decrease is exaggerated, it is termed pulsus paradoxus.
You can check for pulsus paradoxus in the following way:
o Inflate a cuff until no sounds are heard.
o Gradually deflate the cuff until sounds are only audible during expiration.
Note this pressure.
o Continue to deflate the cuff until sounds are audible during both inspiration and
expiration.
Note this pressure.
o The difference between the two pressures is the pulsus paradoxus.
A difference greater than 10 mmHg is abnormal.
Physiological explanation for pulsus paradoxus in simplified terms (you will not be tested
on this, for your information only!):
o Normally, when we take a breath in, our intrathoracic pressure decreases which
makes it easier for venous blood to flow back into the heart, thus more blood
enters the right side of the heart. The fact that more blood enters the right side of
the heart leads to (pulmonary venous return) flow being reduced into the left side
of the heart. This, in turn, means that there is less blood available to pump out of
the left side of the heart when it contracts. This manifests itself as a decrease in
systolic blood pressure.
o In conditions such as cardiac tamponade or pericarditis, there is increased
pressure around the heart and it cannot expand as easily. Hence, when a deep
breath is taken in, the intrathoracic pressure still decreases, but the heart
surrounding being less pliable leads to an exaggeration of the reduction of flow
into the left side of the heart. This means even less blood than usual is available
to be pumped out when the heart contracts. This manifests itself as an even
further decrease in systolic blood pressure.
o When this phenomenon was initially discovered by Kussmaul, he was actually

referring to the fact that the pulse palpated was of variable strength or not
palpable even though he was still able to auscultate cardiac sounds. Hence, the
name is misleading (i.e., not paradoxical), as the direction of change in systolic
blood pressure is the same whether you have a medical condition that causes
pulsus paradoxus or not.
21
Things to Know and Remember:

Blood pressure should be measured in both arms in a new patient.
o Normally, the blood pressure should be very fairly similar in both arms (i.e,
systolic pressure is within 10 mmHg).
Blood pressure can be measured in different positions (e.g., supine, sitting, standing).
o Should be done routinely in a new patient.
o When checking the postural blood pressure, you will want to check the blood
pressure and pulse supine and then immediately afterwards in a standing
position.
A fall of more than 20 mmHg in systolic blood pressure or more than 10
mmHg in diastolic blood pressure and an increase in pulse of 30 beats per
minute or more is abnormal and is termed orthostatic (postural)
hypotension.
Conditions under which a proper blood pressure can be taken:
o Patient should be relaxed.
This means that they should not have been smoking, drinking a caffeinated
beverage or have done any vigorous exercising (such as running to the
clinic so as not to be late for their appointment).
o Patient should be seated with the feet supported (or on the floor if sitting in a
chair).
o Patients arm needs to be at heart level.
The difference between the systolic and diastolic pressures is termed the pulse
pressure.
A blood pressure-measuring apparatus is called a sphygmomanometer (Greek
sphygmos for pulsing and manos for thin).
As the blood pressure cuff is being deflated, five different sounds will be heard.
o They are called Korotkoff sounds and they are caused by turbulent flow in the
artery.
o The sounds are numbered I through V.
Korotkoff sound I is the first sound that you hear and which indicates your
systolic blood pressure level.
Korotkoff sound V is when the sound disappears, which indicates your
diastolic blood pressure.
TEMPERATURE
Temperature is not routinely measured unless an abnormality is suspected.
Tympanic measurements are typically used because they are rapid and convenient.
o Theoretically tympanic measurements also best reflect the core body
temperature.
o Other ways to measure temperature: oral (under tongue), rectal, axillary,
forehead.
The mean tympanic temperature is 36.4C.
o A fever is usually defined as 38C or greater.
22
OXYGEN SATURATION
Usually measured through a pulse oximeter.
Oxygen saturation is not routinely measured unless an abnormality is
suspected.
23
Lymph Nodes Exam

Session 2 Course 1
OBJECTIVES for LYMPH NODES EXAM

Identify the sites of the major superficial lymph tissue.
Cervical.
Occipital.
Post-auricular.
Pre-auricular.
Posterior cervical.
Anterior cervical.
Submandibular.
Submental.
Supraclavicular.
Infraclavicular.
Epitrochlear.
Axillary.
Central.
Lateral.
Medial.
Anterior.
Posterior.
Inguinal.
Demonstrate the maneuvers involved in the palpation of the major superficial lymphatic
tissues.
Describe lymph nodes.
Location.
Size.
Consistency.
Mobility.
Tenderness.
LYMPH NODES
Inspection:
Look for asymmetry in the neck, especially in the supraclavicular and
sternocleidomastoid areas.
Observe axillae for asymmetry or masses.
Palpation:
Palpation should involve a rolling motion of the fingers.
If a node is felt, describe it in terms of:
o Location.
o Size.
o Consistency/texture.
o Mobility.
o Tenderness.
24
Lymph nodes of the head and neck

(also called cervical nodes):
o Occipital.
o Post-auricular.
o Pre-auricular.
o Posterior cervical (behind the
sternocleidomastoid muscle).
o Anterior cervical (in front of the
sternocleidomastoid).
o Submandibular (under the jaw
line).
o Submental (under the chin).
o Supraclavicular (in supraclavicular fossa).
o Infraclavicular (under the clavicle).
Other lymph nodes:

o Epitrochlear
Located 3 cm proximal to the medial humeral epicondyle (or just medial to
the muscle belly of the biceps).
Support the patient's flexed arm while palpating.
o Axillary.
Place the left hand in the right axilla (or the right hand in the left axilla)
with palm toward chest wall.
Point the fingers obliquely toward the apex of the axilla.
Hold the patient's elbow with your other hand and adduct the patients
upper arm to help relax the muscles.
Palpate firmly for the following lymph nodes:
Central.
Lateral.
Medial.
Anterior.
Posterior.
Rake the pulps of the fingers along the thoracic cage.
o Inguinal
Best felt with the patient lying down.
Palpate with rolling motion along the inguinal ligament.
Femoral nodes are felt along the femoral artery from the inguinal
ligament and extending inferiorly 4-5 cm.
25
GENERAL COMMENTS ON LYMPH NODES

Generally, nodes that are firm and immobile are associated with a metastatic process.
Generally, nodes that are tender, warm, or have overlying erythema (redness) are
associated with infectious or inflammatory processes.
Left supraclavicular nodes may be associated with intra-abdominal carcinomas
(Virchows node).
If a node is found on one side of the body, remember to compare it to the other side.
OTHER LYMPHATIC TISSUE
Other lymphatic tissues include:
o Tonsils.
o Peyers patch (clumpings of lymphoid tissue
usually found in the ileum).
26
General Abdominal Exam

Session 3 Course 1
OBJECTIVES for GENERAL ABDOMINAL EXAM

Demonstrate the appropriate positioning of the patient for examination of the abdomen.
Demonstrate the appropriate draping of the patient for examination of the abdomen.
Identify surface quadrants and two regions.
RUQ.
LUQ.
RLQ.
LLQ.
Periumbilical.
Epigastric.
Suprapubic.
Identify the surface anatomy of major abdominal organs in the four surface quadrants.
Liver.
Spleen.
Kidneys.
Stomach.
Gallbladder.
Pancreas.
Appendix.
Demonstrate the inspection of the supine abdomen.
Movement with respiration.
Peristalsis.
Scars.
Discolorations (striae, veins, ecchymoses).
Masses.
General contour (distended, scaphoid, bulging flanks, etc)
Hernias.
Diastasis rectus.
Percuss all four quadrants.
Start away from area of tenderness.
Comment on tenderness.
Comment on tympany and/or dullness.
Demonstrate the technique of fist percussion for costovertebral tenderness.
Demonstrate the technique of palpation.
Start away from area of tenderness.
Superficial.
Deep.
Comment on tenderness.
Comment on masses.
Comment on organomegaly
Abdominal wall tenderness test.
Describe the technique for the DRE (seen in Well Man sub-unit).
.
(Continued on next page)
Auscultate the abdomen.

Bowel sounds.
27
Pitch.
Frequency.
Bruits.
Major arterial vasculature (seen in Year 1, Session 12).

Enlarged organs.
Demonstrate special tests.
Peritonitis.
Guarding.
Shake tenderness.
Cough tenderness.
Percussion tenderness.
Rebound tenderness.
Cholecystitis.
Murphys sign.
Appendicitis.
Identify location of McBurneys point.
Positioning and Draping:

Position the patient so that their abdominal muscles are
relaxed.
o Supine with arms at their sides.
o Pillow under their head.
Drape so that the abdomen is visible from the nipples to at
least the pubis symphysis.
Inspection:
Identify four surface quadrants and two regions:
o Right upper quadrant (RUQ).
o Left upper quadrant (LUQ).
o Right lower quadrant (RLQ).
o Left lower quadrant (LLQ).
o Periumbilical region.
o Epigastric region.
Identify surface anatomy of:

o Liver (RUQ).
o Spleen (LUQ).
o Kidneys (LLQ and RLQ).
o Stomach (LUQ/epigastric).
o Gallbladder (RUQ).
o Pancreas (LUQ).
o Appendix (RLQ).
28
Inspect for: (inspection from the foot of the bed is sometimes more revealing)
o Movement with respiration.
o Peristalsis.
A contraction and relaxation (worm-like) of the muscles of the digestive
system.
o Scars.
The diagram of the location of
common surgical scars is for
your information only and will
not be tested in the Physical
Examination Course.
o Discolorations.
Striae.
Veins.
Ecchymoses.
Periumbilical.
o Called Cullens sign.
o Associated with ectopic pregnancy,
pancreatitis.
Flank.
o Called Grey Turners sign.
o Associated with pancreatitis,
retroperitoneal hemorrhage.
o Masses.
o General contour (e.g., distended, scaphoid, bulging
flanks, etc.)
o Hernias.
Protrusions of abdominal contents through an
abdominal wall defect.
To better assess, have patient lift their head
off the table.
o Diastasis recti.
Type of hernia caused by the separation of the
abdominal rectus muscles.
To better assess, have patient lift their head off the
table.
Ask patient if the abdomen is painful anywhere before you touch

them!
29
Percussion:
Always begin percussion away from any area of reported tenderness.
Percuss all 4 quadrants of the abdomen.
Percuss the central abdomen (periumbilical region).
Comment on any areas of:
o Tenderness.
o Tympany.
o Dullness.
Percuss for costovertebral angle (CVA) tenderness.

o Performed by gently tapping in the CVA region
with the ulnar aspect of the hand either directly
or by placing your other hand over the area
first.
o This area overlies the kidneys.
o Patients with a inflammatory process of the
kidneys (e.g., pyelonephritis, kidney stone,
kidney infection) will complain of pain when this
area is percussed.
Palpation:
Always begin palpation away from any area of reported tenderness.
Always watch a patients face for pain when palpating.
Palpate all four quadrants.

o Light palpation.
Try to identify areas of tenderness, guarding.
o Deep palpation.
Try to identify masses, areas of fullness, organomegaly.
A digital rectal exam (DRE) is part of the abdominal exam.

o Describe the technique in an exam situation. (seen in Well
Man sub-unit).
Inspect for hemorrhoids, fissures, fistulae, rashes, other
abnormalities.
Palpate for sphincter tone, rectal wall, prostate (in
males), masses, presence and color of stool.
Ausculation:
Auscultate for normal bowel sounds.
o Auscultate each quadrant.
o Comment on:
Pitch.
Normal.
High pitched.
Low pitched.
Frequency.
Normal.
Hyperactive.
Hypoactive.
30
o Normal bowel sounds should occur every 5-10 seconds and are high-pitched and
gurgling.
Loud, high pitched, tinkling, frequent sounds are often associated with a
hyperactive bowel (e.g., diarrhea, constipation or early intestinal
obstruction).
Infrequent bowel sounds are association with a hypoactive bowel (e.g.,
ileus, bowel obstruction, peritonitis, use of narcotics).
o Bowel sounds are only truly considered absent if no sounds are heard after
listening for 2 minutes in each quadrant.
Auscultate for bruits. (seen in Year 1 Session 12)

o Bruits are swishing sounds heard over arteries if there is turbulent blood flow.
o Use the stethoscopes bell.
o Major arterial vasculature:
Aorta.
Best heard in midline above
umbilicus.
Mesenteric arteries.
Best heard in the epigastrium.
Renal arteries.
Best heard 5 cm above
umbilicus and 3-5cm to either
side of the midline.
Iliac arteries.
Best heard just below the
umbilicus and 3-5 cm to either
Femoral arteries.
Best heard at mid-inguinal point, lateral corner of pubic triangle.
o Enlarged organs.
Historically, auscultation was performed before percussion and palpation. The thought
was that moving the bowels might alter the bowel sounds. This theory has never been
shown to be true, but many physicians continue to believe that this is the proper order for
the abdominal exam.
Special Tests:
Peritonitis
Peritonitis is the inflammation of the peritoneum, a thin tissue that lines the inside of the
abdomen.
o Sometimes called acute abdomen.
o Patients with peritonitis tend to lay very still and breathe very shallow to minimize
any abdominal movements, and thus pain.
Peritonitis can be assessed through the following tests:
o Guarding/rigid abdomen.
o Shake tenderness.
Bump the bed and watch if this produces pain.
Often used to assess for malingerers as bed can be bumped quite
casually.
Cough tenderness is a similar test but you watch to see if pain is produced
when the patient coughs.
31
o Percussion tenderness.
o Rebound tenderness.
Ask the patient to tell you if it hurts more on pressing down or letting go
(you need to explain this test to the patient before you perform it).
Press down slowly but firmly, hold for a second or two, then let go
suddenly.
A positive rebound tenderness test hurts more on letting go as the
inflamed perineum rebounds
Do as the very last test as patients will not like you afterwards and are
unlikely to keep cooperating.
Cholecystitis
Cholecystitis is an inflammation of the gallbladder and can cause
severe abdominal pains.
Murphys sign.
o Ask the patient to breathe out.
o Place your fingertips beneath/under the right costal margin in
the mid-clavicular line.
o Press in while asking the patient to take a deep breath in.
o Normally, as a patient breathes in, the abdominal content is
pushed downward.
If there is an inflamed gallbladder, it will be pushed
against your fingers and will create pain, causing the
patient to catch his breath (i.e., abruptly stop breathing)
Appendicitis
Appendicitis is an inflammation of the appendix and causes signs of peritonitis.
The usual progression of symptoms: low grade fever dull, constant periumbilical pain
anorexia, nausea, vomiting well-localized constant pain over McBurneys point.
o McBurneys point is located 2/3 of the
distance from the umbilicus to the
anterior superior iliac spine.
All of the peritonitis tests described above will
be positive in a patient with appendicitis.
Below are a few tests to better assess
appendicitis.
o (These are for your information only and
will NOT be tested in the Physical
Examination Course.)
o Rovsing's sign.
Palpate in the LLQ. If pain is felt in RLQ,
this is suggestive of appendicitis.
o Psoas sign.
Pain on extension of the right thigh is
suggestive of an inflamed retro-cecal
appendix.
o Obturator sign.
Pain on internal rotation of the right thigh at
the hip is suggestive of an inflamed pelvic
appendix.
32
o Tenderness on digital rectal examination.

Suggestive of an inflamed appendix inferior to the cecum.
33
Liver and Spleen Exams

Session 4 Course 1
OBJECTIVES for LIVER EXAM

Identify the expected location of the liver.
Inspect for peripheral signs of liver disease.
Scleral icterus.
Jaundiced frenulum.
Palmar erythema.
Thenar atrophy.
Dupuytrens contractures.
Clubbing of nails.
Terrys nails.
Leukonychia.
Asterixis.
Jaundiced skin.
Telangectasias.
Spider nevi.
Petechiae.
Gynecomastia.
Testicular atrophy.
Peripheral edema.
Inspect abdomen.
Masses.
Scars.
Abdominal distension.
Distribution of venous pattern.
Caput medusa.
Ascites.
Percuss liver span.
Upper liver border.
Lower liver border.
Comment on size.
Demonstrate and explain scratch test.
Palpate for liver edge.
Palpation synchronously with deep respiration.
Describe the liver edge.
Texture.
Tenderness.
Pulsatality.
Regularity.
Nodularity.
Auscultate for bruits.
Demonstrate and explain special tests.
Shifting dullness test.
Fluid wave test.
34
Inspection for Peripheral Signs of Stigmata of Liver Disease:

Head.
o Scleral icterus.
o Jaundiced frenulum.
Hands.
o Palmar erythema.
o Thenar atrophy.
o Dupuytrens contractures.
A painless thickening of the
palmar fascia, leading to a
contracture.
Clubbing of nails.
Loss of the Schamroth sign,
which is the diamond shape
usually created when two fingers
are held together.
Terrys nails.
Condition where the nail turns
white proximally, losing the usual
white crescent shape.
Leukonychia (white nails).
Asterixis.
o
o
As patient to hold up hands as if

they were trying stop a bus.
Look for any flapping of the
wrists.
Skin.
o Jaundice.
o Telangectasias.
Small dilated blood vessels on
the skin.
o Spider nevi.
Type of telangectasia that looks
like a spider web.
Have a central blood supply
and are blanchable with central
pressure.
o Petechiae.
Small red or purple spot caused by broken capillaries.
Gynecomastia (in males).
Testicular atrophy (in males).
35
Peripheral edema.
o Should be both inspected and palpated for.
To palpate, press on the anterior tibia (shins) and look for pitting
depressions where you pressed down.
If patient is bed-ridden, make sure to check for edema on coccyx.
Inspection (Central Signs)

The liver is located in the right upper quadrant of the
abdomen.
Masses.
o Especially in right upper quadrant.
Scars.
Abdominal distension.
Distribution of venous pattern.
Caput medusa.
o Distended and engorged paraumbilical veins
radiating from the umbilicus.
Ascites.
o Look for bulging flanks from the foot of the
bed.
Remember to ask the patient if their abdomen is painful anywhere before you touch it!
Percussion:
Percuss for the liver span.
o Start in the chest and percuss downwards in the midclavicular line for the upper border.
o Begin again, this time in the RLQ and percuss up to find the
lower border.
o Measure the liver span.
It is normally less than 12 cm in males and less than
9-10 cm in females.
If you were unable to locate the lower liver edge with the above method, you can try
using the scratch test.
o This test is less accurate but works well with patients with, for example, severe
ascites or who are severely obese.
o Place the diaphragm of your stethoscope just above the right costal margin at the
midclavicular line.
o With your fingernail, lightly scratch the skin of the abdomen along the
midclavicular line, moving from below the umbilicus toward the costal margin.
o When your scratching finger reaches the livers edge, you will hear the scratching
sound as it passes through the liver to your stethoscope.
36
Palpation:
Palpate for the liver edge.
o You can support the ribs on the right side with your left hand and use a one hand
technique for palpation, or you can use both hands to palpate.
o Start palpating in the RLQ and move towards the right costal margin.
While palpating, ask the patient to take deep breaths in and out through
their mouth. Advance and position your palpating hand on expiration and
make sure that it is in place by the time the patient takes a breath in.
As the patient takes a breath in, it creates pressure in the thoracic
cavity, which pushes the abdominal organs downward, making it
easier for them to be felt if your fingertips are already in place.
Describe the liver edge in terms of:

o Texture (e.g., firm or soft).
o Tenderness.
o Pulsatality.
o Regularity.
o Nodularity.
Note: the liver edge is normally soft, non-tender, regular with a sharply
demarcated border and smooth.
Auscultation:
Listen over the liver for any bruits.
Special Tests:
Shifting dullness test
o Percuss at the centre of the abdomen then percuss toward the patients right flank
and mark where dullness arises.
o Roll patient into the right lateral decubitus position (on their right side) and repeat
your percussion technique.
o With ascites, the area of dullness will shift to the dependent side (i.e., the area of
tympany shifts toward the top).
37
Fluid wave test

o Get the patient to place their hand with their ulnar or radial side pressing down in
the centre of their abdomen and applying some pressure.
o Place your hands on either side of the patient.
o Gently tap one side of the abdomen and feel for the tap
on the other side.
If there is a fluid, you will be able to feel a fluid
wave being transmitted to your receiving hand.
If the abdomen is distended because of fatty
tissue (and not ascites), the transmission of the
fatty wave will be stopped by the patients hand
before it can reach your receiving hand.
38
OBJECTIVES for SPLEEN EXAM

Identify the expected location of the spleen.
Identify the expected location for enlargement of the spleen.
Inspect left upper quadrant.
Scars.
Swelling/masses.
Bruising.
Identify the following locations:
Traubes space
Castells point
Demonstrate percussion at:
Traubes space
Castells point
Demonstrate the technique for the palpation of the spleen
Demonstrate manoeuvres to improve sensitivity of palpation for the spleen.
Palpation synchronously with deep respiration.
Positioning of patient on right side.
Elevation of left costovertebral angle by the patient.
Demonstrate auscultation for bruits/rubs over the spleen.
The spleen is an intraperitoneal structure that is usually the size of the patients fist.
It is usually found beneath the 9th, 10th and 11th ribs.
As it enlarges, it follows the direction of the 10th rib toward the umbilicus, then to the
RLQ.
Inspection:
Inspect the left upper quadrant at rest and with deep inspiration for:
o Scars.
o Swelling/masses.
o Bruising.
39
Percussion:
Percuss over Castells point.
o Located at the intersection of the left costal margin and the left anterior axillary
line.
o Ask patient to take a slow deep breath in and then slowly exhale it while
percussing throughout the breath.
o Listen for any changes in tympany.
This area will become dull with inspiration if there is splenomagaly.
If there is no splenomagaly, the area should remain tympanic throughout
the inspiration and expiration (i.e., no changes in sound).
Percuss over Traubes space.

o Located in the triangle formed by the left costal margin, the left anterior axillary
line and a horizontal line at the level of the xyphoid/6th rib.
o This is the area of the gastric air bubble.
o Ask patient to take a slow deep breath
in and then slowly exhale it while
percussing throughout the breath.
o Listen for any changes in tympany.
This area will become dull with
inspiration if there is
splenomagaly.
If there is no splenomagaly, the
area should remain tympanic
throughout the inspiration and
expiration (i.e., no changes in
sound).
Percussion over Castells point and/or Traubes space can also be performed in the
right lateral decubitus position (i.e., with patient laying on their right side).
o This brings the spleen closer to the surface and hence might make it easier to
percuss and palpate.
Palpation:
Palpate for the spleen.
o Can be done with one or two hands.
The two-handed technique involves placing one hand on the
costovertebral angle or beneath the rib cage on the patient's left side,
while the other hand palpates. Lift the CVA or rib cage toward the
examining hand.
Move the hand slowly, so as not to hurt the patient. Use the fingertips or
the side of the fingers. Edge fingers slowly, gently pushing to feel the
spleen edge.
o Palpation for the spleen is much more reliable than percussion to detect
splenomegaly.
40
o Begin palpating lightly at the RLQ, moving toward the left costal margin at the
anterior axillary line.
o Then palpate lightly from the LLQ, moving again toward the costal margin at the
anterior axillary line.
o Repeat these techniques using deep palpation.
If the spleen is not felt with the above techniques:

o Repeat, asking the patient to take deep breaths in and out. Advance and
position your palpating hand on expiration and make sure that it is in place by
the time the patient takes a breath in.
As the patient takes a breath in, it creates pressure in the thoracic cavity,
which pushes the abdominal organs downward, making it easier for them
to be felt if your fingertips are already in place.
o Position the patient on the right side and repeat light and deep palpations, and
palpations with deep inspirations.
o Position the patient supine with their fist at the left costovertebral angle/beneath
the rib cage, stand on the patient's left side and hook your fingers under the
ribcage. Ask the patient to breathe deeply.
o Remember that you can also percuss for the spleen at Castells point or over
Traubes space while the patient is in this position (if not already done earlier).
Auscultation:
Listen over the spleen for bruits and rubs.
o A bruit is a French word for noise. It occurs when there is turbulent blood flow.
Up to 20% of healthy individuals under 40 years old will have abdominal bruits.
o A rub is a dry, grating sound. It is a normal finding over the spleen area.
41
Hand and Wrist Exams

Session 5 Course 2
OBJECTIVES for HAND and WRIST EXAMS

Inspect:
Dorsum of hand.
Skin redness, thinning, thickening.
Wrist redness, swelling, deformity, deviation.
MCP joints redness, swelling, deformity, deviation.
Spaces between MCP joints.
PIP joints redness, swelling, deformity, deviation.
DIP joints redness, swelling, deformity, deviation.
Nail changes.
Palm of hand.
Palmar erythema.
Tendon swelling.
Contractures.
Wasting of thenar eminence.
Wasting of hypothenar eminence.
Wasting of small muscles of the hand.
Inspect for:
Bouchards nodes.
Heberdens nodes.
Mallet finger.
Boutonniere deformities.
Swan neck deformities.
Palpate for:
Tenderness.
Effusion.
Thickening.
Temperature.
All of the following structures:
Wrist joint.
Distal radial ulnar joint.
Radiocarpal joint.
Carpal bones.
MCP joints.
Subluxation.
Stress testing.
Ligament stability.
PIP joints.
Ligament stability.
DIP joints.
Ligament stability.
Palm of hand.
Flexor tendons.
Thickening.
Tenderness.
42
Nodules.
Soft tissues.
Thickening/contractures.
Carpal-metacarpal joint.
Anatomical snuff box.
Scaphoid bone.
Demonstrate the evaluation of the following active ranges of motion:
Forearm.
Pronation.
Supination.
Wrist.
Flexion.
Extension.
Ulnar deviation.
Radial deviation.
Hand.
Flexion of MCPs.
Fingers.
Flexion of PIPs.
Flexion of DIPs.
Abduction.
Adduction.
Opposition.
Demonstrate the evaluation of the following passive ranges of motion:
Wrist:
Flexion.
Extension.
Ulnar deviation.
Radial deviation.
Demonstrate the evaluation of muscle strength:
Forearm.
Pronation.
Supination.
Wrist.
Flexion.
Extension.
Ulnar deviation.
Radial deviation.
Hand.
MCPs.
Fingers.
PIPs.
DIPs.
Abduction.
Adduction.
Opposition.
.
Assess neurovascular status (seen in Year 1 Session 12 and Year 2 Session 3).
Vascular status.
43
Radial pulse.
Capillary refill.
Neurosensory status (light touch and pinprick).
Median nerve.
Ulnar nerve.
Radial nerve.
Demonstrate special tests for:
Carpal tunnel.
Compression test.
Tinnels test.
Phalens sign.
Reverse Phalens sign.
DeQuervains tenosynovitis.
Palpation.
Finkelsteins test.
Important Note: In real life, when performing a musculoskeletal exam, it is always

necessary to:
Examine the joint above.
Examine the joint below.
Perform a neurovascular screen.
In this MSK section of the Physical Exam course, you will notice that each joint exam is
described in isolation. Furthermore, the neurovascular exams are described in the
sessions entitled Peripheral Vascular Exam (Year 1, Session 12) and Peripheral
Neurological Exam (Year 2, Session 3). The dispersion of these topics was made to
better follow the undergraduate course curriculum (e.g., study of neurological concepts
during Course 5).
Inspection (to be done unsupported):
Dorsum
Skin: redness, thinning, thickening.
Wrist: redness, swelling, deformity, deviation.
MCP joints: redness, swelling, deformity, deviation.
Spaces between MCP joints: should be valleys.
PIP joints: redness, swelling, deformity, deviation.
o PIP joint swelling = Bouchards node =
inflammatory and degenerative arthritis.
DIP joints: redness, swelling, deformity, deviation.
o DIP joint swelling = Heberdens node =
degenerative arthritis.
o Mallet finger.
Flexion at DIP.
Boutonnieres deformity.
o Flexion at the PIP and hyperextension at DIP.
Swan neck deformity.
o Hyperextension at PIP and flexion at DIP.
44
Nail changes.
o Such as pitting, ridging, onycholysis (detachment of the nail from the nail bed
distally), oil spot (yellowish pigmentation under the nail due to detachment from
nail bed proximally), hyperkeratosis (thickening and hardening of the nail),
discoloration.
Palmar
Palmar erythema.
Swelling along length of tendons.
Contractures.
Wasting of thenar eminence.
Wasting of hypothenar eminence.
Wasting of small muscles of the hand (between
metacarpal bones).
Palpation:
Feel for:
o Tenderness.
o Effusion.
o Thickening.
o Warmth/temperature.
All deformities should be tested to see if they are fixed or reducible.
Wrist
Distal radial ulnar joint.
o Flat area located between ulnar styloid and distal radius.
Radiocarpal joint (true wrist joint).
o Located at indentation at the end of 3rd metacarpal.
o Also palpate along carpal bones.
MCP joints
Located distal to the metacarpal head.
Dont forget to check the thumb.
Could also do a quick screening exam by squeezing MCPs between forefinger and
thumb.
Also look for step sign, indicative of subluxation.
o Flex MCP down. Run finger up to digit. Pathway should be smooth.
o If subluxed, you will feel a bump (metacarpal bone).
Also a good time to do stress testing through hyperextension.
Also do testing for ligament stability when joints are fully flexed.
o Move the flexed digit from side to side and note any laxity.
45
PIP joints
Use both a 2 and a 4 finger examination technique (index
and thumb of one hand on top and below the joint, and index
and thumb of the other hand holding the joint from sides).
Also test for ligament stability when joints are in 15-20o of
flexion.
DIP joints
Use both a 2 and a 4 finger examination technique (index
and thumb of one hand on top and below the joint, and index
and thumb of the other hand holding the joint from sides).
Also test for ligament stability when joints are in 15-20o of
flexion.
Palm of hand
Flexor tendons.
o Feel for:
Thickening.
Tenderness.
Nodules.
Soft tissues.
o Feel for thickening/contractures.
Radial aspect of wrist
Carpal-metacarpal joint.
o Contained within anatomical snuff box.
o Palpate for tenderness of scaphoid bone.
Range of Motion:
Active:
o Forearm.
Pronation (palm down).
Supination (palm up).
o Wrist.
Flexion.
Extension.
Ulnar deviation.
Radial deviation.
o Hand.
Make fist = rough screen of all joints (MCPs,
PIPs, DIPs).
o Fingers
Karate chop = rough screen of PIPs and DIPs.
Abduction (spread your fingers apart).
Adduction (try to keep your fingers together).
Opposition (form an O by putting together the tip of your
thumb and the tip of each finger).
Passive:
46
o Easiest to simply stress the active ROM when

patient is already doing these motions.
o Wrist:
Flexion.
Extension.
Ulnar deviation.
Radial deviation.
Strength Testing:
Easiest to test simultaneously as active and passive ROM.
Repeat ROM against resistance:
o Forearm.
Pronation.
Supination.
o Wrist.
Flexion.
Extension.
Ulnar deviation.
Radial deviation.
o Hand.
Test MCPs strength in flexion.
o Fingers.
Resist karate chop as a screen.
Can test individual PIPs and DIPs.
When resisting abduction (fingers all spread), use your index finger to try to
push in patients index finger, and your little finger to try to push in patients
little finger.
Try to pull fingers apart while patient has them adducted.
Try to pull each O apart by making an O with your thumb and same
finger as patient is using to check resistance to opposition.
Neurovascular Status
Refer to Year 1 Session 12 and Year 2 Session 3 for complete overview of this topic.
For now, however, here is a quick reminder.
Check vascular status:
o Radial pulse.
o Capillary refill.
Check neurosensory status through light touch and pinprick:

o Median nerve.
o Ulnar nerve.
o Radial nerve.
47
Special Tests:
Carpal tunnel.
o Compression test.
Apply pressure directly over carpal tunnel
area.
Test can be accentuated by extending the
patients wrist.
Test result is abnormal if a pain/tingling is
felt in the first 3-3.5 fingers.
o Tinnels test.
Tap over median nerve as it runs through
the carpal tunnel (i.e., at the crease of the
wrist, but also a few centimeters above and
below it).
Test result is abnormal if a pain/tingling is
felt in the first 3-3.5 fingers.
o Phalens test.
Hold patients wrist in forced flexion for 30-60 seconds.
Patient can also do their own forced flexion by putting the dorsum of
their hands together and being instructed to try to push their elbows
downward as much as possible.
Test result is abnormal if a pain/tingling is felt in the first 3-3.5 fingers.
o Reverse Phalens test.
Hold patients wrist in forced extension for 30-60 seconds.
Patient can also do their own forced extension by putting the palm of
their hands together and being instructed to try to lift their elbows
upward as much as possible,
Test result is abnormal if a pain/tingling is felt in the first 3-3.5 fingers.
48
DeQuervains tenosynovitis.
o Inflammation of the radial tendon sheaths.
o Palpate over tendons/tendon sheath.
Test result is abnormal if a pain is felt underneath palpated area.
o Finkelsteins test.
Ask patient to make a fist after tucking their thumb into their palm. Then
ask them to bend their wrist down toward their little finger (ulnar deviation).
This test can be accentuated by having you press down (gently!) to
accentuate the deviation.
Test result is abnormal if a pain is felt in the distal radial forearm.
49
Cervical Spine and Shoulder Exams

Session 6 Course 2
OBJECTIVES for CERVICAL SPINE

Inspect alignment of head and neck:
Anteriorly
Laterally
Posteriorly
Identify normal lordosis curvature.
Palpate for tenderness:
Paravertebral muscles.
Trapezius muscles.
Sternocleidomastoid muscles.
Spinous processes.
Interspinous ligaments.
Palpate for increased tone:
Paravertebral muscles.
Trapezius muscles.
Sternocleidomastoid muscles.
Demonstrate the evaluation of the following active range of motions:
Flexion.
Extension.
Rotation.
Lateral flexion.
Demonstrate the evaluation of muscle strength against resistance for:
Flexion.
Extension.
Rotation.
Lateral flexion.
Check the following reflexes:
Biceps (C5-6).
Brachioradialis (C5-6).
Triceps (C6-7).

necessary to:
during Course 5).
50
Inspection:
Alignment of the head and neck.

o Check anteriorly, laterally and posteriorly.
o Comment on normal or reverse lordosis.
o Comment on swelling, wasting, and/or spasms of
muscles.
Observe active range of motion:

o
o
o
o
Flexion.
Extension.
Lateral flexion.
Rotation.
Palpation:
Palpate the following muscles for tenderness:
o Trapezius.
o Paraspinals.
o Sternocleidomastoids.
Palpate the following muscles for spasms:

o Trapezius.
o Paraspinals.
o Sternocleidomastoids.
Palpate:
o Spinous processes for tenderness and
crepitation.
o Interspinous ligaments for tenderness.
Repeat range of motion against resistance (strength
check) for:
o Flexion.
o Extension.
o Lateral flexion.
o Rotation.
o Resisted motion needs to held for 5 seconds.
Reflexes:
Check the following reflexes:
o Biceps (C5-6).
o Brachioradialis (C5-6).
o Triceps (C6-7).
Do not forget to demonstrate
how you would elicit reflexes
in someone who is tense.
51
OBJECTIVES for SHOULDER EXAM

Identify surface anatomy:
Clavicle.
Humerus.
Scapula.
Scapular spine.
Acromio-clavicular joint.
Acromion.
Sternoclavicular joint.
Glenohumeral joint.
Deltoids muscles.
Supraspinatus muscles.
Infraspinatus muscles.
Inspect for:
Normal contour of:
Shoulder.
Clavicle.
Muscle wasting.
Dislocations.
Redness.
Swelling.
Palpate joints for tenderness, warmth, deformities and/or swelling:
Sternoclavicular joint.
Clavicle.
Coracoid process.
Bicipital groove.
Biceps tendon.
Acromioclavicular joint.
Glenohumeral joint.
Scapular spine.
Subacromial bursa.
Demonstrate the evaluation of active range of motion:
Flexion.
Extension.
Abduction.
Adduction.
Internal rotation.
External rotation.
Protraction.
Retraction.
Demonstrate the evaluation of passive range of motion:
Flexion.
Extension.
Abduction.
Adduction.
Internal rotation.
External rotation.
52
Demonstrate the evaluation of muscle strength against resistance for:

Flexion.
Extension.
Abduction.
Adduction.
Internal rotation.
External rotation.
Bicipital tendonitis
On palpation.
Yergasons test.
Speeds maneuver.
Glenohumeral stability
Apprehension test.
Frozen shoulder test.
Glenohumeral vs. scapulothoracic motion.
Acromioclavicular disorder.
Cross-arm test.
Rotator cuff injury
Subscapularis
Lift off test.
Supraspinatus
Jobs test (beer can test).
Drop arm test.
Infraspinatus
Resisted external rotation test.
Impingement syndrome
Painful arc test.
Neers test.
Hawkings test.

necessary to:
during Course 5).
53
Inspection:
Muscle wasting, atrophy and/or
swelling of:
o Deltoids.
o Supraspinatus.
o Infraspinatus.
Abnormalities in the contour of:

o Sternoclavicular joints.
o Clavicles.
o Acromioclavicular joints.
o Acromion.
Palpation:
For tenderness, warmth, deformities
and/or swelling (one side at a time):
o Sternoclavicular joint.
o Clavicle.
o Coracoid process.
o Bicipital groove.
o Biceps tendon.
o Acromioclavicular joint.
o Glenohumeral joint.
o Scapular spine.
Subacromial bursa for tenderness.
Range of Motion:
Active:
o Forward flexion.
o Backward extension.
o Abduction.
o Adduction.
o External rotation.
o Internal rotation.
o Protraction.
o Retraction.
Passive:
o Only to be checked if active
ROM is limited, except for
abduction which should
always be checked actively
and passively:
Forward flexion.
Backward extension.
Abduction.
Adduction.
External rotation.
Internal rotation.
54
Strength Testing:
Forward flexion.
Backward extension.
Abduction.
Adduction.
External rotation.
Internal rotation.
Special Tests:
Bicipital tendonitis:
o On palpation.
Localized tenderness when palpating over the groove.
o Yergasons test.
o Speeds maneuver.
Glenohumeral stability:
o Apprehension test.
Checks for anterior shoulder dislocation.
Frozen shoulder test.

o Loss of passive range of motion is usually suspect for this problem.
o The glenohumeral motion is lost and replaced by a scapulothoracic motion in
order to move the shoulder.
o Can be detected by passively attempting to abduct the shoulder while having the
other hand on the scapulothoracic joint.
Acromioclavicular disorder.
o Cross-arm test.
Rotator cuff injury:

o Subscapularis.
Lift off test.
o Supraspinatus.
Jobs test (beer can test).
Drop arm test.
o Infraspinatus.
Resisted external rotation test.
Impingement syndrome:
o Painful arc test.
o Neers test.
o Hawkings test.
55
56
57
Ankle, Foot, and Knee Exams

Session 7 Course 2
OBJECTIVES for ANKLE and FOOT EXAM

Assess gait.
Inspect the ankle for:
Swelling.
Bruising/discolouration.
Redness.
Warmth.
Scars.
Muscle wasting.
Deformities (e.g., varus or valgus).
Inspect the foot for:
Swelling.
Bruising/discolouration.
Redness.
Warmth.
Scars.
Deformities (e.g., hallux valgus, clawing, crowding, hammer toes, cockup
toes).
Nail changes.
Calluses.
Symmetry of the arches.
Shape of the arches (e.g., pes planus, pes cavus).
Along distal 6 cm of tibia.
Along distal 6 cm of fibula.
Medial malleolus.
Lateral malleolus.
Ankle joint capsule.
Heel.
Across the metatarsalphalangeal joints.
Achilles tendon.
Plantar flexion.
Dorsiflexion.
Inversion.
Eversion.
Demonstrate the evaluation of the following passive range of motions:
Plantar flexion.
Dorsiflexion.
Inversion.
Eversion.
Demonstrate the evaluation of muscle strength of:
Plantar flexion.
Dorsiflexion.
58
Inversion..
Eversion.
Laxity of anterior talofibular ligament.
Achilles tendon rupture (Thompson test).
Midtarsal joint sprain.
Assess neurovascular status (seen in Year 1 Session 12 and Year 2 Session 3).

necessary to:
during Course 5).
Inspection:
Observe gait.
o Note any pain when weight bearing.
o Note any valgus or varus ankle deformities when walking.
Inspect the ankle anteriorly, laterally and posteriorly for:

o Swelling.
o Bruising/discoloration.
o Redness.
o Warmth.
o Scars.
o Muscle wasting.
o Deformities (varus and valgus).
While sitting.
While standing.
While walking (if not already done during gait).
Inspect the foot anteriorly and laterally for:

o Swelling.
o Bruising/discoloration.
o Redness.
o Warmth.
o Scars.
o Deformities:
Hallux valgus.
Caused by a fixed lateral deviation
of the big toe.
59
of the main axis
Clawing.
Caused by a fixed flexion deformity.
Crowding.
Hammer toes.
Caused by hyperextension of the MTP joint,
flexion at the PIP and extension at the DIP. Can
be seen in the absence of arthritis.
Cockup toes.
Caused by metacarpal head becoming
displaced toward the floor and leading to the tip
of the toe to lift. Represents synovial inflammation and is always
associated with arthritis
Nail changes.
Calluses.
Symmetry of the arches with standing.
Asymmetric pes planus (flat foot) may indicate
a torn posterior tibial ligament.
Shape of the arches (pes palnus, pes cavus) while
standing.
o
o
o
Palpation (while patient is sitting):

o Along the distal 6 cm of the tibia.
o Along the distal 6 cm of the fibula.
o Medial malleolus.
o Lateral malleolus.
o Around the ankle joint capsule.
o Around the heel.
Looking for plantar fasciitis.
Palpate the distal margin of the calcaneus for
tenderness of the plantar fascial insertion for
plantar fasciitis.
o Across the MTPs.
Squeeze 1st and 5th metatarsals between thumb and forefinger.
Tenderness suggests inflammation (think early rheumatoid arthritis!).
o Achilles tendon.
Also use this opportunity to palpate for any deformities (e.g., rheumatoid
nodules, partial tears).
Range of Motion
Active:
o Plantar flexion.
o Dorsiflexion.
o Inversion.
o Eversion.
Passive:
o Plantar flexion.
o Dorsiflexion.
o Inversion.
Immobilize the joints not being tested.
60
o Eversion.
Immobilize the joints not being tested.
Strength Testing:
Plantar flexion.
Dorsiflexion.
Inversion.
Eversion.
Special Tests:
Laxity of anterior talofibular ligament.
o Assessed with anterior drawer test.
o Patient foot needs to be in a neutral position, hanging in the air.
One hand stabilizes the distal end of the tibia, while the other hand
is placed on the heel. An anterior force is applied to the heel,
attempting to subluxate the talus from beneath the tibia.
o More than 0.5cm of movement or no firm end-point may indicate a
problem with the anterior talofibular ligament.
Achilles tendon rupture.

o Assessed with Thompson test.
o Have the patient kneel on a chair or lie prone. Give the calf a
hard squeeze.
o In a tendon rupture, the foot fails to passively plantarflex when
calf is squeezed.
Midtarsal joint sprain.

o Assessed with Hiss test.
o Injury to this area of the foot is rare, but is more commonly seen
in athletes participating in sports involving jumping (e.g.,
gymnastics) or sports where ankle injuries are common
(e.g., football).
o Hold the heel in one hand and the forefoot in the other.
Attempt to rotate the hands in opposite directions (i.e.,
rotation would occur through the midtarsal (midfoot) joint).
o Pain with this maneuver would make you suspect a
midtarsal joint injury.
61
OBJECTIVES for KNEE EXAM

Describe the surface anatomy of the knee.
Assess gait.
Identify on inspection of the knee joints:
Differences between the joint symmetry.
Normal alignment.
Misalignment/deformities (valgus, varus, hyperextension).
Patellar tracking.
Prominence of tibial tuberosities (e.g., Osgood-Schlatters).
Related muscle wasting.
Related muscle hypertrophy.
Scars.
Redness.
Swelling/masses (e.g., Bakers cyst).
Discoloration/bruising.
Measure quadriceps circumference.
Palpate the knee joint for:
Differences in temperature.
Joint line tenderness.
Crepitus.
Tenderness around sides of patella.
Medial collateral ligament tenderness.
Lateral collateral ligament tenderness.
Check for effusions using the following techniques:
Patellar tap.
Bulge sign.
Ballotment test.
Demonstrate the evaluation of the following active range of motion:
Extension
Flexion
Demonstrate the evaluation of the following passive range of motion:
Extension
Flexion.
Evaluate the stability of the following ligaments:
Medial collateral ligament.
Lateral collateral ligament.
Anterior collateral ligament using:
Anterior drawer test
Lachmans test
Posterior collateral ligament
Examine for meniscal tears using:
McMurrays test
Thessaly test
Demonstrate patellar dislocation using apprehension test.
62

necessary to:
during Course 5).
Inspection (standing):
Bony alignment.
o Look for valgus, varus or hyperextension deformity.
o A line drawn from the iliac crest should transect the middle toe
Swelling/masses.
o Bakers cyst (usually seen posteriorly on the medial side).
Observe gait.
o Look at and comment on posture, balance, swinging of arms,
movement of the legs, smoothness of turns.
o
Types of gait:
Antalgic: in order to avoid pain during weight-bearing, the time in the
stance phase (foot on the ground) of the injured limb is minimized.
Trendelenburg (lurch) gait: when walking, the entire trunk leans
excessively over the hip that is firmly planted on the ground (i.e. the
centre of gravity is kept over the stance leg) while the other side of the
body, leg and upper body, swing forward. This gives the appearance of
the patient lurching one side of their body to move forward.
Ataxic: an unsteady, uncoordinated walk, employing a wide base and the
feet thrown out. Is often due to cerebellar disease, loss of position sense,
or intoxication.
Ask patient to squat to test patellofemoral compartment.
o If there is damage on the underside of the kneecap or misalignment of the
kneecap, the knee can develop a creaking noise when squatting. It can also
cause ill-defined pain over the front of the knee.
Inspection (sitting):
Patellar tracking.
o Observe the tracking of the patella as the knee goes from
extension to flexion.
o Abnormal finding if the patella is pulled to the lateral
aspect of the knee (lateral subluxation of the patella).
Also called Grasshopper eyes.
Prominence of tibial tuberosity.
o Pain and swelling at this site may be an indication of
Osgood-Schlatters disease, especially in active boys
and girls between the ages of 11 and 15. The
symptoms are caused by repeated stress on the
patellar tendon which is the link between the
63
quadriceps and the tibial tuberosity. This stress causes subacute avulsion
fractures and inflammation of the tendon, which leads to excess bone growth in
the tuberosity.
Inspection (laying):
Asymmetry between knees.
Masses
Scars and/or lesions.
Muscle atrophy or hypertrophy.
o Vastus medialis usually goes first).
o Can measure quadriceps by picking a fixed point.
Erythema.
Swelling in medial fossa and/or suprapatellar pouch
Palpation:
Check temperature below, at, and above patella.
o The knee cap is usually the coolest part.
o Compare with other side.
Check for tenderness

o Joint line (one side of the knee at a time)
Try to feel the head of the fibula (lateral),
the medial condyle, and the medial tibial
plateau.
o Collateral ligaments (medial and lateral).
At insertion and origin.
Along ligament for tenderness.
o Patellar edges.
o Pre-patellar bursa (can also be done later, as part of your check for effusions).
Swelling and tenderness in this area is often called Housemaids sign.
o Suprapatellar bursa area (can also be done later, as part of your check for
effusions).
o Pes anserine bursa.
Check for crepitation.

o This can be done either here or during checking of range of motion
(flexion/extension).
o Place a hand over the knee joint and feel for any creaking/cracking.
Check for effusion:

o Bulge sign.
Best to detect small effusions.
Milk up medial side and sweep down lateral
side.
No bulge means that there is no fluid or that
there is a large amount of fluid.
o Ballottement.
Good test to check for large effusions.
Compress the suprapatellar pouch, and then
try move the fluid around the knee back/forth between your fingers.
64
o Patellar tap.
Milk fluid into suprapatellar pouch and trap it there by pushing down on
the pouch. With your index and middle fingers, press down on the
patella.
The test is positive if you feel a clunk when the patella touches the
femur and then bounces off the femur.
Range of Motion:
Active
o Flexion.
o Extension.
Passive
o Flexion.
o Extension.
o Feel for crepitus (medial, lateral, patellar area).
o Careful not to grab another joint.
Ligament, Meniscus and Patellar Tests:

Medial collateral ligament (MCL).
o Create a valgus deformity.
o Look for medial aspect opening.
o Look for instability and pain.
Lateral collateral ligament (LCL).

o Create a varus deformity.
o Look for lateral aspect opening.
Anterior cruciate ligament (ACL).

o Anterior drawer test.
With patient laying down and their foot resting flat on the
bed and with the knee in 90o of flexion, attempt to slide
tibia forward (drawer opening).
Look for instability and pain.
o Lachmans test.
With the patient supine and their knee flexed 20-30o, steady the femur with
one hand while grabbing the leg below the knee with
your other hand. Tug the lower leg upwards (i.e., try to
move the tibia on the femur).
Look for instability and pain.
The test findings are abnormal if the anterior tibial
movement is exagerated or there is no solid end point
felt.
65
Posterior cruciate ligment (PCL).

o With patient laying down and their foot resting flat on the bed, attempt to slide the
tibia backwards (drawer closing).
Test for meniscus tears:

o McMurrays test.
With patient supine and knee half-way flexed,
grab the foot with one hand and place the other
hand along the medial aspect of the knee.
Create a valgus deformity (i.e., apply a valgus
force). While internally rotating the tiba, extend
the knee.
Repeat the test while externally rotating the tibia.
The test findings are abnormal if there is a popping and pain along the
joint line.
o Thessaly test.
While standing on one leg, knee flexed to approximately 20
degrees, the patient twists, rotating the femur on the tibia
medially and laterally three times.
The test should be first performed on the patients
good (non-painful) knee so that they can get a
sense of the amount of flexion and the general feel
of the test.
The test should then be performed on the patients bad (painful)
knee.
The test findings are abnormal if the patients pain is reproduced (i.e., pain
on the medial or lateral joint lines or if there is a sensation of locking or
catching).
66
Patellar apprehension test.

o With the patient supine and their quadricep muscles relaxed, gently push the
patella laterally while slowly flexing the knee.
o The test findings are abnormal if the patient reports a feeling of their kneecap
popping out or contracts their quads (easier to feel if your hand
is placed on their quads.
67
Hip and Thoracolumbar Spine Exams

Session 8 Course 2
OBJECTIVES for HIP EXAM

Describe the surface anatomy of the hip.
Anterior superior iliac spine.
Posterior superior iliac spine.
Pubis symphysis.
Inguinal ligament.
Iliac crest.
Greater trochanter.
Trochanteric bursa.
Assess gait.
Identify on inspection of the hip joints:
Differences between the joint symmetry.
Normal alignment.
Misalignment/deformities.
Related muscle wasting.
Related muscle hypertrophy.
Scars.
Redness.
Swelling/masses.
Discoloration/bruising.
Inspect for:
Levelness of the iliac crests.
Abductor weakness (Trendelenburg sign).
Measure:
True leg length.
Apparent leg length.
Quadriceps circumference.
Along the inguinal ligament.
Inferior to the inguinal ligament.
Over the greater trochanter.
Over the anterior superior iliac spine.
Over the posterior superior iliac spine.
Over the sacro-iliac joints.
Flexion.
Extension.
Abduction.
Adduction.
Demonstrate the evaluation of the following passive range of motion:
Flexion.
Extension.
Abduction.
Adduction.
Internal rotation.
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External rotation.
Demonstrate the evaluation of muscle strength of:
Hip flexors.
Hip extensors.
Hip abductors.
Hip adductors.
Demonstrate special tests:
Thomas test.
Modified Thomas test.

necessary to:
during Course 5).
Inspection:
Comment on surface anatomy of the hip joint by identifying:
o Anterior superior iliac spine.
o Posterior superior iliac spine.
o Pubis symphysis.
o Inguinal ligament.
o Iliac crest.
o Greater trochanter.
o Trochanteric bursa.
69
Observe gait.
o Look at and comment on posture, balance, swinging of arms, movement of the
legs, smoothness of turns.
o
Types of gait:
excessively over the hip that is firmly planted on the ground (i.e. the centre
of gravity is kept over the stance leg) while the other side of the body, leg
and upper body, swing forward. This gives the appearance of the patient
lurching one side of their body to move forward.
Ataxic: an unsteady, uncoordinated walk,
employing a wide base and the feet thrown
out. Is often due to cerebellar disease, loss of
position sense, or intoxication.
Trendelenburg sign.
o Tests for abductor weakness.
o Have the patient stand on one foot.
The iliac crests should stay level.
If there is gluteus medius weakness, the
pelvis will sag towards the non-weightbearing
side.
Assess levelness of iliac crests.

o Unequal heights of the iliac crests (i.e., a pelvic tilt)
suggest unequal lengths of the legs and disappear when a block is placed under
the short leg.
o
Scoliosis and hip abduction or adduction may also cause a pelvic tilt.
Leg lengths.
o From anterior superior iliac spine (ASIS) to medial malleolus (true leg length).
Best done when patient is supine.
Seen in abduction or adduction deformities and scoliosis.
A short and externally rotated leg suggests a hip fracture.
o From umbilicus to medial malleolus (apparent leg length).
o It is important to distinguish true leg length discrepancy from apparent leg length
discrepancy. True leg length discrepancy points to a hip problem on the shorter
side. On the other hand, an apparent leg length discrepancy is usually due to the
tilting of the pelvis.
Measure quadriceps circumference bilaterally.
70
Palpation:
Inguinal ligament tenderness.
o With the patient supine and the heel resting on the
opposite knee, palpate along the inguinal ligament for
tenderness.
Iliopsoas bursitis.
o To detect, palpate below the inguinal ligament.
Trochanteric bursitis.
o To detect, palpate over the greater trochanter.
Range of Motion:
Flexion
o With the patient supine, place your hand under the patients lumbar spine. Ask
patient to bend each knee in turn to the chest and pull it firmly against the
abdomen.
Note when the back touches your hand, indicating normal flattening of the
lumbar lordosis. Any further flexion must arise from the hip joint itself.
o Test both active and passive range of motion.
Extension
o With the patient lying on their side, ask them to extend the thigh backward.
Abduction
o Stabilize the pelvis by pressing down on the opposite ASIS with one hand.
o With the other hand, grasp the ankle and abduct the extended leg until you feel
the iliac spine move.
Restricted hip abduction is common in hip osteoarthritis.
Adduction
o Stabilize the pelvis, hold one ankle, and move the leg medially.
When testing this movement passively it is helpful to abduct the other leg
so that you do not have to change the plane of movement when crossing
the midline
Internal rotation
o Flex the leg to 90o at the hip and knee. Stabilize the thigh with one hand, grasp
the ankle with the other, and swing the lower leg laterally for internal rotation.
o Test only passive range of motion.
71
External rotation
o Flex the leg to 90o at the hip and knee. Stabilize the thigh with one hand, grasp
the ankle with the other, and swing the lower leg medially for external rotation.
o Test only passive range of motion.
Strength Testing:
Easiest to do while doing ROM exams:
o Flexion
o Extension
o Abduction
o Adduction
Special Tests:
Thomas test
o In flexion deformities, when flexing the good hip to
the chest, the bad hip will begin to flex, not allowing
that leg to lay flat. This is called a flexure-contracture.
o The patient is supine, with his pelvis level and square
to his trunk. Stabilize the pelvis by placing your hand
under the patients lumbar spine. Have the patient flex
both his hips, bringing his thighs up onto his trunk.
Have the patient hold one leg to his chest and let his
other leg down until it is flat on the table. If the thigh
rises off the table, the test is positive for a hip flexion
contracture.
This test does not differentiate between
tightness of the iliopsoas versus the rectus femoris.
A flexion deformity may be masked by an increase, rather than a
flattening, in lumbar lordosis and an anterior pelvic tilt.
Modified Thomas test
o This utilizes the same patient position as for the Thomas Test, but
in addition, the patient scoots down the table until his knees are
approximately four inches over the edge. Have the patient
perform the maneuver for the Thomas Test. If the thigh rises off
the table, attempt to flex the knee on that side.
If the knee flexes easily, the tight hip flexor is the iliopsoas
(positive test for iliopsoas). If you are unable to flex the
knee, or resistance is felt, the rectus femoris is tight
(positive test for rectus femoris).
72
OBJECTIVES for THORACOLUMBAR SPINE EXAM

Assess gait.
Inspect thoracolumbar spine for:
Lordosis.
Scoliosis.
Kyphosis.
Swelling/masses.
Redness.
Muscles spasms.
Scars.
Levelness of iliac crests.
Inspect for abductor weakness (Trendelenburg sign).
Paraspinal muscles.
Spinous processes.
Interspinous ligaments.
Sacroiiliac joints.
Sciatic nerve exit.
Bursa
Trochanteric.
Ischial.
Palpate for tone of paraspinal muscles.
Percuss the spine for tenderness.
Flexion.
Extension.
Lateral flexion.
Rotation.
Test strength of nerve roots:
L1-2.
L2-3.
L3-4.
L4-5.
L5.
L5-S1.
S1.
Test sensation of nerve roots:
L4.
L5.
S1.
Test reflexes:
Patellar.
Achilles.
Describe the technique to assess for saddle paresthesia (seen in Well Man subunit).

73
Describe the technique to assess anal reflexes (seen in Well Man sub-unit).
Describe the technique for the DRE (seen in Well Man sub-unit).
Demonstrate special tests:
Modified Schobers.
Straight leg raise.
Crossed straight leg raise.
Sacroiliac stress.

necessary to:
during Course 5).
Standing
Inspection:
Spinal curvatures:
o Comment on lordosis, scoliosis, kyphosis.
Swelling/masses, redness, muscles spasms, scars.
Levelness of iliac crests.
Trendelenburg sign.
o Tests for abductor weakness.
o Have the patient stand on one foot.
The iliac crests should stay level.
If there is gluteus medius weakness, the
pelvis will sag towards the nonweightbearing side.
Palpation:
Paraspinal muscles for tenderness and tone.
Spinous processes for tenderness.
Interspinous ligments for tenderness.
Sacroiliac joints for tenderness.
Percussion:
Percuss the spine for tenderness by thumping (not too hard!) with the ulnar aspect of
your fist.
74
Range of Motion:
Flexion.
o Make sure that the patients knees remain straight during this test.
o Can measure the distance between the fingertips and the floor.
o Note the smoothness and symmetry of movement.
As flexion proceeds, the lumbar concavity should flatten out.
A persisting lumbar lordosis is suspicious for muscle spasms or ankylosing
spondylitis.
Extension.
o Place your hand on the posterior superior iliac spine to give your patient some
support.
Lateral flexion.
o Fingertips should easily reach the level of the knees if no abnormalities.
Rotation.
o Make sure that the knees are straight, feet stay together, and hips remain facing
forward.
o Can also be checked with patient sitting, as this prevents unwanted movement of
the hips/pelvis.
Walking
Inspection:
Observe gait.
legs, smoothness of turns.
o
Types of gait:
or intoxication.
Strength Testing:
o L3-4 deep knee bend (squatting) (quadriceps).
o L5 heel-walking.
o L5-S1 hip extension (gluteus maximus).
o S1 toe-walking.
75
Sitting
Inspection:
Take note of patients ability to get on
and off the table (e.g., no problems,
requires help, seems to be
uncomfortable, and so on).
Palpation:
Test sensation of nerve roots:
o L4 medial malleolus.
o L5 first dorsal web space.
o S1 little toe.
Strength Testing:
o L1-2 hip flexors.
o L2-3 hip adductors.
o L4-5 hip abductors.
Reflexes:
L3-4 patellar reflex.
S1 Achilles reflex.
Do not forget to demonstrate how you
would elicit reflexes in someone who
was not able to relax.
Lying on Side
Palpation:
Identify the following locations and palpate for tenderness:
o Sciatic nerve exit (in buttocks).
o Bursas:
Trochanteric.
Ischial.
Describe the technique to assess for saddle
paresthesia. (seen in Well Man sub-unit).
Describe the technique to assess anal reflex, also
called anal wink. (seen in Well Man sub-unit)
Describe the technique for a DRE. (seen in Well
Man sub-unit)
76
Special Tests:
Modified Schobers test.
o Used to assess spinal motion of the lower back.
o Use a pen to mark the midpoint between the dimples of
Venus (or can also use the posterior superior iliac spine).
Then use a tape measurer to identify and mark two
points: (1) one point is 10 cm superior to the dimples of
Venus point, and (2) one point that is 5 cm inferior to the
dimples of Venus point. Have the patient flex forward as
far as possible. Measure and record the distance
between the superior and inferior points.
Make sure that the patients knees remain straight
during this test.
o If the distance between the two points is less than 20 cm,
you should suspect that the flexion of the lower back is
limited.
Straight leg raise test.

o Commonly used to check for disc protrusion
impinging on nerve roots.
o With patient laying supine, passively flex the hip
while keeping the knee straight on the side where
the pain is felt. Stop when patient reports feeling
pain. Slowly start lower leg until pain resolves.
When pain has resolved, remain at that level and
passively dorsiflex the foot.
This test can also be performed with the
patient sitting down, but this decreases the
sensitivity of the test.
o Pain felt shooting down the affected leg in these
positions is an abnormal finding.
77
Crossed straight leg raise test.

o Usually used in conjunction with the straight leg raise test to confirm the presence
of a lumbar herniated disc.
o With patient laying supine, passively flex the hip while keeping the knee straight
on the side opposite to the side where the pain is felt.
o Pain felt shooting down the affected leg (i.e., not the one in the air) is an abnormal
finding.
Sacroiliac stress test.

o Compression of the pelvis at the level of the SI joints.
78
Jugular Venous Pulse Exam

Session 9 Course 3
OBJECTIVES for JUGULAR VENOUS PULSE EXAM

Demonstrate the evaluation of:
Peripheral palpable blood pressure. (seen in Year 1 Session 1)
Auscultatory blood pressure. (seen in Year 1 Session 1)
Demonstrate positioning for assessment of the jugular venous pressure.
Identify surface anatomy of the course of the internal jugular vein.
Identify characteristics and demonstrate maneuvers that differentiate the jugular
venous pulse from the carotid pulse.
Biphasic waveform.
Occludable.
Not palpable.
Changes with respiration.
Changes with position.
Changes with hepatojugular reflux.
Demonstrate the technique to visualize the shadows of the jugular venous pulsation
with tangential light.
Measure the jugular venous pressure.
Demonstrate and explain the hepatojugular reflux.
Be aware of the characteristic waves and slopes of the jugular venous pulse.
Be aware of the physiologic determinants of the normal waves and slope of the
jugular venous pulse.
Describe the Kussmauls sign.
Review how to evaluate peripheral

palpable blood pressure and
auscultatory blood pressure.
o Refer to notes in Session 1
(Year 1).
Recall: the jugular venous pressure is a

direct manometer of right ventricular
end-diastolic pressure.
Positioning
Approach the patient from their right
side as you will be examining the right
side of their neck.
Start by positioning the bed at 30o to
45o.
Turn patients head slightly to the left.
Raise or lower the head of the bed to
improve viewing if necessary.
o Patients who are very
dehydrated may need to have the head of the bed lowered.
79
o Patients who are in congestive right-sided heart failure or have some types of
pericardial disease may need to have the head of the bed further elevated.
Inspection
Look between the two heads of the sternocleidomastoid for a pulsation.
o The shadows of the pulsation can be visualized by shining a light tangentially
across the patients neck.
The internal jugular vein courses from just lateral of the sternal notch, behind and
between the two heads of the sternocleidomastoid muscles, and toward the angle of the
jaw.
Differentiating
The jugular venous pulse can be differentiated from the carotid artery.
Jugular Pulse
Generally not palpable
Biphasic
Occludable
Changes with respiration ( with inspiration)
Changes with positioning ( in height when sitting up)
Transiently in height with hepatojugular reflux
80
Carotid Pulse
Palpable
Single wave form
No effect
No effect
No effect
No effect
Measuring
The jugular venous pressure can be determined by measuring the vertical distance from
the sternal angle to the top of the internal jugular wave form.
o Position a ruler on the sternal angle, perpendicular to the floor.
o Draw a straight line, parallel to the floor, from the top of the JPV column to the
ruler placed on the sternal angle.
Normal height measured should be 3 cm.
FYI: we measure from the sternal angle as it is a stable
landmark.
o Sternal angle is located on average 5 cm above the
midpoint of the right atrium.
o Hence, you can calculate the pressure in the right
atrium by:
Pressure in right atrium = JVP + 5 cm
Normal pressures in the right atrium are 6-9 cm
H2O.
Hepatojugular Reflux
Also known as the abdominal-jugular reflex.
Ask the patient to breathe normally with their mouth open.
o This prevents a Valsalva maneuver.
Ensure that the patient does not have any tenderness in the abdomen.
Place your right hand over the liver in the right upper quadrant/epigastrium region.
Apply moderate pressure and maintain the compression until you can see the JVP fall
back down or for 15 seconds.
o Moderate pressure means 25-30 mmHg. If you are uncertain how much pressure
that is, inflate a blood pressure cuff, put it on a hard surface, and compress it with
your hand.
The JVP normally rises transiently.
o Should return to normal level within 10
seconds or two respiratory cycles.
o A sustained elevation (>4 cm) for over
10 seconds is pathological.
Waves and Slopes

a wave right atrial contraction.
o Heart sound S1 occurs with a (and c)
wave.
x descent right atrial relaxation ( in pressure).
c wave tricuspid valve closure.
o c wave is normally so small that it is not visible to the
naked eye.
|
x descent descent of the base of the heart.
v wave right atrial filling (from vena cava).
o Heart sound S2 occurs with v wave.
y descent opening of tricuspid valve.
81
Kussmauls Sign
Is the rise of JPV with inspiration.
o Recall that JPV normally decreased with inspiration because of reduced pressure
in the expanding thoracic cavity.
Suggests impaired filling of the right ventricle.
o This could be due for example because of fluid in the pericardium or poor
compliance of the pericardium or myocardium.
82
Respiratory Exam
Session 10 Course 3
OBJECTIVES for RESPIRATORY EXAM

Inspect for and comment on normal respiratory pattern.
Rate.
Rhythm.
Depth.
Symmetry.
Observe for and comment on signs of respiratory distress.
Stridor.
Wheezing.
Hoarse voice.
Inability to speak in full sentences.
Central cyanosis.
Peripheral cyanosis.
Accessory muscles.
Nasal flaring.
Scalene retractions.
Sternocleidomastoid use.
Indrawing.
Suprasternal.
Intercostal.
Subcostal.
Suprasternal notch/tracheal tug.
Inspect for:
Position of trachea.
Pectus excavatum.
Pectus carinatum.
Barrel chest.
Scoliosis.
Kyphosis.
Pallor.
Nail clubbing.
Nicotine stains.
General wasting.
Inspect for and explain paradoxical breathing.
Palpate chest for:
Tenderness.
Rubs.
Crepitus.
Tactile vocal fremitus.
Expansion.
Comment on expansion.
Comment on symmetry.
Hoovers sign.
83
Percuss chest:
Anterior.
Lateral.
Posterior.
Comment on dullness.
Comment on hyperresonance.
Demonstrate and explain how to check for diaphragmatic excursion.
Auscultate chest:
Anterior.
Lateral.
Posterior.
Identify and localize normal sounds.
Tracheal.
Bronchial.
Bronchovesicular.
Vesicular.
Comment on sounds.
Symmetry.
Quality.
Comment on adventitious sounds.
Wheezes/rhonchi.
Crackles/rales.
Rubs.
Demonstrate special tests.
Egophony.
Whispering pectoriloquy.
Positioning and Draping:

Patient should be sitting on either the exam table or a chair.
Patient should be exposed to the waist so that the anterior, lateral and posterior aspects
of the chest can be inspected.
o Female patients can be uncovered intermittently, as needed, during the course of
the examination.
Inspection:
With the patient at rest, inspect and comment on their normal respiratory pattern.
o Rate.
Assess the respiratory rate by counting the number of breaths taken in a
minute.
Count for at least 30 seconds and multiply by two to determine
breaths per minute.
Normal rate averages about 12-16 breaths per minute.
The respiratory rate is typically measured while appearing to be doing
something else (e.g. taking the pulse) so the patient is unaware that it is
being measured.
This is because respiratory rate is the only vital sign which in under
voluntary control.
84
Tip: if you place the patients arm across the chest while palpating pulse,
you can also count respirations. Just keep your fingers on the pulse even
after you have finished taking it.
o Rhythm.
o Depth.
o Symmetry.
The chest movements should be symmetrical.
Listen for abnormal sounds. (Click here for breath sounds.)

o Stridor.
High-pitched musical sound usually heard on inspiration due to an
obstruction of the trachea.
Mild stridor.
Severe stridor.
o Wheezing.
High-pitched whistling sound usually heard on expiration and due to
narrowed airways.
Mild wheeze.
Severe wheeze.
o Hoarse voice.
o Inability to speak in full sentences.
Observe the patient for signs of respiratory distress.

o Central cyanosis.
o Peripheral cyanosis.
o Accessory muscle use.
Nasal flaring.
Scalene retractions.
Sternocleidomastoids
o Indrawing.
Suprasternal.
Intercostal.
Subcostal.
Suprasternal notch/tracheal
tug.
Inspect the chest for:

o Position of the trachea.
o Pectus excavatum.
Latin for hollowed chest.
o Pectus carinatum.
Latin for pigeon chest.
Sternum protrudes forward.
o Barrel chest.
Increased anterior-posterior diameter.
Associated with emphysema.
o Scoliosis.
Spine is curved from side to side.
o Kyphosis.
Hunchback.
85
Inspect for chronic signs of lung disease.

o Pallor.
o Nail clubbing.
Loss of the Schamroth sign,
which is the diamond shape
usually created when two fingers
are held together.
o Nicotine stains.
Hands/nails.
Teeth.
o General wasting.
o Paradoxical breathing.
The abdomen should distend (diaphragm goes
down) when patient takes a breath in, and
deflate (diaphragm goes up) as patient
expires.
Paradoxical breathing is seen when the
diaphragm moves in the opposite direction
than expected, leading the patient to distend
their abdomen as they breathe out and deflate
it as they breathe in.
Associated with chronic obstructive lung
disease.
Palpation:
Palpate the patients chest for:
o Tenderness.
o Rubs.
Feels like a roughness, a sandpaper rubbing type of sensation.
o Crepitus.
Crackling feeling.
Palpate for tactile vocal fremitus.

o Fremitus = palpable vibrations transmitted through the
chest wall when a patient speaks.
o Ask the patient to repeatedly say a phrase that causes a
palpable resonance in the chest (e.g., boy oh boy or
ninety nine or one).
o Use the ulnar surfaces of both hands to quickly
compare vibrations on both sides of the back and to
easily detect differences.
86
Check for chest expansion.

o Standing behind the patient, our hands
should grasp either side of the rib
cage, somewhere between the nipple
line and the umbilical line. Slide your
hands a little towards each other to
raise a bit of loose skin folds. Your
thumbs should be lifted slightly off the
chest, that way they can move freely
during inspiration. Ask the patient to
inhale deeply.
Normally, in healthy adults, the
thumbs should move
symmetrical apart at least 5 cm.
If one thumb moves more than
the other, this may indicate a lung
problem on the side that has reduced
expansion.
o An easier (and more accurate) way to measure chest expansion is to measure the
circumference of the patients chest at the nipple line (or just below for women) in
full expiration, and again at full inspiration. The difference between the two
measurements is the chest expansion.
Check for Hoovers sign.

o With the patient supine, place your hands along the costal margins with your
thumbs close to the patients midline. Ask the patient to breathe out and then
breathe in.
o Normally, as the patient breathings in, your thumbs would move apart and return
closer together when the patient expires.
o Suspect COPD (chronic obstructive pulmonary disease) if, when the patient
breathes in, your thumbs move even closer together.
The chest is usually overinflated and cannot expand normally with
inspiration. As the patient breathes in, the diaphragm pulls the ribs closer
together.
87
Percussion:
Percuss the patients chest moving from side to side and downwards:
o Anteriorly.
o Laterally.
o Posteriorly.
Comment on areas of:

o Dullness.
o Hyperresonnance.
Some percussion tips:

o Avoid percussing too close to
the vertebrae or over the scapula.
o When percussion posteriorly, have the patient cross their arms on their chest.
o Remember to percuss near the right axilla to check the right middle lobe, and
above the clavicles.
Check the diaphragmatic excursion.

o This is used to measure the movement of the diaphragm.
o Ask the patient to breath normally, and by percussion estimate the level of the
diaphragm.
o From this initial level, you will now find the
diaphragm level at expiration and inspiration.
Ask the patient to take a deep breath in
and hold it. From the initial level, percuss
downward to find the new level of the
diaphragm. Make a little mark.
Now ask the patient to take a deep breath
out and hold it. From the initial level,
percuss upward to find the new level of the
diaphragm. Make another little mark.
o Measure the difference between the two marks.
This is normally 5-6 cm.
Auscultation:
Ask the patient to breathe through their mouth and slightly more deeply than normal.
o If the patient breathes through their nose, sounds from the nasopharynx could be
transmitted and interfere with proper auscultation.
Use the diaphragm of your stethoscope.
Compare sounds from side to side, and moving downward.
Click here for breath sounds.
88
Auscultate the lung fields.

o Anteriorly
o Laterally.
o Posteriorly.
Identify and localize normal sounds.

o Tracheal.
Heard over the trachea.
Harsh, sound like air being
blown through a pipe.
Tracheal sound.
o Bronchial.
Heard anteriorly over the 2nd
and 3rd intercostals space,
over large airways.
Have a hollow, blowing
quality, loud, high pitched.
Bronchial sound.
o Bronchovesicular.
Heard posteriorly between the
scapulae and in the central
anterior chest, due to air moving through the bronchi/bronchioles.
Softer than bronchial sound, with a tubular quality.
Bronchovesicular sound.
o Vesicular.
Heard throughout the lung fields, due to air moving through the alveoli.
Have a soft, blowing quality.
Vesicular sound.
Comment on sounds.
o Symmetry.
o Quality.
Comment on adventitious sounds.

o Wheezes.
Also called ronchi.
Continuous musical sounds heard mainly on expiration and made louder
by forced expiration.
Mild wheeze.
Severe wheeze.
o Crackles.
Also called rales.
Can be fine or coarse.
Discontinuous sound as air passes over airway secretions.
Fine crackles.
Coarse crackles.
o Rubs.
Creaking and grating sounds (think: leather on leather).
Produced when two inflamed pleural surfaces rub against each other.
Pleural friction rub.
89
Special Tests:
If abnormalities are noted on percussion or auscultation, consider performing special
tests.
As a general rule, an area of consolidation tends to transmit sounds better than air-filled
lung, and air-filled lungs transmit sound better than an area filled with fluid (effusion).
o If you are having trouble remembering this, think of it this way:
When you are underwater (fluid) and want to talk to a friend who is sitting
underwater next to you, you need to talk very loudly and even then things
sound muffled and garbled.
When a train is coming down the tracks (consolidation), you can feel the
vibrations very strongly if you put your hand on the tracks.
Egophony.
o Ask the patient to say eeeeeee.
o You will normally hear a muffled long e sound.
o If you are listening over an area of consolidation or fluid, the sound will be heard
as ay.
For this reason, this test is sometimes referred to as the bleating goat
test.
o Egophony.
Whispering pectoriloquy.
o As the patient to whisper a phrase while you listen with the diaphragm of your
stethoscope over the area of concern.
o Normally, the whispered voice is barely/indistinctly heard if at all.
o In patients with a consolidation over the area, you will hear the phrase loud and
clear.
o Whispered pectoriloquy. (You will hear three sounds over consolidation, normal,
and over consolidation again.)
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91
Precordial Exam
Session 11 Course 3
OBJECTIVES for PRECORDIAL EXAM

Inspect for:
Deformities of the chest.
Scars.
Lifts/heaves.
Pulsations.
Apex beat.
Identify location of:
Aortic valve.
Pulmonary valve.
Tricuspid valve.
Mitral valve.
Palpate for:
Lifts/heaves.
Thrills.
Palpate for and characterize the apex beat.
Demonstrate two techniques to accentuate the apex beat.
Auscultate over:
Aortic valve.
Pulmonary valve.
Tricupsid valve.
Mitral valve.
Identify normal heart sounds (S1, S2).
Auscultate for extra/abnormal heart sounds:
S3.
S4.
Split S2.
Murmurs.
Opening snap.
Rubs.
Demonstrate techniques to accentuate murmurs.
Mitral murmur.
Aortic murmur.
Note location usual radiation of murmurs.
Mitral murmur.
Aortic murmur.
Inspect for, identify, and palpate carotid pulse.
Characterize carotid pulse in terms of rate, rhythm, amplitude and contour.
(seen in Year 1 Session 1)
Palpate for thrills.
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Inspection:
The patient must be uncovered to the upper abdomen so a full inspection of the
precordium can be performed.
o Female patients can be uncovered intermittently, as needed during the course of
the examination.
Inspect the anterior chest for:

o Deformities.
o Scars.
o Lifts/heaves.
o Pulsations (especially in the areas corresponding to the heart valves).
o Apex beat.
Usually located in the left 5th intercostals space, midclavicular line.
Identify location of heart valves. (Can also be done during auscultation.)

o Aortic valve.
Usually best heard in the 2nd intercostal space of the right sternal border.
o Pulmonary valve.
Usually best heard in the 2nd and 3rd intercostal spaces of the left sternal
border, but can extend even further.
o Tricuspid valve.
Usually best heard in the 4th intercostal space of the left lower sternal
border.
o Mitral valve.
Usually best heard at the apex (around the 5th intercostal space in the midclavicular line).
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Palpation:
Palpate for:
o Lifts/heaves.
A lift/heave is a large movement, usually associated with conditions such
as right ventricular hypertrophy.
Best felt with either the ulnar aspect or the heel of the hand along the left
sterna border.
o Thrills.
A thrill is a palpable (small) vibration caused by turbulent blood flow.
Best felt with fingertips over the valve areas.
Palpate for the apex beat.

o Is only palpable in 30%-50% of adults in the supine position.
In a female with large breasts, you can ask her to move the left breast
upwards or to the left if necessary.
o If palpable, describe in terms of:
Location.
Size
It is usually smaller than a Canadian quarter (< 2 cm) if palpated
supine.
Impulse.
Monophasic vs. biphasic.
Amplitude.
Duration.
Usually lasts less than 2/3 of systole.
o If unable to palpate the apex beat, can try to accentuate it by:
Asking the patient to roll unto their left side.
If palpable, characterize as per above. Remember that when the
apex beat is palpated while the patient is lying on their side, its
diameter is often <4 cm.
Asking the patient to exhale fully and stop breathing for a few seconds.
Percussion:
Percussion of the heart area is not done on routine precordial exams.
However, it can be useful with certain conditions.
o Dullness is increased with a pericardial effusion.
o Dullness is decreased in COPD.
Auscultation:
Hint: in real life, but certainly for an exam, you may want to consider auscultating the
precordium with the patient laying supine, laying on his left side, and sitting up while
leaning forward.
Click here to listen to heart sounds.
Auscultate for S1 and S2.
o S1 is the sound made by the closure of the atrioventricular (AV) valves (the mitral
and tricuspid).
o S2 is the sound made by the closure of the aortic and pulmonic valves.
o To distinguish between S1 and S2, time the sounds with the carotid pulse (check
for carotid bruits first!). S1, pulse, S2.
o Auscultate over all 4 valve areas with the diaphragm of your stethoscope.
Most clinicians will start at either the apex or the base of the heart.
94
o Normal heart sounds.
Auscultate for S3 and S4.

o S3 and S4 are low frequency abnormal diastolic sounds. They occur when there
is rapid ventricular filling.
An S3 occurs early in diastole.
An S4 occurs as the atria contract (late in diastole), during the atrial kick.
Placing the patient in left side accentuates S3 and S4.
o Auscultate at the apex and along the left lower sternal border with the bell of your
stethoscope.
Use the beLL when wanting to hear LLow sounds, such as S3/S4 or
murmurs.
Do not press on your stethoscope. In fact, it is best if you just place it on
the chest and leave it there.
If you press the bell firmly, the skin acts as a diaphragm and the
low-pitch sounds disappear (you can use this technique to make
sure that you really are hearing an S3, S4).
The S3 sound has a gallop rhythm. You can sing (in your head!) the words
Ken-tu-cky or slosh-ing-in to it.
Slosh-ing-in is a reminder of the physiology behind the sound:
blood flowing into an overfilled, non-complaint left ventricle suddenly
decelerates.
The S4 sound has a triple gallop rhythm. You can sing (again, in your
head only!) the words Ten-ne-ssee or a-stiff-wall.
A-stiff-wall is a reminder of the physiology behind the sound: blood
pushed by the atrial contraction hit a ventricle that is abnormally stiff
due to hypertrophy or fribrosis.
o S3 and S4 can be heard in healthy young athletes without any heart problems.
o S3.
o S4.
Auscultate for other heart sounds.
o Split S2.
S2 normally splits with inspiration, and when it does, the dup sound of S2
now sounds like drup.
Splitting is best heard with the diaphragm in the pulmonary valve area, but
can be appreciated in only about 50% of healthy adults.
Split S2.
o Murmurs.
Are best heard with a bell.
A murmur should be defined by its:
Location.
Radiation.
Timing in the cardiac cycle.
Intensity (grade from I to VI).
o Grade I can only be
heard with careful
listening.
o Grade II audible.
o Grade III louder than a grade II murmur.
o Grade IV as loud as a grade III murmur but also has a thrill.
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o Grade V can be heard when only the edge of the

stethoscope touches the chest.
o Grade VI can be heard without stethoscope.
Pitch.
Quality (e.g., harsh, blowing, rumbling, musical).
Shape (e.g., crescendo, decrescendo, etc).
Things that alter it (respiration, exercise, hand grip, squatting,
valsalva, etc.)
Do not worry if you cannot identify all of these characteristics at first! Start
by concentrating on just hearing the murmurs, identifying their location,
radiation and guessing their intensity. When you are feeling more
comfortable with hearing murmurs, you will also want to determine their
timing in the cardiac cycle.
Benign (innocent) murmur.

Mitral regurgitation.
Mitral stenosis.
Pulmonic stenosis.
Aortic insufficiency.
Early aortic stenosis.
Late aortic stenosis.
Patent ductus arteriosum.
To accentuate murmurs:
For aortic murmurs, you can ask the patient to sit up, lean forward,
exhale completely and stop breathing at the end of expiration.
For mitral murmurs, you can ask the patient to roll unto their left
side.
Radiation of murmurs:
Aortic murmurs radiate to the carotids.
Mitral murmurs radiate towards the axillary line.
o Opening snap.
High-pitched sound (use the diaphragm) that occurs in mitral stenosis due
to the sudden opening of the mitral valve.
Opening snap.
o Rubs.
High pitched (use the diaphragm), scratchy sound caused by pericardial
inflammation.
Best heard along the left lower sternal border with the patient sitting up,
leaning forward and briefly holding their breath.
Pericardial rub.
96
Carotid Artery:
Inspect for neck pulsations just medial to the sternocleidomastoid muscles.
Place your fingers on the right carotid artery in the lower third of the neck, press
posteriorly and feel for the pulsations.
o Avoid pressing on the carotid sinus which lies at the level of the thyroid cartilage.
o Never press on both carotids at the same time!
o Describe the carotid pulse in terms of: (refer to Year 1 Session 1)
Rate.
Rhythm.
Amplitude.
Contour.
o Feel for thrills.
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Peripheral Vascular Exam

Session 12 Course 3
OBJECTIVES for PERIPHERAL VASCULAR EXAM

Inspect the lower limbs.
Color.
Hair distribution.
Skin thickness.
Ulcerations.
Varicosities.
Edema.
Scars.
Muscles wasting.
In between toes.
Nail growth and appearance.
Describe differences in signs of arterial and venous insufficiencies.
Skin color.
Skin thickness.
Hair distribution.
Edema.
Ulcerations.
Insufficiency changes.
Palpate for:
Temperature.
Capillary refill.
Edema.
Measure calf circumference.
Identify the point of palpation of the peripheral arteries.
Radial.
Brachial.
Abdominal aorta.
Femoral.
Popliteal.
Dorsalis pedis.
Posterior tibial.
Identify and describe the features of the arterial and brachial pulses.
Rate.
Rhythm.
Symmetry.
Amplitude.
Contour.
Identify and describe the symmetry and amplitude of the following pulses.
Abdominal aorta.
Femoral.
Popliteal.
Dorsalis pedis.
Posterior tibial.
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Demonstrate and explain the technique to assess for a radial-femoral delay.

Demonstrate the correct technique for evaluation of: (seen Year 1, Session 1)
The peripheral palpable blood pressure.
The auscultatory blood pressure.
Demonstrate and explain the technique for identifying pulsus paradoxus. (seen Year
1, Session 1)
Auscultate the peripheral arteries.
Brachial.
Abdominal aorta.
Renal.
Iliac.
Femoral.
Comment on bruits in peripheral arteries.
Identify the surface anatomy of the saphenous veins.
Arterial insufficiency.
Upper extremities Allens test.
Lower extremities Straight leg raise and refill test.
Venous insufficiency.
Lower extremities Incompetent saphenous vein test.
Inspection:
Inspect the lower limbs for:
o Color.
E.g., pallor, cyanosis, redness (rubor), brown
discoloration.
The brown discoloration occurs when
hemosiderin (ferric oxide left from the
breakdown of extravasated hemoglobin)
deposits in the dermal layer. It is
associated with chronic venous insufficiency.
o Hair distribution.
In arterial insufficiency, there is often decreased hair on the
lateral aspect of the legs.
Diabetics often lose hair on their big toes.
o Skin thickness.
Skin thickening vs. skin thinning vs. normal thickness.
o Ulcerations.
In arterial insufficiency, ulcers often appear on toes and
heels.
In venous insufficiency, the ulcers are often located around
the medial malleoli. They are usually shallow and painless.
Pay especially close attention to the foot of a patient who
has lost or altered sensation in their feet (e.g., diabetics).
These patients will often be unaware of ulcers as they
simply cannot feel them.
o Varicosities.
o Edema.
o Scars.
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These can give you a hint as to other vessel-related problems in the body.
Vessels from the legs are sometimes used for heart bypass
surgeries.
Bypass surgeries for obstructions in the legs can also be
performed.
o Muscle wasting.
Muscles rely on a good blood supply to keep health.
Patients can develop pain when walking/exercising due to
vascular insufficiencies in the leg. They tend to avoid moving too
much in an effort to avoid pain.
o In between toes.
It is important to look for fungal infections and broken down skin
in between toes. Such poor conditions can lead to skin infections and
ulcers.
o Nail growth and appearance.
Comparison of signs of arterial and venous insufficiency.

Arterial Insufficiency
Venous Insufficiency
Skin colour
Pallor
Brown discoloration
Skin thickness
Thin skin
Thick skin
Hair/Edema
Decreased hair laterally
Pitting edema
Ulceration on toes and
Ulcers (medial malleoli), shallow
Ulcerations
heels
and painless
Insufficiency
Rubor with dependency
Stasis dermatitis*
changes
* Stasis dermatitis is the earliest skin change of chronic venous
insufficiency. It is most notably characterized by a brown discoloration
(see above).
Palpation:
Temperature.
o Run the back of your hand down both legs simultaneously, thus allowing you to
compare both sides at once.
o Temperature normally slightly decreases when moving distally.
Check capillary refill time.

o Press on a nail (toes or fingers) until it turns white then let go.
o Assess how long it takes for the pink color to return.
o Normally, the pink color should return within 3 seconds or less.
Assess for edema.

o Differentiate between pitting and non-pitting
edema.
Non-pitting edema is usually
associated with lymphedema.
o To palpate, press on the anterior tibia (shins)
and look for pitting depressions where you
pressed down.
Start looking for edema at the ankle
and move your way up the leg. Note
the highest level at which edema is
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noted.
If patient is bed-ridden, make sure to check for edema on coccyx.
Measure calf circumference.

o In order to measure the circumference at the same level, measure a predetermined distance below the tibial tuberosities on both legs.
o Up to 2 cm difference in calf circumference can be normal.
o Only 1 cm difference in leg circumference is allowed at the level of the ankles.
Palpate the following arteries:

o Radial.
Best felt just medial to the radius, usually using the tips or pads of your
index and middle fingers.
o Brachial.
Best felt in the antecubitcal fossa
(inside of elbow).
o Abdominal aorta.
Best felt midline, just above the
umbilicus.
If possible, try to estimate the diameter
between your fingers.
A lateral pulsation indicates a possible
aneurysm.
o Femoral.
Best felt at mid-inguinal point, lateral
corner of pubic triangle.
o Popliteal.
Easier to feel if knee is slightly bent,
thumbs are placed on tibial tuberosities,
and all other eight fingers dig into the back of the knee. It is usually located
laterally.
o Dorsalis pedis.
Best felt lateral to the extensor tendon of the big toe.
Is absent in 10-15% of normal people.
o Posterior tibial.
Best felt slightly behind and below the medial malleolus.
For the radial and brachial arteries, comment on: (seen in Year 1, session 1)
o Rate.
Bradychardic vs. normal vs. tachychardic.
o Rhythm.
Regular vs. regularly irregular vs. irregularly irregular.
o Symmetry.
Compare both sides.
o Amplitude.
Absent vs. decreased vs. normal vs. increased vs. bounding.
o Contour.
Describe the wave form.
For all the other arteries, comment on:

o Symmetry.
101
o Amplitude.
Assess for a radial-femoral delay.

o Normally, the femoral pulse occurs slightly before the radial pulse.
o A radial-femoral delay happens when blood flow to the descending aorta depends
on collateral vessels. In such a case, the radial pulse is felt before the femoral
pulse.
Evaluate the peripheral palpable blood pressure. (seen Year 1, Session 1)
Auscultation:
Evaluate the auscultatory blood pressure. (seen Year 1, Session 1)
Demonstrate and explain the technique for identifying pulsus paradoxus. (seen Year 1,
Session 1)
Auscultate the following arteries:

o Brachial.
Easiest to hear in the antecubital
fossa.
o Abdominal.
Easiest to hear midline above the
umbilicus.
o Renal.
Easiest to hear 5 cm above
umbilicus and 3-5 cm to either
o Iliac.
Easiest to hear just below the
umbilicus and 3-5 cm to either side
of the midline.
o Femoral.
Easiest to hear at mid-inguinal
point, at the lateral corner of the
pubic triangle.
Comment if any bruits are heard.
Special Tests:
To assess for arterial insufficiency:
o In upper extremities Allens test.
Ask the patient to make a tight fist and elevate
it to drain it of all blood.
Occlude the radial and ulnar arteries. Lower
the patients hand.
Ask the patient to open their hand. The palm
should be pale.
Release the pressure on either the radial or
the ulnar artery.
You would normally expect the palm to redden
within seconds (<5 secs).
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If the palm does not redden within seconds, this suggests an arterial
insufficiency.
If the refill time is different after releasing the radial artery than after
releasing the ulnar artery, this suggests an occlusion of the slower
of the two arteries.
If the time is delayed equally for both the ulnar and radial arteries,
this suggests a more proximal occlusion.
If there is no return of colour to the hand after releasing the ulnar
artery (which continuing to compress the radial artery), this indicates
that there is no connection between the deep and superficial palmar
arches.
o In lower extremities Straight leg raise and refill test.

With the patient supine, raise both legs to 45o-60o for about 30 seconds or
until pallor of the feet develops.
This is a difficult test for patients, so be considerate and hold the
legs/feet up for the patient.
If the patient complains of pain at this stage, suspect arterial
insufficiency.
Then ask the patient to sit up and dangle both legs over the side of the
bed.
The natural pink coloring should return to
the feet within 10 seconds normally.
You should also be able to see the
superficial veins of the foot fill within
15 seconds.
If the pallor in the feet persists for more than
10 seconds, suspect arterial insufficiency.
If the feet develop a dusky cyanotic colour
(called rubor) when dangling, this suggest
arterial insufficiency as well.
This is why this test is also sometimes called rubor on dependency
test.
The rubor is called reactive hyperemia. It is due to the dilation of
vessels distal to the occlusion. Then the occlusion is released,
blood flow is greatly increased from normal, producing the red
coloring.
103
To assess for venous insufficiency:

o In lower extremities Incompetent saphenous vein test.
The greater saphenous vein originates from the femoral
vein. It then descends on the anterior thigh towards the
medial aspect of the knee, and then descends towards
the dorsal venous arch of the foot.
Ask patient to stand. Any dilated varicose veins will
become obvious.
Compress the vein proximally with one hand and place
the other hand 15-20 cm away.
Briskly compress and decompress the proximal site.
Normally the hand at the distal site should not feel an
impulse.
Any impulse that is transmitted to the distal site
indicates incompetent saphenous valves between the
two sites.
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Sessions for year 2

Head and Neck Exam
Course 4
OBJECTIVES for HEAD and NECK EXAM

Demonstrate inspection of the head and face.
Demonstrate the inspection of the eye.
Palpebral fissure.
Globe position.
Eyelid.
Lacrimal glands.
Sclera.
Palpebral conjunctiva.
Cornea.
Pupils.
Demonstrate tests for strabismus.
Demonstrate the fundoscopic examination.
Red reflex.
Disk.
Retinal vessels.
Retina.
Macula.
Demonstrate the examination of the external ear.
Inspection.
Palpation.
Demonstrate, using the otoscope, the inspection of the ear canal and tympanic
membrane.
Demonstrate the inspection of the external aspect of the nose.
Demonstrate, using an otoscope, the inspection of the internal aspect of the nose.
Demonstrate the examination of the sinuses.
Inspection.
Palpation.
Transillumination.
Demonstrate the examination of the mouth and oropharynx
Lips
Teeth
Gums
Breath
Tongue
Buccal mucosa
105
HEAD
Note any abnormalities or asymmetry in the head and face.
Hair
o Distribution
o Texture
o Patterns of loss.
Skin lesions head and face.
EYES
Inspection:
Palpebral fissure (area between opened upper/lower eyelids)
o Width
Normal
Increased (eg exophthalmos)
Decreased (eg enophthalmos)
Globe position (inspect from front and side)
o Protusion (Exopthalmos)
o Recession (Enopthalmos)
Eyelid
o Erythema
o Edema
o Rashes
o Crusting/discharge
o Skin lesions eg xanthelasma
Lacrimal gland (upper lid, lateral position)
o Erythema of overlying eyelid
Sclera (whites of the eye) and bulbar conjunctiva
(overlies sclera)
o Color: white, yellow, blue (osteogenesis
imperfecta), red (hemorrhage)
o Lesions
o Edema (aka chemosis)
106
Palpebral conjunctiva
o Inspect for colour (erythema with conjunctivitis, pallor with anemia)
Evert lower lid
Evert upper lid (especially if looking for foreign body)
Cornea
o Shine a penlight obliquely to look for
Scars
Abrasions
Ulcers
Foreign bodies
Arcus Senilis (white ring at the limbus [junction between cornea and
sclera])
o Fluorescein staining will be demonstrated in another module
Pupils
o Size
o Shape
Regular vs irregular
Round vs other
o Symmetry
If pupils unequal, termed anisocoria
Tests for Strabismus:

Alternate cover test
o Ask patient to fixate on an object at end of the room
o Cover left eye (with your right hand)
o Watch for fixation movement in right eye (if present, called strabismus or
heterotropia)
o Uncover left eye
o Cover right eye
o Watch for fixation movement in left eye
107
Fundoscopy
Please refer to the diagram below when reading the fundoscopy method text
Method
o Ask the patient to remover their glasses
o Ask the patient to look straight at distant object (eg corner of door frame)
o If examining patients right eye, take opthalmoscope in right hand and position in
front of your right eye (use left hand, left eye if examining patients left eye)
o Your free hand can be positioned on the patients shoulder for spatial orientation
o Dim room lights
o Hold opthalmoscope 15 cms and slightly to the right (25 degrees) from patients
right eye if examining that eye
o Select 0 on the lens selection disc; look at illuminated lens indicator to
ensure 0 is selected
o Using aperture selection dial, select small aperture; can increase later to large
aperture for a better view
o Look for red reflex (see significance below)
o Slowly move toward the patient; optic disk should come in view when the
examiner is 3-5 cm away from the patient
o If the disc is not focused clearly, use the lens selection disk to bring in to focus
The far sighted eye requires more plus lenses (green numbers)
The near sighted eye requires more minus lenses (red numbers)
o Once the disk is examined, move the light 2 disk diameters temporally to visualize
the macula
o Ask your patient to do following maneuvers to examine periphery
Look up (superior retina)
Look down (inferior retina)
Look temporally (temporal retina)
Look nasally (nasal retina)
108
Red reflex
o Present
o Black (eg cataract)
Optic disk
o Shape (normally round/oval)
o Color (normally red/orange)
o Physiologic cup: pale area on temporal side of the disc
Normal appearance
Papilledema
Retinal vessels
o Arteries: bright red with a central stripe (light reflex)
Note width of light reflex
o Veins
Differentiate for arteries
No light reflex
Size: veins larger in roughly 4:3 ratio
Color: veins are dark red
Pulsation: unless intracranial pressure is elevated, veins pulsate
Look for nicking of veins at arteriovenous crossings
Retina
o Scarring: white or presence of pigment
o Hemorrhages
o Exudates
Macula
o 2-3 disk diameters temporally from disk
o Fovea: smaller, dark red area within macula
Visual fields, visual acuity, papillary responses and extra-ocular movements are covered
Year 2, Course 5, Session 1.
109
EARS
External Examination
Inspect the auricle and surrounding areas
o Size
o Shape
Swelling
o Color eg erythema
o Deformities eg cauliflower ear
o Discharge
Serous
Purulent
Sanguinous
Palpation
o Pain
Without movement (chondritis)
With movement (otitis externa)
Internal inspection
Attach a speculum to a light otoscope
Use largest speculum that will fit
In adults, retract the auricle upwards and backwards
In infants and young children, exert downward traction on the auricle
BE GENTLE- the lining of the bony canal is very sensitive
Inspect the ear canal
o Swelling
o Erythema
o Foreign bodies
Cerumen is often present and may need to be removed to observe the
tympanic membrane (ear drum)
Inspect the tympanic membrane (ear drum)
o Light reflex
o Landmarks
Umbo or center of the light reflex
o Manubrium of malleus (hammer) extending upwards from umbo
o Definition of the manubrium (hammer)
Bulging renders indistinct/obscured
Retraction sharpens definition
o Perforations
110
o Color and sheen

Normal
Shiny and gray
Abnormal
Yellow (serum)
White or chalky (pus)
Blue (blood)
o Fluid- air bubbles
Hearing tests as well as labyrinthine tests are covered when Cranial Nerve VIII is studied in
Year 2, Course 5, Session 1.
NOSE
Nasal patency
Place your finger against one side of the nose to occlude it and ask the patient to
breathe in and out with mouth closed
Repeat on the other side.
External Appearance
Size
o Rhinophyma
Deformities
o Saddle nose
Discharge
Nasal flaring
Internal Appearance
Tools
o Otoscope with nasal speculum- most common tool
o Examiners fingers and light
o Vienna speculum (opens when you squeeze the handles)
Nasal mucosa
o Color
Ulcerations
Septum
o Deviation
o Perforation
111
Turbinates (inferior and middle)
o Swelling
o Color
o Discharge (from middle meatus as it drains frontal, maxillary and anterior ethmoid
sinuses)
o Polyps
SINUSES
Inspection:
Swelling over frontal/maxillary sinus area
Palpation:
Frontal
o Press your thumbs up under the bony brow on each side of the nose
Maxillary
o Press up under the zygoma with your thumbs.
Transillumination:
Frontal
Place light under nasal half of supraorbital ridge and look for a bright area in the
forehead
112
MOUTH AND OROPHARYNX

Lips
o Defects e.g. cleft lip
o Color eg cyanosis
o Lesions such as angular stomatitis, ulcers
o Examine inner aspect by retracting them with a gloved hand or tongue blade
Teeth
o Absence
o Shape eg notching
o Discoloration
o Caries
Gums
o Retraction of gum margin
o Inflammation/pus
o Bleeding gums
o Gingival hypertrophy
Breath
o Smell
Acetone (DKA)
Ammonia (Renal Failure)
Fetor (Cirrhosis)
NB There are many other breath odors in diseases or ingestions
Tongue
o With protusion, assess
Size
Deviation
Coat of tongue
Color
Thickness
o Inspect under surface of tongue
Frenulum
o Palpate tongue (inside mouth to ensure it is
relaxed)
Masses
Sublingual salivary glands
Submaxillary ducts
113
Buccal Mucosa
o Color eg cyanosis
o Lesions
Vesicles
Petechiae
Candida
Ulcers
o Orifice of parotid duct (opposite upper second molar)
Oropharynx
o Uvula
o Hard and soft palate
o Tonsils
Hyperplasia
Ulcers
Masses
Membrane
o Retropharyngeal area
Swelling
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Endocrine System
Course 4
OBJECTIVES for ENDOCRINE SYSTEM

Perform a general inspection.
Weight.
Stature.
Secondary sexual characteristics.
Hair.
Integument (skin).
Identify the thyroid using surface landmarks.
Inspect the neck and upper chest.
Goiter.
Erythema overlying thyroid.
Thyroidectomy scars.
Dilated veins upper chest wall.
Differentiate goiter from other midline cervical masses.
Palpate the thyroid in front and/or behind the patient.
Size.
Shape.
Consistency.
Tenderness.
Mobility.
Auscultation.
Thyroid bruits.
Examine for hyperthyroidism.
Differentiate signs of hyperthyroidism from signs of Graves disease.
Examine for hypothyroidism.
IMPORTANT REMINDER
Many of the endocrine diseases (thyroid disorders, adrenal disorders to name a few) have
an impact on many systems/tissues in the body. These systems are covered in detail in
other sections of the physical exam course. As you will ascertain in the thyroid section,
specifically in the thyroid hormone excess/deficiency sections, an endocrine exam
encompasses a complete physical examination. Putting together a complete physical
examination is not expected at the end of this session but rather will be expected at the end
of the physical examination course.
115
GENERAL INSPECTION
Weight
o Fat distribution (central vs. peripheral)
Stature
o Dowagers hump (osteoporosis)
o Buffalos hump (excess steroids)
Secondary sexual characteristics
o Beard growth in females
o Breast development in males
o Small wrinkles around eyes and mouth (loss of sex steroids)
Hair:
o Male pattern balding / female hirsutism
o Texture
o Dryness
Skin:
o Pigmentation
o Ulcerations of feet and legs
o Skin temperature,
o Moisture/dryness
o Thickness
THYROID EXAMINATION
Prior to beginning the examination of the thyroid, provide the patient with a glass of water.
Nomenclature:
Enlargement of the thyroid gland is termed a goiter.
Inspection:
Inspect from front and side for midline swelling.
o NB causes of lateral neck swelling are covered in lymph nodes, head and neck
examinations
o Movement of swelling with swallow
Moves up: goiter or thyroglossal cyst
Thyroglossal cyst moves with tongue protrusion
No movement: Submental lymph modes, parathyroid gland (rare),
neoplastic infiltration of thyroid (rare)
Erythema (can be seen in thyroiditis)
Scars
o Thyroidectomy scar at base of neck
Palpation:
Done in front or behind patient
Landmarking
o Locate the thyroid cartilage (Adams apple)
o Move down from thyroid cartilage to locate cricoid cartilage
o Locate the thyroid isthmus ( 1cm or so below cricoid
cartilage)
o Locate the thyroid lobes under the sternocleidomastoids
Repeat palpation while the patient swallows
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Size
o approximation
Shape
o Diffuse enlargement vs nodule
o Characterize nodule
Size
Consistency
Tenderness
Mobility
Consistency
o Soft: normal
o Firm: goiter
o Hard: carcinoma
Tenderness
o Can be seen in thyroiditis or hemorrhage into a cyst
Mobility
o Mobile: normal
o Non-mobile: carcinoma
Auscultation:
Using bell, listen for bruits over each thyroid lobe
o Can be seen in hyperthyroidism
Lymph nodes (covered in Year 1- Session 2)
Examination for cervical lymphadenopathy
EXAMINATION FOR HYPERTHYROIDISM
Excess thyroid hormone affects many tissues/systems in the body. Features of
hyperthyroidism are characterized by sympathetic overactivity. Features that are not
characterized by sympathetic overactivity depend on the underlying etiology of
hyperthyroidism. Features of Graves disease (one of the causes of hyperthyroidism) will be
covered in this document. The systems affected by hyperthyroidism are covered elsewhere
in Year 1 and Year 2. Please refer to each systems section for a detailed description of the
examination maneuver(s).
Vital signs:
HR: Tachycardia, atrial fibrillation
BP: Wide pulse pressure (slight increase in systolic and drop in diastolic)
Temperature: Normal or fever
Neurological:
Motor:
o Tremor (fine, found in extended fingers and tongue)
o Hyperkinesia (excessive movements)
o Generalized weakness
Reflexes
o Normal or hyperactive (+/- clonus)
Integument:
Skin: soft, thin and moist
Hair: fine, oily and abundant
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Nails: onycholysis
Head and Neck:

Lid retraction (sclera visible above iris)
Lid lag (upper lid lags behind when observing descent of the eyeball)
Cardiovascular:
Flow murmur
Signs of congestive heart failure
GRAVES DISEASE
In addition to signs of hyperthyroidism, Graves disease can affect the following systems:
Head and Neck:
Exopthalmos (proptosis)
Chemosis
Periorbital edema
Opthalmoplegia
Integument:
Skin
o Pretibial myxedema (pink nodules over shins)
o Thyroid acropachy (thickening of the skin on dorsa of finger and toes)
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EXAMINATION FOR HYPOTHYROIDISM

Lack of thyroid hormone affects many tissues/systems in the body. Features of
hypothyroidism are characterized by a slowing of body metabolism. The systems affected
by hypothyroidism are covered elsewhere in Year 1 and Year 2. Please refer to each
systems section for a detailed description of the examination maneuver(s).
Vital signs:
HR: Normal or bradycardia
BP: Normal or elevations in both systolic/diastolic blood pressures
Temperature: Normal or hypothermia
Neurological:
Speech is slow
Motor
o Hypokinesia (lack of unnecessary movements)
o Generalized weakness
Reflexes
o Hung reflexes (delayed relaxation phase)- seen in knee and ankle
Integument:
Skin
o cold, dry, thick
o hypercarotenemia: palms, circumoral skin yellow
Hair: dry, coarse
o Hair loss in lateral third of eyebrows
Nails: dry, brittle
Head and Neck:
Tongue: large
Voice: hoarse, coarse
Cardiovascular:
Edema
Signs of pericardial effusion
Respiratory:
Signs of pleural effusion
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Cranial Nerves Exam

Session 1 Course 5
OBJECTIVES for CRANIAL NERVES EXAM

Name and examine cranial nerves I through XII:
I Olfactory.
II Optic.
Visual acuity.
Visual fields.
Fundoscopy. (seen in Year 1, Session 16)
Pupils.
Pupillary response.
Direct.
Consensual.
Relative afferent pupillary defect.
Accommodation.
III Oculomotor.
Motor.
Pupils.
Eyelids.
Pupillary response.
Direct.
Consensual.
Relative afferent pupillary defect.
Accommodation.
IV Trochlear.
Motor.
V Trigeminal.
Sensory.
Motor.
Reflexes.
VI Abducens.
Motor.
VII Facial.
Motor.
Sensory.
VIII Vestibulo-cochlear.
Hearing.
Whispering test.
Webers test.
Rinnes test.
Balance.
IX Glossopharangeal.
Motor.
Sensory.
X Vagus.
Motor.
Sensory.
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XI Accessory.
Motor.
XII Hypoglossal.
Motor.
Cranial nerve I Olfactory

o Ask patient to identify a recognizable odour (i.e. coffee, peppermint, vanilla), one
nostril at a time.
Only unilateral loss is of importance.
Cranial nerve II Optic

o Test visual acuity.
Use a hand-held eye chart or a Snellens wall eye chart.
Allow patient to wear their glasses.
Test each eye separately.
If a patient requires glasses to read but does not have them (as
frequently happens in the emergency department), you can create a
pinhole in a piece of paper and ask the patient to try reading again.
If the visual acuity improves with the pinhole, it is unlikely to be a
cranial nerve II issue.
If a patient cannot read the largest letter on the chart, hold fingers in front
of each eye, and ask the patient to count them.
If a patient cannot see fingers held up in front of them, test perception of
hand movement in front of them.
If a patient cannot perceive hand movement, try light perception.
o Test visual fields.
Are tested by confrontation.
Have the patient stand (or sit) about an arms length away from you, cover
the eye that is not being tested, and stare into your opposite eye (e.g., if
testing the right eye, patient should be looking at your left eye).
Using your wiggling finger (or a pen with a red tip), bring in your fingers
diagonally toward the centre of vision from the four main directions halfway
between you and the patient. Ask the patient to tell you when they can first
see the finger.
Have the patient cover one eye and identify how many fingers are
being shown in peripheral fields.
Hold both hands in front of patient; ask if the hands look similar in
order to test for hemianopsia and/or midline defects.
o Fundoscopy.
Refer Head and Eyes Exams.
Look for optic disc (colour, sharpness of borders, size, atrophy),
papilloedema, haemorrhages, exudates.
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o Inspect the pupils.

Size.
Shape.
Symmetry.
Regularity.
o Check pupillary response.
Reflex governed by afferent component of cranial nerve II and autonomic
component of cranial nerve III.
Shine a light from the side into one of the eyes and determine the reaction
to light in both eyes.
Normally, the pupil exposed to light will constrict.
o Direct response.
Normally, the pupil not exposed to light will also constrict.
o Consensual response.
Now move the light from side to side and determine the reaction to light in
both eyes. (swinging flashlight test)
If there is a relative afferent pupillary defect
(RAPD), the affected pupil will dilate
paradoxically soon after the light source is
moved from the normal eye to the abnormal
eye.
Try it out for yourself.
o Test for accommodation.
Ask the patient to look into the distance and then to
focus their eyes on a pen or finger that you hold about
30 cm in front of them.
Normally, both pupils should constrict.
Cranial nerve III Oculomotor

o Inspect the pupils.
Size.
Shape.
Symmetry.
Regularity.
o Inspect eyelids for ptosis (drooping).
Drooping of the lower eyelid is common old age, but can also be
caused by a cranial nerve VII lesion.
A complete cranial nerve III paralysis would result in the affected eye
looking down and out, and ptosis.
o Check pupillary response.
Reflex governed by afferent component of cranial nerve II and
autonomic component of cranial nerve III.
Shine a light from the side into one of the eyes and determine the
reaction to light in both eyes.
Normally, the pupil exposed to light will constrict.
o Direct response.
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Normally, the pupil not exposed to light will also constrict.

o Consensual response.
Now move the light from side to side and determine the reaction to light
in both eyes. (swinging flashlight test)
If there is a relative afferent pupillary defect (RAPD), the affected
pupil will dilate paradoxically soon after the light source is moved
from the normal eye to the abnormal eye.
Lastly, test for accommodation.
Ask the patient to look into the distance and then to focus their
eyes on a pen or finger that you hold about 30 cm in front of
them.
Normally, both pupils should constrict.
o Extra-ocular movements are usually tested together (i.e., cranial nerves III, IV
and VI).
o Ask the patient to look up, down, toward their nose, and up and in.
Tests the superior rectus, the inferior rectus, the medial rectus and
inferior oblique.
Easiest to do this by having patient following your moving finger.
Observe for nystagmus.
Ask about diplopia at the extremes of ROM.
Cranial nerve IV Trochlear

o Extra-ocular movements are usually tested together (i.e., cranial nerves III, IV
and VI).
o Ask the patient to look down and in.
Tests the superior oblique muscles (remember: SO4).
Ask about diplopia.
o In a patient with a cranial nerve IV lesion, there is
often a compensatory head tilt away from the lesion.
The head tilt is toward the shoulder of the
unaffected eye.
An isolated cranial nerve IV lesion is rarely
seen and the ocular findings may be difficult for the non-expert to
observe.
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Cranial nerve V Trigeminal

o This nerve supplies sensation to the face and the muscles of mastication.
o Test sensory function.
Compare from side to side.
Test all three branches.
Ophthalmic (e.g., scalp).
Maxillary (e.g., cheek).
Mandibular (e.g., chin).
Test pinprick and light touch
Before touching the patients face, show the
patient on their hand or arm what the two
sensations will feel like and check whether
patient can differentiate between the two.
Do not stroke the skin, only pinpoint touches.
Temperature is not routinely tested as its loss usually is seen with loss
of pain sensation.
o Test motor function.
Ask the patient to bite down and feel the muscles for
tension.
Temporalis.
Masseters.
o Test the corneal reflex.
Afferent component of corneal reflex is mediated by cranial nerve V.
Ask the patient to look up and away from you.
With a cotton wisp, approach from the side the patient is looking away
from. Gently touch the coloured part of the eye (i.e., the cornea). Look
for a symmetrical blink reflex. Repeat in the other eye.
Be aware that contact lens wearers have often have a decreased
corneal reflex.
We do not routinely test this function of cranial nerve V.
o Test jaw jerk (also called masseter reflex).
This reflex is mediated by the third branch of cranial nerve V.
Ask the patient to let his mouth fall slightly open. Place a finger on the
tip of the jaw and lightly tap it with a reflex hammer.
Normally, the mouth will either slightly close or there will be no reaction.
The jaw jerk will be greatly exaggerated in an upper motor neuron
lesion above the pons.
We do not routinely test this function of cranial nerve V.
Cranial nerve VI Abducens

o Extra-ocular movements are usually tested together (i.e., cranial nerves III, IV and
VI).
o Ask the patient to look to the side.
Tests the lateral rectus muscle (remember: LR6).
In a patient with a cranial nerve VI lesion, there is often a compensatory
head turn.
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The patient will turn their head toward the side of the affected eye.
Loss of lateral (temporal) gaze is usually one of the first functions to be lost
with increased intracranial pressure.
Cranial nerve VII Facial

o This nerve supplies the muscles of facial expression and taste to the anterior 2/3
of the tongue.
o Inspect face.
Facial asymmetry at rest.
Asymmetry of facial expressions.
Smoothing of wrinkles on forehead.
Sagging of lower eyelid (but could also be due to old age).
Smoothing of nasolabial fold.
Unilateral drooping of the corner of the mouth.
Tics/unusual movements.
o Listen to patients speech.
Note any difficulties in enunciating nasal sounds (b, m, p).
o Test motor function.
Wrinkle forehead
Squeeze eyes shut.
Try to open them while patient keeps them shut.
Show teeth.
It is best not to ask patient to smile, as not everyone shows their
teeth when they smile.
Puff out cheeks.
Try to push air out of them while patient tries to
maintain it inside.
Purse the lips to whistle.
Contract platysma muscles.
Ask patient to pull down the corners of their
mouth and/or tense their neck muscles.
o Test taste on anterior 2/3 of the tongue.

We do not routinely test this function of cranial nerve
VII unless there is evidence of lower motor weakness on motor
examination.
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o Be aware of the innervations of muscles of facial expression.

Clinically, be able to distinguish between UMN and LMN lesions.
Cranial nerve VIII Vestibulo-cochlear

o This nerve is responsible for hearing and part of balance.
o Testing of hearing should be done without the patient wearing a hearing aid.
o Inspect eardrum. (Refer to Year 1, Session 17)
Wax.
Other obstructions.
Inflammation.
Perforation.
o Whispered test.
Rub your fingers together next to one ear while whispering (e.g. a number)
in the other.
Try to whisper at the end of your expiration to standardize the
volume.
Whisper about 60 cm away from ear.
o If whispered test is abnormal or partial deafness is suspected for any other
reasons, perform the Weber and Rinne tests.
Weber and Rinne tests help to determine if it is sensory or conductive
hearing loss.
Webers test.
Position a vibrating 256 or 512 Hz tuning fork in the middle of the
forehead.
Usually the sound is heard equally in both ears.
A patient with a sensory hearing loss hears the sound louder in the
normal ear.
A patient with a conductive hearing loss hears the sound louder in
the abnormal ear.
126
Rinnes test.
Pronounced rei-nay.
Position a vibrating 256 or 512 Hx tuning form on the patients
mastoid process.
Ask the patient to tell you when they can no longer hear the sound
of the fork, at which point place the fork next to the patients external
meatus of the ear being tested.
Usually, the sound can still be heard at the meatus after it is no
longer heard through the mastoid.
o You should always listen to the fork yourself once the patient
states that they can or cannot hear a sound at their external
meatus.
A patient with a sensory hearing loss hears the sound at the
external meatus.
A patient with counductive hearing loss cannot hear the sound at the
external meatus.
o Balance is initially evaluated with a Romberg test.

Ask the patient to stand with feet together and arms at their sides. Then
ask the patient to close their eyes while you stand close by, ready to catch
the patient should they start to fall.
It is normal to be slightly unsteady, but not to the point where it looks
like the patient is going to fall.
A patient without a deficit should be able to maintain this position for up to
one minute easily.
Loss of balance indicates cerebellar ataxia, posterior column or vestibular
dysfunction.
Loss of balance is termed a positive Romberg sign.
Cranial nerve IX Glossopharyngeal
o Ask the patient to open their mouth, and inspect the palate with a light source.
Note location of uvula.
With their mouth still open, ask the patient to say Ah.
Observe for symmetrical movement of the soft palate.
Observe for deviation of the uvula.
Also tests cranial nerve X.
o Ask the patient to swallow a small amount of water.
Observe for regurgitation into the nose or coughing.
Also tests cranial nerve X.
o Test gag reflex.
Cranial nerve IX is the sensory component and cranial nerve X is the motor
component of this reflex.
We do not routinely test this function of cranial nerve IX.
o Test posterior 1/3 of the tongue for taste.
We do not routinely test this function of cranial nerve IX.
Cranial nerve X Vagus

o Listen for hoarseness in patients voice.
127
o Ask the patient to open their mouth, and inspect the palate with a light source.
Note location of uvula.
With their mouth still open, ask the patient to say Ah.
Observe for symmetrical movement of the soft palate.
Observe for deviation of the uvula.
Also tests cranial nerve IX.
o Ask the patient to swallow a small amount of water.
Observe for regurgitation into the nose or coughing.
Also tests cranial nerve IX.
o Test gag reflex.
Cranial nerve IX is the sensory component and cranial nerve X is the motor
component of this reflex.
Cranial nerve XI Accessory

o Innervates the trapezius and sternocleidomastoid muscles.
o Inspect the muscles. Ask the patient to shrug their shoulders.
Feel the bulk of the trapezius muscles.
Assess strength by trying to push down on the shrugged shoulder while
asking the patient to resist you.
o Ask the patient to turn their head to one side against resistance.
Feel the bulk of the sternocleidomastoid muscles. Remember turning the
head to the left is done by the right sternocleidomastoid muscle and vice
versa.
Cranial nerve XII Hypoglossal

o Motor nerve for the tongue.
o Inspect the tongue as it lies on the floor of the mouth.
Wasting.
Fasciculations.
o Ask patient to stick out their tongue.
Deviation.
The tongue will deviate towards the affected side.
Fasciculations.
o Test the muscle strength by asking the patient to push the tongue against their
cheek as you apply resistance from the outside with a finger.
o Listen for speech problems.
Lingual speech sounds (l,t,d,n) are usually affected.
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Mini-Mental Status Exam (MMSE)

Session 2 Course 5
OBJECTIVES for MINI-MENTAL STATUS EXAM

Demonstrate a standard mini-mental status examination, including explanation of
nature and purpose of exam to patient.
Be familiar with the Glasgow Coma Scale.
Mini-Mental Status Exam (MMSE):

The MMSE is a tool consisting of 11 questions that test the following five areas of
cognitive function:
o Orientation.
o Registration.
o Attention and calculation.
o Recall.
o Language.
The maximum score is 30/30.
o A score of 23 or less indicates mild cognitive impairment.
o A score of 10 or less indicates severe cognitive impairment.
Ask each question a maximum of three times.

o If the patient does not answer a question, assign a score of 0 to that question.
o If the patient answers incorrectly, assign a score of 0 to that question.
Do not hint, prompt or ask the question again.
Be careful not to provide any physical clues that the answer is incorrect
(e.g., frowning or shaking your head).
o If the patient says What did you say?, simply repeat the question (if within the 3
repetition limit). Do not explain or engage in conversation.
Before starting the exam, make sure that you have the following with you:
o A watch.
o A pencil.
o An eraser.
o Some blank paper.
o A piece of paper with CLOSE YOUR EYES written in large letters.
o A piece of paper with two 5-sided figures (pentagons), intersecting to make a 4sided figure.
129
Perform this exam with the patient sitting down and facing you.
o Make sure that the patient can hear you and understands simple conversation.
Obtain the patients permission to ask questions.
o E.g., Can I ask you some questions about your memory?
Encourage patient to do their best.
o E.g., I am going to ask you some questions and give you some problems to
solve. Please try to answer as best you can.
Questionnaire:
Max Score
o Orientation (allow 10 seconds for each reply)
What year is this?
1
Accept exact answer only.
What season is this?
1
During the last week of the old season or the first
Week of a new season, accept either season.
What month of the year is this?
1
What is todays date?
1
Accept previous or next date also.
What day of the week is this?
1
What country are we in?

1
What province are we in?
1
What town are we in?
1
What is the name of this building?
1
Accept name of hospital or building or institution.
What floor of the building are we on?
1
o Memory
I am going to name 3 objects. After I have said all
three objects, I want you to repeat them. Remember
what they are, because I am going to ask you to name
them again in a few minutes.
Say name of 3 objects slowly at approximately
one second intervals.
E.g., ball, car, man, flag, tree, table, apple, penny, etc.
Please repeat the 3 items for me.
3
Score 1 point for each correct reply on the
first attempt.
Allow 20 seconds for reply.
If patient did not repeat all three items, repeat
them until they are learned or up to a maximum of five times.
o Attention
130
Spell the word world.

You may help the patient spell the word correctly.
Now spell it backwards.
5
Allow 30 seconds for answer.
Easier to score if you write down patients answer.
If the patient cannot spell world even with
assistance, score 0.
Correct answer: DLROW.
Score 4 if one letter omitted.
Score 3 if two letters omitted.
Score 3 if two letters reversed.
Score 2 if three letters reversed or omitted.
Score 1 if four letters reversed.
Alternative: can use serial sevens instead of world.
Decide which one to use before starting.
Do not use serial sevens if patient was unable to
spell world and vice versa.
Subtract 7 from 100 and keep subtracting seven
from what is left until I tell you to stop. (score out of 5)
o May repeat instructions up to three times.
o Allow one minute for answers.
o Write down patients answers.
o Once patient starts, do not interrupt. Allow
Them to proceed until 5 subtractions have
been made. If the patient stops before 5
subtractions have been made, repeat the
original instructions keep subtracting seven
from what is left (to a maximum of three times).
o Correct answers: 93, 86, 79, 72, 65.
o Subtract 1 point for each incorrect answer,
but do not subtract any points if patient subtracts
correctly from an incorrect answer (e.g., 93, 88,
81, 74, 67 would score 4/5).
o Recall (allow 10 seconds)
What were the three objects that I asked you to
remember?
3
Score 1 point for each correct response
regardless of order.
Note: it is important that the order of Memory,
Attention and Recall be exact (e.g., cannot do
Memory-Language-Recall or Memory-AttentionLanguage-Recall, etc).
131
o Language
Show wristwatch. Ask what is it called?
Accept wristwatch or watch.
Do not accept clock, time, etc.
Show pencil. Ask what is it called?
Accept pencil only.
Score 0 for pen.
Id like you to repeat a phrase after me: No ifs, ands
or buts.
Must be exact.
Read the words on this page and then do what it says.
Show patient the sheet with CLOSE YOUR EYES
on it.
If patient only reads and does not then close eyes,
repeat read the words on this page and then do
what it says to a maximum of three times.
Allow 10 seconds for reaction.
Score 1 point only if patient closes eyes.
Patient does not have to read out loud.
Ask patient if they are right or left handed. Alternate
right/left hand in your instructions (e.g., if the patient
is right-handed, ask them to take the piece of paper
in their left hand). Take this paper in your right/left
hand, fold the paper in half once with both hands,
and put the paper down on the floor.
Score 1 if patient takes paper in correct hand.
Score 1 if patient folds it in half.
Score 1 if patient puts it on the floor.
Place design, pencil, eraser and paper in front of patient.
Ask copy this design, please.
Allow multiple tries until patient is finished
and hands it back.
Score 1 point for correctly copied diagram.
Maximum time allowed to get full score is
one minute.
Place pencil and paper in front of patient. Ask, write
a complete sentence on this piece of paper.
The sentence should make sense.
Ignore spelling errors.
MMSE Summary (questions only)

132
o
o
o
o
o
o
o
o
o
o
o
What is the year, season, month, date, day?

Where are we: country, province, town, building, floor?
Repeat three objects.
Spell WORLD backwards (or serial sevens).
Recall three objects.
Name pencil, watch.
Repeat: No ifs, ands or buts.
CLOSE YOUR EYES.
3-stage command.
Copy double pentagons.
Write a sentence.
Glasgow Coma Scale:

The GCS is an objective neurological scale that records the level of consciousness of an
adult patient.
Score is out of 15.
o Remember, an inanimate object (e.g., a chair) would still score 3 on this scale!
o Score in the 3 to 8 range are seen in patients in comas.
It is sometimes difficult for students to initially remember what each category is score out
of. Here is a trick:
o Eye opening category scored of 4 think 4-eyes (what kids call another kid
who wears glasses).
o Motor category scored out of 6 think when someone moves fast, they are
firing on all 6 cylinders!
o Verbal category score out of 5 by default since scale is out of 15 and you will
now remember the maximum score for the other two categories.
Category
Motor
Verbal
Eye Opening
Response
Obeys commands for movement
Purposeful movement to painful stimulus
Withdraws from pain
Abnormal (spastic) flexion, decorticate posture
Extension (rigid) response, decerebrate
posture
None
Oriented
Confused conversation
Inappropriate responses but discernible words
Incomprehensible speech or moaning
None
Spontaneous
Opens to verbal command
Opens to pain
None
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Score
6 points
5 points
4 points
3 points
2 points
1 point
5 points
4 points
3 points
2 points
1 point
4 points
3 points
2 points
1 point
Peripheral Neurological Exam

Session 3 Course 5
OBJECTIVES for PERIPHERAL NEUROLOGICAL EXAM

Motor exam.
Inspect general appearance and posture.
Bulk and Movement.
Proper draping.
Inspect for abnormal muscle movements.
Tics.
Tremors.
Postural.
Resting.
Intention.
Physiological.
Fasciculations.
Inspect for muscle bulk.
Atrophy.
Hypertrophy.
Pronator drift test.
Tone.
Palpate muscles.
Move joints passively.
Spasticity.
Rigidity.
Hypotonia.
Assess for clonus.
Strength.
Assess for muscle strength.
Individual muscles in upper limbs.
Individual muscles in lower limbs.
Describe and apply the muscle strength grade scale.
Reflexes.
Ensure optimal positioning.
Test major deep tendon reflexes.
Biceps (C5-6).
Triceps (C7-8).
Brachioradialis (C6).
Patellar (L3-4).
Ankle (S1).
Demonstrate reinforcement techniques.
Assess for clonus.
Describe and apply the deep tendon reflex grade scale.
Describe and demonstrate the Babinski sign.
Test superficial reflexes.

134
Abdominal (T6-L1).
Cremasteric (L1-2).
Anal (S1-3). (Seen in Well Man sub-unit.)
Sensory exam.
Light touch.
Pinprick.
Temperature.
Vibration.
Proprioception.
Special tests.
Two point discrimination.
Graphesthesia.
Stereognosis.
Coordination exam.
Romberg test.
Upper extremities.
Finger-to-nose test.
Rapid alternating movements test.
Lower extremities.
Heel-to-knee-to-shin test.
Rapid alternating movements test.
Finger-to-nose test.
Gait and balance.
Inspect gait.
Normal.
Heel-to-toe.
Toe walking.
Heel walking.
Inspect for balance.
Compare upper motor neuron lesions and lower motor neuron lesions.
Muscle mass.
Muscle strength.
Muscle tone.
Other motor findings.
Deep tendon reflexes.
Superficial reflexes.
Babinski.
The peripheral neurological exam consists of three large categories:

o Motor and reflexes.
o Sensory.
o Gait, balance, and coordination (cerebellar).
135
Motor:
Start with a visual inspection of the patients general appearance and posture.
o You are looking for any abnormal or unusual positioning of the arms and legs
(e.g., flexion or extension) and/or any abnormal facial features.
See summary table at the end of this session for signs of upper vs. lower
motor neuron lesions that would be apparent on inspection.
Bulk and Movement
In order to do a proper inspection for muscle bulk and abnormal movements, it is
important to drape the patient appropriately.
o You need to properly drape both sides simultaneously as inspection should be a
comparison of one side to the other.
Look for abnormal muscle movements.

o Tics.
These are sudden, involuntary, repetitive and usually jerky muscle
movements.
Usually affect the same muscle group repeatedly.
o Tremors.
Postural.
A tremor that is only present when a specific posture is assumed.
For example when holding the forearms extended and at shoulder
level.
Resting.
Present mostly during relaxation of muscles.
A common example of this type of tremor is the pill-rolling action
that some patients with Parkinsons disease display at rest.
Intention.
Present mostly during deliberate movements, and usually become
more pronounced toward the end of the movement.
Physiological.
Normal fine tremor that most of us experience when
we are anxious or nervous.
Can be accentuated by placing a piece of paper
over the extended arm.
o Fasciculations.
Random contractions or twitching in parts of a muscle at
rest.
They can coarse or fine.
You need very good lighting to assess this properly.
It actually takes a few minutes to inspect for it well.
Look for muscle bulk.

o Compare side to side.
You may want to consider measuring the difference with a measuring tape.
Make sure to pick a steady reference point that will allow for
reproducibility of measurements over time and will ensure that both
limbs are measured at the same level.
o Look for atrophy.
o Look for hypertrophy.
136
E.g., professional tennis players tend to have their dominant arm muscles
larger than the other arm. This is not an atrophy of the muscles of the
smaller arm, but rather a hypertrophy of the overactive arm.
Perform the pronator drift test

o Have the patient sit or stand with their arms
stretched out in front of them, palms facing
upwards, and their eyes closed.
o Normally, the patient can hold this position without
any problems.
o If one of the hands starts to turn the palm inwards
(pronate), suspect an upper motor neuron lesion.
o If one of the arms starts to drift upwards, suspect
cerebellar disease.
Tone
Palpate the muscles for consistency.
o Have the patient grip your index and middle fingers as hard as possible, hold for a
few seconds and then tell them to let go.
Myotonia is the inability to relax the muscles after a voluntary contraction.
Myotonia can also be elicited by percussing a muscle (for example the
thenar eminence) directly.
Passively move joints to assess for tone.

o Spasticity.
Rate-dependent resistance of range of motion.
Also called the clasp-knife phenomena.
Suggests an upper motor neuron lesion.
o Rigidity.
The detection of increased tone is not rate dependent.
Rigidity is throughout the movement.
Also called lead pipe.
o Hypotonia.
Decreased resistance during passive range of motion, and muscles are
soft and limp on palpation.
Assess for clonus.

o Support and partially flex the knee and briskly dorsiflex the foot with your other
hand, then maintain the foot flexed.
o Normally, no rhythmic oscillating movements should be detected while doing this.
o If you can feel the foot rhythmically tapping in your hand, the test would be
positive for clonus.
Strength
An easy screening test for lower limb muscle weakness is to ask the patient to squat and
then stand up.
o Older patients in particular might have trouble doing this, in which case you can
get them to sit on a low chair and ask them to stand without using their arms to
push themselves up.
137
Perform movements against resistance to assess for strength.

o Muscle strength is graded on a 0 to 5 scale (Medical Council Research scale).
0 no contraction.
1 minimal contractions of the muscle.
2 unable to overcome gravity, but movement in the plane is possible.
3 movement against gravity, but not against resistance.
4 partial strength against resistance (can use 4-, 4 and 4+ to indicate
mild, moderate and strong resistance, respectively).
5 full strength against resistance.
o Again, look for differences between sides.
Listed below are the different muscles to be tested.

o The muscles, nerves and nerve roots are noted simply for your reference.
If you are looking at the tables and feeling discouraged, thinking Ill never remember all
of this, cheer up and go to this website: http://neuroexam.med.utoronto.ca/motor_4.htm
o In this video, you can see how the screening for muscle strength is performed
this is what you are expected to be able to perform.
o Start proximally and move distally.
o When doing a screening examination both sides may be done at once. If focal
weakness is suspected then do one side at a time.
Upper extremities
Action
Arm abduction
Elbow flexion
Elbow extension
Extension at the wrist
Flexion of the wrist
Wrist abduction
Finger flexion
Abduction of index finger
Abduction of little finger
Thumb abduction
(perpendicular to plane of
palm)
Thumb adduction
Thumb extension
Muscle(s)
Deltoid
Biceps
Triceps
Forearm extensors
Forearm flexors
Flexor carpi radialis
Flexor digitorum
superficialis and flexor
digitorum profundus
First dorsal interosseous
Abductor digiti minimi
Nerve(s)
Axillary
Musculocutaneous
Radial
Radial
Median and ulnar
Median
Median, anterior
interosseous (FDP I&II),
ulnar (FDP III&IV)
Ulnar
Ulnar
Nerve Roots
C5, C6
C5, C6
C6, C7, C8
C6, C7, C8
C6, C7, C8, T1
C6, C7
Abductor pollicis brevis
Median
C8, T1
Adductor pollicis
Ulnar
Posterior interosseous
(radial)
C8, T1
Extensor pollicis longus
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C7, C8, T1
C8, T1
C8, T1
C7, C8
Lower extremities
Action
Hip flexion
Hip extension
Hip abduction
Hip adduction
Knee extension
Knee flexion
Ankle dorsiflexion
Ankle plantar flexion
Toe extension
Toe flexion
Foot eversion
Foot inversion
Muscle
Illiopsoas
Gluteus maximus
Gluteus medius, gluteus
minimus, tensor fasciae
latae
Adductors
Quadriceps femoris
Hamstrings
Tibialis anterior
Gastrocnemius and
soleus
Extensor digitorum
longus
Flexor digitorum longus,
flexor hallucis longus
Peroneus longus and
brevis
Tibialis posterior
Nerve
Femoral
Interior gluteal
Superior gluteal
Nerve Roots
L1, L2, L3
L5, S1, S2
L4, L5, S1
Obturator
Femoral
Sciatic
Deep peroneal
Tibial
L2, L3, L4
L2, L3, L4
L5, S1, S2
L5, S1
S1, S2
Deep peroneal
L5, S1
Tibial
L5, S1, S2
Superficial peroneal
L5, S1
Tibial
L4, L5
Reflexes
Position yourself in such a way that you will not need to walk from side to side in order to
check reflexes.
o Compare side to side. Do not do one side entirely before doing the other side.
Also, position yourself in such a way that you can palpate the tendon being tested.
o You also want to be able to visualize the muscle connected to the tendon. In
order to elicit a reflex, you simply need to be able to see a muscle contraction. It
is not necessary for the limb to jump.
o Position the limbs with slight tension on the tendon to be tapped, making sure to
palpate the tendon to locate it for stimulation.
Test major deep tendon reflexes.

o Biceps (C5-6).
o Triceps (C7-8).
o Brachioradialis (C6 mainly).
o Patellar (L3-4).
o Ankle (S1).
Note the grade of reflex.

o Deep tendon reflexes are graded on a scale of 0 to 4+.
0 absent.
1+ hypoactive.
2+ normal.
3+ hyperactive.
4+ hyperactive with clonus.
o If a reflex is not present, a reinforcement technique should be used.
You may want to ask the patient to contract an alternate group of muscles
(for example clench your jaw, make a fist, etc.) when you say now.
o If reflexes are hyperactive (3+), test the ankle for clonus.
139
Support and partially flex the knee and briskly dorsiflex the foot with your
other hand, then maintain the foot flexed.
Normally, no rhythmic oscillating movements should be detected while
doing this.
If you can feel the foot rhythmically tapping in your hand, the test would
be positive for clonus.
o Absent reflexes may indicate lower motor neuron disorder.
o Hyperactive reflexes suggest an upper motor neuron disorder.
Test the Babinski response.

o Be sure to explain how the test will be performed to the patient before attempting
it. This is an unpleasant test for most people, and even more so in someone who
has ticklish feet.
o Using a disposable sharp object (e.g., tongue depressor broken in half or the
pointy end of your reflex hammer), stroke the lateral aspect of the foot and then
come across the ball of the foot (just below the toes).
o Normally, a persons big toe will curl downwards at the MTP joint or will not move
at all.
o An abnormal response can occur if the big toe flexes upwards and the other toes
fan out.
However, it should be noted that a small percentage of the population that
do not have any upper motor neuron lesions have up-going toes bilaterally
as a normal response to this test.
However, an up-going toe is expected in children under the age of two.
Otherwise, an up-going toe might be an indication of an upper motor
neuron lesion.
Test superficial reflexes.

o Abdominal (epigastric T6-9, mid-abdomen T9-11, lower abdomen T11-L1).
Gently stroke the abdomen with the dull end of a tongue depressor or your
finger in all four quadrants toward the umbilicus. Observe for contractions.
Normally, a contraction is observed.
Note that patients who have had abdominal surgeries that have cut
across some of these nerves may have an absent reflex.
Also, up to 20% of patients without any type of lesion do not have
this reflex.
This reflex also disappears during coma, deep sleep, and
anesthesia.
This reflex can be difficult to obtain in obese patients.
o Cremasteric (L1-2).
Only performed in male patients.
Stroke downward the inside of the thigh.
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Normally, the cremasteric muscle will pull up the scrotum and testis on the
side being tested.
In patients who are older, have had a hydrocele/varocele/ orchitis,
the reflex may no longer be present.
Test both sides.
o Anal (S2, 3, 4).
As seen in the Well Man sub-unit.
Sensory:
Dr. Keith Brownell has a neat trick to share: assess the dermatomes in a circular
manner.
o Pick a level on the leg/arm and go around it testing for light touch, pinprick and/or
temperature. Then go up a little up, and test all around that level.
o This way, you will know for sure that all the dermatomes have been tested.
o You can also mark out where there is loss of sensation and then look up in a book
which dermatome is most likely affected.
Light Touch
Test sensation in the
distribution of dermatomes.
o Compare to the
opposite side.
o If a difference is
noted, move up the
dermatome.
Pinprick
Test sensation in the
distribution of dermatomes.
o Compare to the
opposite side.
o If a difference is
noted, move up the
dermatome.
Remember that this
sensation can be
decreased/lost/altered as
we age.
141
Temperature
Test sensation in the distribution of dermatomes.
o Compare to the opposite side.
o If a difference is noted, move up the dermatome.
Vibration
Test sensation over the joints.
o Make sure that the patient can feel the vibration over their
sternum before testing any other joints.
o Use a 128 Hz tuning fork.
o Start distally and move proximally if sensation is altered.
E.g., start at the toes, move up to ankle, then to
knee, then to hip.
Proprioception
Test joint position sensation.
o Grasp from the sides either the phalanx that is distal to a DIP (on hands or feet).
While the patient has their eyes open, demonstrate movements up, down and
neutral. Then ask the patient to close their eyes. Randomly move the phalanx
up, down, and into neutral position, asking the patient to tell you which way the
joint was moved after each movement.
It is important to grasp the phalanx from the sides. If you hold the phalanx
from the top and bottom, you will inadvertently provide the patient some
clues as to which way you are moving their finger.
o Start distally.
No need to move proximally if the patient can feel it distally.
o In older patients, this sensation is often decreased/altered, so you may have to
move the joint a little more vigorously in order for them to feel it.
Special Tests
The following test discriminative (cortical) sensations:
o Two point discrimination.
Ask the patient to close their eyes. Touch the patient
with a reshaped paperclip (or two sharp pieces of a
tongue depressor) with either one or two points. Ask
the patient to report how many points they can feel
touching them.
Note the smallest distance at which the patient can
distinguish two separate points and not just one.
Compare from side to side.
The following distances are considered normal:
Lips and finger pads: 2-4 mm.
Palms of hands: 8-15 mm.
Shins or back: 30-40 mm.
142
o Graphesthesia.
Ask the patient to close their eyes. With a capped pen or
your finger, write a number in the palm of the hand or the
top of the foot. Ask the patient to tell you which number you
just wrote.
You need to make sure that the patient knows when you
are writing a new number.
This can be done by gently wiping the surface you
just wrote on or by verbally letting the patient know
that you will be writing a new number.
Stereognosis.
As the patient to close their eyes. Put a common
object in their hand (e.g., a penny, a comb, and
safety pin, etc). Ask the patient to tell you (without
looking!) what object they are holding.
Cerebellar (Coordination):
Perform the Romberg test.

o Ask the patient to stand with their feet
together with their eyes open. Observe
the balance.
FYI: the feet do not have to be
touching, but they do need to be
fairly close.
o Once the patient is stable, ask them to
close their eyes. Observe the balance.
o Normally, a patient should be able to
stand with minimal swaying for up to a
minute.
o A patient that looks like they are about
to fall would be considered to have a
positive Romberg test.
Make sure when performing this
test that you stand behind or
beside the patient, and be
prepared to catch time during
the entire time that their eyes
are closed.
A positive Romberg is often an
indication of loss of
proprioception.
Upper extremities
Perform finger-to-nose test.
o Ask the patient to touch the tip of thier
own nose with their index finger, and
then your index finger which you hold
in front of them and back to their nose.
Continue this movement until you ask
them to stop.
143
When the patient touches your index finger with their index finger, their arm
should be fully outstretched.
After a few movements back and forth, you can move your index finger to a
different location while the patient is moving their arm back towards their
nose. By the time they start reaching out towards your finger, your finger
should no longer be moving.
Test both sides.
o As the patient is performing this test, assess for:
Intention tremor.
Overshooting (patients finger goes past your finger).
Perform rapid alternating movements test.

o Ask the patient to pronate and supinate their hand
back and forth in the palm (or on the dorsum) of
their other hand.
This should be done as rapidly as the
patient can manage.
Remember to check the other side.
o Disease would be suspected in a patient whose movements are slow and clumsy.
Lower extremities
Perform heel-to-shin test.
o Ask the patient to draw a straight line from their ankle to
their knee on their shin using the opposite legs heel. Ask
them to keep going up and down as accurately as they
can.
o Test both sides.
o Normally, a patient can perform this test fairly quickly and
accurately.
o A patient whose heel cannot go up and down in a straight
line (wobbles, oscillates from side to side, overshoots) is
likely to have a cerebellar problem.
This test is usually performed with eyes open. Closing the eyes would not
affect a cerebellar lesion. It might, however, help identify a posterior
column loss.
Perform rapid alternating movements test.

o Ask the patient to tap the sole of their foot in your hand as quickly as they can.
Alternatively, you can ask the patient to tap the heel of their foot on the
opposite shin as quickly as they can.
Test both sides.
o Disease would be suspected in a patient
whose movements are not rhythmical.
Perform a finger-to-toe test.

o With the patient supine, ask them to touch
your index finger with their big toe.
The knee should remain bent.
This test is rarely performed.
o Look for an intention tremor.
144
Gait and Balance:

Observe the patients normal gait.
o Part of this test includes asking them to turn around quickly.
legs, smoothness and steadiness of turns.
o Types of gait:
or intoxication.
Observe heel-to-toe gait.

o This can help you exclude a midline cerebellar lesion.
Observe the patient walking on their toes.

o This can help you exclude an S1 lesion.
Observe the patient walking on their heels.

o This can help you exclude an L4 or L5 lesion which causes footdrop.
Observe the patients balance during all of the above tests.

o If there are concerns and it has not yet been done, make sure to test cranial nerve
VIII (vestibulo-auditory).
Comparison of Upper and Lower Motor Neuron Lesions
145
Upper Motor Neuron Lesion Lower Motor Neuron Lesion

Muscle mass
Slight loss
Decreased/atrophy
Muscle strength
Decreased
Decreased
Muscle tone
Increased (spastic)
Decreased (flaccid)
Superficial reflexes absent
Clonus
Other motor findings
Fasciculations
Fibrillations*
Deep tendon reflexes
Increased
Decreased
Decreased (abdominal,
Superficial reflexes
Unaffected
cremasteric, anal)
Babinski
Toe up (positive)
Toe down
Coordination
Impaired
Unimpaired
* Fibrillations are extremely small, irregular contractions of individual muscle fibres that
cannot be seen with the naked eye.
Some Thoughts on the Neurological Exam in Clinical Setting
At this stage of your training, we have broken down the neurological exam into different
smaller sections, both to help you learn it and to present it in a way similar to which you
might expect to be tested on it for years to come.
However, in reality, there are several things that are done differently in a clinically
setting.
o An idea of the gait is usually obtained from watching the patient walk down the
hallway or around the room.
o The level of consciousness and orientation, nerve palsy, speech impairment,
abnormal movements, etc. are often assessed by watching the patient and taking
a bit of a history.
o The order in which maneuvers are performed are not always in the exact order
that they are presented in this document (e.g., cranial nerves are not always
tested in a I to XII order).
At this point in your training, it is important to learn the different elements, not to be
Speedy Gonzales when doing your neuro exam.
o The order in which the different elements are presented in this Core Document
attempts to demystify the often silent assessment of the patient that is made by
experienced physicians as they enter the room or talk to the patient, and to
provide a structure to your learning.
o As you get to observe physicians doing neurological assessment on patients, take
note of the order in which they do things. You might be able to shave a few
minutes off your neurological assessment during clerkship by simply rearranging
things a little.
146
References
General Inspection, Vital Signs and Draping
http://forums.studentdoctor.net/showthread.php?p=11182059
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Lymph Nodes Exam
http://anatomyuniverse.com/HeadNeckLymphatics.html
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General Abdominal Exam
http://www.operationalmedicine.org/TextbookFiles/FMST_20008/FMST_1408.htm
http://www.cpmc.org/learning/documents/rg-abdom-prepare.html
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The Family Guy screen shot, Fox Broadcasting Company.
Liver and Spleen Exams
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147
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Hand and Wrist Exams

http://orthoinfo.aaos.org/topic.cfm?topic=a00007
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Cervical Spine and Shoulder Exams
http://www.exrx.net/Muscles/Sternocleidomastoid.html
http://www.fotosearch.com/illustration/rotator-cuff.html
http://www.aafp.org/afp/20000515/3079.html
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http://www.smrehab.cn/a/guanjiekangfu/jianguanjie/20100412/51.html
Ankle, Foot and Thoracolumbar Spine Exams
http://www.reflessologia.it/libro_eng_chapter1b.htm
http://www.graphicshunt.com/health/images/hallux_valgus-1317.htm
http://www.peakorthopedics.com/content/claw-toes-and-hammertoes
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http://foreverfitptw.com/Injuries-Conditions/Ankle/Ankle-Anatomy/a~47/article.html
http://www.supercoach.de/thompson.htm
http://www.chiroweb.com/mpacms/dc_ca/article.php?id=42096
http://www.hawaii.edu/medicine/pediatrics/pemxray/v3c03.html
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/
http://destroychronicpain.wordpress.com/problems-we-help-people-with/piriformis-syndrome-pain-in-thebutt/
http://www.accessmedicine.ca/search/searchAMResultImg.aspx?searchStr=leg+bones&rootTerm=straight
+leg+raise+test+procedure&searchType=1&rootID=56597
Hip and Knee Exams
http://www.costume-party.co.uk/marilyn-munroe-costume-1644-p.asp
http://www.aafp.org/afp/2003/0801/p461.html
http://www.utswanesthesia.com/regional/?page_id=91
http://www.sports-injury-info.com/trochanteric-bursitis.html
http://www.tosm.net/bakers_cyst.html
http://boneandspine.com/orthopaedic-images/clinical-photograph-of-knee-effusion/
http://www.shoulderkneecenter.com/knee_acl_tear.htm
148
http://www.theosteocareclinic.com/knees/
http://spinalphysio.kornberg.net/osgood.html
http://www.sonicmend.com/info_bursitis.php
http://crashingpatient.com/trauma/050-knee.htm
http://unlocked-cell.com/thessaly/
http://www.gvle.de/kompendium/knie/0101/0020.html
http://www.argonneclub.anl.gov/ARC/PageKnee.htm
http://www.exploringnature.org/db/detail.php?dbID=24&detID=33
http://www.hkma.org/english/cme/onlinecme/cme201005set.htm
Bates Guide to Physical Examination and History Taking, by Lynn S. Bickley, 7th edition, pages 498-499.
Jugular Venous Pulse Exam

http://www.n3wt.nildram.co.uk/exam/cardio/
http://ak47boyz90.wordpress.com/2009/09/10/l2-central-venous-pressure-cvp-jugular-venous-pulse-jvp/
http://www.ncbi.nlm.nih.gov/books/NBK300/
http://www.clinicalexam.com/pda/c_ref_jvp.htm
Respiratory Exam
http://faculty.etsu.edu/arnall/www/public_html/heartlung/breathsounds/contents.html
http://baldwin-emt.org/moodle/mod/glossary/view.php?g=7
http://www.after50health.com/abnormal-findings-of-the-chest-wall-and-breast.html\
http://doctorumit.com/kifozeng.html
http://www.easternsunacupuncture.com/boston-acupuncture-breathing-instruction-stress
http://soyte.angiang.gov.vn/wps/portal/!ut/p/c4/04_SB8K8xLLM9MSSzPy8xBz9CP0os3j3oBBLczdTEwML
dwsDA09_LxcjF38fAwNfU_2CbEdFAMTd4DQ!/?WCM_GLOBAL_CONTEXT=/wps/wcm/connect/soyte/so
yte/thongtinhoatdong/caulacbotienganh/topic+online+19
http://www.ccjm.org/content/75/4/297.full
http://www.oocities.org/ultradian/rtassess/respassess.htm
http://207.5.42.159/sweethaven/MedTech/RespDisease/lessonMain.asp?mode=1&iNum=0202
http://www.rnceus.com
http://sprojects.mmi.mcgill.ca/mvs/RESP01.HTM
http://davisplus.fadavis.com/tabers21/Animations/animations.cfm?exercise=Adventitious_Breath_Sounds&
title=Adventitious%20Breath%20Sounds
http://www.patient.co.uk/doctor/Chest-Deformity.htm
http://www.shahrukh.co.uk/resp/examination2.html
Clinical Examination: A Systematic Guide to Physical Diagnosis, by Nicholas J. Talley and Simon
OConnor, 6th edition, p. 123.
Precordial Exam
http://www.med.umich.edu/lrc/psb/heartsounds/index.htm
http://depts.washington.edu/physdx/heart/demo.html
http://www.cardiologysite.com/auscultation/html/
http://www.prohealthsys.com/physical/heart_exam.php
http://osler.ucalgary.ca/ume/UT/ASCM1/Physical_Examination/ascm1/Precordial/teaching_points.htm
Peripheral Vascular Exam
http://www.dermatlas.net/atlas/imageinfo.cfm?image=238
https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=tp12624&
http://www.medicinenet.com/edema/article.htm#pitting
http://www.sciencephoto.com/media/265470/enlarge
http://www.gndmoh.com/vb/showthread.php?t=1823
http://www.austincc.edu/nursmods/online/online_lev1/Mod1Part2.php
http://lcstudentwiki.wikispaces.com/Bryce+Page+2
http://fitsweb.uchc.edu/student/selectives/TimurGraham/Modified_Allen%27s_Test.html
http://en.wikipedia.org/wiki/Great_saphenous_vein
Cranial Nerves Exam
http://tattooone.kilu.info/
http://www.drjakesloane.co.uk/Bruxism.html
149
http://articlesofnursing.blogspot.com/2011/06/reflex-tests-jaw-jerk.html
http://www.technomedic.ca/products/Aluminium_Alloy_Tuning_Fork_.shtml
http://www.themcfox.com/health/trigeminal-neuralgia/trigeminal-neuralgia.htm
Bates Guide to Physical Examination and History Taking, by Lynn S. Bickley, 7th edition, p. 170.
http://www.matossianeye.com/site/blog/detail/2011/06/16/the-swinging-flashlight-test.html
http://www.themcfox.com/health/trigeminal-neuralgia/trigeminal-neuralgia.htm
http://www.ncbi.nlm.nih.gov/books/NBK373/
http://www.technomedic.ca/products/Aluminium_Alloy_Tuning_Fork_.shtml
http://www.utoronto.ca/neuronotes/NeuroExam/cranial_5b.htm
http://www.med.yale.edu/caim/cnerves/cn4/cn4_6.html
http://imueos.wordpress.com/2010/11/07/upper-motor-neuron-lower-motor-neuron-lesions/
http://www.bmj.com/content/329/7465/553.long
MMSE
Malloy DW, Alemayehu E, Roberts R. A Standardized Mini-Mental State Examination (MMSE). Amer. J. of
Psychiatry, 1991; 148:102-105.
http://www.med.mcgill.ca/geriatrics/education/clerkship/Senior_Clerkship/Syllabus/13_AppendixC.4.htm
Peripheral Neurological Exam
http://library.med.utah.edu/neurologicexam/html/motor_anatomy.html
http://wn.com/Motor_System_Examinations
http://www.utoronto.ca/neuronotes/NeuroExam/motor_4.htm
http://www.utoronto.ca/neuronotes/NeuroExam/motor_6.htm
http://www.maturespine.com/symptoms/weakness.html
http://medchrome.com/basic-science/anatomy/lesions-of-upper-motor-neurons-and-lower-motor-neurons/
http://emj.bmj.com/content/21/2/216.extract
http://www.wrongdiagnosis.com/f/frolichs_syndrome/book-diseases-5a.htm
http://ytizle.com/Vibratory%20sensation/
http://www.pattersonmedical.ca/app.aspx?cmd=get_product&id=79838
http://www.familypracticenews.com/index.php?id=2934&type=98&tx_ttnews[tt_news]=43976&cHash=da03
e20e36
http://cloud.med.nyu.edu/modules/pub/neurosurgery/sensory.html
http://littleboingmarks.blogspot.com/2010/01/two-illustrations.html
http://hk.myblog.yahoo.com/mrcp_2005/index?&page=3
http://www.osceskills.com/subjects/topics/cerebellar%20exam/cerebellarexam.htm
http://hk.myblog.yahoo.com/mrcp_2005/article?mid=141&fid=-1&action=prev
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Medical Skills Physical Exam

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Medical Skills Physical Exam

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Physical Exam

Sub-Unit of the Medical Skills Program

UNDERGRADUATE MEDICAL EDUCATION

The Physical Exam Course

Dr. Florence Obianyor

The Physical Examination course runs over two years.

Responsibilities and Expectations

Student will be assigned to clinical small groups.

This core document should be considered as a general guide.

This course will be primarily evaluated through OSCE-style assessments.

Written Medical Record

Written Medical Record

SocHx (social history): There are multiple components to this section:

Written Medical Record Sample

CT PE protocol- should give further characterization of RLL mass/right hilar

No evidence active airflow obstruction. Not known to be CO2 retainer, so target

January 13, 2015

January 14, 2015

January 14, 2015

January 20, 2015

January 21, 2015

January 21, 2015

January 27, 2015

February 17, 2015

February 18, 2015

February 18, 2015

February 24, 2015

February 25, 2015

February 25, 2015

Year 2 Class of 2016

Well Woman Sub-Unit

Sessions for Year 1

COMMON MARKERS OF ILLNESS

o Normal rate is 60 to 100 beats per minute for adults.

o When this phenomenon was initially discovered by Kussmaul, he was actually

Things to Know and Remember:

Lymph Nodes Exam

OBJECTIVES for LYMPH NODES EXAM

Lymph nodes of the head and neck

Other lymph nodes:

GENERAL COMMENTS ON LYMPH NODES

General Abdominal Exam

OBJECTIVES for GENERAL ABDOMINAL EXAM

(Continued on next page)

Auscultate the abdomen.

Major arterial vasculature (seen in Year 1, Session 12).

Positioning and Draping:

Identify surface anatomy of:

Ask patient if the abdomen is painful anywhere before you touch

Percuss for costovertebral angle (CVA) tenderness.

Palpate all four quadrants.

A digital rectal exam (DRE) is part of the abdominal exam.

Auscultate for bruits. (seen in Year 1 Session 12)

o Tenderness on digital rectal examination.

Liver and Spleen Exams

OBJECTIVES for LIVER EXAM

Inspection for Peripheral Signs of Stigmata of Liver Disease:

As patient to hold up hands as if

Inspection (Central Signs)

Describe the liver edge in terms of:

Fluid wave test

OBJECTIVES for SPLEEN EXAM

Percuss over Traubes space.

If the spleen is not felt with the above techniques: