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Examination Expected findings Findings

Head - Symmetrical
- Note for lumps and tumors
- Hair distribution and texture
Eyes - Test for EOM
- Visual acuity
- Peripheral vision
- fundoscopy
Ears - otoscopy
- Rinnes test
- Hearing aquity
Neck - Note for presence and absence of lumps, masses
and tenderness (lymphadenopathy)
- Note thyroid gland and palpate it, and trachea
midline
TOTAL SCORE
Thorax Findings
survey of respiration rate, rhythm, depth and effort of
breathing, presence or absence of audible wheezing
Inspection
Shape of the chest, symmetry and movement
location of the trachea
use of accessory muscles
presence of lagging
skin abnormalities, lesions, masses, sinus
tracts
Palpation
technique in doing the test
presence of absence of tenderness
skin abnormalities: palpation of masses
test for chest expansion
test for tactile fremitus
Percussion
technique in doing the test
reporting:
flatness/dullness/resonance/tympany
Auscultation
technique in doing the test
character of breath sounds:
inspiratory and expiratory sounds
(location,pitch, intensity, duration,
decreased/absence)
presence or absence of adventitious sounds
(crackles, wheeze, rhonchi): location, timing,
loudness, pitch, duration
transmitted voice sounds (egophony,
pectoriloquy)
Other presence or absence of cyanosis (central, distal)
clubbing
CVS Findings
Vital signs: BP,CR,RR,Temp
Assessment of JVP
- Positioning
- Technique
- Result/value
Pulsations: IJ and carotid
- Positioning
- Techniques
- findings
The heart:
Inspection and palpation
- Positioning
- Technique
- Reporting of findings
Anatomical location of Aortic, Pulmonic,
RV, LV
PMI (location, description, clinical
correlation)
S3 and S4 , if present

Percussion
- Technique
- Reporting of findings
Auscultation
- Techniques and maneuvers
- Reporting of findings
S1 and S2
Murmurs (timing, location, grading, pitch,
quality and radiation)

Peripheral signs of diseases of the CVS; cyanosis


(central, distal); clubbing
Breast exam and Axilla o Palpate straight line down from
the nipple line to bra line to
Vital signs midsternal
Interview/ history family history, bse, discomfort, - Palpate for consistency, tenderness
pain, lumps, changes in size, dimpling, swelling, (premenstrual), lumps, masses, lymph
discharges nodes, masses, nipple discharges
- With or without mass you must describe
Ask permission (very important)
a. Location (by clock or quadrant)
Define the anatomic borders of the breast
b. Size (cm)
- Clavicle and 2nd rib to the 6th rib c. Shape (round, cystic, disc like shape,
- Sternum to the midaxillary line irregular)
d. Consistency (soft, firm, hard)
Inspection e. Delineation (wel circumscribed or not)
- Proper positioning f. Mobility (dimpling)
a. Arms at sides g. Tenderness
b. Arms over head - Examine both sides
c. Hands on hips - Nipple: palpate and note for elasticity,
d. Leaning forward discharge (color, quantity, origin, odor)
- Describe the color, symmetry, size, contour Male
(masses, dimpling or flattening), thickening
(prominent pores which accompany Inspection
lymphatic obstruction) of the breast - Nipple and areola: nodules, swelling,
- Look for any masses ulceration
- Nipple: size, shape, direction, or discharges, Palpation
rashes, ulceration (very important) - Areola breast tissue: nodules, obesity (soft
- Examine both right and left fatty), glandular (gynecomstia)

Palpation (lateral to medial) Axilla

female - Right hand for left axilla and vice versa


(sitting)
- Position: supine (if patient cannot tolerate
the ideal position, just state the ideal
Inspection
position)
- Rash, infection, unusual pigmentation
- Expose the breast
- 2 ways: vertical and horizontal stripping
Palpation (relax arm down)
- Locate and palpate the lymph nodes (other
names of lymph nodes) - Cup fingers of hand, reach high into the
- Palpate for lateral: supine, roll on opposite axilla, fingers behind pectoral muscle, point
hip, hand on forehead while shoulder to mid clavicle
pressed on bed - Check nodes: pectoral, lateral, subscapular,
o Begin palpation from the axilla to infra and supraclavicular
bra line (vertical strip) to nipple Teach patient how to BSE
line
- Palpate for medial: shoulder flat on bed, Post mastectomy:
hand on neck, lift elbow until level with
- Inspect: scar, axilla, masses, nodularity, s/sx
shoulder
of inflammation, lypmphedema, LN
enlargement
ABDOMEN - If resistance: differentiate from involuntary muscular
spasm from voluntary guarding
Vital signs - Exhale, open mouth = relax abdl mm
Empty bladder. - Deep palpation: delineate abdominal masses
(location, size, consistency, tenderness, pulsation,
Position: Supine. Pillow under head and knees. Arms at sides mobility from respiration)
or folded across the chest. Drape from below nipple to - Assess peritonitis: (+) cough test, guarding, rigidity,
symphysis pubis. rebound tenderness, percussion tenderness

Pain: location (point), timing, description, severity (1-10), LIVER


aggravates and relieves pain
Percussion
Examine pain area last!
- Vertical Liver Span: lower border from midclavicular
Warm hands and steth. Calm. Avoid quick and unexpected from the level below the umbilicus in RLQ, percuss
movements. No long fingernails. upward
- upper border from midclavicular line from nipple to
Distract. If ticklish, pts hands below yours. Watch patients
liver dullness
face for signs of pain or discomfort.
- Normal: 4-8 cm (midsternal); 6-12cm (midclavicular)
IAPePa
Palpation
Inspection
- Left hand behind, parallel to the right 11th and 12th
- Skin: scars, striae, dilated veins, rashes, ecchymosis ribs below. Right hand lateral to the rectus muscle.
- Umbilicus: contour, location, inflammation, bulges for Fingertips below the border of the liver dullness. Ask
hernia patient to breathe with abdomen.
- Abdomen: - Note tenderness
o contour (round, protuberant, scaphoid) - Normal: liver edge is soft, sharp, regular with a
o symmetric? smooth surface, slightly tender
o Flank bulge - Hooking technique if obese: Stand at right of pts
o Hernia (inguinal and femoral) chest. Hook fingers of both hands side by side below
o Visible masses or organs (enlarged liver or border of liver dullness. Press in and up toward costal
spleen) margin. Deep breath.
o Peristalsis - Tenderness of a nonpalpable liver: left hand at the
o Pulsations lower right rib cage and gently strike with the ulnar
surface of the left hand. Compare with left side.
Auscultation
SPLEEN
- Bowel sounds (N: 5-34 per minute)
- Borborygmi prolong hyperperistalsis stomach Percussion
growling
- Percuss the left lower anterior chest wall at the
- Bruit, pulsations (aorta, renal, iliac, femoral)
traubes space
- Friction rubs liver and spleen
- Traubes space from cardiac dullness border at the
Percussion 6th rib to the AAL and down to he costal margin
- Check for splenic percussion sign (lowest left
- Percuss lightly all quadrant: tympany or dullness intercostals space in AAL), deep breath: normal still
- Assess distribution of gas, if mass solid/fluid, size of tympany
liver and spleen
- Liver dullness, gastric air bubble, splenic flexure Palpation

Palpation - Left hand reach over to support and press forward


the lower ribcage. Right hand below left costal margin
- Light palpation: note for tenderness, muscular press toward the spleen. Deep breath. Feel tip or
resistance, rigidity, superficial organs and masses, edge.
pulsations (light, gentle, dipping motion)
- Note for enlargement, tenderness, splenic contour, - Protuberant abdomen w/ bulging flanks
distance between the spleens lowest point and the - Map border between dull and tympany
left costal margin - Shifting dullness
- Repeat with the patient lying on the right side with - Fluid wave
legs flexed at the hips and knees. In this position,
gravity may bring the spleen forward and to the right Organ in Ascitic Abdomen:
into a palpable location.
- Ballottement: straighten and stiffen fingers of one
hand together, place on surface, brief jabbing
KIDNEYS movement toward structure.
- Will displace fluid so you can feel surface.
Palpation: Left kidney:
Appendicitis
- Pts left side. Right hand below and parallel to 12th rib.
Lift. Left hand parallel and lateral to rectus. Deep - Where pain start, where now
breath. At peak of inspiration, capture edge of kidney. - Cough and where pain occurs
Exhale and stop, release. - Check guarding, rigidity, rebound tenderness
- Size, contour, tenderness - Rovsing sign
- Alternative: same with spleen palpation - Obturator sign
- Psoas sign
Palpation: Right kidney: - Rectal/pelvic exam
- Return to right side. Left hand at the back, lift. Right Acute Cholecystitis
hand press deep.
- Usually rounded lower pole. - Murphys sign: hook left thumb or right fingers under
intersection of lateral border of rectus and costal
Percussion Tenderness: margin. Deep breath. Increase tenderness and sudden
- CVAT. Fingertips may cause tenderness. Ball of one stop inspiration = (+)
hand in CVA, strike with ulnar surface of fist. Use Ventral Hernias:
perceptible but painless thud.
- Raise head and shoulders off the bed. Bulge will
BLADDER appear.
- Dome of distended is round and smooth upon Mass in abdl wall or intra abdominal:
palpation. Check tenderness. Percuss if dull. Dullness
will appear if 400-600ml. - Raise head and shoulders off bed. If abdominal wall
mass, will remain palpable. If intra, obscured by mm
AORTA contraction.
- Press firmly deep into abdomen at left of midline and Others
identify aortic pulsation. If >50 years old, assess
width. Press deep in abdomen with hands at sides of - Grey turner sign
aorta. Normal is less than 3cm. - Cullen sign

Ascites:
Peripheral Vascular system - Grade the pulses
o 3+ Bounding
VITAL SIGNS! BP both arms o 2+ Brisk, expected (normal)
Explain and ask permission o 1+Diminished, weaker than expected
Always check bilaterally and compare o 0 Absent, unable to palpate
- Temporal pulse Special techniques:
- Carotid upstroke, listen for bruits - ALLENS TEST:
ARMS: 1. hands in lap, palms up
- Inspect both arms for size, symmetry, and any swelling, 2. tight fist. Compress radial and ulnar
venous pattern, color of the skin and nail beds and the 3. open into relaxed, slightly flexed
texture of the skin 4. release ulnar. If patent, flush within 3-5 secs
- Radial partially flex wrist 5. same with radial artery
- Brachial - flex elbow slightly, artery is medial to the - POSTURAL COLOR CHANGES OF CHRONIC ARTERIAL
biceps tendon at the antecubital crease; also in groove INSUFFICIENCY
between biceps and triceps o Raise both legs to about 60 degrees until
- Epitrochlear nodes: presence of nodes, size, maximal pallor of the feet (within a minute).
consistency,and tenderness (difficult or impossible to o Then ask the patient to sit up with legs dangling
identify in most normally healthy people) flex elbow at down. Compare both feet, noting the time
90deg, forearm supported by hand, reach behind the required for:
arm and feel groove between biceps and triceps mm, Return to pink (<10 sec)
3cm from medial epicondyle Filling veins (~15 sec)
ABDOMINAL AORTIC PULSES: o Check for rubor (dusky redness) to replace the
- Auscultate aortic, renal, femoral bruits pallor (may take >1 min)
- Palpate and estimate width of AA in epigastric area using - MAPPING VARICOSE VEINS
two fingers o With the patient standing, place your palpating
LEGS: fingers gently on a vein and, with your other
- Inspect both legs for size, symmetry, and any swelling, hand below it, compress the vein sharply.
venous pattern, color of the skin and nail beds and the o Feel for a pressure wave transmitted to the
texture of the skin. Venous pattern and any venous fingers of your upper hand.
enlargement. Any pigmentation, rashes, scars, or ulcers o A palpable pressure wave indicates that the two
- Check for tenderness during palpation parts of the vein are connected.
- Palpate the superficial inguinal nodes (horizontal and the o A wave may also be transmitted downward, but
vertical groups): size, consistency, discreteness, and note not as easily.
any tenderness. (Nontender, discrete inguinal nodes up - TRENDELENGBURG TEST (Retrograde Filling Test)
to 1 cm or even 2 cm in diameter are frequently palpable o Patient supine.
in normal people) o Elevate one leg to about 90 degrees to empty it
- Palpate femoral pulse press deeply below inguinal of venous blood.
ligament midway between ASIS and symphysis pubis o Next, occlude the great saphenous vein in the
- Popliteal pulse knees flexed and leg relaxed. Fingertips upper thigh by manual compression, using
of both hands meet at midline behind. enough pressure to occlude this vein.
- Alternative: pt prone, flex knees, lower leg relaxed o Ask the patient to stand for 20 seconds.
against your shoulder, press thumbs into fossa o While you keep the vein occluded, watch for
- Dorsalis pedis dorsum, lateral to extensor tendon of big venous filling in the leg
toe or more laterally o Normally, saph vein fills from below
- Posterior tibial finger behind and slightly below medial o Repid filling suggest communicating valve
malleolus incompetence
- Temperature of the legs o After the patient stands for 20 seconds, release
- Check prominent veins, tendons and bones the compression and look for sudden additional
- Edema use thumbs for 2 secs and grade (1+, 2+, 3+, 4+) venous filling.
at the dorsum of foot, behind medial malleolus, shins. Normally there is none; competent
Check for pitting valves in the saphenous vein block
- If with unilateral edema: measure forefoot, smallest retrograde flow. Slow venous filling
circumference above ankle, largest circum at calf, continues.
midthigh (diff of 1 cm at ankle and 2cm at calf = edema o Normal result is negative-negative
Musculoskeletal system - Stand in front of patient
- Flexion raise arms in front of you and overhead
TEMPOROMANDIBULAR JOINT o Anterior deltoid, pectoralis major, biceps and
coracobrachialis
Inspection:
- Extension raise arms behind you
- Inspect the face for symmetry, swelling or redness. o Latissimusdorsi, teres major, posterior
(swelling may appear as a rounded bulge ~0.5cm deltoid, tricepsbarchii (Long head)
Palpate: - Abduction arms to side and overhead
- In front of the tragus of each ear and ask the patient to o Supraspinatus, middle deltoid, serratus
o Open mouth (fingertips should drop into the anterior
joint spaces as the mouth opens). Pure glenohumeral motion: arms to shoulder
o Range of motion level at 90deg, palms down
Opening and closing, Scapulothoracic motion: palms up and raise
Protrusion and retraction arms additional 60deg
Side-to-side - Adduction cross arm in front of body
o Swelling or tenderness. o Pectoralis major, coracobrachialis,
- Masseters angle of mandible latissimusdorsi, teres major, subscapularis
- Temporal muscles clenching and relaxation of jaw - Internal Rotation one hand behind back and touch
- Pterygoid muscles internally between tonsillar pillars shoulder blade
at mandible o Identify highest spinous process reached
o Subscapularis, anterior deltoid, pectoralis
major, teres major, latissimusdorsi
SHOULDER - External Rotation - one hand behind neck as if
Inspection brushing hair
- Swelling, deformity, muscle atrophy or fasciculations o Infraspinatus, teres minor, posterior deltoid
(fine tremors of the muscles), or abnormal positioning.
- Swelling of the joint capsule anteriorly or a bulge in the Best predictors of rotator cuff tear are supraspinatus
subacromial bursa under the deltoid muscle. weakness on abduction, infraspinatus weakness during
- Color change, skin alteration, or unusual bony contours external rotation, and a positive impingement sign.

Palpation begin medially - Maneuvers for shoulder pain: rotator cuff muscle
- Sternoclavicular joint, trace the clavicle laterally with compression
your fingers. o Crossover test acromioclavicluarjoint
- Acromioclavicular joint Adduct the patients arm across the
- Coracoid process chest
- Greater tubercle o Apley scratch test- overall shoulder rotation
- Biceps tendon in the bicipital groove- tenderness Touch the opposite scapula either
- SITS over or under
o To examine the subacromia land subdeltoid o Neers impingement- rotator cuff tear
bursae and the SITS muscles, first passively Press on the scapula to prevent
extend the humerus by lifting the elbow scapular motion with one hand, and
posteriorly. This rotates these structures so raise the patients arm with the
that they are anterior to the acromion. other. This compresses the greater
Palpate carefully over the subacromial and tuberosity of the humerus against
subdeltoid bursae. The underlying palpable the acromion.
SITS muscles are: o Hawkins impingement sign- rotator cuff tear
Supraspinatusdirectly under the Flex the patients shoulder and elbow
acromion to 90 degrees with the palm facing
Infraspinatusposterior to down. Then, with one hand on the
supraspinatus forearm and one on the arm, rotate
Teres minorposterior and inferior the arm internally. This compresses
to the supraspinatus the greater tuberosity against the
Subscapularisinserts anteriorly and coracoacromial ligament.
is not palpable

o Empty can test (supraspinatus strength)


Range of motion rotator cuff tear
Elevate the arms to90 degrees and
internallyrotate the armswith the Palpation
thumbs pointingdown, as if - Palpate the distal radius and ulna on the lateral and
emptyinga can. Ask thepatient to medial surfaces.
resist as youplace downward - Palpate the groove of each wrist joint with your
pressureon the arms. thumbs on the dorsum of the wrist
o Infraspinatus strength- rotator cuff tear o Swelling, bogginess, or tenderness
&bicipital tendinitis - Palpate the radial styloid bone and the
Ask the patient to place arms at the - Anatomical snuffbox (visible with lateral extension of
side and flex the elbows to 90 the thumb away from the hand), a hollowed
degrees with the thumbs turned up. depression
Provide resistance as the patient - Palpate the eight carpal bones, metacarpals and the
presses the forearms outward. proximal,
o Forearm supination- rotator cuff tear - Middle, and distal phalanges
Flex the patients forearm to 90 o Swelling, bogginess, or tenderness.
degrees at the elbow and pronate - Palpate the medial and lateral aspects of each PIP and
the patients wrist. Provide DIP joint
resistance when the patient o Swelling, bogginess, bony enlargement or
supinates the forearm. tenderness
o Drop-arm sign- rotator cuff tear
Ask the patient to fully abduct the Range of motion: wrist
arm to shoulder level (or up to 90 - Flexion -With palms down, point your fingers toward
degrees) and lower it slowly. Note the floor.
that abduction above shoulder level, o Flexor carpi radialis, flexor carpi ulnaris
from 90 degrees to 120 degrees, - Extension - With palms down, point your fingers
reflects action of the deltoid muscle. toward the ceiling.
o Extensor carpi ulnaris, extensor carpi
ELBOW radialislongus, extensor carpi radialisbrevis
Inspection - Adduction (radial deviation) -With palms down,
- Medial and lateral epicondyles and the olecranon bringyour fingers toward the midline.
process of the ulna (flexed to about 70 degrees) o Flexor carpi ulnaris
o Contours, extensor surface of the ulna and - Abduction (ulnar deviation)-With palms down, bring
the olecranon process your fingers away from the midline.
o Nodules or swelling flexed to about 70 o Flexor carpi radialis
degrees
Palpation Maneuvers
- Olecranon process and epicondyles - Hand grip strength asking the patient to grasp your
- Tenderness or effusion and displacement 2nd and 3rd fingers.
o Tests function of wrist joints, thefinger
Range of motion flexors, and the intrinsic muscles andjoints of
- Flexion - Bend your elbow. the hand.
o Biceps brachii, brachialis,brachioradialis - Finkelsteins test - asking the patient to grasp the
- Extension - Straighten your elbow. thumb against the palm and then move the wrist
o Triceps brachii, anconeus toward the midline in ulnar deviation
- Supination - Turn your palms up, as if carrying a bowl - Carpal Tunnel Syndrome aching, numbness and
of soup. tingling
o Biceps brachii, supinator o Thumb abduction- asking the patient to raise
- Pronation - Turn your palms down. the thumb straight up as you apply downward
- Pronator teres, pronatorquadratus resistance
o Tinels sign - tapping lightly over the course of
WRIST AND HANDS the median nerve
Inspection o Phalens sign -asking the patient to hold
- When the fingers are relaxed they should be slightly thewrists in flexion for 60 seconds.
flexed; the fingernail edges should be in parallel.
- Swelling, deformities of the wrist, hand, or finger
bones, angulation
- Contours of the palm, namely the thenar and
hypothenar eminences.
- Thickening of the flexor tendons or flexion Range of motion: fingers
contractures in the fingers.
- Flexion-Make a tight fist with each hand, thumb - Flexion bend forward and try to reach toes (psoas
across the knuckles.(lumbrical muscles). major and minor, quad lumborum, int and ext oblique,
- Extension-Extend and spread the fingers.(lumbrical rectus ab) note smoothness and symmetry of
muscles). movement, lumbar cavity should flatten
- Abduction and adduction.- Ask the patient to spread - Extension bend back as far as possible (erector
the fingers apart and back together spinae, transversospinalis) support by placing hand
on PSIS with fingers pointing to midline
Range of motion: thumb - Rotation rotate side to side (ab mm, intrinsic mm of
- Flexion- move the thumb back across the palm back) stabilize pelvis by placing one hand on hip and
- Extension - away from the fingers other on the opposite shoulder. Rotate trunk by
- Abduction - thumb in the neutral position with the pulling shoulder anteriorly and hip posteriorly
palm up, then have the patient move the thumb - Lateral bending bend to side from waist (ab mm,
anteriorly away intrinsic mm of back) stabilize pelvis by hand on hip
- Adduction - back down
- Opposition- touch the thumb to each of the other
fingertips. HIP:

Inspection:
SPINE: - Gait 2 phases:
Ideally: pt upright in the normal standing position, feet 1. Stance foot is on the ground ad bears weight
together and arms hanging at the sides. Head and (60%); heelstrike, foot flat, midstance, push off
sacrum at midline. Shoulder and pelvis should be level 2. Swing foor moves forward and does not bear
weight (40%)
Inspection: Observe width of base (2-4 in from heel to heel), shift
- Inspect posture, position of neck and trunk; erect of pelvis, flexion of knee. Must be smooth and with
position of head, neck and back; smooth coordinated continuous rhythm.
neck movement; ease of gait Observe lumbar portion of spine for amount of
- Identify spinous process. Prominent C7 and T1 esp on lordosis. Supine to check for length of legs for
forward flexion; paravertebral mm; PSIS marked by asymmetry.
dimples - Inspect ant and post surface of hip for atrophy or
- Examin from side and behind. Evaluate spinal bruising
curvatures
Palpation:
Palpation: - Anterior:
- Palpate spinous process of all with thumb 1. Iliac crest upper margin of pelvis at T4
- Palpate facet joints between the cervical vertebrae 1 2. Iliac tubercle follow downward curve from crest
inch lateral to spinous process of C2-C7. Neck mm 3. ASIS continue tracking downward
must be relaxed 4. Greater trochanter thumbs on ASIS, move
- In lower lumbar area, check for vertebral step offs to fingers downward and laterally from iliac tubercles
determine prominent spinous processes. Check 5. Pubic tubercle thumbs medially and obliquely;
tenderness same level of greater troch
- Palpate sacroiliac joint dimple over PSIS - Posterior:
- For tenderness do thumping with ulnar surface of fist 1. PSIS under dimples just above buttocks
- Paravertebral mm for tenderness and spasm (knotted - Left thumb and index finger over the posterior
and firm and may be visible) superior iliac spine. Greater trochanter laterally with
- Sciatic nerve: hip flex and lie on opposite side. Midway your fingers at the level of the gluteal fold, and place
between greater trochanter and ischial tuberosity. your thumb medially on the ischial tuberosity.
- Cauda equine syndrome: low back pain radiating to - Inguinal structures: pt supine with heel of leg to be
butt, perineum or legs. examined on opposite knee. Palpate along inguinal
ligament (extends from ASIS to pubic tubercle). Nerve
ROM for NECK: Artery Vein Empty space Lymph node NAVEL
- Flexion chin to chest (SCM, scalene, paravert) - Bursa below inguinal ligament but deeper. If hip os
- Extension look up to ceiling (splenius capitis and painful do this. Pt resting on one side, hip flex and int
cervicis, small intrinsic neck mm) rotated, palpate trochanteric bursa over greater troch.
- Rotation look over one shoulder and another (SCM, Ischiogluteal bursa is not palpable unless inflamed
small intrinsic neck mm)
- Lateral bending bring ear to shoulder (scalene, small ROM for Hip
intrinsic neck) - Flexion bend knee to chest and pull it over to
abdomen (iliopsoas)
ROM for SPINE:
- Extension (hyper) lie face down then bend knee and o Facing the knee, place your thumbs in the
lift it up (glut max) soft-tissue depressions on either side of the
- Abduction lying flat, move lower leg away from patellar tendon.
midline (glut med and min) o Identify the groove of the tibiofemoral joint.
- Adduction lying flat, bend knee and move lower leg Note that the inferior pole of the patella lies
to midline (adductor brevis, longus and magnus, at the tibiofemoral joint line.
pectineus, gracilis) o As you press your thumbs downward, you can
- Ext rotation lying flat, bend your knee and turn lower feel the edge of the tibial plateau. Follow it
leg and foot across midline (int and ext obturators, medially, then laterally, until you are stopped
quad femoris, sup and inf gemelli) by the converging femur and tibia.
- Int rotation lying flat, bend knee and turn lower leg o By moving your thumbs upward toward the
and foot away from midline (iliopsoas) midline to the top of the patella, you can
follow the articulating surface of the femur
Maneuvers for Hip: and identify the margins of the joint.
- Flexion o Note any irregular bony ridges along the joint
1. Pt supine. Hand under lumbar spine. Bend knee up margins.
to chest and put firmly against abdomen. - Medial meniscus & lateral meniscus
2. Note lumbar flattening o Pressing on the medial soft-tissue depression
3. Observe for degree of flexion at hip and knee. along the upper edge of the tibial plateau. It is
Normally ant surface of thigh can touch chest wall easier to palpate the medial meniscus if the
4. Note whether opposite thigh remains extended tibia is slightly internally rotated.
fully o Place the knee in slight flexion and palpate
- Extension the lateral meniscus along the lateral joint
1. Face down, extend thigh toward you in posterior line.
direction - Medial joint compartments of the tibiofemoral joint
2. Alt: near edge of table. Extend leg post o Knee flexed examining table to
- Abduction approximately90 degrees.
1. Stabilize pelvis by pressing down on opposite ASIS o Medially, move your thumbs upward to
with one hand. palpate the medial femoral condyle. The
2. Other hand grasp ankle and abduct extended leg adductor tubercle is posterior to the medial
until you feel iliac spine move. This marks the femoral condyle
limit of hip abduction o Move your thumbs downward to palpate the
- Adduction pt supine. medial tibial plateau.
1. Stabilize pelvis, hold one ankle o Pain or tenderness
2. Move leg medially across body and over opposite - Medial collateral ligament
extremity o Connects the medial epicondyle of the femur
- Ext and Int Rotation to the medial condyle and superior medial
1. Flex leg to 90deg at hip and knee surface of the tibia.
2. Stabilize thigh with one hand, grasp ankle with o Palpate along this broad, flat ligament from its
other origin to insertion.
3. Swing lower leg medially (ext) or laterally (int) - Lateral joint compartments of the tibiofemoral joint
Note: motion of head of femur in acetabulum that o Lateral to the patellar tendon, move your
identifies these movements thumbs upward to palpate the lateral femoral
condyle and downward to palpate the lateral
KNEE tibial plateau.
Inspection o When the knee is flexed, the femoral
- Gait. The knee should be extended at heel strike and epicondyles are lateral to the femoral
flexed at all other phases of swing and stance. condyles.
- Check the alignment and contours of the knees. - Lateral collateral ligament
- Observe any atrophy of the quadriceps muscles. Look o Ask the patient to cross one leg so the ankle
for loss of the normal hollows around the patella, a rests on the opposite knee
sign of swelling in the knee joint and suprapatellar o A firm cord that runs from the lateral femoral
pouch epicondyle to the head of the fibula.
- Note any other swelling in or around the knee. - Patellofemoral compartment
o Locate the patella and trace the patellar
Palpation tendon distally until you palpate the tibial
- Ask the patient to sit on the edge of the examining tuberosity.
table with the knees in flexion. o Ask the patient to extend the knee to make
- The Tibiofemoral Joint. sure the patellar tendon is intact.
- Patellofemoral grinding test
o With the patient supine and the knee Range of motion
extended - Flexion- Bend or flex your knee. Or Squat down to
o Compress the patella against the underlying the floor.
femur, and gently move it medially and o Hamstring group: biceps femoris,
laterally, assessing for crepitus and pain. semitendinosus, and semimembranosus
o Ask the patient to tighten the quadriceps as - Extension -Straighten your leg. Or After you squat
the patella moves distally in the trochlear down to the floor, stand up.
groove. o Quadriceps: rectus femoris, vastus medialis,
o Check for a smooth sliding motion lateralis, and intermedius
- Suprapatellar pouch - Internal Rotation - While sitting, swing your lower leg
o Start 10 cm above the superior border of the toward the midline.
patella, well above the pouch, and feel the o Sartorius, gracilis, semitendinosus,
soft tissues between your thumb and fingers. semimembranosus
o Move your hand distally in progressive steps, - External Rotation -While sitting, swing your lower leg
trying to identify the pouch. away from the midline.
o Continue your palpation along the sides of the o Biceps femoris
patella.
o Note any tenderness or warmth greater than Maneuvers
in the surrounding tissues. - Mcmurray Test - Medial meniscus and lateral meniscus
o Supine, grasp the heel and flex the knee. Cup
Palpation Tests for Effusion in the Knee Joint. your other hand over the knee joint with
- Bulge sign (for minor effusions) fingers and thumb along the medial joint line.
o Knee extended, place the left hand above the o From the heel, externally rotate the lower,
knee and apply pressure on the suprapatellar then push on the lateral side to apply a valgus
pouch, displacing or milking fluid stress on the medial side of the joint. At the
downward. same time, slowly extend the lower leg in
o Stroke downward on the medial aspect of the external rotation.
knee and apply pressure to force fluid into the o The same maneuver with internal rotation of
lateral area. the foot stresses the lateral meniscus.
o Tap the knee just behind the lateral margin of o If a click is felt or heard at the joint line during
the patella with the right hand. flexion and extension of the knee, or if
- Balloon sign ( for major effusions) tenderness is noted along the joint line,
o Place the thumb and index finger of your right further assess the meniscus for a posterior
hand on each side of the patella; with the left tear.
hand, compress the suprapatellar pouch - Abduction (or Valgus) Stress Test - Medial collateral
against the femur. ligament (MCL)
o Feel for fluid entering (or ballooning into) the o Supine and the knees lightly flexed, move the
spaces next to the patella under your right thigh about30 degrees laterally to the side of
thumb and index finger. the table.
- Ballotting the patella (large effusions), you can also o Place one hand against the lateral knee to
o Compress the suprapatellar pouch and stabilize the femur and the other hand around
ballotteor push the patella sharply against the medial ankle.
the femur. o Push medially against the knee and pull
o Watch for fluid returning to the suprapatellar laterally at the ankle to open the knee joint on
pouch. the medial side
- Adduction (or Varus) Stress Test - Lateral collateral
ligament (LCL)
- Gastrocnemius and soleus muscles o The thigh and knee in the same position,
o Their common tendon, the Achilles, is change your position so you can place one
palpable from about the lower third of the hand against the medial surface of the knee
calf to its insertion on the calcaneus. and the other around the lateral ankle.
- Achilles tendon o Push laterally against the knee and pull
o Place the patient prone with the knee and medially at the ankle to open the knee joint
ankle flexed at 90 degrees, or alternatively on the lateral side
o Ask the patient to kneel on a chair.
o Squeeze the calf and watch for plantar flexion
at the ankle
- Anterior Drawer Sign - Anterior cruciate ligament (ACL) Maneuvers
o Supine, hips flexed and knees flexed to 90 - Ankle (Tibiotalar) Joint.
degrees and feet flat on the table, cup your o Dorsiflex and plantar flex the foot at the
hands around the knee with the thumbs on ankle.
the medial and lateral joint line and the - Subtalar (Talocalcaneal) Joint
fingers on the medial and lateral insertions of o Stabilize the ankle with one hand, grasp the
the hamstrings. heel with the other, and invert and evert the
o Draw the tibia forward and observe if it slides foot by turning the heel inward then outward.
forward (like a drawer) from under the femur. - Transverse Tarsal Joint
Compare the degree of forward movement o Stabilize the heel and invert and evert the
with that of the opposite knee. forefoot.
- Lachman Test - Anterior cruciate ligament (ACL) - Metatarsophalangeal Joints
o Place the knee in 15degrees of flexion and o Move the proximal phalanx of each toe up
external rotation. Grasp the distal femur on and down.
the lateral side with one hand and the
proximal tibia on the medial side with the
other. Special techniques
o With the thumb of the tibial hand on the joint - Measuring the Length of Legs
line, simultaneously pull the tibia forward and o If you suspect that the patients legs are
the femur back. unequal in length, measure them. Get the
o Estimate the degree of forward excursion. patient relaxed in the supine position and
- Posterior Drawer Sign - Posterior cruciate ligament symmetrically aligned with legs extended.
(PCL) With a tape, measure the distance between
o Position the patient and place your hands in the anterior superior iliac spine and the
the positions described for the anterior medial malleolus. The tape should cross the
drawer test. knee on its medial side. (unequal- scoliosis)
o Push the tibia posteriorly and observe the
degree of backward movement in the femur.

ANKLE AND FOOT


Inspection
- All surfaces of the ankles and feet, noting any
deformities, nodules, swelling, calluses, or corns.

Palpation
- Palpate the anterior aspect of each ankle joint,
o Bogginess, swelling, or tenderness.
- Achilles tendon
o Nodules and tenderness.
- Posterior and inferior calcaneus, and the plantar fascia
for tenderness.
- Medial and lateral malleolus for tenderness
- Metatarsophalangeal joints
o Tenderness
o Compress the forefoot tbetween the thumb
and fingers. Exert pressure just proximal to
the heads ofthe first and fifth metatarsals.
- Heads of the five metatarsals and the grooves between
them
o Using thumb and index finger. Place your
thumb on the dorsum of the foot and your
index finger on the plantar surface.

Range of motion
- Ankle Flexion (plantar flexion)- Point your foot toward
the floor.
- Ankle Extension (dorsiflexion)-Point your foot toward
the ceiling.
- Inversion- Bend your heel inward.
- Eversion- Bend your heel outward.
NEUROLOGIC EXAMINATION o Motor
Palpating the temporal and masseter
Mental status examination muscles in turn, ask the patient to
clench the teeth. Note the strength
- Level of consciousness
of muscle contraction. Ask \the
o Alert/awake
patient to move the jaw side to side.
o Lethargic o Sensory
o Obtunded Test the forehead, cheeks, and jaw
o Stuporous on each side for pain sensation. The
o Coma patients eyes should be closed. Use
- Attention span a suitable sharp object, occasionally
- Orientaion substituting the blunt end for the
o Place, person, time and date point as a stimulus. Ask the patient
- Memory to report whether it is sharp or
o Recent and remote dull and to compare sides.
- Judgement and insight If you find an abnormality, confirm it
by testing temperature sensation.
- Calculation
Two test tubes, filled with hot and
- Fund of information
ice-cold water
- Thought process
Test for light touch, using a fine wisp
- Mood and affect of cotton. Ask the patient to respond
- Speech whenever you touch the skin.
- langauge o Test the corneal reflex. Ask the patient to look
up and away from you. Approaching from the
Cranial nerves
side, touch the cornea (not just the
- Cranial nerve I: Olfactory conjunctiva) lightly with a fine wisp of cotton.
o Test the sense of smell by presenting the - Cranial nerve VII: Facial
patient with familiar nonirritating odors. First, o Motor
be sure that each nasal passage is open by Inspect the face, both at rest and
compressing one side of the nose and asking during conversation with the patient.
the patient to sniff through the other. The Note any asymmetry and observe
patient should then close both eyes. Test the any tics or other abnormal
other side. movements.
- Cranial nerve II: Optic Ask the patient to:
o Test visual acuity 1. Raise both eyebrows.
o Inspect the optic fundi with your 2. Frown.
ophthalmoscope, paying special attention to 3. Close both eyes tightly so that you
the optic discs cannot open them. Test muscular
Red orange reflex, optic disc, strength by trying to open them, as
physiologic cup, retinal vessels and illustrated.
fovea 4. Show both upper and lower teeth.
o Test the visual fields by confrontation. 5. Smile.
o Direct light reflex 6. Puff out both cheeks.
- Cranial nerve II and III: Optic and Oculomotor
o Inspect the size and shape of the pupils, and o Sensory
compare one side with the other. Check taste anterior 2/3 of the
Anisocoria, or a difference of >0.4 tongue
mm in the diameter - Cranial nerve VIII: Acoustic
o Test the pupillary reactions to light. o Assess hearing with the whispered voice test.
o Check the near response, which tests pupillary o Test for air and bone conduction, using the
constriction (pupillary constrictor muscle), Rinne test, and lateralization, using the Weber
convergence (medial rectus muscles), and test.
accommodation of the lens (ciliary muscle). - Cranial nerve IX and X: Glossopharyngeal and Vagus
- Cranial nerve III, IV, and VI: Oculomotor, Trochlear and o Listen to the patients voice. Is it hoarse, or
Abducens does it have a nasal quality?
o Test the extraocular movements in the six o Difficulty in swallowing?
cardinal directions of gaze o Ask the patient to say ah or to yawn as you
o Check convergence of the eyes. watch the movements of the soft palate and
o Identify any nystagmus, ptosis the pharynx.
- Cranial Nerve V: Trigeminal
o Test the gag reflex. Stimulate the back of the o Test opposition of the thumb. The patient
throat lightly on each side in turn and note should try to touch the tip of the little finger
the gag reflex. with the thumb, against your resistance.
- Cranial nerve XI: Spinal Accessory C8, T1, median nerve
o From behind, look for atrophy or o Flexion, extension, and lateral bending of the
fasciculations in the trapezius muscles, and spine
compare one side with the other. o Thoracic expansion and diaphragmatic
o Ask the patient to shrug both shoulders excursion during respiration
upward against your hands. Note the strength o Test flexion at the hip by placing your hand on
and contraction of the trapezii. the patients thigh and asking the patient to
o Ask the patient to turn his or her head to each raise the leg against your hand.
side against your hand. Observe the L2, L3, L4iliopsoas
contraction of the opposite sternomastoid o Test adduction at the hips. Place your hands
and note the force of the movement against firmly on the bed between the patients
your hand. knees. Ask the patient to bring both legs
- Cranial nerve XII: Hypoglossal together.
o Listen to the articulation of the patients L2, L3, L4adductors
words. o Test abduction at the hips. Place your hands
o Inspect the patients tongue as it lies on the firmly on the bed outside the patients knees.
floor of the mouth. Ask the patient to spread both legs against
o Look for any atrophy or fasciculations. your hands.
o Ask patient to protrude tongue, look for L4, L5, S1gluteus medius and
asymmetry, atrophy, or deviation from the minimus
midline. o Test extension and flexion at the hips. Have
o Ask the patient to move the tongue from side the patient push the posterior thigh down
to side, and note the symmetry of the against your hand.
movement. S1gluteus maximus
o Ask the patient to push the tongue against the o Test extension at the knee. Support the knee
inside of each cheek in turn as you palpate in flexion and ask the patient to straighten the
externally for strength. leg against your hand. The quadriceps is the
strongest muscle in the body, so expect a
Motor forceful response.
- Inspect: body contour, involuntary muscle, atrophy, L2, L3, L4quadriceps
muscle tone o Test flexion at the knee as shown below. Place
- Muscle strength the patients leg so that the knee is flexed
o Test muscle strength by asking the patient to with the foot resting on the bed. Tell the
actively resist your movement. patient to keep the foot down as you try to
straighten the leg.
o Test biceps flexion and extension L4, L5, S1, S2hamstrings
C5, C6 o Test dorsiflexion
o Triceps flexion and extension at the elbow by Mainly L4, L5tibialis anterior
having the patient pull and push against your o Plantar flexion, at the ankle by asking the
hand. patient to pull mainly S1gastrocnemius,
C6, C7, C8 soleus up and push down against your hand.
o Test wrist extension at the by asking the
patient to make a fist and resist your pulling it Cerebellar
down - Rapid alternating movement
C6, C7, C8,radial nerveextensor o Arms
carpi radialis longus and brevis Show the patient how to strike one
o Test the grip. Ask the patient to squeeze two hand on the thigh, raise the hand,
of your fingers as hard as possible and not let turn it over, and then strike the back
them go. Testing both grips simultaneously of the hand down on the same place.
with arms extended or in the lap facilitates Urge the patient to repeat these
comparison. alternating movements as rapidly as
C7, C8, T1 possible.
o Test finger abduction. Position the patients Observe the speed, rhythm, and
hand with palm down and fingers spread. smoothness of the movements.
Instructing the patient not to let you move Repeat with the other hand. The
the fingers, try to force them together. nondominant hand often performs
C8, T1, ulnar nerve somewhat less well.
o Legs A person who cannot stand may be
Ask the patient to tap your hand as tested for a pronator drift in the
quickly as possible with the ball of sitting position.
each foot in turn. Note any slowness tap the arms briskly downward. The
or awkwardness. arms normally return smoothly to
The feet normally perform less well the horizontal position.
than the hands.
o Finger-to-nose test Sensory
Ask the patient to touch your index - Pain
finger and then his or her nose o Use a sharp safety pin, a broken cotton swab
alternately several times. o Ask the patient, Is this sharp or dull?
Move your finger about so that the - Temperature
patient has to alter directions and o Temperature testing is often omitted if pain
extend the arm fully to reach it. sensation is normal, but include it if there are
Observe the accuracy and sensory deficits.
smoothness of movements, and o Touch the skin and ask the patient to identify
watch for any tremor. Normally the hot or cold.
patients movements are smooth and - Fine touch
accurate. o With a fine wisp of cotton, touch the skin
o Heel-to-shin test lightly, avoiding pressure.
Ask the patient to place one heel on o Ask the patient to respond whenever a touch
the opposite knee, and then run it is felt, and to compare one area with another.
down the shin to the big toe. - Vibration
Note the smoothness and accuracy o place it firmly over a distal interphalangeal
of the movements. joint of the patients finger, then over the
Repetition with the patients eyes interphalangeal joint of the bigtoe. Ask what
closed tests for position sense. the patient feels.
Repeat on the other side. o proximal bony prominences (e.g., wrist,
- Gait elbow, medial malleolus, patella, anterior
o Walk across the room superior iliac spine, spinous processes, and
Observe posture, balance, swinging clavicles).
of the arms, and movements of the - Position sense
legs. o Grasp the patients big toe, holding it by its
o Walk heel-to-toe (tandem walking) in a sides between your thumb and index finger,
straight line and then pull it away from the other toes.
o Walk on the toes, then on the heels o Demonstrate up and down as you move
o Hop in place on each foot in turn the patients toe
involves the proximal muscles of the o Then, with the patients eyes closed, ask for a
legs as well as the distal ones response of up or down when moving the
o Do a shallow knee bend, first on one leg, then large toe in a small arc.
on the other - Discriminative sensation
o Rising from a sitting position without arm o Stereognosis
support o Graphesthesia
o stepping up on a sturdy stool o Two-point discrimination.
- stance Touch a finger pad in two places
o Rombergs test simultaneously. Alternate the double
This is mainly a test of position sense. stimulus irregularly with a one-point
The patient should first stand with touch. Be careful not to cause pain
feet together and eyes open and o Point localization.
then close both eyes for 30 to 60 Briefly touch a point on the patients
seconds without support. skin. Then ask the patient to open
Note the patients ability to maintain both eyes and point to the place
an upright posture. touched.
o Pronator drift o Extinction.
The patient should stand for 20 to 30 Simultaneously stimulate
seconds with both arms straight corresponding areas on both sides of
forward, palms up, and with eyes the body. Ask where the patient feels
closed. your touch
o Dermatomes
C2 ears
C3 front and back of the neck o Quickly check the patients color and pattern
C6 lateral aspect of the arms, index of breathing. Inspect the posterior pharynx
and thumb and listen over the trachea for stridor to make
C8 ring and little fingers sure the airway is clear.
L4 knee o If respirations are slowed or shallow, or if the
L5 anterior ankle and foot airway is obstructed by secretions, consider
S5 perianal intubating the patient as soon as possible
Reflexes while stabilizing the cervical spine.
- Biceps (C5, C6) o Assess the remaining vital signs: pulse, blood
- Triceps (C6, C7) pressure, and rectal temperature.
- Barchioradialis (C5, C6) o If hypotension or hemorrhage is present,
- Knee (L2, L3, L4) establish intravenous access and begin
- Ankle (S1) intravenous fluids.
- Abdominal reflexes - Level of consciousness
o stroking each side of the abdomen, above (T8, o Level of consciousness primarily reflects the
T9, T10) and below (T10, T11, T12) the patients capacity for arousal, or wakefulness.
umbilicus It is determined by the level of activity that
o Use a key, the wooden end of a cotton tipped the patient can be aroused to perform in
applicator, or a tongue blade twisted and split response to escalating stimuli from the
longitudinally. examiner.
o Note the contraction of the abdominal o Alert, lethargy, obtunded, stupor, coma
muscles and deviation of the umbilicus - Neurologic evaluation
toward the stimulus. o Pupils
- Plantar Observe the size and equality of the
o Stroke the lateral aspect of the sole from the pupils and test their reaction to light.
heel to the ball of the foot, curving medially The presence or absence of the light
across the ball. reaction is one of the most important
o Some patients withdraw from this stimulus by signs distinguishing structural from
flexing the hip and the knee metabolic causes of coma. The light
- Anal reflex reaction often remains intact in
o stroke outward in the four quadrants from the metabolic coma.
anus o Ocular Movement
Observe the position of the eyes and
Meningeals eyelids at rest.
- Nuchal rigidity Check for horizontal deviation of the
- Brudzinski sign eyes to one side (gaze preference).
- Kernigs sign When the oculomotor pathways are
intact, the eyes look straight ahead.
Staright leg raise test o Oculocephalic Reflex (Dolls Eye Movements)
- Place the patient in the supine position. Raise the This reflex helps to assess brainstem
patients relaxed and straightened leg, flexing the leg function in a comatose patient.
at the hip, then dorsiflex the foot. Holding the upper eyelids open so
- Assess the degree of elevation at which pain occurs, that you can see the eyes, turn the
the quality and distribution of the pain, and the effects head quickly, first to one side and
of dorsiflexion. then to the other.
Asterexis o Oculovestibular Reflex (with Caloric
- Ask the patient to stop traffic by extending both Stimulation)
arms, with hands cocked up and fingers spread. Watch If the oculocephalic reflex is absent
for 1 to 2 minutes, coaxing the patient as necessary to and you seek further assessment of
maintain this position. brainstem function, test the
Winging of the scapula oculovestibular reflex.
- When the shoulder muscles seem weak or atrophic, Note that this test is almost never
look for winging. Ask the patient to extend both arms performed in an awake patient.
and push against your hand or against a wall. Observe o Posture and Muscle Tone
the scapulae. Normally they lie close to the thorax. Observe the patients posture. If
there is no spontaneous movement,
Stuporous or comatose patient you may need to apply a painful
stimulus
- ABC Classify the resulting pattern of
movement as:
Normalavoidantthe
patient pushes the stimulus
away or withdraws.
Stereotypicthe stimulus
evokes abnormal postural
responses of the trunk and
extremities.
Flaccid paralysis or no
response
o Muscle tone
Test muscle tone by grasping each
forearm near the wrist and raising it
to a vertical position.
Note the position of the hand, which
is usually only slightly flexed at the
wrist.
Then lower the arm to about 12 or
18 inches off the bed and drop it.
Watch how it falls. A normal arm
drops somewhat slowly.
- Further Examination
o As you complete the neurologic examination,
check for facial asymmetry and asymmetries
in motor, sensory, and reflex function.
o Test for meningeal signs if indicated.
o As you proceed to the general physical
examination, check for unusual odors.
o Look for abnormalities of the skin, including
color, moisture, evidence of bleeding
disorders, needle marks, and other lesions.
o Examine the scalp and skull for signs of
trauma.
o Examine the fundi carefully.
o Check to make sure the corneal reflexes are
intact. Remember that use of contact lenses
may abolish these reflexes.
o Inspect the ears and nose, and examine the
mouth and throat.