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Physical Appearance
*Age (appears stated)
*Sex (development appropriate to age)
*LOC (alert oriented- person, place, time, situation)
*Skin colour (even, no lesions)
*Facial features (congruent with movement/no distress)
Body Structure
*Stature (height normal for age/ethnicity)
*Nutrition (weight normal range for height/body comp, with even fat distribution)
*Symmetry (body parts equal bilat/relatively in proportion to each other)
*Posture (comfortable/erect)
*Position (relaxed)
*Body build (arm span = height, body length = from crown to pubis/pubis to sole)
Mobility
*Gait (base shoulder width, foot placement accurate, walk smooth/well balanced, associated movements
present)
*ROM (full mobility at each joint, movement deliberate/accurate/coordinated, with no involuntary
movement)
Behavior
*Facial expression (eye contact, expressions = situation)
*Mood/affect (comfortable/cooperative/pleasant)
*Speech (articulation clear/coherent/even pace/word choice = education)
*Dress (appropriate to weather/age/body)
*Personal hygiene (grooming = age/occupation/socioeconomic group, woman’s makeup = age/culture)
Weight
*Remove shoes/heavy outer clothing
Height
*Pt shoeless/stand straight/look straight ahead- use measuring pole on balance scale, align head piece with
top of head
Temperature
*Normal 37* - range of 35.8-37.3 (rectal may be higher)
Pulse
*Radial most common-count for 30 sec and X2 if regular, count 60 sec if irregular
*Assess; Rate- adult resting 60-100 bpm
* Rhythm- even tempo
*Force- rate from 0 (absent) – 3+ (full bounding) 2+ normal
* Elasticity- normal feels springy, straight, and resilient
Respirations
*Adult resting 10-20 rpm
*Relaxed, regular, automatic, silent
*Do not mention assessment
*Count 30 sec X2 or 60 sec if abnormality suspected
Blood Pressure
*Normal adult 120/80
*Varies with-age, sex, race, diurnal rhythm, weight, exercise, emotions, stress
*Determined by
*Cardiac output, peripheral vascular resistance, blood volume, viscosity, elasticity
*Pulse pressure = systolic – diastolic
*Pt lying/sitting with feet flat on floor bare arm at heart level, palpate radial artery and inflate cuff until
pulse obliterated, measure BP by inflating 20-39 mm Hg beyond this point, BELL of stethoscope on
brachial artery and inflate cuff, deflate noting points when first and last sounds are heard
*Orthostatic vital signs-done when pt c/o hypotension/syncope
*Take readings of pulse and BP when pt is supine for baseline, and repeat measurements with pt
sitting then standing (slight decrease will occur)
*Thigh pressure- when arm pressure exceedingly high compare with leg BP
*Normally higher than arm (10-40 mm Hg)
*Pt prone, large cuff around lower 1/3 of thigh centered over politeal artery
Emotional
Appearance
*Age (appears stated)
*Unusual hairstyle/adornments
*Type of eye contact- brief/prolonged, absent, normal
*Cleanliness/grooming- type of clothing-soiled, unkempt, torn, neat/appropriate, socioeconomic status
*Face/body- scars/birthmarks/needle marks, tattoos, glasses, facial hair, earrings/per icings, limp,
weight/height proportionate
*Body frame- robust/frail/slim/obese/athletic
Behavior
*LOC awake, alert, aware, oriented (lethargic/obtunded)
*Activity/movement- akasthesia, hyperactivity, bradykinesia, accessory movements, psychomotor
retardation, agitation, restless, tremors, posture
*Facial expression appropriate to situation/changes, comfortable eye contact
*Attitude- cooperative, hostile, guarded, regressed, suspicious, asocial, open
*Speech effortless/fluent/coherent, conversation appropriate- dysphonia/dysarthria
Mood
* Judge via body language/facial expression/direct questioning “how do you usually feel?”-appropriate to
place/situation/change with topics- euthymic, euphoric, anxious, dysthymic, depressed
Affect
*Subjective assessment of facial expression, tone, personality, direct questioning- “how do you usually
feel?”
*Dimensions
*Range- movement among emotions- full/restricted
*Mobility- labile, flat, restricted
*Reactivity- ability to react appropriately to situation
*Intensity- force of feeling/emotion expressed- increased, flat, blunted, type, appropriateness
*If pt expresses feelings of sadness/hopelessness/despair assess for suicidal tendencies- had
these thoughts before? Do you have a plan? Lethality of plan? Resources?
Cognitive
Appearance
*Posture erect
*Position relaxed
*Body movements voluntary, deliberate, coordinated, even
*Dress appropriate to setting, season, age, gender, social group, body type
*Grooming/hygiene clean, hair neat, makeup appropriate, men shaven/groomed, nails clean
Behavior
*LOC awake, alert, aware, oriented
*Facial expression appropriate to situation/changes, comfortable eye contact
*Speech effortless/fluent/coherent, conversation appropriate
*Mood/affect judge via body language/facial expression/direct questioning-appropriate to
place/situation/change with topics
Cognitive Functions
Orientation
*Time, place, person, situation
*Ask directly “where are you?” “What day of the week is it?/season/year?” “What is your
name/age?”
Attention span
*Give a series of directions (3 steps) and note ability to follow through
Immediate memory/new learning
*Four unrelated words test
Recent memory
*Ask about something you can verify
*24 hour diet recall/how they got to agency etc
Remote memory
*Ask birthday/anniversary/historical events significant to pt
New learning
*Four Unrelated Words Test
Say 4 words; brown, tulip, carrot, ankle pt repeats, ask again few minutes later (5, 10, 30
minute intervals)
Constructional Ability
*Pt writes name and date
*Word comprehension
Point to objects in room/body parts and ask person to name them
*Reading/Writing
Ask to read
Ask to make up and write a sentence-note coherence, spelling and parts of speech
Thought process
*Way pt thinks should be logical, goal directed, coherent, relevant, and able to complete a thought
*Abnormalities- circumstantiality, tangentiality, flight of ideas, loose associations, word salad,
preservation, pressured speech, clang, poverty of thought, echolalia, neologisms, thought blocking
Thought content
*What pt thinks consistent/logical, evaluate thoughts expressed
*Abnormalities- thought insertion, thought broadcasting, obsessions/compulsions,
suicidal/homicidal ideation
Perceptions
*Aware of reality
*Abnormalities- illusions/hallucinations (no external stimuli)
*How do ppl treat you, talk about you, feel being watched/followed
Screen for suicidal/homicidal thoughts
*Pt expresses feelings of sadness/grief assess risk of harming self/others
Ever thought about hurting yourself/do you have a plan
Sexuality
*Sexual orientation/expression
*Comfort with gender identity/role/orientation
*Views regarding sexual activity
*Discussion/concerns regarding sex
*Relationship with same/opposite sex
*Body image (verbal/nonverbal)
*Appropriate dress (seductive/conservative)
*Demonstration of affection to family/others
*History of sexual harassment/assault/incest
*Risk potential
*Sexual activity/level of risk taking
*Vulnerability/exploitation/discrimination
*Knowledge of contraceptives/STD/safe sex practices
*Values
Skin/hair/nails
Inspect/Palpate the Skin
General Pigmentation
*Consistent with ethnicity
*Note freckles, moles, birthmarks
Widespread Colour Change
*Note any pallor, cyanosis, jaundice, erythematic
Temperature
*Use dorsa of hands to check temp bilaterally- warm, equal bilat
Moisture
*Perspiration may be present (note excess- diaphoresis)
*Assess for dehydration (check mucous membranes as well)
Texture
*Smooth, firm, even surface
Thickness
*Uniformly thin over most surface with calluses on areas of high friction
Edema
*Press area with thumbs (malleolus/tibia)
*Grade pitting 1+ - 4+
Mobility/Turgor
*Pinch large fold of skin
*Mobility = ease of rising
*Turgor = ability to return to place when released
Vascularity/Bruising
*Note cherry angiomas/bruising/tattoos
Lesions
*With glove palpate-roll between fingers, scrape, note surrounding skin temp, use magnifying glass
for closer inspection
*If present note; colour, elevation, pattern/shape, size, location/distribution, exudate, blanching
Inspect/Palpate Hair
*Colour- processed, ethnic, age
*Texture
*Distribution- vellus all over body, terminal on eyes/scalp
*Lesions
Separate hair into sections observing the scalp
Inspect/Palpate Nails
Shape/Contour
*Smooth, rounded and clean
*Profile- 160*
*Base firm to palpation
Consistency- smooth, regular, not brittle/splitting, uniform thickness
Colour- translucent nail plate, pink nail bed underneath
*Capillary refill- depress nail edge to blanch then release colour returns in 1-2 seconds
Separate fingers/toes and not skin condition between
Inspect Face
Facial Structures
*Expression- appropriateness
*Symmetry of eyebrows, palpebral fissures, nasolabial folds and sides of mouth
*Note abnormal facial structures/swelling/involuntary movements
Inspect/Palpate Neck
Symmetry
*Head positioned midline; erect, still, neck muscles symmetrical
ROM
*Note any limitations
*Touch chin to chest, turn left-right, touch ear: shoulder, extend head backwards, movements
smooth and controlled
*Test muscle strength (CN XI) by shrug shoulders/turn head against resistance
*As pt moves head note any obvious pulsations/swollen glands
Lymph Nodes
*Normal-movable, discrete, soft, nontender, cervical may be palpable
10 sites
*Preauricular, posterior auricular, occipital, submental, submandibular, jugulodigastric,
superficial cervical, deep cervical chain, posterior cervical, supraclavicular
*Gentle circular motion of finger pads, compare sides symmetrically
*Use one hand for submental, hold chin with other
*Deep cervical tilt head to other side
*Supraclavicular have pt shrug shoulders
*If any are palpable
*Note location, size, shape, discrete/matted, mobility, consistency and tenderness
Trachea
*Midline, note any deviation-palpate for tracheal shift
*Index finger in sternal notch and slip off to each side-space should be symmetric on each side
Thyroid Gland
*Usually not palpable
*Tangential lighting for any swelling
*Give pt glass of water-inspect neck as pt takes a sip/swallows-thyroid tissue should move up as pt
swallows
*Posterior approach-sit up straight with head slightly forward and to right, use fingers of left hand to
push trachea to right, curve right fingers between trachea and sternomastiod and ask pt to take sip of
water-thyroid moves up with trachea/larynx, repeat procedure on the left
Auscultate Thyroid
*If enlarged, Auscultate with BELL for presence of bruit, normally not present
Nose/mouth/throat
Inspect/Palpate Nose
External
*Symmetric, midline, proportionate to other facial features
*Deformity, inflammation, lesions
*Injury suspected palpate gently for pain/break in contour
*Test patency of each nostril (occlude and sniff)
Nasal Cavity
*Use speculum/penlight
*Push tip of nose upward view with head erect then tilt head back
*Inspect mucosa-normal red colour, smooth/moist surface
*Note any swelling, discharge, bleeding, foreign bodies
*Observe septum for any deviation/perforation/bleeding
*Inspect turbinates on lateral walls (middle/inferior) note swelling/polyps
Inspect Mouth
Lips
*Inspect for colour, moisture, cracking, lesions
*Note inner surface as well
Teeth/Gums
*Teeth white/straight evenly spaced and clean
*Note any diseased, absent, loose, abnormally positioned teeth
*Ask to bite down and assess alignment
*Gums are pink, assess for swelling, retraction, bleeding
Tongue
*Pink even colour
*Dorsal surface is roughened from papillae
*Ventral surface smooth, glistening, venous
*Saliva present
*Using glove/cotton gauze swing tongue to side to assess lateral aspects for white spots/lesions
*Inspect U shaped area from white patches, nodules, and ulcerations
Buccal Mucosa
*Hold cheek open with tongue blade
*Pink, smooth, moist
*Assess for colour, nodules, and lesions
Palate
*Shine light to roof of mouth
*Anterior hard palate while with irregular transverse rugae
*Posterior soft palate pinker, smooth, upwardly movable
*Torus palatinus-nodular bony ridge down center of hard palate
*Observe uvula midline-assess mobility by pt saying “ahh” should rise
Inspect Throat
*Using light observe oval, rough surfaced tonsils – pink like mucosa
*Tonsils graded 1+ visible - 4+ touching each other
*View posterior pharyngeal wall by depressing tongue with blade noting colour, exudate, lesions
*Stick out tongue (CN XII) - protrude midline with no tremors, loss of movement or deviation
Peripheral vascular/lymphatic
Inspect/Palpate Arms
*Lift both hands in yours
*Inspect then turnover noting colour of skin, nailbeds, temp, texture, turgor, lesions, edema, clubbing, and
scars
*Check cap refill (1-2 seconds)
*Arms should be symmetric in size
*Palpate both radial pulses, noting rate, rhythm, elasticity and force (2+)
*Palpate ulnar pulses if indicated
*Palpate brachial pulses
*Check epitrochlear node – shake hands with pt reach other hand under elbow in groove between
bicep/triceps- normally not palpable
*Perform MODIFIED ALLEN TEST – occlude radial/ulnar arteries while pt makes a fist several times
which causes hand to blanch, ask pt to open hand, release pressure of ulnar artery and maintain on radial,
normal colour should return in 2-5 seconds
Inspect/Palpate Legs
General
*Inspect legs bilaterally noting skin colour, hair distribution, venous pattern (flat barely visible, note
varicosities), size (asymmetric-measure calf at widest point), lesions, and ulcers
*Palpate for temperature with dorsa of hands bilaterally
*Flex pt’s knee and gently compress gastrocnemius muscle/sharply dorsiflex foot-no tenderness
*Palpate inguinal lymph nodes- small 1cm, movable, nontender
*Palpate femoral, popliteal, dorsalis pedis and posterior tibial arteries – grade 2+
*Check for pretibial edema- depress for 5 seconds then release, grade 1+ - 4+
Trendelenburg Test
*Determines vein competence when varicose veins present
*Pt supine, elevate involved leg 90* until veins empty, place tourniquet high on thigh, help pt stand
and watch for venous filling, 30 seconds, remove tourniquet and observe whether or not varicose
veins suddenly fill from able – should not
Colour Changes
*Suspect arterial deficit
*Raise legs 30 cm off bed, ask pt to wag feet to drain off venous blood – skin colour reflects only
arterial blood, pale but still pink, have pt sit up and dangle legs, compare colour of both feet, note time for colour to
return 10 seconds or less, and time for superficial veins to fill 15 seconds
Special Procedures
REBOUND TENDERNESS (Blumberg’s Sign)
*When pt reports abd pain or when elicit tenderness with palpation
*Choose site away from painful area
*Hold hand 90* to abd and push down slowly and deeply then lift up quickly
*Negative response is no pain on release of pressure
INSPIRATORY ARREST (Murphy’s Sign)
*Normally palpating liver causes no pain but with inflammation of gallbladder it will
*Hold fingers under liver border, ask pt to take deep breath
*Normal response is to complete deep breath with no pain
ILIOPSOAS MUSCLE TEST
*Acute abd pain/appendicitis is suspected
*Pt supine lift RIGHT leg straight up flexing at hip, then push over lower part of right thigh as pt
tries to hold leg up
*Test negative when pt feels no change
OBTURATOR TEST
*Appendicitis is suspected
*Pt supine, lift RIGHT leg, flex at hip and knees
*Hold ankle and rotate leg internally/externally
*Negative response is no pain
Thorax/lungs
Inspect Posterior Chest
Thoracic Cage
*Shape/configuration of chest wall-spinous process in straight line, thorax symmetric with
downward sloping ribs, scapulae located symmetrically
*Symmetric expansion- note respiratory rate, rhythm, quality
*Anteriorposterior diameter < transverse diameter 1:2 or 5:7
*Neck/trapezius muscles equal/developed
*Note position pt takes to breathe-relaxed, support weight with arms at sides/use of accessory
muscles/nasal flaring
*Assess skin/lips/nails colour and condition
Inspect/Palpate Axillae
*Sitting
*Inspect skin-note rash/infection
*Support arm so muscles relaxed, move arm through ROM to allow easier access
*Reach fingers high into Axillae and move in four directions
*Down middle of chest wall
*Anterior border of Axillae
*Posterior border
*Along inner aspect of upper arm
*Usually nodes not palpable, may feel small soft central group, note any enlarged
Palpate Breasts
*Use friction-free technique- hot, soapy lather/talcum powder
*Supine, small pillow under arm of affected side, arm above head
*Pads of first three fingers in gentle rotary motion in grid like pattern all over breast, tail of Spence and
nipple
*Nulliparous woman breast feels-firm, smooth, elastic (may feel inframammary ridge)
*After pregnancy-softer and looser
*Nipple
*Gentle pressure “milk” nipple towards center from areola, repeat in few directions
*Note any indurations, subareolar mass
*Any discharge present, note colour and consistency
*If lump is present note these characteristics
*Location-clock face description
*Size- width x length x thickness
*Shape- oval/round/lobulated/indistinct
*Consistency-soft/firm/hard
*Mobility- free/fixed
*Distinctness- solitary/multiple
*Nipple- displaced/retracted
*Skin- erythmatous/dimpled/retracted
*Tenderness- upon palpation
*Lymphadenopathy- lymph nodes palpable
Male Breast
*Inspect chest wall noting skin surface, any lumps/swelling
*Palpate nipple area for lumps/tissue enlargement, should feel even with no nodules
*Gynecomastia-feels like smooth, firm, movable disc
Eyes
Test Central Vision Acuity
Snellen Eye Chart
*Well-lit spot at eye level 20 feet away (can be closer but must be charted)
*Remove reading glasses only
*Pt holds opaque card up to one eye and reads smallest line of chart possible with other, encourage
to read next smallest line also
*Record results indicating missed/incorrect letters/glasses worn/distance
*Normal vision 20/20 – bigger denominator worse vision
Near Vision
*Pt 40+ years, reports difficulty reading
*Test each eye separately, with glasses on
*Hand held vision screener with various sizes printing
*Hold card 35 cm (14 inches) from eye- normal result 14/14
*Read without hesitancy/moving card
*General background
*Light red to dark brown red corresponding with skin colour
*View of fundus should be clear, no lesions obstructing retinal structures
*Macula
*Inspect last as can be very uncomfortable and cause pupillary constriction
*1DD in size and is located 2DD temporal to disc
*Colour somewhat darker than rest of fundus but is even and homogenous
*Note foveal light reflex-tiny white glistening dot reflecting ophthalmoscope light
Ears
Inspect/Palpate External Ear
Size/Shape
*Equal bilaterally
*No swelling/thickening
Skin
*Colour consistent with facial skin
*Intact, no lumps/lesions
Tenderness
*Move pinna and push on tragus- firm, no pain
*Palpate mastoid process- no pain
External Auditory Meatus
*Note size of opening and choose speculum accordingly
*No swelling, redness, discharge
*Some cerum may be present- gray/yellow to light brown/black, moist/dry
Vestibular Apparatus
Romberg Test
*Assess vestibular apparatus’s ability to maintain standing balance
*Feet together, arms at sides, eyes closed for 20 seconds, no swaying
Heart/neck vessels
Neck Vessels
Carotid Artery
Palpate
*Medial to sternomastiod muscle bilaterally one at a time
*Feel contour-smooth with rapid upstroke and slower downstroke and amplitude-strength 2+
Auscultate
*With BELL
*Pt exhales and holds breath
*Three positions- angle of jaw, midcervical area, base of neck
*For presence of bruit- none should be present
Jugular Venous Pulse
Inspect
*To assess Central Venous Pressure
*Pt supine 30-45*, remove pillow, turn head slightly away, use tangential lighting
*External vein along sternomastiod (strong pulsation), internal at suprasternal notch
Estimate Jugular Venous Pressure
*Pt right side
*Hold vertical ruler at Angle of Louis and straight edge to point of highest pulsation, <2cm note
angle of bed in documentation
Hepatojugular Reflux
*Pt supine, breathe quietly thru open mouth
*Right hand on RUQ just below rib cage
*Watch level of jugular pulsation as push in with hand for 30 seconds
*Empties venous blood from liver and adds to system- if heart can pump this addition the jugular
veins will rise for a few seconds then recede
Precordium
Inspect Anterior Chest
*Tangential lighting
*Note any pulsations (apical pulse) 5th ICS MCL
*Note any heaves/thrills
Palpate Apical Pulse
*Point of maximal impulse, palpable in 50% adults
*Pt supine, slightly to left
*Use one finger pad, small 1 cm X 2 cm
*Pt exhales and holds
*Occupy one interspace 5th ICS medial to MCL, feel short gentle tap if first half of systole
Palpate Precordium
*Palmar aspects gently palpate the apex, left sternal border and base, note any pulsations
Auscultation- AParTMent 22345
*Right 2nd ICS- AORTIC
*Left 2nd ICS- PULMONIC
*Left 3rd ICS- ERB’S POINT
*Left lower sternal border- TRICUSPID
*Left 5th ICS medial MCL- MITRAL
*Begin with DIAPHRAGM –
* Note rate/rhythm- 60-100 bpm, rhythm regular
*Identify S1 and S2- S1 louder at apex/coincides with carotid, S2 louder at base
*Assess S1 and S2 separately-note if each sound is normal, accentuated, diminished or split
*Listen for extra heart sounds- switch to BELL, note timing and characteristics
*Listen for murmurs- listen with BELL noting timing, grade loudness, pitch, pattern, quality,
location, radiation, and posture
*After listening with pt supine, turn to LEFT side and listen at APEX with BELL for presence of
any diastolic filling sounds
*Pt sit up, lean forward and exhale, listen with DIAPHRAGM at base, right and left sides for soft
high pitched early diastolic murmur or aortic or pulmonic regurgitation
Musculoskeletal
GENERAL
Inspection
*Note size/contour of joint
*Skin/tissues over joint for colour/swelling/masses/deformity
Palpation
*Palpate each joint
*Skin for temp/moisture
*Muscles/strength
*Bony articulations
*Joint capsule
*Note any heat/tenderness/stiffness/swelling/masses
*Synovial membrane should not be palpable- if thickened it feels doughy
Range of Motion
*Active- stabilize area proximal to that being moved
*If limitation attempt Passive- anchor joint with one hand and slowly move area with other to its
limit
*If limitation/increase in ROM use a goniometer to measure angle precisely
*Joint motion should not produce tenderness, pain or crepitus
Muscle Testing
*Test strength of prime mover muscle groups for each joint
*Repeat ROM but apply opposing force
*Should be equal bilaterally and resist opposing force
*Grade strength
*5- full ROM, full resistance
*4-Full ROM, some resistance
*3- Full ROM
*2- full passive ROM
*1- slight contraction
*0- no contraction
Cervical Spine
Inspect
*Alignment of head/neck- spine straight, head erect
Palpate
*Spinous processes, sternomastiod, trapezius and paravertebral muscles-firm, no muscle
spasm/tenderness
ROM
*Touch chin: chest- flex 45
*Chin: ceiling- hyper ext 55
*Ear: shoulder- lateral bending 40
*Turn chin: shoulder- rotation 70
Muscle Strength
*Repeat against opposing force
Shoulder
Inspect
*Compare shoulders bilaterally from post/anterior
*Size/contour
*Equality of bony landmarks
*No redness, muscular atrophy, deformity, swelling
*Check anterior joint capsule and subacromial bursa for swelling
Palpate
*Both shoulders
*Start at clavicle- acromioclavicular joint, scapulae, greater tubercle, subacromial bursa, biceps
groove, glenohumeral joint, and axilla
*Note muscular spasm, atrophy, swelling, heat, and tenderness
ROM
*Cup one hand over shoulder to assess for crepitus
*Arms forward above head- forward flex 180
*Arms back down and move back- hyper ext 50
*Rotate internally behind back (try to touch scapulae) – internal rot 90
*Touch palms together behind head with elbows flex/rot posteriorly- external rot 90
*Arms at sides bring above head with elbows extended- abd 180
*Bring arms back down and cross in front of body- add 50
Muscle Strength
*Shrug shoulders
*Flex forward and up
*Abduct against resistance
Hip
Inspect
*Pt stand- note symmetric levels of iliac crests, gluteal folds, and equal sized buttocks
*Smooth even gait reflects equal leg length and functional hip motion
Palpate
*Pt supine – should feel stable, symmetric, no tenderness, crepitus
ROM
*Raise leg with knee extended- flex 90
*Bend knee up to chest, other leg stays straight- flex 120
*Flex knee/hip 90; stabilize holding thigh/ankle, swing foot outward- internal rotation- 40
*Repeat above and swing foot inward- external rotation 45
*Swing leg laterally; stabilize by pushing on opposite asis- abd 40-45
*Swing leg medially, stabilize by pushing on opposite asis- add 20-30
*Standing, swing leg straight behind body, stabilize pelvis- hyper ext 15
Knee
Inspect
*Sitting with legs dangling
*Skin smooth, even coloring, and no lesions
*Assess lower leg alignment- extend in same axis as thigh
*Shape/contour- distinct concavities bilaterally to patella- check for signs of fullness/swelling
*Assess prepatella bursa, suprapatellar pouch or swelling
*Assess quadriceps muscle for atrophy
Palpation
*Start high on thigh in grasping fashion of quads
*Proceed down towards patella, explore suprapatellar pouch- note consistency of tissues;
muscles/soft tissue feels solid and joint feels smooth, warm, no tenderness, thickening or nodularity
*If swelling is present determine if d/t soft tissue swelling or inc fluid
*BULGE SIGN
*Small amt fluid
*Firmly stroke medial aspect of knee to displace fluids
*Tap lateral aspect of knee, watch hollow of medial side, for distinct bulge of fluid
wave, none should be present
*BALLOTTMENT
*Large amt fluid
*Left hand compresses suprapatellar pouch to move fluid into knee joint
*Right hand pushes patella sharply against femur
*If no fluid present patella will already be snug against femur and no change will
occur
*Continue palpation of tibiofemoral joint, infrapatallar fat pad and patella
*Check for crepitus, hold hand on patella as knee is flexed/extended
ROM
*Pt standing
*Bend knee- flex 130-150
*Extend knee- straight line of 0, some hyper ext 15
*Assess knee ROM during ambulation
Muscle Strength
*Maintain knee flexion while you oppose trying to pull leg forward
*Extension demonstrated by pt rising from chair/low squat without using hands for support
Test for meniscal tears
*McMurray’s Test
*History of trauma, giving way, locking, or local knee pain
*Pt supine, stand on affected side
*Hold heel/thigh, flex knee/hip
*Rotate leg in/out to loosen joint
*Externally rotate leg and apply inward pressure on knee
*Slowly extend knee- normally no pain with extension
Ankle/Foot
Inspection
*Inspect both while ambulating and seated
*Compare feet, note position of feet/toes/contour of joints and skin chara
*Foot should align with long axis of lower leg (line from midpatella to between first/second toes)
*Weight bearing fall on middle of foot from heel to second/third toes
*Inspect arch
*Toes point straight and lie flat
*Ankles are smooth bony prominences
*Note location of calluses/bursa reactions
*Examine well-worn shoes for signs of wear and accommodation
Palpate
*Support ankle/grasp heel with fingers and palpate with thumbs
*Explore joint spaces- smooth, depressed, no fullness/swelling/tenderness
*Palpate metatarsalphalangeal joints between thumb and dorsum of fingers on plantar surface
*Pinching motion to palpate interphalangeal joints on medial/lateral sides of toes
ROM
*Point toes to floor- plantar flex 45
*Point toes to nose- dorsiflex- 20
*Turn soles of feet out, stabilize ankle – Eversion 20
*Turn soles of feet in, stabilize ankle- inversion 30
*Flex and straighten toes
Muscle Strength
*Maintain dorsiflexion/plantarflexion against resistance
Spine
Inspect
*Pt standing
*Note alignment of spine-straight from head along spinous processes to gluteal cleft
*Note equal horizontal positions of shoulders, scapulae, iliac crests, gluteal folds and equal spaces
between arm and lateral thorax
*Knees and feet should be aligned with trunk and pointing forward
*From side not normal convex thoracic curve and concave lumbar curve
Palpate
*Palpate spinous processes- straight, nontender
*Palpate paravertebral muscles- firm, non-tender, no spasm
ROM
*Bend forward and tough toes- flex 75-90 smooth/symmetric movements, note concave lumbar
curve should disappear and back is single convex C shaped curve
*Stabilize pelvis
*Pt bends sideways bilaterally- lateral bending 35
*Bend backward- hyper ext 30
*Twist shoulders side to side- rotation 30
STRAIGHT LEG RAISING (LaSegue’s Test)
*Reproduce back/leg pain and confirm presences of herniated nucleus pulposus
*Raise affected leg just short of where pain is produced, then dorsiflex foot
*Raise unaffected leg while leaving other leg flat-inquire about involved side
MEASURE LEG LENGTH DISCREPANCY
*TRUE
*Measure between fixed points- anterior iliac spine to medial malleolus, within 1 cm of each
other
*APPARENT
*Measure from non-fixed points- umbilicus to medial malleolus
Neurological
CRANIAL NERVES
CN 1 Olfactory
*Test in pts report loss of smell, head trauma, abnormal mental status, intracranial lesion suspected
*Test patency of each nare
*Occlude one nostril and provide aromatic substance, pt identifies
CN 2 Optic
*Test visual acuity (Snellen eye chart)
*Test visual field- bowel/confrontation
*Use ophthalmoscope to examine ocular fundus and determine size, shape and colour of optic disc
CN 3 4 6 – Oculomotor, Trochlear, Abducens
*Palpebral fissure equal width
*Check pupils for size, regularity, equality, direct and consensual light reflex and accommodation
*Assess extraocular movements via cardinal positions of gaze- if nystagmus (oscillation) is present note-
bilateral, pendular/jerking, amplitude, frequency, plane of movement
CN 5 Trigeminal
Motor Function
*Palpate temporal/massester muscles as pt clenches teeth- equal strength
*Try to separate jaw by pushing down on chin-normally cannot
Sensory Function
*Pt eyes closed test light sensation by touching cotton wisp to forehead, cheeks and chin- pt says
NOW when feels touch
CN 7 Facial
Motor
*Note mobility and facial symmetry as pt smiles, frowns, close eyes tightly (against your attempt to
open them), lift eyebrows, show teeth and puff cheeks (press pts cheeks in-air escapes equally)
Sensory
*Test only when suspects facial nerve injury
*Test sense of taste by applying cotton applicator with solution of sugar/salt/lemon juice to tongue-
pt identifies taste
CN 8 Acoustic (Vestibulocochlear)
*Test hearing acuity by
*ability to hear normal conversation
*Whispered voice test
*Weber
*Rinne
CN 9 10 Glossopharyngeal/Vagus
Motor
*Depress tongue and note pharyngeal movement as pt says “AHH”, uvula and soft palate rise
midline and tonsillar pillars should move medially
*Elicit gag reflex
Sensory
*Test taste on posterior 1/3 of tongue
CN 11 Spinal Accessory
*Examine sternomastiod/trapezius muscles for equal size
*Check equal strength as pt rotates head/shrugs shoulders against resistance
CN 12 Hypoglossal
*Inspect the tongue- no wasting/tremors
*Note forward thrust in midline as pt protrudes tongue
*Say “light, tight, dynamite” speech should be clear and distinct
Test Reflexes
Deep Tendon Reflexes
*Compare right and left sides
*Grade reflexes
*4+ very brisk, hyperactive
*3+ Brisker than normal
*2+ normal
*1+ diminished
*0 no response
*If no reflex is elicited try further encouragement of relaxation, use REINFORCEMENT- perform
isometric exercise in distal muscle group being tested- upper body tested- clench teeth, lower body
tested- lock fingers together and pull
*Biceps (C5- C6)- support forearm in yours and apply same thumb to pts biceps tendon,
strike thumb with small part of hammer- response is contraction of bicep muscle and flexion
of the forearm
*Triceps (C7-C8)- pt lets arm go limp as you suspend upper arm, strike triceps tendon
directly just above the elbow- response extension of forearm
*Brachioradialis (C5-C6)- hold pt thumb and suspend forearms in relaxed position- strike
forearm directly 2-3 cm above radial styloid process- response flexion and supination of
forearm
*Quadriceps (L2-L4)- lower leg dangles freely, place hand above patella to feel for
contraction of quadriceps muscle- strike tendon just below patella- response is extension of
lower leg
*Achilles (L5-S2)- knee flexed/hip externally rotated, hold foot in dorsiflexion, strike
Achilles tendon directly- response is plantar flexion against hand
*Clonus- test when reflexes are hyperactive, move foot up and down then sharply dorsiflex
foot and hold stretch- normal response is no further movement, clonus present you will feel
and see rapid rhythmic contractions of calf muscle and movement of foot
Superficial Reflexes
*Receptors in skin rather than muscles
*Abdominal- upper (T8-T10) lower (T10-T12)- supine with knees slightly bent use handle
of reflex hammer to stroke skin moving from side of abd toward midline and upper and
lower levels- response is ipsilateral contraction of abd muscles and deviation of umbilicus
toward the stroke
*Cremaster (L1-L2)- on the male lightly stoke the inner aspect of the thigh- response is
elevation of the ipsilateral testicle
*Plantar (Babinski) (L2-S2)- with reflex hammer draw a light stroke up the lateral side of
the sole of the foot and inward across the ball of the foot like an upside down J-response is
plantar flexion of all toes and inversion and flexion of the forefoot
Male Genitalia
Inspect/Palpate Penis
*Skin wrinkled, hairless, without lesions, dorsal vein may be apparent
*Glans smooth, without lesions- uncirmunsribed retract foreskin, compress to note meatus – central, edges
pink, smooth and without discharge
*Palpate shaft – smooth, semi firm and nontender
*Pubic hair at base consistent with development/no pest inhabitants
Inspect/Palpate Scrotum
*Hold penis out of the way
*Note scrotal size, asymmetry normal – left lower than right
*Spread rugae out, lift sac to inspect posterior surface- no lesions
*Palpate gently each scrotal half- contents should slide easily, testes oval, firm, rubbery, smooth, freely
movable, slightly tender and equal bilaterally
*Each epididymis feels discrete, softer than testes, smooth and nontender
*Palpate each spermatic cord from epididymis to external inguinal ring- smooth, non-tender cord
*If mass is found note-
*Tenderness, location to testes, reduce when supine, can you ausculate bowel sounds over it and can
you place fingers over
*Use Transillumination- darken room shine flashlight from behind scrotal contents- normal contents
will not transilluminate
Inspect/Palpate for Hernia
*Inspect inguinal area for a bulge as person stands and bears down- none present
*Palpate inguinal canal shifting weight to opposite side
*Index finger low on scrotal half palpate up length of spermatic cord, invaginating scrotal skin as you go to
external ring (triangular slit like opening)
*Insert finger into canal and ask pt to bear down- feel no change, repeat on other side
*Palpate femoral area for a bulge
Palpate Inguinal Lymph Nodes
*Palpate horizontal chain along groin to inguinal ligament and vertical chain along upper inner thigh
*May feel small <1cm, soft, discrete, movable node
Teach Testicular Self Examination (TSE)
*T- timing, once a month
*S- shower/soapy, warm water relaxes scrotal sac
*E- Examine, check for changes and report ASAP
Female Genitalia
Preparation/Position
*Empty bladder, offer chaperone, ensure privacy, elevate head, explain before doing, stop if any discomfort