Physical Examination Checklist

POM I
General
1) Wash hands before beginning examinationin the C!""
center# yo$ M%"& $se the hand 'i(es that are located in or
near the sinks )remember that they are not (l$mbed)
*) +is(lay a (rofessional demeanor to'ards the (atient d$ring
the exam
a) Introd$ce yo$rself as a medical st$dent
b) %se the (atient,s last name
c) +ress (rofessionally in 'hite coat
-) !((ro(riate interaction 'ith the (atientsensiti.ity to
(ri.acy# comfort and dignity
/) +ra(e the (atient a((ro(riately d$ring each segment of the
exam
0) %se (ro(er se1$encing of the examiniation and (ro(er
(acing
2) !ll (al(ation and a$sc$ltation m$st be done on bare skin
3ital "igns
1) &ake the 4P in one arm )5O&E &6!& 7O% 5EE+ 5O& &!8E
&6E 4P I5 4O&6 !9M" %5E"" "PECI:IC!7 I5"&9%C&E+
&O +O "O)
a) Choose a c$; of a((ro(riate si<e for the (atient
b) Center the bladder of the c$; o.er the brachial artery
i) Identify location of the brachial artery by (al(ation
ii) o'er border of the c$; sho$ld be abo$t *=0 cm
abo.e the antec$bital crease
iii) "ec$re the c$; sn$gly
c) Position the (atient,s arm so that it is slightly >exed at
the elbo' and at raised to heart le.el
d) Estimate the systolic (ress$re by (al(ation of the radial
artery )4ates# (( ?2)
i) Wait 10 seconds after de>ating the c$; before
a$sc$ltating the 4P
e) &ake the 4P# $sing a$sc$ltation
i) isten 'ith the stethosco(e o.er the brachial
artery
ii) In>ate c$; ra(idly to at least 10@ mm 6g
iii) +e>ate at rate of *A- mm 6g (er second
i.) 5ote systolic and diastolic (ress$res
*) &ake the radial ($lse for 10 secs if the rhythm is reg$lar )2@
secs if rate is slo' or fast)
a) %se the (ads of index and middle Bngers
b) Com(ress the radial artery $ntil a maximal ($lsation is
detected
-) Co$nt the res(iratory rate for 1 min$te
a) Watch mo.ement of the chest 'all
6ead
1) Ins(ect the sk$ll# scal(# hair by (arting the hair in at least
three (laces
*) Ins(ect the face
Ears
1) Ins(ect the external eara$ricle or (inna
*) %se the otosco(e to ins(ect the internal a$ditory canal and
the eardr$m and middle ear
a) "elect the largest a.ailable s(ec$l$m for the otosco(e
b) Position the (atient,s head to allo' best insertion of the
otosco(e
c) P$ll the a$ricle gently $('ards and back'ards to
straighten the canal
d) 6old the otosco(e bet'een th$mb and Bngers )see
4ates# ( 102)
e) Insert the s(ec$l$m gently into the ear canal
i) Identify the eardr$m
ii) Identify the cone of light
iii) Identify the malle$s
-) !ssess hearing
a) !sk the (atient to occl$de one ear 'ith a Bnger and
then the examiner 'his(ers softly from 1 or * feet
a'ay to'ard the $noccl$ded ear
i) Choose short 'ords )see 4ates ( 10?)
b) Check air and bone cond$ction
i) Weber test
)1) (lace the base of the lightly .ibrating t$ning
fork Brmly on to( of the (atient,s head
)*) !sk 'here the (atient hears it
ii) 9inne test
)1) Place the base of the lightly .ibrating t$ning
fork on the mastoid bone
)*) When the (atient can no longer hear the
so$nd# 1$ickly (lace the fork close to the ear
canal and ask 'hether so$nd can still be
heard
Eyes
1) Check for .is$al ac$ity $sing a "nellen eye card or eye
chart in the exam room
*) !ssess .is$al Belds )4ates# ( 1/0A1/2)
a) !sk the (atient to look 'ith both eyes into yo$r eyes
b) While yo$ ret$rn the (atient,s ga<e# (lace yo$r hands
abo$t * feet a(art# lateral to the (atient,s ears=
c) Instr$ct the (atient to (oint to yo$r Bngers as soon as
they are seen
d) &hen slo'ly mo.e the 'iggling Bngers of both yo$r
hands along the imaginary bo'l and to'ards the line of
ga<e $ntil the (atient identiBes them
e) 9e(eat this (attern in the $((er and lo'er tem(oral
1$adrants
-) Ins(ect external eye
a) "tand in front of the (atient and s$r.ey the eyes for
(osition and alignment 'ith each other
b) Ins(ect the eyebro's1$antity and distrib$tion
c) Ins(ect the eyelids
d) Ins(ect the region of the lacrimal glands
e) Ins(ect the conC$ncti.a and sclera
i) !sk the (atient to look $( as yo$ de(ress both
lo'er lids 'ith yo$r th$mbs )4ates ( 1/?)#
ex(osing sclera and conC$ncti.a
f) Ins(ect the cornea and lens# $sing a (enlight shined
obli1$e across the eye
g) Ins(ect each iris
h) Ins(ect the ($(ils for si<e# sha(e and symmetry
/) !ssess ($(illary re>exes )t$rn o$t the room light if
necessary)
a) &o lightask the (atient to look into the distance and
shine a bright light obli1$ely into each ($(il in t$rn=
i) 5ote direct reaction($(illary constriction in the
same eye
ii) 5ote indirect reaction($(illary constriction in the
o((osite eye
b) !ssess accomodation D ask the (atient to look
alternately at a (encil held 1@ cm from his eye and into
the distance directly behind it= Obser.e for ($(illary
constriction 'ith near e;ort
0) !ssess Extraoc$lar mo.ements
a) :rom * feet in front of the (atient# shine a light into the
(atient,s eyes and ask the (atient to look at it= Ins(ect
the re>ections in the corneas# 'hich sho$ld be .isible
slightly nasal to the center of the ($(ils
b) !sk the (atient to follo' yo$r Bnger or (encil as yo$
s'ee( thro$gh the six cardinal directions of ga<e
i) &o the (atient,s extreme right
ii) &o the right and $('ard
iii) &o the right and do'n'ards
i.) Witho$t (a$sing in the middle to the extreme left
.) &o the left and $('ards
.i) &o the left and do'n'ards
2) O(hthalmosco(ic exam )"ee E"te(s for $sing the
o(hthalmosco(eF and E"te(s for examining the o(ic disc
and the retinaF in 4ates (( 10* and 10-
5ose
1) Ins(ect the anterior and inferior s$rfaces of the nose
a) P$sh gently on the ti( of the nose to 'iden the nostrils
b) %se a (enlight to .ie' the nasal .estib$le
*) Ins(ect the inside of the nose $sing an otosco(e 'ith the
largest a.ailable s(ec$l$m
a) &ilt the (atient,s head back slightly and insert the
s(ec$l$m )4ates ( 10G)
b) Ins(ect the inf and mid t$rbinates and nasal se(t$m
-) Pal(ate the frontal and maxillary sin$ses for tenderness
)4ates ( 12@
Mo$th and Pharynx
1) Ins(ect the li(s
*) Ins(ect the oral m$cosa $sing a good light and a tong$e
blade
-) Ins(ect the g$ms and teeth
/) Ins(ect the hard (alate
0) Ins(ect the tong$e and >oor of the mo$th
a) !sk the (atient to ($t o$t his tong$e
b) !sk the (atient to ($t his tong$e on the roof of his
mo$th
2) Ins(ect the (harynx
a) &ong$e in normal (osition# ask the (atient to say EahHF
b$t if (harynx not 'ell .is$ali<ed $se a tong$e blade
b) Ins(ect the soft (alate# tonsils and (harynx
5eck
1) !ssess neck 9OM )4ates ( 0@/) by asking the (atient to
(erform the follo'ing mane$.ersI
a) :lexionI to$ch the chin to the chest
b) ExtensionI look $( at the ceiling
c) 9otationI t$rn the head to each side# looking directly
o.er the sho$lder
d) ateral bendingI tilt the head# to$ching each ear to the
corres(onding sho$lder
*) Pal(ate the lym(h nodes )"ee 4ates ( 12-A12/ for s(eciBc
techni1$e)
-) Ins(ect trachea and feel for any de.iation by (lacing a
Bnger along one side of the trachea# noting the s(ace# and
com(are 'ith the o((osite side=
/) Ins(ect the thyroid gland
a) &i( the (atient,s head back
b) ocate the cricoid cartilage and ins(ect the region
belo' for the thyroid
0) Pal(ate the thyroid gland )"ee 4ates ( 12?) D may be
(erformed from either an anterior or (osterior a((roach
a) :lex the neck slightly for'ard
b) Place Bnger of both hands on the (atient,s neck 'ith
index Bngers C$st belo' the cricoid cartilage
c) :eel for the thyroid isthm$s
d) +is(lace the trachea to the right 'ith the Bngers of
yo$r left handH (al(ate 'ith 9 Bngers for the right lobe
of the thyroid
e) 9e.erse the $se of the Bngers to feel the left lobe of
the thyroid
Cranial 5er.es )4ates# (( 02?A0?1)
1) Olfactory )C5 I) D $s$ally not tested
*) O(tic )C5 II) D yo$ ha.e already tested for .is$al Belds=
3is$al ac$ity can be tested 'ith an eye chart
-) Oc$lomotor )C5 III) D yo$ ha.e already tested ($(illary
constriction and the EOM controlled by this ner.e
/) &rochlear )C5 I3) D yo$ ha.e already tested for do'n'ard#
in'ard mo.ement of the eye
0) &rigeminal )C5 3)
a) While (al(ating the tem(oral and masseter m$scles in
t$rn# ask the (atient to clench her teeth
b) Check the forehead# cheeks and Ca' on each side for
(ain and light to$ch
c) Check the corneal re>ex 'ith a 'is( of cotton
2) !bd$cens )C5 3I) D yo$ ha.e already tested for lateral
de.iation of the eye 'ith yo$r extraAoc$lar mo.ement
mane$.ers
?) :acial )C5 3II)
a) !sk the (atient to raise both eyebro's
b) :ro'n
c) Close both eyes tightly
d) "ho' both $((er and lo'er teeth
e) "mile
f) P$; o$t both cheeks
J) !co$stic )C5 3III) D yo$ ha.e already assessed hearing and
(erformed Weber and 9inne mane$.ers
G) Glosso(haryngeal )C5 IK) D tested together 'ith C5 K
1@) 3ag$s )C5 K)
a) !sk the (atient to say EahF and 'atch the mo.ements
of the soft (alate and (harynx
b) Check gag re>ex 'ith a tong$e blade
11) "(inal !ccessory )C5 KI)
a) !sk the (atient to shr$g both sho$lders against yo$r
hands
b) !sk the (atient to t$rn her head to each side against
yo$r hand
1*) 6y(oglossal )C5 KII)
a) !sk the (atient to (rotr$de her tong$e
b) !sk the (atient to ($sh the tong$e against the inside of
each cheek
Posterior thorax
1) &he (atient sho$ld be sitting 'ith the (osterior thorax
ex(osed=
*) &he doctor ass$mes a midline (osition behind the (atient
-) Ins(ect the cer.ical# thoracic and $((er l$mbar s(ine )yo$
'ill check for 9OM of the thoracic and l$mbar s(ine to'ards
the end of the com(lete (hysical 'hen the (atient is
standing $()
/) Pal(ate the s(ino$s (rocesses of each .ertebra for
tenderness 'ith yo$r th$mb or by th$m(ing 'ith the $lnar
s$rface of yo$r Bst )4ates ( 0@-)
0) !ssess for costo.ertebral tenderness
a) Place the ball of one hand in the costo.ertebral angle
and strike it 'ith the $lnar s$rface of yo$r Bst )4ates (
-//)
2) Ins(ect the sha(e and mo.ement of the chest 'all
a) Place yo$r th$mbs at the le.el of the 1@
th
ribs 'ith yo$r
Bngers loosely gras(ing the rib cage and gently slide
them medially=
b) !sk the (atient to inhale dee(ly and obser.e 'hether
yo$r th$mbs mo.e a(art symmetrically
Posterior thorax D l$ng exam
1) Examination techni1$es M%"& be (erformed on bare skin
*) Pal(ate for tactile fremit$s
a) %se either the ball of yo$r (alm or the $lnar s$rface of
yo$r hand for (al(ation
b) !sk the (atient to re(eat the 'ords EninetyAnineF
c) 7o$ may (al(ate one side at a time or $se both hands
sim$ltaneo$sly to com(are sides
d) Pal(ate in fo$r locations on both sides of the chest and
com(are )4ates ( **-)
-) Perc$ss
a) !sk the (atient to kee( both arms crossed in front of
the chest
b) Press the +IP Coint of the left middle Bnger Brmly
against the chest 'all# a.oiding contact 'ith other
Bngers )4ates ( **-)
c) "trike this +IP Coint 'ith the ti( of the right middle
Bnger# s'inging from the 'rist
d) Perc$ss in se.en areas on each side )4ates ( **0)
/) !$sc$ltate for breath so$nds
a) Instr$ct the (atient to breathe dee(ly thro$gh an o(en
mo$th
b) isten 'ith the dia(hragm of the stethosco(e in the
same se.en areas in 'hich yo$ (erc$ssed
!nterior thoraxl$ng exam
1) Examination techni1$es M%"& be (erformed on bare skin
*) &he (atient may be either sitting or s$(ine= &he dra(e
sho$ld be adC$sted to allo' ex(os$re of the area being
examined
-) Ins(ect the sha(e of the (atient,s chest and mo.ement of
the chest 'all )54 'hen mo.ing from the (ost chest 'hen
yo$ ha.e com(leted a$sc$ltating# it is acce(table to
a$sc$ltate the ant chest before ins(ection or (al(ation)
/) Pal(ate for tactile fremit$s
a) %se the ball of the (alm or $lnar s$rface of the hand to
(al(ate in - areas on each side of the anterior chest
)4ates ( *-1)
0) Perc$ss the anterior and lateral chest# com(aring sides# in 2
areas on each side )4ates ( *-1)
a) +is(lace a 'oman breast 'ith yo$r left hand or ask her
to mo.e her breast for yo$
2) !$sc$ltate the anterior chest# com(aring sides in the 2
areas on each side 'here yo$ (erc$ssed=
!xillae D examination of the axillae can be (erformed at the
(resent C$nct$re= It is sometimes (erformed at the end of the
exam# or as (art of a breast exam in a female
1) Ins(ect the skin of each axilla )4ates# (( -1@A-11)
*) Pal(ation axilla
a) !sk the (atient to relax 'ith the arm do'n
b) "$((ort the 'rist or hand 'ith yo$r left hand
c) C$( together the Bngers of yo$r right hand and reach
as high as yo$ can to'ard the a(ex of the axilla
d) Press yo$r Bngers to'ard the chest 'all and slide do'n
to feel (otential 5
e) &o (al(ate for lateral gro$( of 5# feel along the $((er
h$mer$s
-) Pal(ation 9 axilla D re.erse yo$r hands and follo' the ste(s
abo.e
Cardio.asc$lar
1) &he (atient sho$ld be s$(ine 'ith the $((er body raised by
ele.ated the table to abo$t -@= &he dra(e sho$ld be
arranged to ex(ose the (recordi$m= EK!M &EC65IL%E"
M%"& 4E PE9:O9ME+ O5 4!9E "8I5=
*) &he examiner sho$ld stand tat the (atient,s right side
-) Ins(ect the (recordi$m
a) look for a(ical im($lse
b) look for any other mo.ements
/) Pal(ate for (recordi$m
a) %se the (almar s$rfaces of se.eral Bngers to locate the
PMIcan s'itch to one Bngerti( 'hen located
i) +is(lace a 'oman,s breast $('ard or laterally# or
ask her to do this for yo$
ii) 5ote location of PMI# am(lit$de and d$ration
b) Pal(ate for the 93 im($lse along the lo'er left sternal
border
0) !$sc$ltation of the heart
a) isten to the heart 'ith the dia(hragm of yo$r
stethosco(e in the 9 *
nd
IC"# *
nd
IC"# -
rd
or /
th
IC"#
and the lo'er left sternal border )0
th
IC") and at the
a(ex )may also start at the a(ex and (roceed to the
base of the heart)
b) isten to the heart 'ith the bell of yo$r stethosco(e in
the same B.e listening areas
2) Ins(ect the neck for C$g$lar .eno$s ($lsations
a) &$rn the (atient,s head slightly a'ay from the side yo$
are ins(ecting )4ates ( *2?)
b) 9aise or lo'er the bed $ntil yo$ identify the ($lsations
c) Identify the highest (oint of ($lsation
i) Mea$s$re the .ertical distance of this (oint abo.e
the sternal angle
?) Ins(ect the neck for carotid ($lsations
J) Pal(ate the carotid ($lsation
a) Place yo$r left index and middle Bngers )or th$mb) on
the right carotid artery
i) 5ote am(lit$de and conto$r of the ($lse 'a.e
ii) 5e.er (al(ate both carotids sim$ltaneo$sly
b) %se yo$r right Bngers or th$mb to (al(ate the left
carotid artery
G) !$sc$ltate the carotid arteries for br$its 'ith the bell of the
stethosco(e
a) !sk the (atient to take a dee( breath and hold it to
eliminate breath so$nds
!bdomen
1) &he (atient sho$ld be in a s$(ine (osition 'ith arms at side
or folded across the chest
*) &he dra(es sho$ld be arranged to ex(ose the abdoment
from abo.e the xy(hoid (rocess to the sym(hysis ($bis=
-) !((roach the (atient from his right side
/) Ins(ect the abdomen
0) !$sc$late the abdomen as the next ste( in the exam after
ins(ection
a) Place the dia(hragm of the stethosco(e gently on the
abdomen
b) isten for bo'el so$nds
i) istening in one s(ot is s$Mcient
c) isten for an aortic br$it on the midline C$st abo.e the
na.al
2) Perc$ss the abdomen lightly in fo$r 1$adrants
?) Perc$ss for li.er d$llness
a) +eBne the lo'er edge of li.er d$llness in the midA
cla.ic$lar line# starting at a le.el belo' the $mbilic$s
b) +eBne the $((er edge of li.er d$llness in MC# starting
in the area of l$ng resonance
i) Gently dis(lace a 'oman,s breast as necessary
c) Meas$re in centimeters 'ith a r$ler the .ertical s(an of
li.er d$llness in the MC
J) Perc$ss for s(lenic d$llness
a) Perc$ss along the lo'er chest 'all bet'een the l$ng
resonance abo.e and the costal margin mo.ing
laterally )4ates ( -/1)
i) !sk the (atient to take a dee( breath and (erc$ss
again in this area
G) Pal(ate the abdomen lightly in fo$r 1$adrants and in the
s$(ra($bic and e(igastric areas
a) %se a gentle# light di((ing motion )4ates ( --0)
1@) Pal(ate the abdomen dee(ly in all fo$r 1$adrants
a) %se a Brmer di((ing motion
11) Pal(ate for the li.er edge
a) Place yo$r 9 hand on the right abdomen lateral to the
rect$s m$scle# beginning more than - Bngerbreadths
belo' the costal margin
b) !sk the (atient to take in a dee( breath
c) Pal(ate $('ards trying to feel the descending li.er
edge# $sing a rocking motion
i) May also $se the Ehooking techni1$eF described in
4ates ( -/@
1*) Pal(ate for a s(leen ti(
a) 9each o.er and aro$nd the (atient 'ith yo$r left hand
to s$((ort and (ress for'ard the lo'er left rib cage
b) Press in'ard to'ards the s(leen 'ith yo$r right hand#
beginning at least - Bnger breadths belo' the costal
margin
c) !sk the (atient to take in dee( breaths# trying to feel
the s(leen ti( as it comes do'n to meet yo$r Bngerti(s=
1-) Pal(ates for aorta by (ressing dee(ly 'ith one hand on
each side of the aorta )4ates# ( -//)
1/) Pal(ate for the s$(erBcial ing$inal lym(h nodes )4ates# (
/0*)
10) Pal(ate for both femoral artery ($lses
a) Press dee(ly belo' the ing$inal ligament )4ates# ( /0*)
%((er extremityM"8 and Partial 5e$rological )these
mane$.ers m$st be re(eated on both $((er extremities
1) Ins(ect the hands# incl$ding each Bnger# its skin and Coints#
and nails
a) Pal(ate any abnormal Coints
*) Ins(ect the 'rist
-) Pal(ate the distal radi$s and sn$; boxH (al(ate the distal
$lna
/) Pal(ate the radial ($lse on the >exor s$rface of the 'rist#
laterally
a) Com(are the ($lses in both arms
5) Check ROM of the fingers
a) Ask the patient to make a tight fist with each hand
b) Extend and spread the fingers
c) Ask the patient to spread the fingers apart and back together
d) Ask the patient to move the thumb across the pam and touch the base
of the 5
th
finger! and then back across the pam and awa" from the
fingers
e) #ave the patient touch the thumb to each of the other fingertips
$) Check ROM of the wrist %&ates p '(()
a) :lexion
b) Extension
c) %lnar and radial de.iation
?) Check 9OM of the elbo' )4ates ( /G?)
a) :lexion and extensionI ask the (atient to bend and
straighten the elbo'
b) Pronation and s$(inationI 'ith arms at his side# and
elbo's >exed# ask the (atient to t$rn the (alms $( and
then do'n
J) Pal(ate for e(itrochlear lym(h nodes )4ates ( /01)
a) :lex the elbo' to G@
b) )apate in the groove between the biceps and triceps
G) Ins(ect the sho$lder )4ates# ( /G*)
1@) Pal(ate the sho$lder )4ates# ( /G-)
a) ocate the acromion (rocess and the acromiocla.ic$lar
Coint
b) ocate the greater t$bercle of the h$mer$s
c) ocate the coracoid (rocess of the sca($la
11) Check 9OM of the sho$lder )4ates# ( /G-)
a) Watch for smooth# >$id mo.ement as yo$ stand in front
of the (atient and askI
i) 9aise the arms to sho$lder le.el )abd$ct) 'ith
(alms facing do'n
ii) 9aise the arms to a .ertical (osition abo.e the
head 'ith the (alms facing each other
iii) Place both hands behind the neck 'ith elbo's o$t
to the side )external rotation and abd$ction)
i.) Place both hands behind the small of the back
)internal rotation and add$ction)
1*) &est M$scle strength in the $((er extremity )4ates (( 0?/A
0?0)= 7o$ m$st com(are sides
a) &est gri(ask the (atient to s1$ee<e t'o of yo$r
Bngers as hard as (ossible and not let them go
b) &est Bnger abd$ction(osition the (atient,s hand 'ith
(alms do'n and Bngers s(read= &ry to force the Bngers
together
c) &est o((osition of the th$mbthe (atient sho$ld try to
to$ch the little Bnger 'ith the th$mb against yo$r
resistance
d) &est extension of the 'rist by asking the (atient to
make a Bst and resist yo$ ($lling it do'n
e) &est >exion and extension of the elbo' by ha.ing the
(atient ($ll and ($sh against yo$r hand
o'er extremityM"8 and Partial 5e$rological )these
mane$.ers m$st be re(eated on both lo'er extremities
1) &he (atient may be sitting or lying do'n and dra(ed so that
the external genitalia are co.ered 'ith the legs f$lly
ex(osed d$ring the exam
*) Ins(ect both feet and anklecom(are sides
-) Pal(ate the feet and ankles )4ates# ( 01?)
a) !ssess for (edal edema(ress Brmly 'ith yo$r th$mb
o.er the dors$m of the foot# behind each medial
malleol$s and o.er the shins )4ates# ( /00)
b) Pal(ate the anterior as(ect of each ankle Coint
c) Pal(ate the heel# es(ecially the (ost and inf calcane$s
d) Pal(ate the M&P Coints
e) Pal(ate the heads of the B.e metatarsals
/) Pal(ate for the (eri(heral ($lses of the legs
a) +orsalis (edisfeel the dors$m of the foot C$st lateral
to the extensor tendon of the great toe
b) Posterior tibialfeel belo' the medial malleol$s of the
ankle
0) Check 9OM of the ankle )4ates# ( 01J)
a) +orsi>ex and (lantar >ex the foot at the ankle
b) In.ert and e.ert the foot
c) :lex the toes
2) Ins(ect the knee for alignment and conto$rs
?) Pal(ate the knee 'ith the knee in >exion )4ates# ( 011A01-)
a) Identify the medial femoral condyle and the medial
tibial (latea$
b) Identify the tibial t$bercle
c) Identify the lateral femoral condyle and lateral tibial
(latea$
d) Identify the (atellar tendon and ask the (atient to
extend the leg
e) Pal(ate the medial collateral and lateral collateral
ligaments and menisci
f) :eel for s'elling abo.e and to the sides of the (atella
g) Check the (re(atellar# anserine and (o(liteal b$rsae
)4ates ( 01-)
J) Check 9OM of the knee )4ates ( 010)
a) !sk the (atient to >ex and extend the knee 'hile
sitting )or by asking the (atient from a standing
(osition to s1$at and then stand $( again
b) Check internal and external rotation by asking the
(atient to rotate the foot medially and laterally
G) Ins(ect the hi( by obser.ing the (atient,s gait at some time
d$ring the exam )4ates ( 0@2)
1@) Pal(ate the s$rface landmarks of the hi(
a) !nterior s$rfaceI locate the iliac crest# iliac t$bercle
and anterior s$(erior iliac s(ine
b) Posterior s$rfaceI locate the (osterior s$(erior iliac
s(ine# the greater trochanter and the ischial t$berosity
11) Check 9OM of the hi( )4ates# ( 0@GA01@)
a) :lexion'ith the (atient s$(ine# ask him to bend each
knee in t$rn $( to the chest and ($ll it Brmly against
the abdomen
b) !bd$ctiongras( the ankle and abd$ct the extended
leg $ntil yo$ feel the iliac s(ine mo.e
c) !dd$ctionhold one ankle and mo.e the leg medially
across the body and o.er the o((osite extremity
d) 9otation>ex the leg to G@ at hi( and kneeH stabili<e
the thigh 'ith one hand# gras( the ankle 'ith the other
and s'ing the lo'er leg# medially and laterally
1*) Check m$scle strength in the E )4ates# ( 0?2A0?J)
a) &est >exion at the hi((lace yo$r hand on the (atient,s
thigh and asking the (atient to raise the leg against
yo$r hand
b) &est add$ction at the hi(s(lace yo$r hands Brmly on
the bed bet'een the (atient,s knees= !sk the (atient
to bring both legs together
c) &est abd$ction at the hi(s(lace yo$r hands Brmly on
the bed o$tside the (atient,s knees= !sk the (atient to
s(read both legs against yo$r hands
d) &est extension at the hi(sha.e the (atient ($sh the
(osterior thigh do'n against yo$r hand
e) &est extension at the knees$((ort the knee in >exion
and ask the (atient to straighten the leg against yo$r
hand
f) &est >exion at the knee(lace the (atient,s leg so that
the knee is >exed 'ith the foot resting on the bed= &ell
the (atient to kee( the foot do'n as yo$ try to
straighten the leg
g) &est dorsi>exion and (lantar >exion at the ankleask
the (atient to ($ll do'n and ($sh do'n against yo$r
hand
5e$rological D some (arts of the ne$rological exam ha.e been
'o.en into exam of the head and neck and extremities )i=e=
Cranial 5er.e exam and motor testing)= &he remaining
com(onents of the ne$rological exam are co.ered here
1) 9e>exes )4ates# ( 0JJA0G1)
a) 4ice(s re>ex )C0# C2) 'ith (atient,s arm (artially
>exed at the elbo' and (alm do'n# (lace yo$r th$mb
or Bnger Brmly on the bice(s tendon and strike 'ith
re>ex hammer
b) &rice(s re>ex )C2# C?) D >ex the (atient,s arm at the
elbo' 'ith (alm to'ards the body and ($ll it across the
chest= "trike the trice(s tendon abo.e the elbo'
c) 8nee )Patellar) re>ex )*# -# /) D (atient may be
either sitting or s$(ine 'ith knee >exed= &a( the
(atellar tendon C$st belo' the (atella
d) !nkle )!chilles) re>ex )"1) D dorsi>ex the foot at the
ankle and strike the !chilles tendon
e) Plantar )4abinski) res(onse )0# "1) D 'ith a key or the
ti( of the shaft of a re>ex hammer# stroke the lateral
as(ect of the sole from the heel to the ball of the foot#
c$r.ing medially across the ball
*) "ensory )4ates# ( 0J-A0J/)
a) Pain D Create a shar( from a broken tong$e blade
i) Com(are symmetrical areas on the t'o sides of
the body# incl$ding arms# legs and tr$nk
ii) Com(are the distal 'ith the (roximal areas of the
extremities
iii) 3ary the (ace of yo$r testing and occasionally
s$bstit$te the bl$nt end for the (oint# 'hile asking
EIs this shar( or d$llNF or E+oes this feel the same
as thisNF
b) ight to$ch D $sing a Bne 'is( of cotton# to$ch the skin
lightly# a.oiding (ress$re
i) !sk the (atient to res(ond 'hene.er a to$ch is
felt=
ii) Com(are one area 'ith another
c) 3ibration D %se a lo'A(itched t$ning fork )1*J 6<)
i) "et the fork .ibrating and (lace it Brmly o.er a +IP
of a Bnger and of the great toe
ii) !sk 'hat the (atient feels
iii) If .ibration sense is im(aired# mo.e to more
(roximal bony (rominences
d) Ooint (osition sense
i) Gras( the (atient,s big toe# holding it by its sides
and ($ll it a'ay from the other toes so as to a.oid
friction=
ii) +emonstrate E$(F and Edo'nF
iii) With (atient,s eyes closed ask him to identify $(
and do'n mo.ements
i.) Com(are sides
.) Mo.e more (roximally if Coint (osition is im(aired
.i) &est OP" in the %E by mo.ing a Bnger Coint
-) CerebellarPCoordination )4ates# ( 0?JA0J@)
a) 9a(id alternating mo.ements
i) %E D "ho' (atient ho' to strike one hand on the
thigh# Brst 'ith the (alm# then 'ith the back of the
hand= 6a.e the (atient re(eat these alternating
mo.ements as ra(idly as (ossible= 9e(eat 'ith
o((osite hand
)1) O9 "ho' the (atient ho' to ta( the distal Coint
of the th$mb 'ith the ti( of the index Bnger as
ra(idly as (ossible= 6a.e the (atient (erform
the action= Check the o((osite hand
ii) E D ask the (atient to ta( yo$r hand as 1$ickly as
(ossible 'ith the ball of each foot in t$rn
b) PointAtoA(oint mo.ements
i) %E D ask the (atient to to$ch yo$r index Bnger and
then his nose alternately se.eral times= Mo.e yo$r
Bnger abo$t=
ii) E D !sk the (atient to (lace one heel on the
o((osite knee and then r$n it do'n the shin to the
big toe= 9e(eat on the other side
/) Gait
a) !sk the (atient to 'alk across the room# then t$rn and
come back
b) Walk heelAtoAtoe in a straight line
c) Walk on toes then on heels
0) 9omberg &est
a) &he (atient sho$ld Brst stand 'ith feet together and
eyes o(en and then close both eyes for *@A-@ secs
'itho$t s$((ort
4ack
1) 9OM )4ates# ( 0@0)
a) :lexion D 'ith (atient standing# ask him to bend
for'ard to to$ch the toes
b) Extension D (lace yo$r hand on the (osterior s$(erior
iliac s(ine and 'ith yo$r Bngers (ointing to'ards the
midline# ask the (atient to bend back'ard as far as
(ossible
c) ateral bending D ask the (atient to lean to both sides
as far as (ossible