1

Physical Examination  A group of symptoms and/or signs

Marfori, Francis Anthony V, MD, BSN that, occurring together, constitute a
particular disorder
Definition of Terms E.g. – irritable bowel syndrome

Symptoms •Intermittent pain in the lower

Reasons why patient/s see/s the abdomen
physician •Abdominal swelling
•Irregular bowel movements
Unpleasant unusual subjective •Mucus in the feces
sensation which affects the patient’s •Excessive gas
comfort and productivity •Worsening of symptoms after eating

E.g. – pain Introduction

Most patients view physical
Definition of Terms examination with at least some anxiety
The seven attributes of a symptom
•Location A thorough examination does more
Where is it? Does it radiate?
than prevent sickness and prolong the
•Quality lives of healthy men and women
What is it like?

•Quantity or Severity A privilege – show some respect

How bad is it?

•Timing Introduction
When did / does it start? How long
4 fundamentals
does it start? How often does it come? Inspection

Definition of Terms Palpation

The seven attributes of a symptoms
•The Setting in which it occurs, Auscultation
including environmental factors,
personal activities, emotional Percussion
reactions, or other circumstances that
may have contributed to the illness
Introduction
•Factors that make it better or worse Inspection
Examination of patient by way of
•Associated manifestations observing the patient

Definition of Terms Needs: good pair of eyes, good

Signs lighting
Alteration in function / structure
E.g. – color, lesions, pigmentation
which can be detected by a physical
examination Introduction
Palpation
Objective evidence of a disease as Examination of the body by the sense

detected by a physical examination of touch

E.g. – high temperature, flushing, Supplement inspection

marked weight loss
E.g. – fremitus, crepitations, chest
Definition of Terms expansion
Syndrome Introduction
Auscultation
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Act of listening to a sound produced

by the body
Direct – ear; indirect – stethoscope
E.g. – heart sounds, breath sounds,
vascular sounds, peristaltic sounds,
fetal heart sounds
Introduction
On Choosing the exam sequence,
position and handedness
Head to toe (cephalocaudal)

Introduction
•Not from feet, genitalia or rectum to
face or mouth
Percussion
Technique by striking the chest wall
•Not from rectum to vagina
Examine from the patients right side
and perceiving the character of the
Sitting, supine patient depending on
sensation as they are perceived by the
the area examined
ear and palpating fingers
To detect amount of air, presence of
Introduction
fluid, presence of organomegaly
E.g.
•Resonance – percussion of lung Adjusting lighting and environment
containing a normal amount of air Adjust the bed
(normal lung) Ask the patient to move toward you
•Hyperresonance Tangential lighting for examination of
•Flatness – less than normal air (thigh) JVP, thyroid gland, apical impulse
•Dullness – air has been completely
removed (liver) Introduction
•Tympany – air in an enclosed chamber
(gastric air bubble)
Promoting the patient’s comfort
Introduction Show concern for privacy and
Setting the stage comfort
Reflect on your approach to the Draping the patient: visualize one
patient area of the body at a time
Decide on the scope of the
examination Introduction
Choose the examination sequence
Adjust the lighting and the
environment
Make the patient comfortable
Introduction
Hand washing ! ! ! ! !
Introduction
Overview of a comprehensive
Approaching the patient examination
Let the patient know you are a General survey

student Vital signs

May need to spend more time Skin

Avoid interpreting your findings Head

Eyes

Introduction Ears

Nose and sinuses

Mouth and pharynx

Scope of the examination: how
Neck
complete should it be?
Back
Comprehensive?
Posterior thorax and lungs
Focused?
Breast, axilla and epitrochlear nodes
General Principle: new patient
warrants a complete physical
examination, regardless of the chief
complaint or setting
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Musculoskeletal system •Confused state with agitation and

Breasts hallucination
Anterior thorax and lungs Confusion
Cardiovascular system •Mental slowness, inattentiveness
Abdomen •Incoherence in thinking
Rectal examination in men

Genitalia and rectal examination in General Survey – Psyche / Mental State

women General Survey – Psyche / Mental State
Legs Examples of disturbances in
Neurological examination orientation and emotional states
Mental status Korsakoff’s syndrome
•Disorientation state in chronic
alcoholism
General Survey Grave’s disease (hyperthyroidism)
Psyche / mental status •Mentally quick, unusually alert
Apparent state of health Myxedema (hypothyroidism)

Signs of distress •Alligator look – dull, apathetic, lack of

intelligence, swollen face, heavy eyes
Position and posture
Catatonia
Movement and paralysis / paresis •Statue like, in psychiatric patient
Gait General Survey – Apparent State of
Health
Speech Judging from the general appearance
Nutritional status of the patient
Development and stature In good health
Temperature Acutely ill / Chronically ill
Frail / robust
Facies
Skin
General Survey – Cardiac / Respiratory
Distress
General Survey – Psyche / Mental State
Types
Degree of consciousness or Dyspnea
awareness of a patient to his Orthopnea
environment Tachypnea – increase RR
Mood
Bradypnea
•Anxious Hyperpnea – increase RR and depth
•Apathetic
•Depressed Severity
•Elation Mild
•Hostility Moderate
•Withdrawn Severe
Intellect – dull or intelligent
Orientation – time, place and person
Pain, anxiety or depression
General Survey – Psyche / Mental State General Survey – Position and Posture
Levels of consciousness
Coma
One holds the body while sitting and
•Deepest stage, unarousable standing
•Semi-coma – positive response to
pinprick Height and build
Stupor Unusually short or tall
•Marked reduction in mental and Slender or muscular
physical activity Body symmetry
•Sleeping but arousable Look for deformities
Delirium
General Survey – Position and Posture
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May reflect an underlying disease Wide base gait; patient watches the
Scoliosis
ground
Parkinsonian gait
•Abnormal curvature of the spine Short shuffling steps
Lordosis
Scissors gait
•Exaggerated anterior curvature Thigh cross forward with each other

Kyphosis Waddling gait

•Exaggerated posterior curvature Pregnant walk

General Survey - Speech

General Survey – Position and Posture Aphasia / dysphasia - cortical
speech center damaged
Certain position  diagnostic clues Aphasia – loss of
Pneumonia or pleuritis – lying on
production/comprehension of
affected side
spoken/written language
Gall bladder stone – doubling up
Dysphasia – error in choice of words
Cardiac failure – sleeps with head on
Dysarthria
the forearm
Can understand and talks well but has
Asthmatic / pulmonary edema – sits
difficulty in articulation
upright
Cerebellar dysarthria
Meningitis – opisthotonus
Poor in comprehension; irregular
speech
General Survey – Movement and
Aphonia / dysphonia – disease of
Paralysis
larynx
Fasciculations
Aphonia – loss of speech
Visible twitching movement of a
Dysphonia – raspy voice
muscle bundle
Palatal paralysis
Tremors
Nasal speech
Involuntary rhythmic tremulous
Parkinsonism
movements of an extremity
Monotonous weak voice
Intention; at rest; postural
Infantilism
Tics
High pitched voice
Repetitive twitching of small muscle
Hypothyroid
bundles often on face and upper trunk
Monotonous, halting speech
Chorea
Rapid, jerky, irregular, unpredictable,
General Survey – Habitus / Body
involuntary movement of face,
Configuration
extremities or trunk
Athetosis Asthenic (ectomorph)
Slower, more twisting than chorea
Sthenic (medomorph)
Asterexis
Positive jerky alterations of flexion Hypersthenic (endomorph)
and extension at the wrist and
interphalangeal joints General Survey – Nutritional Status
Types
General Survey - Gait Emaciated
Manner in which a person walks Poorly nourished
Fairlynourished
Hemiplegia Well nourished
1 arm is flexed close to side and Obese
immobile; toes dragged
Footdrop / enturned / stiffage General Survey - Development
Like a horse; feet lifted high with Size and proportion of the general
knees flexed  brought down violently body structure
Gait of sensory ataxia / tabetic Well developed
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Fairly developed •Rise of temp every 3 days, a form of

Poorly developed intermittent fever
General Survey - Facies
Giants Myxedema
Acromegalic giants Hypothyroidism; puffy face, swollen
•Large head, prominent jaw, massive eyelids, dull look, coarse and dry skin
head and feet, large nose Hippocratic facie
Infantile giants Face of impending death
•Abnormally large stature with Nephrotic facie
retarded sexual development Pale face; edema of lids
Cardiac
General Survey - Development Cyanosis of lips, flaring of alaque nasi
Dwarves Facie of superior vena cava
Ateliotic dwarves
syndrome
•Small adults, proportionate Duskiness of face, marked
Achondroplastic dwarves
prominence of neck veins
•Abnormally short, normal size head
and trunks General Survey - Facies
Cretin
Parkinsonian facie
•Short, stocky, mentally retarded, thick
Expressionless
lips and tongue, protruding tongue,
widest eyes, pale and coarse skin Risus sardonicus
Sustained exaggerated smile
Progeria
•Small old man, stunted growth Leonine facie
Mitral dwarfism Flattening of the nose, thickened
•Patient with congenital heart forehead and cheeks
Renal dwarfism Moon facie
Round face, (+) acne, hirsutism
General Survey - Temperature Thyrotoxic facie
Normal values Startled look with widened palpebral

Oral: 36.4 – 37.2 degree Celsius fissures

Rectal: 0.3 to 0.5 higher than oral General Survey - Skin
Axillary: 0.3 lower than oral Temperature
General Survey - Temperature
Texture
Types of fever Moisture
Continuous or plateau Turgor
•Temperature remains consistently Color
elevated
Intermittent fever Lesions
•Elevated temporarily at times but
return to normal or subnormal Vital Signs
Remittent Blood pressure
•Rise and fall but never return to
normal
Heart rate and rhythm
Relapsing or Pel-Ebstein Respiratory rate and rhythm
•Short febrile periods are interspersed Temperature
by one or more days of normal
temperature Skin / Integumentary - Color
Low grade afternoon fever
•Usually no higher than 0.5 – 1.0 Color
Increased/loss pigmentation
degree C
Pallor
Tertian fever
Cyanosis
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Yellowing/jaundice
•Patch – larger than 1 cm; measles
Skin / Integumentary - Color rash
Variations in color
Brown •Erythema – confluence of red
•Pregnancy macules
Bronze

•Hemochromatosis
Blue Skin / Integumentary - Lesions
•Heart or lung disease Circumscribed; palpable, elevated
Red solid mass
•Sunburn, fever, blushing •Papule – up to 1 cm; wart, pimple
Yellow •Plaque – larger than 1cm, often
•Jaundice – liver disease coalescence of papule; neurodermatitis
•Carotenemia – increase intake of •Nodules – firmer than papule, up to 1
carrots cm, solid; xanthomas
•Chronic uremic / renal failure – chronic •Tumors – larger than 1 cm, depth may
renal failure be above or beneath skin surface
Decreased color •Weal – papule that is edematous;
•Albinism insect bite
•Vetiligo
•Tinea versicolor Skin / Integumentary - Lesions
Circumscribed superficial elevation of
Skin / Integumentary - Moisture skin by free fluid on a cavity within
Moisture skin lesions
Dryness •Vesicle – up to 1 cm; filled with serous
Sweating fluid; chicken pox
oiliness •Bulla – greater than 1 cm; filled with
serous fluid; secondary burn
Skin / Integumentary – Temperature •Pustule – filled with pus; acne
and Texture
Temperature
Use the back of your fingers Skin / Integumentary - Lesions
Note temp of any red areas Secondary
Loss of skin surface
Texture •Erosion – loss of surface epidermis;
Roughness/ smoothness moist area after rupture of a vesicle
•Ulcer – deeper loss of skin surface;
may bleed and scar; pressure ulcer
Skin / Integumentary – Mobility and •Fissure – linear crack in the skin;
Turgor athlete’s foot
Mobility and Turgor Skin / Integumentary - Lesions
Lift a fold of skin and note the ease Secondary
with which it lifts up (mobility) and the Materials on skin surface
speed with which it returns into place
(turgor)
•Crust – dried residue of serum, pus or
blood; impetigo
•Decreased mobility in edema •Scale – thin flake of exfoliated
•Decreased turgor in dehydration epidermis; dandruff
Skin / Integumentary - Lesions
Primary Skin / Integumentary - Lesions
Circumscribed; flat; non-palpable
Secondary
•Macule – up to 1cm in diameter; Miscellaneous
freckles
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•Lichenification – thickening and Blue nails – Wilson’s nail

roughening of the skin with increased
visibility of the skin furrows; atopic Skin / Integumentary - Tumors
dermatitis
•Atrophy - thinning of the skin with loss To describe tumors
Size of mass
of the normal skin furrows; arterial
Shape
insufficiency
Texture or consistency
•Excoriation - scratch marks /
Mobility
abrasions
Tenderness
•Scar – replacement of damaged tissue Temperature
by fibrous tissue Location
•Keloid – hypertrophoid scar
Head and Neck / ENT
Skin / Integumentary - Lesions
Under the skin / subcutaneous
Hair – quantity, texture, distribution,
pattern of hair loss, lice, baldness
Petechiae – deposit of blood <2mm;
Fine hair – hyperthyroidism
pinpoint
Coarse hair – hypothyroidism
Purpura – bigger; several mm 1cm
Dandruff / flaking of hair
Ecchymosis – larger hemorrhagic area

larger than 1 cm Scalp – presence of flakes, scales;

Herpes zoster – linear, along course tenderness and lumps
of nerves, painful Scaling – psoriasis

Angular lesions – in ringworms Dandruff

Clusters – herpes simplex

Skin / Integumentary - Nails Head and Neck / ENT

Color / Shape / Lesions Skull
Large skull
Cardiac disease – clubbing of fingers •hydrocephalus
(convex) Small skull
•microcephalus
Spoon nails – concave; iron deficient Pagett’s disease
anemia
•protrusion of frontal bones
Beause lines – transverse depression Head and Neck / ENT
in the nail; acute severe illness
Ear
Auricle
Onycosis – separation of nail from
•Shape – Darwin’s tubercle – extension
nail bed; in infection, trauma,
of the rim upward
malnutrition
•Skin color – Tophi – nontender, whitish
nodule
Paronichia – inflammation of skin
•Tug test (move up and down)  pain
around the nails
 otitis externa
External canal
Skin / Integumentary - Nails
•Note any discharge, foreign body,
Splinter hemorrhage – subacute redness, swelling
bacterial endocarditis •Mucosa
•Foreign bodies
White nails – alcoholic cirrhosis •Wax
•E.g. otitis externa – swelling and
redness of external mucosa
Yellow nails – hemochromatosis
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Head and Neck / ENT Mucus retention – cyst; bluish

Ear nodules, non-tender, benign
Use an otoscope (upward and Cancer of the lips – ulcerations

backward, slightly away from the Primary syphilis – button-like; non-

head) tender
Drum – pearly gray white
•Retracted drum Head and Neck / ENT
•Serous otitis media – (+)fluid level + Lips
bubbles Fever blisters / cold sores – herpes

•Exudative otitis – no more luster  simplex virus; recurrent vesicular

reddish eruptions of lips and surrounding
•Perforation tissues
Chancre – button like nodule
Head and Neck / ENT formation of lips; syphilis
Angular cheilitis – fissure at corner of
Ear
Auditory acuity examination
lips due to lack of vitamin B
Mucous retention cyst / mucocele –
•Deafness: conduction and nerve
•Weber test – lateralization; normal – bluish cyst on lips due to clogging of
both ears; CHL – lateralizes to impaired sebaceous glands
Peutz-jeghers syndrome – patchy
ear; NHL – lateralizes to the good ear
•Rinne test – air conduction versus brown discoloration of lips
Carcinoma of lips – lower lips; most
bone conduction; CHL – BC>AC or
BC=AC; NHL – AC>BC common form of oral cancer
•Schwabach’s test – patient versus
physician Head and Neck / ENT
Head and Neck / ENT Roof of mouth
Torus palatinus
Nose
Symmetry, shape and nasal mucosa, •any protrusions of roof of mouth
septum
Inspect anterior and inferior surface Thrush

of the nose •milk curd – like lesions on hard palate;

Note for any deformity due to fungal infections (Candida)
Note any swelling, bleeding, exudates
in nasal mucosa Head and Neck / ENT
Note any deviation, inflammation and Buccal Mucosa
perforation in nasal septum The oral mucosa
Note for polyps •Color
•ulcers

Head and Neck / ENT Apthous ulcer (cancer sore)

Palpate for sinus tenderness •Reddish with whitish center; very
Frontal and maxillary sinuses tender
Head and Neck / ENT Fordyce spots

Lips / mouth •Non-significant yellowish granules

Apthous stomatitis
Ask the patient to remove dentures
Put on gloves if the patient has •Whitish ulcer surrounded by a reddish
suspicious nodules or ulcers area
•Painful
Color: cyanotic
Lumps, cracking, scaliness Head and Neck / ENT
Gums and teeth
Color of gums, normally pink
Chelitis
Chelosis – secondary to vit B complex
deficiency
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Enlargement, nodules, swelling, •Color is very red, very red

growth, teeth deformities, bleeding
Gums
•Covered with grayish exudates up to
the uvula
•Gingivitis – redness, swelling of gum
margins
Head and Neck / ENT
•Periodonitis / pyorrhea – inflammation
of deeper tissue around the teeth; Neck
common cause of tooth loss in adults Inspect noting symmetry, any
•Retracted gums masses, scars,
•Epulis – non tender nodules Thyroid gland enlargement
•Acute necrotizing gingivitis (Trench
mouth / Vincent’s stomatitis) – painful Abnormalities
gingivitis characterized by redness, •Hypothyroidism
swelling and ulceration of gingival •Goiter
tissue; formation of grayish membrane
•Gingival enlargement – gingival tissue Head and Neck / ENT
appear heaped up and partially cover Visible lymph nodes
the teeth •Preauricular
Teeth – growth abnormalities, missing
•Submental
teeth, cavities •Supraclavicular
•Submaxillary
Head and Neck / ENT •Superficial cervical
Tongue •Posterior cervical
Ask the patient to out his tongue,
•Deep cervical chain
inspect for symmetry (test for
hypoglossal nerve, CN XII) Head and Neck / ENT
Inspect sides and undersurface of
tongue, note for reddened areas, Trachea
nodules, ulcers, smoothness, papillae, Inspect for deviation
color, movement Place your finger along one side of
trachea and note space bet it and
Smooth tongue; no papillae sternocleidomastoid. Compare with the
•due top anemia, B12, iron deficiency other side. Spaces should be
Hairy tongue symmetric.
Geographic Head and Neck / ENT
•with smooth area, prominent area of Thyroid gland
papillae Inspect for enlargement
Scrotal or fissure tongue Palpate
•may be normal •Ask the pt to flex neck sl forward
Abnormal hypoglossal CN
•Place the fingers of both hands on the
•deviation to the side; abnormality of
pts neck so your index finger is just
the 12th nerve; towards the affected
below the cricoid cartilage
side
Varicosities
•Ask the patient to sip and swallow
Head and Neck / ENT •Note the size, shape and consistency
and identify nodules and enlargement
The pharynx
Inspect the uvula, tonsils, pharynx •If enlarged, listen over the lateral
lobes with a stet to detect a bruit
Viral phryngitis heard in hyperthyroidism
Eyes
•Mild, pinkish color; slightly swollen
Streptococcal / bacterial pharyngitis Visual acuity
Use Snellen eye chart
•Reddish color, markedly swollen, Position patient 20 ft from the chart
whitish / yellowish exudates on tonsils Test one eye at a time
Diptheria
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E.g. 20/200 ( at 20 ft. the patient can

read print that a normal person can Eyes
read at 200 ft.) Palpebral fissure
Widening
Eyes
•Negroid group with shallow bony
Normal vision orbits
•Carotid cavernous fistula – forward
displacement of eyeball
•Orbital mass
•Grave’s disease – hyperthyroidism
Macular degeneration •Pathologically large eye in high
Eyes myopia
Glaucoma •Bupthalmos – secondary to glaucoma
Eyes
Eyelids
Width of palpebral fissure
Edema of the eyelids
Cataract Color
Eyes Lesions (blepharitis)
Diabetic retinopathy Adequacy with which the eyelids
Eyes close
Color blindness
Red – Green color blindness test

Eyes
Color blindness Eyelids
Red – Green color blindness test Swelling
•Normal eye will see number 57 •Hordeolum or sty
•Red-green deficiencies will see •Chalazion
number 35 Edema
Eyes •Blepharitis - swelling
Palpebral fissure •Acute glomerulonehpritis
Opening formed by upper and lower •Systemic trichinosis
eyelids •Angioneurotic edema – due to allergy
N size 8-10mm in height; 26-29 mm from drugs / food
in length •Venous obstruction of the cavernous
Narrowing sinus and orbital
•Enophthalmos – congenital anomaly Inflammatory sequelae

or fracture of orbit  contents push •Ectropion – outward turning of eyelid

back •Entropion – inward turning
•Congenitally small microphthalmic •Trichiasis – misdirection of eyelashes
eyes inward
•True phimotic narrowing of vertical
and horizontal Eyes
•Ptosis – drooping Conjunctiva
Horner’s syndrome – small pupils, Mucus membrane surrounding the
ptosis, loss of sweating inner lid of the cornea
Oculomotor nerve palsy or paralysis – •Bulbar – covers anterior surface of the
pupillary dilatation, deviation of eyeball
eyeball laterally and downward, ptosis •Palpebral
Myasthenia gravis – depression of Color

upper eyelids
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Vascular pattern against the scleral  Dryness of cornea

background •Sjogren’s syndrome’ severe
Look for any nodules or swelling malnutrition, vitamin A deficiency
Dacryo-Adenitis
Abnormal findings •inflammation of lacrimal gland due to
•Discoloration – anemia; jaundice poor health
•Chemosis – edematous swelling of Epiphora
bulbar conjunctiva •watering of the eye  increase tears
•Petachia – suabacute bacterial Keratomalacia
endocarditis •Softening of cornea due to vitamin A
deficiency
Keratoconus
Eyes •Non inflammatory protrusion of center
Conjunctiva of corneo due to gradual thinning of
Abnormal findings apex
•Subconjunctival hemorrhage –
Eyes
subconjunctival hemorrahge, whooping
cough Pupils
Normal size – 3 to 5 mm in diameter
•Symblepharon – attachment of eyelids
Pupillary reaction to light
to eyeball; trauma, burns
•Degenerative changes Myosis
Pinguencula – yellowish triangular •Less than 2mm; morphine addiction
nodule in bulbar conjunctiva on either Mydriasis
side of iris
•Greater than 6mm; coma, strong
Pterygium – fibrovascular wedge of CT
emotions
in bulbar
Hippus
Eyes
•Abnormal rhythmic variations in size
Conjunctiva of pupil
Abnormal findings Tonic pupil
•Xerophthalmia – dry lusterless •Unequal size of pupils
conjunctiva; due to vitamin A
deficiency Eyes
•Bitot’s spot - shiny gray triangular Extraocular muscles
spot; due to vitamin A deficiency Ask the patient to follow your finger

•Conjunctivitis – redness, tenderness, Make a wide H, lead the patient’s

discharges, crusts gaze

Detects paralysis in EOM

Eyes
Cornea Thorax and Lungs
Pigmentation Inspection
•Arcus (partial) and annulus (complete) Chest wall
senilis – ring around the cornea •Normal ratio, in cm, of AP to lateral
•Kayser-Fleischer ring – greenish brown chest wall diameter 5:7
ring around cornea; in Wilson’s disease
•Types
(copper deposits)
Barrel chest
Ulcerations – trauma, after Herpes
•Equal diameter
zoster
Pectus carinatum / chicken or pigeon
Keratitis – inflammation
breast
Hurler’s disease (Gargoylism) –
•Protrusion of chest / sternum forward
ground glass appearance of cornea
together with costal cartilage; greater
AP diameter
Eyes
Pectus excavatum / funnel chest
Cornea
 12

•Lesser AP diameter; depression of

chest Thorax and Lungs
Auscultation
Thorax and Lungs Listen to the breath sounds

Inspection •Breath sounds usually louder in upper

Respiratory pattern anterior lung field
•Rate, depth and regularity of
breathing; normal value 12 – 16 cpm,  Types of breath sounds
other books 12 – 20 cpm •Vesicular breath sounds
Produced by air from trachea to
•Types alveoli; long on inspiration, short on
Tachypnea – rapid, shallow breathing;
expiration
restrictive lung disease
•Bronchial breath sounds
hyperpnea / hyperventilation – rapid,
Auscultating near bigger airways;
deep breathing; exercise, anxiety
short on inspiration, long on expiration
Bradypnea – slow breathing; coma
•Bronchiovesicular breath sounds
Kussmaul’s breathing – deep and fast;
Near on lower part of lung; long on
increase in depth and rate; diabetic
inspiration, short on expiration
ketoacidosis
Thorax and Lungs
Thorax and Lungs
Auscultation
Inspection Abnormal breath sounds
Respiratory pattern •Rales – noises produced by air
•Types passage thru liquid or thru a narrowed
Cheyne-Stokes respiration – period of tube by edema or spasm
hyperpnea followed by apnea; Types:

cerebrovascular stroke •Rale – passage of air with a fluid in a

Biot’s respiration / ataxic breathing –
very irregular breathing; brain damage
at the medulla
Sighing respiration – hyperventilation
syndrome
Obstructive breathing - increased
respiratory rate  patient lacks
sufficient time for full expiration
Thorax and Lungs
Palpation
Identifytender areas
Assessment of observed findings
Assessment of chest expansion
Assessment of tactile fremitus
Thorax and Lungs
Percussion
Percuss anterior and lateral chest
Heart produces an area of dullness
small bronchiole or alveoli
•Fine / repitant rales – heard at the
terminal end of inspiration
•Coarse rales – crackling, bubbling,
gurgling, non-continuous sounds
•Rhonchus / rhonci – noise from bigger
airways (trachea); fluid / exudate in
bigger area
•Wheeze – piping or whistling sound on
air passage thru an obstructed airway
Thorax and Lungs
Auscultation
Abnormal breath sounds
•Pleural friction rub – grating,
crackling, squeaking sound and heard
when pleura rub against each other
•Hamman’s sign – crunching sound at
anterior chest wall and synchronous
with heart beat

 Percussion sounds Thorax and Lungs

•Resonance
•Hyperresonance
Auscultation
Vocal resonance
•Dullness
•Flatness •Pectoriloquy
•Tympany Hear the words itself; consolidation
 13

•Bronchophony
Loud but can not hear proper word Cardiovascular System
•Egophony Cardiovascular System
With nasal or bleating quality; fluid Palpation
effusion Pulsation usually accompanies
Cardiovascular System dilatation or enlargement
Inspection
Precordium Carotid pulsations
•Rectangular space overlying heart, •Grading of pulses
great vessels and pericardium •+4  0
•Boundaries •If 0 pulse – inadequate circulation;
Upper – 2
nd
rib thrombosis
Lower – 6
th
rib
Left – midclavicular line
•Auscultation
Bruit – murmurlike sound of a
Right – parasternal line
vascular rather than cardiac origin
•Apical beat
Represents the brief early pulsation
of the left ventricle as it moves
Cardiovascular System
anteriorly during conrtraction and
touches the chest wall Percussion
5
th
or 4th ICS left MCL Estimates cardiac border
Measures less then 2.5 cm

Point of maximum impulse

Auscultation
Know your stethoscope!
Cardiovascular System
•The diaphragm: better for picking up
Inspection high pitched sounds of S1 and S2,
Jugular veins murmurs of aortic and mitral
•Measure of the right atrium regurgitation, pericardial friction rubs.
•Indicator of cardiac function and right •The bell: more sensitive to low
heart hemodynamics pitched sounds of S3 and S4 and the
•Best estimated from the internal murmur of mitral stenosis
jugular vein, usually on the right
Cardiovascular System
•Jugular venous pressure - normal
pressure 7 – 8cm water Auscultation
S1 – closure of mitral valve; loudest
at apex
Cardiovascular System S2 – closure of aortic valve; loudest

Inspection at base
Steps for assessing the JVP S3 – due to ventricular filling in early

•Raise the head slightly on a pillow to diastole

relax the sternocleidomastoid muscle S4 – due to contraction of LA in late

•Raise the head of the bed at 30º. Turn diastole to propel remaining blood to
the patients head slightly away from LV
the side you are inspecting
•Use tangential lighting, identify ext Rate – fast or slow; rhythm – regular
jugular vein then find the internal or irregular
jugular vein Cardiovascular System
•Identify the highest pulsation in the Auscultation
right internal jugular vein Murmurs
•Extend a card horizontally from this •A musical sound produced by
point and a centimeter ruler vertically turbulent flow of blood
from the sternal angle. This distance •Normally a laminar flow of blood in BV
above the angle in cm, is the JVP
 velocity of blood flow progressively
 14

increase towards center  velocity Lower inner

reaches critical level  turbulence  Upper outer
Lower outer
vibration  murmurs

Cardiovascular System Breast and Axilla

Auscultation Female breasts
Inspection
Murmurs
•Characteristics •Size and symmetry
Location
•Skin color
Timing
•Nipple
Size and shape
Duration
Direction to which they point
Pitch
Rashes or ulcerations
Intensity
Discharge
•Grade I – need to tune in
•Grade II – faint but audible
•Grade III – loud Breast and Axilla
•Grade IV – loud and with a thrill, fully Palpation
placed diaphragm Patient in supine position
•Grade V – loud and with a thrill, Use fingerpads of 2nd, 3rd, 4th fingers
partially placed diaphragm Vertical strip pattern
•Grade VI – thrill, diaphragm is away •Examine for consistency
Quality – harsh, blowing, rumbling,
•Tenderness
cresendo, decresendo, or cresendo-
decresendo •Nodules
•Conssitency or elasticity
Cardiovascular System •Induration
Types of murmurs Health Teachings for Breast Self-
Midsystolic murmurs Examination
•Innocent murmurs Breast and Axilla
•Physiologic murmurs Axilla
•Pathologic murmurs Inspection
Pulmonic stenosis
•Presence of rash, infection and
Aortic stenosis
unusual pigmentation
Hypertrophic cardiomyopathy
Palpation
•Feel for presence of enlarged lymph
nodes
Types of murmurs
 Pansystolic (Holosystolic) murmurs Abdomen
•Mitral regurgitation
•Tricuspid regurgitation Steps for enhancing abdominal exam
Patient should have an empty bladder
•Vetricular septal defect
Make the patient comfortable in a
Diastolic murmurs
supine position
•Aortic regurgitation
Have the patient keep arms at the
•Mitral stenosis
sides or folded across the chest
Ask the patient to point any areas of
Breast and Axilla
pain and examine these areas last
Female – lies between the 2nd and 6th
Warm your hands and stet, avoid long
ribs, between sternal edge and
fingernails
midaxillary line
Approach slowly and avoid quick
Nipple – located centrally, surrounded
unexpected movements
by areola
Distract the patient with conversation
Parts of breast
or question
Tail
Abdomen
Upper inner
Inspection
 15

 Skin Grating sound, inflammation of

•Color peritoneal surface of an organ
•Cullen sign •Placental souffle
Bluish / yellowish blue discoloration Soft blowing sound due to blood flow
around umbilicus due to retro / intra- to placenta
peritoneal bleeding caused by rupture •Fetal heart beats
ectopic pregnancy and hemorrhage
•Spider angioma / spider nevi
Abdomen
Reddish hyperpigmentation of the
chest wall; liver cirrhosis
Palpation
Light palpation
•Stria
•Identify abdominal tenderness,
Rupture of the elastic fibers of skin
muscular resistance, superficial organs
due to overstretching; bluish, pinkish,
and masses
silvery white
•Fingers together, flat on the
•Veins
abdominal surface, palpate the
Caput medussae – cluster of dilated
abdomen with a light, dipping motion
vein radiating to umbilicus due to
•Feel all quadrants
portal hypertension
•Presence of nodules
•Scars
•Muscle rigidity / guarding
•Rashes and other lesions
•Tenderness
Direct
Abdomen
Rebound / indirect tenderness
Inspection Murphy’s sign (acute cholecystitis)
Contour of the abdomen versus Murphy’s punch sign
•Described as Ballotment test

Distended Abdomen
Flat Palpation
Scaphoid
Deep palpation
Pulsations
•Required to delineate abdominal
Peristaltic movements masses
•Identify masses and note their
Abdomen location, size, shape, consistency,
Auscultation tenderness
Performed first before palpation and •Enlargement of different organs
percussion Abdomen
Alters bowel sounds Percussion
Auscultate for Organs and fluids

•Bowel sounds Normal span of the liver dullness

Increased bowel sounds or decrease / •MCL – 6 – 12cm

absent bowel sounds •MSL – 4 – 8cm
Normal 5-34/minute Tests for fluids in the abdomen

•Systolic bruits •Shifting dullness

Vascular sounds resembling cardiac •Fluid wave test
murmurs •Puddle sign – up to 20ml
•Venous hum
Soft, continuous sound, between the Genitourinary Tract
umbilicus and xiphoid process Kidney tenderness
Murphy’s punch sign
Abdomen Costovertebralangle tenderness
Auscultation Kidney punch sign
Auscultate for
•Friction rub Male Genitalia
Inspection
 16

Size of penile shaft – as stomach Female Genitalia - Internal

enlarges, shaft decreases Assess the support of vaginal walls
Skin: excoriations
Separate the labia
Glans: ulcers(balanitis), scars, signs of
Ask the patient to strain down
inflammation Note for bulging of vaginal walls
Look for nits, lice around the base of

the penis
•Cystocele
Prepuce
•rectocele
•Phimosis
Prepuce cannot be retracted Female Genitalia - Internal
•Paraphimosis Use speculum
Prepuce is stuck at the glans Select a speculum of appropriate size
Lubricate it with warm water
 Abnormalities
•Infantilism Female Genitalia - Internal
•Virilism
•Elephantiasis
The Cervix
Normal cervix may be round, oval or
•Hermaphroditism
slitlike
Pinkish in non pregnant state
Male Genitalia
Note for polyps
Penis Mucupurulent discharges
Palpate for any abnormality, Masses
tenderness, induration
Palpation of the shaft may be omitted Female Genitalia - Internal
in young asymptomatic patients
If you retract the foreskin, replace it
Uterus/ovaries
Perform a bimanual exam
before proceeding on to examine the
Palpate the uterus: place your hand
scrotum
midway between umbilicus and
Male Genitalia
symphysis pubis
The scrotum •Note for size, shape, consistency,
Lift the scrotum so you can see the mobility
posterior surface Palpate the ovaries
•Note any swelling, lumps, •Note for size, shape, consistency,
•Cryptorchidism (undescedned testes) mobility
Palpate each testes and note size, •Normal ovaries are somewhat tender
shape, consistency, tenderness
•Difficult to feel in obese or poorly
•Painless nodule raises the possibility relaxed patients
of CA Female Genitalia
Pregnant Woman
Female Genitalia - External
Inspect
Mons pubis:
Fundic height
excoriations, red maculopapules
•Tape measure
suggest pediculosis pubis
The labia minora
•Symphisis pubis 12 – 14
wks AOG
Clitoris
Urethral meatus
•Between SP and umbilicus 16 wks
AOG
Vaginal opening
•Umbilicus 20 – 22
wks AOG
Inflammation
Ulceration •Xiphoid process 36 wks
AOG
Swelling
Nodules
External genitalia
•Bleeding, presenting parts
 17

 Anus for hemorrhoids Anus, Rectum and Prostate

Side-lying position is satisfactory
Pregnant Woman
Patient’s buttocks close to the edge
Palpation of the examining table near you
Abdomen
•Mass or organs Flex the patient’s hip and knees, esp
top leg
•Fetal movements
5 in 10 minutes Drape appropriately, adjust light
•Uterine contractility Glove your hands, spread the
5 in 10 minutes, moderate buttocks apart

Pregnant Woman Anus, Rectum and Prostate

Palpation Inspect perianal area
Abdomen Ulcers
•Leopold’s Maneuvers Inflammation
L1 – fundic grip; part of the fetus in Hemorrhoids
the upper pole Venereal warts
L2 – umbilical grip; fetal back Perianal abscess
L3 – pelvic grip; presenting part

L4 Anus, Rectum and Prostate

Anus and rectum
Pregnant Woman Palpation

Bimanual examination •Insert index finger over the anus

Index and middle finger Observe

•Palpate – cervix – position, shape, •Sphincter tone

consistency, regularity, mobility and •Tenderness
tenderness •Induration
•Irregularities or nodules
•Palpate – uterus – size, shape,
consistency and mobility, tenderness •Insert index finger into the rectum
Note for
and masses
•Nodules
•Palpate – each ovary •Irregularities
•Induration
Rectovaginal Examination •Prostate gland
Index finger – vagina; middle finger –
rectum
•Retroverted uterus Anus, Rectum and Prostate
Pregnant Woman Male
Palpation – prostate gland
Auscultation
Fetal heart beat •Identify the lateral lobes
Normal 120-160 beats per minute •Median sulcus
•Size
Anus, Rectum and Prostate •Shape
•Consistency – rubbery
Least popular •Nodules or tenderness - nontender
May cause discomfort, Anus, Rectum and Prostate
embarrassments After the rectal exam…
Requires Gently withdraw your fingers
Gentleness Wipe the patient’s anus, or give him
Slow movement of the fingers tissue
Calm demeanor Note the color of any fecal matter on
Explanation your glove
 18

Anus, Rectum and Prostate Causes: infectious diseases

Female Peripheral Vascular System
Follows male except usual position is Pulses
lithotomy Abnormal wave
Note for •Quick pulse – Celer – rapid rise and
•Cervix fall
•Retroverted uterus •Slow pulse – Tardus – prolonged rise
•Vaginal tampon and fall
•Tumor •Pulses magnus
Pulse is big

Peripheral Vascular System Rise and fall is rapid: pulsus magnus

What pulses? et celer

Causes: aortic insufficiency
Any artery that can be pressed
against the bone and hear the surface •Pulsus parvus
Small pulse
of the body
Pulsus parvus et tardus
E.g.
Plateau pulse
•Radial
•Popliteal
•Femoral Peripheral Vascular System
•Carotid Pulses
•Brachial Abnormal rhythm
•Pulsus regularis
Peripheral Vascular System •Pulsus irregularis
Factors that affect the pulse
Normal – 60 – 100 bpm
Age Musculoskeletal System
Size of patient Temporomandibular joint
Emotions Inspection and palpation
Physical activity •Inspect for swelling and redness
Sex – increase in female
•Palpate for clicking
Peripheral Vascular System
•Range of motion
Pulses Opening and closing
Compare both sides – a must Protrusion and retraction
Determine quality lateral

•Size of fullness – height of pulse

•Type of wave Musculoskeletal System
Upstroke Shoulder
Downstroke Inspection
Peak •Shoulder and shoulder girdle
•Rhythm – equidistant •Scapula
•Tension •Note: swelling, deformity or muscle
atrophy or fasciculations
•Vessel wall
Palpation
•Top of the shoulder
Peripheral Vascular System
•Lateral aspect of the shoulder
Pulses •Anterior shoulder
Abnormal rate •Landmarks: acromion,
•Pulses frequens acromioclavicular joint, coracoid
Increase pulse rate process
Causes: Graves; hyperthyroidism •ROM: flexion, extension, abduction,
•Pulsus rarus adduction, internal and external
Decrease pulse rate rotation
 19

•ROM: flexion, extension, abduction,

Musculoskeletal System adduction, internal and external
Elbow rotation
Inspection and palpation •Tests
Anvil test – (+) pain  early disease
•Inspect contours of the elbow
of hip joint
•Nodules and swelling Thomas sign of lordosis

•Palpate olecranon process and Trendelenburg’s sign – sagging of

epicondyles unsupported buttock
Tenderness in lateral epicondyles – •Fractures
tennis elbow Posterior and anterior hip dislocation

In medial epicondyles – pitcher’s or Musculoskeletal System

golfer’s elbow
•ROM: flexion and extension; pronation Knee
Inspection
and supination
•Deformities •Deformities, swelling, atrophy of
muscle
Cubitus valgus – carrying angle above

10 degree •Note for position of patella

Cubitus varus – carrying angle below •Genu valgum, genu varum, genu
10 degree recurvatum
•ROM: flexion and extension
Musculoskeletal System •Bulge sign – (+) fluid within knee joint
Wrist •Tests (next slide)
Inspection and palpation Musculoskeletal System
•Swelling, tenderness, deformities •Tests
Abduction stress test – (+) partial tear
•Carpal tunnel syndrome – median
nerve of the medial collateral ligament
Adduction stress test – (+) partial tear
Tests: Tinel’s sign and hyperflexion
test; Phalen’s test of the lateral collateral ligament
Anterior drawer sign – (+) tear in the
Musculoskeletal System
ACL
Hand
Lachman test – ACL tear
Inspection and palpation –
Posterior drawer sign – (+) isolated
deformities, abscess, nodes
PCL tears
Common deformities
McMurray test – (+) medial meniscus
•Ulnar drift / deviation
and lateral meniscus tear
•Clawhand deformity – median nerve
injury
Musculoskeletal System
•Carpal spasm / obstetrician’s hand –
hypocalcemic tetany Ankle and foot
•Wrist drop – radial nerve palsy Ankle joint – ROM; pitting edema;
•Dupuytren’s contracture – contraction joint swelling
of middle finger Foot
•Heberden’s nodes – distal phalanx, •Inspection
osteoarthritis Deformities, nodules, swelling,
•Haygarth’s nodes – proximal, calluses or corns
rheumatoid arthritis •Palpation
Musculoskeletal System Achilles tendon, metatarsophalangeal

Hip and lower extremities Musculoskeletal System

Inspection
•Measurement of leg length – ASIS to
tip of medial malleolus
•Abnormalities of gait; list to one side;
asymmetry of buttocks; lateral tilting
of the pelvis
•Ankle and foot deformities
Talipes calcaneovalgus – eversion and
dorsiflexion of foot
Talipes equinovarus – club foot
Pes cavus – high-arched foot
 20

Pes palnus – flat foot Ask the patient to lean to both sides
Hallux valgus – lateral deviation of the as far away as possible
great toe •Pain or tenderness especially with
Ram’s horn nail – overgrowth of radiation to the leg warrants careful
toenail neurologic testing for possible cord or
Bunion nerve root compression
Podagra – inflammation of 1st MTP Neurological Examination
joint – gout
Musculoskeletal System
Test for cerebral function
The spine Test for cerebellar function
Inspect the patient’s posture Test for cranial nerves
Assess erect position of the head Test for motor system
Neck stiffness signals arthritis,
muscle strain Test for sensory system
Lateral deviation of the head suggest Test for reflexes
torticollis from contraction of the Cerebral Function
sternocleidomastoid muscle How patient is able to communicate
Musculoskeletal System Intellectual performance
Recent and remote memory
Spine
Drape the patient to expose the •What did you eat this breakfast?
entire back •When is you birthday?
Patient should be standing upright Capacity to calculate
Inspect from the sides to evaluate the •100 minus 7 ……
spinal curvature •7 x 7 x 7 …..
Musculoskeletal System Orientation as to the 3ps
Palpate the spinous processes of Cerebral Function
each vertebra Intellectual performance
Abstract reasoning
Tenderness suggests fracture,
dislocation, underlying infection, •Strike while the iron is hot?
General information
arthritis
Similarities and differences

Musculoskeletal System •Apple, banana, guava

•Ball, moon, coin
Flexion: ask the patient to bend
General behavior and mood
forward to touch the toes dresses
Deformity of the thorax on forward
bending in scoliosis Cerebral Function
Musculoskeletal System
Specific cerebral function test
Extension: place your hand on the
Cortical sensory interpretation
post superior iliac spine with fingers
pointing toward the midline, ask the •Patient recognizes or identifies
patient to bend backward as far as familiar objects in any special senses
possible •Visual, auditory and tactile agnosia
Decreased spinal mobility in Cortical motor interpretation

osteoarthritis and ankylosing •Apraxia – inability to carry out

spondylitis purposive or skilled movements in the
absence of paralysis, motor and
sensory impairment
Musculoskeletal System Cerebral Function
Lateral bending Test for language or speech
Aphasia – impairment of
Stabilizethe pelvis by placing your
hand on the patients hip understanding or the use of the
language
 21

•Brocas motor aphasia Cerebellar system for rhythmic

Anterior branch of middle cerebral
artery
Telegraphic speech
Can get a lot of information across
with few words and with use of fingers
•Wernikes sensory aphasia
Posterior branch of MCA
Comprehension problem
Talks excessively without any sense
movement and steady posture
Vestibular system for balance
Sensory system for position sense
Cerebellar System
Tests
Finger to nose test
Figure of 8
Rapid alternative movement

•Global aphasia
•Adiadochokinesia – inability to
perform this test
Both sensory and motor
Walk in tandem fashion
Cannot express and understand
Point to point or heel to shin test
Cerebral Function
Coordination
Other disorders of speech Rapid alternating movements
Cerebellar speech disturbance
•Jerky, scanning; due to incoordination Dysdiadochokinesis:
of the muscles
Rhythm disturbance in speech
•one movt cant be followed quickly by
its opposite and movements are slow,
•Poorly coordinated, irregular speech irregular and clumsy
with unnatural separation of syllables
Parkinson’s or basal ganglia disease
•Seen in cerebellar disease
•Monotonous, weak and barely a
whisper Point to point movement
Cerebral Function Dysmetria:

Other disorders of speech •finger may initially overshoot its mark

but finally reaches it fairly well
Diffuse brain disease
•Difficulty in pronunciation of
•In cerebellar disease
polysyllabic words
Athetosis
•Impaired coordination of tongue Gait
muscles Walk across the room
Nervous individual Walk heel to toe
Nasal speech Ataxia
•Gait that lacks in coordination, with
Cerebellar System reeling and instability
Function for synergy, coordination •May be due to cerebellar disease, loss
and balance of position sense, intoxication
Findings
Dystaxia Romberg test
•Difficulty in controlling voluntary Test for position sense
movements Patient stands with feet together
Dysarthria eyes open then close eyes for 20-30 s
•Slurred speech due to impaired In ataxia due to position sense,
articulation patient stands fairly well with eyes
Hypotonia open but loses balance when eyes are
•Rag-doll posture, floppiness or loose closed
jointed appearance In cerebellar ataxia, patient has
Coordination difficulty standing when standing
Coordination of muscle movt whether eyes are open or closed
requires that 4 areas of the nervous
system function in an integrated way Motor System
Motor system, for muscle strength Grade of motor strength
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Draw stick figure and put grading Presence of incoordination

5/5 normal with full resistance Errors in rate, force, direction, and
4/5 raise extremity with slight range of motion
resistance
3/5 can only be raised against Tests for gait
gravity Tests for presence of involuntary
2/5 gross movement but not movements
against gravity Sensory System
1/5 flicker of movement Patient’s eyes are closed
0/5 no movement
Primary form of sensation
Motor System
Superficial
Status of motor system •Superficial touch
6 parts •Superficial pain
•Muscle strength •Superficial temperature
•Inspection of muscle substance Deep

•Testing for muscle tone •Vibration sense

Pallesthesia – sensibility to vibration
•Presence of incoordination Pallhyposthesia – diminish vibration
•Test for gait sense
•Test for presence of involuntary Pallanesthesia – absence

movements •Position sense

Motor System The sensory system
Tests for muscle strength Pain and temperature (spinothalamic
Deltoid muscles – arm forward, let tract
patient resist downward pressure of Position and vibration
the examiner sense(posterior columns)
Shoulder girdle – arms forward, palms
upward, maintain position for a few Light touch (both pathways)
minutes
Hand grip – gripping
Pain
Extensor pollicis and anterior tibialis – Use a sharp pin
walk on toes Ask the patient: “is this sharp or
Motor System dull”,
Tests for muscle strength “does this feel the same as this?”
Gastrocnemius – walk on heels Analgesia(absence of pain)
Quadriceps femoris muscle – rise Temperature
from squatting position
Motor strength, sensory and
Omitted if pain sensation is normal
cerebellar function – stand on one foot, Use 2 tubes with hot and cold water
jump in place Ask the patient to identify whether
Abdominal muscles – rise from sitting
its hot or cold
position without support Light touch
Motor System
Use cotton, touch the skin lightly
Inspection for muscle substances avoiding pressure
Atrophy
Fasciculation
Calloused skin is relatively
insensitive
Anesthesia is absence of touch
Testing for muscle tone sensation
Hypertonic / spasticity Position sense
Isotonic
Hypotonic / flaccidity Grasp the patient’s big toe
Motor System
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Demonstrate “up” and down” then Chaddock’s sign – scratch lateral

with the patient’s eyes closed, ask for malleolus of ankle
a response or “up” or “down” Motor System
Sensory System Disease
Hemiplegia – paralysis of ½ of the
Cortical and discriminatory forms of
sensation body
Paraplegia – lower half of the body
Stereognosis – eyes closed, place
Quadriplegia – all four extremities
object on patient’s hand  identify, if
Monoplegia – one extremity
not astereognosis
Diplegia – like parts usually lower
Number identification –
extremities
agraphesthesia
Cranial Nerves
Point localization
Texture discrimination CN I – olfactory nerve
Deep Tendon Reflexes (DTR) Sense of smell
Abnormalities
General principles for eliciting deep
reflexes •Anosmia – absence
Strike with a sudden blow •Hyperosmia
Desirable point for blow – tendon •Parosmia – perverted sense of smell
Muscle should be slightly stretched •Cacosmia – smelling of unpleasant
by the position of the limb or by odors due to decomposition of tissue;
pressure of the tendon expiration
Limb should be relaxed;
•Olfactory hallucination
reinforcement may be used
Cranial Nerves
Deep Tendon Reflexes (DTR)
CN II – optic nerve
Grading Vision
Grade 0 absent
Test for visual acuity
Grade 1 + hypoactive
•Snellen’s chart
Grade 2 ++ physiological
•20/200 – patient can read print at 20
Grade 3 +++
feet when a normal eye can read at
hyperactive, brisk
200 ft
Grade 4 ++++ markedly
Ophthalmoscopic exam
hyperactive with
•Orange red-reflex
transient clonus
•Optic disc
Grade 5 +++++ markedly
•Retinal vessels
hyperactive with
•Other retinal parts
sustain clonus
•Macula
Deep Tendon Reflexes (DTR)
Superficial reflexes Cranial Nerves
Upper abdominal skin reflex Test for visual fields
Midabdominal skin reflex •Blind right eye – right optic nerve
Lower abdominal skin reflex •Bitemporal hemianopsia – optic
Cremasteric reflex chiasma
Superficial anal reflex •Left homonymous hemianopsia – right
optic tract
Deep Tendon Reflexes (DTR) •Homonymous left upper quadrantic –
Abnormal reflexes in pyramidal tract right parietal lesion of optic radiation
disease Cranial Nerves
Babinski’s sign Color blindness
•Dorsiflexion of great toe •Use Ishihara’s chart
•Fanning of all toes •Scotoma – blind spots on visual fields
•Dorsiflexion of ankle •Achromatism – colorless
•Flexion of hip and knee •Dichromatism – 2 colors only
Oppenheim’s sign – knuckles at shin •Monochromatism – 1 color only
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•Amblyopia – total blindness Disease

•Hemeralopia – day blindness •Bell’s palsy
•Nyctalopia – night blindness Cranial Nerves

Cranial Nerves
CN VIII – auditory / acoustic
Hearing and balance
CN III – oculomotor Cochlea – deafness and tinnitus
For puppilary constriction
Vestibular – vertigo
Most extraocular movements
•Levator palpebral muscle – eyelid
•Caloric test
Cranial Nerves
movement
•Medial rectus – towards nasal CN IX – glossopharyngeal
•Superior rectus – upward Motor
•Inferior rectus – downward •pharynx; gag reflex
•Inferior oblique – upward, outward Sensory
•Superior oblique – downward, outward •Tastes – posterior 1/3 of tongue
Diseases Cranial Nerves
•Oculomotor nerve palsy
•Ptosis CN X – vagus
Motor
•External ophthalmoplegia
Cranial Nerves •Palate, pharynx, larynx
Sensory
CN IV – trochlear
Innervates superior oblique muscle of
•Pharynx and larynx
Tests for
the eye
Downward and outward •Gag reflex; swallowing; voice
Disease
•Divergent squint
Cranial Nerves
Cranial Nerves
CN V – trigeminal CN XI – spinal accessory
Motor – temporal and masseter Innervates sternomastoid muscle –
muscles (jaw clenching); lateral lateral movement of neck; upper
movement of jaw; mastication portion of trapezius
Sensory – ophthalmic (corneal reflex); Tests – lifting of shoulder

maxillary and mandibular Cranial Nerves

Diseases CN XII – hypoglossal
•Trigeminal nerve neuralgia Innervates tongue movement

•Tic doloreaux – severe headache

secondary to CN V palsy Summary
Cranial Nerves Sensory
CN VI – abducens •CN I, II and VIII
Motor
Innervates lateral rectus muscles of
the eye – lateral deviation of the eye •CN III, IV, VI, XI and XII
Disease Both

•Paralytic strabismus or convergent •CN V, CN VII, CN IX and CN X

Mental Status Examination
strabismus – cross-eyed
Cranial Nerves Presentation
Appearance
CN VII – facial Activity
Motor
Attitude toward
•Facial movement examiner/examination
•Closing of mouth, eyes Attention
•Symmetry or asymmetrical Orientation
Sensory Concentration
•Tastes Memory
 25

Speech
Thought content and process
Mood – feeling tone of the subject
observed
Affect – outward behavior
Perceptions
Intelligence
Insight
Judgment