Physical Examination Checklist by hcj

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									                         Physical Examination Checklist                               Eyes
                                     POM I                                            1) Check for visual acuity using a Snellen eye card or eye chart in the exam
                                                                                           room
General                                                                               2) Assess visual fields (Bates, p 145-146)
1) Wash hands before beginning examination—in the CLASS center, you                        a) Ask the patient to look with both eyes into your eyes
     MUST use the hand wipes that are located in or near the sinks (remember               b) While you return the patient’s gaze, place your hands about 2 feet
     that they are not plumbed)                                                                 apart, lateral to the patient’s ears.
2) Display a professional demeanor towards the patient during the exam                     c) Instruct the patient to point to your fingers as soon as they are seen
     a) Introduce yourself as a medical student                                            d) Then slowly move the wiggling fingers of both your hands along the
     b) Use the patient’s last name                                                             imaginary bowl and towards the line of gaze until the patient
     c) Dress professionally in white coat                                                      identifies them
3) Appropriate interaction with the patient—sensitivity to privacy, comfort                e) Repeat this pattern in the upper and lower temporal quadrants
     and dignity                                                                      3) Inspect external eye
4) Drape the patient appropriately during each segment of the exam                         a) Stand in front of the patient and survey the eyes for position and
5) Use proper sequencing of the examiniation and proper pacing                                  alignment with each other
6) All palpation and auscultation must be done on bare skin                                b) Inspect the eyebrows—quantity and distribution
                                                                                           c) Inspect the eyelids
Vital Signs                                                                                d) Inspect the region of the lacrimal glands
1) Take the BP in one arm (NOTE THAT YOU NEED NOT TAKE THE BP                              e) Inspect the conjunctiva and sclera
      IN BOTH ARMS UNLESS SPECIFICALLY INSTRUCTED TO DO SO)                                     i)     Ask the patient to look up as you depress both lower lids with
      a) Choose a cuff of appropriate size for the patient                                             your thumbs (Bates p 147), exposing sclera and conjunctiva
      b) Center the bladder of the cuff over the brachial artery                           f)   Inspect the cornea and lens, using a penlight shined oblique across the
            i)     Identify location of the brachial artery by palpation                        eye
            ii) Lower border of the cuff should be about 2.5 cm above the                  g) Inspect each iris
                   antecubital crease                                                      h) Inspect the pupils for size, shape and symmetry
            iii) Secure the cuff snugly                                               4) Assess pupillary reflexes (turn out the room light if necessary)
      c) Position the patient’s arm so that it is slightly flexed at the elbow and         a) To light—ask the patient to look into the distance and shine a bright
            at raised to heart level                                                            light obliquely into each pupil in turn.
      d) Estimate the systolic pressure by palpation of the radial artery (Bates,               i)     Note direct reaction—pupillary constriction in the same eye
            pp 76)                                                                              ii) Note indirect reaction—pupillary constriction in the opposite
            i)     Wait 15 seconds after deflating the cuff before auscultating the                    eye
                   BP                                                                      b) Assess accomodation – ask the patient to look alternately at a pencil
      e) Take the BP, using auscultation                                                        held 10 cm from his eye and into the distance directly behind it.
            i)     Listen with the stethoscope over the brachial artery                         Observe for pupillary constriction with near effort
            ii) Inflate cuff rapidly to at least 150 mm Hg                            5) Assess Extraocular movements
            iii) Deflate at rate of 2-3 mm Hg per second                                   a) From 2 feet in front of the patient, shine a light into the patient’s eyes
            iv) Note systolic and diastolic pressures                                           and ask the patient to look at it. Inspect the reflections in the corneas,
2) Take the radial pulse for 15 secs if the rhythm is regular (60 secs if rate is               which should be visible slightly nasal to the center of the pupils
      slow or fast)                                                                        b) Ask the patient to follow your finger or pencil as you sweep through
      a) Use the pads of index and middle fingers                                               the six cardinal directions of gaze
      b) Compress the radial artery until a maximal pulsation is detected                       i)     To the patient’s extreme right
3) Count the respiratory rate for 1 minute                                                      ii) To the right and upward
      a) Watch movement of the chest wall                                                       iii) To the right and downwards
                                                                                                iv) Without pausing in the middle to the extreme left
Head                                                                                            v) To the left and upwards
1) Inspect the skull, scalp, hair by parting the hair in at least three places                  vi) To the left and downwards
2) Inspect the face                                                                   6) Ophthalmoscopic exam (See ―Steps for using the ophthalmoscope‖ and
                                                                                           ―Steps for examining the opic disc and the retina‖ in Bates pp 152 and 153
Ears
1) Inspect the external ear—auricle or pinna                                          Nose
2) Use the otoscope to inspect the internal auditory canal and the eardrum and        1) Inspect the anterior and inferior surfaces of the nose
     middle ear                                                                            a) Push gently on the tip of the nose to widen the nostrils
     a) Select the largest available speculum for the otoscope                             b) Use a penlight to view the nasal vestibule
     b) Position the patient’s head to allow best insertion of the otoscope           2) Inspect the inside of the nose using an otoscope with the largest available
     c) Pull the auricle gently upwards and backwards to straighten the canal              speculum
     d) Hold the otoscope between thumb and fingers (see Bates, p 156)                     a) Tilt the patient’s head back slightly and insert the speculum (Bates p
     e) Insert the speculum gently into the ear canal                                           159)
          i)    Identify the eardrum                                                       b) Inspect the inf and mid turbinates and nasal septum
          ii) Identify the cone of light                                              3) Palpate the frontal and maxillary sinuses for tenderness (Bates p 160
          iii) Identify the malleus
3) Assess hearing                                                                     Mouth and Pharynx
     a) Ask the patient to occlude one ear with a finger and then the examiner        1) Inspect the lips
          whispers softly from 1 or 2 feet away toward the unoccluded ear             2) Inspect the oral mucosa using a good light and a tongue blade
          i)    Choose short words (see Bates p 157)                                  3) Inspect the gums and teeth
     b) Check air and bone conduction                                                 4) Inspect the hard palate
          i)    Weber test                                                            5) Inspect the tongue and floor of the mouth
                (1) place the base of the lightly vibrating tuning fork firmly on         a) Ask the patient to put out his tongue
                      top of the patient’s head                                           b) Ask the patient to put his tongue on the roof of his mouth
                (2) Ask where the patient hears it                                    6) Inspect the pharynx
          ii) Rinne test                                                                  a) Tongue in normal position, ask the patient to say ―ah;‖ but if pharynx
                (1) Place the base of the lightly vibrating tuning fork on the                  not well visualized use a tongue blade
                      mastoid bone                                                        b) Inspect the soft palate, tonsils and pharynx
                (2) When the patient can no longer hear the sound, quickly
                      place the fork close to the ear canal and ask whether sound
                      can still be heard
Neck                                                                               Posterior thorax – lung exam
1) Assess neck ROM (Bates p 504) by asking the patient to perform the              1) Examination techniques MUST be performed on bare skin
     following maneuvers:                                                          2) Palpate for tactile fremitus
     a) Flexion: touch the chin to the chest                                            a) Use either the ball of your palm or the ulnar surface of your hand for
     b) Extension: look up at the ceiling                                                      palpation
     c) Rotation: turn the head to each side, looking directly over the                 b) Ask the patient to repeat the words ―ninety-nine‖
           shoulder                                                                     c) You may palpate one side at a time or use both hands simultaneously
     d) Lateral bending: tilt the head, touching each ear to the corresponding                 to compare sides
           shoulder                                                                     d) Palpate in four locations on both sides of the chest and compare
2) Palpate the lymph nodes (See Bates p 163-164 for specific technique)                        (Bates p 223)
3) Inspect trachea and feel for any deviation by placing a finger along one side   3) Percuss
     of the trachea, noting the space, and compare with the opposite side.              a) Ask the patient to keep both arms crossed in front of the chest
4) Inspect the thyroid gland                                                            b) Press the DIP joint of the left middle finger firmly against the chest
     a) Tip the patient’s head back                                                            wall, avoiding contact with other fingers (Bates p 223)
     b) Locate the cricoid cartilage and inspect the region below for the               c) Strike this DIP joint with the tip of the right middle finger, swinging
           thyroid                                                                             from the wrist
5) Palpate the thyroid gland (See Bates p 167) – may be performed from                  d) Percuss in seven areas on each side (Bates p 225)
     either an anterior or posterior approach                                      4) Auscultate for breath sounds
     a) Flex the neck slightly forward                                                  a) Instruct the patient to breathe deeply through an open mouth
     b) Place finger of both hands on the patient’s neck with index fingers             b) Listen with the diaphragm of the stethoscope in the same seven areas
           just below the cricoid cartilage                                                    in which you percussed
     c) Feel for the thyroid isthmus
     d) Displace the trachea to the right with the fingers of your left hand;
           palpate with R fingers for the right lobe of the thyroid
     e) Reverse the use of the fingers to feel the left lobe of the thyroid

Cranial Nerves (Bates, pp 567-571)                                                 Anterior thorax—lung exam
1) Olfactory (CN I) – usually not tested                                           1) Examination techniques MUST be performed on bare skin
2) Optic (CN II) – you have already tested for visual fields. Visual acuity can    2) The patient may be either sitting or supine. The drape should be adjusted
     be tested with an eye chart                                                        to allow exposure of the area being examined
3) Oculomotor (CN III) – you have already tested pupillary constriction and        3) Inspect the shape of the patient’s chest and movement of the chest wall
     the EOM controlled by this nerve                                                   (NB when moving from the post chest when you have completed
4) Trochlear (CN IV) – you have already tested for downward, inward                     auscultating, it is acceptable to auscultate the ant chest before inspection or
     movement of the eye                                                                palpation)
5) Trigeminal (CN V)                                                               4) Palpate for tactile fremitus
     a) While palpating the temporal and masseter muscles in turn, ask the              a) Use the ball of the palm or ulnar surface of the hand to palpate in 3
           patient to clench her teeth                                                        areas on each side of the anterior chest (Bates p 231)
     b) Check the forehead, cheeks and jaw on each side for pain and light         5) Percuss the anterior and lateral chest, comparing sides, in 6 areas on each
           touch                                                                        side (Bates p 231)
     c) Check the corneal reflex with a wisp of cotton                                  a) Displace a woman breast with your left hand or ask her to move her
6) Abducens (CN VI) – you have already tested for lateral deviation of the eye                breast for you
     with your extra-ocular movement maneuvers                                     6) Auscultate the anterior chest, comparing sides in the 6 areas on each side
7) Facial (CN VII)                                                                      where you percussed.
     a) Ask the patient to raise both eyebrows
     b) Frown
     c) Close both eyes tightly
     d) Show both upper and lower teeth
     e) Smile
     f)    Puff out both cheeks                                                    Axillae – examination of the axillae can be performed at the present juncture. It
8) Acoustic (CN VIII) – you have already assessed hearing and performed            is sometimes performed at the end of the exam, or as part of a breast exam in a
     Weber and Rinne maneuvers                                                     female
9) Glossopharyngeal (CN IX) – tested together with CN X                             1) Inspect the skin of each axilla (Bates, pp 310-311)
10) Vagus (CN X)                                                                    2) Palpation L axilla
     a) Ask the patient to say ―ah‖ and watch the movements of the soft                  a) Ask the patient to relax with the L arm down
           palate and pharynx                                                            b) Support the L wrist or hand with your left hand
     b) Check gag reflex with a tongue blade                                             c) Cup together the fingers of your right hand and reach as high as you
11) Spinal Accessory (CN XI)                                                                  can toward the apex of the axilla
     a) Ask the patient to shrug both shoulders against your hands                       d) Press your fingers toward the chest wall and slide down to feel
     b) Ask the patient to turn her head to each side against your hand                       potential LN
12) Hypoglossal (CN XII)                                                                 e) To palpate for lateral group of LN, feel along the upper humerus
     a) Ask the patient to protrude her tongue                                     3) Palpation R axilla – reverse your hands and follow the steps above
     b) Ask the patient to push the tongue against the inside of each cheek

Posterior thorax
1) The patient should be sitting with the posterior thorax exposed.
2) The doctor assumes a midline position behind the patient
3) Inspect the cervical, thoracic and upper lumbar spine (you will check for
     ROM of the thoracic and lumbar spine towards the end of the complete
     physical when the patient is standing up)
4) Palpate the spinous processes of each vertebra for tenderness with your
     thumb or by thumping with the ulnar surface of your fist (Bates p 503)
5) Assess for costovertebral tenderness
     a) Place the ball of one hand in the costovertebral angle and strike it
            with the ulnar surface of your fist (Bates p 344)
6) Inspect the shape and movement of the chest wall
     a) Place your thumbs at the level of the 10th ribs with your fingers
            loosely grasping the rib cage and gently slide them medially.
     b) Ask the patient to inhale deeply and observe whether your thumbs
            move apart symmetrically
Cardiovascular                                                                             b)   Press inward towards the spleen with your right hand, beginning at
1) The patient should be supine with the upper body raised by elevated the                      least 3 finger breadths below the L costal margin
     table to about 30°. The drape should be arranged to expose the precordium.           c) Ask the patient to take in deep breaths, trying to feel the spleen tip as
     EXAM TECHNIQUES MUST BE PERFORMED ON BARE SKIN.                                            it comes down to meet your fingertips.
2) The examiner should stand tat the patient’s right side                             13) Palpates for aorta by pressing deeply with one hand on each side of the
3) Inspect the precordium                                                                 aorta (Bates, p 344)
     a) look for apical impulse                                                       14) Palpate for the superficial inguinal lymph nodes (Bates, p 452)
     b) look for any other movements                                                  15) Palpate for both femoral artery pulses
4) Palpate for precordium                                                                 a) Press deeply below the inguinal ligament (Bates, p 452)
     a) Use the palmar surfaces of several fingers to locate the PMI—can
           switch to one fingertip when located                                       Upper extremity—MSK and Partial Neurological (these maneuvers must be
           i)     Displace a woman’s breast upward or laterally, or ask her to do     repeated on both upper extremities
                  this for you                                                        1) Inspect the hands, including each finger, its skin and joints, and nails
           ii) Note location of PMI, amplitude and duration                                a) Palpate any abnormal joints
     b) Palpate for the RV impulse along the lower left sternal border                2) Inspect the wrist
5) Auscultation of the heart                                                          3) Palpate the distal radius and snuff box; palpate the distal ulna
     a) Listen to the heart with the diaphragm of your stethoscope in the R           4) Palpate the radial pulse on the flexor surface of the wrist, laterally
           2nd ICS, L 2nd ICS, L 3rd or 4th ICS, and the lower left sternal border         a) Compare the pulses in both arms
           (5th ICS) and at the apex (may also start at the apex and proceed to the   5) Check ROM of the fingers
           base of the heart)                                                              a) Ask the patient to make a tight fist with each hand
     b) Listen to the heart with the bell of your stethoscope in the same five             b) Extend and spread the fingers
           listening areas                                                                 c) Ask the patient to spread the fingers apart and back together
6) Inspect the neck for jugular venous pulsations                                          d) Ask the patient to move the thumb across the palm and touch the base
     a) Turn the patient’s head slightly away from the side you are inspecting                   of the 5th finger, and then back across the palm and away from the
           (Bates p 267)                                                                         fingers
     b) Raise or lower the bed until you identify the pulsations                           e) Have the patient touch the thumb to each of the other fingertips
     c) Identify the highest point of pulsation                                       6) Check ROM of the wrist (Bates p 499)
           i)     Meausure the vertical distance of this point above the sternal           a) Flexion
                  angle                                                                    b) Extension
7) Inspect the neck for carotid pulsations                                                 c) Ulnar and radial deviation
8) Palpate the carotid pulsation                                                      7) Check ROM of the elbow (Bates p 497)
     a) Place your left index and middle fingers (or thumb) on the right                   a) Flexion and extension: ask the patient to bend and straighten the
           carotid artery                                                                        elbow
           i)     Note amplitude and contour of the pulse wave                             b) Pronation and supination: with arms at his side, and elbows flexed,
           ii) Never palpate both carotids simultaneously                                        ask the patient to turn the palms up and then down
     b) Use your right fingers or thumb to palpate the left carotid artery            8) Palpate for epitrochlear lymph nodes (Bates p 451)
9) Auscultate the carotid arteries for bruits with the bell of the stethoscope             a) Flex the elbow to 90°
     a) Ask the patient to take a deep breath and hold it to eliminate breath              b) Palpate in the groove between the biceps and triceps
           sounds                                                                     9) Inspect the shoulder (Bates, p 492)
                                                                                      10) Palpate the shoulder (Bates, p 493)
Abdomen                                                                                    a) Locate the acromion process and the acromioclavicular joint
1) The patient should be in a supine position with arms at side or folded                  b) Locate the greater tubercle of the humerus
    across the chest                                                                       c) Locate the coracoid process of the scapula
2) The drapes should be arranged to expose the abdoment from above the                11) Check ROM of the shoulder (Bates, p 493)
    xyphoid process to the symphysis pubis.                                                a) Watch for smooth, fluid movement as you stand in front of the patient
3) Approach the patient from his right side                                                      and ask:
4) Inspect the abdomen                                                                           i)     Raise the arms to shoulder level (abduct) with palms facing
5) Ausculate the abdomen as the next step in the exam after inspection                                  down
    a) Place the diaphragm of the stethoscope gently on the abdomen                              ii) Raise the arms to a vertical position above the head with the
    b) Listen for bowel sounds                                                                          palms facing each other
         i)     Listening in one spot is sufficient                                              iii) Place both hands behind the neck with elbows out to the side
    c) Listen for an aortic bruit on the midline just above the naval                                   (external rotation and abduction)
6) Percuss the abdomen lightly in four quadrants                                                 iv) Place both hands behind the small of the back (internal rotation
7) Percuss for liver dullness                                                                           and adduction)
    a) Define the lower edge of liver dullness in the mid-clavicular line,            12) Test Muscle strength in the upper extremity (Bates pp 574-575). You must
         starting at a level below the umbilicus                                           compare sides
    b) Define the upper edge of liver dullness in MCL, starting in the area of             a) Test grip—ask the patient to squeeze two of your fingers as hard as
         lung resonance                                                                          possible and not let them go
         i)     Gently displace a woman’s breast as necessary                              b) Test finger abduction—position the patient’s hand with palms down
    c) Measure in centimeters with a ruler the vertical span of liver dullness                   and fingers spread. Try to force the fingers together
         in the MCL                                                                        c) Test opposition of the thumb—the patient should try to touch the little
8) Percuss for splenic dullness                                                                  finger with the thumb against your resistance
    a) Percuss along the L lower chest wall between the lung resonance                     d) Test extension of the wrist by asking the patient to make a fist and
         above and the costal margin moving laterally (Bates p 341)                              resist you pulling it down
         i)     Ask the patient to take a deep breath and percuss again in this            e) Test flexion and extension of the elbow by having the patient pull and
                area                                                                             push against your hand
9) Palpate the abdomen lightly in four quadrants and in the suprapubic and
    epigastric areas
    a) Use a gentle, light dipping motion (Bates p 335)
10) Palpate the abdomen deeply in all four quadrants
    a) Use a firmer dipping motion
11) Palpate for the liver edge
    a) Place your R hand on the right abdomen lateral to the rectus muscle,
         beginning more than 3 fingerbreadths below the costal margin
    b) Ask the patient to take in a deep breath
    c) Palpate upwards trying to feel the descending liver edge, using a
         rocking motion
         i)     May also use the ―hooking technique‖ described in Bates p 340
12) Palpate for a spleen tip
    a) Reach over and around the patient with your left hand to support and
         press forward the lower left rib cage
Lower extremity—MSK and Partial Neurological (these maneuvers must be               Neurological – some parts of the neurological exam have been woven into exam
repeated on both lower extremities                                                  of the head and neck and extremities (i.e. Cranial Nerve exam and motor testing).
1) The patient may be sitting or lying down and draped so that the external         The remaining components of the neurological exam are covered here
     genitalia are covered with the legs fully exposed during the exam              1) Reflexes (Bates, p 588-591)
2) Inspect both feet and ankle—compare sides                                              a) Biceps reflex (C5, C6) — with patient’s arm partially flexed at the
3) Palpate the feet and ankles (Bates, p 517)                                                  elbow and palm down, place your thumb or finger firmly on the
     a) Assess for pedal edema—press firmly with your thumb over the                           biceps tendon and strike with reflex hammer
           dorsum of the foot, behind each medial malleolus and over the shins            b) Triceps reflex (C6, C7) – flex the patient’s arm at the elbow with
           (Bates, p 455)                                                                      palm towards the body and pull it across the chest. Strike the triceps
     b) Palpate the anterior aspect of each ankle joint                                        tendon above the elbow
     c) Palpate the heel, especially the post and inf calcaneus                           c) Knee (Patellar) reflex (L2, L3, L4) – patient may be either sitting or
     d) Palpate the MTP joints                                                                 supine with knee flexed. Tap the patellar tendon just below the
     e) Palpate the heads of the five metatarsals                                              patella
4) Palpate for the peripheral pulses of the legs                                          d) Ankle (Achilles) reflex (S1) – dorsiflex the foot at the ankle and
     a) Dorsalis pedis—feel the dorsum of the foot just lateral to the extensor                strike the Achilles tendon
           tendon of the great toe                                                        e) Plantar (Babinski) response (L5, S1) – with a key or the tip of the
     b) Posterior tibial—feel below the medial malleolus of the ankle                          shaft of a reflex hammer, stroke the lateral aspect of the sole from the
5) Check ROM of the ankle (Bates, p 518)                                                       heel to the ball of the foot, curving medially across the ball
     a) Dorsiflex and plantar flex the foot at the ankle                            2) Sensory (Bates, p 583-584)
     b) Invert and evert the foot                                                         a) Pain – Create a sharp from a broken tongue blade
     c) Flex the toes                                                                          i)    Compare symmetrical areas on the two sides of the body,
6) Inspect the knee for alignment and contours                                                       including arms, legs and trunk
7) Palpate the knee with the knee in flexion (Bates, p 511-513)                                ii) Compare the distal with the proximal areas of the extremities
     a) Identify the medial femoral condyle and the medial tibial plateau                      iii) Vary the pace of your testing and occasionally substitute the
     b) Identify the tibial tubercle                                                                 blunt end for the point, while asking ―Is this sharp or dull?‖ or
     c) Identify the lateral femoral condyle and lateral tibial plateau                              ―Does this feel the same as this?‖
     d) Identify the patellar tendon and ask the patient to extend the leg                b) Light touch – using a fine wisp of cotton, touch the skin lightly,
     e) Palpate the medial collateral and lateral collateral ligaments and                     avoiding pressure
           menisci                                                                             i)    Ask the patient to respond whenever a touch is felt.
     f)    Feel for swelling above and to the sides of the patella                             ii) Compare one area with another
     g) Check the prepatellar, anserine and popliteal bursae (Bates p 513)                c) Vibration – Use a low-pitched tuning fork (128 Hz)
8) Check ROM of the knee (Bates p 515)                                                         i)    Set the fork vibrating and place it firmly over a DIP of a finger
     a) Ask the patient to flex and extend the knee while sitting (or by asking                      and of the great toe
           the patient from a standing position to squat and then stand up again               ii) Ask what the patient feels
     b) Check internal and external rotation by asking the patient to rotate the               iii) If vibration sense is impaired, move to more proximal bony
           foot medially and laterally                                                               prominences
9) Inspect the hip by observing the patient’s gait at some time during the exam           d) Joint position sense
     (Bates p 506)                                                                             i)    Grasp the patient’s big toe, holding it by its sides and pull it
10) Palpate the surface landmarks of the hip                                                         away from the other toes so as to avoid friction.
     a) Anterior surface: locate the iliac crest, iliac tubercle and anterior                  ii) Demonstrate ―up‖ and ―down‖
           superior iliac spine                                                                iii) With patient’s eyes closed ask him to identify up and down
     b) Posterior surface: locate the posterior superior iliac spine, the greater                    movements
           trochanter and the ischial tuberosity                                               iv) Compare sides
11) Check ROM of the hip (Bates, p 509-510)                                                    v) Move more proximally if joint position is impaired
     a) Flexion—with the patient supine, ask him to bend each knee in turn                     vi) Test JPS in the UE by moving a finger joint
           up to the chest and pull it firmly against the abdomen                   3) Cerebellar/Coordination (Bates, p 578-580)
     b) Abduction—grasp the ankle and abduct the extended leg until you                   a) Rapid alternating movements
           feel the iliac spine move                                                           i)    UE – Show patient how to strike one hand on the thigh, first
     c) Adduction—hold one ankle and move the leg medially across the                                with the palm, then with the back of the hand. Have the patient
           body and over the opposite extremity                                                      repeat these alternating movements as rapidly as possible.
     d) Rotation—flex the leg to 90 at hip and knee; stabilize the thigh with                       Repeat with opposite hand
           one hand, grasp the ankle with the other and swing the lower leg,                         (1) OR Show the patient how to tap the distal joint of the
           medially and laterally                                                                           thumb with the tip of the index finger as rapidly as
12) Check muscle strength in the LE (Bates, p 576-578)                                                      possible. Have the patient perform the action. Check the
     a) Test flexion at the hip—place your hand on the patient’s thigh and                                  opposite hand
           asking the patient to raise the leg against your hand                               ii) LE – ask the patient to tap your hand as quickly as possible with
     b) Test adduction at the hips—place your hands firmly on the bed                                the ball of each foot in turn
           between the patient’s knees. Ask the patient to bring both legs                b) Point-to-point movements
           together                                                                            i)    UE – ask the patient to touch your index finger and then his
     c) Test abduction at the hips—place your hands firmly on the bed                                nose alternately several times. Move your finger about.
           outside the patient’s knees. Ask the patient to spread both legs                    ii) LE – Ask the patient to place one heel on the opposite knee and
           against your hands                                                                        then run it down the shin to the big toe. Repeat on the other
     d) Test extension at the hips—have the patient push the posterior thigh                         side
           down against your hand                                                   4) Gait
     e) Test extension at the knee—support the knee in flexion and ask the                a) Ask the patient to walk across the room, then turn and come back
           patient to straighten the leg against your hand                                b) Walk heel-to-toe in a straight line
     f)    Test flexion at the knee—place the patient’s leg so that the knee is           c) Walk on toes then on heels
           flexed with the foot resting on the bed. Tell the patient to keep the    5) Romberg Test
           foot down as you try to straighten the leg                                     a) The patient should first stand with feet together and eyes open and
     g) Test dorsiflexion and plantar flexion at the ankle—ask the patient to                  then close both eyes for 20-30 secs without support
           pull down and push down against your hand
                                                                                    Back
                                                                                    1) ROM (Bates, p 505)
                                                                                         a) Flexion – with patient standing, ask him to bend forward to touch the
                                                                                            toes
                                                                                         b) Extension – place your hand on the posterior superior iliac spine and
                                                                                            with your fingers pointing towards the midline, ask the patient to
                                                                                            bend backward as far as possible
                                                                                         c) Lateral bending – ask the patient to lean to both sides as far as
                                                                                            possible

								
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