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Description
Cardiovascular Examination refill
Document Sample
Clinical skills
2003-2004
Physical examination
Clinical skills module
Prepared by:
H.K.Al-Awadhi
S.H.Al-Darmaki
M.E.Al-Suwaidi
A.M.Al-Mazrooei
N.A.Ghalib
R.O.Hamoudi
Please Refer to Bates Physical Examination and History Taking for more
information..
Cardiovascular Examination:
Look profissonal
Greeting
o Hello
o I am …
o Can I examine you?
Remove your clothes, please
Ask the patient to sit on the bed
Inspection (describe):
o Not in pain
o Not distress
o Not sweating
o Normal/Abnormal hair distribution
o Presence of scars
o Presence of rashes
o Hands:
No sweating, scars, rash in the hands
Look for pallor inside the hand creases (if pale means low Hb)
Check the refill time in the nails
Look for cyanosis in the nail beds
If you find splinter hemorrhage in the nails, that may
indicate endocarditis
If you find pitting nails, that may indicate, psoriasis
Look for clubbing in the base of the nail beds
o Check the radial pulse
Check for rate, regularity, characteristics and volume
The volume might be small (thready) in dehydration
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o Check the blood pressure and the respiratory rate
In the exam tell the examiners that you want to do it, and they may
tell you not to do it so as to save time
In the face:
o Look for central cyanosis in:
The conjunctiva of the eyes
Ask the patient to look upwards while you pull the lower
lid downwards
Gum and tongue in the mouth
Pull the lower lip downwards to inspect the gum and aske
the patient to protrude his/her tongue to inspect it.
Let the patient lay down at a 45o by moving the bed
Check the carotid pulse:
o Start with the trachea at the suprasternal notch and then move laterally
until you reach the pulse of the carotid artery.
o You should check both sides, but don’t check them together so you don’t
press the carotid bodies and cause bradycardia
Whenever you have 2 sides check both and compare between the
2 for differences.
o Auscultate the carotid arteries for bruit, using the bell of the stethoscope.
Normally we should hear nothing
You should listen to the carotids by the bell of the stethesope
A bruit indicates stenosis
A stenosis may lead to embolism
Measure the JVP:
o Put a ruler, vertically, on the sternal notch and with another ruler that you
should move to the upper border of the jugular vein pulsation, read the
reading on the first vertical ruler (angle of louis)
o Measuring the JVP at the Rt. side is better because it is closed to the Rt.
heart
A trick for the exam:
Press the external jugular vein and say the JVP is normal.
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Then start checking the heart:
No midline scar:
o there was no bypass surgery
Feel the apex beat by you finger tips and put your hand flattened on the chest
wall. Then count with your other hand for 5 intercostal spaces, starting with your
small finger at the 2nd rib adjacent to the sternal angle
o When you want to feel the beat place your palm over the chest
o The sternal angle is adjacent to the 2nd rib.
o The apex beat is located in the left 5th intercostals space at the mid
clavicular line.
If you can’t find the apex beat in the exam, say: “I can’t find it but
I think it is here” and tell the examiners wehre.
Feel and listen to the pulse of the valves:
o with your palm feel at the parasternal side of the chest ( at the Lt. side of
it)
Feel for heave, thrill (abnormal pulsations) or a left.
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o At the apex beat site, also with your palm, feel for the apex beat.
o In the CVS examination you don’t palpate the chest for pain.
o After listening to the 4 valve areas say: I can here S1 and S2 (normal
findings).
o You should hear no S3 or S4 normally as well as no murmurs
o You should listen to the valves at the following locations:
Aortic valve: in the 2nd Rt. intercostal space (below the clavicle)
Pulmonary valve: in the 2nd Lt. intercostal space (below the
clavicle)
Hear you listen to the 1st and 2nd heart sound to detect any
splitting that would widen with respiration.
Tricuspid valve: in the Lt. 3rd intercostal space
Mitral valve and apex beat: in the 5th intercostal space.
To hear the mitral murmur clearer ask the patient to turn to the side and by using
the bell of the stethoscope, hear the murmur on the heart apex and the anterior
axillary line.
o Here you are listening to S1
o Do not press the bell on the chest wall.
o Here you can hear the gallop rhythm or the mitral valve stenosis murmur
which is a low pitched murmur.
To hear the aortic valve murmur clearer ask the patient to sit straight and then ask
him/her to breathe in, out and then hold the breath. As the patient is holding
his/her breath, listen to the murmur in the aortic valve area using the diaphragm of
the stethoscope.
o This will make the aortic valve murmur louder
o Here you are listening to S2
o Remember, you should ask the patient to breath in, breath out and then to
hold the breath, so you can hear the murmur best.
Check for Lt. heart failure usually at the lower lobes of the lung
o Do both percussion and auscultation ( in this step you are looking for the
presesnce of fluid in the lungs)
When auscultating the patient’s heart, ask him/her to breath deeply
through the mouth.
Remember, when you are doing percussion or auscultation for the
cardiovascular system you only have to check for the lower lobes
of the lungs, while for the respiratory system you have to check all
the 8 usual sites
Check for petting edema on both legs ( this petting edema is an indication of Rt.
heart failure.
o Check behined the tibia, medial mallules and the front of the ankles.
Peripheral vascular examination:
In the lower extremities: (you should examine both legs)
o Start with inspection for
Scars, rashes, hair distribution, swelling and refill time.
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o Check for petting edema on both legs
o Feel for the temperature of the lower extremities by the dorsum of your
hands starting from the foot up the leg and femur
o Check between the toes of each leg for any fungal infections (mostly
candidiasis)
o Check for the pulse:
The dorsalis pedis artery
You can find it by going upwards between the big toe and
the toe next to it
The posterior tibialis
Behind the medial malleulus
The popletial artery
You should flex the patienst knee and push your fingers
deeply in the popleteal fossa so you could feel the pulse
The femoral artery at the groin
The abdominal aorta, aortic bifurcation and iliac arteries.
The aortic bifurcation is located “roughly” below the
umbilicus.
o Thomas test: Hold the patients both legs upwards at an angle of about
60o for about 20-30 sec and then let the patient to sit down on the bed with
his/her legs hanging down. Normally the patient’s legs must restore their
normal pink colors in about 10 sec. the purpose of this examination is to
look for pallor in the lower extremities.
If the patient is having a really bad vascular disease in his lower
extremities, the patient will say that he is in pain when his/her legs
are left up. This is due to the lack of O2 delivery to his/her lower
exteremities.
Respiratory Examination:
Look professional
Greeting
o Hello
o I’m…..
o Can I examine you?
Ask the patient to remove his/her clothes
Ask the patient to sit on the bed
Inspection
o Thin or fat
o Chest movement
o Accessory muscles usage
o Patient is relaxed or distressed
o Presence of rashes, scars and normal/abnormal hair distribution
Breathing
o RR ( symmetrical or asymmetrical, noisy breathing, regular or irregular
breathing)
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Fingers
o Peripheral cyanosis (base of nail beds) – this indicates the O2 saturation
o Clubbing
o Refill time
Hand
o Palmer creases for pallor – this indicates the Hb level.
o sweaty
Radial pulse:
o Check for Rate, Regularity, volume, quality (characteristic)
Blood pressure
Face
o Check for central cyanosis in the mucosa of the lips and gums (pull the
lower lip down wards to check this), and inner sides of the cheeks (with
the aid of the tongue depressor.
o Check for paleness in the conjunctiva
Ask the patient to look upwards while you pull the lower lid
downwards
Ask the patient to lay down on the bed at a 45o
Neck
o Check the central position of the trachea ( is it adjacent to the sternal
notch)
o Check for lymph nodes enlargement. These lymph nodes are:
Occipital lymph nodes
Post oracular lymph nodes
Pre oracular (temporal) lymph nodes
Sub mandibulare lymph nodes
Sub mental lymph nodes
Anterior and posterior cervical lymph nodes
Supra and infra clavicular lymph nodes
Check the 5 lymph nodes groups in the axilla:
o Anterior (at the anterior axillary fold)
o Posterior ( at the posterior axillary fold)
o Medial ( against the chest wall)
o Lateral (against the humerus bone)
o Apical ( deep in the apex of the axilla)
To examine the axillary lymph nodes:
o Support the patient’s arm on your arm, and by your other hand feel the
previously mentioned axillary lymph nodes.
In general, when examining the chest:
o Check for chest expansion ( from front and back)
By pulling the skin of his chest together at the midline and then ask
the patient to breathe in deeply and look if the skin gets back to its
original position while still holding your hands on the chest wall.
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o Percussion from front and back in 8 positions
Don’t forget to percuss on the apex of the lungs ( above the
clavicle)
On the back side of the patient, percuss from superior to inferior
until you find an area in which the sound of percussion changes
from resonance to dull ( at expiration). This is the level of the
diaphragm. Then repeat the same on inspiration and locate the
level of the diaphragm. Normally the diaphragm will drop about 2
cm. from expiration to inspiration.
o Tichtile fremutus also in 8 positions with the patient repeating the number
99 in each position at auscultation
o Oscultation :
The patient has to breathe through mouth and repeat the number 99 in
each of the 8 positions (from and back)
Also this has to be done without the patient repeating the number of 99
each time (from front and back
Examining the Breasts:
Each breast is located between the 2nd and the 6th ribs.
First inspect the skin
o Color, hairdistributin, dimples, pain, discharges and scars (surgery)
Usually if the patient has undergone a breast surgery, you will find
the scar at the lower border of the breast.
The breast is divided to 4 areas + the tail of the breasts for descriptive purposes
o Those areas are the upper Rt. and Lt. quadrants and the lower Rt. and Lt.
Quadrants.
Palpate the breasts for abnormal lumps or tenderness
o There are 3 ways to examine the breast that you should do all for each
patient:
Examine with your fingers in a
horizontal directions
spiral way
directing with your fingers towards the nipple helps to
identify the presence of any discharges.
THYROID EXAMINATION:
Look professional
Greeting
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o Hello
o I am …
o Can I examine you?
Remove your clothes, please
Ask the patient to sit on the bed
Inspection (describe):
o Not in pain
o Not distress
o Not sweating
o Normal/Abnormal hair distribution
o Presence of scars
o Presence of rashes
Hands:
o Clubbing ( in lung cancer thyroid hormone may be produced)
o Check for: pallor, sweating, temperature
o Shaking hands
(put a paper on the patients dorsal side of hand as s/he is extending
his/her arms in front of him/her and inspect whether the paper is
shaking)
Check the radial pulse for:
o rate, regularity, characteristics and volume
o in relation to thyroid hormone production you may get tachycardia or
bradycardia
Check the BP
Face:
o Check for bulging eyes
In such eyes the upper eyelid is above the upper border of the iris
o Check for lid lag
You examine this by moving your finger in front of the patient’s
each eye. If the eyeball and the eyelid follows your finger as you
move it up, and then when you move your finger downwards and
the eyeball follow it but the eyelid does not, the there is a lid lag in
that eye.
Check lymph nodes enlargement (the occipital, peri- and post-auricular,
submandibular, submental, anterior and posterior deep cervical, and supra-
clavicular lymph nodes) except for the axillary lymh nodes which you don’t check
in this examination.
Inspect for thyroid gland enlargement both from anterior and lateral sides of the
patient.
o If the patient has an enlargement, the thyroid will move downwards as the
patient swallows because of the thyroid facia.
o Do the thyroid function tests (laboratory test) in order to know the
function of the thyroid gland
Stand behind the patient and locate the thyroid cartilage with your fingers
o Then ask the patient to drink water and notice whether the thyroid is
moving or not
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Percuss on the upper part of the chest, below the clavicle:
o When the thyroid is enlarged it can’t extend up wards due to the fascial
attachments, but it can extend down wards and, therefore, compress the
trachea.
Listen to any possible bruit on the carotids using both the bell and the diaphragm
of the stethoscope
o In hyperthyroidism, there is an increase in HR and blood flow which may
cause murmur like sounds on the carotids.
Abdominal Examination:
Look profissonal
Greeting
o Hello
o I am …
o Can I examine you?
Can you remove your clothes, please!
Ask the patient to sit on the bed
General inspection
o Not distressed
o Not sweating
o Not in pain
o No scars
o No rash
o Normal hair distribution
o Look at the hands:
No rash, scars, sweating, normal hair distribution
No cyanosis in the nail beds
No paleness in the palms’ creases
No clubbing in the bases of the nail beds
Usually clubbing can indicate cancer
Look at the theaner eminence and the hypotheaner eminences in
the hand ( No muscle wasting)
Their color become pink in liver disease (known as palm
erythema or liver palm)
Dupytron’s contracture: thickening of the flexor tendon of the ring
finger that occurs usually in liver disease.
When the disease gets worse, the ring finger can bend due
to the tendon’s contraction
Liver flap: it is the vibration – shaking - of the hand when you
push it backwards(dorsiflexion of 90o) and it usually occurs in liver
disease but this is a very rare sign
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o In the face look for:
Jaundice, in the sclera, and for pallor, in the conjunctiva.
Ask the patient to look upwards while you pull the lower
lid downwards
Most commonly liver cancer occurs secondary to bone or lung cancer
Ask the patient to lay down relaxing his/her abdominal muscles.
Abdominal inspection:
o Not distended
o No scars, rashes
o Normal abdominal shape ( No abdominal distension)
o Normal hair distribution on the abdomen
In chronic liver disease you get less hair distribution
o No gynecomastia (enlarged breast) – often asymmetrical gynecomastia
that usually occurs in liver disease
o No umbilical hernia
Mostly occurs in children
Palpation ( using your fingers):
o There are to ways to divide the abdomen for the description purposes
(1)
Upper Rt. Quadrant Upper Lt. Quadrant
(URQ) (ULQ)
Lower Rt. Quadrant Lower Lt. Quadrant
(LRQ) (LLQO
(2)
Rt. Subcostal Epigastric Lt. Subcostal
Rt. Renal Umbilical Lt. Renal
Rt. Inguinal Hypogastric Lt. Inguinal
Or
Suprapubic
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o After you palpate the patient’s abdomen say: there is no pain, no
tenderness.
o You can chose any one of these 2 dividing systems, but the 2nd is a better
system so you be more accurate and do not miss any area in auscultation
and palpation
o Remember, on both auscultation and palpation you should go through all
the 9 areas.
o Remember, you should do superficial and then the deep palpation
In deep palpation you are checking for tenderness
o Start palpation from the area that there is no pain
If you started from the painful area the patient’s abdominal
muscles will tense and he/she wouldn’t let you to examine him/her
properly
o The most common pathology of the abdomen is appendicitis in which the
pain is usually in the Rt. iliac fossa.
Percussion
o To determine the size of the liver and the spleen
o For the liver (on the Rt. side of the abdomen)
Start percussing from below the clavicle on the midclavicular line
downwards until the area in which you start to hear a dull sound
and make a mark
If you hear a hollow sound: indicates gases
If you hear dull sound: indicates fluid or feces
Then start percussing from the Rt. iliac region and when you reach
the area in which you hear a dull sound make another mark
Then measure the distance between the 2 marks so that you the
size of the liver.
o Do the same for the spleen
o You should percuss all areas of the abdomen
Palpating the liver, spleen and the kidneys.
o For the liver:
Palpate for the edge and ask the patient to breathe in deeply and
move towards the site of the lower liver edge
Start from the iliac area and move upwards.
o When you palpate, palpate upwards.
Whenever the patient is expiring take off your hand from
the abdominal wall
Inspiration pushes the liver downwards while expiration
moves it back to its original place.
o When you palpate for the spleen also ask the patient to breathe in deeply.
Start palpating for it from the lower Rt. side and go towards the
upper Lt. side in an oblique direction.
When you palpate, palpate upwards
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Push the spleen from the back as well as superiorly from the
inferior intercostals margin or you can roll the patient to the Rt.
and push the spleen in the same this way.
o To palpate the kidneys:
Push the back with one hand and the front with the other hand
In general:
o When you feel for the edge of the liver, it may reveal pain.
Usually in case of cancer, as in liver cancer, the patient has no
pain.
However, if there is pain, then inflammation is indicated as in case
of hepatitis.
o In case of kidney:
With kidney cancer, feeling for the kidneys is not painfull.
However, in case of kidney inflammation, feeling the kidneys is
usually painful to the patient.
Feel the pulse of the abdominal aorta on the Lt. side of the midline in the
abdomen.
Auscultation
o You may hear abnormal bowl sounds in bowl obstruction or may hear
vascular bruit – mainly in renal artery stenosis
There are 2 techniques to detect ascitis ( fluid in the abdomen):
o Succusion splash
o Shifting dullness
There are 2 tests used to check for ascitis:
o Ssccusion splash: put your hand on one side with the patients hand on the
medline and then prekle the side of the patient’s abdomen opposite to your
hand.
If there is acsitis you will feel the wave of the prekle on your hand.
The hand of the patient at the medline will prevent the movement
of the prekle’s waves through the skin.
o Shifting dullness: Percuss on the abdomen until you get to the area of
dullness (indicates the presence of fluid) and then roll the patient towards
you and percuss again. If you can still hear the dullness, then the patient
has ascitis (fluid in the abdominal cavity)
Musculoskeletal Examination:
Always tell that you are going to check the active movements or the passive
movements.
We start with checking the temporomandibular joint (TMJ).
o Inspect the joint for any swelling, redness and deformity.
o Palate the joint for tenderness.
o Ask the patient to open his/her mouth and:
Palpate the normal movement over the joint
Check the pain over normal movement.
Check the range of movement.
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The Upper Limbs:
Introduce your self
Inspect the hands for any swelling, redness or deformity
Palpate the joints of the hand:
o The interpharyngeal joints
o The metacarpopharyngeal jonts
o The wrist joint
Do the active movements for the hand by asking the patient to:
o Make a fist
o Abduct and adduct the fingers
o Flex and extend the hand at the wrist joint
o Medial and lateral deviations of the wrist joints
Do the movements passively
Examine the thumb:
o Inspect the thumb for swelling, redness, and deformity.
o Palpate over the thumb joints
o Do the following movements both passively and actively:
Flexion – Extension
Adduction – Abduction
Opposition – Deposition
Palpate the scaphoid bone (located at the base of the anatomical snuff box)
Inspect the elbow for redness, deformity or swelling
Palpate the elbow joint
o Feel the lateral and medial epicondyles
o Feel the head of the radius ( as the arm is in the supine position)
Do the active movements:
o Flexion
o Extension
o Supination
o Pronation
o Enternal and external rotation
Do the movements passively
Inspect the shoulder for redness, deformity and swelling
Palpate and feel the sternoclavicular joint, acromioclavicular joint and the scapula
(the spine and the borders of the scapula)
Also palpate the head of the humerus and the long head (tendon) of the biceps
muscle.
Do the active movements of the shoulder
o Flexion and extension
o Full abduction and adduction
Do the movements passively
Repeat the examination for both limbs
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Lower Limb:
Say hello to the patient and introduce your self
Ask the patient to remove his trousers and to lay down
Inspect the lower limb for any rashes, scars, swelling, redness or deformity
Check between toes for candidiases or any other fungal infections
Palpate each of the toes joints for tenderness and may be swelling
o Palpate the distal joints from the sides
o Palpate the proximal joints by putting your fingers anteriorly and
posteriorly
Ask the patient (actively) to flex, extend, abduct and then adduct the toes’ joints.
Do the movement passively
Palpate each of the following:
o The base of the 5th metatarsal joint
o The medial and lateral maleulus
o Tarsal bone
Ask the patient (actively to flex, extend, abduct and then adduct the ankle joint.
Do the movements passively
Inspect the knee for rashes, scars, swelling, redness, or deformity
palpate the patella
bend the knee 90o and on the sides of the joint check the joint line (between the
femoral and tibial bones
o check it medially and laterally
With one hand draw (drive) it on the top of the patient’s thigh (anteriorly) and
using your other hand push on the patella to check for edema presence
Push both your handsint the popleteal fossa and hold the patients leg and then pull
it in order to check for the cruciate ligament
Ask the patient (actively) to flex and extend his knee joint
Do the movement passively
Hold the patient’s thigh and ask him to abduct and then adduct his knee joints (
actively)
Do the movements passively
Note: normally one can abduct and adduct his knee to a very limited extend
Ask the patient (actively) to rotate his leg medially and laterally
Do the movements passively
Check for knee joint hyperextension by holding the patient’s thigh and ask him to
extend his leg
Hip joint movement:
Ask the patient to move his leg toward his chest (flexsion)
Do the movement passively
Ask the patient to abduct and then adduct his thigh at his hip joint
Do the movement passively
Ask the patient o lay on his abdomen and move his thigh up ( extension)
Do the movement passively
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Then finally ask the patient to move for a short distance and inspect him while
doing that
Spine:
Say hello and introduce your self to the patient
Inspect for pain, deformity, redness, rashes and scars ( and that the patient is not
distress
Check the movements:
o Ask the patient to flex and extend his/her head
o Ask patient to rotate his/her head to the right and to the left side
o Ask the patient to bend his/her head to both Rt. and Lt. sides
o The total number of movements here are 6
o These were active movements. Now repeat the movements passively
Ask the patient to lay down on his/her abdomen with his face on his hands
o This will make all his/her back muscles relaxed, so that you can feel
his/her occipital bone, C3, C4, C5, C6, C7 spinus processes
The bed should be straight
Ask the patient to roll on his/her Lt. side (this is if you are a Rt. handed person, if
you are a Lt. handed person ask the patient to roll on his/her Rt. side this will
help if you want to take a spinal puncture) and coiled (embryo position).
o From the iliac crest move your finger straight to the spine and you will be
between the spinus processes of L3 and L4 ( this is the usual site for spinal
puncture)
o Spinal cord ends usually at L1, and in some people it ends at L2
Straight led raising test: ask the patient to lie down on his/her back, the raise both
his/her legs together -passively
Ask the patient to sit on the bed and cross his/her arms on his/her chest, then ask
him/her to rotate to the left and right sides
Ask the patient to stand up and reach his/her toes with his/her fingers
o Inspect the spine for being straight No scoliosis
Nervous System Examination:
This examination has 4 components:
1. Cranial nerves examination
2. Sensory nerves examination
3. Motor nerves examination
4. Cerebellum examination
CRANIAL NERVES EXAMINATION:
Olfactory (CN I):
o Purely sensory: carry afferent impulses for sense of smell.
o Clinical testing:
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First: make sure that each nostril is patent:
Ask the patient to close one nostril and to expirate through
the other
Repeat this with the other nostril.
Second:
Ask the patient to close his/her eyes
Ask the patient to sniff an aromatic substance (such as
vanilla or oil) with each nostril.
Optic (CN II):
o Purely sensory: carry afferent impulses for vision
o Clinical testing:
Visual fields:
Ask the patient to close the unexamined eye.
Move your fingers as you are getting your hand closer to
the side of the patient’s head until the patient says that
he/she can see you moving fingers.
Do this in all sides in order to detect the patients visual
fields superiory, laterally and inferiory
Repeat this with the other eye.
Fundus examination:
Using the ophthalmoscope
Oculomotor (CN III):
o Chiefly motor nerves: Motor to the eye.
Trochlear (CN IV):
o Primarily motor nerves: supplies the superior oblique muscle.
Abducens (CN VI):
o Primarily motor nerves: supplies the lateral rectus muscle.
Cranial nerves III, IV, and VI are tested together
Near reflex:
Ask the patient to look at a distant point the patient’s pupil will dilate
As the patient is looking at the distance, ask him/her to look at your finger in
front of his/her eyes the patient’s pupil will constrict
Accommodation test:
Move your finger away and near the patient eyes and notice the pupil size
change.
Light reflex test:
Ask the patient to look at a distance
Examine each eye alone
Light a torch in front of the patient’s eye
Both patient eyes should constrict as a reflex to the light in front
of one eye.
Check both eyes
The afferent pathway is by the optic nerve and the efferent
pathway is by the oculomotor nerve.
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For the III, IV and VI CN:
Examine the eye movements: superiorly, laterally, inferiorly ( Do the H
shape movement with your finger)
Trigeminal (CN V):
o has a sensory and a motor component:
o The motor component:
Put your hands on both sides of the patient’s face on the muscles of
mastication
Ask the patient to bite down.
Feel the muscles on contraction and on relaxation.
(the trigeminal nerve supplies the muscles of mastication)
o The sensory component:
Has 3 branches: ophthalmic, maxillary, mandibular.
Is examined by: touch, light touch, temperature
Ask the patient to close his/her eyes and tells you when
ever he/she fells the touch, light touch and temperature
Check both sides of the face and compare the sensation on
both sides.
Don’t use the needle for the touch sensation
examination in order to control infections.
o Croneal reflex:
Ask the patient to look up and then touch the lower part of the
cornea lightly by a wisp of cotton.
This reflex is elicited by the ophthalmic division.
Facial (VII CN):
o Has 5 divisions: the frontal, maxillary, buccal, mandibular, and cervical.
o Taste:
The facial supplies the anterior 2/3 of the tongue.
o This CN is responsible for the facial movements.
Ask the patient to look up (notice his eye brow moving up)- the
frontal division is responsible for this movements
Ask the patient to close his eyes strongly and with your hands try
to open them against his strong closure.
Ask the patient to show you his/her teeth
Ask the patient to smile, (to use his/her boxinator muscle), grin,
frown, and puff his/her cheeks.
Remember: there is no sensation in CN VII, except for the taste
sensation in the anterior 2/3 of the tongue.
Vestibulocochlear (CN VIII):
o Whispering test:
In this test you want to detect the lowest level of sound hearing by
the patient and the longest distance at which the patient can hear
your whispering.
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You should repeat this test with each ear.
Put your finger in the untested ear of the patient.
Put your other hand near your mouth as you are whispering at
different distances from the patient’s tested ear.
Ask the patient to repeat what you are whispering.
o Weber test ( test for lateralization):
Put a vibrating fork on the middle of the patient’s head
Ask the patient to tell you at which ear s/he hears better or whether
s/he hears equally at both sides.
Normally the patient will hear equally at both ears.
If the patient hears at one ear better than the other one, then:
The patient has hear loss in the ear couldn’t hear with, or
The patient has a better bone conduction on the side s/he
heard better with
Repeat with each ear
o Rinne test ( test for air and bone conduction):
Put a vibrating fork on the mastoid bone behind the tested ear.
Ask the patient to tell you hen s/he stops hearing it
When the patient says that s/he has stopped hearing the vibrating
fork, place the fork in front of the tested ear.
Normally the patient will continue to hear the vibrating fork on air
conduction. Thus air conduction is stronger.
Repeat with each ear.
Glossopharyngeal (CN IX):
o Ask the patient to open his/her mouth
o Observe the symmetrical 2 side palates. ( they both should be raised)
Accessory ( CN XI):
o This nerve supplies the trapezius and the sternocleidomastoid muscles.
o Ask the patient to raise his/her shoulders forcefully against your hands.
o This test is for the trapezius muscle.
o Put your hand on one side of the patient’s face and ask him/her to turn
his/her head against your hand.
o Repeat this with the other side of the patient’s head.
o Thos test is for the sternocleidomastoid muscle.
Hypoglossal ( CN XII):
o Ask the patient to get his/her tongue out
o If one side of the paired hypoglossal nerve is damaged, the tip of the
patient’s tongue will point towards the side of the affected nerve.
Usually the CN IX and the CN XII examination is done together.
Jaw Reflex:
In this exam you are checking the trigeminal (CN V) nerve.
Put your finger beneath the lower lip of the patient and pull it down wards
slightly.
Then with the hammer hit your finger.
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If this was not working, for reinforcement, lock his hands and pull while
testing the reflex:
Rt. hand
Lt. hand
SENSORY NERVES EXAMINATION
*Remember*
You should know the different dermatomes of the body
On inspecting the patient make sure that the patient is:
Not distressed
Speaks normally
Has normal responce
In this examination you should evaluate:
Pain
o The sensory input to the brain is the highest from the ear drum and the
cornea.
o There is 2 types of pain: anticipated pain and experienced pain
o Pain pinprick: the patient's skin is touched with the sharp end of a pin with
sufficient pressure that the patient feels pain (not just pressure -- but
hopefully not so much as to puncture and bleed). The patient may be
asked to look away while the examiner tests whether he/she can
differentiate between being touched by the sharp end as opposed to the
dull end of the pin.
o You are testing here whether the pain is sharp or dull, also whether the
sensation is similar between different dermatomes and sites supplied by
different nerves
o Pain pathways: pinprick tests the integrity of the spinothalamic tracts that
carry pain and temperature sensation from the body surface to the brain.
o On nerve damage, the sensation over the affected nerve distribution is
impaired
o On upper motor neurons (spinal cord) damage, the sensation over the
dermatomes supplied by that spinal nerve root is impaired.
Temperature
Light touch
o The examiner uses different sensory modalities to stimulate the surface of
the patient's body.
o Light touch: the examiner touches the patient's skin very gently with a
cotton wisp or his/her finger tip.
o Light touch: the perception of light touch to the skin is carried along the
dorsal columns of the spinal cord
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o sensory deficits can be quantitated by asking the patient to compare right
and left
Vibration
o Put the vibrating fork on the joint and let the patient tell you:
What does s/he feel?
Tell you when s/he stops feeling it.
o The joints that are preferred to examine are the index, toe joint and over
the medial mallulous
Always check the distal joints first and if they are normal then
there is no need to check the proximal joints
Position
o You can tell the position due to the sensory nerves present in the joints
o Position sense position sense is tested by moving the patient's fingers or
toes up and down with the hand or foot immobile.
o This sensation is carried to the brain via the dorsal columns.
Discrimination: has many subdivisions:
o Stereognosis: The ability to recognize objects by sense of touch (object
identification), with the patient’s eyes being closed
o Number identification: the ability to identify a umber written on the palm,
for exaple, with the patient’s eyes being closed
o 2 points discrimination: The ability to identify 2 points of touch on
deferent dermatomes
o Point localization: the ability to identify the site of touch, with the
patient’s eyes being closed
o Extension:
MOTOR NERVES EXAMINATION:
Motor activity requires the combine and co-ordinated activity of the cerebellum,
upper motor neurons (part of the CNS), lower motor neurons (part of the PNS) and
the muscles.
The patient should be sitting with each of his hands on the corresponding thigh
Upper limbs:
1. Inspect (arms, thenar and hypothenar muscles)
Patient is not distressed
Assess muscle characteristics:
o Muscle Symmetry, muscle bulk
o Muscle wasting, fasciculations (atrophy, involuntary contractions)
o Observe the patient’s body position at rest and during movement. And
watch for involuntary movements.
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2. Check for TONE (resistance to passive stretch):
Ask the patient to relax.
While supporting the patient’s elbow, flex and extend patient’s fingers, wrist,
elbow and shoulder. The patient arm should move easily and smoothly
with little resistance.
Or rotate each joint: elbow by holding the arm by one hand and forearm by
another and rotating the elbow joint. And the same for wrist joint.
3. Check for POWER (patient muscle strength):
Ask the patient to move against the resistance produced by you, example:
o Ask the patient to adduct the shoulders while you trying to abduct
them and vice versa. [Dr's hand on bicep, not forearm, to assess
shoulder power].
o Ask the patient to flex the elbow while you trying to extend it and vice
versa
o Ask the patient to flex the wrist while you trying to extend it and vice
versa.
o Ask the patient to adduct the fingers while you trying to abduct them
and vice versa.
o Test for opposition and deposition of the patients hand
o Ask the patient to squeeze (grip) your one or two fingers by his fingers
and while you are trying to take your fingers out of his grip.
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Direction of patent’s movements.
Direction of resistance produced by doctor.
4. REFLUXES:
To reinforce arm reflexes, ask the patient to clench his teeth
Biceps (C5, C6)
1. The patient's arm should be partially
flexed at the elbow with the palm down.
2. Place your thumb or finger firmly on the
biceps tendon.
3. Strike your finger with the reflex
hammer.
4. You should feel the response even if
you can't see it.
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Triceps (C6, C7)
1. Support the upper arm and let the
patient's forearm hang free.
2. Strike the triceps tendon above the
elbow with the broad side of the
hammer.
3. If the patient is sitting or lying down,
flex the patient's arm at the elbow and
hold it close to the chest.
Brachioradialis (C5, C6)
1. Have the patient rest the forearm on
the abdomen or lap.
2. Strike the radius about 1-2 inches
above the wrist.
3. Watch for flexion and supination of
the forearm
Lower limb:
1. Inspect (muscles of the legs)
Patient is not distressed
Assess muscle characteristics:
o Muscle Symmetry, muscle bulk
o Muscle wasting, fasciculations (atrophy, involuntary contractions)
o Observe the patient’s body position at rest and during movement. And
watch for involuntary movements.
2. Check for TONE:
The patient should lay down on the bed, hold his thigh by one hand and use
the other hand to rotate the knee joint by holding the leg. ( flexion, extension)
Extend the leg at the knee, hold the leg near to the ankle joint by one hand and
use the other hand to hold the foot and to rotate the ankle joint (flexion,
extension).
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3. Check for POWER (patient muscle strength):
Ask the patient to abduct the hip joint, while you are trying to adduct it (by
placing the hand on the anterior surface of the thigh and provide
resistance) and vice versa (by placing the hand on the posterior surface of
the thigh and provide resistance)
Ask the patient flex the hip, while you are trying to extend it by pushing at
thigh and vice versa
Ask the patient flex the knee, while you are trying to extend it and vice
versa.
Ask the patient flex the ankle, while you are trying to extend it and vice
versa. (dorsiflextion, planter flexion)
Direction of patient’s movements.
Direction of resistance produced by doctor.
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Clinical skills
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4. REFLUXES:
If the leg reflexes are diminished or abscent, use
reenforcement by asking the patinet to
lock his hands and pull while testing
the reflex
Knee (L2, L3, L4)
1. Have the patient sit or lie down with the
knee flexed.
2. Strike the patellar tendon just below the
patella.
3. Note contraction of the quadraceps and extension of the knee.
Ankle (S1)
Plantar reflux (Babinski)
1.Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer
or key.
2.Note movement of the toes, normally flexion (withdrawal).
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Clinical skills
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CEREBELLUM EXAMINATION:
Ask the patient to strike one
hand on the thigh, raise the
hand, turn it over, and then
strike it back down as fast as
possible.
Ask the patient to tap the distal
thumb with the tip of the index
finger as fast as possible.
o (previous two test used to for testing dysdiadochokinesia)
Ask the patient to touch your index finger and their nose alternately several times.
Move your finger about as the patient performs this task.
Hold your finger still so that the patient can touch it with one finger. Ask the
patient to move their finger up and return to your finger with their eyes first
opened and then closed.
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Pronator Drift:
Ask the patient to stand for 20-
30 seconds with both arms
straight forward, palms up, and
eyes closed.
Instruct the patient to keep the
arms still while you tap them
briskly downward.
A smooth return to position is
normal.
Ask the patient to place one heel on the opposite knee and run it down the shin to
the big toe. Repeat with the patient's eyes closed.
A: Beginning the test
B: Normal result. The heel runs
smoothly and straight down the sheen.
C: abnormal result. The heel is jerky
and may fall off the sheen.
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Clinical skills
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Ask the patient to wake normally across the room,
turn and come back.
Ask the patient to walk heel-to-toe in a straight line.
Ask the patient to walk on their toes in a straight line
Ask the patient to walk on their heels in a straight line
Ask the patient to hop in place on each foot.
Remember: walking heel-to-toe
Be prepared to catch the patient if they are unstable.
Ask the patient to stand with the feet together and eyes closed for 5-10 seconds
without support.
If patient has central cerebellum lesion, patient may fall down.
Remember always:
1. Remember that you should be respectful and always treat the patient in the
same way you want to be treated as a patient
2. In the exam, you have to do every thing unless the examiners asked you not
to do something
3. You get marks for looking as if you know what you are doing (professional).
4. During the exam tell the examiners what you are doing
5. Always stay in the right side of the patient while examining the patient
6. Remember to check both sides whenever you have a pair of an organ or part
of the body
TIPS..
Remember, the femoral vein is the most medial vessel in the femur at the groin,
and then comes the femoral artery and the femoral nerve.
o It is important to recognize this when doing a catheterization.
When you are checking a lump, check for:
o Number
o Shape spherical/ irregular
o Size
o Tenderness/ painfulness
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Clinical skills
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o Over laying skin intact/ discharge
o movement:
Attached to the skin/ movable/ attached to deep structures such as
the muscles
o Surface smooth/ nodular
o Discharge
o Texture hard/ soft
Types of lumps in scrutum:
o Cancer of testis young people get it more than old people
o Epididymal cyst
o Hernia should be examined while the patient is standing up
It would feel on palpation:
Soft, continuous to the abdomen
You should ask the patient to cough:
You will feel a cough impulse on your fingers.
Types of hernias: ( they feel soft like lumps)
o Inguinal hernias external and internal : can happen in infants
o Umbilical hernias mainly in infants
o Femoral hernias most common in old females
To examine a prostate tumor:
o Remember that the prostate is located inferior to the bladder anterior to the
rectum.
o Insert your finger in to the rectum with the aid of gloves and a lubricant
(gel) – rectal examination
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