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					Step             What to look for              How to perform                         Examples of Abnormalities                      Page
Patient Seated                                                                                                                       In 9th ed.
 1. Check        BMI                                                                  Rapid changes in weight (over a few days)      92-93,
height and       Underweight: <18.5                                                   suggest changes in body fluids, not tissues.   104
weight           Normal: 18.5-24.9                                                    Other causes include malignancy,
                 Overweight: 25.0-29.9                                                diabetes mellitus, hyperthyroidism,
                 Obesity I: 30.0-34.9                                                 chronic infection, depression, diuresis
                 Obesity II: 35.0-39.9                                                and successful dieting
                 Obesity III (extreme): > 40                                          Truncal fat with thin limps in Cushing’s
                                                                                      syndrome and metabolic, or insulin
                                                                                      resistance syndrome
                                                                                      Very short stature is seen in Turner’s
                                                                                      syndrome, childhood renal failure, and
                                                                                      achondroplastic and hypogonadism and
                                                                                      Marfan’s syndrome. Height loss occurs
                                                                                      with osteoporosis and vertebral
                                                                                      compression fractures.

 2. Wash                                       Wash hands in the presence of
hands                                          the patient before beginning
                                               examination for 15-20 seconds.
                                               Dry hand first, then turn off faucet
                                               with paper towels. Make sure
                                               nails are short. Remove jewelry
 3. Inspect      Signs of distress, pain,      What you write can help you            Notice any clutching of the chest, pallor,     103-104
general          anxiety or depression         remember who each patient is           diaphoresis; labored breathing, wheezing,
appearance                                     and what they look like                cough
                                                                                      Wincing, sweating, protectiveness of painful
                                                                                      areas
                                                                                      Anxious face, fidgety movements, cold or
                                                                                      moist palms, inexpressive or flat affect,
                                                                                      poor eye contact, psychomotor slowing
 4. Check oral   Normal temp: 96-99 degrees    Have patient stick thermometer         Fever or pyrexia refers to elevated body       112
temperature                                    under tongue, close lips, and wait     temperature. Causes include: infection,
                                               3-5 minutes                            trauma such as surgery or crush
                                               Using tempedot: place under            injuries, malignancy, blood disorders
                                               tongue for 1 minute                    such as acute hemolytic anemia, drug
                                                                                      reactions, and immune disorders such
                                                                                      as collagen vascular disease.
                                                                                      Hyperpyrexia refers to extreme elevation

                                               Alice Fong – Phys Clin Lab Fall 09 Page 1
                                                                                          in temp (greater than 106 degrees).
                                                                                          Hypothermia is under 95 degrees. Chief
                                                                                          cause is exposure to cold, other causes
                                                                                          include paralysis, interference with
                                                                                          vasoconstriction as from sepsis or excess
                                                                                          alcohol, starvation, hypothyroidism, and
                                                                                          hypoglycemia
 5. Palpate,       Fast: > 100                     With the pads of your index and        Irregular rhythms include atrial fibrillation   111,
compare, count     Normal: 60-100                  middle fingers, compress the           and atrial or ventricular premature             Table 8-
radial pulse       Slow: < 60                      radial artery until a maximal          contractions.                                   1, p. 324,
                                                   pulsation is detected. If the          Fast HR  tachycardia                           Table 8-
                                                   rhythm is regular and the rate         Slow HR  bradycardia, second-degree            2, p. 325
                                                   seems normal, count the rate for       AV block, complete heart block
                                                   15 seconds and multiple by 4           Selected heart rates and rhythm on table 8-
                                                   Hold both wrists and compare           1.
                                                   pulses for symmetry & pliability       Selected irregular rhythms on table 8-2
                                                   (before or after counting)
 6. Count          Observe rate, rhythm, depth,    Count the number of respirations       Prolonged expiration suggests narrowing in      112
respiratory rate   and effort of breathing.        in 1 min (or 30 sec and x2) either     the bronchioles
                   Normal adult takes 14-20        by visual inspection or subtly
                   breaths/min in a quiet,         listen over the patient’s trachea.
                   regular pattern                 Lamden suggests doing it after
                   Tachy: > 24                     taking radial pulse but keeping
                   Brady: < 10                     fingers there so patient doesn’t
                                                   change rhythm consciously.
 7. Measure        Normal: < 120/80                Center the inflatable bladder over     Falsely high readings can be caused by       108-111
blood pressure     Prehypertensive: 120-           the brachial artery. The lower         cuffs that are too short or narrow, brachial
                   139/80-89                       border of the cuff should be about     artery is much below heart level, loose cuff
                   Hypertensive I: 140-159/90-     2.5 cm above the antecubital           or a bladder that balloons outside the cuff
                   99                              crease. Secure cuff snuggly.           An unrecognized auscultatory gap may lead
                   Hypertensive II: > 160/ > 100   Position arm so it’s slightly flexed   to serious underestimation of systolic
                                                   at the elbow and at heart level.       pressure or overestimation of diastolic
                   Definition of hypertensive      Feel the radial artery with fingers    pressure. An ausculatory gap is associated
                   crisis: >180/115-120            of one hand, and rapidly inflate       with arterial stiffness and atherosclerotic
                                                   cuff until pulse disappears. Add       disease
                                                   30 mm Hg to it and place bell          Venous congestion may produce artificially
                                                   over the artery.                       low systolic and high diastolic pressure
                                                   Deflate cuff at a rate of about 2-3    Pressure difference of more than 10-15 mm
                                                   mm/second. Note the level until        Hg suggest arterial compression or
                                                   you heard the sound of at least 2      obstruction on the side with the lower
                                                   consecutive beats. This is             pressure
                                                   Alice Fong – Phys Clin Lab Fall 09 Page 2
                                                     systole pressure. When sound
                                                     disappears, it gives you the
                                                     diastolic pressure
 8. Inspect         No scars, rashes, ulcers,        Ask about any moles patient         Pallor from decreased redness in anemia,       126-128
skin and nails      discoloration or lesions         might be concerned with, then       decreased blood flow                           Tables 5-
                    noted. No induration, nodule     assess with ABCDE                   Central cyanosis can be caused by              1 to 5-10
                    thickening.                      Inspect and palpate skin of arms,   advanced lung dz, congenital heart dz, and     p. 132-
                    Pink, smooth and hard nails.     palms, legs, back in good           abnormal hemoglobin                            147
                    No clubbing, biting or           lighting. Check nail blanching by   Jaundice suggests liver dz or excessive        Table 5-
                    thickening. No tenderness        pressing.                           meolysis of RBCs                               13, p.
                    on palpation                                                         Skin conditions on table 5-1 to 5-10.          150-151
                                                                                         Findings in or near the nails on table 5-13.

 9. Inspect and     Hair quality without                                                 Alopecia refers to hair loss – diffuse,        128
palpate the hair,   courseness. No evidence of                                           patchy or total. Sparse hair in                Table 5-
scalp, skull        thinning or alopecia.                                                hypothyroidism. Fine silky hair in             12 on p.
                    Scalp texture without                                                hyperthroidism                                 149
                    evidence of scaliness,                                               Trichotillomania - hair loss from pulling,
                    flaking or tenderness                                                plucking or twisting hair
                    Skull size & contour without                                         Tinea Capitis (Ringworm) - round scaling
                    irregularity, tenderness or                                          patches of alopecia. Usually caused by
                    masses                                                               fungal infection from tinea tonsurans.
                                                                                         Hair loss conditions on table 5-12
10. Inspect face    Facial expression                                                    Selected facies on Table 6-3, summary:         177
                    symmetrical. No edema,                                               Cushing’s syndrome – moon face with red        Table 6-3
                    scars, masses, weakness, or                                          cheeks, hirsutism                              on p. 211
                    tenderness                                                           Nephritic syndrome – periorbital edema,
                                                                                         puffy pale face, lips may be swollen
                                                                                         Myxedema – lateral eyebrows thin,
                                                                                         periorbital edema, puffy dull face with dry
                                                                                         skin
                                                                                         Parotid gland enlargement – large
                                                                                         swelling obscures ear lob
                                                                                         Acromegaly – brow prominent, soft tissues
                                                                                         of nose, ears, lips, enlarged
                                                                                         Parkinson’s dz – stare, decreased mobility
11. Inspect         Position and alignment           Inspect position and alignment,     Abnormal protrusion in Grave’s dz or           180
eyes                without deviation                eyebrows, eyelids, and lacrimal     ocular tumors                                  Table 6-
(position/alignme   Eyelids and lacrimal             apparatus by standing in front of   Lateral sparseness in eyebrows seen in         5, p. 213,
nt, lids,           apparatus without swelling,      patient.                            hypothyroidism                                 6-6 p.
eyebrows,           discoloration, ptosis, lagging   Conjuctiva and sclera – ask         Red inflamed lid margins in blepharitis,       214
                                                     Alice Fong – Phys Clin Lab Fall 09 Page 3
lacrimal              or obstruction. No thinning       patient to look up as you depress      often with crusting
appratus,             of eyebrow margins                both lower lids with thumbs to         Excessive tearing may be due to increased
conjunctiva,                                            expose. Note vascular patterns         production or impaired drainage of tears,
sclera)                                                 and color.                             causes include conjunctival inflammation
                                                                                               and corneal irritation, ectropion
                                                                                               Variations and abnormalities of the eyelids
                                                                                               on table 6-5
                                                                                               Lumps and swellings in and around the
                                                                                               eyes on table 6-6.
12. Inspect           Cornea without arcus. Lens        Use oblique lighting to inspect        Occasionally the iris bows abnormally far       181-182,
cornea, lens, iris,   without opacities. No             cornea, lens, and iris.                forward, forminga very narrow angle with        Table 6-
PERRLA,               shadow on medial iris.            Test the pupillary reaction to light   the cornea. The light then casts a              9, p. 217
corneal               Pupils equal round,               by asking patient to look into the     crescentic shadow. This increases the risk
reflections           responsive to light and           distance, and shine a bright light     for acute narrow-angle glaucoma - a
                      accommodation.                    obliquely into each pupil in turn.     sudden increase in intraocular pressure
                      Corneal reflections               Flash light twice in each eye to       when drainage of the aqueous humor is
                      symmetrical                       test for both direct and               blocked. In open-angle glaucoma – the
                                                        consensual reaction. Use your          common form – the mormal spatial relation
                                                        hand to pt. nose vertically to         btw iris and cornea is preserved and the iris
                                                        separate light from other eye          is fully lit.
                                                        Test the near reaction –               Miosis refers to constriction of the pupils,
                                                        accommodation by having them           mydriasis to dilation
                                                        look behind you at the wall then       Pupillary abnormalities on table 6-9
                                                        close up at a finger then back
                                                        again
13. Funduscopic       Optic cup: Optic disc = 1:2.      -Darken room. Switch                   Absense of the red reflex suggest an            184-188
exam                  Disc margins sharp                ophtalmoscope light and turn the       opacity of the lens (cataract) or possibly of   Tables 6-
                      temporally. No swelling,          lens disc until you see the large      the vitreous. Less commonly, a detached         11 to 6-
                      cupping or atrophy. A/V           round beam of white light. Turn        retina, or in children, a retinoblastoma        16, p.
                      crossings sharp without           lens to 0 diopeter. Remember to        may obscure this reflex. Do not be fooled       219-225
                      nicking, banking or tapering.     hold scope in right hand to            by an artificial eye.
                      Retina without hemorrhage,        examine patient’s right eye, and       In myopia (nearsighted) – retinal structures
                      exudate or lesions                vice versa.                            look larger than normal
                                                        - Hold ophthalmoscope firmly           An enlarged cup suggests chronic open-
                                                        braced against the medial aspect       angle glaucoma
                      What to look for: optic disc in   of your bony orbit, with the           Papilledema – swelling of the optic disc
                      the physiologic cup, artery,      handle tilted at about a 20 degree     and anterior bulging of the physiologic cup.
                      vein, retina, fovea               slant from the vertical.               Signals serious disorders of the brain,
                      surrounded by the macula          - Instruct patient to look slightly    subarachonoid hemorrhage, trauma, and
                                                        up and over your shoulder at a         mass lesions
                                                        point directly ahead on the wall       Loss of venous pulsations in pathological
                                                        Alice Fong – Phys Clin Lab Fall 09 Page 4
                                                    - place yourself about 15 in. away     conditions such as head trauma, meningitis,
                                                    from patient at an angle 15            or mass lesions may be an early sign of
                                                    degrees lateral to the patient’s       elevated intracranial pressure
                                                    line of vision. Shine light on pupil   Macular degeneration is an important
                                                    and look for the orange glow in        cause of poor central vision in elderly.
                                                    the pupil – the red reflex. Note       Types include dry atrophic and wet
                                                    any opacities                          exudative.
                                                    - Now place thumb of your other        Undigested cellular debris, called drusen,
                                                    hand across the patient’s              may be hard and sharply defined, or soft
                                                    eyebrow, move scope towards            and confluent with altered pigmentation
                                                    their eye.                             Vitreous floaters may be seen as dark
                                                    See p. 186-188 for examing optic       specks or strands between the fundus and
                                                    disc and retina                        the lens.
                                                                                           Abnormalities seen in fundoscopic exam on
                                                                                           tables 6-11 to 6-16.
14. Inspect        Auricle without lesions,                                                Lumps on or near the ear on table 6-17:       189
external ears      deformity or masses                                                     Keloid – firm, nodular, hypertropic mass of   Table 6-
                                                                                           scar tissue                                   17, p.
                                                                                           Tophi – A deposit of uric acid crystals       226
                                                                                           characteristic of chronic tophaceious gout.
                                                                                           Basal cell carcinoma – raised nodule
                                                                                           shows the lustrous surface and
                                                                                           telangiectatic vessels of basal cell
                                                                                           carcinoma
15. Palpate        No tenderness with pressure      If ear pain, move the auricle up       Movement of the auricle and tragus (the tug   189
auricle, tragus,   on tragus or mastoid             and down, press the tragus and         test) is painful in acute otitis externa
mastoid                                             press firmly behind the ear            (inflammation of the ear canal), but not in
                                                                                           otitis media (inflammation of the middle
                                                                                           ear). Tenderness behind the ear may be
                                                                                           present in otitis media.
16. Otoscopic      Canal clear of excess            Position patient’s head so you         Nontender nodular swellings covered by        189-190
exam               cerumen. Tympanic                can see comfortably through the        normal skin deep in the ear canals            Table 6-
                   membrane translucent, non-       otoscope. To straighten the ear        suggests exostoses. These are                 18, p.
                   bulging. No evidence of          canal, grasp auricle firmly but        nonmalignant overgrowths, which may           227-228
                   discharge or retraction. Light   gently and pull it upward,             obscure the drum.
                   reflex visible B/L.              backward and slight away from          In acute otitis externa, the canal is often
                                                    the head.                              swollen, narrowed, moist, pale, and tender.
                   What to look for: tympanic       Holding the scope handle               It may be reddened.
                   membrane, cone of light (if      between your thumb and fingers,        In chronic otitis externa, the skin of the
                   absent = bad), umbo, handle      brace your hand against the            canal is often thick, red, and itchy.
                   of the malleus, short            patient’s face. Your hand and          Red bulging drum of acute purulent otitis
                                                    Alice Fong – Phys Clin Lab Fall 09 Page 5
                    process, incus, parts           instrument thus follow                media; amber drum of a serious effusion
                    tensa/flaccida                  unexpected movement by the            An unusually prominent short process and
                                                    patient.                              a prominent handle that looks more
                                                    Insert speculum gently into ear       horizontal suggest a retracted drum.
                                                    canal directing it down and           A serious effusion, a thickened drum or
                                                    inspect                               purulent otitis media may decrease motility
                                                                                          of the drum.
                                                                                          Abnormalities of the eardrum on table 6-18
17. Inspect         Nasal mucosa and                Gentle pressure on the tip of the     Tenderness of the nasal tip or alae suggest   192-193
nasal passages      turbinates pink, septum         nose with your thumb usually          local infection such as a furuncle
                    midline, asymmetry between      widens the nostrils and, and with     Deviation of the lower septum is common
                    the two sides is normal.        the aid of the penlight, you can      and may be easily visible. It rarely
                                                    get a partial view of each nasal      obstructs air flow.
                    Note color, swelling,           vestibule.                            In viral rhinitis the mucosa is reddened
                    bleeding, and exudate for       You can inspect the inside of the     and swollen; in allergic rhinitis it may be
                    the nasal mucosa.               nose with an otoscope and the         pale, bluish, or red.
                    Note any deviations,            largest ear speculum available.       Fresh blood or crusting may be seen.
                    inflammation, or perforation    Tilt patient’s head back a bit and    Causes of septal perforation include
                    of the septum                   insert the speculum gently into       trauma, surgery, and the intranasal use of
                                                    the vestibule. Hold scope handle      cocaine or amphetamines.
                                                    to one side to avoid patient’s chin   Polyps are pale, semitransclucent masses
                                                    and improve your mobility.            that usually come from the middle meatus.
                                                    Direct speculum posteriorly, then     Ulcers may result from nasal use of
                                                    upward in small steps, try to see     cocaine.
                                                    the inferior and middle turbinates,
                                                    the nasal septum, and narrow
                                                    nasal passage between them
                                                    Remember to discard used
                                                    speculas!
18. Palpate         No sinus tenderness present     Press up on the frontal sinuses       Local tenderness together with symptoms       193
sinuses             over frontal or maxillary       from under the bony brow,             such as pain, fever, and nasal discharge,
                    bilaterally.                    avoiding pressure on eyes.            suggest acute sinusitis involving the
                                                    Press up on the maxillary sinus       frontal or maxillary sinuses.
                                                                                          Transillumination may be diagnostically
                                                                                          useful. Technique for this on p. 202.
19. Inspect         Lips are pink & moist. Buccal   Use penlight and tongue               Bright red edematous mucosa underneath        193-194,
lips, tongue,       mucosa & gingival without       depressor to inspect (or have pt      a denture suggests denture sore mouth.        Table 6-
teeth, gums,        plaques, lesions, ulcers,       pant like a dog)                      There may be ulcers or papillary              20, p.
buccal and labial   leukoplakia or masses.          Pharynx: Instruct pt to open          granulation tissue.                           230-231.
mucosa, pharynx     Teeth in good repair with       mouth and say “ah.”                   Abnormalities of the lips on table 6-20.      Table 6-
                    few/many fillings.                                                    Findings in the pharynx, palate, and oral     21, p.
                                                    Alice Fong – Phys Clin Lab Fall 09 Page 6
                  Pharynx pink without           If pt wears dentures, offer a        mucosa on table 6-21.                             232-234
                  exudate, swelling or           paper towel and ask pt to remove     Gums and teeth: redness of gingivitis;
                  erythema. Tonsils present      them so you can see mucosa           black line of lead poisoning.
                  with no redness, swelling or   underneath.                          Torus palatinus, a midline lump on roof of
                  erythema.                                                           mouth (p. 233).
                                                                                      Asymmetric protrusion of tongue suggests
                                                                                      a lesion of CN XII.
                                                                                      In CN X paralysis, the soft palate fails to
                                                                                      rise and the uvula deviates to the opposite
                                                                                      side.
20. Palpate       Tongue, labial & buccal        Using glove, ask pt to open          Cancer of the tongue is the 2nd most              194-195,
tongue, buccal    mucosa, palate & floor of      mouth, “scan” with finger and        common cancer of the mouth. Cancer of             Table 6-
and labial        mouth palpated without         penlight the upper and lower         the lip is 1st. Any persistent nodule or ulcer,   23, p.
mucosa, palate,   masses, ulcers or induration   buccal mucosa, floor and roof of     red or white, must be suspect. Induration of      237-238
floor of mouth                                   mouth. Use sponge/gauze, hold        the lesion further increases the possibility of
                                                 tongue with gauze and pull out to    malignancy. Cancer occurs most often on
                                                 side, palate with other finger       the side of the tongue, next most often at
                                                 along lateral margin. Look for       the base.
                                                 induration in all areas              Findings in or under the tongue on table 6-
                                                                                      23.
21. Inspect       Trachea midline. No jugular    If not deviated, chart “trachea      Masses in the neck may push the trachea           198
neck (trachea,    vein distention.               midline”                             to one side. Tracheal deviation may also
veins)                                                                                signify important problems in the thorax,
                                                                                      such as a mediastinal mass, atelectasis or
                                                                                      a large pneumothorax
22. Inspect       No enlargement                 Use tangential lighting, inspect     Goiter is a general term for an enlarged          198-199
thyroid                                          region below cricoid cartilage for   thyroid gland.
                                                 gland. Ask pt to swallow and can
                                                 actually see gland moving if there
                                                 is a mass
23. Palpate       Thyroid palpable without       Place both hands on neck just        With swallowing, the lower border of the          198-200,
thyroid           masses, nodules,               inferior to cricoid cartlage. Have   thyroid gland rises and looks less                Table 6-
                  enlargement or tenderness      pt flex neck slightly forward.       symmetric.                                        24, p.239
                                                 Stand behind patient and palpate     Although physical characteristics of the
                                                 with fingertips or stand in front    thyroid gland, such as size, shape, and
                                                 and palpate with thumbs. Should      consistency, are diagnostically important,
                                                 feel homogenous. Be sure to          assessment of thyroid function depends
                                                 palpate isthmus and then move        upon symptoms, signs elsewhere in the
                                                 laterally for the lobes.             body and lab tests.
                                                 Have pt. swallow.                    Thyroid enlargement and function on table
                                                 Instructions also given on p. 200    6-24
                                                 Alice Fong – Phys Clin Lab Fall 09 Page 7
                                                                                     The thyroid is soft in Grave’s disease, firm
                                                                                     in Hashimoto’s thyroiditis, malignancy.
                                                                                     Benign and malignant nodules, tenderness
                                                                                     in thryoiditis.
                                                                                     A localized systolic or continuous bruit may
                                                                                     be heard in hyperthroidism.
24. Inspect     Respiratory even &              Stand behind pt and open gown        Deformities of the thorax on table 7-4.         253,
posterior and   unlabored. Chest A/P: lateral   to observe post chest wall. Look     Abnormal retraction of the interspaces          Table 7-
lateral chest   = 1:2. Ribs slope oblique. No   at skin. Watch skin btw ribs –       during inspiration can be seen in severe        4, p.273
                ICS retraction or unilateral    does it depress during               asthma, COPD, or upper airway
                lag. No contractions of SCM     inspiration? (if not, chart “no      obstruction.
                or scalenes noted.              evidence of ICS retraction” = No     Unilateral impairment or lagging of
                                                COPD)                                respiratory movement suggests disease of
                                                                                     the underlying lung or pleura.
25. Palpate     No significant increase or      Palpate and compare symmetric        There can be intercostal tenderness over        253-254
posterior and   decrease in tactile fremitus    areas of the lungs in the pattern    an inflamed pleura.
lateral         palpable bilaterally. No        shown on p. 254 (4 places each       Bruises over a fractured rib.
chest/check     deformities or tender areas     side  levators, mid scapular,       Although rare, sinus tracts (blind,
fremitis        noted over posterior lung       inferior angle of scap, teres)       inflammatory, tubelike structures opening
                fields                          Use either the ball (the bony part   onto the skin) usually indicate infection of
                                                of the palm at the base of the       the underlying pleura and lung (as in TB,
                                                fingers) or the ulnar surface of     actinomycosis).
                                                your hand to optimize the            Causes of unilateral decrease or delay in
                                                vibratory sensitivity of the bones   chest expansion include chronic fibrotic
                                                in your hand. Ask pt to repeat the   disease of the underlying lung or pleura,
                                                words “99” (in same 4 places)        pleural effusion, lobar pneumonia, pleural
                                                                                     pain with associated splinting, and
                                                                                     unilateral bronchial obstruction.
                                                                                     Fremitis is decreased or absent when the
                                                                                     voice is soft or when the transmission of
                                                                                     vibrations from the larynx to the surface of
                                                                                     the chest is impeded. Causes include an
                                                                                     an obstructed bronchus; COPD; separation
                                                                                     of the pleural surfaces by fluid (pleural
                                                                                     effusion), fibrosis (pleural thickening), air
                                                                                     (pneumothorax), or an infiltrating tumor;
                                                                                     and a very thick chest wall.
26. Percuss     Resonant percussion tones       Place middle finger over area to     Percussion notes and their characteristics      255-258
posterior and   noted over posterior lung       percuss and strike with other        on p. 256.
lateral chest   fields.                         finger or reflex hammer. Percuss     Dullness replaces resonance when fluid or
                                                seven areas.                         solid tissue replaces air-containing lung or
                                                Alice Fong – Phys Clin Lab Fall 09 Page 8
                                                                  1      1             occupies the pleural space beneath your
                                                                  2      2             percussing fingers. Examples include: lobar
                                                                  3      3             pneumonia, in which the alveoli are filled
                                                           6      4      4        6    with fluid and blood cells; and pleural
                                                           7      5      5        7    accumulations of serous fluid (pleural
                                                  Be sure to percuss #1 on the left    effusion), blood (hemothorax), pus
                                                  and then #1 on the right to          (empyema), fibrous tissue, or tumor.
                                                  compare, then follow with #2 on      Generalized hyperresonance may be
                                                  the left and #2 on the right, etc.   heard over the hyperinflated lungs of
                                                                                       emphysema or asthma, but it is not a
                                                  MUST PERCUSS ON SKIN                 reliable sign. Unilateral hyperresonance
                                                  DIRECTLY                             suggests a large pneumothorax or possibly
                                                                                       a large air-filled bulla in the lung.
                                                                                       An abnormally high level of the diaphragm
                                                                                       suggests pleural effusion or atelectasis or
                                                                                       diaphragmatic paralysis.
27. Auscultate   Lung fields clear to             Ascultate in the same areas and      Sounds from bedclothes, paper gowns, and 258-261,
posterior and    ausculation, vesicular           order as percussion. Remember        the chest itself can generate confusion in    Table 7-
lateral chest    sounds noted in all              to move diaphragm after exhale       auscultation. Hair on the chest may cause     5, p. 274
                 peripheral fields posteriorly.   not during. Use diaphragm b/c        crackling sounds. Either press harder or
                 No adventitious sounds           better for high pitched sounds.      wet the hair. If the pt is cold or tense, you
                 auscultated.                     Lung sounds: vesicular,              may hear muscle contraction sounds –
                                                  bronchovesicular, bronchial,         muffled, low-pitched rumbling or roaring
                 Breath sounds: Vesicular         tracheal                             noises.
                 (soft – over most of both                                             A change in the pt’s position may eliminate
                 lungs), bronchovesicular         MUST ALWAYS ASCULTATE                this noise. You can reproduce this sound on
                 (intermediate – often in the     DIRECTLY ON SKIN.                    yourself by doing a Valsalva maneuver
                 1st and 2nd interspaces                                               (straining down) as you listen to your own
                 anteriorly and btw scapulae),                                         chest.
                 bronchial (loud – over the                                            Breath sounds may be decreased when air
                 manubrium if heard at all),                                           flow is decreased (as by obstructive lung
                 and tracheal (very loud –                                             disease or muscular weakness) or when
                 over the trachea in the neck)                                         the transmission of sound is poor (as in
                                                                                       pleural effusion, pneumothorax, or
                                                                                       emphysema). A gap suggests bronchial
                                                                                       breath sounds.
                                                                                       Adventitious or added breath sounds on
                                                                                       p.260
                                                                                       Normal and altered breath and voice
                                                                                       sounds on table 7-5

                                                  Alice Fong – Phys Clin Lab Fall 09 Page 9
Patient Supine
28. Inspect the   PMI visible & palpable at the     Pt is supine with head elevated to    S1 is decreased in 1st degree heart block,       308
precordium        left 5th ICS at the MCL or 7-9    30 degrees. Tangenitial lighting is   and S2 is decreased in aortic stenosis
(measure PMI)     cm left of the MSL                best. Put Left arm over head –        Thrills may accompany lound, harsh, or
                                                    externally rotate.                    rumbling murmurs as in aortic stenosis,
                                                    Stand on pt’s LEFT side               patent ductus arteriosus, ventricular septal
                                                    Gown options (for females):           defect, and less commonly, mitral stenosis.
                                                    Gown open to back, pull L arm         They are palpated more easily in patients
                                                    out and expose L breast and           that accentuate the murmur.
                                                    hemithorax during exam.               On rare occasions, a pt has dextrocardia –
                                                    Gown open to back, take both          a heart situation on the right side The apical
                                                    arms out and pull gown down to        pulse will then be found on the right. If you
                                                    waist, cover breasts with towel or    cannot find an apical impulse, percuss for
                                                    drape.                                the dullness of heart and liver and for the
                                                    Instruct female pt to pull L breast   tympany of the stomach. In situs inversus,
                                                    up with R hand                        all three of these structures are on opposite
                                                    Can fold a post-it like an L-shape    sides from normal. A right-sided heart with
                                                    and apply over impulse                normally placed liver and stomach is
                                                                                          usually associated with congenital heart dz.
29. Palpate the   No lifts, heaves, or thrills      Determine vertical position (an       The apical impulse may be displaced              308-313,
precordium        palpated at base, left sternal    ICS) and horizontal position (cm      upward and to the left by pregnancy or a         Table 8-
                  border, subxiphoid, or apex       from midsternal line)                 high left diaphragm.                             3, p. 326
                  of precordium                     Assess diameter, amplitude and        Lateral displacement from cardiac
                                                    duration of PMI.                      enlargement in congestive heart failure,
                                                    Note any thrills with palpation.      cardomyopathy, ischemic heart dz.
                                                    Remember to measure distance          Displacement in deformities of the thorax
                                                    of PMI from sternum using tape        and medialstinal shift.
                                                    measure (normal 7-9 cm)               In the left lateral decubitus position, a
                                                                                          diameter greater than 3 cm indicates left
                                                                                          ventricular enlargement.
                                                                                          Increased amplitude may also reflect
                                                                                          hyperthroidism, severe anemia,
                                                                                          pressure overload of the left ventricle, or
                                                                                          volume overload of the left ventricle.
                                                                                          A brief middiastolic impulse indicates an
                                                                                          S3; an impulse just before the systolic
                                                                                          apical beat itself indicates an S4.
                                                                                          A marked increase in amplitude with little or
                                                                                          no change in duration occurs in chronic
                                                                                          volume overload of the right ventricle, as
                                                   Alice Fong – Phys Clin Lab Fall 09 Page 10
                                                                                        from an atrial septal defect.
                                                                                        In obstructive pulmonary dz, hyperinflated
                                                                                        lung may prevent palpation of an enlarged
                                                                                        right ventricle in the left parasternal area.
                                                                                        The impulse is felt easily, however, high in
                                                                                        the epigastrium where heart sounds are
                                                                                        also often heard best.
                                                                                        Variation and abnormalities of the
                                                                                        ventricular impulses on table 8-3.
30. Percuss        Percussive dullness of left      Percuss from lateral-most margin    A markedly dilated failing heart may have a     313
cardiac border     ventricle at or medial to MCL    of rubs at 5th rib and move         hypokinetic apical impulse that is displaced
                                                    medially and hear when sound        far to the left. A large pericardial effusion
                                                    changes from resonant to dull       may make the impulse undectable.
31. Auscultate     RRR, no murmurs, clicks,         Bring knees up (bent) so feet are   Pulmonic sounds are usually heard best in       313-316,
heart              rubs, snaps, or extra sonds.     on table.                           the 2nd and 3rd left interspaces, but may       Tables 8-
                   S1 & S2 not diminished,          Auscultate at 6 places:             extend further.                                 4 to 8-10,
                   exaggerated or abnormally        R 2nd ICS – Aortic, S2 loudest      Having a pt roll partly onto the left side in   p. 327-
                   split.                           here, listen for split here         the left lateral decubitus position (bringing   334.
                                                    L 2nd ICS – Pulmonic                left ventricle close to the chest wall),
                                                    L 3rd ICS – Erbs pt                 accentuates or brings out a left sided S3
                                                    L 4th ICS                           and S4 and mitral murmurs, esp. mitral
                                                    L 5th ICS – Tricuspid               stenosis.
                                                    Apex – mitral, S1 loudest here      Having a pt sit up, lean forward, exhale
                                                    Listen with bell & diaphragm        completely, and stop breathing in expiration
                                                    Diaphragm: S1,S2, murmurs of        accentuates or brings out aortic murmurs.
                                                    aortic and mitral regurg,           You may easily miss the soft diastolic
                                                    pericardial friction rub            murmur of aortic regurgitation unless you
                                                    Bell – S3, S4, mitral valve         listen at this position.
                                                    prolapse                            See tables 8-4 to 8-10 for all variations in
                                                    REMEMBER TO ASCULTATE               heart sounds during auscultation.
                                                    ON SKIN
32. Auscultate     No bruits auscultated at the     Listen with bell – common to hear   Small, thready or weak pulse in                 305,
carotid arteries   carotids                         S1. Can ask pt to exhale and        cardiogenic shock; bounding pulse in            Table 8-1
                                                    hold                                aortic insufficiency.                           and 8-2,
                                                    Bruit: a murmur-like sound of       Delayed carotid upstroke in aortic stenosis     p. 324-
                                                    vascular rather than cardiac        Pulsus alternans bigeminal pulse (beat-to-      325.
                                                    origin                              beat variation); paradoxical pulse
                                                    ASCULTATE ON SKIN                   (respiratory variation).
                                                                                        A carotid bruit with or without a thrill in a
                                                                                        middle-aged or older person suggests but
                                                                                        does not prove arterial narrowing. An aortic
                                                   Alice Fong – Phys Clin Lab Fall 09 Page 11
                                                                                             murmur may radiate to the carotid artery
                                                                                             and sound like a bruit.
                                                                                             If you hear a murmur in the neck during
                                                                                             auscultation, have person sit up and if it
                                                                                             goes away, then it’s a subclavian bruit,
                                                                                             not a carotid bruit
                                                                                             If there are murmurs and you push on the
                                                                                             jugular veins and it goes away, then it’s a
                                                                                             venous hum, not a carotid bruit (turbulence
                                                                                             in the jugular vein).
                                                                                             Irregular rhythms on table 8-1, selected
                                                                                             heart rates and rhythms on table 8-2
33. Auscultate        No bruits auscultated at the      Have pt raise knees so feet are      Bowel sounds may be altered in diarrhea,     376,
abdomen, mid-         abdominal aorta, renal, iliac     on table.                            intestinal obstruction, paralytic ileus, and Table 10-
epigastrium and       or femoral arteries. Bowel        Areas for auscultation               peritonitis.                                 10, p.406
femoral areas         sounds auscultated.               R iliac  R renal  aortic  L       A bruit in one of these areas that has both
                                                        renal  L iliac  L femoral  R      systolic and diastolic components strongly
                                                        femoral                              suggest renal artery stenosis as the
                                                        Make sure to contact skin directly   cause of hypertension.
                                                        for all areas                        Bruits with both systolic and diastolic
                                                        Sequence: first listen for bowel     components suggest the turbulent blood
                                                        sounds (clicks and gurgles) using    flow of partial arterial occlusion or
                                                        diaphragm. Then listen for bruits    arterial insufficiency.
                                                        using the bell.                      Sounds of the abdomen on table 10-10.
                                                        ASCULTATE ON SKIN
34. Palpate           Carotid, femoral, tibial &        Palpate carotid one at a time.       A torturous and kinked carotid artery may       305,
carotid, tibial and   pedal pulses all brisk or         For tibial and pedal pulses,         produce a unilateral pulsatile bulge.           Table 4-
pedal pulses          normal bilaterally. No thrills    palpate both sides at the same       Decreased pulsations may be caused by           7, p.119,
                      palpated                          time to compare.                     decreased stroke volume, but may also           485
                                                        Dorsalis pedis pulse – btw 1st and   result from local factors in the artery such
                      Amplitudes of pulses:             2nd metatarsal                       as atherosclerotic narrowing or occlusion.
                      4+ bounding, 3+ increased,        Posterior tibial pulse – just        Pressure on the carotid sinus may cause a
                      2+ brisk = normal, 1+             posterior to medial malleoli         reflex drop in pulse rate or blood pressure.
                      diminished and weaker than
                      expected, 0 = absent                                                   The dorsalis pedis artery may be
                                                                                             congenitally absent or may branch higher in
                                                                                             the ankle. Search for a pulse more laterally.
                                                                                             Decreased or absent pedal pulses
                                                                                             (assuming a warm environment) with
                                                                                             normal popliteal and femoral pulses
                                                                                             suggest occlusive dz in the lower popliteal
                                                       Alice Fong – Phys Clin Lab Fall 09 Page 12
                                                                                            artery or its branches – a pattern often
                                                                                            associated with diabetes mellitus.
                                                                                            Sudden arterial occlusion, as from
                                                                                            embolism or thrombosis, causes pain and
                                                                                            numbness or tingling. The limb distal to the
                                                                                            occlusion becomes cold, pale, and
                                                                                            pulseless. Emergency tx is required.
                                                                                            Coldness, especially when unilateral or
                                                                                            associated with other signs, suggests
                                                                                            arterial insufficiency from inadequate
                                                                                            arterial circulation

                                                                                            Abnormalities of the arterial pulse and
                                                                                            pressure waves on table 4-9
35. Check for       No evidence of edema at           Use thumbs, squeeze for 5             Edema causes swelling that may obscure           486,
pedal, tibial and   foot, ankle or tibia              seconds and let go: on top of         the veins, tendons, and bony prominence.         Table 14-
pre-tibial edema                                      tibia, dorsum of foot, posterior to   Some peripheral causes of edema on table         4, p.496
                                                      medial malleolus.                     14-4.
                                                      Always do bilaterally and             Causes of pitting edema: prolonged
                                                      compare symmetry.                     standing or sitting, congestive heart failure
                                                      Graded on a scale from 1 to 4          decreased cardiac output, increased
                                                      Move to pt’s right side for next      hydrostatic pressure in the veins or
                                                      part.                                 capillaries, nephritic syndrome, cirrhosis, or
                                                                                            malnutrition.
36. Inspect         No masses, dilated veins,         Inspect skin, umbilicus, contours     Pink-purple striae of Cushing’s syndrome.        374-376.
abdomen             scars, peristalsis, pulsations    of abdomen using TANGENTIAL           Dilated veins of hepatic cirrhosis or of         Table 10-
                    or hernias noted                  LIGHTING.                             inferior vena cava obstruction.                  8 and 10-
                                                      Best to be standing on pt.’s          Bulging flanks of ascites; suprapubic bulge      9, p.404-
                                                      RIGHT SIDE now.                       of a distended bladder or pregnant uterus,       405
                                                                                            hernias.
                                                                                            Asymmetry can be from an enlarged organ
                                                                                            or mass
                                                                                            Lower abdomen mass of an ovarian or a
                                                                                            uterine tumor.
                                                                                            Increased peristaltic wave of intestinal
                                                                                            obstruction
                                                                                            Localized bulges in the abdominal wall on
                                                                                            table 10-8
                                                                                            Protuberant abdomens on table 10-9
37. Percuss         Percussion of abdomen             Start at RLQ  RUQ  LUQ             A protuberant abdomen that is tympanitic         377,
abdomen             produces scattered areas of       LLQ  center (follow large            throughout suggests intenstinal                  Table 10-
                                                     Alice Fong – Phys Clin Lab Fall 09 Page 13
                 tympani and dullness           intestines from cecum to sigmoid,       obstruction                                    9, p.405
                                                then up the rectus abdominus)           Large dull areas might indicate an
                                                Note any large areas of dullness        underlying mass such as pregrant uterus,
                                                                                        ovarian tumor, distended bladder, large
                                                                                        liver or spleen
                                                                                        Dullness in both flanks indicates further
                                                                                        assessment for ascites (see p. 387-389).
                                                                                        In situs inversus (rare), organs are
                                                                                        reversed: air bubble on the right, liver
                                                                                        dullness on the left
38. Palpate      No masses or tenderness        Same flow as above. Palpate first       Involuntary rigidity (muscular spasm)          376-379
abdomen and      noted x 4 quadrants with       with a light, gentle, dipping           typically persists despite the relaxation
measure aortic   light & deep palpation. NO     motion (raise hand when moving          maneuvers. It indicates peritoneal
pulsation        rebound tenderness. Aortic     from place to place). Then              inflammation.
                 pulsations < 3 cm.             repeat a 2nd time deeper.               Abdominal masses may be categorized in
                                                MUST WATCH PT’S FACE                    5 ways:
                                                DURING PALPATION TO SEE                 Physiologic (pregnant uterus)
                                                ANY REACTIONS OF PAIN.                  Inflammation(colon diverticulitis)
                                                Measure aortic pulsation by using       Vascular (aortic aneurysm)
                                                both hands vertically on pt.            Neoplastic (carcinoma of colon)
                                                abdomen a few cms apart from            Obstructive (distended bladder or dilated
                                                umbilicus and have pt breath in         loop of bowel)
                                                and out as you move deeper in to        Increased pulsation of an aortic aneurysm
                                                feel pulse.                             or of an increased pulse pressure

39. Palpate      Liver without tenderness or    Position L hand under flank, and        Firmness or hardness of the liver, bluntness   380-382,
bimanually for   enlargement                    R hand under costal margin (~3-4        or rounding of its edge, and irregularity of   Table 10-
liver                                           cm) and lateral to the rectus           its contour suggest an abnormality of the      12, p.
                                                abdominus mm                            liver                                          409
                                                Have pt breathe in and then out,        The edge of an enlarged liver may be
                                                while they breathe out  move           missed by starting palpation too high in the
                                                hand under costal margin                abdomen
                                                Hold position while pt breathes in      Tenderness over the liver suggests
                                                again. Should fell lower border of      inflammation, as in hepatitis, or
                                                liver                                   congestion, as in heart failure
                                                                                        Liver enlargement: apparent and real on
                                                                                        table 10-12.
40. Palpate      Spleen without tenderness      From pt’s R side, put L hand            An enlarged spleen may be missed if the        382-384
bimanually for   or enlargement                 under ribcage and palpate with R        examiner starts too high in the abdomen to
spleen                                          hand. Same technique as with            feel the lower edge.
                                                liver. Normally you will not feel it.   A palpable spleen tip, though not
                                               Alice Fong – Phys Clin Lab Fall 09 Page 14
                                                                                      necessarily abnormal, may indicate splenic
                                                                                      enlargement. The spleen tip below is just
                                                                                      palpable deep to the left costal margin.
                                                                                      The enlarged spleen is palpable about 2 cm
                                                                                      below the left margin on deep inspiration
41. Palpate      Areas palpated without         Palpate in a circular motion the      A “tonsillar node” that pulsates is really the   170, 196-
cervical lymph   tenderness, enlargement, or    following bilaterally:                carotid artery. A small, hard, tender            197
nodes            induration                     Preauricular, posterior auricular,    “tonsillar node” high and deep btw the
                                                occipital, tonsillar, submental,      mandible and the sternomastoid is probably
                                                submaxillary, superficial cervical,   a styloid process
                                                deep cervical, posterior cervical,    Enlargement of the supraclavicular node,
                                                supraclavicular. Not normally         esp. on the left, suggests possible
                                                palpable.                             metastatis from a thoracic or an abdominal
                                                                                      malignancy
                                                                                      Tender nodes suggest inflammation; hard
                                                                                      or fixed nodes suggest malignancy
                                                                                      Diffuse lymphadenopathy raises the
                                                                                      suspicion of HIV or AIDS
42. Palpate      Areas palpated without         Palpate axillary nodes bilaterally:   Lymphedema of the arm and hand may               340, 481-
axillary and     tenderness, enlargement, or    Apical, pectoral, lateral,            follow axillary node dissection and radiation    482
epitrochlear     induration                     subscapular, infraclavicular          therapy.
nodes                                           Palpate epitrochlear nodes.           An enlarged epitrochlear node may be
                                                                                      secondary to a lesion in its drainage area or
                                                                                      may be associated with generalized
                                                                                      lymphadenopathy
43. Palpate      Areas palpated without         Find inguinal ligament between        Lymphadenopathy refers to enlargement            483
inguinal nodes   tenderness, enlargement, or    ASIS and pubic symphysis.             of the nodes, with or without tenderness.
and femoral      induration                     Palpate horizonal and vertical        Try to distinguish btw local and generalized
pulse                                           groups. Shotty nodes are              lymphadenopathy, by finding either (1) a
                                                common in this area. Bilateral.       casative lesion in the drainage area, or (2)
                                                Don’t be shy in this area, be         enlarged nodes in at least 2 other
                                                professional.                         noncontiguous lymph node regions.
                                                                                      A diminished or absent pulse indicates
                                                                                      partial or complete occlusion proximally; for
                                                                                      example, all pulses distal to the occlusion
                                                                                      are typically affected. Chronic arterial
                                                                                      occlusion, usually from atherosclerosis,
                                                                                      causes intermittent claudication.
                                                                                      An exaggerated, widened femoral pulse
                                                                                      suggests a femoral aneurysm, a pathologic
                                                                                      dilation of the artery.
                                               Alice Fong – Phys Clin Lab Fall 09 Page 15
44. Inspect and   No signs of inflammation of      Squeeze/palpate feet, ankles,        MANY abnormalities. Look at page                 515, 517,
palpate joints    the joints or surrounding        knees, hips, fingers, wrists,        numbers for all abnormalities.                   521, 524-
                  tissues                          elbows and shoulders bilaterally     Swelling over the olecranon process in           527, 532-
                                                                                        olecranon bursitis; inflammation or synovial     536, 540-
                                                                                        fluid in arthritis.                              542, 546,
                                                                                        Tenderness over the distal radius is in          550, 553-
                                                                                        Colle’s fracture.                                555
                                                                                        Tenderness over the “snuffbox” in scaphoid
                                                                                        fracture, the most common injury of the
                                                                                        carpal bones.
45. Test ROM      ROM of the lower extremities     Hip (raise and lower thigh for       MANY abnormalities. Look at page                 541-542,
of lower          equal B/L without limitation,    each side, bring limb to Abd and     numbers for all abnormalities.                   550-552,
extremity         pain or crepitus                 Add. Internal and external rot)      In flexion deformity of the hip, as the          554-555
                                                   Knee (Have pt put feet flat on       opposite hip is flexed, the affected hip does
                                                   table and point toes toward each     not allow full leg extension, and the affected
                                                   other and away from each other)      thigh appears flexed.
                                                   Ankle (ask pt to put soles of feet   Flexion deformity may be masked by an
                                                   together, then soles face the        increase, rather than flattening, in lumbar
                                                   walls)                               lordosis and an anterior pelvic tilt.

Patient Seated
46. Test ROM      ROM of the upper                 Pt is seated.                        MANY abnormalities. Look at page              515-517,
of upper          extremities equal B/L without    Check ROM of shoulders (6),          numbers for all abnormalities.                521, 526-
extremity         limitation, pain or crepitus     elbow (4), wrists (4) and fingers    Localized tenderness or pain with adduction 527
                                                   (4)                                  suggests inflammation or arthritis of the
                                                                                        acromioclavicular joint.
                                                                                        Full elbow extension makes intra-articular
                                                                                        process, effusion, or hemarthrosis unlikely.
                                                                                        Conditions that impair range of motion
                                                                                        include arthritis, tenosynovitis, Dupuytren’s
                                                                                        contracture.

47. Inspect the   No scoliosis or kyphosis of                                           Increased thoracic kyphosis occurs with          533
spine and renal   the spine noted.                                                      aging. In children a corrected structural
angles                                                                                  deformity should be pursued.
                                                                                        In scoliosis, there is a lateral and rotatory
                                                                                        curvature of the spine to bring the head to
                                                                                        midline.
                                                                                        Unequal shoulder heights seen in scoliosis,
                                                                                        Sprengel’s deformity of the scapula,

                                                  Alice Fong – Phys Clin Lab Fall 09 Page 16
                                                                                          winging of the scapula.
                                                                                          Birthmarks, port-wine stains, hairy patches,
                                                                                          and lipomas often overlie bony defects such
                                                                                          as spina bifida.
                                                                                          Café-au-lait spots, skin tags, and fibrous
                                                                                          tumors in neurofibromatosis
48. Percuss the     Percussion of the spine &       Percuss spine from T1-L5. Use         Herniated intervertebral discs, most            532-534
spine and renal     renal angle without evidence    fist to percuss over spinous          common between L5 and S1 or between L4
angles              of tenderness.                  processes                             and L5, may produce tenderness of the
                                                    Check for costovertebral angle        spinous processes, the intervertebral joints,
                                                    tenderness (can use finger            the paravertebral muscles, the sacrosciatic
                                                    palpation or fist percussion         notch, and the sciatic nerve.
                                                    start higher and move down)           Rheumatoid arthritis may also cause
                                                                                          tenderness of the intervertebral joints.
                                                                                          Remember that tenderness in the
                                                                                          costovertebral angles may signify kidney
                                                                                          infection rather than a musculoskeletal
                                                                                          problem.
49. Test ROM        Cervical ROM without pain       Flex (touch chin to chest)            Limitations in range of motion can arise        534-535
of cervical spine   or limitation                   Extend (look at ceiling)              from stiffness from arthritis, pain from
                                                    Lat Flex: R ear to R shoulder,        trauma, or muscle spasm such as torticollis
                                                    then L                                It’s important to assess any complaints or
                                                    Lat Rot: look over R shoulder,        findings of neck, shoulder, or arm pain or
                                                    then L                                numbness for possible cervical cord or
                                                                                          nerve root compression.
                                                                                          Tenderness at C1-C2 in rheumatoid arthritis
                                                                                          suggests possible risk for subluxation and
                                                                                          high cervical cord compression
50. Test ROM        Lumbar ROM without pain or      Flex: bend forward                    Deformity of the thorax on forward bending      535-536
of lumbar spine     limitation                      Extend: arch back                     in scoliosis.
                                                    Lat flex: lean to R, lean to L        Persistence of lumbar lordosis suggests
                                                    Lat Rot: cross arms over              muscle spasm or ankylosing spondylitis.
                                                    shoulder and turn to R and then L     Decreased spinal mobility in osteoarthritis
                                                                                          and ankylosing spondylitis, among other
                                                                                          conditions.
                                                                                          Underlying cord or nerve root compression
                                                                                          should be considered. Note that arthritis or
                                                                                          infection in the hip, rectum, or pelvis may
                                                                                          cause symptoms in the lumbar spine.
51. Check           CN is intact                    Far vision: take pt out to hall and   Vision of 20/200 means that at 20 feet the      177-178,
visual acuity (CN                                   have them cover one eye and           patient can read print that a person with       612,
                                                   Alice Fong – Phys Clin Lab Fall 09 Page 17
II)                                stand 20 ft from the Snellen chart      normal vision could read at 200 feet. The        Table 6-
                                   and ask them to read smallest           larger the second number, the worse the          9, p.217
                                   line. Missing 2 or more = fail.         vision.
                                   Cover other eye and repeat.             Myopia is impaired far vision
                                   OD = right eye, OS = left eye           Presbyopia is the impaired near vision,
                                   Record whether contacts were            found in middle-aged and older people. A
                                   used                                    presbyopic person often sees better when
                                   Near vision: have pt cover one          the card is farther away.
                                   eye, use Rosenbaum card and             In the US, a person is usually considered
                                   start with 20/20 line and work          legally blind when vision in the better eye,
                                   your way up                             corrected by glasses, is 20/200 or less.
                                                                           Legal blindness also results from a
                                                                           constricted field of vision: 20 degrees or
                                                                           less in the better eye.
                                                                           Ptosis in 3rd nerve palsy, Horner’s
                                                                           syndrome (ptosis, meiosis, anhidrosis),
                                                                           myasthenia gravis
                                                                           Pupillary abnormalities on table 6-9
52. Test EOM       CN is intact    Stand in front of pt. Tell pt to hold   Sustained nystagmus within the binocular         183-184,
(CN III, IV, VI)                   head very still and follow pen with     field of gaze is seen in a variety of            Table 17-
                                   only their eyes. Make a big H in        neurologic conditions.                           4, p. 655-
                                   space, then bring pen to nose.          Lid lag and poor convergence can be seen         656,
                                   Look for loss conjugate                 in hyperthyroidism.                              Table 6-
                                   movements, check convergence,           In paralysis of the CN VI, illustrated below,    10, p.218
                                   ID nystagmus, look for ptosis           the eyes are conjugate in right lateral gaze
                                                                           but not in left lateral gaze, left
                                                                           infranuclearopthalmoplegia
                                                                           In the lid lag of hyperthyroidism, a rim of
                                                                           sclera is seen between the upper lid and
                                                                           iris; the lid seems to lag behind the eyeball.
                                                                           Nystagmus on table 17-4,
                                                                           Dysconjugate gaze on table 6-10
53. Check          CN is intact    Ask pt to clench teeth and              Weak or absent contraction of the temporal       613
strength of                        palpate for strength of masseter        and masseter muscles on one side
temporalis and                     and temporalis mm.                      suggests a lesion of CN V. Bilateral
masseter (CN V)                                                            weakness may result from peripheral or
                                                                           central involvement. When the patient has
                                                                           no teeth, this test may be difficult to
                                                                           interpret.
54. Check          CN is intact    Can be tested in many ways but          Absense of blinking suggests a lesion of         614-615,
facial muscles                     important to test both upper and        CN V. A lesion of CN VII (innervates the         Table 17-
                                  Alice Fong – Phys Clin Lab Fall 09 Page 18
(CN VII)                            lower segments of the face.            muscles that close the eyes) may also           5, p.657-
                                    Have pt raise eyebrows and             impair this reflex.                             658.
                                    smile (or puff out cheeks)             Flattening of the nasolabial fold and
                                                                           drooping of the lower eyelid suggest facial
                                                                           weakness.
                                                                           A peripheral injury to CN VII, as in Bell’s
                                                                           palsy, affects both the upper and lower
                                                                           face; a central lesion affects mainly the
                                                                           lower face.
                                                                           In unilateral facial paralysis, the mouth
                                                                           droops on the paralyzed side when the
                                                                           patient smiles or grimaces.
                                                                           Types of facial paralysis on table 17-5.
55. Check           CN is intact    Can use a watch that ticks loudly      Nystagmus may indicate vestibular               615,
auditory acuity                     or rub fingers together. Have pt       dysfunction.                                    Table 6-
(CN VIII)                           close their eyes and cover one         Patterns of hearing loss on table 6-19,         19,
                                    ear and ask them if they can hear      nystagmus on table 17-4.                        p.229,
                                    it. Instruct them to tell you when                                                     Table 17-
                                    they can no longer hear it and                                                         4, p. 655-
                                    move slowly away from ear until                                                        656.
                                    they say stop. Chart distance.
                                    Check both sides for asymmetry.
                                    If hearing loss is present, test for
                                    lateralization and compare air
                                    and bone conduction.
56. Check           CN is intact    Ask pt to open mouth, stick out        Hoarseness in vocal cord paralysis; a nasal 615-616,
phonation, uvula,                   tongue and say “ahh.” Check            voice in paralysis of the palate.                Table 16-
tongue (CN IX,                      uvula and soft palate with             Pharyngeal or palatal weakness is exhibited 2, p.591
X, XII)                             penlight. Palate will rise, pharynx    by difficulty swallowing.
                                    opens up, and uvula rises              The palate fails to rise with a bilateral lesion
                                    symmetrically.                         of the vagus nerve. In unilateral paralysis,
                                    Ask pt to push tongue against          one side of the palate fails to rise and ,
                                    cheek to test for strength             together with the uvula, is pulled toward the
                                                                           normal side (see p. 195).
                                                                           Unilateral absence of this reflex suggests a
                                                                           lesion of CN IX, perhaps CN X.
                                                                           For poor articulation, or dysarthria,see
                                                                           table 16-2, disorders of speech. Atrophy
                                                                           and fasciculations in amyotrophic lateral
                                                                           sclerosis, polio.
                                                                           In a unilateral cortical lesion, the protruded
                                   Alice Fong – Phys Clin Lab Fall 09 Page 19
                                                                                              tongue deviates transiently in a direction
                                                                                              away from the side of the cortical lesion.
57. Check            CN is intact                       Traps: From behind, have pt           Weakness with atrophy and fasciculations        615-616
strength of SCM                                         shrug shoulders, tell pt to hold it   indicates a peripheral nerve disorder. When
and trapezius                                           while you push down on                the trapezius is paralyzed, the shoulder
(CN XI)                                                 shoulders                             droops, and the scapula is displaced
                                                        SCM: Ask pt to slightly rotate to     downward and laterally.
                                                        side and hold their head still and    A supine patient with bilateral weakness of
                                                        push against their head to see if     the sternomastoids has difficulty raising the
                                                        mm locks                              head off the pillow.
58. Check            Muscle strength 5+ at C5-T1        Biceps (C5): bent elbows and          Weakness of extension is seen in                619-621
muscle strength      bilaterally                        have pt hold while you push           peripheral nerve disease such as radial
of biceps, wrist                                        down on forearms                      nerve disease such as radial nerve damage
ext., triceps,       Muscle strength is graded on       Wrists (C6): flex wrists, have        and in central nervous system disease
finger flex/abd.     a 0 to 5 scale:                    them hold and you pull                producing hemiplegia, as in stroke or
(C5-T1)              0 – No muscular contraction        Triceps (C7): forearm prone,          multiple sclerosis.
                     detected                           have pt hold while you push           A weak grip may be due to either central or
                     1 – a barely detectable            Grip (C8): Have pt grip your          peripheral nervous system disease. It may
                     flicker or trace of contraction    fingers to test for finger flexion    also result from painful disorders of the
                     2 – active movement of the         Ab/Add of thumb (T1): Have pt         hands.
                     body part with gravity             hold out fingers and hold them        Weak finger abduction in ulnar nerve
                     eliminated                         still while you push 2 at a time      disorders.
                     3 – active movement against        together                              Weak opposition of the thumb in median
                     gravity                                                                  nerve disorders such as carpal tunnel
                     4 – active movement against                                              syndrome
                     gravity and some resistance
                     5 – active movement against
                     full resistance without
                     evident fatigue. This is
                     normal muscle strength.
59. Check            Muscle strength 5+ at L2-S1        Hip/Psoas (L2): Have pt try to        Symmetric weakness of the proximal              622-625
muscle strength      bilaterally                        bring thigh up while you press        muscles suggests a myopathy or muscle
of psoas, quads,                                        down on them in sitting position      disorder; symmetric weakness of distal
ankle dorsiflex,                                        Patellar/Quads (L3): Have pt try      muscles suggest a polyneuropathy, or a
toe ext., ankle                                         to extend knee while you push         disorder of the peripheral nerves.
plantar flex, (L2-                                      against legs
S1)                                                     Dorsiflex (L4): Have pt dorsiflex
                                                        and you push down on foot
                                                        Toe extension (L5): Have pt lift
                                                        toes while you hold them down
                                                        Achilles/Ankle Plantarflexion
                                                       Alice Fong – Phys Clin Lab Fall 09 Page 20
                                                      (S1): Have pt point toes down
                                                      while you try to pull up on feet
60. Check DTR        DTR’s 2+ bilaterally             Biceps (C5): Take thumb, put on       Hyperactive reflexes suggest central          633-637
at biceps,                                            biceps tendon and hit your thumb      nervous system disease. Sustained
triceps, patellar,   4+ - Very brisk, hyperactive,    with hammer                           clonus confirms it. Reflexes may be
achilles (C6/7/8)    with clonus                      Triceps (C7): Find tendon and         diminished or absent when sensation is
(L3/4) (S1)          3+ - Brisker than avg,           hold up arm from elbow (have pt       lost, when the relevant spinal segments are
                     possible but not necessarily     relax arm). Hit the tendon with       damaged, or when the peripheral nerves
                     indicative of dz                 hammer.                               are damaged. Diseases of muscles and
                     2+ - average, normal             Patellar (C): Hit patellar ligament   neuromuscular junctions may also
                     1+ - somewhat diminished,        directly                              decrease reflexes.
                     low normal                       Achilles(S1): passively dorsiflex     The slowed relaxation phase of reflexes in
                     0 – no response                  ankle and strike tendon               hypothyroidism is often easily seen and
                                                                                            felt in the ankle reflex.
61. Check            No sensory deficits noted        Use a Q-tip – make a sharp side       Unilateral decrease in or loss of facial      613, 630
sensory with         with pain or light touch on      by breaking the wood end, make        sensation suggests a lesion of CN V or of
sharp and light      upper or lower extremities       a soft side by pulling the cutton     interconnecting higher sensory pathways.
touch on face,                                        off the tip slightly                  Such a sensory loss may also be
upper and lower                                       Explain to pt that you will be        associated with a conversion reaction.
extremities.                                          touching the with something
                                                      sharp or soft and they will need to   Meticulous sensory mapping helps to
                                                      tell you what they feel               establish the level of a spinal cord lesion
                                                      (demonstrate beforehand)              and to determine whether a more peripheral
                                                      Have them close their eyes            lesion is in a nerve root, a majored
                                                      Touch bilaterally in this order:      peripheral nerve, or one of its branches.
                                                      Above eyebrow -                       Compare symmetric areas  hemisensory
                                                      At zygomatic arch                     loss due to a lesion in the spinal cord or
                                                      Middle of mandible                    higher pathways.
                                                      Shoulder – C4                         Symmetric distal sensory loss suggests a
                                                      Lat epicondyle of humerus – C5        polyneuropathy. You may miss this finding
                                                      Thumb – C6                            unless you compare distal and proximal
                                                      Middle finger – C7                    areas.
                                                      Pinky finger – C8
                                                      Med epicondyle of humerus –T1
                                                      Upper thigh – L1
                                                      mid thigh – L2
                                                      medial epicondyle of femur – L3
                                                      behind medial malleolus – L4
                                                      big toe – L5
                                                      lateral malleolus – S1
                                                      SHARP: Anterior Spinothalamic
                                                     Alice Fong – Phys Clin Lab Fall 09 Page 21
                                                tract: pain and temperature,
                                                crude touch (use stick)

                                                SOFT: Posterior column:
                                                position, vibration and fine touch


Patient
Standing
62. Check gait   Gait coordinated and smooth    Have pt walk across room or          Abnormalities of gait increase risk of falls.    627,
                                                down hall and turn around and        A gait that lacks coordination, with reeling     Table 17-
                                                walk back                            and instability, is called ataxic. Ataxia may    8, p. 663-
                                                Look for cerebellar dz  altered     be due to cerebellar disease, loss of            664.
                                                gait, ataxia                         position sense, or intoxication.
                                                                                     Tandem walking may reveal an ataxia not
                                                                                     previously obvious.
                                                                                     Walking on toes and heels may reveal
                                                                                     distal muscular weakness in the legs.
                                                                                     Inability to heel-walk is a sensitive test for
                                                                                     corticospinal tract weakness.
                                                                                     Abnormalities of gait and posture on table
                                                                                     17-8.
63. Assess                                      Most of this comes from hx           Patients with psychotic disorders often lack     584
judgment and                                    intake. Usually best to assess       insight into their illness. Denial of
insight                                         during interview                     impairment may accompany some
                                                                                     neurologic disorders.
                                                                                     Judgment may be poor in delirium,
                                                                                     dementia, mental retardation, and psychotic
                                                                                     states. Anxiety, mood disorders,
                                                                                     intelligence, education, income, and cultural
                                                                                     values also influence judgment.
                                                                                     Disorientation occurs especially when
                                                                                     memory or attention is impaired, as in
                                                                                     delirium.
64. Assess       Oriented x3                    Can ask specific questions: date,    Causes of poor performance include               584-585
orientation to                                  time, name, names of relatives,      delirium, dementia, mental retardation,
person, place,                                  etc.                                 and performance anxiety.
and time                                                                             Poor performance may be the result of
                                                                                     delirium, the late stage of dementia, mental
                                                                                     retardation, loss of calculating ability,
                                                                                     anxiety, or depression. Also consider the

                                               Alice Fong – Phys Clin Lab Fall 09 Page 22
                                                                               possibility of limited education.
65. Assess                                   Remembering dates and illness,    Remote memory may be impaired in the           585
recent and                                   when they started taking med,     late stage of dementia.
remote memory                                etc.                              Recent memory is impaired in dementia
                                                                               and delirium. Amnestic disorders impair
                                                                               memory or new learning ability significantly
                                                                               and reduce a person’s social or
                                                                               occupational functioning, but they do not
                                                                               have the global features of delirium or
                                                                               dementia. Anxiety, depression, and mental
                                                                               retardation may also impair recent memory.
66. Assess      No depression, anxiety or    Usually done during history       Moods include sadness and deep                 581,
mood            mood disorders noted         intake. Depression, suicidal      melancholy; contentment, joy, euphoria,        Table 16-
                                             ideations. “What do you see for   and elation; anger and rage; anxiety and       1, p.590
                                             yourself in the future?”          worry; and detachment and indifference.
                                                                               Disorders of mood on table 16-1.




                                            Alice Fong – Phys Clin Lab Fall 09 Page 23

				
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