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
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
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
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
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
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
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
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
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
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
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-
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
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
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
Adventitious or added breath sounds on
Normal and altered breath and voice
sounds on table 7-5
Alice Fong – Phys Clin Lab Fall 09 Page 9
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
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.
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
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
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
Asymmetry can be from an enlarged organ
Lower abdomen mass of an ovarian or a
Increased peristaltic wave of intestinal
Localized bulges in the abdominal wall on
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
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
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
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
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.
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
Full elbow extension makes intra-articular
process, effusion, or hemarthrosis unlikely.
Conditions that impair range of motion
include arthritis, tenosynovitis, Dupuytren’s
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
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
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
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),
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
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
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
A peripheral injury to CN VII, as in Bell’s
palsy, affects both the upper and lower
face; a central lesion affects mainly the
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
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
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
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
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
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
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
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