Physical Examination Checklist POM I General 1) Wash hands hands before before beginn beginning ing exami examinati nation— on—in in the CLASS CLASS center, you MUST use the hand wipes that are located in or near the sinks (remember that they are not plumbed) 2) Display Display a professi professional onal demea demeanor nor towar towards ds the patient patient durin during g the exam a) Introduc Introduce e yours yourself elf as a medic medical al student student b) Use the the pat patien ient’s t’s last last name name c) Dress Dress prof profess ession ionall ally y in whi white te coa coatt 3) Appropri Appropriate ate inter interacti action on with with the patient patient—sen —sensiti sitivity vity to privacy, comfort and dignity 4) Drape Drape the patie patient nt appropr appropriat iately ely during during each each segment segment of of the exam 5) Use proper proper sequenci sequencing ng of the the examini examiniati ation on and and proper proper pacing 6) All palpat palpation ion and and auscult auscultati ation on must be be done on on bare skin skin Vital Signs 1) Take Take the the BP in one one arm arm (NOTE (NOTE THAT THAT YOU YOU NEED NEED NOT TAKE THE BP IN BOTH ARMS UNLESS SPECIFICALLY INSTRUCTED TO DO SO) a) Choose Choose a cuff cuff of appropri appropriate ate size size for for the the patie patient nt b) Center Center the the bladder bladder of of the cuff cuff over over the the brachi brachial al arter artery y i) Identify Identify locatio location n of the brachial brachial artery artery by by palpat palpation ion ii) Lower Lower border border of the the cuff cuff shou should ld be about about 2. 2.5 5 cm above the antecubital crease iii) iii) Secure Secure the the cuff cuff snugly snugly c) Positio Position n the pati patient’ ent’s s arm so that it is sligh slightly tly flexed flexed at at the elbow and at raised to heart level d) Estimate Estimate the the systoli systolic c pressure pressure by palpat palpation ion of the the radial radial artery (Bates, pp 76) i) Wait Wait 15 seco seconds nds afte afterr defla deflati ting ng the the cuff cuff befor before e auscultating auscultating the BP e) Take Take the the BP, BP, usin using g auscu auscult ltat ation ion i) Liste Listen n with with the the stet stethos hoscop cope e over over the bra brach chial ial artery ii) ii) Inflat Inflate e cuff cuff rapid rapidly ly to at at least least 150 150 mm Hg Hg iii) iii) Deflate Deflate at at rate rate of of 2-3 mm Hg per seco second nd iv) Note systolic systolic and diastoli diastolic c pressur pressures es 2) Take Take the radial radial pulse pulse for for 15 secs secs if the rhyth rhythm m is regular regular (60 (60 secs if rate is slow or fast) a) Use the the pads pads of inde index x and mid middle dle fing finger ers s b) Compress Compress the the radial radial artery artery until until a maximal maximal pulsa pulsation tion is detected 3) Count Count the the respi respirat rator ory y rate rate for 1 minut minute e a) Watch Watch movem movement ent of the the ches chestt wall wall Head 1) Inspect Inspect the the skull, skull, scalp, scalp, hair hair by partin parting g the hair hair in at least least three places 2) Insp Inspec ectt the the fac face e Ears 1) Inspect Inspect the externa externall ear—a ear—auric uricle le or or pinna pinna 2) Use the the otoscop otoscope e to inspec inspectt the inter internal nal audito auditory ry canal canal and the eardrum and middle ear a) Select Select the largest largest availa available ble specul speculum um for for the otosc otoscope ope b) Positio Position n the patie patient’s nt’s head head to allo allow w best inser insertion tion of of the otoscope c) Pull the auricle auricle gently gently upwar upwards ds and and back backward wards s to straighten the canal d) Hold Hold the otoscope otoscope between between thumb thumb and fingers fingers (see (see Bates, p 156) e) Insert Insert the the specu speculum lum gently gently into into the ear canal canal i) Iden Identtify ify the the eard eardru rum m ii) ii) Iden Identi tify fy the the con cone e of lig light ht iii) iii) Ident Identify ify the malle malleus us 3) Asse Assess ss h he earin ring a) Ask the the patie patient nt to occlu occlude de one ear with with a finge fingerr and then the examiner whispers softly from 1 or 2 feet away toward the unoccluded ear i) Choose Choose short short words words (see (see Bat Bates es p 157) 157) b) Check Check air and bone bone con conduc ducti tion on i) Weber test (1) place place the base base of the lightl lightly y vibrating vibrating tuning tuning fork firmly on top of the patient’s head (2) Ask where where the the patie patient nt hears hears it ii) Rinne test
(1) Place Place the base of of the lightly lightly vibrat vibrating ing tuning tuning fork on the mastoid bone (2) When the the patient patient can can no longe longerr hear the the sound, quickly place the fork close to the ear canal and ask whether sound can still be heard
Eyes 1) Check Check for visua visuall acuity acuity using using a Snell Snellen en eye card or eye eye chart in the exam room 2) Ass Assess ess visu visual al fiel fields ds (Bat (Bates, es, p 145145-146 146)) a) Ask the the patient patient to look look with with both both eyes eyes into your eyes eyes b) While While you retur return n the pati patient’ ent’s s gaze, gaze, place place your hands hands about 2 feet apart, lateral to the patient’s ears. c) Instruct Instruct the pati patient ent to point point to your your finge fingers rs as soon soon as as they are seen d) Then Then slowly slowly move move the the wiggli wiggling ng finger fingers s of both both your hands along the imaginary bowl and towards the line of gaze until the patient identifies them e) Repeat Repeat this this patter pattern n in the the upper upper and lowe lowerr temporal temporal quadrants 3) Insp Inspec ectt exte extern rnal al eye eye a) Stand Stand in front front of the patie patient nt and and survey survey the the eyes eyes for position and alignment with each other b) Inspect Inspect the eyebr eyebrows— ows—qua quantit ntity y and distribu distributio tion n c) Insp Inspec ectt the the eyel eyelid ids s d) Inspect Inspect the region region of of the the lacrim lacrimal al gland glands s e) Inspe Inspect ct the the conju conjunct nctiva iva and and scler sclera a i) Ask the the patien patientt to loo look k up as as you you depre depress ss both both lower lids with your thumbs (Bates p 147), exposing sclera and conjunctiva f) Inspect Inspect the cornea cornea and lens, lens, using using a penlig penlight ht shine shined d oblique across the eye g) Insp Inspec ectt eac each h iri iris s h) Inspect Inspect the pupil pupils s for size, size, shape shape and and symmetr symmetry y 4) Assess Assess pupilla pupillary ry reflex reflexes es (turn (turn out out the room room light light if necessary) a) To light light—ask —ask the patie patient nt to look look into into the dist distance ance and and shine a bright light obliquely into each pupil in turn. i) Note Note direc directt reac reaction tion—pup —pupilla illary ry const constrict riction ion in the same eye ii) Note Note indirect indirect reac reaction tion—pup —pupilla illary ry constri constricti ction on in the the opposite eye b) Assess Assess accomo accomodati dation on – ask ask the the patie patient nt to look alternately at a pencil held 10 cm from his eye and into the distance directly behind it. Observe for pupillary constriction with near effort 5) Ass Assess ess Extrao Extraocul cular ar movem movemen ents ts a) From 2 feet in front front of the the patien patient, t, shine shine a light light into into the the patient’s eyes and ask the patient to look at it. Inspect the reflections in the corneas, which should be visible slightly nasal to the center of the pupils b) Ask the the patient patient to follo follow w your finger finger or pencil pencil as you you sweep through the six cardinal directions of gaze i) To the the pati patien ent’ t’s s extr extrem eme e righ rightt ii) ii) To the the rig right ht and and upw upwar ard d iii) iii) To the the righ rightt and and downw downwar ards ds iv) Without Without pausi pausing ng in the the middle middle to the the extreme extreme left left v) To the the lef leftt and and upwa upward rds s vi) vi) To the the left left and and downw downwar ards ds 6) Ophthalm Ophthalmosco oscopic pic exam (See “Steps “Steps for for using using the ophthalmoscope” and “Steps for examining the opic disc and the retina” in Bates pp 152 and 153 Nose 1) Inspect Inspect the the anteri anterior or and and inferior inferior surfaces surfaces of of the nose nose a) Push gentl gently y on the the tip of of the nose nose to to widen widen the the nostril nostrils s b) Use a penlig penlight ht to to view view the the nasal nasal vesti vestibule bule 2) Inspect Inspect the the inside inside of of the nose using using an otosco otoscope pe with with the the largest available speculum a) Tilt Tilt the patie patient’s nt’s head head back back slig slightly htly and and insert insert the the speculum (Bates p 159) b) Inspect Inspect the the inf and mid mid turbin turbinate ates s and nasal nasal septum septum 3) Palpate Palpate the the frontal frontal and and maxilla maxillary ry sinuses sinuses for tende tendernes rness s (Bates p 160
Mouth and Pharynx 1) Inspect the lips 2) Inspect the oral mucosa using a good light and a tongue blade 3) Inspect the gums and teeth 4) Inspect the hard palate 5) Inspect the tongue and floor of the mouth a) Ask the patient to put out his tongue b) Ask the patient to put his tongue on the roof of his mouth 6) Inspect the pharynx a) Tongue in normal position, ask the patient to say “ah;” but if pharynx not well visualized use a tongue blade b) Inspect the soft palate, tonsils and pharynx
Neck 1) Assess neck ROM (Bates p 504) by asking the patient to perform the following maneuvers: a) Flexion: touch the chin to the chest b) Extension: look up at the ceiling c) Rotation: turn the head to each side, looking directly over the shoulder d) Lateral bending: tilt the head, touching each ear to the corresponding shoulder 2) Palpate the lymph nodes (See Bates p 163-164 for specific technique) 3) Inspect trachea and feel for any deviation by placing a finger along one side of the trachea, noting the space, and compare with the opposite side. 4) Inspect the thyroid gland a) Tip the patient’s head back b) Locate the cricoid cartilage and inspect the region below for the thyroid 5) Palpate the thyroid gland (See Bates p 167) – may be performed from either an anterior or posterior approach a) Flex the neck slightly forward b) Place finger of both hands on the patient’s neck with index fingers just below the cricoid cartilage c) Feel for the thyroid isthmus d) Displace the trachea to the right with the fingers of your left hand; palpate with R fingers for the right lobe of the thyroid e) Reverse the use of the fingers to feel the left lobe of the thyroid Cranial Nerves (Bates, pp 567-571) 1) Olfactory (CN I) – usually not tested 2) Optic (CN II) – you have already tested for visual fields. Visual acuity can be tested with an eye chart 3) Oculomotor (CN III) – you have already tested pupillary constriction and the EOM controlled by this nerve 4) Trochlear (CN IV) – you have already tested for downward, inward movement of the eye 5) Trigeminal (CN V) a) While palpating the temporal and masseter muscles in turn, ask the patient to clench her teeth b) Check the forehead, cheeks and jaw on each side for pain and light touch c) Check the corneal reflex with a wisp of cotton 6) Abducens (CN VI) – you have already tested for lateral deviation of the eye with your extra-ocular movement maneuvers 7) Facial (CN VII) a) Ask the patient to raise both eyebrows b) Frown c) Close both eyes tightly d) Show both upper and lower teeth e) Smile f) Puff out both cheeks 8) Acoustic (CN VIII) – you have already assessed hearing and performed Weber and Rinne maneuvers 9) Glossopharyngeal (CN IX) – tested together with CN X 10) Vagus (CN X)
a)
Ask the patient to say “ah” and watch the movements of the soft palate and pharynx b) Check gag reflex with a tongue blade 11) Spinal Accessory (CN XI) a) Ask the patient to shrug both shoulders against your hands b) Ask the patient to turn her head to each side against your hand 12) Hypoglossal (CN XII) a) Ask the patient to protrude her tongue b) Ask the patient to push the tongue against the inside of each cheek Posterior thorax 1) The patient should be sitting with the posterior thorax exposed. 2) The doctor assumes a midline position behind the patient 3) Inspect the cervical, thoracic and upper lumbar spine (you will check for ROM of the thoracic and lumbar spine towards the end of the complete physical when the patient is standing up) 4) Palpate the spinous processes of each vertebra for tenderness with your thumb or by thumping with the ulnar surface of your fist (Bates p 503) 5) Assess for costovertebral tenderness a) Place the ball of one hand in the costovertebral angle and strike it with the ulnar surface of your fist (Bates p 344) 6) Inspect the shape and movement of the chest wall
a) b)
Place your thumbs at the level of the 10 th ribs with your fingers loosely grasping the rib cage and gently slide them medially. Ask the patient to inhale deeply and observe whether your thumbs move apart symmetrically
Posterior thorax – lung exam 1) Examination techniques MUST be performed on bare skin 2) Palpate for tactile fremitus a) Use either the ball of your palm or the ulnar surface of your hand for palpation b) Ask the patient to repeat the words “ninety-nine” c) You may palpate one side at a time or use both hands simultaneously to compare sides d) Palpate in four locations on both sides of the chest and compare (Bates p 223) 3) Percuss a) Ask the patient to keep both arms crossed in front of the chest b) Press the DIP joint of the left middle finger firmly against the chest wall, avoiding contact with other fingers (Bates p 223) c) Strike this DIP joint with the tip of the right middle finger, swinging from the wrist d) Percuss in seven areas on each side (Bates p 225) 4) Auscultate for breath sounds a) Instruct the patient to breathe deeply through an open mouth b) Listen with the diaphragm of the stethoscope in the same seven areas in which you percussed
Anterior thorax—lung exam 1) Examination techniques MUST be performed on bare skin 2) The patient may be either sitting or supine. The drape should be adjusted to allow exposure of the area being examined 3) Inspect the shape of the patient’s chest and movement of the chest wall (NB when moving from the post chest when you have completed auscultating, it is acceptable to auscultate the ant chest before inspection or palpation) 4) Palpate for tactile fremitus a) Use the ball of the palm or ulnar surface of the hand to palpate in 3 areas on each side of the anterior chest (Bates p 231)
5)
6)
Percuss the anterior and lateral chest, comparing sides, in 6 areas on each side (Bates p 231) a) Displace a woman breast with your left hand or ask her to move her breast for you Auscultate the anterior chest, comparing sides in the 6 areas on each side where you percussed.
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9)
Axillae – examination of the axillae can be performed at the present juncture. It is sometimes performed at the end of the exam, or as part of a breast exam in a female 1) Inspect the skin of each axilla (Bates, pp 310-311) 2) Palpation L axilla a) Ask the patient to relax with the L arm down b) Support the L wrist or hand with your left hand c) Cup together the fingers of your right hand and reach as high as you can toward the apex of the axilla d) Press your fingers toward the chest wall and slide down to feel potential LN e) To palpate for lateral group of LN, feel along the upper humerus 3) Palpation R axilla – reverse your hands and follow the steps above
Cardiovascular
1) The patient should be supine with the upper body raised by
2) 3)
4)
5)
elevated the table to about 30 °. The drape should be arranged to expose the precordium. EXAM TECHNIQUES MUST BE PERFORMED ON BARE SKIN. The examiner should stand tat the patient’s right side Inspect the precordium a) look for apical impulse b) look for any other movements Palpate for precordium a) Use the palmar surfaces of several fingers to locate the PMI—can switch to one fingertip when located i) Displace a woman’s breast upward or laterally, or ask her to do this for you ii) Note location of PMI, amplitude and duration b) Palpate for the RV impulse along the lower left sternal border Auscultation of the heart
a)
6)
7)
Listen to the heart with the diaphragm of your stethoscope in the R 2 nd ICS, L 2nd ICS, L 3rd or 4th ICS, and the lower left sternal border (5 th ICS) and at the apex (may also start at the apex and proceed to the base of the heart) b) Listen to the heart with the bell of your stethoscope in the same five listening areas Inspect the neck for jugular venous pulsations a) Turn the patient’s head slightly away from the side you are inspecting (Bates p 267) b) Raise or lower the bed until you identify the pulsations c) Identify the highest point of pulsation i) Meausure the vertical distance of this point above the sternal angle Inspect the neck for carotid pulsations
Palpate the carotid pulsation a) Place your left index and middle fingers (or thumb) on the right carotid artery i) Note amplitude and contour of the pulse wave ii) Never palpate both carotids simultaneously b) Use your right fingers or thumb to palpate the left carotid artery Auscultate the carotid arteries for bruits with the bell of the stethoscope a) Ask the patient to take a deep breath and hold it to eliminate breath sounds
Abdomen 1) The patient should be in a supine position with arms at side or folded across the chest 2) The drapes should be arranged to expose the abdoment from above the xyphoid process to the symphysis pubis. 3) Approach the patient from his right side 4) Inspect the abdomen 5) Ausculate the abdomen as the next step in the exam after inspection a) Place the diaphragm of the stethoscope gently on the abdomen b) Listen for bowel sounds i) Listening in one spot is sufficient c) Listen for an aortic bruit on the midline just above the naval 6) Percuss the abdomen lightly in four quadrants 7) Percuss for liver dullness a) Define the lower edge of liver dullness in the midclavicular line, starting at a level below the umbilicus b) Define the upper edge of liver dullness in MCL, starting in the area of lung resonance i) Gently displace a woman’s breast as necessary c) Measure in centimeters with a ruler the vertical span of liver dullness in the MCL 8) Percuss for splenic dullness a) Percuss along the L lower chest wall between the lung resonance above and the costal margin moving laterally (Bates p 341) i) Ask the patient to take a deep breath and percuss again in this area 9) Palpate the abdomen lightly in four quadrants and in the suprapubic and epigastric areas a) Use a gentle, light dipping motion (Bates p 335) 10) Palpate the abdomen deeply in all four quadrants a) Use a firmer dipping motion 11) Palpate for the liver edge a) Place your R hand on the right abdomen lateral to the rectus muscle, beginning more than 3 fingerbreadths below the costal margin b) Ask the patient to take in a deep breath c) Palpate upwards trying to feel the descending liver edge, using a rocking motion i) May also use the “hooking technique” described in Bates p 340 12) Palpate for a spleen tip a) Reach over and around the patient with your left hand to support and press forward the lower left rib cage b) Press inward towards the spleen with your right hand, beginning at least 3 finger breadths below the L costal margin c) Ask the patient to take in deep breaths, trying to feel the spleen tip as it comes down to meet your fingertips. 13) Palpates for aorta by pressing deeply with one hand on each side of the aorta (Bates, p 344) 14) Palpate for the superficial inguinal lymph nodes (Bates, p 452) 15) Palpate for both femoral artery pulses a) Press deeply below the inguinal ligament (Bates, p 452) Upper extremity—MSK and Partial Neurological (these maneuvers must be repeated on both upper extremities 1) Inspect the hands, including each finger, its skin and joints, and nails a) Palpate any abnormal joints 2) Inspect the wrist 3) Palpate the distal radius and snuff box; palpate the distal ulna 4) Palpate the radial pulse on the flexor surface of the wrist, laterally
a) 5)
Compare the pulses in both arms
Check ROM of the fingers a) Ask the patient to make a tight fist with each hand b) Extend and spread the fingers c) Ask the patient to spread the fingers apart and back together
d)
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7)
8)
Ask the patient to move the thumb across the palm and touch the base of the 5th finger, and then back across the palm and away from the fingers e) Have the patient touch the thumb to each of the other fingertips Check ROM of the wrist (Bates p 499)
a) Flexion b) Extension c) Ulnar and radial deviation Check ROM of the elbow (Bates p 497) a) Flexion and extension: ask the patient to bend and straighten the elbow b) Pronation and supination: with arms at his side, and elbows flexed, ask the patient to turn the palms up and then down Palpate for epitrochlear lymph nodes (Bates p 451)
a) b)
Flex the elbow to 90 ° Palpate in the groove between the biceps and triceps
9) Inspect the shoulder (Bates, p 492) 10) Palpate the shoulder (Bates, p 493) a) Locate the acromion process and the acromioclavicular joint b) Locate the greater tubercle of the humerus c) Locate the coracoid process of the scapula 11) Check ROM of the shoulder (Bates, p 493) a) Watch for smooth, fluid movement as you stand in front of the patient and ask: i) Raise the arms to shoulder level (abduct) with palms facing down ii) Raise the arms to a vertical position above the head with the palms facing each other iii) Place both hands behind the neck with elbows out to the side (external rotation and abduction) iv) Place both hands behind the small of the back (internal rotation and adduction) 12) Test Muscle strength in the upper extremity (Bates pp 574575). You must compare sides a) Test grip—ask the patient to squeeze two of your fingers as hard as possible and not let them go b) Test finger abduction—position the patient’s hand with palms down and fingers spread. Try to force the fingers together c) Test opposition of the thumb—the patient should try to touch the little finger with the thumb against your resistance d) Test extension of the wrist by asking the patient to make a fist and resist you pulling it down e) Test flexion and extension of the elbow by having the patient pull and push against your hand
Lower extremity—MSK and Partial Neurological (these maneuvers must be repeated on both lower extremities 1) The patient may be sitting or lying down and draped so that the external genitalia are covered with the legs fully exposed during the exam 2) Inspect both feet and ankle—compare sides 3) Palpate the feet and ankles (Bates, p 517) a) Assess for pedal edema—press firmly with your thumb over the dorsum of the foot, behind each medial malleolus and over the shins (Bates, p 455) b) Palpate the anterior aspect of each ankle joint
c) Palpate the heel, especially the post and inf calcaneus d) Palpate the MTP joints e) Palpate the heads of the five metatarsals 4) Palpate for the peripheral pulses of the legs a) Dorsalis pedis—feel the dorsum of the foot just lateral to the extensor tendon of the great toe b) Posterior tibial—feel below the medial malleolus of the ankle 5) Check ROM of the ankle (Bates, p 518) a) Dorsiflex and plantar flex the foot at the ankle b) Invert and evert the foot c) Flex the toes 6) Inspect the knee for alignment and contours 7) Palpate the knee with the knee in flexion (Bates, p 511-513) a) Identify the medial femoral condyle and the medial tibial plateau b) Identify the tibial tubercle c) Identify the lateral femoral condyle and lateral tibial plateau d) Identify the patellar tendon and ask the patient to extend the leg e) Palpate the medial collateral and lateral collateral ligaments and menisci f) Feel for swelling above and to the sides of the patella g) Check the prepatellar, anserine and popliteal bursae (Bates p 513) 8) Check ROM of the knee (Bates p 515) a) Ask the patient to flex and extend the knee while sitting (or by asking the patient from a standing position to squat and then stand up again b) Check internal and external rotation by asking the patient to rotate the foot medially and laterally 9) Inspect the hip by observing the patient’s gait at some time during the exam (Bates p 506) 10) Palpate the surface landmarks of the hip a) Anterior surface: locate the iliac crest, iliac tubercle and anterior superior iliac spine b) Posterior surface: locate the posterior superior iliac spine, the greater trochanter and the ischial tuberosity 11) Check ROM of the hip (Bates, p 509-510) a) Flexion—with the patient supine, ask him to bend each knee in turn up to the chest and pull it firmly against the abdomen b) Abduction—grasp the ankle and abduct the extended leg until you feel the iliac spine move c) Adduction—hold one ankle and move the leg medially across the body and over the opposite extremity
d)
Rotation—flex the leg to 90 at hip and knee; stabilize the thigh with one hand, grasp the ankle with the other and swing the lower leg, medially and laterally 12) Check muscle strength in the LE (Bates, p 576-578) a) Test flexion at the hip—place your hand on the patient’s thigh and asking the patient to raise the leg against your hand b) Test adduction at the hips—place your hands firmly on the bed between the patient’s knees. Ask the patient to bring both legs together c) Test abduction at the hips—place your hands firmly on the bed outside the patient’s knees. Ask the patient to spread both legs against your hands d) Test extension at the hips—have the patient push the posterior thigh down against your hand e) Test extension at the knee—support the knee in flexion and ask the patient to straighten the leg against your hand f) Test flexion at the knee—place the patient’s leg so that the knee is flexed with the foot resting on the bed. Tell the patient to keep the foot down as you try to straighten the leg g) Test dorsiflexion and plantar flexion at the ankle—ask the patient to pull down and push down against your hand °
a) Neurological – some parts of the neurological exam have been woven into exam of the head and neck and extremities (i.e. Cranial Nerve exam and motor testing). The remaining components of the neurological exam are covered here 1) Reflexes (Bates, p 588-591) a) Biceps reflex (C5, C6) — with patient’s arm partially flexed at the elbow and palm down, place your thumb or finger firmly on the biceps tendon and strike with reflex hammer b) Triceps reflex (C6, C7) – flex the patient’s arm at the elbow with palm towards the body and pull it across the chest. Strike the triceps tendon above the elbow c) Knee (Patellar) reflex (L2, L3, L4) – patient may be either sitting or supine with knee flexed. Tap the patellar tendon just below the patella d) Ankle (Achilles) reflex (S1) – dorsiflex the foot at the ankle and strike the Achilles tendon e) Plantar (Babinski) response (L5, S1) – with a key or the tip of the shaft of a reflex hammer, stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball 2) Sensory (Bates, p 583-584) a) Pain – Create a sharp from a broken tongue blade i) Compare symmetrical areas on the two sides of the body, including arms, legs and trunk ii) Compare the distal with the proximal areas of the extremities iii) Vary the pace of your testing and occasionally substitute the blunt end for the point, while asking “Is this sharp or dull?” or “Does this feel the same as this?” b) Light touch – using a fine wisp of cotton, touch the skin lightly, avoiding pressure i) Ask the patient to respond whenever a touch is felt. ii) Compare one area with another c) Vibration – Use a low-pitched tuning fork (128 Hz) i) Set the fork vibrating and place it firmly over a DIP of a finger and of the great toe ii) Ask what the patient feels iii) If vibration sense is impaired, move to more proximal bony prominences d) Joint position sense i) Grasp the patient’s big toe, holding it by its sides and pull it away from the other toes so as to avoid friction. ii) Demonstrate “up” and “down” iii) With patient’s eyes closed ask him to identify up and down movements iv) Compare sides v) Move more proximally if joint position is impaired vi) Test JPS in the UE by moving a finger joint 3) Cerebellar/Coordination (Bates, p 578-580) a) Rapid alternating movements i) UE – Show patient how to strike one hand on the thigh, first with the palm, then with the back of the hand. Have the patient repeat these alternating movements as rapidly as possible. Repeat with opposite hand (1) OR Show the patient how to tap the distal joint of the thumb with the tip of the index finger as rapidly as possible. Have the patient perform the action. Check the opposite hand ii) LE – ask the patient to tap your hand as quickly as possible with the ball of each foot in turn b) Point-to-point movements i) UE – ask the patient to touch your index finger and then his nose alternately several times. Move your finger about. ii) LE – Ask the patient to place one heel on the opposite knee and then run it down the shin to the big toe. Repeat on the other side 4) Gait a) Ask the patient to walk across the room, then turn and come back b) Walk heel-to-toe in a straight line c) Walk on toes then on heels 5) Romberg Test
The patient should first stand with feet together and eyes open and then close both eyes for 20-30 secs without support
Back 1) ROM (Bates, p 505) a) Flexion – with patient standing, ask him to bend forward to touch the toes b) Extension – place your hand on the posterior superior iliac spine and with your fingers pointing towards the midline, ask the patient to bend backward as far as possible c) Lateral bending – ask the patient to lean to both sides as far as possible
