CLET FINAL VERBALS Flashcards
MENTAL STATUS EVALUATION
1 Orientation 2 Level of Alertness, Attention, and Cooperation 3 Memory 4 Language 5 Calculations 6 Apraxia 7 Sequencing tasks 8 Abstraction
ORIENTATION
Ask the patient’s name, location, and date
LEVEL OF ALERTNESS, ATTENTION, and COOPERATION
Ask the patient to spell a word forward and back ward Ask the patient to repeat a string of integers forward and backward Ask the patient to name the months forward and backward
MEMORY
Recent - Ask patient to recall three items after 5 minute delay Remote - Ask patient to recall certain historical facts within patient’s memory (lifetime) ** “Where did you go to high school?”
LANGUAGE
Object naming - Ask patient to name 3 objects/shapes Repetition - Ask patient to repeat words or a sentence Reading - Ask patient to read a sentence
CALCULATIONS
Simple additions and subtractions, should be 2 or more steps - ask patient to do a calculation
APRAXIA
Following a complex motor command like “pretend to comb your hair” or “pretend to brush your teeth”
SEQUENCING TASKS
Ask the patient to tap the table with: fist, open palm, then side of open hand (rock, paper, scissors) perform as rapidly as possible
ABSTRACTION
Ask patient to interpret a proverb or colloquialism “The early bird gets the worm”
DIADOCHOKINESIA
Patting Test: Rapid, rhythmic, alternating movements. Have patient pat leg with each hand as fast as possible * Mostly testing cerebellum (coordination and gait)
DIADOCHOKINESIA alt.
Supination - Pronation *Mostly testing cerebellum (coordination and gait)
DYSMETRIA
Index finger test: Have patient touch your (doctor’s index finger) (while Dr. moves finger to all 4 quadrants) and then his/her nose alternately several times. (Note tremors or lack of coordination)
GAIT
Gait- observe patient walking toward and away, note posture, stability, foot elevation, trajectory of leg swing, balance, and arm motions. Tandem gait- ask the patient to walk heel to toe (police DUI test, walk in a straight line) (cerebellum). Forced gait testing- ask the patient to walk on heels for 6 steps and then on toes for 6 steps (test lumbar roots).
INSIDE, OUTSIDE, HEELS, AND TOES
What are the 2 spinothalamic tract tests?
Crude touch and Pain (pinprick)
CRUDE TOUCH
Ask the patient to identify when he or she is being touched with the dull end of the neurotip. (inability = spinothalamic tract involvement)
PAIN (PINPRICK)
Ask the patient to identify when he or she is being touched with the pin or toothpick or the neurotrip (inability = spinothalamic tract involvement)
What are the Dorsal Column Tests?
1 Vibration - Pallesthesia 2 Light Touch 3 Joint Position Sense 4 Romberg Test
VIBRATION PALLESTHESIA
Place the handle of a vibrating 128 Hz tuning fork on the joint line of the upper and lower extremities. utilize 3 distal interphalangeal joints. If abnormal continue to evaluate proximally until a normal finding is achieved at the base of the 5th metacarpal or metatarsal, and the radial and ulnar styloid processes, or medial and lateral malleoli. Ask the patient to identify when he or she feels vibration and when the doctor has stopped the vibration (inability = dorsal column involvement)
LIGHT TOUCH
ask the patient to identify when he or she is being touched with a cotton swab or brush. (inability = dorsal column involvement)
JOINT POSITION SENSE
Dr. stabilizes lateral surface of fingers or toes and asks patient to identify if finger or toe is up or down. Start with DIP, if positive, then move to PIP, then MCP of the lower extremity and then proceed to the upper extremity. If negative at any time, then move to the next digit. (inability = dorsal column involvement)
ROMBERG TEST
ask the patient to stand with the feet shoulder width apart, and with eyes closed, while doctor stands close to steady the patient. (swaying, or falling = dorsal column involvement)
What does Discriminatory Sensation test?
Tests the integrity of the somatosensory cortex***
POINT LOCALIZATION (TOPOGNOSIS)
Ask the patient to identify multiple points the doctor touches with the dull end of the neurotip, a paperclip, or toothpick
SHARP VS DULL DESCRIMINATION
Ask the patient to identify whether the sharp or dull end of the neurotip is being applied to multiple points on the skin of each extremity.
STEREOGNOSIS
Ask the patient to identify familiar objects (keys, pencils, coins) by the sense of touch.
“WHAT’s different about these” ?
** SOMATOSENSORY CORTEX
GRAPHESTHESIA
Ask the patient to identify numbers or letters traced lightly on the skin.
BAROGNOSIS
Ask the patient to identify the difference between two same sized objects of different weight.
TWO POINT DISCRIMINATION
Determine the smallest area in which two points can be separately perceived on the hands. Touch the patient with a paperclip opened wide enough that two separate stimuli are felt, then bring the stimuli closer together until only one is felt. Repeat in three locations (fingertip, finger & palm). Compare bilaterally.
* State that you would measure the 2 and see if it gets better/worse
What is the Westphal sign?
Absence of any DTR (especially patellar; LMNL)
DIRECT LIGHT
RESPONSE: Ipsilateral pupillary constriction when light is shined in the eye AFFERENT: Optic N. II (ipsilateral to light source) INTEGRATING CENTER: Midbrain EFFERENT: Oculomotor Nerve III (ipsilateral to light source)
INDIRECT LIGHT
RESPONSE: Contralateral pupillary constriction when light is shined in the eye AFFERENT: Optic N. II (Ipsilateral to light source) INTEGRATING CENTER: Midbrain EFFERENT: Oculomotor N. III (Contralateral to light source)
ACCOMMODATION
RESPONSE: Convergence of the eyes with with pupillary constriction AFFERENT: Optic N. II INTEGRATING CENTER: Occipital Cortex EFFERENT: Oculomotor N III
CAROTID SINUS
RESPONSE: Reduction in heart rate when examiner presses the carotid sinus AFFERENT: Glossopharyngeal N. IX INTEGRATING CENTER: Medulla EFFERENT: Vagus Nerve X
OCULOCARDIAC
RESPONSE: Reduction in heart rate when examiner presses the eye AFFERENT: Trigeminal N. V INTEGRATING CENTER: Medulla EFFERENT: Vagus N. X
CILLIOSPINAL
RESPONSE: Pupillary dilation when examiner pinched the base of the neck at the cervical sympathetic chain AFFERENT: Cervical Sympathetic Chain INTEGRATING CENTER: T1-T2 Spinal Cord EFFERENT: Cervical Sympathetic Chain
CORNEAL
RESPONSE: Blinking and tearing of the eye upon touching the cornea with a cotton wasp AFFERENT: Trigeminal N. V INTEGRATING CENTER: Pons EFFERENT: Facial N VII
GAG/PHARYNGEAL
RESPONSE: Gagging upon touching the back of the throat with a tongue depressor AFFERENT: Glossopharyngeal N. IX INTEGRATING CENTER: Medulla EFFERENT: Vagus N X
UVULAR/PALATEAL
RESPONSE: Raising of the uvula upon phonation, or touching with a tongue depressor AFFERENT: Glossopharyngeal IX INTEGRATING CENTER: Medulla EFFERENT: Vagus N
INTERSCAPULAR
RESPONSE: Drawing inward of scapular when skin or interscapular space is irritated AFFERENT: T2-T7 Spinal Nerves INTEGRATING CENTER: T2-T7 Spinal Cord EFFERENT: Dorsal Scapular Nerve
ABDOMINAL
RESPONSE: Umbilicus deviation to the stroked side. Absence is normal only if bilateral (see Beevor sign) AFFERENT: Upper T7-10, Lower T11 - T12 INTEGRATING CENTER: Spinal Cord T7-T12 EFFERENT: Upper T7-10, Lower T11-T12
PLANTAR
RESPONSE: Plantar flexion (curling) of toes upon stroking sole of foot AFFERENT: Tibial N INTEGRATING CENTER: Spinal Cord S1-S2 EFFERENT: Tibial N.
GLABELLA aka MCCARTHY
Contraction of orbicularis occuli muscle upon percussion of supraorbital ridge (glabella)
HOFFMAN
Clawing of the fingers and thumb (flexion and adduction of thumb with flexion of the fingers) upon flicking tip of index finger into extension
TROMNER
Flexion of the fingers and thumb upon tapping palmar surface or tips of middle three fingers
ANKLE CLONUS
Continued involuntary contraction (sustained plantar flexion) or foot upon quick forcible dorsiflexion of the foot
BABINSKI
Dorsiflexion of the big toe and fanning or splaying of other toes upon stimulation of the plantar surface of the foot (lateral to medial) (Plantar Reflex)
What are the alternate ways to elicit Babinski?
Oppenheim Sign Chaddock Sign Gordon Sign Schaefer Sign
Oppenheim Sign
Application of pressure to anterior tibia stroking downward
Chaddock Sign
Stroking down the lateral leg around the lateral malleolus
Gordon Sign
Squeezing the calf
Schaefer Sign
Squeezing the achilles tendon
OLFACTORY NERVE (I)
a) Ask about disorders of sense of smell and of taste (will diminish with loss of smell) b) Using a penlight, make sure nostrils are not blocked. c) Occlude one nostril at a time (eyes should be closed) Have patient sniff familiar and non-irritating odors, use the milder scent first. Ask the patient: 1) Do you smell anything? 2) Can you identify the substance?
OPTIC NERVE (II)
a) Inspect external structures of eye b) Inspect the optic fundi with ophthalmoscope c) Test visual acuity Screen by reading print Screen with shapes and/or colors d) Confrontation Test Examine directly in front and level with patient’s face Have patient cover one eye Bring object into view from eight different directions (P-A) per eye e) Direct light reflex- ipsilateral pupillary constriction f) Indirect light reflex (consensual reflex)- contralateral pupillary constriction g) Accommodation reflex Test ability of the eyes to adapt for near vision Instruct patient to follow object inward from a distance Convergence of the eyes, constriction of the pupil
OCULOMOTOR (III), TROCHLEAR (IV), and ABDUCENS (VI)
The following four tests are for CN III specifically: a. Check for ptosis b. Direct light reflex c. Indirect light reflex d. Accommodation reflex The following will test CN III, IV, and VI combined: a) Extraocular movements with six cardinal fields of gaze. Observe patient’s eyes for normal conjugate, or parallel movements of the eyes and nystagmus as you have him/her follow your finger or pencil while it makes a wide “H” in the air: Trochlear = down and in Abducens = lateral Oculomotor all other fields.
(V) Trigeminal Nerve (Ophthalmic, Maxillary, and Mandibular)
a) Oculocardiac Reflex: Take pulse, apply pressure over the patient’s closed eye, pulse rate should decrease 2-3 beats per 15 sec. b) Test corneal reflex with wisp of cotton, should see blinking and tearing c) Test pain (sharp pinprick) on face bilateral in all 3 divisions (3 places per division for a total of 18 touches) d) Test for light touch to the face with wisp of cotton or brush in all 3 divisions (3 places per division for a total of 18 touches) e) Light touch to anterior 2/3 of tongue, inside cheeks, and hard palate with toothpick. (Use a penlight to view the inside of the mouth) f) Have patient clench teeth, palpate masseter and temporalis muscles at rest & motion.
FACIAL NERVE (VII)
a) Ask the patient about changes in taste sensations sweet, salty, and sour on the anterior two thirds of the tongue. b) Inspect face for asymmetry (at rest and during motion) Ask the patient to perform the following: Raise eyebrows Close eyes tightly Show teeth Puff out cheeks Smile Frown
VESTIBULO-COCHLEAR NERVE (VIII)
Sensory-Cochlear Portion a) Screening tests to confirm side of hearing loss: Finger Rub Test: Assess hearing by rubbing fingers together near the EAM (external auditory meatus), find maximal distance sound can be heard. Whisper Test Have patient close his eyes (to prevent lip-reading) and cover the ear on the side not being tested. Place your head/mouth 2 feet from the ear being tested and whisper words to the patient and ask patient to repeat the words. You can also ask questions to the patient and have the patient answer yes or no to each question. b) Distinguish between perceptive and conductive hearing loss using a 512 Hz tuning fork by using Weber and Rinne tests. Weber Test Procedure: Place the handle of the vibrating tuning fork on the midline of the skull and ask the patient to compare the intensity of the sound in the two ears. Indicates: (-) Normal: sound is equal in both ears. (+) Conductive deafness: sound lateralizes to the bad ear. (+) Sensorineural deafness: sound lateralizes to the good ear. CLINICAL SCIENCES DIVISION 94 Rinne Test Procedure: Place the handle of a vibrating tuning fork against the mastoid bone for bone conduction. Begin counting or timing the interval with a watch. Ask the patient to tell you when the sound is no longer heard, noting the amount of time. Then quickly hold the vibrating fork near the external ear canal without touching the patient (.5 to 1”) for air conduction, and again have the patient indicate when the sound ceases. Again, note the amount of time. Indicates: Normal: air conduction persists twice as long as bone conduction Abnormal: Conduction deafness: air conduction is absent, equal to, or less than bone conduction. Abnormal: Sensorineural deafness: air conduction and bone conduction are both radically decreased or absent. Vestibular Portion Fukuda Step Test Procedure: Patient marches in place, eyes closed for 50 steps. Positive: A turning to one side Indicates: Vestibular lesion on the side of rotation Hallpike Dix Maneuver Procedure: Patient is seated with head turned 45º to the right or left. Examiner quickly brings the patient into the supine position with head extended off the table. Examiner notes any nystagmus. Patient is then brought to the seated position. Repeat with head turned to the opposite direction. Positive: Nystagmus starting 2-5 seconds after movement and stopping within 30 seconds. Indicates: Benign positional vertigo Barany Whirling Chair Test Procedure: Seated patient is spun in chair in one direction Indicates: Normal: fast component of nystagmus will be in the direction of the spin. Vestibulo-ocular Reflex Procedure: Dr. holds patient’s head and instructs patient to fix vision on the doctor’s face. Observe and note spontaneous nystagmus. Dr. then turns patient’s head into rotation, lateral flexion, and flexion and extension. Indicates: Normal patient should maintain eye contact eyes moving at the same speed in the opposite direction of head movement. Inability to maintain fixation or spontaneous nystagmus indicates a vestibular lesion.
GLOSSOPHARYNGEAL AND VAGUS IX AND X
a) Note any hoarseness of the voice. b) Ask the patient about change in bitter taste sensation on the posterior third of the tongue. c) Uvula reflex = Patient says “ah” while doctor shines light in mouth and depresses tongue as necessary Watch for symmetrical rising of soft palate. Unilateral paralysis = One side of palate does not rise and uvula deviates to the normal side. d) Gag reflex. e) Have patient swallow while you palpate thyroid cartilage. f) Carotid sinus reflex.
SPINAL ACCESSORY NERVE XI
a) Trapezius Muscle Inspect Palpate Muscle test b) Sternocleidomastoid Muscle Inspect Palpate Muscle test - Ask patient to rotate head to one side. Dr. instructs patient to hold, while Dr. attempts to return the head to neutral.
HYPOGLOSSAL NERVE XII
a) Inspect tongue for: 1. Atrophy 2. Fasciculations 3. Deviation b) Have patient stick out tongue and test bilateral with tongue depressor, or use the tongue in cheek method Unilateral paralysis = Protruded tongue deviates to involved side.
BOWEL SOUNDS OF ABDOMEN
POSITIVE: Listen for frequency and character INDICATES: 1. hyperactive ( > 35/min) 2. Normoactive (5-35/min) 3. Hypoactive (1-4/min) 4. Absent (0 bowel sounds, but you must listen for 5 continuous minutes) - Medical emergency (obstruction or perforation)
** 5 seconds per quadrant
FRICTION RUBS
POSITIVE: High pitched sandpaper rubbing sound associated with respiration INDICATES: Inflammation of peritoneal surface of the liver and/or spleen from infection, tumors, or infarct
MAJOR ARTERIES OF THE ABDOMEN FOR BRUITS
POSITIVE: Harsh, musical wooshing sound (bruit) INDICATES: Possible vascular disease
VENOUS HUM IN THE ABDOMEN
POSITIVE: Soft, low pitched, continuous sound that is louder during diastole INDICATES: Increased collateral venous circulation
SCAN ABDOMINAL REGIONS FOR TONE
POSITIVE: Detect the presence of fluid, air, or solid masses INDICATES: Size and shape of the organs
PERCUSS THE URINARY BLADDER
POSITIVE: Dullness of suprapubic area INDICATES: Distended bladder
PERCUSS THE LIVER FOR SIZE
NORMAL: Usual span of liver is approximately 6-12 cm (2 1/2 to 4 1/2 in) INDICATES: A span greater than this may indicate liver enlargement (hepatomegaly) A lesser span may suggest atrophy
PERCUSS FOR GASTRIC AIR BUBBLE
POSITIVE: Tympany INDICATES: Location of the fundus of the stomach
PERCUSS THE SPLEEN
POSITIVE: Dullness INDICATES: Location of the spleen and/or splenomegaly
LIGHT PALPATION OF THE ABDOMEN
POSITIVE: Pain, tenderness, muscle guarding, and masses
DEEP PALPATION OF THE ABDOMEN
POSITIVE: Pain, tenderness, muscle guarding, and masses
DISTINGUISH A SUPERFICIAL FROM A DEEP MASS
POSITIVE: 1. Mass remains visible and/or palpable 2. Mass is no longer visible and/or palpable INDICATES: 1. Superficial Mass 2. Deep Mass
PALPATE FOR LIVER EDGE USING STANDARD MANEUVER
POSITIVE: Nodules, tenderness, irregularity INDICATES: Liver Disease
GALLBLADDER PALPATION
POSITIVE: Increased pain and reflex apnea (Murphy’s SIGN) INDICATES: Cholecystitis
PALPATE FOR SPLEEN
POSITIVE: Palpable Spleen INDICATES: Splenomegaly
PALPATE AROUND THE UMBILICUS
POSITIVE: Bulges, nodules, and or irregularities INDICATES: Possible abdominal hernia
PALPATE THE ABDOMINAL AORTA PULSE
POSITIVE: Prominent lateral pulsation INDICATES: Possible aortic aneurysm
PERFORM KIDNEY ENTRAPMENT
POSITIVE: Increased pain over the kidney INDICATES: Nephritis
PALPATE THE URINARY BLADDER
POSITIVE: Smooth rounded dense mass INDICATES: Distended bladder
BLUMBERG’S SIGN
POSITIVE: Sharp pain upon rebound in any of the 4 quadrants
INDICATES: Peritonitis
** Once in every 4 quadrants, start RUQ and go clockwise
ROVSING’S SIGN
POSITIVE: Sharp pain upon rebound in the right lower quadrant when pressing into the left lower quadrant INDICATES: Appendicitis
TEST FOR ASCITES: FLUID WAVE
POSITIVE: Easily detected fluid wave
INDICATES: Ascites (pathological increase of fluid in the abdomen)
PSOAS SIGN
POSITIVE: Increased pain in Right Lower Quadrant
INDICATES: Appendicitis
OBTURATOR SIGN
POSITIVE: Increased pain in right lower quadrant INDICATES: Ruptured appendix or pelvic abscess
MURPHY’s PUNCH
POSITIVE: Increased pain over the kidney INDICATES: Nephritis of inflamed kidney
PALPATION OF POSTERIOR THORAX
POSITIVE: Pain, tenderness, masses, sensations and further assess for any abnormalities
TACTILE FREMITUS (posterior thorax)
POSITIVE:
- Increase Fremitus
- Decreased or Absent Fremitus
INDICATES:
- Fluid or a solid mass within the lungs e.g. Lung Consolidation
- Excess air in the lungs e.g. Emphysema
RESPIRATORY EXCURSION
POSITIVE: Loss of symmetry in the movement of the thumbs
INDICATES: Underlying lung problem on one or both sides
PERCUSSION of POSTERIOR THORAX
Normal: Resonance
Abnormal: Dullness indicates mass or fluid in the lung (Lung cancer or pneumonia) Hyper-resonance indicates trapped air in the lung (Emphysema, atelectasis or pneumothorax)
** 1 FOR UPPER LOB, 2 SPOTS INTERSCAPULAR, 2 SPOTS MIDDLE, 2 SPOTS LATERAL
DIAPHRAGMATIC EXCURSION
POSITIVE: Limited measurement
INDICATES: Pathologies of pulmonary (eg result of emphysema (bilateral limited movement), abdominal (result of massive ascites, tumor), or superficial pain (fractured rib)
NORMAL BREATH SOUNDS (both anterior and posterior are same verbals)
Listen for Characteristics: Pitch, Intensity, duration of the normal breath sounds of Bronchial (best heard over the trachea), and Broncho-vesicular (best heard over the main bronchus and upper right posterior lung field), Vesicular (best heard over the periphery of the lung)
** ONE SPOT PER AREA BILATERALLY
VOCAL RESONANCE POSTERIOR
SEATED ONLY Normal: The sounds transmitted are usually muffled and indistinct and are best heart medially
* 10 AREAS TOTAL
VOCAL RESONANCE: WHISPERED PECTORILOQUY
POSITIVE: Increased clarity and loudness of spoken sounds INDICATES: Presence of consolidation in the lung
VOCAL RESONANCE: EGOPHONY
POSITIVE: Increased clarity and nasal quality of “E” becoming “A” INDICATES: Presence of consolidation in the lung
PALPATION of THE ANTERIOR THORAX
POSITIVE: Pain, tenderness, masses, sensations, and further assess for any abnormalities
PALPATION of the LYMPH NODES of the THORAX and AXILLA
POSITIVE:
- Enlarged, hard, immobile, non-tender
- Enlarged, soft, mobile, tender
INDICATES:
- Cancer
- Infection
TRACHEAL POSITION
POSITIVE: Deviation of the trachea INDICATES: Underlying pathology
PERCUSSION OF ANTERIOR THORAX
NORMAL: Resonance ABNORMAL: Dullness indicates mass or fluid in the lung (pneumonia or lung cancer) Hyper-resonance indicates trapped air in the lung (Emphysema, Atelectasis or Pneumothorax)
COSTOCHONDRITIS
POSITIVE: Pain at the costochondral junction INDICATES: Inflammation at the costochondral junction
POSSIBLE RIB FRACTURES
POSITIVE: Pain radiating from site of fracture
INDICATES: Possible rib fracture
CHECK THE 5 CARDIAC AREAS FOR PULSATIONS
POSITIVE: Impulse that rhythmically lifts your fingers
INDICATES: Possible cardiac hypertrophy
*aortic, pulmonic, aoritc, erb’s, tricuspid, mitral
CHECK FOR APICAL IMPULSE
NORMAL: Normal size is approximately 1 cm
ABNORMAL: Displacement of the apical impulse right or left
CHECK FOR EPIGASTRIC PULSATIONS
POSITIVE:
- Pulsations coming from superior to inferior
- Pulsations coming from inferior to superior
INDICATES:
- May indicate right ventricular enlargement
- May indicate abdominal aortic aneurysm
CHECK THE 5 CARDIAC AREAS FOR THRILLS
POSITIVE: A fine, palpable, rushing vibration
INDICATES: Grade IV murmur or higher
PAIRING OF S1 AND CAROTID PULSE
NORMAL: S1 and the carotid pulse should be synchronous
** Listen at S1 for 5 seconds first, and then get carotid pulse and listen 5 seconds again
IDENTIFY THE LOCATION AND SIZE OF HEART (PERCUSS)
1) Men = 3, 4, 5 with VERTICAL mark going lateral to medial. Women = 3 and 5 with VERTICAL mark going lateral to medial (move breast tissue down, move it up)
2) Percuss down the right sternal border beginning at Aortic Area. Dullness is heard at the 6th intercostal space indicating the superior border of liver (make 1 horizontal mark)
AUSCULTATE FOR HIGH PITCHED GENERAL CARDIAC SOUNDS
NORMAL: Listen for rate and rhythm
*Use DIAPHRAGM and PALPATE angle of Louis first,
*5 SECONDS EACH AREA (1-5)
AUSCULTATE FOR LOW PITCHED GENERAL CARDIAC SOUNDS
NORMAL: Listen for rate and rhythm
** USE THE BELL and palpate ANGLE of LOUIS (1-5)
LISTEN IN THE MITRAL AREA FOR S1 AND PALPATE THE CAROTID PULSE - CHECK FOR PAIRING OF THE TWO
NORMAL: S1 and the carotid pulse should be synchronous
** USE DIAPHRAGM, pair the two for 3-5 seconds and ask the patient to take a deep breath in, EXHALE and HOLD
LISTEN AT THE PULMONIC AREA TO S2 DURING DIASTOLE
VERBALIZE: S2 is heard loudest at base during diastole. I am listening for accentuated, diminished, and splitting, and splitting of S2, abnormal heart sounds and pulmonic murmurs
* USE THE DIAPHRAGM and use the PULMONIC AREA (2nd IC space on LEFT)
SPECIAL MANEUVER FOR MITRAL MURMUR
BELL
(deep breath in AFTER left lateral decubitus position, 3-5 seconds)
SPECIAL MANEUVER FOR AORTIC MURMUR
DIAPHRAGM
EXHALE AND HOLD
Bony Palpation: SHOULDER
- Sternoclavicular Articulation
- Clavicle
- Coracoid Process
- Acromioclavicular Articulation
- Acromion
- Greater Tuberosity of the Humerus
- Bicipital Groove
- Lesser Tuberosity of the Humerus
- Spine of the Scapula
- Body of Scapula
- Scapulothoracic Articulation
Soft Tissue Palpation: SHOULDER
- Rotator Cuff Muscle: Supraspinatus, Infraspinatus, Teres Minor, Subscapularis
- Subacromial Bursa
- Subdeltoid Bursa
- Axillary Borders: Pectoralis Major, Serratus Anterior, Axillary Lymph Nodes, Latissimus Dorsi, Bicipital Tendon
- Prominent Muscles of Region: Sternocleidomastoid, Biceps, Deltoid as a whole, (anterior, middle and posterior portion of deltoid), Trapezius, Rhomboid (minor and major)
RANGE OF MOTION: SHOULDER
- Flexion: 180
- Abduction: 180
- External Rotation: 90
- Internal Rotation: 70
- Extension: 60
- Adduction: 50
Scapular retraction, elevation, protaction
Yergason Test (Cipriano)
POSITIVE:
- Localized Pain and/or tenderness at the bicipital groove
- Audible click or the biceps tendon subluxes or dislocates
INDICATES:
- Bicipital Tendinitis
- Instability of the biceps tendon possibly associated with a torn transverse humeral ligament
Abbott-Saunders Test
POSITIVE:
- Palpable and/or audible click
INDICATES:
- Subluxation or dislocation of the biceps tendon due to a rupture of the transverse humeral ligament or tendon subluxation beneath subscapularis muscle belly/tendon
SPEED TEST
POSITIVE:
- Pain and/or tenderness in the bicipital groove
INDICATES:
- Bicipital Tendinitis
APLEY TEST:
POSITIVE:
- Exacerbation of pain
INDICATES:
- Degenerative tendinitis of rotator cuff tendons (usually supraspinatus)
IMPINGEMENT SIGN:
POSITIVE:
- Pain in the shoulder
INDICATES:
- Overuse injury to the supraspinatus and possibly biceps tendon
DUGAS TEST
POSITIVE:
- Inability to touch the opposite shoulder and/or inability of the elbow to touch the chest
INDICATES:
- Acute dislocation of the shoulder (glenohumeral joint)
ANTERIOR APPREHENSION TEST
POSITIVE:
- Patient will have a noticeable look of apprehension or alarm on their face with possible pain
INDICATES:
- Chronic anterior dislocation of the shoulder (glenohumeral joint)
POSTERIOR APPREHENSION TEST
POSITIVE:
- Patient will have a noticeable look of apprehension or alarm on their face with possible pain
INDICATES:
- Chronic Posterior dislocation of the glenohumeral joint
DROP ARM TEST/ aka CODMAN DROP ARM TEST
POSITIVE:
- Patient will not be able to lower the arm slowly or the arm drops suddenly
INDICATES:
- Rotator cuff tear, usually supraspinatus
DAWBARN TEST
Deep palpation of shoulder elicits well-localized tender area, by subacromial bursa
POSITIVE:
- Decrease in pain and/or tenderness
INDICATES:
- Subacromial bursitis
BONY PALPATION OF THE ELBOW
- Medial Epicondyle
- Medial Supracondylar line of the humerus
- Groove of the ulnar nerve
- Trochlea
- Olecranon
- Olecranon fossa
- Lateral Epicondyle
- Lateral Supracondylar line of the humerus
- Radial head
SOFT TISSUE PALPATION of ELBOW
- Biceps muscle
- Triceps muscle
- Suprcondylar Lymph Nodes
- Brachial Artery
- Medial Collateral Ligament
- Lateral Collateral Ligament
- Ulnar Nerve
- Olecranon Bursa
- Wrist flexor muscles (Palpate as a unit and individually)
- Pronator Teres
- Flexor Carpi Radialis
- Palmaris Longus
- Flexor Carpi Ulnaris
- Elbow Flexors muscles “mobile wad of three” (palpate as a unit and individually)
- Brachioradialis
- Extensor Carpi Radialis Longus
- Extensor Carpi Radialis Brevis
Range of motion: ELBOW
- Elbow Flexion: 150
- Elbow Extension: 0
- Forearm Supination (radio-ulnar joint): 80
- Forearm Pronation: 80
MEDIAL COLLATERAL LIGAMENT TEST
POSITIVE:
- Excessive gapping & pain
INDICATES:
- Medial Collateral ligament tear and/or instability
LATERAL COLLATERAL LIGAMENT TEST
POSITIVE:
- Excessive gapping & pain
INDICATES:
- Lateral collateral ligament tear and/or instability
TINEL ELBOW SIGN
” This is my Taylor Reflex Hammer it feels something like this, is that ok? “
POSITIVE:
- Pain and/or tenderness at the site being tapped and paresthesia in the ulnar nerve distribution area (fingers 4,5)
INDICATES:
- Neuroma of the ulnar nerve
COZEN TEST
POSITIVE:
- Pain over the lateral epicondyle
INDICATES:
- Lateral Epicondylitis (Tennis Elbow)
MILLS TEST
POSITIVE:
- Pain over the lateral epicondyle
INDICATES:
- Lateral Epicondylitis (Tennis elbow)
GOLFER ELBOW TEST
POSITIVE:
- Pain over the medial epicondyle
INDICATES:
- Medial Epicondylitis
BONY PALPATION: CERVICAL SPINE
ANTERIOR ASPECT:
- Hyoid Bone
- Thyroid Cartilage
- First Cricoid Ring
- Mandible
POSTERIOR ASPECT:
- Occiput
- Inion (EOP)
- Superior Nuchal Line
- Mastoid Processes
- Spinous processes of Cervical Vertebrae
- Facet Joints
SOFT TISSUE PALPATION: CERVICAL SPINE
- Sternocleidomastoid muscle
- Anterior lymph node chain
- Posterior lymph node chain
- Thyroid gland
- Carotid Pulse
- Supraclavicular Fossa
- Trapezius Muscle
- Greater Occipital Nerves
- Superior Nuchal Ligament
RANGE OF MOTION: CERVICAL SPINE
ACTIVE AND PASSIVE
- Flexion 50
- Extension 60
- Lateral Bending Left 45
- Lateral Bending Right 45
- Left Rotation 80
- Right Rotation 80
FORAMINAL COMPRESSION
POSITIVE:
- Exacerbation of localized cervical Pain
- Exacerbation of cervical pain with a radicular component
INDICATES:
- Foraminal Encroachment or facet pathology without nerve root compression
- Foraminal Encroachment or facet pathology with nerve root compression
CERVICAL DISTRACTION TEST
POSITIVE:
- Diminished or absence of local cervical pain
- Diminished or absence or radiating pain
- Increase of cervical pain
INDICATES:
- Foraminal encroachment without nerve root compression
- Foraminal encroachment with nerve root compression
- Muscular strain, ligamentous sprain, myospasm or facet capsulitis
SPINAL PERCUSSION TEST
” This is my Taylor reflex hammer it feels something like this “
POSITIVE:
- Local Pain
- Radiating
INDICATES:
- Possible fractured vertebrae, ligamentous involvment (spinous pain), and muscular involvment (muscular pain)
- Possible disc pathology
SHOULDER DEPRESSION TEST
POSITIVE:
- Localized pain on the side being tested
- Radicular pain on either side
INDICATES:
- Localized Pain: Dural sleeve adhesion, and muscular adhesion/contracture, or spasm, or ligamentous injury
- Radiating Pain: On side being tested neurovascular bundle compression, dural sleeve adhesions, or Thoracic Outlet Syndrome. On opposite side being tested foraminal encroachment with nerve root compression
VALSALVA MANEUVER
POSITIVE: Radiating pain from site of lesion (usually recreating the complaint in cervical or lumbar area of the spine)
INDICATES: Space occupying lesion (e.g. disc pathology)
SWALLOWING TEST
POSITIVE: Difficulty in swallowing
INDICATES: Space-Occupying lesion at anterior portion of cervical spine. Possibly esophageal or pharyngeal injury, anterior disc defect, muscle spasm or osteophytes etc.
SOTO-HALL SIGN
POSITIVE: Generalized pain in the cervical region, which may extend down to the level of T2
INDICATES: Non-specific test for structural integrity of cervical region
KERNIG SIGN
POSITIVE: Inability to fully extend the leg and/or pain (usually in the neck region)
INDICATES: Meningeal irritation/meningitis
O’ DONOGHUE MANEUVER
POSITIVE:
- Pain during passive range of motion
- Pain during resisted range of motion
INDICATES:
- Ligamentous sprain. (Passive ROM stresses ligaments)
- Muscle/tendon strain. (Active ROM stresses muscles and tendons)
Bony Palpation Wrist and Hand
Radial Syloid Process
Ulnar Styloid Process,
Lister’s Tubercle,
Scaphoid (navicular),
Lunate, Triquetrium,
Pisiform,
Trapezium,
Trapezoid,
Capitate,
Hamate,
Hook of Hamate,
Metacarpals,
Phalanges
Soft Tissue Palpation: Wrist and Hand
Ulnar Artery,
Radial Artery,
Palmaris Longus Tendon,
Carpal Tunnel Region,
Thenar Eminence,
Hypothenar Eminence,
Palmar Aponeurosis,
Tissues surrounding proximal interphalangeal joints,
Tissues surrounding distal interphalangeal joints,
Distal tufts of fingers
Range of Motion: Wrist and Hand
Wrist Flexion 80,
Wrist Extension 70,
Wrist Ulnar Deviation 30,
Wrist Radial Deviation 20,
Finger Abduction,
Finger Adduction,
Finger Flexion,
Finger Extension,
Thumb Flexion,
Thumb Extension,
Finger Opposition
Tinel Wrist Sign
” This is my Taylor reflex hammer, it feels something like this, is that ok? “
POSITIVE: Reproduction of pain, tenderness, and/or paresthesia in the median nerve distribution area (1st, 2nd, 3rd, and the lateral 1/2 of the 4th digit)
INDICATES: Median Neuritis, possibly Carpal Tunnel Syndrome
PHALEN SIGN AND REVERSE PHALEN SIGN
aka Prayer Sign
Elbows same level as shoulders for 60 seconds
POSITIVE: Reproduction of pain and/or paresthesia in the median nerve distribution area (thumb, 2nd, 3rd, and the lateral 1/2 of the 4th digit)
INDICATES: Median Neuritis, possibly Carpal Tunnel Syndrome
FINKELSTEIN TEST
POSITIVE: Pain distal to the radial styloid process
INDICATES: Stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons (DeQuervain’s Disease)
ALLEN TEST
57, 58, 59, 60 …… both hands pumping, bring them down both closed, open at same time, then let off of one artery and compare (TURN HEAD)
POSITIVE: A delay of more than 10 seconds (Evans 5 sec) in returning a reddish color to the hand
INDICATES: Radial or Ulnar Artery insufficiency. The artery held (occluded) by the examiner is not the artery being tested
RETINACULAR TEST
Patient presents with difficulty flexing the DIP joint
POSITIVE:
1) Flexion of the distal interphalangeal joint cannot be achieved
2) Flexion of the distal interphalangeal joint is achieved
INDICATES:
1) Joint Capsule Contracture
2) Tight Retinacular Ligament
BUNNEL - LITTLER TEST
Patient presents with difficulty flexing the PIP joint
POSITIVE:
- Flexion of the proximal interphalangeal joint cannot be achieved
- Flexion of the proximal interphalangeal joint is achieved
INDICATES:
- Joint Capsule Contracture
- Tight intrinsic muscles
Explain the “Initial Examination Procedure” of testing nerve roots:
“This is my pinwheel, it’s pointy and prickly and feels something like this, is that ok?”
- C4 on right compared to C4 on left (dermatome above)
- C5 on right compared to C5 on left (dermatome package)
- C6 on right compared to C6 on the left (dermatome below)
Explain the Secondary Examination Procedure with nerve roots:
FIRST
- C4 on the right side compared to C5 on the right side
- C5 of right side compared to C6 of right side
SECOND
- C4 of left side compared to C5 of left side
- C5 of left side compared to C6 of left side
“Can you feel this? AND does it feel like this?
S2 NERVE ROOT
- DISC LEVEL: S1
- SENSATION: Posterior aspect of thigh over popliteal fossa on to posterior medial calf
BONY PALPATION: LUMBAR SPINE
- Lumbar Spinous Processes
- Sacral Tubercles
- Iliac Crest
- PSIS
RANGE OF MOTION: LUMBAR SPINE
- FLEXION: 25
- EXTENSION: 30
- LEFT LATERAL BENDING: 25
- RIGHT LATERAL BENDING: 25
- LEFT ROTATION: 30
- RIGHT ROTATION: 30
HOOVER SIGN
- POSITIVE: Lack of counter-pressure to opposite side
- INDICATES: Lack of organic basis for paralysis (Malingering/hysteria). With organic hemiplegia, the patient will still exert downward pressure when attempting to raise paralyzed leg
STRAIGHT LEG RAISER (SLR)
- POSITIVE: Radiating pain and/or dull posterior thigh pain
-
INDICATES: Sciatic radiculopathy or tight hamstrings.
- Positive between 35-70 degrees equals possible discogenic sciatic radiculopathy
- > 70 equals tight hamstrings
GOLDTHWAIT SIGN
- POSITIVE: Localized pain, low back or radiating pain down the leg
-
INDICATES: Lumbo-sacral or sacroiliac pathology
- Pain occuring after the lumbar spinouses move equals possible lumbo-sacral problem
- Pain occuring before the lumbars move equals possible sacroiliac problem
BRAGARD SIGN
- POSITIVE: Radiating pain in posterior thigh
- INDICATES: Sciatic Radiculopathy
BUCKLING SING (CIPRIANO)
- POSITIVE: Pain in the posterior thigh with sudden knee flexion (buckle)
- INDICATES: Sciatic Radiculopathy
BOWSTRING SIGN
- POSITIVE: Pain in the lumbar region or radiculopathy
- INDICATES: Sciatic nerve root compression, helps rule out tight hamstrings
LASEGUE TEST
- POSITIVE: Reproduction of sciatic pain before 60 degrees
- INDICATES: Sciatica
MILGRAM TEST
- POSITIVE: Inability to perform test and/or low back pain
- INDICATES: Weak abdominal muscles or space occupying lesion
VALSALVA MANEUVER
- POSITIVE: Radiating pain from site of lesion (usually recreating the complaint in cervical or lumbar area of the spine)
- INDICATES: Space occupying lesion (e.g. disc pathology)
BECHTEREW TEST
- POSITIVE: Reproduction of radicular pain or inability to perform correctly due to tripod sign
- INDICATES: Sciatic radiculopathy
NERI BOWING TEST (Neri Sign)
- POSITIVE: Pain accompanied by flexion of the knee on the affected side and body rotation away from the affected side
- INDICATES: Positive with a variety of low back pathologies. Hamstring tension on the pelvis may trigger the response
ANTERIOR INNOMINATE aka MAZION PELVIC MANEUVER (ADVANCEMENT SIGN)
- POSITIVE:
The inability to bend at the waist more than 45 degrees, because of either/or
- Radiating pain along the sciatic nerve, either unilateral or bilateral
- Low back pain (lumbar or pelvic regions)
-
INDICATES:
- Sciatic neuralgia or radiculopathy, etc., possibly due to lumbar disc pathology
- Anterior (rotational) displacement of the ilium relative to the sacrum
LEWIN STANDING TEST
- POSITIVE:
Radiating pain down the leg causing flexion of the patient’s knee or knees
- INDICATES:
Gluteal, lumbosacral or sacroiliac pathologies
HEEL WALK
- POSITIVE:
Inability to perform the test
- INDICATES:
L4-L5 disc lesion (L5 nerve root)
TOE WALK
- POSITIVE:
Inability to perform test
- INDICATES:
L5-S1 disc lesion (S1 nerve root)
ELY HEEL TO BUTTOCK TEST (Evans calls this Ely sign as an a.k.a.)
POSITIVE:
- Inability to raise the thigh
- Pain in the anterior thigh
- Pain in the lumbar region
INDICATES:
- Iliopsoas spasm
- Inflammation of lumbar nerve roots
- Lumbar nerve root adhesions
RANGE OF MOTION:
HIP AND PELVIS
- Flexion 120
- Extension 30
- Abduction 45
- Adduction 45
- Internal Rotation 45
- External Rotation 45
- Flexion and Adduction
- Flexion, Abduction, and External rotation
LEG LENGTH DISCREPANCY
POSITIVE:
- Different Measurements
INDICATES:
- True = bony abnormality above or below level of trochanter difference (anatomical short leg).
- Apparent = pelvic Obliquity (Tilted pelvis)
ALLIS SIGN
POSITIVE:
- Difference in height and anteriority of the knees
INDICATES:
- If one knee is lower = ipsilateral congenital hip dislocation or tibial discrepancy (anatomical short leg)
- If one knee is anterior = ipsilateral congenital hip dislocation or femoral discrepancy (contralateral anatomical short leg)
THOMAS TEST
POSITIVE:
- Lumbar spine maintains lordosis (should flatten) and hip or leg flexes
INDICATES:
- Contracture of the hip flexors (iliopsoas)
ANVIL TEST
POSITIVE:
- Localized pain in long bone or in hip joint
INDICATES:
- Possible Fracture of long bones, or hip joint pathology
PATRICK TEST aka FABERE sign
POSITIVE:
- Pain in the hip region
INDICATES:
- Hip joint pathology
LAGUERRE TEST
POSITIVE:
- Pain in the hip joint
- Pain in the sacroiliac joint
INDICATES:
- Hip joint pathology
- Mechanical problem of the sacroiliac joint
GAENSLEN TEST
POSITIVE:
- Pain on the affected SI joint stressed into extension
INDICATES:
- General sacroiliac joint lesion, anterior sacroiliac ligament sprain, or inflammation of the SI joint
LEWIN - GAENSLEN TEST
POSITIVE:
- Pain on the affected SI joint stressed into extension
INDICATES:
- General sacroiliac joint lesion, anterior sacroiliac ligament sprain, or inflammation of the SI joint
HIBB TEST
POSITIVE:
- Pain in the hip region
- Pain in the buttock/pelvic region
INDICATES:
- Hip joint pathology
- Sacroiliac joint lesion
OBER TEST
POSITIVE:
Affected thgih remains in abduction (Normal biomechanics, the thigh/hip will adduct)
INDICATES:
Contraction of the iliotibial band or tensor fascia lata, (usually secondary to synovitis of the hip, secondary to trauma of the gluteus medius and maximus)
PELVIC ROCK TEST aka ILIAC COMPRESSION TEST
POSITIVE:
- Pain in either sacroiliac joint
INDICATES:
- Sacroiliac joint lesion
NACHLAS TEST
POSITIVE:
- Pain in the buttock and/or pain in the lumbar region
INDICATES:
- Sacroiliac joint lesion, or Lumbar pathology
YEOMAN TEST
POSITIVE:
- Pain deep in the SI joint
INDICATES:
- Sprain of the anterior sacroiliac ligaments
ELY SIGN (ELY TEST - CIPRIANO)
POSITIVE:
- Hip on side being tested will flex causing the buttock to raise off the table
INDICATES:
- Rectus Femoris or hip flexor contracture
ELY HEEL TO BUTTOCK TEST (cipriano)
POSITIVE:
- Inability to raise the thigh
- Pain in the anterior thigh
- Pain in the lumbar region
INDICATES:
- Iliopsoas spasm
- Inflammation of lumbar nerve roots
- Lumbar nerve root adhesions
TRENDELENBURG TEST
POSITIVE:
- High iliac crest on supported side and low crest on side of elevated leg
INDICATES:
- Weak gluteus medius muscle on the supported side
BONY PALPATION: KNEE
- Patella
- Medial Tibial plateau
- Tibial tubercle
- Medial Femoral Condyle
- Lateral Tibial Plateau
- Lateral Femoral Condyle
- Fibula head
SOFT TISSUE PALPATION:
KNEE
- Quadriceps muscles (Palpate as a unit and individually)
- Vastus Lateralis
- Vastus Medialis
- Vastus Intermedius
- Rectus Femoris
- Infrapatellar Tendon
- Bursae
- Prepatellar
- Superficial Infrapatellar
- Medial Meniscus
- Lateral Meniscus
- Pes Anserine Area
- Sartorius
- Gracilis
- Semitendinosus
- Popliteal Fossa
- Lateral Collateral Ligament
- Medial Collateral Ligament
- Gastrocnemius Muscle
RANGE OF MOTION:
KNEE
- FLEXION : 135
- EXTENSION: 0
- INTERNAL ROTATION
- EXTERNAL ROTATION
McMURRAY SIGN
POSITIVE:
- Clicking sound or pain by knee joint
INDICATES:
- Tear of medial meniscus if positive on external rotation
- Tear of lateral meniscus if positive on internal rotation
- The greater the angle the knee is flexed when the positive is elicited, the more posterior the meniscal injury
MEDIAL COLLATERL LIGAMENT TEST aka ABDUCTION STRESS TEST aka VALGUS STRESS TEST
POSITIVE:
- Gapping and/or elicited pain above/at/or below joint line
INDICATES:
- Tear and/or instability of the medial collateral ligament
LATERAL COLLATERAL LIGAMENT TEST aka ADDUCTION STRESS TEST aka VARUS STRESS TEST
POSITIVE:
- Gapping and/or elicited pain above/at/or below the joint line
INDICATES:
- Tear and/or instability of the lateral collateral ligament
BOUNCE HOME TEST
POSITIVE:
- Knee does not go into full extension (slight flexion remains)
INDICATES:
- Diffuse swelling of the knee, accumulation of fluid, due to possible torn meniscus
DRAWER TEST
POSITIVE:
- Gapping > 6 mm (tibia moves posterior) when the leg is pushed
- Gapping > 6 mm (tibia moves anterior) when the leg is pulled
INDICATES:
- Torn posterior cruciate ligament
- Torn anterior cruciate ligament
LACHMAN TEST
POSITIVE:
- Gapping with the tibia moving away from the femur
INDICATES:
- Anterior Cruciate ligament or posterior oblique ligament instability
APPREHENSION TEST FOR PATELLA
POSITIVE:
- Apprehension, distress or facial expression, contraction of quadriceps to bring patella back in line
INDICATES:
- Chronic patella dislocation or pre-disposition to dislocation
PATELLA FEMORAL GRINDING TEST
(aka Clarke Sign)
POSITIVE:
- Retropatellar pain and the patient is unable to hold the quadriceps contraction
INDICATES:
- Degenerative changes of the patellar facets and/or within the trochlear groove (chondromalacia patella)
PATELLA BALLOTTEMENT TEST
POSITIVE:
- A floating sensation of the patella
INDICATES:
- A large amount of swelling in the knee
APLEY COMPRESSION TEST
POSITIVE:
- Patient points to the side of pain
INDICATES:
- Pain on the medial side is medial meniscus tear. Pain on the lateral side indicates lateral meniscus tear
APLEY DISTRACTION TEST
POSITIVE:
- Patient will point to side of pain
INDICATES:
- Pain on the medial side indicates medial collateral ligament tear. Pain on the lateral side indicates lateral collateral ligament tear
DRAWER SIGN
POSITIVE:
- Translation with the talus moving away from or toward the tibia
INDICATES:
- With tibia pushed/foot pulled; a tear/instability of the anterior talofibular ligament
- With tibia pulled/foot pushed; a tear/instability of posterior talofibular ligament
ANKLE DORSIFLEXION TEST (Hoppenfeld)
POSITIVE:
- The foot cannot dorsiflex with knee extended, but is able to with knee flexed
- The foot cannot dorsiflex in either knee position
INDICATES:
- Contracture of the gastrocnemius muscle
- Contracture of the soleus muscle
RIGID OR SUPPLE FLAT FEET TEST
POSITIVE:
- Absence of medial longitudinal arch in both positions
- Presence of medial longitudinal arch while seated with a loss of medial longitudinal arch while standing
INDICATES:
- Rigid Flat Feet
- Supple Flat Feet
HOMANS SIGN
POSITIVE:
Deep pain in the calf
INDICATES:
Deep vein thrombophlebitis
THOMPSON TEST
POSITIVE:
- Absence of foot plantarflexion motion
INDICATES:
- Achilles tendon rupture
MORTON TEST
POSITIVE:
- Sharp pain in the forefoot
INDICATES:
- Metatarsalgia or neuroma (usually at the 3rd and 4th metatarsal interspace)
C5 NERVE ROOT
- DISC LEVEL: C4
-
MUSCLE TESTS (2):
- Shoulder Abduction: Deltoid (axillary nerve)
- Forearm Flexion: Biceps (musculocutaneous nerve)
- REFLEX: Biceps
- SENSATION: Lateral Arm
C6 NERVE ROOT
- DISC LEVEL: C5
-
MUSCLE TEST (1):
- Wrist Extension: Extensor carpi radialis longus and brevis, and extensor carpi ulnaris (radial nerve)
- REFLEX: Brachioradialis
- SENSATION: Anterior Lateral Forearm, palm, thumb, and 2nd digit
C7 NERVE ROOT
- DISC LEVEL: C6
-
MUSCLE TESTS (3):
- Elbow Extension: Triceps (Radial Nerve)
- Wrist Flexion: Flexor carpi radialis (Median Nerve), Flexor ulnaris (ulnar nerve)
- Finger Extension: Extensor digitorum communis, extensor indicis profundus, extensor digiti minimi (Radial nerve)
- REFLEX: Triceps
- SENSATION: 3rd digit, middle of palm
C8 NERVE ROOT
- DISC LEVEL: C7
-
MUSCLE TEST (1):
- Finger Flexion: Flexor digitorum superficialis, flexor digitorum profundus, lumbricals (median and ulnar nerves)
- REFLEX: NONE*
- SENSATION: 4th and 5th digits, antero-medial hand and forearm
T1 NERVE ROOT
- DISC LEVEL: T1
-
MUSCLE TESTS (2):
- Finger Abduction: Dorsal Interossei (ulnar nerve)
- Finger Adduction: Palmer Interossei (ulnar nerve)
- REFLEX: NONE**
- SENSATION: Antero-medial arm (distal aspect of arm to proximal aspect of forearm)
L4 NERVE ROOT
- DISC LEVEL: L3
-
MUSCLE TEST (1):
- Foot Dorsiflexion and Inversion: Tibialis Anterior (deep fibular/peroneal nerve)
- REFLEX: Patellar Tendon
- SENSATION: Medial aspect of leg, medial foot, medial aspect of big toe
L5 NERVE ROOT
- DISC LEVEL: L4
-
MUSCLE TESTS (4):
- Foot Dorsiflexion: Gastrocnemius, Soleus
- Big Toe Dorsiflexion: Extensor hallucis longus (deep fibular/peroneal nerve)
- Toes 2, 3, 4 dorsiflexion: Extensor digitorum longus and brevis (deep fibular/peroneal nerve)
- Hip and Pelvis Abduction: Gluteus medius and minimus (superior gluteal nerve)
- REFLEX: NONE*
- SENSATION: Lateral leg, dorsum of foot, and middle third toes
S1 NERVE ROOT
- DISC LEVEL: L5
-
MUSCLE TESTS (3):
- Foot Plantarflexion: Gastrocnemius and Soleus (Tibial Nerve)
- Foot Plantar Flexion and Eversion: fibular/peroneus longus and brevis (superficial fibular/peroneal nerve)
- Hip Extension: Gluteus Maximus (Inferior gluteal nerve)
- REFLEX: Achilles
- SENSATION: Posterior aspect of the leg, lateral aspect of foot, and lateral aspect of little toe
SOFT TISSUE PALPATION: LUMBAR SPINE
- Paraspinal Muscles (palpate as a unit and individually) superficial layer
- Spinalis
- Longissimus
- Iliocostalis
- Gluteus Medius
- Gluteus Maximus
- Sciatic Nerve
- Hamstrings
- Biceps Femoris
- Semitendinosus
- Semimembranosus
- Anterior Abdominal Muscles
BONY PALPATION: HIP AND PELVIS
ANTERIOR
- ASIS
- Iliac Crest
- Iliac Tubercle
- Greater Trochanter
POSTERIOR
- PSIS
- Ischial tuberosity
- Coccyx
SOFT TISSUE PALPATION: HIP & PELVIS
- Femoral Triangle Borders
- Sartorius
- Adductor Longus
- Inguinal Ligament
- Quadriceps Muscle (palpate as a unit and individually)
- Vastus Lateralis
- Vastus Medialis
- Vastus Intermedius
- Rectus Femoris
- Greater Trochanteric Bursa
- Gluteus Medius
- Gluteus Maximus
- Sciatic Nerve
- Cluneal Nerves
- Hamstrings
- Biceps femoris
- Semitendinosus
- Semimembranosus
BONY PALPATION:
FOOT AND ANKLE
- Calcaneus
- Sustentaculum Tali
- Medial Malleolus
- Lateral Malleolus
- Talus
- Navicular
- Cuboid
- 3 Cuneiforms
- 5 Metatarsals
- Metatarsophalangeal joints
SOFT TISSUE PALPATION:
FOOT AND ANKLE
- Tibialis Posterior tendon
- Tibialis Anterior Tendon
- Peroneous Brevis
- Achilles tendon
- Deltoid Ligament
- Spring ligament
- Anterior Talofibular ligament
- Posterior tibial artery
- Dorsal pedal artery
- Plantar Aponeurosis
RANGE OF MOTION:
FOOT AND ANKLE
- Ankle Dorsiflexion 20
- Ankle Plantarflexion 50
- Subtalar Inversion 5
- Subtalar Eversion 5
- 1st MTP Joint Flexion
- 1st MTP Joint Extension
L HERMITTE SIGN
+ : Electric shock like sensations down the spine and or through extremities i : Dural irritation, severe spinal cord injury, inflammation, or degeneration
KERNIG SIGN
+ : Inability to fully extend the leg and/or pain (usually in neck region) i : Meningeal irritation/meningitis
BRUDZINSKI SIGN
+ : Involuntary knee flexion i : Meningeal irritation or nerve root lesion (classic test for meningitis)
SOTO HALL SIGN
+ : Generalized pain in cervical region, which may extend down to the level of T2 i : Non-specific test for structural integrity of cervical region
FORAMINAL COMPRESSION TEST
+ : 1) Exacerbation of localized cervical pain 2) Exacerbation of cervical pain with a radicular component i : 1) Foraminal encroachment or facet pathology without nerve root compression 2) Foraminal encroachment or facet pathology WITH nerve root compression
JACKSON COMPRESSION
+ : 1) Exacerbation of localized cervical pain 2) Exacerbation of cervical pain with a radicular component i : 1) Foraminal encroachment without nerve root pressure or facet pathology 2) Foraminal encroachment with nerve root compression (one would then want to evaluate the myotome, reflex and dermatome of the nerve root involved)
MAXIMAL CERVICAL COMPRESSION
+ : Pain on the concave side i : Foraminal encroachment with or without nerve root compression (based on presence or absence of radicular component)
VALSALVA MANEUVER
+ : Radiating pain from site of lesion (usually positive in cervical or lumbar area of the spine) i : Space Occupying lesion (e.g. disc pathology)
CERVICAL DISTRACTION TEST
+ : 1) Diminished or absence of local cervical pain 2) Diminished or absence or radiating pain 3) Increase of cervical pain i: 1) Foraminal encroachment without nerve root compression 2) Foraminal encroachment with nerve root compression 3) Muscular strain, ligamentous sprain, myospasm or facet capsulitis
BAKODY SIGN (shoulder abduction test)
+ : Decrease or absence of radiating pain i : Cervical foramina compression, nerve root entrapment (usually C5/C6 level because this motion elevates the supra scapular nerve and relieves traction on the upper brachial plexus)
ADAM SIGN
+ : 1) A “C” or “S” shaped scoliosis is observed to straighten 2) A “C” or “S” shaped scoliosis does not straighten (look for rib humping, muscular imbalance, and symmetry in hand length) i: 1) Negative: evidence of a functional scoliosis, trauma or subluxation 2) Positive: evidence of a pathologic or structural scoliosis
SCHEPELMANN SIGN
+ : Pain on the concave or convex side i : Pain on the concave side indicates intercostal neuritis (thoracic dermatomes can be evaluated in the corresponding intercostal spaces) while pain on the convex side indicates fibrous inflammation of the pleura (or possible intercostal myofascitis)
BEEVOR SIGN
+ : Superior or inferior movement of the umbilicus i : Superior movement of the umbilicus is indicative of a spinal cord lesion at the level of T11-T12 or lower abdominal weakness. Inferior movement of the umbilicus is indicative of nerve root involvement T7-T10
ROOS TEST aka E.A.S.T (elevated arm stress test)
+ : Ischemic pain, heaviness of the arms, or numbness and tingling of the hand i : Thoracic outlet syndrome on side involved (Evan’s considers this test to be most accurate for TOS evaluation)
ADSON TEST
+ : Pain and/or paresthesia, decreased or absent pulse amplitude , pallor i : Compression of neurovascular bundle by scalenus anticus or cervical rib
COSTOCLAVICULAR MANEUVER aka EDEN TEST
+ : Pain and/or paresthesia, decreased or absent pulse amplitude, pallor i : Compression of the neuromuscular bundle between the clavicle and 1st rib
HYPERABDUCTION MANEUVER aka WRIGHT TEST
+ : Pain and/or paresthesia, decreased or absent pulse amplitude, pallor. i : Compression of the axillary artery by pectoralis minor or coracoid process. TOS
TINEL ELBOW SIGN
+ : Pain and/or tenderness at the site being tapped and paresthesia in the ulnar nerve distribution area (fingers 4, and 5) i : Neuroma of the ulnar nerve
FROMET PAPER SIGN
+ : The patient is seen to flex the thumb thereby recruiting the median nerve to compensate for apparent weakness i : Ulnar nerve paralysis (weakness or palsy of the adductor polices muscle)
PHALEN SIGN and REVERSE PHALEN SIGN aka “Prayer Sign”
**** Hold for 60 seconds ***** + : Reproduction of pain and/or paresthesia in the median nerve distribution area (1st, 2nd, 3rd, and lateral 1/2 of 4th digit) i : Median Neuritis, possibly Carpal Tunnel Syndrome
TINEL WRIST SIGN
+ : Reproduction of pain, tenderness and/or paresthesia in the median nerve distribution area (thumb, 2nd, 3rd, and lateral 1/2 of the 4th digit) i : Median neuritis, possibly Carpal Tunnel Syndrome
MINOR SIGN
+ : Knee flexion of the affected leg while supporting upper body weight (hand on back or thigh) on unaffected side i : Sciatica, lumbosacral or sacroiliac joint lesion
BELT TEST (Supported Adam Test, Supported Forward Bending Test)
+ : Low Back Pain i : 1) Pain while bending with the sacrum stabilized and unstabilized = Lumbar involvement 2) Pain during sacrum non-stabilized bending, and no pain during sacrum stabilized bending = pelvic involvment
MILGRAM TEST
+ : Inability to perform test and/or low back pain i : Weak abdominal muscles or space occupying lesion
HEEL WALK
+ : Inability to perform test i : L4-L5 disc lesion (L5 nerve root)
TOE WALK
+ : Inability to perform test i : L5-S1 disc lesion (S1 nerve root)
KEMP TEST
+ : 1) Pain usually radicular, recreating existing sciatic pain 2) Pain - Local i : 1) Disc Protrusion: - In medial disc protrusion, Kemps will be positive as the patient is leaning AWAY from the side of pain - In lateral disc protrusion Kemps will be positive as the patient is leaning INTO the side of pain 2) Localized pain may indicate lumbar spasm or facet capsulitis
STRAIGHT LEG RAISE (SLR)
+ : Radiating pain and/or dull posterior thigh pain i : Sciatic radiculopathy or tight hamstrings. Positive between 35-70 degrees = possible discogenic sciatic radiculopathy > 70 degrees = tight hamstrings
LINDNER SIGN
+ : Pain along sciatic distribution or sharp, diffuse pain (leg) i : Sciatic radiculopathy
TURYN SIGN
+ : Pain in the gluteal region or radiating sciatic pain i : Sciatic Radiculopathy
BRAGARD SIGN
+ : Posterior thigh and leg pain i : Sciatic radiculopathy (usually from disc lesion)
SICARD SIGN
+ : Posterior thigh and leg pain i : Sciatic radiculopathy (usually from disc lesion)
BONNET SIGN
+ : Pain in the posterior thigh or leg i : Immediate pain is sciatic neuropathy from piriformis syndrome
FAJERSZTAJN TEST aka Well-Leg-Raising Test of Fajersztajn
+ : 1) Pain down affected leg 2) Decrease in pain down affected leg i : 1) Medial disc protrusion 2) Lateral disc protrusion
FEMORAL STRETCH TEST (Femoral Nerve Traction Test)
+ : Pain on the anterior portion of the thigh i : Traction on the femoral nerve indicating involvement of the 2nd, 3rd, and 4th lumbar nerve roots
TINEL FOOT SIGN
+ : Paresthesia radiating into the foot i : Tarsal tunnel syndrome
MORTON TEST
+ : Sharp pain the forefoot i : Metatarsalgia or neuroma (usually at the 3rd and 4th metatarsal interspace)
