Clinical Exams Flashcards
Head + neck exam
C spine
- Pain at rest? Tenderness? ROM
Inspect anteriorly
- Face - Battle’s sign, raccoon eyes
- Teeth + oral cavity
- Nose - check both nostrils are patent
Inspect laterally
- Ears + TM
Inspect posteriorly
- Posterior head
- Trapezius
Palpation
- Nasal bones, zygoma and orbital rims, mandible and maxilla
Eyes
- Pupillary size + response
- EOM
- Visual acuity
- Visual fields
- Sclera, iris, pupil
- Fundoscopy to assess retina
- Red reflex
- Cornea (fluorescein stain, cobalt blue light)
- IOP
- Accommodation reflex
Special tests
- Cerebellum
- Cranial nerve exam
- Concussion testing
- Peripheral nerve exam
How to examine cerebellum
Finger to nose
Pronate/ supinate clap
Gait
Pronator Drift - close eyes, arms extended out straight palms up
Romberg
Cranial nerve exam
1: Olfactory - any changes to sense of smell?
2: Optic - pupil size, shape, symmetry, visual acuity using snellen chart, pupillary reflexes (direct + consensual), accommodation reflex, color vision using Ishihara plates, visual fields + neglect, fundoscopy
3, 4 + 6: Oculomotor, trochlear + abducens - H movement
5: Trigeminal - sensory (ophthalmic, maxillary, mandibular), masseter palpation, open jaw against resistance, jaw jerk and corneal reflex
7: Facial - change to taste? change to hearing? Raise eyebrows, close eyes, blow out cheeks, big smile, pursed lips
8: Vestibulocochlear - whisper test, Rinne’s (tuning fork on mandible, when no longer able to hear, move in front of ear - air should be louder than bone), Weber’s (tuning fork midline of forehead, sound should be equal - sound louder on affected ear = conductive, sound louder on intact ear = sensorineural), turning test (march on spot w/ arms outstretched in front + eyes closed - vestibular lesion pt turns towards side of lesion)
9 +10: Glossopharyngeal + vagus - problems with swallowing? Inspect uvula, ask pt to cough, ask pt to swallow
11. Accessory - inspect trap + SCM, shrug shoulders against resistance, turn head against resistance
12: Hypoglossal - inspect tongue, protrude tongue, push tongue against resistance in cheek
How to examine for ?concussion
Compare to baseline
Orientation - where are we, what happened, who am I, what year is it
Vestibulo-ocular testing
Move eyes from side to side (finger to finger) + up and down
Keep eyes focused on examiner then turn head side to side and up and down
Peripheral nerve exam
Sensation to upper deltoid (C4), lateral elbow (C5), tip of thumb (C6), tip of middle finger (C7), tip of little finger (C8), medial elbow (T1), medial side of knee (L3), medial malleolus (L4), 1st webspace (L5), lateral heel (S1)
Power - deltoid (C5), biceps (C5/6), wrist extension (C6/7), triceps (C7), middle finger flexion (C8), fingers splayed (T1), test quads (L3/4) by squatting, tibialis anterior (L4) by heel walking, Trendelenburg test for hip adductors (L5), test gastrocnemius with toe walk (S1/2)
Reflexes - biceps jerk (C5/6), brachioradialis (C6), triceps (C7), patella tendon (L3/4), achilles tendon (S1/S2), abdo reflexes (upper muscles = T7-T10, lower T10-L1)
How to do C spine exam
Gait - cervical stenosis
Inspection posteriorly
- Scars? Erythema? Wasting?
- Alignment
Shoulders + iliac crests should be symmetrical
Head should be straight and directly above sacrum
Touch toes and look for symmetry of ribs (rib hump = scoliosis)
Inspection laterally
- Cervical + lumbar lordosis
- Thoracic kyphosis
Inspection anteriorly
- Shoulder alignment
- Cervical AROM - flexion, extension, rotation left + right, lateral flexion left + right
- Hold hips stable then ask pt to laterally rotate left and right
Movement
Flexion, extension
Rotation left + right, rotation + extension together
Lateral flexion left + right (pain = brachial plexus injury)
Palpation
Soft tissue of neck for masses
Prominent vertebrae = C7
Spinous processes - irregularities, steps, tenderness
Mastoid
Occipital region
Trapezius
Levator scapulae
Neurological assessment
Sensation to upper deltoid (C4), lateral elbow (C5), tip of thumb (C6), tip of middle finger (C7), tip of little finger (C8), medial elbow (T1)
Power - deltoid (C5), biceps (C5/6), wrist extension (C6/7), triceps (C7), middle finger flexion (C8), fingers splayed (T1)
Reflexes - biceps jerk (C5/6), brachioradialis (C6), triceps (C7)
Check radial pulses
Check shoulder ROM
Special Tests
Spurlings test (nerve root compression/ radicular pain) - rotate neck towards side of pain, move neck into extension + then apply axial load
How to do lumbar spine exam
Gait - lumbar stenosis causes pts to lean forward
Inspection posteriorly
Scars? Erythema? Wasting? Patch of hair (spina bifida)? cafe au lait spots (neurofibromatosis)?
Alignment
Shoulders + iliac crests should be symmetrical
Head should be straight and directly above sacrum
Touch toes and look for symmetry of ribs (rib hump = scoliosis)
Inspection laterally
Cervical + lumbar lordosis
Thoracic kyphosis
Inspection anteriorly
Shoulder alignment
Movement
Forward flexion (pain = discogenic pain)
Extension (pain = pars defect)
Extension to right and left
Hold hips stable then ask pt to laterally rotate left and right
Lateral flexion - note how far down leg hand can go
Schober’s test
Mark level of iliac crest/ find dimples of venus (landmark for L4 spinous process)
Measure 10cm above + 5cm below, keep tape measure still at these marks
Ask athlete to forward flex, if <5cm change = lumbar stiffness
Palpation
Iliac crest, SI joint, paravertebral tenderness
Spinous processes - irregularities, steps, tenderness
Neurological assessment
Power - check standing - test quads (L3/4) by squatting, tibialis anterior (L4) by heel walking, Trendelenburg test for hip adductors (L5), test gastrocnemius with toe walk (S1/2)
Get pt sitting, then flex hip against resistance and test iliopsoas muscle (L2)
Then lift foot up so foot + leg is at 90 degrees to hip - truly positive straight leg will cause pt to lean back in tripod position
Lie pt supine for dermatomes - medial side of knee (L3), medial malleolus (L4), 1st webspace (L5), lateral heel (S1)
Test power extensor hallucis longus (L5)
Reflexes - patella tendon (L3/4), achilles tendon (S1/S2), abdo reflexes (upper muscles = T7-T10, lower T10-L1)
Check pulses in feet
Special tests
Slump test - chin on chest, flex forward and slump - ankle in dorsiflexion, straighten leg - then lift head up - if pain improves = radicular pain
Straight leg raise - with pt lying supine, lift heel up - pain should only start at 30 degrees
If pain occurs, lessen off and then dorsiflexing ankle - if this reproduces pain, it is positive (Lasegue’s test)
Ankylosing spondylitis
Chest expansion <2.5cm
Schober’s: identify level of PSIS (approx at level of L5), mark midline at 5 cm below iliac spine and 10 cm above iliac spine. Patient bends at waist to full forward flexion. Measure distance between 2 lines (started 15 cm apart).
Normal: distance between 2 lines increases to >20 cm.
Abnormal: distance does not increase to >20 cm.
Check ROM in hip (pt supine, flex hip and knee and rotate from side to side)
FABER - ?SIJ pathology, pars stress #
Femoral nerve stretch test
If ?cauda equina
Sensation in perineum
DRE for anal tone
Cremesteric reflex
Shoulder exam
Inspection anteriorly
Scars, erythema, swelling, muscle wasting (deltoid, pectoral)
Bony lumps, callouses - (AC joint more prominent?)
Sulcus sign (pull down on arm, if depression appears - ?instability)
Inspection laterally
Deltoid (atrophy = C5 plexus injury)
Inspect + palpate axilla
Inspect posteriorly
Supraspinatus, infraspinatus
Trapezius, latissimus dorsi
Abduct arms to assess movement of scapular (winging = long thoracic nerve palsy or CN 11 palsy)
ROM
C spine flexion, extension, rotation, lateral flexion
Abduction (180 degrees), adduction (50 degrees), forward flexion (180), horizontal flexion (130), extension (90), external rotation (60), internal rotation (thumb up back)
Hands behind head = abduction + external rotation
Hands behind back = adduction + internal rotation
Palpation
Sternoclavicular joint, clavicle, AC joint, acromion, subacromial bursa, greater tuberosity of humerus (insertion of supraspinatus tendon), externally rotate arm with finger there to palpate long head biceps tendon, humeral head, GH joint, coracoid process
Posterolateral corner of acromion, scapular spine, inferior angle of scapula, supraspinatus, infraspinatus, trapezius, rhomboids
Special tests
Spurling’s test
Painful arc
Drop arm test
Speed test
Empty can test
Hawkins’ test
Cross arm adduction
Resisted external rotation
Gerber’s lift off
Apprehension test
Yergason’s
Neers test
Sulcus sign
Impingement test
Compression rotation test
O’Brien test
What is Spurlings test for?
cervical radiculopathy
Painful arc test
Impingement
pain at 30-60 degrees, dissipates at 120 degrees
Drop arm test
hold arm at 90 degrees to body, remove support and ask pt to keep arm there (supraspinatus)
Speed test
arm straight, forward flexion to 90 degrees, palm up, resisted downwards pressure + palpate bicipital tendon
pain = bicipital tendonitis, labral tear
Empty can test
push at deltoids (supraspinatus)
Hawkins’ test
shoulder flexed to 90, bend elbow to 90 degrees, internally rotate humerus (causing greater tuberosity to bump against acromion)
pain = impingement, AC or rotator cuff pathology
Cross arm adduction
compresses AC joint
Resisted external rotation
infraspinatus
Gerber’s lift off
subscapularis
Apprehension test
lying supine, abduct arm to 90 degrees w/ elbow flexed then slowly externally rotate - place hand over proximal humerus
if apprehension improves - test = positive
Yergason’s
Resisted supination + palpate biceps tendon
biceps tendonitis/ labrum
Neers test
The examiner should stabilize the patient’s scapula with one hand, while passively flexing the arm while it is internally rotated. If the patient reports pain in this position, then the result of the test is considered to be positive
subacromial nerve impingement
Sulcus sign
apply downwards traction, sulcus sign = inferior instability
Impingement test w/ LA
inject subacromial bursa w/ lidocaine = sx improvement = impingement not tear
Compression rotation test
patient supine, pts arm abducted to 90 degrees + elbow flexed to 90 degrees, examiner applies axial force to humerus
positive = pain/ clicking = labral tear?)
O’Brien test
pt standing, arm forward flexed to 90 degrees w/ elbow in full extension. With adducted arm to 10 degrees and internally rotated humerus, examiner applies downward force to arm as pt resists. Pt then supinates arm and repeats resistance.
Positive = pain w/ internal rotation, reduced w/ external rotation
SLAP or AC lesions
Upper cut test
forearm supinated, elbow flexed to 90 degrees, hand in fist. Pt brings first towards chin against resistance.
Pain = biceps tendinopathy
Elbow exam
Neck + shoulder
Inspect
C spine ROM
Shoulder ROM
Inspection
Scars, erythema, swelling, muscle wastimh
Carrying angle (normally 5 degrees in males, 10-15 degrees in females)
Palpation
Anteriorly: medial epicondyle, common flexor origin, ulnar nerve, biceps tendon, brachial pulse
Posteriorly: medial + lateral epicondyle, olecranon
Laterally: lateral epicondyle, radial head, common extensor origin
Movement
Arms abducted to 90 degrees then flex elbows (touch hands to shoulders)
Supination + pronation
Special tests
Passively flex wrist + extend elbow (pain over common extensor origin - lateral epicondylitis)
Passively extend wrist + extend elbow (pain over common flexor origin - medial epicondylitis)
Tinel’s test - tap along the line of the ulnar nerve
Valgus instability - with elbow extended, brace lateral side of elbow, apply valgus force (elbow will open if MCL is insufficient)
Valgus stress test = flexes elbow to 30 degrees, apply valgus stress. Positive if pain or instability (UCL sprain). Moving valgus test - apply valgus force as elbow is moved through flexion + extension. Pain between 70-120 degrees flexion is positive for UCL injury
Neuro - make a fist (median nerve), thumbs up (radial nerve), make circle with thumb + forefinger (anterior interosseous branch of medial nerve), starfish (ulnar nerve)
Check radial + ulnar pulses
Hand + wrist exam
Screen neck, shoulder + elbow
Cervical, shoulder + elbow ROM
Inspection
Palmar aspect: alignment (fingers should be slightly flexed in rest), scars, erythema, palmar creases, swelling, wasting, thenar + hypothenar eminence
Radial surface: alignment of thumb
Dorsal aspect: scars, erythema, nails
Ulnar aspect: scars, swelling
Palpation
Dorsal aspect: radius to lister’s tubercle, scapholunate interval, radial styloid, ulnar styloid, extensor carpi ulnaris tendon, triangular fibrocartilage, anatomical snuffbox (pain = scaphoid injury), abductor pollicis longus tendons (pain = de Quervain’s tenosynovitis), extensor pollicis longus (hooks around pulley of lister’s tubercle), ulnar head, ulnar styloid
Palmar aspect: pisiform, flexor carpi ulnaris tendon, hook of hamate, transverse carpal ligament (base of thenar eminence - carpal tunnel lies under), tubercle of scaphoid, carpal-metacarpal joint, MCP joints, phalanges, PIP, DIP
Movement
Make a fist (flexion), flatten hand onto table (extension), spread fingers apart (abduction), fingertips to thumb (thumb flexion + opposition), wrist extension + flexion, supination, pronation, wrist ulnar + radial deviation
Neurological
Sensation: radial edge of palmar aspect 2nd digit (median), ulnar edge of palmar aspect 5th digit (ulnar), 1st webspace dorsal aspect (radial), C6 - thumb, C7 - middle finger, C8- little finger
Power:
Median nerve: make fist + make circle w/ thumb + forefinger, resisted thumb abduction + palpate muscle bellies
Ulnar nerve: starfish, palpate hypothenar eminence w/ resisted starfish, Froment’s test (adductor pollicis test): grip paper in 1st webspace, pull paper out - IP joint should not flex - if they flex, adductor pollicis is weak
Radial nerve: wrist + thumb extension
Palpate radial + ulnar pulses
Median nerve: radial half of palmar surface
Ulnar nerve: ulnar side of palmar + dorsal surface
Radial nerve: radial side of dorsal surface
Special tests
Finger special tests
Flexor pollicis longus
Flexor digitorum profundus
Flexor digitorum superficialis tendon
UCL test
Extension of DIP against resistance
Functional tests: writing, picking up small objects, grip strength
Hip exam
Gait
Trendelenburg - weakness of hip abductor muscles causes pt to put weight on affected side and opposite pelvis drops. Pt may compensate by swinging shoulders towards affected side
Antalgic gait - pt spends less time on affected limb, shortening stance
Drop foot gait - ankle can’t dorsiflex
Neurological
Tip toe walking (gastrocsoleus - S1)
Heel walking (tibialis anterior - L4)
Squat (quadriceps - L3)
Trendelenburg test (L5)
Lift opposite leg (stand on one leg) - pelvis should not drop and shoulders should not sway over
Inspect posteriorly
Scars, glutes + hamstrings for wasting
Screen for lumbar flexibility w/ finger + thumb apart on lumbar spine + pt flexing forward
Leg length assessment - knees extended, feet aligned - palpate iliac crests - level? If not, put blocks under shorter leg until they are
Inspect anteriorly, supine
Scars, swelling
Palpation (supine)
ASIS, AIIS, pubic symphisis, hip joint, greater trochanter, gluteal tendons, lumbar, SI joint
Movement
Flexion - place hand under lumbar spine - flex hip until lumbar flattens out - this is limit of flexion, measure angle
Internal + external rotation - legs extended (hold from ankles) and knees bent
Abduction + adduction with examiners arm across iliac crest to stop pelvis from tilting
Sensation: medial side of knee (L3), medial malleolus (L4), 1st webspace (L5), lateral heel (S1)
Special tests
Hip special tests
Thomas test
Leg length measurements
Abductor tests
Adductor tests
Psoas tests
Inguinal tests
Femoral stretch test
Straight leg raise
FABER
Ober’s test
Groin tests
Knee exam
Gait
Use of walking aids
Inspection anteriorly
Shoes + orthotics
Scars, rashes, erythema
Swelling around suprapatellar pouch + prepatellar bursa
Valgus (knock kneed)
Varus (bow legs)
Normal alignment - slight valgus (5 degrees men, 7 degrees women)
Feet - hemosiderin deposition, loss of hair, nail atrophy
Inspection laterally
Scars
Quadriceps wasting
Check extension of knee
Inspection posteriorly
Scars, swelling
Wasting of hamstrings or calves
Gait
Trendenlenburg gait?
Knee should be fully extended at heel strike + flexed otherwise
Thrust - lateral or medial deviation of knee at heel strike
Neurological assessment
Tip toe walking (S1)
Heel walking (L4)
Trendelenburg test (L5)
Squat (L3)
Palpation
Tibial tubercle, joint line, meniscus medial + lateral condyle
Medial epicondyle, MCL, pes anserine bursa
Lateral tibial condyle, lateral epicondyle, LCL, fibular head, biceps femoris tendon
Prepatellar bursa, patella edges + movement, assess for effusion (swipe or patella tap)
Popliteal fossa, popliteal pulse
Movement
Extension
Flexion (active + passive)
Special tests
Quadriceps wasting - measure circumference of thigh about a hand breath above patella
MCL + LCL - apply valgus and varus force to knee (in extension + at 30 degrees flexion)
PCL + ACL
PCL sag sign
Anterior + posterior drawer
Lachman
Meniscus
Hold thigh down onto bed, lift heel off bed - if painful ?meniscus injury
Fully flex hips and knees and apply pressure - if painful ?meniscus injury
Hip
Check passive hip flexion + internal + external rotation
Neurological
Straight leg raise
Sensation: medial side of knee (L3), medial malleolus (L4), 1st webspace (L5), lateral heel (S1)
Pulses
