Tests detail Flashcards
General observation - what to look for - 6 items.
Posture. Assymetry. Gait. Involuntary movements. Atrophy. Skin condition/lesions.
Vital signs - Height and weight
Ask patient as part of history taking. Note build. If necessary check tables to determine over or underweight. BMI over 30 is obese.
Vital signs - Aural temperature
Thermometer in ear and hold for 2-3 s. Normal is 37. 7. Higher in evening.
Vital signs - Radial pulse rate
Compress radial artery at wrist with index and middle fingers. Count for 15s x 4. If very irregular, count for 60s. Normal is 60 to 100. >100 Tachycardia. <60 Braycardia. T is normal with stress or exercise. B is normal at rest for athletes.
Vital signs - Radial pulse regularity and amplitude
Compress radial artery at wrist with index and middle fingers. Regular - may vary with respiration. Regularly irregular - pattern with skipped beats. Irregularly regular - no pattern. Strong or weak?
Vital signs - Respiration rate
Observe patient’s brathing without announcing it. Notice any difficulty or irregularity. Count for 15s x 4. Normal is 14 to 20 with the occasional sigh.
Vital signs - Blood pressure - before procedure
Patient ot sit quietly for 5 mins before. Room quiet and warm. No alchohol or smoking 15 mins before. Check neither arm is contraindicated - lymphoedema. Check arm is free of clothing.
Vital signs - Blood pressure - Procedure
Palpate brachial pulse. Position arm with elbow crease at heart level - e.g on table. Fit cuff 2.5cm above crease centred on brachial artery. Arm slightly flexed. Measured in mmHg. Bilateral on first visit. Pump up cuff while palpating radial pulse till it annot be felt - systolic. Defleat and wait 15s. Place bell of stethascope on brachial artery and inflate about 30 above. Decrease slowly until 2 consecutive beats are heard - systolic. Decrease further till sound muffles and disappears - diastolic. Record to nearest 2mmHg. Check both sides if first visit. Twice on each arm and take higher reading.
Vital signs - Blood pressure - Interpretation of readings.
Use worst classification if s and d differ. Optimal under 120/80. Normal under 130/85. High-normal under 140/90. Hypertension: grade 1 under 160/100, grade 2 under 180/110. Grade 3 over. Difference of > 10 - 15 each side indicates compression or obstruction. Initial reading may be high due to white coat syndrome.
Extra vital signs - Oral temperature
Glass thermometer - shake down and place under tongue for 3-5 mins. Electronic - use disposable cover, insert under tongue, takes 10 s. Normal varies during day 35.8 morning, 37.3 evening. Over 38.5 is fever.
Extra vital signs - Axilliary temperature
Normal 36.3 - least accurate.
Extra vital signs - Orthostatic hypotension
Take blood pressure in 3 positions: supine after resting for 3 to 10 mins, sitting and standing within 3 mins. A difference of > 20 is positive.
Extra vital signs - Leg blood pressure
Normal for systolic to be 5 to 10 mmhg lower in legs. Large cuff around thigh, prone patient or flexed leg for popliteal. Can also measure dorsalis pedis.
Cerebral function tests - procedure
Assess while taking case history
Cerebral function tests - interpretation
Doesnt know time, day, date, place. Cannot name everyday objects. Cannot follow verbal instructions. Difficulty writing. Possible dementia. Sifficulty speaking, articualtion, fluency, vocabulary. Possible dementia or dysphasia.
Standing and walking freely - procedure
Observe patient standing and ask then to walk.
Heel and toe walking - procedure
Ask patient to walk away with on toes and back towards you on heels.
Tandem walk - procedure
Ask patient to walk in a straight line with heel touching the toe of the previous foot.
Rhomberg’s - procedure
Ask patient to stand with feet close together. Ask patient to close eyes.
Rebound test - procedure
Ask patient to stand with eyes closed and arms outstretched. Strike firmly down on one arm .
Finger to nose - procedure
Patient seated. Ask patient to point at own nose and your finger, several times with finger moved each time
Rapid alternating hand - procedure
Ask patient to alternately tap dorsal and palmer side of hand quickly on thigh - one hand then other. Demonstrate.
Heel down shin - procedure
Patient sitting. Ask patient to place one heel on opposite knee and run it down the shin and off at ankle. Demonstrate.
Standing and walking freely - interpretation
Check for sway when standing (vestibular problem); sways but corrects (hysteria). Check gait for veering, balance, intention tremor, ataxia (cerebellum, MS); shuffling, resting tremor (parkinsons); antalgic (pain avoidance), spastic paralysis gait (possible spinal cord lesion).
Heel and toe walking - interpretation
Difficulty could indicate balance, co-ordination problems or muscle weakness. Toe drop - L4 myotome, tib anterior. Heel drop - S1 myotome, Gastroc, soleus.
Tandem walk - interpretation
Patient veers to the side. Possible CN VIII (vestibular), eyes and feet, proprioception, cerebellum.
Rhomberg’s - interpretation
Positive if sway is significantly greater with eyes closed. Indicates proprioception problem, peripheral neuropathy or dorsal column.
Rebound test - interpretation
Excessive rebound swinging indicates problem with cerebellar function.
Finger to nose - interpretation
Action, intention, endpoint tremor or dysmetra indicates cerebellar lesion. May also have nystagmus & hypotonia (cerebellar dytaxia).
Rapid alternating hand - interpretation
Lack of co-ordiantion and unevenness of rhythm and force indicates dysdiadochokinesia (Cerebellar function).
Heel down shin - interpretation
Leg dystaxia/ lack of coordination indicates problem with cerebellar function.
Motor function - Passive ankle and wrist flexion/extension - procedure
Patient supine and relaxed. Manipulate resting joint to feel muscle tone and elasticity. Use different speeds and anatomical movements on ankle, elbow and wrist.
Clonus - procedure
Patient supine and relaxed. Flex knee slightly. Place hand on sole of foot and briskly dorsiflex. Maintain pressure.
Babinski sign - procedure
Patient supine and relaxed. Hold ankle and stroke end of reflex hammer slowly from heel up lateral foot and sweep across ball of foot, avoiding base of toes.
Motor function - Passive ankle and wrist flexion/extension - interpretation
Normal is slight resistance through whole range. Spacticity - pyramidal lesion. Cogwheel Rigidity - extra pyramidal e.g. parkinsons. Hypotonia - Peripheral neuropathy, myopathy, central lesion or congenital e.g cerebral palsy or downs syndrome.
Clonus - interpretation
A few clonic jerks is normal. Oscillating flexion/extention as long as pressure maintained indicates UMN lesion.
Babinski sign - interpretation
Normal (No babinski sign) - toes curl, foot withraws, jump, no movement. Poitive - Big toe extends. Babinki sign is normal in infants. In adults it can indicate UMN lesion.
Vibration sense - procedure
Patient supine. Eyes closed. Hold large tuning fork to DIP joint of toe and finger and ask patient if they can feel it.
Proprioception - procedure
Patient supine, Support arm, grasp sides of finger and show up and down. Ask patient to close eyes and move finger to up or down position and ask which. Repeat for other side and toes.
Limb repositioning - procedure
Sitting. Ask patient to close eyes. Move limb into position. Say to patient to remember it and move arm back to it.
Touch localisation - procedure
Ask patient to point where you touch. Touch arms and legs
Sensory inattention - procedure
Ask patient to point where you touch.Touch both arms or both legs
Stereognosis - procedure
Ask patient to close eyes and place and object in their hand. Ask what it is.
Graphaesthesia - procedure
Ask patient to close eyes and draw a number or letter on their hand.
Vibration sense - interpretation
Lack of feeling in glove and stocking ditribution - peripheral neuropathy, possibly diabetes. Other lack of vibration sense indicates dorsal column problem. With Rhomberg, areflexia & hypotonia - sensory dytaxia.
Proprioception - interpretation
Failure to indicate whether finger/toe is up or down correctly could indicate malingering, hysteria, neurodisease (Dorsal column) or unclear communicaiton to patient.
Limb repositioning - interpretation
Failure to reproduce the limb position - Proprioception problem (Dorsal column).
Touch localisation - interpretation
Failure to tell where touch is - dorsal column problem.
Sensory inattention - interpretation
Patient only recognising one side when both are touched - Brain lesion
Stereognosis - interpretation
Failure to recognise objects by touch - Parietal lobe lesion
Graphaesthesia - interpretation
Failure to recognise a number or letter drawn on the hand - Parietal lobe or dorsal column
History of anosmia - procedure
Ask patient if they have any difficulty with sense of smell.
Visual fields - procedure
Patient covers one eye. “Tell me when you see my fingers.” Wiggle fingers from 4 corners.
Neglect - procedure
Hold fingers to left and right of patients head. “Point to any finger that moves.” Wiggle one then other, then both. Repeat in inferior and superior quadrants.
Pupillary light reactions - procedure
Dim lighting. Ask patient to look into the distance. Shine pentorch into one eye from side. Observe reflex in each eye. Repeat for other eye.
Pursuit - procedure
Hold finger 50 cm in front of patient. Draw H slowly. Ask patient to follow it without moving the head and say if they see double.
Vergence - procedure
Ask patient to look into the distance then at your finger 50 cm away.Ask patient to follow as you move finger towards their nose. Look for nystagmus. Also check for ptosis.
Temporalis, masseter and pterygoid strength - procedure
Notice whether the jaw is deviated to one side or cannot close. Palpate temporlis while patient clenches jaw. Palpate temporalis while patient bites. Ask patient to deviate jaw to sideagainst resistance.
Light touch and pain on V1, V2 and V3 - procedure
Use cotton wool and medipin. Test each side and ask patient if they feel it. Compare with neck. If impaired test temperature also. V1 - opthalmic - forehead. Above eye. V2 - maxilliary - upper cheek. V3 - mandibular - lower cheek near chin.
Function of facial muscles - procedure
Ask patient to raise eyebrows (frontalis), Close eyes tightly (obicularis oculi), purse lips (buccinator, orbicualris oris), grimace (platysma)
Screen hearing - procedure
Ask patient to cover one ear and repeat a phrase whispered in the other ear.
Weber’s - procedure
Strike tuning fork and place on top of patients head. Ask if they can hear it equally in both ears.
Rinnes - procedure
Strike tuning fork and place on mastoid process. Ask patient to say when it disappears. Place fork by ear and ask if they can hear it.
Swallowing - procedure
Ask patient if they have any problems swallowing.
Uvula - procedure
Ask patient to open mouth wide and shine pentorch in. Use tongue depresor to observe uvula. Ask patient to say “Ahh”.
Trapezius, and sternocleidomastoid strength - procedure
Observe back and shoulders. Ask patient to raise shoulders against resistance for 5 secs. Observe and palpate SCM. One hand on shoulder, other on side of forehead. Ask patient to turn head towards hand and upwards. Ask patient to deviate jaw against resistance.
Observe tongue - procedure
Observe tongue. Ask patient to protude tongue.
Tongue strength - procedure
Ask patient to push tongue against cheek.
History of anosmia - interpretation
CN 1 lesion. Upper respiratory tract infection. Head injury. Degenerative disease. Tumour. Aneurism in circle of willis. Raised ICP.
Visual fields - interpretation
Pattern defects. Bitemporal hemianopia (lateral blindness in each eye) - optic chiasm lesion. Homonomous hemianopia - Optic tract (contralateral), radiation or occipital cortex (macula spared). Quadrantanopia - radiations (Upper = temporal. Lower = parietal. Contralateral.) Monocular blindness - optic nerve lesion (ipsilateral).
Neglect - interpretation
Patient only sees hand one when both sides are wiggled - Parietal cortex or parieto-occipital cortex lesion.
Pupillary light reactions - interpretation
Pupil should constrict for normal reflex. Direct and consensual impaired when testing same eye - Optic nerve lesion (afferent). No reflex in one eye regardless of which is tested - oculomotor lesion (efferent).
Pursuit - interpretation
Normal movement is full, smooth & co-ordinated. No double vision or nystagmus (uncontrolled movements) Double vision indicates eyes are not co-ordinated. Problem when looking down and L or R may be CN IV on opposite side (possible cerebellar tumour). Problem when looking L or R may be CN VI on same side (VI is long so could indicate raised ICP). Others CN III (CIII passes circle of willis). Nystagmus may indicate CN VIII (vestibular). All with V & possible proptosis indicates cavernous sinus and orbital fissure.
Vergence - interpretation
Normal movement is full, smooth & co-ordinated. Possible CN III. Nystagmus may indicate CN VIII (vestibular) or cerebellar lesion. Ptosis indicates CN III lesion, Horners syndrome or myesthenia gravis.
Temporalis, masseter and pterygoid strength - interpretation
Lack of muscle tone, inability to clench jaw, jaw deviation - CN V lesion (motor)
Light touch and pain on V1, V2 and V3 - interpretation
Map any area of sensory deficit. One division sensory deficit - peripheral nerve or nucleus. All divisions - ganglion or nucleus. If dissociated - pons, medulla or spinal cord. Sharp deficit may result from trigeminal neuralgia.
Function of facial muscles - interpretation
Lack of muscle strength or asymmetry in upper and lower face indicates CN VII motor lesion. Lower face only - UMN contralateral (tumour or vascular). Upper and lower face - LMN ipsilateral (Bells Palsy). Bilateral - LMN (Pontine lesion, Guillan Barre, lyme disease or muscle disease).
Screen hearing - interpretation
Patient cannot hear a whispered phrase well enough to repeat it - conductive (e.g. earwax) or sensoryneural deafness.
Weber’s - interpretation
Normal is equal sound in both ears. Louder in one ear indicates conductive deafness in the louder ear (less background noise) or sensoryneural deafness in the quieter ear (less hearing).
Rinnes - interpretation
Positive test if patient hears sound louder through air when it has faded through bone. Positive test is normal unless Webers is also positive. Bothe positive indicates sensorineural deafness (lesion in cochlear apparatus, cerebellopontine angle or brain stem). Negative (bone conduction longer than air) indicates conductive deafness (wax).
Swallowing - interpretation
Problems swallowing. Speech impairment. CN IX and X. If CN XI is also affected - jugular foramen syndrome.
Uvula - interpretation
Normal for uvula to move symmetrically. If asymetrical or arch of soft palate dropped - LMN lesion (uvula moves towards unaffected side).
Trapezius, and sternocleidomastoid strength - interpretation
Dropped shoulder. Weakness of trapezius. SCM atrophy or . weakness (when turning to opposite side). Traps and SCM on same side - LMN lesion (peripheral accessory nerve palsy). Possible jugular foramen syndrome with X and IX. Ips SCM and contra traps - UMN CN XI
Observe tongue - interpretation
Unilateral deviation. Atrophy. Flaccid. Fascicualtions - LMN lesion ips side. Small fascicualtions - Bilat LMN. Unilateral deviation, no atrophy - Unilateral UMN lesion contra side. Reduced range of movements - Bilat UMN. CNXII
Tongue strength - interpretation
Weak tongue to one side indicates CN XII lesion. Use observation to determine lesion type
Dermatomes general
Ask patient to close eyes and say when touched with cotton wool. Repeat with medipin. Sharp = Spinothalamic tract. Soft - dorsal column.
Dermatome C5
Upper arm - lateral (top)
Dermatome C6
Lateral forearm, thumb and forefinger.
Dermatome C7
Middle finger
Dermatome C8
Ring and little fingers. Medial forearm.
Dermatome T1
Distal part of medial upper arm.
Dermatome L2
Upper thigh
Dermatome L3
Middle thigh to medial knee
Dermatome L4
Medial lower leg
Dermatome L5
Top of foot and front of lower leg
Dermatome S1
Lateral side of lower leg and foot
Deltoid
Ask patient to raise both arms and maintain position resisting pressure. Apply pressure steadily. C5 myotome. Only do for axillary nerve.
Biceps
Arm bent. Steady under elbow and put pressure on forearm away from
body. C5 or C6 myotome. Musculocutaneous nerve. Use for C5 myotome.
Triceps
Arm bent. Steady under elbow and put pressure on forearm towards body. C7 myotome. Radial nerve. Use for C7 myotome.
Wrist flexors, finger flexors
Hold out hand palm up and bend middle finger. Resist straightening it. Hold forearm palm up and put pressure on hand downwards. C8 myotome. Flexor carpi radialis/ulnaris. Median and ulnar nerve. Use only the finger for myotome C8 and wrist only for peripheral nerves.
Wrist extensors
Hold forearm palm down with wrist extended and put pressure on hand. C6 or C7 myotome. Extensor carpi ulnaris. Posterior interosseus nerve. Use for C6 myotome.
Finger adductors/abductors.
Ask patient to spread fingers and put pressure to close each pair. Put your fingers between theirs and ask them to squeeze. T1 myotome. Palmar interossei. Ulnar nerve. Use for T1 myotome, but only little finger.
Hip flexion
Ask patient to raise knee against resistance. Myotomes L1/L2. Femoral nerve. Do supine using both hands to resist. Use for L2.
Knee extension
Foot hanging. Steady knee and hold ankle. Ask patient to resist while foot is pushed back. Myotomes L3/L4. Femoral nerve. Use for L3.
Knee flexion
Foot hanging. Steady knee and hold ankle. Ask patient to resist while foot is pushed forward. Myotome L5. Use only for sciatic nerve.
Hallux extension
Foot on ground. Patient raise toe against resistance. Myotome L5. Deep peroneal nerve. Use for L5.
Ankle dorsiflexion
Walking on heels test completed earlier for balance. Myotome L4 or L5. Deep peroneal nerve. Tibialis anterior. Use for L4.
Ankle plantarflexion
Walking on toes test completed earlier for balance. Myotome S1. Tibial nerve. Gastroc or soleus. Use for S1.
Biceps reflex
Ensure patient relaxes. Support arm. Find tendon with thumb, just proximal to anterior elbow. Strike own thumb with hammer. C5. Musculocutaneous nerve.
Brachioradialis reflex
Ensure patient relaxes. Support arm. Find tendon with thumb, proximal to lateral wrist. Strike own thumb with hammer. C6. Radial nerve
Triceps reflex
Ensure patient relaxes. Support elbow with arm hanging down. Find tendon proximal to posterior elbow. Strike tendon with hammer. C7. Radial nerve
Patellar reflex
Ensure patient relaxes and leg hanging. Find tendon distal to knee. Strike tendon with hammer. L4. Femoral nerve.
Achilles reflex
Ensure patient relaxes lying prone. Stretch tendon slightly by pushing toes. Find tendon just proximal to Ankle. Strike tendon with hammer. S1. Sciatic nerve.
Hallpike manouvre
Patient seated. Explain test. Qickly lay patient down to supine with head extended and rotated to one side. Check for nausea, dizziness, horizonal nystagmus. Raise to sitting and repeat 5 times. Positive for BPPV if nystagmus fatigues.
Fitz-ritson test
Seat patient in swivel chair. Rotate head only. Dizziness indicates vestibular, vascular or proprioceptive problem. Allow to settle. Rotate body only. If also dizzy, then rule out vestibular.
Respiratory examination - position
Patient seated with hands crossed to opposite shoulders.
Respiratory examination - observation
Check for deformities or asymmetry. Check rhythm, depth and effort of breathing.
Respiratory examination - rib expansion - procedure
Hands spread out on patients back with thumbs on T10. Ask patient to breath deeply and feel rib cage expand.
Respiratory examination - rib expansion - what to look for
Check range, smoothness and symmetry of movement. Decrease delay or asymmetry in movement may indicate fibrotic disease, pleural effusion , pneumonia or obstruction.
Respiratory examination - tactile fremitus - procedure
Make fist and place ulnar surface on patients back. Ask them to say “99”. Four points - 3 medial and 1 lateral.
Respiratory examination - tactile fremitus - what to look for
Feel vibrations. Decreased or absent indicates obstruction, COPD, fluid between plaural sufaces, fibrosis, pneumothorax or tumour.
Respiratory examination - percussion - procedure
Place palpating finger flat on back and hit it with 2 fingers twice - 7 points on each side. 5 medial and 2 lateral.
Respiratory examination - percussion - what to look for
Normal lung sound is resonant. Dullness indicates fluid or solid tissue e.g. lobar pneumonia, pleural efusion, haemothorax or empyema. Too large area of resonance indicates hyperinflated lungs - asthma, emphysema uilateral hyperresonance indicates pneumothorax or air filled bulla.
Respiratory examination - auscultation - procedure
Instruct patient to breathe deeply. Use diaphram of stethascope to listen at 7 points on each side - 5 medial and 2 lateral. One breath for each point - be carful to time it rght for patient.
Respiratory examination - auscultation - what to look for
Left may be quieter. Ok to hear the heart. Listen for crackles or wheezing.
Extra Respiratory tests - Bronchophany
Patient says 99 during auscultation. Should sound dull and muffled. Clear sound indicates airless lung.
Extra Respiratory tests - Egophony
Patient says “eee” during auscultation. If it sounds like “ay” there is lobal consolidation - pneumonia.
Extra Respiratory tests - Whispered pectoriloquy
Ask patient to whisper “99” during auscultation. Should not be heard. Loud clear sounds indicate lung consolidation.
CV Exam - Observation - what to look for
Finger clubbing: Bulbous distal phalanx. One or more digits, uni or bilateral. Can affect toes. Cyanosis: Bluish colour Oedema: Pitting or non pitting. Uni or bilateral.
CV Exam of Heart - Position
Patient supine with upper body elevated 30 degrees. Stand on patient’s right.
CV Exam of Heart - Palpation
Palpate apical impulse (Interspaces L4,5. Mid clv line).
CV Exam of Heart - Percussion
Percuss from left from resonance to cardiac dullness (Interspaces L3,4,5). Checks size of heart.
CV Exam of Heart - Auscultation
Auscultation supine with diaphram: Aortic (Interspace R2), pulmonary (Interspace L2), tricuspid( Interpaces L3,4,5), mitral(Apex - L4,5 Mid clv line)). Checks valves for extra sounds.
CV Exam of Carotid artery
Located at medial borger of SCM level with cricoid cartilage. Palpation of pulse for amplitude, wave contour and thrills. Ask patient to hold breath. Auscultation for bruits (blowing or rushing sound) using diaphram and maybe also bell. Ask patient to hold breath.
CV Exam of Vertebrobasilar artery - 2 tests
Maignes: Seated. Rotation, lat flexion, extension - support patient if they fall. Eyes in neutral pos, hold 30s. DeKleyns: lying supine. Ext and rotate. Positive is any 3 of 3NA5D
What are 3NA5D
Nausea. Nystagmus. Numbness. Ataxia. Drop attack. Dixzziness. Dyplopia. Dysarthria. Dysphagia.
CV Exam - Peripheral pulse amplitude - where?
Radial done in vital signs. Dorsalis pedis (foot).
CV Exam - Capilliary refil.
Press finger nail and notice how long it takes for redness to return. Long time indicates problem with peripheral blood supply.
Extra CV Tests - Mitral stenosis
Ausculatate apex (interspaces 4,5. Mid clav line) using bell while lying on left side.
Extra CV Tests - Aortic regurgitation
Ausculatate aortic valve (left sternal borner and apex/ interspace L3,4) using diaphram while sitting forwards and exhalation held.
Extra CV Tests - Juggular venous pressure.
Patient reclined at 45%. Measure the distance from the highest jugular venous pulse to the sternal angle - not learned yet.
Extra CV Tests - Additional peripheral pulses - where?
Posterior tibial, popliteal, femoral. Test to find where occlusion is.
Extra CV Tests - Allen’s test.
Patient to open and close hand rapidly. Place thumbs over radialand ulnar arteries. Patient to open hand. Release one thumb. Watch how hand flushes. Persistant palor indicates occlusion.
Extra CV Tests - Buerger’s test.
test for arterial sufficiency in lower limb. Measure angle to which leg can be raised before it becomes pale.
Extra CV Tests - Homan’s sign.
To check for DVT. Patient prone. Passively Dorsiflex foot while palpaling calf. Pain in calf or pain with palpation is positive. Unreliable test.
Abdominal exam - Position
Patient supine with knees bent. Stand on patient’s right.
Abdominal exam - Observation - what to look for?
Skin lesions.Scars, Striae (stretch marks), Veins, Rashes, Peristalsis or pulsations.Umbilicus. Contour symetrical. Inflamation. Masses
Abdominal exam - Auscultation - Procedure?
Arteries: Aorta (central), Renal and iliac (L and R). Bowel sounds - 4 quadrants, 5-10 s each.
Abdominal exam - Auscultation - what to look for?
Bruits in arteries. Bowel sounds - 5 to 34 sounds per minute. Best in RLQ.
Abdominal exam - Percussion - procedure?
Percuss general abdomen, liver and spleen. Pad of finger flat. Percuss with rebound. Liver - percuss from mid clavicular line below and above. Spleen - lowest costal interspace percuss, breath in and percuss again to compare.
Abdominal exam - Percussion - what to look for?
Dull - muscle or bone. Timpanic - organs. Resonant - lungs. No dull sounds in abdomen, unless there is a mass. Liver is dull. Check for splenic dullness (infection) - percussion changes from timpanic to dull with breath in.
Abdominal exam - Palpation - what to look for?
Tenderness, abnormal texture or enlargement
Abdominal exam - Light palpation - procedure?
One hand cover all quadrants.
Abdominal exam - Deep palpation - procedure?
Two hands. Deep and slow. Cover all quadrants.
Abdominal exam - Palpation of liver - procedure?
Left hand under post inf R ribs, right hand along right costal margin. Deep breath for liver to slip under hand. Normal is smooth regular and soft.
Abdominal exam - Palpation of spleen - procedure?
Left hand under lower left rib cage, right hand below left costal margin. Press in towards spleen. Deep breath. Should not be palpable.
Abdominal exam - Palpation of kidneys - procedure?
One hand behind patient,other on the midline. Breath in then out, then sweep top hand across to catch kidney. Should not be palpable. Alternative is kidney ballotment
Abdominal exam - Palpation of abdominal aorta - procedure?
Palpate size down to the bifucation to iliac arteries. Normal is < 3cm. Ensure Auscultation is done first.
Extra abdominal tests - Rebound tenderness - procedure.
Press fingers slowly into areas of tenderness and release quickly.
Extra abdominal tests - Rebound tenderness - what to look for.
Signs or sounds indicating pain on release indicates peritoneal inflammation e.g. appendicitis.
Extra abdominal tests - McBurney’s sign.
Deep tenderness at McBurney’s point indicated acute appendicitis. One third of the distance from R ASIS to umbilicus.
Extra abdominal tests - Psoas sign - procedure.
Place hand proximal to right knee and ask patient to raise knee against the hand.
Extra abdominal tests - Psoas sign - what to look for.
Increased abdominal pain indicates psoas muscle irritated by inflamed appendix
Extra abdominal tests - Murphy’s sign - procedure
Hook left thumb or right fingers under costal margin by lateral border of rectus muscle. Ask patient to take a deep breath.
Extra abdominal tests - Murphy’s sign - what to look for
Sharp increase in tenderness with sudden stop in inspiratory effort indicates acute cholecystitis (inflamation of gall bladder)
Extra abdominal tests - Costovertebral angle tenderness - procedure
Patient seated. Palpate both costovertebral angles with fingertips. If not tender, use fist percussion - one hand on costovertebral angle, the other strikes it with ulnar surface of fist.
Extra abdominal tests - Costovertebral angle tenderness - what to look for.
Tenderness from palpation or fist percussion indicated pylonephritis or musculoskeletal.
General observation and palpation cervical
Look and feel checking for aysymmetry, tensions, subluxations and compensatory posture. Rust’s sign: Patient supporting head in hands. Indicates serious pathology. Instability due to fracture, RA, severe sprain or subluxation. Bakody’s sign: Patient puts hand on head to reduce radicualr symptoms. Indicates Nerve root compression or disc herniation in C5-C6 area.
Cervical ROM
Flex 75, Ext 70, Lat 45, Rot 80. Endfeel = tissue stretch. Passive should move further. Pain on active and passive - ligament sprain. Pain on active resisted - muscle strain.
Valsalva’s (cervical)
Ask patient to take deep breath and hold while bearing down. Take care for dizzyness or fainting. Look for increased pain, local or radicular. Indicates possible SOL - herniated disc, tumour, ostophyte.
Cervical distraction
Stand behing patient. Grasp beneath mastoid processes with fingers pointing up and exert pressure upwards. +ve is relief ofradicualr pain. Indicates foraminal encroachment or disc lesion. Increase in pain indicates muscle straij, spasm, ligament sprain or facet capsualitis. Decrease in local pain indicates facet impingement.
Cervical compression
Gently apply pressure downwards axially through patient’s head. If radicualr symptoms: Repeat in rotation. Repeat in flexion. Repeat in max foraminal compression (Rotation, lat flex and extension). +ve is increase of radicular symptoms. Indicates nerve root or facet joint pathology on ips side. Increase in local pain indicates joint damage or muscle strain (on contra side).
Maignes/Dekleyns. 3N, A, 5Ds
First palpate carotid/ subclavian arteries for pulsations and listen for bruits. If +ve for either of these do not perform test. Maignes: Patient to rotate, lat flex and extend head to limit. Eyes ahead but not at extreme of vision. Hold 30 s. +ve is Nausia, Numbness, Nystagmus, Ataxia, Drop attack (fall without faint), Dizziness, Diplopia (vision), Dysarthria (speaking), Dysphagia (swallowing). Indicates VBAI (vertibral basilar artery insuficincy on ips side). Dekleyns is same test lying supine with head off end of bench.
Tuning fork
Large tuning fork. Use of shoulder to let patient feel it. Ask Patient to flex head. Place on each SP in turn. Look for feeling different or pain. Indicates possible fracture.
Percussion
Patient to flex head. Use tomahawk hammer to tap own finger on each SP and surrounding muscles. Local pain indicates possible fracture, ligament sprain or muscle strain. Radicular pain indicates possible disc defect.
Shoulder depression
Stand behing patient. Apply downward pressure on shoulder while laterally flexing patient’s head to opposite side. Increase in local pain on stretched side indicates muscular strain, adhesions, spasm or ligament injury. Increase in radicular painon stretched side indicates brachial plexus, dural sleeve adhesion or TOS. Increase in pain on compressed side indicates nerve root compression or foraminal encroachment.
TOS - Roos
Hands up, elbows 90 deg, palms forward. Slowly open and close hands for 3 minutes. +ve is patient cannot keep arms up, or experiences ischemic pain, heaviness, weakness, numbness or tingling in hand. Indicates Thoracic outlet syndrome.
TOS - Adsons/halsteads.
Locate radial pulse. Ext rotate and extend shoulder. Adsons: Patient to look towards you, deep breath and hold. +ve is disappearance of pulse. Halsteads: look away, no breath. Same +ve. Either indicate spasm or hypertrophy of scalenes as cause of TOS.
TOS - Wrights
Take radial pulse. Abduct arm above shoulder. +ve is absence of pulse. Indicates spasm or overuse of pectoralis minor.
TOS - Costoclavicular
Patient extends both shoulders so arms are behind.Locate both radial pulses. Patient to force shoulders back, flex neck and take a deep breath. +ve is no pulse. Indicates costoclavicular syndrome (postural) or cervical rib.
Kernig’s
For suspected menengitis or subarachnoid headache (heamorrhage). Patient supine. Flex hip with leg straight until pain is felt - like SLR, but active. Then bend knee. +ve if pain disappears. Indicates meningeal irritation, nerve root involvement or dural irritation. Brudinski-kernig: As above with flexed neck.
Nerve tension tests - ulnar, median radial.
Ulnar: Patient to place hand on cheek fingers downward. +ve is tingling in ring & little fingers. Median: penguin - extend elbow & wrist. Rotate head to opp side. +ve is tingling in 1st 3.5 digits. Radial: arm as for median but tuck thumb into palm. +ve is tingling in posterior arm or snuff box area. Indicates nerve impingement.
Lumbar general observation
Standing posture and gait. Look for asymmetry; antalgic posture - loss of lordosis & lateral shift when standing. ASIS inferior to PSIS. Scoliosis. All indicate acute back pain. Minors sign: Standing up using only healthy side. Affected leg flexed. Indicates sciatic radiculopathy.
Lumbar ROM
Active then patient crosses arms for passive. Hold elbow and support lumbar spine. For lat flex, hold shoulder and lumbar spine. Passive ROM can be combined with kemps test .Flex 60, Ext 35, Lat 20, Rot 18. Endfeel = tissue stretch. Passive should move further. Pain on active and passive - ligament sprain. Pain on active resisted - muscle strain.
Valsalvas (lumbar)
Ask patient to take deep breath and hold while bearing down. Take care for dizzyness or fainting. +ve is increased pain, local or radicular. Indicates possible SOL - herniated disc, tumour, ostophyte.
Kemps
Patient crosses arms to shoulders. Hands on elbow and PSIS. Bend into extension, lateral flexion and rotation. +ve if symptoms reproduced. Local pain incicates facet joint or muscle strain. Peripheral pain indicates nerve root or inflamatory. Lateral disc lesion - pain same side. medial - opposite side.
SLR
Patient lying supine. Passively raise straight leg. Ays side first. Until patient complains of pain or tightness in back or posterior leg. + ve is pain from back to leg in sciatic dist. Pain to 35 deg indicates piriformis syndrome or SI joint dysfunction, 35 to 70 dural involvement-meningeal irritation or SOL, 70 plus, facet joints or SI dysfunction. Symptoms in the other leg indicate SOL medial to nerve root. In both indicates central disc protrusion - check for cauda equina symptoms
Tuning fork (lumbar)
Large tuning fork. Use of shoulder to let patient feel it. Patient to bend forward. Place on each SP in turn 4 at a time. Look for feeling different or pain. Indicates possible fracture.
Percussion (lumbar)
Use tomahawk hammer to tap own finger on each SP and surrounding muscles. Local pain indicates possible fracture, ligament sprain or muscle strain. Radicular pain indicates possible disc defect.
Braggards
Supine: If SLR +ve. Lower leg slowly until symptoms alleviated. Dorsiflex the foot. +ve if symptoms are reproduced. Indicates SOL within spinal cord or menengitis.
Kernig’s sign
Supine: If menengitis is suspected. Active hip flexion with straight leg until pain is felt. Then bend knee. +ve if pain goes. Indicates Meningeal irritation, nerve root or dural irritation.
Sign of buttock
Supine: Perform SLR until pain is felt. Flex knee. Try to flex hip further. +ve if hip flexion does not increase further. Indicates buttock pathology such as bursitis, tumour, absess or glut strain. Possible SI joint problem.
Goldthwaites
Supine: If SLR +ve. Place one hand with fingers between spinous processes of Lx. L2 to S1. With other perform SLR. Pain before movement of spine indicates SI joint. Pain while spine joints moving indicates lumbar problem.
Gaensleins
Patient lies supine near edge of bench with test hip over the edge. Patient draws up both legs then extend the test leg. Apply slight pressure on test knee to increase extension. +ve is pain. Indicates ipsilateral SI joint lesion, hip pathology or L4 nerve root. Can be done on side if bench is too low.
Gap & Squish
Supine - Gap: Cross hands on ASIS. Apply posterior and lateral pressure. +ve is glut or posterior leg pain. Indicates sprain of anterior SI ligaments. Squish: Hands on ASIS’s. Apply inferior and medial pressure. +ve is pain in SI joints. Indicates sprain of posterior SI ligaments.
Nachlas
Patient lying prone. Passively flex knee as far as possible so heel approaches buttocks.Ensure hip is not rotated. +ve is pain or numbness in anterior thigh. Indicates femoral nerve lesion L2,3,4 or tight quads.Local pain at SI joint indicates SI problem.
Yeomans
Prone: Flex knee to 90 deg. Lift extending hip. Pain in SI joints indicates anterior SI ligaments. Pain in lumbars indicates lumbar. Anterior thigh parasthesia indicates femoral nerve.
Piriformis test
Prone on edge of bench: Flex knee and hip with foot on bench, knee off bench. Stabilise hip and apply downward pressure to knee to medially rotate hip. Pain in muscle indicates tight piriformis. Pain in buttock and radiating down leg indicates pinching of sciatic nerve - piriformis syndrome.
Segmental instability
Prone on end of bench. Apply pressure to lumbar spine and ask patient to lift both legs. +ve if pain goes when muscles engage. Indicates lumbar instability. Possible spondylolisthesis.
Pheasant
Prone: Apply gentle pressure to lumbar spine, while passivly flexing knees until both heels reach buttocks. +ve if pain in leg when spine hyperextends.
Trendelenburg’s
Standing: Patient balances on one leg at a time. Watch pelvis. Side of pelvis on uplifted leg should rise. +ve if it falls. Indicates weak or dysfunctional glut med on supporting leg side
Adams/supported
Standing: If there is limited movement or pain on forward flexion. Place your pelvis at patients back and hold ASIS’s to remove SI joint action. Patient bends forwards. Movement better or painless indicates SI joint problem. Otherwise lumbar problem.
Gillets
Standing: If you suspect SI joint involvement. Patient faces wall, with hands on wall. One hand on S2 SP and other on PSIS. Patient lifts knee to hip level. PSIS should move inferiorly & smoothly. Compare sides. One hand on apex of sacrum and other on iscial tuberosity. Ischial tuberosity should flare laterally. +ve is hitching, lack of or too much movement. Indicates SI hyper or hypomobility. PSIS or Ishial tuberosity moving superiorly indicates fixation.
Stork standing
Standing on one leg extending back. +ve Is pain in back. Indicates pars fracture on side of supporting leg.
Upper limb observation - shoulder
Step deformity indicates dislocation. Winging scapula indicates rhomboid weakness, instability or nerve lesion.
Shoulder ROM - active
Abduction 175. Forward flexion 170. Scaption 175. Extension 55. Int rotation 80. Ext rotation 85. Check scapulohumeral rythmn 2:1
Shoulder ROM - passive
End feel tissue stretch except abduction may be bone to bone. Restriction indicates bony or soft tissue blockage. Painful arc 60 to 120 indicates pinched bursa or tendons. Painful arc 170 to 180 indicates joint pathology or impingement.
Dawbarns sign
Pain on palpation of bursa that dissapears when arm is passively abducted indicates subacromial bursa.
Apley scratch
One hand over shoulder and other under to touch scapula behind back. Reduced ROM indicates frozen shoulder or rotator cuff strain. Pain indicates tendonitisin top arm shoulder.
Drop arm
Patients arm is abducted to 90 deg. They then slowly lower it. +ve is severe pain or inability to slowly lower arm. Indicates rotator cuff tear.
Empty can
Ask patient to elevate to 90 deg in scaption. Point thumb to floor. Push down while patient resists. Pain inidcates supraspinatus muscle or tendon tear or neuropathy of superscapular nerve.
Lift off
Ask patient to place dorsum of hand agaist lumbar spine and lift away from back. Apply resustance to test muscle. Inability to do so indicates subscapularis.
Speed’s
Restited active flexion of straight arm while palpating bicipital groove. Tenderness on palpation indicates tendonitis. Weakness indicates biceps rupture.
Yergason’s
Resisted active lat rotation and supination while palpating bicipital groove. +ve id tendon pops out of groove. Indicates transverse humeral ligament is torn.
Hawkins-Kennedy
Shoulder abducted 90 and elbow flexed. Internally rotate arm. Pain indicates pupraspinatus tendonitis, tendonosis or impingement.
Neer impingement
Pasively and forcibly elevate arm in scaption, with palm down and up. Pain with palm down indicates supraspinatus impingement. Pain with palm up indicates biceps long head impingement.
Dugas’
Ask patient to place hand on opposite shoulder and lower elbow to chest. Inability to do so indicates dislocation.
Anterior apprehension
Abduct arem to 90 deg and slowly ext rotate it. Apprehension indicates anterior instability or dislocation of humerus.
Anterior drawer for shoulder
Supine: Patients hand in your axilla. Other hand stabilises posterior scapula and coracoid process. Distract humerus. Abnormal movement indicates anterior instability of glenohumeral joint.
Posterior apprehension
Supine: Flex patients arm to 90 deg. Internally rotate and flex elbow. Push on elbow posteriorly. Apprehension indicates posterior intabiliy or dislocation of the humerus.
Posterior drawer for shoulder
Supine: Elbow up at 90 to body. Stabilise scapula and coracoid process. Forse humerus posteriorly. Abnormal movement indicates posterior instability of glenohumeral joint.
Elbow ROM - active
Flex 145. Ext 5. Sup 90. Pron 85.
Elbow ROM - passive
End feel: Flexion - tissue approx. Ext - bone to bone. Sup and pron - tissue stretch.
Valgus and varus elbow instability
One hand at wrist one at elbow. Slightly flex elbow and stabilise. Palpate lateral colateral ligament and apply varus force (adduction) to forarm. Palpate medial colateral ligament and apply valgus (abduction) force. Laxity, decreased mobility or change in pain indicates instability.
Lateral epicondylitis (tennis elbow)
Resisted extension of middle finger. Pain over lateral epicondyle indicates tennis elbow.
Medial epicondylitis
Place thumb on medial epicondyle. Passively supinate forearm extending elbow and ask patient to flex wrist against resistance. Pain over medial epicondyle indicates medial epicondylitis. (Golfers elbow)
Wartenburg’s
Spread patients fingers on table. Ask them to bring fingers together. Inability to move little finger with otehrs indicates ulnar nerve neuropathy.
Elbow flexion
Ask patient to fully flex elbows, extend wrists and depress shoulders. Hold for 3 - 5 mins.Tingling in ulnar disribution indicates cubital tunnel syndrome.
Pinch grip
Ask patient to pinch together index finger and thumb. Pad to pad instead of tip to tip inidcates pathologyof the anterior interossious nerve.
Pronator teres syndrome
Ask patient to flex elbow. Ask patient to strongly resist extension and pronation. Tingling in median nerve distribution indicates pronator teres syndrome.
Upper limb observation - wrist
Wrist: ulnar tunnel triad - tenderness over ulnar tunnel, clawed ring finger, hypothenar atrophy.
Wrist ROM - active
Flex 85. Ext 80. Radial deviation 15. Ulnar deviation 40.
Wrist ROM - passive
End feel: Flex & ext - tissue stretch. Deviation - Bone to bone.
Lunotriquetral ballotment
Countermove the lunate and triquetrum. (next to pisiform) A - P. Pain, laxity or crepitus indicates lunotrquetral instability.
Watson
Wrist in ulnar deviation and slight extension. Grasp scaphoid (nearest carpal to thumb) and move A-P. Pain, laxity or crepitus indicates scaphoid instability.
Finkelstein’s
Patient makes a fist with thumb inside and deviates towards ulna. Pain in wrist can indicate tenosynovitis of tendons at wrist.
Tinel’s
Tap over carpal tunnel. Tingling in first 3.5 digits (median dist) indicates nerve compression
Phalen’s
Patient flexes wrists and puts backs of hands together for 1 min. Tingling in med nerve dist (first 3.5 digits) indicates carpal tunnel syndrome.
Allens
pationt opens and closes hand several times rapidly, then squeezes it. Palce your thumbs over radial and ulnar arteries. Patient opens hand and release one artery to see how long it takes for hand to flush. Repeat for other artery.
Lower limb observation - hip
Check gait - shorter stride, bent knee, swinging leg with whole trunk.
Hip ROM - Active
Supine except ext: Flex 110. Ext 10. Abd 40. Add 30. Med rot 35. Lat rot 50.
Hip ROM - Passive
Supine: End feel tissue stretch. Flexion and adduction may be tissue approximation. Restriction indicates bony or soft tissue blockage.
Anvil test
Supine: Elevate straight leg. Compress towards hip to take up slack in hip and strike heel. Hip pain indicates fracture, arthritis or infection. Leg pain indicates possible fracture in area of pain.
Patrick Faber
Supine: Flexion, ABduction, External Rotation. Flex knee over other leg like a 4. stabilise pelvis and push down on knee. +ve if cannot get parallel with bench. Indicates arthritis, sprain, strain, fracture, tight hip adductors, iliopsoas spasm or SI joint.
Scouring
Supine: Flex and adduct hip so it faces opposite shoulder and you feel resistance. Maintaining resistance and flexion, move hip in an arc to abduction. +ve is pain, irregualrity of movement or apprehension. Indicates hip pathology such as OA or transient synovitis.
Hip telescoping
Supine. Hip and knee at 90 deg. Puch knee into bench and distract away. +ve is excesseive movement, pain or apprehension. Indicates instability, dislocation or ligament damage.
Thomas
Supine: Patient brings one knee to chest holds it. +ve if other leg lifts off bench. Indicates tight hip flexors. If leg abducts it indicates a tight ITB.
Ely’s
Prone: Passively flex patient’s knee.=ve if hip flexes. Indicates tight rec fem.
Ober’s
Side lying. Lower leg flexed at knee and hip for stability. Abduct and extend top leg with knee straight. Slowly lower it. +ve if it fails to lower all the way. Indicates tight ITB.
Lower limb observation - knee
Observe standing: varus, valgus, swelling, patella.
Knee ROM - Active
Flex 135. Ext 15. Med rot 25. Lat rot 35.
Knee ROM - Passive
Flexion - tissue approximation. Other - Tissue stretch. Check patellar movement.
Valgus stress
Supine: Hold ankle on medial side. Apply lateral to medial stress on the knee. Straight leg then 30 deg. Pain indicates MCL sprain.
Varus stress
Supine: Hold ankle on lateral side side. Apply medial to lateral stress on the knee. Straight leg then 30 deg. Pain indicates LCL sprain.
Lachman
Supine: Knee in 30 deg flexion. One hand stabilise femur. Other move tibia anteriorly. +ve is mushy endfeel. Indicates sprain or rupture
Posterior sag sign
Supine: Hip 45 deg. Knee 90 deg.+ve is sag of tibia. Indicates PCL tear.
Drawer sign
Supine with hip 45 deg and knee 90 deg. Sit on foot. Push and pull. Excessive movement indicates torn ACL (Pull) or PCL (Push)
Slocum
Same position as drawer sign, but medially rotate foot 30 deg. Draw tibia anteriorly. Excessive movement indicates anterolateral instabiliy, LCL or PCL. Repeat with foot 15 deg laterally. Excessive movement indicates anteromedial instability, MCL or ACL tear.
McMurray
Supine. Knee fully flexed to buttock. One hand on heel, one on knee. Medially rotate tibia and extend leg. Pain indicates lateral meniscus. Repeat laterally rotating. Pain indicates medial meniscus. +ve is pain or snaps & clicks.
Bounce home test
Supine: Fully flex the knee and passively extend it. Pain, rubbery end feel or block to full extention indicate meniscal tear.
Apley’s
prone: knee flexed to 90 deg. Anchor patients thigh with your knee. Distract and compress while rotating tibia medially and laterally. More pain on distraction indicates ligament. More pain on compression inidcates meniscus.
Stroke
Supine: Starting inferior to joint line on medial side of knee, stroke superior to suprapatellar pouch. Other hand stroke inferiorly on lateral side. Look for a wave of fluid. Indicates swelling.
Patellar ballotment test.
Tap patella or apply slight pressure. Feels like floating if swelling is present.
Clarke’s
Supine. Knee extended.Apply pressure posteriorly to proximal patella while patient contracts quads. Pain indicates chondromalacia patella.
Wilson’s
Seated: Ask patient to extend knee to 30 deg with tibia medially rotated. Rotate tibia laterally. +ve if pain goes when rotated laterally. Indicates osteochondritis dessicans.
Lower limb observation - ankle and foot
Atsnding and walking. Supination, pronation, swelling, nail condition. joints. Check shoes for wear.
Ankle ROM - Active
Plantar 50. Dors 20. Sup 50. Pron 20.
Ankle ROM - Passive
End feel tissue stretch. Useful to check weight bearing too.
Anterior drawer
Supine: Stabilise leg. Hold foot in 20 plant & draw talus anteriorly. Excessive movement indicates injury to anterior talofibular ligament.
Posterior drawer
Supine: Stabilise talus. Hold foot in 20 plant & draw lower leg anteriorly. Excessive movement indicates injury to posterior ankle ligaments.
Thompson’s
Prone. Knee flexed to 90 deg. Squeeze muscles. Observe for plantarflexion. Lack of it indicates achillies tendon rupture. Local pain indicates muscle strain.
Morton’s
Supine: Grasp foot and squeeze metatarsal heads together. Pain indicates stress fracture or morton’s neuroma.
Tinels sign of the ankle
Anterior ankle - anterior deep peroneal nerve. Medial malleolus - posterior tibial nerve. Tap. =ve is parasthesia. Indicates nerve compression.
Buerger’s
Supine: Elevate patients leg and ask them to dorsiflex and plantarflex foot for 2 mins. Ask patient to sit up. +ve if redness takes > 1 m to return. Indicates vascualr compromise. E.g. diabetes or atherosclerosis.
