Physical Assessment Exam Study Guide Pt 3

PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Liver Span 1. Percuss downward from the chest in the right midclavicular line until you detect the top edge of liver dullness. 2. Percuss upward from the abdomen in the same line until you detect the bottom edge of liver dullness. 3. Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult. Splenic Dullness 1. Percuss the lowest costal interspace in the left anterior axillary line. This area is normally tympanic. 2. Ask the patient to take a deep breath and percuss this area again. Dullness in this area is a sign of splenic enlargement. Palpation General Palpation 1. Begin with light palpation (1cm deep). At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression (so watch the patient's face, not your hands). Voluntary or involuntary guarding may also be present. 2. Proceed to deep palpation (5-8 cm deep) after surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness. Palpation of the Liver Standard Method 1. Place your fingers just below the right costal margin and press firmly. 2. Ask the patient to take a deep breath. 3. You may feel the edge of the liver press against your fingers. Or it may slide under your hand as the patient exhales. A normal liver is not tender. 4. Usual location is about 1-2 cm. below right costal margin. Alternate Method This method is useful when the patient is obese or when the examiner is small compared to the patient. 1. Stand by the patient's chest. 2. "Hook" your fingers just below the costal margin and press firmly. 3. Ask the patient to take a deep breath. 4. You may feel the edge of the liver press against your fingers. Palpation of the Aorta 1. Press down deeply in the midline above the umbilicus. 2. The aortic pulsation is easily felt on most individuals. 3. A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm. Palpation of the Spleen 1. Use your left hand to lift the lower rib cage and flank. 2. Press down just below the left costal margin with your right hand. 3. Ask the patient to take a deep breath. 4. The spleen is not normally palpable on most individuals. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Measurement of Abdominal girth 1. Measure the distance around the abdomen at a specific point, usually at the level of the belly button (navel). Special Tests A. Rebound Tenderness (Blumberg sign) This is a test for peritoneal irritation. Warn the patient what you are about to do. 1. Press deeply on the abdomen with your hand. 2. After a moment, quickly release pressure. 3. If it hurts more when you release, the patient has rebound tenderness. B. Costovertebral Tenderness This is often associated with renal disease. 1. Warn the patient what you are about to do. 2. Have the patient sit up on the exam table. 3. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles. 4. Compare left and right sides C. Shifting Dullness This is a test for peritoneal fluid (ascites). 1. Percuss the patient's abdomen to outline areas of dullness and tympany. 2. Have the patient roll away from you. 3. Percuss and again outline areas of dullness and tympany. If the dullness has shifted to areas of prior tympany, the patient may have excess peritoneal fluid. D. Psoas Sign This is a test for appendicitis. 1. Place your hand above the patient's right knee. 2. Ask the patient to flex the right hip against resistance. 3. Increased abdominal pain indicates a positive psoas sign. E. Obturator Sign This is a test for appendicitis. 1. Raise the patient's right leg with the knee flexed. 2. Rotate the leg internally at the hip. 3. Increased abdominal pain indicates a positive obturator sign. 4. Not used as much lately as there is a question on how well it predicts appendicitis F. Assessment of hernia 1. Often need to assess standing up ***************************************************************************************** PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE G. Musculoskeletal System General Considerations 1. The patient should be undressed and gowned as needed for this examination. 2. Some portions of the examination may not be appropriate depending on the clinical situation (performing range of motion on a fractured leg for example). 3. The musculoskeletal exam is all about anatomy. Think of the underlying anatomy as you obtain the history and examine the patient. 4. When taking a history for an acute problem always inquire about the mechanism of injury, loss of function, onset of swelling (< 24 hours), and initial treatment. 5. When taking a history for a chronic problem always inquire about past injuries, past treatments, effect on function, and current symptoms. 6. The cardinal signs of musculoskeletal disease are pain, redness (erythema), swelling, increased warmth, deformity, and loss of function. 7. With Musculoskeletal system, Always begin with inspection, palpation and range of motion, regardless of the region you are examining (except abdomen). Specialized tests are often omitted unless a specific abnormality is suspected. 8. A complete evaluation will include a focused neurologic exam of the affected area. Regional Considerations 1. 2. 3. 4. 5. Remember that the clavicle is part of the shoulder. Be sure to include it in your examination. The patella is much easier to examine if the leg is extended and relaxed. Be sure to palpate over the spinous process of each vertebrae. It is always helpful to observe the patient standing and walking. Always consider referred pain, from the neck or chest to the shoulder, from the back or pelvis to the hip, and from the hip to the knee. 6. Pain with, or limitation of, rotation is often the first sign of hip disease. 7. Diagnostic hints based on location of pain: Back Side Front Shoulder Pain Muscle Spasm Bursitis or Rotator Cuff Glenohumeral Joint Hip Pain Sciatica Bursitis Hip Joint Inspection 1. Look for scars, rashes, or other lesions. 2. Look for asymmetry, deformity, or atrophy. 3. Always compare with the other side. Palpation 1. 2. 3. 4. Examine each major joint and muscle group in turn. Identify any areas of tenderness. Identify any areas of deformity. Always compare with the other side. Range of Motion 1. Start by asking the patient to move through an active range of motion (joints moved by patient). 2. Proceed to passive range of motion (joints moved by examiner) if active range of motion is abnormal. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Active Range of Motion 1. 2. 3. 4. 5. Ask the patient to move each joint through a full range of motion. Note the degree and type (pain, weakness, etc.) of any limitations. Note any increased range of motion or instability. Always compare with the other side. Proceed to passive range of motion if abnormalities are found. Passive Range of Motion 1. 2. 3. 4. 5. Ask the patient to relax and allow you to support the extremity to be examined. Gently move each joint through its full range of motion. Note the degree and type (pain or mechanical) of any limitation. If increased range of motion is detected, perform special tests for instability as appropriate. Always compare with the other side. Specific Joints 1. 2. 3. 4. 5. 6. Fingers - flexion/extension; abduction/adduction Thumb - flexion/extension; abduction/adduction; opposition Wrist - flexion/extension; radial/ulnar deviation Forearm - pronation/supination (function of BOTH elbow and wrist) Elbow - flexion/extension Shoulder - flexion/extension; internal/external rotation; abduction/adduction (2/3 glenohumeral joint, 1/3 scapulo-thoracic) 7. Hip - flexion/extension; abduction/adduction; internal/external rotation 8. Knee - flexion/extension 9. Ankle - flexion (plantar flexion)/extension (dorsiflexion) 10. Foot - inversion/eversion 11. Toes - flexion/extension 12. Spine - flexion/extension; right/left bending; right/left rotation Notes 1. Scoliosis = lateral curvature of spine with unequal leg length. Minimal with young children which resolves with change of position. More common as a concern in adolescents. 2. Kyphosis = “hunchback”; over-curvature of the thoracic vertebrae 3. Flatfoot = pronation of foot in children. Comes from turning of medial side of foot. Normal for 12-30 months; abnormal otherwise. 4. “knock knees” – knees together when standing. Normal to age 7years; abnormal older. 5. “bow legs” – normal to age 3 years; abnormal older. 6. Toe walking – usually stops by 3 months after start of walking. Special Tests – Upper Extremities A. Snuffbox Tenderness (Scaphoid) 1. Identify the "anatomic snuffbox" between the extensor pollicis longus and brevis (extending the thumb makes these structures more prominent). 2. Press firmly straight down with your index finger or thumb. 3. Any tenderness in this area is highly suggestive of scaphoid fracture. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE B. Drop Arm Test (Rotator Cuff) 1. Start with the patient's arm abducted 90 degrees. 2. Ask the patient to slowly lower the arm. 3. If the rotator cuff (especially the supraspinatus) is torn, the patient will be unable to lower the arm slowly and smoothly. The arm will fall to the side. C. Impingement Sign (Rotator Cuff) 1. Start with the patient's arm relaxed and the shoulder in neutral rotation. 2. Abduct the arm to 90 degrees. 3. Significant shoulder pain as the arm is raised suggests an impingement of the rotator cuff against the acromion. D. Flexor Digitorum Superficialis Test 1. Hold the fingers in extension except the finger being tested. 2. Ask the patient to flex the finger at the proximal interphalangeal joint. 3. If the patient cannot flex the finger, the tendon is cut or non-functional. E. Flexor Digitorum Profundus Test 1. Hold the metacarpophalangeal and proximal interphalangeal joints of the finger being tested in extension. 2. Ask the patient to flex the finger at the distal interphalangeal joint. 3. If the patient cannot flex the finger, the tendon is cut or non-functional. Vascular and Neurologic Tests A. Allen Test (Radial/Ulnar Arteries) 1. 2. 3. 4. Ask the patient to make a tight fist. Compress both the ulnar and radial arteries to stop blood flowing to the hand. Ask the patient to open the hand. Release pressure on the ulnar side. The hand should "pink" up in a few seconds unless the ulnar artery is occluded. 5. Repeat the process for the radial artery as indicated. B. Phalen's Test (Median Nerve) 1. Ask the patient to press the backs of the hands together with the wrists fully flexed (backward praying). 2. Have the patient hold this position for 60 seconds and then comment on how the hands feel. 3. Pain, tingling, or other abnormal sensations in the thumb, index, or middle fingers strongly suggest carpal tunnel syndrome. C. Tinel's Sign (Median Nerve) 1. Use your middle finger or a reflex hammer to tap over the carpal tunnel. 2. Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome. Special Tests - Lower Extremities A. Collateral Ligament Testing 1. 2. 3. 4. 5. 6. 7. 8. 9. The patient should be supine with the legs resting on the exam table. Hold the leg to be examined in 20-30 degrees of flexion. Place one hand laterally just below the knee. Grasp the leg near the ankle with your other hand. Gently push with both hands in opposite directions to stress the knee. If the knee joint "opens up" medially, the medial collateral ligament may be torn. Reverse your hands and repeat the stress. If the knee joint "opens up" laterally, the lateral collateral ligament may be torn. Repeat the test using posterior stress. The normal knee has a distinct end point. If the tibia moves back under the femur, the posterior cruciate ligament may be torn. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE B. Anterior/Posterior Drawer Test (Cruciate Ligaments) 1. Ask the patient to lie supine on the exam table with knees flexed to 90 degrees and feet flat on the table. 2. Sit on or otherwise stabilize the foot of the leg being examined. 3. Grasp the leg just below the knee with both hands and pull forward. 4. If the tibia moves out from under the femur, the anterior cruciate ligament may be torn. 5. Without changing the position of your hands, push the leg backward. 6. If the tibia moves back under the femur, the posterior cruciate ligament may be torn. C. Ballotable Patella (Major Knee Effusion) 1. Ask the patient to lie supine on the exam table with leg muscles relaxed. 2. Press the patella downward and quickly release it. 3. If the patella visibly rebounds, a large knee effusion (excess fluid in the knee) is present. D. Milking the Knee (Minor Knee Effusion) 1. 2. 3. 4. Ask the patient to lie supine on the exam table with leg muscles relaxed. Compress the suprapatellar pouch with your thumb, palm, and index finger. "Milk" downward and laterally so that any excess fluid collects on the medial side. Tap gently over the collected fluid and observe the effect on the lateral side, or ballot the patella as outlined above. 5. A fullness on the lateral side indicates that a small knee effusion is present. E. Homan’s sign 1. Flex the knee, gently press the calf anteriorly against the tibia OR dorsiflex the foot toward the thigh 2. Normal = no pain 3. Abnormal = presence of pain occurs with other conditions but a deep vein thrombosis should be ruled out. Tests - Back A. Straight Leg Raising (L5/S1 Nerve Roots) 1. Ask the patient to lie supine on the exam table with knees straight. 2. Grasp the leg near the heel and raise the leg slowly towards the ceiling. 3. Pain in an L5 or S1 distribution suggests nerve root compression or tension (radicular pain). 4. Dorsiflex the foot while maintaining the raised position of the leg. 5. Increased pain strengthens the likelihood of a nerve root problem. 6. Repeat the process with the opposite leg. 7. Increased pain on the opposite side indicates that a nerve root problem is almost certain. B. FABER Test (Hips/Sacroiliac Joints) FABER stands for Flexion, ABduction, and External Rotation of the hip. This test is used to distinguish hip or sacroiliac joint pathology from spine problems. 1. Ask the patient to lie supine on the exam table. 2. Place the foot of the effected side on the opposite knee (this flexes, abducts, and externally rotates the hip). 3. Pain in the groin area indicates a problem with the hip and not the spine. 4. Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest. 5. Pain in the sacroiliac area indicates a problem with the sacroiliac joints. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE H. Neurologic Examination General Considerations 1. Always consider left to right symmetry 2. Consider central vs. peripheral deficits 3. Organize your thinking into seven categories: a) Mental Status b) Cranial Nerves c) Motor d) Coordination and Gait e) Reflexes f) Sensory g) Special Tests Mental Status: 1. Assess level of consciousness; facial expression and body language; speech; cognition and functioning 2. Assess while doing health history General notes: 1. Cerebral – mental status 2. Cerebellum – gait, coordination, balance, etc. Cranial Nerves: 1. Sensory, motor, parasympathetic or mixed Observation 1. 2. 3. 4. 5. 6. Ptosis (III) Facial Droop or Asymmetry (VII) Hoarse Voice (X) Articulation of Words (V, VII, X, XII) Abnormal Eye Position (III, IV, VI) Abnormal or Asymmetrical Pupils (II, III) I – Olfactory 1. Sensory nerve: Tests sense of smell 2. Not routinely tested unless indicated. II – Optic 1. Sensory nerve: vision 2. Test Visual Acuity: Use Snellen eye chart or a Rosenbaum pocket card at a 14 inch "reading" distance). Process is on pg. 10 under “Examination of eye”. 3. Screen Visual Fields by Confrontation. Process is on pg. 11 under “Examination of eye”. III – Oculomotor 1. Mixed nerve: (A) Motor: controls extraocular movements (EOM), opening eyelids; (B) Parasympathetic: pupil constriction, iris shape 2. Observe for Ptosis (drooping eyelid) 3. Test Extraocular Movements Process is on page 11 under “Examination of Eye” 4. Test Pupillary Reactions to Light. Process is on page 11 under “Examination of Eye” PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE IV – Trochlear 1. Motor nerve: inward and down movement of eye 2. Test Extraocular Movements (Inward and Down Movement). Process is on page 11 under “Examination of Eye” V - Trigeminal 1. Mixed nerve. (A) Motor: muscles of mastication; (B) sensory: face, scalp, mouth, nose 2. Test Temporal and Masseter Muscle Strength a. Ask patient to both open their mouth and clench their teeth. b. Palpate the temporal and masseter muscles as they do this. 3. Test the Three Divisions for Pain Sensation a. Explain what you intend to do. b. Use a suitable sharp object to test the forehead, cheeks, and jaw on both sides. c. Substitute a blunt object occasionally and ask the patient to report "sharp" or "dull." d. If you find and abnormality then: Test the three divisions for temperature sensation with a tuning fork heated or cooled by water. e. Test the three divisions for sensation to light touch using a wisp of cotton. 4. Test the Corneal Reflex (normally not checked unless specific concerns) a. Ask the patient to look up and away. b. From the other side, touch the cornea lightly with a fine wisp of cotton. c. Look for the normal blink reaction of both eyes. d. Repeat on the other side. e. Use of contact lens may decrease this response. VI – Abducens 1. Motor: lateral eye movement 2. Test Extraocular Movements (Lateral). Process is on page 11 under “Examination of Eye” VII – Facial 1. Mixed: (A) Motor: muscles used for facial expressions, close eye and mouth; (B) Sensory (sense of taste in the front 2/3 of tongue; (C) Parasympathetic: saliva and tear secretion 2. Sense of taste not usually checked unless specific concerns 3. Observe for Any Facial Droop or Asymmetry a) Ask Patient to do the following, note any lag, weakness, or asymmetry: Raise eyebrows b) Close both eyes to resistance c) Smile d) Frown e) Show teeth f) Puff out cheeks 4. Test the Corneal Reflex (See C.N. V above) VIII - Acoustic 1. Sensory: Hearing and Equilibrium 2. Initial test: a) Face the patient and hold out your arms with your fingers near each ear. b) Rub your fingers together on one side while moving the fingers noiselessly on the other. c) Ask the patient to tell you when and on which side they hear the rubbing. d) Increase intensity as needed and note any asymmetry. e) Test hearing with normal voice and whispers 3. If abnormal, proceed with the Weber and Rinne tests. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE 4. Test for Lateralization (Weber) a) Screening tool – not used as often as in past b) Use a 512 Hz or 1024 Hz tuning fork. c) Start the fork vibrating by tapping it on your opposite hand. d) Place the base of the tuning fork firmly on top of the patient's head. e) Ask the patient where the sound appears to be coming from (normally in the midline). f) Normal is to hear equally in bone ears. If louder in one ear, it is abnormal. Abnormal indicates conductive hearing loss in that ear or sensory hearing loss in opposite ear. 5. Compare Air and Bone Conduction (Rinne) a) Screening tool – not used as often as in past b) Use a 512 Hz or 1024 Hz tuning fork. c) Start the fork vibrating by tapping it on your opposite hand. d) Place the base of the tuning fork against the mastoid bone behind the ear. e) When the patient no longer hears the sound, hold the end of the fork near the patient's ear (air conduction is normally greater than bone conduction). f) Normal (positive result) = hearing sound still once moved behind mastoid bone. Abnormal = not hearing the sound, usually indicates conductive hearing loss. IX – Glossopharyngeal 1. Mixed: motor: (A) Motor: pharynx (phonation and swallowing); (B) Sensory: taste on posterior 1/3 of tongue; gag reflex; (C) parasympathetic: parotid gland, carotid reflex. X – Vagus 1. Mixed – (A) Motor: pharynx and larynx (swallowing and talking); (B) Sensory: general sensation from carotid body, carotid sinus, pharynx, viscera; (C) parasympathetic: carotid reflex. Slows heart rate. 2. Listen to the patient's voice, is it hoarse or nasal? 3. Ask patient to swallow 4. Ask patient to Say "Ahhh". Watch the movements of the soft palate and the pharynx. 5. Test gag reflex. On an unconscious or uncooperative patient, stimulate the back of the throat on each side. It is normal to gag after each stimulus. XI – Spinal Accessory 1. 2. 3. 4. Motor: trapezius and sternomastoid muscles From behind, look for atrophy or asymmetry of the trapezius muscles. Ask patient to shrug shoulders against resistance. Ask patient to turn their head against resistance. Watch and palpate the sternomastoid muscle on the opposite side. XII – Hypoglossal 1. 2. 3. 4. 5. Motor: movement of tongue Listen to the articulation of the patient's words. Observe the tongue as it lies in the mouth Ask patient to: Protrude tongue Move tongue from side to side PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Assessment of Motor responses Observation Involuntary Movements 1. 2. 3. 4. 5. Compare muscle symmetry left to right Proximal vs. distal Atrophy Pay particular attention to the hands, shoulders, and thighs. Gait Muscle Tone 1. 2. 3. 4. 5. Ask the patient to relax. Flex and extend the patient's fingers, wrist, and elbow. Flex and extend patient's ankle and knee. There is normally a small, continuous resistance to passive movement. Observe for decreased (flaccid) or increased (rigid/spastic) tone. Muscle Strength Test strength by having the patient move against your resistance. Always compare one side to the other. Grade strength on a scale from 0 to 5 "out of five": Grading Motor Strength Grade Description 0/5 No muscle movement 1/5 Visible muscle movement, but no movement at the joint 2/5 Movement at the joint, but not against gravity 3/5 Movement against gravity, but not against added resist 4/5 Movement against resistance, but less than normal 5/5 Normal strength Test the following: 1. Flexion at the elbow (C5, C6, biceps) 2. Extension at the elbow (C6, C7, C8, triceps) 3. Extension at the wrist (C6, C7, C8, radial nerve) 4. Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1) 5. Finger abduction (C8, T1, ulnar nerve) 6. Opposition of the thumb (C8, T1, median nerve) 7. Flexion at the hip (L2, L3, L4, iliopsoas) 8. Adduction at the hips (L2, L3, L4, adductors) 9. Abduction at the hips (L4, L5, S1, gluteus medius and minimus) 10. Extension at the hips (S1, gluteus maximus) 11. Extension at the knee (L2, L3, L4, quadriceps) 12. Flexion at the knee (L4, L5, S1, S2, hamstrings) 13. Dorsiflexion at the ankle (L4, L5) 14. Plantar flexion (S1) Pronator Drift 1. Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed. 2. Instruct the patient to keep the arms still while you tap them briskly downward. 3. The patient will not be able to maintain extension and supination (and "drift into pronation) with upper motor neuron disease. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Coordination and Gait A. Rapid Alternating Movements 1. Ask the patient to strike one hand on the thigh, raise the hand, turn it over, and then strike it back down as fast as possible. 2. Ask the patient to tap the distal thumb with the tip of the index finger as fast as possible. 3. Ask the patient to tap your hand with the ball of each foot as fast as possible. B. Point-to-Point Movements 1. Ask the patient to touch your index finger and their nose alternately several times. Move your finger about as the patient performs this task. 2. Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patient to move their arm and return to your finger with their eyes closed. 3. Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the patient's eyes closed. C. Romberg 1. Be prepared to catch the patient if they are unstable. 2. Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without support. 3. The test is said to be positive if the patient becomes unstable (indicating a vestibular or proprioceptive problem). D. Gait. Ask the patient to: 1. Walk across the room, turn and come back 2. Walk heel-to-toe in a straight line 3. Walk on their toes in a straight line 4. Walk on their heels in a straight line 5. Hop in place on each foot 6. Do a shallow knee bend 7. Rise from a sitting position Reflexes Deep Tendon Reflexes 1. The patient must be relaxed and positioned properly before starting. 2. Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response. 3. Reflexes can be reinforced by having the patient perform isometric contraction of other muscles (clenched teeth). 4. Exaggerated hyperactive reflexes in a pregnant woman may be related to pre-eclampsia. 5. Reflexes should be graded on a 0 to 4 "plus" scale: Tendon Reflex Grading Scale Grade Description 0 Absent 1+ or + Hypoactive 2+ or ++ "Normal" 3+ or +++ Hyperactive without clonus 4+ or ++++ Hyperactive with clonus May indicate disease but also may be normal Indicative of disease (see definition below) PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Check DTRs A. Biceps (C5, C6) The patient's arm should be partially flexed at the elbow with the palm down. 1. Place your thumb or finger firmly on the biceps tendon. 2. Strike your finger with the reflex hammer. 3. You should feel the response even if you can't see it. B. Triceps (C6, C7) Support the upper arm and let the patient's forearm hang free. 1. Strike the triceps tendon above the elbow with the broad side of the hammer. 2. If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close to the chest. C. Brachioradialis (C5, C6) Have the patient rest the forearm on the abdomen or lap. 1. Strike the radius about 1-2 inches above the wrist. 2. Watch for flexion and supination of the forearm. D. Abdominal (T8, T9, T10, T11, T12) Use a blunt object such as a key or tongue blade. 1. Stroke the abdomen lightly on each side in an inward and downward direction above (T8, T9, T10) and below the umbilicus (T10, T11, T12). 2. Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus. F. Knee (L2, L3, L4) Have the patient sit or lie down with the knee flexed. 1. Strike the patellar tendon just below the patella. 2. Note contraction of the quadraceps and extension of the knee. G. Ankle (S1, S2) Dorsiflex the foot at the ankle. 1. Strike the Achilles tendon. 2. Watch and feel for plantar flexion at the ankle. Clonus 1. Definition: rapid rhythmic contractions of same muscle 2. If the reflexes seem hyperactive, test for ankle clonus: a) Support the knee in a partly flexed position. b) With the patient relaxed, quickly dorsiflex the foot. c) Observe for rhythmic oscillations Plantar Response (Babinski) 1. Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key. 2. Note movement of the toes, normally flexion (withdrawal). 3. Extension of the big toe with fanning of the other toes is abnormal in other than a young child. This is referred to as a positive Babinski 4. Positive Babinski is normal to age 24 months. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Assessment of Sensory responses General 1. 2. 3. 4. 5. Explain each test before you do it. Unless otherwise specified, the patient's eyes should be closed during the actual testing. Compare symmetrical areas on the two sides of the body. Also compare distal and proximal areas of the extremities. When you detect an area of sensory loss map out its boundaries in detail. Vibration 1. Use a low pitched tuning fork (128 Hz). Test with a non-vibrating tuning fork first to ensure that the patient is responding to the correct stimulus. 2. Place the stem of the fork over the distal interphalangeal joint of the patient's index fingers and big toes. 3. Ask the patient to tell you if they feel the vibration. 4. If vibration sense is impaired proceed proximally: a) Wrists b) Elbows c) Medial malleoli d) Patellas e) Anterior superior iliac spine f) Spinous processes g) Clavicle Position Sense 1. 2. 3. 4. 5. 6. Grasp the patient's big toe and hold it away from the other toes to avoid friction. Show the patient "up" and "down." With the patient's eyes closed ask the patient to identify the direction you move the toe. If position sense is impaired move proximally to test the ankle joint. Test the fingers in a similar fashion. If indicated move proximally to the metacarpophalangeal joints, wrists, and elbows. Dermatomal Testing 1. If vibration, position sense, and subjective light touch are normal in the fingers and toes you may assume the rest of this exam will be normal. Pain 1. Use a suitable sharp object to test "sharp" or "dull" sensation. 2. Test the following areas: a) Shoulders (C4) b) Inner and outer aspects of the forearms (C6 and T1) c) Thumbs and little fingers (C6 and C8) d) Front of both thighs (L2) e) Medial and lateral aspect of both calves (L4 and L5) f) Little toes (S1) PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Temperature 1. Often omitted if pain sensation is normal. 2. Use a tuning fork heated or cooled by water and ask the patient to identify "hot" or "cold." 3. Test the following areas: a) Shoulders (C4) b) Inner and outer aspects of the forearms (C6 and T1) c) Thumbs and little fingers (C6 and C8) d) Front of both thighs (L2) e) Medial and lateral aspect of both calves (L4 and L5) f) Little toes (S1) Light Touch 1. Test several areas on both the upper and lower extremities. 2. Use your fingers to touch the skin lightly on both sides simultaneously. Ask the patient to tell you if there is difference from side to side or other "strange" sensations. 3. Use a fine wisp of cotton or your fingers to touch the skin lightly. Ask the patient to respond whenever a touch is felt. 4. Test the following areas: a) Shoulders (C4) b) Inner and outer aspects of the forearms (C6 and T1) c) Thumbs and little fingers (C6 and C8) d) Front of both thighs (L2) e) Medial and lateral aspect of both calves (L4 and L5) f) Little toes (S1) Discrimination 1. Since these tests are dependent on touch and position sense, they cannot be performed when the tests above are clearly abnormal. 2. Graphesthesia: a) With the blunt end of a pen or pencil, draw a large number in the patient's palm. b) Ask the patient to identify the number. 3. Stereognosis a) Use as an alternative to graphesthesia. b) Place a familiar object in the patient's hand (coin, paper clip, pencil, etc.). c) Ask the patient to tell you what it is. 4. Two Point Discrimination a) Use in situations where more quantitative data are needed, such as following the progression of a cortical lesion. b) Use an opened paper clip to touch the patient's finger pads in two places simultaneously. c) Alternate irregularly with one point touch. d) Ask the patient to identify "one" or "two." e) Find the minimal distance at which the patient can discriminate Routine pediatric neuro testing: 1. Plantar (Babinski) – described above. Normal to age 24 months. 2. Moro (startle) – normal to about 4 months 3. Rooting – birth to about 3-4 months 4. Palmar grasp – birth, stronger at 1-2 months, gone by 3-4 months PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE I. Genito-urinary and wellness Male: Prostate screening 1. Digital exam – recommended annually. Hemocult any specimen. 2. PSA – lab test. Recommendations vary – every 1-2 years Testicular Self-exam: 1. Start age 15 on 2. Remember: Timing: 1 x month Shower – warm water Examine – should be no lumps Men should also perform BSE but are less likely to have routine mammograms Female: Mammogram 1. Follow current recommendations Breast Self Exam (BSE): 1. perform monthly right after menses or day 4-7 of cycle 2. include raising arms to look for retraction Pap smear. – tests for cervical cancer 1. Specimens taken from (in order) vaginal pool, cervical scrape, endocervical specimen. 2. Post hysterectomy and cervix removal – scrape from end of vagina and cervical pool. General notes: ***When taking the exam—there are questions about what should cause concern—think about the nurse action being incorrect. “What action should be discussed with the nurse?” means what nurse action was incorrect? Pediatric General notes: 1. To compare leg length measurement, measure from anterior superior iliac spine. Cross to the medial side of knee and measure to the medial malleolus. Further testing can be done by x-ray 2. Key milestones in children: (not inclusive) 2 months 4 months 5 months 6 months 7 months 8 months 12 months smiles recognizes parents babbles few words sits up with support grasps things; may hold bottle begins crawling sits without support; stranger anxiety walks alone