Physical Examination Checklist POM I General 1) Wash hands before beginning examinationin the C !

"" center# yo$ M%"& $se the hand 'i(es that are located in or near the sinks )remember that they are not (l$mbed) *) +is(lay a (rofessional demeanor to'ards the (atient d$ring the exam a) Introd$ce yo$rself as a medical st$dent b) %se the (atient,s last name c) +ress (rofessionally in 'hite coat -) !((ro(riate interaction 'ith the (atientsensiti.ity to (ri.acy# comfort and dignity /) +ra(e the (atient a((ro(riately d$ring each segment of the exam 0) %se (ro(er se1$encing of the examiniation and (ro(er (acing 2) !ll (al(ation and a$sc$ltation m$st be done on bare skin 3ital "igns 1) &ake the 4P in one arm )5O&E &6!& 7O% 5EE+ 5O& &!8E &6E 4P I5 4O&6 !9M" %5 E"" "PECI:IC! 7 I5"&9%C&E+ &O +O "O) a) Choose a c$ff of a((ro(riate si;e for the (atient b) Center the bladder of the c$ff o.er the brachial artery i) Identify location of the brachial artery by (al(ation ii) o'er border of the c$ff sho$ld be abo$t *<0 cm abo.e the antec$bital crease iii) "ec$re the c$ff sn$gly c) Position the (atient,s arm so that it is slightly flexed at the elbo' and at raised to heart le.el d) Estimate the systolic (ress$re by (al(ation of the radial artery )4ates# (( =2) i) Wait 10 seconds after deflating the c$ff before a$sc$ltating the 4P e) &ake the 4P# $sing a$sc$ltation i) isten 'ith the stethosco(e o.er the brachial artery ii) Inflate c$ff ra(idly to at least 10> mm 6g iii) +eflate at rate of *?- mm 6g (er second i.) 5ote systolic and diastolic (ress$res *) &ake the radial ($lse for 10 secs if the rhythm is reg$lar )2> secs if rate is slo' or fast) a) %se the (ads of index and middle fingers b) Com(ress the radial artery $ntil a maximal ($lsation is detected -) Co$nt the res(iratory rate for 1 min$te a) Watch mo.ement of the chest 'all 6ead 1) Ins(ect the sk$ll# scal(# hair by (arting the hair in at least three (laces *) Ins(ect the face Ears 1) Ins(ect the external eara$ricle or (inna *) %se the otosco(e to ins(ect the internal a$ditory canal and the eardr$m and middle ear a) "elect the largest a.ailable s(ec$l$m for the otosco(e b) Position the (atient,s head to allo' best insertion of the otosco(e c) P$ll the a$ricle gently $('ards and back'ards to straighten the canal d) 6old the otosco(e bet'een th$mb and fingers )see 4ates# ( 102) e) Insert the s(ec$l$m gently into the ear canal i) Identify the eardr$m ii) Identify the cone of light iii) Identify the malle$s -) !ssess hearing a) !sk the (atient to occl$de one ear 'ith a finger and then the examiner 'his(ers softly from 1 or * feet a'ay to'ard the $noccl$ded ear i) Choose short 'ords )see 4ates ( 10=) b) Check air and bone cond$ction i) Weber test )1) (lace the base of the lightly .ibrating t$ning fork firmly on to( of the (atient,s head )*) !sk 'here the (atient hears it ii) 9inne test )1) Place the base of the lightly .ibrating t$ning fork on the mastoid bone )*) When the (atient can no longer hear the so$nd# 1$ickly (lace the fork close to the ear canal and ask 'hether so$nd can still be heard

Eyes 1) Check for .is$al ac$ity $sing a "nellen eye card or eye chart in the exam room *) !ssess .is$al fields )4ates# ( 1/0?1/2) a) !sk the (atient to look 'ith both eyes into yo$r eyes b) While yo$ ret$rn the (atient,s ga;e# (lace yo$r hands abo$t * feet a(art# lateral to the (atient,s ears< c) Instr$ct the (atient to (oint to yo$r fingers as soon as they are seen d) &hen slo'ly mo.e the 'iggling fingers of both yo$r hands along the imaginary bo'l and to'ards the line of ga;e $ntil the (atient identifies them e) 9e(eat this (attern in the $((er and lo'er tem(oral 1$adrants -) Ins(ect external eye a) "tand in front of the (atient and s$r.ey the eyes for (osition and alignment 'ith each other b) Ins(ect the eyebro's1$antity and distrib$tion c) Ins(ect the eyelids d) Ins(ect the region of the lacrimal glands e) Ins(ect the con@$ncti.a and sclera i) !sk the (atient to look $( as yo$ de(ress both lo'er lids 'ith yo$r th$mbs )4ates ( 1/=)# ex(osing sclera and con@$ncti.a f) Ins(ect the cornea and lens# $sing a (enlight shined obli1$e across the eye g) Ins(ect each iris h) Ins(ect the ($(ils for si;e# sha(e and symmetry /) !ssess ($(illary reflexes )t$rn o$t the room light if necessary) a) &o lightask the (atient to look into the distance and shine a bright light obli1$ely into each ($(il in t$rn< i) 5ote direct reaction($(illary constriction in the same eye ii) 5ote indirect reaction($(illary constriction in the o((osite eye b) !ssess accomodation A ask the (atient to look alternately at a (encil held 1> cm from his eye and into the distance directly behind it< Obser.e for ($(illary constriction 'ith near effort 0) !ssess Extraoc$lar mo.ements a) :rom * feet in front of the (atient# shine a light into the (atient,s eyes and ask the (atient to look at it< Ins(ect the reflections in the corneas# 'hich sho$ld be .isible slightly nasal to the center of the ($(ils b) !sk the (atient to follo' yo$r finger or (encil as yo$ s'ee( thro$gh the six cardinal directions of ga;e i) &o the (atient,s extreme right ii) &o the right and $('ard iii) &o the right and do'n'ards i.) Witho$t (a$sing in the middle to the extreme left .) &o the left and $('ards .i) &o the left and do'n'ards 2) O(hthalmosco(ic exam )"ee B"te(s for $sing the o(hthalmosco(eC and B"te(s for examining the o(ic disc and the retinaC in 4ates (( 10* and 105ose 1) Ins(ect the anterior and inferior s$rfaces of the nose a) P$sh gently on the ti( of the nose to 'iden the nostrils b) %se a (enlight to .ie' the nasal .estib$le *) Ins(ect the inside of the nose $sing an otosco(e 'ith the largest a.ailable s(ec$l$m a) &ilt the (atient,s head back slightly and insert the s(ec$l$m )4ates ( 10D) b) Ins(ect the inf and mid t$rbinates and nasal se(t$m -) Pal(ate the frontal and maxillary sin$ses for tenderness )4ates ( 12> Mo$th and Pharynx 1) Ins(ect the li(s *) Ins(ect the oral m$cosa $sing a good light and a tong$e blade -) Ins(ect the g$ms and teeth /) Ins(ect the hard (alate 0) Ins(ect the tong$e and floor of the mo$th a) !sk the (atient to ($t o$t his tong$e b) !sk the (atient to ($t his tong$e on the roof of his mo$th 2) Ins(ect the (harynx a) &ong$e in normal (osition# ask the (atient to say BahEC b$t if (harynx not 'ell .is$ali;ed $se a tong$e blade b) Ins(ect the soft (alate# tonsils and (harynx

5eck 1) !ssess neck 9OM )4ates ( 0>/) by asking the (atient to (erform the follo'ing mane$.ersF a) :lexionF to$ch the chin to the chest b) ExtensionF look $( at the ceiling c) 9otationF t$rn the head to each side# looking directly o.er the sho$lder d) ateral bendingF tilt the head# to$ching each ear to the corres(onding sho$lder *) Pal(ate the lym(h nodes )"ee 4ates ( 12-?12/ for s(ecific techni1$e) -) Ins(ect trachea and feel for any de.iation by (lacing a finger along one side of the trachea# noting the s(ace# and com(are 'ith the o((osite side< /) Ins(ect the thyroid gland a) &i( the (atient,s head back b) ocate the cricoid cartilage and ins(ect the region belo' for the thyroid 0) Pal(ate the thyroid gland )"ee 4ates ( 12=) A may be (erformed from either an anterior or (osterior a((roach a) :lex the neck slightly for'ard b) Place finger of both hands on the (atient,s neck 'ith index fingers @$st belo' the cricoid cartilage c) :eel for the thyroid isthm$s d) +is(lace the trachea to the right 'ith the fingers of yo$r left handE (al(ate 'ith 9 fingers for the right lobe of the thyroid e) 9e.erse the $se of the fingers to feel the left lobe of the thyroid Cranial 5er.es )4ates# (( 02=?0=1) 1) Olfactory )C5 I) A $s$ally not tested *) O(tic )C5 II) A yo$ ha.e already tested for .is$al fields< 3is$al ac$ity can be tested 'ith an eye chart -) Oc$lomotor )C5 III) A yo$ ha.e already tested ($(illary constriction and the EOM controlled by this ner.e /) &rochlear )C5 I3) A yo$ ha.e already tested for do'n'ard# in'ard mo.ement of the eye 0) &rigeminal )C5 3) a) While (al(ating the tem(oral and masseter m$scles in t$rn# ask the (atient to clench her teeth b) Check the forehead# cheeks and @a' on each side for (ain and light to$ch c) Check the corneal reflex 'ith a 'is( of cotton 2) !bd$cens )C5 3I) A yo$ ha.e already tested for lateral de.iation of the eye 'ith yo$r extra?oc$lar mo.ement mane$.ers =) :acial )C5 3II) a) !sk the (atient to raise both eyebro's b) :ro'n c) Close both eyes tightly d) "ho' both $((er and lo'er teeth e) "mile f) P$ff o$t both cheeks G) !co$stic )C5 3III) A yo$ ha.e already assessed hearing and (erformed Weber and 9inne mane$.ers D) Glosso(haryngeal )C5 IH) A tested together 'ith C5 H 1>) 3ag$s )C5 H) a) !sk the (atient to say BahC and 'atch the mo.ements of the soft (alate and (harynx b) Check gag reflex 'ith a tong$e blade 11) "(inal !ccessory )C5 HI) a) !sk the (atient to shr$g both sho$lders against yo$r hands b) !sk the (atient to t$rn her head to each side against yo$r hand 1*) 6y(oglossal )C5 HII) a) !sk the (atient to (rotr$de her tong$e b) !sk the (atient to ($sh the tong$e against the inside of each cheek Posterior thorax 1) &he (atient sho$ld be sitting 'ith the (osterior thorax ex(osed< *) &he doctor ass$mes a midline (osition behind the (atient -) Ins(ect the cer.ical# thoracic and $((er l$mbar s(ine )yo$ 'ill check for 9OM of the thoracic and l$mbar s(ine to'ards the end of the com(lete (hysical 'hen the (atient is standing $() /) Pal(ate the s(ino$s (rocesses of each .ertebra for tenderness 'ith yo$r th$mb or by th$m(ing 'ith the $lnar s$rface of yo$r fist )4ates ( 0>-) 0) !ssess for costo.ertebral tenderness a) Place the ball of one hand in the costo.ertebral angle and strike it 'ith the $lnar s$rface of yo$r fist )4ates ( -//) 2) Ins(ect the sha(e and mo.ement of the chest 'all a) Place yo$r th$mbs at the le.el of the 1>th ribs 'ith yo$r fingers loosely gras(ing the rib cage and gently slide them medially< b) !sk the (atient to inhale dee(ly and obser.e 'hether yo$r th$mbs mo.e a(art symmetrically

Posterior thorax A l$ng exam 1) Examination techni1$es M%"& be (erformed on bare skin *) Pal(ate for tactile fremit$s a) %se either the ball of yo$r (alm or the $lnar s$rface of yo$r hand for (al(ation b) !sk the (atient to re(eat the 'ords Bninety?nineC c) 7o$ may (al(ate one side at a time or $se both hands sim$ltaneo$sly to com(are sides d) Pal(ate in fo$r locations on both sides of the chest and com(are )4ates ( **-) -) Perc$ss a) !sk the (atient to kee( both arms crossed in front of the chest b) Press the +IP @oint of the left middle finger firmly against the chest 'all# a.oiding contact 'ith other fingers )4ates ( **-) c) "trike this +IP @oint 'ith the ti( of the right middle finger# s'inging from the 'rist d) Perc$ss in se.en areas on each side )4ates ( **0) /) !$sc$ltate for breath so$nds a) Instr$ct the (atient to breathe dee(ly thro$gh an o(en mo$th b) isten 'ith the dia(hragm of the stethosco(e in the same se.en areas in 'hich yo$ (erc$ssed

!nterior thoraxl$ng exam 1) Examination techni1$es M%"& be (erformed on bare skin *) &he (atient may be either sitting or s$(ine< &he dra(e sho$ld be ad@$sted to allo' ex(os$re of the area being examined -) Ins(ect the sha(e of the (atient,s chest and mo.ement of the chest 'all )54 'hen mo.ing from the (ost chest 'hen yo$ ha.e com(leted a$sc$ltating# it is acce(table to a$sc$ltate the ant chest before ins(ection or (al(ation) /) Pal(ate for tactile fremit$s a) %se the ball of the (alm or $lnar s$rface of the hand to (al(ate in areas on each side of the anterior chest )4ates ( *-1) 0) Perc$ss the anterior and lateral chest# com(aring sides# in 2 areas on each side )4ates ( *-1) a) +is(lace a 'oman breast 'ith yo$r left hand or ask her to mo.e her breast for yo$ 2) !$sc$ltate the anterior chest# com(aring sides in the 2 areas on each side 'here yo$ (erc$ssed<

!xillae A examination of the axillae can be (erformed at the (resent @$nct$re< It is sometimes (erformed at the end of the exam# or as (art of a breast exam in a female 1) Ins(ect the skin of each axilla )4ates# (( -1>?-11) *) Pal(ation axilla a) !sk the (atient to relax 'ith the arm do'n b) "$((ort the 'rist or hand 'ith yo$r left hand c) C$( together the fingers of yo$r right hand and reach as high as yo$ can to'ard the a(ex of the axilla d) Press yo$r fingers to'ard the chest 'all and slide do'n to feel (otential 5 e) &o (al(ate for lateral gro$( of 5# feel along the $((er h$mer$s -) Pal(ation 9 axilla A re.erse yo$r hands and follo' the ste(s abo.e

Cardio.asc$lar 1) &he (atient sho$ld be s$(ine 'ith the $((er body raised by ele.ated the table to abo$t ->I< &he dra(e sho$ld be arranged to ex(ose the (recordi$m< EH!M &EC65IJ%E" M%"& 4E PE9:O9ME+ O5 4!9E "8I5< *) &he examiner sho$ld stand tat the (atient,s right side -) Ins(ect the (recordi$m a) look for a(ical im($lse b) look for any other mo.ements /) Pal(ate for (recordi$m a) %se the (almar s$rfaces of se.eral fingers to locate the PMIcan s'itch to one fingerti( 'hen located i) +is(lace a 'oman,s breast $('ard or laterally# or ask her to do this for yo$ ii) 5ote location of PMI# am(lit$de and d$ration b) Pal(ate for the 93 im($lse along the lo'er left sternal border 0) !$sc$ltation of the heart a) isten to the heart 'ith the dia(hragm of yo$r stethosco(e in the 9 *nd IC"# *nd IC"# -rd or /th IC"# and the lo'er left sternal border )0th IC") and at the a(ex )may also start at the a(ex and (roceed to the base of the heart) b) isten to the heart 'ith the bell of yo$r stethosco(e in the same fi.e listening areas 2) Ins(ect the neck for @$g$lar .eno$s ($lsations a) &$rn the (atient,s head slightly a'ay from the side yo$ are ins(ecting )4ates ( *2=) b) 9aise or lo'er the bed $ntil yo$ identify the ($lsations c) Identify the highest (oint of ($lsation i) Mea$s$re the .ertical distance of this (oint abo.e the sternal angle =) Ins(ect the neck for carotid ($lsations G) Pal(ate the carotid ($lsation a) Place yo$r left index and middle fingers )or th$mb) on the right carotid artery i) 5ote am(lit$de and conto$r of the ($lse 'a.e ii) 5e.er (al(ate both carotids sim$ltaneo$sly b) %se yo$r right fingers or th$mb to (al(ate the left carotid artery D) !$sc$ltate the carotid arteries for br$its 'ith the bell of the stethosco(e a) !sk the (atient to take a dee( breath and hold it to eliminate breath so$nds !bdomen 1) &he (atient sho$ld be in a s$(ine (osition 'ith arms at side or folded across the chest *) &he dra(es sho$ld be arranged to ex(ose the abdoment from abo.e the xy(hoid (rocess to the sym(hysis ($bis< -) !((roach the (atient from his right side /) Ins(ect the abdomen 0) !$sc$late the abdomen as the next ste( in the exam after ins(ection a) Place the dia(hragm of the stethosco(e gently on the abdomen b) isten for bo'el so$nds i) istening in one s(ot is s$fficient c) isten for an aortic br$it on the midline @$st abo.e the na.al 2) Perc$ss the abdomen lightly in fo$r 1$adrants =) Perc$ss for li.er d$llness a) +efine the lo'er edge of li.er d$llness in the mid?cla.ic$lar line# starting at a le.el belo' the $mbilic$s b) +efine the $((er edge of li.er d$llness in MC # starting in the area of l$ng resonance i) Gently dis(lace a 'oman,s breast as necessary c) Meas$re in centimeters 'ith a r$ler the .ertical s(an of li.er d$llness in the MC G) Perc$ss for s(lenic d$llness a) Perc$ss along the lo'er chest 'all bet'een the l$ng resonance abo.e and the costal margin mo.ing laterally )4ates ( -/1) i) !sk the (atient to take a dee( breath and (erc$ss again in this area D) Pal(ate the abdomen lightly in fo$r 1$adrants and in the s$(ra($bic and e(igastric areas a) %se a gentle# light di((ing motion )4ates ( --0) 1>) Pal(ate the abdomen dee(ly in all fo$r 1$adrants a) %se a firmer di((ing motion 11) Pal(ate for the li.er edge a) Place yo$r 9 hand on the right abdomen lateral to the rect$s m$scle# beginning more than - fingerbreadths belo' the costal margin b) !sk the (atient to take in a dee( breath c) Pal(ate $('ards trying to feel the descending li.er edge# $sing a rocking motion i) May also $se the Bhooking techni1$eC described in 4ates ( -/> 1*) Pal(ate for a s(leen ti( a) 9each o.er and aro$nd the (atient 'ith yo$r left hand to s$((ort and (ress for'ard the lo'er left rib cage

Press in'ard to'ards the s(leen 'ith yo$r right hand# beginning at least - finger breadths belo' the costal margin c) !sk the (atient to take in dee( breaths# trying to feel the s(leen ti( as it comes do'n to meet yo$r fingerti(s< 1-) Pal(ates for aorta by (ressing dee(ly 'ith one hand on each side of the aorta )4ates# ( -//) 1/) Pal(ate for the s$(erficial ing$inal lym(h nodes )4ates# ( /0*) 10) Pal(ate for both femoral artery ($lses a) Press dee(ly belo' the ing$inal ligament )4ates# ( /0*) %((er extremityM"8 and Partial 5e$rological )these mane$.ers m$st be re(eated on both $((er extremities 1) Ins(ect the hands# incl$ding each finger# its skin and @oints# and nails a) Pal(ate any abnormal @oints *) Ins(ect the 'rist -) Pal(ate the distal radi$s and sn$ff boxE (al(ate the distal $lna /) Pal(ate the radial ($lse on the flexor s$rface of the 'rist# laterally a) Com(are the ($lses in both arms 0) Check 9OM of the fingers a) !sk the (atient to make a tight fist 'ith each hand b) Extend and s(read the fingers c) !sk the (atient to s(read the fingers a(art and back together d) !sk the (atient to mo.e the th$mb across the (alm and to$ch the base of the 0th finger# and then back across the (alm and a'ay from the fingers e) 6a.e the (atient to$ch the th$mb to each of the other fingerti(s 2) Check 9OM of the 'rist )4ates ( /DD) a) :lexion b) Extension c) %lnar and radial de.iation =) Check 9OM of the elbo' )4ates ( /D=) a) :lexion and extensionF ask the (atient to bend and straighten the elbo' b) Pronation and s$(inationF 'ith arms at his side# and elbo's flexed# ask the (atient to t$rn the (alms $( and then do'n G) Pal(ate for e(itrochlear lym(h nodes )4ates ( /01) a) :lex the elbo' to D>I b) Pal(ate in the groo.e bet'een the bice(s and trice(s D) Ins(ect the sho$lder )4ates# ( /D*) 1>) Pal(ate the sho$lder )4ates# ( /D-) a) ocate the acromion (rocess and the acromiocla.ic$lar @oint b) ocate the greater t$bercle of the h$mer$s c) ocate the coracoid (rocess of the sca($la 11) Check 9OM of the sho$lder )4ates# ( /D-) a) Watch for smooth# fl$id mo.ement as yo$ stand in front of the (atient and askF i) 9aise the arms to sho$lder le.el )abd$ct) 'ith (alms facing do'n ii) 9aise the arms to a .ertical (osition abo.e the head 'ith the (alms facing each other iii) Place both hands behind the neck 'ith elbo's o$t to the side )external rotation and abd$ction) i.) Place both hands behind the small of the back )internal rotation and add$ction) 1*) &est M$scle strength in the $((er extremity )4ates (( 0=/?0=0)< 7o$ m$st com(are sides a) &est gri(ask the (atient to s1$ee;e t'o of yo$r fingers as hard as (ossible and not let them go b) &est finger abd$ction(osition the (atient,s hand 'ith (alms do'n and fingers s(read< &ry to force the fingers together c) &est o((osition of the th$mbthe (atient sho$ld try to to$ch the little finger 'ith the th$mb against yo$r resistance d) &est extension of the 'rist by asking the (atient to make a fist and resist yo$ ($lling it do'n e) &est flexion and extension of the elbo' by ha.ing the (atient ($ll and ($sh against yo$r hand

b)

o'er extremityM"8 and Partial 5e$rological )these mane$.ers m$st be re(eated on both lo'er extremities 1) &he (atient may be sitting or lying do'n and dra(ed so that the external genitalia are co.ered 'ith the legs f$lly ex(osed d$ring the exam *) Ins(ect both feet and anklecom(are sides -) Pal(ate the feet and ankles )4ates# ( 01=) a) !ssess for (edal edema(ress firmly 'ith yo$r th$mb o.er the dors$m of the foot# behind each medial malleol$s and o.er the shins )4ates# ( /00) b) Pal(ate the anterior as(ect of each ankle @oint c) Pal(ate the heel# es(ecially the (ost and inf calcane$s d) Pal(ate the M&P @oints e) Pal(ate the heads of the fi.e metatarsals /) Pal(ate for the (eri(heral ($lses of the legs a) +orsalis (edisfeel the dors$m of the foot @$st lateral to the extensor tendon of the great toe b) Posterior tibialfeel belo' the medial malleol$s of the ankle 0) Check 9OM of the ankle )4ates# ( 01G) a) +orsiflex and (lantar flex the foot at the ankle b) In.ert and e.ert the foot c) :lex the toes 2) Ins(ect the knee for alignment and conto$rs =) Pal(ate the knee 'ith the knee in flexion )4ates# ( 011?01-) a) Identify the medial femoral condyle and the medial tibial (latea$ b) Identify the tibial t$bercle c) Identify the lateral femoral condyle and lateral tibial (latea$ d) Identify the (atellar tendon and ask the (atient to extend the leg e) Pal(ate the medial collateral and lateral collateral ligaments and menisci f) :eel for s'elling abo.e and to the sides of the (atella g) Check the (re(atellar# anserine and (o(liteal b$rsae )4ates ( 01-) G) Check 9OM of the knee )4ates ( 010) a) !sk the (atient to flex and extend the knee 'hile sitting )or by asking the (atient from a standing (osition to s1$at and then stand $( again b) Check internal and external rotation by asking the (atient to rotate the foot medially and laterally D) Ins(ect the hi( by obser.ing the (atient,s gait at some time d$ring the exam )4ates ( 0>2) 1>) Pal(ate the s$rface landmarks of the hi( a) !nterior s$rfaceF locate the iliac crest# iliac t$bercle and anterior s$(erior iliac s(ine b) Posterior s$rfaceF locate the (osterior s$(erior iliac s(ine# the greater trochanter and the ischial t$berosity 11) Check 9OM of the hi( )4ates# ( 0>D?01>) a) :lexion'ith the (atient s$(ine# ask him to bend each knee in t$rn $( to the chest and ($ll it firmly against the abdomen b) !bd$ctiongras( the ankle and abd$ct the extended leg $ntil yo$ feel the iliac s(ine mo.e c) !dd$ctionhold one ankle and mo.e the leg medially across the body and o.er the o((osite extremity d) 9otationflex the leg to D> at hi( and kneeE stabili;e the thigh 'ith one hand# gras( the ankle 'ith the other and s'ing the lo'er leg# medially and laterally 1*) Check m$scle strength in the E )4ates# ( 0=2?0=G) a) &est flexion at the hi((lace yo$r hand on the (atient,s thigh and asking the (atient to raise the leg against yo$r hand b) &est add$ction at the hi(s(lace yo$r hands firmly on the bed bet'een the (atient,s knees< !sk the (atient to bring both legs together c) &est abd$ction at the hi(s(lace yo$r hands firmly on the bed o$tside the (atient,s knees< !sk the (atient to s(read both legs against yo$r hands d) &est extension at the hi(sha.e the (atient ($sh the (osterior thigh do'n against yo$r hand e) &est extension at the knees$((ort the knee in flexion and ask the (atient to straighten the leg against yo$r hand f) &est flexion at the knee(lace the (atient,s leg so that the knee is flexed 'ith the foot resting on the bed< &ell the (atient to kee( the foot do'n as yo$ try to straighten the leg g) &est dorsiflexion and (lantar flexion at the ankleask the (atient to ($ll do'n and ($sh do'n against yo$r hand

5e$rological A some (arts of the ne$rological exam ha.e been 'o.en into exam of the head and neck and extremities )i<e< Cranial 5er.e exam and motor testing)< &he remaining com(onents of the ne$rological exam are co.ered here 1) 9eflexes )4ates# ( 0GG?0D1) a) 4ice(s reflex )C0# C2) 'ith (atient,s arm (artially flexed at the elbo' and (alm do'n# (lace yo$r th$mb or finger firmly on the bice(s tendon and strike 'ith reflex hammer b) &rice(s reflex )C2# C=) A flex the (atient,s arm at the elbo' 'ith (alm to'ards the body and ($ll it across the chest< "trike the trice(s tendon abo.e the elbo' c) 8nee )Patellar) reflex ) *# -# /) A (atient may be either sitting or s$(ine 'ith knee flexed< &a( the (atellar tendon @$st belo' the (atella d) !nkle )!chilles) reflex )"1) A dorsiflex the foot at the ankle and strike the !chilles tendon e) Plantar )4abinski) res(onse ) 0# "1) A 'ith a key or the ti( of the shaft of a reflex hammer# stroke the lateral as(ect of the sole from the heel to the ball of the foot# c$r.ing medially across the ball *) "ensory )4ates# ( 0G-?0G/) a) Pain A Create a shar( from a broken tong$e blade i) Com(are symmetrical areas on the t'o sides of the body# incl$ding arms# legs and tr$nk ii) Com(are the distal 'ith the (roximal areas of the extremities iii) 3ary the (ace of yo$r testing and occasionally s$bstit$te the bl$nt end for the (oint# 'hile asking BIs this shar( or d$llKC or B+oes this feel the same as thisKC b) ight to$ch A $sing a fine 'is( of cotton# to$ch the skin lightly# a.oiding (ress$re i) !sk the (atient to res(ond 'hene.er a to$ch is felt< ii) Com(are one area 'ith another c) 3ibration A %se a lo'?(itched t$ning fork )1*G 6;) i) "et the fork .ibrating and (lace it firmly o.er a +IP of a finger and of the great toe ii) !sk 'hat the (atient feels iii) If .ibration sense is im(aired# mo.e to more (roximal bony (rominences d) Loint (osition sense i) Gras( the (atient,s big toe# holding it by its sides and ($ll it a'ay from the other toes so as to a.oid friction< ii) +emonstrate B$(C and Bdo'nC iii) With (atient,s eyes closed ask him to identify $( and do'n mo.ements i.) Com(are sides .) Mo.e more (roximally if @oint (osition is im(aired .i) &est LP" in the %E by mo.ing a finger @oint -) CerebellarMCoordination )4ates# ( 0=G?0G>) a) 9a(id alternating mo.ements i) %E A "ho' (atient ho' to strike one hand on the thigh# first 'ith the (alm# then 'ith the back of the hand< 6a.e the (atient re(eat these alternating mo.ements as ra(idly as (ossible< 9e(eat 'ith o((osite hand )1) O9 "ho' the (atient ho' to ta( the distal @oint of the th$mb 'ith the ti( of the index finger as ra(idly as (ossible< 6a.e the (atient (erform the action< Check the o((osite hand ii) E A ask the (atient to ta( yo$r hand as 1$ickly as (ossible 'ith the ball of each foot in t$rn b) Point?to?(oint mo.ements i) %E A ask the (atient to to$ch yo$r index finger and then his nose alternately se.eral times< Mo.e yo$r finger abo$t< ii) E A !sk the (atient to (lace one heel on the o((osite knee and then r$n it do'n the shin to the big toe< 9e(eat on the other side /) Gait a) !sk the (atient to 'alk across the room# then t$rn and come back b) Walk heel?to?toe in a straight line c) Walk on toes then on heels 0) 9omberg &est a) &he (atient sho$ld first stand 'ith feet together and eyes o(en and then close both eyes for *>?-> secs 'itho$t s$((ort 4ack 1) 9OM )4ates# ( 0>0) a) :lexion A 'ith (atient standing# ask him to bend for'ard to to$ch the toes b) Extension A (lace yo$r hand on the (osterior s$(erior iliac s(ine and 'ith yo$r fingers (ointing to'ards the midline# ask the (atient to bend back'ard as far as (ossible c) ateral bending A ask the (atient to lean to both sides as far as (ossible