Sarsing tine Pied ewan Ppa Mark Frere Alo RS-ALAS NURSING SKILLS Physical Assessment Lecturer: Mark Fredderick R. Abgjo R.N, MAN PHYSICAL ASSESSMENT Objectives: » Obiain physical data about the client's fametional abilities > Supplement, confirm, oF refuse data obtained in the ursing history Obvain data thac will help the nurse data establish ‘nursing diagnoses and plan the clients care. » Evaluate the physiologic outcomes of bealth eare and thus the progress of a patient’ health problem > Sersen presence of cancer CEPHALOCAUDAL ORDER OF EXAMINATION AREAS HEENT ANUS AND RECTUM LOWER EXTREMITIES Now! SKIN IS CHECK THROUGHTOUT THE ASSESSMENT cs General Concepts: Approach the client calmly and confidently = Provide privacy © Make sure thar all needed instuments ate available before staring the physical assessment © Several positions are frequently required ducing the assessment, Consider the clients ability 10 assume @ position © Be systemitic und organized when assessing the client. (Inspection, Palpation, Percussion, Auscullation © Ma client is seriously il, assess the systems of the body that are more at risk © Perform painful procedues at dhe end of the examination METHODS OF EXAMINING ® INSPECTION ® PALPATION ® PERCUSSION ® AUSCULTATION INSPECTION > Visual examination ofthe ps sand deliberate manner. fent done ina methadical PALPATION > Is the use of hand w couch for the purpose of determining temperature, moisture, sizc, shape, position, texture, consistency, and movement ‘TYPES OF PALPATION Light Palpation > Tocheck musele ine and assess fr tenderness Techniques: Place the hand with fingers together parallel to the area being palpued. Press down 1 w 2 cm. Repeat in ever-widening circles unt the area to be ‘examined is covered. Deep Palpation ® Tovidentfy abdominal organs and abdominal masses. Techniques: With fingers together, approach the area to be examinad ata 60 degree angle and use the pads and tips of the fingers af one hand to press in om. Two — handed Deep Palpaion place the fingers of one hand on top of those ofthe ether. a ty PERCUSSION > Siiking of the body surface with shor, shan strokes jin order to procuce palpable vibrations and characteristic sound, This used 10 determine the location, size, shape, and density of underiying stractures; to detect the presence of air or fluid in a body space: and to elicit tenderness. “TYPES OF PERCUSSION Direct Percussion > Percussion in which one hand is used and the swiking finger (plexor) of the examiner touches the surfice being pereusse! Techniques Using sharp rapiel movements from the wrist, strike the body surface to he percussed withthe pals of 10, tHe, or four fingers or with the pad of the middle finger alone, Primarily used to assess sinuses in the adult Indircet Percussion "> Percussion in which two hands are used and the plexor stsikes the finger of the examuines’s other hand, whic isin contact with the body surface being percussed (pleameter) Techniques Strike ata Fight angle to the pleximoter using quick sharp but relaxed weist motion. Withdraw the plexor immediately alter the strike to avoid camping the vibration. Strike each are twice and then move to a new area Blunt > Lnar surface of the hand oF fist is used in place of the Fingers to strike the body surface, either direcly or indiraty,Piped Se puede rk ner R Ad RN.MMAN PERCUSSION SOUNDS 1. RESONANCE - Hollow sound, Ex. normal lung. 2 HYPERRESONANCE. — Booming sound. Ex. ous lun, musical or drum sound. Ex, Stomach and intestines 4. DULLNESS — Thud sound. Ex. Enlarged spleen, fall ‘extremely dll sound, Ex. Musele or AUSCULTATION Listening to sounds praduced inside the body EQUIPMENTS FOR PHYSICAL EXAMINATION ¥ —Sphygmomanameter and stethoscope Y Thermometer ¥ Nos Speculum ¥ —Opmnhalmoscope ¥ Groscope % Vaginal Speculum ¥ Catton Applicators Y Tuning fork Y Reflex hammer ¥ Clean gloves ¥ Labeicant (GENERAL SURVEY, VITAL SIGNS GENERAL SURVEY 1. Physical Appearance 2. Level of Conciousmess/ awareness DD Alermess- Pationt is awake and aware of self snd environment ® Lethargy — When spoken wo in a loud voice, patient appears drowsy but opens eye, and Took a you, responds to questions, then falls asleep © Obtundation — When shaken gently. puient ‘opens eye and looks at you hut responds slovy and is somewhat confused, Stupor ~ Pasient arouses fom sleep only after painful stim. ® Coma — Despite repeated painful stimuli, patient remains unarcusable with eyes close. 5. Apperance in relation to chronological age 4. Signs of distress 5, Nutritional status 66 Body strc 1. Obvious physical delormities 8, Mobility 9, Bohavior 10. Odes of body and breath 1 Facial Expression 12. Mood & affect, 13. Speech SYSTEMS ASSESSMENT INTEGUMENTARY SYSTEM Functions of the Skinz vey Protection ‘Absorption Regulation Syahesis Sensory Procedure: Inspects skin surfaces 2. Palpuies with fingertips for edema and skin wrgor 53. Palpates skin temperature contralaterally using back of hands Assessment: Health History Presenting probes (Changes in the eolor and texture ofthe skin, hair cand nails YY Pruritas ¥ Infections Y Tumors and other lesions ¥ Dermastis ¥ echymones ¥_ Dryness + Lifestyle practices ¥ Hygienic pracices Y Skinexposure © Nutrition / diet Intake of vitamins and essential matrents War and Food allergies + Use of medications 4 Steroids ¥ Antibiotics ¥ Vitamins ¥ Hormones ¥ Chemotherapeutic drugs ‘+ Past medical history Renal and hepatic disease ¥ Collagen and other connective tissue diseases Trauma or previous surgery Food, drug or contact allergies + Family mica history Diabetes mellius Yagi dors ¥ Blood dyserasias Specific dermatologic problems Y Cancer Physical Examination © Color Areas of uniform color Pigmentation Y Reiness ¥ undice YY Cyanosis ‘Vascular changes ¥ Purpuric lesion = Ecchymoses + Petechiae ‘Vascular lesions = Angiomas = Hemangion Venous sa Lesions Color ‘Type Size Distribution Location Consistency RRR KK Annular © Linear * Ciwalar + Clusered Edema (pitting oF non-pitting) Moisture content ‘Temperature (increased or decreased; distribution of temperature changes) Texture Mobility /TurgorPiped Se ‘rire Mark Fer Ajo RNALAN Effects of Aging in the Skin ‘Skin vascularity and the numberof sweat and sebaceous glands decrease, afectn thermoregulation. Inflammatory response and pain perception diminish ‘Thinning epidermis and profonged wound healing make elderly more prone to injury and skin infections Skin Primary Lesions of the Skin a eee eee ee ‘Macule isa small pot dat i not palpable and is less than | em indiamter Patch is a large spot that s net palpable & thats > Papule isa small superficial bump that is elevated & that is <1 em. Plaque is lunge superficial bump that is elevated & > Tom. [Nodule is small bus component & is < Tem ‘Tumor isa large bump with a significant deep component & is > Lem. (Cyst is aac containing fluid or semisolid mater call or cll produes. ‘Vesicle sa small hid-filedbuibbe that is usually superficial & that is < 05 em, Bulla is large Muid-iled bubble that is superficial or ep & that i> 0.5 em. Pustule is pus containing bubble often categorized with a significant deep ‘aeoning 6 whether or not dhe ate eeated Wo hai follicies: follicular - generally indicative of local infection + folliculitis -supeical, generally multiple = furuncte- deeper form of folliculitis * carhuncte - deeper, multiple follicles coalescing Secondary esions ofthe Skin . teh eee ‘Scale is the accumulation o excess shedding ofthe Seale ery importa inte frend Dosis since its presence indicaes thatthe ulamis vote 4 Seales typically presem where there is ‘epidermal inflammation ie. psoriasis, tinea, (Crust is dried exudate ic, ood, serum. pos) on the skin surtace Excoriatlon isa loss of skin due w seratching of picking Lichenificatin isan incrase in skin lines & creases from chronic rubbin ‘Maceration is ra, wet sue Figs is a linear crack inthe skin; often very painful Erosion isa superficial open wound with loss of spiders ar mocosa oly [Ulcer isa deep open wound with partial or complete loss ofthe dermis of submucosa Distinct Lesions of the Skin . ee ee ‘Wheal or hive describes. short lived (< 24 hows), edematous, well circumscribed papule or plague seen ‘Burrow isa small dhreadlike curvilinear papulo that is virtually pathognomonic af seabies ‘Comedone is smal, pinpoint lesion, ypially refored 10 as “whiteheads” or "blackheads." Atrophy is thinning ofthe epidermal andr dermal Keloid overgrowthe original wound boundaries and Isehronic in nature & _ Hypertrophie sear on the other hand does not ‘overgeow the wound boundaries 4 Fibrosis or sclerosis describes dermal scatring/thickening reactions © Mili isa small superficial cyst containing keratin (usually <1-2 mmin size Vaseutar Skin Lesions 4 Petechiae is a round or purple macule, associated with bleeding tendencies ar emboli to skin 4 Kechymosis a round oriregular macular lesion larger tun petechiae, color vavies and changes rom black. yellow and green hes. Associated with ranma and bleeding edencies 4 Chery Angioma, popular and round, ed or puple. may blanch with pressure and s normal age-related skin ateratio 4 Spider Angioma is «red, ameriole lesion, central body with radiating branches. Commonly seen on face.neckarms and trunk. Associated with liver disease, pregnancy and viB deficiency A Telangiectasia , shaped varies: spider like or linear, bluish in color ar sometimes red, Does act blanch when pressure applied. Secondary to superficial lain of venous vessels and capillaries. Edlema - the presence of large amounts of fluid inthe interstitial spaces. Usually due w uid collecting in the subcutaneous tisare. Edema may be localized or generalized A. Some causes are lymphatic obstruction, increased vascular permeability, decreased fencolic pressure due co low levels of plasma proteins (especially albumin), oF renal or ‘andiac disease. B, Collections of edema are named according tothe site: 1, Anasarcs - massive generalized edema 2. Ankle 3. Ascites - pettoneal cavity 4. Hydrotorax - dioracie cavity 5. Periorbital- around the eyes 6. Sacral - lower back C. Edema occurs in dependent areas firs. 1D. Edema is grad on a scale considering the ‘depth of the indentation and the length of time wo gem to normal. Assessment: Pees firmly with finger for 5 seconds Rang | Assiament te ‘Sum depth, recovers immediately 2 3-10) mm, duration 10-15 see 3 TT-20 mi, duration 15-30 sea ns 20 mn, duration 230 sec 1. Observe the size, shape and contour ofthe skull, 2. Observe scalp in several areas by separating the hair at various locations: inguire about any injures. presence of lie, nits, dandeuf or lesions. 3, Palpate the bead by running de pads ofthe fingers cover the ete surface of skull: inquire about tenderness upon doing so. (wear gloves ifnecessary) Observe and feel the baie condition. ‘Test Cranial Nerve VIE Test Cranial Newwe VSarsing tine Pied ewan ‘Popared by: Mark Frere Abo RSMAS Normal Findings: 1 Stet Generally round, with prominences inthe frontal and ccipital area. (Narmocephalic). No tenderness nated upon palpation Scalp ‘Lighter in color than the complexion, Can he moist orci. *Noscars noted. Fre from lice, nits and dandru, No lesions should be noted. “No tenderiens nor masses on palpation, 3. Hair ‘Can be black, brown or hurgundy depending onthe Evenly distbuced covers the whole scalp (No evidences of Alopecia) + Maybe thick or thin, coarse or smooth Neither bite nord. » EACE Observe the face for shape. 2. Inspect foe Symmetry. . Inspect forthe palpebral fissure (distance between the eye lids); should be equal in both eyes. 'b. Ask te patient io smile, There should be bilateral [Nasolabial fold (creases extending from the angle of the comer ofthe mou). Slight asymmetry inthe fold isnormal {© Moth are mes, them the Face is symmetsical 3. Test the functioning of Cranial Nerves tha! innervates the Facial stvctures NV (Trigeminal 1. Semory Funcion Ask the client to close the eyes Run cotton wisp over the fore head, check and jaw on both sides ofthe face, [Ask the client if heshe fet it, and where she fees it (Check for comneal reflex using cotton wisp. ‘The normal response in blinking. 2, Motorfunction [Ask the client to chew or clench the jaw ‘The client should be able to clench or chew with sirength and orc. NV (Facial) 1. Sensory function (Thismerve innervate the anterice 2/3 of the tongue) Place a sweet, sour sally, orbiter substance near the tip of the tongue "Noma, the client can ideotify the taste 2. Moter function Ask the elient smile, frown, raise eye brow, close eye lids, Whistle, or putf the cheeks Narmat Findings: ‘Shape miybe oval or rounded. Face is symmetrical [No involuntary moscle movements, Can move facial muscles a will. Intact cranial nerve V and VI EYE/EVERROW/EVELASH Normal findings: Eyebrows ‘Symmetrical and inline wih each her ‘Maybe black, brown ar bland depending on race Evenly distributed Evenly placed and inline with each other. [Non protruding. [Equal palpebral fissure Evelushes ‘Color dependent on race Evenly distributed Tumel outwaed EYELIDS / LACRIMAL APPARATU Inspect the eyetids for position and syonmetry 2. Palpate the eyelids forthe lacrimal glands © Toexamine the lacrimal gland, the examiner, Highly slide the pad ofthe inde finger against the clicat's Upper orb sin 4+ Inquire for any pain or tenderness 3.Palpate for the nasolacrimal duct wo check for obstruction, #Toassess the nasolacrimal dic, the examiner preses with the index finger agains the cient’ lower inner orbital rim, at the lacrimal soe, NOT AGAINST THE NOSE. + In the presence of blockage. this will cause regurgitation of fluid inthe puncta Normat Findings: 5 jpper eyelids cover the small portion ofthe itis, cornea, and sclera when eyes ate open. No PTOSIS noted. (drooping of upper cycids) Meets completely when eyes ate closed Symmetrical TLacrimal gland is normally non palpable No tendemess on palpation. No regurgitation ffom the nasolarimal duct. CONJUNCTIVA, ‘The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and having the client look up, down and co each side. When separating the lids, the examiner should exert no NO PRESSURE against the eyeball: rather. theSarsing tine Pied ewan ‘Popared by: Mark Frere Abo RSMAS ‘examiner should old the lids apainst te ridges ofthe bony ‘orbit surrounding tho eye In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done as follow: 1 Ask he client 1 look down but keep his eyes sighdly open. “This relaxes the levator muscles, whereas closing the eyes contracts the obicularis muscle, preventing ld everson. 2. Genily grasp the upper eyelashes and pull gently downward. Do not pal the lashes outward or upward this, too, causes muscles contraction 3. Place cotton Up application about Lean above the Hid ‘margin and push gently downward withthe applicator while still dholding the Lashes. This evers the ld 4. Hold he lashes ofthe everted lid against the upper ridge of ‘the bony orbit, just beneath the eyebow, never pushing against the eyebrow. ‘5. Examine the lid for selling infection and presence of foreign objects 6. Toetum the lid its normal postion, move the ld slighty Forward and ask the client look up and to bliak, The lid ‘elurs easly its orm position, Normal Filings: Hoth conjunctivae are pinkish or ted in color. With presence of many minutes capillaries, Moist No cers [No foreign objects SCLERAE ‘The sclera is easily inspected during the assessment ofthe conjunctivae, Normal bntings: Sclerae is white in color (aniterc selera) [No yellowish discoloration Getrie sclera), Some capillaries mayhe visible. Same people may have pigmented positions. CORNEA “The comea is bes inspected by directing penlight obliquely from several positions Normal findings: ‘There should he no irregularities on the surface Looks smooth, ‘The comes is clear or transparent, The features ofthe itis shouldbe fully visible though th cornea, “There isa positive corneal reflex. ANTERIOR CHAMBER /1RIS ‘The anterior chamber andthe its axe easily inspected {in onjonetion withthe cornea. Te technique of oblique ithumination i also useful in ascssing the anterior chamber. Nonmal Findings: ‘The anterior chaser is ransparca ‘No noted any visible materials, Color ofthe iris depends on the person's race (black, blue, brown or gwen). From tho sid view, the irs should appear flat and should not bbe hulging forwand. There should be NO crescent shadow casted don the other side when illuminated from one sie, PUPIL Examination of te pupils involves several inspections, including assessment of the size, shape reaction to light is directed is observed for direct response of constriction, ‘Simultaneously, the other eye is observed for consensual response of constriction. “The test for papillary accommodation is the examination forthe change in papillary size as the is switched froma distant toa near objoct 1. Ask the cient to stare athe ajects across room, 2. Then ask the client to fix his gaze on the examiner's index fingers, which is placed 5S inches From the client's nose, 3. Visualization of ditant objects normally causes papillary dilation and visualization of nearer objects causes papillary consrition and convergence ofthe eye. Normal Findings: Pupillary size ranges from 3 —T im, and are cqual in size. [Equally round. CConsrictbrisklyslugsishly when lightis directed tothe eye, both directly and consensta Pupils dilate when looking st distant objects, and constrict, ‘when looking at nearer objects Teall of which ate met, we document the findings using the notation PERRLA, pupils equally round, reactive to light, and accommodateSarsing tine Pied ewan ‘Popared by: Mark Frere Abo RSMAS Normal pupil Abnormal pupil @ Room ight OQ, <@D Tight igh ©... OD (CRANIAL NERVE IL (OPTIC NERVE) ‘Tho optic nome is assessed by testing fo visual acuity and peripheral vision ‘Visual acuity is tested using a spelen chat, for those who are iliterate and unfamiliar with the wester alphabet the iMiorate Feat in which the leer F faces in cfferemt slirections, maybe used. The chart has a standardized number at the end of each line of lesters: these numbers indicates the sdogtee of visual aity when measured at a distance af 20 fot. “The numerator 20 i the distance in fet between the ‘hast and the client, or the standard testing distance, The ‘denominator 20 is te distance from which dhe normal eye can read the lettering, which correspond tothe mumiher atthe end of cach leter Line; therefore the larger the denominator the poorer the version. ‘Measurement of 20/20 vision isan indication of either rfiactive enor of some other optic disorder. ddeoNoudsun = a teeing for visual scuity you may refer to the following: 1 The room used for this test should be well lighted. 2. person wha wears corrective lenses should be tested with {and without them to check ffo the adequacy of corection, 3. Only one eye should be tested at atime; the other eye should be covered by an opaue card or eye cover, not with client's finger. 4. Make the clint read the chart by pointing at letter sundomly at each lin: maybe started from largest wo smallest oF 5. Apenon who can read the largest leter on the chart (20/200) shouldbe checked if they can perceive hand movement albcut 12 inches stom theit eyes, o if they ean perceive the light ‘of the penlight directed to their yes etiphetal Vision or visual ies ‘The asessment of visual aeuity is indicative of the functioning ofthe macula ara, the area of central vision. However, it does not test the sensitivity of the other areas ofthe retina which perceive the move peripheral stimuli. The Visual field confrontation test, peovide a rather gross measurement of peripheral vision ‘The performance ofthis test assumes dha the examiner has normal visual field, sine tha clients visual fields ate toe compared with the examiners, Follow the steps on conducting the test 1. The examiner and dhe elien sit or stand opposite each other, withthe oyes at the same, hexizontal level with the distance of 15 ~2 feet apart. 2. The client covers the eye with opaque card, and the ‘examiner cavers the eye thats apposite to the cient covered eye. 3. Instruct the client wo stare directly at dhe examiner's eye, ‘while the examiner stares atthe clients open eye. Neither looks fut atthe abject approaching from the periphery. 4. The examiner hod an object such as pencil or penlight in his hand and gradually moves itin from the periphery of bot directions horizontally and from above and below. 5. Normally the cliew should see the same time the examiners ‘sees i, The normal visual field is 180 degress VE ML IV. “Oculomator,Frochlear Abdicens All the 3 Cranial neves are tested atthe same time by assessing the Exira Ocular Movement (EOM) or the six cardinal Position of ze, Follow the given steps 1. Stand ditectly in font of the client and bold a finger or a penlight about I from the client's eyes 2. Instruct the clicnt to follow the direction the abject hold by the examiner by eye movements only; that is with out moving, the neck. 5. The marse moves the objet ina clackwise direction hexagonally 4. Instruct the client w fix his gaze momentarily on the extreme positon in each ofthe six cardinal gazes, 5. The examiner should watch for any jerky movements of the eve (aystagmu 66. Normally the client can hold the postion and there shoul bbe no nystagmus.Piped Se ‘rire Mark Fer Ajo RNALAN ‘Test for Accomodation EAR 1 Inspect the auricles ofthe ears for parallel appearance and skin color. 2: Palpate the auricles and the mastoid process fr firmness of the cartilage ofthe auricles, tenderness when manipulating the auricles and the mastoid process. 3. Inspect the auditory meatus or the ear canal for color, presence of cerumen, discharges, and foreign bodies. size position, 4. Foradul pull the pinna upward and backward o suaighien the aral ». For children pull the pinna downward and backward to straighten the canal 4. Perform o1oseopic examination ofthe noting the color and fandmarks. Normal Findings: ‘The earlobes ae bean shaped, parallel, and symmetrical ‘The upper connection ofthe eat lobe is parallel wih dhe outer ccamtnus of the oye Skin is same in color asin the complexion, No lesions noted on inspection, ‘The auricles are has afi cartilage on palpation, ‘The pinna recils when folded, ‘There is no pain or cenderness an the palpation of the auricles and mastoid process “The ear canal has normally some cerumen of inspection No discharges or sions noced a the ea cul ‘On otoscopic examination the tympanic membrane appears ‘lat, translucent and pearly gray im color i aot ‘CRANIAL NERVE VIL Examination ofthe Dearing acuity and balance. nerve VIII involves testing for Hearing Acuity AL Volee test ‘The examiner stands 2 fon tho sido ofthe ear tobe rst. Ingmict the client ta occlude the ear cana ofthe other ear. ‘The examiner then covers the mouth, and wing a soit spoken voice, whispers non-sequentil number (eg. 35.7) for the client o repeat. 4, Normally the client willbe able o heae and repeat the nomber, 5. Repeat the procedure at the other ca, 1B. Watcher test ‘Ask the cient w close the eyes, 1 2. Placea mechanical watch I~ 2 inches away the client's ear 3. Ask the client fhe hears anything 4. Ihe client says yes, the examiner should validate by asking at what are yoo hearing and at what ide 5) Repeat the procedure on the other eat, 6. Normally the elient can idemify the sound and at what ide it was heard ‘Taming Fork Test ‘This est is useful in determining whether the cliemt has a conductive hearing loss (problem of external or mile ear) ora perceptive hearing loss (sensorineural). There are 2 types of tuning fork west being conducted 1. Weber's test assesses hone conduction this isa test of sound lateralization; vibrating tuning fork is placed on the mile ofthe fore head of top ofthe skull, Normal: hear sounds equally in both eats (No Latcralization of sound) Conduction loss - Sound lteralizes wo defective ear (Heard Joutier on defective ear) as few extrancous sounds are carried through the extemal and mide eat. Sensorineural loss ~ Sound lteralizes on hetter ear 2. Rinne Test ~ Compares bone conduction with air condition. Vibrating wning fork placed on the mastoid process Instruction cient o inform the examiner when he no longer hears the ting fork sounding. ©. Posiion in de tuning fork in font of the elient’s ear eanal ‘when he no longer hears it Nosnal: Sound should be heaed when caning fork is placed in front ofthe ear canal as sirconductione bone condoetion by 21 (positive inne test) Conduction loss: Sound is heard longer by bone conduction than byair conduction Sensorineural loss Sound is heard longer by air conduction than by bone concietion NOSE AND PARANASAL. SINUSES “The externa portion of the nose is inspected for the Following L ay 2 Pateney of nares (done by occluding nosetril one ata time, land noting fo difficulty in breathing) 3. Flaring of alaenas 4 Discharge “The external nares are palpated fr: 1. Displacement of one and eantlage 2. Fortenderness and massesPiped Se ‘rire Mark Fer Ajo RNALAN ‘The inesnal nares are inspected by heperextending the neck of the client, the ulnar aspect of the examiner's hard over the fore ‘head ofthe client, and using the thumb to push the tip ofthe nose upward while shining Tight imo the nari, Iaspect forthe following: L.Posiion ofthe septum, 2. Chock septum for perforation, (can also he checked by lirecting the lighted penlight onthe side ofthe nas, illumination a the other side suguests perforation). 3, Thenasal mucosa (turbinates) for swelling, exudates and change in calor Paranasal Sinuses Examination ofthe paranasal sinuses is indirectly. Information about their condition is gained by inspection and palpation of the overlying tissues. Only frontal and maxillary Sinuses ate accesible for examination, By pulpating both cheeks simultaneously. one can determine tendemess of the maxillary sinusitis, and pressing the ‘thumb just below the eyebrows, we can determine tendemess af the foatal sinuses. VASA bated Se Normal Filings 1. Nose inthe midline 2. No Discharges. 3. No flaring alae mas 4. Hoth nares are patent, 5. No bone and cartilage deviation noted on palpation. 6. Notendemess nawed on palpation 7. Nasal septum in the mid line and not perforated 8. The nasal mucosa is pinkish to red in color. (Increased redness turbinates ave typical of allergy). 9. No tendemess nored on palpation ofthe paranasa sinuses. OLFACTORY NERV ‘To test the adequacy of function ofthe olfetory nerve: 1. The cients asked to close his eyes and occlude ‘The examiner places swomatic and easily distinguish nose (¢4.coffee. ‘Ask the client 1 identity the odor, 4. Bach side is tested separately. ideally with two different substances mourn, Mouth and Oropharyns Lips are inspected for wet and surface abnormalities, Color Edema Nonmal Findings 1. Wit visible margin 2. Symmetrical in appearance and movement 3. Pinkish in color 4. Nodes Palpate the temporomandibular while th ‘wide and then closed for: 1 Crepitous 2. Deviations 3 Tendomess Normal Findings 1. Moves smoothly mo crepitous. 2. No deviations noted 3. No painor tenderness on palpation and jaw Gums are inspected for 1. Color 2. Bleeding 3. Retraction of gums [Normal Findings 1. Pinksh in color 2. No gum leeding 3. No receding gums Teeth ace inspectad fr: Number Color Dental carries Denial fillings Alignment and malocctusions (2 teeth inthe space for 1,0 overlapping tcth) ‘Tooth loss Breath should also be assessed dating te provesSarsing tine Pied ewan ‘Popared by: Mark Frere Abo RSMAS ‘Normal Findings: 28 for chikdren and 32 for adults, White t yellowish in color ‘With ox without dena carries and/or dental fillings ‘With o€ without malocslusions, [No halitons ‘Tomgue is palpated fr: Teaure ‘Normal Findings: 1. Pinkish with whit taste hudson the surface, 2. Nolesions note. 3. No varicosities on ventral surface. 4. Fronulomis thin attaches to the posterior 1/3 ofthe ventral aspect of the tongue. 3. Gag eller is present {6 Able to move the tongue freely and with strength 7. Surface ofthe tongue is rough. vu is inspected for: L. Postion 2 Color 3. Cranial Nerve X (Vagus nerve) ~ Tested by asking the client to say “Al” note thatthe uvula will move upwaed and forwaed, Normal Findings: 1. Positioned in the mid line 2. Pinkish to red in color 3. No swelling or lesion noted. 4. Moves upward and backwards whon asked to say “ah “Tonsis ace inspected for: 1. nflmation 2 Se [A Grosing systom used to describe the size ofthe tonsils can be used 4¢ Grade 1 —Tonsils being the pillar. 4# Grade 2~ tween pillar and vl, © Grade 3 Touching the uvula © Grade tn the midline. NECK ‘The neck is inspected for postion symmetry and obvieus lumps Visibility of the dhyroid gland and Jugular Venous Distension. ‘Normal Findings: “The neck is straight [No visible mass or lamps. Symmetrical [No jugular venous distension (aiggestive of cardiac congestion). bepe ‘The neck is palpated just above the suprastemal note using the ‘thumb and the index finger. “The neck is palpated just above the suprastemal note using the thumb and the index finger. Nonmal Findings: The tachea i palpable 2. Wis positioned inthe fine and straighs. spa nodes are palpated using palmar tips ofthe fingers via systemic circular movements, Describe Iymph nodes in termsof size, regulaity, comsistency, tenderness and fixation to sumounding ussues. fateh! foo Spade pode — seine [Normal Findings 1. May not be palpable Maybe aormllypalpsble in thin liens. Non ender palpable. Firm with sith ound surface Slisly movable. ‘About ess than Tem in size “The hyo is nitally served y standing in from ofthe lien and asking the client sallow. Palprion of the thyroid can he done either by posterior or anterior appmach Indication of Lymph Nodes © Occipital: Head infection © _ Submental: Dental Carroctions, Oral int © SubMandibular Infection © SCMUpper: Lymphoma © Supractaviewar: Cancer Pesteior Approach 1. Let the client sit on ache while the examiner stands bei him. 2, Inexamining the isthmus ofthe thyroid, locate the ‘ricoid cartilage and directly below that is the isthmusPiped Se ‘rire Mark Fer Ajo RNALAN 3. Ask he client swallow while feeling for any telargeient ofthe thyroid isthmus 4. To facilitate examination of each lobe, the client is ‘asked to urn his head slightly toward dhe side wo be examined to displace the stemocleidomastoid, while the other bund ofthe examiner pushes the thyroid canilage towards the side ofthe thyroid lobe 10 be examined, 15. Ask the patient to swallow a the procedure is being done. 6 The examiner may also palate for thyroid enlargement by placing the thumb deep to and behind the Memocleidomastoid muscle, while the index and rmiidle fingers are placed deep 10 and in font of the nuscle, 7. Then the procedure is epeated on the oer side Anterior approach: |. The examiner stands infront ofthe client andl with the palmar surice ofthe middle and index fingers palpaces bolove the cricoidcaniage 2. Ask the cient ta swallow while palpation is being done. 3. Inpolpating the lobes ofthe thyroid, similar procedure is done asin posterior approach, The client is asked to ‘urn his head slightly to one side and then the other of the Tobe to he examined. 4. Again the examiner displaces the thyroid cartilage towards the side ofthe lobe t be examines, 5. Again. the examiner palpates the arca and hooks thumb and fingers arnund the stemocleidomastoid muscle Normal Findings 1. Normal the thyroid is nom palpable. 2. Isthmus maybe visible in a thin neck, 3. Nonodules are palpable ‘Auscultaion of the Thyroid is necessary when thee is thyroid enlargement. The examiner may hear bruts, a a result of increased and turbulence in blood flow in an enlarged thysci, 4¢ Check the Range of Movement of the neck ‘THORAX Lung borders Inde anerior thors the upices ofthe lungs extend for approximately 3-4 cm above the claviees. The inferior boners ofthe lungs cross the si ib atthe midelavigular Line In he posterior hora, the apices extend of T10 on expiration fo the spinous process of T2 on inspiration Inthe Lateral Thorax, the lungs exten from the apex ‘of dhe anilla to the #° ib ofthe midaillary line. ‘Lung Fissures ‘The right oblique (diagonal fissure extend from the area ofthe spinous process of the 3 thoraci vertebra, laterally and downward unit ¢ crosses the 5 nib a the midillary line. It 0 then continues ant medially 1 end atthe 6° rib a the ‘midelaviculr ine, “The Fight horizontally fissure extends from the ib slighily posterior othe right midaxillary line and runs horizontally to thee area af the 4" ib atthe tight sternal border, “The left oblique Aigo) fissure exten from the spinous proces of the 3" thoraic velar aterally and di nvatd oe left nid axilla line at the 5" and Contin anteriorly and medially until it terminates atthe 6 ib in the midelaviculr ine Borders of the Diaphragm. Anteriony. on expiation, the right dome of the yhragm is located atthe level ofthe 5 rib the Imidelavicular line and be left dome isa the level ofthe 6 ib, Postetory, cm expiration, the diaphragms at the level ofthe spinous process of T10; stray iis atthe B® nib atthe rmidaxillary ine. On inspiration the diaphragm moves approximately 15 cm downvard Inspection ofthe Thorax For adequate inspection of the thorax, the client should he sitting Uupeight without support and uncovered to the wast “The examiner should observe 1, Shape of dhe dhoras ad is symmeuy. 2. Thoracic configuration. 3. Retractions at the ICS om inspiration, (cuprasterma costal, substernal) 4. Bulging structures atthe ICS during ‘expiration 5, position ofthe spin. 6 Normal Findings {©The shape of the thorax in a normal adult is eliptical the anteroposterior diameter is less than the transverse diameter a approximately a ratio of 1:2 ‘© Moves symmetrically on breathing with no obvious No fall chest which issuggestve of rib fracture No ches retractons must be noted asthis may suggest dliticulty in breathing, ‘© No bulging t the ICS must be noted as this may obstruction on expiration, abnormal masses, or canliomegaly ©The spine shouldbe suaight, with lightly curvature in the thoracic are, ‘© There shouldbe no scoliosis, kyphosis, oF lordosis Breathing maybe diaphragmtically of costally Expiration is usually lager the inspiration, Palpation of the ThoraxSarsing tine Pied ewan Ppa Mark Frere Alo RS-ALAS General palpation The examiner should specifically palpate any areas of anormality."The temperature and turgor the skin should be assessed. Palpate for Jumps, masses and areas of tenderness. Palpate foe thoracic expansion or ting excursion, A Actin fe tains hand as plas Overthe arora che wid the tubs Extend along thecosal magi, pong tothe ayphoad proces Postion the hunt ae pled tthe evel of he 10" 1 and he pas are pases on he ponerineral ches 3, Intact clic to exe fin theo inhale dep © Thecxamer the armont of thsi cxposio ding quit wd dep inspiration and ever for iversence of thet on Dorma, symmetry of esprion between shelf and rh mores shod ek tthe thunbsare wept a separate ‘pprasinatly 35cm (12 inches) shri dep inspiron. Palpate fo the tactile i A. Place the palm or the ulnar aspect of the thane bilaterally symmetrical on the chest ‘Wall starting from the cop, then at then ‘medial thoracic wall, nd at the anterolateral) 1B, Each time the hands move down, ask the client wo say ninety-nine Repeat the procedure a the posterior thomcic wal D. Normally, cctile flemitus should be bilaterally symmetrical, Mos incense inthe 2 ICS at the sternal border, near the area of bronchial bifurcation. Low pitched voiues of ‘males are more reaily palpated than higher pitched voices of females. E, Basicubnormalies ike increased wtile fremitus maybe suggestive of consoldation decreased tactile fremitus may be suggestive of obstuctions, thickening of pleura, of collapse of lings, Percussion of the Thorax. ‘Anericethora: A B. Patient maybe pl supine position Percuss systematically at shat 5 em intervals from, the upper to lower chest, moving leit o right t lef. (Pereus over the ICS, avoiding the ribs. Use indirect percussion starting a the apices ofthe lungs. ‘The examiner notes the sound produced during each percussion, ‘Whispered Pecrorioguy ~ Ask the client top whisper“ (Over normal lung Ussue it would almost be indistinguishable over consolidated lung it would be loud and clear Pereuss the diaphragmatic excursion Normal Breath Sound [ Wesieutar ‘Sof, ow pitch | Lung perpher [sence | Medic | Laser blowing [ironehiat La jich | Trachea Abnormal Breath Sound Dependent lobes] Random, sodden reinflaion of alveoli fivids ‘Trachea brondhi_| Fluids. mucusPiped Se ‘rire Mark Fer Ajo RNALAN Wheres ‘Altung fads] Severely manowed bronchus Pleural Friction | Tateral long field | Inflamed Prewa Rub Elderly Physical Changes of Thorax and Breathing Patterns kyphosis Anteroposterior diameter ofthe chest widens Breathing rate and shythm are unchanged at rest Inspiratery muscles become less powerful, and inspiration reserve volume decreases. Expiration may require the use of accessory muscles [eflation of the lng is incomplete Siall airways lose their cartilaginous support and elastic roll laste rssic ofthe alveoli loses is stretehability and changes to fibrous issue, Exertional capacity also decreases © Cilia inthe airways deerease in number and are tess effective in removing mucus, therefore they are at ‘greater risk for pulmonary infections © 696 e080 Inspeetion ofthe Heart ‘The chest wall and cpigastram is inspected while the client sin supine position. Observe for pulsation and heaves cr ils Normal Finding: 1 Pulsation of the apical impulse maybe visible. (chs can gives some indication ofthe cardiac siz). 2. There should be na lif or heaves Jugular Venous Pressure 1 Postion the patient supine with the head of the table clevated 30 degrees, {Use tangential, side lighting to observe for venous pulsations inthe neck. 3. Look fora rapid, double (sometimes triple) wave with cach heart heat. Use light presse just above the Serna end of the davick wo eliminate the pulsations and rule outa earorid origin, 4. Adjust the angle of table clevation to bring out the ‘venous pulsation, 5. _Kdemify the highest point of pulsation. Using a brizantal line from this point, meas verically fom the steal angle {6 This measurement shauld be less than 4 em in @ ‘oral healthy adult. Precordial Mavement 2 1. Posiion the patent supine with the head of the table slightly elevated. Always examine from the patent's ight side 3, Inspect for precocdial movement. Tangential lighting will make movements mere visible 4. Palpute for precordial activity in general, You may feel “exuus" such as thrills or exaggerated ventricular impulses 5. Palpate for the point of maximal impulse (PMLor apical pulse). Its normally located in de 4th or Sy Joreastal space just medial tothe midelavicular line and is less than the size of a quarter. 6. Note the location, size, and quality ofthe Palpation of the Heart ‘The entire precondium is palpated methodically using the palms and the fingers, Beginning atthe apex. moving tothe left sternal border and then 1 the hase ofthe heart, [Normal Findings 1 No, palpable pulsation over the aortic, pulmonic, and ital valves Apical pulsation canbe felt on palpation, 5. ‘There should be no noted abnormal heaves, and thil felt over the apex. Percussion ofthe Heart The technique of percussion is of imited value in eariac assessment. It can e used to determine borders of eardiae dullness Auseultation ofthe Heart Aortic Puknonic Tricuspid Miral Anatomie areas jor auscultation of the heart Aortic valve — Right 2™11CS sternal border. Pulmonic Valve ~ Left 2" CS sternal border “Tricuspid Valve ~~ Left $"1CS sternal harder. Mitral Valve ~ Left ICS midclavicula ine Positioning the client for auscultation: © te the heart sounds are fant or undetectable, try listening wo them with the patient seated and learning forward, o¢ lying on his let sie, which brings the heart closer to the surface ofthe chest © Having the client seated and leaning forward s best suite for hearing high-pitched sounds related to somilunar vals problem,Sarsing tine Pied ewan ‘Popared by: Mark Frere Abo RSMAS 4¢) The lef Lateral eecumbent position is best sited low pitched sounds such as mata valve problems and extra heart sounds Auscultating the heart 1. Auscultate the heart in all anatomic areas aortic, pplmonie,ricuspid and mitral 2. Listen for the S1 and S2 sounds (SI closure of AV vabes; S2 closure of semalunar valve). 1 sound is best heard over tbe mitral valve; $2 best heand over the aodtric valve 3. Listen for abnormal heart sounds e.g. $3, $4, and Murmurs 4 Count heart rte atthe apical pulse for ane full minute. Normal Findings: 1 & 82 can be heard at all anatomic site ‘No abwormat heart sounds is heard (e.g, Murmurs, $3 & 54), 3. Carine rte ranges from 60 — 100 bpm. PERIPHERAL CIRCULATION Inspect: © Color © Edema © Susisulcersfesions © Varicosities © Haie/nail changes Palpate: © Temperature © Edema © Tenderness © Symmetry of pulses Chronic Venous Insufficiency Pain None to aching pain on dependency Pulse Normal a Normal w cyanotic: petechiae or brown, pigmentation BREAST ‘With fingertips | | close together, Lh gently probe ach breast {none of these |” three patterns | Va | Breast self-exam: = — Manual inspection (standing) ®ADAM Inspection ofthe Breast ‘There ae 4 majorsiuing position of the cient used for clinical breast examination, [very client should he examined in each position, 1. The client is seated with her arms on her side, 2. ‘The clint is seated with her arms abdhicted aver the hea. 3, The client is seuted und is pushing her hands inco her hips, simultaneously eliciting contraction of the pectoral muscles, 4. The client is seated and is learning over while the examiner assists in supporting and balancing her © While the client is performing these maneuvers, the breasts are careflly observed for symmetry, bulging retraction, and fixation © An abpomlity may not be apparent in the breasts at Fest a mass may cause the breasts, through invasion of the suspensory ligaments to fix, preventing them from upward movement in postion ad 4 © Position 3 specifically assists in eliciting dimpling if ‘mass has inflated and shortened suspensory igament Chronic Arterial Insufficiency, Pain Tnvernitent claudication Pulse Decreased Color, Pale Temperature | Warm Temperature | Cool Edema Prownt Edema Absent or mild ‘Thin, shiny auophie skin, hair Tos, Skin Changes | Detmutitisskin pigmentation Changes chee onl Ulceration | Toes points of trauma Uleeration Medial side of ankle Genre | Maydevciop Gangrene Does net develop Normal Findings 1 The everlying the breast shold he even,Piped Se ‘rire Mark Fer Ajo RNALAN 2 May or may not be completely symmetrical at rest 3 ‘The cola is rounded of aval, with same color, (Color ‘aes form light pink to dark brown depenai sce). A. Nipples ate rounded, cverted, same size and equal in color. 5. No“orange pee!” skin is noted which is prevent in cxdema 6. The veins maybe visible but not engorge and prominent. 7. Nobviousmass noted 8 Not fixated and moves bilaterally when bunds are abducted over the head. otis learning forward 9, Noretractions or dimpling Palpation of the Breast ‘© Palpate the breast along imaginary concentric circles, following a clockwise rotary motion, from the periphery to the center going tothe nipples. Be sure thatthe breast is adequately surveyed. Breast examination is best done 1 week post memes ‘¢ Each areolar areas are carefully palpated to determine the presence of underlying masses ‘+ Each nipple is gently compressed wo assess forthe presence of masses or discharge Normal Findings: 4¢ No fumps or masses are palpable. ¢Notendemess upon palpation '¢ No discharges fom the nipples NOTE: The male breasts are observed by adapting the techaigues used for female clients, However the various siting position used for woman is unnecessary. ABDOMEN In abdominal assessment, be sure that the client has emptiod the ‘ladder for comfort. Pace the clit in a supine position with the knees slightly flexed to relax abdominal moses. Inspection ofthe abdomen ‘¢ Inspect for skin integrity Pigmentation, lesions, striae, scars, veins, and umbilicus), © Contour (lat, rounded, seapols) © Distension © Respiratery movement ‘+ Visible peristalsis, = Pusations Normal Findings: '¢ Skin color is uniform, no lesions © Some clients may have striae or sca. ¢ No venous engorgement, Contour may be fat, rounded or seapoid ‘¢ Thin clients may have visible peristalsis. Acric pulsation maybe visible on thin elients Auscultation ofthe Abdomen This method precedes percussion because bowel ‘motility, and thas howel sounds, may be increased by palpation or percussion. ©The stcthoscope and the hands shouldbe warmed if they are cold, they may initiate conraction ofthe slndominal musles. © Light pressure onthe stethoscope is sufficient to detect bowel sounds and brats Itsstnal suas are relatively high-pitched, the hell may he used in exploring arterial muemurs and venous hum. Peristaltie sounds, “These sounds afe produced by the movements of air and fluids through the gastrointestinal tract, Perstalss can provide diagnostic clues relevant to the mati of bowel, Listening to the bowel sound (borborygmi) can be facilitated by following these step > Divide the abdomen in four quadrants Listen over all auscultation sites, staring a the right lower ‘quadants, following the cross pattern of the imaginary lines in creating the abdominal quadrants. This direction ‘ensures that we follow the ditection of bowel movement. Peristaic sounds are quite ieregular. Thus itis recommended that he examiner listen for at least 5 minutes, especially at the periumbilical area, before ‘concluding that ao howl sounds are present ‘The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 3 — 15 seconds. It is suiggested that the number of bowel sound may be as ow as 3 to as hgh as 20 per minute, oF roughly, ove bowel sound, Tor each breath sound. Some factors that affect howel sound: Presence of Food inthe GI tract. 1 2. State of digestion 3. Pathologic conditions ofthe bowel (inflammation, Gangrene. paralytic ileus, peritonitis). 4. Bowel surgery 5. Constipation o Discs. 6. Electrolyte imbalances 7. Bowel obstruction dletocting fai in the peritoneum (ascites) gaseous distension, and ‘masses and in assessing solid strictures within the abdomen, 4 The direction of abominal percussion follows the tuuscultaton site at each abdominal guardaat, ‘©The entire abdomen should be percussed ighudy or 2 zonoral picture af the areas oF tympany and dullness ‘© Tympany will predominate because of the presence of sin the small and large bowel. Solid masses will percuss as dull, suchas fiver in the RUQ, spleen attheSarsing tine Pied ewan ‘Popared by: Mark Frere Abo RSMAS 6° or 9" rib jus posterior vo orat the mid axillary line ‘on the left side '¢ Percussion inthe abdomen can also be used in ‘assessing the liver span and size of the spleen. Percussion ofthe liver ‘The palms ofthe left hand is placed over the region of liver dullness. ‘The area is strucked lightly with 2 fisted sight hand, 2 Normully tenderness should notbe elicited by tis ‘method, 3. Tendesness elicited by this method is usually a result of hepatitis or cholecystitis Renal Percussion (Can be done by either initeet or direct method Percussion is done over the costoverlebral junction, Tenderness elicited by such method suggests renal inflammation, pre Palpation of the Abdomen Light palpation 4 ttisagenicexploration performed while the clint is in supine positon. With the examines ands paral ‘oie floor The fingers depress the abdominal val, at each patra, by approsinstely {cm wits digging at ently palpating with slow cular motion ¢Thismetodis used forclcting igh temeress large masses, and muscles and muscle guarding ‘Tensing of abdominal musculature may occur because of “Tho examinor’s hands are too cold or are pressed to vigorously or deep into the abdomen, 2 The client is ellish or ards involuntarily. Presence of subjacent pathologie condition, ‘Normal Findings: 1. Notenemess noted, 2. With smooth and consistent tension, 3. Nomuscles guarding, Deep Palpation ‘© tis the indentation ofthe abdomen performed by pressing the distal half ofthe palmar susfaces of the fingers into the abdominal wal. © The abdominal wall may slide back and forth while the fingers move hack and forth over tho organ boing examined, Is © Deeper structures, like the liver, and eto peritoneal organs ke the kidney, or masses may be felt widh this method. 4 Intheahsence of disease, pressure produced by deep palpation may produce tenderness over the cecum, the Siginod eoloa, and the aorta. Liver palpation: “There are two types of bi manual palpation recommended for palpation of the liver. The frst one isthe superimposition ofthe right bund over dhe left hand. Ask the patient to tke 3 normal breaths. ‘Then ask the client to breath deeply and hold, This ‘would push the liver down to facilitate pulpaion, 3. Presshand deeply over the RUQ “The second methods: 1. The examiners left hand is placed beneath the client athe level ofthe right 11" and 12" ibs. 2. Place the examiner's right hands parallel tthe costal margin or the RUQ. 3, An upwaed pressure is placed beneath the clien (0 push he liver towards the examining right hand, while the sight hand is pressing into the abdominal wall, 4. Askthe client to breah deeply. 5 Astheclien inspires, the liver maybe felt o slip beneath the examining fingers. Nonmal Findings ‘©The liver usually can not be palpated in anormal adult However, in exizemely thin butothewise well Individuals it may be felt athe costal margins © When the normal liver margin is palpated it must be smooth, regular in contour, fim and non-tender MUSCULOSKELETAL Assess the patie’ posture, stance, and gait Prepare the pationt forthe examination Inspect foe any gross abnormalities, Inspect and palpate the tempocomaddibular joint and jaw Inspect and palpate the nock and spine Assess the ROM ofthe neck ‘Assos the ROM of the spine Inspect and palpate the upper and lower extremities, assessing each joint and muscle RANGE OF MOTION Lateral ange‘Nursing sts Physed tees rapa by ark Fer R, Abo RSALAS 6 ‘TEMPORAL MADIBULAR JOINT AND JAW RANGE OF MOTION: ELBOW Elevation | \Depression 1a Internat ; rotation | External rotation Cireumduction RANGE OF MOTIONSHOUDLERS "oration { \) _ wins adaldvaton RANGE OF MOTION: FINGERS rotation 0° rotation pineconePiped Se ‘rire Mark Fer Ajo RNALAN RANGE OF MOTION:KNEES tuctn RANGE OF MOTION:HIPS. Neurological Assessment EXTREMITIES Observation Involuntary Movements ¥ —-Mnscle Symmetry v Lett Proxinl ss, Distal ¥ Atrophy Pay particular attention to the hands, shoulders, and thighs. ¥ Gait A, Musele Tone 1. Ask the patient 0 2 Flew and extend the patiem’s fingers, wrist, and elbow. 3. Flex and extend patients ankle and knee. 4. There is normally @ small, continuous resistance to passive movement, 5. Observe for decreased (Maecid) or increased (Giektspastic) tone. B, Muscle Strength “Tes strength by having the patient move against your resistance Always compare one side to the other ‘Grade strength on a sale from (10.5 “out of five Grading Motor Strength “rade | Description 5 Nomuscle movement 5 Visible muscle movement, but no movement atthe joint 5 Movement atthe jit, but not agains rovity 4 Moe ein ery bu on gi ai 4/5 Movement agains resistance, bt ess than nora 5/5 Nowmal strength “Test the following 1. Flexion at the elbow (C5, C6, biceps) 2. Extemion at the elbow (C6, C7. C8, wiceps) 3. Extension atthe wrist (C6, CT, CX, radial neve) 4. Squeeze two of your fingers as hard as posible ip" C7,C8,T1) 5. Finger abauetion (C8, TH, ulnar nerve) 6. Oppostion ofthe thumb (C8, TH, median nerve) 7. Flexion at the hip (2, L3. L,iiopseas) 8 9 Auction atthe hips (12, 1.3. L4, adductors) [Absuction atthe hips (L4, 15, SI, gluteus medius and minimus) 10. Extension atthe hips (SI, gluteus maximus) 1. Extension atthe knee (12, 13, L4, quadriceps) 12, Flexion at the knee (L4, L5, $1, $2, hamstrings) 15. Dorsilexion at the ankle (LA, 5) 14, Plantar flexion (S1) Pronator Drift 1. Askthe patient to stand for 20-30 seconds with bot ‘ms straightforward, palms up, and eyes closed 2. Instruct the patient to Keep the ams still while you tap them briskly downvard 3, The patient will not be able to maintain extension and. supination an "i nto prmon wih upper moter C. Coordination and Gait Rapid Alternating Movements 1 Askethe patient to strike one hand om the thigh, raise the hand, we it ove, and then suike it back down as fast as possible 2. Ask the patient to tap the distal dhumb wit te tip of the index finger as fast as possible 3, Ask the patient to rap your hand with the bal of each foot as fist as posible Point-to-Point Movements 1 Askete patient to touch yourindex finger and their nose altemately several fimes. Move your finger about asthe patient performs this task, 2. Hold your finger stil so thatthe pation ean touch it with one aem and finger cutstretched. Ask the patient tomove their arm and return your finger with their ees closed.Piped Se ‘rire Mark Fer Ajo RNALAN 3. Ask dhe puient to place one heel on the opposite knee land run it down the shin tothe hig toe. Repeat with the patient’ eyes close. Romberg 1. Be prepared wo catch the puiemtifthey ae unstable. ‘Ask the patient to stand with the feet together and eyes closed for §-10 seconds without support. 3. The testis sid to be postive ithe patient becomes unstable (indicating a vestibular ar proprioceptive problem) Gait ‘Ask the patient ‘Walk across the room, tum and come hack Walk heel-to-t ina straight line ‘Walk on thei toes in a straight line ‘Walk on their heels ina straight line Hop in place on each foot Do ashallow knee bend Rise from a siting position ser ePRE D. Reflexes Deep Tendon Reflexes ¥ Thepatienn before starting, ¥ Reflex response depends on the force of your stimulus, Use wo more force than you need 0 provoke 8 definite response Reflexes cam be reinforced by having the patient perfoom isometie contraction of oiber muscles (clenched teeth). Reflexes should be graded on a 0 104 "plus" scale: st be relaxed and positioned properly ‘Tendon Reflex Grading Seale Grade Description 0 Absent Isor+ —Hypoactive Deort+ "Normal Seorse Hyperactive without onus 4+ or-+4++ Hyperactive with clomis Biceps (C5, C6) 1. ‘The patients arm should be partially flexed atthe elbow wich the palm down Pace your thumb ofnger firmly on the biceps tendon. ‘Suike your finger wih the reflex hammer. 4. You should feel the response even if you cant see it Triceps (C6, C7) 1. Suppose dhe upper arm and lt the patient's Frese hang free. 2. Strike dhe triceps tendon above the elbow withthe broad side ofthe hammer. 3. the patients siting or ying down, flex the patient's farm at the elbow and hold close t the chest Brachioradialis (C5, C6) 1. Mave te patient rest the forearm on the abdomen or Tap. 2. Ske the radius shout 1-2 inches above the wrist. 3. Watch fr flexion and supination ofthe foreatm, Abdominal (18, 79, T10, 711, 712) L._ Usea bluntobject suchas a key or tongue blade, 2. Stroke the abdomen lightly on cach side in an inward ant dovmard dieetion above (T8, 79, T10) and below the umbilicus (T10, TH, T12). 3. Note the contraction ofthe abdominal muscles and deviation ofthe umbilicus towards the stimulus Knee (L2, 13,14) 1. Have the patient stor lie down with the knee flexed, 2. Strike the patella tendon just below the utells 3. Note contraction of the quadraceps and extension of the knee Ankle (S1, 82) 1 Dorsifles the foot tthe ankle. 2. Strike the Achilles tendon 3. Watch and feel for planar flexion a the ankle Clonus Ifthe reflexes seem hyperactive, test for ankle clomus: 1 Support the knce in partly flexed position, 2, Wilh the pation relaxed, quickly dosflen the foot 3, Observe for thythmic oscillations, Plantar Response (Babinski) 1. Soke the lateral aspect ofthe sole of cach foot withthe end of a reflex hammer oe key. Note movement of the tes, normally Aexion (withdrawal), 3. Extension of the hig toe with fanning of the other toes is soir. Tis is referred 1o asa postive Babinski E. Sensory General Explain each test before you doit, ¥ Unless otherwise specified, the patient's oyes should be closed during the actual testing ¥ Compare symmetrical areas on the two sides ofthe body. ¥ Also compare distal and proximal arcas af the ¥ When you detect an area of sensory loss map out its boundaries in det 1. Vibration Use a low pitched tuning fork (1281, 1. Test with a nonsvibrating tuning fork fst 10 consi that the patient is responding to the correct, stirs,Piped Se ‘rire Mark Fer Ajo RNALAN 2. Place the stem of the fork over the distal intgphalangeal joint of the patient's index fingers and big toes. 3. Askthe patient o cell you if they fet the vibration, If vibration sense isimpaired proceed proximally: 1 2 3 4 5 6 7 Wrists Elbows ‘Medial mulleoli Patetlas “Anterior supero Spinous processes Chavickes ‘Use your fingers to toueh the skin lightly om bot sides simultaneously Test several areas om both the upper and lower 4 Ast the patient to tll you if there is difference from, Side wo side or ober "srange" sensations, 3. Position Sense |. Grasp the patient's big toe and hold it away from the other toes fo avoid friction. ‘Show the patient “up and “down.” 3. With the patien’s eyes close ask the patient 10 Identify the directen you mave the toe. 4. position sense is impaited move prox the ankle join. “Test the fingers ina similar fashion 6. indicated move proximally to the ‘metacarpophalangeal joins, wrists, and elbows ly ote 4. Dermatomal Testing Lf vibration, postion sense, and subjective light touch are normal in the fingers and 10es you may assuine the rest of dis ‘exam will be norma, 5. Pain Use a suitable sharp abject to test "sharp" o “dull” sensation. ‘Tes the following areas Shoulders (C4) Inner and outer aspects of the forearms (C6 and TY) ‘Thumbs and ltl fingees (C6 and C8) Frat of bah thighs (L2) ‘Medial and lateral aspect of beth calves (L and 1.5) Lite tes (S1) 5. Temperature + Often omitted if pain sensation is normal. Use a tuning fork heated or cooled by water and ask the patient 1 identify "hot" ar “cold ‘Tes the following areas: 1. Shoulders (C4) 2. Inner and outer aspects of the forearms (C6 and TH) 3. Thumbs and litle fingers (Cé and C8) Front of bos thighs 2) 9 5. Medial and lateral aspect ofboth calves (LA and LS) 6 Littetoes (SI) 6. Light Touch ‘© Usea fine whisp of couon or your fingers wo voush the skin lightly 4+ Askthe patient to respond whenever a touch is elt, “Test the following areas Shoulders (C4) Inner and outer aspects of the forearms (C6 and T1) “Thumbs and Hite fingers (C6 and C8) Front ofboth thighs (L2) Medial and lateral aspect of both calves (LA and LS) Litde toes (1) 7.Diserimination Since these tests are dependent on touch and postion sense, they cannot be performed when the tests above ae clearly abnormal Graphesthesia 1. Withthe blunt end of a pen or pencil draw alarge ‘number inthe patient's palm. 2. Ask the patient to identity the number Stereognosis 1. Useas an altemative to graphestbesia ++ Place familiar object in the patient's han (coin, paperclip, pencil, etc) 3. Askihe patient 16 tell you what itis ‘Two Point Discrimination 1. Use situations where more quantitative data are needed, such as following the progression of cortical lesion. + Use an opened paperclip to touch the patient's finger pads in to places simultaneously. Alternate iregularly with one point touch 4. Askthe patient o identify “one” oF tw." 5. Find the minimal distance at which the patient can discriminate SAMPLE CHARTING Ms. X isa young, healthy-appearing woman, well-groomed, fit, and in good spits. Height is $4", weight 135 Ibs, BP 12080, HR 72 and regulae, RR 16, lemperature 375°C. SKIN: Color good, Skin warm and moist, Nails without clubbing er eyanosis EENT: Head ~ skull is wormocephalicfatraumatic(NCIAT), Maie with average texture, res visual acuity 20/20 bilaterally. Sclera white; conjunctiva pink Pupils constcit 4 mm to 2 mm, equally round and reactive to light and accommodations Ears acuity good, Weber midline, Nose nasal mucosa pink, septum midline, no sinus tenderness. Throat(mouth) — ral ‘mucos pink: dentition good: pharynx without exudates, "Neck — trachea midline. Neck supple: thyroid isthmus palpable, lobe not ft Lymph nodes — no cervical adenopathy. THORAX AND LUNGS:Piped Se ‘rire Mark Fer Ajo RNALAN INSPECTION = AP diameter mt increased = Fullexpansion equal bilaterally PALPATION, = Novendemess = No clargement of lymph nodes = Fremitus equal bilaterally PERCUSSION = Lung field resonant = Diaphragmatic excursion —4em bilaterally AUSCULTATION Breath sounds clear = Norales,shonehi, or ubs © BREAST AND AXILLAE: © Breast symmetric and without masses. Nipples without discharge. - —Noanillary adenopathy CARDIOVASCULAR EXAM: = PMl.s tapping, 2 cm lateral tothe nidstemal Line in he S*ICS ‘Good Si and S2 = Ne murmurs or extra sounds ABDOMEN: ‘Abdomen is protuberant wid active bowel sounds. It {is soft and non-tender; no masses of hhepatosplenomegaly. Liver span is Jems edge is smovth and palpable I em below the right costal margin, Splcen and kidneys not fel SCULOSKELETAL SYSTEM: Good range of mod swelling oF deform ~ Mental status: alent, relaxed and cooperative. Thought process coberem. Oriemed to person, place, and Cranial nerves: X11 intact = Motor: Good! muscle bulk and tove. Strength 5/5 throughout (Cerebellar: RAM, intact. Gait with normal ase, Romberg — maintains balance with eyes closed. No pronator dri. Sensory: Pinprick, light touch, postion intact = Reflexes: 2+ and symmetsic