MED OSCE NOTES: Checklists

HEENT

Head As you inspect the head:“Size of the head is proportional to the

· Hair – quantity and distribution rest of the body.”
· Scalp- scaliness, lumps and depression, swellings As you inspect the hair and scalp: “Hair is of adequate quantity
· Skull- normocephalic; depressions, deformities, lumps or and distributed equally throughout the scalp, without any signs
tenderness of patchy hair loss. Scalp does not have any visible scaling,
· Face – symmetry, involuntary movements, lesions, nor does it have lumps upon palpation.”
edema and masses
· Skin- color, pigmentation, lesions.
Visual Acuity is at 20/20 (report in 2 numbers, refer to the
Eyes Rosenbaum chart).
· Ask about vision
· Visual Acuity – note if patient is wearing glasses Ocular and eyelids are symmetric. No obstructions with
· Visual Field lacrimal duct. White conjunctiva and pink sclera. No opacities
· Inspection with cornea and lens and crescentic shadow is absent in iris.
o Eyelid
o Ocular symmetry Visual fields are normal, patient was able to see both wiggling
o Eyebrows fingers at the same time.
o Lacrimal secretions
o Conjunctiva and Sclera Conjunctiva is pinkish, sclera is anicteric. Pupils are 4 mm
o Cornea and Lens constricting to 2 mm, equally round and reactive to light and
o Iris accommodation.
o Pupils No defect in extraocular movements (or eye deviated
· Extraocular movements – “H” medially/laterally or strabismus)
· Fundoscopy: ROR; Optic disc margins

Ears Pinna is normoset. No scars, lesions, lumps, discharge

· Ask how is his hearing observed.
· External ears
o Normoset Auditory acuity. Patient wa able to hear whispered letters and
o tug test: tenderness in auricle and tragus numbers at a distance of ____, for both ears. No deafness
o Tenderness in mastoid area reported.
· Otoscope – ear canal and tympanic membrane
· Rubbing fingers – 3-4 inc
· Whispered - 2 feet behind 3 letters and 3 numbers
· Weber Weber: Normal = sound was heard bilaterally
· Rinne Rinne: AC > BC

Nose
· Color of nasal mucosa Nasal mucosa is pink, with no signs of inflammation, bleeding,
· Septum deviation discharge or exudates, ulcers or polyps. No septal deviation.
· Tenderness in the area
· Cover one ala and forcefully exhale Turbinates are observed
· Inferior and middle turbinates
· Maxillary and frontal sinus: transillumination Sinuses are not tender upon palpation

Mouth, throat and neck: Mucosa is pink with no signs of inflammation, bleeding, and
· Lips – color, symmetry and moisture ulcers.
· Oral mucosa- color, lesions, ulcers
· Pharynx – exudates
· Gums and teeth – ulceration, bleeding and dentition No use of dentures
· Roof of the mouth
· Tongue Tongue is not deviated upon protrusion
· Uvula Uvula moves upward and backward, without L/R deviation
· Neck Lymph nodes on the neck are nonpalpable
o lymph nodes
· Trachea- deviation
No tracheal deviation.
 ​CHEST AND LUNGS

INSPECTION

History (PQRST OF symptoms)

· Check for cyanosis of the face RR is 14 breaths/min. No respiratory distress.
· How patient speaks Patient did not use any accessory muscles during respiration.
· Shape and symmetry of chest and back:
o AP < TV diameter TVD>APD. No chest lag Chest is symmetric and there is no
o Chest is symmetric mass, no lesions, swellings or scars.
· RR – rate, rhythm, labored or not, use of accessory
muscles
· Clubbing of nails
· Position patient while breathing
o Tripod position or comfortably sitting upright
· Trachea – midline or any deviation
· Movement of chest and abdomen
· Skin – lesions, scars

PALPATION

· Tenderness Ask patient if there is pain upon breathing. No tenderness or

· Bony deformities pain upon palpation. No bone deformities. Chest is symmetric
· Symmetric – “chest is symmetric during respiration” (10th rib) during respiration.
· Tactile fremitus – tres tres or 99 Tactile fremitus is symmetric. Vibration is present bilaterally.
o Normal is resonant
o Solid obstruction
o Hypo
· Crepitus
· Pleural friction rub

PERCUSSION

· Percuss along points of palpation There is resonance over the lung fields upon percussion.
o Tympanic – gastric bubble
o Hyperresonant – asthma, emphysema
o Resonant – normal
o Dull – solid mass
o Flat – muscle

AUSCULTATION

​· Request patient to cough first Vesicular breath sounds are heard over lung field. Tracheal
· Normal breath sounds over the trachea in the neck. Bronchial sounds heard over the
o Tracheal – inspiration = exp manubrium. Bronchovesicular sounds over the first and second
o Bronchial – exp > ins ICS and between the scapula.
o Bronchovesicular – insp = exp
o Vesicular – insp > exp
· Abnormal sounds
 ​CARDIOVASCULAR

INSPECTION

While patient is supine with elevated head at 30 degrees
● JVP
● Carotid pulse (with palpation)
Inspection:
● Adynamic or Dynamic precordium
● Bulging or not; if bulging, symmetrical or not
● Pulsations: apex beat; 5th ics midclavicular line
● Note for any scars from operations
● Visible S3 & S4
● JVP is measured at __cm above the sternal
angle__(actual measure + 5cm)cm in total distance
above the right atrium with the head elevated at 30
degrees. (normal is <3cm, <8cm)
● Carotid pulse upstroke was smooth, brisk, without
thrills or bruits
● Apex beat is found 7-9cm lateral to the midsternal
line and 1-2cm medial to left midclavicular line at the
level of 5th ICS

PALPATION

While patient is supine with elevated head at 30 degrees ● No heaves, lifts and thrills upon palpation
● Left 3rd, 4th and 5th ICS and palpate for systolic
impulse of RV and assess (LADD) if palpable
● Heaves and lifts (palm or finger pads)
● Thrills (ball of hand)
○ Start at the area of valves
○ L & R 2nd ICS
○ Sternal border
○ Apex (4th or 5th ICS) Location
○ S3 & S4 (palpate with carotid upstroke) ● LOCATION: Apex beat is palpated at 7-9cm lateral
to the midsternal line and 1-2cm medial to left
Left lateral decubitus position midclavicular line at the level of 5th ICS.
● Palpate for apical impulse ● DIAMETER: measures usually <2.5cm
● Assess (LADD) ● AMPLITUDE: normally is small and feels brisk and
○ Location tapping
○ Amplitude ● DURATION: you can auscultate while palpating.
○ Duration Normally apical impulse occupy 1st ⅔ of systole
○ Diameter

AUSCULTATION

Left lateral decubitus position (accentuates a left-sided S3

and S4 and mitral murmurs, especially mitral stenosis)
● Auscultate at the apex with​ BELL
Supine, with head elevated 30 degrees
● Landmarks: 2nd ICS (R & L); left sternal border, 5th
ICS - Apex to base or base to apex
● S1 – 5th ics
● S2- 2nd ics (right) aortic (left) pulmonic
● S3 – apex beat ​USE BELL ● At the base (aortic area & pulmonic area), S2 is
● S4- not heard; pathologic ​USE BELL louder than S1 and may split with respiration
● At the apex, S1 is usually louder than S2 unless PR
interval is prolonged

Sitting, leaning forward, after full exhalation (accentuates ● No murmurs were heard
aortic murmurs)
● Murmur ​USE BELL
 Identifying Heart Murmurs
● Be sure you are listening in a quiet room
● Time the murmur—is it in systole or diastole?
● Locate where the murmur is loudest on the precordium—at the base, along the sternal border, at the apex?
● Conduct any necessary maneuvers, such as having the patient lean forward and exhale or turn to the left lateral
decubitus position.
● Determine the shape of the murmur—for example, is it crescendo or decrescendo, is it holosystolic?
● Grade the intensity of the murmur from 1 to 6

● Identify associated features such as the quality of S1 and S2, the presence of extra sounds such as S3, S4, or an
opening snap, or the presence of additional murmurs

● Location of Maximal Intensity

○ Determined by the site where the murmur originates. Find the location by exploring the area where you hear
the murmur. Describe where you hear it best in terms of the interspace and its relation to the sternum, the
apex, or the midsternal, the midclavicular, or one of the axillary lines.
● Radiation or Transmission From the Point of Maximal Intensity
○ Site of origin, the intensity of the murmur, the direction of blood ow, and bone conduction in the thorax.
Explore the area around a murmur and determine where else you can hear it
● Pitch
○ This is categorized as high, medium, or low
● Quality
○ This is described in terms such as blowing, harsh, rumbling, and musical

ABDOMEN
*script is for ​normal​ findings

INSPECTION

Lesions, scars, ecchymoses, tattoos, etc.
Striae (color?), dilated blood vessels
Contour (flat, distended, globular, protuberant), symmetry
Inspection of the abdomen reveals no lesions, scars, rashes,
visible striae, and dilated blood vessels. The abdomen is
symmetrically flat, with no visible masses or bulges. There is no
visible peristalsis or pulsations noted. The umbilicus is inverted
and found __ cm inferior to the xiphoid process.

If gusto niyo na lang magpanggap, normal daw na distance is

Visible masses, bulges about 17cm.

Visible peristalsis, pulsations

Umbilicus (inverted, everted)

Distance of umbilicus from xiphoid process (cm)

 AUSCULTATION

Bowel sounds Bowel sounds are normoactive at 10 per minute. No bruits were
Normal: 5-34/min heard over the aortic, renal, iliac, and femoral arteries. There was
Hypo-/hyperactive/no bowel sounds no venous hum, hepatic, and splenic friction rub heard.

Bruit (use diaphragm of steth)

Aortic (epigastrium)
Renal A. (lumbar area)
Iliac A. (lateral to umbilicus)
Femoral A.

Venous Hum

Friction rub (ask Px to inhale&exhale)

Hepatic
Splenic

PALPATION

*ask permission of Px first, ask if there are areas of

tenderness

Light palpation (1cm deep) - RLQ first There is no tenderness and no palpable masses across all
quadrants of the abdomen.

Deep palpation (4-5cm deep) - RLQ first

Bimanual palpation of RUQ (Liver) Upon inspiration, the liver edge was palpated approximately 3 cm
below the right costal margin in the midclavicular line. The liver
edge is soft and smooth.

OR

Hooking Technique (Liver) The liver is not palpable.

Bimanual palpation of LUQ (Spleen) Spleen is not palpable.

Middleton’s Method (spleen)

PERCUSSION

Abdomen (all quadrants) Percussion of the abdomen reveals tympanitic sounds all
throughout (​pero pwede din may areas of dullness if may feces​).

Liver Span (N: 6-12 cm @ RMCL) Liver span is 6 cm in the right midclavicular line.

Splenic dullness (note other methods for detecting this: There is no splenic dullness.
Traube’s space, Castell’s method, Nixon’s method)
 SPECIAL TESTS

Shifting dullness (ascites) There is no fluid wave and shifting dullness (​constant yung​ ​border
ng tympanitic and dull​)
Fluid wave (ascites)

Ballotment maneuver (ID organs in ascitic abdomen)

Aortic pulsation assessment (if Px >50 years old): assess The abdominal aorta is 3 cm wide.
width of abdominal aorta (N: 3-5 cm)

TESTS FOR ASSESSMENT OF PERITONITIS

Direct & rebound tenderness There is no direct or rebound tenderness. Rovsing’s sign and
Rovsing’s sign (away from site of pressure) Blumber’s sign are negative. Psoas and obturator signs are
Blumberg’s sign (at site of pressure) negative. There is no jar tenderness and costovertebral angle
tenderness.

Murphy’s sign is negative. (​pwede to sabihin while doing

McBurney’s Point (appendicitis) bimanual palpation of liver kasi dun naman magkakaroon ng
inspiratory arrest​)
Psoas sign

Obturator sign

Jar tenderness

Costovertebral angle tenderness/Kidney punch

Murphy’s sign*

NERVOUS SYSTEM
Things to note:
● PROCEDURE: MSE → Cranial → Motor → Sensory → reflex
● Symmetry
● CNS or PNS origin of lesion
○ PNS spinal nerves (in pairs) - 8 cervical, 12 thoracic, 5 lumbar, 5 sacral ,1 coccygeal
● Motor (UMN or LMN) - CST, Corticobulbar, Basal ganglia (tone, posture, gait) , Cerebellar tracts (position, gait, tone)
● Sensory
○ Spinothalamic (pain, temp, crude (light) touch)
○ Posterior column tracts (position, vibration, two point (fine) touch)
● DTR - reflex arc
○ Stimulus - Receptor - Afferent - Center - Efferent - Effector - Response
○ Sensory nerve → Spinal cord synapse → motor nerve → NMJ → muscle fibers
 MSE (Bates 11th Ed, Ch. 5)

1. Appearance and Behavior

a. Level of consciousness - is the patient awake and alert? Does he respond to the your questions
appropriately and reasonably quick?
b. Posture and motor behavior - note body posture and ability to relax. Observe pace, range and character of
movements
c. Dress, grooming and personal hygiene
d. Facial expression - observe face when at rest and when interacting with others
e. Manner, affect and relationship with persons and things - drawing on above observations, assess his affect
(external expression of his inner emotional state). Observe openness, approachability and reaction to others
and his surroundings
2. Speech and Language
a. Assess the ​quantity, rate, volume, articulation ​(are words spoken clearly and distinctly?), ​fluency
b. Be alert for abnormalities of spontaneous speech: hesitancies and gaps in flow, monotonous,
circumlocutions or paraphasias
c. Test for aphasia: word comprehension, repetition, naming, reading comprehension, writing
3. Mood
a. Explore the patient’s perception of his mood: How did you feel about that? How is your overall mood?
b. What has the patient’s mood been like? How intense has it been? Has it been labile or unchanging?
How long has it lasted? Is it appropriate to the patient’s circumstances?
4. Thoughts and perceptions
a. Thought process - Assess the logic, relevance, organization, and coherence of the patient’s thought
processes as revealed in the patient’s words and speech -> Does speech progress logically toward a
goal?
b. Thought content - assess information relevant to thought content during the interview -> “You mentioned
a few minutes ago that a neighbor was responsible for your entire illness. Can you tell me more
about that?” “What do you think about at times like these?”
c. Perceptions - hallucinations, illusions
d. Insight - note whether the patient is aware that a particular mood, thought, or perception is abnormal
or part of an illness.
e. Judgement - assess by noting the patient’s responses to family situations, jobs, use of money, and
interpersonal conflicts
5. Cognitive
a. Orientation- time, place, person
b. Attention - digit span, serial 7s, spelling backward
c. Remote memory - events relevant to patient’s past (birthday, anniversary, war)
d. Recent memory - events of the day
e. New learning ability - like digit span, test patient’s registration and immediate recall.
f. Information and vocabulary
g. Calculating ability
h. Abstract thinking - proverbs (Don’t count your chickens before they’re hatched), similarities (how are
these two alike: A cat and a mouse?)
i. Constructional ability
6. MMSE
a. Orientation to time
b. Registration - I am going to say 3 words. You say them back after I stop (repeat 5 times, but score only the
first trial)
c. Naming
d. Reading - please read this and do what it says
 CRANIAL NERVES

I Test for olfaction

1. Check if nostrils are patent: Inhale with each nostril closed.
2. “Close your eyes, sniff, and try to identify this odor.”
3. Must have: coffee or tobacco inside a cigarette

II Test for vision ​(refer to HEENT checklist)

● Visual acuity, Visual field Do static (counting fingers) first, if with defect, do kinetic (wiggling).
● Fundoscopy
● Inspection Including pupil inspection (same size? pinpoint? dilated?)

II and III Pupillary reaction to light

1. Dim the room lights
2. Ask the patient to look into the distance
3. Shine a bright light obliquely into each pupil in turn
4. Look for direct and consensual reactions
5. Record pupil size and any asymmetry or irregularity
6. IF ABNORMAL, proceed to test for accomodation.

Pupillary reaction to accomodation

1. Hold your finger about 10cm from the patient’s nose
2. ASk the patient to alternately look into the distance and at your finger
3. Pupillary response: Distant gaze: DILATION; near gaze: CONSTRICTION

III, IV, and VI Test for extraocular movements ​(refer to HEENT checklist)

V Sensory compartment
 A. Test for pain sensation
1. Explain the procedure to the patient
2. Ask thetient to close theri eyes.
3. Touch the sharp tip to the forehead, cheeks, and jaws of each side
4. The patient must identify when the sharp end touches their face
5. If ABNORMAL, proceed to TEMPERATURE SENSATION TEST

B. Temperature sensation test

1. Must have: hot or cold test tubes
2. Touch the skin of the patient
3. Ask if it’s hot or cold
C. Test for light touch: ​fine wisp of cotton to SKIN
D. Test for corneal reflex: ​fine wisp of cotton to CORNEA; Response: blinking

Motor compartment
1. Ask the patient to close their jaw as you palpate the temporalis and masseter muscles
2. Result: muscles must be ​ttaut
aught for pterygoids, ask patient to open mouth, doctor tries to close

VII Motor compartment

1. Look for asymmetry in facial expressions: smile, puff out cheeks, clench eyes tightly, wrinkle
brows including asymmetry at rest
Sensory compartment
1. Must haves: cotton applicator, different flavor: sweet, salty, bitter, sour
2. Ask the patient to protrude anterior ⅔ of the tongue.
3. Apply to each side of the tongue
4. Ask the patient what taste it corresponds to.

Past pointing test (test for vestibular portion) - up and down arms,
VIII Test for auditory acuity ​(refer to HEENT checklist) back to fingers of examiner (open eyes first then close eyes)

CN X: swallow (pharyngeal muscles), speech

IX and X Check the uvula and gag reflex ​(refer to HEENT checklist) (laryngeal muscles), cough reflex

XI Shrug shoulders, turn head in both directions and raise head from bed AGAINST the force of your hand

XII Check tongue ​(refer to HEENT checklist)

 MOTOR EXAMINATION (Chap 17 12th ed)

A. Body Position (paralysis) - ​Observe position AT REST and while MOVING

B. Involuntary movement (tremors, tics, chorea, fasciculations, dyskinesias, athetosis, dystonia)​ - If found, note
location, quality, rate, rhythm, and amplitude, and their relation to posture, activity, fatigue, emotion, and other factors.

C. ​ trophy ​- uni/bilateral?, proximal/distal?

Muscle bulk (size and contour)​ - Flat or concave, A
● Inspect hands, shoulders, thighs
● Hands - thenar, hypothenar, between metacarpals, dorsal interosseous (note the age of patient)

D. Muscle Tone (muscle tension) - ​feeling the muscle’s resistance to passive stretch
● Upper Ex
○ Relax the patient, hold one hand and other hand is to support the elbow
○ Flex and extend the patient’s fingers, wrist, and elbow, and put the shoulder through a moderate ROM
○ If decrease resistance, shake the wrist. Observe floppiness. (flaccid/hypotonia)
○ If inc resistance observe variation of ROM and observe jerkiness (Spasticity vs Rigidity)
● Lower Ex - relax patient, support thigh and hold foot

E. Muscle strength (paresis/plegia) - ​varies depending on age, sex, muscle activity (​Note: dominant side is usually
slightly stronger than the nondominant side​)
● Ask patient to move actively AGAINST RESISTANCE
● If dec strength, test against gravity and eliminated gravity

STRENGTH Sorry ang hirap kasi iexplain kaya may pix. Note, yung may asterisks (*) wala sa Bates pero nasa 2020 trans.

UPPER EXT LOWER EXT (all position are SUPINE unless stated)

*Shoulder Adduction ​(Pec major) Hip flexion ​(iliopsoas)

C5-T1 L2, L3, L4 -FEMORAL N
Elbow flexed, abducted 45 deg → adduct muscle Doctor place hand on thigh → patient lift leg

*Shoulder Abduction ​(deltoid) Hip extension ​(gluteus maximus)

C5, C6 - AXILLARY N. S1 - INF GLUTEAL N
Elbow flexed, abducted 45 deg → abduct Patient PRONE, doctor on thigh → patient lift upward
Elbow Flexion ​(biceps) Hip adduction ​(adductor muscle- gracilis, adductor magnus,
C5, C6 - MUSCULOCUTANEOUS longus, brevis, pectineus)
Elbow 90 deg, palm upward → Pull against doctor hand L4, L5, S1
Doctor both hands between knees, → patient both legs
together

Elbow Extension ​(triceps) Hip abduction ​(gluteus medius, minimus)

C6, C7, C8 - RADIAL L4, L5, S1
Elbow abducted and supported, 90 deg → Push against doctor Doctor both hands lateral to knees → patient spread legs
hand

*Wrist Flexion Knee flexion ​(hamstrings)

C7, C8, T1 - MEDIAN & ULNAR L4, L5, S1 - SCIATIC
Doctor on palms → Patient flex Patient PRONE knee flexed, supported, foot on bed →

Wrist Extension ​(extensor carpi radialis, longus, brevis) Knee extension ​(quad femoris - rectus femoris, vastus
C6, C7, C8 - RADIAL N. lateralis, medialis, intermedius)
Patient make a fist → resist against grav L2, L3, L4- FEMORAL N
Knee flexed, supported → patient lift leg
Finger grip ​(flexor digitorum profundus) Foot dorsiflexion ​(tibialis anterior)
C7, C8, T1 - half MEDIAN, half ULNAR L4, L5
Squeeze doctor’s two fingers as hard as possible → doctor Doctor hand on dorsal foot → patient lift up
have difficult removing finger

Finger abduction ​(interossei) Foot plantar flex ​(Gastroc, soleus)

C8, T1 - ULNAR N. S1
Palm down, finger spread → doctor force finger together Doctor hand on sole foot → patient push down

Thumb opposition Summary

C8, T1 - MEDIAN N.
Thumb touch little finger
Upper ext
● Shoulder ​- adduct*, abduct*
● Elbow ​- flex, ext
● Wrist ​- flex*, ext
● Fingers ​- grip, abduct, thumb opposition

Lower ext
● Hips ​- flex, ext, abduct, adduct
● Knee ​- flex, ext
● Foot ​- dorsiflex, plantar flex
 GAIT AND COORDINATION (part of motor exam)

Test for:
● Motor -​ muscle strength
● Cerebellar (nystagmus, dysarthria, hypotonia, ataxia) -​ rhythmic movement, posture
● Vestibular - ​ balance, eye and head coordination, body movement
● Sensory - ​position sense

A. Rapid alternating movement (dysdiadochokinesia) ​- Observe speed, rhythm, smoothness of movements.

● Hands: ​strike one hand on the thigh, raise the hand, turn it over, and then strike the back of the hand down on the
same place. Repeat these as rapidly as possible. Repeat to other hand
● Fingers: ​tap distal joint of thumb by using same side index finger
● Legs: ​tap doctor’s hand with ball of foot (heel part). Note slowness or awkwardness

B. Point-to-point movement
● Finger-to-nose (boop) test (dysmetria, intention tremor): ​patient touch doctor’s index finger then touch his/her nose
(booping him/herself). Make sure patient fully extend arm
● Arms (past pointing): ​place finger above head of patient and lower again, make patient touch it. Close eye then
repeat process
● Heel-to-shin test: ​knee level to big toe. Repetition with closed eyes. Other side

C. Gait and other related body movements

● Normal walk (ataxia). ​Observe posture, balance, swinging or arms, movement of legs.
● Heel-to-toe walk/Tandem walk: ​ walk straight
● Walk on toes only (tip-toe) (distal weakness), Walk on heels only (distal weakness, CST damage)
● Hop in place with one foot (proximal and distal muscle weakness)
● Shallow knee bend with one foot. ​Support elbow if patient is at risk of falling
● Rising with sitting position, Stepping up on stool

D. Stance
● Romberg test (cerebellar or post. column ataxia):​ stand, feet together, eyes open. Close eyes for 30-60 secs.
Observe patient’s upright posture
● Pronator drift test: ​stand with hands straight forward, palms up, eyes closed. Try to tap arms downward. Observe
return of arms on same level. Sitting may also be used

SENSORY EXAMINATION

Focus on areas that have numbness or pain, motor or reflex abnormalities suggesting lesion of SC or PNS, and trophic
changes (absent or excessive sweating, atrophic skin, or cutaneous ulceration)
ALWAYS START AT FINGERS/TOES for Vibration/Position sense
● Compare symmetry, prox/distal, dermatomes
● Map out boundaries if detected sensory loss

PAIN (Spinothalamic) - Safety pin/ blunt tool - Analgeia

● Eyes closed → Sharp vs dull
TEMPERATURE (Spinothalamic) ​(omitted if normal pain sensation) - t​ est tube/tuning fork hot and cold
● Eyes closed → Hot vs cold
LIGHT TOUCH (STT and PCT) - cotton - Anesthesia
● Eyes closed → Cotton wisp, tissue (avoid pressure)
VIBRATION (Post Col) - tuning fork
● Test with a non-vibrating tuning fork first to ensure that the patient is responding to the correct stimulus
● Place the stem of the fork over the distal interphalangeal joint (index fingers and big toes) NOT ON THE BONE → Ask
the patient when the vibration stops → if impaired do more proximal
PROPRIOCEPTION (Post Col)
● Hold the big toe/finger (not much pressure). → Move up then down. Ask the patient of the direction of toe’s movement.
DISCRIMINATION (for touch and position sense intact)
● Stereognosis- coin, cotton ball, pen, clip: ​Close eyes and feel the object. Identify the object place on the hands.
● Graphesthesia (number ID): ​Close eyes use eraser side of pencil. Identify what is written on the hands.
● Two-point discrimination: ​Close eyes. Use a pin, clip or caliper to touch two near locations. Ask how many location
are touched and determine the distance at which the patient can discriminate. ​Normal: >4-5 mm
● Point localization: ​closed eyes. Touch patient → open eyes then patient point area touched
● Extinction: ​Close eyes. Touch two location at the same time. Ask how many locations are touched.
 REFLEXES

DEEP TENDON REFLEXES (biceps, patellar, achilles) - Neurohammer (Hyperreflexia)

Use Jendrassik maneuver if low reflex on both side

Relax the patient → swing the hammer freely between thumb and finger (rapid wrist movement). Note speed, force, amplitude

Ankle reflex - S1 ​(sitting or lying down USE BLUNT SIDE OF HAMMER) 1,2 tie my shoe
Knee reflex - L2-L4 ​(flexed knee) (2),3,4 kick the door
Biceps reflex - C5, C6 ​(sitting or lying down) 5,6 pick up sticks
Supinator/Brachioradialis - C5, C6 ​(slightly pronated, USE BLUNT SIDE OF HAMMER) (6),7,8 hold the gate
Triceps reflex - C6, C7 ​(sitting or supine)
*ankle clonus test​ (supine)

CUTANEOUS REFLEX
Upper Abdomen - T8 - T10 ​(strike each quadrant of abdomen, USE KEY, APP STICK) Tandaan niyo na lang na
Lower abdomen - T10 - T12 T10 is umbilicus kaya
Plantar- L5, S1​ (lateral sole - ​babinski reflex​) kasama siya either upper
Anal - S2-S4 or lower tapos ± 2 nerves

SPECIAL TECHNIQUES
A. Meningeal Signs
● Neck mobility: ​supine, hands on patient head ---> flex neck forward until chin touch chest
● Brudzinki’s Sign: ​flexed neck → observe knee and hip reaction
● Kernig’s sign: ​knee flexed, raised thigh → straighten knee → Normal: no pain
B. Lumbrosacral Radiculopathy (for low back pain and sciatica): normal: ​discomfort in butt and hamstrings
● Straight-leg Raise test: ​supine → raise leg, extend knee, dorsiflex → observe height, quality, distribution
C. Asterixis (metab encephalopathy): ​stop traffic (finger spread, extend arms) → observe for 1-2 mins
D. Winging of Scapula (dystrophy): ​extend both arms and push against hand or wall → observe scapula

Mental Status:​ Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and time. Detailed
cognitive testing deferred.
Cranial Nerves:​ I—not tested; II through XII intact.
Motor​: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar—Rapid alternating movements (RAMs), finger-to-nose
(F→N), heel-to-shin (H→S) intact. Gait with normal base. Romberg—maintains balance with eyes closed. No pronator drift.
Sensory​: Pinprick, light touch, position, and vibration intact.
Reflexes​: 2 and symmetric with plantar reflexes downgoing