st

3. Place the 1 ruler horizontally at the level of the highest

CARDIO VASCULAR SYSTEM point
nd
INTERVIEW: General Rules a. And place 2 ruler vertically on top of the
st
WASH HANDS BEFORE TOUCHING THE PATIENT sternal angle at 90 degrees with 1 ruler
INTRODUCE SELF AND CHECK THE IDENTITY OF THE PATIENT b. Note for the vertical distance in CENTIMETER
RIGHT SIDE OF THE PATIENT. (CM)
nd
____________, a 2 year

May I know your name sir/mam?

EXPLAIN THE PURPOSE AND OBTAIN CONSENT
I will be your student Doctor for today who will
examine your HEART/CARDIOVASCULAR to check if
there are any abnormalities.
Is that okay for you?

EXAMINATION OF THE JUGULAR VENOUS PRESSURE (JVP)

1. Stay at the RIGHT side of patient
a. Position the patient SUPINE on bed
b. And RAISE the head of the bed to about 30-45
degrees angle

2. Let the patient head turn to the LEFT

a. Identify the RIGHT jugular vein
b. And note for its highest point of pulsation by
tangential lightning ( Use a penlight)

NOTE: JVP is usually check when there is a presence

of neck vein distention and I will just perform this for
demonstration only
Jugular venous pressure is 3 4 cm WATER (H2O) from
sternal angle of Louis

Normal JVP:
3 4 from Sternal Angle of Louis or
8 9 from the Right Atrium

There is no neck vein distention and

visible pulsation upon tangential lightning
 INSPECTION: CAROTID ARTERIAL PULSE PROPER WAY OF PULSATION
4. Carotid Pulses: Check amplitude & bruits 5. RADIAL ARTERY PALPATE ON BOTH HANDS SIMULTANEOUSLY
ONE AT A TIME ONLY
Checking for AMPLITUDE

6. BRACHIAL ARTERY - PALPATE ON BOTH HANDS SIMULTANEOUSLY

7. FEMORAL ARTERY - PALPATE ON BOTH FEMORAL SIMULTANEOUSLY

Auscultate for BRUIT

8. POPLITEAL ARTERY - PALPATE BOTH POPLITEAL SIMULTANEOUSLY

Carotid arterial pulse is palpable strong and bounding

There is no bruit heard in the carotid artery

PULSATION: PALPABLE PULSES

Check strength, symmetry, rates & rhythm
5. Radial
6. Brachial
7. Femoral
8. Popliteal
9. Posterior Tibialis
10. Dorsalis Pedis
9. POSTERIOR TIBIALIS PALPATE ON BOTH FOOT SIMULTANEOUSLY

10. DORSALIS PEDIS PALPATE ON BOTH FOOT SIMULTANEOUSLY

Peripheral pulses such as:

Radial
Brachial
Femoral
Popliteal
Posterior Tibialis
and Dorsalis Pedis (may be present or absent) nd
Aortic area - 2 right ICS parasternal line
Arteries are all strong and are symmetrically and nd
Pulmonic area - 2 left ICS parasternal line
bilaterally palpable Tricuspid area - Left xiphisternal junction or 4th to 5th
left ICS lower sternal border
PALPATION OF PRECORDIUM th
Mitral area 5 left ICS MCL 1-2cm medial to the MCL

11. Stay at the right side of the patient in supine

Angled at 90 degrees

12. Expose precordial area, illuminate with penlight at

tangential angle
13. Look for precordial bulging & pulsation
Precordium is adynamically palpable
No visible bulging and pulsation upon tangential lighting
 16. If palpable, measure the size (diameter) with fingers
(breath) or ruler
Note for force of pulsation

th
14. Look for APEX BEAT at usual location 5
space (ICS) 1-2 cm medial to LMCL
Note for location
th
6 intercostal Apical beat (Point of Maximal Impulse) is
th
Palpable at 5 ICS LMCL on sitting position and on the
Left lateral decubitus position, it is 1-2 cm in diameter
Precordium is dynamically / adynamically palpable

Note:
1. Adynamic - apex beat is not visible but may or may not be
palpable
2. Dynamic - apex beat visible and palpable but normal in size
and amplitude
3. Hyperdynamic - increased diameter and amplitude of apex
beat associated with rocking movement (heave) of the
precordium.

PRECORDIAL HEAVES, THRILLS AND HEAVES

th
The APEX BEAT is at the 5 Intercostal Space Left
MidClavicular Line (ICS) (LMCL) is also the Point of
Maximal Impulse (PMI)

15. If not possible, palpate with index & middle finger with
patient supine or left lateral decubitus

17. Check for Precordial Heaves:

a. Patient is still supine
b. Palpate with heel of right hand at apex beat
area for strong pulsations (LVH)
c. Left side of lower sternum for (RVH)
 21. PRECORDIAL AUSCULTATION:
a. Warm stethoscope with hands
b. Identify VALVULAR AREAS:
Mitral
Tricuspid
Aortic
Pulmonic

th
Mitral area 5 left ICS MCL 1-2cm medial to the MCL
Tricuspid area - Left xiphisternal junction or 4th to 5th
left ICS lower sternal border
nd
Aortic area - 2 right ICS parasternal line
To palpate heaves and lifts, use your palm and/or hold nd
Pulmonic area - 2 left ICS parasternal line
your finger pads flat or obliquely against the chest. rd
3 ICS

18. Check for Thrills: 22. Using bell or diaphragm auscultate at the valvular areas by
a. Using the ball of the hands, palpate for fine inching from apex to base or vice-versa
vibrations at the:
th
Apex beat 5 ICS LMCL for mitral
valve thrill
Left lower sternum for tricuspid valve
thrill
nd nd
19. 2 ICS LPSL for pulmonic thrill and 2 ICS RPSL for aortic
valve thrill
For thrills, press the ball of your hand (the padded area of
your palm near the wrist) firmly on the chest to check for
a buzzing or vibratory sensation caused by underlying
turbulent flow.

20. Check for Precordial Lifts:

a. Using the pad of the middle and index fingers,
nd
palpate for abnormal pulsations on the 2 ICS
LPSL for pulmonary arterial lift
nd
b. 2 ICS RPSL for abnormal aortic artery
dilatation
To palpate heaves and lifts, use your palm and/or hold
your finger pads flat or obliquely against the chest.

No HEAVES, THRILLS and LIFTS palpated on both sides of the

ventricles
No pulsation at the base, parasternal or epigastric area
 S1 is longer than S2 at the apex
S2 is longer than S1 at the base

26. Note for splitting of S1 at the tricuspid area in relation to

respiration

Physiologic splitting is not appreciated

27. Precordial Auscultation:
a. Maneuverers Positioning at left lateral
decubitus to enhance apical heart sounds

23. Check for the Heart rate:

Using be diaphragm at the apex beat
a. Normal: 60 -1 00 / min
b. Bradycardia: <60 / min
c. Tachycardia: >100 / min b. Leaning forward to enhance basal heart sounds

Heart rate is ___ beats per minute (bpm) and is normal

24. Check for Rhythm:
a. Regular
b. Irregular
c. Skipped

With Normal Rate and Rhythm (NRR)

Bradycardia is regular rhythm
Tachycardia is regular rhythm

25. Check for S1 and S2, compare the character of sounds at

the apex and basal area
28. Detecting:
a. Abnormal heart sounds using bell of
stethoscope auscultate for S3 and S4 at the
mitral and tricuspid areas

No S3, No S4 heard at the mitral and tricuspid area

No extra heart sounds heard.

29. Check for turbulent sounds (murmurs) at the different

valvular areas:
a. Describe as to timing only
b. Friction rub

No murmur heard at the different valvular areas

No friction rub heard
 OLFU MD2024 | CLINICAL MEDICINE

SPINE AND EXTREMITIES

SCRIPT

GENERAL RULES
Palpate the hands and fingers for crepitus, tenderness,
1. WASH HANDS BEFORE TOUCHING THE PATIENT nodules that cannot be seen by the naked eye, muscle
Show in the video that you washed your hands with atrophy, or bony enlargement
soap and water; or disinfected with alcohol
Ma am/Sir, okay lang po ba kung hawakan ko
2. INTRODUCE SELF & PATIENT IDENTIFICATION kamay niyo para po tignan kung may kakaiba?
Let the patient know who you are
Check the patient identification

Good morning, po! My name is _________, I m a 2nd

year medical student. I will be the one examining
you today. May I know your name?

3. EXPLAIN THE PURPOSE

Explain why you need to do the physical exam
Obtain consent from the patient
The patient hands and fingers are brown in color
pine end extremities to The nails are pinkish in color
check if there are any abnormalities. Would that be Hands and fingers have no bony deformities
okay for you? No nodes palpated on each side of the fingers
No bogginess, mass, nor lesions
No crepitus observed
No tenderness and warmth noted
The rubrix said to start from cervical spine, but Dr.
Jusayan suggested to start from distal to proximal. 3. RANGE OF MOTION
This script will be following that suggestion.

Ma am/Sir, pakigaya po ako

HANDS/FINGERS
1. INSPECTION FLEXION Patient clenches fists
You don Patient un-clenches fists
Patient should be upright EXTENSION
and stretch fingers out

ABDUCTION Spread the fingers

Check the dorsum of the hand for deformities, nodes,
bagginess, color of the skin, presence of scars, even
color of nailbeds, clubbing of fingernails ADDUCTION Bring fingers together

You don t touch the patient. You just describe if there Move thumb away from
THUMB ABDUCTION
is any evidence of deformities. plane of hand

Bringing thumb to plane of

THUMB ADDUCTION
2. PALPATION hand
This is where you have to touch the patient, ask for
Touch thumb to each
consent OPPOSITION
fingertip

1
 Palpate the bony landmarks using your thumb
1. Radius (lateral)
2. Ulna (medial)

Ma am/Sir, may masakit po ba?

Upon checking the wrist joint, there are no deformities,

bogginess, masses, and tenderness noted. The radius
and ulna are palpable on both hands.

3. RANGE OF MOTION

Ma /Sir, pakigaya po ako

DORSIFLEXION Bend hands down

The patient can perform full range of motion as to
flexion, extension, abduction, adduction, thumb PALMAR FLEXION Bend hands up
abduction, thumb adduction, and opposition.
Deviate fingers sideways
MEDIAL DEVIATION
OR towards the midline
Deviate fingers sideways
Patient had difficulty doing __________. LATERAL DEVIATION
away from the body

WRIST JOINTS
1. INSPECTION
You don
Patient should be upright

Check the for deformities, nodes, and bagginess that

are visible

You don describe if there

is any evidence of deformities.

2. PALPATION

Palpate wrists for crepitus (the same sound when you

rub your hair against your thumb), tenderness, nodules
that cannot be seen by the naked eye, muscle atrophy,
The patient can perform full range of motion as to
or bony enlargement, and temperature of the joint
dorsiflexion, palmar flexion, lateral & medial deviation
(because often times if there s inflammation, the joint
is tender and warm)
OR Patient had difficulty doing __________.

2
 FOREARM 4. RANGE OF MOTION
1. INSPECTION
You don Ma /Sir, pakigaya po ako
Patient should be upright

Check the skin color, muscle tone, PRONATION Forearm faces up

atrophy/hypertrophy of muscles, bony deformities
SUPINATION Forearm faces down
You don describe if there
is any evidence of deformities.

2. PALPATION

Palpate forearm using your thumb and index finger for

bony enlargement, crepitus, skin temperature, and
tenderness of muscle

Ma /Sir, may masakit po ba?

The patient skin is brown in color The patient can do range of motion of the forearm as
No bony deformities, atrophy, or hypertrophy to pronation and supination
observed, tenderness and warmth noted
Muscle tone is hard/rigid/soft, no crepitus noted OR

3. MEASURE CIRCUMFERENCE The patient has difficulty in doing pronation and

Measure 2 inches away from cubital fossa supination of the forearm

ELBOW
1. INSPECTION
You don
Patient should be upright

Check for gross deformities, swelling, nodules, and the

bony landmarks
1. Olecranon bursa
2. Olecranon process
3. Lateral and Medial epicondyle

You don describe if there

is any evidence of deformities.

The circumference of the patient s forearm is ____

on the right, and _____ on the left
The forearms are symmetrical/asymmetrical

3
 2. PALPATION

Palpate elbow using your thumb and index finger for

bony enlargement, crepitus, tenderness of the muscle,
and skin temperature

Ma /Sir, may masakit po ba?

No bony deformities
No tenderness and warmth noted
Muscle tone is normal, no crepitus observed

3. MEASURE CIRCUMFERENCE The patient can do range of motion of the elbow as to

Start measuring from 2 inches above flexion, extension, pronation, and supination

OR

The patient has difficulty in doing flexion, extension,

pronation or supination of the elbow

UPPER ARM
1. INSPECTION
You don
Patient should be upright

Check for gross deformities, swelling, nodules,

hypertrophy/atrophy of muscles
1. Biceps
2. Triceps
The circumference of the patient elbow is ____ on
the right, and _____ on the left You don describe if there
The elbows are symmetrical/asymmetrical is any evidence of deformities.

4. RANGE OF MOTION
2. PALPATION

Ma /Sir, pakigaya po ako

Palpate upper arm using your thumb and index finger
for bony enlargement, crepitus, point of tenderness of
Bring your arm towards biceps/triceps, muscle tone and skin temperature
FLEXION
you
Bony landmark of upper arm
EXTENSION Straighten both arms
-Humerus
Rotate arms, with palm
PRONATION Ma /Sir, may masakit po ba?
facing down
Rotate arms, with palm
SUPINATION
facing up No bony deformities
No tenderness and warmth noted
Muscle tone is hard/rigid/soft
No crepitus observed

NO RANGE OF MOTION FOR UPPER ARM!

4
 SHOULDER JOINT Patient can do range of motion of the shoulder joint as
1. INSPECTION to flexion, extension, abduction, adduction, internal
You don rotation, and external rotation
Patient should be upright

Check for gross deformities, swelling, nodules

You don describe if there

is any evidence of deformities.

2. PALPATION

Palpate shoulder for bony deformities, nodules,

tenderness of the muscle, crepitus, and signs of
inflammation

Bony landmarks
-Sternum
-Sternoclavicular Joint
- Acromion
- Coracoid process
- Greater tuberosity of humerus

Ma /Sir, may masakit po ba?

No bony deformities
No tenderness and warmth noted
No nodules
No crepitation noted

3. RANGE OF MOTION
Patient should be standing upright

Ma /Sir, pakigaya po ako

Raise arm above the head CERVICAL SPINE

FLEXION
or behind neck
1. INSPECTION
Put the arms towards the
EXTENSION You don
small of your back
Patient should be upright
Bring arms together to the
ADDUCTION
side
Look at the curvature of the spine, position yourself at
Patient will swing arm
ABDUCTION the side of the patient, it must be concave. Abnormal is
extended laterally away
flattened or convex shaped. At the front view, check
Patient elbow in flexed
the midline position for malalignment.
position, arm raised at
INTERNAL ROTATION shoulder level, palm facing
You don describe if there
floor, forearm rotate
is any evidence of deformities.
anteriorly
Elbow in flexed position,
arm raised at shoulder level,
EXTERNAL ROTATION
palm facing floor, forearm
rotate posteriorly

5
 2. PALPATION

Palpate cervical spine for bony deformities, tenderness

of the muscle, crepitus, and heat

Bony landmark
-C7

Ma /Sir, may masakit po ba? THORACOLUMBAR SPINE

Cervical spine has no gross deformities. It is concave
in its curvature. There are no lesions, no nodules on
palpation. There is no tenderness, heat, crepitus, and
nodules palpated on C7
1. INSPECTION
Patient should be standing upright
Ask patient to remove shirt to expose the spine
Sir, okay lang po ba pakitanggal po ng damit para
mas makita natin ng mabuti yung spine niyo?

Look at the curvature of the spine. Stand at the back

(straightness) and side (vertical profile/curvature) of
your patient. This is to check the curvature and vertical
alignment of patient.

You don describe if there

is any evidence of deformities.

3. RANGE OF MOTION 2. PALPATION

Patient should be standing upright
Palpate for muscle spam lateral to the spine using ulnar
Ma /Sir, pakigaya po ako aspect (thumb) of your hand.

The thoracolumbar spine curvature should be convex.

Put chin on chest, look
FLEXION
down
EXTENSION Opposite of flexion, look up
Turn head to left and right
ROTATION
without moving body
Tilt head towards left and
LATERAL BENDING
right shoulder
Patient can do range of motion as to flexion, extension,
rotation, and lateral bending (left and right)
The thoracic spine curvature is convex and well-
aligned. There are no gross visible deformities and no
mass. Upon palpation, the spinal muscles are soft,
there is no spasticity. There is no crepitation on
thoracic spine.
The lumbar spine is straightened and well-aligned. The
curvature is concave. There are no gross deformities.
Upon palpation, there is no gross deformities, no
crepitation, no tenderness, and no nodules

6
 HIPS
1. INSPECTION
You don
Patient should be standing upright
Ask patient to lower the shorts to adequately expose
hip joint (don t expose pubis area)
y lang po ba ibaba natin ng onti yung shorts
niyo para makita po ng maayos ang balakang niyo?

Check if there are any swelling, deformities, and bony

enlargement, and bruising. Look at the bony features if
they are well-aligned with the left and right side.
3. RANGE OF MOTION - Sacrum
-Iliac crest
Patient should be standing upright
- Ischial spine

You don describe if there

Ma /Sir, pakigaya po ako is any evidence of deformities.

2. PALPATION
FLEXION Body bends forward

EXTENSION Body bends backward
Body bends to the left and
LATERAL BENDING
right
Patient turn head and
SPINAL ROTATION shoulder as one unit,
holding the pelvis stationary
Palpate for the bony features. Check if there are any
nodules, tenderness, swelling, muscle atrophy, and
warmth.
The iliac crest is symmetrical. There are no bone
deformities, no muscle atrophy, bruising, and swelling.
No tenderness and warmth noted.

3. RANGE OF MOTION
Patient should be standing upright

Ma /Sir, pakigaya po ako

Raising the leg toward the

FLEXION
front
Pushing the leg toward the
EXTENSION
back
Movement of the leg away
ABDUCTION from the midline of the
body
Movement of the leg
ADDUCTION towards from the midline
of the body
INTERNAL ROTATION Turn the foot to the midline
Patient can do range of motion of the thoracolumbar
spine as to flexion, extension, lateral bending, and Turn the foot to the lateral
spinal rotation without difficulty. EXTERNAL ROTATION
side to the leg

7
 Patient is positive for straight leg test. He felt sciatic
pain when the leg was raised at ___°

OR

Patient can do range of motion as to flexion, extension, Patient is negative for straight leg test.
abduction, adduction, and external rotation of hips
FABER/ PATRICK S TEST
4. SPECIAL TEST Flexion, Abduction and External Rotation
If the test reproduces posterior pelvic pain
Patient should be lying down
contralaterally, it is considered a positive test indicating
Sir, higa po kayo, may mga gagawin lang po
that the sacroiliac joint is involved
tayong test habang nakahiga po kayo, ha. Okay lang
Leg flexed and the thigh abducted and externally
po ba hawakan yung paa niyo?
rotated. (Figure of 4, depress it) Do it bilaterally (L/R)
STRAIGHT LEG TEST/ LASEGUE TEST
Assess for lumbosacral nerve root irritation May masakit po ba sa may bandang likod? Pwet?
Arms crossed, raise one the leg 60-70° from the table Singit?
to check for shooting pain from the buttocks to the leg

Itataas ko po ang iyong paa. Sabihin niyo po sa akin

if may masakit po sa bandang likod niyo papunta sa
paa niyo.

8

Patient felt groin pain when Patrick test was done,
which indicates he is positive for Patrick test.
OR
Patient is negative for Patrick s test
GAENSLEN S TEST
To test for Hip or Sacroiliac Joint Dysfunction
A positive test occurs if it produces low back pain
Hyperflex hip and dangle opposite leg (at edge of bed)
to do passive hyperextension of same joint
May masakit po ba sa may bandang likod kapag
nilalagyan ng pressure yung paa?
There is pain around the back area when pressure was
applied. Patient is positive for Gaenslen s test.
OR Patient is negative for Gaenslen s test.
THOMAS TEST/ ILIOPSOAS TEST
Used to measure the flexibility of the hip flexors
A positive test occurs if the iliopsoas muscle is
shortened, or a contracture is present, the lower
extremity on the involved side will be unable to fully
extend at the hip.
Patient on supine flexes the hip, and pull knee to chest
Sir, may masakit po ba sa may bandang likod niyo
kapag nilalapit sa dibdib yung paa?
9
Patient is positive for Thomas test due to:
1) Unable to maintain their lower back and sacrum
against the table;
2) Hip has a large posterior tilt or hip extension greater
than 15°;
3) Knee unable to meet more than 80° flexion
There is no erythema, malalignment, deformities,
swelling, lesions, knee dimpling, effusion, bursitis, or
crepitus noted.
There is no warmth, tenderness, thickening or swelling
over the joints.

OR Patient is negative for Thomas test.

3. MEASURE CIRCUMFERENCE
Start measuring from 2 inches above and below
KNEE JOINT
patellar prominence
1. INSPECTION
You don
Patient should be sitting

Inspect for any gross deformities, nodules, visible

lesions, bony abnormalities, malalignment, evidence of
inflammation (erythema, swelling), knee dimpling,
effusion, and bursitis

You don describe if there

The circumference of the patient knee is ____ on
is any evidence of deformities.
the right, and _____ on the left
The knees are symmetrical/asymmetrical

4. RANGE OF MOTION
Patient should be sitting upright

Ma /Sir, pakigaya po ako

FLEXION Bend knee

EXTENSION Straighten knee

2. PALPATION

Assess mobility, tenderness, nodules, thickening of

swelling, warmth, and crepitus.
Patient can do range of motion as to flexion and
Bony landmark extension on both knees without difficulty
-Patella

10
 ANKLE JOINT/FOOT No erythema, swelling, malalignment, deformities,
1. INSPECTION nodules, no callus and corns, no warmth and
You don tenderness, no edema
Patient should be sitting upright
3. RANGE OF MOTION
Look for any evidence of swelling or inflammation, Patient should be sitting upright
gross deformities, nodules, callus and corns, redness,
nail lesions, discoloration of skin/nailbeds,
Ma /Sir, pakigaya po ako
You don describe if there
is any evidence of deformities. Top of your foot points
DORSIFLEXION away from your leg (foot
drop)
PLANTAR FLEXION Foot points upward

INVERSION Tilt sole of the foot inward

Tilt sole of the foot

EVERSION
outward

2. PALPATION
Palpate for crepitus, tenderness, warmth, nodules,
edema (pitting or non-pitting), extent of edema
Patient can do range of motion as to dorsiflexion,
plantarflexion, inversion and eversion on both feet
without difficulty

Bony landmarks:
-Lateral and medial malleolus
- Calcaneus

11
 SUMMARY CERVICAL SPINE
1. WASH HANDS 1. Inspection
2, INTRODUCE AND CONFIRM PATIENT IDENTIFICATION 2. Palpation
3. PURPOSE OF EXAMINATION 3. Range of Motion
-Flexion/Extension
HANDS/FINGERS -Rotation
1. Inspection -Lateral bending
2. Palpation -Bony landmark: C7
3. Range of Motion
-Flexion/Extension THORACOLUMBAR SPINE
-Abduction/Adduction 1. Inspection
-Thumb adduction/abduction 2. Palpation
-Opposition 3. Range of Motion
-Flexion/Extension
WRIST JOINTS -Lateral bending
1. Inspection -Spinal rotation
2. Palpation
3. Range of Motion HIPS
-Dorsiflexion 1. Inspection
-Palmar flexion 2. Palpation
-Medial/Lateral deviation 3. Range of Motion
*Bony Landmark: RADIUS (L) and ULNA (M) -Flexion/Extension
-Abduction/Adduction
FOREARM -Internal/External rotation
1. Inspection 4. Special Test
2. Palpation -Straight leg test (raising leg)
3. Range of Motion -FABER/Patrick test (figure of 4)
-Pronation/Supination -Gaenslen s test (one leg dangling on floor)
-Thomas test (push leg towards chest)
ELBOW
1. Inspection KNEE JOINT
2. Palpation 1. Inspection
3. Measure circumference (2in above and below cubital fossa) 2. Palpation
4. Range of Motion 3. Measure circumference (2in above and below popliteal fossa)
-Flexion/Extension 4. Range of Motion
-Pronation/Supination -Flexion/Extension
*Bony landmark: OLECRANON BURSA, OLECRANON *Bony landmark: PATELLA
PROCESS, LATERAL & MEDIAL EPICONDYLE
ANKLE JOINT/FOOT
UPPER ARM 1. Inspection
1. Inspection 2. Palpation
2. Palpation 3. Range of Motion
*Bony landmark: HUMERUS -Dorsiflexion/Plantar flexion
*Muscles: BICEPS & TRICEPS -Inversion/Eversion
*Bony landmark: LAERAL & MEDIAL MALLEOLUS,
SHOULDER JOINT CALCANEUS
1. Inspection
2. Palpation WHAT TO CHECK DURING INSPECTION?
3. Range of Motion Skin color, gross deformities, swelling, visible lesions,
-Flexion/Extension swelling, nail color, nail lesions, nail bed, bruising, redness,
-Adduction/Abduction inflammation, knee dimpling, effusion, bursitis, corns and
-Internal and External Rotation callus
*Bony landmark: STERNUM, STERNOCLAVICULAR JOINT, WHAT TO CHECK DURING PALPATION?
ACROMION, CORACOID PROCESS, GREATER TUBEROSITY Tenderness, nodules, bony abnormalities, warmth, crepitus,
OF HUMERUS swelling, muscle atrophy/hypertrophy, and muscle tone

12
 OLFU MD2024 | CLINICAL MEDICINE

NEUROLOGIC EXAM
SCRIPT (CHECKLIST-BASED)

GENERAL RULES CALCULATE

1. Wash hands (Show in video) Ask patient a simple equation only
2. Introduce self and check patient identification Next, can you tell me the answer to this equation: 5+5?
ing, po! My name is _______, I nd
year medical Patient shows good judgment and calculation ability
student. I will be the one examining you today. May I know your
name? ORIENTATION
3. Explain the purpose of the examination and obtain consent. 10. What is the complete date today?
I will be conducting a neurological exam to determine your 11. Where are you now?
neurologic function. Would that be okay for you? 12. Who are you? Who am I?
What is the date today? Do you know where you are right now?
CEREBRUM Can you tell me your name? Do you know who I am?
Let s begin. First, I will be assessing your cerebral function. Patient is oriented to person, place, and time
APHASIA
1. Ask patient to repeat spoken phrase/sentence CRANIAL NERVES
Can you repeat the following phrase for me? CN 1 OLFACTORY NERVE
I LOVE CLINICAL MEDICINE 13. Test patency of nostril (patient
covering his nostril)
2. Ask patient to name objects shown 14. Doctor covering nostril of patient
(Three objects completely non-associated letting him smell substance
I will be showing you 3 things. Can you tell me what they are? 15. Identify smell
1. Ballpen 2. Hairbrush 3. Baso * D t use pungent/irritating smell
like alcohol and perfume.
3. Command patient to do something
Can you please get the pen from my hand using your left hand? Now, I want you to close your eyes and cover your nostril using
your finger. Inhale. Now the other nostril. Next, I will let you smell
4. Report if patient has fluent/non-fluent dysarthric, aphonic speech a substance, and I want you to tell me what is it.
The patient is alert, conscious, and coherent The olfactory nerve is intact. The patient is able to identify in both
Speaks fluently and with ease. nostrils the scent of [coffee]
Is able to follow simple commands.
CN 2 OPTIC NERVE
PROSOPAGNOSIA 16. Patient places fine print to read 14
5. Ask patient to name familiar faces inches in front of the eye tested
Next, I d like for you to tell me the name of this person? 17. Cover non-tested eye
The patient was able to recognize the person in the photo.
I want you to cover one eye using
your hand. Now, I will be showing
APRAXIA you a Snellen s chart, I want you to
6. Ask patient to use/manipulate objects read the smallest letters down
Next, I ll be giving you a hairbrush. Can you please demonstrate below if you can.
to me how to use one?
The patient was able to use the object given without any difficulty Optic nerve is intact. Patient has a vision of [20/20], and can read
the smallest letter in the Jaeger s chart at 1 foot distance. Patient
has a normal confrontation test.
MEMORY
7. Immediate memory 18. Do pupillary light testing (Describe
Can you repeat to me the following numbers: 2, 4, 6, 8, 10 size of pupil & reaction to light)

8. Recent memory Now, look straight ahead. I will be

Can you tell me what did we celebrate last November 1? making a shield using my hand
between your eyes. I will then shine
9. Remote memory light on your pupils.
Can you tell me what did we celebrate last December 25, 2020? The pupillary size on both the left and right light reflex is [2-3mm]
and equally reactive to light. The pupillary light reflex is normal.
Patient shows good recall of immediate, recent, and remote
memories

1
 CN 3 - OCULOMOTOR, 4 - TROCHLEAR, AND 6 - ABDUCENS
19. Note if with ptosis or none
20. Monitor eye muscle movement and nystagmus
I want you too look at this penlight and follow its movement using
your eyes only, no head movements.
The motor part of CN7 is intact.
strength is normal and equal bilaterally. The patient can smile,
wrinkle forehead, puff cheeks, and purse lips equally; Patient can
symmetrically close eyes completely.
26. Show to preceptor the solution as test
substance; Show to preceptor a paper list
of possible taste
27. Ask patient to protrude tongue; Place
test solution on one side of the tongue; Ask
patient to point in the list taste of substance
28. Place another solution in other half of
tongue, identify taste (pointing to the list)

Now we will be testing your taste sensation. I want you to close

your eyes and protrude your tongue. I will be putting different
substances on your anterior tongue. After doing so, I want you to
point to me on this piece of paper the taste of the solution.
The sensory part of CN7 is intact. The patient is able to
distinguish different kinds of taste sensation in the anterior 2/3 of
the tongue.

CN 8 VESTIBULO-COCHLEAR
29. Rinne test (N = AC > BC)
Put tuning for on mastoid process, and then in front of ear.

The patient has intact extraocular muscle movement and is

negative for ptosis and nystagmus;
I will conduct what we call a Rinne test.
CN 5 - TRIGEMINAL
I will put this behind your ear and I want
21. Test symmetrical areas of the face for pin prick you to raise your hand if you don t hear
Forehead V1 anything. Now, I will put it beside your
Cheeks V2 ear. Again, raise your hand if you don t
Pre-mandibular area V3 hear anything.

Close your eyes. I will be touching 30. Weber test (N = vibration heard on both ears)
some parts of your face and you Put tuning fork on top of head.
tell me if you can feel the Next is what we call a Weber test. Tell me where you hear the
sensation. Is the sensation equal? vibration most, if left, right, or equal side.
The sensory part of CN5 is intact.
The patient can feel light touch on the lower, middle, and upper Hearing is normal bilaterally. The patient is normal for the Rinne
portion of the face on both sides test and Weber test.

22. Ask patient to open mouth (note for jaw deviation)

CN 9 - GLOSSOPHARYNGEAL AND 10 - VAGUS
Can you open your jaw and fight the
31. Ask patient to speak
resistance of my hand
32. Inquire about presence/absence of
dysphagia (swallowing difficulty)
23. Ask to clench teeth
Can you speak? I want you to drink
Now can you clench your teeth for
this glass of water and tell me if there
me? (Show gigil)
are any difficulty swallowing
The motor part of CN5 is intact. The
33. Note palatal and pharyngeal wall motion
patient can clench teeth and move jaw
34. Note position of uvula
side to side. There is no jaw deviation.
Now I want you to open your mouth so I can assess your uvula.
Say ahhhhh.
CN 7 - FACIAL
Patient is negative for dysarthria and dysphagia; Uvula is in the
24. Wrinkle forehead; close eyes tightly midline and muscles surrounding are moving symmetrically; Patient
25. Smile, puff cheeks, purse lips is negative for hoarseness

Next, can you show me the 35. Do the gag reflex

following: wrinkle your forehead, Now I will assess your gag reflex
close your eyes tightly, smile, puff Patient has normal gag reflex;
cheeks, and purse your lips

2
 CN 11 SPINAL ACCESSORY
36. Ask patient to elevate shoulders; Ask
patient to offer resistance upon head rotation
I need you to raise your shoulders and fight
the resistance as I try to push it down. Next
turn your head to the side and fight the
resistance from my hand, now other side.
The patient is able to shrug his shoulder
against pressure and is able to turn head side
to side against pressure
CN 12 HYPOGLOSSAL
37. Note position of protruded tongue
38. Ask patient to do ROM of tongue
39. Note patient for hemi atrophy/fasciculation of tongue
I need you to stick your tongue out and retract it? Next can you
move it to the left, and right? Next can you put it on your palate
and protrude?
There is negative fasciculation of the tongue. The tongue is
midline on protrusion, with no atrophy or hypertrophy noted. Patient
can do normal range of motion of the tongue.
CEREBELLUM
Next, I will be assessing your cerebellum function.
40. Ask patient to stand from his seat and walk commenting stance
and gait. Note for signs of disequilibrium and difficulty taking a seat
Can you stand up and walk casually from here to there?
41. Ask patient to do tandem gait
Can you walk again as if you re
walking on a tightrope? With one
foot in front of another.
The patient can stand and sit, stand and walk, sustain tandem
erect.
42. Each limb tested for finger to nose
test; arm in full extension; move target
with eyes of patient open
Now, close your eyes. Can you touch
my index finger with your index finger
using your right/left hand? Keep going
back and forth. Same with the other
finger in your other hand
The patient can perform finger to nose test
43. Each limb tested for heel to shin
test: ask patient to elevate one leg and
place heel on opposite knew
45. Do procedure using other leg
Place your right heel on your left
knee and slide it down the front of
your leg, lift it up and put it back on
your knee. Just keep doing that.
Next, for the other side.
Patient can do perform heel to shin test.
MOTOR EXAMINATION
Next will be your motor assessment.
46. Inspect size, note if with fasciculation of limb
47. Passive flexion/extension of 4 limbs for tone
Close eyes
Pronation/supination of arms (Pronator drift)
I m going to inspect first your arms. Can you put it in front of
you? Next, close your eyes and turn your arm over. Keep it still
and your eyes closed. Now, turn your arm over once again.
There are no visible scars. No hypertrophy/atrophy of muscles.
No fasciculations, wasting, or involuntary movements.
Now I m going to assess the tone of your muscles. Let your arms
get floppy or don t put any effort as I hold it.
Patient has good muscle tone. Muscle bulk is normal. No
flaccidity, spasticity, and rigidity of the extremities.
48. Test muscle strength of each limb both proximal and distal parts
with correct MMT grading (check strength against resistance)
UPPER EXTREMITY
49. Adduction/abduction at shoulder joint
50. Flexion/extension at elbow joint
51. Flexion/extension at wrist joint
52. Grip joint
LOWER EXTREMITY
53. Flexion/extension at hip joint
54. Flexion/extension at knee joint
55. Flexion/extension at ankle joint
I will be doing a couple of range of motions, and I want you to
resist it or oppose the action as it happens.
Muscle power is 5/5 bilaterally on both upper and lower
extremities.
3
 SENSORY SYSTEM
Now, we will assess your sensory system.
74. Examine pain sensation in the face (Trigeminal Nerve) Touch
with a pin the forehead, maxilla, and area above the mandible
symmetrically

I will touch areas of your face using a toothpick. Respond to yes

every time you feel the sensation. Is the sensation equal on both
sides?
The patient can feel pain sensation on forehead, maxilla, and
portion above the mandible symmetrically.

75.Touch with a pin the proximal and

distal parts of the limbs symmetrically
(foot, leg, thigh, hand, forearm, arm)
I will test the sensation of your
limbs. Respond to time
you feel the sensation. Is the
Upper Extremity: Biceps & Triceps
sensation equal on both sides?
56. Supports arm while doing reflexes
The patient can feel light touch on proximal and distal parts of the 57. Does biceps on both sides followed by triceps on both sides
limbs symmetrically 58. Grades reflexes correctly
Allow me to support your arm as I test your reflexes on both
76. Examine proprioceptive sense: position
biceps and triceps.
sense. Using the fourth digit of the fingers (R/L)
Reflex of left and right biceps and triceps of patient are both 2 =
and using the big toe (R/L)
normal
I will touch your ring
Lower Extremity:
finger/big toe. Close
Knee Jerk
your eyes, and tell me
59. Palpates depression on the knee; strike knee depression using
which way I m
pointed end of reflex hammer
moving it. Up or
60. Proceeds to do reflex on the opposite leg
down? Now, other
61. Grades reflex correctly
side.
Allow me to support your arm as I test your reflexes on both biceps
and triceps.
Patient s position test is intact.
Sit down properly as I test your reflexes of your knees.
Reflex of left and right knees of patient are both 0 = absent
Can you please stand, feet together with
Ankle
eyes open, then with eyes closed. Hold
62. Properly supports / position ankle; palpates the Achilles tendon;
your position for 30 secs.
strike tendon using blunt end of reflex hammer
63. Proceeds to do reflex on the opposite leg
Patient is negative for Romberg test. 64. Grades reflex correctly
Bend your foot upward (dorsiflex) and relax. I will test your ankle
reflexes on both feet.
Reflex of left and right ankle of patient are both 2 = normal
Babinski Reflex
DEEP TENDON REFLEXES 65. Position of patient
I will be 66. Use of blunt
assessing instrument
your 67. Use of correct
reflexes strength of stimulus
next. 68. Technique of
examination
69. Test both soles
Patient is negative for Babinski reflex

MENINGEAL SIGNS
Last for this neurologic exam is to conduct test for meningeal signs.

4
NUCHAL RIGIDITY
70. Ask patient to lie flat & flexes neck
71. Note tone of neck muscle
I need you to lie down flat on the
sofa and then flex your neck. I will
assess for the tone of your neck
muscle.
Patient is negative for nuchal rigidity

BRUDZINSKI
72. While doing A Mentions (+) Finding of Brudzinski test

Remember:
BrudziNsKi:
Neck flexion
leads to Knee
flexion

Next, what we ll do is the Brudzinski test. While you are lying

down, I will passively flex your neck. And if you involuntarily flex
your hip or knee, it means you are positive for it.
Patient is negative for Brudzinski test

73. Flexion at hip joint / extension at knee joint mentions (+) finding

Remember:
KErnig sign =
Knee Extension
if painful

Lastly, what we Kernig s test. While you are lying down,

I will flex your knee and leg at 90°. And if you feel any pain or
resistance as I lift your knee up, you are positive for this test.
Patient is negative for

And that concludes our neurologic exam. Thank you so much for
your cooperation. *Alcohol*

5
 CEREBRUM
1. Can you repeat the following phrase for me: I LOVE CLINMED
2. I will be showing you 3 things. Can you tell me what they are?
Ballpen, Hairbrush, Baso
3. Can you please get the pen from my hand using your left hand?
The patient is alert, conscious, and coherent
Speaks fluently and with ease.
Is able to follow simple commands.
5. Next, I d like for you to tell me the name of this person?
The patient was able to recognize the person in the photo.
6. Next, I ll be giving you a hairbrush. Can you please demonstrate to me how to
use one?
The patient was able to use the object given without any difficulty
7. Can you repeat to me the following numbers: 2, 4, 6, 8, 10
8. Can you tell me what did we celebrate last November 1?
9. Can you tell me what did we celebrate last December 25, 2020?
Patient shows good recall of immediate, recent, and remote memories
10. Next, can you tell me the answer to this equation: 5+5?
Patient shows good judgment and calculation ability
11. What is the date today? Do you know where you are right now? Can you tell me
your name? Do you know who I am?
Patient is oriented to person, place, and time
CRANIAL NERVES
CN I: Now, I want you to close your eyes and cover your nostril using your finger.
Inhale. Now the other nostril. Next, I will let you smell a substance, and I want you to
tell me what is it.
The olfactory nerve is intact. The patient is able to identify in both nostrils the
scent of coffee
CN II. I want you to cover one eye using your hand. Now, I will be showing you a
can.
Optic nerve is intact. Patient has a vision of [20/20], and can read the smallest
test
Now, look straight ahead. I will be making a shield using my hand between your
eyes. I will then shine light on your pupils.
The pupillary size on both the left and right light reflex is [2-3mm] and equally
reactive to light. The pupillary light reflex is normal.
CN III, IV, VI: I want you to look at this penlight and follow its movement using your
eyes only, no head movements.
The patient has intact extraocular muscle movement and is negative for ptosis
and nystagmus;
CN V: Close your eyes. I will be touching some parts of your face and you tell me if
you can feel the sensation. Is the sensation equal?
The sensory part of CN5 is intact. The patient can feel light touch on the lower,
middle, and upper portion of the face on both sides
Can you open your jaw and fight the resistance of my hand? Now can you clench
your teeth for me? (Show gigil)
The motor part of CN5 is intact. The patient can clench teeth and move jaw side
to side. There is no jaw deviation.
CN VII: Next, can you show me the following: wrinkle your forehead, close your
eyes tightly, smile, puff cheeks, and purse your lips
The motor part of CN7 is intact.
and equal bilaterally. The patient can smile, wrinkle forehead, puff cheeks, and
purse lips equally; Patient can symmetrically close eyes completely.
Now we will be testing your taste sensation. I want you to close your eyes and
protrude your tongue. I will be putting different substances on your anterior
tongue. After doing so, I want you to point to me on this piece of paper the taste of
the solution.
The sensory part of CN7 is intact. The patient is able to distinguish different
kinds of taste sensation in the anterior 2/3 of the tongue.
CN VIII: I will conduct what we call a Rinne test. I will put this behind your ear and I
want you to raise your hand if you don t hear anything. Now, I will put it beside your
ear. Again, raise your hand if you don t hear anything.
Next is what we call a Weber test. Tell me where you hear the vibration most, if left,
right, or equal side.
Hearing is normal bilaterally. The patient is normal for the Rinne test and Weber
test.
CN IX and X: Can you speak? I want you to drink this glass of water and tell me if
there are any difficulty swallowing. Now I want you to open your mouth so I can
assess your uvula. Say ahhhhh.
Patient is negative for dysarthria and dysphagia; Uvula is in the midline and
muscles surrounding are moving symmetrically; Patient is negative for hoarseness
CN XI: Now I will assess your gag reflex
Patient has normal gag reflex;
CN XII: I need you to raise your shoulders and fight the resistance as I try to push it
down. Next turn your head to the side and fight the resistance from my hand, now
other side.
The patient is able to shrug his shoulder against pressure and is able to turn
head side to side against pressure
CN XIII: I need you to stick your tongue out and retract it? Next can you move it to
the left, and right? Next can you put it on your palate and protrude?
There is negative fasciculation of the tongue. The tongue is midline on
protrusion, with no atrophy or hypertrophy noted. Patient can do normal range of
motion of the tongue.
CEREBELLUM
Next, I will be assessing your cerebellum function. Can you stand up and walk
casually from here to there? Can you walk again as if you re walking on a
tightrope? With one foot in front of another.
The patient can stand and sit, stand and walk, sustain tandem walking all
Now, close your eyes. Can you touch my index finger with your index finger using
your right/left hand? Keep going back and forth. Same with the other finger in your
other hand
The patient can perform finger to nose test
Place your right heel on your left knee and slide it down the front of your leg, lift it
up and put it back on your knee. Just keep doing that. Next, for the other side.
Patient can do perform heel to shin test.
MOTOR
Next will be your motor assessment. I m going to inspect first your arms. Can you
put it in front of you? Next, close your eyes and turn your arm over. Keep it still and
your eyes closed. Now, turn your arm over once again.
There are no visible scars. No hypertrophy/atrophy of muscles. No
fasciculations, wasting, or involuntary movements.
Now I m going to assess the tone of your muscles. Let your arms get floppy or
don t put any effort as I hold it.
Patient has good muscle tone. Muscle bulk is normal. No flaccidity, spasticity,
and rigidity of the extremities.
I will be doing a couple of range of motions, and I want you to resist it or oppose
the action as it happens.
Muscle power is 5/5 bilaterally on both upper and lower extremities.
SENSORY
Now, we will assess your sensory system. I will touch areas of your face using a
toothpick. Respond to yes every time you feel the sensation. Is the sensation
equal on both sides?
The patient can feel pain sensation on forehead, maxilla, and portion above the
mandible symmetrically
I will test the sensation of your limbs. Respond to time you feel the
sensation. Is the sensation equal on both sides?
The patient can feel light touch on proximal and distal parts of the limbs
symmetrically
I will touch your ring finger/big toe. Close your eyes, and tell me which way I m
moving it. Up or down? Now, other side.
Patient s position test is intact.
Can you please stand, feet together with eyes open, then with eyes closed. Hold
your position for 30 secs.
Patient is negative for Romberg test.
DEEP TENDON REFLEXES
I will be assessing your reflexes next. Allow me to support your arm as I test your
reflexes on both biceps and triceps.
Reflex of left and right biceps and triceps of patient are both 2 = normal
Sit down properly as I test your reflexes of your knees.
Reflex of left and right knees of patient are both 0 = absent
Bend your foot upward (dorsiflex) and relax. I will test your ankle reflexes on both
feet.
Reflex of left and right ankle of patient are both 2 = normal
Next is the Babinski test.
Patient is negative for Babinski test
MENINGEAL SIGNS
Last for this neurologic exam is to conduct test for meningeal signs.
I need you to lie down flat on the sofa and then flex your neck. I will assess for the
tone of your neck muscle.
Patient is negative for nuchal rigidity
Next, what we ll do is the Brudzinski test. While you are lying down, I will passively
flex your neck. And if you involuntarily flex your hip or knee, it means you are
positive for it.
Patient is negative for Brudzinski test
Lastly, what we Kernig s test. While you are lying down, I will flex your
knee and leg at 90°. And if you feel any pain or resistance as I lift your knee up, you
are positive for this test.
Patient is negative for
And that concludes our neurologic exam. Thank you so much for your cooperation.
*Alcohol*
6
 RESPIRATION
CHEST AND LUNGS RATE strictly 1 full minute
INTERVIEW: General Rules I:E RATIO (Inspiratory to Expiratory Ratio)
WASH HANDS BEFORE TOUCHING THE PATIENT RHYTHM
INTRODUCE SELF AND CHECK THE IDENTITY OF THE PATIENT LAGGING
MIDLINE BEHIND THE SUPRASTERNAL NOTCH RETRACTIONS
PATIENT. INTERCOSTAL SPACE RETRACTIONS
nd
____________, a 2 year SUBCOSTAL RETRACTIONS
» The respiratory rate is ___ cpm with adequate
EXPLAIN THE PURPOSE AND OBTAIN CONSENT depth and regular rhythm
I will be your student Doctor for today who will » Inspiratory phase is longer than expiratory
examine your Chest and Lungs to check if there are phase without lagging
any abnormalities. » No abnormal retractions in the suprasternal
Is that okay for you? notch, intercostal and subcostal area
» There is no visible contraction of accessory
PREPARE THE PATIENT AS TO POSITION AND EXPOSURE
ASK THE PATIENT TO REMOVE HIS SHIRT muscles of respiration
Sternocleidomastoid
Scalene Anterior, Medius, Posterior
What is your name?
Pectoralis major and minor

INSPECTION
PALPATION
SKIN:
PALPATE BOTH ANTERIOR AND POSTERIOR CHEST WALL FOR:
COLOR
TENDERNESS Ask the patient kung may masakit ba
SCAR
DIAPHORESIS
VISIBLE SUBCUTANEOUS BLOOD VESSELS
MASS
MASS AND OTHER SKIN LESION(S)
CREPITATIONS (SUBCUTANEOUS EMPHYSEMA)
MUSCLE DEVELOPMENT
» Upon palpation of the anterior, lateral and
» BROWN/FAIR in color
» No visible scars noted
» No tenderness
» No subcutaneous blood vessels noted
» No diaphoresis
» No mass, no lesions seen
» No masses felt on the skin, muscle, ribs, scapula
» And with good muscle development
and spine
» No palpable crepitation noted
CHEST WALL
SHAPE
REQUEST PATIENT TO CROSS ARMS ON HIS CHEST FOR
SYMMETRY
POSTERIOR WALL EXAMINATION
RIBS ANGLE
IDENTIFY THE RIBS AND INTERCOSTAL SPACE ANTERIORLY
INTERCOSTAL SPACE RETRACTION / BULGING
AND POSTERIORLY
INTERCOSTAL SPACE NARROWING / WIDENING
» Bony thorax is elliptical in shape
TACTILE FREMITUS TRES-
» It is symmetrical with no bony deformities
INSTRUCT TO PATIENT ON HOW TO CREATE FREMITUS
» Anteriorposterior (AP) Diameter to Transverse
ANTERIOR CHEST WALLS CORRECT AREAS FOR
Diameter is 1/3
FREMITUS DETECTION
» No abnormal retractions or bulging of the
intercostal spaces
» No narrowing or widening of the intercostal
spaces
 POSTERIOR CHEST WALLS CORRECT AREAS FOR
FREMITUS DETECTION

PERCUSSION
CORRECT TECHNIQUE OF PLACING HANDS

»
There is remarkably equal tactile fremitus on all
the lung fields
Spoken words are normal and equally felt
I MCL

LAGGING
ANTERIOR CHEST WALLS
PROPER INSTRUCTIONS TO PATIENT
CORRECT PLACEMENT OF THE PLEXIMETER ALONG THE
INTERCOSTAL SPACES
Then watch the distance between your thumbs
as they move apart during inspiration, and feel
PLEXOR STRIKE THE DISTAL INTERPHALENGEAL JOINTS
for the range of symmetry of the rib cage as it
PERCURSS ALL AREAS NEEDED TO BE PERCUSSED
expands.
INCLUDING THE SUPRACLAVICULAR FOSSA
PROPER PLACEMENT OF HANDS:
th COMPARING IDENTICAL LEVELS OF THE RIGHT AND LEFT
Place your thumbs at about the level of 10
CHEST WALLS
ribs, with your fingers loosely grasping and
parallel to the rib cage » Upon percussion, the thorax is resonant in all
lung fields except on the:
ANTERIOR CHEST WALLS th
3-5 Left Intercostal Space (LICS) location
POSTERIOR CHEST WALLS of the heart and to
th
» Chest expansion is symmetrical without lagging 7 Right Intercostal Space (RICS)
Midclavicular Line (MCL)
 AUSCULTATION
USE THE DIAPHRAGM OF THE STETHOSCOPE IN
AUSCULATIONS
Bell for area 1 --- 1

POSTERIOR CHEST WALLS

REQUEST PATIENT TO CROSS ARMS ON HIS CHEST FOR
EXAMINATION OF POSTERIOR CHEST WALLS
SAME PROCEDURE TO ANTERIOR CHEST WALLS
ANTERIOR CHEST WALLS
» Resonant on all lung fields
AUSCULTATED ALL AREAS NEEDED TO BE EXAMINED
INCLUDING THE SUPRACLAVICULAR FOSSA
AT EACH AREA OF EXAMINATION LISTEN TO BOTH PHASE
OF RESPIRATION
COMPARING IDENTICAL LEVELS OF THE RIGHT AND LEFT
CHEST WALLS
REPORT AUSCULATION FINDINGS
BREATH SOUNDS HEARD Ask patient to breath
INTENSITY BREATH SOUNDS
VOCAL FREMITUS
BRONCHOPHONY
WHISPER PECTORILOQUY
EGOPHONY

POSTERIOR CHEST WALLS

REQUEST PATIENT TO CROSS ARMS ON HIS CHEST FOR
EXAMTION OF POSTERIOR CHEST WALLS
SAME PROCEDURE TO ANTERIOR CHEST WALLS

» Breaths sounds are vesicular in all lung fields,

st nd
except in 1 and 2 intercostal space (IC) and in
between scapulae posteriorly
» Negative for ADVENTITIOUS BREATH SOUNDS,
such as:
» Crackles
» Wheezes
» Rhonchi and
» Friction rub
» SOUNDS ARE MUFFLED AND INDISTINCT Tres tres-

Negative for
With equal vocal fremitus
» SOUNDS ARE INDISTINCT AND CANNOT BE
HEARD CLEARLY
Negative for WHISPHERED

» SOUNDS ARE MUFFLED

Negative for
 HEENT SCRIPT MD2024

INTRODUCTION

• Wash hands before touching
the patient (Alcohol can be
used)
• Introduce yourself and check
the identification of the patient.
• Explain the purpose of the
examination and obtain consent
(Clean your hands with alcohol or wash hands)
“Good morning po. I am _____________, a 2nd year medical student. I’ll be doing your
HEENT examination today. May I know your name?”
“Don’t hesitate to tell me if you feel uncomfortable during the examination. Start na po
tayo?”

HEAD

Inspection
(Use a PENLIGHT for the INSPECTION — can separate hair in some areas to expose the
• Observe head position
scalp to check for lesions and scales)
• Inspect the skull for size,
shape, symmetry
“The head is midline in position with no abnormal head movement. The skull is normocephalic,
• Inspect the scalp for lesions,
oval in shape and symmetrical. There are no visible lesions, scales, and deformities. The hair is
scales
black, well distributed, abundant, and thick.
• Hair for color, distribution or
hair pattern
(Warm the hands for palpation; Palpate for the TEMPORAL ARTERY)
Palpation
“Palpate ko lang po scalp nyo. Sabihin nyo po if masakit”
• Palpate the scalp for
tenderness, swelling,
“There is no tenderness, swelling, abnormal prominence, and depression. The hair is smooth
abnormal prominence,
and dry. The temporal artery are NOT VISIBLE BUT PALPABLE with STRONG/WEAK
depression
palpation.”
• Palpate the hair for texture

FACE

• Color, shape, symmetry (Use a PENLIGHT for the INSPECTION!! Wag itatapat sa eyes please)
• Lesions, edema, abnormal
facial movements “The face is brown in color, round/oblong/heart shaped, and symmetrical. There are no lesions,
edema, hypo pigmentation and hyperpigmentation.”
“Can you please smile then frown?”
“There are no abnormal facial movements and expression.”

EYES

Inspection
• Symmetry or alignment of the
eyes
• Eyebrows: for texture, loss
extraordinary, growth of hair,
seborrhea
• Eyelashes: normally curves
outward, note for matting any
infection occurring in the
glands around the eyelash
hair follicle (stye)
• Eyelids: note for swelling,
redness, ptosis
• Conjunctiva & sclera: color
and vascularity
• Cornea & lens: transparency,
opacity
• Iris: color, markings, shape
• Pupils: size, shape, equality
• Reaction to light — direct &
consensual
Reaction to distance —
accommodation
!!! SHINE THE LIGHT AT THE SIDE WHEN USING A PENLIGHT. AUTOMATIC 0 IF YOU
SHINE DIRECTLY INTO THE PATIENT’S EYES !!!
(Use a PENLIGHT for eyes, eyebrows, eyelashes) “Eyes are symmetrical. Eyebrows are black,
fine in texture, negative in extra growth, no loss, no seborrhea, and well distributed. Eyelashes
are black, short/long, present in upper and lower eyelids. It curves outward. No style. Eyelids
are slightly brown, no welling, redness and ptosis. No abnormal lid movements.”
(Hold the lower lid of the patient and have the patient look up and vice versa) “Tingin po kayo
sa taas.” (The hold the upper lid and as the patient to look down) “Then sa baba”
“The palpebral conjunctiva and bulbar conjunctiva is pink in color, no swelling or hematoma.
The sclera is while in color, well vascularized, no lesions.”
(Use a PENLIGHT) “Both cornea and lens are clear and transparent. Negative for opacities.
Both irises is brown, circular, well demarcated. Both pupils are equal to 2-3mm, round in shape,
symmetrical, and equal”
(Use PENLIGHT. Cover the midline. Shine from temporal or at the side or at the bottom)
“Pakilagay lang po yung kamay dito.” (Place their hand at the middle of the face)
“Positive for direct and consensual reaction to light”
(Show penlight at arm’s length and bring object closer to patient) “Follow the penlight w your
eyes) “There is convergence of the eyeballs. Positive for accommodation reflex.”

!"

Visual Acuity
• Near vision (Jaeger)
Fundoscopic Exam
• Te c h n i q u e / U s e o f
ophthalmoscope
• Proper positioning of the
patient
• Inspect the presence of red
orange reflex
External Ear
• Inspect the size, symmetry,
lesion, nodules, deformities
• Palpate the mastoid process
using the index & middle
fingers
• P re s s t h e t r a g u s i n w a rd
towards the ear canal using
the index & middle ear
• External auditory canal:
discharge, foreign body
• Otoscopic examination:
proper technique of handling
the instrument procedure
• Tympanic membrane: color,
intact
• Tuning fork test: either
Weber or Rinne’s test
• Inspect & palpate the nose:
appearance, discharge, flaring
of ala nasi
• Evaluate the latency of the
nostril one at a time
!"
HEENT SCRIPT MD2024
(Have the patient cover the eye w the palm and read the jaeger chart. ONE EYE AT A TIME)
“Pakicover na lang po ng kanang/kaliwang mata. Pakibasa po dito”
“The patient can read the smallest written text”
(Have the patient look straight. Examiner should be standing 15 inches away from patient, 5
degrees at the side of the patient. Eye should be at the spotlight. For examining the right
eye, hold the opthalmoscope with a right hand and use the right eye to examine. VICE
VERSA) ”Tingin lang po kayo sa pader. Relax lang po”
“Positive for red orange reflex”
EARS
(Use a PENLIGHT) “Both ears are C-shaped and symmetrical. No lesions, nodules, deformities
seen. External auditory canal is patent, walls pinkish in color, no discharge and no foreign
bodies”
(Palpate mastoid process & press tragus inward towards the ear with index & middle finger)
”Masakit po ba?” → “Negative for mastoid and tragus tenderness"
(Hold the otoscope with the examining hand like a pen and extend the middle finger to anchor
on anterior ear. The thumb and index finger of the other hand should pull the concha upwards
and backwards with the 3 fingers on the head) ”Sisilipin ko lang po yung tenga nyo”
“Typanic membrane is pearly white in color with good cone of light, no bulging, no retraction,
no perforation”
(WEBER’S TEST → flick the tips of the tuning fork, place at the midline of the head
Normal finding: equal na ring or walang naririnig.
Negative “lateralization of the vibration” → baka may ossification o may foreign body
“May naririnig po ba kayo sa parching tenga?”
“The patient heard the vibration equally in both ears. No lateralization.”
(RINNE’S TEST → stimulate the tuning fork, place the base on the mastoid until the patient
can’t feel the vibration anymore, place it near the ear until wala na marring ang patient
AC > BC: if naririnig ni patient after matzos dun sa mastoid process)
“Sabihin nyo po pag wala nang vibration” … “Sabihin nyo po if wala na kayong naririnig.”
“Air conduction if greater than bone conduction
NOSE
(Use a PENLIGHT) “The nose is triangular in shape, symmetrical/asymmetrical, and blunt. No
discharge and flaring of ala nasi”
(Have them close one of the nostrils then place a tissue under the opened nostril)
“Pakitakpan po ang kanang plong then hinge kayo. Kabila naman po”
“The nose is patent, no secretions, no bleeding, no obstruction”
 HEENT SCRIPT MD2024

• Note nasal septum position:
deviation on perforation
• Inspect nasal mucosa: color,
discharge, inflammation
• Paranasal sinuses (Frontal &
Maxillary): inspect & palpate /
Tranillumination test
(Hold the PENLIGHT with the right hand — thumb at the tip of the nose and 4 fingers at
the forehead. Have the patient tilt their head backwards)
“Titingnan ko lang po yung ilong nyo.”
“Nasal septum is straight at the midline and no perforation. The nasal mucosa is pinkish. No
discharge and inflammation”
(Palpate the frontal and maxillary sinuses)

(Use a PENLIGHT. Don’t turn it on until it’s on the patient’s skin.)

FRONTAL SINUS → place the penlight underneath the eyebrow on the medial side,
pointing towards the forehead
MAXILLARY SINUS → place the penlight under the cheekbone, have patient open their
mouth, look at the soft palate)
“No tenderness upon palpation. No clouding of the paranasal sinuses upon transillumination
test”

ORAL CAVITY

• L i p s : c o l o r, m o i s t u r e ,
symmetry, lesions
• Buccal mucosa & gums:
(Use a PENLIGHT) “Lips are pink, dry/moist, symmetrical, with no lesion.”
color, moisture & lesions
• Teeth: # of teeth present or
(Have patient open their mouth. Look with penlight and tongue depressor) “Pakibukas po
missing, color, caries
ang bunganga” → ”Buccal mucosa and gums are pinkish, moist, with no lesion. Teeth are
• To n g u e : s i z e , p o s i t i o n ,
yellowish with a complete set”
tremors, coating, lesions
• Floor of the mouth, soft
(Have the patient move the tongue up and down, left and right. Still with PENLIGHT)
palate & hard palate: bony
“Paki-move naman po nung tongue nyo up and down tapos left and right”
p ro t u b e r a n c e , m a s s e s &
”Tongue is pinkish in color, in midline position upon protrusion and retraction, can move with
lesions
no difficulty. No tremors, no coating, no lesions noted. The hard and soft palate is pinkish, no
• Uvula: position
masses, lesions and bony protuberance.”
• To n s i l s : t e c h n i q u e o f
exposure, size, color, any
“Say ‘ah’” → ”Uvula is midline. Tonsils and pharynx are adequate in size and pinkish, no
inflammation, exudates
enlargement, no inflammation and exudates.”
• Pharynx: technique of
exposure, mucosa, any
inflammation exudates, color

NECK

• Evaluate range of motion (Hold the patient’s shoulder)

RANGE OF MOTION: Flexion, Extension, Lateral bending, Lateral rotation
“Tungo po kayo, tingala, bend sa kanan, bend sa kaliwa, tingin sa kanan, tingin sa kaliwa”
”No deviation of movement. Intact range of motion without any difficulties”

!"
 HEENT SCRIPT MD2024

• Lymph nodes: technique & “I’ll just palpate your neck"

completeness of examination, (Palpate using index and middle finger. Stand behind the patient. Palpate the 10 lymph
describe size, consistence, nodes and mention them)
tenderness if enlarge nodes ✓ Periauricular
are found ✓ Posterior auricular
• Thyroid gland: technique of ✓ Occipital
exam, describe size, ✓ Jugulodigastric
consistency, tenderness if ✓ Superficial cervical
palpable ✓ Deep cervical chain
• Trachea: position ✓ Posterior cervical
✓ Supraclavicular
✓ Submandibular
✓ Submental → Left hand on top of the head, other hand at the submittal lymph node

”Negative for lymphadenopathies”

(Still standing behind the patient, palpate the sides and for the thyroid)
“Tingala po kayo tapos lunok po”
“Thyroid gland moves with deglutition. It is soft, palpable with no tenderness and
enlargement”

(Move to the front of the patient. Place the finger along the sides of the trachea and note
the space between it and the sternomastoid. Compare with the other side.)
“Trachea is in the midline

!"
 OLFU MD2024 | CLINICAL MEDICINE 1st Sem

GENERAL SURVEY, VITAL SIGNS, AND SKIN

20 September 2021 | Dr. Eristotel Paulino
th
edition

A. GENERAL SURVEY 3. LEVEL OF COMFORT / PREFERRED POSITION OF PATIENT

appearance description Position of patient that gives him most comfort or relief
Observation of the patient begins with the first moments of your
interaction Example:
Done systematically from head to toe, front to back, from side to COPD Sit up and lean forward (tripod position)
side, from proximal to distal parts of the body Orthopnea Sitting position
Manner is subtle so as not to intimidate Platypnea Prefer supine position
Trepopnea Lying on one side (down with the good lung)
B. GENERAL APPEARANCE TOF Squatting position
1. APPARENT STATE OF HEALTH Pancreatitis Doubles up or fetal position
Try to make a general judgment based on observations throughout
the encounter. Support it with significant details. 4. LEVEL OF CONSCIOUSNESS
Reflects . Is determined
Is the patient acutely or chronically ill, frail, or fit and robust? by the level of activity that the patient can be aroused to perform in
Are his looks appropriate for his age? response to escalating stimuli from the examiner.

2. FACIES Is the patient awake, alert, and responsive to you and other in the
Distinctive facial expression or appearance associated with a environment? If not, promptly assess the level of consciousness
specific medical condition
Awake, opens eyes
Are there characteristic facies? Looks at you
Examples: Responds fully & appropriately to
ALERTNESS stimuli and command
Arousal intact
Speak to the patient in a normal tone of
Stare of hyperthyroidism voice

Appears drowsy but open eyes and

looks at you
Respond to questions
LETHARGY Follows command
Falls asleep
The flat or sad affect of o If this happens, speak to the
myxedema patient in a loud voice

Opens eyes & looks at you

Responds slowly
Somewhat confused
OBTUNDATION Alertness & interest in the environment
Puffy face with loss of are decreased
eyebrows in o Shake the patient as if awakening
hypothyroidism a sleeper

Arouses from sleep only after a painful

stimulus
Verbal responses are slow or even
absent
syndrome Patient lapses into an unresponsive
STUPOROUS state when the stimulus ceases
If there is minimal awareness of self or
environment, apply a painful stimulus:
o Rub your knuckles over sternum
o Pinch a tendon
palsy o Push the nail cuticle

1
 Asleep 5. DRESS, GROOMING, & PERSONAL HYGIENE
Remains unarousable with eyes closed Appropriateness is the standard.
COMATOSE/
o If there is no evident response to
UNCONSCIOUS
any painful stimuli, apply repeated How is the patient dressed? Is Excess clothing may reflect
painful stimuli the clothing suitable for the the cold intolerance of
temperature and weather? Is it hypothyroidism, hide skin rash
GLASGOW COMA SCALE clean and appropriate to the or needle marks, mask
setting? anorexia, or signal personal
MOTOR RESPONSE (6) lifestyle preferences
6 Obeys Holes or slippers suggest
5 Localizes gout, bunions, edema, or other
4 Withdraws shoes. Are
painful foot conditions. Run-
there cut-outs or holes? Are
3 Decorticate down shoes can contribute to
the shoes run-down?
2 Decerebrate foot and back pain, calluses,
1 None falls, and infection
Copper bracelets suggest
Is the patient wearing unusual
VERBAL RESPONSE (5) joint pain. Tattoos and
jewelries? Are there body
5 Oriented piercings can be associated
piercings?
4 Confused with alcohol and drug use
3 Inappropriate Words
2 Incomprehensible Sounds fingernails, use of cosmetics.
polish suggest the length of a
1 None possible illness. Bitten
personality, mood, lifestyle,
fingernails may reflect stress
EYE OPENING (4) and self-regard
4 Spontaneous Do personal hygiene and
Neglected appearance may
grooming seem appropriate to
3 To speech appear in depression and
2 To pain dementia, but should be
occupation, and
1 None
socioeconomic group?
GLASGOW COMA SCALE GCS (M_V_E)
6. ODORS OF BODY AND BREATH
14-15 Fully awake
11-13 Lethargy Odors can be important diagnostic clues, like the fruity odor of
6-10 Stuporous diabetes or the scent of alcohol.
4-5 Semi comatose
Example:
3 Comatose
DKA Acetone or fruity odor
Uremia Ammoniacal fish breath
Liver failure Musty odor or rotten egg
Tuberculosis Stale beer
Bronchiectasis Bad breath
Dental cavities/ Gum disease Bad breath
Nasopharyngeal CA Foul smelling breath
Melena Fishy foul smelling
Anaerobic infection Fecal odor

7. FACIAL EXPRESSION
Observe the facial expression at rest, during conversation and social
interactions, and during the physical examination

Watch for eye contact:

o Normal o Unblinking o Averted quickly
o Sustained o Absent

8. POSTURE, GAIT, AND MOTOR ACTIVITY

posture?
Is patient restless or quiet?
Patients often prefer sitting
upright in left-sided heart
failure and leaning forward
with arms braced in chronic
obstructive pulmonary
disease.
Anxious patients appear
agitated and restless.
Patients in pain often avoid
movement.

2
 Is there apparent involuntary Look for tremors, other
motor activity? Are some body involuntary movements, or
parts immobile? Which ones? paralysis
Does the patient walk smoothly,
with comfort, self-confidence,
An impaired gait increases
and balance, or is there a limp,
risk of falls.
fear of falling, loss of balance, or
any movement disorder?

ABNORMAL POSTURES

DECORTICATE RIGIDITY

Ambulation Device: Walk with support, by wheelchair or stretcher

Abnormal flexor response
Upper arms are flexed
tight to the sides with
elbows, wrists, and fingers
flexed
Legs are extended and
internally rotated
Examples: Feet are plantar flexed
Implies that a destructive
Fast and frequent lesion of the corticospinal
Hyperthyroidism
movement tracts within or very near
Slowed activity Hypothyroidism the cerebra hemispheres
Leaning forward with
COPD
arms braced
Sitting up Heart failure

GAIT ABNORMALITIES Abnormal extensor

DECEREBRATE RIGIDITY response
Jaws are clenched and
Spinal cord disease with lower extremities
neck extended
SCISSORS spasticity
Arms are adducted and
GAIT Gait is stiff, patient advanced his legs slowly,
stiffly extended at the
and thigh tend to cross forward on each
elbows, with forearms
other every step. Steps are short
pronated, wrists & fingers
Basal ganglia defects of Parkinson disease flexed
Posture is stopped with flexion of head, Legs are stiffly extended
arms, hips, and knees at the knees, within the
PARKINSON Slow in getting started feet plantar flexed
GAIT Steps are short and shuffling with involuntary This posture may occur
hastening (festination) spontaneously or in
Arms swings are decreased and patient turn response to stimuli as:
light, noise, or pain
Postural control is poor Due to lesions in midbrain,
Seen in foot drop, usually secondary to pons, diencephalon,
peripheral motor unit disease severe
STEPPAGE Drag the feet or lift them high, with knees hypoxia/hypoglycemia
GAIT flexed and bring down with a slap onto the
floor, appearing as if walking up stairs
Cannot walk on their heels TREMORS AND INVOLUNTARY MOVEMENTS
Tibialis anterior and toe extensors are weak Tremors are rhythmic oscillatory movements
Seen in disease of the cerebellum
CEREBELLAR Tremors are prominent at rest
Gait is staggering, unsteady and wide based
ATAXIA With exaggerated difficulty on turns RESTING TREMORS Disappear or decrease with
He cannot stand steadily with feet together (Static) voluntary movements
Example: Parkinsonism
POSTURAL TREMORS Appears when the affected part is
(Action) actively maintaining a posture

3
 May worsen somewhat with Quantity = Talkative or silent
intention Rate = Speech fast or slow
Example: Hyperthyroidism (fine and Loudness = speech loud or soft
rapid tremor), Anxiety, and Fatigue Fluency
Absent at rest
Appear with activity ABNORMALITIES OF SPEECH
Often get worse as the target is Loss of voice
INTENTION TREMORS neared APHONIA Due to diseases affecting
Due to disorders of cerebellar the larynx or its nerve supply
pathways Less severe impairment in
Example: Multiple Sclerosis volume, quality or pitch of
voice
ORAL-FASCIAL DYSKINESIAS May be hoarse or only speak
Rhythmic, repetitive, bizarre movements that involve the face, in whisper
DYSPHONIA
mouth, jaw, & tongue Due to:
Grimacing, pursing lips, protrusions of tongue, opening & closing o Laryngitis
the mouth, deviations of jaw o Laryngeal tumors
The trunk and limbs are less often involved occur in longstanding o Vocal cord paralysis
psychosis (CNX)
Tardive Dyskinesias: Due to late complications of psychotropic Defect in the muscular
drugs as phenothiazines control of the speech
apparatus: lips, tongue,
TICS palate, pharynx
Brief repetitive, stereotyped, coordinated movements occurring Words may be nasal, slurred,
at irregular intervals as: indistinct
Repetitive winking, grimacing, shoulder shrugging DYSARTHRIA Central symbolic aspect of
Due to: language is intact
o Due to:
o Phenothiazines o Motor lesions of CNS
o Amphetamines and PNS
o Parkinsonism
o Cerebellar disease
ATHETOSIS
APHASIA
Slower & more twisting and writhing than chorea Disorder in producing or
Larger amplitude understanding language
Aphasia
Most commonly involve the face, and distal extremities Due to lesions in dominant
Often associated w/ spasticity hemisphere
c. Global Aphasia
Due to: Cerebral palsy
Word comprehension is fair to good
DYSTONIA Impaired speech flow, non-fluent
Similar to athetoid movements Telegraphic speech, omission of key words,
Often involve larger portions of the body including the trunk laborious effort
Grotesque, twisted postures may result Aphasia Inflection & articulation are impaired, but
Due to: (Expressive) words are meaningful
o Spasmodic torticollis Reading comprehension is intact
o Phenothiazines Writing is impaired
o Primary torsion dystonia Lesion on post inferior frontal lobe
Can hear words but cannot relate them to
CHOREA previous experiences
Brief, rapid, jerky, irregular and unpredictable Fluent speech, often rapid, and effortless
Occur at rest or interrupt normal coordinated movements Articulation is good but sentences lack
Seldom repeat themselves (unlike Tics) meaning and words are malformed
Aphasia
Often involve the face, head, lower arms, & hands (paraphasia) or invented (neologisms)
(Receptive)
Due to: Speech may be totally incomprehensible
o Reading comprehension is impaired
o Writing is impaired
Lesions on post superior temporal lobe
Word comprehension is absent or reduced
9. SPEECH AND LANGUAGE
GLOBAL
E skills both receptive and APHASIA Spontaneous speech absent or reduced to
expressive (Expressive only few words or sounds
Voice quality = volume, quality, pitch & Receptive) Reading comprehension is severely impaired
Articulation = evaluate spontaneous speech for pronunciation & Writing is severely impaired
ease of expression:
o Imprecise pronunciation of consonants
o Slurring, repetition, stuttering 10. MOODS AND AFFECT
o Difficulty articulating, hesitations Assess during the interview

4
 Sadness, deep melancholy, contentment, joy, euphoria, elation, Arrythmia
anger, rage, anxiety, worry, detachment, indifference. Bradypnea/tachypnea
Affect maybe broad, restricted, labile, blunted, flat or animated Hypernea
Cyanosis
11. DEVELOPMENT Signs of use of accessory
Note the general body proportions and look for any deformities. muscle of respiration:
RESPIRATORY DISTRESS
retractions of intercostals,
Body built suprasternal,
Unusual short or tall supraclavicular, subcostal
Slender or lanky, muscular or stocky Flaring of ala nasi
Is the body symmetrical? Abnormal breathing
Sexual development Wincing, sweating,
Body habitus are called somatotypes protectiveness of painful
o Sthenic, hypersthenic, hyposthenic PAIN area; facial grimacing;
o Mesomorph, ectomorph, endomorph unusual posture favoring
one limb or body area

RESPIRATORY DEPTH
Deep and rapid respiration
that occurs normally after
HYPERPNEA
exercise or abnormally with
fever or various disorders
HYPERVENTILATION Rapid and deep breathing
Breathing is too slow and
12. NUTRITIONAL STATUS HYPOVENTILATION shallow to meet the needs of
Thin, overweight, obese the body
BMI = body weight (kg) / height (m2) Abnormally slow and
HYPOPNEA
shallow breathing
CLASSIFICATION OF BMI
Underweight <18.5 NORMAL BREATHING: The respiratory rate is about 14-20 per min
Normal 18.5 24.9 kg/m2 in normal adults and up to 44 per min in infants.
Overweight 25-29.9
Obesity I 30-34.9
Obesity II 35-39.9
Extreme Obesity III 40<

13. AMBULATION ABNORMAL BREATHING

Must be noted upon entry into the ER or consultation room Slow breathing < 16/min
Ambulation with assistance with different mobility equipment Causes:
device is seen in patient with problems with balance or walking o Diabetic coma
Wheelchair borne patients are usually those with easy fatigability BRADYPNEA o Respiratory muscle
Acutely patients are usually stretcher-borne fatigue
o Drug induced
14. FEBRILE/AFEBRILE o Increased ICP
Febrile: Body temperature greater than 38.0 °C 24 h before or Rapid breathing > 20 / min
after the seizures Can be shallow as:
Afebrile: Those having a body temperature less than 38.0 °C 24 h o Restrictive lung
before and after the seizures. disease
o Pleuritic chest pain
o Pathology on/below
15. SKIN COLOR AND LESIONS
diaphragm
Inspect for any changes in skin color, scars, plaques, or nevi. TACHYPNEA Can also be rapid deep:
o Anxiety
Generalized: o After exertion
o Jaundice o Metabolic acidosis
o Pallor o CVD
o Edema o Hypoxia
o Skin lesions o Hypoglycemia
o Hyperventilation
16. SIGNS OF DISTRESS APNEA Periods of no breathing
Signs of cardiac/respiratory distress: Clutching the chest, pallor, Rapid deep breathing
diaphoresis; labored breathing, wheezing, cough Tachypnea & hyperpnea
KAUSSMAUL BREATHING
Air hunger
Causes: Metabolic acidosis
High/low BP Breathing punctuated by
CARDIAC DISTRESS SIGHING RESPIRATION
Tachycardia/bradycardia frequent sighs

5
 If occasional it may be
normal
Due to: hyperventilation
syndrome
Prolonged expiration
Narrow airways increase
OBSTRUCTIVE BREATHING
resistance to airflow
Cause: Asthma, COPD
Periods of deep and fast
breathing, then become
shallow and slow, then
apnea
Repetitive pattern of
CHEYNE-STOKES breathing
BREATHING (PERIODIC Crescendo/decrescendo
BREATHING) sequence of respiration with
interval of apnea
This breathing comes at
regular periodic pattern
Causes:
o Heart failure
o Uremia
o Increased ICP
o Brain damage
(cerebral)
Unpredictable irregularities
Breathing may be shallow or
deep and stop (apnea)
(ATAXIC BREATHING) Periods of apnea occur at
irregular pattern
Causes:
o Respiratory failure
o Brain damage
(medulla)
o Increased ICP CARDIAC/HEART RATE
Count in full minute
17. COHERENCE Place diaphragm of stethoscope over the apex beat
The logic Note if there are irregularities on the heart beat (RHYTHM)
R
how people think NORMAL 60-100 /min
Speech that is comprehensible and logical
BRADYCARDIA <60 /min
With meaningful connections, no abrupt changes in topic, or
disordered grammar or word use TACHYCARDIA >100 /min

C. VITAL SIGNS RESPIRATORY RATE

Count in full minute
1 Pulse rate Patient must not be aware that you are counting his RR
2 Cardiac or heart rate Pretend that you are still counting the PR but actually
3 Respiratory rate counting RR
4 Body temperature Normal 16-20 cycles/min
5 Height Note for regularities, pattern, depth of breathing
6 Weight
7 Blood pressure

PULSE RATE
Count in full minute or (PR in 30 secs multiplied by 2)
Palpate arterial pulse using pads of index and middle fingers
Arterial pulses that can be palpated:
o Radial, brachial
BODY TEMPERATURE
o Carotid
o Femoral, popliteal, dorsalis pedis Fluctuation:
o Temporal o Early AM = fall as low as 35.8C
Note for amplitude of pulse: bounding (strong), thready (weak) o Late PM = rise as high as 37.3C
o Female during ovulation
Several routes to get temperature
o Oral, axillary, temple, tympanic membrane, rectal

6
Thermometer TECHNIQUE
o Glass (prohibited)
o Digital / electronic
A. ORAL TEMPERATURE
o Patch
1. Insert thermometer under the tongue
o Temporal artery heat scanner
2. Instruct the patient to close the lips
3. Wait 3 to 5 minutes, READ
4. Reinsert it for another minute, read
If still rising reinsert again for 1min until reading became stable
5. Hot & cold liquids, smoking, can alter the reading

B. RECTAL TEMPERATURE
1. Ask patient to lie on one side w/ hip flexed
2. Lubricate the tip of thermometer
FEBRILE TEMPERATURE 3. Insert it about 3 to 4 cm into the anal canal w/ direction
ORAL 37.5C (99.5 F) towards umbilicus
RECTAL 38C (100.5F) 4. Remove after 3 min or wait about 10 sec for digital reading to
appear
37C (98.9F)
AXILLARY
Slower to pick up temperature changes
Lower than oral temp by 1C
Higher than oral temperature by 0.4 to 0.5 C
TEMPORAL ARTERY 37.5C
37.5C
C. AXILLARY TEMPERATURE
Lower than rectal temperature 1. Put the thermometer in the axilla
TYMPANIC MEMBRANE 2. Ask the patient to held the arms close to torso
by 0.8C
3. It will take 3 to 5 minutes to register
0.4 to 0.5C higher than oral
Less accurate
FEVER GRADE
D. TEMPLE TEMPERATURE
LOW >37.5C to 38.5C
1. Dry and clean temporal area
MODERATE 38.6C to 39.5C
2. Thermometer probe place on temporal artery between the
HIGH 39.6C to 40C
eye socket and hairline
VERY HIGH >40C
E. TYMPANIC MEMBRANE TEMPERATURE
Hyperoxia
Higher than oral reading by 0.8C
o Temperature is >40C
Ear is a protected cavity, not affected by several factors
o Seen in:
compared to oral
Sepsis
Presence of cerumen may obstruct the heat radiation from
Intracranial hemorrhage
tympanic membrane
Thyroid storm
Need to straighten the ear canal by pulling the pinna upward
Hyperthermia
then backward.
o Failed in thermoregulation
o Seen in:
Heat stroke HEIGHT
Adverse drug reactions Measure barefoot
Units should be in centimeters/inches
PATTERNS OF FEVER
WEIGHT
Temp always above normal throughout Weigh the patient preferably with shoes off
SUSTAINED OR Units should be in kilograms
the day.
CONTINUOUS Provides one index of caloric intake
Maximum diurnal variation of 0.5 to 1C
Temp remains above normal throughout Changes in weight can occur with changes in body fluid status,
REMITTENT the day fat, muscle mass
Fluctuate more than 1.1 C
Episodes of fever separated by days or CALCULATION OF BODY MASS INDEX (BMI)
INTERMITTENT
hours of normal temperature More accurate measures of body fat than weight alone
Form of intermittent with bouts of fever Assess nutritional status
RELAPSING
occurring every 5 to 7 days Guidelines for estimating increasing risks to patient health
People with low muscle mass and reduced nutrition may appear
n

7
 4. Palpate the brachial artery just medial to the bicep tendon,
and center the inflatable bladder over it w/ the lower
border of the cuff 2.5 to 3 cm above antecubital fossa
5. Position the patient arm so that it is slightly flexed at the
elbow & resting on the flat surface.
6. Estimate systolic pressure by palpation. Try to feel the
radial artery w/ fingers of one hand, rapidly inflate the cuff
until the radial pulse disappear. This the estimated
palpatory systolic BP.
7. Deflate the cuff promptly & completely and wait 15 to 30
seconds
8. Place the bell of a stethoscope lightly over the brachial
artery. Korotkoff sounds are low pitch, so best heard
with bell
9. Inflate the cuff 30 mmHg higher than the estimated
palpatory BP
10. Deflate it slowly at rate of about 2 to 3 mmHg per second.
Note the level at which you hear the sounds of at least 2
CLASSIFICATION OF BMI consecutive beats. This is SYSTOLIC PRESSURE
Underweight <18.5 11. Continue to lower the pressure slowly until the sounds
Normal 18.5 24.9 kg/m2 become muffled & then disappear
Overweight 25-29.9 12. To confirm disappearance of sounds, inflate the cuff
Obesity I 30-34.9 20mmHg higher, then deflate the cuff rapidly to zero. The
Obesity II 35-39.9 disappearance point, gives the best estimate of true
Extreme Obesity III 40< DIASTOLIC PRESSURE

If BMI >35, measure the waist circumference just above the hips.
Risk for diabetes, hypertension, and cardiovascular disease
increases significantly if the waist circumference is 35 inches or
more in women and 40 inches or more in men.
BLOOD PRESSURE
Read both systolic & diastolic levels to the nearest 2 mmHg. Wait 2
or more minutes & repeat. Average your readings. If the first 2
readings differ by more than 5mmHg, take additional readings.
BP should be taken in both arms at least once. Normally, there may
be a difference in pressure of 5mmHg & sometimes up to 10mmHg.
Subsequent readings should be made on the arm with high pressure

OTHER THINGS TO REMEMBER

INDIRECT METHOD USING SPHYGMOMANOMETER
1. Patient have rested for at least 5 min.
2. Should not have eaten or smoked for 30 minutes prior
3. Patient arm should be resting, free of clothing, &
positioned so that the brachial artery is at heart level
1. Palpate the brachial artery to confirm it has a viable pulse
2. There should be no AV fistulas/graft or signs of
lymphedema
3. When using mercury sphygmomanometer, keep the
manometer vertical and make all readings at eye level with
the meniscus
4. When using an aneroid instrument, hold the dial so that it
faces you directly
5. Avoid slow or repetitive inflations of the cuff, because the
resting venous congestion can cause false readings
6. An aneroid manometer becomes inaccurate with
repeated use and needs periodic calibration.
7. If adult patient is very thin use a pediatric cuff
8. If a patient has an obese arm, and there is no available
bigger cuff, a standard cuff can be wrapped around the
forearm and stethoscope place on radial artery. The size
of the cuff and the site of auscultation should be recorded
9. If repeated measurement is needed wait at least 15 sec
between readings w/ the cuff fully deflated. Can also
remove the cuff & elevate the arm for 1 to 2 minutes

CORRECT BLOOD PRESSURE CUFF

Width of the inflatable bladder of the cuff should be about 40% of
upper arm circumference = about 12 14cm in adult
Length of inflatable bladder should be about 80% of upper arm
circumference almost long enough to encircle the arm.
The standard cuff is 12 x 23 cm, appropriate up to arm
circumference of 28cm

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 Note for color changes
Hyper/hypopigmentation
COLOR
Pallor/ cyanosis/ jaundice
Redness/erythema
MOISTURE Dryness/ sweating/ oiliness
Roughness/ smoothness/
TEXTURE
coarse

Compare BP in the arms and legs

Compare BP in supine and upright position
Relatively low BP should always be interpreted in the light of:
o Past reading
o P

BLOOD PRESSURE ON LOWER EXTREMITIES

To determine the BP in the leg
Use wide, long thigh cuff that has a bladder size of 18 x 42cm
Apply it to the midthigh.
Center the bladder over the posterior surface, wrap securely
Listen over the popliteal artery
Preferably patient should be in prone
When cuff of proper size is used for both arm and leg, blood
pressure should be equal
The usual arm cuff, improperly used on the leg gives a falsely high
reading

ORSTOTHATIC/POSTURAL HYPOTENSION
1. Measure BP in SUPINE after patient is resting up to 10min
2. Get also BP w/in 3 min after patient stand up

DBP >10mmHg

BP taken when the patient is supine tend to be lower than those Use the back of your
taken upright. hand/fingers to make this
TEMPERATURE
Preferred position is patient seated assessment
BP generally increases with age Warm/Cold
The taller & heavier the individual, the more likely BP will be higher Gently pinch a small section
than in a shorter or leaner person on the forearm, sternal area,
glabellar area, between the
D. SKIN EXAMINATION thumb & forefinger & then
Examination by inspection and palpation release the skin
MOBILITY AND TURGOR
Adequate exposure of the skin is necessary Observe:
Look also for areas not usually exposed: o Ease with which it lifts
o Axillae, buttocks, perineum, back of thighs, inguinal. up
Pay careful attention to intertriginous areas o Speed at which it
returns into place
It is important to use
specific terminology to E. SKIN TURGOR
describe skin lesions and Should not be tested at the back of patient hands because it is
rashes. Good descriptions loose & thinnest
include each of the ff Skin should be resilient, moves easily when pinched (MOBILITY)
elements: number, size, Should return to place immediately when release (TURGOSITY)
color, shape, texture, In elderly, it should be done on:
primary lesion, location, o Inner aspect of thigh
and configuration o Sternum
o Glabellar area

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 A circumscribed,
palpable, solid lesion
more than 0.5cm in
PLAQUE
diameter, often formed
by the confluence of
papules.

A small, fluid filled

lesion, <0.5 cm in
diameter, raised above
the plane of
VESICLE surrounding skin. Fluid
is often visible and the
lesion are translucent
F.
SKIN LESIONS
Generalized/ localized Ex. Chickenpox
LOCATION AND A circumscribed
Exposed/ intertriginous,
DISTRIBUTION collection of leukocytes
skinfold
Linear/ clustered/ annular/ and free fluid that
PUSTULE
arciform/ geographic/ varies in size
PATTERN AND SHAPES
serpiginous
Dermatomal Ex. Pimple
TYPES OF SKIN LESIONS A circumscribed
collection of free fluid
COLOR
more than 0.5cm in
BULLA
diameter
PRIMARY SKIN LESIONS
Ex. Blisters
Macule Plaque Vesicle A raised, erythematous,
Patch Nodule Bulla edematous, papule /
Papule Pustule Wheal (hive) plaque, usually
representing short-
lived vasodilatation and
A circumscribed, flat Vaso permeability
MACULE discoloration, 0.5 cm or WHEAL
smaller Ex: Urticaria

A large (>0.5 cm) flat Papule = elevated

lesion with a color Plaque = non-elevated
different from Wheal = combination
surrounding skin
PATCH SECONDARY SKIN LESIONS
Differs from macule
only in size
Scale Fissure Scar
Crust Ulcer
Ex. Vitiligo
Erosion Atrophy
hypopigmentation
A small, solid lesion,
Excess dead
<0.5 cm in diameter,
epidermal cells that
PAPULE raised above the
are produced by
surface of surrounding
abnormal
skin & hence palpable SCALES
keratinization and
A large (0.5 5.0 cm),
shedding.
firm lesion raised above
the surface of
Ex: Psoriasis
NODULE surrounding skin
A collection of
dried serum and
Differs from papule
cellular debris. Also
only in size CRUST

Ex: Impetigo
A solid, raised growth
TUMOR
>5cm in diameter

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 Area of skin
denuded by H. NAILS
complete or partial Inspection & Palpation
EROSION loss of epidermis. Note for:
o Color pale, cyanotic, yellow
No associated loss o Length, configuration
of dermis o Symmetry, cleanliness
A focal loss of Nails protect the distal ends of the fingers and toes.
epidermis and The firm rectangular and usually curving nail plate gets its pink
dermis color from the vascular nail bed to which the plate is firmly
ULCER attached
Heals with scarring Note the whitish moon, or lunula, and the free edge of the nail
plate. It should appear smooth and convex. Note fore ridging,
Ex: Ecthyma grooves, depression, and pitting
Roughly one-fourth of the nail plate, the nail root, is covered by
Linear, angular the proximal nail fold
erosions that may The cuticle extends from the fold and, functioning as a seal,
EXCORIATION be covered by crust protects the space between the fold and the plate from external
and are caused by moisture.
scratching Lateral nail folds cover the sides of the nail plate. Nail edges
should be smooth & rounded
Note that the angle between the proximal nail fold and nail plate is
A linear loss of normally less than 180°.
epidermis and Fingernails grow approximately 0.1 mm daily; toenails grow more
FISSURE dermis with sharply slowly
defined, nearly Anonychia: Complete absence of nail
vertical walls

An abnormal
formation of
connective tissue,
implying dermal
SCAR
damage.

Due to injury or
surgery

A depression in the METHOD TO OBSERVE

skin, resulting from
1. Place a ruler or sheet of paper across the nail and the
thinning of the
dorsal surface of the finger and examine the angle formed
ATROPHY epidermis or dermis
by the proximal nail fold and nail plate
2. SCHAMROTH TECHNIQUE: Place the together the nail
EX. Striae
(dorsal) surfaces of the fingertips of corresponding
(strechmarks)
fingers from the right and the left hands
Normally w/ diamond shape window
G. HAIR
CLUBBING
Observe for body hair
Quantity, distribution Loss the diamond shape window
Hair loss (ALOPECIA): Signs of chronic hypoxemia
o Asymmetric/ gradual symmetric
Color TEST FOR NAIL BED ADHERENCE
Texture: Coarse, fine, curly, straight, shiny, smooth, resilient, Gently squeeze the nail beds between your thumb and the pad of
dryness, brittleness your finger

TWO TYPES
Covers the body
Fine Vellus Short, fine,
Hair inconspicuous, and
relatively unpigmented
On the scalp, pubic,
axillary, arms and legs,
beard of male, and
Coarse
eyebrows
Terminal Hair
Coarser, thicker, more
conspicuous, and
usually pigmented

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