Clinical Sciences Diagnosis Laboratory Manual July 2008

CLINICAL DIAGNOSIS
LABORATORY
MANUAL
FOREWORD
The purpose of this Clinical Sciences Laboratory Manual is to serve as a starter kit to help the student build a
solid foundation of skills that will be utilized throughout your education at Life University.
This manual cannot be used as a sole reference source for state boards or national boards. All reference sources
for boards should be obtained from that individual state or the National Board of Chiropractic Examiners
(NBCE).
Any examination or testing procedure that you are taught in class that is not listed in this manual may also be
used for testing and should be referenced in the required textbook for that course.
This manual does not exclude you from reading or using the textbook(s) required or recommended in each
respective course.
If this manual is lost, misplaced, stolen, or missing for any reason you will be required to obtain another copy
from the library and not from your lecture instructor or the Clinical Sciences Division.
Each course will have further instructions or addendums to include to this packet so please ensure that you
understand what is expected of you for your course.
Good luck as you proceed in your journey through Life University and in Chiropractic!!
CLINICAL SCIENCES DIVISION 2

VISCERAL DIAGNOSIS
DIAG 2725

COURSE OUTLINE
WEEK 1
HOUR 1 Introduction to course
Discuss laboratory syllabus
Discuss final examination
Necessary equipment for course
HOUR 2 Explain the concepts of inspection, palpation, percussion, and auscultation

St
ude ntsmus trea dint hel ecturet ext
book( Mos by ’sGuide to Physical
Examination, 5th edition) the following items before coming to class Week 2:
* Inspection Chapter 3, pg. 53-54

* Palpation Chapter 3, pg. 54
* Percussion Chapter 3, pg. 54-56
* Auscultation Chapter 3, pg. 57
* Measurement of Vital Signs Chapter 3, pg. 57-60
* Blood Pressure Measurement Chapter 14, pg. 476-480
HOUR 3 Perform and explain the Blood Pressure and Vital Signs
HOUR 4 Student Practice
WEEK 2
HOUR 1 Blood Pressure/ Vital Signs practice
HOUR 2 Teach Gowning for Head and Neck Exam

Perform and explain the Head and Neck Exam
HOUR 4 Clinical Integration of the Head and Neck Exam
WEEK 3
HOUR 2 Perform and explain the Vascular Exam

Teach Blood Vessels for Vascular Exam/Gowning
HOUR 4 Clinical Integration of the Vascular Exam

WEEK 4
HOUR 2 Perform and explain the Chest and Lung Exam (Posterior)
HOUR 4 Clinical Integration of the Chest and Lung Exam (Posterior)
WEEK 5
HOUR 1 Blood Pressure/ Vital Signs practical
HOUR 2 Blood Pressure/ Vital Signs practical
HOUR 3 Perform and explain the Chest and Lung Exam (Anterior)
WEEK 6
HOUR 1 Clinical Integration of the Chest and Lung Exam (Anterior)
HOUR 2 Review
HOUR 3 Perform and explain the Heart Exam
HOUR 4 Clinical Integration of the Heart Exam/ Student Practice
WEEK 7
HOUR 1 Perform and explain the Abdomen Exam
HOUR 3 Continue the Abdomen Exam
HOUR 4 Clinical Integration of the Abdomen Exam/Student Practice
WEEK 8
HOUR 1 Review
HOUR 3 Clinical Integration

WEEK 9 & 10
HOURS 1-4 Testing

Laboratory Examinations
1. Each student will perform one of the following or any area of the following examinations during the
final laboratory practical:
 Vascular examination, Head and Neck (combined as one exam)

 Chest and Lungs
 Heart
 Abdomen
2. The purpose of the examination is to apply practical examination techniques and as well as integrative
analysis upon patient presentation up to the level of instruction at this point. Clinical application will
be introduced in class and integrative thinking will be demonstrated.
3. Each student has 12 minutes to complete the entire examination process. The format of each exam must be
followed exactly to receive full credit. Any deviation from the order will result in a five point reduction.
4.Thes t
udentwi l
lbeg ive navi t
alsignse xami na ti
ont ove rifythes tudent’sabili
tyt opr ope rl
yassessvi tal
signs. The vital signs exam is worth 10 points of the practical examination. Partial credit may be given at
theins t
ruct
or ’sd iscretion.Knowl edgeoft ermswi llbee xpe c ted.
5. Laboratory final examinations, including the vital signs examination, are worth 50 points totally. The
maximum points for lab is 50 points which will come from the practical exam (vitals (10 pts.) and practical
(40 pts). Students that are unable to demonstrate hands on proficiency during the practical will not be
allowed to pass the class even if their total points are passing. Students must have a passing grade in
both the lecture and the lab to complete and pass the class successfully.
6. The student is responsible for adequate preparation for the final examination.
7. If a student does not show up to take the final laboratory examination during their assigned time, the only
acceptable excuses are those listed in the Student Handbook, Section II; Excuses.
8. The student is only allowed to miss 4 lab classes = 8 hours of lab (excused or unexcused). Missing 5 or
more classes will result in an automatic failure of the lab course and the student will not be allowed to
taket hef i
nall abor atorypr acti
cal.I tist hes t
ude nt ’sr e
spons ibilit
ytoke e pupwi tht hema terialthat
is presented during their absences.
Laboratory Decorum
1. Students in this lab are expected to be both Doctor and patient.
Thei ll
us trati
oni nMos by’sPhys icalExami nationHandbook,5th edition, demonstrates the amount of
patient exposure for each examination as will be demonstrated in lab.
2. While participating in lab, students will be expected to gown their patient properly as well as be able
to demonstrate proper gowning technique for a male as well as a female patient.
3. The final lab may be administered by any Clinical Sciences Laboratory Instructor.

Contributing Source
MOSBY’ SGUI DETO

PHYSICAL EXAMINATION
(Seidel, Ball, Dains, Benedict)
Equipment for Course

1. Adult Blood Pressure 8. Underwear/shorts
Cuff Men –boxer briefs
2. Stethoscope –Bell & Women –bikini panty
Diaphragm 9. Small tape measure -
3. Eyebrow marking pencil cloth
4. 2 Gowns (oversized –
velcro fasteners)
5. Thermometer
6. Sterile covers for
thermometer
7. Watch 2nd hand
GREETING A PATIENT
Hello, I am _____________________________.
I will be conducting a patient examination today.
Anything we discuss during this visit will be completely confidential.
Ify ouha vea nyque stionsorc oncernd uringt oda y
’sapp o i
ntme nt,ple as
edon othes itate to ask.
If at anytime you experience any discomfort or pain during the examination, please let me
know.
Do I have your permission to proceed?
Before I begin any physical examination on my patient, I will assess my

pati
e nt
’svi t
a lsigns .Iwi llcheck the pulse for rate, rhythm, amplitude,
and contour, respiratory rate, temperature, and blood pressure.
Vital signs
1. Pulse
 Rate
 Rhythm
 Amplitude
 Contour
2. Respiratory Rate
3. Temperature
4. Blood Pressure
Vital signs Explanation

Pulse
 Palpate each arterial pulse for the following:
1. Rate
 Pulsations per 60 seconds
 Resting pulse rate for a normal adult should be between 60 to 90 pulsations per minute
2. Rhythm
 Regularity of the heart pattern.
 An irregular heart pattern, which then continues in the same regular pattern over and over, may
indicate sinus arrhythmia.
 A pattern less, unpredictable rhythm may indicate heart disease.
3. Amplitude
 Height or intensity of the pulse.
 Measured using the following scale:
 4 = bounding
 3 = full
 2 = expected
 1 = diminished
 0 = absent
4. Contour
 Description of the pulse wave in a healthy artery.
 Should be either rounded, smooth or domed shaped.
 Each wave is compared to the following wave for any differences.
Blood pressure
 Pe
riphe
ralme
asur
eme
ntofa
nindi
vidua
l’sc
ardi
ova
scular capacity.
Respiratory rate
 Watcht her is
eandf a l
loft hepa t
ient’sche s
twhi l
ethe
ybr
eat
he.
 Count the number of cycles during 60 seconds.
Temperature
 Assess mentofa nindi vidua l’
sbodyt emp e r
atur e.
 Measured in one of the following ways:
 Oral
 Axillary
 Rectal
 Tympanic membrane: not reliable if the patient has tympanic tubes or implants.
Blood Pressure Explanation
Palpatory Systolic
 This should be performed before taking the auscultatory blood pressure.
 Helps to avoid errors of underestimating the systolic pressure.
 This event may occur if the patient has an auscultatory gap.
Place the blood pressure cuff so that:

 Center of bladder is over the brachial artery (use cuff arrows as a guide).
 Inferior edge of the cuff should be 2-4 cm above the antecubital fossa.
 Thec uf fshoul dbes nuge noug hont hepa ti
ent’sa rm,s otha tt
hedoc torc anonl
yge
t1-2 fingers up
underneath the inferior edge of the cuff.
 Establish the radial pulse, using the finger pads of the 2nd and 3rd fingers.
 Inflate the cuff pressure up until the radial pulse disappears.
 Quickly inflate the cuff 30 mm Hg above the level where the radial pulse disappeared.
 Release cuff pressure at approximately 3 mm Hg / second.
 The pressure where the radial pulse reappears is the palpatory systolic pressure.
Auscultation
 Check both arms using the bell (or diaphragm) of the stethoscope.
 Wait 15-30 seconds before reinflating the cuff on the same arm.
 Place the bell of the stethoscope over the brachial artery.
 The arm should be level with the heart (if possible).
 Inflate the cuff 30 mm Hg above the palpatory systolic pressure.
 Release the cuff pressure 3 mm Hg / second.
 Listen for first loudest audible sound (Korotkoff) which indicates systolic b/p.
 Listen for the last loudest audible sound that indicates diastolic b/p.
 Normal adult blood pressure ranges:
 Systolic blood pressure 100-140 mm Hg
 Diastolic blood pressure 60-90 mm Hg
 Pulse pressure 30-40 mm Hg
Additional Blood Pressure Notes

Technique
 The patient should have rested for at least 5 minutes and ideally should not have eaten or smoked for 30
minutes.
 Thepa tient
’sa rms houl dber e sting,freeofc lothing ,a ndpos i
tioneds ot hatt hebr a chiala rtery(a tt
he
antecubital fossa) is at heart level - roughly level with the 4th interspace at its junction with the sternum.
 Whe nt hepa tienti ss eat
e d,r estingt hea rm onat ableal ittl
ea bovet hepa t
ient’swa istiss uita
ble.The
pa tient’sowne f
f orttos uppor tthea rmma yr aisethebl oodpr e ssure.
 If the brachial artery is much below heart level, blood pressure appears falsely high.

Cuff Size
 Cuffs that are too short or too narrow may give false high readings.
 Using a regular size cuff on an obese arm may lead to a false diagnosis of hypertension.
 A loose cuff or a bladder that balloons outside the cuff leads to false high readings.
Systole
 Period of ventricular contraction.
 Pressure in the left ventricle rises rapidly, then levels off, and starts to fall as most of its blood is ejected from
the left ventricle into the aorta and from the right ventricle into the pulmonary artery.
 Systole is indicated by the first heart sound, palpable apex beat and peripheral pulse.
Diastole
 Period of ventricular relaxation.
 Ventricular pressure falls almost to zero, and blood flows from atrium to the ventricle.
 Late in diastole, ventricle pressure rises slightly during atrial contraction.
 Ventricular diastole begins with the onset of the second heart sound and ends with the onset of the first heart
sound.
Blood Pressure
 Should be taken in both arms. Normally there may be a difference in pressure of 5-10 mm Hg. Pressure
difference of 10-15 mm Hg suggests arterial compression or obstruction on the side with the lower pressure.
Blood pressure readings tend to be higher in the right arm.
 The arm that has the hig hestr eadingi sa c cepteda sbe i
ngt hec l
ose stt ot hepa tient’struebl oodpr ess
ure.
Lack of symmetry between the left and right extremities suggests impaired circulation. Compare the strength
of the upper extremity pulses with those of the lower extremities and the left with the right.
 Ordinarily, the femoral is as strong as or stronger than the radial pulse. If this is reversed or if the femoral
pulsation is absent, coarctation of the aorta must be suspected. Coarctation of the aorta is a congenital
stenosis or narrowing most commonly of the aortic arch.
Auscultatory Gap
 A silent interval that may be present between the systolic and diastolic pressure.
 Widens with systolic hypertension in elderly persons (loss of arterial pliability) or drops in diastolic pressure
usually seen in chronic severe aortic regurgitation.

Head and Neck Examination
Patient seated
Neck exposed –below the clavicles
Inspection
1. Hair
 Color
 Distribution
2. Head
 Position
 Tilt
 Rotation
3. Scalp Surface
4. Skull
 Size
 Shape
 Symmetry
 Condition
5. Face
 Shape
 Symmetry
 Structural abnormalities
6. Battle Sign
7. De Mus ett
e’sSign
8. Neck
 Symmetry of muscles
 Webbing
 Masses
9. Tracheal Position
10. Patient Swallowing
11. Distended Veins or Arteries
12. Skin Color Variations
13. Ranges of Motion
Palpation
1. Skull
 Symmetry
 Condition
2. Scalp
 Freely moveable
3. Hair
 Texture
4. Temporal Arteries
 Thickening or hardness
5. Hyoid Bone
6. Thyroid
7. Cricoid Cartilages

8. Patient Swallowing
9. Thyroid Gland
10. Tracheal Tug
11. Lymph Nodes (check for: size; consistency; mobility; condition)
 Occipital
 Postauricular
 Preauricular
 Tonsilar
 Submandibular
 Submental
 Facial
 Anterior cervical chain
 Posterior cervical chain
 Supraclavicular
Auscultation
 Use bell of stethoscope to listen for arterial bruits
1. Temporal Arteries
2. Over Eyes (not recommended)
Thyroid Gland (soft bruits)
 Patient seated with neck exposed

Head and Neck Examination Explanation
Inspection
1. Hair noting color and distribution
 Palpate the hairline behind the ears and crown of the head. It should be smooth, symmetrically
distributed and have no split or cracked ends.
 Fine, silky hair is associated with hyperthyroidism.
2. Head
 Position
 Head should be held upright and still.
 Tilt
 Favors a good eye or a good ear with unilateral hearing or vision loss.
 Can also be shortening of the sternocleidomastoid muscle (torticollis).
 Rotation
 Head should be centered over the neck and trunk.
3. Scalp surface
 Lesions, scabs, parasites, nits and hair loss.
4. Skull
 Size, shape, symmetry and condition.
5. Face
 Shape and symmetry
 At rest, movement and expression.
 Look for tics, muscle spasms, edema, puffiness, lack of expression and/or excessive perspiration.
 Structural abnormalities
 Of the mouth, eyelids, eyebrows and nose.
6. Battle sign
 Bruising over a mastoid
 Cause: Skull fracture.
7. DeMusette sign
 Jerking and bobbing of the head.
 Associated with:
 Tremor
 Nodding movement synchronized with the pulse indicates aortic insufficiency.
8. Condition of the neck

 Symmetry of muscles
 SCM and trapezius muscles.
 Webbing: Chromosomal anomalies.
 Masses: Enlarged thyroid gland.
 Edema: Local infection.
9. Tracheal position
 The trachea should be centered with no lateral deviation or pulsations.

10. Patient swallowing
 Space occupying lesion.
 Thyroid tissue that glides upward when swallowing may be enlarged thyroid.
11. Distended veins or arteries

 Hypertension.
12. Skin color variations

 Variations according to race, sex, and body type. Some slight asymmetry is common.
13. Ranges of motion

 Movement should be smooth, painless, and not cause dizziness.
 Flexion, extension, rotation, and lateral bending.
Palpation
1. Skull
 Gentle rotary movement noting symmetry & smoothness.
 Bones are indistinguishable.
 Ridge of sagittal suture may be felt on some people.
2. Scalp
 Freely moveable on skull with no tenderness, swelling or depression on palpation.
3. Hair texture
 Palpate the hairline behind the ears and crown of the head. It should be smooth, symmetrically
distributed and have no split or cracked ends.
 Fine, silky hair is associated with hyperthyroidism.
4. Temporal arteries
 Thickening or hardness.
 If thick and hard it is a possible temporal arteritis.
5. Hyoid bone
 Located adjacent to C3.
6. Thyroid and cricoid cartilage

 Located adjacent to C4 & C5 for thyroid cartilage and C6 for cricoid cartilage.
7. Patient swallowing
 Thyroid cartilage movement should be smooth, painless, symmetrical and midline.
 It should be smooth and rhythmic. There should be no need to swallow twice.
 Difficulty in swallowing may be an enlarged thyroid gland or a space-occupying lesion in the
anterior spine.
8. Palpate thyroid gland

 Noting nodules, tenderness, size, shape, configuration, consistency, and tenderness.

9. Tracheal tug
 Use the thumb and 2nd finger to palpate each side of the trachea just below the thyroid isthmus. If
a downward tug sensation is felt with a synchronous pulse, this is evidence of an aortic aneurysm.
10. Lymph nodes (size; consistency; mobility; condition)

 Occipital nodes at the base of the skull
 Postauricular nodes located superficially over the mastoid process
 Preauricular nodes located in front of the ear
 Tonsillar nodes at the angle of the mandible
 Submandibular nodes halfway between the angle and the tip of the mandible
 Submental nodes in the midline behind the tip of the mandible.
 Facial nodes located in the maxillary region
 Anterior cervical chain nodes at the anterior border of the SCM
 Posterior cervical chain nodes along the posterior border of the SCM
 Supraclavicular nodes located just above the clavicle
Auscultation
1. Temporal arteries for bruits (Bell)
2. Over the eyes (Bell)
3. Thyroid gland for soft bruits (Bell)

 If a hypermetabolic state is present, there will be an increased blood supply in the area.

Vascular Examination
 Patient is supine
 Patient is disrobed to the waist
Inspection
1. Venous Pulsations in the Jugular Veins (45° angle)
2. Fundoscopic Exam
3. Skin Color
4. Skin Thickness
5. Finger and Toe Nails
6. Hair Condition on the Extremities
7. Ulcerations
8. Edema
9. Stasis Dermatitis
10. Path of the Greater Saphenous Vein:
 Tortuosity
 Dilation
11. Path of the Lesser Saphenous Vein:
 Tortuosity
 Dilation
Palpation
1. Arterial Pulses (Palpate the following arteries for: rate, rhythm, amplitude, contour)
 Carotid  Abdominal Aorta
 Subclavian  Femoral
 Brachial  Popliteal
 Radial  Dorsalis Pedis
 Ulnar  Posterior Tibialis
2. Palpate Arterial Wall Thickness (not recommended)
3. Skin Temperature of the Extremities
4. Edema (pitting; ankle region)
Auscultation
1. Arterial Bruits (bell of the stethoscope)
 Temporal
 Carotid
 Subclavian
 Abdominal Aorta
 Femoral
2. Venous Hum (bell of the stethoscope)
 Epigastrium
 Base of the neck (bilateral)

Vascular Examination Explanation
Inspection
1. Venous pulsations in jugular veins
Patient must be in a reclining position at a 45-degree angle.
Reliable indication of the volume and pressure in the right side of the heart
 Variation may indicate:
 Right ventricle fails because of left ventricular failure
 Constrictive pericarditis
 Superior vena cava obstruction.
Observe the left and right jugular veins for symmetry.
 Distention on one side only suggests a localized abnormality.
 When the vein pressure increased because of intracardiac events, the veins are distended bilaterally.
2. Funduscopic exam:
 Red light reflex
 Disc/cup ratio
 Vessels
 General background
 Macula
3. Skin color
Variations according to race, sex and body type:
 Pallor: White
 Rubor: Red
 Cyanosis: Blue
 Jaundice: Yellow
4. Skin thickness
Areas of pressure (callus) such as the palms, soles of the feet and elbows.
Note whole body for moles, eczema, scars, keloids, psoriasis, seborrhea and ulcerations.
5. Abnormalities of the finger and toe nails

 Paronchia: Hang nail
 Clubbed nails: Respiratory or heart problems
 Spooned nails (Koilonchia): Iron deficiency anemia, fungal infection, hypothyroidism
 Pitted: Psoriasis
 Broad and flat: Secondary syphilis
6. Hair condition on extremities

Note the color, quality and quantity of the hair.
Note for hair loss, which can be either localized or generalized.
Note for inflammation of hair follicles.

7. Ulcerations
A crater-like circumscribed lesion of the skin resulting from tissue death (necrosis)
Accompanies some infectious, inflammatory or malignant conditions.
8. Edema
Swelling resulting from an excessive accumulation of serous fluid in the tissues of the body.
Possible Causes:
 Venous obstruction
 Increased capillary fluid pressure
 Renal failure
 Congestive heart failure
 Corticosteroid usage
 Inflammatory responses
9. Stasis dermatitis
Persistent inflammation of the skin of the lower legs with a tendency toward brown pigmentation
Commonly associated with venous incompetence.
The usual consequences are increased edema, secondary bacterial infection, and eventually ulceration.
10. Pathway of Greater Saphenous Vein

Starting at the medial malleolus, medial calf, medial knee, medial thigh and ends at the femoral vein.
 Tortuosity: Having many twists and turns.
 Dilation: To become wider.
11. Pathway of Lesser Saphenous Vein

Starting at the lateral malleolus, posterior calf and ends at the popliteal vein.
 Tortuosity: Having many twists and turns.
 Dilation: To become wider.
Palpation
 Use the distal pads of the second and third fingers. Palpate firmly however do not occlude the artery. The
thumb may be used to feel for the brachial and femoral pulses due to the tendency of the arteries to move
or roll during palpation.
1. Arterial pulses (feel for these qualities):

 Rate:
 Count the number of pulsations for 60 seconds or count the number of pulsations for 30 seconds and
double the count.
 Average resting pulse rate 60 to 90 pulsations per minute.
 Rhythm:
 The regularity of the heart pattern.
 An irregular heart pattern, which continues in a regular pattern, may indicate sinus arrhythmia.
 Patternless, unpredictable rhythm may indicate heart disease.
 Amplitude:
 The height or intensity of the pulse. Measured using the following scale:
 4 = bounding
 3 = full
 2 = expected
 1 = diminished
 0 = absent
 Contour
 The description of the pulse wave in a healthy artery.
 Should be either rounded, smooth, or domed shaped. Compare each wave to the following wave for
any differences.
2. Feel for the following arterial pulses:

 Carotid: In the neck, just lateral to below thyroid cartilage at the level of C3. Do NOT palpate
both CAROTID ARTERIES at same time.
 Subclavian: At base of neck, mid clavicular.
 Brachial: Just medial to biceps tendon.
 Radial: Lateral and ventral side of wrist.
 Ulnar: Medial and ventral side of wrist.
 Abdominal Aorta: One inch superior and one inch lateral to left of the umbilicus.
 Femoral: Inferior and medial to the inguinal ligament.
 Popliteal: Press firmly in popliteal fossa.
 Dorsalis pedis: Medial dorsum of the foot.
 Posterior Tibialis: Behind medial malleolus.
3. Palpate artery wall thickness

 Not recommended.
 Possibility exists of dislodging a piece of plaque from an artery wall.
Skin temperature of extremities

 Use the back of the hand.
 Coolness or coldness to the touch may suggest reduced blood flow to that area.
 Increased heat may suggest inflammatory process or pooling of blood to an area.
4. Edema
 Swelling resulting from an excessive accumulation of serous fluid in the tissues of the body.
 Possible Causes:
 Venous obstruction
 Increased capillary fluid pressure
 Renal failure
 Congestive heart failure
 Corticosteroid usage
 Inflammatory responses

Auscultation
1. Bruit
 Use the bell of the stethoscope and ask the patient to hold their breath.
 Bruits are low-pitched unexpected sounds that may indicate local obstruction or vigorous blood flow.
 Listen over the following area:
 Temporal
 Carotid
 Subclavian
 Abdominal aorta
 Femoral
2. Venous hum
 Use the bell of the stethoscope and ask the patient to hold their breath. The head should be turned to one
side and titled slightly upward.
 When present it is a low-pitched continuous sound that is louder during diastole.
 Common in children and usually has no pathologic significance. It is caused by turbulent of blood flow
in the internal jugular veins.
 In adults it usually occurs with:
 Anemia
 Pregnancy
 Thyrotoxicosis
 Intracranial arteriovenous malformation
 Must not be confused with carotid bruit, patent ductus arteriosus or an aortic regurgitation
 Listen over the following areas:
 Epigastrum - Area is located in the soft tissue just below the xiphoid process
 Base of neck
 Auscultate over the supraclavicular space at the medial end of the clavicle and along the anterior
border of the SCM.

Signs of Vascular Abnormalities
 Patient is disrobed to the waist *Supplemental Notes for Lecture*
Arterial insufficiency
1. Decrease or absent pulse
2. Pallor
3. Coolness or coldness of extremity
Venous stasis
1. Normal pulses
2. Normal color or cyanosis
3. Normal temperature
4. Pitting edema
Signs Common to Both Arterial Insufficiency and Venous Stasis

1. Atrophy of skin with hair loss
2. Ulceration
3. Pain
4. Gangrene
Thromboplebitis
1. Palpate for tenderness P-A at calves
2. Note any palpable cords
3. Redness
4. Heat (use back of hand)
5. Homan’ ssig n

Signs of Vascular Abnormalities Explanation
Arterial Insufficiency
1. Decrease or absent pulse
2. Pallor
 A white color to the skin or mucous membranes.
 Causes:
 Edema
 Vasoconstriction
 Exposure to cold
 Severe pain
 Hemorrhage
 Shock and/or lack of breathing.
3. Coolness or coldness of extremity
Venous Stasis
 Chronic venous insufficiency manifested by edema and dilated superficial veins.
 Patient may complain of fullness, aching or tiredness in the leg or have no discomfort.
1. Normal pulses
2. Normal color or cyanosis
 A blue color of the lips, ears, nails of the hands and feet.
 Due to hemoglobin not bound to oxygen or possible pulmonary or cardiac difficulty.
3. Normal temperature
4. Pitting edema
 Excessive accumulation of interstitial fluid.
 Press index finger over medial malleolus for several seconds.
 A depression that does not rapidly fill and resume its original shape is evidence of orthostatic edema.
 Edema with thickening and ulceration of the skin = deep venous obstruction or valvular incompetence.
 Persistent inflammation of the skin of the lower legs with a tendency toward brown pigmentation.
 Indicates venous incompetence.
 The usual consequences are increased edema, secondary bacterial infection and eventually ulceration.
Signs Common to both Arterial Insufficiency and Venous Stasis

1. Atrophy of skin with hair loss
 Wasting away of the skin.
2. Ulceration
 A localized defect due to the sloughing off of inflammatory necrotic tissue.
3. Pain
 Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was
palpated.
 May be classified as:
 Burning  Gradual or sudden onset  Dull
 Aching  Sharp  Lancinating
 Cramping  Throbbing  Knifelike

4. Gangrene
 Tissue death due to loss of blood supply.
 Followed by a bacterial infection and putrefaction (enzymatic decomposition producing a foul smelling
odor).
Thrombophlebitis
 Thrombosis and inflammation of the venous walls.
 May precede or follow clot formation.
 Causes:
 The lesion may occur without previous cause
 Mechanical or chemical trauma
 Suppurative disease
 Ischemia, anemia
 Polycythemia
 Leukemia.
 Positive sign is deep pain in the calf.
1. Palpate for tenderness at calves

If thrombosis is present calf should be tender.
2. Note any palpable cords
If thrombosis is present the vein should be thicker.
3. Redness
If thrombosis is present calf should be red.
4. Heat
Use the back of the hand. If thrombosis is present calf should be hot.
5. Homan’ ssi
g n–Source Cipriano pp 360-360f.
Instruct: Pa tientsupi ne .Exa mi nerr ais
espa ti e
nt’slega pproxima tel
y30de gr
e e
swith
kne ei ne xtens ion.Exa mi nerthe ndor sif
lexesthepa t
ie nt
’sfoota
ndsque e
zest he
calf.
(There are sources that Do Not recommend squeezing the calf due to danger of
thrombus formation possibly being released into the venous system.)
Positive: Deep pain in the calf.
Indicates: Thrombophlebitis

Examination of the Chest and Lungs
 Patient is seated and disrobed to the waist for:
 Inspection, palpation, percussion, and auscultation of the posterior thorax
 Inspection and auscultation of the anterior
 The patient is supine for:
 Palpation and percussion of the anterior thorax
 Thepat ient ’
sar msar ec r os
sedandl i
fted for:
 Exam of the posterior thorax (at least for the examination of the triangles of auscultation)
Inspection (anterior & posterior)

1. Thoracic landmarks
2. Anterior to Posterior Diameter
3. Respiration
4. Symmetry of Thoracic Cage Movement
5. Inspect the ribs
6. Inspect the Intercostal Spaces (ICS)
7. Dyspnea
8. Flaring of the Alae
9. Breath odor
10. Accessory Muscle Use
11. Flushing of the Skin
12. Pallor
13. Cyanosis
14. Cicatrix
15. Skin Lesions
16. Vascular Abnormalities
17. Clubbing of the nails
Palpation (posterior)
1. Pain
2. Tenderness
3. Masses
4. Sensations
5. Further Assess Any Abnormalities Found
6. Tactile Fremitus
7. Respiratory Excursion (T8-T10 region, posterior)
Percussion (posterior)
1. Begin at the Lung Apices
2. Compare Side-to-Side
3. Determine Diaphragmatic Excursion

Auscultation (posterior, then anterior)
1. Patient is Directed to Breath through their Mouth
2. Listen for These Characteristics:
 Pitch
 Intensity
 Duration
3. Listen for Normal Breath Sounds:
 Vesicular
 Bronchovesicular
 Bronchial
4. Listen for Adventitious Breath Sounds:
 Crackles
 Wheezes
 Rubs
5. Vocal resonance (doctor has the patient recite words)
 Bronchophony
 Whispered pectoriloquy
 Egophony
Palpation (anterior, with patient supine –ALL of chest wall on male –exclude
breast area on female)
1. Pain
2. Tenderness
3. Masses
4. Sensations
5. Further Assess Any Abnormalities Found
6. Trachael Position
7. Lymph Nodes:
 Supraclavicular  Lateral axillary
 Infraclavicular  Medial axillary
 Epitrochlear  Anterior axillary
 Posterior axillary
8. Costochondritis
9. Possible Rib Fractures (can also use: 128 Hz tuning fork)
Percussion (anterior, with patient supine)

1. Begin at Lung Apices
2. Compare Side-to-Side
3. Identify the Location of:
 Liver (2 marks)
 Gastric air bubble (1 mark)
 Spleen (1 mark)

Chest and Lungs Explanation
 Patient is seated and disrobed to the waist for:
 Inspection, palpation, percussion, and auscultation of the posterior thorax
 Inspection and auscultation of the anterior
 The patient is supine for:
 Palpation and percussion of the anterior thorax
 Thepat ient ’
sar msar ec r os
sedandl i
fte df or:
 Exam of the posterior thorax (at least for the examination of the triangles of auscultation)
Inspection (anterior and posterior)

1. Thoracic Landmarks
 Compare structures across the midsternal line for equality in:
 Size
 Shape
 Symmetry
 The chest is usually not absolutely symmetrical, but one side can compare to the other.
2. Anterior to Posterior Diameter: normal ratio is 1:2

 Barrel Chest
 The ribs are more horizontal.
 The spine at least somewhat kyphotic and the sternal angle is more prominent.
 Note the A-P vs. lateral diameter (normal is 1:2, emphysema 1:1).
 Cause: compromised respiration as in chronic asthma or emphysema.
 Pectus Carinatum (pigeon breast)

 Prominent sternum
 Hepato-splenomegaly frequently occurs in rickets, the abdomen becomes distended and the lower
ribs may be pushed anteriorly, causing a transverse groove just above the costal arch. This forward
projection of the sternum is often asymmetrical.
 Cause: congenital problem or rickets.
 Pectus Excavatum (funnel chest)

 The lower part of the sternum is deeply depressed backward, producing an oval hollow in the lower
sternum and upper epigastric regions. This does not appear to produce disturbances in vital
functions.
 Prominent sternum
 Cause: congenital problem or rickets.
 Rickets A systemic disease of the infant and young child. It is the childhood equivalent of osteomalacia
in the mature skeleton. The essential pathological alteration involves deficiencies of vitamin D, calcium
or phosphate. The classic vitamin D deficiency presentation develops between 6 months and 1 year of
age. Symptoms consist of muscle tetany, irritability, weakness, delayed development, and small statue
and bone deformities. The most notable clinical finding is multiple costocardial bumps (rachitic rosary).
 Flail Chest
 Injury to the chest wall and loss of rigidity causes a condition call Paradoxical Breathing: in which
the chest wall goes in on inspiration and out on expiration.
 Cause: Three or more broken ribs at the sternum or the separation of several contiguous costal
cartilage resulting in abnormal movement of that chest wall.

 Rachitic Rosary
 Soft tissue swellings occurring around the growth plates due to hypertrophied cartilage at the
anterior ribcage.
 Cause: Only exists during the active rickets and heals without a trace.
 Gibbus Deformity
 Angular kyphosis
 Extensive disintegration of discs and wedging of the involved vertebrae.
 Causes:
 Secondary tuberculosis: may develop a reversal of the height/width ratio of the vertebral bodies.
Normally weight bearing lumbar vertebrae in the human is wider than they are tall. In long
standing gibbus deformity tremendous biomechanical stress is placed upon the uninvolved
vertebral body immediately caudal to the gibbus. This stress may alter the appearance of this
vertebra whereby it becomes taller than it is broad.
 Kyphosis
 Abnormally increased convexity in the curvature of the thoracic spine as viewed from the side.
 Scoliosis
 Lateral curvature of the vertebral column.
3. Respiration
 Rate is the number per minute with a normal of 10-20.
 Rhythm is the pattern; steady, even, uneven or thready.
 Effort is breathing without apparent distress.
4. Symmetry of Thoracic Cage Movement

 Observe the muscles used for normal breathing:
 Diaphragm
 Intercostals
 Trapezius
5. Inspect the Ribs

 Slope: The slope of the ribs should be down to the floor almost perpendicular (900). In a barrel chest the
ribs are almost parallel to the floor.
 Motion: The ribs should rise and fall at the same time during inspiration and expiration. If one side of
the rib cage is not expanding at the same time or with the same volume as the other rib cage, this may be
an indication of a phrenic nerve problem.
 Local lag: One side of the diaphragm will lag behind, usually a phrenic nerve problem.
6. Intercostal Spaces (ICS)

 Bulging:
 Noted on expiration
 Causes: Air outflow obstruction or compression by a tumor, aneurysm, or enlarged heart.
 Retraction
 Noted on inspiration
 Causes: Significant air inflow obstruction, asthma, and bronchiolitis.

7. Dyspnea
 Difficult and labored breathing.
 Shortness of breath commonly found in pulmonary or cardiac compromise.
 Tachypnea is greater than 20 respirations per minute
 Bradypnea is less than 10 respirations per minute, which may be normal for athletes.
8. Flaring of the Alae

 Pa t
ient’snos t
rilsf
lar
e.
 Occurs during inspiration
 Common sign of air hunger, particularly when the alveoli are considerably involved.
9. Breath Odor
 Sme l
lthepat
ient ’
sbr e athfora nyoft hef ollowingitems :
 Foul odor: tonsillar and dental infections.
 Acetone odor: diabetics and individuals in starvation acidosis.
 Musty odor: severe liver disease.
 Alcohol odor: ingestion of alcohol or drugs.
10. Accessory Muscle Use

 The following muscles are recruited to help in the breathing process. These muscles stabilize the upper
thoracic cage so it is not pulled down.
 Platysma
 Scalenus Muscles
 Sternocleidomastoid (SCM)
 Causes: Possible COPD
11. Flushing of the Skin

 A red color to the skin or mucous membranes.
 Cause: increased blood flow to an area due to muscle activity.
12. Pallor
 A white color to the skin or mucous membranes.
 Causes:
 Edema
 Vasoconstriction
 Exposure to cold
 Severe pain
 Hemorrhage
 Shock and/or lack of breathing
13. Cyanosis
 A blue color of the lips, ears, nails of the hands and feet
 Cause:
 Hemoglobin that is not bound to oxygen
 Possible pulmonary or cardiac difficulty

14. Skin lesions
 Macules Localized changes in skin color. They may be small or large and are not
palpable.
 Papules Are solid and elevated and are less than 5mm in diameter.
 Nodules Are solid and elevated and are greater than 5mm in diameter. They extend
deeper into the dermis or subcutaneous tissue levels.
 Vesicles Accumulation of fluid between the upper skin layers, which produces, and
elevation covered by a translucent epithelium. Their diameter is less than 5
mm.
 Bullae Accumulation of fluid between the upper skin layers, which produces, and
elevation covered by a translucent epithelium. Their diameter is greater than 5
mm.
 Pustules Tiny abscesses in the skin or pus filled vesicles or bullae.
 Scales Thin sheets of dried cornified epithelium, which clings to the epidermis.
15. Cicatrix
 Large scars from burns, operations or lacerations.
 May cause difficulty in chest expansion due to lack of skin elasticity.
16. Vascular abnormalities

 Appear as distention of veins and/or arteries.
17. Clubbing of the Nails

 The angle of the nail bed approaches or exceeds 1800 (normal angle is 1600).
 The mechanism for the occurrence of clubbing of the nails is unknown.
 Causes:
 Pulmonary disease  Cardiovascular disease
 Bronchiectasis  Cyanotic congenital heart disease
 Emphysema  Subacute bacterial endocarditis
 Tuberculosis  Secondary polycythemia
 Lung cancers  Not as common: Cirrhosis, Colitis, Thyroid disease
Palpation (posterior)
 Patient is seated
 There should be bilateral symmetry and some elasticity of the rib cage. The sternum and xiphoid should be
relatively inflexible and the thoracic spine rigid. Begin at the apex of the lungs (Chronus isthmus) and
continue over the trap muscles. At the interscapular area patient should cross their arms (Scapula moves
outward) so that the ICS can be felt without hindrance of the scapula. Below the scapula the patient
uncrosses the arms and relaxes, continue to palpate out to the axillary area and down the slope of the ribs)
1. Pain
palpated.

2. Masses
 Collection of cells clumped together.
 Note the size, shape, consistency, motility and pulsations.
3. Tenderness
 Unpleasant feeling when a specific area is touched. Not present unless area is palpated.
4. Sensations
 A feeling, impression, or awareness of a bodily state or condition that results from the stimulation of a
sensory receptor site.
5. Further assess any abnormalities that were found on Inspection
6. Respiratory Excursion ( T8 to T10 area posterior)

 Take a tissue pull with the ball of the hand from axillary to mid-line and use thumbs as markers.
 Place thumbs along spinal processes at the level of 10th rib with palms lightly in contact with the
posterolateral surface.
 Watch thumbs diverge during quiet and deep breathing.
 Ask patient to take a deep breath in and out through their mouth. Watch for symmetry of movement
bilaterally.
 Repeat this process 3 times.
 Lag indicates an underlined lung problem on that side.
7. Tactile Fremitus
 Transmission of the spoken word through the lung and soft tissue being felt by the ball of the hand (most
sensitive to fremitus).
 Using the ball of the hand have patient say a resonance sound (such as blue moon, toy boat, etc.) each
ti
mey out ouc hthepa ti
ent’st horax.
 Check for symmetry of vibration in the following areas:
1,2 Apices of lungs
3,4 Intersc a
pula ra r
ea( armsc rossed,a voi dTp’ s
)
5,6 Triangle of auscultation (arms crossed and elevated)
7,8 Medial base of lungs (Dr. should use ulnar surface of the hands)
9,10 Lateral base of lungs (Dr. should use ulnar surface of the hands)
 Note the fremitus level of the diaphragm bilaterally. The right side maybe slightly higher due to the
density of the liver and there maybe a decrease in fremitus at the heart and aortic area. Fremitus is felt
best parasternally at 2nd intercostal space at the level of bronchi bifurcation.
 Decreased or absent fremitus:
 Air in the lungs
 Emphysema
 Pleural thickening or effusion
 Massive pulmonary edema
 Bronchial obstruction
 Increased fremitus:
 Often coarser or rougher in feel
 Fluids or a solid mass within the lungs
 Lung consolidation
 Heavy but non-obstructive bronchial secretions
 Compressed lung or tumor

Percussion (posterior)
 Patient seated
 Must have patient cross and lift arms for percussion of the intrascapular regions
 Percussion note will transmit into tissue to determine density. Depress as much soft tissue as possible.
1. Percuss the 10 primary areas (5 on each side)

1,2 Apices of lungs
3,4 Interscapulara rea(a rmsc rossed,a voidTP’ s)
5,6 Triangle of auscultation (arms crossed and elevated)
7,8 Medial base of lungs
9,10 Lateral base of lungs
2. Begin at lung apices
3. Compare side to side
4. Diaphragmatic Excursion
 Ask patient to breathe deeply and hold.
 Percuss along the scapular line until a change in note from resonance to dullness is heard. This is the
lower border of the diaphragm. (Breathe in allows the diaphragm to move down)
 Mark the point with a skin pencil at the scapular line.
 Allow the patient to breathe and then repeat the procedure on the other side.
 Ask the patient to take several breaths and then to exhale as much as possible and hold.
 Percuss up from marked point and make a mark at the change from dullness to resonance, bilateral.
 Remind the patient to start breathing. Measure and record the distance in centimeters between the
marks on each side. Right side marks will be slightly higher due to the liver mass.
 Diaphragmatic excursion distance is usually 3 to 5 cm.
 Excursion limited by:
 Several types of lesions
 Pulmonary (emphysema)
 Abdominal (massive ascites)
 Superficial painful (fractured rib).
 The diaphragm is innervated by spinal nerves C3, C4, C5 and the phrenic nerve.
Auscultation (posterior, then anterior)

 Patient is seated
 May have patient cross and lift arms (to listen to the triangles of auscultation)
 Check for normal and abnormal breath sounds. If abnormal sounds are heard ask patient to clear lungs by
coughing.
 Posterior: Auscultate the 10 primary areas (5 on each side)
1,2 Apices of lungs
3,4 Interscapular area (arms crossed)
5,6 Triangle of Auscultation (arms crossed and elevated)
7,8 Medial base of lungs
9,10 Lateral axillary area
 Anterior: Auscultate the 8 primary areas (4 on each side)
1,2 Above the clavicles
3,4 Just above the breasts
5,6 Just below the breasts medially
7,8 Just below the breasts laterally
1. Patient should breathe through mouth

 Helps accentuate breath sounds each time they are touched with stethoscope.
2. Listen for these characteristics:

 Pitch: Quality of tone or sound dependent on rapidity of vibrations.
 Intensity: The strength or depth of a sound.
 Duration: The length or continuance of a sound
3. Normal breath sounds:

 Vesicular:
 Heard over most of lung fields
 Low pitch
 Short expirations
 Listen for abnormal audible breath sounds.
 Bronchovesicular
 Heard over main bronchus area and over upper right posterior lung field
 Medium pitch
 Expiration equals inspiration.
 Bronchial
 Heard only over trachea
 High pitch
 Loud and long expirations
4. Adventitious breath sounds:

 Crackles
“Mi ni at
uree xplosions
”whi choc c urwhe npr evi ouslyc los
eda irwa y
sope ns udde nly,a l
lowi ngpr e
ssur
e
upstream and downstream to equalize.
 Early Crackles
 Conducted to the mouth and are not altered by coughing.
 They are caused by delayed elastic recoil that allows the airways to shut during expiration.
 Cause: chronic bronchitis, emphysema or asthma.
 Late Crackles
 Not conducted to the mouth, dependent on gravity and are found at the base of the lungs.
 Are heard when lung compliance is reduced and elastic recoil is augmented.
 Cause: sclerodema, congestive cardiac failure, and fibrosing alveolitis.
 Wheezes
 Partial obstruction of bronchioles (small airways).
 Heard almost everywhere.
 Whistling or high pitched sound as in asthma.
 Rubs
 Loss of lubricating fluid between pleura causing opposing surface rub together producing a sound
similar to that from rubbing two dry pieces of leather together.
 May be constant, lasting for only a few respiratory movements, then disappearing for a while.
5. Vocal resonance (doctor has the patient recite words)

 Using the diaphragm of the stethoscope, & listening at any point on the thoracic cage
 Patient recites certain words or phrases, in a deep & resonant manner.
 Ty
pic
alphr as
e s
,suc ha s
:“toyboa t”,“b luemoon” ,etc...
 Bronchophony
 Th edoc torc anheart hepa tient’swor dsclear
lyt hrought heste
thos cope,whi l
et hepa t
ients
peaks
in a normal conversational tone and volume
 Whispered Pectoriloquy
 Th edoc torc anheart hepa tient’swor dsclear
lyt hrought heste
thos cope,whi l
et hepa t
ients
peaks
in whispers.
 Egophony
 The patient speaks in a normal conversational tone and volume, and when they say t
helett
er“
E”,
itsoundsl iket helet
te r“A”t hr
o ught heste
thos cope.
Palpation (anterior)
 Begin above the clavicles; work down below the clavicles into the ICS spaces, check the slope of the ribs,
the axilla and finally the base of the lungs.
1. Masses
 Collection of cells clumped together.
 Note the size, shape, consistency, motility and pulsations.
2. Tenderness
 Unpleasant feeling when a specific area is touched. Not present unless area is palpated.
3. Pain
palpated.
4. Sensations
 A feeling, impression, or awareness of a bodily state or condition that results from the stimulation of a
sensory receptor site.
5. Further assess any other abnormalities found on Inspection
6. Tracheal position
 The trachea should be centered with no deviation to the left or to the right.
 It should not have any evident pulsations.
7. Lymph Nodes
 The lymph nodes are normally present but are not felt. Infection within lymph nodes are soft, tender and
easily moveable.
 Cancer within lymph nodes are hard, non-tender and non-moveable
 Supraclavicular
 Infraclavicular
 Epitrochlear
 Lateral axillary
 Medial axillary
 Anterior axillary
 Posterior axillary
8. Costochondritis
 If patient complains of chest pain, use a knife-edge hand (hypothenar) and apply pressure.
 Checking for tenderness or any inflammation of the rib/cartilage junction.
 Other possible causes are rib or intercostal muscle strain or an anterior vertebra.
9. Rib Fractures
 Use a knife-edge hand and depress the sternum. Pain should radiate from the site.
 A 128 Hz tuning fork can also be used on the side of the suspected fractured rib.
Percussion (anterior)
1. Begin at the apices of the lungs
2. Compare side-to-side
3. Identify location of:
 Liver onpa tie
nt ’
srights i
dea tthe6thICSmi dclavicula rline( 2ma rks
)
 Gastric air bubble onp ati
ent’slef
tside midclavicular line (1 mark)
 Spleen onpa t
ient’
slefts i
debe t
we enthe8th-10th ICS midaxillary line (1 mark)

LUNG SOUNDS
This tape contains recordings of breath sounds that you are likely to hear while examining the chest
of the normal individuals and patients with pulmonary disease. To hear the sounds reproduced most
realistically, you should listen to the tape through a stethoscope. * Be sure that the earpieces are
pointing forward. Then hold the bell 2 to 3 inches from the speaker of your tape recorder. If you
place the bell on the speaker, you will hear more noise than breath sounds. If you listen to the sounds
without a stethoscope, they will sound unnaturally loud and booming. This phenomenon, known as
the Fletcher-,Munson effect, is due to the frequency response characteristics of the human ear. On
some of the sounds on this tape, you will hear a short beep just before or during inspiration.
Listen now to normal vesicular breath sounds. . .. Note the relatively soft, low, pitched character of
normal. vesicular breath sounds, sometimes described as a sighing or gentle rustling. These sounds
are heard over most of the peripheral parts of the lung. The inspiratory phase is markedly longer than
the expiratory phase. Expiration is much quieter than inspiration, and there is no pause between
inspiration and expiration. The term vesicular is a misnomer; it arose from experiments
perf0rmedinthe nineteenth century suggesting that these normal sounds originated in the alveoli,
then called vesicles. In fact, modern engineering concepts make it more likely that the e sounds
emanate from e the turbulent flow of air in the lobar and segmental bronchi, not the alveoli. Now
listen again to normal vesicular breath sounds. . ..
Listen to bronchial breath sounds.. .. These characteristically loud, high-pitched bronchial breath
sounds resemble the sound of air blowing through a hollow pipe. Their expiratory phase is louder
and longer than their inspiratory phase. They are present normally only over the manubrium, and
there is a distinct pause between the inspiratory and expiratory phases. The appearance of bronchial
breath sounds over the periphery of the lung may mean abnormal sound transmission because of
consolidated lung tissue, as in pneumonia. Now listen to bronchial breath sounds over the chest of a
patient with pneumonia. Note that the heart sounds are also audible.. ..
These are bronchovesicular breath sounds. . .. Bronchovesicular breath sounds are a mixture of
bronchial and vesicular sounds. Their inspiratory and expiratory phases are about equal in length.
They are normally audible in two places: (1) anteriorly near the mainstem bronchi in the first and
second intercostal spaces; and (2) posteriorly between the scapulae. They may be heard elsewhere in
the presence of lung consolidation. Listen again to bronchovesicular breath sounds.. ..
The following are tracheal breath sounds ...... Tracheal breath sounds, not usually auscultated, are
present over the extrathoracic portion of the trachea. They are very loud, very high-pitched, and have
a harsh, hollow quality, the expiratory phase being slightly longer than the inspiratory phase. Listen
again to tracheal breath sounds. . . .
*Note: While listening to this tape, you may find it helpful to stop the tape recorder, take off your
stethoscope, and rest your ears periodically.
Here are breath sounds over a cavity in the lung.. .. These sounds are also called amphorous breath
sounds. Expiration is equal in length to inspiration but lower in pitch. There is a pause between
inspiration and expiration, and the heart tones are audible. Now listen again to amphorous breath
sounds....

Crackles are short, explosive, nonmusical sounds. They may be classified as high-or low pitched.
High pitched crackles are also called fine crackles; low-pitched crackles are also called coarse
crackles. Listen now to high-pitched crackles. . .. Now listen to low-pitched crackles. . .. Crackles
are due to the sudden opening of very small airways. Listen again to high pitched crackles. . .. Listen
again to low-pitched crackles. . ..
Crackles may be classified as to position in the respiratory cycle. You will now hear early
inspiratory crackles. . .. Early inspiratory crackles are characteristic of severe airway obstruction and
appear to be produced in the proximal and larger airways. They are not silenced by cough or change
of posture. Among the diseases associated with early inspiratory crackles are chronic bronchitis,
asthma, and emphysema. Listen again to early inspiratory crackles ...
The following are late inspiratory crackles. . .. Late inspiratory crackles appear to originate in
peripheral airways and may occasionally be associated with an end-inspiratory wheeze. Late
inspiratory crackles are characteristic of restrictive pulmonary disease and may be heard in
interstitial fibrosis, asbestosis, pneumonia, pulmonary congestion of heart failure, pulmonary
sarcoidosis, scleroderma, and rheilmatoid lung. Listen again to later inspiratory crackles. . ..
Sometimes crackles are produced by the accumulation of secretions in the airway. When the
secretions are profuse, the crackles can be heard over the mouth as well as over the chest wall, a sign
known to. ancient physicians as the death rattle. You will now hear a death rattle in a dying patient,
over the mouth. . ..
Listen now to the sound of wheezing. ... A wheeze, sometimes called a rhonchus, is a musical
pulmonary sound. The musical character is determined by the spectrum of frequencies that make up
the sound. The lowest frequency, called the fundamental, sets the pitch of the wheeze. Wheezes may
be described as high""pitched, in which case they are also called sibilant rhonchi, or low pitched, in
which case they are also called sonorous rhonchi. Listen to a high pitched wheeze. . .. Now listen to a
low-pitched wheeze. ...
Wheezing is produced by a bronchus narrowed to the point of closure, whose opposite walls oscillate
between the closed and barely open position. The sound made by a vibrating reed instrument, such
as an oboe or the mouthpiece of a child's toy trumpet, is generated in the same manner as a wheeze.
If the wheeze is made up of a single musical note, it is called a monophonic
wheeze. Listen to the following example of a monophonic wheeze........ If a wheeze is composed
of several dissonant notes starting and ending at the same time, it is called a polyphonic wheeze. All
forms of obstructive lung disease may be associated with polyphonic wheezing. Listen to a
polyphonic wheeze....
Stridor is a particularly loud musical sound of constant pitch. Listen to this example of stridor in a
child with croup. . .. Although nothing except its intensity distinguishes stridor from a monophonic
wheeze to the ear, stridor comes from obstruction of central airways such as the trachea or larynx.
Wheezing is produced in more peripheral airways. Listen again to stridor.
Listen to a pleural friction rub. . .. The smooth, moist layers of the normal pleura move easily and
silently over one another. But when the surface is thickened by fibrin deposits or coarsened by
inflammatory or neoplastic cells, the sliding motion is impeded by frictional resistance. The sound
produced, the pleural friction rub, resembles the sound of leather sliding on leather. Listen again to a
pleural friction rub. . ..

The following sound is a squawk. . .. Many squawks are inspiratory, but this squawk is both
inspiratory and expiratory, louder on inspiration and softer on expiration. The squawk is a musical
sound found in some patients with diffuse pulmonary fibrosis, especially if associated with an
allergic inflammation of the alveoli known as hypersensitivity pneumonitis. Here is the squawk
again. . ..
The presence of a bronchopleurocutaneous fistula may be accompanied by a bronchial leak squeak,

which you will now hear. . .. The squeak is a high pitched sound over the affected chest area during a
sustained Valsalva maneuver, the pitch being higher in smaller fistulas than in larger fistulas. This
squeak was recorded without a stethoscope directly over a fistula. Listen again to a bronchial leak
squeak.. . .
Egophony, which is the Greek word for the voice of a goat, refers to the nasal or bleating quality of
speech transmitted through consolidated lung tissue, as in pneumonia. Occasionally, egophony will
be heard over a pleural effusion where there is collapse of the underlying lung. When egophony
occurs, the patient says E, the letter will sound like A, because there is transmission of the higher
frequencies, or formants. First you will hear the letter E spoken over the healthy side Now you
will hear the letter E spoken over the area of consolidation Now you will hear the sounds of the
microphone is moved from one side to the other, stating with the healthy side....
In the normal lung, whispered sounds are not transmitted because they lack the lower frequencies
best transmitted by aerated lung tissue, and they are inaudible over the normal chest. However,
through airless, consolidated lung tissue the high-'pitched whispered sounds above 200 cycles are
transmitted, and whispering becomes audible. You will hear this phenomenon, whispered
pectoriloquy, now. The patient will whisper the words "one, two, three," and you will hear the
sound first over the normal lung...... Then over the consolidated lung ..... Listen now as we
alternate between sides. Note that the heart sounds are clearly audible over the consolidated area.

Heart Examination
 Patient is Supine
 Patient is Disrobed to the Wai
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 The Heart Examination Requires the Use of a Tangential Light Source
Inspection
1. Dyspnea
2. Pulsations at the APETME areas
3. Apical Impulse [aka: PMI (point of maximal intensity)]
4. Precordial Heaves
5. Abnormalities of the Fingernails
6. Cyanosis
7. Pitting Edema at the ankles
Palpation
1. Check (A.P.E.T.M.E.) Areas for Pulsations (using your finger pads)
 Aortic
 Pulmonic
 Er b’spoi nt
 Tricuspid
 Mitral
While at this location - Check for an Apical Impulse to include:
Location
Amplitude
 Epigastric Pulsations:
Pulsations coming from superior to inferior to the finger pads
May indicate: right ventricular enlargement
Pulsations coming inferior to superior (actually P-A) to the finger pads
May indicate: abdominal aortic aneurysm
2. Check the A.P.E.T.M.E. Areas for Thrills (using the ball of your hand)
 Thrills: turbulent blood flow, causing palpable vibrations
 Aortic
 Pulmonic
 Er b’spoi nt
 Tricuspid
 Mitral
Percussion
1. Identify the Location and Size of the Heart
2. Percuss from Lateral to Medial
 The left 3rd, 4th, and 5th Intercostal Spaces (males) - Make 3 vertical marks
 The left 3rd and 5th Intercostal Spaces (females) - Make 2 vertical marks
3. Percuss down the right sternal border
 Dullness is heard at the 6th intercostal space indicating the superior border of the liver.
 Make 1 horizontal mark (males and females)

Auscultation
1. Listen in the mitral area for S1 and palpate the carotid pulse –check for pairing of the two
2. Att hepul monica reaorEr b’ spoi ntusing the diaphragm –
Check for:
 Rate
 Rhythm
Identify Systole and Diastole
 At rates less than 100 bpm - Systole (time between S1 and S2), is shorter than diastole
 At rates less than 100 bpm - Diastole (time between S2 and S1), is longer then systole
3. Use the diaphragm 1st - auscultate the following areas for general cardiac sounds:
 Aortic
 Pulmonic
 Er b’
sp oint
 Tricuspid
 Mitral
 Epigastric
4. Use the bell 2nd - auscultate the following areas for general cardiac sounds:
 Aortic
 Pulmonic
 Er b’
sp oint
 Tricuspid
 Mitral
 Epigastric
5. Listen at the Apex to S1
 S1 is louder at the apex
6. Listen at the Apex during Systole –listen for splitting that is
 Accentuated
 Diminished:
 Other abnormal heart sounds
 Mitral murmurs
7. Listen at the Pulmonic area to S2
 S2 is louder at the base
8. Listen at the Pulmonic area during Diastole –listen for splitting that is
 Accentuated
 Diminished:
 Other abnormal heart sounds
 Pulmonic murmurs
9. Special Maneuver for Mitral Murmurs
 Patient is positioned in the left lateral recumbent position
10. Special Maneuver for Aortic Murmurs
 Patient in seated position

Heart Explanation
 Patient is disrobed to the waist (gowns can be utilized to protect patient modesty)
 The heart examination requires the use of a tangential light source
 All abnormalities should be described in terms of their location and timing in the cardiac cycle
Inspection
1. Dyspnea
 Difficult and labored breathing with shortness of breath.
 Commonly found with pulmonary or cardiac compromise.
 Tachypnea: 20 or more respirations per minute.
 Bradypnea: 10 or less respirations per minute (may be normal for athletes).
 Watch for bilateral symmetry of movement of the chest wall, during inspiration and expiration.
2. Pulsations in any of the following areas

 Pulsations are more exaggerated lifts and heaves of the chest and can provide clues to the size and
symmetry of the heart.
 Aortic: Right side at 2nd ICS
 Pulmonic: Left side at 2nd ICS
 Er b’ sPoint : Left side 3rd ICS
 Tricuspid: Left side 4th ICS
 Mitral: Left side 5th ICS, ~7-10 cm lateral of sternum
 Epigastric: Soft tissue inferior to tip of xyphoid process.
3. Check apical impulse

 aka PMI (point of maximal intensity or maximal impulse
4. Precordial heaves (dilated, failing heart)

 Visual inspection at the left heart side checking for thrusting up or down at each heart beat.
 Indicates: Severe ventricular dilatation or heart failure (congestive heart disease)
5. Abnormalities of the finger and toe nails

 Paronchia: Hang nail
 Clubbed nails: Respiratory or heart problems
 Spooned nails (Koilonchia): Iron deficiency anemia, fungal infection, hypothyroidism
 Pitted: Psoriasis
 Broad and flat: Secondary syphilis
6. Cyanosis
 Blue color of the lips, ears or nails (due to hemoglobin not bound to oxygen)
 Indicates possible pulmonary or cardiac difficulty.

7. Edema (ankle edema)
 Excessive accumulation of interstitial fluid.
 Press index finger over the bony prominence of the tibia or medial malleolus for several seconds.
 A depression that does not rapidly fill and resume its original shape is evidence of orthostatic edema and
is not usually accompanied by thickening or pigmentation of the overlying skin {Right sided heart
failure}.
 Edema accompanied with thickening and ulceration of the skin is associated with:
 Deep venous obstruction
 Valvular incompetence
 Stasis dermatitis
Palpation
1. Check the A.P.E.T.M. areas for pulsations
 Using the pads of the fingers.
 Use gentle touch and let the movements rise to your fingers, because sensations will decrease as you
increase pressure.
2. Check apical impulse for amplitude and location

 The visible, palpable, pushing force against the chest caused by left ventricular contractions.
 Usually synchronous with the carotid pulse and the first heart sound.
 Appears near the apex of the heart, its location is often a clue to cardiac size.
 It should be visible at the 5th left ICS about 7-9 cm from the midsternal line and can be easily obscured
by obesity, large breasts and great muscularity.
 Normal size of 2.5 cm and usually only occupies one interspace.
 Absence, in addition to faint heart sounds, in the left lateral recumbent position:
 Intervening extracardiac problem
 Pleural or pericardial fluid
 Forceful and widely distributed, fills systole, or is displaced laterally and downward:
 Increased cardiac output
 Left ventricular hypertrophy.
 A lift along the left sternal border:
 May be caused by right ventricular hypertrophy.
 Displaced upward and to the left:
 Possibly due to pregnancy or a high left diaphragm.
 Amplitude is usually small and feels like a tapping sensation.
3. Check the epigastrium for pulsations

 Fingertips below and under apex of sternum pointing toward left shoulder. Instruct patient to inhale and
hold breath while you palpate for pulsations.
 Pulsations coming from S to I to the fingertips may be right ventricular enlargement.
 Pulsations coming from I to S to the fingertips may be abdominal aortic aneurysm.

4. Check the A.P.E.T.M. areas for Thrills
 Use the ball of the hand
 Thrills are best felt through bone.
 A thrill is a fine, palpable, rushing vibration resulting from:
 Aortic stenosis
 Mitral stenosis
 Patient ductus
 Arteriosclerosis
 Ventricular septal defect.
 This indicates a Grade III or better murmur.
Percussion
1. Identify the Location and Size of the Heart
 Note any dextrarotation or enlarged heart.
2. Percuss from Lateral to Medial

 The left 3rd, 4th, & 5th Intercostal Spaces (males) - 3 vertical marks
 The left 3rd & 5th Intercostal Spaces (females) - 2 vertical marks
3. Percuss down the right sternal border

 Dullness is heard at the 6th intercostal space indicating the superior border of the liver.
 Make (1) horizontal mark (males & females)
Auscultation
 Use firm pressure with the diaphragm (high pitched sounds)
 Use light pressure with the bell (low pitched sounds).
1. Palpate the carotid pulse and pair with S1 at the Mitral Area
Patient takes a deep breath in, exhales and holds
2. Listen for general cardiac s

ounds( us epulmoni core rb’spoint s)
 Rate
 Count the number of pulsations for 60 seconds
 The resting pulse rate is usually between 60 and 90 pulsations per minute.
 Rhythm
 The regularity of the heart pattern.
 An irregular heart pattern, which continues in a regular pattern, may indicate sinus arrhythmia.
 A patternless, unpredictable rhythm may indicate heart disease.
3. Auscultate the following areas:

 First with the diaphragm of the stethoscope
 Second with the bell of the stethoscope
 Aortic: Right side at 2nd ICS
 Pulmonic: Left side at 2nd ICS
 Er b’ sPoi nt: Left side 3rd ICS
 Tricuspid: Left side 4th ICS
 Mitral: Left side 5th ICS, ~7-10 cm lateral of sternum
 Epigastric: Soft tissue inferior to tip of xyphoid process.

4. Identify S1 and S2 (heard best with the diaphragm)
 Systole (S1 to S2), is shorter than diastole, at rates less than 100 bpm
 Period of ventricular contraction.
 Left ventricle pressure rises rapidly, levels off, and starts to fall when the blood is ejected from the left
ventricle to the aorta and from the right ventricle into the pulmonary artery.
 Systole is indicated by the first heart sound, palpable apex beat and peripheral pulse
 Diastole (S2 to S1), is longer then systole, at rates less than 100 bpm
 Period of ventricular relaxation.
 Ventricular pressure falls almost to zero, and blood flows from atrium to the ventricle. Late in diastole,
ventricle pressure rises slightly during atrial contraction.
 Ventricular diastole begins with the onset of the second heart sound and ends with the onset of the
first heart sound.
 S1 is louder at the apex
 S1 sounds are comprised of the following:
 Contraction of ventricles.
 Increased intraventricular pressure
 Closure of the mitral and tricuspid valves with blood rebounding in the ventricles transmitting
vibrations to the chest
 Opening of the aortic and pulmonic leaflets
 S2 is louder at the base
 S2 sounds are comprised of the following:
 Relaxation of the ventricles
 Decreased intraventricular pressure
 Aortic and pulmonic leaflets approximate with arterial back pressure completing closure
 Sudden stopping of the back flow set up the vibrations to the chest
5. Listen to S1 and evaluate for splitting:

 Not usually heard. If occurring it may be heard in the mitral area on deep inspiration.
 Accentuated
 Tachycardia
 High cardiac output states {exercise, anemia, hyperthyroidism}.
 In these conditions the mitral valve is still open wide at the onset of ventricular systole and then
closes quickly.
 Diminished
 Bradycardia and first degree heart block {delayed conditions from atria to ventricles).
 The mitral valve has had time after atrial contraction to float back into an almost closed position
before ventricular contraction shuts it.
 Diminishing also occurs by mitral valve calcification as in mitral regurgitation and in reduction of
left ventricular contractility as in congestive heart failure or coronary heart disease.

6. Listen During Systole for:
 Abnormal heart sounds
 The valves of the heart should close without noise, unless they are roughened, thickened, damaged
or altered in some fashion as a result of a disease.
 If abnormal they produce clicks, gallops and/or snapping sounds.
 Listen for pericardial friction rubs.
 Abnormal heart murmurs
 Disruption of the flow of blood into, through or into out of the heart.
 Low pitched murmurs such as ventricular filling murmurs are produced by blood flowing under
relatively low pressure
 High pitched murmurs such as aortic or mitral regurgitation is produced by blood flowing through
narrow orifices under increased pressure.
7. Listen to S2 and evaluate for splitting:

 An expected event which is greatest at the peak of inspiration
 Accentuated
 Tachycardia
 High cardiac output states {exercise, anemia, hyperthyroidism}.
 In these conditions the mitral valve is still open wide at the onset of ventricular systole and then
closes quickly.
 Diminished
 Bradycardia and first degree heart block {delayed conditions from atria to ventricles).
 The mitral valve has had time after atrial contraction to float back into an almost closed position
before ventricular contraction shuts it.
 Diminishing also occurs by mitral valve calcification as in mitral regurgitation and in reduction of
left ventricular contractility as in congestive heart failure or coronary heart disease.
8. Listen During Diastole for:

 Abnormal heart sounds
 The valves of the heart should close without noise, unless they are roughened, thickened, damaged
or altered in some fashion as a result of a disease.
 If abnormal they produce clicks, gallops and/or snapping sounds.
 Listen for pericardial friction rubs.
 Abnormal heart murmurs
 Disruption of the flow of blood into, through or into out of the heart.
 Low pitched murmurs such as ventricular filling murmurs are produced by blood flowing under
relatively low pressure
 High pitched murmurs such as aortic or mitral regurgitation are produced by blood flowing through
narrow orifices under increased pressure.
9. Special Maneuver for Mitral Murmurs

 Patient in left lateral recumbent position
 Use bell (low pitched murmurs) at apical impulse area
 Ask patient to take in a deep breath and hold.
10. Special Maneuver for Aortic Murmurs

 Patient in seated position
 Li s
tena tthele f
ts t
erna lborder( Erb’ spoint)f orbesthearts oundsus ingt hediaphragm (high pitched
murmurs).
 Ask patient to take a deep breath in and lean forward while exhaling all the air.
REVISED - AUSCULTATION OF THE HEART –Sp 08
1. At the Mitral ,area, use the diaphragm and auscultate for S1 while palpating the carotid
pulse to see if they are paired. Have the patient take in a deep breath, exhale, and hold.
2. Auscultate the APETME areas using the diaphragm for general cardiac sounds.
3. Auscultate the APETME areas using the bell for general cardiac sounds.
4. Identify S1 - While staying at the Mitral area, state that S1 is best heard at the apex. State that during
systole you will be listening for splitting that is either accentuated or diminished. State that you are also
listening during systole for murmurs or other abnormal heart sounds.
5. Identify S2 - Move to the Pulmonic area, state that S2 is best heard at the base of the heart. State that during
diastole you will be listening for splitting that is either accentuated or diminished. State that you are also
listening during diastole for murmurs or other abnormal heart sounds.
6. Move to Erb's point and listen for rate and rhythm. State that for rates less than 100 bpm, S1 to S2 is short
and S2 to S1 is long.
S S S S
1 2 1 2
LUB DUB LUB DUB
7. Have the patient assume a left lateral recumbent position (about 45 degrees),
place the bell at the Mitral area, take a deep breath and hold. Listen for mitral
murmurs.
8. Have the patient assume a seated position. Place the diaphragm at the Aortic area
or Erb's point. Have the patient breathe in and let it out in a slow sigh as they lean
forward. Listen for Aortic murmurs.
APETME = Aortic, Pulmonic, Erb's point, Tricuspid, Mitral, Epigastric

HEART SOUNDS
This tape/CD is a supplement to the text Understanding Heart Sounds and Murmurs, With an
Introduction to Lung Sounds by Tilkian and Conover. We recommend that you read the text and
study the illustrations carefully before using the tape/CD. For best results, use either a quality home
or a personal stereophonic/CD system. With the home unit, the quality of what you hear can be
enhanced by lowering the volume and listening with the diaphragm of your stethoscope.
Let us start with the normal first and second heart sounds, S1 and S2, as heard at the second left
intercostal space.
This the familiar lub dub, lub dub, with no additional sounds of murmurs. Concentrate on the second
sound and notice its two components, A2 andP2, approximately 30msec apart.
As you move the stethoscope to the apex in the normal person, P2 is not heard well and the second
sound has one component, A2.
These are the normal heart sounds at the apex with a single component of S2.
Move back to the second left intercostal space to hear again the normal pulmonic component of the
second heart sound.
Several conditions (e.g., right bundle branch block) increase the interval between A2 and P2, causing
a late or delayedP2 and thus producing a widely split second sound, which is best heard at the
second left intercostal space.
Note the wide splitting of the second sound at 50 msec
and now at 70 msec apart.
If there is associated pulmonary hypertension, then the wide splitting of S2 will be appreciated at the
apex as well as the base of the heart.P2 will be accentuated.
A frequently heard abnormal sound is the presystolic atrial gallop or the fourth heart sound, S4,
coinciding with atrial contraction. This sound precedes the first heart sound by 40 to 110 msec and is
frequently associated with a coronary artery disease or hypertension. Listen again to the normal heart
sounds at the apex.
Now listen for the S4 gallop preceding the first heart sound by 110 msec.
For best results, you should use the bell of the stethoscope and listen at the apex, with the patient in
the left lateral position.
An S4 is frequently present with severe hypertension, and this may be accompanied by a loud
second sound.
Note the increased intensity of the second heart sound.

An S4 sound may be closer to the first heart sound, at 80 msec apart
or only 40 msec apart.
When an 84 is so close to the first heart sound, it may be difficult to distinguish it from the first
component of the first heart sound.
For review:
Normal first and second heart sounds at the apex.
84 atrial gallop at 110 msec from 81,
at 80 msecfrom 81,
and at 40 msec from 8 1.
An 84 gallop maybe associated with sinus tachycardia. Here is a presystolic 84 gallop at a heart rate
of 100 beats/min.
Another important heart sound is the ventricular gallop or the third heart sound, also called S3 gallop
or protodiastolic gallop. When at the bedside, use the bell of the stethoscope pressed gently against
the skin and listen at the apex with the patient in the left lateral position. Listen first to the normal
heart sounds.
Now you will hear a left ventricular S3 sound 15'0 msec after the second sound,
Lub dub-ub, lub dub-ub, the "ub" timing with S3.
S3 gallops can be faint and heard only with utmost concentration.
83 gallops are frequently heard in heart failure and are accompanied by fast heart rates. Here is an S3
gallop with sinus tachycardia of 1 a beats/min.
83 gallops produced in the right ventricle are best heard at the left lower sternal border and tend to
increase with inspiration.
Now that you have learned to recognize the third heart sound, we will add the previously learned
fourth heart sound and thus you will hear 84-81..S2-S3, the so-called quadruple rhythm or gallop.
Now the S3 gallop is removed and you hear only the presystolic 84 sound.
Adding the third heart sound again.
It may be difficult to distinguish four discrete sounds during fast heart rates. Listen now to both S3
and S4 gallop sounds at a heart rate of 110 beats/min.
This is most reminiscent of the galloping of a horse.
With rapid heart rates, the third and fourth heart sounds are sometimes perceived as a single mid-
diastolic sound: the so-called summation gallop.
For best results, use the bell of the stethoscope applied lightly at the point of maximum impulse,
with the patient in the left lateral position.
For review:
An atrial gallop,
A left ventricular S3 gallop,
And a summation gallop.
If you are now familiar with the normal heart sounds and the frequently heard third and fourth heart
sounds proceed to the next lesson. If in doubt, return to the beginning and review these sounds
before proceeding further.
Another common heart sound is the systolic ejection sound. Listen again to the familiar first and
second heart sounds.
And now listen to an early systolic ejection about 70 msec after the first sound.
Such sounds are frequently produced by the aortic or pulmonic valves and should not be confused
with S4 gallop sounds. When at the bedside, use the diaphragm of the stethoscope pressed firmly
against the chest wall. Again, a systolic ejection sound.
When these sounds appear later in systole they are called mid-systolic clicks, heard best at the apex.
First, the normal heart sounds.
And now, a mid-systolic click.
Such clicks may be multiple and are frequently associated with mid-to late systolic murmurs. They
reflect mitral valve prolapse with mitral regurgitation. Here is a mid-systolic click with a mid- to late
systolic murmur.
Another important abnormal heart sound it the opening snap of mitral stenosis: a sharp, high-pitched
sound heard early in diastole 40 to 120 msec after the second heart sound. This accompanied by a
loud first sound.
Listen again to the first and second heart sounds at the fourth left intercostal space. Use the
diaphragm of the stethoscope.
Now listen for the opening snap 80 msec after the second heart sound.
This must be distinguished from a widely split second heart sound,
or a later occurring S3 gallop sound.
The quality, location, and timing of these various sounds, as well as the respiratory variation, aid in
their differentiation.
For review:
A split second sound, heard at the second left intercostal space.
the opening snap of mitral stenosis, heard at the fourth left intercostal space,
and an S3 gallop, heard at the apex with the bell of the stethoscope.
Now that you have acquired a basic familiarity with the commonly heard heart sounds, we will listen
for some murmurs. A frequently heard systolic murmur is that of mitral regurgitation. It is heard best
at the apex, occurs throughout systole, and has a high-pitched, blowing character.
First, the normal heart sounds at the apex.
And now, the murmur of mitral regurgitation.
Frequently, a significant degree of mitral regurgitation is accompanied by a ventricular gallop or a

third heart sound.
Concentrate on mid-diastole to appreciate the accentuated third heart sound.
Tricuspid regurgitation should not be confused with mitral regurgitation. This murmur is loudest at
the left sternal border and subxiphoid area and is louder during inspiration and diminishes on
expiration.
Listen carefully to the respiratory variation of inspiration,
and expiration.
Tricuspid regurgitation may be accompanied by an S3 gallop, generated in the right ventricle. This
sound, like the murmur of tricuspid regurgitation, will be' accentuated during inspiration.
Listen to tricuspid regurgitation with right ventricular S3 gallop.
Mitral regurgitation, when caused by rheumatic fever, is frequently accompanied by mitral stenosis.
This is characterized by a loud first heart sound, a normal second heart sound, and a diastolic
opening snap followed by a rumbling murmur.
To start: the normal first and second heart sounds.
Now, note the appearance of the opening snap and the accentuated first heart sound.
Frequently, a diastolic rumble follows the opening snap.
Listen with the bell of the stethoscope for the diastolic rumble of mitral stenosis.
In combined mitral stenosis and mitral regurgitation, the systolic murmur of mitral regurgitation is
also present.
Again, here is the diastolic rumble of mitral stenosis.
And now, the combined mitral stenosis and mitral regurgitation.

Mitral stenosis is frequently accompanied by atrial fibrillation. Here, the heart rate is irregular and
atrial contractions are absent. The diastolic mitral rumble persists, while the presystolic accentuation
may be less pronounced.
First, the normal heart sounds during atrial fibrillation.
And now the opening snap of mitral stenosis with the diastolic rumble.
Now, combined mitral stenosis and mitral regurgitation with atrial fibrillation.
Let's turn our attention to the' aortic valve. Mild aortic stenosis is characterized by a medium-
pitched, rough systolic murmur, peaking in early to mid-systole. Listen again to the first and second
heart sounds at the aortic area.
And now listen to the murmur of mild aortic stenosis, heard best with the diaphragm of the
stethoscope applied firmly to the skin.
Note that A2 is well preserved.
With increasing degrees of aortic stenosis, A2 is diminished and the murmur is harsher and peaks
later in systole.

Examination of the Abdomen
 Patient supine, and their bladder is empty
 Patient is exposed from the xiphoid to the pubis
 Patient’sa r
msa r
ea tthe irsides,a ndt he
irheadi sons
omef
orm ofs
uppor
t
Inspection
1. Skin color
2. Masses
4. Contour
5. Other Abnormalities
Auscultation
1. Bowel sounds (use diaphragm of stethoscope)
 Listen for frequency and character.
 Hyperactive (> 35/min)
 Normoactive (5-35/min)
 Hypoactive (1-4/min)
 Absent (0 bowel sounds, but you must listen for 5 continuous minutes)
2. Friction rubs (use diaphragm of stethoscope )
 Liver
 Spleen
3. Major arteries for bruits (use bell of stethoscope )
 Aorta
 Renals
 Common iliacs
4. Epigastrium for venous hums (use bell of stethoscope )
Percussion
1. Scan all (4) quadrants in a sequential manner
2. Check for a distended bladder
3. Check for liver size (2 marks)
4. Check for dullness of the spleen (1 mark)
5. Check f ort ympanyoft hes tomac h( aka:“gastr
icai
rbubbl
e”)
Palpation
1. Light palpation in all (4) quadrants for:
 Pain
 Tenderness
 Muscle guarding
 Masses
2. Deep palpation in all (4) quadrants for:
 Pain
 Tenderness
 Muscle guarding
 Masses
 Distinguish a superficial from a deep mass (by having patient lift their legs or ½ sit-up)
3. Feel for liver edge
 Standard maneuver
4. Mur phy’ ssi
gn
5. Gallbladder
6. Cont inuet opal pateforli
ver
’se
dge
 Mi ddlet
on’ sma neuve
r
 Hooking maneuver
7. Check for spleen
8. Check around umbilicus
9. Check aorta
10. Kidney entrapment
11. Urinary bladder
12. Rebound Tenderness
 Rovs i
ng ’
sSi g n
 Bl umbe rg’sSi gn
13. Tests for Ascites
 Fluid Wave
 Shifting Dullness
 Puddle Sign
14. Pain Assessment
15. Psoas Sign
16. Obturator Sign
17. Mur phy’ sPunc h

Abdomen Explanation
 Patient is supine & their bladder is empty
 Patient is exposed from xiphoid to pubis
 Patient’sa r
msa reatthe irsides&t hei
rhe a
disr
est
ingons
omes
uppor
t
Inspection
1. Skin Color
 Jaundice/Ictarus
 The yellowing of the skin and sclera due to the buildup of bilirubin in the blood.
 Cause: liver dysfunction.
 Cyanosis
 Blue color to the lips, ears or nails due to hemoglobin not bound to oxygen.
 Cause: Possible pulmonary or cardiac difficulty.
 Cul len’ sSi
g n
 Bluing near umbilicus
 Cause: intra-abdominal bleeding.
 Ecchymosis of Flanks
 Bulges in lateral flanks of abdomen having a blue color
 Cause: acute hemorrhagic pancreatitis.
 Striae (blue or pink)
 Stretch marks.
 Cause: If deep blue or purple can be indicative of Cus hing ’
sSy ndr ome(Hyperadrenalism).
2. Masses
 Hernias
 Protrusion of abdominal contents through abdominal muscles.
 Sist e
rMar yJos eph’sNodul es
 Enlarged lymph nodes around umbilicus.
 Cause: Possibly due to metastatic carcinoma.
 Organomegaly
 Enlarged organs usually the liver and spleen.
 Caput Medusa
 Radiating veins around umbilicus.
 Cause: Portal hypertension, Liver/heart congestion.
 Distended Skin Veins
 Cause: Possibility of thrombosis, ascites or enlarged liver.
 Visible Pulsations
 Usually normal.
 Cause: Can be result of abdominal aortic aneurysm
 Aorta rising and falling could indicate blockage.

4. Contour
 Bulging Flanks
 Cause: Intra-abdominal pressure or possible ascites.
 General Distention and Everted Umbilicus
 Cause: Sign of intra-abdominal pressure.
 Scaphoid Abdomen
 Concave stomach
 Cause: malnutrition, hernia.
5. Other Abnormalities
 Visible Peristalsis
 Obstruction causing visible movement.
 Hypermotility of G.I. tract.
 Diastasis Recti
 Separation of rectus abdominis at the linea alba.
 Seen with pregnancy.
 Scars/Keloids
 Scar: thin to thick fibrous tissue that replaces normal skin.
 Keloid: Irregular-shaped, elevated, progressively enlarging scar. Grows beyond wound boundaries.
Caused by excessive collagen formation during healing.
 Post-surgical or healed wound.
Auscultation
1. Bowel Sounds (Diaphragm)
 Place diaphragm of stethoscope for 15 seconds in each of the 4 quadrants (one minute total) and hold it in
place with very light pressure.
 Listen for bowel sounds and note their frequency and character.
 Usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per min.
 Auscultate to listen to bowel motility and discover vascular sounds.
 Hyperactive: Possible diarrhea (36 and higher per minute).
 Normoactive: Normal (5 to 35 per minute).
 Hypoactive: Constipation (1 to 4 per minute).
 Absent: Obstruction w/ possible blockage. Medical emergency (ZERO sounds for 5 min.).
2. Friction Rubs (Diaphragm)

 A high pitched sound associated with respiration (have patient take 3 deep breaths).
 If present will produce a sandpaper rubbing sound.
 Inflammation of peritoneal surface of an organ from infection or tumors.
 Liver: Between the 6th and 10th ICS midclavicular line on right.
 Spleen: Between the 6th and 10th ICS midaxillary line on left.
3. Major Arteries for Bruits (Bell)

 Aorta: One inch above and one inch to left of umbilicus.
 Renals: Two inches above and two inches lateral from umbilicus. Bilateral.
 Common Iliacs: Two inches down and two inches lateral from umbilicus. Bilateral.

4. Epigastric Region for Venous Hums (Bell)
 Place the bell of the stethoscope below the tip of the xiphoid process and ask the patient to hold their breath.
 Common in children and it usually has no pathologic significance.
 When present it is a low-pitched continuous sound that is louder during diastole.
 Must not be confused with carotid bruit, patent ductus arteriosus or an aortic regurgitation.
 When found in adults it usually occurs with:
 Anemia
 Pregancy
 Thyrotoxicosis
 Intracranial arteriovenous malformation.
Percussion
 To determine the size and shape of the organs and to detect the presence of fluid, air, or solid masses
1. Scan All 4 Quadrants in a sequential manner
 Percuss all quadrants or regions of the abdomen for a sense of overall tympany and dullness.
 Tympany is the predominate sound due to air pressure in the stomach and intestines.
 Dullness is heard over the organs and solid masses.
2. Check for Distended Bladder

 Percuss from ASIS to ASIS.
 If present, dullness in the suprapubic area will be evident.
3. Check for Liver Size and mark (2 marks)

 Begin liver percussion at the right midclavicular line over an area of tympany. [Always begin with an
area of tympany and proceed to an area of dullness, because that sound change is easier to detect than
the change from dullness to tympany].
 Continue downward until the percussion tone changes to one of dullness, which is the upper border of
the liver and mark.
 The upper border usually begins at the 5th to 7th intercostal spaces. An upper border below this may
indicate downward displacement or liver atrophy.
 Percuss upward along the midclavicular line to determine the lower border of the liver and mark.
 The lower border us usually at the costal margin or slightly below it. A lower liver border that is more
than 2 to 3 cm (3/4 to 1 in.) below the costal margin may indicate organ enlargement or downward
displacement of the diaphragm because of emphysema or other pulmonary disease.
 The usual span of the liver is approximately 6 to 12 cm (21/2 to 4 1/2 in.).
 A span greater than this may indicate liver enlargement
 A lesser span suggests atrophy.
 Age and gender influence liver size.
4. Check for Dullness of Spleen (1 mark)

 The spleen is percussed just posterior to the midaxillary line on the left side.
 A small area of splenic dullness may be heard from the 6th to 10th ICS.
5. Check Tympany of Stomach

 Percuss down the midclavicular line on the left side.
 This is the predominate sound because of air in stomach and intestines.

Palpation
 Is used to assess the organs of the abdominal cavity and to detect muscle spasm, masses, fluid, and area of
tenderness.
 The abdominal organs are evaluated for size, shape, mobility, consistency, and tension.
1. Light Palpation in all (4) quadrants for:

 No more than 1cm depth. Skin should feel smooth with consistent softness.
 Pain
 Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was
palpated.
 May be classified as: mild, severe, chronic, acute, piercing, burning, dull or sharp.
 Tenderness
 Unpleasant feeling when a specific area is touched.
 Not present unless area is palpated.
 Muscle guarding
 Patient gasps for breath and/or the abdomen becomes tense (apprehensive).
 Masses
 Collection of cells clumped together.
 Note its size, shape, consistency, motility and/or pulsations.
2. Deep Palpation in all (4) quadrants for: (place the knees of the patient into flexion to relax the abdominal
muscles).
 Delineation of organs and to detect less obvious masses.
 Use palmar surface of extended fingers, pressing deeply and evenly into the abdominal wall.
 Palpate all four quadrants, moving the fingers back and forth over the abdominal contents.
 Palpate about 1 ½ to 2 inches deep or deeper if patient is obese. Tenderness not elicited with light or
moderate palpation may become evident.
 Deep pressure may also evoke tenderness in the healthy person over the cecum, sigmoid colon, aorta and
in the midline near the xiphoid process.
 Pain
 Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was
palpated.
 May be classified as: mild, severe, chronic, acute, piercing, burning, dull or sharp.
 Tenderness
 Unpleasant feeling when a specific area is touched.
 Not present unless area is palpated.
 Muscle guarding
 Patient gasps for breath and/or the abdomen becomes tense (apprehensive).
 Masses
 Collection of cells clumped together.
 Note its size, shape, consistency, motility and/or pulsations.
 Distinguish if mass is superficial or deep
 Have patient do a half sit-up or leg raise with both feet several inches off the table.
 A superficial mass it will still be palpable or visible (superficial to abdominal muscles).
 A deep mass it will not be palpable or visible because the abdominal muscles will obscure the mass.

3. Pal
pat
ef orthel i
ve r( feelf orthel iver ’se dge )
 Usually not palpable. If the edge is felt it should be smooth, even and nontender.
 You are trying to feel for nodules, tenderness and irregularity.
 Standard Maneuver
 Doctor places their left hand under the patient at the 11th and 12th ribs pulling posterior-anterior and
superior to elevate the liver toward the abdominal wall.
 Place your right hand on the abdomen, fingers pointing toward the head and extended so the tips rest
on the right midclavicular line below the level of liver dullness.
 Have the patient breath normally a few times and then take a deep breath and hold. As the patient
exhales push fingers gently but deeply in and up. Try to feel the liver edge as the diaphragm pushes
it down to meet your fingertips.
 Usually it is not palpable.
4. Gallbladder
 Using finger pads push inferior to the liver at the 10 ICS.
 The healthy gallbladder may not be palpable.
 A tender palpable gallbladder may indicate cholecystitis.
 A nontender palpable gallbladder may indicate a common bile duct obstruction.
5.Mur
phy’ sSi gn
 Patient experiences pain and abruptly stops inspiration (reflex apnea, inspiratory arrest) upon
application of any one of the three Feeling Liver Edge tests, or in palpation of the gallbladder.
Cause: Inflamed gallbladder (aka cholecystitis).
 Mi
ddl eton’ sManue ver
 Have patient place their fist under ribs 11 and 12 on the right side.
 Place your right hand on the abdomen, fingers pointing toward the head and extended so the tips rest
on the right midclavicular line below the level of liver dullness.
 Use same breathing instructions as above.
 Hooking Maneuver
 Hook your fingers over the right costal margin below the border of liver dullness.
 Standont hepa tient
’sr ightsidef acinghi sorhe rf eet.
 Press in and up toward the costal margin with your fingers.
 Use same breathing instructions as above.
6. Check for Spleen

 Whi les t
a ndi
ngont hepa tient ’srightside ,r
eacha crosswit
hy ourle f
thanda ndpl aceitbe neat
ht he
patient under the left costovertebral angle.
 Pull posterior-anterior to lift the spleen toward the abdominal wall.
 Pl a cethep al
ma rs urfaceofy ourr ightha ndwi thf i
ng erse
xtende dont hepa tie
nt ’sa bdome nbe lowt he
left costal margin.
 Press your fingertips anterior-posterior toward the spleen as you ask the patient to take a deep breath and
hold.
 Try to feel the edge of the spleen as it moves downward toward your fingers.
7. Check around umbilicus

 Using finger pads palpate for tenderness, bulges or nodules.
 The umbilicus can be everted, but not protruded.
8. Check Abdominal Aorta
 Palpate deeply using your fingertips one inch to the left and one inch up from the umbilicus.
 If a bounding pulse is felt it could be indication of an aortic aneurysm.
9. Kidney Entrapment
 On the right side, place one hand under the pa tient’srig htflanka ndt heot he rhanda tther ightcostal
margin.
 Ask the patient to take a deep breath. At the height of inspiration, press the fingers of your two hands
together to capture the kidney between the fingers.
 Ask the patient to breathe out and hold the exhalation while you slowly release your fingers.
 If you have entrapped the kidney you may feel it slip beneath your fingers.
 Same procedures for the left kidney except doctor moves to the left side of patient.
10. Urinary bladder

 Using finger pads palpate in the suprapubic region.
 The bladder should not be felt unless it is distended.
 If distended it will feel like a smooth, round tense mass.
11. Rebound Tenderness

 Blumbe r g’sSign
 This is a maneuver to access all four quadrants.
 Patient supine, hold your hand at a 900 a nglet
opa ti
ent’sabdome nwi ththef ingerse xtende d.Press
gently and deeply into the abdomen region. Rapidly withdraw your hand and fingers.
 The return to position (rebound) of the structures which were compressed by your fingers causes a
sharp stabbing pain at the site of a problem.
 Indicates: peritonitis.
 Rovsing Sign
 Re boundt ende rnesste stinthel owerl eftqua dra nta ndthepa t
ientha spa
inove
rMc
Bur
ney
’spoi
nt
(lower right quadrant, from the umbilicus to 2/3rd toward the ASIS).
 Indicates: appendicitis.
12. Tests for Ascites

 Fluid Wave
 This procedure requires three hands, so the patient will have to help the examiner.
 Patient supine, ask them to press the edge of their hand and forearm firmly along the vertical midline of the
abdomen. This position helps stop transmission of a wave through adipose tissue.
 Place your hands on each side of the abdomen and strike one side sharply with your fingertips or
perform a deep rebound tenderness test.
 Feel for the impulse of a fluid wave with the fingertips of your other hand.
 An easily detected fluid wave suggests as ascites, however the maneuver is not conclusive.
 A fluid wave can sometimes be felt in people without ascites and may not occur in people with early
ascites.
 Shifting Dullness
 Puddle Sign

13. Pain assessment
 There are 3 Rules for assessment:
 Does the patient give warning not to touch a certain area? Examiner palpates this area carefully
wa tchingpa t
ient’sf a
ciale xpression.
 Examiner asks patient if they are hungry. Patients with an organic cause (appendicitis, intrabdominal
infection) are not hungry, usually nauseated.
 Examiner asks patient to point to site of pain. If pain is in a specific point then it has a greater
significant importance.
 Some Qualities of Pain:
 Burning: Peptic ulcer
 Aching: Appendiceal irritation
 Gradual onset: Infection
 Sudden onset: Duodeneal ulcer, obstruction, acute pancreatitis
 Knifelike: Pancreatitis
 Cramping: Gastroenteritis
14. Psoas Sign

Instruct: Patient supine. Examiner places superior hand on right iliac crest and inferior
handonpa t
ient’sr i
ghtt
high.Ins tr
uctpa tienttora isestr aightl egont heright side
against resistance.
Positive: Increased pain.
Indicates: Appendicitis
15. Obturator Sign

Instruct: Patient supine. Instruct patient to flex their hip to 90 degrees and their knee to 90
degr e
e s.Exa mi ne rplac ess uper i
orha ndonpa tient ’
sr i
ghtkne eandi nf eri
orh a nd
aroundpa tient’sr i
g htankl e.Pa tientint ernallya nde xt
ernallyr ot
a te
st he i
rrig ht
hip against resistance, given by the examiner.
Positive: Increased pain.
Indicates: Ruptured appendix or pelvic abscess
16.Mur phy’ sPunc h

 Place palm of your hand over the right posterior costovertebral angle (Region should be from T10 to T12)
and strike your hand with the ulnar surface or the fist of your other hand.
 Repeat this maneuver over the left costrovertebral angle.
 The patient should perceive the blow as a thud, but it should not cause tenderness or pain.
 Pain indicates: inflamed kidney (nephritis) due to a variety of disorders (kidney stones,
infection, etc.)

Orthopedic
Diagnosis
Diagnosis 2730

Orthopedic Clinical Assessment 2730
50 Point Final Examination
Weeks 9 & 10
06 points Bony palpation
06 points Soft tissue palpation
05 points Range of motion
10 points Nerve Root Evaluation / Package (cervical or lumbar)
4 points (muscle test)
2 points (reflex test)

4 points (sensation test)
04 points Orthopedic test [all correct or no points]
03 points Doctor/patient interaction
50 points Total
Bony palpation = Each student will name (recite from memory) and palpate the structures of one joint on a patient.
Soft tissue palpation = Each student will name (recite from memory) and palpate the structures of one joint on a patient.
Range of motion = Each student will name the action for each motion (recite from memory), name the degrees for each motion (recite
from memory) and demonstrate the motions of one joint on themselves.
Nerve Root Evaluation / Package = Each student will talk their way through and perform either a cervical or lumbar nerve root
evaluation on a patient.
Orthopedic Tests = Each student will talk their way through and perform 5 tests on a patient. They will also explain the positive sign
and the indication for each test. Each test is graded as an all or nothing item. If the test is performed wrong; the student gives the
wrong positive sign and/or indicator then all points are forfeited for that test.
Doctor/patient interaction = Each student will be subjectively graded by the instructor on their skills. Doctor and student introduction must be given.
The Final Laboratory Examination may be administered by any Clinical Sciences Division
Laboratory instructor, should your laboratory instructor be unable to test you.

Essential Final Laboratory Examination Information
 The final practical laboratory examination is worth 50 points [25%] of the total grade for the course. You MUST PASS the Final
Lab exam (> 70) in order to pass the class. The student is responsible for adequate preparation for the final examination. There
are no retakes/re-examinations if a student does not perform well.
 Students are responsible for all information presented in lecture and/or during lab instructions. Students are also responsible for
all information coming from handouts and reference texts. All information for special tests are from the required textbook,
Illustrated Orthopedic Physical Assessment, by Evans (E) and the lab packet.
 If a student does not take the final laboratory examination during his/her scheduled time and does not provide an acceptable
excuse in accordance with the Student Handbook, then he/she will receive a ZERO (0) for their final laboratory examination
grade.
 If a student does not take the final examination during his/her scheduled time and does provide an acceptable excuse according to
the Student Handbook, then there is no forfeiture of points. The day the student returns back to school, the student must
contact and reschedule with his/her instructor an acceptable time to take his/her final laboratory examination.
Students in this lab are expected to be both Doctor and patient. The dress code for the final examination is as follows; males are to
wear gym shorts, females are to wear gym shorts and either an aerobics top, jogging bra, or a bathing suit top. NOTE: There will
be a 3 POINT DEDUCTION FROM the LAB PRACTICAL EXAM FOR NOT WEARING PROPER TESTING ATTIRE!
 There will be no deviation from the testing procedures on page 2 of this note booklet nor will any deletion of material occur for
the final laboratory practical.
 The design of this lab is to be a hands-on experience. The Instructors should budget their time to achieve this goal.
 Each student must have the proper equipment for the final lab examination and may not
share their equipment.
 Each student has 12 minutes to complete the final laboratory examination.

 Upon completion of each regional examination the student must check for any correlation between the positive findings and
subluxations at the related spinal levels.
The Final Laboratory Examination may be administered by any Clinical Sciences Division
Laboratory instructor, should your laboratory instructor be unable to test you.

It is expected the student will greet the patient with the following standardized
introduction.
This will be included in the test format.
Standard Introduction:
Hello, I am (Student first name)

I will be conducting a patient history/exam/chiropractic adjustment today.
Anything we discuss during this visit will be completely confidential.
Ify ouhav eanyquest i
onsorconcer nsdur ingtoday’sappoi nt mentpl easedonot
hesitate to ask.
If at any time you experience any discomfort or pain during the exam/adjustment
please let me know.
Do I have your permission to proceed?

SHOULDER EXAM
INSPECTION
1) For any obvious unnatural movement or posture
2) For any topical abnormalities
Scars/keloids
Discoloration
Abrasions
Blebs
Other apparent pathology
3) For any asymmetry of structure:
Clavicle - dislocation or fracture
Deltoid - atrophy, flaring or dislocation shape changes
Scapular winging or congenital deformity
PALPATION
Bony Palpation
1) Sternoclavicular articulation
2) Clavicle
3) Coracoid process
4) Acromioclavicular articulation
5) Acromion
6) Greater tuberosity of the humerus
7) Bicipital groove
8) Less tuberosity of the humerus
9) Spine of the scapula
10) Body of scapula
11) Scapulothoracic articulation
Soft Tissue Palpation
1) Rotator Cuff Muscles

 Supraspinatus
 Infraspinatus
Teres minor
Subscapularis
2) Subacromial bursa
3) Subdeltoid bursa
4) Axillary borders
 Pectoralis major
Serratus anterior
 Axillary lymph nodes
 Latissimus dorsi
 Bicipital tendon
5) Prominent muscles of region
 Sternocleidomastoid
 Biceps
 Deltoid (palpate as a group and individually)
Anterior portion
Middle portion
Posterior portion
 Trapezius
 Rhomboid muscles (palpate as a unit and individually)
Minor
Major
RANGE OF MOTION
Active and Passive
Flexion (forward) 180 
Extension 60
Abduction 180
Adduction 50
External rotation = (from horizontal abduction of arm) 90
Internal rotation = (from horizontal abduction of arm) 70
Scapular retraction (attention)
Scapular protraction (reaching)
Scapular elevation (shoulder shrug)
Reflex
 Biceps
 Triceps
Sensation (Covered under cervical spine packages)
SPECIAL TESTS
1) Dugas Test, pg. 224 E
2) Anterior Apprehension Test, pg. 202-205 E
3) Posterior Apprehension Test, pg. 202-205 E
4) Codman’ sDr opAr m Test,pg.214-219 E
5) Dawbar n’sTest,pg.222, 223E
6) Yergason Test, pg. 268-269 E (pg. 103 Cipriano)
7) Abbott-Saunder ’sTest ,pg.188-191 E
Speed’ sTest ,pg.254-255 E
Apley’sScr atchTes takaApl ey’sScr at
chTes t,pg.200E
Impingement Sign, pg. 236 E

Shoulder Special Tests
Dugas Test
Instruct: Patient seated, examiner instructs patient to place the hand of the
affected side on the opposite shoulder and then bring the affected elbow
to the chest.
Positive: Inability to touch the opposite shoulder and/or inability of the elbow to touch the chest.
Indicates: Acute dislocation of the shoulder (glenohumeral joint).
Confirmation Tests:
Apprehension Test, Radiography
Anterior Apprehension Test

Instruct: Patient seated, examiner abducts the patients shoulder, flexes the
pati
ent ’
sel bowandt hengr adual lyex ter
nallyr ot
atestot hepat ient’
s
shoulder.
Positive: Patient will have a noticeable look of apprehension or alarm on their face with possible
pain.
Indicates: Chronic anterior dislocation of the shoulder (glenohumeral joint).
Confirmation Tests:
Dugas’Test ,Radi ogr aphy
Posterior Apprehension Test

Instruct: Patient supine, examinerf lexespat i
ent ’
sshoul der,fl
exespat i
ent ’
sel bow
andi nternal lyrotatesthepat i
ent ’
sshoul der .Ex aminerpl aceshi s/ herhandont he
pati
ent ’
sel bowandgr adual l
yappl iesi ncreasingpost eri
orpr essur e.
Positive: Patient will have a noticeable look of apprehension or alarm on their face with possible
pain.
Indicates: Chronic posterior dislocation of the shoulder (glenohumeral joint).
Confirmation Tests:
Dugas’Test ,Radi ogr aphy
Dr opAr m Test/a. k.a.Codman’ sDr opAr m Test

Instruct: Patient seated, examiner passively abducts patients arm to slightly over 90 degrees and
removes support, if patient can maintain arm, then
instructs patient to slowly lower their arm.
Positive: Patient will not be able to lower the arm slowly or the arm drops suddenly.
Indicates: Rotator cuff tear, usually supraspinatus.
Confirmation Tests:
Apl ey’sScr atch,I mpingementSi gn
Dawbar
n’sTest–deep palpation of shoulder elicits well-localized tender area, by
subacromial bursa
Instruct: Patient seated, examiner applies pressure below the affected acromial process with
his/her fingertips. Note for pain or tenderness. Examiner continues to apply pressure
whi l
eabduct ingt hepat ient’sarm past 90 degrees.
Positive: Decrease in pain and/or tenderness.
Indicates: Subacromial bursitis.
Confirmation Tests:
MRI
Yer gason’ sTest( Cipr iano)
Instruct: Pat i
entseat ed,ex ami nerflexespat i
ent’sel bowt o90degr ees.Ex aminerst abil
i
zes
pat i
ent’sel bowwi t
honehandandex er t
ssl ightinf
eriortracti
on.Ex aminerusest hei
r
other hand and graspssl ightlyabov epat ient ’
swr i
st.Ex aminerof f
er sresistancewhil
e
patient is instructed to externally rotate his/her shoulder and slightly supinate.
Positive: 1) Localized pain and/or tenderness at the bicipital groove.
2) Audible click or the biceps tendon subluxes or dislocates
Indicates: 1) Tendinitis
2) Instability of the biceps tendon possibly associated with a torn transverse humeral
ligament
Confirmation Tests:
AbbotSaunder ’sTest ,Speed’ sTest
Abbott-Saunders Test
Instruct: Patient seated,ex ami nerf ull
yabduct sandex ternall
yr otatest hepat ient’s
aff
ectedar m.Ex ami nerpl aceshi s/herfingersont hepatient ’
sbi ci
pital
grooveandt hensl owlyl ower st hepat i
ent ’
saffectedar mt ot heirside.
Positive: Palpable and/or audible click.
Indicates: Subluxation or dislocation of the biceps tendon. (Rupture of transverse ligament or
tendon subluxation beneath subscapularis muscle belly)
Confirmation Tests:
Speed’ sTest ,Yergason’ sTest
Speed’ sTest
Instruct: Patient seated with forearm supinated, and elbow flexed to 45 degrees. Examiner
places his/her fingers on patients bicipital groove with their opposite hand on the
patients forearm. Instruct the patient to flex his/her shoulder, maintain supination and
completely extend the elbow as the doctor applies resistance.
Positive: Pain and/or tenderness in the bicipital groove.
Indicates: Bicipital tendinitis.
Confirmation Tests:
Abbott-Saunder ’sTest ,Yergason’ sTes t
Apl ey’sTest
Instruct: Patient seated. Have him/her place the affected hand behind the head and touch the
oppositesuper iorangl eoft hescapul a=Apl ey’sscrat chsuperior
Then patient is instructed to place the hand behind the back to touch inferior angle of
scapula=Apl ey ’
sscr atchi nferior
Positive: Exacerbation of pain
Indicates: Degenerative tendinitis of rotator cuff tendons (usually Supraspinatus.)
Impingement Sign
Instruct: Patientseat edwi thar msatsi de,ex aminersli
ghtlyabduct spatient ’
sarm( handshoul
d
be pronated) and moves it fully through flexion (will jam greater tuberosity and
anterior/inferior surface of the acromion)
Positive: Pain in the shoulder
Indicates: Overuse injury to the supraspinatus and possibly biceps tendon.

ELBOW EXAM
INSPECTION
1) For any unnatural movement or posture
Scars/ keloids
Discoloration
Abrasions
Blebs
3) For any asymmetry of structure
4)Cubi tusVal gus( mor e“Langl e”t
hanthenor
mal6°t
o15°
)
5) Cubitus Varus (gunstock deformity)
PALPATION
Bony Palpation
1) Medial epicondyle
2) Medial supracondylar line of the humerus
3) Groove of the ulnar nerve
4) Trochlea
5) Olecranon
6) Olecranon fossa
7) Lateral epicondyle
8) Lateral supracondylar line of the humerus
Radial head

1) Ulnar nerve
2) Wrist flexor muscles (palpate as a unit and individually)
 Pronator teres
 Flexor carpi radialis
 Palmaris longus
 Flexor carpi ulnaris
3) Medial collateral ligament
4) Supracondylar lymph nodes
5) Brachial Artery
6) Triceps muscle
7) Lateral collateral ligament
8) Biceps
9) Olecranon bursa
10) ElbowFl ex orsmuscl es“
mobi lewadoft hr
ee”( pal pateasauni
tandi
ndi
vi
dual
l
y)
 Brachioradialis
 Extensor carpi radialis longus
 Extensor carpi radialis brevis

RANGE OF MOTION
Active and Passive
Elbow flexion 150
Elbow extension 0
Forearm supination (radio-ulnar joint) 80
Forearm pronation 80
Reflex
Biceps, Brachioradialis, & Triceps
SPECIAL TESTS
1) Medial Collateral Ligament, pg. 314,315 E

2) Lateral Collateral Ligament Test, pg. 314,315 E
3) Ti
nel ’
sEl bowSi gn,pg.318-320 E
4) Coz en’sTest ,pg.300-310 E
5) Mill
’sTest ,pg.316-317 E
6) Golfer’
sEl bowTest ,pg.306-309 E
Medial Collateral Ligament Test (Abduction Stress Test)

Instruct: Patient seated, examiner stabilizes the lateral aspect of the arm and
places an abduction (valgus) pressure on the medial forearm.
Positive: Excessive gapping & pain.
Indicates: Medial collateral ligament instability.
Confirmation Test:
MRI
Lateral Collateral Ligament Test (Adduction Stress Test)

Instruct: Patient seated, examiner stabilizes the medial aspect of the arm and
placesanadduct ion(varus)pr essur eont
hepat i
ent’
sl at eralforear
m.
Positive: Excessive gapping & pain.
Indicates: Lateral collateral ligament instability.
Confirmation Test:
MRI
Tinel ’
sEl bow Sign
Instruct: Patient seated, with a Taylor reflex hammer, examiner taps over the groove between
the medial epicondyle and the olecranon process.
Positive: Pain and/or tenderness at the site being tapped and paresthesia in the
ulnar nerve distribution area (fingers 4,5).
Indicates: Neuroma of the ulnar nerve.
Confirmation Test:
Nerve Conduction Testing

Cozen’ sTest
Instruct: Patient seated, examiner instructs patient to make a fist and place wrist into extension.
Examiner instructs patient to resist as examiner tries to push extended wrist into flexion.
Positive: Pain over the lateral epicondyle.
Indicates: Lateral epicondylitis (Tennis Elbow).
Confirmation Test:
Mill’
sTest
Mi l
l’sTest (maneuver) (Evans)
Instruct: Patient seated at rest with forearm supinated. In a smooth continuous motion the Dr.
passi velymax imal lyf l
exest hepat i
ent ’
selbow,t henwr i
standt henf inger
s.Whi l
e
mai ntainingwr i
standf i
ngerf lexi
on,t heDr .passi velyext
endst hepat i
ent
’sel bow( the
forearm is now pronated)
Positive: Pain over the lateral epicondyle.
Indicates: Lateral epicondylitis (Tennis Elbow).
Confirmation Test:
Coz en’sTest
Gol fer’sElbow Test

Instruct: Patient seated, examiner instructs patient to extend the elbow and supinate hand.
Examiner instructs patient to flex the wrist against resistance.
Positive: Pain over the medial epicondyle.
Indicates: Medial Epicondylitis
Confirmation Tests:
Coz en’sTest ,Mill
’sTest

WRIST and HAND
INSPECTION
Is hand held in a protected position?
Is hand held in a restricted manner?
Isthe“ att
itude”oft hehandnor mal ?
Scars/keloids
Discoloration
Abrasions
Blebs
Any missing fingers?
Any fingernail pathology?
Any muscle atrophy or finger contractures?
PALPATION
Bony Palpation
1) Radial styloid process
2) Scaphoid (Navicular)
3) Lunate
4) Lister’stuber cl
e( Dorsalt
uber
cle)
5) Triquetrium
6) Pisiform
7) Trapezium
8) Trapezoid
9) Capitate
10) Hook of hamate
11) Ulnar styloid process
12) Metacarpals
13) Phalanges

1) Ulnar artery
2) Radial artery
3) Palmaris longus tendon
4) Carpal tunnel region
5) Thenar eminence
6) Hypothenar eminence
7) Palmar aponeurosis
8) Tissues surrounding proximal interphalangeal joints
9) Tissues surrounding distal interphalangeal joints
10) Distal tufts of fingers

RANGE OF MOTION
Active and Passive

Wrist flexion 80
Wrist extension 70
Wrist ulnar deviation 30
Wrist radial deviation 20
Finger abduction
Finger adduction
Thumb flexion (MCP)
Thumb extension (MCP)
Finger flexion (MCP)
Finger extension (MCP)
Finger Opposition
Reflex
none
Peripheral Nerves
Radial Nerve Median Nerve Ulnar Nerve

Dorsum of the hand on the The radial portion of the The ulnar side of the dorsal
radial side of the third palm and the palmar and palmar surfaces
metacarpal as well as surfaces of the thumb, and the 4th and 5th digit.
the dorsal surfaces of 2nd and 3rd and lateral
the thumb, 2nd and 3rd ½ of the 4th digit.
digit as far as the DIP
joints.

SPECIAL TESTS
 Ti
nel ’
sWr istSi gnpg.390-391 E
 Phalen’sSi gna. k.a.Rev ersePhal en’
sSi
gn&Pr
ayer
’sSi
gn,pg.
380-383E
 Fi
nkel st
ein’ sTest ,pg.366-369 E
 Bunnel -Littler Test, pg. 350-353 E
 Retinacular Test, pg. 390-391 E
 Al
len’sTest ,pg.342-345 E
Tinel ’
sWr i
stSi gn
Instruct: Patient seated with wrist supinated, examiner taps over the palmar (volar)
surface of the wrist. (flexor retinaculum).
Positive: Reproduction of pain, tenderness and/or paresthesia in the median nerve
distribution area (thumb, 2nd, 3rd, and the lateral ½ of fourth finger).
Indicates: Carpal Tunnel Syndrome
Confirmation Tests:
Phal en’sTest,Rev ersePhal en’ sTes t,Ner v eConduct i
onTest ing
Phal en’ sSignAND Rever sePhal en’sSigna. k.a.Pr ayer ’

ssi gn
Instruct: Patient seated, examiner instructs patient to flex both wrists to
maximum degree and approximate until point of pain or 60 seconds.
Prayer sign = maximally extend wrist (palms together), elbows same level as
shoulders for 60 seconds.
Positive: Reproduction of pain and/or paresthesia in the median nerve distribution
area (thumb, 2nd , 3rd and the lateral side of the 4th digit).
Confirmation Tests:
Tinel’sSi gn,NerveConduct i
onTes ti
ng
Finkel st ei
n’sTest
Instruct: Patient seated, examiner instructs patient to place his/her thumb across the palmar
surface of the hand and make a fist. Have patient flex elbow and instruct patient to ulnar
deviate his/her hand.
Positive: Pain distal to the radial styloid process.
Indicates: Stenosing tenosynovitis of the abductor pollicis longus and extensor
polli
cisbr ev i
st endons( DeQuer vai
n’sDi sease)
.
Confirmation Tests:
Blood Testing, MRI

Bunnel -Littler Test
Instruct: Patient seated, examiner places metacarpophalangeal joint in extension and tries to flex
the proximal interphalangeal joint. If no flexion is possible then there is either a joint
capsule contracture or tight intrinsic muscles. To differentiate, examiner places the
metacarpophalangeal joint in a few degrees of flexion and attempts to move the
proximal interphalangeal joint into flexion.
Positive: (1) Flexion of the proximal interphalangeal joint cannot be achieved.
(2) Flexion of the proximal interphalangeal joint is achieved.
Indicates: (1) Joint capsule contracture.
(2) Tight intrinsic muscles.
Confirmation Tests:
Retinacular Test, Blood testing, Radiography
Retinacular Test
Instruct: Patient seated, examiner places proximal interphalangeal joint in neutral and tries to flex
the distal interphalangeal joint. If no flexion is possible then there is either a joint
capsule contracture or tight retinacular ligaments. To differentiate, examiner places the
proximal interphalangeal joint in a few degrees of flexion and attempts to move the
distal interphalangeal joint into flexion.
Positive: (1) Flexion of the distal interphalangeal joint cannot be achieved.
(2) Flexion of the distal interphalangeal joint is achieved.
Indicates: (1) Joint capsule contracture.
(2) Tight retinacular ligament.
Confirmation Tests:
Retinacular Test, Blood testing, Radiography
Allen’ sTest
Instruct: Patient seated, examiner instructs patient to raise his/her hand above the heart level of
his/her head and to open and close his/her fist for 60 seconds. Examiner occludes both
the radial and ulnar artery at the wrist and then lowers the patient's arm with the fist
closed and allows the fist to rest on patient's thigh. Examiner instructs patient to open
closed fist and releases digital pressure over one artery while keeping the other artery
occluded. Record the filling time, while comparing color to the other hand. Then repeat
procedure for other artery.
Positive: A delay of more than 10 seconds (Evans 5 sec.) in returning a reddish color to the hand.
Indicates: Radial or ulnar artery insufficiency. The artery held (occluded) by the examiner is not
the artery being tested.
Confirmation Tests:
Vascular Assessment
**A negative Allen's Test must be obtained before using the radial artery in neurovascular
compression tests.**

CERVICAL SPINE
INSPECTION
Scars/keloids
Discoloration
Abrasions
Blebs
Muscle splinting
Muscle atrophy
Congenital deformity
PALPATION
Bony Palpation
Anterior Aspect
1) Hyoid Bone
2) Thyroid Cartilage
3) First Cricoid Ring
4) Mandible
Posterior Aspect
1) Occiput
2) Inion (EOP)
3) Superior Nuchal Line
4) Mastoid Processes
5) Spinous Processes of Cervical Vertebrae
6) Facet Joints
1) Sternocleidomastoid muscle
2) Anterior lymph node chain
3) Posterior lymph node chain
4) Thyroid gland
5) Carotid pulse
6) Supraclavicular fossa
7) Trapezius muscle
8) Greater occipital nerves
9) Superior nuchal ligament

RANGE OF MOTION
Active and Passive
Flexion 60
Extension 75
Lateral bending left 45
Lateral bending right 45
Left rotation 80
Right rotation 80
Reflexes
None
Sensations (Covered under cervical spine packages)
SPECIAL TESTS
1) Foraminal Compression Test, pg. 94-97 E

2) Cervical Distraction Test, pg. 88-93 E
3) Shoulder Depressor, pg.130-131 E
4) Valsalva Maneuver, pg. 148-151 E
5) Swallowing Test, pg. 142,143 E
6) Soto Hall Sign, pg. 132-135 E
7)Ker nig’sSi gn,pg.538-539 E
8) Spinal Percussion Test, pg. 136-137
9) O'Donoghue Maneuver, pg. 120-125
Foraminal Compression Test

Instruct: Patient seated with examiner standing behind. Examiner clasps his/her hands over
pat i
ent’
sheadandex ertsgr adualincr easi ngdownwar dpressur
e.Exami nerr epeat
sthi
s
procedur ewi t
ht hepat i
ent ’
sheadr otatedr ightandt henlef
t.
Positive: 1) Exacerbation of localized cervical pain.
2) Exacerbation of cervical pain with a radicular component.
Indicates: 1) Foraminal encroachment or facet pathology without nerve root
compression.
2) Foraminal encroachment with nerve root compression or facet pathology (then
evaluate the myotome, reflex & dermatome of the nerve root involved).
Confirmation Tests:
Shoulder Depression Test, Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI,
Cervical Distraction Test

Instruct: Patientseat ed:t heex ami nergr
aspst hepat i
ent’
sheadwi thbot hhandsandgr adual
l
y
exerts upward pressure keeping hands off TMJ and ears.
Positive: 1) Diminished or absence of pain.
2) Increase of cervical pain.
Indicates: 1) Foraminal encroachment (local pain diminishes), nerve root compression
(Radicular pain diminishes).
2) Muscular strain, ligamentous sprain, myospasm, facet capsulitis.

Confirmation Tests:
Foraminal Compression Test, Shoulder Depression Test, Reflex and Sensory Testing, Radiography,
MRI, Nerve Conduction Testing
Spinal Percussion Test

Instruct: Patient seated with head in slight flexion, percuss each cervical spinous process(es)
and the associated musculature with the pointed end of a reflex hammer.
Positive: 1) Local pain
2) Radiating pain
Indicates: 1) Possible fractured vertebrae, ligamentous involvement (spinous pain), muscular
involvement (muscular pain).
2) Possible disc pathology.
Shoulder Depression Test

Instruct: Pat ientseated,ex ami nerst abil
izespat ient ’
slaterally flexed head while
pushing down on shoulder.
Positive: 1) Localized pain on the side being tested.
2) Pain on opposite side being tested.
Indicates: 1) Localized Pain:
Dural sleeve adhesion, and muscular adhesion/contracture, or spasm, or ligamentous
injury.
2) Radicular Pain:
On side being tested neurovascular bundle compression, dural sleeve adhesions, or
Thoracic Outlet Syndrome
On opposite side being tested foraminal encroachment with nerve root compression.
Confirmation Tests:
Cervical Distraction, Foraminal Compression Test, Sensory and Reflex Testing, and MRI
Valsalva Maneuver
Instruct: Patient seated, examiner instructs patient to take a deep breath and hold,
while bearing down as if having a bowel movement.
Positive: Local or Radiating pain from site of lesion.
Indicates: Space occupying lesion.
Confirmation Tests:
Swallowing Test, Shoulder Depression Test, Cervical Distraction, Foraminal Compression Test,
Sensory and Reflex Testing, MRI
Swallowing Test
Instruct: Patient seated: examiner instructs the patient to swallow.
Positive: Difficulty in swallowing.
Indicates: Space-occupying lesion at anterior portion of cervical spine. Possibly esophageal or
pharyngeal Injury, anterior disc defect, muscle spasm or osteophytes etc.
Confirmation Testing:
Valsal va’sTest
,Sensor yandRef l
exTes ti
ng,MRI

Soto Hall Sign
Instruct: Patientsupine,ex ami nerf l
ex espat i
ent ’
sheadt owar dhi s/ herchestwhil
e
exerti
ngdownwar dpr essur eonpat ient ’
ss t
ernum wi thhy pothenareminenceofi
nfer
ior
hand.
Positive: Generalized pain in the cervical region, which may extend down to the level
of T2.
Indicates: Non-specific test for structural integrity of cervical region.
Confirmation Tests:
O’Donoghue’ sTest ,Spi
nalPer cussi onTest, Swallowing Test, Valsalva Test, Sensory and Reflex
Testing, MRI
Ker nig’sSi gn
Instructs: Patient supine, examiner passively flexes patient ’
shi pto90degr eesandthepat
ient
’s
kneet o90degr ees.Ex ami nerextendspat ient
’sleg completely.
Positive: Inability to fully extend the leg and/or pain (usually in the neck region.)
Indicates: Meningeal irritation/ meningitis.
Confirmation Tests:
Brudz inski’
sSign,LumbarTap
O'Donoghue Maneuver (One of the best tests for Whiplash injury used by an
examiner, can also be utilized on ANY joint in the body to determine
sprain/strain injury )
Instruct: Patient is seated, examiner grasps the patient's head with both hands and passively
takes the cervical region through a range of motion. The examiner then takes the
cervical region through isometric contractions.
Positive: 1) Pain during passive range of motion.
2) Pain during resisted range of motion.
Indicates: 1) Ligamentous sprain. (Passive ROM stresses ligaments)
2) Muscle/tendon strain. (Active ROM stresses muscles and tendons)

Evaluation of Nerve Root Lesions
Involving the Upper Extremity
Always use the MRS system in the correct order, any deviation will result in a loss of points
1) Muscle –test and name the muscle/s and nerve for each neurological package being tested
2) Reflex –test and name the appropriate reflex being tested; if no reflex it must be stated.
3) Sensation –t estt heappr opr
iatedermat omef ort
heneur ologi calpac kageandi t
’scor respondi
ng
dermatome above and below following the format enclosed from Hoppenfeld
Evaluation is to be in this order: Muscle test (motor), Reflex, Sensation (dermatome)
Testing individual nerve root C5

a) Disc Level C4
b) Muscle tests (2) Shoulder abduction: deltoid (axillary nerve)
Forearm flexion: biceps (musculocutaneous nerve)
c) Reflex Biceps
d) Sensation Lateral arm

a) Disc Level C5
b) Muscle test (1) Wrist extension: extensor carpi radialis longus
& brevis, and extensor carpi ulnaris ( radial nerve)
c) Reflex Brachioradialis
d) Sensation Anterior lateral forearm, palm, thumb and 2nd digit

a) Disc Level C6
b) Muscle tests (3) Elbow extension: triceps (Radial Nerve)
Wrist flexion: flexor carpi radialis (Median Nerve), flexor carpi
ulnaris (Ulnar Nerve)
Finger extension: extensor digitorum communis, extensor
indicis profundus, extensor digiti minimi (radial nerve)
c) Reflex Triceps
d) Sensation 3rd digit, middle of palm

a) Disc Level C7
b) Muscle test (1) Finger flexion: flexor digitorum superficialis, flexor digitorum
profundus, lumbricals (median and ulnar nerves)
c) Reflex None
d) Sensation 4th and 5th digits, antero-medial hand and forearm
Testing individual nerve root T1

a) Disc Level T1
b) Muscle tests (2) Finger abduction : dorsal interossei (ulnar nerve)
Finger adduction : palmer interossei (ulnar nerve)
c) Reflex None
d) Sensation Antero-medial arm (distal aspect of arm to proximal aspect of
forearm)

Dermatomes of the Upper Extremity
Initial Examination Procedure
Example (Examination of C5 package dermatomes)
Patient seated, anatomical position, eyes closed.
Verbage = Can you feel this? AND does this feel like this?
C4 of right side compared to C4 of left side (dermatome above)

C5 of right side compared to C5 of left side (dermatome package)
C6 of right side compared to C6 of left side (dermatome below)
Secondary Examination Procedure

Example (Examination of C5 package dermatomes)
Verbage = Can you feel this? AND does this feel like this?
First
C4 of right side compared to C5 of right side
C5 of right side compared to C6 of right side
Second
C4 of left side compared to C5 of left side
C5 of left side compared to C6 of left side

Involving the Upper Extremity
(Examined As Follows)
Muscle –test and name the muscle/s and nerve for each neurological package being tested
Reflex –test and name the appropriate reflex being tested; if no reflex it must be stated.
Sensation –t
estt
heappr opr i
ateder mat omef ort
heneur ol
ogi calpac
kageandi t
’scor
respondi
ng
Always use the MRS system in the correct order:

 Muscle
 Reflex
 Sensation
Muscle (motor) Reflex Sensation

(dermatome)
One hand above joint of Rapid flick of hammer
motion for stability on tendon Patient seated
One hand used as No tension in muscles Anatomical position

short lever to test around tendon
muscle Eyes closed
Always bilateral
No hands on joints Pin to skin (verbiage
Skin on skin used = does this feel
Gradual increase in like this), skin on
pressure Always bilateral skin
Always bilateral Always bilateral
Test sensation above

and below
For the evaluation of Nerve Root Lesions follow pages 22, 23, and 24 of this laboratory
handout. Students are not to follow the Cipriano or Evans protocol for this section.
***** LECTURE MATERIAL ONLY *****

Involving the Thoracic and Upper
Lumbar Spine Regions
Testing individual nerve root levels T2-T12

a) Disc Level T2-T12
b) Muscle test (1) Rib elevation : intercostals [segmented innervated and difficult to evaluate
individually], rectus abdominus
c) Reflex: None (can perform superficial abdominal reflex)
d) Sensation: T4 = nipple line
T7 = xyphoid process
T10 = umbilicus
T12 = groin
**There is sufficient overlap of these areas so that no anesthesia will occur
if only one nerve root is involved.**
Testing individual nerve roots L1, L2 and L3 pg. 234

a) Disc Level T12-L2
b) Muscle test (1) Primary hip flexor : iliopsoas (L1-L3)
c) Reflex None
d) Sensation Anterior thigh, obliquely from lateral to medial {L1 top of thigh, L2 middle
of thigh, L3 lower thigh}
Testing individual nerve roots L2, L3 and L4 pg. 236

a) Disc Level L1-L3
b) Muscle tests (2) Primary knee extensors : Quadriceps Femoris, Vastus
Medialis, Vastus Intermedius ( L2-L4, Femoral Nerve)
Primary adductor : Adductor longus, Adductor Brevis, Adductor Magnus
(L2-L4, Obturator Nerve)
c) Reflex Patellar
d) Sensation L2 middle of thigh, L3 lower thigh, L4 anteriomedial leg below the knee
and medial side of the foot

LUMBAR SPINE
INSPECTION
Scars/keloids
Discoloration
3) Infection signs
4. Heating pad redness
5. Birthmarks
6. Cafe-au-lait spots
4) Abrasions
5) Blebs
6) Other apparent pathology
Lipoma
Hairy patches
For any asymmetry of structure
Shoulders level
5. Left vs. right symmetry
6. Listing to one side
7. Hyperlordosis vs. kyphosis
PALPATION
Bony Palpation
1) Lumbar spinous processes
2) Sacral tubercles
3) Iliac crest
4) PSIS

1) Paraspinal muscles (palpate as a unit) superficial layer
 Spinalis
 Longissimus
 Iliocostalis
2) Sciatic nerve
3) Gluteus Maximus
4) Gluteus Medius
5) Hamstrings
 Biceps femoris
 Semitendinosus
 Semimembranosus
6) Anterior abdominal muscles

RANGE OF MOTION
Active and Passive
Flexion 25
Extension 30
Left lateral bending 25
Right lateral bending 25
Left rotation 30
Right rotation 30
Reflex
Patellar and Achilles
Sensation (Covered under lumbar spine packages)
SPECIAL TESTS
1) Hoov er’sSign,pg.1000-1001 E
2) Straight Leg Raiser (SLR), pg. 602-605 E
3) Gol dthwait’sSi gn,pg.644-645 E
4) Bragar d’sSi gn,pg.506-507 E
5) Buckling Sign pg. 209 C
6) Bowstring Sign, pg. 504-505 E
7) Lasegue’ sTestpg.548E
8) Milgram’ sTest ,pg.574-575 E
9) Valsalva Maneuver, pg. 148-151 E
10) Becht erew’sTest pg. 496-499 E
11) Ant eriorInnomi nat eTest,akaMaz i
on’sPelvi
c Maneuver, pg. 630 E
(Advancement Sign)
12) Lewin Standing Test pg. 556-557
13) Ner i
'sBowi ngTest( Neri’
sSi gn)pg.582-583
14) Heel Walk, pg. 526 E
15) Toe Walk, pg. 526 E
16) Ely's Heel to Buttock Test, pg. 518-519 (
Evan’
scal
lst
hisEl y’ssignasana.
k.a.
)
Hoover ’sSi gn
(Used to differentiate organic versus hysterical leg paralysis)
Instructs: Patient supine, examiner instructs patient to lift the affected leg while the examiner
places one hand under the heel of the non-affected leg (healthy side).
Positive: Lack of counter-pressure on the healthy side
Indicates: Lack of organic basis for paralysis (Malingering/hysteria).
With organic hemiplegia, the patient will still exert downward pressure when attempting
to raise paralyzed leg)

Straight Leg Raiser (SLR)
Instruct: Pat i
entsupine,ex ami nerr ai
sespat ient ’
slegsl owl
yto900 or to the point
of pain.
Positive: Radiating pain and/or dull posterior thigh pain.
Indicates: Sciatic radiculopathy or tight hamstrings. Positive between 35 –70 degrees
= possible discogenic sciatic radiculopathy (Cipriano)
Confirmation Tests:
Becht er
ew’ sTes t,Br aggar d’sTest,Lasegue’ sTest ,Lewi n’
sSt andingTest
Gol dthwai t’
sSi gn
Instruct: Patient supine examiner places the fingers of their superior hand under the interspinous
spaces of the patient's lower lumbar vertebrae. Examiner then raises one of the
patient's extended legs.
Positive: Localized pain, low back or radiating pain down the leg.
Indicates: Lumbo-sacral or sacroiliac pathology. Pain occurring after the lumbar spinouses move
= possible lumbo-sacral problem. Pain occurring before the lumbars move = possible
sacroiliac problem.
Confirmation Tests:
BeltTest ,Gaenslan’ sTes t
Bragar d’sSign
Instruct: Patient supine, examiner performs a (SLR) on the patient. Examiner
lowers the raised leg (5 degrees) from the point of pain and sharply
dorsifl
ex espat i
ent’
sf oot.
Positive: Radiating pain in posterior thigh.
Indicates: Sciatic radiculopathy
Confirmation Tests:
Becht er ew’
sTes t,Las egue’ sTest ,SLRTes t
Buckling Sign (Cipriano)

Instruct: Patient is supine, examiner performs a SLR on the patient.
Positive: Pain in the posterior thigh with sudden knee flexion (buckle).
Indicates: Sciatic radiculopathy.
Confirmation Tests:
Becht er ew’
sTes t,Br aggar d’sTest ,Lasegue’ sTest,Lewi n’sSt andingTest
Bowstring Sign
Instruct: Patienti ssupi ne,ex aminerpl acespat ient’slegont heirshoul derandf irst
applies pressure to the hamstring muscle if pain is not elicited then apply
pressure to the popliteal fossa.
Positive: Pain in the lumbar region or radiculopathy.
Indicates: Sciatic nerve root compression, helps rule out tight hamstrings.
Confirmation Tests:
Heel Walk Test, Toe Walk Test, Milgram’ sTest,Ner i
’sBowi ngTest

Lasegue’ sTest
Instruct: Patient Supine. Hip and leg bent to 90 degrees. Slowly extend the knee (keeping hip at
or close to 90 degrees).
Positive: Reproduction of sciatic pain before 60 degrees
Indicates: Sciatica
Confirmation Tests:
Becht erew’sTest,Br aggard’sTest ,Lewi n’sSt andi ngTest ,SLRTest
Mi l
gr am’ sTest
Instruct: Patientsupi ne,ex aminerr aisesbot hofpat ient’slegs2-3 inches off the
table and instructs patient to hold legs off the table for 30 seconds.
Positive: Inability to perform test and/or low back pain.
Indicates: Weak abdominal muscles or space occupying lesion.
Confirmation Tests:
Bows tr
ingTest ,Heel Wal kTest ,ToeWal kTest ,Kemp’ sTest ,Ner i
’sBowi ngTest
Valsalva Maneuver
Instruct: Patient seated, examiner instructs patient to take a deep breath and hold
while bearing down as if straining at a bowel movement.
Positive: Radiating pain from site of lesion (usually positive in cervical or lumbar area of the
spine).
Indicates: Space occupying lesion (e.g. disc pathology).
Confirmation Tests:
Swallowing Test, Shoulder Depression Test, Cervical Distraction, Foraminal Compression Test,
Sensory and Reflex Testing, MRI
Becht er ew’
sTest
Instruct: Patient seated, examiner instructs patient to extend one knee at a time alternately, then
both together.
Positive: Reproduction of radicular pain or inability to perform correctly due to tripod sign.
Confirmation Tests:
Bragar d’ sTest
,Lasegue’ sTest ,Lewin’sSt andi ngTest ,Straight Leg Raising Test
Neri's Bowing Test ( Ner i

’sSign)
Instruct: Examiner instructs patient to bend forward from the waist.
Positive: Pain accompanied by flexion of the knee on the affected side and body
rotation away from the affected side.
Indicates: Positive with a variety of low back pathologies. Hamstring tension on the pelvis may
trigger the response.
Confirmation Tests:
Bows tr
ingSign,HeelWal kTest ,ToeWal kTest,Kemp’ sTest ,Mi
lgr
am’ sTes t

Anterior Innominate Test a.k.a. Mazi on’sPel vic Maneuver (Advancement Sign)
Instruct: The patient is standing. Examiner instructs patient to advance one leg forward
approximately 2-3 feet. Patient is then instructed to bend forward from the waist and
touch the advanced foot with both hands (advanced knee should be straight).
Positive: The inability to bend at the waist more than 45 degrees, because of either/or
(1) radiating pain along the sciatic nerve, either unilateral or bilateral
(2) low back pain (lumbar or pelvic regions)
Indicates: (1) sciatic neuralgia or radiculopathy, etc., possibly due to lumbar disc pathology
(2) anterior (rotational) displacement of the ilium relative to the sacrum.
Note: this test puts a strain on the sciatic nerve in a similar manner to the Straight Leg
Raise, Lasegue, and Bechterew tests. If this test is positive (sciatica), those tests should
beal so.I nconsi stencyofposi ti
vesi gns,al ongwi thapat i
ent ’
si nabilityt
ostateex actly
when and where the pain occurs, may indicate malingering.
Lewin Standing Test

Instruct: Examiner instructs patient to bend forward slightly at the waist with knees slightly flexed.
Examiner first brings one knee into complete extension. Next the examiner brings the
other knee into complete extension. Finally the examiner brings both knees into
complete extension.
Positive: Radiating pain down the leg causing flexion of the patient's knee or
knees.
Indicates: Gluteal, lumbosacral or sacroiliac pathologies.
Confirmation Tests:
Becht er
ew’ sTes t
,Br agar
d’st
est
,Lasegue’
sTes
t,SLRTest
Heel Walk
Instruct: Patient walks on heels.
Positive: Inability to perform test.
Indicates: L4-L5 disc problem (L5 nerve root).
Confirmation Tests:
Bows tr
ingTest ,Kemp’ sTest ,Milgram’ sTest
,Ner i
’
sBowi
ngTest
Toe Walk
Instruct: Patient walks on toes.
Indicates: L5-S1 disc problem (S1 nerve root).
Confirmation Tests:
Bows tr
ingTest ,Kemp’ sTest ,Milgram’ sTest
,Ner i
’
sBowi
ngTest

Ely's Heel to Buttock Test ( Ev an’ scal l
sthisEl
y’
ssignasana. k.a.)
Instruct: Patient prone, examiner flexes the knee of the patient's affected leg to 90 degrees.
Examiner then approximates the heel of the affected leg to the contralateral buttock and
hyperextends the thigh off the table.
Positive: (1) Inability to raise the thigh.
(2) Pain in the anterior thigh.
(3) Pain in the lumbar region.
Indicates: (1) Iliopsoas spasm.
(2) Inflammation of lumbar nerve roots.
(3) Lumbar nerve root adhesions.
Confirmation Tests:
Femoral Stretch Test

Involving the Lower Extremity and Lumbar Spine
Reflex –test and name the appropriate reflex being tested; if there is no reflex it must be stated.
Sensation –tes
ttheappropriat
eder matomef ortheneur ol
ogi calpackageandi t
’scorrespondi
ng
Evaluation is to be in this order: Muscle test (motor), Reflex, Sensation (dermatome)
Testing individual nerve root L4

a) Disc Level L3
b) Muscle test (1) Foot dorsiflexion & inversion: tibialis anterior (deep peroneal
nerve)
c) Reflex Patellar Tendon
d) Sensation Medial aspect of leg, medial foot, medial aspect of big toe
Testing individual nerve root L5

a) Disc Level L4
b) Muscle tests (4) Foot dorsiflexion
Big toe dorsiflexion: extensor hallucis longus (deep peroneal
nerve)
Toes 2,3,4 dorsiflexion: extensor digitorum longus & brevis
(deep peroneal nerve)
Hip and Pelvis abduction: gluteus medius & minimus (superior gluteal
nerve)
c) Reflex None
d) Sensation Lateral leg, dorsum of foot, and middle three toes
Testing individual nerve root S1

a) Disc Level L5
b) Muscle tests (3) Foot Plantarflexion: Gastrocnemius and Soleus (Tibial
Nerve)
Foot plantar flexion and eversion: peroneus longus & brevis (Superficial
Peroneal Nerve).
Hip extension: gluteus maximus (Inferior Gluteal Nerve).
c) Reflex Achilles
d) Sensation Posterior aspect of the leg, lateral aspect of foot, and lateral
aspect of little toe.
Testing individual nerve root S2

a) Disc Level S1
b) Sensation Posterior aspect of thigh over popliteal fossa onto posteromedial
calf

Dermatomes of the Lower Extremity
Initial Examination Procedure
Example (Examination of L5 package dermatomes)
Verbage = Can you feel this? And does this feel like this?
L4 of right side compared to L4 of left side (dermatome above)

L5 of right side compared to L5 of left side (dermatome package)
S1 of right side compared to S1 of left side (dermatome below)
Secondary Examination Procedure

Example (Examination of L5 package dermatomes)
Verbage = Can you feel this? And does this feel like this?
First
L4 of right side compared to L5 of right side
L5 of right side compared to S1 of right side
Second
L4 of left side compared to L5 of left side
L5 of left side compared to S1 of left side

Involving the Lower Extremity
(Examined As Follows)
Reflex –test and name the appropriate reflex being tested; if no reflex it must be stated.
Sensation –test the appropriate dermatome for the neurologi
calpackageandi t
’scorrespondi
ng
Always use the MRS system in the correct order:

 Muscle
 Reflex
 Sensation
Muscle (motor) Reflex Sensation

(dermatome)
One hand above joint of Rapid flick of hammer
motion for stability on tendon Patient seated
One hand used as No tension in muscles Anatomical position

short lever to test around tendon
muscle Eyes closed
Always bilateral
No hands on joints Pin to skin (Verbiage
Skin on skin used = does this feel
Gradual increase in like this)
pressure Always bilateral Skin on skin
Always bilateral Always bilateral
Test sensation above

and below
The evaluation of Nerve Root Lesions follow pages 32, 33, and 34 of this laboratory
handout. Students are not to follow the Cipriano or Evans protocol for this section.

HIP and PELVIS
INSPECTION
 Gait
 Gluteus medius or maximus lurch
 Scars/keloids
 Discoloration
 Abrasions
 Blebs
 Other apparent pathology
 Iliac Spines on same plane
 Hyperlordotic/Kyphotic lumbar spine
 Gluteal folds symmetry
PALPATION
Bony Palpation
Anterior
1) ASIS
2) Iliac crest
3) Iliac tubercle
4) Greater trochanter
Posterior
1) PSIS
2) Ischial tuberosity
3) Coccyx

1) Femoral triangle borders
 Sartorius
 Adductor longus
 Inguinal ligament
1) Quadriceps muscles (palpate as a unit and individually)
 Vastus Lateralis
 Vastus Medialis
 Vastus Intermedius
 Rectus Femoris
3) Greater trochanteric bursa
4) Gluteus medius
5) Gluteus maximus
6) Sciatic nerve
7) Cluneal nerves
8) Hamstrings
 Biceps femoris
 Semitendinosus
 Semimembranosus

RANGE OF MOTION
Active and Passive
Flexion 120
Extension 30
Abduction 45
Adduction 45
Internal rotation 45
External rotation 45
Flexion and Adduction
Flexion, Abduction and External Rotation
Reflex - None
SPECIAL TESTS
1) Leg Length Discrepancy (true and apparent), pg. 696 E
2) All
is’Si gn,pg.698E
3) Thomas Test, pg. 736 E
4) Anvil Test, pg. 702 E
5) Patrick Test aka Faber Sign, pg. 728 E
6) Laguer re’sTest ,pg.654-655
7) Gaensl en’sTest ,pg.640-641 E
8) Lewi nGaensl en’sTest ,pg.656E
9) Hibb’sTest, pg. 646 E
10) Ober ’sTes t
,pg.726E
11) Pelvic Rock Test aka Iliac Compression Test, pg. 648-651 E
12) Trendel enbur g’sTest ,pg.738E
13) Nachlas Test, pg. 578-579 E
14) Yeoman's Test, pg. 670-671
15) Ely’sSi gn( ElyTest ),pg346 Cipriano

Leg Length Discrepancy
Instruct: Patient supine, (True) examiner takes a cloth measuring tape and measures from ASIS
to the medial malleoli of the same leg. Examiner then measures from ASIS to the
medial malleoli of the opposite leg. (Apparent) Examiner takes a cloth tape measure
and measures from the umbilicus to the medial malleoli of one leg and then measures
from the umbilicus to the medial malleoli of the opposite leg.
Positive: Different measurements.
Indicates: True = bony abnormality above or below level of trochanter difference. (anatomical short
leg)
Apparent = pelvic obliquity (Tilted pelvis).
Confirmation Test:
Radiography
Allis’Si gn (
Gal eaz zi’
sSi gn)=( Pediat r
icTestusedf or1mont ht o2y ears-old can also be
used in adults)
Instruct: Patient is supine, examiner instructs patient to place both feet flat
(approximate great toes and medial malleoli bilateral) on the
bench while flexing both knees to 90 degrees.
Positive: Difference in height and anteriority of the knees.
Indicates: (1) If one knee is lower = ipsilateral congenital hip dislocation or tibial
discrepancy (anatomical short leg)
(2) If one knee is anterior = ipsilateral congenital hip dislocation or femoral
discrepancy (anatomical short leg)
Confirmation Test:
Radiography
Thomas Test
Instruct: Patient supine, examiner instructs patient to approximate each knee one at a time to
his/her chest and hold.
Positive: Lumbar spine maintains lordosis (should flatten) and opposite hip does not straighten.
Indicates: Contracture of the hip flexors (iliopsoas).
Confirmation Tests:
Ober ’sTest,Trendel enber g’sTest
Anvil Test
Instruct: Patient supine, examiner elevates the affected leg while keeping the knee extended.
The examiner then makes a fist and strikes t heaf f
ectedl
eg’s
inferior calcaneus.
Positive: Localized pain in long bone or in hip joint
Indicates: Possible fracture of long bones, or hip joint pathology.
Confirmation Test:
Radiography

Pat ri
ck’sTesta.k.a. FABERE sign
Instruct: Patient supine,ex ami nerf
lexes,abduct sandex ter
nal l
yr ot
at est hepat ients’hi
psot
hat
the ankle rests above or below the contralateral knee. Examiner then extends the hip
by pushing just superior to the knee while stabilizing the contralateral ASIS.
Positive: Pain in the hip region.
Indicates: Hip joint pathology.
Confirmation Tests:
Laguer re’sTest,Radi ography
Laguer r e’
sTest
Instruct: Patient is supine, examiner grasps the affected leg, flexes and externally rotates the hip
and abducts the thigh (this test is similar to Patrick except the ankle of the affected leg
is not resting on the contralateral knee). Examiner applies pressure to the end range of
motion while stabilizing the contralateral ASIS (rest ankle on forearm and with other
hand reach under arm to stabilize).
Alternate Procedure (Cipriano): examiner exerts downward pressure on knee with
superior hand, and exerts upward pressure on the ankle with the inferior hand.
Positive: (1) Pain in the hip joint
(2) Pain in the sacroiliac joint.
Indicates: (1) Hip joint pathology
(2) Mechanical problem of the sacroiliac joint
Confirmation Test:
Pat ri
ck’sTest,Hi bb’sTest
Gaensl en’sTest
Instruct: Patient in the supine position with the affected side of the sacroiliac joint
as close to the edge of the table as is possible. The patient then grasps the unaffected
leg just below the knee and approximates the knee to his chest. The examiner then
places a downward pressure on the affected thigh until it is lower than the edge of the
table.
Positive: Pain on the affected SI joint stressed into extension.
Indicates: General sacroiliac joint lesion, anterior sacroiliac ligament sprain, or
inflammation of the SI joint.
Confirmation Tests:
BeltTest ,Gol
dthwai t’sTes t,Yeoman’ sTest
Lewin - Gaensl en’sTest

Instruct: Patient lying on his unaffected side, instruct patient to flex his inferior leg. Examiner
grasps the superior leg and brings into extension while stabilizing the lumbosacral joint
(extension of the leg stresses the sacroiliac joint and anterior joint ligaments on the side
of leg extension).
Positive: Pain on the side of extension.
Indicates: General sacroiliac joint lesion, anterior sacroiliac ligament sprain, or
inflammation of the SI joint.
Confirmation Tests:
Gaensl an’sTest ,Yeoman’ sTest

Hibb’ sTest
Instruct: Patient prone, examiner stabilizes pelvis on near side while grasping the opposite ankle
and flexing the knee to 90 degrees. The examiner maximally flexes the knee and then
slowly internally rotates the thigh (pushing lateral on the leg). Compare bilateral.
Positive: (1) Pain in the hip region.
(2) Pain in the buttock/pelvic region.
Indicates: (1) Hip joint pathology.
(2) Sacroiliac joint lesion.
Confirmation Test:
Laguer r e’
sTest
Ober ’
sTest
Instruct: Patient on his/her side, examiner flexes the affected while abducting and extending the
hip. Perform bilaterally.
Positive: Affected thigh remains in abduction. (Normal biomechanics, the thigh/hip will
adduct.)
Indicates: Contraction of the iliotibial band or tensor fascia lata, (usually secondary to
synovitis of the hip, secondary to trauma of the gluteus medius and maximus)
Confirmation Tests:
Thomas’ Test
,Tr endel enber g’sTest
Pelvic Rock Test aka Iliac Compression Test

Instruct: Patient lies on their side. Examiner places both hands on the lateral portion
ofthepat i
ent’si l
ium.Ex ami nerpushesdownwar d(l
ateraltomedi al)ont he
pati
ent ’si l
ium.Testbi l
ater ally
.
Positive: Pain in either sacroiliac joint.
Indicates: Sacroiliac joint lesion.
Confirmation Test:
Radiography
Nachlas Test
Instruct: Patient prone, examiner takes the heel of the affected leg and approximates it to the
ipsilateral buttock while stabilizing the pelvis to prevent hip flexion.
Positive: Pain in the buttock and/or pain in the lumbar region.
Indicates: Sacroiliac joint lesion, or Lumbar pathology.
Confirmation Tests:
Lewi n’sSupineTest ,Mi nor’sSi gn,Spi nalPer cussionTes t( l
umbar )

Yeoman's Test
Instruct: Patient prone, examiner flexes patient's leg to ipsilateral buttock and then
extends thigh.
Positive: Pain deep in the SI joint.
Indicates: Strain/sprain of the anterior sacroiliac ligaments.
Confirmation Tests:
Gaensl an’sTest,Lewi nGaensl an’sTest
Ely’sSi gn(
El yTest–Cipriano),
Instruct: Patient prone, examiner passively flexes the patient's knee toward the ipsilateral buttock.
Positive: Hip on side being tested will flex causing the buttock to raise off the table.
Indicates: Rectus femoris or hip flexor contracture.
Confirmation Tests:
Ely's Heel to Buttock Test ( Ev an’ scal l

sthisEl
y’
ssignasana. k.a.)
Instruct: Patient prone, examiner flexes the knee of the patient's affected leg to 90 degrees.
Examiner then approximates the heel of the affected leg to the contralateral buttock and
hyperextends the thigh off the table.
Positive: (1) Inability to raise the thigh.
(2) Pain in the anterior thigh.
(3) Pain in the lumbar region.
Indicates: (1) Iliopsoas spasm.
(2) Inflammation of lumbar nerve roots.
(3) Lumbar nerve root adhesions.
Confirmation Tests:
Trendel enburg’sTest
Instruct: Patient stands on foot of involved side of hip problem. Observe level of hips.
Positive: High iliac crest on supported side and low crest on side of elevated leg.
Indicates: Weak gluteus medius muscle on the supported side.
Confirmation Tests:
Ober ’sTest ,Thomas’ Tes t

KNEE
INSPECTION
 Gait
 Scars/keloids
 Discoloration
 Abrasions
 Blebs
 Swelling
1. Local - bursal swelling over patella and tibial tubercle
2. Diffuse - may obscure normal contour of knee
3. Knee slightly flexed (flexion houses greater volume)
 Atrophy - muscular area above knee
 Common knee deformities
1. Genu varum (bowed legs)
2. Genu valgum (knock knees)
3. Genu recurvatum (back knee)
PALPATION
Bony palpation
1) Patella
2) Medial tibial plateau
3) Tibial tubercle
4) Medial femoral condyle
5) Lateral tibial plateau
6) Lateral femoral condyle
7) Fibula head

Quadriceps muscles Quadriceps muscles (palpate as a unit and individually)
 Vastus Lateralis
 Vastus Medialis
 Vastus Intermedius
 Rectus Femoris
2) Infrapatellar tendon
3) Bursae
 Prepatellar
 Superficial infrapatellar
4) Medial meniscus
5) Lateral meniscus
6) Pes anserine area
 Sartorius
 Gracilis
 Semitendinosus
7) Popliteal fossa
8) Lateral collateral ligament
9) Medial collateral ligament
10) Gastrocnemius muscle
RANGE OF MOTION
Active and Passive
Flexion 135
Extension 0
Internal rotation
External rotation
Reflex
Patellar
SPECIAL TESTS
1) McMurray Sign, pg. 796 E

2) Medial Collateral Ligament Test aka Abduction Stress Test, pg. 760 E
3) Lateral Collateral Ligament Test aka Adduction Stress Test, pg. 762 E
4) Bounce Home Test, pg. 770 E
5)Dr awer ’
sTest ,pg.776E
6)Lachman’ sTest ,pg.786E
7) Apprehension Knee Test aka Apprehension Test for Patella, pg. 768E
8)Pat ellaFemor alGr i
ndingTestakaCl arke’
ssi gn,pg.774E
9) Patella Ballottment Test pg. 800 E
10)Apl ey ’sCompr essi
onTest ,pg.764E
11)Apl ey ’sDi stracti
onTes t
,pg.764-767 E
McMurray Sign
Instruct: Pat ientsupi ne,ex ami nerf l
exespat ient ’
saf fect edhi pto90degr eesandt heaffected
knee to 90 degrees. Examiner grasps the heel of the affected leg and applies external
rotation to the knee. Examiner places his/her hand on the lateral aspect of the affected
knee and applies a valgus stress. Examiner maintains the external rotation and valgus
stress on the knee and extends the affected leg slowly to the top of the table while
palpating the medial knee joint line. (Occasional variance= repeat with internal rotation
and varus stress)
Positive: Clicking sound or pain by knee joint.
Indicates: Tear of medial meniscus if positive on external rotation
Tear of lateral meniscus if positive on internal rotation
The higher the leg is raised when positive is elicited, the more posterior the meniscal
injury.
Confirmation Tests:
Bounc eHomeTest ,Apley ’
sCompr essionTest ,MRI
Medial Collateral Ligament Test a.k.a. Abduction Stress Test a.k.a. Valgus Stress test
Instruct: Pati
entsupi ne,ex ami nerstabili
z es the l at er
alt
hi gh oft
he pat
i
ent’s af
fect
ed leg.
Examiner grasps just superior to the medial ankle of the affected leg and gradually
pushes laterally (to open medial side of joint).
Positive: Gapping and/or elicited pain above/at/or below joint line
Indicates: Torn medial collateral ligament.
Confirmation Tests:
Apley ’sDi st
racti
onTes t,Radi ogr aphy ,MRI

Lateral Collateral Ligament Test a.k.a. Adduction Stress Test a.k.a. Varus Stress test
Instruct: Pat i
entsupi ne,ex ami nerstabiliz
est
hemedi al thi
ghoft hepat ient’s
affected leg. Examiner grasps just superior to the lateral ankle of the
affected leg and gradually pushes medially (opening the lateral side of the joint).
Positive: Gapping and/or elicited pain above/at/or below joint line
Indicates: Torn lateral collateral ligament.
Confirmation Tests:
Apley ’sDi st
ractionTes t,Radi ogr aphy ,MRI
Bounce Home Test

Instruct: Pat i
entsupi ne,ex ami nerinstruct
spat ientt of l
exhi sleg,ex aminergr aspsthepat i
ent’
s
heel and knee of the affected leg. Examiner pulls affected leg slowly into extension
(passively).
Positive: Knee does not go into full extension (slight flexion remains).
Indicates: Diffuse swelling of the knee, accumulation of fluid, due to possible torn
Meniscus.
Confirmation Tests:
Apley ’sCompr essionTes t,McMur ray’sTest ,MRI
Drawer Test
Instruct: Patient supine, examiner flexes the hip and the knee of the pat ient’s
affected leg until the foot is flat on the table. Examiner sits on the foot of
thepat ient’saffect edl eg.Ex ami nergr aspsbehi ndthepat ient’
sf l
ex ed
knee and exerts a pushing and pulling pressure into the affected knee.
Positive: (1) Gapping > 6mm (tibia moves posterior) when the leg is pushed.
(2) Gapping > 6mm (tibia moves anterior) when the leg is pulled.
Indicates: (1) Torn posterior cruciate ligament.
(2) Torn anterior cruciate ligament.
Confirmation Test:
Lachman’ sTest
Lachman’ sTest
Instruct: Pat i
entsupi ne,ex aminerput st hepat i
ent skneeata300 angle of flexion and from this
’
angle the examiner grasps both the proximal end of the tibia with one hand and the
distal end of the femur with the other, and attempts to pull tibia forward in order the feel
thej ointplay .(variati
onofDr awer s’test)
Positive: Gapping with the tibia moving away from the femur.
Indicates: Anterior cruciate ligament or posterior oblique ligament instability.
Confirmation Test:
Drawer Test
Apprehension Test for the Patella

Instruct: Patient supine (or seated with quadriceps relaxed and resting over examiners leg at a
30 degree flexion), examiner pushes the patella laterally.
Positive: Apprehension, distress of facial expression, contraction of quadriceps to bring patella
back in line.
Indicates: Chronic patella dislocation or pre-disposition to dislocation.
Confirmation Test:
MRI
Patella Femoral Grinding Test ( a.k.
a.Cl arke’
ssign)
Instruct: Patient supine, affected knee extended examiner uses the web of the hand to move the
patella to an inferior position. Examiner instructs patient to tighten the quadriceps
muscles as the examiner continues to hold the patella in the inferior direction.
Positive: Retropatellar pain and the patient is unable to hold the quadriceps contraction.
Indicates: Degenerative changes of the patellar facets and /or within the trochlear
groove (chondromalacia patella).
Confirmation Test:
Radiography
Patella Ballottment Test

Instruct: Patient supine with knee extended. Anterior to posterior pressure is applied over the
patella.
Positive: A floating sensation of the patella is a positive finding.
Indicates: A large amount of swelling in the knee.
Confirmation Tests:
Radiography, MRI
Apl ey’sCompr essi onTest

Instruct: Patient prone,ex aminerf lexespat i
ent’
saff
ect edkneet o90degr ees.St
abi
li
zepati
ent
’
s
thi
ghwi t
hy ourknee,Pl acedownwar dpr
essur eont hepat ient’
sheel whi
l
eint
ernal
l
yand
externallyr otati
ngt hepat i
ent ’
sfoot
.
Positive: Patient points to side of pain.
Indicates: Pain on medial side is medial meniscus tear. Pain on the lateral side
indicates lateral meniscus tear.
Confirmation Tests:
McMur ray’sTest,BounceHomeTest ,MRI
Apl ey’sDi st
ract ionTest
Instruct: Patient prone, examiner flexes patient affected knee to 90 degrees. Examiner places
his/herk neeonpat ient’saf fect edthighf orst abi
li
z ati
on.Ex ami nergr aspst
hepat
i
ent
’s
foot and pulls the leg while internally and externally rotating the tibia.
Positive: Patient will point to side of pain.
Indicates: Pain on the medial side indicates medial collateral ligament tear. Pain on
the lateral side indicates lateral collateral ligament tear.
Confirmation Tests:
Medial and Lateral Collateral Ligament Tests, Radiography, MRI

FOOT and ANKLE
INSPECTION
5. Check for external appearance of the shoe
2) Excessive medial or lateral wear
3) Scuffed toes
4) Holes, nails, torn stitching
 Scars/keloids
 Discoloration
 Abrasions
 Blebs
 Count toes
 Toes flat and/or straight
 Toes proportional to each other
 Domed shaped medial longitudinal arch
 Color changes of foot from weight bearing to non-weight bearing
 Color changes of foot from non-weight bearing to weight bearing
 Thickness of skin
 Unilateral or bilateral swelling
PALPATION
Bony Palpation
1) Calcaneus
2) Sustentaculum tali
3) Medial malleolus
4) Lateral malleolus
5) Talus
6) Navicular
7) Cuboid
8) 3 Cuneiforms
9) 5 Metatarsals
10) Metatarsophalangeal joints

1) Tibialis posterior tendon
2) Spring ligament
3) Tibialis anterior tendon
4) Deltoid ligament
5) Peroneus brevis
6) Achilles tendon
7) Plantar aponeurosis
8) Anterior talofibular ligament
9) Posterior tibial artery
10) Dorsal pedal artery

RANGE OF MOTION
Active and Passive
Ankle Dorsiflexion 20
Ankle Plantarflexion 50
Subtalar Inversion 5
Subtalar Eversion 5
1st MTP Joint Flexion
1st MTP Joint Extension
Reflex
Achilles
SPECIAL TESTS
1) Drawer Sign, pg. 842 E

2) Ankle Dorsiflexion Test pg.345 C
3) Rigid or Flat Feet Test (see lab packet)
4) Homans’Si gn,pg.868E
5) Thompson’ sTest ,pg.884E
6) Mor ton’sTest ,pg.874-875
Drawer Sign (Anterior Drawer Sign of the ankle)

Instruct: Patient seated, examiner grasps just superior to the ankle with one hand and around
the calcaneus of the affected foot with the other hand. Examiner pulls (draws) the
calcaneus anteriorly and pushes the tibia posteriorly, the reverse procedure by pulling
the ankle anterior and calcaneus posterior.
Positive: Translation with the talus moving away from or toward the tibia.
Indicates: 1) With tibia pushed/ foot pulled; a tear/instability of the anterior talofibular
ligament.
2) With tibia pulled/foot pushed; a tear/instability of posterior talofibular
ligament.
Confirmation Test:
MRI
Ankle Dorsiflexion Test (Hoppenfeld) –Patient experiences difficulty dorsiflexing the foot
Instruct: With the patient seated, the examiner tries to dorsiflex foot of affected leg; first with the
knee extended, then again with the knee flexed.
Positive: (1) the foot cannot dorsiflex with knee extended, but is able to with knee flexed.
(2) the foot cannot dorsiflex in either knee position
Indicates: (1) contracture of the gastrocnemius muscle
(2) contracture of the soleus muscle

Rigid or Supple Flat Feet Test (Hoppenfeld)
Instruct: Pat i
enti sseat edandt
hens tands,ex ami nerobser vespat i
ent’sfeetwhi l
eseat edand
while standing.
Positive: (1) Absence of medial longitudinal arch in both positions.
(2) Presence of medial longitudinal arch while seated with a loss of medial longitudinal
arch while
standing.
Indicates: (1) Rigid flat feet
(2) Supple flat feet
Homans’Si gn
Instruct: Patient supine, examiner raises the extended affected leg about 12 " off the table or 45
° and then forcibly dorsiflexes the foot of the affected leg. (Squeezing the calf is
recommended by some sources, yet other sources feel it is contra-indicated, please
note that this is a verbal component to be explained in examination.)
Positive: Deep pain in the calf.
Indicates: Deep vein thrombophlebitis.
Confirmation Tests:
Vascular Testing, Palpation
Thompson’ sTest
Instruct: Patient prone with leg flexed to 90 degrees by examiner. Examiner squeezes the belly
of the calf muscle of the affected leg.
Positive: Absence of foot plantarflexion motion.
Indicates: Achilles tendon rupture.
Confirmation Test:
MRI
Mor t
ons’Test
Instruct: Patient supine, examiner grasps the affected forefoot with one hand and applies
transverse pressure across the metatarsal heads.
Positive: Sharp pain in the forefoot.
Indicates: Metatarsalgia or neuroma (usually at the 3rd and 4th metatarsal interspace).

MUSCLE GRADING CHART –Oxford or Van Allen’
sSc
ale
Muscle Gradations Descriptions
5 Normal Against gravity with full resistance, complete range of

motion evident
4 Good Against gravity with some resistance, complete range of

motion evident
3 Fair Against gravity, complete range of motion evident
2 Poor Gravity eliminated, complete range of motion evident
1 Trace Slight contractility with no joint motion evident
0 Zero Contractility is not evident
REFLEX GRADING CHART- We

xle
r’sSc
ale
Reflexes are usually graded on a 0 to 5+ scale.
5+ Highly increased response, sustained clonus, possibility of disease pathology exists
4+ Highly increased response, increased possibility disease pathology exists, hyperactive
3+ Slightly increased response, possibility of disease pathology exists
2+ Normal response
1+ Slightly diminished, lower than normal response, hypoactive
0 No response

Neurological Diagnosis
DIAG 2740

1) Purpose of the Neurological Examination
When there is no readily observable neurological deficiency or in the case of apparent neurological involvement,
examination procedures are employed to assess the integrity of the nervous system, they are used to:
A. Localize the level or site of involvement
B. Identify the nature and/or extent of the lesion
We will learn to evaluate the patients:

Mental function Sensory system
Motor System Reflexes
Coordination and gait Cranial nerves
2) Mandatory Lab Equipment and Materials

Neurological or percussion hammer 128 Hz tuning fork
Pinwheels 512 Hz tuning fork
Neurotips Tape measure
Tongue depressors Sterile cotton swabs
Penlight Cards with shapes, text, and colors
2 containers of aromatics Paperclips and toothpicks
3) Suggested Equipment
Opthalmoscope (Mandatory for next quarter special senses lab)
4) Required Attire
Dress casually for all labs. Pants, Sweatpants, or Shorts
NOTE: 3 POINT DEDUCTION FROM LAB PRACTICAL EXAM
FOR NOT WEARING PROPER TESTING ATTIRE!
5) Performing sensory and reflex tests (refer to topic outline for dressing
requirements)
Everyone should wear shorts
Men should wear short sleeve shirts
Women should wear aerobic or bathing suit tops
(In cold weather, wear these items under an outer layer of clothing)

Essential Final Laboratory Examination Information
The final practical laboratory examination is worth 50 points. You MUST PASS the Final Lab exam (> 70) in order to pass
the class. The student is responsible for adequate preparation for the final examination. There are no
retakes/reexaminations if a student does not perform well.
The student MUST introduce him/herself to the patient in the following manner:
"Hello I am ____, I will be performing a neurological exam on you today. Anything we discuss during this visit will be
compl etel yconfi
dential .Ifyouhav eanyquest ionsorconcer nsdur ingtoday ’sappointment,pleasedonothesi tatet oask.
If at any time you experience pain or discomfort during the exam please let me know. Do I have your permission to
proceed?"
Students are responsible for all information presented in lecture and/or lab instruction. Students are also responsible for
all information coming from handouts and reference texts.
If a student does not take the final laboratory examination during his/her scheduled time and does not provide an
acceptable excuse in accordance with the Student Handbook, then he/she will receive a zero for their final laboratory
examination grade.
If a student does not take the final examination during his/her scheduled time and does provide an acceptable excuse
according to the student Handbook, then there is no forfeiture of points. The day the student returns back to school,
the student must contact and reschedule with his/her instructor an acceptable time to take his/her final laboratory
examination.
Each student must haveadoctor

’sbag(ful
l
yequipped)f
oreachl
abandf ort
hefi
nalexaminat i
on.Twost udentsmaynot
shar
eadoct or’sbag.Eachstudentwil
lbeexpect
edtoshowpersonalr
esponsi
bil
i
tyf
orhis or her own equipment.
Students in this lab are expected to be both doctor and patient. The dress code for the final examination is as follows;
males are to wear gym shorts, females are to wear gym shorts and a tank top. NOTE: 3 POINT DEDUCTION FROM
LAB PRACTICAL EXAM FOR NOT WEARING PROPER TESTING ATTIRE!
Each student will have 12 minutes for the examination.
Should your laboratory instructor be unable to test you, your examination may be administered by any Clinical Science
faculty.

Mental Status Evaluation
1) Orientation
Askt hepat ient’sname,l ocation,anddat e
2) Level of alertness, attention, and cooperation
Ask the patient to spell a word forward and backward
Ask the patient to repeat a string of integers forward and backward
Ask the patient to name the months forward and backward
If the patient displays difficulty with Orientation or Attention higher level of evaluation is needed.
3) Memory
Recent- recall three items after 5 minute delay
Remote- recall certain historical f
act swi t
hinpatient
’smemor y( l
ifeti
me)
“Wher edi dy ougot ohi ghschool ?”
4) Language
Object naming
Repetition of single words and sentences
5) Calculations
Simple additions and subtractions, should be two or more steps
6) Apraxia
Following a compl exmot orcommandl i
ke“ pretendt ocomby ourhai r”or
“pr
et endt obr ushy ourt eeth”
7) Sequencing tasks
Ask the patent to tap the table with: fist, open palm, then side of open
hand (rock, paper, scissors) perform as rapidly as possible
8) Abstraction
Abst r
actioni nterpretat i
onofapr ov er borcol loquial
ism “Theear lybirdgets
thewor m”
The Motor System Examination

Inspection
1)Checkl imbsandt r
unkf orfascicul
ati
on’
s( hands,shoul
der
,andt
high)
,
involuntary movements or abnormal positions.
2) Look for atrophy/hypertrophy.
3) Observe posture
Testing Muscle Strength

1) Passively move limbs through range of motion noting resistance and rigidity
2) Ask patient to hold arms straight out front palms up for 20 to 30 sec with eyes
closed, look for drift to one side or pronator drift.
3) Test muscle strength at multiple joints and record.
Oxf
ordorVanAl
len’
sScal
e
Joint Lock Resistance Motion Motion Evidence of
Against Gravity Contraction
Gravity Neutral
5 X X X X X
4 X X X X
3 X X X
2 X X
1 X
0

Coordination and Gait (mostly testing cerebellum)
1) Diadochokinesia –Patting Test: Rapid rhythmic alternating movements.
Have patient pat leg with each hand as fast as possible.
2) Diadochokinesia –Supination –Pronation Test: Have patient pronate and
supinate palms as rapidly as possible.
3) Dysmetria- Have patient touch your index finger and then his/her nose
alternately several times. (Note tremors or lack of coordination)
4) Dysmetria- Heel-Shin: Have patient run their heel from his/her knee to his/her
foot.
6) Gait- observe patient walking toward and away, note posture, stability, foot
elevation, trajectory of leg swing, balance, and arm motions.
Tandem gait- ask the patient to walk heel toe.
Forced gait testing- ask the patient to walk on heels and toes.
The Sensory System Examination

When performing a sensory examination:
1) Compare the stimulus bilateral
2) Scatter the stimuli through multiple dermatomes
3) Note the degree of perception of stimulus
4) Have patient close eyes
Screening (Start on distal extremities work proximal) (EYES CLOSED)

1) Point Localization (Topognosis): The ability to recognize points being
touched on the body. (use dull side of Neurotip on skin)
2) Pain (pinprick)- use sharp end of neurotip) stimuli on the hands and feet
(spinothalamic).
3) Vibration –Pallesthesia- Place the handle of a vibrating 128 Hz tuning fork
on the bony prominances of the upper and lower extremities. Start distal work
pr oxi
mal.Ask“ cany ouf eelvibr at
ion?and “ whendoesi tstop?”( Dr.St opsi
t
) .
4) Light Touch- Gently stroke skin with a wisp of cotton or with a camel hair
brush.
5) Joint Position Sense-Examiner moves patient's fingers and toes, he/she is
asked to describe the digit position.
6) Romber g’ stest - ask the patient with eyes open, then closed, note any
swaying
Discriminatory Sensation (EYES CLOSED)

1) Sharp vs Dull discrimination- Alternate sharp and dull (use a neurotip)
stimuli on the hands and feet (spinothalamic).
2) Stereognosis: The ability to recognize familiar objects by the sense of touch.
3) Graphesthesia: The ability to recognize numbers traced lightly on the skin.
4) Barognosis: The ability to distinguish between different weights.
5) Two Point discrimination: Determining the smallest area in which two points
can be separately perceived. (use paperclip)
6) Double Simultaneous Stimulation
Extinction- only one side is felt
Displacement- one side is felt normally and the other displaced toward
midline
Synesthesia- one side is felt normally and the other is a vague burning

Reflexes
Involuntary, stereotyped, motor responses to stimuli. They are extremely important in the diagnosis and localization of
neurological lesions.
Reflexes are divided into 4 groups:

1) Deep tendon a.k.a. myotactic reflexes
2) Visceral a.k.a. organic reflexes
3) Superficial reflexes
Cutaneous
Mucous membrane
4) Pathological reflexes
When testing reflexes be aware that it involves:

1) A specific procedure
2) An afferent or sensory nerve
3) An integrating center
4) An efferent or motor nerve
Deep Tendon Reflexes –reaction of a muscle to being passively stretched by percussion on the tendon
Have patient relax
Mildly stretch muscle/tendon
Strike tendon briskly
Test bilaterally
Reflex Response Afferent/Efferent Integrating Center

Biceps Elbow Flexion Musculocutaneous C5 Spinal Cord
Nerve
Brachioradialis Slight Forearm Flexion Radial Nerve C6 Spinal Cord
Triceps Elbow Extension Radial Nerve C7 Spinal Cord
Patellar Knee Extension Femoral Nerve L2, 3, 4 Spinal Cord
Achilles Foot Plantar Flexion Tibial Nerve S1, 2 Spinal Cord
West
phal
’ssi
gn–absence of any DTR (especially patellar; LMNL)
Jendr assi k’
smaneuver AKA Reinforcement Test or Cortical Distraction Test
A form of cortical distraction that brings out a reflex when hard to elicit
Pt. hooks hands together by flexed fingers and pulls on the clenched hands at the moment the reflex is performed.
Significance of Abnormal Deep Tendon Reflex Response

Reflex responses are graded subjectively according to a classification scheme based on a scale of 0-5 called the Wexler
Reflex Scale.
Wexler Reflex Grading Chart

Reflexes are usually graded on a 0 to 5+ scale.
5+ Highly increased response, increased possibility disease pathology exists,
sustained clonus.
4+ Highly increased response, increased possibility disease pathology exists,
hyperactive
3+ Slightly increased response, possibility of disease pathology exists
2+ Normal response
1+ Slightly diminished, lower than normal response, hypoactive
0 No response

Decreased or absent reflex = Generally indicates a lower motor neuron lesion (can include peripheral nerve disease,
posterior column involvement, cerebellar disease, hypothyroidism)
Increased reflex = Generally indicates upper motor neuron lesion (can include motor cortex, pyramidal tract lesions,
strychnine poisoning, hyperthyroidism)
Visceral Reflexes:
Reflex Response Afferent Integrating Efferent
Center
Direct Light Ipsilateral Optic Nerve II Midbrain Oculomotor
pupillary
constriction when
Nerve III
light is shined in
the eye
Indirect Light Contralateral Optic Nerve II Midbrain Oculomotor
pupillary
constriction when
Nerve III
light is shined in
the eye
Accommodation Convergence of Optic Nerve II Occipital Oculomotor
the eyes,
pupillary
Cortex Nerve III
constriction, Lens
convexity when
object is brought
into near vision
Carotid Sinus Reduction in Glossopharyngeal Medulla Vagus Nerve X
heart rate when
examiner presses
Nerve IX
the carotid sinus
Oculocardiac Reduction in Trigeminal Nerve V Medulla Vagus Nerve X
heart rate When
examiner presses
the eye
Ciliospinal Pupillary dilation Cervical T1-T2 Spinal Cervical
when examiner
pinches the base
Sympathetic Chain Cord Sympathetic
of the neck at the Chain
cervical
sympathetic chain
NOTE: Do not perform occulocardiac reflex while contact lenses are in place.

Superficial Reflexes:
Reflex Response Afferent Integrating Efferent
Center
Corneal Blinking and Trigeminal Pons Facial Nerve
tearing of the Nerve V VII
eye upon
touching the
cornea with a
cotton wisp
Gag/Pharyngeal Gagging upon Glossopharyngeal Medulla Vagus Nerve
touching the Nerve IX X
back of the
throat with a
tongue
depressor
Uvular/Palateal Raising of the Glossopharyngeal Medulla Vagus Nerve
uvula upon Nerve IX X
phonation, or
touching with a
tongue
depressor
Interscapular Drawing T2-T7 Spinal Nerves T2-T7 Spinal Dorsal
inward of Cord scapular
scapular when nerve
skin or
interscapular
space is
irritated.
Abdominal Umbilicus Upper T7-10 Spinal Cord T7- Upper
deviation to the Lower T11-12 T12 T7-10
stroked side. Lower
Absence is T11-12
normal only if
bilateral
Plantar Plantar flexion Tibial Nerve Spinal Cord Tibial Nerve
(curling) of S1-S2
toes upon
stroking sole of
foot
Significance of Abnormal Superficial Reflexes

(+) is normal/present
(-) is abnormal/diminished or absent
Abnormal in both lower motor neuron and upper motor neuron lesion. When combined with exaggerated deep tendon
reflexes and positive pathological reflexes are diagnostic Upper Motor Neuron Lesion (UMNL).
NOTE: Do not perform the corneal reflex with contact lenses in place.

Pathological Reflexes –performed with STRONG stimulus
Head Abnormal Response (Upper Motor Neuron Lesion)
Glabella aka Contraction of orbicularis occuli muscle upon percussion of supraorbital ridge
McCar thy’s (glabella)
Upper Abnormal Response (Upper Motor Neuron Lesion)

Extremity
Hof
fman’
s Clawing of the fingers and thumb (flexion and adduction of thumb with flexion of
the fingers) upon flicking tip of index finger into extension
Tr
omner
’s Flexion of the fingers and thumb upon tapping palmar surface or tips of middle
three fingers
Lower Abnormal Response (Upper Motor Neuron Lesion)

Extremity
Ankle Clonus Continued involuntary contraction (flexion and extension) of foot upon quick
forcible dorsiflexion of the foot
Babinski Dorsiflexion of the big toe and fanning or splaying of other toes upon
stimulation of the plantar surface of the foot (lateral to medial)
Alternative ways to elicit babinskiÕs sign:
Oppenhei m’ ssi gn - application of pressure to anterior tibia stroking downward
Chaddock’ ssi gn- stroking down the lateral leg around the lateral malleolus
Gor don’ ssi gn- squeezing the calf
Schaef er’ssign - squeezing the achilles tendon
Significance of Abnormal Pathological Reflexes

(-) = Normal/absent (adults and children over 5 to 7 months)
(+) = Abnormal/present (adults)
Presence of these reflexes in corticospinal tract diseases (pyramidal tracts, lateral columns) indicates an UMNL
Clinical Signs of Upper Motor Neuron

1) Spasticity of muscles with possible contractures
2) Decreased muscle strength, little or no atrophy
3) Presence of pathological reflexes
4) Altered superficial reflexes
5) Hyperactive deep tendon reflexes
6) No fasciculations (twitches)
Clinical Signs of Lower Motor Neuron

1) Flaccidity of muscles
2) Loss of muscle strength and tone, noticeable muscle atrophy
3) Absence of pathological reflexes
4) Decreased or absent deep tendon reflexes
5) Altered superficial reflexes
6) Fasciculations (twitches)

Examination of the Cranial Nerves
(I) Olfactory Nerve

Ask about disorders of sense of smell and of taste (will diminish with loss of smell)
a) Using a penlight, make sure nostrils are not blocked.
b) Occlude one nostril at a time (eyes should be closed)
Have patient sniff familiar and non-irritating odors, use the milder scent first.
Ask the patient:
1) Do you smell anything?
2) Can you identify the substance?
(II) Optic Nerve

a) Inspect external structures of eye
b) Inspect the optic fundi with opthalmascope
c) Test visual acuity
Screen by reading print
Screen with shapes and/or colors
d) Test visual fields by confrontation (peripheral vision) a.k.a. Wiggling test
Examine directly in front and level with patient's face
Have patient cover one eye
Bring object into view from eight different directions per eye
e) Direct light reflex- ipsilateral pupillary constriction
f) Indirect light reflex (consensual reflex)- contralateral pupillary constriction
g) Accommodation reflex
Test ability of the eyes to adapt for near vision
Instruct patient to follow object inward from a distance
Convergence of the eyes, constriction of the pupil, convexity of the lens
(III) Oculomotor, (IV) Trochlear, and (VI) Abducens

Nerves
The following four tests are for CN III specifically:
a. Direct light reflex
b. Indirect light reflex
c. Accommodation reflex
d. Check for ptosis
The following will test CN III, IV, and VI combined:

a) Extraocular movements with six cardinal fi eldsofgaz e.Obser vepat i
ent ’
s
eyes for normal conjugate, or parallel movements of the eyes and nystagmus
as you have him/her follow your finger or pencil while it makes a wide "H" in
the air:
Trochlear = down and in
Abducens = lateral
Oculomotor all other fields.

(V) Trigeminal Nerve (Ophthalmic, Maxillary, and Mandibular)
a) Have patient clench teeth, palpate masseter and temporalis muscles
b) Test pain discrimination (sharp-dull) on face bilateral
c) Test for light touch to the face with wisp of cotton or brush
d) Test corneal reflex with wisp of cotton, should see blinking and tearing
e) Light touch to anterior 2/3 of tongue, inside cheeks, and hard palate with
toothpick. (Use a penlight to view the inside of the mouth)
f) Oculocardiac Reflex (Must ask patient if he/she wears contacts) Take pulse,
appl ypr essur eov erthepat ient
’scl osedey e,pul ser ateshoulddecr ease2-3 beats
per 15 sec.
(VII) Facial Nerve

a) Inspect face for asymmetry (at rest and during motion)
Ask the patient to perform the following:
Raise eyebrows
Close eyes tightly
Show teeth
Puff out cheeks
Smile
Frown
b) Ask the patient about changes in taste sensations sweet, salty, and sour on the anterior two thirds
of the tongue.
(VIII) Vestibulo-Acoustic Nerve

Sensory-Cochlear Portion
a) Screen tests include identifying hearing loss by:
Finger Rub Test:
Assess hearing by rubbing fingers together near the EAM, find maximal
distance sound can be heard.
Whisper Test
Have patient close his eyes (to prevent lip-reading) and cover the ear on the
side not being tested. Place your head/mouth 2 feet from the ear being tested
and whisper words to the patient and ask patient to repeat the words. You can
also ask questions to the patient and have him/her answer yes or no to each
question. Repeat this procedure at varying (usually increasing) distances or
with loud, medium and soft tones.
b) Distinguish between perceptive and conductive hearing using 512 Hz tuning forks
Weber ’sTest
Procedure: Place the handle of the vibrating tuning fork on the midline of the skull
and ask the patient to compare the intensity of the sound in the two ears.
Indicates: (-) Normal: sound is equal in both ears.
(+) Conductive deafness: sound lateralizes to the bad ear.
(+) Sensorineural deafness: sound lateralizes to the good ear.

Rinne’ sTest
Procedure: Place the handle of the tuning fork against the mastoid process. Have
the patient signal when the sound ceases, then hold the fork near the
external ear without touching the patient, again have the patient indicate
when the sound ceases.
Indicates: (+) Normal: air conduction persists twice as long as bone conduction
(-) Conduction deafness: air conduction is equal to bone conduction or
air conduction is less than bone conduction.
(-) Sensorineural deafness: air conduction and bone conduction are
both radically decreased or absent.
Vestibular Portion
Labyrinthine Test for Positional Nystagmus

Procedure: Pat ientseat ed,ex amineri nspect spat ient’sey esforspont aneous
nystagmus. Then inspect for nystagmus for 30 seconds in each of the
following positions:
Patient supine
Turn head to one side
Turn head to the other side
Pat i
ent ’sheadhangi ngoft het able
Patient returns to seated position
Indicates: Normal: the fast component of the eye movement will be in the direction
the patient is being moved. (Nystagmus is named for the fast
component).
Peripheral Lesion: the patient will exhibit nystagmus within 2-5 seconds,
does not change direction if the patient is stationary, and disappears
within 30 seconds.
Medullary Lesion: Nystagmus begins immediately upon movement and
may change direction while the patient is stationary (also patient does
not have vertigo).
Bar any’sWhir
li
ngChai rTest
Procedure: Seated patient is spun in chair in one direction
Indicates: Normal: fast component of nystagmus will be in the direction of the spin.
Mittlemyer
Instruct: Patient marches in place, eyes open then closed.
Positive: A turning to one side
Indicates: Side of vestibular lesion
Vestibulo-ocular Reflex
Procedure: Dr .holdspat i
ent ’
sheadandi nst r
uctspati
enttofi
xv i
si
onont hedoc t
or ’
s
face.Dr .thent urnspat i
ent’sheadi nt
orotat
ion,l
ater
alfl
exion,and
flexion and extension.
Indicates: Normal patient should maintain eye contact eyes moving at the same
speed in the opposite direction of head movement. Abnormal findings
are detailed in labyrinthine test above.

(IX) Glossopharyngeal and (X) Vagus Nerve
a) Note any hoarseness of the voice.
b) Uvula reflex = Patient says "ah."
Watch for symmetrical rising of soft palate.
Bilateral lesion of Vagus = Palate does not rise.
Unilateral paralysis = One side of palate does not rise and uvula will deviates
to the normal side.
c) Gag reflex.
d) Have patient swallow while you palpate thyroid cartilage.
e) Carotid sinus reflex.
f) Ask the patient about change in bitter taste sensation on the posterior third of the tongue.
(XI) Spinal Accessory Nerve

a) Trapezius Muscle
Inspect
Palpate
Muscle test
b) Sternomastoid Muscle
Inspect
Palpate
Muscle test
(XII) Hypoglossal Nerve

a) Inspect tongue for:
Atrophy
Fasciculations
b) Have patient stick out tongue and test bilateral with tongue depressor, or use the
tongue in cheek method
Unilateral paralysis = Protruded tongue deviates to involved side.

CERVICAL and LUMBAR
NERVE ROOT EVALUATION
1) Muscle –test and name the muscle/s and nerve for each nerve root level
being tested
2) Reflex –test and name the appropriate reflex being tested; if no reflex it must be
stated.
3) Sensation –t estt
heappr opri
ateder mat omef ort heneur ologi calpackageandi t
’s
corresponding dermatome above and below following the format enclosed from
Hoppenfeld
Muscle (motor) Reflex Sensation (dermatome)

One hand above joint Rapid flick of hammer on Anatomical position
of motion for stability tendon
Eyes closed
One hand used as No tension in muscles
short lever to test around tendon Cover the entire dermatome
muscle
Pin to skin (ask: does this feel
No hands on joints like this?)
Gradual increase in Test dermatome above and

pressure below
BILATERAL BILATERAL BILATERAL
Muscle Grading- Oxf

ordorVanAl
len’
sScal
e(page 7)
Reflex Grading- Wexl

er’
sScal
e(page 10)

Evaluation of Cervical Nerve Roots
Neurological Level: C5
a) Disc Level C4
b) Muscle tests (2) Shoulder abduction: deltoid (Axillary nerve)
Forearm flexion: biceps (Musculocutaneous Nerve)
c) Reflex Biceps
d) Sensation Lateral arm and shoulder
a) Disc Level C5
b) Muscle test (1) Wrist extension extensor carpi radialis longus &
brevis, extensor carpi ulnaris (Radial Nerve)
c) Reflex Brachioradialis
d) Sensation Anterior lateral forearm, palm, thumb and index finger
a) Disc Level C6
b) Muscle tests (3) Elbow extension: triceps (Radial Nerve)
Wrist flexion: flexor carpi radialis (Median Nerve), flexor
carpi ulnaris (Ulnar Nerve) Finger extension: (Radial Nerve)
c) Reflex Triceps
d) Sensation Middle finger, middle of palm
a) Disc Level C7
b) Muscle test (1) Finger flexion: (Median Nerve)
c) Reflex None
d) Sensation 4th and 5th phalanges, antero-medial hand and forearm
Neurological Level: T1
a) Disc Level T1
b) Muscle tests (2) Finger abduction: dorsal interossei (Ulnar Nerve)
Finger adduction: palmer interossei (Ulnar Nerve)
c) Reflex None
d) Sensation Medial arm (distal aspect of arm to proximal forearm)

Dermatomes of the Upper Extremity
Examination Procedure
Example (Examination of C5 dermatome) Patient seated, anatomical position, eyes closed.
1. Bilateral Comparison
Questioning = Does this feel like this?
C4 of right side compared to C4 of left side (dermatome above)
C5 of right side compared to C5 of left side (dermatome level)
C6 of right side compared to C6 of left side (dermatome below)
3. Unilateral Comparison
First
C4 of right side compared to C5, C5 compared to C6 of right side
Second
Repeat on the other side

Involving the Thoracic Spine
Neurological Level: T2-T12
a) Disc Level T2-T12
b) Muscle test (1) Rib Elevation: Intercostals [segmentally innervated and
difficult to evaluate individually], rectus abdominus.
T7-T12( L1)Beev or ’
sSi gn
c) Reflex None (can do superficial abdominal reflex)
d) Sensation T4: Nipple line
T7: Xyphoid process
T10: Umbilicus
T12: Inguinal ligament
There is sufficient overlap of these areas so that no anesthesia will occur if only one nerve root is
involved.
Evaluation of Multiple Lumbar Nerve Roots

Neurological Levels: L1, L2 and L3
a) Disc Level T12-L2
b) Muscle test (1) Primary hip flexor: iliopsoas (L1-L3)
c) Reflex None
d) Sensation Anterior thigh, obliquely from lateral to medial.
(L1 top of thigh, L2 middle of thigh, L3 lower thigh).
Neurological Level: L2, L3 and L4

a) Disc Level L1-L3
b) Muscle tests (2) Primary knee extensors: Quadriceps Femoris, Vastus
Medialis, Vastus Intermedius (L2-L4, Femoral nerve).
Primary adductor: Adductor longus, Adductor Brevi,
Adductor Magnus (L2-L4, Obturator nerve).
c) Reflex Patellar
d) Sensation L2 middle of thigh, L3 lower thigh, L4 anteromedial leg
below the knee and medial side of the foot.

Evaluation of Individual Lumbar Nerve Roots
Neurological Level: L4
a) Disc Level L3
b) Muscle test (1) Foot inversion with slight dorsiflexion: tibialis anterior
(Deep Peroneal/fibular Nerve)
c) Reflex Patellar Tendon
d) Sensation Medial aspect of leg, medial foot, medial aspect of big toe
Neurological Level: L5
a) Disc Level L4
b) Muscle tests (4) Foot dorsiflexion
Big toe dorsiflexion: extensor hallucis longus (Deep
Peroneal/fibular Nerve)
Toes 2,3,4 dorsiflexion: extensor digitorum longus and
brevis (Deep Peroneal/fibular Nerve)
Hip/Thigh abduction: gluteus medius & minimus (Superior
Gluteal nerve)
c) Reflex None
d) Sensation Lateral leg, dorsum of foot, middle three toes
Neurological Level: S1
a) Disc Level L5
b) Muscle tests (3) Foot Plantar flexion: Gastrocnemius and Soleus (Tibial
Nerve)
Foot plantar flexion and eversion: peroneus longus and
brevis (Superficial Peroneal/fibular Nerve).
Hip extension: gluteus maximus (Inferior Gluteal Nerve).
c) Reflex Achilles
d) Sensation Posterior aspect of the leg, lateral aspect of foot, lateral
aspect of little toe.

Dermatomes of the Lower Extremity
Examination Procedure
Example (Examination of L4 dermatome) Patient seated, anatomical position, eyes closed.
1. Bilateral Comparison
L3 of right side compared to L3 of left side (dermatome above)
L4 of right side compared to L4 of left side (dermatome level)
L5 of right side compared to L5 of left side (dermatome below)
Unilateral Comparison
First
L3 of right side compared to L4, L4 compared to L5 of right side
Second
Repeat on the other side

Spinal Cord and Meningeal Testing
L’Her mi tte’
sSi gn
Procedure: Patient sitting or supine, patient flexes his/her head toward his/her chest
or,perEv an’s,Dr .acti
v el
yf l
ex espat ient’
sheadt owar dchest .
Positive: Electric shock-like sensations down the spine and/or through
extremities.
Indicates: Dural irritation, severe spinal cord injury or degeneration, (MS patients
exhibit a positive 30% of the time).
Confirmation Tests:
Soto Hall Test, Sensory and Reflex Testing, Nerve Conduction Testing, MRI
Ker nig’sSign
Procedure Pat ientsupi ne,ex ami nerpassi velyflexespat i
ent ’
shi pto90degr ees
andt hepat i
ent ’sk neet o90degr ees.Ex aminerex t
endspat i
ent ’
sl eg
completely.
Positive: Inability to fully extend the leg and/or pain (usually in the neck region).
Indicates: Meningeal irritation/meningitis.
Confirmation Tests:
Brudz i
nski’
sSi gn,LumbarTap
Brudzinski Sign
Procedure: Patient supine, examiner flexes patient's head to the chest.
Positive: Involuntary knee flexion.
Indicates: Meningeal irritation or nerve root lesion (classic test for meningitis)
Confirmation Tests:
Kernig’sSign,LumbarTap

Cervical Spine and Nerve Root Testing
Soto Hall Sign
Procedure: Patient supine, exami nerf l
ex espat ient’sheadt owar dhi s/
herchest
whilest abi
lizi
ngt hepat i
ent’sst ernum wi thhy pot henarofi nfer
iorhand.
Positive: Generalized pain in the cervical region which may extend down to the
level of T2.
Indicates: Nonspecific test for structural integrity of cervical region.
Foraminal Compression Test

Procedure: Patient seated with examiner standing behind. Examiner clasps his/her
handsov erpatient’
sheadandex ertsincr easingdownwar dpr essur
e.
Examiner repeats this procedur ewi tht hepat ient’sheadrotatedri
ght
and then left.
Indicates: 1) Foraminal encroachment or facet pathology without nerve root
compression.
2) Foraminal encroachment with nerve root compression (one would
then want to evaluate the myotome, reflex and dermatome of the nerve
root involved).
Confirmatory Tests:
Jackson Compression, Maximal Cervical Compressi onTest ,Bakody ’sTest,Shoul derDepression
Test, Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI, Nerve Conduction
Testing
Jackson Compression
Procedure: Patient seated with examiner standing behind. Examiner laterally flexes
the patient's head to one side and clasps his/her hands over patient's
head and exerts increasing downward pressure. Perform bilaterally.
Indicates: 1) Foraminal encroachment without nerve root pressure or facet
pathology.
7) Foraminal encroachment with nerve root compression (one would
8) then want to evaluate the myotome, reflex and dermatome of the nerve
root involved)
Confirmatory Tests:
Forami nalCompr ession,Max imalCer v i
calCompr essionTest ,Spurl
ing’sTest ,Bakody ’sTest,

Maximal Cervical Compression
Procedure: Patient seated with examiner standing behind. The examiner instructs
the patient to rotate the head and hyperextend the neck. Perform
bilaterally.
Positive: 1) Pain on the concave side
2) Pain on the convex side
Indicates: 1) Foraminal encroachment with or without nerve root compression
(based on presence or absence of radicular component)
2) Muscular strain
Confirmation Tests:
Forami nalCompr ession,Jacks on’sCompr es si
onTest ,Bak ody’s Test, Shoulder Depression Test,
Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI, Nerve Conduction Testing
Valsalva Maneuver
Procedure: Patient seated, examiner instructs patient to take a deep breath and hold
while bearing down as if having a bowel movement.
Positive: Radiating pain from site of lesion.
Indicates: Space occupying lesion
Confirmation Tests:
Dej
er ine’
sTr iad,Swal lowi
ngTest ,Naf
fzi
ger
’sTest,BakodySi
gn,MaximalCerv
icalCompr
ession,
Shoulder Depression Test, Cer
vicalDi
str
act
ion,Jackson’
sCompres
sion,For
aminalCompressi
on
Test
,Spur l
ing’sTes t
,SensoryandRef l
exTesti
ng,MRI
Cervical Distraction Test

Procedure: Pat i
entseat ed,t heex ami nergr
aspst hepat i
ent’
sheadwi thbot hhands
and gradually exerts upward pressure keeping hands off TMJ and ears.
Positive: 1) Diminished or absence of pain.
2) Increase of cervical pain.
Indicates: 1) Foraminal encroachment (local pain diminishes), nerve root
compression (Radicular pain diminishes).
2) Muscular strain, ligamentous sprain, myospasm, facet capsulitis.
Confirmation Tests:
Forami nalCompr essi onTest,JacksonCompressi
on,Maxi
malCervi
calCompressi
onTes t,Spurl i
ng’
s
Test,Bakody ’
sTest ,Shoul
derDepr essi
onTest
,Refl
exandSensor
yTesti
ng,Radiography, MRI,
Bakody Sign (Shoulder abduction Test)

Procedure: Patient seated, examiner instructs patient to place the palm of the
affected side flat on top of their head.
Positive: Decrease or absence of radiating pain.
Indicates: Cervical foraminal compression, nerve root entrapment (usually C5/C6
level because this motion elevates the subscapular nerve and puts
traction on the lower brachial plexus).
Confirmation Tests:
Foraminal Compression, Maximal Compressi on,Jackson’ sCompr essi
onTest ,Spur l
ing’sTes t
,
Thoracic Spine and Nerve Root Testing
Adam's Sign (positions)
Instruct: Patient standing, with examiner standing behind patient, examiner looks for evidence of
scoliosis. Examiner instructs patient to bend forward at the waist with fingers extended
and hands together. Examiner observes for evidence of change in the scoliosis.
Positive: 1)A“ c”or“ s”shapeds coli
os i
sisobser v edt ost r
ai ghten.
2)A“ c”or“ s”shapeds coli
os i
sdoesnotst raighten( lookf orr i
bhumpi ng,musc ular
imbalance, and asymmetry in hand length).
Indicates: 1) Negative: evidence of a functional scoliosis
2) Positive: evidence of a pathologic or structural scoliosis as well as trauma or
subluxation.
Confirmation Tests:
Postural Analysis, Radiography
Schepelmann's Sign
Procedure: Patient seated arms fully abducted and raised over head, examiner
instructs patient to laterally flex thoracic spine to the left side and then to the right side.
Positive: Pain on the concave or convex side.
Indicates: Pain on the concave side indicates intercostal neuritis while pain on the
convex side indicates fibrous inflammation of the pleura (or possible
intercostal myofascitis).
Beevor's Sign
Procedure: Patient supine, examiner instructs patient cross his/her arms across the
chest and perform a partial sit up.
Positive: Superior movement of the umbilicus.
Indicates: Superior movement of the umbilicus is indicative of a spinal cord lesion
at the level of T10 or lower abdominal weakness.
Inferior movement of the umbilicus is indicative of nerve root involvement
T7 –T10.
Confirmation Tests:
Sensory testing of thoracic nerve roots, MRI

Upper Extremity Testing
Roos’Testa.k.a. E.A.S.T (elevated arm stress test)
Instruct: Patient standing, instruct patient to bring arms out in front of their body,
bend the elbows to 90°. The patient then externally rotates the arms and
opens and closes their fists bilaterally at a moderate pace for up to 3 minutes.
Positive: Ischemic pain, heaviness of the arms, or numbness and tingling of the
hand.
Indicates: Thoracic outlet syndrome on side involved ( Ev
an’sconsi der st hi
st estt
obemost
accurate for TOS evaluation)
Confirmation Tests:
Roo’sTest ,HalsteadTest
,Adson’
sTest
,Wr
ight
’sTest
,Shoul
derDepr
essi
onTest
,Eden’
sTest
Adson's Test (Scalene Maneuver and Scalenus Anticus Test)

Procedure: Patient seated with arms at side and elbows fully extended. Examiner finds radial
pulse, slightly abducts affected arm and has patient take a deep breath and hold, then
instruct patient to rotate head and elevate chin toward examiner while holding the
breath. Note positive or negative findings, if negative then rotate head to the opposite
side and repeat the procedure.
Positive: Pain and/or paresthesia, decreased or absent pulse, pallor.
Indicates: Scalenus anticus syndrome or cervical rib syndrome. (usually same side)
Decrease or absence of radial pulse indicates compression of
subclavian artery.
Paresthesia/radiculopathy indicates compression of the brachial
plexus at the neurovascular bundle by scalenius anticus or cervical
rib.(usually opposite side)
Confirmation Tests:
Hal
st eadManeuv er,Shoul
derDepr
essi
onTest
,Wr
ight
’sTest
,Eden’
sTest
Halstead's Maneuver
Instruct: Patient seated, examiner finds and monitors radial pulse in neutral position with one
hand and with the otherhandt r
actionthepat ient
’sar mt owar dt hef l
oor .Ex ami ner
instructs patient to elevate chin and hyperextend their neck. If the test is negative (the
pulse does not disappear), then rotate the head to the opposite side and repeat.
Indicates: Compression of the neurovascular bundle by scalenus anticus or cervical
rib.
Confirmation Tests:
Roo’sTest ,Ads on’sTest
,Shoul
derDepr
essi
onTest

Costoclavicular Maneuver a.k.a. Eden's Test
Procedure: Patient seated, examiner finds radial pulse and instructs patient to sit
erects, force shoulders back, chest out and touch chin to chest.
Indicates: Compression of the neurovascular bundle between the clavicle and 1st
rib.
Confirmation Tests:
Shoul derDepr essionTest
,Adson’
sTest
,Hal
steadTest
,Wr
ight
’sTest
Hyperabduction Maneuver a.k.a. Wr ight’

sTest
Procedure: Patient seated, examiner finds radial pulse and hyperabducts the
patient's arm.
Indicates: Compression of the axillary artery by pectoralis minor or coracoid
process. Thoracic outlet syndrome.
Confirmation Tests:
Adson’sTest ,Hal steadTest
,Shoul
derDepr
essi
onTes
t,Eden’
sTest
Tinel’sEl bow Si
gn
Procedure: Patient seated, examiner taps with the Taylor reflex hammer over the
groove between the medial epicondyle and the olecranon process.
Positive: Pain and/or tenderness at the site being tapped and paresthesia in the
ulnar nerve distribution area (fingers 4,5).
Indicates: Neuroma of the ulnar nerve.
Confirmation Test:
Fromet ’sPaperSign
Procedure: The patient is instructed to hold a piece of papaer between any two
adducted fingers. The doctor tries to remove the paper.
Positive: The patient is unable to maintain grip on the paper.
Indication: Ulnar nerve paralysis.
Comfirmation Tests:
Phal en’sSignAND Rever sePhal en’ sSi gna. k. a.Prayer ’ssign

Procedure: Patient seated, examiner instructs patient to flex both wrists to
maximum degree and approximate until point of pain or 60 seconds.
Prayer sign = maximally extend wrist (palms together), elbows same
level as shoulders for 60 seconds.
Positive: Reproduction of pain and/or paresthesia in the median nerve distribution
(thumb, index finger, middle finger, and the thumb side of ring finger).
Confirmation Tests:
Ti
nel’sSign,Ner v eConduct
i
onTes
ti
ng

Tinel’sWr i
stSign
Procedure: Patient seated with wrist supinated, examiner taps with the Taylor reflex
hammer over the palmar (volar) surface of the wrist. (flexor retinculum).
Positive: Reproduction of pain, tenderness and/or paresthesia in the median
nerve distribution thumb, index finger, middle finger, and the lateral
aspect of ring finger).
Confirmation Tests:
Phalen’sTest ,Rev ersePhal
en’
sTes
t, Nerve Conduction Testing
Lower Extremity Testing

Minor's Sign
Instruct: Examiner instructs patient to stand. Observe for abnormal motion.
Positive: Knee flexion of affected leg while supporting upper body weight (hand on
back or thigh) on unaffected side.
Indicates: Sciatica, lumbosacral or sacroiliac joint lesion
Confirmation Tests:
Nachl as’
Test ,SpinalPer
cussi
onTest
,Sc
iat
i
caTest
s
Bel tTest( Suppor t

edAdam’ sTest ,Suppor t
edFor war dBendi ngTest )
Procedure: Patient standing. Have patient bend forward and note for presence of low
backpai n.Wi thpat i
entst andi
ng,st abil
izepat ient’
sil
iaccr est
sandbr ace
hipagai nstpat i
ent’
ss acrum.Hav epat ientbendf orwar dasy ou
immobilize the pelvis.
Positive: Low back pain
Indicates: 1) Pain in during unsupported and supported bending = Lumbar
involvement
2) Pain in during unsupported, no pain during supported bending =
pelvic involvement
Confirmation Tests:
Gaensl an’sTest,Gol dt
hwai
t’
sTest
Mi l
gr am’ sTest
Instruct: Patientsupi ne,ex aminerr aisesbot hofpat ient’slegs2-3 inches off the
table and instructs patient to hold legs off the table for 30 seconds.
Positive: Inability to perform test and/or low back pain.
Indicates: Weak abdominal muscles or space occupying lesion.
Confirmation Tests:
Bows tr
ingTest ,Heel Wal
kTest
,ToeWal
kTest
,Kemp’
sTest

Heel Walk
Procedure: Patient walks on heels.
Indicates: L4-L5 disc problem (L5 nerve root)
Confirmation Tests:
BowstringTest ,Kemp’sTest
,Mi
l
gram’
sTest
,Ner
i’
sBowi
ngTest
Toe Walk
Procedure: Patient walks on toes.
Indicates: L5-S1 disc problem (S1 nerve root).
Confirmation Tests:
Bows tr
ingTest ,Kemp’sTest
,Mi
l
gram’
sTest
,Ner
i’
sBowi
ngTest
Kemp’ sTest
Procedure: Patient either seated or standing with arms crossed in front of the chest. Examiner
stands behind patient and stabilizes at the PSIS. With other hand examiner reaches
around patient and grasps patient ’
ss houl der.Ex ami nerpassivelybr i
ngsshoul
derback
and obliquely pushes shoulder towards opposite PSIS.
Positive: 1) Pain usually radicular, recreating existing sciatic pain
2) Pain - local
Indicates: 1) Disc protrusion:
•Inmedi aldiscpr otrusion Kemps will be positive as the patient
is leaning AWAY from the side of pain.
•Inl at
eraldiscpr ot rusi
onKempswi llbeposi ti
veasthepat i
enti s
leaning INTO the side of pain.
2) Localized pain may indicate lumbar spasm or facet capsulitis.
Confirmation Tests:
Bows tr
ingTest ,Kemp’sTest
,Mi
l
gram’
sTest
,Heel
Wal
kTest
,ToeWal
kTest
,Faj
ersz
taj
n'
sTest
Lindner's Sign
Instruct: Patient supine, examiner flexes patient's head toward the chest.
Positive: Pain along sciatic distribution or sharp, diffuse pain (leg)
Indicates: Sciatic radiculopathy
Confirmation Tests:
Braggard’sSi gn,Faj er
szt
ajn’
sTest
,Las
egue’
sTest
,St
rai
ghtLegRai
si
ngTest
,
Straight Leg Raiser (SLR)

Procedure: Pat ientsupi ne,ex aminerr aisespatient ’
sleg slowly to 90º or to
the point of pain.
Positive: Radiating pain and/or dull posterior thigh pain.
Indicates: Sciatic radiculopathy or tight hamstrings.
Confirmation Tests:
Braggard’sTest ,Faj er
szt
ajn’
sTest
,Las
egue’
sTest
,Li
ndner
’sTest

Bragar d’sSi
gn
Procedure: Patient supine, examiner performs a (SLR) on the patient. Examiner
lowers the raised leg (5º) from the point of pain and sharply
dorsifl
ex espat i
ent ’
sf oot.
Positive: Radiating pain in posterior thigh.
Indicates: Sciatica
Confirmation Tests:
Faj
er szt
ajn’sTest ,Las
egue’
sTest
,St
rai
ghtLegRai
si
ngTest
Sicard's Sign
Instruct: Examiner lowers raised leg (see SLR) 5 degrees from point of pain and dorsiflexes
patient's big toe.
Positive: Posterior thigh and leg pain.
Indicates: Sciatic radiculopathy, usually from disc lesion
Confirmation Tests:
Becht er
ew’ sTes t
,Br agar
d’sTest,Faj
ers
ztajn’
sTest
,Lasegue’
sTest
,Li
ndner
’sTes
t,St
rai
ghtLeg
Raisi
ngTest ,Turyn’ sTes
t,Lewin’
sStandingTest
Turyn's Sign
Instruct: Patient supine, examiner dorsiflexes the big toe of the affected extremity.
Positive: Pain in the gluteal region or radiating sciatic pain.
Confirmation Tests:
Becht er
ew’ sTes t
,Br agar
d’sTest,Faj
ers
ztajn’
sTest
,Lasegue’
sTest
,Li
ndner
’sTes
t,St
rai
ghtLeg
Raisi
ngTest ,Turyn’ sTes
t,Lewin’
sStandingTest
,Sicar
d’sTest
Bonnet's Sign
Procedure: Patient supine, examiner strongly internally rotates and adducts the
affected leg across the midline and then performs a straight leg raiser
test.
Positive: Pain in posterior thigh or leg.
Indicates: Sciatica (possibly piriformis syndrome)
Confirmation Tests:
Bragard’
sTes t,Fajersz
taj
n’sTest
,Las
egue’
sTest
,Li
ndner
’sTest
,St
rai
ghtLegRai
si
ngTest
Fajersztajn's Test a.k.a. Well-Leg-Raising Test of Fajersztajn a.k.a. Cross-over Sign

Procedure: Patient is supine. Examiner performs a SLR on the patient's unaffected
leg to 75º or until it produces pain down the affected leg. If no pain is
produced, examiner dorsiflexes the foot.
Positive: 1) Pain down affected leg.(Cross-Over Sign)
2) Decrease in pain down affected leg.
Indicates: 1) Medial disc protrusion
2) Lateral disc protrusion.
Confirmation Tests:
Bragard’
sTes t,Lasegue’
sTest
,Li
ndner
’sTest
,St
rai
ghtLegRaising Test

Femoral Stretch Test (Femoral Nerve Traction Test)
Procedure: Patient lies on the unaffected leg side, hip and knee slightly flexed,
patient straightens back and flexes neck. The affected leg is extended by
the examiner at the hip approx. 15º. The affected knee is flexed
(stretching femoral nerve).
Positive: Pain on the anterior portion of the thigh.
Indicates: Traction on the femoral nerve indicating involvement of the 2nd, 3rd and
4th lumbar nerve roots.
Confirmation Tests: El
y’
sSi
gn
Tinel’sFootSign
Procedure: Doctor taps the region of the medial plantar nerve, posterior to the
medial malleolus
Positive: Paresthesia radiating into the foot.
Indication: Tarsal tunnel syndrome
Confirmation Tests:
Duchene’ ssign,nerve conduction study
Mor ton’ sTest

Procedure: Doctor squeezes the metatarsal heads.
Positive: Sharp pain in the forefoot.
Indication: Metatarsalgia or neuroma
Confirmation Tests:
St
runsky ’
ssi gn,ner v
econduct
ions
tudy

ADDITIONAL TESTS
Bracelet Test
Instruct: Patient seated, examiner gives mild to moderate compressive pressure to
dorsum ofpat ients’wr i
st( t
humbenci rclesr adialsideofwr ist,indexfinger
encircles ulnar side i.e. squeeze wrist) and then have patient attempt to make a fist.
Perform bilaterally.
Positive: Acute forearm, wrist and hand pain
Indicates: Significant for Rheumatoid Arthritis. Confirm with diagnostic imaging and
laboratory tests.
Confirmation Tests:
Blood testing, Radiography
Naf fziger’sTest
Instruct: With the patient seated comfortably, the examiner occludes the jugular veins bilaterally
for 30 –40 seconds. The patient is then instructed to cough deeply.
CONTRAINDICATED for geriatric patients. EXTREME CARE when performing on a
patient with atherosclerosis.
Positive: Radicular pain (typically in lumbars, possibly cervical or thoracic)
Indicates: Space-occupying lesion
Confirmation Tests:
Dejer i
ne’sTr i
ad,Val sal
va’
sTest
,Swal
l
owi
ngTes
t(i
ncer
vicalspi
ne)
,Ver
tebr
alAr
ter
yTest
i
ng(
in
cervical Spine)
Forestier's Bowstring Sign

Instruct: Patient is standing. Examiner instructs the patient to lateral bend to one side and then
the other.
Positive: Ipsilateral tightening and contracture of the paraspinal musculature (normally the
contralateral musculature will contract)
Indicates: Ankylosing Spondylitis (Marie Strumpell's Disease), further evaluate.
Confirmation Tests:
Minor’sSign,Nachl asTes
t,Spi
nalPer
cussi
on,Bl
oodt
est
ing,Radi
ogr
aphy
Chest Expansion Test

Instruct: Patient is standing or sitting. Examiner measures the diameter of the thoracic cage at
the level of the 4th intercostal space. The patient then maximally inhales, a
measurement is taken. The patient relaxes and then maximally exhales, a
measurement is taken.
Positive: Males = less than two inches expansion
Females = Less than 1 1/2 inches expansion
Indicates: Thoracic fixation, commonly found with ankylosing conditions such as Ankylosing
Spondylitis.
Confirmation Tests:
Amoss’ sSi gn,Forrest
i
er’
sBowst
ri
ng,RangeofMot
ion,Bl
oodt
est
ing, Radiography

NON-ORGANIC EXAMS
Based upon area of Chief Complaint
Cervical:
Libman’ sSi
gn
Instruct: Patient seated, examiner places a gradual increasing amount of pressure on the
pati
ent ’
smast oi
dunt ilitbec omesnot i
ceablyuncomf ortable.Compar ebi lat
eral.
Positive: Response of pain.
Indicates: I
sani ndicat orofthepat i
ent ’
spai nthr
eshold.Canbeus eddur ingi nt
erpretati
onof
palpation findings during rest of exam.
Can be indicator for unusually low threshold to pain, possible malingerer.
Confirmation Tests:
Mankopf ’
sSi gn
Any Area, General:
Magnuson’ sTest
Instruct: Patient standing or seated, examiner instructs patient to point to site of pain and
examiner marks spot. Examiner distracts patient by performing some irrelevant test.
Patient is instructed to point to site of pain again.
Positive: Patient does not point to same site both times, significant difference in location of site of
pain.
Indicates: Lack of organic basis for LBP (Malingering). Patient with true pain will point to site of
pain both times.
Confirmation Tests:
Axi
al tr
unkLoadi ng,Bur
n’sBenchTes
t,Fl
exedHi
p,Fl
i
psi
gn,Tr
unkRot
ati
onal
Tes
t
Mannkopf ’
sSi gn
Instruct: Pat i
entseat edorsupi ne,ex ami nerest abli
shespat ient
’srest i
ngr adi
alpul ser ate.
Without changing the pat ient’
sposi tion,theex aminerirri
tatest hepatient ’
sareaof
complaint while monitoring their pulse rate.
Positive: An increase in pulse rate by 10 or more beats/min. is a positive (normal) sign. If no
increase is noted or less than 10/min. = No organic reason for pain.
Indicates: Positive is normal. Patient with true pain will experience an increase of 10 beats per
minute, which is equal to approximately a 10 percent or more increase in their pulse
rate.
Confirmation Tests:
Li
bman’ sTest

Low- Back, Patient on Table:
Bur n’sBenchTest
Instruct: Patient kneels on exam table and is instructed to touch the floor (have them bend from
t
hewai st)witht hei
rfinger ti
pswhileex ami nerst abili
z espat ient’
sl eg.
Positive: Response of pain in low back area, inability or unwillingness to do test.
Indicates: Lack of organic basis for LBP (Malingering). All stress is placed on posterior leg
muscles.
Confirmation Tests:
Axi
al TrunkLoadi ng,Fl
exedHi
p,Fl
i
pSi
gn,Magnuson’
s,Tr
unkRot
ati
onTest
Flexed-Hip Test
Instruct: Pat i
entsupi ne,ex ami nerplacesonehandundert hepat i
ent’
sl umbarspi newi th
fingertips touching the spinous processes (usually at L5/S1). Examiner passively flexes
pat i
ent ’
skneet o90degr eesandpat i
ent ’
shi pt o90degr ees.
Positive: Patient complains of pain in the lumbar region and/or leg pain.
Indicates: Lack of organic basis for LBP (Malingering), if patient complains of pain in the lumbar
region and/or leg before any spinous process separation is felt by the examiner.
Confirmation Tests:
Axi
al TrunkLoadi ng,Bur
n’sBench,Fl
i
pSi
gn,Magnuson’
sTes
t,Tr
unkRot
ati
onTest
Flip Sign
Instruct: Patient supine; the examiner performs a SLR and notes the degree of movement and
location of pain. The patient is then asked to be seated, with legs hanging off the table
edge, as the examiner tells the patient he/she is going to examine the knee joint. While
doing the examination, a SLR is performed in the seated position.
Positive: Patient does not complain of pain.
Indicates: Lack of organic basis for LBP (Malingering). The same degree of movement and
location of pain should occur in either position.
Confirmation Tests:
Axi
n’sBench,Fl
exedHi
p,Magnuson’
sTest
,Tr
unkRot
ati
onTest
Low- Back, Patient Standing:
Axial Trunk-Loading Test

Instruct: Patient standing, examiner places downward pressure on the head with both hands
whilenotdi sturbi
ngt hepat i
ent’spr es
ent i
ngpost ur e.
Positive: Patient complains of pain in the lumbar region.
Indicates: Lack of organic basis for LBP (Malingering). The axial loading may produce pain in the
cervical region but should not produce pain in the lumbar region.
Confirmation Tests:
Burn’sBench,Fl ipSi gn,Fl
exedHi
p,Magnus
on’
sTest
,Tr
unkRot
ati
onTest

Trunk Rotational Test
Instruct: Patientst andingwi tharmscr ossedagai nstc hest,ex ami nergraspspat i
ent ’spelvis.
Examiner instructs patient to rotate trunk to one side. Examiner simultaneously rotates
pati
ent ’
spel vi
si nsamedi r
ec t
iont hatpat ientr otates.Repeatpr ocedur eto other side.
Positive: Patient complains of low back pain.
Indicates: Lack of organic basis for pain (Malingering). In this test the whole spine is being moved
as one unit, not in segments.
Confirmation Tests:
Axi
n’sBench,Fl
i
pSi
gn,Magnuson’
sTes
t,Fl
exedHi
p

SPECIAL SENSES
DIAG 3750

OPTHALMOSCOPY AND OTOSCOPY
Examining the patient
 Always perform an external examination of the eye before proceeding to use the ophthalmoscope
 Assess for:
 Bilateral symmetry
 Scars, abrasions other noticeable marks
 Discharge, alteration of sclera color
 Eye lids, eye brows
 Normal constriction, dilation, reflexes
The Ophthalmoscope
1) Viewing aperture
2) Focus wheel
 Black (green) # - spherical convex (positive) lenses, converge rays. For Hyperoptic eye
 Red # - spherical concave (negative) lenses, diverge rays. For myopic eye
 Lenses are necessary because different people have different refractive errors, the appropriate lens is
necessary to focus on the retina.
3) Choosing the proper aperture (Shape or color of light beam) :
 Blue - fluorescein dye to evaluate cornea and circulatory system
 Green –(red free), used to see if dark spots are pigment or dried blood, which is darker than the pigment
spots
 Cross hatch - estimate size and distance of lesions for a landmark
 Slit - light bends over irregularities –for checking for retinal detachments
 Polarizing filter (grayish aperture) use to cut glare
 The larger round white beam gives broadest view of the fundus when pupil is dilated.
 Use the small or medium beam for an undilated pupil
Using the Ophthalmoscope

1. Use your right eye (hold ophthalmoscope in right hand) to view patients right eye, left for left.
2. Have patient maintain focus at a distant object.
3. Obtain a red light reflex - position ophthalmoscope 12 - 15”f r
om pa t
ientse yea nds light lyt ot heside,di
rec
t
beam into pupil.
4. At a 15 degree angle to the pupil, move close to patient, rest hand on cheek.
5. Start focus wheel on 0 (or focus ten feet away) and move back and forth until you have retinal vessel on
focus , which is usually the –2( red2) .*Us einde
xf inge ronf oc usingwhe elwhi levi e wi ngf u ndus.Don’t
keep moving the light on and off of the pupil. This will cause it to constrict due to facilitation.
6. Follow the retinal vessel back towards the disc. Pivot around the pupil, you will need to tilt the
ophthalmoscope in order to see the different fields of the fundus.
7. The disc lies slightly nasal to center of retina.
Examining the Disc

1. Shape - round to oval
2. Margins - distinct, nasal margins being less so.
3. Pigment and/or scleral crescents, myelinated nerve fibers (all considered to be normal variants)
4. Color - normally orangish-pink, deeper color nasally.
 Too pale - optic atrophy
 Too red - hyperemia
5. Cup/disc ratio - less than a ratio of 1:2.
 Large cup or differences bilaterally, suspect Glaucoma.
Examination of the Vessels
1. Nasal vessels –those that go from the disc towards nose are more horizontal.
2. Temporal vessels, those going towards ear, curve more.
1) Veins –are wider and darker than arteries
2) Arteries –are narrower and brighter than veins, and taper towards the periphery.
3) Note:
 Blood flow - obstructed or not. Look for arterial venous crossing (can change course of vein,
vein will appear wider distal to the crossing, but crossings close to the disc cannot be judged
accurately), Look for regularity of the blood column, multiple constrictions, focal
constrictions.
 Caliber: size and width of the vessels, generalized narrowing, attenuated arteries, enlarged
veins
 A:V ratio - should be 2:3 or 3:4, *if <1:2 they are not WNL
4) Central retinal artery occlusion (CRA)
 Lessened blood supply to retina, retinal edema
 Bloodless appearance, arteries narrowed or absent
 Macula - cherry red appearance (not involved)
 Sudden visual loss - *medical emergency
5) Central retinal vein occlusion (CRV)
 Hemorrhagic appearance
 Look for hemorrhages
 Vision will become obscured
6) Arterial light reflex
 Reflection of light by medial coat of retinal arterioles this is normal.
 Widening of the reflex - early sign of arteriolar sclerosis.
 Copper wiring - orange color of the reflex at later stage of sclerosis.
Examination of the background

Blood and choroidal plexus behind retina, the pigment cells in the choroid and pigment layer of the retina all
contribute to general appearance of the background.
1. Normal pigment varies and usually corresponds to skin tones:
 lighter skin tone the individual the more light reflected and easier it is to see the choroidal vascular
pattern.
 Tigroid - normal variation
2. Integrity of the fundus - the following are not normal:
 Hemorrhages - solid, flame shaped, linear, dot and blot
 Micro aneurysms-small, sharp point-like red spots
 Cotton wool areas - result from occlusion of terminal arterioles and resultant swelling of the axons
occur along vessels and obscure the vessel
 Exudates - result from venous micro infarction and stasis.
 Yellowish, flat and do not completely obscure vessels posterior to them
 Retinal edema
 Drusen - small yellow dots, symmetrically distributed, seen in both eyes, they are a precursor
of macular degeneration

Examination of the Macula
1. Area of highest concentration of cones and has the greatest visual acuity (Macula Lutea)
2. Fovea –a pit in center of macula, 2 disc diameters temporal and slightly lower to the disc is more pigmented
than rest of retina, has an avascular appearance. Vessels approach but do not cross the macula; it has a deeper
blood supply for the choroid.
3. Have patient look at light of ophthalmoscope; this puts the macula in full view.
 Look for hemorrhages, exudates, edema
 Any pigment change is abnormal
The Otoscope
 Speculum:
 Reusable - boil to clean or soak in alcohol. 4 sizes 2mm, 3mm, 4mm, 5mm
 Disposable - 2 sizes 2.5mm, 4mm
 In order to obtain the maximum field of view, choose the largest speculum which fits comfortably in the
patient’se ar.
Examination the patient
Always do an external examination first
 Hearing - Weber, Rinne, Bing, Schwabach
 Inspect –bilaterally for shape, redness, scars, mastoiditis, discharge, lumps, cauliflower ear, wax (cerumen),
foreign bodies etc.
 Palpate the pinna for any tenderness, nodules and granules.
Using the Otoscope

1) Choose largest comfortable speculum, have patient tilt head away from you.
2) Straighten the outer ear canal
 Adults - up and back
 Children - down and back
3) Hold otoscope like a pencil (between thumb and forefinger) resting hand against patients cheek. Do not put
pressure on the anterior wall with your speculum (it is VERY pain sensitive).
4) Be able to demonstrate recognition of anatomical landmarks of the tympanic membrane (T.M.):
 malleus
 Cone of light
 umbo
 pars flaccida
 short process
 pars tensa
 incus and stapes when visible
5) Be able to recognize normal from abnormal appearance of tympanic membrane
6) Normal: clarity varies with skin pigmentation from almost clear like Saran Wrap to Wax paper appearance.
 pale gray ovoid semi-transparent membrane
 situated obliquely at end of bony external auditory canal
 ha ndleofma ll
e use xtendsdowna ndba cke ndsa tthe“coneofl ight”
 the incus and its articulation with head of the stapes may be seen through a very clear membrane at
the posterior superior quadrant.
 An abnormal membrane can be red or swollen or both, be retracted, demonstrate a loss of landmarks
or malposition of landmarks due to abnormal tension on the membrane.

Internal nasal examination
 Use speculum with a bright light
 Never use pressure on the sensitive septum
 Can view:
 Vestibules
 Middle meatus
 Mucosa
 Septum
 Inferior and middle turbinate bones
 Normal nasal mucosa has a red appearance
 Common cold - swollen erectile turbinates, bright red mucosa and discharge
 Allergic rhinitis - swollen erectile turbinates, polyps
 Atrophic rhinitis - turbinates are atrophic. Mucosa covered with crust and pus. Offensive odor
ozena.
 Ethmoidal maxillary or frontal sinusitis –are associated with a history of chronic nasal discharge
(sinusitis can be unilateral or bilateral and involve any of the sinuses).
 Cystic fibrosis - presents with several edematous boggy, saccular masses in nasal passage called
polyps.
 Polyps are more commonly associated with chronic allergies
 Polyps occur most frequently in the middle meatus. They are pale, non-tender and move freely on
their stalk and are often confused with turbinates which are pink, tender and immobile.

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CLINICAL DIAGNOSIS

CLINICAL SCIENCES DIVISION 2

CLINICAL SCIENCES DIVISION 3

HOUR 2 Explain the concepts of inspection, palpation, percussion, and auscultation

* Inspection Chapter 3, pg. 53-54

HOUR 4 Student Practice

HOUR 2 Teach Gowning for Head and Neck Exam

HOUR 3 Student Practice

HOUR 4 Clinical Integration of the Head and Neck Exam

HOUR 2 Perform and explain the Vascular Exam

HOUR 4 Clinical Integration of the Vascular Exam

CLINICAL SCIENCES DIVISION 4

HOUR 3 Student Practice

HOUR 4 Clinical Integration of the Chest and Lung Exam (Posterior)

HOUR 2 Blood Pressure/ Vital Signs practical

HOUR 4 Student Practice

HOUR 3 Perform and explain the Heart Exam

HOUR 4 Clinical Integration of the Heart Exam/ Student Practice

HOUR 2 Student Practice

HOUR 3 Continue the Abdomen Exam

HOUR 4 Clinical Integration of the Abdomen Exam/Student Practice

HOUR 2 Student Practice

HOUR 3 Clinical Integration

HOUR 4 Student Practice

CLINICAL SCIENCES DIVISION 6

 Vascular examination, Head and Neck (combined as one exam)

CLINICAL SCIENCES DIVISION 7

MOSBY’ SGUI DETO

Equipment for Course

Before I begin any physical examination on my patient, I will assess my

Vital signs Explanation

Place the blood pressure cuff so that:

Additional Blood Pressure Notes

CLINICAL SCIENCES DIVISION 11

CLINICAL SCIENCES DIVISION 12

CLINICAL SCIENCES DIVISION 13

CLINICAL SCIENCES DIVISION 14

8. Condition of the neck

CLINICAL SCIENCES DIVISION 15

11. Distended veins or arteries

12. Skin color variations

13. Ranges of motion

6. Thyroid and cricoid cartilage

8. Palpate thyroid gland

CLINICAL SCIENCES DIVISION 16

10. Lymph nodes (size; consistency; mobility; condition)

2. Over the eyes (Bell)

3. Thyroid gland for soft bruits (Bell)

CLINICAL SCIENCES DIVISION 17

CLINICAL SCIENCES DIVISION 18

5. Abnormalities of the finger and toe nails

6. Hair condition on extremities

CLINICAL SCIENCES DIVISION 19

10. Pathway of Greater Saphenous Vein

11. Pathway of Lesser Saphenous Vein

1. Arterial pulses (feel for these qualities):

2. Feel for the following arterial pulses:

3. Palpate artery wall thickness

Skin temperature of extremities

CLINICAL SCIENCES DIVISION 21

CLINICAL SCIENCES DIVISION 22

Signs Common to Both Arterial Insufficiency and Venous Stasis

CLINICAL SCIENCES DIVISION 23