Clinical Sciences Diagnosis Laboratory Manual July 2008

CLINICAL DIAGNOSISLABORATORY

MANUAL

CLINICAL SCIENCES DIVISION 2

FOREWORD

The purpose of this Clinical Sciences Laboratory Manual is to serve as a starter kit to help the student build asolid 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 sourcesfor 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 beused 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 eachrespective course.

If this manual is lost, misplaced, stolen, or missing for any reason you will be required to obtain another copyfrom 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 youunderstand what is expected of you for your course.

Good luck as you proceed in your journey through Life University and in Chiropractic!!


VISCERAL DIAGNOSIS

DIAG 2725


COURSE OUTLINE

WEEK 1

HOUR 1 Introduction to courseDiscuss laboratory syllabusDiscuss final examinationNecessary equipment for course

HOUR 2 Explain the concepts of inspection, palpation, percussion, and auscultationStudents must read in the lecture textbook (Mosby’s Guide to PhysicalExamination, 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 ExamPerform 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 ExamTeach 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 thefinal 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 integrativeanalysis upon patient presentation up to the level of instruction at this point. Clinical application willbe 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 befollowed exactly to receive full credit. Any deviation from the order will result in a five point reduction.

4. The student will be given a vital signs examination to verify the student’s ability to properly assess vital signs. The vital signs exam is worth 10 points of the practical examination. Partial credit may be given at

the instructor’s discretion. Knowledge of terms will be expected.

5. Laboratory final examinations, including the vital signs examination, are worth 50 points totally. Themaximum 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 beallowed to pass the class even if their total points are passing. Students must have a passing grade inboth 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 onlyacceptable 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 ormore classes will result in an automatic failure of the lab course and the student will not be allowed to

take the final laboratory practical. It is the student’s responsibility to keep up with the material that is presented during their absences.

Laboratory Decorum1. Students in this lab are expected to be both Doctor and patient.The illustration in Mosby’s Physical Examination Handbook, 5th edition, demonstrates the amount ofpatient 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 ableto 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’S GUIDE TO PHYSICAL EXAMINATION(Seidel, Ball, Dains, Benedict)

Equipment for Course

1. Adult Blood PressureCuff

2. Stethoscope–Bell &Diaphragm

3. Eyebrow marking pencil4. 2 Gowns (oversized–

velcro fasteners)5. Thermometer6. Sterile covers for

thermometer7. Watch 2nd hand

8. Underwear/shortsMen–boxer briefsWomen–bikini panty

9. Small tape measure -cloth

GREETING A PATIENT

Hello, I am _____________________________.I will be conducting a patient examination today.Anything we discuss during this visit will be completely confidential.If you have any questions or concern during today’s appointment, please do not hesitate to ask.If at anytime you experience any discomfort or pain during the examination, please let meknow.Do I have your permission to proceed?

Before I begin any physical examination on my patient, I will assess mypatient’s vital signs. I will check the pulse for rate, rhythm, amplitude,and contour, respiratory rate, temperature, and blood pressure.


Vital signs1. Pulse

Rate Rhythm Amplitude Contour

2. Respiratory Rate3. Temperature4. Blood Pressure

Vital signs ExplanationPulse 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 Peripheral measurement of an individual’s cardiovascular capacity.

Respiratory rate Watch the rise and fall of the patient’s chest while they breathe. Count the number of cycles during 60 seconds.

Temperature Assessment of an individual’s body temperature. Measured in one of the following ways:

OralAxillaryRectalTympanic 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. The cuff should be snug enough on the patient’s arm, so that the doctor can only get 1-2 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. The patient’s arm should be resting, free of clothing, and positioned so that the brachial artery (at the

antecubital fossa) is at heart level - roughly level with the 4th interspace at its junction with the sternum. When the patient is seated, resting the arm on a table a little above the patient’s waist is suitable. The patient’s own effort to support the arm may raise the blood pressure.

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 highest reading is accepted as being the closest to the patient’s true blood pressure. Lack of symmetry between the left and right extremities suggests impaired circulation. Compare the strengthof 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 femoralpulsation is absent, coarctation of the aorta must be suspected. Coarctation of the aorta is a congenitalstenosis 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 seatedNeck exposed–below the clavicles

Inspection1. Hair

Color Distribution

2. Head Position Tilt Rotation

3. Scalp Surface4. Skull

Size Shape Symmetry Condition

5. Face Shape Symmetry Structural abnormalities

6. Battle Sign7. DeMusette’s Sign8. Neck

Symmetry of muscles Webbing Masses

9. Tracheal Position10. Patient Swallowing11. Distended Veins or Arteries12. Skin Color Variations13. Ranges of Motion

Palpation1. Skull

Symmetry Condition

2. Scalp Freely moveable

3. Hair Texture

4. Temporal Arteries Thickening or hardness

5. Hyoid Bone6. Thyroid7. Cricoid Cartilages


8. Patient Swallowing9. Thyroid Gland10. Tracheal Tug11. 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 bruits1. Temporal Arteries2. Over Eyes (not recommended)

Thyroid Gland (soft bruits) Patient seated with neck exposed


Head and Neck Examination Explanation

Inspection1. Hair noting color and distribution

Palpate the hairline behind the ears and crown of the head. It should be smooth, symmetricallydistributed 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.

Palpation1. 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

Auscultation1. 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

Inspection1. Venous Pulsations in the Jugular Veins (45° angle)2. Fundoscopic Exam3. Skin Color4. Skin Thickness5. Finger and Toe Nails6. Hair Condition on the Extremities7. Ulcerations8. Edema9. Stasis Dermatitis10. Path of the Greater Saphenous Vein:

Tortuosity Dilation

11. Path of the Lesser Saphenous Vein: Tortuosity Dilation

Palpation1. Arterial Pulses (Palpate the following arteries for: rate, rhythm, amplitude, contour)

Carotid Subclavian Brachial Radial Ulnar

Abdominal Aorta Femoral Popliteal Dorsalis Pedis Posterior Tibialis

2. Palpate Arterial Wall Thickness (not recommended)3. Skin Temperature of the Extremities4. Edema (pitting; ankle region)

Auscultation1. 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

Patient is supine Patient is disrobed to the waist

Inspection1. 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 colorVariations according to race, sex and body type:

Pallor: White Rubor: Red Cyanosis: Blue Jaundice: Yellow

4. Skin thicknessAreas 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 extremitiesNote 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. UlcerationsA crater-like circumscribed lesion of the skin resulting from tissue death (necrosis)Accompanies some infectious, inflammatory or malignant conditions.

8. EdemaSwelling 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 dermatitisPersistent inflammation of the skin of the lower legs with a tendency toward brown pigmentationCommonly associated with venous incompetence.The usual consequences are increased edema, secondary bacterial infection, and eventually ulceration.

10. Pathway of Greater Saphenous VeinStarting 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 VeinStarting 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 moveor 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


Auscultation1. 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 anteriorborder of the SCM.


Signs of Vascular Abnormalities Patient is supine Patient is disrobed to the waist *Supplemental Notes for Lecture*

Arterial insufficiency1. Decrease or absent pulse2. Pallor3. Coolness or coldness of extremity

Venous stasis1. Normal pulses2. Normal color or cyanosis3. Normal temperature4. Pitting edema5. Stasis dermatitis

Signs Common to Both Arterial Insufficiency and Venous Stasis1. Atrophy of skin with hair loss2. Ulceration3. Pain4. Gangrene

Thromboplebitis1. Palpate for tenderness P-A at calves2. Note any palpable cords3. Redness4. Heat (use back of hand)5. Homan’s sign


Signs of Vascular Abnormalities Explanation Patient is supine Patient is disrobed to the waist

Arterial Insufficiency1. Decrease or absent pulse2. 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 pulses2. 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 temperature4. 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.

5. Stasis dermatitis 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 Stasis1. 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 waspalpated.

May be classified as: Burning Aching Cramping

Gradual or sudden onset Sharp Throbbing

Dull Lancinating 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 calvesIf thrombosis is present calf should be tender.

2. Note any palpable cordsIf thrombosis is present the vein should be thicker.

3. RednessIf thrombosis is present calf should be red.

4. HeatUse the back of the hand. If thrombosis is present calf should be hot.

5. Homan’s sign –Source Cipriano pp 360-360f.Instruct: Patient supine. Examiner raises patient’s leg approximately 30 degrees with

knee in extension. Examiner then dorsiflexes the patient’s foot and squeezes the calf.(There are sources that Do Not recommend squeezing the calf due to danger ofthrombus 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

The patient’s arms are crossed and lifted for: Exam of the posterior thorax (at least for the examination of the triangles of auscultation)

Inspection (anterior & posterior)1. Thoracic landmarks2. Anterior to Posterior Diameter3. Respiration4. Symmetry of Thoracic Cage Movement5. Inspect the ribs6. Inspect the Intercostal Spaces (ICS)7. Dyspnea8. Flaring of the Alae9. Breath odor10. Accessory Muscle Use11. Flushing of the Skin12. Pallor13. Cyanosis14. Cicatrix15. Skin Lesions16. Vascular Abnormalities17. Clubbing of the nails

Palpation (posterior)1. Pain2. Tenderness3. Masses4. Sensations5. Further Assess Any Abnormalities Found6. Tactile Fremitus7. Respiratory Excursion (T8-T10 region, posterior)

Percussion (posterior)1. Begin at the Lung Apices2. Compare Side-to-Side3. Determine Diaphragmatic Excursion


Auscultation (posterior, then anterior)1. Patient is Directed to Breath through their Mouth2. 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–excludebreast area on female)1. Pain2. Tenderness3. Masses4. Sensations5. Further Assess Any Abnormalities Found6. Trachael Position7. Lymph Nodes:

Supraclavicular Infraclavicular Epitrochlear

Lateral axillary Medial axillary Anterior axillary Posterior axillary

8. Costochondritis9. Possible Rib Fractures (can also use: 128 Hz tuning fork)

Percussion (anterior, with patient supine)1. Begin at Lung Apices2. Compare Side-to-Side3. 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

The patient’s arms are crossed and lifted for: 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 forwardprojection 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 vitalfunctions.

Prominent sternum Cause: congenital problem or rickets.

Rickets A systemic disease of the infant and young child. It is the childhood equivalent of osteomalaciain the mature skeleton. The essential pathological alteration involves deficiencies of vitamin D, calciumor phosphate. The classic vitamin D deficiency presentation develops between 6 months and 1 year ofage. Symptoms consist of muscle tetany, irritability, weakness, delayed development, and small statueand 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 longstanding gibbus deformity tremendous biomechanical stress is placed upon the uninvolvedvertebral body immediately caudal to the gibbus. This stress may alter the appearance of thisvertebra 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 bean 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 Patient’s nostrils flare. Occurs during inspiration Common sign of air hunger, particularly when the alveoli are considerably involved.

9. Breath Odor Smell the patient’s breath for any of the following items: 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 5mm.

Bullae Accumulation of fluid between the upper skin layers, which produces, andelevation covered by a translucent epithelium. Their diameter is greater than 5mm.

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

Bronchiectasis Emphysema Tuberculosis Lung cancers

Cardiovascular disease Cyanotic congenital heart disease Subacute bacterial endocarditis Secondary polycythemia

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) andcontinue over the trap muscles. At the interscapular area patient should cross their arms (Scapula movesoutward) so that the ICS can be felt without hindrance of the scapula. Below the scapula the patientuncrosses the arms and relaxes, continue to palpate out to the axillary area and down the slope of the ribs)

1. Pain Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was

palpated. May be classified as:

Burning Aching Cramping




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.) eachtime you touch the patient’s thorax.

Check for symmetry of vibration in the following areas:1,2 Apices of lungs3,4 Interscapular area (arms crossed, avoid Tp’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 thedensity of the liver and there maybe a decrease in fremitus at the heart and aortic area. Fremitus is feltbest 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 lungs3,4 Interscapular area (arms crossed, avoid TP’s)5,6 Triangle of auscultation (arms crossed and elevated)7,8 Medial base of lungs9,10 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 lungs3,4 Interscapular area (arms crossed)5,6 Triangle of Auscultation (arms crossed and elevated)7,8 Medial base of lungs9,10 Lateral axillary area

Anterior: Auscultate the 8 primary areas (4 on each side)1,2 Above the clavicles3,4 Just above the breasts5,6 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“Miniature explosions” which occur when previously closed airways open suddenly, allowing pressure 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.


Typical phrases, such as: “toy boat”, “blue moon”, etc... Bronchophony

The doctor can hear the patient’s words clearly through the stethoscope, while the patient speaks in a normal conversational tone and volume

Whispered Pectoriloquy The doctor can hear the patient’s words clearly through the stethoscope, while the patient speaks

in whispers. Egophony

The patient speaks in a normal conversational tone and volume, and when they saythe letter “E”, it sounds like the letter “A” through the stethoscope.

Palpation (anterior) Patient is supine 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 Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was

palpated. May be classified as: Burning Aching Cramping



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) Patient is supine1. Begin at the apices of the lungs2. Compare side-to-side3. Identify location of:

Liver on patient’s right side at the 6th ICS midclavicular line (2 marks) Gastric air bubble on patient’s leftside midclavicular line (1 mark) Spleen on patient’s left side between the 8th-10th ICS midaxillary line (1 mark)


LUNG SOUNDS

This tape contains recordings of breath sounds that you are likely to hear while examining the chestof the normal individuals and patients with pulmonary disease. To hear the sounds reproduced mostrealistically, you should listen to the tape through a stethoscope. * Be sure that the earpieces arepointing forward. Then hold the bell 2 to 3 inches from the speaker of your tape recorder. If youplace the bell on the speaker, you will hear more noise than breath sounds. If you listen to the soundswithout a stethoscope, they will sound unnaturally loud and booming. This phenomenon, known asthe Fletcher-,Munson effect, is due to the frequency response characteristics of the human ear. Onsome 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 ofnormal. vesicular breath sounds, sometimes described as a sighing or gentle rustling. These soundsare heard over most of the peripheral parts of the lung. The inspiratory phase is markedly longer thanthe expiratory phase. Expiration is much quieter than inspiration, and there is no pause betweeninspiration and expiration. The term vesicular is a misnomer; it arose from experimentsperf0rmedinthe 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 soundsemanate from e the turbulent flow of air in the lobar and segmental bronchi, not the alveoli. Nowlisten again to normal vesicular breath sounds. . ..

Listen to bronchial breath sounds.. .. These characteristically loud, high-pitched bronchial breathsounds resemble the sound of air blowing through a hollow pipe. Their expiratory phase is louderand longer than their inspiratory phase. They are present normally only over the manubrium, andthere is a distinct pause between the inspiratory and expiratory phases. The appearance of bronchialbreath sounds over the periphery of the lung may mean abnormal sound transmission because ofconsolidated lung tissue, as in pneumonia. Now listen to bronchial breath sounds over the chest of apatient with pneumonia. Note that the heart sounds are also audible.. ..

These are bronchovesicular breath sounds. . .. Bronchovesicular breath sounds are a mixture ofbronchial 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 andsecond intercostal spaces; and (2) posteriorly between the scapulae. They may be heard elsewhere inthe presence of lung consolidation. Listen again to bronchovesicular breath sounds.. ..

The following are tracheal breath sounds ...... Tracheal breath sounds, not usually auscultated, arepresent over the extrathoracic portion of the trachea. They are very loud, very high-pitched, and havea harsh, hollow quality, the expiratory phase being slightly longer than the inspiratory phase. Listenagain to tracheal breath sounds. . . .

*Note: While listening to this tape, you may find it helpful to stop the tape recorder, take off yourstethoscope, and rest your ears periodically.

Here are breath sounds over a cavity in the lung.. .. These sounds are also called amphorous breathsounds. Expiration is equal in length to inspiration but lower in pitch. There is a pause betweeninspiration and expiration, and the heart tones are audible. Now listen again to amphorous breathsounds....


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 coarsecrackles. Listen now to high-pitched crackles. . .. Now listen to low-pitched crackles. . .. Cracklesare due to the sudden opening of very small airways. Listen again to high pitched crackles. . .. Listenagain to low-pitched crackles. . ..

Crackles may be classified as to position in the respiratory cycle. You will now hear earlyinspiratory crackles. . .. Early inspiratory crackles are characteristic of severe airway obstruction andappear to be produced in the proximal and larger airways. They are not silenced by cough or changeof 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 inperipheral airways and may occasionally be associated with an end-inspiratory wheeze. Lateinspiratory crackles are characteristic of restrictive pulmonary disease and may be heard ininterstitial fibrosis, asbestosis, pneumonia, pulmonary congestion of heart failure, pulmonarysarcoidosis, scleroderma, and rheilmatoid lung. Listen again to later inspiratory crackles. . ..

Sometimes crackles are produced by the accumulation of secretions in the airway. When thesecretions are profuse, the crackles can be heard over the mouth as well as over the chest wall, a signknown 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 musicalpulmonary sound. The musical character is determined by the spectrum of frequencies that make upthe sound. The lowest frequency, called the fundamental, sets the pitch of the wheeze. Wheezes maybe described as high""pitched, in which case they are also called sibilant rhonchi, or low pitched, inwhich case they are also called sonorous rhonchi. Listen to a high pitched wheeze. . .. Now listen to alow-pitched wheeze. ...

Wheezing is produced by a bronchus narrowed to the point of closure, whose opposite walls oscillatebetween the closed and barely open position. The sound made by a vibrating reed instrument, suchas 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 monophonicwheeze. Listen to the following example of a monophonic wheeze........ If a wheeze is composedof several dissonant notes starting and ending at the same time, it is called a polyphonic wheeze. Allforms of obstructive lung disease may be associated with polyphonic wheezing. Listen to apolyphonic wheeze....

Stridor is a particularly loud musical sound of constant pitch. Listen to this example of stridor in achild with croup. . .. Although nothing except its intensity distinguishes stridor from a monophonicwheeze 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 andsilently over one another. But when the surface is thickened by fibrin deposits or coarsened byinflammatory or neoplastic cells, the sliding motion is impeded by frictional resistance. The soundproduced, the pleural friction rub, resembles the sound of leather sliding on leather. Listen again to apleural friction rub. . ..


The following sound is a squawk. . .. Many squawks are inspiratory, but this squawk is bothinspiratory and expiratory, louder on inspiration and softer on expiration. The squawk is a musicalsound found in some patients with diffuse pulmonary fibrosis, especially if associated with anallergic inflammation of the alveoli known as hypersensitivity pneumonitis. Here is the squawkagain. . ..

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 asustained Valsalva maneuver, the pitch being higher in smaller fistulas than in larger fistulas. Thissqueak was recorded without a stethoscope directly over a fistula. Listen again to a bronchial leaksqueak.. . .

Egophony, which is the Greek word for the voice of a goat, refers to the nasal or bleating quality ofspeech transmitted through consolidated lung tissue, as in pneumonia. Occasionally, egophony willbe heard over a pleural effusion where there is collapse of the underlying lung. When egophonyoccurs, the patient says E, the letter will sound like A, because there is transmission of the higherfrequencies, or formants. First you will hear the letter E spoken over the healthy side Now youwill hear the letter E spoken over the area of consolidation Now you will hear the sounds of themicrophone 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 frequenciesbest 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 aretransmitted, and whispering becomes audible. You will hear this phenomenon, whisperedpectoriloquy, now. The patient will whisper the words "one, two, three," and you will hear thesound first over the normal lung...... Then over the consolidated lung ..... Listen now as wealternate between sides. Note that the heart sounds are clearly audible over the consolidated area.


Heart Examination Patient is Supine Patient is Disrobed to the Waist (utilization of gowns can be used to protect the patient’s modesty) The Heart Examination Requires the Use of a Tangential Light Source

Inspection1. Dyspnea2. Pulsations at the APETME areas3. Apical Impulse [aka: PMI (point of maximal intensity)]4. Precordial Heaves5. Abnormalities of the Fingernails6. Cyanosis7. Pitting Edema at the ankles

Palpation1. Check (A.P.E.T.M.E.) Areas for Pulsations (using your finger pads)

Aortic Pulmonic Erb’s point Tricuspid Mitral

While at this location - Check for an Apical Impulse to include:LocationAmplitude

Epigastric Pulsations:Pulsations coming from superior to inferior to the finger pads

May indicate: right ventricular enlargementPulsations coming inferior to superior (actually P-A) to the finger pads

May indicate: abdominal aortic aneurysm2. 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 Erb’s point Tricuspid Mitral

Percussion1. Identify the Location and Size of the Heart2. 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)


Auscultation1. Listen in the mitral area for S1 and palpate the carotid pulse–check for pairing of the two2. At the pulmonic area or Erb’s point using the diaphragm–

Check for: Rate RhythmIdentify 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 Erb’s point Tricuspid Mitral Epigastric

4. Use the bell 2nd - auscultate the following areas for general cardiac sounds: Aortic Pulmonic Erb’s point 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 supine 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

Inspection1. 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 Erb’s Point: 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 heartfailure}.

Edema accompanied with thickening and ulceration of the skin is associated with: Deep venous obstruction Valvular incompetence Stasis dermatitis

Palpation1. 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.

Percussion1. 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 sounds (use pulmonic or erb’s points) 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 Erb’s Point: 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 Listen at the left sternal border (Erb’s point) for best heart sounds using the diaphragm (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 carotidpulse 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 alsolistening 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 duringdiastole you will be listening for splitting that is either accentuated or diminished. State that you are alsolistening 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 shortand S2 to S1 is long.

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 mitralmurmurs.

8. Have the patient assume a seated position. Place the diaphragm at the Aortic areaor Erb's point. Have the patient breathe in and let it out in a slow sigh as they leanforward. Listen for Aortic murmurs.

APETME = Aortic, Pulmonic, Erb's point, Tricuspid, Mitral, Epigastric

S1

S2

S1

S2


HEART SOUNDS

This tape/CD is a supplement to the text Understanding Heart Sounds and Murmurs, With anIntroduction to Lung Sounds by Tilkian and Conover. We recommend that you read the text andstudy the illustrations carefully before using the tape/CD. For best results, use either a quality homeor a personal stereophonic/CD system. With the home unit, the quality of what you hear can beenhanced 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 leftintercostal space.

This the familiar lub dub, lub dub, with no additional sounds of murmurs. Concentrate on the secondsound 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 secondsound 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 thesecond heart sound.

Several conditions (e.g., right bundle branch block) increase the interval between A2 and P2, causinga late or delayedP2 and thus producing a widely split second sound, which is best heard at thesecond 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 theapex 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 isfrequently associated with a coronary artery disease or hypertension. Listen again to the normal heartsounds 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 inthe left lateral position.

An S4 is frequently present with severe hypertension, and this may be accompanied by a loudsecond 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 firstcomponent 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 rateof 100 beats/min.

Another important heart sound is the ventricular gallop or the third heart sound, also called S3 gallopor protodiastolic gallop. When at the bedside, use the bell of the stethoscope pressed gently againstthe skin and listen at the apex with the patient in the left lateral position. Listen first to the normalheart 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 S3gallop 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 toincrease with inspiration.

Now that you have learned to recognize the third heart sound, we will add the previously learnedfourth 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 S3and 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 heartsounds proceed to the next lesson. If in doubt, return to the beginning and review these soundsbefore proceeding further.

Another common heart sound is the systolic ejection sound. Listen again to the familiar first andsecond 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 confusedwith S4 gallop sounds. When at the bedside, use the diaphragm of the stethoscope pressed firmlyagainst 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. Theyreflect mitral valve prolapse with mitral regurgitation. Here is a mid-systolic click with a mid- to latesystolic murmur.

Another important abnormal heart sound it the opening snap of mitral stenosis: a sharp, high-pitchedsound heard early in diastole 40 to 120 msec after the second heart sound. This accompanied by aloud first sound.

Listen again to the first and second heart sounds at the fourth left intercostal space. Use thediaphragm 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 intheir 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 listenfor some murmurs. A frequently heard systolic murmur is that of mitral regurgitation. It is heard bestat 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 athird 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 atthe left sternal border and subxiphoid area and is louder during inspiration and diminishes onexpiration.

Listen carefully to the respiratory variation of inspiration,

and expiration.

Tricuspid regurgitation may be accompanied by an S3 gallop, generated in the right ventricle. Thissound, 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 diastolicopening 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 isalso 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 andatrial contractions are absent. The diastolic mitral rumble persists, while the presystolic accentuationmay 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 secondheart sounds at the aortic area.

And now listen to the murmur of mild aortic stenosis, heard best with the diaphragm of thestethoscope 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 peakslater in systole.


Examination of the Abdomen Patient supine, and their bladder is empty Patient is exposed from the xiphoid to the pubis Patient’s arms are at their sides, and their head is on some form of support

Inspection1. Skin color2. Masses3. Vascular Abnormalities4. Contour5. Other Abnormalities

Auscultation1. 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 )

Percussion1. Scan all (4) quadrants in a sequential manner2. Check for a distended bladder3. Check for liver size (2 marks)4. Check for dullness of the spleen (1 mark)5. Check for tympany of the stomach (aka: “gastric air bubble”)

Palpation1. 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. Murphy’s sign5. Gallbladder6. Continue to palpate for liver’s edge

Middleton’s maneuver Hooking maneuver

7. Check for spleen8. Check around umbilicus9. Check aorta10. Kidney entrapment11. Urinary bladder12. Rebound Tenderness

Rovsing’s Sign Blumberg’s Sign

13. Tests for Ascites Fluid Wave Shifting Dullness Puddle Sign

14. Pain Assessment15. Psoas Sign16. Obturator Sign17.Murphy’s Punch


Abdomen Explanation Patient is supine & their bladder is empty Patient is exposed from xiphoid to pubis Patient’s arms are at their sides & their head is resting on some support

Inspection1. 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.

Cullen’s Sign 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 ofCushing’s Syndrome(Hyperadrenalism).

2. Masses Hernias Protrusion of abdominal contents through abdominal muscles.

Sister Mary Joseph’s Nodules Enlarged lymph nodes around umbilicus. Cause: Possibly due to metastatic carcinoma.

Organomegaly Enlarged organs usually the liver and spleen.

3. Vascular Abnormalities 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.

Auscultation1. Bowel Sounds (Diaphragm)

Place diaphragm of stethoscope for 15 seconds in each of the 4 quadrants (one minute total) and hold it inplace 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 masses1. 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 thanthe change from dullness to tympany].

Continue downward until the percussion tone changes to one of dullness, which is the upper border ofthe liver and mark.

The upper border usually begins at the 5th to 7th intercostal spaces. An upper border below this mayindicate 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 downwarddisplacement 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 abdominalmuscles). 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. Palpate for the liver (feel for the liver’s edge) 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 pushesit 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. Murphy’s Sign 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).

Middleton’s Manuever 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. Stand on the patient’s right side facing his or her feet. Press in and up toward the costal margin with your fingers. Use same breathing instructions as above.

6. Check for Spleen While standing on the patient’s right side, reach across with your left hand and place it beneath the

patient under the left costovertebral angle. Pull posterior-anterior to lift the spleen toward the abdominal wall. Place the palmar surface of your right hand with fingers extended on the patient’s abdomen below the

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 patient’s right flank and the other hand at the right costal

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 Blumberg’s Sign This is a maneuver to access all four quadrants. Patient supine, hold your hand at a 900 angle to patient’s abdomen with the fingers extended. 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 Rebound tenderness test in the lower left quadrant and the patient has pain over McBurney’s point

(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 carefullywatching patient’s facial expression.

Examiner asks patient if they are hungry. Patients with an organic cause (appendicitis, intrabdominalinfection) 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 greatersignificant 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 SignInstruct: Patient supine. Examiner places superior hand on right iliac crest and inferior

hand on patient’s right thigh. Instruct patient to raise straight leg on the right sideagainst resistance.

Positive: Increased pain.Indicates: Appendicitis

15. Obturator SignInstruct: Patient supine. Instruct patient to flex their hip to 90 degrees and their knee to 90

degrees. Examiner places superior hand on patient’s right knee and inferior hand around patient’s right ankle. Patient internally and externally rotates their right hip against resistance, given by the examiner.

Positive: Increased pain.Indicates: Ruptured appendix or pelvic abscess

16. Murphy’s Punch 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.)


OrthopedicDiagnosis

Diagnosis 2730


Orthopedic Clinical Assessment 273050 Point Final Examination

Weeks 9 & 1006 points Bony palpation06 points Soft tissue palpation05 points Range of motion10 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]04 points Orthopedic test [all correct or no points]04 points Orthopedic test [all correct or no points]04 points Orthopedic test [all correct or no points]04 points Orthopedic test [all correct or no points]03 points Doctor/patient interaction50 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 (recitefrom 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 rootevaluation 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 signand the indication for each test. Each test is graded as an all or nothing item. If the test is performed wrong; the student gives thewrong 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 DivisionLaboratory 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 FinalLab exam (> 70) in order to pass the class. The student is responsible for adequate preparation for the final examination. Thereare 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 forall 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 acceptableexcuse in accordance with the Student Handbook, then he/she will receive a ZERO (0) for their final laboratory examinationgrade.

If a student does not take the final examination during his/her scheduled time and does provide an acceptable excuse according tothe Student Handbook, then there is no forfeiture of points. The day the student returns back to school, the student mustcontact 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 towear gym shorts, females are to wear gym shorts and either an aerobics top, jogging bra, or a bathing suit top. NOTE: There willbe 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 forthe 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 notshare 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 andsubluxations at the related spinal levels.

The Final Laboratory Examination may be administered by any Clinical Sciences DivisionLaboratory instructor, should your laboratory instructor be unable to test you.


It is expected the student will greet the patient with the following standardizedintroduction.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.If you have any questions or concerns during today’s appointment please do not hesitate to ask.If at any time you experience any discomfort or pain during the exam/adjustmentplease let me know.Do I have your permission to proceed?


SHOULDER EXAMINSPECTION1) For any obvious unnatural movement or posture2) For any topical abnormalities

Scars/keloidsDiscolorationAbrasionsBlebsOther apparent pathology

3) For any asymmetry of structure:Clavicle - dislocation or fractureDeltoid - atrophy, flaring or dislocation shape changesScapular winging or congenital deformity

PALPATION

Bony Palpation1) Sternoclavicular articulation2) Clavicle3) Coracoid process4) Acromioclavicular articulation5) Acromion6) Greater tuberosity of the humerus7) Bicipital groove8) Less tuberosity of the humerus9) Spine of the scapula10) Body of scapula11) Scapulothoracic articulation

Soft Tissue Palpation

1) Rotator Cuff Muscles Supraspinatus InfraspinatusTeres minorSubscapularis

2) Subacromial bursa3) Subdeltoid bursa4) Axillary borders

Pectoralis majorSerratus anterior Axillary lymph nodes Latissimus dorsi Bicipital tendon

5) Prominent muscles of region Sternocleidomastoid Biceps Deltoid (palpate as a group and individually)

Anterior portionMiddle portion


Posterior portion Trapezius Rhomboid muscles (palpate as a unit and individually)

MinorMajor

RANGE OF MOTIONActive and PassiveFlexion (forward) 180 Extension 60Abduction 180Adduction 50External rotation = (from horizontal abduction of arm) 90Internal rotation = (from horizontal abduction of arm) 70Scapular retraction (attention)Scapular protraction (reaching)Scapular elevation (shoulder shrug)

Reflex Biceps Triceps

Sensation (Covered under cervical spine packages)

SPECIAL TESTS1) Dugas Test, pg. 224 E2) Anterior Apprehension Test, pg. 202-205 E3) Posterior Apprehension Test, pg. 202-205 E4) Codman’s Drop Arm Test, pg. 214-219 E5) Dawbarn’s Test, pg. 222,223 E6) Yergason Test, pg. 268-269 E (pg. 103 Cipriano)7) Abbott-Saunder’s Test, pg. 188-191 ESpeed’s Test, pg. 254-255 EApley’s Scratch Test aka Apley’s Scratch Test, pg. 200 E Impingement Sign, pg. 236 E


Shoulder Special Tests

Dugas TestInstruct: Patient seated, examiner instructs patient to place the hand of the

affected side on the opposite shoulder and then bring the affected elbowto 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 TestInstruct: Patient seated, examiner abducts the patients shoulder, flexes the

patient’s elbow and then gradually externally rotates to the patient’s shoulder.

Positive: Patient will have a noticeable look of apprehension or alarm on their face with possiblepain.

Indicates: Chronic anterior dislocation of the shoulder (glenohumeral joint).Confirmation Tests:Dugas’ Test, Radiography

Posterior Apprehension TestInstruct: Patient supine, examiner flexes patient’s shoulder, flexes patient’s elbow

and internally rotates the patient’s shoulder. Examiner places his/her hand on the patient’s elbow and gradually applies increasing posterior pressure.

Positive: Patient will have a noticeable look of apprehension or alarm on their face with possiblepain.

Indicates: Chronic posterior dislocation of the shoulder (glenohumeral joint).Confirmation Tests:Dugas’ Test, Radiography

Drop Arm Test / a.k.a. Codman’s Drop Arm TestInstruct: Patient seated, examiner passively abducts patients arm to slightly over 90 degrees and

removes support, if patient can maintain arm, theninstructs 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:Apley’s Scratch, Impingement Sign

Dawbarn’s Test–deep palpation of shoulder elicits well-localized tender area, bysubacromial bursa

Instruct: Patient seated, examiner applies pressure below the affected acromial process withhis/her fingertips. Note for pain or tenderness. Examiner continues to apply pressurewhile abducting the patient’s arm past 90 degrees.

Positive: Decrease in pain and/or tenderness.Indicates: Subacromial bursitis.Confirmation Tests:MRI


Yergason’s Test (Cipriano)Instruct: Patient seated, examiner flexes patient’s elbow to 90 degrees. Examiner stabilizes

patient’s elbow with one hand and exerts slight inferior traction. Examiner uses their other hand and grasps slightly above patient’s wrist. Examiner offers resistance while 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) Tendinitis2) Instability of the biceps tendon possibly associated with a torn transverse humeralligament

Confirmation Tests:Abbot Saunder’s Test, Speed’s Test

Abbott-Saunders TestInstruct: Patient seated, examiner fully abducts and externally rotates the patient’s

affected arm. Examiner places his/her fingers on the patient’s bicipitalgroove and then slowly lowers the patient’s affected arm to their side.

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’s Test, Yergason’s Test

Speed’s TestInstruct: 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 thepatients forearm. Instruct the patient to flex his/her shoulder, maintain supination andcompletely extend the elbow as the doctor applies resistance.

Positive: Pain and/or tenderness in the bicipital groove.Indicates: Bicipital tendinitis.Confirmation Tests:Abbott-Saunder’s Test, Yergason’s Test

Apley’s Test Instruct: Patient seated. Have him/her place the affected hand behind the head and touch the

opposite superior angle of the scapula = Apley’s scratch superiorThen patient is instructed to place the hand behind the back to touch inferior angle ofscapula = Apley’s scratch inferior

Positive: Exacerbation of painIndicates: Degenerative tendinitis of rotator cuff tendons (usually Supraspinatus.)

Impingement SignInstruct: Patient seated with arms at side, examiner slightly abducts patient’s arm (hand should

be pronated) and moves it fully through flexion (will jam greater tuberosity andanterior/inferior surface of the acromion)

Positive: Pain in the shoulderIndicates: Overuse injury to the supraspinatus and possibly biceps tendon.


ELBOW EXAMINSPECTION1) For any unnatural movement or posture2) For any topical abnormalities

Scars/ keloidsDiscolorationAbrasionsBlebsOther apparent pathology

3) For any asymmetry of structure4) Cubitus Valgus(more “L angle” than the normal 6° to 15°)5) Cubitus Varus (gunstock deformity)

PALPATIONBony Palpation1) Medial epicondyle2) Medial supracondylar line of the humerus3) Groove of the ulnar nerve4) Trochlea5) Olecranon6) Olecranon fossa7) Lateral epicondyle8) Lateral supracondylar line of the humerus

Radial head

Soft Tissue Palpation1) Ulnar nerve2) Wrist flexor muscles (palpate as a unit and individually)

Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris

3) Medial collateral ligament4) Supracondylar lymph nodes5) Brachial Artery6) Triceps muscle7) Lateral collateral ligament8) Biceps9) Olecranon bursa10) Elbow Flexors muscles “mobile wad of three” (palpate as a unit and individually)

Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis


RANGE OF MOTIONActive and PassiveElbow flexion 150Elbow extension 0Forearm supination (radio-ulnar joint) 80Forearm pronation 80

ReflexBiceps, Brachioradialis, & Triceps


SPECIAL TESTS

1) Medial Collateral Ligament, pg. 314,315 E2) Lateral Collateral Ligament Test, pg. 314,315 E3) Tinel’s Elbow Sign, pg. 318-320 E4) Cozen’s Test, pg. 300-310 E5) Mill’s Test, pg. 316-317 E6) Golfer’s Elbow Test, 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

places an adduction (varus) pressure on the patient’s lateral forearm.Positive: Excessive gapping & pain.Indicates: Lateral collateral ligament instability.Confirmation Test:MRI

Tinel’s Elbow SignInstruct: 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’s TestInstruct: 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’s Test

Mill’s Test (maneuver) (Evans)Instruct: Patient seated at rest with forearm supinated. In a smooth continuous motion the Dr.

passively maximally flexes the patient’s elbow, then wrist and then fingers. While maintaining wrist and finger flexion, the Dr. passively extends the patient’s elbow (theforearm is now pronated)

Positive: Pain over the lateral epicondyle.Indicates: Lateral epicondylitis (Tennis Elbow).Confirmation Test:Cozen’s Test

Golfer’s Elbow TestInstruct: 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 EpicondylitisConfirmation Tests:Cozen’s Test, Mill’s Test


WRIST and HAND

INSPECTION1) For any obvious unnatural movement or posture

Is hand held in a protected position?Is hand held in a restricted manner?Is the “attitude” of the hand normal?

2) For any topical abnormalitiesScars/keloidsDiscolorationAbrasionsBlebsOther apparent pathology

3) For any asymmetry of structureAny missing fingers?Any fingernail pathology?Any muscle atrophy or finger contractures?

PALPATION

Bony Palpation1) Radial styloid process2) Scaphoid (Navicular)3) Lunate4) Lister’s tubercle (Dorsal tubercle)5) Triquetrium6) Pisiform7) Trapezium8) Trapezoid9) Capitate10) Hook of hamate11) Ulnar styloid process12) Metacarpals13) Phalanges

Soft Tissue Palpation1) Ulnar artery2) Radial artery3) Palmaris longus tendon4) Carpal tunnel region5) Thenar eminence6) Hypothenar eminence7) Palmar aponeurosis8) Tissues surrounding proximal interphalangeal joints9) Tissues surrounding distal interphalangeal joints10) Distal tufts of fingers


RANGE OF MOTION

Active and PassiveWrist flexion 80Wrist extension 70Wrist ulnar deviation 30Wrist radial deviation 20Finger abductionFinger adductionThumb flexion (MCP)Thumb extension (MCP)Finger flexion (MCP)Finger extension (MCP)Finger Opposition

Reflexnone


Peripheral Nerves

Radial NerveDorsum of the hand on the

radial side of the thirdmetacarpal as well asthe dorsal surfaces ofthe thumb, 2nd and 3rddigit as far as the DIPjoints.

Median NerveThe radial portion of the

palm and the palmarsurfaces of the thumb,2nd and 3rd and lateral½ of the 4th digit.

Ulnar NerveThe ulnar side of the dorsal

and palmar surfacesand the 4th and 5th digit.


SPECIAL TESTS

Tinel’s Wrist Sign pg. 390-391 E Phalen’s Sign a.k.a. Reverse Phalen’s Sign & Prayer’s Sign, pg.380-383E Finkelstein’s Test, pg. 366-369 E Bunnel -Littler Test, pg. 350-353 E Retinacular Test, pg. 390-391 E Allen’s Test, pg. 342-345 E

Tinel’s Wrist SignInstruct: 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 SyndromeConfirmation Tests:Phalen’s Test, Reverse Phalen’s Test, Nerve Conduction Testing

Phalen’s Sign AND Reverse Phalen’s Sign a.k.a. Prayer’s signInstruct: 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 asshoulders for 60 seconds.

Positive: Reproduction of pain and/or paresthesia in the median nerve distributionarea (thumb, 2nd , 3rd and the lateral side of the 4th digit).

Indicates: Carpal Tunnel SyndromeConfirmation Tests:Tinel’s Sign, Nerve Conduction Testing

Finkelstein’s TestInstruct: 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 ulnardeviate his/her hand.

Positive: Pain distal to the radial styloid process.Indicates: Stenosing tenosynovitis of the abductor pollicis longus and extensor

pollicis brevis tendons (DeQuervain’s Disease).Confirmation Tests:Blood Testing, MRI


Bunnel -Littler TestInstruct: 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 jointcapsule contracture or tight intrinsic muscles. To differentiate, examiner places themetacarpophalangeal joint in a few degrees of flexion and attempts to move theproximal 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 TestInstruct: 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 jointcapsule contracture or tight retinacular ligaments. To differentiate, examiner places theproximal interphalangeal joint in a few degrees of flexion and attempts to move thedistal 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’s TestInstruct: 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 boththe radial and ulnar artery at the wrist and then lowers the patient's arm with the fistclosed and allows the fist to rest on patient's thigh. Examiner instructs patient to openclosed fist and releases digital pressure over one artery while keeping the other arteryoccluded. Record the filling time, while comparing color to the other hand. Then repeatprocedure 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 neurovascularcompression tests.**


CERVICAL SPINE

INSPECTION1) For any obvious unnatural movement or posture2) For any topical abnormalities

Scars/keloidsDiscolorationAbrasionsBlebsOther apparent pathology

3) For any asymmetry of structureMuscle splintingMuscle atrophyCongenital deformity

PALPATION

Bony Palpation

Anterior Aspect1) Hyoid Bone2) Thyroid Cartilage3) First Cricoid Ring4) MandiblePosterior Aspect1) Occiput2) Inion (EOP)3) Superior Nuchal Line4) Mastoid Processes5) Spinous Processes of Cervical Vertebrae6) Facet Joints

Soft Tissue Palpation

1) Sternocleidomastoid muscle2) Anterior lymph node chain3) Posterior lymph node chain4) Thyroid gland5) Carotid pulse6) Supraclavicular fossa7) Trapezius muscle8) Greater occipital nerves9) Superior nuchal ligament


RANGE OF MOTIONActive and PassiveFlexion 60Extension 75Lateral bending left 45Lateral bending right 45Left rotation 80Right rotation 80

ReflexesNone

Sensations (Covered under cervical spine packages)

SPECIAL TESTS

1) Foraminal Compression Test, pg. 94-97 E2) Cervical Distraction Test, pg. 88-93 E3) Shoulder Depressor, pg.130-131 E4) Valsalva Maneuver, pg. 148-151 E5) Swallowing Test, pg. 142,143 E6) Soto Hall Sign, pg. 132-135 E7) Kernig’s Sign, pg. 538-539 E8) Spinal Percussion Test, pg. 136-1379) O'Donoghue Maneuver, pg. 120-125

Foraminal Compression TestInstruct: Patient seated with examiner standing behind. Examiner clasps his/her hands over

patient’s head and exerts gradual increasing downward pressure. Examiner repeats this procedure with the patient’s head rotated right and then left.

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 rootcompression.

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,Nerve Conduction Testing

Cervical Distraction TestInstruct: Patient seated: the examiner grasps the patient’s head with both hands 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:Foraminal Compression Test, Shoulder Depression Test, Reflex and Sensory Testing, Radiography,MRI, Nerve Conduction Testing

Spinal Percussion TestInstruct: 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 painIndicates: 1) Possible fractured vertebrae, ligamentous involvement (spinous pain), muscular

involvement (muscular pain).2) Possible disc pathology.

Shoulder Depression TestInstruct: Patient seated, examiner stabilizes patient’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 ligamentousinjury.

2) Radicular Pain:On side being tested neurovascular bundle compression, dural sleeve adhesions, orThoracic Outlet SyndromeOn opposite side being tested foraminal encroachment with nerve root compression.

Confirmation Tests:Cervical Distraction, Foraminal Compression Test, Sensory and Reflex Testing, and MRI

Valsalva ManeuverInstruct: 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 TestInstruct: 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:Valsalva’s Test, Sensory and Reflex Testing, MRI


Soto Hall SignInstruct: Patient supine, examiner flexes patient’s head toward his/her chest while

exerting downward pressure on patient’s sternum with hypothenar eminence of inferior hand.

Positive: Generalized pain in the cervical region, which may extend down to the levelof T2.

Indicates: Non-specific test for structural integrity of cervical region.Confirmation Tests:O’Donoghue’s Test, Spinal Percussion Test, Swallowing Test, Valsalva Test, Sensory and ReflexTesting, MRI

Kernig’s SignInstructs: Patient supine, examiner passively flexes patient’s hip to 90 degrees and the patient’s

knee to 90 degrees. Examiner extends patient’s leg completely.Positive: Inability to fully extend the leg and/or pain (usually in the neck region.)Indicates: Meningeal irritation/ meningitis.Confirmation Tests:Brudzinski’s Sign, Lumbar Tap

O'Donoghue Maneuver (One of the best tests for Whiplash injury used by anexaminer, can also be utilized on ANY joint in the body to determinesprain/strain injury )

Instruct: Patient is seated, examiner grasps the patient's head with both hands and passivelytakes the cervical region through a range of motion. The examiner then takes thecervical 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 LesionsInvolving the Upper Extremity

Always use the MRS system in the correct order, any deviation will result in a loss of points1) Muscle–test and name the muscle/s and nerve for each neurological package being tested2) Reflex–test and name the appropriate reflex being tested; if no reflex it must be stated.3) Sensation– test the appropriate dermatome for the neurological package and it’s corresponding

dermatome above and below following the format enclosed from HoppenfeldEvaluation is to be in this order: Muscle test (motor), Reflex, Sensation (dermatome)

Testing individual nerve root C5a) Disc Level C4b) Muscle tests (2) Shoulder abduction: deltoid (axillary nerve)

Forearm flexion: biceps (musculocutaneous nerve)c) Reflex Bicepsd) Sensation Lateral arm

Testing individual nerve root C6a) Disc Level C5b) Muscle test (1) Wrist extension: extensor carpi radialis longus

& brevis, and extensor carpi ulnaris ( radial nerve)c) Reflex Brachioradialisd) Sensation Anterior lateral forearm, palm, thumb and 2nd digit

Testing individual nerve root C7a) Disc Level C6b) Muscle tests (3) Elbow extension: triceps (Radial Nerve)

Wrist flexion: flexor carpi radialis (Median Nerve), flexor carpiulnaris (Ulnar Nerve)Finger extension: extensor digitorum communis, extensorindicis profundus, extensor digiti minimi (radial nerve)

c) Reflex Tricepsd) Sensation 3rd digit, middle of palm

Testing individual nerve root C8a) Disc Level C7b) Muscle test (1) Finger flexion: flexor digitorum superficialis, flexor digitorum

profundus, lumbricals (median and ulnar nerves)c) Reflex Noned) Sensation 4th and 5th digits, antero-medial hand and forearm

Testing individual nerve root T1a) Disc Level T1b) Muscle tests (2) Finger abduction : dorsal interossei (ulnar nerve)

Finger adduction : palmer interossei (ulnar nerve)c) Reflex Noned) Sensation Antero-medial arm (distal aspect of arm to proximal aspect of

forearm)


Dermatomes of the Upper Extremity

Initial Examination ProcedureExample (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 ProcedureExample (Examination of C5 package dermatomes)Patient seated, anatomical position, eyes closed.

Verbage = Can you feel this? AND does this feel like this?

FirstC4 of right side compared to C5 of right sideC5 of right side compared to C6 of right side

SecondC4 of left side compared to C5 of left sideC5 of left side compared to C6 of left side


Evaluation of Nerve Root LesionsInvolving the Upper Extremity

(Examined As Follows)

Always use the MRS system in the correct order, any deviation will result in a loss of pointsMuscle–test and name the muscle/s and nerve for each neurological package being testedReflex–test and name the appropriate reflex being tested; if no reflex it must be stated.

Sensation– test the appropriate dermatome for the neurological package and it’s corresponding dermatome above and below following the format enclosed from Hoppenfeld

Always use the MRS system in the correct order: Muscle Reflex Sensation

Muscle (motor)

One hand above joint ofmotion for stability

One hand used asshort lever to testmuscle

No hands on joints

Gradual increase inpressure

Always bilateral

Reflex

Rapid flick of hammeron tendon

No tension in musclesaround tendon

Always bilateral

Skin on skin

Always bilateral

Sensation(dermatome)

Patient seated

Anatomical position

Eyes closed

Pin to skin (verbiageused = does this feellike this), skin onskin

Always bilateral

Test sensation aboveand below

For the evaluation of Nerve Root Lesions follow pages 22, 23, and 24 of this laboratoryhandout. Students are not to follow the Cipriano or Evans protocol for this section.

***** LECTURE MATERIAL ONLY *****


Evaluation of Nerve Root Lesions

Involving the Thoracic and UpperLumbar Spine Regions

Testing individual nerve root levels T2-T12a) Disc Level T2-T12b) Muscle test (1) Rib elevation : intercostals [segmented innervated and difficult to evaluate

individually], rectus abdominusc) Reflex: None (can perform superficial abdominal reflex)d) Sensation: T4 = nipple line

T7 = xyphoid processT10 = umbilicusT12 = 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. 234a) Disc Level T12-L2b) Muscle test (1) Primary hip flexor : iliopsoas (L1-L3)c) Reflex Noned) 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. 236a) Disc Level L1-L3b) 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 Patellard) Sensation L2 middle of thigh, L3 lower thigh, L4 anteriomedial leg below the knee

and medial side of the foot


LUMBAR SPINEINSPECTION1) For any obvious unnatural movement or posture2) For any topical abnormalities

Scars/keloidsDiscoloration

3) Infection signs4. Heating pad redness5. Birthmarks6. Cafe-au-lait spots

4) Abrasions5) Blebs6) Other apparent pathology

LipomaHairy patchesFor any asymmetry of structure

Shoulders level5. Left vs. right symmetry6. Listing to one side7. Hyperlordosis vs. kyphosis

PALPATION

Bony Palpation1) Lumbar spinous processes2) Sacral tubercles3) Iliac crest4) PSIS

Soft Tissue Palpation1) Paraspinal muscles (palpate as a unit) superficial layer

Spinalis Longissimus Iliocostalis

2) Sciatic nerve3) Gluteus Maximus4) Gluteus Medius5) Hamstrings

Biceps femoris Semitendinosus Semimembranosus

6) Anterior abdominal muscles


RANGE OF MOTIONActive and PassiveFlexion 25Extension 30Left lateral bending 25Right lateral bending 25Left rotation 30Right rotation 30

ReflexPatellar and AchillesSensation (Covered under lumbar spine packages)

SPECIAL TESTS

1) Hoover’s Sign, pg. 1000-1001 E2) Straight Leg Raiser (SLR), pg. 602-605 E3) Goldthwait’s Sign, pg. 644-645 E4) Bragard’s Sign, pg. 506-507 E5) Buckling Sign pg. 209 C6) Bowstring Sign, pg. 504-505 E7) Lasegue’s Test pg. 548 E8) Milgram’s Test, pg. 574-575 E9) Valsalva Maneuver, pg. 148-151 E10) Bechterew’s Test pg. 496-499 E11) Anterior Innominate Test, aka Mazion’s Pelvic Maneuver, pg. 630 E

(Advancement Sign)12) Lewin Standing Test pg. 556-55713) Neri's Bowing Test (Neri’s Sign) pg. 582-58314) Heel Walk, pg. 526 E15) Toe Walk, pg. 526 E16) Ely's Heel to Buttock Test, pg. 518-519(Evan’s calls this Ely’s sign as an a.k.a.)

Hoover’s Sign(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 sideIndicates: Lack of organic basis for paralysis (Malingering/hysteria).

With organic hemiplegia, the patient will still exert downward pressure when attemptingto raise paralyzed leg)


Straight Leg Raiser (SLR)Instruct: Patient supine, examiner raises patient’s leg slowly to 900 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:Bechterew’s Test, Braggard’s Test, Lasegue’s Test, Lewin’s Standing Test

Goldthwait’s SignInstruct: 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 thepatient'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 = possiblesacroiliac problem.

Confirmation Tests:Belt Test, Gaenslan’s Test

Bragard’s SignInstruct: Patient supine, examiner performs a (SLR) on the patient. Examiner

lowers the raised leg (5 degrees) from the point of pain and sharplydorsiflexes patient’s foot.

Positive: Radiating pain in posterior thigh.Indicates: Sciatic radiculopathyConfirmation Tests:Bechterew’s Test, Lasegue’s Test, SLR Test

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:Bechterew’s Test, Braggard’s Test, Lasegue’s Test, Lewin’s Standing Test

Bowstring SignInstruct: Patient is supine, examiner places patient’s leg on their shoulder and first

applies pressure to the hamstring muscle if pain is not elicited then applypressure 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’s Test, Neri’s Bowing Test


Lasegue’s TestInstruct: 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 degreesIndicates: SciaticaConfirmation Tests:Bechterew’s Test, Braggard’s Test, Lewin’s Standing Test, SLR Test

Milgram’s TestInstruct: Patient supine, examiner raises both of patient’s legs 2-3 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:Bowstring Test, Heel Walk Test, Toe Walk Test, Kemp’s Test, Neri’s Bowing Test

Valsalva ManeuverInstruct: 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

Bechterew’s TestInstruct: 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.Indicates: Sciatic radiculopathy.Confirmation Tests:Bragard’s Test, Lasegue’s Test, Lewin’s Standing Test, Straight Leg Raising Test

Neri's Bowing Test(Neri’s Sign)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:Bowstring Sign, Heel Walk Test, Toe Walk Test, Kemp’s Test, Milgram’s Test


Anterior Innominate Test a.k.a.Mazion’s Pelvic 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 andtouch 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 LegRaise, Lasegue, and Bechterew tests. If this test is positive (sciatica), those tests shouldbe also. Inconsistency of positive signs, along with a patient’s inability to state exactly when and where the pain occurs, may indicate malingering.

Lewin Standing TestInstruct: 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 theother knee into complete extension. Finally the examiner brings both knees intocomplete extension.

Positive: Radiating pain down the leg causing flexion of the patient's knee orknees.

Indicates: Gluteal, lumbosacral or sacroiliac pathologies.

Confirmation Tests:Bechterew’s Test, Bragard’s test, Lasegue’s Test, SLR Test

Heel WalkInstruct: Patient walks on heels.Positive: Inability to perform test.Indicates: L4-L5 disc problem (L5 nerve root).Confirmation Tests:Bowstring Test, Kemp’s Test, Milgram’s Test, Neri’s Bowing Test

Toe WalkInstruct: Patient walks on toes.Positive: Inability to perform test.Indicates: L5-S1 disc problem (S1 nerve root).Confirmation Tests:Bowstring Test, Kemp’s Test, Milgram’s Test, Neri’s Bowing Test


Ely's Heel to Buttock Test(Evan’s calls this Ely’s sign as an a.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 andhyperextends 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


Evaluation of Nerve Root LesionsInvolving the Lower Extremity and Lumbar Spine

Always use the MRS system in the correct order, any deviation will result in a loss of pointsMuscle–test and name the muscle/s and nerve for each neurological package being testedReflex–test and name the appropriate reflex being tested; if there is no reflex it must be stated.

Sensation– test the appropriate dermatome for the neurological package and it’s corresponding 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 L4a) Disc Level L3b) Muscle test (1) Foot dorsiflexion & inversion: tibialis anterior (deep peroneal

nerve)c) Reflex Patellar Tendond) Sensation Medial aspect of leg, medial foot, medial aspect of big toe

Testing individual nerve root L5a) Disc Level L4b) Muscle tests (4) Foot dorsiflexion

Big toe dorsiflexion: extensor hallucis longus (deep peronealnerve)Toes 2,3,4 dorsiflexion: extensor digitorum longus & brevis(deep peroneal nerve)Hip and Pelvis abduction: gluteus medius & minimus (superior glutealnerve)

c) Reflex Noned) Sensation Lateral leg, dorsum of foot, and middle three toes

Testing individual nerve root S1a) Disc Level L5b) Muscle tests (3) Foot Plantarflexion: Gastrocnemius and Soleus (Tibial

Nerve)Foot plantar flexion and eversion: peroneus longus & brevis (SuperficialPeroneal Nerve).Hip extension: gluteus maximus (Inferior Gluteal Nerve).

c) Reflex Achillesd) Sensation Posterior aspect of the leg, lateral aspect of foot, and lateral

aspect of little toe.

Testing individual nerve root S2a) Disc Level S1b) Sensation Posterior aspect of thigh over popliteal fossa onto posteromedial

calf


Dermatomes of the Lower Extremity

Initial Examination ProcedureExample (Examination of L5 package dermatomes)Patient seated, anatomical position, eyes closed.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 ProcedureExample (Examination of L5 package dermatomes)Patient seated, anatomical position, eyes closed.Verbage = Can you feel this? And does this feel like this?

FirstL4 of right side compared to L5 of right sideL5 of right side compared to S1 of right side

SecondL4 of left side compared to L5 of left sideL5 of left side compared to S1 of left side


Evaluation of Nerve Root LesionsInvolving the Lower Extremity

(Examined As Follows)

Always use the MRS system in the correct order, any deviation will result in a loss of pointsMuscle–test and name the muscle/s and nerve for each neurological package being testedReflex–test and name the appropriate reflex being tested; if no reflex it must be stated.

Sensation–test the appropriate dermatome for the neurological package and it’s corresponding dermatome above and below following the format enclosed from Hoppenfeld

Always use the MRS system in the correct order: Muscle Reflex Sensation

Muscle (motor)

One hand above joint ofmotion for stability


No hands on joints


Always bilateral

Reflex

Rapid flick of hammeron tendon


Always bilateral

Skin on skin

Always bilateral

Sensation(dermatome)

Patient seated

Anatomical position

Eyes closed

Pin to skin (Verbiageused = does this feellike this)Skin on skin

Always bilateral

Test sensation aboveand below

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


HIP and PELVISINSPECTION1) For any obvious unnatural movement or posture

Gait Gluteus medius or maximus lurch

2) For any topical abnormalities Scars/keloids Discoloration Abrasions Blebs Other apparent pathology

3) For any asymmetry of structure Iliac Spines on same plane Hyperlordotic/Kyphotic lumbar spine Gluteal folds symmetry

PALPATION

Bony PalpationAnterior1) ASIS2) Iliac crest3) Iliac tubercle4) Greater trochanter

Posterior1) PSIS2) Ischial tuberosity3) Coccyx

Soft Tissue Palpation1) 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 bursa4) Gluteus medius5) Gluteus maximus6) Sciatic nerve7) Cluneal nerves8) Hamstrings

Biceps femoris Semitendinosus Semimembranosus


RANGE OF MOTIONActive and PassiveFlexion 120Extension 30Abduction 45Adduction 45Internal rotation 45External rotation 45Flexion and AdductionFlexion, Abduction and External Rotation

Reflex - NoneSensation (Covered under lumbar spine packages)

SPECIAL TESTS1) Leg Length Discrepancy (true and apparent), pg. 696 E2) Allis’ Sign, pg. 698 E3) Thomas Test, pg. 736 E4) Anvil Test, pg. 702 E5) Patrick Test aka Faber Sign, pg. 728 E6) Laguerre’s Test, pg. 654-6557) Gaenslen’s Test, pg. 640-641 E8) Lewin Gaenslen’s Test, pg. 656 E9) Hibb’s Test, pg. 646 E10) Ober’s Test, pg. 726 E11) Pelvic Rock Test aka Iliac Compression Test, pg. 648-651 E12) Trendelenburg’s Test, pg. 738 E 13) Nachlas Test, pg. 578-579 E14) Yeoman's Test, pg. 670-67115) Ely’s Sign (Ely Test), pg346 Cipriano


Leg Length DiscrepancyInstruct: 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 themedial malleoli of the opposite leg. (Apparent) Examiner takes a cloth tape measureand measures from the umbilicus to the medial malleoli of one leg and then measuresfrom 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’ Sign (Galeazzi’s Sign) = (Pediatric Test used for 1 month to 2 years-old can also beused in adults)

Instruct: Patient is supine, examiner instructs patient to place both feet flat(approximate great toes and medial malleoli bilateral) on thebench 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 femoraldiscrepancy (anatomical short leg)

Confirmation Test:Radiography

Thomas TestInstruct: 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’s Test, Trendelenberg’s Test

Anvil TestInstruct: Patient supine, examiner elevates the affected leg while keeping the knee extended.

The examiner then makes a fist and strikesthe affected leg’s inferior calcaneus.

Positive: Localized pain in long bone or in hip jointIndicates: Possible fracture of long bones, or hip joint pathology.Confirmation Test:Radiography


Patrick’s Testa.k.a. FABERE signInstruct: Patient supine, examiner flexes, abducts and externally rotates the patients’ hip so that

the ankle rests above or below the contralateral knee. Examiner then extends the hipby pushing just superior to the knee while stabilizing the contralateral ASIS.

Positive: Pain in the hip region.Indicates: Hip joint pathology.Confirmation Tests:Laguerre’s Test, Radiography

Laguerre’s TestInstruct: 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 legis not resting on the contralateral knee). Examiner applies pressure to the end range ofmotion while stabilizing the contralateral ASIS (rest ankle on forearm and with otherhand reach under arm to stabilize).Alternate Procedure (Cipriano): examiner exerts downward pressure on knee withsuperior 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:Patrick’s Test, Hibb’s Test

Gaenslen’s TestInstruct: 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 unaffectedleg just below the knee and approximates the knee to his chest. The examiner thenplaces a downward pressure on the affected thigh until it is lower than the edge of thetable.

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:Belt Test, Goldthwait’s Test, Yeoman’s Test

Lewin - Gaenslen’s TestInstruct: 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 sideof 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:Gaenslan’s Test, Yeoman’s Test


Hibb’s TestInstruct: 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 thenslowly 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:Laguerre’s Test

Ober’s TestInstruct: 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, Trendelenberg’s Test

Pelvic Rock Test aka Iliac Compression TestInstruct: Patient lies on their side. Examiner places both hands on the lateral portion

of the patient’s ilium. Examiner pushes downward (lateral to medial) on the patient’s ilium. Test bilaterally.

Positive: Pain in either sacroiliac joint.Indicates: Sacroiliac joint lesion.Confirmation Test:Radiography

Nachlas TestInstruct: 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:Lewin’s Supine Test, Minor’s Sign, Spinal Percussion Test (lumbar)


Yeoman's TestInstruct: 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:Gaenslan’s Test, Lewin Gaenslan’s Test

Ely’s Sign (Ely Test –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:Femoral Stretch Test

Ely's Heel to Buttock Test(Evan’s calls this Ely’s sign as an a.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 andhyperextends 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

Trendelenburg’s TestInstruct: 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’s Test, Thomas’ Test


KNEEINSPECTION1) For any obvious unnatural movement or posture

Gait2) For any topical abnormalities

Scars/keloids Discoloration Abrasions Blebs Other apparent pathology

3) For any asymmetry of structure Swelling

1. Local - bursal swelling over patella and tibial tubercle2. Diffuse - may obscure normal contour of knee3. 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)

PALPATIONBony palpation1) Patella2) Medial tibial plateau3) Tibial tubercle4) Medial femoral condyle5) Lateral tibial plateau6) Lateral femoral condyle7) Fibula head

Soft Tissue PalpationQuadriceps muscles Quadriceps muscles (palpate as a unit and individually)

Vastus Lateralis Vastus Medialis Vastus Intermedius Rectus Femoris

2) Infrapatellar tendon3) Bursae

Prepatellar Superficial infrapatellar

4) Medial meniscus5) Lateral meniscus6) Pes anserine area

Sartorius Gracilis Semitendinosus

7) Popliteal fossa8) Lateral collateral ligament9) Medial collateral ligament10) Gastrocnemius muscle


RANGE OF MOTIONActive and PassiveFlexion 135Extension 0Internal rotationExternal rotationReflexPatellarSensation (Covered under lumbar spine packages)

SPECIAL TESTS

1) McMurray Sign, pg. 796 E2) Medial Collateral Ligament Test aka Abduction Stress Test, pg. 760 E3) Lateral Collateral Ligament Test aka Adduction Stress Test, pg. 762 E4) Bounce Home Test, pg. 770 E5) Drawer’s Test, pg. 776 E6) Lachman’s Test, pg. 786 E7) Apprehension Knee Test aka Apprehension Test for Patella, pg. 768E8) Patella Femoral Grinding Test aka Clarke’s sign, pg. 774 E9) Patella Ballottment Test pg. 800 E10) Apley’s Compression Test, pg. 764 E11) Apley’s Distraction Test, pg. 764-767 E

McMurray SignInstruct: Patient supine, examiner flexes patient’s affected hip to 90 degrees and the affected

knee to 90 degrees. Examiner grasps the heel of the affected leg and applies externalrotation to the knee. Examiner places his/her hand on the lateral aspect of the affectedknee and applies a valgus stress. Examiner maintains the external rotation and valgusstress on the knee and extends the affected leg slowly to the top of the table whilepalpating the medial knee joint line. (Occasional variance= repeat with internal rotationand 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 rotationThe higher the leg is raised when positive is elicited, the more posterior the meniscalinjury.

Confirmation Tests:Bounce Home Test, Apley’s Compression Test, MRI

Medial Collateral Ligament Test a.k.a. Abduction Stress Test a.k.a. Valgus Stress testInstruct: Patient supine, examiner stabilizes the lateral thigh of the patient’s affected leg.

Examiner grasps just superior to the medial ankle of the affected leg and graduallypushes laterally (to open medial side of joint).

Positive: Gapping and/or elicited pain above/at/or below joint lineIndicates: Torn medial collateral ligament.Confirmation Tests:Apley’s Distraction Test, Radiography, MRI


Lateral Collateral Ligament Test a.k.a. Adduction Stress Test a.k.a. Varus Stress testInstruct: Patient supine, examiner stabilizes the medial thigh of the patient’s

affected leg. Examiner grasps just superior to the lateral ankle of theaffected leg and gradually pushes medially (opening the lateral side of the joint).

Positive: Gapping and/or elicited pain above/at/or below joint lineIndicates: Torn lateral collateral ligament.Confirmation Tests:Apley’s Distraction Test, Radiography, MRI

Bounce Home TestInstruct: Patient supine, examiner instructs patient to flex his leg, examiner grasps the patient’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’s Compression Test, McMurray’s Test, MRI

Drawer TestInstruct: Patient supine, examiner flexes the hip and the knee of the patient’s

affected leg until the foot is flat on the table. Examiner sits on the foot ofthe patient’s affected leg. Examiner grasps behind the patient’s flexed 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’s Test

Lachman’s TestInstruct: Patient supine, examiner puts the patient’s knee at a 300 angle of flexion and from this

angle the examiner grasps both the proximal end of the tibia with one hand and thedistal end of the femur with the other, and attempts to pull tibia forward in order the feelthe joint play. (variation of Drawers’ 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 PatellaInstruct: 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. Clarke’s sign)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 quadricepsmuscles 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 TestInstruct: 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

Apley’s Compression TestInstruct: Patient prone, examiner flexes patient’s affected knee to 90 degrees. Stabilize patient’s

thigh with your knee, Place downward pressure on the patient’s heel while internally and externally rotating the patient’s foot.

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:McMurray’s Test, Bounce Home Test, MRI

Apley’s Distraction TestInstruct: Patient prone, examiner flexes patient affected knee to 90 degrees. Examiner places

his/her knee on patient’s affected thigh for stabilization. Examiner grasps the patient’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 ANKLEINSPECTION1) For any obvious unnatural movement or posture

5. Check for external appearance of the shoe2) Excessive medial or lateral wear3) Scuffed toes4) Holes, nails, torn stitching5) For any topical abnormalities

Scars/keloids Discoloration Abrasions Blebs Other apparent pathology

6) For any asymmetry of structure 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

PALPATIONBony Palpation1) Calcaneus2) Sustentaculum tali3) Medial malleolus4) Lateral malleolus5) Talus6) Navicular7) Cuboid8) 3 Cuneiforms9) 5 Metatarsals10) Metatarsophalangeal joints

Soft Tissue Palpation1) Tibialis posterior tendon2) Spring ligament3) Tibialis anterior tendon4) Deltoid ligament5) Peroneus brevis6) Achilles tendon7) Plantar aponeurosis8) Anterior talofibular ligament9) Posterior tibial artery10) Dorsal pedal artery


RANGE OF MOTIONActive and PassiveAnkle Dorsiflexion 20Ankle Plantarflexion 50Subtalar Inversion 5Subtalar Eversion 51st MTP Joint Flexion1st MTP Joint Extension

ReflexAchilles

Sensation (Covered under lumbar spine packages)

SPECIAL TESTS

1) Drawer Sign, pg. 842 E2) Ankle Dorsiflexion Test pg.345 C3) Rigid or Flat Feet Test (see lab packet)4) Homans’ Sign, pg. 868 E5) Thompson’s Test, pg. 884 E6) Morton’s Test, 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) thecalcaneus anteriorly and pushes the tibia posteriorly, the reverse procedure by pullingthe 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 talofibularligament.

Confirmation Test:MRI

Ankle Dorsiflexion Test (Hoppenfeld)–Patient experiences difficulty dorsiflexing the footInstruct: 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 positionIndicates: (1) contracture of the gastrocnemius muscle

(2) contracture of the soleus muscle


Rigid or Supple Flat Feet Test (Hoppenfeld)Instruct: Patient is seated and then stands, examiner observes patient’s feet while seated and

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 longitudinalarch whilestanding.

Indicates: (1) Rigid flat feet(2) Supple flat feet

Homans’ SignInstruct: 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 isrecommended by some sources, yet other sources feel it is contra-indicated, pleasenote 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’s TestInstruct: 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

Mortons’ TestInstruct: 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’s Scale

Muscle Gradations Descriptions

5 Normal Against gravity with full resistance, complete range ofmotion evident

4 Good Against gravity with some resistance, complete range ofmotion 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- Wexler’s Scale

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 DiagnosisDIAG 2740


1) Purpose of the Neurological ExaminationWhen 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 involvementB. Identify the nature and/or extent of the lesion

We will learn to evaluate the patients:Mental function Sensory systemMotor System ReflexesCoordination and gait Cranial nerves

2) Mandatory Lab Equipment and Materials

Pinwheels 512 Hz tuning fork

128 Hz tuning fork

Paperclips and toothpicks

Cards with shapes, text, and colors

Sterile cotton swabs

Tape measure

2 containers of aromatics

Penlight

Tongue depressors

Neurotips

Neurological or percussion hammer

3) Suggested EquipmentOpthalmoscope (Mandatory for next quarter special senses lab)

4) Required AttireDress casually for all labs. Pants, Sweatpants, or ShortsNOTE: 3 POINT DEDUCTION FROM LAB PRACTICAL EXAMFOR NOT WEARING PROPER TESTING ATTIRE!

5) Performing sensory and reflex tests (refer to topic outline for dressingrequirements)

Everyone should wear shortsMen should wear short sleeve shirtsWomen 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 passthe class. The student is responsible for adequate preparation for the final examination. There are noretakes/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 becompletely confidential. If you have any questions or concerns during today’s appointment, please do not hesitate to ask. If at any time you experience pain or discomfort during the exam please let me know. Do I have your permission toproceed?"

Students are responsible for all information presented in lecture and/or lab instruction. Students are also responsible forall 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 anacceptable excuse in accordance with the Student Handbook, then he/she will receive a zero for their final laboratoryexamination grade.

If a student does not take the final examination during his/her scheduled time and does provide an acceptable excuseaccording 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 laboratoryexamination.

Each student must have a doctor’s bag (fully equipped) for each lab and for the final examination. Two students may notshare a doctor’s bag. Each student will be expected to show personal responsibility for his 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 FROMLAB 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 Sciencefaculty.


Mental Status Evaluation1) Orientation

Ask the patient’s name, location, and date 2) Level of alertness, attention, and cooperation

Ask the patient to spell a word forward and backwardAsk the patient to repeat a string of integers forward and backwardAsk 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) MemoryRecent- recall three items after 5 minute delayRemote- recall certain historical facts within patient’s memory (lifetime)“Where did you go to high school?”

4) LanguageObject namingRepetition of single words and sentences

5) CalculationsSimple additions and subtractions, should be two or more steps

6) ApraxiaFollowing a complex motor command like “pretend to comb your hair” or “pretend to brush your teeth”

7) Sequencing tasksAsk the patent to tap the table with: fist, open palm, then side of open

hand (rock, paper, scissors) perform as rapidly as possible8) Abstraction

Abstraction interpretation of a proverb or colloquialism “The early bird gets the worm”

The Motor System Examination

Inspection1) Check limbs and trunk for fasciculation’s (hands, shoulder, and thigh),

involuntary movements or abnormal positions.2) Look for atrophy/hypertrophy.3) Observe posture

Testing Muscle Strength1) Passively move limbs through range of motion noting resistance and rigidity2) 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.

Oxford or Van Allen’s Scale

Joint Lock Resistance MotionAgainstGravity

MotionGravityNeutral

Evidence ofContraction

5 X X X X X4 X X X X3 X X X2 X X1 X0


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 andsupinate palms as rapidly as possible.

3) Dysmetria- Have patient touch your index finger and then his/her nosealternately several times. (Note tremors or lack of coordination)

4) Dysmetria- Heel-Shin: Have patient run their heel from his/her knee to his/herfoot.

6) Gait- observe patient walking toward and away, note posture, stability, footelevation, 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 bilateral2) Scatter the stimuli through multiple dermatomes3) Note the degree of perception of stimulus4) 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 proximal. Ask “can you feel vibration? and “when does it stop?” (Dr. Stops it). 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) Romberg’s test- 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 feltDisplacement- one side is felt normally and the other displaced toward

midlineSynesthesia- one side is felt normally and the other is a vague burning


ReflexesInvoluntary, stereotyped, motor responses to stimuli. They are extremely important in the diagnosis and localization ofneurological lesions.

Reflexes are divided into 4 groups:1) Deep tendon a.k.a. myotactic reflexes2) Visceral a.k.a. organic reflexes3) Superficial reflexes

CutaneousMucous membrane

4) Pathological reflexes

When testing reflexes be aware that it involves:1) A specific procedure2) An afferent or sensory nerve3) An integrating center4) An efferent or motor nerve

Deep Tendon Reflexes–reaction of a muscle to being passively stretched by percussion on the tendonHave patient relaxMildly stretch muscle/tendonStrike tendon brisklyTest bilaterally

Slight Forearm Flexion

Elbow Flexion

Elbow Extension

Knee Extension

Foot Plantar Flexion Tibial Nerve

Femoral Nerve

Radial Nerve

Radial Nerve

MusculocutaneousNerve

S1, 2 Spinal Cord

L2, 3, 4 Spinal Cord

C7 Spinal Cord

C6 Spinal Cord

C5 Spinal Cord

Achilles

Patellar

Triceps

Brachioradialis

Biceps

Integrating CenterAfferent/EfferentResponseReflex

Westphal’s sign–absence of any DTR (especially patellar; LMNL)

Jendrassik’s maneuver AKA Reinforcement Test or Cortical Distraction TestA form of cortical distraction that brings out a reflex when hard to elicitPt. 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 ResponseReflex responses are graded subjectively according to a classification scheme based on a scale of 0-5 called the WexlerReflex Scale.

Wexler Reflex Grading ChartReflexes 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,

hyperactive3+ Slightly increased response, possibility of disease pathology exists2+ Normal response1+ Slightly diminished, lower than normal response, hypoactive0 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:

CervicalSympatheticChain

Vagus Nerve X

Vagus Nerve X

OculomotorNerve III

OculomotorNerve III

OculomotorNerve III

T1-T2 SpinalCord

Medulla

Medulla

OccipitalCortex

Midbrain

Midbrain

CervicalSympathetic Chain

Trigeminal Nerve V

GlossopharyngealNerve IX

Optic Nerve II

Optic Nerve II

Optic Nerve II

Pupillary dilationwhen examinerpinches the baseof the neck at thecervicalsympathetic chain

Reduction inheart rate Whenexaminer pressesthe eye

Reduction inheart rate whenexaminer pressesthe carotid sinus

Convergence ofthe eyes,pupillaryconstriction, Lensconvexity whenobject is broughtinto near vision

Contralateralpupillaryconstriction whenlight is shined inthe eye

Ipsilateralpupillaryconstriction whenlight is shined inthe eye

Oculocardiac

Ciliospinal

Carotid Sinus

Accommodation

Indirect Light

Direct Light

EfferentIntegratingCenter

AfferentResponseReflex

NOTE: Do not perform occulocardiac reflex while contact lenses are in place.


Superficial Reflexes:

Reflex Response Afferent IntegratingCenter

Efferent

Corneal Blinking andtearing of theeye upontouching thecornea with acotton wisp

TrigeminalNerve V

Pons Facial NerveVII

Gag/Pharyngeal Gagging upontouching theback of thethroat with atonguedepressor


Medulla Vagus NerveX

Uvular/Palateal Raising of theuvula uponphonation, ortouching with atonguedepressor


Medulla Vagus NerveX

Interscapular Drawinginward ofscapular whenskin orinterscapularspace isirritated.

T2-T7 Spinal Nerves T2-T7 SpinalCord

Dorsalscapularnerve

Abdominal Umbilicusdeviation to thestroked side.Absence isnormal only ifbilateral

Upper T7-10Lower T11-12

Spinal Cord T7-T12

UpperT7-10LowerT11-12

Plantar Plantar flexion(curling) oftoes uponstroking sole offoot

Tibial Nerve Spinal CordS1-S2

Tibial Nerve

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 tendonreflexes 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

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 Neuron1) Spasticity of muscles with possible contractures2) Decreased muscle strength, little or no atrophy3) Presence of pathological reflexes4) Altered superficial reflexes5) Hyperactive deep tendon reflexes6) No fasciculations (twitches)

Clinical Signs of Lower Motor Neuron1) Flaccidity of muscles2) Loss of muscle strength and tone, noticeable muscle atrophy3) Absence of pathological reflexes4) Decreased or absent deep tendon reflexes5) Altered superficial reflexes6) Fasciculations (twitches)

Flexion of the fingers and thumb upon tapping palmar surface or tips of middlethree fingers

Clawing of the fingers and thumb (flexion and adduction of thumb with flexion ofthe fingers) upon flicking tip of index finger into extension

Tromner’s

Hoffman’s

Abnormal Response (Upper Motor Neuron Lesion)UpperExtremity

Contraction of orbicularis occuli muscle upon percussion of supraorbital ridge(glabella)

Glabella akaMcCarthy’s

Abnormal Response (Upper Motor Neuron Lesion)Head

Babinski Dorsiflexion of the big toe and fanning or splaying of other toes uponstimulation of the plantar surface of the foot (lateral to medial)Alternative ways to elicit babinskiÕs sign:Oppenheim’s sign - application of pressure to anterior tibia stroking downwardChaddock’s sign- stroking down the lateral leg around the lateral malleolusGordon’s sign- squeezing the calfSchaefer’ssign - squeezing the achilles tendon

Ankle Clonus Continued involuntary contraction (flexion and extension) of foot upon quickforcible dorsiflexion of the foot

Abnormal Response (Upper Motor Neuron Lesion)LowerExtremity


Examination of the Cranial Nerves

(I) Olfactory NerveAsk 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 Nervea) Inspect external structures of eyeb) Inspect the optic fundi with opthalmascopec) Test visual acuity

Screen by reading printScreen with shapes and/or colors

d) Test visual fields by confrontation (peripheral vision) a.k.a. Wiggling testExamine directly in front and level with patient's faceHave patient cover one eyeBring object into view from eight different directions per eye

e) Direct light reflex- ipsilateral pupillary constrictionf) Indirect light reflex (consensual reflex)- contralateral pupillary constrictiong) Accommodation reflex

Test ability of the eyes to adapt for near visionInstruct patient to follow object inward from a distanceConvergence of the eyes, constriction of the pupil, convexity of the lens

(III) Oculomotor, (IV) Trochlear, and (VI) AbducensNerves

The following four tests are for CN III specifically:a. Direct light reflexb. Indirect light reflexc. Accommodation reflexd. Check for ptosis

The following will test CN III, IV, and VI combined:a) Extraocular movements with six cardinal fields of gaze. Observe patient’s

eyes for normal conjugate, or parallel movements of the eyes and nystagmusas you have him/her follow your finger or pencil while it makes a wide "H" inthe air:

Trochlear = down and inAbducens = lateralOculomotor all other fields.


(V) Trigeminal Nerve (Ophthalmic, Maxillary, and Mandibular)a) Have patient clench teeth, palpate masseter and temporalis musclesb) Test pain discrimination (sharp-dull) on face bilateralc) Test for light touch to the face with wisp of cotton or brushd) Test corneal reflex with wisp of cotton, should see blinking and tearinge) 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, apply pressure over the patient’s closed eye, pulse rate should decrease 2-3 beats

per 15 sec.

(VII) Facial Nervea) Inspect face for asymmetry (at rest and during motion)

Ask the patient to perform the following:Raise eyebrowsClose eyes tightlyShow teethPuff out cheeksSmileFrown

b) Ask the patient about changes in taste sensations sweet, salty, and sour on the anterior two thirdsof the tongue.

(VIII) Vestibulo-Acoustic NerveSensory-Cochlear Portiona) Screen tests include identifying hearing loss by:

Finger Rub Test:Assess hearing by rubbing fingers together near the EAM, find maximaldistance sound can be heard.Whisper TestHave patient close his eyes (to prevent lip-reading) and cover the ear on theside not being tested. Place your head/mouth 2 feet from the ear being testedand whisper words to the patient and ask patient to repeat the words. You canalso ask questions to the patient and have him/her answer yes or no to eachquestion. Repeat this procedure at varying (usually increasing) distances orwith loud, medium and soft tones.

b) Distinguish between perceptive and conductive hearing using 512 Hz tuning forks

Weber’sTestProcedure: 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’sTestProcedure: Place the handle of the tuning fork against the mastoid process. Have

the patient signal when the sound ceases, then hold the fork near theexternal ear without touching the patient, again have the patient indicatewhen 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 NystagmusProcedure: Patient seated, examiner inspects patient’s eyes for spontaneous

nystagmus. Then inspect for nystagmus for 30 seconds in each of thefollowing positions:

Patient supineTurn head to one sideTurn head to the other sidePatient’s head hanging of the tablePatient returns to seated position

Indicates: Normal: the fast component of the eye movement will be in the directionthe patient is being moved. (Nystagmus is named for the fastcomponent).Peripheral Lesion: the patient will exhibit nystagmus within 2-5 seconds,does not change direction if the patient is stationary, and disappearswithin 30 seconds.Medullary Lesion: Nystagmus begins immediately upon movement andmay change direction while the patient is stationary (also patient doesnot have vertigo).

Barany’s Whirling Chair TestProcedure: Seated patient is spun in chair in one directionIndicates: Normal: fast component of nystagmus will be in the direction of the spin.

MittlemyerInstruct: Patient marches in place, eyes open then closed.Positive: A turning to one sideIndicates: Side of vestibular lesion

Vestibulo-ocular ReflexProcedure: Dr. holds patient’s head and instructs patient to fix vision on the doctor’s

face. Dr. then turns patient’s head into rotation, lateral flexion, and flexion and extension.

Indicates: Normal patient should maintain eye contact eyes moving at the samespeed in the opposite direction of head movement. Abnormal findingsare detailed in labyrinthine test above.


(IX) Glossopharyngeal and (X) Vagus Nervea) 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 deviatesto 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 Nervea) Trapezius Muscle

InspectPalpateMuscle test

b) Sternomastoid MuscleInspectPalpateMuscle test

(XII) Hypoglossal Nervea) Inspect tongue for:

AtrophyFasciculations

b) Have patient stick out tongue and test bilateral with tongue depressor, or use thetongue in cheek method

Unilateral paralysis = Protruded tongue deviates to involved side.


CERVICAL and LUMBARNERVE ROOT EVALUATION

1) Muscle–test and name the muscle/s and nerve for each nerve root levelbeing tested

2) Reflex–test and name the appropriate reflex being tested; if no reflex it must bestated.

3) Sensation– test the appropriate dermatome for the neurological package and it’s corresponding dermatome above and below following the format enclosed fromHoppenfeld

Anatomical position

Eyes closed

Cover the entire dermatome

Pin to skin (ask: does this feellike this?)

Test dermatome above andbelow

BILATERAL

Rapid flick of hammer ontendon


BILATERAL

One hand above jointof motion for stability


No hands on joints


BILATERAL

Sensation (dermatome)ReflexMuscle (motor)

Muscle Grading- Oxford or Van Allen’s Scale (page 7)

Reflex Grading- Wexler’s Scale (page 10)


Evaluation of Cervical Nerve RootsNeurological Level: C5a) Disc Level C4b) Muscle tests (2) Shoulder abduction: deltoid (Axillary nerve)

Forearm flexion: biceps (Musculocutaneous Nerve)c) Reflex Bicepsd) Sensation Lateral arm and shoulder

Neurological Level: C6a) Disc Level C5b) Muscle test (1) Wrist extension extensor carpi radialis longus &

brevis, extensor carpi ulnaris (Radial Nerve)c) Reflex Brachioradialisd) Sensation Anterior lateral forearm, palm, thumb and index finger

Neurological Level: C7a) Disc Level C6b) Muscle tests (3) Elbow extension: triceps (Radial Nerve)

Wrist flexion: flexor carpi radialis (Median Nerve), flexorcarpi ulnaris (Ulnar Nerve) Finger extension: (Radial Nerve)

c) Reflex Tricepsd) Sensation Middle finger, middle of palm

Neurological Level: C8a) Disc Level C7b) Muscle test (1) Finger flexion: (Median Nerve)c) Reflex Noned) Sensation 4th and 5th phalanges, antero-medial hand and forearm

Neurological Level: T1a) Disc Level T1b) Muscle tests (2) Finger abduction: dorsal interossei (Ulnar Nerve)

Finger adduction: palmer interossei (Ulnar Nerve)c) Reflex Noned) Sensation Medial arm (distal aspect of arm to proximal forearm)


Dermatomes of the Upper Extremity

Examination ProcedureExample (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 ComparisonQuestioning = Does this feel like this?First

C4 of right side compared to C5, C5 compared to C6 of right sideSecond

Repeat on the other side


Evaluation of Nerve Root LesionsInvolving the Thoracic SpineNeurological Level: T2-T12a) Disc Level T2-T12b) Muscle test (1) Rib Elevation: Intercostals [segmentally innervated and

difficult to evaluate individually], rectus abdominus.T7-T12 (L1) Beevor’s Sign

c) Reflex None (can do superficial abdominal reflex)d) Sensation T4: Nipple line

T7: Xyphoid processT10: UmbilicusT12: Inguinal ligament

There is sufficient overlap of these areas so that no anesthesia will occur if only one nerve root isinvolved.

Evaluation of Multiple Lumbar Nerve RootsNeurological Levels: L1, L2 and L3a) Disc Level T12-L2b) Muscle test (1) Primary hip flexor: iliopsoas (L1-L3)c) Reflex Noned) Sensation Anterior thigh, obliquely from lateral to medial.

(L1 top of thigh, L2 middle of thigh, L3 lower thigh).

Neurological Level: L2, L3 and L4a) Disc Level L1-L3b) 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 Patellard) 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: L4a) Disc Level L3b) Muscle test (1) Foot inversion with slight dorsiflexion: tibialis anterior

(Deep Peroneal/fibular Nerve)c) Reflex Patellar Tendond) Sensation Medial aspect of leg, medial foot, medial aspect of big toe

Neurological Level: L5a) Disc Level L4b) Muscle tests (4) Foot dorsiflexion

Big toe dorsiflexion: extensor hallucis longus (DeepPeroneal/fibular Nerve)Toes 2,3,4 dorsiflexion: extensor digitorum longus andbrevis (Deep Peroneal/fibular Nerve)Hip/Thigh abduction: gluteus medius & minimus (SuperiorGluteal nerve)

c) Reflex Noned) Sensation Lateral leg, dorsum of foot, middle three toes

Neurological Level: S1a) Disc Level L5b) Muscle tests (3) Foot Plantar flexion: Gastrocnemius and Soleus (Tibial

Nerve)Foot plantar flexion and eversion: peroneus longus andbrevis (Superficial Peroneal/fibular Nerve).Hip extension: gluteus maximus (Inferior Gluteal Nerve).

c) Reflex Achillesd) Sensation Posterior aspect of the leg, lateral aspect of foot, lateral

aspect of little toe.


Dermatomes of the Lower Extremity

Examination ProcedureExample (Examination of L4 dermatome) Patient seated, anatomical position, eyes closed.

1. Bilateral ComparisonQuestioning = Does this feel like this?

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 ComparisonQuestioning = Does this feel like this?First

L3 of right side compared to L4, L4 compared to L5 of right sideSecond

Repeat on the other side


Spinal Cord and Meningeal TestingL’Hermitte’s Sign Procedure: Patient sitting or supine, patient flexes his/her head toward his/her chest

or, per Evan’s, Dr. actively flexes patient’s head toward chest.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

Kernig’s SignProcedure Patient supine, examiner passively flexes patient’s hip to 90 degrees

and the patient’s knee to 90 degrees. Examiner extends patient’s leg completely.

Positive: Inability to fully extend the leg and/or pain (usually in the neck region).Indicates: Meningeal irritation/meningitis.

Confirmation Tests:Brudzinski’s Sign, Lumbar Tap

Brudzinski SignProcedure: 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’s Sign, Lumbar Tap


Cervical Spine and Nerve Root TestingSoto Hall SignProcedure: Patient supine, examiner flexes patient’s head toward his/her chest

while stabilizing the patient’s sternum with hypothenar of inferior hand.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 TestProcedure: Patient seated with examiner standing behind. Examiner clasps his/her

hands over patient’s head and exerts increasing downward pressure. Examiner repeats this procedure with the patient’s head rotated right and then left.


Indicates: 1) Foraminal encroachment or facet pathology without nerve rootcompression.

2) Foraminal encroachment with nerve root compression (one wouldthen want to evaluate the myotome, reflex and dermatome of the nerveroot involved).

Confirmatory Tests:Jackson Compression, Maximal Cervical Compression Test, Bakody’s Test, Shoulder Depression Test, Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI, Nerve ConductionTesting

Jackson CompressionProcedure: Patient seated with examiner standing behind. Examiner laterally flexes

the patient's head to one side and clasps his/her hands over patient'shead and exerts increasing downward pressure. Perform bilaterally.


Indicates: 1) Foraminal encroachment without nerve root pressure or facetpathology.

7) Foraminal encroachment with nerve root compression (one would8) then want to evaluate the myotome, reflex and dermatome of the nerve

root involved)

Confirmatory Tests:Foraminal Compression, Maximal Cervical Compression Test, Spurling’s Test, Bakody’s Test, Shoulder Depression Test, Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI,Nerve Conduction Testing


Maximal Cervical CompressionProcedure: Patient seated with examiner standing behind. The examiner instructs

the patient to rotate the head and hyperextend the neck. Performbilaterally.

Positive: 1) Pain on the concave side2) 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:Foraminal Compression, Jackson’s Compression Test, Bakody’s Test, Shoulder Depression Test,Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI, Nerve Conduction Testing

Valsalva ManeuverProcedure: 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:Dejerine’s Triad, Swallowing Test, Naffziger’s Test, Bakody Sign, Maximal Cervical Compression, Shoulder Depression Test, Cervical Distraction, Jackson’s Compression, Foraminal Compression Test, Spurling’s Test, Sensory and Reflex Testing, MRI

Cervical Distraction TestProcedure: Patient seated, the examiner grasps the patient’s head with both hands

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 rootcompression (Radicular pain diminishes).

2) Muscular strain, ligamentous sprain, myospasm, facet capsulitis.

Confirmation Tests:Foraminal Compression Test, Jackson Compression, Maximal Cervical Compression Test, Spurling’s Test, Bakody’s Test, Shoulder Depression Test, Reflex and Sensory Testing, Radiography, MRI,Nerve Conduction Testing

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 putstraction on the lower brachial plexus).

Confirmation Tests:Foraminal Compression, Maximal Compression, Jackson’s Compression Test, Spurling’s Test, Shoulder Depression Test, Cervical Distraction Test, Reflex and Sensory Testing, Radiography, MRI,Nerve Conduction Testing


Thoracic Spine and Nerve Root TestingAdam'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 extendedand hands together. Examiner observes for evidence of change in the scoliosis.

Positive: 1) A “c” or “s” shaped scoliosis is observed to straighten.2) A “c” or “s” shaped scoliosis does not straighten (look for rib humping, muscular imbalance, and asymmetry in hand length).

Indicates: 1) Negative: evidence of a functional scoliosis2) Positive: evidence of a pathologic or structural scoliosis as well as trauma orsubluxation.

Confirmation Tests:Postural Analysis, Radiography

Schepelmann's SignProcedure: 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 possibleintercostal myofascitis).

Beevor's SignProcedure: 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 involvementT7–T10.

Confirmation Tests:Sensory testing of thoracic nerve roots, MRI


Upper Extremity TestingRoos’ Test a.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 andopens 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 thehand.

Indicates: Thoracic outlet syndrome on side involved(Evan’s considers this test to be most accurate for TOS evaluation)

Confirmation Tests:Roo’s Test, Halstead Test, Adson’s Test, Wright’s Test, Shoulder Depression Test, Eden’s Test

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, theninstruct patient to rotate head and elevate chin toward examiner while holding thebreath. Note positive or negative findings, if negative then rotate head to the oppositeside 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 ofsubclavian artery.Paresthesia/radiculopathy indicates compression of the brachialplexus at the neurovascular bundle by scalenius anticus or cervicalrib.(usually opposite side)

Confirmation Tests:Halstead Maneuver, Shoulder Depression Test, Wright’s Test, Eden’s Test

Halstead's ManeuverInstruct: Patient seated, examiner finds and monitors radial pulse in neutral position with one

hand and with the other hand traction the patient’s arm toward the floor. Examiner instructs patient to elevate chin and hyperextend their neck. If the test is negative (thepulse does not disappear), then rotate the head to the opposite side and repeat.

Positive: Pain and/or paresthesia, decreased or absent pulse, pallor.Indicates: Compression of the neurovascular bundle by scalenus anticus or cervical

rib.

Confirmation Tests:Roo’s Test, Adson’s Test, Shoulder Depression Test


Costoclavicular Maneuver a.k.a. Eden's TestProcedure: Patient seated, examiner finds radial pulse and instructs patient to sit

erects, force shoulders back, chest out and touch chin to chest.Positive: Pain and/or paresthesia, decreased or absent pulse, pallor.Indicates: Compression of the neurovascular bundle between the clavicle and 1st

rib.

Confirmation Tests:Shoulder Depression Test, Adson’s Test, Halstead Test, Wright’s Test

Hyperabduction Maneuver a.k.a. Wright’s Test Procedure: Patient seated, examiner finds radial pulse and hyperabducts the

patient's arm.Positive: Pain and/or paresthesia, decreased or absent pulse, pallor.Indicates: Compression of the axillary artery by pectoralis minor or coracoid

process. Thoracic outlet syndrome.

Confirmation Tests:Adson’s Test, Halstead Test, Shoulder Depression Test, Eden’s Test

Tinel’s Elbow SignProcedure: 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:Nerve Conduction Testing

Fromet’s Paper SignProcedure: 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:Nerve Conduction Testing

Phalen’s Sign AND Reverse Phalen’s Sign a.k.a. Prayer’s signProcedure: 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 samelevel 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).

Indicates: Carpal Tunnel Syndrome

Confirmation Tests:Tinel’s Sign, Nerve Conduction Testing


Tinel’s Wrist SignProcedure: 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 lateralaspect of ring finger).

Indicates: Carpal Tunnel Syndrome

Confirmation Tests:Phalen’s Test, Reverse Phalen’s Test, Nerve Conduction Testing

Lower Extremity TestingMinor's SignInstruct: 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:Nachlas’ Test, Spinal Percussion Test, Sciatica Tests

Belt Test (Supported Adam’s Test, Supported Forward Bending Test)Procedure: Patient standing. Have patient bend forward and note for presence of low

back pain. With patient standing, stabilize patient’s iliac crests and brace hip against patient’s sacrum. Have patient bend forward as you immobilize the pelvis.

Positive: Low back painIndicates: 1) Pain in during unsupported and supported bending = Lumbar

involvement2) Pain in during unsupported, no pain during supported bending =

pelvic involvement

Confirmation Tests:Gaenslan’s Test, Goldthwait’s Test

Milgram’s TestInstruct: Patient supine, examiner raises both of patient’s legs 2-3 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:Bowstring Test, Heel Walk Test, Toe Walk Test, Kemp’s Test


Heel WalkProcedure: Patient walks on heels.Positive: Inability to perform test.Indicates: L4-L5 disc problem (L5 nerve root)

Confirmation Tests:Bowstring Test, Kemp’s Test, Milgram’s Test, Neri’s Bowing Test

Toe WalkProcedure: Patient walks on toes.Positive: Inability to perform test.Indicates: L5-S1 disc problem (S1 nerve root).

Confirmation Tests:Bowstring Test, Kemp’s Test, Milgram’s Test, Neri’s Bowing Test

Kemp’s TestProcedure: 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 reachesaround patient and grasps patient’s shoulder. Examiner passively brings shoulder back and obliquely pushes shoulder towards opposite PSIS.

Positive: 1) Pain usually radicular, recreating existing sciatic pain2) Pain - local

Indicates: 1) Disc protrusion:• In medial disc protrusion Kemps will be positive as the patient

is leaning AWAY from the side of pain.• In lateral disc protrusion Kemps will be positive as the patient is

leaning INTO the side of pain.2) Localized pain may indicate lumbar spasm or facet capsulitis.

Confirmation Tests:Bowstring Test, Kemp’s Test, Milgram’s Test, Heel Walk Test, Toe Walk Test, Fajersztajn's Test

Lindner's SignInstruct: 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’s Sign, Fajersztajn’s Test, Lasegue’s Test, Straight Leg Raising Test,

Straight Leg Raiser (SLR)Procedure: Patient supine, examiner raises patient’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’s Test, Fajersztajn’s Test, Lasegue’s Test, Lindner’s Test


Bragard’s SignProcedure: Patient supine, examiner performs a (SLR) on the patient. Examiner

lowers the raised leg (5º) from the point of pain and sharplydorsiflexes patient’s foot.

Positive: Radiating pain in posterior thigh.Indicates: Sciatica

Confirmation Tests:Fajersztajn’s Test, Lasegue’s Test, Straight Leg Raising Test

Sicard's SignInstruct: 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:Bechterew’s Test, Bragard’s Test, Fajersztajn’s Test, Lasegue’s Test, Lindner’s Test, Straight Leg Raising Test, Turyn’s Test, Lewin’s Standing Test

Turyn's SignInstruct: Patient supine, examiner dorsiflexes the big toe of the affected extremity.Positive: Pain in the gluteal region or radiating sciatic pain.Indicates: Sciatic radiculopathy.

Confirmation Tests:Bechterew’s Test, Bragard’s Test, Fajersztajn’s Test, Lasegue’s Test, Lindner’s Test, Straight Leg Raising Test, Turyn’s Test, Lewin’s Standing Test, Sicard’s Test

Bonnet's SignProcedure: Patient supine, examiner strongly internally rotates and adducts the

affected leg across the midline and then performs a straight leg raisertest.

Positive: Pain in posterior thigh or leg.Indicates: Sciatica (possibly piriformis syndrome)

Confirmation Tests:Bragard’s Test, Fajersztajn’s Test, Lasegue’s Test, Lindner’s Test, Straight Leg Raising Test

Fajersztajn's Test a.k.a. Well-Leg-Raising Test of Fajersztajn a.k.a. Cross-over SignProcedure: 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 isproduced, examiner dorsiflexes the foot.

Positive: 1) Pain down affected leg.(Cross-Over Sign)2) Decrease in pain down affected leg.

Indicates: 1) Medial disc protrusion2) Lateral disc protrusion.

Confirmation Tests:Bragard’s Test, Lasegue’s Test, Lindner’s Test, Straight LegRaising 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 bythe 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:Ely’s Sign

Tinel’s Foot SignProcedure: Doctor taps the region of the medial plantar nerve, posterior to the

medial malleolusPositive: Paresthesia radiating into the foot.Indication: Tarsal tunnel syndrome

Confirmation Tests:Duchene’s sign, nerve conduction study

Morton’s TestProcedure: Doctor squeezes the metatarsal heads.Positive: Sharp pain in the forefoot.Indication: Metatarsalgia or neuroma

Confirmation Tests:Strunsky’s sign, nerve conduction study


ADDITIONAL TESTSBracelet TestInstruct: Patient seated, examiner gives mild to moderate compressive pressure to

dorsum of patients’ wrist (thumb encircles radial side of wrist, index finger encircles ulnar side i.e. squeeze wrist) and then have patient attempt to make a fist.Perform bilaterally.

Positive: Acute forearm, wrist and hand painIndicates: Significant for Rheumatoid Arthritis. Confirm with diagnostic imaging and

laboratory tests.

Confirmation Tests:Blood testing, Radiography

Naffziger’s TestInstruct: 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 apatient with atherosclerosis.

Positive: Radicular pain (typically in lumbars, possibly cervical or thoracic)Indicates: Space-occupying lesion

Confirmation Tests:Dejerine’s Triad, Valsalva’s Test, Swallowing Test (in cervical spine), Vertebral Artery Testing (in cervical Spine)

Forestier's Bowstring SignInstruct: 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’s Sign, Nachlas Test, Spinal Percussion, Blood testing, Radiography

Chest Expansion TestInstruct: 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, ameasurement is taken. The patient relaxes and then maximally exhales, ameasurement is taken.

Positive: Males = less than two inches expansionFemales = Less than 1 1/2 inches expansion

Indicates: Thoracic fixation, commonly found with ankylosing conditions such as AnkylosingSpondylitis.

Confirmation Tests:Amoss’s Sign, Forrestier’s Bowstring, Range of Motion, Blood testing, Radiography


NON-ORGANIC EXAMSBased upon area of Chief Complaint

Cervical:Libman’s SignInstruct: Patient seated, examiner places a gradual increasing amount of pressure on the

patient’s mastoid until it becomes noticeably uncomfortable. Compare bilateral.Positive: Response of pain.Indicates: Is an indicator of the patient’s pain threshold. Can be used during interpretation of

palpation findings during rest of exam.Can be indicator for unusually low threshold to pain, possible malingerer.

Confirmation Tests:Mankopf’s Sign

Any Area, General:

Magnuson’s TestInstruct: 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 ofpain.

Indicates: Lack of organic basis for LBP (Malingering). Patient with true pain will point to site ofpain both times.

Confirmation Tests:Axial trunk Loading, Burn’s Bench Test, Flexed Hip, Flip sign, Trunk Rotational Test

Mannkopf’s SignInstruct: Patient seated or supine, examiner establishes patient’s resting radial pulse rate.

Without changing the patient’s position, the examiner irritates the patient’s area of complaint while monitoring their pulse rate.

Positive: An increase in pulse rate by 10 or more beats/min. is a positive (normal) sign. If noincrease 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 perminute, which is equal to approximately a 10 percent or more increase in their pulserate.

Confirmation Tests:Libman’s Test


Low- Back, Patient on Table:Burn’s Bench TestInstruct: Patient kneels on exam table and is instructed to touch the floor (have them bend from

the waist) with their fingertips while examiner stabilizes patient’s leg.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:Axial Trunk Loading, Flexed Hip, Flip Sign, Magnuson’s, Trunk Rotation Test

Flexed-Hip TestInstruct: Patient supine, examiner places one hand under the patient’s lumbar spine with

fingertips touching the spinous processes (usually at L5/S1). Examiner passively flexespatient’s knee to 90 degrees and patient’s hip to 90 degrees.

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:Axial Trunk Loading, Burn’s Bench, Flip Sign, Magnuson’s Test, Trunk Rotation Test

Flip SignInstruct: 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 tableedge, as the examiner tells the patient he/she is going to examine the knee joint. Whiledoing 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:Axial Trunk Loading, Burn’s Bench, Flexed Hip, Magnuson’s Test, Trunk Rotation Test

Low- Back, Patient Standing:

Axial Trunk-Loading TestInstruct: Patient standing, examiner places downward pressure on the head with both hands

while not disturbing the patient’s presenting posture.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’s Bench, Flip Sign, Flexed Hip, Magnuson’s Test, Trunk Rotation Test


Trunk Rotational TestInstruct: Patient standing with arms crossed against chest, examiner grasps patient’s pelvis.

Examiner instructs patient to rotate trunk to one side. Examiner simultaneously rotatespatient’s pelvis in same direction that patient rotates. Repeat procedure to 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:Axial Trunk Loading, Burn’s Bench, Flip Sign, Magnuson’s Test, Flexed Hip


SPECIAL SENSESDIAG 3750


OPTHALMOSCOPY AND OTOSCOPYExamining the patientAlways perform an external examination of the eye before proceeding to use the ophthalmoscopeAssess for:Bilateral symmetry Scars, abrasions other noticeable marksDischarge, alteration of sclera colorEye lids, eye browsNormal constriction, dilation, reflexes

The Ophthalmoscope1) Viewing aperture2) Focus wheelBlack (green) # - spherical convex (positive) lenses, converge rays. For Hyperoptic eyeRed # - spherical concave (negative) lenses, diverge rays. For myopic eyeLenses 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 systemGreen–(red free), used to see if dark spots are pigment or dried blood, which is darker than the pigment

spotsCross 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 glareThe 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 Ophthalmoscope1. 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” from patients eye and slightly to the side, direct

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 (red 2). *Use index finger on focusing wheel while viewing fundus. 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 theophthalmoscope in order to see the different fields of the fundus.

7. The disc lies slightly nasal to center of retina.

Examining the Disc1. Shape - round to oval2. 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 atrophyToo red - hyperemia

5. Cup/disc ratio - less than a ratio of 1:2.Large cup or differences bilaterally, suspect Glaucoma.


Examination of the Vessels1. 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 arteries2) 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 judgedaccurately), Look for regularity of the blood column, multiple constrictions, focalconstrictions.

Caliber: size and width of the vessels, generalized narrowing, attenuated arteries, enlargedveins

A:V ratio - should be 2:3 or 3:4, *if <1:2 they are not WNL4) Central retinal artery occlusion (CRA)

Lessened blood supply to retina, retinal edemaBloodless appearance, arteries narrowed or absentMacula - cherry red appearance (not involved) Sudden visual loss - *medical emergency

5) Central retinal vein occlusion (CRV)Hemorrhagic appearanceLook for hemorrhagesVision will become obscured

6) Arterial light reflexReflection 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 backgroundBlood and choroidal plexus behind retina, the pigment cells in the choroid and pigment layer of the retina allcontribute 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 vascularpattern.

Tigroid - normal variation2. Integrity of the fundus - the following are not normal:

Hemorrhages - solid, flame shaped, linear, dot and blotMicro aneurysms-small, sharp point-like red spotsCotton wool areas - result from occlusion of terminal arterioles and resultant swelling of the axons

occur along vessels and obscure the vesselExudates - result from venous micro infarction and stasis.Yellowish, flat and do not completely obscure vessels posterior to them

Retinal edemaDrusen - small yellow dots, symmetrically distributed, seen in both eyes, they are a precursor

of macular degeneration


Examination of the Macula1. 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 deeperblood supply for the choroid.

3. Have patient look at light of ophthalmoscope; this puts the macula in full view.Look for hemorrhages, exudates, edemaAny pigment change is abnormal

The Otoscope Speculum:Reusable - boil to clean or soak in alcohol. 4 sizes 2mm, 3mm, 4mm, 5mmDisposable - 2 sizes 2.5mm, 4mm In order to obtain the maximum field of view, choose the largest speculum which fits comfortably in thepatient’s ear.

Examination the patientAlways do an external examination firstHearing - 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 Otoscope1) Choose largest comfortable speculum, have patient tilt head away from you.2) Straighten the outer ear canal

Adults - up and backChildren - down and back

3) Hold otoscope like a pencil (between thumb and forefinger) resting hand against patients cheek. Do not putpressure 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.):malleusCone 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 membrane6) 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 canalhandle of malleus extends down and back ends at the “cone of light” 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 examinationUse speculum with a bright lightNever use pressure on the sensitive septumCan view:

VestibulesMiddle meatusMucosa Septum Inferior and middle turbinate bonesNormal nasal mucosa has a red appearanceCommon cold - swollen erectile turbinates, bright red mucosa and dischargeAllergic rhinitis - swollen erectile turbinates, polypsAtrophic 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.

Clinical Sciences Diagnosis Laboratory Manual July 2008

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Transcript of Clinical Sciences Diagnosis Laboratory Manual July 2008