Examination Expected findings Findings

Head - Symmetrical
- Note for lumps and tumors
- Hair distribution and texture
Eyes - Test for EOM
- Visual acuity
- Peripheral vision
- fundoscopy
Ears - otoscopy
- Rinnes test
- Hearing aquity
Neck - Note for presence and absence of lumps, masses
and tenderness (lymphadenopathy)
- Note thyroid gland and palpate it, and trachea
midline
TOTAL SCORE
 Thorax Findings
survey of respiration rate, rhythm, depth and effort of
breathing, presence or absence of audible wheezing
Inspection
Shape of the chest, symmetry and movement
location of the trachea
use of accessory muscles
presence of lagging
skin abnormalities, lesions, masses, sinus
tracts
Palpation
technique in doing the test
presence of absence of tenderness
skin abnormalities: palpation of masses
test for chest expansion
test for tactile fremitus
Percussion
technique in doing the test
reporting:
flatness/dullness/resonance/tympany
Auscultation
technique in doing the test
character of breath sounds:
inspiratory and expiratory sounds
(location,pitch, intensity, duration,
decreased/absence)
presence or absence of adventitious sounds
(crackles, wheeze, rhonchi): location, timing,
loudness, pitch, duration
transmitted voice sounds (egophony,
pectoriloquy)
Other presence or absence of cyanosis (central, distal)
clubbing
 CVS Findings
Vital signs: BP,CR,RR,Temp
Assessment of JVP
- Positioning
- Technique
- Result/value
Pulsations: IJ and carotid
- Positioning
- Techniques
- findings
The heart:
Inspection and palpation
- Positioning
- Technique
- Reporting of findings
Anatomical location of Aortic, Pulmonic,
RV, LV
PMI (location, description, clinical
correlation)
S3 and S4 , if present

Percussion
- Technique
- Reporting of findings
Auscultation
- Techniques and maneuvers
- Reporting of findings
S1 and S2
Murmurs (timing, location, grading, pitch,
quality and radiation)

Peripheral signs of diseases of the CVS; cyanosis

(central, distal); clubbing
Breast exam and Axilla
Vital signs
Interview/ history family history, bse, discomfort,
pain, lumps, changes in size, dimpling, swelling,
discharges
Ask permission
Define the anatomic borders of the breast
- Clavicle and 2nd rib to the 6th rib
- Sternum to the midaxillary line
Inspection
- Proper positioning
a. Arms at sides
b. Arms over head
c. Hands on hips
d. Leaning forward
- Describe the color, symmetry, size, contour
(masses, dimpling or flattening), thickening
(prominent pores which accompany
lymphatic obstruction) of the breast
- Look for any masses
- Nipple: size, shape, direction, or discharges,
rashes, ulceration (very important)
- Examine both right and left
Palpation (lateral to medial)
female
- Position: supine (if patient cannot tolerate
the ideal position, just state the ideal
position)
- Expose the breast
- 2 ways: vertical and horizontal stripping
- Locate and palpate the lymph nodes (other
names of lymph nodes)
- Palpate for lateral: supine, roll on opposite
hip, hand on forehead while shoulder
pressed on bed
o Begin palpation from the axilla to
bra line (vertical strip) to nipple
line
- Palpate for medial: shoulder flat on bed,
hand on neck, lift elbow until level with
shoulder
o Palpate straight line down from
the nipple line to bra line to
midsternal
- Palpate for consistency, tenderness
(premenstrual), lumps, masses, lymph
nodes, masses, nipple discharges
- With or without mass you must describe
(very important)
a. Location (by clock or quadrant)
b. Size (cm)
c. Shape (round, cystic, disc like shape,
irregular)
d. Consistency (soft, firm, hard)
e. Delineation (wel circumscribed or not)
f. Mobility (dimpling)
g. Tenderness
- Examine both sides
- Nipple: palpate and note for elasticity,
discharge (color, quantity, origin, odor)
Male
Inspection
- Nipple and areola: nodules, swelling,
ulceration
Palpation
- Areola breast tissue: nodules, obesity (soft
fatty), glandular (gynecomstia)
Axilla
- Right hand for left axilla and vice versa
(sitting)
Inspection
- Rash, infection, unusual pigmentation
Palpation (relax arm down)
- Cup fingers of hand, reach high into the
axilla, fingers behind pectoral muscle, point
to mid clavicle
- Check nodes: pectoral, lateral, subscapular,
infra and supraclavicular
Teach patient how to BSE
Post mastectomy:
- Inspect: scar, axilla, masses, nodularity, s/sx
of inflammation, lypmphedema, LN
enlargement
ABDOMEN
Vital signs
Empty bladder.
Position: Supine. Pillow under head and knees. Arms at sides
or folded across the chest. Drape from below nipple to
symphysis pubis.
Pain: location (point), timing, description, severity (1-10),
aggravates and relieves pain
Examine pain area last!
Warm hands and steth. Calm. Avoid quick and unexpected
movements. No long fingernails.
Distract. If ticklish, pts hands below yours. Watch patients
face for signs of pain or discomfort.
IAPePa
Inspection
- Skin: scars, striae, dilated veins, rashes, ecchymosis
- Umbilicus: contour, location, inflammation, bulges for
hernia
- Abdomen:
o contour (round, protuberant, scaphoid)
o symmetric?
o Flank bulge
o Hernia (inguinal and femoral)
o Visible masses or organs (enlarged liver or
spleen)
o Peristalsis
o Pulsations
Auscultation
- Bowel sounds (N: 5-34 per minute)
- Borborygmi prolong hyperperistalsis stomach
growling
- Bruit, pulsations (aorta, renal, iliac, femoral)
- Friction rubs liver and spleen
Percussion
- Percuss lightly all quadrant: tympany or dullness
- Assess distribution of gas, if mass solid/fluid, size of
liver and spleen
- Liver dullness, gastric air bubble, splenic flexure
Palpation
- Light palpation: note for tenderness, muscular
resistance, rigidity, superficial organs and masses,
pulsations (light, gentle, dipping motion)
- If resistance: differentiate from involuntary muscular
spasm from voluntary guarding
- Exhale, open mouth = relax abdl mm
- Deep palpation: delineate abdominal masses
(location, size, consistency, tenderness, pulsation,
mobility from respiration)
- Assess peritonitis: (+) cough test, guarding, rigidity,
rebound tenderness, percussion tenderness
LIVER
Percussion
- Vertical Liver Span: lower border from midclavicular
from the level below the umbilicus in RLQ, percuss
upward
- upper border from midclavicular line from nipple to
liver dullness
- Normal: 4-8 cm (midsternal); 6-12cm (midclavicular)
Palpation
- Left hand behind, parallel to the right 11th and 12th
ribs below. Right hand lateral to the rectus muscle.
Fingertips below the border of the liver dullness. Ask
patient to breathe with abdomen.
- Note tenderness
- Normal: liver edge is soft, sharp, regular with a
smooth surface, slightly tender
- Hooking technique if obese: Stand at right of pts
chest. Hook fingers of both hands side by side below
border of liver dullness. Press in and up toward costal
margin. Deep breath.
- Tenderness of a nonpalpable liver: left hand at the
lower right rib cage and gently strike with the ulnar
surface of the left hand. Compare with left side.
SPLEEN
Percussion
- Percuss the left lower anterior chest wall at the
traubes space
- Traubes space from cardiac dullness border at the
6th rib to the AAL and down to he costal margin
- Check for splenic percussion sign (lowest left
intercostals space in AAL), deep breath: normal still
tympany
Palpation
- Left hand reach over to support and press forward
the lower ribcage. Right hand below left costal margin
press toward the spleen. Deep breath. Feel tip or
edge.
 - Note for enlargement, tenderness, splenic contour, - Protuberant abdomen w/ bulging flanks
distance between the spleens lowest point and the - Map border between dull and tympany
left costal margin - Shifting dullness
- Repeat with the patient lying on the right side with - Fluid wave
legs flexed at the hips and knees. In this position,
gravity may bring the spleen forward and to the right Organ in Ascitic Abdomen:
into a palpable location.
- Ballottement: straighten and stiffen fingers of one
hand together, place on surface, brief jabbing
KIDNEYS movement toward structure.
- Will displace fluid so you can feel surface.
Palpation: Left kidney:
Appendicitis
- Pts left side. Right hand below and parallel to 12th rib.
Lift. Left hand parallel and lateral to rectus. Deep - Where pain start, where now
breath. At peak of inspiration, capture edge of kidney. - Cough and where pain occurs
Exhale and stop, release. - Check guarding, rigidity, rebound tenderness
- Size, contour, tenderness - Rovsing sign
- Alternative: same with spleen palpation - Obturator sign
- Psoas sign
Palpation: Right kidney: - Rectal/pelvic exam
- Return to right side. Left hand at the back, lift. Right Acute Cholecystitis
hand press deep.
- Usually rounded lower pole. - Murphys sign: hook left thumb or right fingers under
intersection of lateral border of rectus and costal
Percussion Tenderness: margin. Deep breath. Increase tenderness and sudden
- CVAT. Fingertips may cause tenderness. Ball of one stop inspiration = (+)
hand in CVA, strike with ulnar surface of fist. Use Ventral Hernias:
perceptible but painless thud.
- Raise head and shoulders off the bed. Bulge will
BLADDER appear.
- Dome of distended is round and smooth upon Mass in abdl wall or intra abdominal:
palpation. Check tenderness. Percuss if dull. Dullness
will appear if 400-600ml. - Raise head and shoulders off bed. If abdominal wall
mass, will remain palpable. If intra, obscured by mm
AORTA contraction.
- Press firmly deep into abdomen at left of midline and Others
identify aortic pulsation. If >50 years old, assess
width. Press deep in abdomen with hands at sides of - Grey turner sign
aorta. Normal is less than 3cm. - Cullen sign

Ascites:
Peripheral Vascular system
VITAL SIGNS! BP both arms
Explain and ask permission
Always check bilaterally and compare
- Temporal pulse
- Carotid upstroke, listen for bruits
ARMS:
- Inspect both arms for size, symmetry, and any swelling,
venous pattern, color of the skin and nail beds and the
texture of the skin
- Radial partially flex wrist
- Brachial - flex elbow slightly, artery is medial to the
biceps tendon at the antecubital crease; also in groove
between biceps and triceps
- Epitrochlear nodes: presence of nodes, size,
consistency,and tenderness (difficult or impossible to
identify in most normally healthy people) flex elbow at
90deg, forearm supported by hand, reach behind the
arm and feel groove between biceps and triceps mm,
3cm from medial epicondyle
ABDOMINAL AORTIC PULSES:
- Auscultate aortic, renal, femoral bruits
- Palpate and estimate width of AA in epigastric area using
two fingers
LEGS:
- Inspect both legs for size, symmetry, and any swelling,
venous pattern, color of the skin and nail beds and the
texture of the skin. Venous pattern and any venous
enlargement. Any pigmentation, rashes, scars, or ulcers
- Check for tenderness during palpation
- Palpate the superficial inguinal nodes (horizontal and the
vertical groups): size, consistency, discreteness, and note
any tenderness. (Nontender, discrete inguinal nodes up
to 1 cm or even 2 cm in diameter are frequently palpable
in normal people)
- Palpate femoral pulse press deeply below inguinal
ligament midway between ASIS and symphysis pubis
- Popliteal pulse knees flexed and leg relaxed. Fingertips
of both hands meet at midline behind.
- Alternative: pt prone, flex knees, lower leg relaxed
against your shoulder, press thumbs into fossa
- Dorsalis pedis dorsum, lateral to extensor tendon of big
toe or more laterally
- Posterior tibial finger behind and slightly below medial
malleolus
- Temperature of the legs
- Check prominent veins, tendons and bones
- Edema use thumbs for 2 secs and grade (1+, 2+, 3+, 4+)
at the dorsum of foot, behind medial malleolus, shins.
Check for pitting
- If with unilateral edema: measure forefoot, smallest
circumference above ankle, largest circum at calf,
midthigh (diff of 1 cm at ankle and 2cm at calf = edema
- Grade the pulses
o 3+ Bounding
o 2+ Brisk, expected (normal)
o 1+Diminished, weaker than expected
o 0 Absent, unable to palpate
Special techniques:
- ALLENS TEST:
1. hands in lap, palms up
2. tight fist. Compress radial and ulnar
3. open into relaxed, slightly flexed
4. release ulnar. If patent, flush within 3-5 secs
5. same with radial artery
- POSTURAL COLOR CHANGES OF CHRONIC ARTERIAL
INSUFFICIENCY
o Raise both legs to about 60 degrees until
maximal pallor of the feet (within a minute).
o Then ask the patient to sit up with legs dangling
down. Compare both feet, noting the time
required for:
Return to pink (<10 sec)
Filling veins (~15 sec)
o Check for rubor (dusky redness) to replace the
pallor (may take >1 min)
- MAPPING VARICOSE VEINS
o With the patient standing, place your palpating
fingers gently on a vein and, with your other
hand below it, compress the vein sharply.
o Feel for a pressure wave transmitted to the
fingers of your upper hand.
o A palpable pressure wave indicates that the two
parts of the vein are connected.
o A wave may also be transmitted downward, but
not as easily.
- TRENDELENGBURG TEST (Retrograde Filling Test)
o Patient supine.
o Elevate one leg to about 90 degrees to empty it
of venous blood.
o Next, occlude the great saphenous vein in the
upper thigh by manual compression, using
enough pressure to occlude this vein.
o Ask the patient to stand for 20 seconds.
o While you keep the vein occluded, watch for
venous filling in the leg
o Normally, saph vein fills from below
o Repid filling suggest communicating valve
incompetence
o After the patient stands for 20 seconds, release
the compression and look for sudden additional
venous filling.
Normally there is none; competent
valves in the saphenous vein block
retrograde flow. Slow venous filling
continues.
o Normal result is negative-negative
Musculoskeletal system - Stand in front of patient
- Flexion raise arms in front of you and overhead
TEMPOROMANDIBULAR JOINT o Anterior deltoid, pectoralis major, biceps and
coracobrachialis
Inspection:
- Extension raise arms behind you
- Inspect the face for symmetry, swelling or redness. o Latissimusdorsi, teres major, posterior
(swelling may appear as a rounded bulge ~0.5cm deltoid, tricepsbarchii (Long head)
Palpate: - Abduction arms to side and overhead
- In front of the tragus of each ear and ask the patient to o Supraspinatus, middle deltoid, serratus
o Open mouth (fingertips should drop into the anterior
joint spaces as the mouth opens). Pure glenohumeral motion: arms to shoulder
o Range of motion level at 90deg, palms down
Opening and closing, Scapulothoracic motion: palms up and raise
Protrusion and retraction arms additional 60deg
Side-to-side - Adduction cross arm in front of body
o Swelling or tenderness. o Pectoralis major, coracobrachialis,
- Masseters angle of mandible latissimusdorsi, teres major, subscapularis
- Temporal muscles clenching and relaxation of jaw - Internal Rotation one hand behind back and touch
- Pterygoid muscles internally between tonsillar pillars shoulder blade
at mandible o Identify highest spinous process reached
o Subscapularis, anterior deltoid, pectoralis
major, teres major, latissimusdorsi
SHOULDER - External Rotation - one hand behind neck as if
Inspection brushing hair
- Swelling, deformity, muscle atrophy or fasciculations o Infraspinatus, teres minor, posterior deltoid
(fine tremors of the muscles), or abnormal positioning.
- Swelling of the joint capsule anteriorly or a bulge in the Best predictors of rotator cuff tear are supraspinatus
subacromial bursa under the deltoid muscle. weakness on abduction, infraspinatus weakness during
- Color change, skin alteration, or unusual bony contours external rotation, and a positive impingement sign.

Palpation begin medially
- Sternoclavicular joint, trace the clavicle laterally with
your fingers.
- Acromioclavicular joint
- Coracoid process
- Greater tubercle
- Biceps tendon in the bicipital groove- tenderness
- SITS
o To examine the subacromia land subdeltoid
bursae and the SITS muscles, first passively
extend the humerus by lifting the elbow
posteriorly. This rotates these structures so
that they are anterior to the acromion.
Palpate carefully over the subacromial and
subdeltoid bursae. The underlying palpable
SITS muscles are:
Supraspinatusdirectly under the
acromion
Infraspinatusposterior to
supraspinatus
Teres minorposterior and inferior
to the supraspinatus
Subscapularisinserts anteriorly and
is not palpable
- Maneuvers for shoulder pain: rotator cuff muscle
compression
o Crossover test acromioclavicluarjoint
Adduct the patients arm across the
chest
o Apley scratch test- overall shoulder rotation
Touch the opposite scapula either
over or under
o Neers impingement- rotator cuff tear
Press on the scapula to prevent
scapular motion with one hand, and
raise the patients arm with the
other. This compresses the greater
tuberosity of the humerus against
the acromion.
o Hawkins impingement sign- rotator cuff tear
Flex the patients shoulder and elbow
to 90 degrees with the palm facing
down. Then, with one hand on the
forearm and one on the arm, rotate
the arm internally. This compresses
the greater tuberosity against the
coracoacromial ligament.

o Empty can test (supraspinatus strength)

Range of motion rotator cuff tear
 Elevate the arms to90 degrees and
internallyrotate the armswith the
thumbs pointingdown, as if
emptyinga can. Ask thepatient to
resist as youplace downward
pressureon the arms.
o Infraspinatus strength- rotator cuff tear
&bicipital tendinitis
Ask the patient to place arms at the
side and flex the elbows to 90
degrees with the thumbs turned up.
Provide resistance as the patient
presses the forearms outward.
o Forearm supination- rotator cuff tear
Flex the patients forearm to 90
degrees at the elbow and pronate
the patients wrist. Provide
resistance when the patient
supinates the forearm.
o Drop-arm sign- rotator cuff tear
Ask the patient to fully abduct the
arm to shoulder level (or up to 90
degrees) and lower it slowly. Note
that abduction above shoulder level,
from 90 degrees to 120 degrees,
reflects action of the deltoid muscle.
ELBOW
Inspection
- Medial and lateral epicondyles and the olecranon
process of the ulna (flexed to about 70 degrees)
o Contours, extensor surface of the ulna and
the olecranon process
o Nodules or swelling flexed to about 70
degrees
Palpation
- Olecranon process and epicondyles
- Tenderness or effusion and displacement
Range of motion
- Flexion - Bend your elbow.
o Biceps brachii, brachialis,brachioradialis
- Extension - Straighten your elbow.
o Triceps brachii, anconeus
- Supination - Turn your palms up, as if carrying a bowl
of soup.
o Biceps brachii, supinator
- Pronation - Turn your palms down.
- Pronator teres, pronatorquadratus
WRIST AND HANDS
Inspection
- When the fingers are relaxed they should be slightly
flexed; the fingernail edges should be in parallel.
- Swelling, deformities of the wrist, hand, or finger
bones, angulation
- Contours of the palm, namely the thenar and
hypothenar eminences.
- Thickening of the flexor tendons or flexion
contractures in the fingers.
Palpation
- Palpate the distal radius and ulna on the lateral and
medial surfaces.
- Palpate the groove of each wrist joint with your
thumbs on the dorsum of the wrist
o Swelling, bogginess, or tenderness
- Palpate the radial styloid bone and the
- Anatomical snuffbox (visible with lateral extension of
the thumb away from the hand), a hollowed
depression
- Palpate the eight carpal bones, metacarpals and the
proximal,
- Middle, and distal phalanges
o Swelling, bogginess, or tenderness.
- Palpate the medial and lateral aspects of each PIP and
DIP joint
o Swelling, bogginess, bony enlargement or
tenderness
Range of motion: wrist
- Flexion -With palms down, point your fingers toward
the floor.
o Flexor carpi radialis, flexor carpi ulnaris
- Extension - With palms down, point your fingers
toward the ceiling.
o Extensor carpi ulnaris, extensor carpi
radialislongus, extensor carpi radialisbrevis
- Adduction (radial deviation) -With palms down,
bringyour fingers toward the midline.
o Flexor carpi ulnaris
- Abduction (ulnar deviation)-With palms down, bring
your fingers away from the midline.
o Flexor carpi radialis
Maneuvers
- Hand grip strength asking the patient to grasp your
2nd and 3rd fingers.
o Tests function of wrist joints, thefinger
flexors, and the intrinsic muscles andjoints of
the hand.
- Finkelsteins test - asking the patient to grasp the
thumb against the palm and then move the wrist
toward the midline in ulnar deviation
- Carpal Tunnel Syndrome aching, numbness and
tingling
o Thumb abduction- asking the patient to raise
the thumb straight up as you apply downward
resistance
o Tinels sign - tapping lightly over the course of
the median nerve
o Phalens sign -asking the patient to hold
thewrists in flexion for 60 seconds.
Range of motion: fingers
 - Flexion-Make a tight fist with each hand, thumb
across the knuckles.(lumbrical muscles).
- Extension-Extend and spread the fingers.(lumbrical
muscles).
- Abduction and adduction.- Ask the patient to spread
the fingers apart and back together
Range of motion: thumb
- Flexion- move the thumb back across the palm
- Extension - away from the fingers
- Abduction - thumb in the neutral position with the
palm up, then have the patient move the thumb
anteriorly away
- Adduction - back down
- Opposition- touch the thumb to each of the other
fingertips.
SPINE:
Ideally: pt upright in the normal standing position, feet
together and arms hanging at the sides. Head and
sacrum at midline. Shoulder and pelvis should be level
Inspection:
- Inspect posture, position of neck and trunk; erect
position of head, neck and back; smooth coordinated
neck movement; ease of gait
- Identify spinous process. Prominent C7 and T1 esp on
forward flexion; paravertebral mm; PSIS marked by
dimples
- Examin from side and behind. Evaluate spinal
curvatures
Palpation:
- Palpate spinous process of all with thumb
- Palpate facet joints between the cervical vertebrae 1
inch lateral to spinous process of C2-C7. Neck mm
must be relaxed
- In lower lumbar area, check for vertebral step offs to
determine prominent spinous processes. Check
tenderness
- Palpate sacroiliac joint dimple over PSIS
- For tenderness do thumping with ulnar surface of fist
- Paravertebral mm for tenderness and spasm (knotted
and firm and may be visible)
- Sciatic nerve: hip flex and lie on opposite side. Midway
between greater trochanter and ischial tuberosity.
- Cauda equine syndrome: low back pain radiating to
butt, perineum or legs.
ROM for NECK:
- Flexion chin to chest (SCM, scalene, paravert)
- Extension look up to ceiling (splenius capitis and
cervicis, small intrinsic neck mm)
- Rotation look over one shoulder and another (SCM,
small intrinsic neck mm)
- Lateral bending bring ear to shoulder (scalene, small
intrinsic neck)
ROM for SPINE:
- Flexion bend forward and try to reach toes (psoas
major and minor, quad lumborum, int and ext oblique,
rectus ab) note smoothness and symmetry of
movement, lumbar cavity should flatten
- Extension bend back as far as possible (erector
spinae, transversospinalis) support by placing hand
on PSIS with fingers pointing to midline
- Rotation rotate side to side (ab mm, intrinsic mm of
back) stabilize pelvis by placing one hand on hip and
other on the opposite shoulder. Rotate trunk by
pulling shoulder anteriorly and hip posteriorly
- Lateral bending bend to side from waist (ab mm,
intrinsic mm of back) stabilize pelvis by hand on hip
HIP:
Inspection:
- Gait 2 phases:
1. Stance foot is on the ground ad bears weight
(60%); heelstrike, foot flat, midstance, push off
2. Swing foor moves forward and does not bear
weight (40%)
Observe width of base (2-4 in from heel to heel), shift
of pelvis, flexion of knee. Must be smooth and with
continuous rhythm.
Observe lumbar portion of spine for amount of
lordosis. Supine to check for length of legs for
asymmetry.
- Inspect ant and post surface of hip for atrophy or
bruising
Palpation:
- Anterior:
1. Iliac crest upper margin of pelvis at T4
2. Iliac tubercle follow downward curve from crest
3. ASIS continue tracking downward
4. Greater trochanter thumbs on ASIS, move
fingers downward and laterally from iliac tubercles
5. Pubic tubercle thumbs medially and obliquely;
same level of greater troch
- Posterior:
1. PSIS under dimples just above buttocks
- Left thumb and index finger over the posterior
superior iliac spine. Greater trochanter laterally with
your fingers at the level of the gluteal fold, and place
your thumb medially on the ischial tuberosity.
- Inguinal structures: pt supine with heel of leg to be
examined on opposite knee. Palpate along inguinal
ligament (extends from ASIS to pubic tubercle). Nerve
Artery Vein Empty space Lymph node NAVEL
- Bursa below inguinal ligament but deeper. If hip os
painful do this. Pt resting on one side, hip flex and int
rotated, palpate trochanteric bursa over greater troch.
Ischiogluteal bursa is not palpable unless inflamed
ROM for Hip
- Flexion bend knee to chest and pull it over to
abdomen (iliopsoas)
 - Extension (hyper) lie face down then bend knee and
lift it up (glut max)
- Abduction lying flat, move lower leg away from
midline (glut med and min)
- Adduction lying flat, bend knee and move lower leg
to midline (adductor brevis, longus and magnus,
pectineus, gracilis)
- Ext rotation lying flat, bend your knee and turn lower
leg and foot across midline (int and ext obturators,
quad femoris, sup and inf gemelli)
- Int rotation lying flat, bend knee and turn lower leg
and foot away from midline (iliopsoas)
Maneuvers for Hip:
- Flexion
1. Pt supine. Hand under lumbar spine. Bend knee up
to chest and put firmly against abdomen.
2. Note lumbar flattening
3. Observe for degree of flexion at hip and knee.
Normally ant surface of thigh can touch chest wall
4. Note whether opposite thigh remains extended
fully
- Extension
1. Face down, extend thigh toward you in posterior
direction
2. Alt: near edge of table. Extend leg post
- Abduction
1. Stabilize pelvis by pressing down on opposite ASIS
with one hand.
2. Other hand grasp ankle and abduct extended leg
until you feel iliac spine move. This marks the
limit of hip abduction
- Adduction pt supine.
1. Stabilize pelvis, hold one ankle
2. Move leg medially across body and over opposite
extremity
- Ext and Int Rotation
1. Flex leg to 90deg at hip and knee
2. Stabilize thigh with one hand, grasp ankle with
other
3. Swing lower leg medially (ext) or laterally (int)
Note: motion of head of femur in acetabulum that
identifies these movements
KNEE
Inspection
- Gait. The knee should be extended at heel strike and
flexed at all other phases of swing and stance.
- Check the alignment and contours of the knees.
- Observe any atrophy of the quadriceps muscles. Look
for loss of the normal hollows around the patella, a
sign of swelling in the knee joint and suprapatellar
pouch
- Note any other swelling in or around the knee.
Palpation
- Ask the patient to sit on the edge of the examining
table with the knees in flexion.
- The Tibiofemoral Joint.
o Facing the knee, place your thumbs in the
soft-tissue depressions on either side of the
patellar tendon.
o Identify the groove of the tibiofemoral joint.
Note that the inferior pole of the patella lies
at the tibiofemoral joint line.
o As you press your thumbs downward, you can
feel the edge of the tibial plateau. Follow it
medially, then laterally, until you are stopped
by the converging femur and tibia.
o By moving your thumbs upward toward the
midline to the top of the patella, you can
follow the articulating surface of the femur
and identify the margins of the joint.
o Note any irregular bony ridges along the joint
margins.
- Medial meniscus & lateral meniscus
o Pressing on the medial soft-tissue depression
along the upper edge of the tibial plateau. It is
easier to palpate the medial meniscus if the
tibia is slightly internally rotated.
o Place the knee in slight flexion and palpate
the lateral meniscus along the lateral joint
line.
- Medial joint compartments of the tibiofemoral joint
o Knee flexed examining table to
approximately90 degrees.
o Medially, move your thumbs upward to
palpate the medial femoral condyle. The
adductor tubercle is posterior to the medial
femoral condyle
o Move your thumbs downward to palpate the
medial tibial plateau.
o Pain or tenderness
- Medial collateral ligament
o Connects the medial epicondyle of the femur
to the medial condyle and superior medial
surface of the tibia.
o Palpate along this broad, flat ligament from its
origin to insertion.
- Lateral joint compartments of the tibiofemoral joint
o Lateral to the patellar tendon, move your
thumbs upward to palpate the lateral femoral
condyle and downward to palpate the lateral
tibial plateau.
o When the knee is flexed, the femoral
epicondyles are lateral to the femoral
condyles.
- Lateral collateral ligament
o Ask the patient to cross one leg so the ankle
rests on the opposite knee
o A firm cord that runs from the lateral femoral
epicondyle to the head of the fibula.
- Patellofemoral compartment
o Locate the patella and trace the patellar
tendon distally until you palpate the tibial
tuberosity.
o Ask the patient to extend the knee to make
sure the patellar tendon is intact.
- Patellofemoral grinding test
 o With the patient supine and the knee
extended
o Compress the patella against the underlying
femur, and gently move it medially and
laterally, assessing for crepitus and pain.
o Ask the patient to tighten the quadriceps as
the patella moves distally in the trochlear
groove.
o Check for a smooth sliding motion
- Suprapatellar pouch
o Start 10 cm above the superior border of the
patella, well above the pouch, and feel the
soft tissues between your thumb and fingers.
o Move your hand distally in progressive steps,
trying to identify the pouch.
o Continue your palpation along the sides of the
patella.
o Note any tenderness or warmth greater than
in the surrounding tissues.
Palpation Tests for Effusion in the Knee Joint.
- Bulge sign (for minor effusions)
o Knee extended, place the left hand above the
knee and apply pressure on the suprapatellar
pouch, displacing or milking fluid
downward.
o Stroke downward on the medial aspect of the
knee and apply pressure to force fluid into the
lateral area.
o Tap the knee just behind the lateral margin of
the patella with the right hand.
- Balloon sign ( for major effusions)
o Place the thumb and index finger of your right
hand on each side of the patella; with the left
hand, compress the suprapatellar pouch
against the femur.
o Feel for fluid entering (or ballooning into) the
spaces next to the patella under your right
thumb and index finger.
- Ballotting the patella (large effusions), you can also
o Compress the suprapatellar pouch and
ballotteor push the patella sharply against
the femur.
o Watch for fluid returning to the suprapatellar
pouch.
- Gastrocnemius and soleus muscles
o Their common tendon, the Achilles, is
palpable from about the lower third of the
calf to its insertion on the calcaneus.
- Achilles tendon
o Place the patient prone with the knee and
ankle flexed at 90 degrees, or alternatively
o Ask the patient to kneel on a chair.
o Squeeze the calf and watch for plantar flexion
at the ankle
Range of motion
- Flexion- Bend or flex your knee. Or Squat down to
the floor.
o Hamstring group: biceps femoris,
semitendinosus, and semimembranosus
- Extension -Straighten your leg. Or After you squat
down to the floor, stand up.
o Quadriceps: rectus femoris, vastus medialis,
lateralis, and intermedius
- Internal Rotation - While sitting, swing your lower leg
toward the midline.
o Sartorius, gracilis, semitendinosus,
semimembranosus
- External Rotation -While sitting, swing your lower leg
away from the midline.
o Biceps femoris
Maneuvers
- Mcmurray Test - Medial meniscus and lateral meniscus
o Supine, grasp the heel and flex the knee. Cup
your other hand over the knee joint with
fingers and thumb along the medial joint line.
o From the heel, externally rotate the lower,
then push on the lateral side to apply a valgus
stress on the medial side of the joint. At the
same time, slowly extend the lower leg in
external rotation.
o The same maneuver with internal rotation of
the foot stresses the lateral meniscus.
o If a click is felt or heard at the joint line during
flexion and extension of the knee, or if
tenderness is noted along the joint line,
further assess the meniscus for a posterior
tear.
- Abduction (or Valgus) Stress Test - Medial collateral
ligament (MCL)
o Supine and the knees lightly flexed, move the
thigh about30 degrees laterally to the side of
the table.
o Place one hand against the lateral knee to
stabilize the femur and the other hand around
the medial ankle.
o Push medially against the knee and pull
laterally at the ankle to open the knee joint on
the medial side
- Adduction (or Varus) Stress Test - Lateral collateral
ligament (LCL)
o The thigh and knee in the same position,
change your position so you can place one
hand against the medial surface of the knee
and the other around the lateral ankle.
o Push laterally against the knee and pull
medially at the ankle to open the knee joint
on the lateral side
 - Anterior Drawer Sign - Anterior cruciate ligament (ACL)
o Supine, hips flexed and knees flexed to 90
degrees and feet flat on the table, cup your
hands around the knee with the thumbs on
the medial and lateral joint line and the
fingers on the medial and lateral insertions of
the hamstrings.
o Draw the tibia forward and observe if it slides
forward (like a drawer) from under the femur.
Compare the degree of forward movement
with that of the opposite knee.
- Lachman Test - Anterior cruciate ligament (ACL)
o Place the knee in 15degrees of flexion and
external rotation. Grasp the distal femur on
the lateral side with one hand and the
proximal tibia on the medial side with the
other.
o With the thumb of the tibial hand on the joint
line, simultaneously pull the tibia forward and
the femur back.
o Estimate the degree of forward excursion.
- Posterior Drawer Sign - Posterior cruciate ligament
(PCL)
o Position the patient and place your hands in
the positions described for the anterior
drawer test.
o Push the tibia posteriorly and observe the
degree of backward movement in the femur.
Maneuvers
- Ankle (Tibiotalar) Joint.
o Dorsiflex and plantar flex the foot at the
ankle.
- Subtalar (Talocalcaneal) Joint
o Stabilize the ankle with one hand, grasp the
heel with the other, and invert and evert the
foot by turning the heel inward then outward.
- Transverse Tarsal Joint
o Stabilize the heel and invert and evert the
forefoot.
- Metatarsophalangeal Joints
o Move the proximal phalanx of each toe up
and down.
Special techniques
- Measuring the Length of Legs
o If you suspect that the patients legs are
unequal in length, measure them. Get the
patient relaxed in the supine position and
symmetrically aligned with legs extended.
With a tape, measure the distance between
the anterior superior iliac spine and the
medial malleolus. The tape should cross the
knee on its medial side. (unequal- scoliosis)

ANKLE AND FOOT

Inspection
- All surfaces of the ankles and feet, noting any
deformities, nodules, swelling, calluses, or corns.

Palpation
- Palpate the anterior aspect of each ankle joint,
o Bogginess, swelling, or tenderness.
- Achilles tendon
o Nodules and tenderness.
- Posterior and inferior calcaneus, and the plantar fascia
for tenderness.
- Medial and lateral malleolus for tenderness
- Metatarsophalangeal joints
o Tenderness
o Compress the forefoot tbetween the thumb
and fingers. Exert pressure just proximal to
the heads ofthe first and fifth metatarsals.
- Heads of the five metatarsals and the grooves between
them
o Using thumb and index finger. Place your
thumb on the dorsum of the foot and your
index finger on the plantar surface.

Range of motion
- Ankle Flexion (plantar flexion)- Point your foot toward
the floor.
- Ankle Extension (dorsiflexion)-Point your foot toward
the ceiling.
- Inversion- Bend your heel inward.
- Eversion- Bend your heel outward.
NEUROLOGIC EXAMINATION o Motor
Palpating the temporal and masseter
Mental status examination muscles in turn, ask the patient to
clench the teeth. Note the strength
- Level of consciousness
of muscle contraction. Ask \the
o Alert/awake
patient to move the jaw side to side.
o Lethargic o Sensory
o Obtunded Test the forehead, cheeks, and jaw
o Stuporous on each side for pain sensation. The
o Coma patients eyes should be closed. Use
- Attention span a suitable sharp object, occasionally
- Orientaion substituting the blunt end for the
o Place, person, time and date point as a stimulus. Ask the patient
- Memory to report whether it is sharp or
o Recent and remote dull and to compare sides.
- Judgement and insight If you find an abnormality, confirm it
by testing temperature sensation.
- Calculation
Two test tubes, filled with hot and
- Fund of information
ice-cold water
- Thought process
Test for light touch, using a fine wisp
- Mood and affect of cotton. Ask the patient to respond
- Speech whenever you touch the skin.
- langauge o Test the corneal reflex. Ask the patient to look
up and away from you. Approaching from the
Cranial nerves
side, touch the cornea (not just the
- Cranial nerve I: Olfactory conjunctiva) lightly with a fine wisp of cotton.
o Test the sense of smell by presenting the - Cranial nerve VII: Facial
patient with familiar nonirritating odors. First, o Motor
be sure that each nasal passage is open by Inspect the face, both at rest and
compressing one side of the nose and asking during conversation with the patient.
the patient to sniff through the other. The Note any asymmetry and observe
patient should then close both eyes. Test the any tics or other abnormal
other side. movements.
- Cranial nerve II: Optic Ask the patient to:
o Test visual acuity 1. Raise both eyebrows.
o Inspect the optic fundi with your 2. Frown.
ophthalmoscope, paying special attention to 3. Close both eyes tightly so that you
the optic discs cannot open them. Test muscular
Red orange reflex, optic disc, strength by trying to open them, as
physiologic cup, retinal vessels and illustrated.
fovea 4. Show both upper and lower teeth.
o Test the visual fields by confrontation. 5. Smile.
o Direct light reflex 6. Puff out both cheeks.
- Cranial nerve II and III: Optic and Oculomotor
o Inspect the size and shape of the pupils, and o Sensory
compare one side with the other. Check taste anterior 2/3 of the
Anisocoria, or a difference of >0.4 tongue
mm in the diameter - Cranial nerve VIII: Acoustic
o Test the pupillary reactions to light. o Assess hearing with the whispered voice test.
o Check the near response, which tests pupillary o Test for air and bone conduction, using the
constriction (pupillary constrictor muscle), Rinne test, and lateralization, using the Weber
convergence (medial rectus muscles), and test.
accommodation of the lens (ciliary muscle). - Cranial nerve IX and X: Glossopharyngeal and Vagus
- Cranial nerve III, IV, and VI: Oculomotor, Trochlear and o Listen to the patients voice. Is it hoarse, or
Abducens does it have a nasal quality?
o Test the extraocular movements in the six o Difficulty in swallowing?
cardinal directions of gaze o Ask the patient to say ah or to yawn as you
o Check convergence of the eyes. watch the movements of the soft palate and
o Identify any nystagmus, ptosis the pharynx.
- Cranial Nerve V: Trigeminal
 o Test the gag reflex. Stimulate the back of the
throat lightly on each side in turn and note
the gag reflex.
- Cranial nerve XI: Spinal Accessory
o From behind, look for atrophy or
fasciculations in the trapezius muscles, and
compare one side with the other.
o Ask the patient to shrug both shoulders
upward against your hands. Note the strength
and contraction of the trapezii.
o Ask the patient to turn his or her head to each
side against your hand. Observe the
contraction of the opposite sternomastoid
and note the force of the movement against
your hand.
- Cranial nerve XII: Hypoglossal
o Listen to the articulation of the patients
words.
o Inspect the patients tongue as it lies on the
floor of the mouth.
o Look for any atrophy or fasciculations.
o Ask patient to protrude tongue, look for
asymmetry, atrophy, or deviation from the
midline.
o Ask the patient to move the tongue from side
to side, and note the symmetry of the
movement.
o Ask the patient to push the tongue against the
inside of each cheek in turn as you palpate
externally for strength.
Motor
- Inspect: body contour, involuntary muscle, atrophy,
muscle tone
- Muscle strength
o Test muscle strength by asking the patient to
actively resist your movement.
o Test biceps flexion and extension
C5, C6
o Triceps flexion and extension at the elbow by
having the patient pull and push against your
hand.
C6, C7, C8
o Test wrist extension at the by asking the
patient to make a fist and resist your pulling it
down
C6, C7, C8,radial nerveextensor
carpi radialis longus and brevis
o Test the grip. Ask the patient to squeeze two
of your fingers as hard as possible and not let
them go. Testing both grips simultaneously
with arms extended or in the lap facilitates
comparison.
C7, C8, T1
o Test finger abduction. Position the patients
hand with palm down and fingers spread.
Instructing the patient not to let you move
the fingers, try to force them together.
C8, T1, ulnar nerve
o Test opposition of the thumb. The patient
should try to touch the tip of the little finger
with the thumb, against your resistance.
C8, T1, median nerve
o Flexion, extension, and lateral bending of the
spine
o Thoracic expansion and diaphragmatic
excursion during respiration
o Test flexion at the hip by placing your hand on
the patients thigh and asking the patient to
raise the leg against your hand.
L2, L3, L4iliopsoas
o Test adduction at the hips. Place your hands
firmly on the bed between the patients
knees. Ask the patient to bring both legs
together.
L2, L3, L4adductors
o Test abduction at the hips. Place your hands
firmly on the bed outside the patients knees.
Ask the patient to spread both legs against
your hands.
L4, L5, S1gluteus medius and
minimus
o Test extension and flexion at the hips. Have
the patient push the posterior thigh down
against your hand.
S1gluteus maximus
o Test extension at the knee. Support the knee
in flexion and ask the patient to straighten the
leg against your hand. The quadriceps is the
strongest muscle in the body, so expect a
forceful response.
L2, L3, L4quadriceps
o Test flexion at the knee as shown below. Place
the patients leg so that the knee is flexed
with the foot resting on the bed. Tell the
patient to keep the foot down as you try to
straighten the leg.
L4, L5, S1, S2hamstrings
o Test dorsiflexion
Mainly L4, L5tibialis anterior
o Plantar flexion, at the ankle by asking the
patient to pull mainly S1gastrocnemius,
soleus up and push down against your hand.
Cerebellar
- Rapid alternating movement
o Arms
Show the patient how to strike one
hand on the thigh, raise the hand,
turn it over, and then strike the back
of the hand down on the same place.
Urge the patient to repeat these
alternating movements as rapidly as
possible.
Observe the speed, rhythm, and
smoothness of the movements.
Repeat with the other hand. The
nondominant hand often performs
somewhat less well.
 o Legs
Ask the patient to tap your hand as
quickly as possible with the ball of
each foot in turn. Note any slowness
or awkwardness.
The feet normally perform less well
than the hands.
o Finger-to-nose test
Ask the patient to touch your index
finger and then his or her nose
alternately several times.
Move your finger about so that the
patient has to alter directions and
extend the arm fully to reach it.
Observe the accuracy and
smoothness of movements, and
watch for any tremor. Normally the
patients movements are smooth and
accurate.
o Heel-to-shin test
Ask the patient to place one heel on
the opposite knee, and then run it
down the shin to the big toe.
Note the smoothness and accuracy
of the movements.
Repetition with the patients eyes
closed tests for position sense.
Repeat on the other side.
- Gait
o Walk across the room
Observe posture, balance, swinging
of the arms, and movements of the
legs.
o Walk heel-to-toe (tandem walking) in a
straight line
o Walk on the toes, then on the heels
o Hop in place on each foot in turn
involves the proximal muscles of the
legs as well as the distal ones
o Do a shallow knee bend, first on one leg, then
on the other
o Rising from a sitting position without arm
support
o stepping up on a sturdy stool
- stance
o Rombergs test
This is mainly a test of position sense.
The patient should first stand with
feet together and eyes open and
then close both eyes for 30 to 60
seconds without support.
Note the patients ability to maintain
an upright posture.
o Pronator drift
The patient should stand for 20 to 30
seconds with both arms straight
forward, palms up, and with eyes
closed.
A person who cannot stand may be
tested for a pronator drift in the
sitting position.
tap the arms briskly downward. The
arms normally return smoothly to
the horizontal position.
Sensory
- Pain
o Use a sharp safety pin, a broken cotton swab
o Ask the patient, Is this sharp or dull?
- Temperature
o Temperature testing is often omitted if pain
sensation is normal, but include it if there are
sensory deficits.
o Touch the skin and ask the patient to identify
hot or cold.
- Fine touch
o With a fine wisp of cotton, touch the skin
lightly, avoiding pressure.
o Ask the patient to respond whenever a touch
is felt, and to compare one area with another.
- Vibration
o place it firmly over a distal interphalangeal
joint of the patients finger, then over the
interphalangeal joint of the bigtoe. Ask what
the patient feels.
o proximal bony prominences (e.g., wrist,
elbow, medial malleolus, patella, anterior
superior iliac spine, spinous processes, and
clavicles).
- Position sense
o Grasp the patients big toe, holding it by its
sides between your thumb and index finger,
and then pull it away from the other toes.
o Demonstrate up and down as you move
the patients toe
o Then, with the patients eyes closed, ask for a
response of up or down when moving the
large toe in a small arc.
- Discriminative sensation
o Stereognosis
o Graphesthesia
o Two-point discrimination.
Touch a finger pad in two places
simultaneously. Alternate the double
stimulus irregularly with a one-point
touch. Be careful not to cause pain
o Point localization.
Briefly touch a point on the patients
skin. Then ask the patient to open
both eyes and point to the place
touched.
o Extinction.
Simultaneously stimulate
corresponding areas on both sides of
the body. Ask where the patient feels
your touch
o Dermatomes
C2 ears
 C3 front and back of the neck o Quickly check the patients color and pattern
C6 lateral aspect of the arms, index of breathing. Inspect the posterior pharynx
and thumb and listen over the trachea for stridor to make
C8 ring and little fingers sure the airway is clear.
L4 knee o If respirations are slowed or shallow, or if the
L5 anterior ankle and foot airway is obstructed by secretions, consider
S5 perianal intubating the patient as soon as possible
Reflexes while stabilizing the cervical spine.
- Biceps (C5, C6) o Assess the remaining vital signs: pulse, blood
- Triceps (C6, C7) pressure, and rectal temperature.
- Barchioradialis (C5, C6) o If hypotension or hemorrhage is present,
- Knee (L2, L3, L4) establish intravenous access and begin
- Ankle (S1) intravenous fluids.
- Abdominal reflexes - Level of consciousness
o stroking each side of the abdomen, above (T8, o Level of consciousness primarily reflects the
T9, T10) and below (T10, T11, T12) the patients capacity for arousal, or wakefulness.
umbilicus It is determined by the level of activity that
o Use a key, the wooden end of a cotton tipped the patient can be aroused to perform in
applicator, or a tongue blade twisted and split response to escalating stimuli from the
longitudinally. examiner.
o Note the contraction of the abdominal o Alert, lethargy, obtunded, stupor, coma
muscles and deviation of the umbilicus - Neurologic evaluation
toward the stimulus. o Pupils
- Plantar Observe the size and equality of the
o Stroke the lateral aspect of the sole from the pupils and test their reaction to light.
heel to the ball of the foot, curving medially The presence or absence of the light
across the ball. reaction is one of the most important
o Some patients withdraw from this stimulus by signs distinguishing structural from
flexing the hip and the knee metabolic causes of coma. The light
- Anal reflex reaction often remains intact in
o stroke outward in the four quadrants from the metabolic coma.
anus o Ocular Movement
Observe the position of the eyes and
Meningeals eyelids at rest.
- Nuchal rigidity Check for horizontal deviation of the
- Brudzinski sign eyes to one side (gaze preference).
- Kernigs sign When the oculomotor pathways are
intact, the eyes look straight ahead.
Staright leg raise test o Oculocephalic Reflex (Dolls Eye Movements)
- Place the patient in the supine position. Raise the This reflex helps to assess brainstem
patients relaxed and straightened leg, flexing the leg function in a comatose patient.
at the hip, then dorsiflex the foot. Holding the upper eyelids open so
- Assess the degree of elevation at which pain occurs, that you can see the eyes, turn the
the quality and distribution of the pain, and the effects head quickly, first to one side and
of dorsiflexion. then to the other.
Asterexis o Oculovestibular Reflex (with Caloric
- Ask the patient to stop traffic by extending both Stimulation)
arms, with hands cocked up and fingers spread. Watch If the oculocephalic reflex is absent
for 1 to 2 minutes, coaxing the patient as necessary to and you seek further assessment of
maintain this position. brainstem function, test the
Winging of the scapula oculovestibular reflex.
- When the shoulder muscles seem weak or atrophic, Note that this test is almost never
look for winging. Ask the patient to extend both arms performed in an awake patient.
and push against your hand or against a wall. Observe o Posture and Muscle Tone
the scapulae. Normally they lie close to the thorax. Observe the patients posture. If
there is no spontaneous movement,
Stuporous or comatose patient you may need to apply a painful
stimulus
- ABC Classify the resulting pattern of
movement as:
 Normalavoidantthe
patient pushes the stimulus
away or withdraws.
Stereotypicthe stimulus
evokes abnormal postural
responses of the trunk and
extremities.
Flaccid paralysis or no
response
o Muscle tone
Test muscle tone by grasping each
forearm near the wrist and raising it
to a vertical position.
Note the position of the hand, which
is usually only slightly flexed at the
wrist.
Then lower the arm to about 12 or
18 inches off the bed and drop it.
Watch how it falls. A normal arm
drops somewhat slowly.
- Further Examination
o As you complete the neurologic examination,
check for facial asymmetry and asymmetries
in motor, sensory, and reflex function.
o Test for meningeal signs if indicated.
o As you proceed to the general physical
examination, check for unusual odors.
o Look for abnormalities of the skin, including
color, moisture, evidence of bleeding
disorders, needle marks, and other lesions.
o Examine the scalp and skull for signs of
trauma.
o Examine the fundi carefully.
o Check to make sure the corneal reflexes are
intact. Remember that use of contact lenses
may abolish these reflexes.
o Inspect the ears and nose, and examine the
mouth and throat.