Revision date July 2019

Academic Year 2019-2020

Rocky Vista University

College of Osteopathic Medicine

Laboratory Manual for Clinical

Medicine
Department of Primary Care

This manual is NOT for resale or reproduction. All photos and charts were taken or made for
this manual. This is the property of RVUCOM and its affiliates, to be used for teaching
purposes only.
 Student Doctor: __________________________________________________________

Copyright © 2017 Rocky Vista University Department of Primary Care

All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or
transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or
otherwise without written permission from the publisher.
2
 Table of Contents
Taking a medical History
The Art of Interviewing ................................................................................................................................. 5
Types of Difficult Patents ............................................................................................................................ 9
Taking a Medical History ........................................................................................................................... 12
Physical Exam by System
Skin ........................................................................................................................................................... 19
Vital Signs ................................................................................................................................................. 28
General Assessment and Physical Exam Overview .................................................................................. 31
HEENT and Neck ...................................................................................................................................... 36
Eyes .......................................................................................................................................................... 48
Peripheral Vascular and Lymph System ................................................................................................... 56
Cardiovascular System ............................................................................................................................. 65
Respiratory System ................................................................................................................................... 74
Gastrointestinal System ............................................................................................................................ 82
Male Genitalia ........................................................................................................................................... 92
Female Genitalia ....................................................................................................................................... 97
Breasts ................................................................................................................................................... 102
MSK: Neck and Upper Extremities .......................................................................................................... 106
MSK: Back and Lower Extremities .......................................................................................................... 120
Neuro Part I ............................................................................................................................................ 133
Neuro Part II ........................................................................................................................................... 142
Special Evaluations
Pediatric Exam ........................................................................................................................................ 153
Geriatric Exam ........................................................................................................................................ 163
Psychiatric Exam .................................................................................................................................... 167
Procedures
Medical Safety and OSHA Regulations, Gown and Glove, and Aseptic Technique ................................. 169
Injections ................................................................................................................................................ 172
Venipuncture, IV’s, Glucose Finger Stick and Glucose Monitoring .......................................................... 175
Peripheral Nerve Blocks and Field Blocks ............................................................................................... 180
Lumbar Puncture .................................................................................................................................... 181
Catheterization of the Urinary Bladder .................................................................................................... 184
Splinting and Casting .............................................................................................................................. 185
3
Joint Injections ........................................................................................................................................ 189
Nasogastric Intubation Insertion .............................................................................................................. 192
Suturing Technique ................................................................................................................................. 194
Documentation
Oral Case Presentation ........................................................................................................................... 198
Medical History SOAP Note .................................................................................................................... 201
Procedure Note ....................................................................................................................................... 204
Psychiatric Progress Note ....................................................................................................................... 205
Admissions Orders .................................................................................................................................. 206
Pediatric Admissions Order ..................................................................................................................... 208
Routine Labs ........................................................................................................................................... 210
Appendixes
Abbreviations .......................................................................................................................................... 214
Other Abbreviations ................................................................................................................................. 215
USPSTF A and B Recommendations ...................................................................................................... 216
Competency Exam Lists .......................................................................................................................... 220

4
 The Art of Interviewing
(Bates 12th edition pp. 65-99)

Communication is the key to a successful patient encounter. Good communication skills are the
foundation of excellent medical care. The main purpose of the interview is to gather information
pertinent to the patient’s illness or condition.

Summary of good Physician-Patient Interpersonal Skills:

1. Introduce yourself. Clarify patient name.

2. Set an agenda
3. Listen without interrupting
4. Appropriately use open ended, direct and forced questions
5. Stay organized, follow a logical thought process
6. Do not use jargon
7. Use good facilitative behavior: make eye contact, lean forward, engage, express empathy either
verbally or with body language
8. Recognize with the patient how their condition/issue could be affecting work, or family
9. Demonstrate respect, cultural sensitivity
10. Appropriately encourage questions
11. Concisely summarize the visit
12. Appear professional and confident

Communication Skills
Non-Verbal Skills

Listen and observe the patient.

Give the patient time to answer your questions
and try to get “cues and clues” from your patient’s
communication, body posture and answers.

Proximity
The spatial separation individuals maintain during
social interaction.

Spatial Zones
Intimate zone – less than 1.5 ft.
(appropriate for GU/Gyn exams)
Personal zone – 1.5 to 4 ft. (appropriate
for patient interviews and most of PE.)
Social zone – 4 ft. to 12 ft.
Public zone – more than 12 ft.

Body language
This includes facial expressions, head movements, gesturing. Both interviewer and patient
can be communicating through body language. Consider patient’s cultural and ethnic
background because different cultures have different standards of nonverbal behavior.

5
 Eye contact
Maintaining eye contact with the patient usually conveys interest in the patient.

Posture
Will help define your overall attitude with the patient. An “open posture” allows a patient to
feel more comfortable in communicating with you. When the physician sits down, the patient
perceives he/she is interested. It is suggested for the physician to be at OR below the eye
level of the patient. Proper posture and eye contact can be defined by the acronym: SOLER.

SOLER
Positioned Squarely in relation to the patient
Maintain an Open posture with the patient
Lean slightly towards the patient
Maintain Eye contact with the patient
Relax as you conduct the interview

Verbal Skills
Open-ended questions
Used to gather general information from the patient. Useful in opening the interview with the
patient or changing a topic. An open-ended question allows the patient to tell his or her story
spontaneously. Often starts with “How” or “What”

Example:
“Tell me about your chest pain.”
“What brings you into the office today?”

Closed-ended or direct questions

Used to clarify and add detail to the medical history. The patient gives specific responses with
little room for explanation. Usually a one-word or brief answer. Questions often start with the
words, “Is”, “Are”, “Do” or “Did”.

Example:
“Where does it hurt?”
“Did the symptoms start today?”

Language
Talk to your patients in words they will understand and with which they will be comfortable.
Do not use medical jargon or talk at an educational level above their comprehension.
Recommendation for most patients is 8th grade English. Some populations may require more
simple words. Use interpreter as needed. Be aware for linguistic information relayed by the
patient such as voice inflection, rate of speech, loudness, throat clearing, etc.

Other Techniques to Use in an Interview

Silence
Most useful with quiet or silent patients. Maintain eye contact. Quiet intervals do NOT need
to be filled.

6
Facilitation
Can be verbal or non-verbal communication to allow the patient to continue speaking. A
nodding of the head.

Example: “Tell me more”, “Uh huh”

Confrontation
A response based on an observation by the interviewer that points out something about the
patient’s behavior or response.

Example: “You look upset or concerned about something.”

Interpretation
This is a type of confrontation based on inference rather than observation.

Example: “You seem quite sad about that.”

Reflection
A response by the interviewer that echoes or restates that which has just been expressed by
the patient. The tone of voice is important in reflection.

Example: the patient states, “I have been so depressed for the past 3 years”, the
physician responds, “You have been depressed for 3 years?”

Support
A response by the interviewer that shows interest and/or understanding for the patient.

Example: the patient states, “I just can’t quit smoking, I have tried several times.” The
physician responds, “I would like to help you quit for good.”

Reassurance
The interviewer either understands or approves of the patient’s words or actions.

Example: “It is great that you have quit smoking.”

Empathy
Is a response that recognizes the patient’s feelings and does not criticize. It is an
understanding, not an emotional state of sympathy.

Example: “I understand things have been very difficult with your son lately.”

Transitions
Are statements that allow a patient to better understand your questions or allow the interview
to flow more smoothly.

Example: “I am now going to ask you some questions about your family history.”

Summarization
Giving a quick summary can be beneficial in many ways. It shows that you have been
listening. It communicates what you know and what you don’t know about their problem(s).
And it allows them to add or correct information.

7
 Empowering the patient
Embrace their perspective. Show interest in them not just the problem. Follow their lead into
the discussion. Sharing information, especially at transition points. Being transparent about
your clinical reasoning. Letting the patient know your limitations.

Conducting the Interview

 Wash your hands before the interview or physical examination.
 Greet the patient, make eye contact, shake hands, smile
 Make the patient comfortable as possible.
 Start with an open-ended question to get the chief complaint
 Proceed with open-ended and closed-ended questions to develop the HPI
 Listen and take notes on important facts and dates
 Use different interviewing techniques to help the interview
 Summarize or restate the patient’s story during and at the end of the interview, ask
if the patient has anything else to add or if he/she has any questions.

Transition to the Physical Exam

Tell your patient that with their permission you would like to begin the physical exam. Explain to them
what you need as far as dress, position, and what they can expect you will look at and why.

Ending the Interview and Examination with the Patient

 Always ask the patient if he/she has any further questions.

 Be sure the patient has expressed any comments and concerns they may have
before leaving the doctor-patient encounter.
 Recap the basic history of the chief complaint to the patient. This is a brief summary
and it helps the patient and the physician reflect on the answers and history.
 Be sure to always explain to the patient what will be happening next. For example, in
the case of a student doctor let the patient know you will “report your findings to the
attending physician”

NOTES

8
 Types of Difficult Patients
(Bates 12th edition pp. 86-99)

Seductive
This patient has a fantasy of developing a relationship with his/her doctor. Gives compliments, may
dress inappropriately and may constantly request you do physical exams that allow the patient to
expose themselves or is inappropriate for the situation.

Be professional, maintain a little more distance, less empathy and reassurance.

Angry
The hostile patient. The patient can be sarcastic and abrupt. Attempts to make the physician angry
by “pushing your buttons.”

Try confrontation, avoid becoming defensive and proceed with directed questions for
the issue of the visit or encounter.

Paranoid
Believes that someone or something is out to get him and that you are part of the elaborate plan.
Suspicious.

Reassurance, be non-threatening (don’t anger the patient) and don’t try to make the
patient understand the truth.

Insatiable
Always has an agenda with lots of questions and feels that the physician never spends enough time.
This patient can “drain the energy from you.”

Take charge of the interview, set limits and define closure.

Ingratiating
The patient fears disapproval or rejection and therefore is always trying to please the physician with
his/her answers.

Don’t feed on the patient’s anxiety and try to encourage accurate answers.

Aggressive
Easily irritated and acts enraged about things that that would not normally cause this type of
response. Personality disorder. A controlling personality that is usually pleasant and cooperative if
things are going their way.

Try not to evoke anger or anxiety during the interaction.

Help–rejecting
Sees many physicians/specialists and states that no one can find the root of his/her problem. The
patient has frequent return visits usually without improvement. If the patient does improve, another
problem usually emerges.

Requires strong emotional support and reasoning.

9
Demanding
This patient uses intimidation, anger and guilt to get what they want with the staff and the physician.
“I am sick and I refuse to leave until I am seen by the doctor?”

Set limits for the patient.

Compulsive
Every detail of the patient’s life needs to be an official justification from the physician. The patient
needs the physician’s confirmation and reassurance.

Give specific guidelines about health needs. Let the patient have control or partner in
health care and decisions.

Dependent
This patient needs emotional and physical support from others to live life. This patient looks for
compassionate doctors and demands lots of time and energy – calls during the night, weekends,
e-mail and office visits.

Be direct and provide limits without making the patient feel rejected.

Masochistic
Needs to go thru life with mental suffering. Self-sacrifice. The world is on the patient’s shoulders.
They will tell you they can handle any illness or medical problem. These patients usually do not
physically abuse themselves or cause harm or pain.

Never promise a cure, do not play into the mental suffering. Confront and try to
understand why the patient feels the need to do this.

Borderline
Personality disorder. Impulsive behavior with mood swings from anger to fear to love and friendship.
You can never trust that you are hearing the truth.

Reassure and be aware of the patient’s condition when working with them.

Silent
This patient often lacks self-esteem and afraid of saying or doing something wrong. Often associated
with depression.

Use open-ended questions, but if not responsive will need direct questioning,
reassurance, facilitation and confrontation.

Over talkative
This patient dominates the conversation, gives long answers and has an aggressive personality.

Occasionally interrupt, redirect the patient with direct questions and move the
conversation along. Avoid open-ended questions, facilitation or silence techniques.

Confusing patients
These patients may multiple complaints or a “positive review of systems”. Or they may be
misunderstood. Some may be actually confused or have a mental impairment.

10
Crying Patients
Their emotions express the severity of the issue or their lability of the situation.

Using supportive remarks like “I am glad you are able to express your emotions”

Silent Patients
Silence may be an expression of their personality or that they may be collecting their thoughts. Many
providers are uncomfortable with silence in the interview. Watching for non-verbal cues can be
helpful.

Language Barriers
Patients speaking different languages and not knowing English creates a large barrier to obtaining
an adequate history. Having an interpreter is invaluable. An interpreter that understands the
complaint(s) and can communicate this is much more beneficial. Being prepared for this in the
community that the provider serves will save time and frustration. Many services exist that can assist
medical facilities if an interpreter is not readily available.

Low Literacy
Obtaining information from patients that do not understand your questioning will create a frustrating
interview. In addition, if patients do not understand directions they will not take the medicine
appropriately or follow the directions have given them – whether written or verbalized.

Impairments – Deaf and/or Blind

These handicaps can become an access to health care issue for many people. It is almost like
having the language barrier. Someone who is able to communicate with the deaf by signing, or
someone that can assist with blindness barriers would be helpful during the visit.

Cultural Differences
Many different cultures exist in this country, which can create some uncomfortable situations for the
medical provider. Religious factors can be an important of the patients’ culture and can create its
own barrier or misunderstandings for the care of patients. Taking the social history regarding these
issues is valuable when considering the complaint(s) and how to approach the plan.

Sensitive Topics – may need a different approach

Approach by not being judgmental and explaining that this is important information. Also,
acknowledging your own discomfort will help you to work through the topics. Using open ended
questions will be most helpful.

Sexual History Family Violence Mental History

Death and Dying Alcohol and Drug Usage

NOTES

11
 Taking a Medical History
Remember: If it is not documented, it was not done!
(Bates 12th edition pp 5-13)

Initial Steps
Wash hands
Always wash hands or use hand sanitizer before touching or examining a patient.

Introduce yourself, clarify the patients name

My name is Student Doctor Last Name, are you Ms. Smith? What would you like me to call you? Ms.
Smith? Sally? Other?

Start to develop rapport or create patient comfort if needed

It is important to engage with them, express compassion

History
Elicit the Chief Complaint (CC)
“What brings you in today?” or “How can I help you today?”

History of the Present Illness (HPI)

(Can use the OLD CAAARTS PPP pneumonic for this section)

To include the following information:

 Onset/Setting: when did the condition start, what were you doing when it started?
 Location: Where does it hurt? Where do symptoms occur?
Remember, if it is
 Duration: is the pain constant?
 Character/Quality: Describes the character of the pain. intermittent, ask
 Can you describe the pain? Is it sharp or dull? Stabbing or How long does it
aching? last?
 Aggravating factors: What makes the pain/issue worse? AND
 Alleviating factors: What makes the pain/issue better?
 Associated Symptoms: Other symptoms that may be related to How often does it
the patient’s chief complaint that will assist in making the occur?
diagnosis.
 If the patient is unsure what may be related, you may need to prompt them by asking
about a few specific symptoms that you are wondering if they have. Do you have any
vomiting, change in stools, weight loss or fatigue? …. ROS symptoms.
 Radiation: Does the pain radiate anywhere?
 Timing: Are there certain times when the pain/issue is worse or better? how long does
the pain/issue last, or how often does the pain/issue occur?

12
  Severity:
 If patient’s complaint is pain, use the pain scale below to help qualify their pain.

 If NOT pain, severity can be judged by how the issue is affecting their routine life or
work
 Prior occurrence: have they ever experienced this before?
 Progression: is it getting worse?
 Perceived cause(s): What do you think caused it?
 Risk Factors: From past medical, family, social history; behaviors

Past Medical / Surgical History

General state of health
How would you describe your general health?

Childhood illnesses
What childhood illnesses have you had? When? For serious illnesses, ask them what kind of
treatment they had.

Adult illnesses and Chronic Conditions

What medical illnesses have you been, or are you being treated for as an adult?
If any, what illnesses, how long, any medications, etc. Any obstetrical history can also be
asked and documented here.

Accidents/injuries/fractures
Have you been involved in any accidents that have caused bone fractures, concussions or
other injuries?

Surgeries
Have you had any past surgeries? If so, what and when? What was the outcome?

Example: abdominal mass removed; adenocarcinoma, negative lymph nodes, chemo

therapy for six months followed by radiation, now in remission.

Hospitalizations
Have you ever been hospitalized for a medical illness?
If positive, for what and when? Have you been hospitalized for childbirth? What was the
method of delivery (vaginal, C-section)?

13
 Immunizations
What immunizations have you received and when? When was your last tetanus vaccine? Did
you receive the normal childhood vaccines? Remember adult vaccines too (Influenza, Tdap or
Td, pertussis, shingles, pneumococcal, meningococcal, HPV, Hepatitis A, Hepatitis B, MMR).
www.cdc.gov

Screening tests
Have you had any blood work done to check your sugar, cholesterol, etc. Have you had a
mammogram, pap smear, prostate exam, or colonoscopy? If so, when and what was the
result?
U.S. Preventive Services Task Force (USPSTF) screening guidelines: www.ahrq.gov

Current Medications

What medications is the patient taking:

 Prescription (birth control)

 Over the counter (OTC)?
 Supplements? Herbal and Vitamins

*Ask about each medications dosage and strength. What is the strength in mg or
mcg, how often is the medication taken, how many tablets, how long the patient has
been taking the medication and for what reason? If you do not know the medication,
look it up!

Allergies

 Does the patient have any allergies to medications?

 Any environmental or seasonal allergies (ex: hay fever, molds, pollen)?
 Any food allergies?

If yes:
What are they allergic to?
AND
What is the type of reaction? (rash, hives, itch, swelling, difficulty breathing etc.)

If no:
If the patient has no allergies to medication, you can write, “NKDA” (no known drug
allergies). If they have no allergies to food or the environment you should specify what
you asked. “No allergies to food or environment.”
*You must ALWAYS ask all three and document all three (meds, food, environment) *

Social History

Substances

Tobacco
Current and any prior history of tobacco use? Include type used (cigarettes, cigars,
chewing tobacco). How many packs/day and how many years? Documentation: 1
pack per day (ppd) for 20 years = 20 pack years
14
 Alcohol
Does the patient use any type of products? How much does the patient consume in a
day, week or month?

Street drugs
Has the patient ever used or does now use any recreational or street drugs? What
type, frequency of use, and how long?

Caffeine
Does the patient drink caffeinated beverages? How much?

Home situation / daily life

How does the patient describe their home situation? Who else lives in the household? Does
the patient feel safe at home?

Safety measures
Do you use seat belts or bike helmets? Are there any guns in the house?

Diet
Does the patient eat 3 meals/day? What is the patient’s diet like?
Exercise
Does the patient exercise? What kind, intensity and how often?

Sleep patterns
How many hours of sleep does the patient get at night? Is it restful sleep? Does the patient
have difficulty falling asleep or staying asleep? If so, why?

Occupation/Education
What does or did the patient do in terms of work or a career? Any possible environmental
exposures?

Sexual History
Is the patient in a committed relationship? Male or female? What is the patient’s marital or
divorce status? Is the patient sexually active? How many sexual partners in the patient’s
lifetime? How many current partners? Any history of sexually transmitted diseases (ex:
gonorrhea, chlamydia, herpes, syphilis)? Type of contraception?

Important life experiences and outlook

Has there been any particular experiences that have shaped your life or you would like to
share? How are things going in your life?

Religious beliefs relevant to health

Does the patient have any religious beliefs that may affect healthcare?

Sexual History
Is the patient sexually active? How many sexual partners in the patient’s lifetime? How many
current partners? Any history of sexually transmitted
diseases (ex: gonorrhea, chlamydia, herpes, syphilis)? Type of contraception? Sexual
orientation should be clarified during the sexual history.

15
Family History

 Ask the health status and age of immediate family members and close relatives.
 Your patient receives more risk from primary family member medical issues. These include
parents, and siblings. Investigate these family members individually.
 Extended family might confer risk to your patient. An example of how to assess This
efficiently would be “Is there any major health issues in other extended Family?” and let
your patient convey those who have major issues without needing to ask about each one.
 If any immediate family members are deceased, what ages did each die and what was the
cause of death? (if it is known when they died)
 As you learn more pathology, you may want to confirm or clarify with the patient if any
family members have specific conditions you are concerned may have particularly higher
risk for your patient. Examples are: diabetes, hypertension,
 heart disease, thyroid disease, and cancer.

Review of Systems (R.O.S.)

General
any weight change, fever, chills, fatigue, appetite changes, weakness, general health, night
sweats

Skin
itching, rashes, easy bruising, sores, discoloration, mole changes, changes in hair texture,
loss of hair, lumps, dry skin, change in skin color

HEENT

Head
headache (this section will overlap with neuro), history of head trauma

Eyes
use of glasses, visual changes, double vision, pain, redness, discharge, last eye
examination

Ears
ringing, changes in hearing, infections, discharge, pain, dizziness, use of hearing aid

Nose
nosebleeds, congestion, sinus infections, polyps, injury, nasal obstruction

Throat and Mouth

frequent sore throats, hoarseness, bleeding gums, voice changes, postnasal drip,
sores or ulcers in the mouth, dental problems

Chest/Pulmonary
cough, sputum production, difficulty breathing or shortness of breath (dyspnea), coughing up
blood (hemoptysis), chest pain with breathing (pleurisy), wheezing

Cardiac
chest pain, palpitations, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea,
dyspnea at rest, last EKG
16
Gastrointestinal
nausea, vomiting, diarrhea, constipation, heartburn, blood in the stool (hematochezia), black
stools (melena), abdominal pain, change in appetite, rectal pain, hemorrhoids, food
intolerance, hematemesis, bloating, difficulty swallowing (dysphagia), painful swallowing
(odynophagia), jaundice

Urinary
frequent urination, urgency, incontinence, dysuria, hesitancy, blood in the urine (hematuria),
nocturia, flank pain, change in urine color or odor

Genitalia

Male genitalia
prostate problems, sexual/erectile dysfunction, penile lesions, discharge, scrotal
masses, hernias, STD’s, self-examination

Female genitalia/GYN
Age at menarche? Date of last menstrual period (L.M.P.)? Age at menopause? Type
of contraception? Date and results of last PAP smear and mammogram? Any itching,
discharge, pain on intercourse (dyspareunia), pain with menses (dysmenorrhea), or
fertility problems? Any previous pregnancies? If so, get information on Gravidity and
Parity:

G PFPAL: # Full term, # Preterm, # Abortions, # Live births

The Gravida-Para Notation
G – gravida-number of pregnancies
P – para-outcome of pregnancies
F = full-term > 37 weeks’ gestation
P = premature
A = abortion < 20 weeks (induced or spontaneous)
L = live births

Examples:
G2P1011 2 pregnancies, 1 full term delivery, 0 preterm deliveries, 1 abortion,
1 living
G3P3003 3 pregnancies, 3 full-term deliveries and all living
G5P2032 5 pregnancies, 2 full term deliveries, 3 abortions, 2 living
G4P3205 4 pregnancies, 3 full-term deliveries, 2 preterm deliveries, 5 living
(prem = twins)
G3P3002 3 pregnancies, 3 full term deliveries, 2 living (1 dec from SIDS)

Breasts (male and female)

lumps or masses, tenderness, nipple discharge, pain, tenderness, self-breast examination

Lymphatic/Hematologic
any palpable lymph nodes, bruising, bleeding easily, blood clots

Musculoskeletal
weakness, paralysis, joint stiffness and pain, joint swelling, limitation of movement, back pain,
muscle cramps, deformities

17
Vascular
pain in the legs while walking, swelling of the legs, varicose veins, cool extremity, loss of hair
on legs, ulcers, change in skin color

Neurological
fainting, dizziness, history of head trauma, loss of consciousness, paralysis, and memory
changes, tremors, unsteady gait, hallucinations, disorientation, headaches

Endocrine
increased thirst, weight changes, goiter, heat or cold intolerance, flushing, sweating, truncal
obesity

Psychiatric
depression, mood changes, anxiety, problems with attention, hallucinations, suicidal ideas or
attempts

NOTES

18
 SKIN
(Bates 12th edition pp 173-213)

History questions:

 Timing of the onset of rash or lesion

 Duration
 Itching or pain
 Size and color changes
 If had before and if so, previous treatment
 Exposures
 Occupation
 Drugs, medications, or supplements used

Exam components: (include scalp, hair and nails)

 Color
 Moisture
 Temperature
 Texture
 Mobility and turgor
 Lesions

Describing skin lesions

Use these descriptors when documenting skin lesions

 Location and distribution

 Erythema or none
 Surface characteristics and palpation
 Type of lesion – deep palpation
 Color
 Borders and shape
 Arrangement of lesions
 Special sites – scalp, nails, genitalia

ABCDE’s of suspicious nevi (moles)

A: Asymmetry
B: Borders
C: Color
D: Diameter
E: Elevation

19
Primary Skin Lesions

20
21
Secondary Skin Lesions – the result of scratching, picking or healing of primary
lesions

Other Lesions

22
Other

Blanching vs. Nonblanching: hemorrhagic lesions and non-vascular lesions do not blanch. Vascular
(inflammatory or congenital) lesions do blanch.

Sample Documentation:

Example normal: Skin: color pink, skin warm and dry. Nails without clubbing or cyanosis. No
suspicious nevi. No rashes, petechiae or ecchymoses noted.

Example abnormal: Skin: color pink, Nails without clubbing or cyanosis. There is an irregularly
shaped 5mm dark brown macule on the dorsal aspect of the left forearm. Scattered 1-2 mm cherry-
red papules over the chest and abdomen consistent with hemangiomas. Lower right lip and
umbilicus with piercings. 10-inch tattoo of butterfly on the posterior aspect of the left shoulder.

23
 Student Handout: Dermatology Exam Lab
General If Indicated…
Inspection:
 Buccal mucosa (color, lesions)
 Conjunctiva (color, lesions)
 Skin (color, moisture, tem-
perature, texture, mobility
and turgor, lesions)
 Nails (color, shape)
 Hair (quantity, distribution, texture)
Palpation
 Scalp and Hair
 Fingernails
 Toenails
 Skin

Agenda:
1. Complete a general skin examination on your partner, inspect and palpate; include the hair,
scalp and nails.
2. Try to find and describe at least 5 skin lesions on the members of your group. Note size,
location, distribution, color, shape and borders, surface characteristics and palpation,
arrangement of the lesions.
3. Locate and identify the lesions on the body map provided.
4. Optional: Do a skin scraping and KOH prep at the station in the front of the lab.
5. Complete the worksheet and body map, review with your preceptor and have it signed off to
receive credit for the lab.

Questions:
1. Describe these lesions:

2. Describe this lesion:

24
 3. Match the following:

_____ Macule A. Flat, > 1 cm

_____ Patch B. Solid elevation, < 1 cm
_____ Plaque C. Elevated, > 1 cm
_____ Vesicle D. Flat, < 1 cm
_____ Papule E. Elevation with clear fluid, < 1 cm

4. Label these lesions:

Worksheet for Dermatology Lab

General skin exam-include hair and nails

Color

Moisture and Temperature

Texture

Mobility and turgor

Lesions

Identifying Skin Lesions - describe and name the lesion

1.

25
2.

3.

4.

5.

26
NOTES

27
 Vital Signs
(Bates 12th edition pp. 123-138)

Temperature
Use thermometer and verbalize results. Oral, rectal, axillary and external ear canal are sites where
temperature can be obtained either with a glass thermometer OR an electronic device. Make sure to
measure the temperature for the appropriate amount of time for the particular device and location
you are using.

Average normal temperature= Fahrenheit:98.6oF and Celsius: 37oC

Pulse
Palpate the radial pulse over the distal radius with index and middle fingers. Count the number of
pulses for 15 seconds and then multiply x 4 to get beats per minute (bpm).

State the rate (bpm) and pattern of the pulse as regular or irregular.
Normal = 60 – 100 bpm and regular.
Less than 60 bpm = bradycardia
Greater 100 bpm = tachycardia

Respirations
Count the number of respirations for 30 seconds than multiply x 2 to get the number of respirations
per minute. Hint: watch the chest rise to count the respirations while also still holding the patient’s
wrist when taking a pulse. This is so the patient doesn’t know you are watching their breathing and
changes the rate.

A variety of respiratory patterns can be identified as regular or irregular, fast, slow, deep or shallow,
labored with or without use of accessory muscles, or not breathing

State the rate (bpm) and pattern of the respirations

Normal = 12-20 breaths per minute
Less than 12 breaths per minute = bradypnea
Greater 20 breaths per minute = tachypnea
Periods of no breathing= apnea
Irregular breathing with intermittent increased and decreased rates and periods of apnea
=Cheyne-Stokes breathing
Rapid deep breathing (hyperventilation) from metabolic acidosis=Kussmaul’s respirations

Height, Weight, and Body Mass Index:

Weigh the patient on the same scale, with shoes off, during each Classification Range
visit. Height is also measured with shoes off. The patient’s height Underweight < 18.5
and weight is needed to calculate the body mass index (BMI). Normal 18.5 – 24.9
Overweight 25 – 30
BMI = weight in kg ÷ height in m2
Obese > 30

28
 Pulse Oximetry
This measures the proportion of oxygenated hemoglobin in the blood. Simply insert the patient’s
finger into the device and record the reading. Typical devices will also display the pulse rate as well.
If the patient is wearing nail polish on the fingernails, can check pulse ox using a toe. If there is nail
polish on both fingernails and toenails, and patient objects to removing it with acetone, then can use
an earlobe.

Blood Pressure
Apply the BP cuff

Be sure the cuff is the correct size for the patient’s arm. The cuff should be snug enough not
to slip off the arm but examiner can slide one to two fingers under the cuff.

Stand to the side of the patient and cradle the patient’s slightly flexed arm between your elbow
and waist. This technique leaves both of your hands free and allows the patient to relax their
arm, in addition to keeping the arm at heart level.

Place the cuff approximately one inch above the antecubital fossa with the arrow on the cuff
pointing to the artery.

Palpate the brachial pulse

Place the pads of the fingers over the antecubital fossa and medial to the biceps tendon to
palpate the pulse.

Obtain a palpatory systolic blood pressure

Monitor the brachial or radial artery with your fingers. Pump the cuff 20-30mmHg above the
pressure at which the artery no longer has a palpable pulse. Slowly deflate the cuff, noting
the pressure on the sphygmomanometer that is associated with the reappearance of a
palpable pulse. Then rapidly release the valve and the pressure from the BP cuff. Verbalize
your results.

Obtain an Auscultatory blood pressure with the stethoscope

Re-inflate the BP cuff 20-30 mmHg above the palpatory pressure. Hold the arm at the level of
the heart. Place the diaphragm OR bell of the stethoscope over the brachial artery and
release the valve slowly while listening. Note the pressure when the first sounds appear
(systolic blood pressure SBP) and when the sounds disappear (diastolic blood pressure DBP)

Category Systolic BP Diastolic BP

Normal <120 <80
Elevated 120-129 80
Stage 1 Hypertension 130-139 80-89
Stage 2 Hypertension >140 >90

(From ACC/AHA new blood pressure guidelines 2017 www.acc.org)

29
 Orthostatic Blood Pressure
This is a series of two blood pressure and pulse readings to determine if there is a significant
difference when the patient changes position. A blood pressure and pulse are obtained from the
patient in lying position. They should have been lying down for 5 minutes. With the BP cuff still on
the patient, have the patient either sit or stand and repeat a blood pressure and pulse reading after 1
minute.

It is considered a positive test or orthostatic change if:

 SBP drops 20 mmHg or more, OR

 DPP drops 10mm or more, OR
 HR increases 15 beats per minute or more

Example:

Lying flat 5 minutes BP 159/90 HR 120

Seated 1 minute BP 146/80 HR 130
Standing 1 minute BP 128/90 HR 140

This can be due to volume depletion. These include fluid loss and dehydration, blood loss or failure
of adaptive reflexes to compensate for a change in position. Normally, the blood pressure and heart
rate will rise slightly as a natural response to a change in position from supine to sitting or standing.

NOTES

30
 General Assessment and Physical Exam Overview
(Bates 12th edition pp. 111 – 123)

General Assessment
The general assessment or survey should be the start to any physical examination of a patient, no
matter how brief or comprehensive and is an important part of the examination. The general
assessment should give the examiner an overall picture or “feel” for the patient regarding medical
stability.

Apparent State of Health

Try to make a general judgment of the patient’s general health based on observations made
throughout the encounter.

Level of Consciousness (LOC)

Is the patient awake, alert and responsive? Is the patient lethargic, difficult to arouse, or
comatose?

Signs of Distress
Does the patient look comfortable or uncomfortable? Any signs of pain, cardiac or respiratory
distress, anxiety or depression, etc.?

Body Habitus
Is the patient underweight or overweight? Emaciated or morbidly obese?

Skin Color and Obvious Lesions

Is the skin pale, blue, red, black, or any other color? Is the color of skin usual for ethnicity?
Are there any obvious scars, moles, or rashes?

Dress, Grooming and Personal Hygiene

Does the patient appear appropriate or inappropriate for the situation?

Facial Expression
Observe during conversation and the examination.

Posture, Gait and Motor Activity

Observe the patient’s posture and gait. Any balance issues? Any involuntary movements?

Odors of Body and Breath

Can be important diagnostic clues.

31
 Overview of Physical Examination Techniques
During this lab session, practice the general concepts of Inspection, Palpation, Percussion and
Auscultation. All of these skills need to be practiced and mastered. (These are essential steps to
do in each examination. There may be times when all 4 steps are not used but it is important to
remember thinking of doing these when possible!)

Also, during this lab session, become familiar with the diagnostic equipment.

Techniques

Inspection

Describe your visual findings in respect to the physical examination; such as chest, abdomen
or extremities. Try to verbalize findings to your partner; it may not be as easy as you think!!

Palpation

Use one and two hands to gently push down and make concentric circles over the skin in an
effort to feel below the skin. There is shallow and deep palpation. Try closing your eyes, does
this help? Imagine the anatomy under your hands. Be gentle!!!

Percussion

Make solid contact with the hand contacting the skin.

Use your dominant hand (2nd and/or 3rd fingers) to tap on the shaft of the third finger of the
other hand to produce a sound. Watch the wrist action, it is like “throwing a dart”.

Auscultation

Place the stethoscope properly in ears and listen for heart, lung and abdominal sounds using
the bell AND diaphragm. Do you hear a difference between to two sides of the stethoscope
head?

Diagnostic Equipment

 Stethoscope
 Sphygmomanometer (Blood pressure cuff)
 Otoscope
 Ophthalmoscope
 Panoptic Ophthalmoscope (optional)
 Reflex hammer
 Tuning forks
 Eye charts

Samples of General Assessments:

Very pleasant, cooperative, healthy-appearing male in no acute distress, well developed and well
nourished, good hygiene, seems to be somewhat uncomfortable due to his shoulder pain, skin is

32
normal color and without any obvious lesions, can ambulate without difficulty.

This is an obese white female, in moderated distress secondary to being short of breath, she is well
groomed, appears older than stated age, clothing somewhat disheveled, gait is slow and cautious.

The pt appears sad and fatigued; clothes are wrinkled. Speech is slow and words are mumbled.
Thought processes are coherent but insight into current life events is limited. The pt is oriented to
person, place and time.

Student Handout: Vitals and GA Lab

General If Indicated…
Palpatory Blood Pressure

Auscultatory Blood Pressure Orthostatic Blood pressure

Heart Rate

Respiratory Rate

Height and Weight

Pulse oximetry

Agenda:
1. Take history from your preceptor on reason for visit.
2. Take vitals on your lab partner and DOCUMENT:
a. Temperature: (estimate)
b. Ht. (verbal)
c. Wt. (verbal)
d. BMI (calculate or use a chart)
e. Pulse (count for 15 second and multiply by 4), then
f. Respirations (count for 30 seconds and multiply by 2)
g. BPs (check both palpatory systolic and then ausculatory systolic and diastolic BP)
h. Pulse Ox %
i. Orthostatic ausculatory blood pressures, minimum of 2 positions
3. Collect data on the 9 components of the General Assessment (refer to your lab manual for
assistance).
a. Apparent state of heath
b. Level of consciousness
c. Signs of distress
d. Body habitus
e. Skin Color and obvious lesions
f. Dress, grooming and hygiene
g. Facial expression
h. Posture, gait, and motor activity
i. Body and breath odor
4. Perform a general skin exam and then a focused skin exam on the patient’s complaint.
33
Questions:

1. Why is a palpatory BP performed?

2. In what settings would you need to check an orthostatic BP?

3. What items would go on a problem list for this patient?

Note:
 Due Friday at 5 pm
 Full history
 Comprehensive ROS
 Vitals (record vitals on your lab partner)
1. Detailed General Assessment:
2. Apparent state of health
3. Level of Consciousness
4. Signs of Distress
5. Body Habitus
6. Skin Color and Obvious Skin Lesions
7. Dress, grooming and hygiene
8. Body and Breath Odor
9. Facial Expressions
10. Posture, gait, and motor activity
 Skin Exam
 Osteopathic exam:
 Assessment:
1. CC: __________________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of __________________________
 Plan
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

34
NOTES

35
 HEENT and Neck
(Bates 12th edition pp. 242-266)

During this laboratory session, the student will perform a complete head, ear, nose, paranasal sinus,
throat and neck examination on their partner and apply the diagnostic reasoning behind each part of
the examination.

History:

 Headache
 Change in vision: blurred vision, loss of vision, floaters, flashing lights
 Eye pain, redness or tearing
 Double vision
 Hearing loss, earache, ringing in the ears
 Dizziness and vertigo
 Nosebleeds (epistaxis)
 Sore throat, hoarseness
 Swollen glands
 Goiter

Exam components:

 Inspection
 Palpation
 Percussion
 Auscultation
 Otoscopic Exam

Head
The examination of the head consists of:

 Inspection
 Palpation

Inspect
Describe the head, scalp and hair. Record any asymmetry, scalp lesions, patterns of alopecia,
texture and distribution of hair.

Palpate

Palpate the head and the scalp. Note any deformities, asymmetry, masses or tenderness.

Sample Documentation:

Head: Scalp symmetric without deformity, nodules or tenderness, hair distribution even, face with
good symmetry, skin without discoloration, warm and without lesion, no tenderness to palpation over
the sinuses.

36
 Eyes
Please refer to chapter 8: Eye Exam. (We will address this in a separate lab session)

Sample Documentation:

Eyes: inspection: no asymmetry or discharge, periorbital palpation non-tender, pupils equal, round
and reactive to light. Extra-ocular muscles intact.

Ears
The examination of the ear consists of:

 Inspection and palpation of the external ear structures

 Auditory acuity testing
 Otoscopic examination

Inspect and palpate the external ear structures.

Inspection

Look at the pinna and post auricular skin. Look for symmetry of the ear alignment on the
head and for size and contour of the ears. Observe for swelling, redness, skin lesions,
deformities, nodules, discharge, etc. on the external ear structures.

Palpation

Note any pain elicited by gently pulling on the pinna or pressing on the tragus (possible sign of
an external ear infection). Palpate for anterior nodules. Palpate the mastoid bone and pre and
post auricular lymph nodes for tenderness or enlargement.

Auditory Acuity Testing

Evaluation of CN VIII

Ask the patient to occlude one ear and in the other ear the examiner either whispers a few
words or can rub together the patient’s hair next to the unblocked ear, asking the patient to
indicate when and what is being heard. This is usually documented as “hearing intact” or
“auditory hearing intact”.

The Weber test

This test is useful in conjunction with the Rinne Test to determine whether a unilateral hearing
loss is conductive or sensorineural in origin.

Procedure
Place a vibrating 256 Hz or 512 Hz tuning fork on the midline of the patient’s scalp and
ask the patient to indicate the ear in which the sound is heard the loudest. Do not use
your 128 Hz tuning fork (why?).

A sensorineural hearing loss the sound will lateralize to the unaffected or

37
 undamaged ear. In other words, the sound goes away from the side of the
sensorineural loss because “the good ear hears better”.

A conductive hearing loss the sound will lateralize to the affected or damaged ear. In
other words, the sound will go to the side of the conduction defect because the
surrounding noise is not heard as well in the damaged ear and this produces a
sensation of a louder bone conduction, thus “the bad ear will appear to hear better”.

The Rinne test

This test is based on the fact that air conduction, the usual route of sound conduction, is more
efficient than bone conduction in which the vibration of the skull directly stimulates the
cochlea.

Procedure
Firmly place the handle of a vibrating 256 Hz or 512 Hz tuning fork on the mastoid
process of the ear being tested. Have the patient indicate the moment they can no
longer hear the sound being generated by the tuning fork on the skull. Then remove the
tuning fork from the mastoid process and place the still vibrating tines of the fork near
the patient’s external canal. Ask the patient if they can still hear the sound. Normally,
air conduction can be heard after bone conduction no longer can be heard. This is
written AC > BC.

Conductive hearing loss

will make bone conduction greater than air conduction, reversing the normal pattern.
This is written BC > AC.

Sensorineural hearing loss

produces decreased auditory acuity due to impaired inner ear or cochlear nerve
impulses regardless of how the vibrations reach the cochlea.

Otoscopic Examination
With the use of the otoscope, the examiner will evaluate the external auditory canals and the
tympanic membranes.

External auditory canal (EAC)

The EAC curves and ends in a forward and downward position towards the tympanic
membrane. Describe any EAC canal redness, swelling, tenderness, skin lesions, cerumen
impaction, foreign bodies or discharge.

Tympanic membrane (TM)

Visualize the TM and describe:
 Color of the membrane
 Translucency or opacity
 Normal landmarks, i.e., cone of light
 Injection, i.e. increased blood vessels
 Integrity of the membrane
 Bulging or retraction of the membrane
 Any movement with insufflation bulb?

38
 Use of the Otoscope:

1. Put the largest speculum (otoscope tip) that fits comfortably into the patient’s ear onto
the otoscope.
2. Turn the light on by compressing the small button and turning the ring around the top
part of the handle of the otoscope.
3. Use your free hand to straighten the ear canal by pulling the helix of the ear gently up,
out and back. (In children pull the helix down and back)
4. With your other hand put the lighted scope into the ear in a direction that angles down
and towards the nose.
5. There are two hand positions for holding the instrument: handle up towards the sky, or
handle down with the thumb and index finger directing the instrument. The facilitator
will demonstrate both.
6. Protect the patient from injury to the
eardrum by ALWAYS BRACING with two
hands!!!
7. Try to look first at the external ear canal (EAC)
and then at the eardrum (tympanic
membrane=TM). There should be a cone of
light visualized on the anterior inferior
quadrant of the TM. Can you identify or name
any other structures on the TM?
8. The pneumatic insufflator can be attached,
squeeze the bulb and see if the TM moves,
which is a normal finding. If no movement is
seen, the patient may have fluid or infection
behind the TM. There also will be no
movement if the TM is perforated.

Sample Documentation:

Ears: Pinna normal size, symmetry and architecture. Non-tender to palpation without mass or
Preauricular adenopathy. Canals fully patent and without lesion. TM gray, well-shaped without
perforation and moves normally to insufflation. Hears finger rub bilaterally, “Weber is Midline” or
Weber without localization, Rinne AC>BC bilaterally.

Abnormal: The sound lateralizes to one ear.

Nose and Paranasal Sinuses

Examination of the nose and paranasal sinuses consists of:

 External inspection
 Palpation
 Olfaction (CN I)
 Internal examination
 Percussion and Transillumination of the sinuses

39
External Nasal Examination

Inspection and Palpation of the nose

Inspect the external nose for any swelling, trauma, or congenital abnormalities.
Is the nose midline or deviated? Inspect the openings of the nares for any discharge, lesions
or rashes. Palpate the nose for any tenderness or deformities.

Patency of the nares

Gently occlude one naris at a time and evaluate for patency of each naris by asking the
patient to sniff.

Olfaction (CN I)
Evaluate olfaction by the ability to recognize a common scent such as coffee, vanilla or cinnamon.

Internal Nasal Examination

The key to the internal examination of the nose is proper position of the head by tilting
the patient’s head back into a “sniffing position.” Gently lift the tip of the nose with your thumb
and using an otoscope with the largest speculum, look almost straight back to visualize the
intranasal structures.

Identify the nasal septum (medially) and the nasal turbinates (laterally). Comment on the
mucosal color (i.e. – pale, pink or red, moistness, any mucosal bleeding, polyps, discharge,
swelling or trauma).

Evaluate the nasal septum for any deviation, narrowing or perforations; and the nasal
turbinates (inferior and middle are usually visible) for discharge (purulent, watery, cloudy,
bloody, etc.) and mucosal characteristics.

Sample Documentation:

Nose: Nose is symmetric without swelling, deformity or tenderness. Nares patent bilaterally without
septal perforation, or septal deviation, clear discharge, pink mucosa, turbinates are without swelling,
no polyps visualized.

Palpation and/or percussion of the paranasal sinuses

Press or percuss with the 2nd /3rd digits over the areas of the frontal and maxillary sinuses to
elicit any tenderness or bogginess (which may indicate a
sinus infection or inflammation).

Transillumination of the sinuses

This examination is done in a darkened room. Usually, if there is fluid, mucosal thickening or
mass, there may be a decreased glow of light on that side.

Maxillary sinuses
using a bright light source (penlight, otoscope head or trans-illuminator), direct the light
downward from under the medial aspect of the eye. Ask the patient to open their mouth

40
 and observe the glow in the hard palate. An alternative method, the light can be
directed from inside the mouth upward on the hard palate.

Frontal sinuses
using a bright light source as above, shine the light upwards from the medial aspect of
the eyebrow and observing the glow above the eye.

Throat and Oral Cavity

Examination of the nose and paranasal sinuses consists of:

 Inspection
 Palpation

Lips
Inspect lips and describe color, any lesions, bleeding, etc.

Oral Cavity

Inspection: Examine with a light source and tongue depressor.

Mucosa
Evaluate for any lesions, color changes or white patches, injection, swelling, papules,
ulcers, erosions, painful areas and hemorrhages (petechiae).

Teeth and Gums

Check state of dentition, receding gums, malformation or discoloration of teeth, caries,
hygiene, etc.

Tongue
Can be describe as geographic or smooth. Are there any lesions, color changes,
ulcers, masses, etc.? The tongue should be pale pink, glistening, moist and without
growths or lesions.

Uvula
Should be midline and without deviation. Same color as the palate.

Posterior Pharynx
Tonsils present or not, redness, nasal drainage, exudates, injection, swelling, ulcers,
erosions and other changes similar to the mucosa exam.

Hard and Soft Palate

Evaluate for any ulcerations, masses, plaques, hemorrhages (petechiae), etc.

Stenson’s ducts
Visualize the dimple and opening opposite the 2nd upper molar on the buccal mucosa.

Floor of the mouth

Ask the patient to elevate the tongue to the roof of the mouth so the examiner can

41
 visualize under the tongue

Observe soft palate as patient says “ah” (CN IX & X)

Symmetrical elevation of the soft palate in the midline as the patient says “ah”
demonstrates normal coordinating function of CN’s IX & X. Phonation is also a function
of CN X which is tested simultaneously as the patient says “ah”.

Abnormal finding
The soft palate will not elevate symmetrically and the uvula will be pulled to the
opposite side of the cranial nerve lesion or palsy because the weak or non-
functioning side is unable to pull with equal force.

Gag Reflex (CN IX & X)

Gently and quickly touch the posterior tongue to illicit the gag reflex.
Symmetrical elevation of the soft palate and uvula indicates an “intact gag reflex”.
Sensation is provided by CN IX and the motor response is provided by CN X.

Tongue Protrusion (CN XII)

Observe the tongue for fasciculation/tremor while the tongue rests on the floor of the
mouth. Observe the position of the tongue as the patient is asked to “stick out” their
tongue. Midline protrusion of the tongue indicates intact hypoglossal
nerve (CN XII). A weakness of CN XII on one side will cause the tongue to deviate to
the side of the lesion.

Palpation:
Tongue
Ask the patient to stick out their tongue and gently grasp the tongue with an unfolded
gauze wrapped around it. The tongue is palpated gently with the gloved fingers of the
free hand with special attention given to the lateral sides of the tongue. The lateral
margins of the tongue are palpated carefully because the
majority of lingual cancers are found in this area.

Floor of the Mouth

Ask the patient to elevate their tongue to the roof of the mouth. The examiner then
palpates the floor of the mouth. Masses/tumors, fullness and stones in the
ducts can be found using this technique.

Wharton’s ducts: located on either side of the frenulum at the base of the tongue.
This is done by placing a gloved finger under the
tongue and palpating the entire floor of the mouth
for lesions, masses, tenderness, swelling, etc.

Stenson’s ducts: Palpate the opening of

Stenson’s ducts and the parotid glands bilaterally
for any tenderness or enlargement.

Sample documentation:

oral mucosa pink, dentition good, tongue midline, pharynx

without exudates.

42
 Neck
Inspection:

Inspect the position of the patient’s head over the neck. The head is typically held symmetrically over
the shoulders. Check for swelling, scars or masses. Note any enlargement of thyroid gland.

Palpate:

Lymph Nodes

Palpate cervical lymph node chains and evaluate lymph nodes for size, tenderness, mobility,
consistency and symmetry. Describe your findings. Normally, lymph nodes should not be
palpable or fixed. Palpate the following chains:

Pre auricular
in front of the tragus; drains face auditory canal, conjunctiva

Post auricular
behind the ear, above the mastoid process; drains the scalp and auditory canal

Tonsillar
at the angle of the jaw; drains face
and oral cavity

Submandibular
below and in front of the angle of
the mandible; drains lower jaw and
teeth

Submental
under the chin; drains lower face
and floor of the mouth

Occipital
base of the skull; drains posterior
skull

Anterior cervical
at the angle of the jaw with a chain along anterior border of SCM to clavicle; drains
face, tonsils and pharynx

Posterior cervical
located beneath the posterior margin of the SCM with a chain going down to posterior
base of neck; drains posterior scalp, ear, skin of posterior neck

Supraclavicular
lies deep and behind the clavicles; drains thorax, abdomen, arms, breasts, cervical
chain.

43
Thyroid Gland

Inspection

Evaluate the thyroid for enlargement and symmetry.

Palpation

Evaluate the thyroid gland for size, consistency, tenderness, and nodules. If the thyroid gland
is enlarged (goiter) or tender, consider auscultation over the lateral
lobes with a stethoscope to detect a bruit, which occasionally is heard with
hyperthyroidism. The thyroid may be small or not palpable in the elderly from
atrophy, or individuals on thyroid hormone replacement which creates feedback to the gland
that internal production is no longer needed shrinking the gland.

Anterior approach:
The examiner stands in front of and facing the patient and flexes the patient’s neck
slightly forward to relax the SCM muscle. The examiner’s left hand should displace the
larynx to the left. The examiner then palpates the consistency and configuration of the
left thyroid lobe with and without swallowing. The examiner palpates the full length of
the left lobe using the fingertips of the right hand. The hands are reversed and this
technique is repeated for examining the right lobe.

Posterior approach:
The examiner stands behind the seated patient,
placing their hands around the patient’s neck,
which is slightly extended. The examiner correctly
positions his/her fingers and systematically
palpates both lobes of the thyroid with and without
swallowing. The examiner gently pushes the
trachea to one side with the fingers of one hand
and palpates the thyroid gland with the fingers of
the other hand. This maneuver is repeated for
both sides of the thyroid.

Trachea
The examiner can place the tracheal cartilage between the thumb and 2nd /3rd fingers and
gently move it side to side to test if it is fixed to the surrounding neck structures or freely
moveable.

Thyroid and Cricoid cartilage

After locating the thyroid cartilage, palpate just inferior to locate the cartilage of the cricoid.
Take notice of the space or indentation between the thyroid and cricoid cartilage. It is this
space that is used for an emergency airway (tracheotomy) if there is an obstruction above this
level.

Sample Documentation:

Neck: neck structures symmetric to inspection, trachea midline, thyroid lobes symmetric, non- tender
44
and without nodules. No dysphagia. No anterior/posterior cervical, occipital, pre or post auricular,
submental, tonsillar, submandibular or supraclavicular lymphadenopathy.

Student Handout: HEENT Exam Lab

General If Indicated…
Inspection: hair, scalp, skull, face, skin, lash- Inspection
es, eyebrows, eyelids, sclera, cornea, pupil,  TMJ
drainage, swelling, nasal symmetry or devia-
tion, pinna, lobe symmetry, size, lips, oral mu-
cosa, teeth, tongue, uvula, hard/soft palate,
floor of mouth, posterior oropharynx, tonsils
Palpation: nodules, hair texture, scalp or facial Palpation
tenderness, lymph nodes, periorbital tender-  Sinuses
ness, nasal tenderness, teeth (do with gloves),  Transillumination
buccal mucosa, floor of mouth, tongue, tra-  Trachea
chea, thyroid  TMJ
 Head and face
 Lymph Nodes
 Thyroid with swallow
Otoscopic Ear Exam: canal, TM, insufflation Gross Hearing
 Finger Rub or whisper test
**proper bracing!**  Weber
 Rinne
Insufflation
Eye Vision
 Pupil light reflexes  Peripheral fields
 EOMI  Visual acuity
 Fundoscopic exam
Otoscopic Nose Exam: patency, septum, dis-
charge, mucosal color, turbinates, polyps,
Transillumination in dark room

** proper bracing!**

Oral Exam:
 Light
 Tongue blade
 “Say Ah”
Osteopathic:

Questions:

1. Which of the findings below create the need to perform a Rinne test?
a. History of hearing loss that is worse is one ear vs the other
b. History of an etiology that would cause sensorineural loss
c. History of an etiology that would cause conductive loss
d. When Weber lateralizes

45
 2. For each of the following findings, describe how to perform the test and what your results
would be that match the finding: (use the attached chart)
a. Bone conduction is better than air conduction

b. Weber lateralizes to the left ear

c. You determine a sensorineural loss in the right ear

Weber lateralizes Rinne test

Conductive loss
Good ear Worse sound/Softer AC > BC (positive/nl
test)
Bad ear Better sound/Louder BC > AC (negative/abn
test)
Sensorineural loss

Good ear Better sound AC > BC (positive test)

AC > BC (positive test)

Bad ear Worse sound

Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Detailed HEENT exam
 Osteopathic exam
 Assessment:
1. CC: __________________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of __________________________
 Plan
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

46
NOTES

47
 Eyes
(Bates 12th edition pp. 226-242)

During this laboratory session, the student will perform a complete eye examination on their partner
and apply the diagnostic reasoning behind each part of the examination.

History:

 Change in vision
 Blurred vision
 Loss of vision
 Floaters
 Flashing lights
 Eye pain
 Redness or tearing
 Double vision
 Corrective lenses

Exam components:

1. Inspection
2. Visual acuity
3. Visual fields
4. Extraocular movements
5. Pupillary response
6. Fundoscopic examination

Inspection
Inspect and evaluate the eyes and periorbital structures which include:

 Position and alignment of the eyes

 Eyebrows
 Eyelids
 Lacrimal apparatus
 Conjunctiva and sclera
 Cornea and lens
 Anterior chamber
 Iris and Pupils

Visual Acuity
This can be completed by using the Snellen eye chart viewed at 20ft (distant vision) from the patient
and/or with a pocket-sized eye chart (i.e. Rosenbaum) viewed at a distance designated on the card
(near vision).

The patient is instructed to cover the untested eye and then read the smallest line that is clear to
him/her and must identify at least half the letters. Repeat the procedure for the other eye and for
near and far vision if indicated. Record your results (e.g., 20/40). The first number indicates the
distance the patient is from the chart; the second number indicates the distance at which a normal

48
eye could read the chart.

For near vision and holding a hand held chart 14 inches, the visual acuity nomenclature is adjusted
for the distance. Visual acuity should be tested with and without corrective lenses if the patient uses
them.

Visual Fields
Visual fields are screened and evaluated by “confrontation testing”, which means the patient is tested
against the examiner’s own visual fields.

The examiner should stand about 2 feet in front and at eye level with the patient. Ask the patient to
cover or close an eye (i.e.-right) while the examiner does the same with the opposite eye (i.e.-left).
The examiner can wiggle their fingers as the fingers are brought into the patient’s arc of vision
starting at the four quadrants (right upper, right lower, left upper, left lower). The examiner’s testing
hand is initially placed at the most lateral aspect of the patient’s arc of vision and is slowly brought
inwards until the patient visualizes the fingers in their peripheral vision. The examiner asks the
patient to tell the examiner when the fingers are first visualized. This procedure is repeated on the
opposite eye. Any discrepancy between the examiner’s visual fields and the patient’s is recorded.
(We must assume the examiner has normal visual fields).

A defect in the visual fields using confrontation method could be recorded effectively by the use of
this simple diagram. Shade in the area(s) that cannot be visualized by the patient. OS=left eye,
OD=right eye, OU=both eyes.

Extraocular Movements
Extraocular movements (EOM)

Note: (LR6SO4 the rest are CN3)

Tests CN III, IV and VI. With the patient’s head straight and steady (the examiner may need to hold
the patient’s chin), have the patient follow the examiner’s finger or light source as the examiner
traces a large a large “H”. Look for nystagmus at the extreme limits of gaze, especially lateral and
vertical gaze and ask the patient to report any diplopia (double vision) to ensure minor abnormalities
will not be missed.

49
Isolated muscle function testing vs anatomic use of muscle from neutral:

Right Eye Right Eye

Function Testing (EOM) Anatomic Movement

For example:

When moving the eye from a neutral position (looking straight forward) to up and out (superior
and lateral gaze) the inferior oblique (IO) is the major muscle involved in accomplishing this
movement. BUT, to single out and test the integrity of the superior rectus (SR), you need to
immobilize the inferior oblique function by moving the globe completely laterally then asking
the patient to follow your finger superior. This will test the integrity of the superior rectus, NOT
the normal function of the inferior oblique.

Be able to identify the cranial nerve dysfunction corresponding to the isolated muscle
dysfunction.

This is normal muscle function from a neutral position and the corresponding cranial nerve.

Convergence
Ask the patient to follow your finger or light source as the examiner moves it towards the bridge of
the nose. Normally, the eyes should converge and follow the object within 5-8 cm of the nose.

Pupillary Responses
Pupillary response to light

Have the patient fixate on a distant point or object while shining a light source from the temporal
aspect of the eye. Observe and note both the direct and indirect (consensual) pupillary response of
each eye. Repeat the maneuver on the opposite eye. The normal response would be the constriction
on the pupil in each eye.

Accommodation
Ask the patient to focus on a distant object in the room and then focus on an object (finger or pen) 4-
5 inches from the eye. A normal response is a constriction of the pupils.

50
 The Fundoscopic Examination
The Parts of the Ophthalmoscope: (traditional head)

There are two dials for adjustments:

1. Dial on the front of the ophthalmoscope head: Light aperture and filter.
 The smaller light aperture size with white light is used for un-dilated pupil.
 The red-free filter (looks green) excludes red light and allows the doctor to see
blood vessels and hemorrhages better because they appear black with this light.

2. Dial on the side of the ophthalmoscope head: Diopter wheel

 Corrects for refractory errors between the doctor and the patient to get focused on
the back of the retina.
 Always start a “0” and move dial in one direction or the other until the view becomes
focused.
 The red (negative numbers) correct for near-sightedness.
 The green (positive numbers) correct for far-sightedness.

Use of the Traditional Ophthalmoscope Head:

1. Dimming the room lights can assist with the examination. (Do not do this in SP encounters,
however!)
2. Adjust the aperture to be appropriate for your patient’s pupil size in the dark.
3. The examiner and patient can remove glasses because the ophthalmoscope can correct
for refractions. Set the lens diopter wheel to “0”.
4. Ask the patient to fixate on a distant object straight ahead.
5. First, inspect the anterior chamber by casting a light beam from each side and observe for
anterior cloudiness or irregularities.
6. The examiner uses the mirror image eye as the eye being examined on the patient to
avoid nose bumping (right/right and left/left)
7. The examiner holds the instrument right up to his/her brow.
8. Start about 14 inches away and at 20o lateral angle from the patient’s midline.
9. Hold patient’s brow slightly up and shine the light into the patient’s pupil and look for the
red reflex of the retina. The red reflex indicates there is no obstruction of light to the retina.
10. Slowly move in adjusting the diopter wheel to focus on the retina of the eye. Once you
start to see blood vessels, you can adjust the focus with the diopter wheel until everything
in your field of view is focused. Remember a near-sighted examiner will turn towards the
red numbers (negative diopters) and a far- sighted examiner will turn towards the green
numbers (positive diopters) as they try to focus.

Use of the Panoptic head:

1. The un-dilated eye should be examined using the small aperture dial. This can be
accomplished by setting the vertical green line in the midline.
2. The examiner’s eyebrow goes flush up to the flat side of the scope. Use the focus wheel to
focus your panoptic scope on an object at least 10 feet away.
3. The examiner positions themselves about 6 inches away and about 20 degrees on the
temporal side of the patient. Looking through the scope, shine the light on the eye and

51
 observe for the red reflex.
4. Slowly come towards the patient following the red reflex in as the examiner looks into the
pupil.
5. The eye cup must contact the patient’s brow and should be compressed about half way to
maximize the optic view.
6. The examiner then can optimize the view by adjusting the focus wheel as needed. You
will see 5X the field of view.

Structures of the Retina

Optic Disc
Describe the disc in terms of shape, margins and color. The disc should be round, have sharp
borders and be pink to yellow- orange with a center physiologic cup. The cup to disc ratio
should be 1:2 OR 1:3.

Retinal Vessels
The retinal vessels divide into four main branches that supply all four quadrants of the eye
with blood. Arteries are 2/3 to 4/5 the size of veins and have a light reflex, so arteries look
brighter red and thinner. Normally the artery to vein ratio is expressed as 2:1. When
hypertension occurs, A-V nicking or copper wire affect can be observed. Please refer to your
text book.

Macula and Fovea

This is an avascular area of the retina temporal to the optic disc. Ask the patient to look
directly into the light source or use the red filter. Observe for abnormalities such as micro-
hemorrhages and whitish exudates. Most examiners save this maneuver as the last one of the
eye examination.

Sample Documentation:

Eyes are symmetrical, no discharge or lid swelling. Periorbital palpation is non-tender. Visual acuity
20/20 b/l, color vision intact. Visual field testing without defect. Sclera white, conjunctiva pink b/l.
+Red reflex b/l, pupils are 4 mm constricting to 2 mm, equally round and reactive to light and
accommodation. Fundoscopic exam: Disc margins sharp, no hemorrhages or exudates, no arteriolar
narrowing.

Other Tests
Cover test

Also called “Cover/Uncover test”. This technique is used to evaluate the alignment of the eyes.
Should be done on young children to assess for a “lazy eye” diagnosed as strabismus. The patient is
asked to focus on a distant object with both eyes. Each eye is covered and uncovered while the
examiner carefully looks for any movement or deviation of either eye. Without the stimulus of vision,
the covered “weak” eye will either “sneak” inward (esophoria) or outward (exophoria).

Eyelid eversion

This technique looks for imbedded foreign bodies (FB) under the upper eyelid. A clean cotton tipped
applicator is gently pushed and rotated onto the upper eyelid as the examiner takes a clean hand

52
and gently pulls the eyelid upwards to wrap around the applicator. The examiner should have a
sterile cotton tipped applicator available as well as a blue light to help identify and potentially remove
a small FB from the underside of the eyelid of sclera of the eye.

General If Indicated…
Inspection (EYES: symmetry, eye lashes, eye- Inspection
brows, eyelids, color, pupil size and shape,  TMJ
cornea, conjunctiva, swelling, discharge, red-
ness)
Palpation Palpation
 Head and face  Sinuses
 Lymph Nodes  Transillumination
 Thyroid with swallow  Trachea
 TMJ
Otoscopic Ear Exam Gross Hearing (finger rub or whisper test)
 Weber
 Rinne
Insufflation
Eye Vision
Pupil light reflexes  Peripheral fields
Direct  Visual acuity
Indirect  Fundoscopic exam
EOMI
**See chart below for items to learn in lab**
Otoscopic Nose Exam

Oral Exam
Light
Tongue blade
“Say Ah”
Osteopathic exam

Student handout: Eye Exam Lab (from HEENT exam list)

Questions:

1. Describe the significant fundoscopic changes you are examining for in each of these
diagnoses:
a. Diabetes Mellitus

b. Uncontrolled prolonged hypertension

c. HIV/AIDS

53
 2. Describe what 20/40 vision means

3. What major characteristics would you find in your exam of a person with Horner’s Syndrome?

4. What items would go on a problem list for this patient?

ITEM Done in lab

Visual Acuity
Near Vision – w & w/o corrective lenses Far
Vision - w & w/o corrective lenses Color vision
Visual field Testing
By confrontation
Student level with the patient
External Examination Con-
junctiva and sclera Cor-
nea, lens and pupil Ex-
ternal Structures
Extra-ocular movements
Six cardinal directions
Convergence
Pupillary Reflexes Direct/
Indirect response Accom-
modation
Ophthalmoscope Exam
Proper technique of the ophthalmoscope Red
reflex
Identification of retinal structures
Optic disc
Blood vessels
Macula and fovea

Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Detailed eye exam
 Osteopathic Exam
 Assessment:
1. CC: ___________________________
a. (ddx #1)

54
 b. (ddx #2)
c. ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of ______________________
 Plan
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

NOTES

55
 Peripheral Vascular and Lymphatic System
(Bates 12th edition pp. 509-538)

During this laboratory session, the student will perform a complete peripheral vascular and lymph
examination on their partner and apply the diagnostic reasoning behind each part of the examination.

History:

 Abdominal, flank or back pain

 Pain or weakness in the arms or legs
 Intermittent claudication
 Cold, numbness, pallor in the legs, hair loss
 Swelling in calves, legs or feet
 Color change in fingertips or toes in cold weather
 Swelling with redness or tenderness

Exam components:

 Inspection
 Palpation
 Pulses
 Lymph nodes
 Auscultation
 Special tests (if indicated)

Inspection

Look for symmetry of the upper and lower extremities, compare extremity size, edema,
cyanosis, varicose veins, skin color

Palpation

Temperature, edema, nodules, pulses, lymph nodes

Pretibial Edema
Pitting edema occurs when fluid collects in the tissue. By pressing a thumb or finger
firmly against the tissue for a few seconds, a dent can be produced. When the finger is
withdrawn the dent may persist for several minutes.

Scaling edema (0-4)

0 – none
+1 – 2 mm
+2 – 4 mm
+3 – 6 mm
+4 – 8 mm

The examiner starts near the level of the ankle and describes how far the edema
extends proximally. Add location; for example, foot, ankle, pretibial, knee, thigh

56
Sample Documentation

2+ pitting edema noted b/l to the knees

Pulses

Compare and grade pulses bilaterally. Use one or two fingers (index and middle) to palpate
pulses. Look for decreased, increased or absent pulses in the upper and lower extremities. A
normal pulse is reported as 2+. Never examine pulses over clothing or socks. Be sure to
compare each extremity bilaterally and give a 0-4 grade for each pulse. Evaluation of the
peripheral vascular system also includes auscultation of some arteries listening for arterial
bruits.

Grading Pulses

0+ Absent
1+ Diminished
2+ Normal
3+ Increased
4+ Bounding

Clinical Pearl – 5P’s - 5 signs of acute arterial occlusion:

 Pain
 Paresthesia
 Paralysis
 Pallor
 Pulseless

Neck Pulses

Carotid Artery
Gently palpate one carotid artery in order to locate it, then listen for bruits. If no bruits
are noted, proceed to palpate the pulse. Ask the patient to hold their breath while
listening.

**Vigorous palpation of the carotid arteries can stimulate the carotid-sinus reflex and
cause an unwanted drop in blood pressure**

Upper Extremity Pulses

Brachial Artery
Palpate in and above the antecubital fossa of the elbow, just medial to the biceps
tendon and muscle. Palpation of the brachial arteries can be done
simultaneously. Evaluate and compare the strength and timing of the pulses.

Radial Artery
Can evaluate and compare both at the same time by standing in front of the patient and
grasping the patient’s wrists and palpating the radial side of the wrist. Evaluate and
compare the strength and timing of the pulses simultaneously.
57
 Abdominal Pulses

Abdominal Aorta
Palpate for this artery gently and deeply in the mid-abdomen between the xiphoid
process and the umbilicus with both hands. When assessing the width of the aorta,
place one hand on each side of the aorta with palms face down. A normal adult aorta is
about 2-3 cm wide. An aortic aneurysm is a pathologic dilation of the aorta. Auscultate
for aortic bruits with the diaphragm of the stethoscope two inches above the umbilicus.

Renal Artery
Auscultate with the diaphragm the location of the renal arteries. First, find the location
for listening to the aorta (midline, 2 inches above the umbilicus) and then move 1-2
inches laterally to the right and the left of the mid-position to listen for renal bruits. The
renal arteries are not normally palpable.

Femoral Artery
With the patient supine, the examiner can palpate the femoral pulse below the inguinal
ligament midway between the pubic symphysis and the ASIS bilaterally. Evaluate and
compare the timing and strength of the pulse bilaterally. Auscultate bilaterally with the
diaphragm of the stethoscope for femoral artery bruits. A femoral bruit may indicate an
obstruction in the aorto-ilio-femoral vasculature.

Lower Extremity Pulses

Popliteal Artery
This pulse is found in the popliteal fossa posteriorly behind the knee. With the patient
supine and the knee slightly flexed, apply a gentle and firm pressure with the fingers of
both hands into the popliteal fossa. This can be a deep and difficult pulse to palpate.
Vary pressure and position slightly as you search for this pulse.

Dorsalis Pedis Artery

This pulse can be palpated with the examiner’s 2nd and 3rd digits placed on the dorsal
mid-foot just lateral to the extensor tendon of the great toe. The pulse is best felt with
the foot in dorsiflexion. Evaluate and compare both pulses bilaterally.

Posterior Tibial Artery

This pulse can be palpated posterior to the medial malleolus of each ankle. It is best
felt in plantar flexion of the foot.

Lymph Nodes
The examiner should carefully and gently palpate the lymph nodes of the body. If lymph nodes are
noted, the examiner should give a description of the size, consistency, location, tenderness,
presence of local redness or edema and if single or multiple lymph nodes are found.

Palpate and evaluate the following groups of lymph nodes:

Pre auricular:
Anterior to the tragus

58
Post auricular:
Behind the ear, above the mastoid process

Occipital:
Base of the skull

Tonsillar:
At the angle of the jaw

Submandibular:
Below and in front of the angle of the
mandible

Submental:
Under the chin

Anterior cervical:
Along the anterior border of the SCM
to the clavicle

Posterior cervical:
Posterior margin of the SCM with a chain going down the posterior base of the neck

Supraclavicular:
Behind the clavicles

Infraclavicular:
Inferior to the clavicles

Axillary Region:
 Lateral: along upper, medial, humerus
 Central: deep in axilla
 Subscapular: Inferior to central
 Pectoral: inferior to subscapular

Epitrochlear:
Medial aspect of the arm, about 3 cm above the elbow

Inguinal:
 Horizontal Group – anterior thigh below the inguinal ligament
 Vertical Group – near the superior portion of the saphenous vein

Popliteal:
Behind the knee.

59
Special Tests

Adson’s Test
Determines compression of the
subclavian artery seen in thoracic outlet
syndrome by an extra cervical rib or tight
scalenes. To do this test you should feel
the radial pulse and then while continuing
to feel it extend, abduct and externally
rotate the arm. Then have the patient turn
their head either toward or away from the
side being tested. If the radial pulse
diminishes then the test is positive.

Homans’ Sign
Evaluates for deep venous thrombosis of the calf.

With leg relaxed supine or sitting, the patient extends the leg fully.
Firmly and abruptly dorsi-flex the patient’s foot stretching the calf.
Palpation of the calf may also be done at this time but caution
should be taken with palpation as this can dislodge a clot.
Discomfort either with dorsiflexion or with palpation of the
stretched calf is a positive test.

Allen’s Test
Determines whether arterial insufficiency exists in the hand by determining the patency of the
ulnar-radial arch of the hand.

Technique:
The examiner occludes both the ulnar and radial arteries by placing finger pressure
over the arteries at the same time. The patient is asked to pump a fist several times
and then leave it open. The examiner releases pressure over one of the arteries and
observes the patient’s palm color return to its normal color. The maneuver is repeated
with the other artery. If the patient’s hand remains pale after the examiner releases the
pressure occluding one blood vessel, there may be an occlusion of blood flow in the
ulnar-radial arch of that hand. The entire maneuver is repeated on the opposite hand
for comparison. Commonly flow returns faster with the radial artery than with the ulnar
artery.

60
Ankle-Brachial Index Test

Instructions for Measuring ABI

1. Pt. should rest supine in a warm room for at least 10 min before testing
2. Place blood pressure cuffs on both arms and ankles as illustrated, then apply
ultrasound gel over brachial, dorsalis pedis and posterior tibial arteries.
3. Measure systolic pressures in the arms
a. Use vascular Doppler to located brachial pulse
b. Inflate cuff 20 mm Hg above last audible pulse
c. Deflate cuff slowly and record pressure at which pulse becomes audible
d. Obtain 2 measures in each arm and record the average as the brachial
pressure in that arm
4. Measure systolic pressures in ankles
a. Use vascular Doppler to locate dorsalis pedis pulse
b. Inflate cuff 20 mm Hg above last audible pulse
c. Deflate cuff slowly and record pressure at which pulse becomes audible
d. Obtain 2 measures in each ankle and record the average as the dorsalis
pedis pressure in that leg
e. Repeat above steps for posterior tibial arteries
5. Calculate ABI:
 Right ABI = highest right average ankle pressure (DP or PT)/ highest
average arm pressure (right or left)
 Left ABI=highest left average ankle pressure (DP or PT/highest average
arm pressure (right or left)
Site 1st 2nd Average Site 1st 2nd Average
reading reading reading reading
Left Right
brachial brachial
Left DP Left DP
Left PT Right PT

ABI Calculator
Enter values:
Ankle _______Hg
Brachial ______Hg
ABI: ___________

Interpretation:
>0.90 (with a range of 0.90-1.30) =
normal lower extremity blood flow
<0.89 to >0.60 = Mild PAD
<0.50 to >0.40 = Moderate PAD
<0.39 = Severe PAD

61
Sample Documentation:

Extremities are without swelling or cyanosis, varicose veins noted in the bilateral lower extremities,
regular hair pattern, no ulcers, skin texture smooth. Peripheral pulses 2+/4 for upper and lower
extremities, no bruits noted at femoral arteries or aorta. Allen test shows good bilateral collateral
flow. Ankle-Brachial index normal at 0.9, negative Homan’s sign. No lymphadenopathy noted.

Student Handout: PV and Lymph Exam Lab

General If Indicated...
Inspect upper and lower extremities (color,
edema, varicose veins, hair pattern, ulcers)
Palpation
 Edema (grade)
 Skin texture
 Skin turgor
 Skin temperature
 Pulses (grade)
a. Carotid
b. Brachial
c. Radial
d. Popliteal
e. Dorsalis Pedis
f. Posterior tibialis
 Lymph nodes
a. Preauricular
b. Postauricular
c. Occipital
d. Tonsillar
e. Submandibular
f. Submental
g. Anterior cervical
h. Posterior cervical
i. Supraclavicular
j. Axillary
k. Epitrochlear
l. Popliteal
Auscultation (bruits)
 Carotid
 Abdominal Aorta
 Renal arteries
 Iliac arteries
Special Tests:
 Allen test
 Roos
 Adsons
 Ankle Brachial Index
 Homans
 Postural color change

62
Questions:

1. List the arteries you can auscultate.

2. What is the most common diagnosis Roos test supports?

a. What two structures could be affected in a positive Roos test.

3. Your patient has a brachial BP of 146/86 and an ankle BP of 58/42.

a. What is the ankle-brachial index?

b. What disease do you suspect is occurring?

4. You are seeing a patient who is dyspneic, tachypneic, complains of chest pain and has a
PaO2 of 87%. You suspect a pulmonary embolus as the etiology. What findings on the
peripheral exam would you expect to see?

5. What items would you include on a problem list for this patient?

Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Detailed PV and Lymph exam
 Osteopathic exam:
 Assessment:
1. CC: _____________________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of __________________________
 Plan:

63
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

NOTES

64
 Cardiovascular System
(Bates 12th edition pp. 343-354, 373-412)

During this laboratory session, the student will perform a complete cardiac examination on their
partner and apply the diagnostic reasoning behind each part of the examination.

History:

 Chest pain
 Palpitations
 Shortness of breath (dyspnea, orthopnea, paroxysmal nocturnal dyspnea
 Swelling (edema)
 Fainting (syncope)
 Heart disease history, personal or family
 Elevated blood pressure

Exam components:

 Inspection
 Palpation
 Auscultation
 Murmurs

An understanding of the cardiac cycle and cardiovascular anatomy is essential in performing an

accurate cardiovascular examination.

Inspection
Inspection of the anterior chest wall for motion
Normally, the heartbeat causes no visible chest wall motion. Observe and comment if you
visualize heaves or lifts (a forward thrusting of the chest wall). May indicate enlarged
ventricle(s), atria or a ventricular aneurysm.

Inspection of the patient’s skin color, nails, face, eyes, mouth, chest configuration, extremities
(capillary refill) and blood pressure can give you clues to a possible heart or lung condition.

65
 Cyanosis, pectus carinatum or excavatum, plethora, hypertension

Palpation
Palpation of the anterior chest wall

The examiner gently places their hand on the patient’s sternum and left side of the chest
palpating (as well as observing) for any heaves (feels like a lift of the hand). Palpating heaves
represents the same potential pathology as observing it with inspection Then palpate
overeachcardiacvalve for thrills.. Thrills are the vibration made by abnormal valve leaflets and
can be palpated on murmurs graded 4/6 or louder.

Sample Documentation:

symmetrical without pectus excavatum or pectus carinatum, no cyanosis of the face or extremities.
No tenderness of the chest wall. No heaves or thrills noted.

Palpation of the apical impulse = Point of Maximal Impulse, (PMI)

The examiner places one or two fingers at the 5th intercostal space (ICS) at the mid-clavicular
line (MCL) to assess for localized motion. Placing the patient in the left lateral decubitus
position may help with trying to palpate the PMI. Verbalize the exact location of the PMI. If the
PMI is displaced laterally, inferiorly or felt in more than one intercostal space at a time could
indicate left ventricular hypertrophy (LVH).

Sample documentation:

PMI is approx. 3 cm at MCL 5th ICS

Auscultation
Auscultate the heart sounds at the five listening posts first with the diaphragm and then repeat
with the bell of the stethoscope. The ideal patient position is supine with the head/chest elevated to
30 degrees. A screening exam is often done seated in practice.

Auscultatory areas. The places where valvular movement can be heard are not the actual anatomic
locations of the valves. Rather, the sounds represent the direction of blood flow. The Aortic Valve
sound can be heard best at the second intercostal space near the right sternal border. The second
aortic sound may be heard at Erb's point at the third intercostal space, just left of the sternum. The

66
Pulmonic Valve is best heard at the second intercostal space near the left sternal border. The
Tricuspid Valve sound is best heard at the left lower sternal border, and the Mitral Valve sound is
best heard at the fifth intercostal space at the apex of the heart (mid clavicular line, MCL)

The 5 classic listening posts are as follows: (RSB = right sternal border) (LSB = left sternal border)

(Mnemonic – All Physicians Take Money = Aortic, Pulmonic, Tricuspid, Mitral)

Listen for each heart sound closely, starting with timing of the S1 and S2 heart sounds, which are
normal. Evaluate the rate and the rhythm of the heart sounds. Try to picture in your mind the events
of the cardiac cycle as you listen to the heart sounds.

The period of time between:

S1 and S2 is systole

S2 and S1 is diastole

An abnormal heart sound such as a S3 is heard right after the S2 and a S4 heard just before
the S1. Remember, murmurs are named where they are heard in the cardiac cycle. See
illustration below.

S4 S1 S2 S3 S4 S1 S2 S3
SYSTOLE DIASTOLE SYSTOLE
67
Listen for the physiologic S2 splitting during inspiration usually heard best over the pulmonic post.

Listen closely for abnormal heart sounds such as S3, S4, murmurs and/or rubs. Rub: A scraping or
grating noise heard when two serous surfaces have abnormal contact/friction with each other in
movement. This happens with certain pathology of the pericardium (pericarditis) and the pleural
surfaces (pleural effusion). Can be heard during both systole and diastole, or inhalation and
exhalation since it is any movement that causes it.

Sample Documentation:

Crisp S1/S2, no S3/S4, no murmurs noted, physiologic splitting of S2 noted at Erb’s point (3rd ICS
LSB). No carotid bruits noted, no mitral or aortic murmurs noted with leaning forward or squatting
respectively

The Carotid Arteries

Auscultate and palpate the carotid arteries (one side at a time)
With the patient’s head slightly turned to one side, the examiner places the diaphragm or bell of the
stethoscope over the carotid artery. It is recommended to gently palpate the artery to get the right
location before you listen. Ask the patient to hold their breath during the auscultation so not to mask
any possible bruits. The presence of a bruit may indicate a narrowed carotid artery or a murmur that
is radiating from the heart.

Vigorous palpation of the carotid arteries can stimulate the carotid-sinus reflex and cause and
unwanted drop in blood pressure.

Time the heart sounds to the carotid pulse

The examiner uses one hand to palpate a carotid artery and the other hand to hold the diaphragm of
the stethoscope to a listening post of the heart (suggest Erb’s Point). The heart sound that precedes
the carotid pulse is S1 (closure of the tricuspid and mitral valves) and the heart sound that follows
the pulse S2 (closure of the aortic and pulmonic valves).

Peripheral Pulses
Check radial, popliteal, dorsalis pedis, posterior tibialis

Grading Pulses

0+ Absent
1+ Diminished
2+ Normal
3+ Increased
4+ Bounding

68
 Murmurs
If you detect a heart murmur, the examiner must identify and be able to describe the murmur.
Murmurs are usually evaluated by the following criteria:

Timing
Is the murmur systolic or diastolic? Both?

Shape
Crescendo, decrescendo, crescendo-decrescendo or plateau in intensity

Location
Determine which listening post the murmur is heard best.

Radiation
Does the sound of the murmur radiate from the point where it is heard?

Intensity/Grade
Expressed as a 6-point scale below.

Pitch
Categorized as high, medium or low.

Quality
Described in terms such as blowing, harsh, rumbling and musical.

Grades of Murmurs

i. Lowest, often not heard by the inexperienced

ii. Low intensity
iii. Medium intensity without thrill
iv. Medium intensity with thrill
v. Loud with stethoscope on the chest, with thrill
vi. Loudest and audible with stethoscope removed from chest, with thrill

Sample Documentation:

normal: no murmurs noted

abnormal example: high-pitched, crescendo-decrescendo, III/VI systolic murmur heard best at R 2nd
ICS

Positioning Maneuvers
Mitral Stenosis
Place the patient in the left lateral decubitus position and listen over the apex of
the heart. This accentuates the murmur and S3 or S4 sounds.

69
Aortic Regurgitation

Auscultate the cardiac base with the patient leaning forward. Ask the patient take a deep breath and
then exhale completely, holding their breath while the examiner listens to both sides of the sternum
at the 2nd ICS for the high pitched diastolic murmur of AR.

70
Sample Documentation:

normal example: carotid upstrokes are brisk, no bruits noted. pulses are 2+/4 for carotid, radial,
brachial, femoral, popliteal, dorsalis pedis and posterior tibialis b/l.

Abnormal example: carotid upstrokes brisk, + bruit noted on right side. Radial, brachial, femoral
pulses 2+/4 bilaterally, dorsalis pedis and posterior tibialis 1+/4 bilaterally.

Other Tests
Jugular Venous Pressure (JVP) With the
head of the patient raised 30 degrees, turn the
patients head to the left and identify the
internal jugular vein, looking for the height of
the pulsation. Raise or lower the bed to find
this height as needed. Place a cm ruler
vertically from the sternal angle and using
another straight edge connect a perpendicular
line from the height of the pulse to the ruler.
Height above 3-4 cm from the sternal angle (8-
9 cm above the right atrium) referred to as
“neck vein distension” reflects increase in
central venous pressure. This can be a sign of
heart failure, pulmonary hypertension or
constrictive pericarditis (tamponade) among other things.

Sample Documentation:

jugular venous pressure (JVP) is 2 cm above the sternal angle with head of bed (HOB) at 30
degrees.

71
 Hepatojugular Reflux (HJR)
With the patient lying in the supine position, ask the patient to breath normally with their mouth
open as the examiner applies a gentle but firm upward pressure for about 10 seconds over
the patient’s liver while observing for distention of the neck veins. Normally, the examiner will
observe some transient distention of the jugular veins for about 2-3 seconds. If the vein
distention is higher than normal or lasts longer than normal (8-10 seconds) this is considered
abnormal. This test assesses for right ventricular function and elevated central venous
pressure.

Sample documentation:

no Hepatojugular reflux

Student Handout: Cardiovascular Exam Lab

General If Indicated…
Inspection precordium: chest shape, wall mo-
tion, color of skin, oral mucosa
Palpation front over precordium (tenderness) Palpation
 Heaves  Any area of reported pain
 Thrills (what is the difference  JVP height
between heaves and thrills?)  PMI
Pulses (compare bilaterally) Other Pulses
 Carotid  Brachial
Radial  Aorta
 Pedal  Femoral
 Tibialis posterior  Popliteal
 Dorsalis pedis
Auscultation: Diaphragm and Bell: Auscultation
 Aortic post  Carotid arteries: hold breath
 Pulmonic post  Left lateral decubitus at mitral post
 Erb’s point  Leaning forward at aortic post
 Tricuspid post  Valsalva/Squat-Stand over Erb’s
 Mitral post
Osteopathic exam

Questions:

1. If you palpate a thrill at the aortic post, what would you expect to hear when you auscultate at
this same post?

2. What are you listening for at the 3rd ICS on LSB?

3. What accounts for the first heart sound?

72
 4. What are things you should recognize in your patient with acute MI?

5. What items would go on a problem list for this patient?

Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Detailed cardiac exam
 Osteopathic exam
 Assessment:
1. CC: ___________________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of ______________________
 Plan
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

NOTES

73
 Respiratory System
(Bates 12th edition pp. 303-312, 317-329)

During this laboratory session, the student will perform a complete respiratory examination on their
partner and apply the diagnostic reasoning behind each part of the examination.

History:

 Chest pain
 Shortness of breath (dyspnea)
 Wheezing
 Cough
 Blood-streaked sputum (hemoptysis)
 Daytime sleepiness
 Smoking history
 Occupational toxin/fume exposure

Exam components:

 Inspection
 Palpation
 Auscultation
 Percussion
 Special tests

Inspection
Inspect and observe the anterior and posterior chest and respiratory motion. Note the shape of the
chest (i.e.-barrel chest, clavicular abnormalities, pectus excavatum or carinatum deformities), spinal
deformities, respiratory rate and pattern (normal is about 12 - 20 bpm and regular). Is there use of
accessory muscles or chest retractions?

Examine the fingers for clubbing and the nasal/oral mucosa and extremities for cyanosis.

Review vertical anatomic lines as described in the Cardiovascular chapter. Is there chest symmetry
anatomically and in respiratory motion?

Palpation
Posterior Chest

Palpate the posterior chest for:

Tenderness of the ribs, spine and paravertebral muscles.

Posterior chest excursion: The examiner places their hands flat against the patient’s
back with the thumbs parallel to the midline at about the tenth rib level and use the
thumbs to tent the skin on each side going towards the midline. Ask the patient to
inhale deeply and allow your hands to gently follow the patient’s full respiration while
examining for symmetry of movement.
74
 Tactile fremitus: Normal lung transmits a palpable vibratory sensation to the chest
wall. This is referred to as fremitus and can be detected by placing the ulnar aspects of
both hands firmly against either side of the chest while the patient says the words
"Ninety-Nine." Is it present? Symmetric?

Asymmetric decreased fremitus indicates possible unilateral pleural effusion,

pneumothorax or neoplasm (decreases transmission of low frequency sounds).
Asymmetric increased fremitus indicates possible pneumonia (increases transmission
through consolidated tissue).

Consolidation is a region of normally compressible lung tissue that has filled with liquid.
Try to avoid hand placement over the scapulae. (Hint: ask the patient to cross their
arms in front of them.)

Sample Documentation:

Tactile fremitus present and symmetric.

Anterior Chest
Palpate the anterior chest for:

Tenderness of the ribs, sternum and intercostal muscles.

Tracheal mobility and position. The trachea can be palpated below the thyroid and
cricoid cartilages and is laterally bordered by the sternocleidomastoid muscle. The
examiner can use their 2nd and 3rd fingers on both sides of the trachea and gently
move it from side to side to test for tracheal fixation.

Anterior chest excursion. Gently rest your hands along the lateral ribs and/or the upper
ribs and instruct the patient to inhale
deeply and gently follow the motion of the ribs with your hands for a full respiration,
observing for possible asymmetry of movement.

Auscultation
 The examiner uses the diaphragm of the stethoscope firmly applied to the skin.
 The patient is requested to breathe with the mouth open in order to accentuate their
breathing and avoid upper respiratory sounds.
 Compare side to side for a full respiratory cycle.

Posterior lung fields

Avoid the scapula, start at the top and go downward and move away from the spine as you
progress lower. Some examiners prefer to start at the bottom and move up thereby not
missing faint wheezes or crackles at bases that might clear with the increased respiratory
effort. (total 6 places)

Anterior lung fields

The examiner may begin above the clavicles or just below the clavicles and then moves to
another point at least 4-5 inches inferior to this. (total 4 places).
75
 Lateral lung fields
Auscultate at two levels on each side starting high in the axilla. This location is in the mid-
axillary line bilaterally. (total 4 places)

Types of Normal Breath Sounds

Tracheal Breath Sounds

harsh, loud, high pitched heard over the trachea.

Bronchial Breath Sounds

loud and high pitched heard over the manubrium.

Broncho-vesicular Breath Sounds

a mixture of bronchial and vesicular sounds heard over the 1st and 2nd ICS anteriorly
and between the scapulae posteriorly (main stem bronchi area).

Vesicular Breath Sounds

soft low pitched sounds heard over most of the general lung fields.

Sample Documentation:

normal exam: Clear to auscultation bilaterally, breath sounds are vesicular, no wheezes, rales or
rhonchi.

Other Breath Sounds Often Described in Auscultation Indicating Pathology

Crackles (rales or crepitation)

short, nonmusical sounds heard mostly during inspiration (hair rubbing next to the ear).
Ex. Pneumonia, congestive heart failure, fibrosis

Wheezes
musical sounds mostly heard during expiration when airflow goes through a narrowed
bronchus. All that wheezes is not asthma.
Ex. Asthma, COPD, bronchitis

Rhonchi
lowered pitched, bubbly sounds heard in inspiration or expiration (air over fluid due to
inflammation or airway secretions).
Ex. Secretions in the large airways

76
 Pleural rub
grating sound heard best at the end of inspiration or beginning of expiration and
described as “creaking leather”. Heard when the pleural surfaces are inflamed or
thickened by a pathologic process.

Evaluate for Egophony, Bronchophony and Whispered Pectoriloquy

The three abnormalities describe below can be found over a lung consolidation
pneumonia or pulmonary edema). This is because voice sounds carry more clearly through
fluid than air.

Egophony
To perform this test, the examiner listens with the stethoscope over the posterior
auscultation points and asks the patient to say the letter “e”. If the “e” sounds instead
like “ay” this is an abnormal finding.

Bronchophony
Again, listening over the posterior auscultation points, the examiner asks the patient to
say “99”. If this sounds louder or more clear, this is an abnormal finding. The “99” will
sound muffled when heard through normal lung tissue.

Whispered Pectoriloquy
Lastly, but similarly, the examiner listens over the posterior auscultation points while
asking the patient to whisper “1,2,3. Abnormal: the “1,2,3’ sounds more clear. Normal:
the “1,2,3” sounds faint or is not heard at all.

The chart at the end of this chapter will help differentiate which test is most helpful. Typically,
it is not necessary to do all three.

Sample Documentation:

normal example: Full and symmetric lung excursion, No wheezes, rales or rhonchi. No
bronchophony, egophony, or whispered pectoriloquy. Abnormal example: lung excursion slightly
decreased on right side, rales noted posterior right base, + egophony posterior right base. (or + e to
a changes posterior right base).

Percussion
Posterior percussion
The examiner percusses posteriorly in the rib interspaces. Percuss from side to side at least
at five to six levels.

77
 Anterior percussion
Anteriorly percuss from side to side starting from above the clavicles (lung apices) and
continuing down at four to five intercostal levels.

Lateral percussion
Percuss the lateral lung fields. Start at the axilla and continue down at two to three levels for
each side.

Sample Documentation:

normal example: no dullness to percussion.

abnormal example: dull to percussion over the lower left lung base

78
 Tactile Fremitus
Percussion Adventitious
Condition Trachea Breath Sounds and Transmitted
Note Sounds
Voice Sounds
Vesicular, except
Normal: tracheobronchial tree you may hear None, except you
and alveoli clear; pleurae are bronchovesicular may hear a few
Resonant Midline
thin and close together; and bronchial transient inspiratory Normal
unimpaired mobility of the sounds over the crackles at the
chest wall large bronchi and base of the lungs
trachea
None, or you hear
Chronic Bronchitis: bronchi scattered course
are chronically inflamed; a crackles in early
Resonant Midline Vesicular Normal
productive cough is present. inspiration and
May develop airway maybe expiration;
obstruction. or wheezes or
rhonchi
Left-Sided Heart Failure
Late inspiratory
(Early): increased pressure in
crackles in the
the pulmonary veins causes
Resonant Midline Vesicular dependent portion Normal
congestion and interstitial
of the lungs;
edema: bronchial mucosa may
possible wheezes
become edematous.
Increases over
the involved area
Dull over Late inspiratory with
Consolidation: alveoli fill with Bronchial over the
the airless Midline crackles over the bronchophony,
fluid or blood cells involved area
area. involved area egophony, and
whispered
pectoriloquy
Usually absent when
Usually absent
Atelectasis (labor obstruction): plug persists. The
May be when plug
when o plug (mucus or FB) in exceptions include:
Dull over shifted persists. In
the mainstream bronchus right upper lobe
the airless to the None exception (right
obstructs air flow. Affected atelectasis, where
area affected upper lobe
lung tissue collapses into an adjacent tracheal
side atelectasis) may
airless state. sounds may be
be increased
transmitted
Pleural Effusion: fluid Shifted
Decrease to absent, Decreases to
accumulates in the pleural toward
Dull to flat but bronchial breath absent, but may
space, separates the air filled opposite None, except a
over the sounds may be be increases
lung from the chest wall, side in a possible pleural rub
fluid heard near top of toward the top of
blocking the transmission of large
large effusion a large effusion
sound. effusion
Pneumothorax: air leaks into
Hyper Shifted
the pleural space – usually
resonant or towards Decreased to
unilaterally – the lung recoils Decreased to absent None, except a
tympanitic opposite absent over the
form that chest wall. Pleural air over the pleural air possible pleural rub
over the side if pleural air
blocks the transmission of
pleural air much air
sound.
Chronic Obstructive
None, or the
Pulmonary Disease (COPD): Decreased
crackles, wheezes,
slow and progressive, distal air Diffusely
Decreased to and rhonchi of
space enlarges and lungs hyper Midline
absent associated chronic
become hyper inflated. resonant
bronchitis
Chronic Bronchitis is often
seen.
Asthma: widespread
narrowing of the
Resonant
tracheobronchial tree
to diffusely Often obscured Wheezes, possible
diminishes air flow to a Midline Decreased
hyper when wheezing crackles
fluctuating degree. During an
resonant
attack, air flow decreases
further, and lungs hyper inflate.
79
 Student handout: Pulmonary Exam Lab
General If Indicated…
Inspection front and back: landmarks, chest
deformities, rate, depth and effort of breathing,
accessory muscle use, position of trachea
General palpation front and back: tenderness Palpation
 Reported area of pain
 Excursion
 Tactile fremitus “99”
Auscultation: “Deep breath, open mouth” Auscultation: (pick one)
(compare side to side)  Egophony “ee”
 Anterior: 2 areas bilaterally  Bronchophony “99”
 Lateral: axillary line 2 bilaterally  Whispered pectoriloquy “123”
(hands on hips)
 Superior
 Inferior
 Posterior: 3 areas bilaterally (hug)
For lab: Percuss chest anterior and posterior Percussion
 Posterior diaphragm excursion
 Anterior, Posterior, Lateral
points compared bilaterally
Osteopathic:

Questions:

1. A screening exam for the respiratory system includes:

2. “Positive” tactile fremitus is:

Normal
Abnormal
A dumb way to document this finding

3. Define “positive” egophony

4. Describe the possible abnormal exam findings in the pulmonary system that may occur over
an area of consolidation.

5. What items should be put on a problem list for this case?

80
Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Cardiac exam (screening)
 Lung exam (detailed)
 Osteopathic exam
 Assessment:
1. CC:________________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of _______________________
 Plan
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

NOTES

81
 Gastrointestinal System
(Bates 12th edition pp. 449-464, 470-487)

During this laboratory session, the student will perform a complete abdominal examination on their
partner and apply the diagnostic reasoning behind each part of the examination.

History:

GI:
 Abdominal pain: acute and chronic
 Indigestion, nausea, vomiting, loss of appetite, early satiety
 Difficulty swallowing, painful swallowing
 Change in bowel function
 Diarrhea, constipation
 Jaundice

GU:
 Suprapubic pain
 Difficulty urinating, urgency or frequency
 Hesitancy, decreased stream in males
 Excessive urination or excess urination at night
 Urinary incontinence
 Blood in the urine
 Flank pain and ureteral colic

Exam components include:

 Inspection
 Auscultation (before palpation or percussion!)
 Light Palpation
 Deep Palpation
 Percussion

Tips for enhancing the abdominal exam:

1. Ask the patient if they need to empty bladder.

2. Make the patient comfortable in the supine position, with a pillow under the head and
perhaps another under the knees.
3. Ask the patient to keep the arms at the sides or folded across the chest. If the arms are
above the head, the abdominal wall stretches and tightens, making palpation difficult.
4. Put a drape over the lower part of the patient’s body. Ask the patient to pull the gown up
to the level of the xiphoid process (or examiner can ask permission to move the gown
up). Then examiner or patient can lower the drape to the level of the anterior iliac spines.
Drape male and female patient the same way.
5. Before you begin palpation, ask the patient to point with one finger to any areas of pain so
you can examine these areas last.
6. Warm your hands and stethoscope. To warm your hands, rub them together or place them
under hot water.
7. Approach the patient calmly and avoid quick, unexpected movements. Watch the patient's
face for any signs of pain or discomfort. Make sure your fingernails are closely trimmed.

82
 8. Distract the patient if necessary with conversation or questions. If the patient is frightened
or ticklish, begin palpation with the patient's hand under OR over yours. After a few
moments, slip your hand underneath to palpate directly.

Draping the Patient

Inspection
Inspection of the abdomen starts with fully exposing the patient’s entire abdomen
while at the same time protecting their modesty. See Tip #3 on previous page and refer to the photos
above to properly accomplish this.

Inspect for:

Scars
Striae
Rashes and lesions
Dilated veins
Umbilicus (inflammation or hernia
Contour (flat, round, protuberant, scaphoid)

83
 Quadrants of the Abdomen

Sample documentation:

inspection reveals no scars or striae, no rashes or distention, umbilicus without herniation.

Auscultation
Auscultate the abdomen before performing percussion or palpation because these maneuvers may
alter the frequency of the bowel sounds.

Bowel Sounds
With the diaphragm of the stethoscope listen over the middle of each quadrant for the
characteristic high-pitched clicks and gurgles of normal bowel sounds. If no bowel sounds are
heard after two minutes, the patient has absent bowel sounds. Decreased or absent bowel
sounds can represent an ileus.

Note: if bowel sounds are difficult to hear, the right lower quadrant of the
abdomen is a good place to listen. Increased bowel sounds can occur with
hyperperistalsis, diarrhea and early intestinal obstruction.

Abdominal aorta and renal arteries

Place the diaphragm of the stethoscope 2”-3” inches above the umbilicus in the midline and
listen for an aortic bruit. Then move the stethoscope 1” to 2” inches laterally of this point and
listen for renal artery bruits. A bruit is the sound of turbulent blood flow through a narrowed
artery heard during systole. Other sites to listen for bruits are the iliac and femoral arteries
bilaterally.

84
Percussion

Percuss all four quadrants

The examiner percusses all four abdominal quadrants. Expect to hear tympany due to gas in
the stomach and bowel.

Percuss the liver span

Begin in the right mid-clavicular line (mid-chest) and percuss downward towards the right
upper quadrant of the abdomen. The examiner will first hear resonance over the lung and
then dullness over the liver and finally tympany as the colon
is reached. The dullness represents the liver span and should be measured and not exceed
10 cm in length.

Sample documentation:

Liver span is approx. 7 cm in right MCL, edge not felt.

Kidney tenderness – (CVA tenderness)

Place the ball of one hand over the posterior CVA angle and strike it with the ulnar surface of
the other hand. Pain with percussion could suggest renal inflammation or infection.

Sample Documentation:

normal example: Negative Lloyds or no CVAT (no costovertebral angle tenderness).

Palpation

Palpate the painful area LAST! Always watch the patient’s face!

Light palpation
This detects tenderness, inflammation or spasm of the abdominal wall muscles. Using the
pads of the fingers placed side by side, slowly and gently press in all four abdominal
quadrants.

Deep palpation
Repeat the palpation of all four quadrants to evaluate deeper structures by exerting a
downward pressure gently and steadily with your hands, one hand on top of the other. With
deep palpation, the examiner can assess for tenderness, organ size and presence of masses.

85
Sample Documentation:

normal example: Abdomen is soft, no tenderness to light or

deep palpation.

Sample documentation:

Abdomen is soft, flat. No tenderness to light or deep

palpation. No palpable masses, no hepatosplenomegaly.
Liver span is approx. 7 cm in right MCL, edge not felt.

Palpation of the Abdominal Organs

The Liver:
The examiner places the left hand under the patient’s right side between the 11th and
12th rib. The right hand is placed at the top of the right upper quadrant with fingers
parallel to the rectus muscle or at a slightly more oblique angle and under the ribs. Ask
the patient to take a deep breath and try to palpate the liver edge as it comes down to
meet your fingertips.
If palpable, the normal liver edge is soft, regular and smooth. Not all livers are palpable.

Hooking technique to palpate the liver

The examiner stands at the patient’s head and takes both hands and “hooks” the
fingers under the right costal margin (liver edge) and gently pulls upward and inward
while the patient inhales deeply.

The Spleen
The examiner places the left hand laterally and beneath the patient’s lower left rib
cage. The patient is asked to take a deep breath and then asked to exhale maximally.
As this is done, the examiner’s right hand, which is resting just below the left costal
margin, is slipped inward and upward in the direction of the patient’s left mid axillary
line. As the patient inhales again, the spleen descends and the tip of an enlarged
spleen may be felt.
Usually a normal spleen is not palpable.

The Kidneys
The examiner stands on one side of the patient at a time. To palpate the right kidney,
the examiner stands on the right side of the patient and places the left hand behind the
patient’s right flank and lifts upward. The examiner then uses the right hand to palpate
deeply just below the right costal margin, just lateral to the midline. Ask the patient to
breathe deeply and with inspiration the lower pole of the right kidney will descend and
may be palpated. The same technique is used to palpate the left kidney.
Normally, neither kidney is palpated.

The Aorta
Palpate deeply, but gently with two hands in the mid abdomen between the xiphoid
process and the umbilicus as if you were reading your watch. Evaluate the aortic pulse
for width and pulsation. The aortic pulsation should not exceed 3.0 cm. A large pulsatile
mass may suggest an abdominal aortic aneurysm.

86
 Note – in thin people the aorta may appear enlarged and pulsating, but this is
likely normal.

Sample documentation:

normal example: No hepatosplenomegaly or tenderness, kidneys non-palpable, non-tender. Aorta

not enlarged, no palpable masses.

Other abdominal tests (if indicated):

Rebound tenderness
The examiner presses down in an area of pain with slow, firm gentleness and then quickly
releases the pressure. Pain associated with the release of pressure rather than on exertion of
pressure is referred to as “rebound tenderness” and is often due to an irritated or inflamed
peritoneum (peritonitis). This often indicates an acute abdomen. Make sure you tell the
patient what you are doing before this test so that they can tell you which part hurts.

Rovsing’s Sign
Press deeply and evenly in the left lower quadrant, then quickly withdraw your fingers. A
positive test creates referred pain in the right lower quadrant either with pressure or
withdrawal. This can indicate acute appendicitis

McBurney’s Point
McBurney’s point is 1/3 the distance between anterior superior iliac spine (ASIS) to umbilicus.
Deep tenderness at this point can be a sign of acute appendicitis.

Murphy’s sign
The examiner places their fingertips just below the liver edge and as the patient inhales, the
examiner presses inward toward the gallbladder. Pain during inspiration causing the patient
to stop inhaling is suggestive of an acutely inflamed gallbladder.

Lloyd’ Sign (costovertebral angle tenderness CVAT)

Firmly tap with the ulnar side of the hand over the costovertebral angle. Pain could suggest
renal inflammation or infection. (alternatively, examiner can place one hand on the patient’s
back over the costovertebral angle, then examiner can gently strike his/her flat hand with the
ulnar side of the fist.)

Evaluation of Ascites

Fluid wave
Instruct the patient to place his/her hand in
the midline of his/her abdomen. The examiner then taps one
flank while lightly touching the other side feeling for a wave of
fluid. Detection of a fluid wave suggests ascites.

Shifting dullness
With the patient in the supine position, the examiner begins
percussion in the middle of the abdomen, moving lateral in
several directions. Map the borders of tympany and dullness.
Then have the patient turn on one side and percuss and
again mark the borders between tympany and dullness.

87
 When the patient is turned on their side, the gas filled bowel will float to the top of the
ascites. Therefore, if ascites is present, the fluid will seek its lowest level and the
dullness will shift to the more dependent side, (area of the abdomen closest to the
exam table), while tympany shifts to the top.

Rectal Examination

In clinic, this must be done on any patient with abdominal complaints!!

Position
Drape the patient, lie on their side, and flex hips and knees (top hip flexed more than the
bottom)

Inspection
The sacrococcygeal and perianal regions

Examination
The anus and rectum
 Lubricate gloved finger
 Talk through the exam with the patient
 Place finger over anus
 As sphincter relaxes insert finger into anal canal
 Observe sphincter tightness
 Feel for any masses or other abnormalities
 In men the prostate can be palpated anteriorly
 Do not force the exam if there is a lot of pain or distress

Sample documentation:

No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Stool
hemocult negative

Osteopathic correlation
Remember the viscera-somatic reflexes. These are localized visceral stimulus producing patterns of
reflex response in segmentally related structures Region of spinal cord

88
89
 Student Handout: Abdominal Exam Laboratory
General If Indicated…
Inspection (adequate exposure with proper
draping, scars, striae, rashes, dilated veins,
contour, appearance of umbilicus)
Auscultation: all 4 quadrants Auscultation additional
Aorta
Renal arteries
Palpation Palpation
 Light in 4 quadrants  Kidneys
 Deep in 4 quadrants  Aorta
 Liver  Rebound over area of tenderness
 Spleen  Rovsing’s sign
 Murphy’s sign
 McBurney’s point
 Rectal exam (with FOBT)
Percussion all 4 quadrants Percussion
 Lloyds sign
 Liver span
 Shifting dullness
 Fluid wave
Osteopathic exam

Questions:
1. How would a positive Rovsing’s test help your differential?

2. If a patient came in with fever, fatigue and flank pain what test would help you arrive at a
possible diagnosis?

3. You would do a fluid wave test if you suspected that a patient had what condition?

4. What risk factors would cause you to do an exam of the aorta and renal arteries?

5. What items would go on a problem list for this patient?

90
Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Screening heart exam
 Screening lung exam
 Detailed abdominal exam
 Osteopathic exam
 Assessment:
1. CC: _______________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of __________________________
 Plan
1. Labs or tests
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

NOTES

91
 Male Genitalia
(Bates 12th edition pp. 541-544, 550-561)

During this laboratory session, the student will perform a complete male GU examination on the
models and apply the diagnostic reasoning behind each part of the examination.

History:

 Sexual health
 Penile discharge or lesions
 Scrotal pain, swelling or lesions *It is best to have a
 Sexually transmitted infections (STI’s) chaperone for this
exam*
Exam components:

 Inspection
 Palpation
 Evaluation for hernias
 Rectal and Prostate examination

Inspection
Skin and Hair
Inspect the hair, hair distribution and skin in the pubic
region. Evaluate for fungal infections (“Jock Itch”),
excoriations and other rashes.

Penis and Scrotum

Inspect the penis and scrotum for any infections,
rashes, or excoriations. If the patient is
uncircumcised, instruct the patient to retract the
foreskin in order to inspect the glans. Inspect the
glans. Gently compress or spread the glans in order
to open and inspect the urethral meatus and evaluate
for any discharge.

Palpation
Penis
Palpate the penis from the glans to the base of the penis. Note the presence of any scars, ulcers,
nodules, induration or signs of inflammation.

Scrotum and Testes

Palpate the skin of the scrotum for any tenderness, nodules or masses.
Each teste is palpated separately. Gently grasp the teste with both hands
and “roll” the teste between the examiner’s hands. Note for size, shape and
consistency of each teste. Locate the epididymis superior and posterior to
each teste and gently palpate. Normally this feels nodular and cord like.
Locate and palpate each spermatic cord between the epididymis and the
superficial inguinal ring. Note any nodules, swelling or tenderness.

92
 Transillumination of the Scrotum
If a scrotal mass is detected, transillumination of the scrotum may be indicated.

Technique:
 Darken the room.
 Apply a bright light source to each side of the scrotum.

Vascular structures, blood, hernias and normal testicles do not trans- illuminate.

Transmission of light in the form of a red glow in the scrotum indicates a fluid
containing cavity, i.e.: hydrocele or spermatocele.

Hydrocele – abnormal collection of fluid in the tunica vaginalis.

Spermatocele – pea-sized, non-tender mass that contains spermatozoa, usually attached to the
upper pole of the epididymis.

Hernias
Inspect the inguinal and femoral areas carefully for bulges.
Instruct the patient to turn his head to the side to cough or
strain down.

Palpate for an inguinal hernia.

 With the patient standing and using the
examiner’s right index finger for the patient’s
right side and left index finger for the patient’s left
side, invaginate loose scrotal tissue with your
finger upward into the inguinal canal. The index
finger should reach the external inguinal ring and
may be open to allow the finger to enter easily.
 Instruct the patient to turn his head and either
cough or strain down.
 A bulge against either the tip or pad of the examiner’s finger may indicate the presence of
a hernia.

93
Sample documentation:

Normal male hair distribution. Circumcised. No penile discharge or lesions. No scrotal swelling or
discoloration. Testes descended b/l, smooth, without masses. Epididymis non-tender. No inguinal or
femoral hernias or enlarged lymph nodes.

The Prostate and Rectal Examination

The prostate gland lies anterior to the wall of the rectum. The prostate is
a bi-lobed, heart shaped structure approximately 4cm in diameter.
Normally it is smooth and firm and has the consistency of a hard rubber
ball.

Technique:
The standing position is commonly used for men, but the left lateral
prone position, “Sims Position” can also be used.

With a lubricated gloved index finger, the examiner can

introduce the lubricated finger gently into the rectum. The
sphincter can be relaxed with gentle pressure from the
examiner’s finger.

Sphincter tone should be assessed.

Once in the rectum, palpate the lateral, posterior and

anterior wall of the rectum and evaluate for any irregularities
or masses.

Palpate the prostate gland under the anterior wall of the

rectum. Evaluate the size, shape and consistency of the
prostate gland.

Cancer – hard, irregular nodules, asymmetric gland.

BPH – symmetrical enlarged, soft gland, may bulge into the rectal lumen.

Prostatitis – tender, boggy and fluctuant gland (Chapman’ Reflex

– lateral thigh)

Fecal Occult Blood Testing (Hemocult)

Any fecal material on the glove due to the rectal examination should be tested for occult blood with a
Hemocult card and developer if indicated.

Sample documentation:

Prostate smooth, not enlarged, without nodules and non-tender with palpable median sulcus. No
perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Stool
hemocult negative

94
 Testicular Self-Examination
Testicular cancer is the most common cancer of young men between the ages of 15 and 35. All male
patients should be instructed to perform monthly testicular self- examinations.

The Self-Exam

 Examine both testicles individually.

 Stand in front of mirror and check for swelling or any visual abnormalities.
 Place your first two fingers under the testicle and your thumb on top.
 Gently roll between fingers feeling for any lumps or areas of pain.
 Note: one testicle may be larger than the other, this is normal.
 Locate the epididymis – this is not a lump.
 If any lumps or pain are found, see your doctor immediately.

Student Handout: Male GU Lab

General If Indicated…
Inspection: (skin and pubic hair, foreskin,
glands, urethral meatus)
Palpation
 Penis
 Scrotum and contents (each testicle,
epididymis, spermatic cord)
 Inguinal lymph nodes
 Hernias
Prostate Exam
 Identify posterior surface of the
prostate, lateral lobes, and median
sulcus, note shape, size, and
consistency, nodules, tenderness
Anal Exam
 Inspect
 Fissures
 Hemorrhoids
 Palpate
 Sphincter tone
 Masses
 Tenderness
Special Tests
 FOBT

Questions:

1. What is the age group most at risk for testicular cancer?

2. What age do we start doing routine DRE’s?

95
 3. What age do we recommend screening colonoscopies?

4. What age do we recommend serum PSA testing?

Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Screening heart exam
 Screening lung exam
 Screening abdominal exam
 Detailed male GU exam
 Osteopathic exam
 Assessment:
1. CC: ________________________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of ______________________
 Plan
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

NOTES

96
 Female Genitalia
(Bates12th edition pp. 565-574, 583-595)

During this laboratory session, the student will perform a complete female GU examination on the
models and apply the diagnostic reasoning behind each part of the examination.

The examination of the female genitalia and pelvis is often viewed with apprehension by the patient,
as well as the novice examiner. An examination performed slowly and gently with adequate
explanation goes a long way to develop a good doctor-patient relationship and put the patient and
examiner at ease. A chaperone is necessary for this exam.

History: The Gravida-Para Notation

 Menarche, menstruation, menopause, G – gravida-number of pregnancies

 postmenopausal bleeding P – para-outcome of pregnancies
 Obstetric history (see box)
 Vulvovaginal symptom F = full-term > 37 weeks gestation
 Sexual health P = premature
 Pelvic pain- acute and chronic A = abortion < 20 weeks (induced or
spontaneous)
 Sexually transmitted infections (STI’s)
L = living
The exam components:
Please note that the best way to take an obstetric
history is to simply list each pregnancy and the
 Inspection of the external genitalia
outcome. This abbreviation system is an attempt
 Palpation of the external genitalia
to make a shorter way to summarize the obstetric
 The internal examination (three parts)
history but it leaves a lot of scenarios inadequately
 The speculum examination
reported (ectopic pregnancies, C-sections,
 The bimanual examination
extreme prematurity for example).
 The rectovaginal examination

Preparation for the Examination

More than any other examination, good preparation and having all needed supplies and equipment
ready prior to starting the examination will assure a smooth and organized experience for both the
patient and examiner.

Supplies and Equipment:

 Examination gloves
 Appropriate sized vaginal speculum
 Water soluble lubricant
 Good light source
 Cervical brushes and scrapers
 Cotton tipped applicators
 Glass slides, cover slips and normal saline
 Hemocult testing card and developer
 Bacteriologic and/or other diagnostic tests as indicated

97
Positioning the Patient:
 Always start the examination with the patient adequately covered and draped to respect
the patient’s privacy and dignity (cloth covers are nice).
 The traditional position to place the patient for the examination is called the lithotomy
position. The head of the examination table is elevated so the patient and the
examiner can maintain eye contact during the examination. The heel rests or “stirrups” of
the examination table are extended and the patient’s heels are placed in each heel rest.
Instruct the patient to slide all the way down so her buttocks are right at the edge of the
table. Ask the patient to “let her legs fall and drop her knees to each side”. Never tell the
patient to “spread her legs”.
 The examiner should be seated on a stool between the patient’s legs with a good light
source, an assistant at their side and only then should the patient be uncovered and
exposed to start the examination.

Inspection and Palpation of the External Genitalia

Inspect and evaluate the following external Structures:

External genitalia
Hair
Labia majora
Labia minora
Clitoris
Urethral meatus
Vaginal introitus
Bartholin’s glands
Perineum
Anus

Gently spread the labia with two fingers to inspect the clitoris, urethral meatus and vaginal introitus.
Gently palpate the Bartholin’s glands at the 4 and 8 o’clock positions of the vaginal introitus with one
finger just inside the introitus and the other finger on the outside.

The Speculum Examination

Choose the appropriate speculum size for the

patient.

With the examiner’s index and middle fingers

separate the labia while applying gentle pressure
downward on the perineum. Ask the patient to
relax the muscles under your fingers.

Introduce the speculum into the vaginal introitus

at a 45-degree angle over your

fingers. Once the speculum is about 1” – 2” Picture by Tiemdow Phumiruk MD

inches inside the vagina, rotate it to the horizontal.

Keep the tip of the speculum pointed posterior or downward while gently and slowly
advancing it.
98
 Gently open the blades of the speculum and locate the cervix,
usually just beyond the top blade. Gentle and slight repositioning of the speculum to locate the
cervix is common. The cervix should “drop down” between the blades of the speculum.

Proper position of the speculum to examine the cervix.

The Cervix

Inspect the cervix for color, discharge, erythema, erosion, ulceration, leukoplakia,
scars and masses. Note the cervical os; shape and size, open or closed.

Pap Smear
Usually consists of two to three specimen collections:

Ectocervix: cervical scrape. Rotate a wooden or plastic cervical scraper 360 degrees
around the cervical os and transfer the specimen onto a slide or into a specimen jar.

Endocervix: insert a cervical brush gently into the cervical os and rotate back and
forth. Transfer the specimen onto a slide or into a specimen jar.

Additional Specimen Collection: Bacterial/Viral Cultures – if indicated. Insert a sterile

cotton tipped swab into the cervical os for 30+ seconds to obtain a specimen and
transport in the appropriate medium.

The Wet Mount or “Hanging Drop”

 Using a cotton tipped swab, obtain a small sample of mucus from the
posterior fornix of the vagina.
 Transfer the specimen to a clean microscope slide.
 Add 1-3 drops of normal saline to the slide and place a cover slide
over the specimen.
 Inspect the specimen with a microscope under high and low power.

Vaginal Walls
Release the tension on the speculum blades and as the speculum is slowly withdrawn,
inspect the walls of the vagina for masses, ulcerations, lacerations and leukoplakia.
The wall of the vagina should be smooth and non-tender. A scant to moderate amount
of colorless to white mucus is normal.

The Bimanual Examination

The bimanual examination is used to palpate and evaluate the uterus and adnexa.

 Lower the head of the exam table.

 Lubricate the index and middle finger of a gloved hand, usually the examiner’s dominant
hand.
 From a standing position between the patient’s legs, insert the two fingers into the vagina,
exerting gentle pressure downward.
 The other gloved hand is exerting gentle downward pressure above the symphysis pubis
in the lower abdomen.

99
 Palpate the cervix – note its position, consistency and mobility. The cervix should
have the consistency of one’s nose.
Gently try to move the cervix and note any “cervical motion tenderness”.

Palpate the uterus – note its position, size, shape, consistency and any tenderness.

Palpate the adnexa – with the examining hand turned upward, gently slide the fingers
into the left and right lateral fornix, while the other examining hand applies a gentle
downward pressure on the lower abdomen.
The adnexa and its structures should be evaluated for size, shape, consistency,
mobility and tenderness. In most instances, normal adnexa structures (i.e.: ovaries,
fallopian tubes, etc.) cannot be palpated.

Palpate the uterosacral ligament – after examination of the adnexa, the examiner
should slide their fingers under the cervix to the posterior fornix in order to palpate the
uterosacral ligament and the Pouch of Douglas.

The Rectovaginal Examination

The rectovaginal examination allows for better evaluation of the posterior portion of the pelvis
and cul-de-sac.

Explain to the patient that you are going to

examine the vagina and rectum. Change and re-
lubricate a new examination glove.

Inspect the anus for fissures, hemorrhoids, polyps,

prolapsed or other rectal growths.

Slowly introduce the lubricated glove, index finger

in the vagina and middle finger in the rectum
as far as comfortably possible for the patient.

Palpate the rectovaginal septum - is it

thickened, tender, nodules or masses.
Picture by Tiemdow Phumiruk MD

Palpate the rectum – With the middle finger, palpate the rectal vault for masses or
tenderness.

Fecal Occult Blood Testing (Hemocult) Slowly remove the examining hand. Test any fecal
material on the glove for occult blood with a Hemocult testing card and developer.

Sample documentation:

No inguinal adenopathy. External genitalia without erythema, lesions, or masses. Vaginal mucosa is
pink. Cervix parous (or nulliparous), pink and without discharge or lesion. Uterus anterior, midline,
smooth, and not enlarged. No adnexal tenderness. Pap smear obtained. Rectovaginal wall intact.
Rectal vault without masses. Stool hemocult negative.

100
Clinical Pearls for Completing a Good Female Genitalia Examination
 Maintain eye contact with the patient.
 Tell the patient what you are going to do before you do it – nobody likes those kinds of
surprises.
 Expose what you need to examine only when you need to examine it – always respect the
patient’s modesty and dignity.
 Be empathic to the patient’s apprehension with the examination.
 Have all your equipment and materials ready before you start the examination.
 Be slow and gentle.
 Always have a female attendant present while conducting the examination.

101
 Breasts
(Bates 12th edition pp. 419-422, 434-443)

During this laboratory session, the student will perform a complete breast examination on the models
and apply the diagnostic reasoning behind each part of the examination. This examination requires a
chaperone. Look at the skin of the breast and nipples to evaluate for color, contour, symmetry, skin
changes such as dimpling or retractions, and discharge.

History:

 Breast lump or mass

 Breast discomfort or pain
 Nipple discharge
 History of breast cancer, personal or family
 History of breast feeding

Exam components:

 Inspection
 Palpation

Inspection
Inspection should be done in several positions:

 Arms at sides
 Leaning forward
 Arms overhead
 Supine
 Hands on hips

Look at the skin of the breast and nipples to evaluate for:

Color
Contour
Symmetry
Skin changes such as dimpling or retractions, and discharge.

Look at the axilla for:

Presence of rashes
Signs of infection
Pigmentation changes.

Palpation
Palpation the breasts with the patient in the supine position with the arm on the side being examined
raised overhead. This spreads out the breast tissue. Using the pads of the fingers, palpate the entire
breast area from just underneath the clavicle to the inframammary fold, and from the sternum to the
posterior axillary line. DON’T FORGET THE TAIL of SPENCE. Be systematic in covering the entire
area.

102
Common patterns of palpation include:

Vertical Horizontal Wheel and Spoke

Palpation is done by making small circles at each point to really feel the contour of the underlying
tissue. Use moderate pressure. Feel for tissue consistency and tenderness. Compare these findings
bilaterally and correlate it with the patients timing in their menstrual cycle. Many breasts especially
those of younger women are very firm and have several irregular bumpy feeling areas. This is
commonly seen in fibrocystic breast disease.

If any nodules are identified, note the following:

~ Location ~ Size
~ Shape and delineation ~ Density/consistency
~ Mobility ~ Tenderness

Nipple
Palpate the nipple to note its elasticity and the presence of discharge. If the patient complains
of discharge, try to determine its location by compressing one section of the areola with your
index finger in a radial pattern to see if and where it is expressed.

Note: Any discharge is considered abnormal and should be evaluated unless it is milky
discharge in a lactating female.

Axilla
Palpate the axilla for any lymph nodes by feeling the anterior pectoral fold, the lateral humeral,
medial ribcage and posterior scapular folds. Also feel for supraclavicular and infraclavicular
nodes.

Sample documentation:

normal example: Breasts symmetric and smooth without nodules or masses. Nipples without
discharge. No axillary lymphadenopathy.

Abnormal example: Breast pendulous with diffuse fibrocystic changes. Single firm 1X1 cm mass,
mobile and non-tender, with overlying peau d’orange appearance in right breast, upper outer
quadrant at 11 o’clock, 2 cm from the nipple.

103
 Student handout: Female GU Lab
General If Indicated…
Breast Exam
Inspection (symmetry, size, skin changes,
nipple inversion or eversion or discharge)
Palpation (masses, tenderness, axil-
lary lymphadenopathy)
Pelvic Exam
Inspection
 Mons (female hair pattern, lice,
growths)
 Vulva (edema, growths, dis-
charge, clitoral adhesions, discol-
oration)
 Perineum (intact, repaired episioto-
my, growths, Bartholin glands,
skene’s glands, urethra)
 Vagina (color, growths, discharge,
tone)
 Cervix (color, size, growths, ero-
sions, appearance of os (split,
round, open, closed), deviation
from midline)
Palpation
 Uterus (size, shape, consistency, posi-
tion, mobility, tenderness, deviation
from midline, flexion, version)
 Adnexa (masses, enlarge-
ment, tenderness)
 Recto‐vaginal (hemorrhoids, mass-
es, strictures, fistulas)
 Inguinal lymph nodes
(enlargement, tenderness)
Rectal Exam
 Inspect
 Fissures
 Hemorrhoids
 Palpate
 Sphincter tone
 Masses
 Tenderness
 Special test: FOBT
Osteopathic exam:

Questions:

1. What do ‘normal’ ovaries feel like?

104
 2. What age do we start doing routine DRE’s?

3. What age do we recommend screening mammography?

4. What age do we recommend pap smear testing?

5. What age do we recommend screening colonoscopy?

Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Screening heart exam
 Screening lung exam
 Screening abdominal exam
 Detailed female GU exam
 Osteopathic exam
 Assessment:
1. CC: ___________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of ____________________
 Plan
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

NOTES

105
 MSK: Neck and Upper Extremities
(Bates12th edition pp. 625-635, 642-666)

History:

 Joint pain: articular or extra-articular, acute or chronic, inflammatory on non- inflammatory,

localized or diffuse
 Joint pain: associated constitutional symptoms and systemic manifestations from other organ
systems
 Neck pain
 Low back pain
 History of trauma? Mechanism of injury

Exam components: (do bilaterally wherever possible!)

 Inspection
Note symmetry, deformities, skin changes, scars, lesions, muscle atrophy and signs of
inflammation, such as redness, swelling or induration.
 Palpation
Note palpable lesions (i.e. nodules), muscle atrophy, swelling, crepitus, warmth, tenderness
and areas of muscle spasm.
 Range of Motion
Active: The patient independently takes his/her joint(s) through a full range of motion.
Compare both sides observing limitations in ROM and laxity.
Passive: The examiner takes the patient’s joint(s) through its range of motion. Compare both
sides.

Neck
Inspection and palpation of the cervical spine
Patient seated
Inspect and palpate the neck muscles. Verbalize findings of any visible lesions
Verbalize if there is asymmetry of the head in relationship to how it is held over the shoulders.
Do you feel any tissue texture changes? (i.e.: spasm, redness, sweat, masses)

Range of Motion of the cervical spine:

Active ROM

Examiner monitors C7 spinous process.

Flexion
patient puts chin to chest; viewed by examiner from the posterolateral aspect.

Extension
patient attempts to extend his head back so the back of the head touches the neck (at
about the C7 spinous process). viewed by examiner from the posterolateral aspect.

106
 Rotation
patient rotates head to each side, trying to touch the chin to each shoulder; viewed by
examiner from front or back.

Side bending
patient tries to touch the ear to the corresponding shoulder; viewed by examiner from
front or back.

Passive ROM

Flexion and Extension

The examiner gently grasps the patient’s head, while manually monitoring at
C7spinousprocess as the head is taken these directions.

Side bending
The examiner places a hand on the shoulder opposite to the direction to the patient’s
head to limit assistance of the muscles. The examiner’s other hand
should be placed on the parietal-temporal region (stay away from pushing on
the jaw) gently assisting the patient’s head into the side bending.

Rotation
The examiner places their hand on the patient’s skull and rotates the head in both
directions. Gently stabilizing the opposite shoulder will assure the examiner that the
patient has not used their body to assist in the head rotation.

Additional Evaluation of the cervical spine (if indicated)

Temporomandibular Joint (TMJ)

The examiner places their index finger in front of the tragus of each ear and instructs the
patient to open and close their mouth. Note clicking, popping, tenderness or jaw deviation on
the left and right sides. Assess that the jaw opens to a width of 3 fingers, less than 3 fingers
is abnormal finding.

Sternocleidomastoid (SCM) muscle

The patient rotates their head to each side against the examiner’s gentle but apparent
resistance. This testing is done when the patient is complaining of neck
pain and or weakness and allows the examiner to assess if the pain is reproduced with
muscle activation.

Upper Trapezius muscle

The patient pushes or shrugs shoulders upward against examiner’s resistance or the patient
can maintain “shrugged shoulders” as the examiner pushes downwards to test the ability of
the patient to resist this force.

**By testing the SCM and trapezius muscle, the examiner additionally assesses functionality
of Cranial Nerve XI**

Sample documentation:

No deformities noted, no tenderness to palpation, Full range of motion (FROM) in flexion/extension,

side bending and rotation in active and passive testing.

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 Upper Extremities
Review the bones and joints of the shoulder, elbow, wrist, and hand. Also, the important boney
landmarks.

Shoulders (always examine bilaterally!)

Inspect

Palpate

Range of Motion

 Active ROM:
In active ROM, the patient simply “copies” the instructions or movements given by the
examiner.
 Passive ROM:
The examiner must manually guide each extremity through its full range of motion. This
allows the examiner to assess for any joint or muscle resistance and compare sides.

There are six directions of motion in the shoulder joint:

Abduction
Take arm away from side of body, touch hands overhead.

Adduction
Take arm towards the midline of the body
and across chest

Flexion
Take arm forward all the way up toward
the head in a sagittal plane. The patient’s palms should face
medial towards their body.

Extension
Take arms backwards, again palms facing
medially in a sagittal plane.

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 External rotation
The elbow is flexed and anterior surface of the arm rotates outward OR arms in the
“surrender” position (shoulder abducted 90 o and elbow flexed at 90o and fingers to the
sky)

Internal rotation
The elbow is flexed and anterior surface of the arm rotates inward OR arms in the
“scarecrow” position (shoulder abducted 90 o and elbow flexed to 90o and fingers face
the ground)

**Note: Always take a joint to its maximum range of motion.

Apley’s Scratch test

This is a gross measurement of shoulder

range of motion and tests several
movements simultaneously. If it is abnormal,
then ranges of motion should be tested
individually in order to assess where the
deficits lie. Know which combined ROM
apply to each position.

Resisted Muscle Testing (if indicated)

You are evaluating for pain when muscle groups activated. Take the patient through each
range of motion with slight resistance to see if this elicits and/or reproduces pain

**Note: this is resistance testing which is different than strength testing.

{Strength testing is done for neurological screening (UE: bicep/triceps flexors/extensors,

forearm flexors/extensors. LE: hip flexors/extensors, knee flexors/extensors). Testing is for
maximal effort and is graded 0-5.}

Sample documentation:

Normal example: No deformities or lesions noted on inspection, no tenderness to palpation

bilaterally. Full range of motion in extension, flexion, adduction, abduction, internal and external
rotation.

Abnormal example: No deformities noted on inspection, tender to palpation over the right
acromioclavicular joint and the anterior aspect of the right shoulder. Limited range of motion (to
approx. 90 degrees) in active testing in both flexion and abduction. + pain but no limited range of

109
motion in adduction on the right. Normal abduction bilaterally. Full range of motion in active and
passive internal and external rotation. + crossover test, right side. Negative empty can, negative
infraspinatus test, negative lift-off, Positive Neer’s sign right side, negative Hawkins.

Elbows

Inspect

Palpate

Range of Motion
 Active ROM
 Passive ROM

Evaluate each elbow for passive ROM, active ROM in:

Flexion:
bend arm upward at the elbow

Extension:
put straight with patient’s fingertips pointing down to the ground

Supination:
(Perform with elbows bent at 90 degrees)
palmar surface of hand turns upward

Pronation:
(Perform with elbows bent at 90 degrees) palmar surface of hand turns downward

Sample documentation:

normal example: No deformities or lesions noted on inspection, no tenderness to palpation b/l.

FROM at the elbow in active and passive testing.

Wrists

Inspect

Palpate

Range of Motion
 Active ROM
 Passive ROM

Evaluate each wrist for passive ROM, active ROM in:

Flexion:
Move palm toward forearm

Extension:
Move back of hand toward forearm
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 Radial deviation:
side bend hand 1st digit towards forearm

Ulnar deviation:
side bend hand 5th digit towards forearm

Hands

Inspect

Palpate

Range of Motion
 Active ROM
 Passive ROM

Evaluate each hand for passive ROM, active ROM in:

Abduction:
spread open extended fingers

Adduction:
closes extended fingers

Extension:
opens hand and straightens (extends) fingers

Flexion:
make a fist with all phalangeal joints

Opposition:
touch thumb to 5th fingertip

Resisted open fingers:

Another finger strength test is to have the patient’s fingers spread bilaterally and resist
the examiners effort to approximate them. Both hands may be done simultaneously.

Special Tests
Perform bilaterally when applicable

Students are to become familiar with these tests and their diagnostic purposes. The simulated
patient experiences will require the student to perform a few selected techniques as well as be
responsible for the information on the written exam.

111
Neck

Compression Test
This test is used to provoke symptoms of a pinched nerve in the neck.
Direct vertical compression without side bending or rotation.

Distraction Test
This test is used to confirm radicular pain is coming from
the neck if distraction relieves them. This test is
only done when patient actually having symptoms at
time of exam.

Cervical Foraminal Compression Test (Spurling’s Maneuver)

This test is used to provoke symptoms of nerve impingement. The head is
side bent to the affected side, while the examiner presses straight down
on the head Often this is modified by bending the head backward and
turning it to both sides during the testing. This is called the maximum
cervical compression test.

Shoulder

Rotator cuff is comprised of 4 muscles, 3 that insert into the greater tuberosity of the
humerus and 1 that inserts anteriorly. Known by the pneumonic “SITS”.

Supraspinatus
Directly inserts under the
acromion

Infraspinatus
Inserts just posterior to the
supraspinatus

Teres minor
Inserts posterior and inferior
to the Supraspinatus

Subscapularis
Inserts anteriorly to the joint
and is not palpable

Rotator cuff tendonitis

Pain with activity of the shoulder suggests inflammation of the rotator cuff.

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Tear of the rotator cuff Manifests with pain typically over the deltoid, exacerbated by
overhead activity and at night for unknown reasons. Weakness may also be associated.

Supraspinatus muscle injured 90% of the time.

Supraspinatus: Empty Can Test

Raise the patient’s arm out to the side and then bring it forward
a few inches and turn the hand over so that the thumb points
toward the ground (like your dumping out a can of soda).
Holding the arm in this position put gentle pressure downward
on the patient’s arms. If they are unable to fully resist, this is a
positive test for rotator cuff damage most specific to the
supraspinatus muscle. Do both arms simultaneously to make
it more obvious.

Supraspinatus: Drop Arm Test

A secondary test to do if the empty can test is positive. The patient’s arm is passively
abducted to 90o and the patient is asked to slowly lower the arm. A sudden drop from
weakness or pain indicates a potential rupture of the supraspinatus tendon. Alternatively, the
examiner can gently push on the arm when abducted to 90°. Pain and weakness suggest
supraspinatus tear. (Deltoid = 90°- 120°)

Other Rotator Cuff Tests:

Infraspinatus/Teres Minor
Place arms at patient’s side with elbows flexed to 90°
thumbs turned up. Provide resistance as the patient
presses outward.

Subscapularis: Lift-Off
Test
With arm internally rotated so the dorsum of the hand
rests on the lower back. Have the patient push posteriorly
against resistance. Inability to push outward against
examiner indicates subscapularis weakness. Important to
compare bilaterally.

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 Subscapularis: Bear Hug Test
The patient crosses a hand to the opposite shoulder and
attempts to oppose an examiner effort to lift the hand off
the shoulder. Inability to resist the examiners effort is
subscapularis weakness.

Biceps Pathology

Biceps muscle and tendon run proximal to the bicipital groove on the
anterior aspect of the humerus. Tenderness to palpation localized to this
area may be due to bicipital tendonitis.

Speed’s test
Raise the patient’s straight arm forward to be
parallel with the floor, with the palm facing
upward. Ask the patient to resist you pushing it back down. If pain occurs in
the area of the bicipital groove the test is positive.

Yergason’s test
The patient should be seated or standing, with the humerus in neutral
position and the elbow in 90 degrees of flexion. The patient is asked to
externally rotate and supinate the arm against examiner’s resistance. It
tests the ability of the transverse humeral ligament to hold the biceps
tendon in the bicipital groove. Test is positive if pain or snapping is
reproduced in the bicipital groove.

Gleno-humeral dislocation or subluxation

Creates an unstable shoulder that is at risk of recurrent dislocation. Patient reports feeling
instability in shoulder.

Apprehension test
Put the patients arm in the “surrender” position, abducted
90° and elbow flexed at 90° and externally rotated. Put
one hand on the forearm and the other hand on the back
of the shoulder and push gently forward. This may be
accompanied by increasing external rotation of the arm
backward. Any pain or a look of alarm on the patient’s
face is a positive test. This test can be performed in the
supine position as well.

114
 Hawkin's impingement sign
Flex the patient's shoulder and elbow to 90°, palm facing down.
With one hand on the forearm and one hand on the elbow,
rotate the arm by applying upward force at the elbow and
downward force on the forearm. This compresses the greater
tuberosity against the coraco-acromial ligament. Pain may
indicate a rotator cuff tear. This is most likely from impingement
of supraspinatus or long head of the biceps muscle. To confirm
a supraspinatus lesion, use a drop arm or empty can test.

Neer's impingement sign

Used to detect sub acromial impingement. Start by
stabilizing the scapula. Do this by holding the posterior
aspect of the shoulder (note: the scapula must not be
involved in the motion of the arm). Next, apply a
combination of internal rotation of the humerus and
pronation of the forearm during passive forward flexion.
This will compress the greater tuberosity of the humerus
against the acromion. The long head of the biceps and
supraspinatus tendon are often involved if pain is elicited.
Use this test in combination with a drop arm or empty can
test to localized the supraspinatus tendon as the likely
pathology.

Glenoid Labrum Integrity

O’Brien’s Test
Flex arm to 90°, adduct across the chest, and internally rotate with the
thumb pointing down. Then push down on the arm. Pain is a positive
test for a Labral tear (SLAP- Superior Labrum Anterior to Posterior).

Different from Crossover test due to internal rotation of the arm with
downward pressure.

Acromioclavicular Joint Dysfunction:

Crossover Test
Adduct the arm across the patient’s chest to put strain on the
acromioclavicular joint by forcing acromion into distal end of the clavicle.
May suggest AC joint pathology if painful.

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Elbow

Lateral Epicondylitis (tennis elbow):

Denoted by pain over the lateral epicondyle of the humerus and along
the extensor tendon of the forearm. Often worse with extension type
activities such as opening the door knob, pouring a pitcher of water,
playing tennis. Palpate the lateral epicondyle and muscle attachments
with one hand while having patient extend their wrist against your
resistance. Increased pain in the region of the lateral epicondyle is a
positive test. Any resisted use of forearm extensors can be used for
diagnosis.

Medial Epicondylitis (golfers elbow)

Pain on medial epicondyle of the humorous and long the flexor
tendons of the forearm. Often worse with flexion type activities such as
lifting and golf.

To test this, have the patient flex their wrist against your resistance
while you palpate the medial epicondyle.

Collateral ligament disruption

Valgus and Varus Stress Tests

For the valgus stress test, push on the lateral side of the
elbow while abducting the distal forearm away from the
body. Feel for looseness. For the Varus stress test, do the
opposite.

Wrist
Palpate the bones of the wrist and evaluate for symmetry and motion
bilaterally. Make sure to palpate in the anatomic snuff box to check
scaphoid for tenderness, this bone is commonly injured in falls onto the
wrist. It can be problematic for non-union in fractures because of its
limited blood supply.

Hand

Tenosynovitis of the thumb abductors and extensors (De Quervain’s Disease). Patient
will probably experience weaker grip strength.

Finkelstein test
Ask the patient to put their thumb inside of their gripped fist, and then
gently push down to ulnar deviate the hand. If pain occurs along the radial
side of the thumb or wrist, the test is positive for tenosynovitis of the thumb
abductors and extensors.
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Thumb Ulnar collateral ligament instability: Sprain of that
ligament results in pain and weakness under stress.

Put a stress on the MCP joint of the thumb by deviating the thumb
radially, any pain or laxity when compared to the opposite hand
indicates instability.

Grind Test: To perform the grind test for thumb carpometacarpal arthritis, ask the
patient to rest the hand palm up on the examination table with the thumb in palmar
abduction. Grasp the metacarpal base, apply a slight longitudinal axial load, and rotate
the thumb carpometacarpal joint. This is painful in patients with arthritis of this joint.

Student Handout: MSK Neck and UE Exam

NECK General If Indicated….

Inspection (symmetry, deformities, swelling, TMJ-jaw deviation
erythema, lesions, check TMJ-jaw deviation)
General palpation (spasm, redness, sweat, Palpation of any MSK area of
masses, check TMJ-tenderness) pain TMJ-tenderness
Active OR passive ROM TMJ- clicking, popping, opening width
(flexion, extension, side-bending, rotation, Special Tests:
check TMJ- clicking, popping, opening width)  Compression test
 Spurling’s Maneuver
 Distraction test (when would you
do this?)
Osteopathic

ELBOWS General If Indicated…

Inspection (symmetry, deformities, swelling,
erythema, lesions, always compare both sides)
General palpation Palpation of any MSK area of pain

Active OR passive ROM Elbow ROM

(flexion, extension, supination, pronation)  Varus/Valgus Stress
 Medial/lateral Epicondylitis
Osteopathic

WRIST/HAND General If Indicated…

Inspection (symmetry, deformities, swelling,
erythema, lesions, always compare both
sides)
General palpation Palpation of any MSK area of pain

Active OR passive ROM Wrist/Hand Tests

ROM (wrists: flexion, extension, radial devia-  Finkelstein
tion, ulnar deviation. Fingers: abduction, ad-  Ulnar collateral ligament
duction, extension, opposition (thumb))  First carpometacarpal grind
Osteopathic

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 SHOULDERS General If Indicated…
Inspection (symmetry, deformities, swelling,
erythema, lesions, always compare both
sides)
General palpation Palpation of any MSK area of pain

Active OR passive ROM Shoulder special tests:

(abduction, adduction, flexion, extension, inter-  Supraspinatus
nal rotation, external rotation. Can do Apley’s  Empty can
Scratch test)  Drop-Arm (when is this helpful?)
 Infraspinatus
 Resisted external rotation
 Subscapularis
 Lift-Off
 Bear hug
 Impingement
 Hawkins (supraspinatus,
long head biceps)
 Neers (subacromial impingement)
 AC Joint
 Crossover
 Labrum
 O’Briens
 Biceps
 Speeds test
 Yergason’s test
 Glenohumeral dislocation
 Apprehension test
Osteopathic  Spencers
 Cervical spine
 Upper thoracic spine
 Radial head

Questions:
1. Name the muscle groups that make up the “rotator cuff”.

2. What muscle does the “Drop Arm” test help you to assess?

3. Explain when a “Distraction Test” is helpful.

4. Pain elicited while doing general palpation in any MSK area of testing should prompt what
maneuvers?

118
 5. What items would go on a problem list for this patient?

6. What other dermatological findings might you find on this patient besides the rash on elbows
and neck?

Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Detailed MSK exam
 Osteopathic exam
 Assessment:
1. CC: ________________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of ________________________
 Plan:
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

NOTES

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 MSK: Back and Lower Extremities
(Bates 12th edition pp. 666-695)

History:

 Joint pain: articular or extra-articular, acute or chronic, inflammatory or non- inflammatory,

localized or diffuse
 Joint pain: associated constitutional symptoms and systemic manifestations from other organ
systems
 Neck pain
 Low back pain
 History of trauma? Mechanism of injury

Exam components:

 Inspection
Note symmetry, deformities, skin changes, scars, lesions, muscle atrophy and signs of
inflammation, such as redness, swelling or induration.
 Palpation
Note palpable lesions (i.e. nodules), muscle atrophy, swelling, crepitus, warmth, tenderness
and areas of muscle spasm.
 Range of Motion
Active: The patient independently takes his/her joint(s) through a full range of motion.
Compare both sides observing limitations in ROM and laxity.
Passive: The examiner takes the patient’s joint(s) through its range of motion. Compare both
sides

Back
Inspect
Inspect the patient standing- look at skin, muscles, symmetry. Check
spinal alignment: examiner has the patient flex forward and then
palpates down the patient’s spinous processes to check for alignment of
the vertebrae. Examiner views the spine primarily posteriorly but also
from the side to view any obvious asymmetry. Look for unilateral
paravertebral muscle elevation (rib humping) – this may indicate a
scoliotic curve

Palpate
All the spinous processes and thoracolumbar paravertebral muscles for tenderness or spasm.
All sacroiliac articulations for tenderness.

Percuss
Along the spinous processes of the vertebrae. Examiner can use either the fist or percuss
with fingers to check for tenderness.

120
Range of Motion

Active ROM:
Be sure to stabilize the patient at the hips with ROM.

Flexion:
patient bends forward with knees extended

Extension:
patient arches back (bend backwards from waist)
Be sure to stand behind the patient to protect from
falling.

Side Bending:
patient’s arm slides down the lateral aspect of corresponding leg

Rotation:
patient rotates each shoulder forward as the examiner stabilizes the hips

Lower Extremities
Hips
Examine bilaterally!!!

Inspect

Palpate

Range of Motion

Evaluate full extent in passive ROM: (Patient supine, Draping is important here!)

Abduction:
patient’s straightened leg is taken away from the midline of the body

Adduction:
patient’s straightened leg is taken across the midline of the body under the other leg

Flexion:
patient’s knee is bent and leg is lifted up to his chest

Extension:
tested by having the patient turn on their stomach and the examiner lifts either
straightened leg or one that is flexed at the knee to the ceiling. Another method is to
have a supine patient drop a leg (from the hip) off the side of the exam table.

121
 Internal rotation:
With the knee fully extended, the foot is rotated medially. OR, if the hip and knees are
flexed to 90o (while patient is lying supine), rotate the lower leg laterally. Think about
the acetabulum movement.

External Rotation:
With the knee fully extended, the foot is rotated laterally, OR, if the hip and knee are
flexed to 90o (while the patient is lying supine), rotate the lower leg medially.

Additional testing (if indicated)

If the patient has complaints of pain and or weakness then examiner can do resisted muscle
testing to see if pain is reproduced, this is NOT strength testing.

**{Strength testing is done for neurological screening (UE: bicep/triceps flexors/extensors,

forearm flexors/extensors. LE: hip flexors/extensors, knee flexors/extensors). Testing is for
maximal effort and is graded 0-5.}**

Adductors:
Patient seated: The patient pushes their thighs inward medially against the examiner’s
hand resistance. Can do both sides at the same time.

Abductors:
Patient seated: The patient pushes their thighs outward against your hands. Can do
both sides at the same time. Testing gluteus medius and minimus

Flexors:
patient seated: The patient tries to lift their leg up to the sky against the examiner’s
resistance to check iliopsoas. This is tested one leg at a time.

Extensors:
Patient seated: Place a hand under one thigh. Ask the patient to push their thigh
downward. Gluteus maximus is tested with this maneuver. This is tested one leg at a
time.

Internal rotators:
This test best done with patient supine. Bend the hip and knee to 90 degrees. Support
the upper leg/hip and rotate the leg so that the foot swings laterally and the femur
rotates internally at the hip. Have the patient turn the leg against your resistance in the
opposite direction.

External Rotation:
This test best done with patient supine. Bend the hip and knee to 90 degrees. Support
the upper leg rotate the leg so that the foot swings medially and the femur rotates
externally at the hip. Have the patient turn the leg against your resistance in the
opposite direction.

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Knees

Inspect
Genu valgum (knock knee) or varum (bow leg)?

Palpate

Range of Motion (active and/or passive)

(Patient supine, or if seated make sure they can fully flex the knee without running in to the
exam table.)

Flexion:
Patient fully bends knee

Extension:
Patient straightens knee
Tip: Knee flexion and extension can be accomplished passively at the same time the
examiner tests ROM.

Additional testing (if indicated):

This is done to evaluate if there is reproducible pain when muscle groups are activated.
Again, this is NOT strength testing:

Extension:
Patient extends at the knee while the examiner resists holding the lower anterior leg.
Tests quadriceps.

Flexion:
Patient flexes knee while examiner resists holding the posterior aspect of the lower leg.
Tests hamstrings.

Ankle

Inspect

Palpate

Range of Motion (active and/or passive):

Dorsiflexion:
Patient’s foot point to the ceiling

Plantar flexion:
Patient’s foot points downward to the floor.

Inversion:
Stabilize the lower leg and bend the foot inward.

Eversion:
Stabilize lower leg (as with inversion) and bend the foot outward.

123
 Additional testing (if indicated)
This is done to evaluate if there is reproducible pain when muscle groups are activated:

Dorsiflexion:
Patient’s foot points to the ceiling while patient resists examiner.

Plantar flexion:
Patient’s foot points downward to the floor while patient resists examiner.

Inversion:
Stabilize the lower leg and bend the foot inward while patient resists examiner.

Eversion:
Stabilize lower leg (as with inversion) and bend the foot outward while patient resists
examiner

Foot
Inspect

Palpate

Range of Motion (active and/or passive)

Inversion:
stabilize heel, invert (inward) foot at mid-tarsal joint

Eversion:
stabilize heel, evert (outward) foot at mid-tarsal joint. It is very important that the
examiner instructs the patient correctly, uses correct hand placement at the ankle joint
and takes the patient’s foot into inversion and eversion (not medial and lateral deviation
when testing for motion of the ankle and foot).

Gait
Evaluate for gait: (the patient should take several steps of each without shoes)

 Walking normally across the floor

 Walking on Toes
 Walking on Heels
 Walking in Tandem (heel to toe in a straight line)
 Hopping on each Leg in place if possible to test leg strength and cerebellar function. Stepping
up on a stool is an alternative.

Stance
when the foot is on the ground and bears weight (60% of the walking cycle)

Swing
when the foot moves forward and does not bear weight (40% of the cycle)

124
 Special Tests (if indicated)
Students are to become familiar with these tests and their diagnostic purposes. The simulated
patient experiences will only require the student to perform a few select techniques as well as be
responsible for the material on the written exam.

Hip
Trendelenburg test
Evaluates gluteus medius for weakness. First, observe the PSIS
dimples while the patient is standing on both legs. Next have
patient stand on one leg. Normally, the gluteus medius on
standing leg side should contract elevating pelvis on opposite
side (negative test). If the pelvis drops on the raised leg side,
this reveals a weakened gluteus medius (positive test) on the
side of the standing leg.

Thomas test:
For flexion contractures of the iliopsoas. Flex hip(s) with patient
supine so thigh touches abdomen. Then upon extending one
hip, it should lie flat on the table. The test is positive (abnormal)
if hip does not fully extend to lie flat.

Straight leg raising test

Tests for sciatica or central lumbar nerve impingement
(Sciatica=irritation of sciatic nerve)

The examiner stabilizes one hip

(either side), then lifts the patient’s
leg while straight and relaxed
upwards as far as the patient can
comfortably go or to about 60°. If
the patient complains of
reproduction of their pain up to 60°
it supports a central lumbar or
125
 sacral nerve irritation. Dorsi-flexing the foot may exacerbate the radicular pain. Irritation from
sciatica is often identified between 40-60 degrees of hip flexion. Pain initiated with more hip
flexion is often due to tight hamstrings.

Patrick or Fabere Test

Hip Joint

Flexion ABduction External Rotation

The patient is lying supine. The foot of the involved side is placed
on the opposite knee. The hip is now flexed, abducted, and
externally rotated. Increase the range of motion by pressing one
hand down on the knee and another hand on the opposite ASIS.
This may represent sacroiliac joint pathology.

FADIR Test

Flexion ADDuction Internal Rotation

Patient is lying supine. Examiner raises one leg with hip flexed to 90
degrees and knee flexed to 90 degrees, then adducts and internally
rotates the hip (foot and ankle rotated away from midline. This may
represent femoral acetabular impingement.

Knee
Anterior and Posterior Drawer tests
Tests for cruciate ligament instability.

Place the knee into 90 degrees of flexion with the patient

lying on their back. Pull or push on the tibia with both hands
to attempt to slide it forward and backward with respect to
the femur. More than 2 cm of anterior or posterior motion
between the patella and the tibial plateau indicates
instability of either the anterior (forward motion) or posterior
(backward motion) cruciate ligament.

Lachman test:
 Knee flexed 15˚ and externally rotated
 Grasp femur with one hand and tibia with other hand.
 Move femur and tibia in opposite directions
 Forward movement of tibia against femur suggests positive test
= ACL tear

126
Varus and Valgus stress tests:
Tests medial & lateral collateral ligaments: MCL and LCL

These tests look for increased motion (laxity) and pain of

the ligament usually due to injury or partial tear of the
ligaments. When these “adduction (varus) or abduction
(valgus) stress tests” do not affect the stability of the joint,
the patient is said to have ‘intact” collateral ligaments. A
valgus stress is where you push medially on the knee
while abducting the lower leg to test the MCL. With varus
stress you push laterally on the knee and adduct the
lower leg to test the LCL. These tests are done with the
knee is slight flexion.

Apley’s Compression Test

Tests for injury to the menisci of the knee.

Patient prone with knee flexed to 90˚. Stabilize the thigh with one hand while pushing down
onto the heel to compress the medial and lateral menisci. Rotate heel during compression
noting any pain.

McMurray’s test
To test the medial meniscus, the examiner palpates the postero-medial joint line of the knee
while extending the knee and externally rotating the tibia. A valgus stress is also applied.

To test the lateral meniscus, the examiner palpates the postero-lateral joint line while
extending the knee and internally rotating the tibia. A varus stress is also applied.

Thessaly’s Test
More sensitive meniscal test than McMurray.

With the patient standing and holding on to you for balance, lift
the affected leg and bend the leg now standing on about 5
degrees. Apply internal and external rotation through the hips
creating a standing grind on the meniscus. Repeat on the same
leg at 20 degrees. Then test the affected side. Testing for
meniscal tears.

127
 Patellofemoral Grind Test
Evaluates for chondromalacia or patellofemoral syndrome.

Patient lies supine with knee extended. Then compress patella against femur
and instruct the patient to tighten the quads. Assess for roughness of motion,
crepitus, and pain.

Apprehension Test
Evaluates for recent patellar dislocation. Patient supine.

While watching their expression, gently grasp patella and slowly move medially and laterally.
Significant apprehension or guarding is a positive test and may indicate a dislocation injury.

Ballottement test
Evaluates for major fluid or effusion in or around the knee joint.

Carefully extend the patient’s knee and instruct to relax the

quadriceps muscle. Push the patella sharply against the femur.
Watch for fluid returning to the suprapatellar pouch.

Bulge sign (for minor effusions)

With knee extended, place the left hand above the knee and apply pressure on the
suprapatellar pouch, displacing or “milking” fluid downward. Stroke downward on the medical
aspect of the knee and apply pressure to force fluid into the
lateral area. Tap the knee just behind the lateral margin of the patella with the right hand.

Balloon sign (for major effusions)

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. Feel for fluid entering (or
ballooning into) the spaces next to the patella under your right thumb and index finger.

Thompson’s Test
Evaluates for Achilles rupture. Patient prone with foot extending off the table. Squeeze the
calf and observe for plantar flexion of the foot. Lack of plantar flexion indicates an Achilles
rupture. Compare to unaffected side.

Ankle

128
 Anterior Drawer Sign of the Ankle:
To evaluate for joint instability of the ankle, which
involves the anterior talofibular ligament.

With the patient sitting on edge of table, grip the

calcaneus in the palm of
one hand and the lower tibia with other. Pull the
calcaneus forward while pushing tibia posterior. In a
normal ankle there should be no movement. A positive
test is > 5 mm displacement or pain.

Talar Tilt (Also called the inversion stress test)

To evaluate the calcaneofibular ligament, the anterior talofibular
ligament and the posterior talofibular ligament (depending on the
position of the foot).

With hands in same position as for the drawer test you invert the heel
instead of pulling the calcaneus forward. In plantarflexion with inversion
you are testing the anterior talofibular ligament; in neutral position with
inversion you are testing the calcaneofibular ligament; in dorsiflexion
with inversion you are testing the posterior talofibular ligament.

Ankle: External rotation Stress Test (Kleiger Test):

Patient seated. Stabilize leg with one hand and cup the heel with the other
hand. This tests for two different things: if you plantar flex the foot and
then evert, this tests the deltoid ligament. If you dorsi-flex and externally
rotate there will be pain in the anterior tibiofibular ligament or the
interosseous membrane (high ankle sprain).

Squeeze Test:
(this test is also for high ankle sprain)

Squeeze the tibia and fibula between your hands and see if there is pain in the tibiofibular
ligament area or higher along the interosseous membrane.

129
 Student handout: MSK Back and LE Exam
BACK General If Indicated….
Inspection (observe the spine with patient
standing, check alignment, paravertebral mus-
cle fullness, symmetry)
General palpation (spinous processes, Palpation of any MSK area of
paravertebral muscles, sacroiliac articulations) pain
Active OR passive ROM Special Test:
(stabilize the hips)  Straight leg raise
Osteopathic

HIPS General If Indicated…

Inspection (symmetry, swelling, lesions)

General palpation (tenderness) Palpation/resisted muscle testing of any MSK

area of pain
Active OR passive ROM Hips
(*best with patient supine: abduction, adduc-  Gait
tion, flexion, extension, internal rotation, exter-  Trendelenburg
nal rotation)  Thomas
Remember proper draping!  FABER/FADIR
Osteopathic

KNEES General If Indicated…

Inspection (swelling, effusion, lesions, deformi-
ties, erythema, symmetry, always compare
both sides)
General palpation (tenderness) Palpation/resisted muscle testing of any MSK
area of pain
Active OR passive ROM Knees
(flexion, extension) Anterior/posterior Drawers or Lachman’s
Varus/Valgus
Thessaly or McMurray
Apley’s Compression test
Apprehension
Patello-femoral Grind
Palpate for effusion
Lower leg
Thompson
Osteopathic:

130
 ANKLES General If Indicated…
Inspection (swelling, lesions, deformities, ery-
thema, symmetry, always compare both sides)
General palpation Palpation/resisted muscle testing of any MSK
area of pain
Active OR passive ROM Ankle
(dorsiflexion, plantarflexion, eversion, inver-  Kleiger
sion)  Squeeze Test
 Talar Tilt
 Drawer
Osteopathic

Questions:

1. What does a ‘positive’ Trendelenburg test tell you?

2. What tests would you do to evaluate a patient that you suspect has SI joint pathology?

3. A patient has knee pain with instability, what is the most likely area of the knee that is
compromised?

4. Where should the examiner stand when evaluating the patient’s back in active and passive
ROM?

5. What other dermatological findings might you look for in this patient besides the rash on his
elbows and the back of his neck?

Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Detailed Back and LE MSK exam
 Osteopathic exam

131
 Assessment:
1. CC:__________________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of ____________________
 Plan
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

NOTES

132
 Neuro Part I: Peripheral Nervous System
(Bates 12th edition pp: 711-732, 741-767)

History:

 Weakness (generalized, proximal or distal)

 Numbness, abnormal or absent sensation
 Pain

Exam Components:

 Inspection
 Palpation
 Strength Testing
 Reflex Testing
 Sensory Testing

Inspection
Compare symmetry and contour of muscle mass for upper and lower extremity muscle groups.
Observe and comment on atrophy and fasciculations.

Palpation
Check for tenderness, masses and swelling.

Strength Testing
Muscle tone

Assess best through passive ROM. Increased muscle tone can be observed by noting spasticity,
ankle clonus or rigidity in a muscle group which may be due to an upper motor neuron (UMN)
lesion. Decreased muscle tone can be observed by noting hypotonia or a flaccid extremity which
may be due to a lower motor neuron (LMN) lesion. Rigidity is the increased resistance
throughout the range of motion. Somatic dysfunction may have hyper- sympathetic tone.

Muscle strength

Test muscle groups (extensors and flexors) in the upper and lower extremity using active ROM
against your resistance. Muscle strength is graded 0-5 with 5/5 representing normal, full function.

Muscle strength grading 0-5

0 No muscular contraction detected

1 Barely detectable or trace of a muscle contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity with some resistance
5 Active movement against full resistance of the examiner.
This is normal muscle strength
133
Remember that a muscle is strongest when shortest, and weakest when longest. Give the patient the
advantage as you try to overcome the resistance and judge true the muscle’s true strength. Some
patients give way during tests of strength due to pain, misunderstanding of the test, an effort to help
the examiner, conversion disorder, or malingering.

Grip Strength (“squeeze my fingers”)

The examiner places the index and middle finger of the right hand into the right palm of the patient,
and then places the index and middle fingers of the left hand into the left palm of the patient and
crosses the patient’s forearms. The patient is asked to squeezed the fingers of both hands
simultaneously. This tests grip strength and reduces the likelihood of malingering because of the
visual cue confusion that is produced by the hand crossing. It is also good to test thumb strength
through resisted effort in flexion.

Muscle Weakness
Proximal muscle weakness is often due to muscle disease. Distal muscle weakness is often due
to central nervous system disease.

All muscle groups are innervated by specific nerve roots. See below.

Common Muscle Groups and their Nerve Roots

1. Shoulder abduction – C4
2. Elbow flexion – C5, C6, biceps
3. Elbow extension – C6, C7, C8, triceps
4. Wrist extension – C6, C7, C8, radial nerve
5. Finger flexion (hand grip) – C7, C8, T1
6. Finger abduction – C8, T1, ulnar nerve
7. Thumb opposition – C8, T1, median nerve
8. Hip flexion – L2, L3, L4, iliopsoas
9. Hip adduction – L2, L3, L4, adductors
10. Hip abduction – L4, L5, S1, gluteus medius and minimus
11. Hip extension – S1, gluteus maximus
12. Knee extension – L2, L3, L4, quadriceps
13. Knee Flexion – L4, L5, S1, S2, hamstrings
14. Ankle dorsiflexion – L4, L5,
15. Plantar flexion – S1

Reflex testing
There are 2 types of reflexes, superficial and deep tendon reflexes. Deep tendon reflexes are
graded on a 0-4 scale, with a normal reflex described as 2/4 or 2+/4+. The reflex hammer is held
between the thumb and index finger and is swung by a lose motion of the wrist (like throwing a dart)
producing a gentle tap over the tendon tested.

Always compare one side of the body to the other when testing reflexes, as they should be equal
responses. Hyperactive deep tendon reflexes usually are indicative of CNS lesions, while
hypoactive or absent deep tendon reflexes often represent PNS lesions. A reflex of 0 is usually
pathologic, but a reflex of 4 is always pathologic.
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DTR’S

Deep Tendon Reflex Grading Scale

Grade Description
0 Absent
1 Hypoactive, Diminished
2 Normal, Average
3 Hyperactive, Brisk
4 Hyperactive with clonus

Biceps
The patient’s arm should be partially flexed at the elbow and the examiner’s thumb or
finger placed on the biceps tendon. Strike with the reflex hammer so the blow is aimed
at the digit and observe for flexion of the elbow and the contraction of the biceps
muscle. Tests nerve roots C5-C6.

Triceps
Relax and flex the patient’s arm at the elbow. Support the arm with the arm held
horizontal and the forearm hanging vertically. Strike the triceps tendon about 1-2
inches above the elbow. Observe for contraction of the triceps muscle and extension of
the elbow. Tests nerve roots C6-C7.

Brachioradialis
Relax, flex and partly pronate the patient’s arm in their lap. Strike about 1- 2 inches
above the styloid process of the radius and observe for flexion and supination of the
forearm. Tests nerve roots C5-C6.

Patellar
With the patient seated, let the leg dangle off the table with the knee flexed. Briskly
strike the patellar tendon just below the patella. Observe
for contraction of the quadriceps with extension of the knee. Tests for nerve roots L2,
L3 and L4.

Ankle
With the patient seated, let the leg dangle and gently dorsi-flex the ankle while striking
the Achilles tendon just above the its insertion into the calcaneus. Observe and feel for
plantar flexion of the foot and ankle. Tests nerve root S1.

Ways to improve DTR results:

Reinforcement: Called the Jendrassik maneuver. An action that enhances the
spinal reflex of a deep tendon reflex by engaging muscles above the level of the
reflex to be tested at the moment of testing. This muscle use counters some of
the normal descending inhibitory brainstem input to reflex arc interneurons
allowing more signal through the spinal reflex arc for a visible response. The
most common areas where this is used are bicep and patella. Compare the
response on both sides. Just prior to hammer strike:

 For upper extremity DTR’s:

Have the patient scrunch his/her face.

135
  For lower extremity DTR’s:
Have the patient pull against hands clasped in front of him/her.

Superficial Reflexes

Abdominal
With the patient supine, the examiner lightly but briskly strokes each quadrant of the
abdomen with a tongue blade in a lateral to medial direction. Observe for the
contraction of the abdominal muscles and deviation of the umbilicus toward the
stimulus. Tests nerve roots T8, T9,
T10 above the umbilicus and nerve roots T10, T11, T12 below the umbilicus.

Plantar
Use the handle of a reflex hammer or tongue depressor to stroke the lateral aspect of
the sole of the foot from the heel to the ball of the foot. Observe the movement of the
toes. Dorsiflexion of the big toe is an abnormal finding, often accompanied by fanning
of the other toes, this
constitutes a “Babinski response”. It often indicates an upper motor neuron lesion in
the corticospinal tract or brain.

Negative Response (down going) Positive Response (up going)

Ankle Clonus:
Repetitively dorsi-flex the patient’s foot several times and then hold it in the fully dorsi-
flexed position to observe and feel the foot for rhythmic oscillations. If positive, this may
be an indication of CNS disease.

Hoffmann’s Reflex:
This test involves loosely holding the middle finger and flicking
the fingernail downward, allowing the middle finger to flick
upward reflexively. The test is considered positive if there is
flexion of the interphalangeal joint of the thumb, with or without
flexion of the index finger proximal or distal interphalangeal
joints. Indicates possible lesion in the corticospinal tract.

Anal Wink:
Level S3, S4, S5

Cremasteric Reflex
Level L1, L2

136
Sensory Function Testing

Common muscles and their sensory nerve root innervations (dermatomes):

1. Shoulder muscles (C4)
2. Inner and outer aspects of the forearms (C6 and T1)
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2)
5. Medial and lateral aspect of both calves (L4 and L5)
6. Little toes (S1)

Testing needs to compare symmetric areas on each side of the body, including the arms, legs and
trunk. Always explain and show the patient how these tests will be performed with the patient’s eyes
open, and then perform each test with the patient’s eyes closed. When testing pain, temperature
and light touch sensation, the examiner must compare the distal with the proximal areas of each
extremity. Loss of distal sensory function typically occurs before any proximal loss.

137
Light touch
Use a wisp of cotton, monofilament, or finger pads to gently touch the patient’s skin bilaterally.
Circumferential testing of upper and lower aspects of the arms and the legs will encompass
both dermatomes and peripheral cutaneous distributions. Map out any areas that are reported
numb or with altered sensation.

Pain or temperature sensation (spinothalamic, cross at same level, unmyelinated crude

sensation)

For testing pain: use a “broken” cotton tipped applicator stick to test between sharp
and dull sensation at the distal upper and lower extremities. Never use a safety pin to
perform this test.

For temperature: assess by testing with a cold metal object like the handle of your
reflex hammer. The same nerve fibers carry both pain and temperature sensations.
Testing for both increases sensitivity of the test.

Vibration sense (posterior column, cross at medulla, myelinated highly refined sensation)

Using a 128-hertz tuning fork, tap the tines of the tuning fork on your hand to start the
vibrations and then place the end of the tuning fork on a distal extremity bony
prominence bilaterally. Ask the patient what they feel rather than coach the patient
by asking if they feel the vibration, or confirming when they feel it, have them
indicate when it stops, eyes closed, when you stop the fork from vibrating. If
normal you may assume the more proximal areas will be normal. (posterior columns
and peripheral neuropathy –B12 deficiency and diabetes)

Proprioception (position sense- posterior column)

Gently grasp the patient’s thumb or big toe, holding it by its sides between your thumb and
index finger. Demonstrate “up and down” as you move the digit slowly upward and
downward. Then with the patient’s eyed closed, ask for a response of “up or down” when
moving the digit. (posterior columns and peripheral neuropathy)

Discriminative Sensations:

Tests ability of the sensory cortex to correlate, analyze and interpret sensations.

Extinction
Simultaneously touch two corresponding areas on both sides of the body. Ask where
the patient feels your touch. Normally both sides are felt. If the patient only feels one
side, extinction of sensation is present. (sensory cortex)

2-point discrimination
Using the two ends of an opened paper clip or two sticks from a cotton swab, touch the
finger pad in two places simultaneously. Find the minimal distance at which the patient
can discriminate one from two points (normally less than 5 mm on the finger pads). The
test may be used on other body parts, but normal distances vary widely from one body
region to another. (sensory cortex)

138
 Stereognosis
The patient is asked to close their eyes and then a common object is placed in the
hand and the patient is asked to identify the object by feel. Example-use keys, watch,
coins, pens, etc. An abnormality can represent a problem in the integration of function
between the parietal and occipital lobes.

Graphesthesia
Ask the patient to identify a number or letter written in the palm of the hand with the
eyes closed. Orient the letters or numbers towards the patient. This test evaluates for
parietal lobe lesions.

Special Tests for Peripheral Neuropathies

Thoracic outlet syndrome

“Roos” Test
Arms abducted to 90°, externally rotated with elbows bent at
90°, and extended to feel tension across the chest. Then the
patient slowly opens and closes his hands for 2 or 3 minutes. If
there is weakness, numbness or tingling of the hand or arm the
test is positive.

Carpal Tunnel Syndrome

Compression of the median nerve as it passes through the carpal tunnel. Irritation of the nerve
causing symptoms confirms the diagnosis.

Tinel’s sign
Can be performed over many nerves. Below are examples of
Tinel’s signs over the median nerve running through the carpal
tunnel and the ulnar nerve running behind the medial epicondyle
of the elbow. The examiner taps over the nerve with their finger or
reflex hammer. It is a positive test if pain or tingling is elicited in
the distribution of the nerve.

Phalen’s Test
Evaluates for median nerve entrapment in the carpal tunnel.

Place the back of your hands together completely flexing the wrists
for a total of 1 minute. If numbness occurs in the distribution of the
first 3 digits, the test is positive.

Prayer Test
The same result can be obtained by dorsi-flexing the wrists and putting
the palms together in a “praying position”

139
 Student handout: PNS Exam Laboratory
General If Indicated…
Inspection: (atrophy, swelling,
deformities)

General palpation: (focus on the involved area)

Strength Sensation: eyes closed

 Flexors and extensors UE  2‐point discrimination
 Bicep  Toe proprioception
 Tricep  Temperature
 Forearm Flexors
 Forearm Extensors
 Hands
 Flexors and extensors LE
 Hip flexors
 Hip extensors
 Quadriceps
 Dorsiflexors
 Plantar flexors
DTR DTR
 Upper Extremity Upper extremity reinforcement
 Bicep Lower extremity reinforcement
 Brachioradialis Babinski: done when in the
 Tricep periphery but reflects CNS lesion
 Lower Extremity  Clonus: done when in the
 Patellar periphery but reflects CNS lesion
 Achilles  Hoffmann’s test
Sensation: eyes closed SPECIAL TESTS:
 Soft and sharp  Tinels
 Dermatomes  Phalens
 Peripheral cutaneous  Prayers
- UE and/or LE  Roos
 Vibration
 Distal boney prominence, bilateral
- UE and/or LE
Osteopathic:

Questions:

1. Name seven significant risk factors for stroke.

2. What important components in strength testing create a more sensitive exam?

3. Describe the method to perform an appropriate toe or thumb proprioception exam.

140
 4. What items would go on a problem list for this patient?

Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Detailed PNS exam
 Osteopathic exam
 Assessment:
1. CC: _________________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of ________________________
 Plan
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up

NOTES

141
 Neuro Part II: Central Nervous System
Mental Status, Cerebellum, and Cranial Nerves
(Bates 12th edition pp. 735-740,769-773)

History:

 Headache
 Dizziness or Vertigo
 Syncope and Near-syncope
 Seizures
 Tremors or involuntary movements
 History of head trauma

Exam Components:

 Mental Status Examination

 Cranial Nerves
 Cerebellum (includes gait testing if possible)

142
 The Mental Status Exam: “LOL AMEN”
Level of Consciousness (LOC)(fully alert, lethargic/sleepy, stuporous, comatose)
Orientation (person, place, time)
Language (spontaneous/fluent/articulation, comprehension/commands, naming, repetition)

***These first three may be sufficient in most cases***

Attention (digit span, spelling, months/days forwards/backwards)

Memory (anterograde (recent), retrograde (distant))
Executive/Intellectual function (verbal fluency, similarities, proverbs, estimates)
Non-dominant Hemisphere (visual-spatial and construction skills, neglect, music)

LOC

 Alert: fully awake without stimulation, and able to cooperate in a history and PE
 Lethargic: pt. prefers to sleep but will stay awake with minimal verbal or physical
stimulation.
 Stuporous: pt. requires repeated physical stimulation to stay awake
 Comatose: a sleep-like state in which the patient cannot be awakened: no further mental
testing is possible.

Orientation

 Test for Person (name), Place and Date (time)

 Can also add fourth factor: awareness of the reason for being in the hospital or doctor’s
office.
 Documentation: “AOX3” which is a minimum mental status exam for patients with no
apparent neurological disease.

Language
Describe the patient’s language, articulation, rate of speech, use of loud or soft voice, fluency,
quantity of talking, organization of thoughts and sentences (have patient repeat words or simple
phrases, read a paragraph, write a sentence, carry out a three-step function, name some simple
objects)

 Aphasia (dominant hemisphere impairment)

 Broca’s aphasia –retained understanding, brief “telegraphic” output, frontal lobe
 Wernicke’s Aphasia- fluent, poor understanding, superior temporal lobe
 Anomia – inability to name objects and inability to repeat
 Agraphia- limitations in writing
 Dysarthria: slurred or thick speech

Attention
 Months of the year (or days of week) forward and then backward
 Serial sevens
 Read a series of letters, have patient raise his/her hand when they hear the letter A

143
  Have patient spell “WORLD” backwards

Memory

 Test recent memory: Remember 3 words, then repeat them after approximately 3-10
minutes. (recalling 0 or 1 word on two attempts is pathologic). Can also ask other
questions like “how long have you been in the hospital?” (make sure it is something you
can verify)
 Test remote memory: Can you name some recent presidents?”, When did Vietnam War
occur? When did you graduate from high school? When did you get married? (Again,
make sure these are things you can verify.)

Executive Function (loss of executive function is diagnostic of dementia)

Can be tested in many ways: recent news events, recalling recent presidents,
general fund of knowledge distances, geography) determining similarities of two objects,
interpretation of common proverbs.

 Apraxia
 Agnosia.
 Hemispatial neglect: no appreciating that there are people or objects in the left side of the
room or on the left side of a drawing of photograph in spite of normal vision.
 Anosognosia: inability to recognize hemiparesis in a patient’s left arm or left leg (common
after a stroke)
 Dressing agnosia: inability to button clothes or put an arm in a sleeve on the left side, or
shave or put makeup on the left side of the face.

Non-dominant (right) hemisphere

Test by having the patient draw or copy simple and then increasingly complicated figures such as a
circle, a square, a cube, a hose or a clock with all the numbers.

 Parietal lobe: visual-spatial skills, constructions, awareness of one’s own body especially
to the left visual field
 Temporal lobe: loss of musical abilities, tendency to psychiatric disturbances (psychosis,
depression, bipolar, anxiety)
 Occipital lobe: left homonymous hemianopia and prosopagnosia (inability to recognize
faces including one’s own)

144
 The Cranial Nerves
CN I (Olfactory)

Sense of Smell – Present the patient with a familiar odor, i.e.: coffee or vanilla.

CN II (Optic)

Visual Acuity – Test for visual acuity with a Snellen eye chart.

Visual Fields by Confrontation – Compare the examiner’s visual fields to the patient’s visual
fields. See lab session, “Examination of the Eye.”

Optic Fundi – Evaluate the optic fundi with the ophthalmoscope. See laboratory session,
“Examination of the Eye.”

Pupillary Reflexes – Evaluate pupillary response to direct and indirect light. CNII senses the
light.

CN III (Oculomotor)

Pupillary Reflexes – Evaluate pupillary response to light direct (into the eye evaluating) and
indirect (opposite pupil) and accommodation. CNIII controls the ciliary muscle.

Extraocular Movements – Evaluate the eye movements in the six cardinal directions (see
chart below). Check for convergence of the eyes. Identify any loss of motion or nystagmus.
CNIII controls the levator palpebrae, superior and inferior rectus, inferior oblique, and medial
rectus. (see examination of the eye)

145
CN IV (Trochlear)

Extraocular Movements – CNIV controls the superior oblique muscle which causes the eyes
to look down and outward. (see examination of the eye)

CN V (Trigeminal)
Motor Branch – Palpate the temporal and masseter muscles and ask the patient to clinch
their teeth. Note the strength of the muscle contraction.

Sensory Branch – Use a suitable sharp object to test for light touch and pain sensation
bilaterally for the distribution of the 3 branches of the trigeminal nerve. Ask patient to report
“sharp” or “dull” and compare sides.

The Corneal Reflex (CN V and CN VII) – Ask the patient to look up and away from the
examiner. With a very fine wisp of cotton, approach the patient from the temporal side and
very gently touch the patient’s cornea. A normal response is the blinking of both eyelids. The
trigeminal nerve senses the stimulus and the facial nerve controls the motor response.

CN VI (Abducens)

Extraocular Movements – CNVI controls the lateral rectus muscle. Check for ability of the
eyes to laterally deviate. Identify any loss of motion or nystagmus. (see examination of the
eye)

CN VII (Facial)

Motor Function (Facial Movements) – Evaluate upper and lower facial muscle movement
and strength. Ask patient to raise both eyebrows, frown, close both eyes tightly so the
examiner cannot open them, smile and puff out both cheeks.

Sensory Function – Provides taste to the anterior 2/3 of the tongue.

CN VIII (Vestibulocochlear)
Hearing – Patient should be able to hear fingers or hair being rubbed next to each ear. Also
test for lateralization (Weber test) and compare air and bone conduction (Rinne test) with 256
hz tuning fork. See details in Laboratory Chapter on the HEENT exam.

Vestibular Function – Specific testing of vestibular functions are seldom included in the
cranial nerve exam

CN IX and X (Glossopharyngeal and Vagus)

Voice – What is the quality of the patient’s voice? Is it hoarse? Vocal cords are controlled by
CN X.

Movements of the Soft Palate – Ask the patient to say “ah” and observe the symmetrical rise
of the soft palate and uvula. The uvula should remain in the midline.

146
 Gag Reflex – The examiner uses a tongue blade to touch both sides of the oropharynx to
elicit a gag. Sensation is provided by CN IX and the motor response is provided by CN X.

CN XI (Spinal Accessory)

Shoulder and Neck Movements - Innervates the sternocleidomastoid (SCM) muscle and
trapezius muscle. The motor function is assessed by asking the patient to shrug their
shoulders and by turning the head against resistance bilaterally.

CN XII (Hypoglossal)
Tongue Symmetry and Position – Patient is requested to stick out their tongue and note the
position (midline or deviated) and any atrophy or fasciculation. Ask the patient to move the
tongue side to side.

Cerebellar Function Testing and the Spinal Cord Tracts

The following tests are done to evaluate coordination and the function of the cerebellum.

Finger-to-Nose test – The examiner can hold a finger at arm’s length from the patient and
ask the patient to touch your index finger and then their nose alternately several times. Move
your finger so the patient has to alter directions and extend the arm fully. Observe the
patient’s movements for smoothness and accuracy. In cerebellar disease, the movements
are clumsy, unsteady and vary in speed and force. This is defined as dysmetria.

Heel-to-shin test – Ask the patient to run the heel of one foot down the shin of the other leg.
Observe for smoothness and accuracy of the movements. Repeat on the other leg. In
cerebellar disease, the heel may overshoot the knee and then oscillate from side to side. Also
dysmetria, may cause ataxia.

Rapid Alternating Movements – (dysdiadochokinesia) – The examiner can ask the patient to
flip their hand (one side at a time) rapidly on their thigh or ask the patient to touch their thumb
to each finger (opposition) on their hand as quickly as possible. The inability to perform these
maneuvers is called dysdiadochokinesis.

Romberg test – A test for position sense. The patient stands with feet together and eyes
open and then closes both eyes up to 20 -30 seconds without support. Observe the patient’s
ability to maintain an upright posture. The examiner must protect the patient from any
potential falls. A positive test occurs if the patient cannot maintain full balance with eyes
closed and suggests a lesion in the posterior column of the spinal cord. Cerebellar ataxia
occurs during the Romberg test when imbalance is found prior to closing the eyes.

Pronator drift – Done at the same time as Romberg. The patient stands up to 20-30-
seconds with arms straight forward, palms up and eyes closed. Pronation and downward drift
of one forearm, either spontaneous or with a brisk, downward tap from the examiner on the
arms, suggests a lesion in the corticospinal tract.

Plantar Reflex (Babinski) - Run a moderately pointed instrument (such as a tongue blade or
the back end of a reflex hammer) up the lateral border of the foot and along the forefoot. If the
great toe extends and the other toes splay rather than all the toes flexing, the test is positive

147
 for an upper motor neuron lesion and is often associated with brain damage from trauma or
tumor.

Negative Response (good) Positive Response (bad)

Gait
Have the patient walk back and forth to assess their regular gait. Then have them walk on tip-
toes, then heels, then tandem walk. This assesses balance.

Sample documentation:

normal example: Alert, relaxed and cooperative. Thought process coherent. Oriented to person,
place and time. Detailed cognitive testing deferred. Cranial nerves: I not tested, II – XII intact. Motor:
good muscle bulk and tone. Strength 5/5 throughout. Cerebellar-Rapid alternating movements, finger
to nose, heel-to-shin intact. Gait with normal base. Romberg-maintains balance with eyes closed. No
pronator drift. Sensory: sharp, light touch, position and vibration intact. Reflexes 2/4 and symmetric
for UE and LE bilaterally with plantar reflexes downgoing.

Special Tests: (for meningeal signs)

Brudzinski’s Neck Sign

Kernig’s Sign

Sample documentation:

normal example: Alert, relaxed and cooperative. Thought process coherent. Oriented to person,
place and time. Detailed cognitive testing deferred. Cranial nerves: I not tested, II – XII intact. Motor:
good muscle bulk and tone. Strength 5/5 throughout. Cerebellar- Rapid alternating movements,
finger to nose, heel-to-shin intact. Gait with normal base. Romberg-maintains balance with eyes
closed. No pronator drift. Sensory: sharp, light touch, position and vibration intact. Reflexes 2/4 and
symmetric for UE and LE bilaterally with plantar reflexes downgoing.

148
 Student Handout: CNS Exam Lab
General If Indicated…
Mental Status (LOL AMEN) (AMEN)
LOL: Attention
Level of Consciousness: Digit span: subtract 7 from 100
Alert, lethargic, stuporous, coma- Spelling: WORLD backwards
tose Months/days forward then
Bright, flat, anxious, paranoid… back-
Attentive, cooperative, detached… ward
Orientation: Memory
Person, place and time asked spe- Recent (anterograde)
cifically = A&O x3 vs A&O Remote (retrograde)
Language: Executive function
Articulate Verbal fluency
Fluent Similar
Comprehends commands: simple Proverbs
to harder Non-dominant hemisphere
Naming items Construction
Repetition: repeat this sentence
_________or series of num-
bers
Cranial Nerve Exam
I: Olfactory
II: Optic
III: Oculomotor
IV: Trochlear
V: Trigeminal motor
V: Trigeminal sensory
VI: Abducens
VII: Facial
VIII: Vestibulochoclear
IX: Glossopharyngeal
X: Vagus
XI: Spinal Accessory
XII: Hypoglossal
Cerebellar
 Dysdiadochokinesis:
 rapid alternating movement
 Dysmetria:
 Finger to nose (make pt reach)
 Heel down shin
 Proprioception/Ataxia
 Romberg with pronator drift
(PROTECT Pt.!)
 Balance
 Regular gait
 Tandem
 Walk on toes/heels
Special Tests
o Strait leg raise o Kernig
o Brudzinski o Spurlings
o Distraction o Babinski
o Ankle clonus

149
Questions:

1. How do you properly check for ankle clonus and what is the best way to document your
findings?

2. What are we learning when we perform the ‘Romberg’ test?

3. Name the additional tests that can be performed on your patient that has high fever and
nuchal rigidity?

4. What is the best way to document findings for the Babinski test?

5. What items would go on a problem list for this patient?

Note:
 Due Friday at 5 pm
 Full history
 Focused ROS
 Vitals
 General Assessment
 Detailed CNS exam
 Osteopathic exam
 Assessment:
1. CC: ____________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of _______________________
 Plan
1. Labs or tests (reasons why)
2. Treatments: medication, PT…
3. OMT treatment
4. Pt. education
5. Follow up
150
NEURO TERMS:

Agnosia

Agraphia

Allodynia

Anesthesia

Anomia

Anosognosia

Aphasia

Apraxia

Dysarthria

Dysesthesia

Hemi-spatial neglect

Hyperalgesia

Hyperesthesia

Hypoesthesia

Myopathy

Neuropathy

Paresis

Paresthesia

Plegia

Polyneuropathy

151
NOTES

152
 Pediatric Exam
(Bates 12th edition pp. 799-923)

General Considerations
Be flexible with the sequence of your exam. Begin by examining areas that require a calm infant
such as respiratory and cardiovascular. Save the less tolerated portions such as oropharynx and
ears for later. Examine the area of complaint at the end. You may alter the exam sequence
depending on the age group that you are examining (i.e. children older than 5 years can generally
tolerate the ear/oral exam placed in the sequence with the rest of the HEENT exam). Older children
can often tolerate the adult sequence of examination (head to toe).

Age descriptions
Newborn=first 28 days of life
Infant=29 days to 11 months
Toddler=12 months to 23 months
Child=2 years to 9 years
Preadolescent=10 years to 13 years (10-12 yrs. female; 11-13 yrs. male)
Adolescent=14 years to 18 (21) years

Techniques of Exam
Observation

General appearance, comfort, wellbeing, activity level, body habitus & nutritional status

Developmental milestone assessment

Confirm infant has met appropriate milestones for age. Physical or behavioral signs of
development/maturation of infants and children. Rolling over, crawling, walking, and talking
are considered developmental milestones and provide important information regarding the
child's development. The milestones are different for each age range. These milestones
include physical growth, motor skills (both fine and gross motor), cognitive/behavioral skills,
language skills and social interaction. Refer to the following chart.

153
 Language (expressive/
Age Motor Cognitive/Behavioral Social
receptive)
Full Term  Becomes alert w/ sound
 Fixates on face/
Infant  Moro reflex
of bell/voice
object & briefly
follows
 Follows objects past midline
2 months
 Lifts head & shoulders off bed in prone
position
 Head lag disappears by 5M
 Moro disappears by 3-6M
4 months  Bears weight on forearms while prone  Laughs out loud and squeals
 Imitates social inter-
action
 Rolls from prone to supine
 Bears weight while held standing
 Transfers objects from one hand to another

6 months
 Reaches for objects  Turns directly to sound &  Babbles consonant sounds
 Sits with support voice  Imitates speech
 Rolls over in both directions
 Stranger anxiety
 Bangs 2 blocks together  Turns when name called

9 months  Mama & Dada (nonspecific) Recognizes com-
 Sits without support  Plays peek a boo mon objects & peo-
ple
 Takes a few steps
12 months  Pincer grasp
 Speaks 1 additional word besides  Follows a single
 Assists with dressing Mama & Dada step command with
(1 yrs.)
 Drinks from a cup held by another person
 Mama & Dada specific gesture
 Pulls to stand & cruises
 Gives & takes a ball
 Drinks from a cup  Speaks 3-6 additional words be-
 Scribbles with a crayon sides Mama & Dada
15 months
 Puts cube into a cup  Points to one body part

 Walks independently  Follow single step command without

the need for parental gesture
 Stoops to floor & recovers to standing posi-
tion
 Feeds self with spoon
 Stacks 2 cube tower
18 months  Imitates household chores  10-20 word vocabulary
 Throws ball
 Walks upstairs while holding hand
 Builds a tower of 4 blocks
16-19
months  Releases a raisin into a bottle
 Spontaneous scribbling (18M)
 Builds a tower of 6 cubes
 Greater than 50 words vocabulary
 Washes and dries hands
 Starts using pronouns (I, me, you,
24 months
(2 yrs.)  Removes clothing etc.)
 Kicks ball  Speech is 50% intelligible to
 Jumps with 2 feet
strangers (2/4)

 Copies a circle
 Imitates a vertical line
 Puts on a shirt/shorts drawn with a crayon  Speaks with 5-8 word sentences
36 months  Stacks a tower of 8 cubes  Knows the name of a  Speech is 75% intelligible to
(3 yrs.)
 Stands on 1 foot for 1-2 seconds friend strangers (3/4)
 Pedals a tri-cycle  Understands basic adjec-  Starts using ‘what’, ‘who’
tives (tired, hungry, etc.)
 Climbs stairs alternating feet
 Dresses & brushes teeth  Asks questions: ‘where? Why?
 Walks up and down stairs without help How? What?’
4 years
 can create a simple drawing of a person   Pretend plays
balances in 1 foot for 4 seconds
Names 4 colors  Speech is 100% understandable to
 strangers (4/4)

 Draws a person with 6 body parts  Plays board games

5 years  Prepares a bowl of food  Counts 5 blocks  Defines words
 Skips, alternating feet  Names all primary colors
 Ties shoelaces  Writes name
6 years  Counts 10 objects
 Rides a bicycle  Knows right from left

154
Growth Charts

 Plot weight for age, height for

age, and head circumference for
age at every visit.
 Record results as percentile
range
 Example: girls weight for age
growth chart:
 Measure and record head
circumference until 36 months
 Change over 2 percentile groups
is concerning for growth problems

Respiratory

Inspection:
breathing pattern, skin color, signs of distress (i.e. accessory muscle use, nasal flaring)

Palpation:
along rib angles for masses or tenderness

Percussion:
reserved for older children (see respiratory examination section)

Auscultation:
anterior and posterior posts (see respiratory examination section)

Cardiovascular
Inspection:
Anterior chest for motion (often seen in infants)- AKA precordial activity, inspect skin, nails,
face, & chest configuration. These observations can give you a clue about possible cardiac
problems.

Palpation:
Palpate for precordial activity. Increased activity should raise possibility of pathological
process

Feel for a “thrill” (palpable consequences of blood flowing rapidly from higher to lower
155
pressure)

Compare brachial & femoral pulses bilaterally. Diminished pulses in femoral as compared to
brachial may indicate coarctation of the aorta

Auscultation: (BP not routinely measured in children less than 3 yrs. of age)
Listen with bell and diaphragm at 4 listening posts (see CV exam section). If a murmur is
noted, changing positions (lying flat/seated/standing) can help you distinguish from an
innocent (benign) murmur from a pathologic one. (see CV examination for describing
murmurs

Murmurs:
Physical finding Innocent murmur Atrial septal defect
Precordial activity Normal Increased
First heart sound
Normal Normal
(S1)
Second heart Splits and moves with Widely split and fixed (i.e., does not
sound (S2) respiration move with inspiration)
Crescendo/decrescendo Crescendo/decrescendo
Systolic murmur
(supine) Possibly vibratory at lower left
"Flow" at upper left sternal border
sternal border
Systolic murmur
Decreases in intensity Does not change
(standing)
Inflow "rumble" across tricuspid
Diastolic murmur Venous hum
valve area

Venous hum

 Sound caused by flow of venous blood from head and neck into thorax
 Continuous sound while sitting
 Disappears when light pressure is placed over the jugular vein, when head is turned or
when lying supine
 Common, not pathologic; all other diastolic murmurs are pathologic and need referral to
cardiologist

Still’s Murmur

 Sound made from blood flow as it crosses the valve. Since

infants/children have less tissue between the heart and the
stethoscope these sound
can be auscultated. Diamond shaped murmurs are
crescendo/decrescendo.
 Grade II/VI, musical/
vibratory, mid systolic, Ventricular septal defects (VSD)
LLSB, decreased in intensity are holosystolic (obscures closure
when lying supine. sound of mitral/tricuspid valves).
Common in children and not
S1 = 1st heart sound
pathologic P = pulmonic heart sound
2
A2 = aortic heart sound

156
Abdominal

Observation:
Shape, contour, rashes & presence of hernias

Auscultation:
Listen for bowel sound in all 4 quadrants

Percussion:
See abdominal exam section

Palpation: (see abdominal section ‘palpation’)

Light and deep palpation to identify masses and tenderness. Note size of liver & spleen

Should be able to palpate kidney in an infant.

Lymph nodes
Palpate occipital, pre/post auricular, anterior cervical, submandibular, submental, supraclavicular,
axillary & inguinal chains

Evaluate for size (i.e. 4cmX4cm), tenderness, mobility, consistency, symmetry

 Normally nodes should be <2cm (<size of M&M), mobile, and non-tender

Genitals
Assess external genitalia for Tanner Stages of development

Males

 Visually inspect genitalia looking for rashes, masses,

erythema, or discolorations
 Gently retract foreskin to visualize urethral meatus to
identify if urethral open is in correct position
(positioning of the opening lower than normal is
known as hypospadias)
 Confirm that testes are descended bilaterally
 Look for possible retractile testicles if you are unable
to find the testicles
 Retractile testicle=testicles that are located within
the inguinal canal and are able to be drawn into the
scrotal sac
 Not abnormal and no need to refer these patients to
urology
 Testes with descend over time (usually by 2 years of
age)
 Palpate for inguinal/femoral hernias

157
 Females

 Visually inspect genitalia looking for

rashes, masses, erythema, or
discolorations
 Gently separate labia majora on each
side and look for labial adhesions
 Labial adhesions are membranous
structures that develop as a result of
fusion of the adjacent mucosal
surfaces of the labia minora.
 Most common in children <5 years of
age unless adhesion is so extensive
that it inhibits urination or
development of frequent urinary
infections it is left untreated. Once
puberty begins estrogens will cause
adhesion to disappear. Identify the
hymenal opening
 Hymen = a fold of mucous membrane
that surrounds or partially covers the
external vaginal opening. It forms part
of the vulva, or external genitalia.
 Imperforate hymen=hymenal opening nonexistent; will
require minor surgery if it has not corrected itself by
puberty to allow menstrual fluids to escape (pictured
in bottom right corner).
 Palpate for inguinal/femoral hernias

(Examples of various
types of hymen)

Hip

After 3 months of age the following test are less reliable for signs of
hip dislocation. Perform Ortolani/Barlow maneuvers or equivalent
screening tests till infant is walking (around 12-15 months)

Ortolani test evaluates for presence of posteriorly dislocated hip

158
 Barlow test evaluates for ability to sublux or dislocate intact but unstable hip

Head

Inspection:
Note any asymmetries of head shape, position of the head on neck, hair line, position of the
ears (i.e. low-set), or rashes

Palpation:
Note any masses or tenderness

Feel anterior and posterior fontanelles for patency/tension

The fontanelle allows the skull to deform during birth to ease its passage through the birth
canal and for expansion of the brain after birth.

If depressed (sunken) can indicate dehydration

If bulging/tense can indicate increased intracranial pressure

from intracranial infection/trauma

Frontal fontanel=anterior fontanelle

 Largest fontanelle
 Measures about 4 cm in its anteroposterior and
2.5 cm in its transverse diameter
 The anterior is not completely closed until about
9-18 months of age.

Occipital fontanel=posterior fontanelle

 Size: 0.5-0.7 cm in transverse diameter
 Posterior fontanelle closes by 8 weeks of age.

Eyes
Note position & spacing of eyes, palpebral fissures, color, sclera, conjunctiva, eyelids, pupil
size & presence of discharge
Corneal light reflex= also known as the blink reflex, is an involuntary blinking of the eyelids
elicited by stimulation (such as touching or a foreign body) of the cornea, or bright light.

159
 Red reflex

Reddish-orange reflection from the eye's retina that is observed when using an
ophthalmoscope from approximately 12 inches from the eye. This examination is done
in a dimly lit or dark room.

 Many eye problems may be detected by this test, such as:

 Cataracts - show leukocoria, or white coloration of the eye
 Retinoblastoma - shows leukocoria.
 Visual tracking/extra ocular movements
 Often done by having the infant follow your face while their head is
held without moving
 For child/adolescent perform eye examination as shown in section labeled eye
examination

Nose
Inspection:
See HEENT Lab Section

Palpation:
See HEENT Lab Section

Internal nasal examination

Patency of nares

Gently occlude one naris at a time if nare is occluded then the infant will have difficulty
breathing and get upset (infants are obligate nose breathers). This is a sign that the nasal
passage on the opposite side is not patent or occluded. Do the same on the opposite nare.

Mouth

Inspect

Lips - describe color, lesions, bleeding, etc.

Oral cavity
Examine with a light source and tongue depressor:

Buccal mucosa/Hard and soft palate - evaluate for lesions, color changes, white
patches, swelling, papules, ulcers, erosions, hemorrhages (petechiae)

Gingivae/Teeth - evaluate and note how many teeth (if infant), discoloration of
teeth, caries

Tongue - evaluate for lesions, color changes, ulcers, masses; can be described
as geographic or smooth; observe for fasciculations (abnormal if present)

Uvula - should be midline & without deviation and the same color as the palate
 Aids in closing off the nasopharynx with swallowing
 With tongue depressor slide it back to posterior pharynx which causes
160
 the infant/child to “gag” this test examines CNIX/X. This test is
abnormal if no gag reflex in obtained. This will also allow you to
visualize the posterior pharynx in most infants.

Neck

Inspect:
position of head over the neck and note any masses visualized
Often find abnormal positioning in infant with torticollis (tightness of sternocleidomastoid
muscle on one side)

Palpate:
neck and note any masses

Back
Inspect:
for any lesions, color changes (i.e. Mongolian spots or moles), hair tufts, masses, deformities

Palpate:
spine feeling for scoliosis, incomplete closure of spine

In older children, have them stand and bend forward and touch their toes. Feel their spine as
they do this to note any curvature of the spine. Also, look for symmetry on either side of the
spine in the thoracic area.

Neurologic
See Neurologic Examination sections in lab manual for children/adolescents.
 Perform examination of primitive reflexes in infants (see chart below).
 Elicit deep tendon reflexes in infant (See Neurologic Examination sections for explanation
on deep tendon reflexes)

Babinski’s sign
 Stroke bottom of patient’s foot with tongue depressor or opposite end of reflex hammer
 Can identify disease of the spinal cord and brain and also exists as a
 Primitive reflex in infants (upward response).
 When non-pathological, it is called the plantar reflex and a downward response is elicited,
while the term Babinski's sign (or Koch's sign) refers to an upward response that is
pathological in origin.

161
Primitive Reflexes
Primitive Reflex Maneuver Ages
Palmar Grasp Place finger in hand and press against palmar surface ~ grasp finger B to 3-4m

Plantar Grasp (Babinski) Touch sole at base toes ~ toes curl out and upward B to 6-8m

Hold supine support head, back, legs; abruptly lower 2 feet ~ arms abduct& extend,
Moro (Startle Reflex)
hands open, & legs flex, +/-cry B to 4 m
Supine, turn head to one side, holding jaw over shoulder ~ arm/leg on that side extend
Asymmetric Tonic Neck
& opposite arm/leg flex B to 2 m
Hold around trunk & lower till feet touch surface ~ hips/knees/ankles extend, partially
Positive Support
bearing weight (sags after 20 sec) B or 2m to 6m

Rooting Stroke perioral skin at corner mouth ~ mouth opens & turns head toward side stimulated
B to 3-4m
Trunk Incurvation Support in prone position, stoke one side of back 1cm from midline from shoulder to
(Galant’s) buttocks ~ spine curves toward stimulated side B to 2m
B (best after day
Hold upright, have one sole touch table ~ hip & knee of that foot will flex & other foot will
Placing/Stepping 4) to variable to
step forward
disappear

Landau Suspend prone ~ head lifts up& spine will straighten

B to 6m
Suspend prone & slowly lower the head toward surface ~ arms/legs will extend in pro- 4-6m& does not
Parachute
tective fashion disappear

Ears

See Head, Ears, Nose, Sinus, & Throat Examination section for inspection, palpation, and otoscopic
exams

Inspection:
Observe appearance and placement

Palpate:
pinnae, tragus, & mastoid

Otoscopic exam:
Best to do this exam in parent’s lap

Pneumatic otoscopy if suspect otitis media

Skin

In addition to adult section on exam of skin:

Inspection:
look for rashes, lesions, masses, moles, birth marks

Record description of skin finding in dermatologic terms including location, size, shape, color,
tenderness, induration

162
 Geriatric Medicine and Exam
(Dr. Crimin-Geriatric Medicine and Exam PowerPoint)
(Bates 12th Edition pp. 955-1003)

The Focus of Geriatric Care

The main goal in geriatric care is enriching the “health span” of a patient’s life by providing the basics
of life: food, water, shelter, dignity, social interaction (involvement of friends and family) and a quality
of life not just a quantity of life.

The Geriatric History

The approach to the history of a geriatric patient is somewhat unique. A thorough review of their
medications, side effects, adverse reactions and supplements/OTCs is essential. Specific questions
that need to be addressed are:

 Living conditions
 Medical alerts
 Power-of-attorney (POA) and advanced directives (AD)
 Ability to drive
 Ability to manage funds
 Ability to perform activities of daily living (ADLs)
 Mobility and use of assistive devices
 Sleep
 Cognition
 Diet
 Communication
 Hearing, vision and speech
 Swallowing and appetite
 Bowel and bladder function
 Pain
 Change in any of the patient’s condition

These are questions that are normally not addressed in a non-geriatric patient.

The Geriatric Physical Exam

Weight:
 Assess “ins and out” (I & Os)
 Have they lost weight? Why?
 Have they gained weight? Why?

Pulse and Blood Pressure, Carotids, Pulse Oximetry:

 Almost all elderly patients will have atherosclerosis and some may have decreased tissue
perfusion (<90% on pulse ox, cold hands, acrocyanosis)
 Some elderly patients of problems with autonomics and have orthostatic changes

163
HEENT:
 Inspect and palpate for temporal arteritis (pain to palpation over the temporal artery)
 Decreased vision (macular degeneration or presbyopia)
 Decreased hearing (presbycusis), hearing aids
 Poor dentition/false teeth, dentures
 Decreased olfaction

Chest and Lung Exam:

 Inspect for kyphotic changes that could mechanically impair lung capacity and respirations
 Palpate for breast cancer as mammography screening stops at age 65
 Auscultate for diminished breath sounds, rales, rhonchi and wheezing

Cardiovascular Exam:
 Inspect for pacemaker placement
 Palpate for thrills and heaves
 Auscultate for carotid bruits
 Auscultate the heart for rhythm and murmurs (1/3 of octogenarians have a systolic murmur)

Abdominal Exam:
 Inspect for altered contour due to compression fractures in the lower thoracic/upper lumbar
spine
 Palpate for abdominal aortic aneurysm (AAA) in smokers
 Palpate for peritoneal signs (rebound tenderness) due to asymptomatic perforation or
inflammation
 Fecal Occult Blood Test (FOBT) for peptic ulcer disease (PUD) and lower GI bleeding

Genitourinary Exam:
 Digital rectal exam (DRE) for suspicion of benign prostatic hypertrophy (BPH)
 Inspect and smell for urinary and bowel leakage/incontinence
 Urinalysis (UA) with microscopy (micro) and culture and sensitivity (C&S) if urinary tract
infection (UTI) suspected (sometimes asymptomatic)
 Inspect and do pelvic exam with complaints of vaginal bleeding or frequent UTIs (may be due
to bladder/rectal or uterine prolapse)

Musculoskeletal Exam:
 Document mobility and assistive devices
 Inspect and palpate for deformities related to arthritis and synovitis
 Inspect and palpate for compression fractures and kyphosis.

Neurologic Exam:
 Cranial nerve exam (especially CN I-olfaction) if deficits are elicited through the history
 Cognition with mini mental status exam (MMSE-see CNS exam)
 Gag reflex and speech to assess risk of aspiration due to dysphagia
 Observe gait for cerebellar stability (shuffling gait could be Parkinson’s)

164
 Evaluation for functional impairments
Falls due to gait disturbances:
 Review the history (especially medications)
 Observe gait and perform cerebellar/mental status/proprioception/sensory/strength testing
 Cardiac exam for dysrhythmias/postural hypotension/murmurs

Urinary incontinence:
a common factor leading to institutionalization and social isolation, 4 types of incontinence (stress,
urge, overflow, functional)
 Obtain vital signs
 Palpate and percuss over the bladder and percuss over the kidneys (Lloyd’s)
 Pelvic exam for prolapse
 UA/Micro/C&S as above

Constipation:
the definition of constipation is patient specific
 Consider causes (medications, mechanical obstruction, metabolic, dehydration, inactivity)
 Obtain history (what is normal for this patient, change in medications, any abdominal pain or
distention)
 Abdominal exam with “if indicated tests” (see Abdominal Exam)
 Rectal exam (tone-neurologic, impacted stool, hemorrhoids, strictures or fissures, FOBT)

Special Clinical Issues

Pressure ulcers (ischemic soft tissue injury usually over a boney prominence):
 Risk factors (immobility, poor nutritional status, incontinence, vascular insufficiency, altered
level of consciousness)
 Inspect the skin carefully, especially over boney prominences such as the ischial tuberosities

Staging of Pressure Ulcers

Pressure-induced injury staging[1].
(A) Stage 1 – Skin intact but with nonblanchable redness.
(B) Stage 2 – Partial-thickness loss of skin with exposed dermis.
(C) Stage 3 – Full-thickness loss of skin, in which adipose (fat) is visible in the
ulcer and granulation tissue and epibole (rolled wound edges) are often
present.
(D) Stage 4 – Full-thickness skin and tissue loss with exposed or directly
palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.
[1]Reference:
National Pressure Ulcer Advisory Panel. www.npuap.org.Images reproduced
with permission from: Nettina SM. The Lippincott manual of nursing practice,
7th ed. Philadelphia: Lippincott Williams & Wilkins, 2001. Copyright © 2001
Lippincott Williams & Wilkins.
Graphic 67475 Version 5.0

165
Other:

Cognitive impairment: is it benign senescent forgetfulness (mild recall/ difficulty with memory on
MMSE) or is it dementia/delusions (loss of memory, language, visuospatial orientation, executive
functions) with increased safety concerns?

Depression: non-specific presentation, widely under-recognized, perform a PHQ-9 exam (see

below).

Sensory impairment: increases safety risks

 Olfaction loss (spoiled food in the refrigerator)
 Vision loss (presbyopia, cataracts, glaucoma, macular degeneration, diabetic retinopathy)
 Hearing loss leads to isolation and frustration of others
 Decrease in thirst perception may lead to dehydration

Polypharmacy (greater than five medications): it is essential to review the patient’s

medications for drug interactions, medication errors and altered pharmacodynamics and
pharmacokinetics (refer to American Geriatric Society’s Beer’s List of potentially dangerous
medications in the elderly)
 Consider altered volume of distribution due to loss of lean body mass
 Cytochrome P450 activity decreases with age
 Renal filtration and tubular function decreases with age
 Multiple physicians and pharmacies
 Family/friends/media obstruct care by telling patients to stop their medications
 Knowledge of medications is often poor
 Prophylactic medications
 Duplicate medications

Developed by Drs. Robert L Spitzer, Janet BW Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer, Inc. No permission
required to reproduce, translate, display or distribute. Graphic 59307 Version 10.0

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 Psychiatric Evaluation
(Bates 12th edition pp. 147-169)

Creating therapeutic impact

 Let the patient talk freely.

 Listen!
 Don’t ignore the “elephant in the room”.
 Be respectful, courteous, and sensitive.
 Normalize
 Share stories to let them know they are not alone.
 Try to avoid labeling a patient: Focus on symptoms.
 Give the patient a sense of hope.

Contents of the Psychiatric Interview and Documentation

Patient Identification
 Name
 Age/DOB
 Gender and Race
 Marital Status
 Occupation
 Referral Source
 Other informants

History (Subjective)
 Chief Complaint
 History of Present Illness
 Past Psychiatric History
 Past Medical History
 Social History
 Personal History
 Family History

Mental Status Exam (Objective)

 Appearance and Attitude
 Motor Activity
 Thought and Speech
 Mood and Affect
 Perceptions
 Orientation
 Time Person Place
 Memory
 Immediate recall 3 of 3 Objects Recall of Historical Events
 General Information
 Last 5 Presidents? Distance NY to LA? Temp H2O boils?
 Calculations
 Serial 7s Serial 3s Daily Living Calculations

167
  Capacity to read and write Yes No
 Visuospatial ability
 Clock drawing test Draw a circle or square
 Attention and Concentration
 Digit Span forward _____ backward _____
 Abstraction
 Proverb Interpretation and/or Similarities ________________
 Judgment and Insight
 Smoke in a theatre? Letter on sidewalk?
 Suicide/Homicide: absent present passive active plan

Diagnosis (Assessment)
Axis I- Clinical syndromes
Axis II- Personality disorders
Axis III- Medical conditions
Axis IV- Psychosocial stressors
Axis V- Global Assessment of Functioning (0-100): Now and Highest in past year

Treatment Plan (Plan)

 Biological: Medications and Procedures
 Psychological: Psychotherapy
 Sociological: Social agencies and support

Benefits of Rating scales

 Quantifying symptoms
 Making diagnoses
 Saving time

Examples of commonly used Scales you should be familiar with

Hamilton Depression Scale Hamilton Anxiety Scale Mania Rating Scale

Madison Scale for Psychogenic Pain CAGE questions
Connor’s Scale for ADHD

NOTES

168
 Medical Safety and OSHA Regulations, Gown and
Gloving and Aseptic Technique
Reviewing videos on the procedure can be very useful. YouTube and Procedures Consult (part of
MD Consult) and others by nursing and scrub tech. organizations are a few that have been
recommended.

Scrubbing
The use of sterile technique begins in the locker room. Change into scrub clothing (remove t-shirts
and tuck the scrub shirt into the pants.) Scrub clothes may occasionally be worn on the wards,
provided that they are covered by a clinic coat or some other
form of gown.

Next you will put on your cap, mask and shoe covers. If required, put in the back strap inside your
shoe, it is for grounding purposes. The idea is to cover your nose, mouth and all your hair. Full
hoods are necessary for men with beards. If you wear glasses, it is often helpful to tape the mask to
the bridge of your nose to prevent fogging during the case. Then tape the glasses to your forehead if
you think they may be loose enough to fall off.

Do not wear nail polish and remove any loose jewelry, watches and rings before scrubbing. Special
precautions such as double gloving and eye protection should be performed when operating on
patients with communicable diseases such as hepatitis and AIDS.

The surgical scrub: brush stroke method

1. Turn on water and regulate flow and temperature. Many sinks now come equipped
with leg or foot controls, take note.
2. Open scrub package and lay aside. Make sure that you are not allergic to any of the
soaps or disinfectants used in the scrub.
3. Wet hands and arms and perform a pre-scrub wash with a provided detergent to about
2 inches above the elbows.
4. Rinse hands and arms thoroughly, being careful not to touch any unsterile object.
5. Retrieve the sterile brush and file. Moisten the brush to create lather, and then use the
file to clean under the fingernails. Fingernails should be cleaned under running water.
6. Discard the file into the appropriate receptacle; be careful not to touch anything.
7. Produce lather with the sponge side of the brush and then use the sponge’s bristle to
scrub under the fingernails with about 30 strokes.
8. Consider each finger, hand and arm as being four planar sided. Each surface should
then be scrubbed with about 20 circular strokes. Use the bristle side of the brush for
the digits and the sponge side for the hand and arm (to 2 inches past the elbow) on
one side before moving to the other.
9. Add soap or water to the brush as needed during the scrubbing process.
10. Discard the brush into the appropriate receptacle.
11. Rinse hands and arms thoroughly, allowing water to run from the hands to the elbows.
12. Lean forward as you dry your hands and arms with a sterile towel. DO not allow any
part of the towel or your hands to touch an unsterile object. Use one end of the towel
to thoroughly dry one hand and arm, then use the opposite end of the towel to dry the
other hand and arm. Many times the scrub nurse will assist you in the drying process,

169
 after you enter the OR. If that is the case, you enter the room by pushing the door
“open” with your back, spinning around as you enter the room. Also, make sure that
your arms are held high above your waist.

Gowning and gloving

You are now ready to don your surgical gown:

Important note: If you touch the outside of the gown while putting it on, it is then considered
contaminated and must be discarded. After scrubbing, the hands and arms are considered
contaminated if they fall below the waist or touch the body. Only certain areas are considered
sterile after donning the gown: the sleeves (Excluding the axillary region) and the front of the
gown from the waist to a few inches below the neck opening.

Self-gowning method

1. Pick up the gown in its wrapper. Pull the wrapper’s tab away from you and grasp with
the hand holding the gown. Continue this until all 4 corners have been opened
revealing the sterile gown. The grown is folded with the inside revealed. Grasp the
gown and remove it from the packaging.
2. Grasp the inside shoulder seams and open the gown with the armholes facing toward
you. While holding the gown, allow it to fall open without touching any unsterile objects
(including your body).
3. Slide your arms into the sleeves about ¾ of the way down.
4. Have an assistant pull the gown up and over your shoulders while you slide your arms
to the beginning of the sleeve cuffs and grasp them from the inside to prevent your
hands from protruding beyond the sleeve cuff. Have the assistant fasten the back of
the gown.

Donning surgical gloves - closed cuff method

This method is preferable because you are less likely to contaminate yourself.

1. Open sterile gloves and have them

ready to pick up before you begin
donning the gown.
2. Create a tuck in the cuff of the
gown by grasping the material with
your hand from within the cuff.
3. Pick up one glove by the folded cuff
edge with the sleeve- covered
hand. It may be easier to put on the
left glove first if you are right-
handed, and vice versa if you are
left handed.
4. The Final Gown Tie occurs after
donning your gloves. Grasp the
paper tab attached to the front of
the gown and hand the opposite
5. end to the scrub nurse or an assistant. Remember you are now sterile. The assistant
may not be!!!!!
6. Release the paper tab and turn around in a circle while the assistant remains holding

170
 firmly on to the paper tab.
7. Have the assistant securely hold the paper tab as you pull the belt loose from the paper
tab and tie it to the belt tie attached to the front of the gown.

Open cuff method

The open cuff method is usually done when you do not have an assistant. This is done
commonly in the office setting for small procedures. After opening the packaging on a flat
surface, touching only the outside of the package.

1. Pick up the sterile glove with your fingertips making sure that you are only manipulating
the inside portion of the glove, and slide your opposite hand into the glove. Be careful
not to touch any portion of the glove sleeve or exterior of the glove with your hand.
2. Release the glove after it has been pulled over the sleeve cuff
3. Grab the other sterile glove with the already gloved hand by placing fingers within the
fold of the glove.
4. Stretch the glove over the opposite hand and pull the cuff down over the sleeve cuff.

“Sharps” handling
Aseptic technique, handling sharps and needles

Sharps are any item that can cause any type of percutaneous injury. The injury can occur with the
patient as well as the healthcare provider. You will have the opportunity to handle various types of
“sharps” while under supervision so you can become
familiar with how to handle these devices in a safe
manner.

If possible, get a good look at the “sharp” prior to

opening the packaging and READ any instructions
that may accompany it. You should always don
gloves prior to working with any type of sharp.
Remember; always handle all sharps as though they
are already “contaminated” with a body fluid.

The SHARPS provided for this lab will include various

types of syringe/needle combinations, scalpels,
suturing and other surgical items. Please look at and
handle all of them. Be sure to dispose of properly
before the end of the laboratory.

In case of injury, please inform your facilitator

immediately.

NOTES

171
 Injections
Giving injections is a regular and commonplace activity and good injection technique can make the
experience for the patient relatively painless. Mastery of the techniques without developing the
knowledge base from which to work from can put the patient at risk of unwanted complications.

ID – Intradermal Injection
The intra-dermal route provides a local, rather than systemic effects and is primarily used for
diagnostic purpose such as allergy and tuberculin testing or for local anesthetics.

Procedure:

1. Using a 1cc syringe with a 27 gauge 1/2” needle and using aseptic technique Draw up 0.1
cc of normal saline into the syringe.
2. Prepare and clean the injection site with an alcohol swab.
3. On a human subject use the mid- ventral surface of
either forearm, not directly over a vein.
4. At a 10-15O angle, the bevel of the needle up, slide
the needle just under the epidermis.
5. Inject the saline until it creates a wheal on the skin
surface.
6. Gently remove the needle and place a band aid if
necessary.

SQ – Subcutaneous Injection
The subcutaneous injection route is used for slow, sustained absorption of medication, up to 1-2 ml
being injected into the subcutaneous tissue. It is
ideal for medications such as insulin,
which require a slow steady release.

Procedure:

1. Using a 1cc syringe with a 25 gauge 5/8”

needle
2. Using aseptic technique draw up 0.3 cc of normal saline into
the syringe.
3. Prepare and clean the injection site with an alcohol swab.
4. On a human subject use the mid-dorsal surface of the triceps
muscle of either
5. arm.
6. “Pinch up” a fold of skin and either at a 45O or 90O degree angle to the skin, push the
needle into the skin to the hub of the needle and the inject the saline.
7. Gently remove the needle and place a band aid if necessary.

IM – Intramuscular Injection
Intramuscular injections deliver medication into well perfused muscle, providing rapid systemic action

172
and absorbing relatively large doses from 1ml in the deltoid muscle to 5ml in other sites. The
proposed site of injection should be inspected for signs of inflammation, swelling, infection and any
skin lesions should be avoided. Similarly, two to four hours after the injection, the site should be
checked to ensure there has been no adverse reactions.

Procedure:

1. Using a 3cc syringe with a 25 gauge 5/8” needle and

using aseptic technique, draw up 0.5 cc of normal saline
into the syringe.
2. Prepare and clean the injection site with an alcohol
swab. On a human subject use the deltoid muscle of
either arm.
3. Use the Z track technique (see below)
4. Hold the syringe between your thumb and index finger
(like you would throw a dart), and with a firm and
accurate thrust, push the needle at a 90O angle into the
skin to the hub of the needle.
5. Pull gently back on the syringe plunger to check for blood. If nothing is aspirated back into
the syringe, slowly inject the contents of the syringe.
6. Gently remove the needle and place a band aid if necessary.

The Z Track Technique

The Z track technique was introduced for medications that stained the skin or were particularly
irritant. It is now recommended to use with the full range of IM medications and is believed to
reduce pain as well as the incidence of leakage. It involves pulling the skin downwards or to
one side at the intended site. This moves the cutaneous and subcutaneous tissue tissues
approximately 1-2 cm. The needle is inserted and the injection is given. Allow ten seconds
before removing the needle to allow the medication to diffuse into the muscle. On removal of
the needle the retracted skin is released. The tissues then close over the deposit site of
medication and prevents it from leaking.

Aspiration
Although aspiration is no longer recommended on SQ injections, it should be practiced with all
IM injections. If a needle is mistakenly placed in a blood vessel, the drug may be given
intravenously and could cause an embolus as a
result of the chemical components of the drug. Following insertion of the needle into the
muscle, aspiration should be maintained for several seconds to allow for any blood to appear.
If blood is aspirated, the syringe should be removed and discarded and a fresh syringe
prepared. If no blood appears, proceed to inject at a rate of
approximately 1 ml every 10 seconds.

Sites for Intramuscular Injections

There are five sites available for IM injections:
The deltoid muscle
Used for vaccines such as Hepatitis B, MMR and tetanus. Volume
limited to 1cc.

173
 The dorso-gluteal site
Uses the Gluteus Maximus muscle. Location is the upper
outer quadrant of either buttocks. Complication
include damage to the sciatic nerve or superior gluteal artery
from a misplaced injection.

The ventro-gluteal site

Accesses the gluteus medius
muscle and is safer.

The vastus lateralis site

A quadriceps muscle on the lateral (outer) side of the femur. This
site is the primary site for children and infants. Complications
include injury to the femoral nerve and muscle atrophy.

The rectus femoris site

An anterior quadriceps muscle, easily accessed for self-
administration and infants.

Injections and Universal Precautions

At the completion of this lab exercise, each student should have completed and demonstrated
minimal competency in:

 Administration of the 3 types of Cutaneous Injections

 Use of Universal Precautions and Aseptic Technique with all techniques

During the lab, please complete the following:

Cutaneous injections

 Aseptic Techniques and Universal Precautions used pre, during and post- performance of all
injections.
 Practice all injection types on the hot dog and fruit provided.
 Transfer of medication into a sterile syringe. We will be using .9% NS for all injections.
(Facilitators may demonstrate mixing of meds into a syringe)
 Proper administration of each type of injection on another student:
 ID Proper angle and “wheal” produced (.1 cc in 1 cc syringe)
 SQ proper angle and depth (.5cc in 3 cc syringe)
 IM proper angle, depth and aspirating (.5cc in 3 cc syringe)
 Demonstrate Universal Precautions in the disposal of used needles and syringes
 Practice on joint models if available
 Demonstrate proper removal of gloves

There is no write-up for this lab. If you are the last group, please help your facilitator with

174
 Venipuncture, IV’s, Glucose Finger Sticks and Glucose
Monitoring
Venipuncture

Venipuncture is the process used to obtain blood samples for analysis.

Necessary supplies

 Tourniquet
 Vacutainer
 Gloves
 Alcohol swabs
 Appropriate needle and device (Vacutainer or Butterfly)
 Syringe or Blood specimen tubes
 Gauze pads or cotton balls
 Band-Aid
 ID Labels for sample collected

Technique:
1. Attach Vacutainer to needle
2. Position the patient’s arm at a comfortable position for both the patient and yourself. Resting
the arm on a table is always useful.
3. Apply the tourniquet snugly above the antecubital fossa in slip knot fashion for easy removal.
4. Have the patient open and close their fist several times to distend the veins.
5. Select a vein that feels full when compressed with your fingers.
6. Clean the area with the alcohol swab in concentric circles starting from the center and working
outward.
7. Put on your gloves.
8. Remove the needle cover.
9. Use the non-dominant hand to apply traction above and below the vessel to anchor it and
keep it from moving side to side.
10. Use your dominant hand, grasp the Vacutainer/needle device and insert the needle at a 15-30
-degree angle until you can feel it break through the surface of the vein and see a flashback of
blood into the needle hub.
11. If no flashback is seen partially withdraw the needle and reposition and advance again. If you
accidentally withdraw the needle from the skin, you can’t re-insert it and must use a clean
needle.
12. Withdraw the appropriate amount of blood needed for the tests being ordered. Then before
removing the needle, release the tourniquet. Place the gauze or cotton ball over the site and
just after removing the needle apply pressure.
13. Apply a bandage to the patient.
14. Label the blood samples.

Peripheral IV Catheterization
Starting a successful IV takes time, practice and patience. Once you have mastered this procedure,
you will see the following steps are simply guidelines to help beginners. As your experience and

175
skills grow, you will develop your own techniques.

Necessary Supplies

 Gloves (non-sterile
 appropriately sized IV catheter
 alcohol or betadine preps
 a bag of IV solution
 a tourniquet
 IV tubing
 skin tape
 gauze pads

Selection of the IV Site

Assess specific patient factors such as pre-existing catheters, anatomic deformity, site restrictions
(e.g. – mastectomy, arteriovenous (AV) fistula or graft), risk of mechanical complications and risk of
infection.

 Site selection should avoid areas of flexion and bony prominences.

 Select veins on the non-dominant forearm.
 Basilic or cephalic veins on the posterior (dorsal) forearm are the preferred site.
 Metacarpal veins on the dorsum of the hand are the easiest to visualize, but are more liable to
block and prone to infiltration.
 The antecubital fossa veins should be reserved for emergency use.

Local Anesthetic
Local anesthetic of the skin can be used to help reduce the pain and discomfort of the IV
insertion. Particularly in children and if a larger bore catheter is indicated.

Topical anesthetic

A lidocaine based cream or ointment can be applied to the insertion site 30-60 minutes before
the procedure.

Local anesthetic

Subcutaneous lidocaine (1% or 2%) with a tuberculin syringe to produce a small wheal under
the skin at the IV insertion site.

Procedure for Starting an IV

Before starting any procedure, always explain to the patient the procedure, inform the patient there
will be some initial pain or discomfort and have the patient consent to the procedure.

1. Assemble and arrange all needed supplies so they are easily accessible.
2. Connect the IV tubing to the solution bag and allow the fluid to run through the entire length of
the tubing, eliminating air or “priming the tubing”. It is NOT necessary to eliminate all the air.
This is venous blood heading to the lungs.
176
 3. Tear several pieces of tape, 6 to 8 inches long in length and place them in an accessible
location.
4. Place protective gloves over your hands at this time.
5. Locate a suitable venipuncture site as described above.
6. Tie a tourniquet using a “slip-knot” proximal to the venipuncture site on the extremity.
7. Choose a vein that is well fixed (not-rolling) by palpating with your fingers. Be careful not to
choose a vein with multiple valves near the venipuncture site.
8. Clean the site with alcohol or betadine preps and allow to dry.
9. Place the catheter between your thumb and middle finger with your index finger on the top of
the catheter.
10. Hold the catheter at a 30o to 45o angle and enter the skin with the needle’s bevel facing
upward.
11. Continue to advance the catheter until you feel a “pop” and see the “flashback of
12. blood” within the needle’s transparent chamber.
13. Reduce the angle of the needle and advance it about 5mm more. (now here comes the tricky
part), slide the catheter of the needle in a gentle twisting back and forth motion, whiling
continuing to hold the catheter hub. Do not advance the needle, just the IV catheter, until it
is 1mm to 3mm from the puncture site.
14. Withdraw the needle completely from the catheter and occlude the blood flow from the
catheter gently with a finger or thumb.
15. Remove the tourniquet.
16. With the other hand, firmly attach the IV tubing set to the catheter hub, which has already
been primed.
17. Open the clamps of the IV tubing to start the flow from the IV bag to ensure patency.
18. If the patient complains of pain or burning at the IV site or the skin appears to be swelling and
there is not good flow from the IV bag, the IV may be infiltrated. Remove the catheter and
repeat the procedure at a different site.
19. Using a small gauze pad, wipe away the excess blood or fluids from the surface of the skin.
20. Using the pre-torn pieces of tape, secure the catheter hub and IV tubing to the patient’s skin.
A small piece of gauze under the hub and IV tubing is sometimes helpful.
21. Once everything is secure, recheck the IV solution’s flow and check for any kinks in the
tubing.

Glucose Finger Sticks and Monitoring

Checking a Blood Glucose level?

 All people with diabetes can benefit from checking their blood glucose.
 Using a meter is the most accurate way to check.
 Keep a log of your results and review them with your team to gauge how well your diabetes
plan is working.
 Blood glucose monitoring is the main tool to check diabetes control.
 This check tells the patient or provider a blood glucose level at any one time. Keeping a log of
the results is vital. A record brought to
 the health care provider, can show a good picture of the patient’s response to their diabetes
care plan.

Who should check?

Experts feel that anyone with diabetes can benefit from checking their blood glucose. The American

177
Diabetes Association recommends blood glucose checks if you have diabetes and are:

 taking insulin or diabetes pills

 on intensive insulin therapy
 pregnant
 having a hard time controlling your blood glucose levels
 having severe low blood glucose levels or ketones from high blood glucose levels
 having low blood glucose levels without the usual warning signs

Glucose Finger Stick Procedure

1. Use Universal Precautions.

2. After washing your hands, insert a test strip
into the meter.
3. Use an alcohol swab to cleanse the fingertip.
4. Use a lancing device to puncture the side of
the fingertip to get a drop of blood.
5. Gently squeeze or massage the finger until a
drop of blood forms. (Required sample sizes
vary by meter.)
6. Touch and hold the edge of the test strip to the
drop of blood, and wait for the result.
7. The blood glucose level will appear on the
meter's display.

Note: All meters are slightly different, so always refer to your user's manual for specific
instructions.

Other tips for checking:

 With some meters, you can also use the forearm, thigh or fleshy part of the hand.
 There are spring-loaded lancing devices that are less painful.
 If using the fingertip, stick the side of the fingertip by the fingernail to avoid having sore
spots on the frequently used part of the finger.

What are the typical ranges?

Here are the blood glucose ranges for adults with diabetes:

Glycemic control
A1C <7.0%
Pre-prandial plasma glucose (before a meal) 70–130 mg/dl (5.0–7.2 mmol/l)
Postprandial plasma glucose (after a meal) <180 mg/dl (<10.0 mmol/l)
Blood pressure <130/80 mmHg

Lipids
LDL <100 mg/dl (<2.6 mmol/l)
Triglycerides <150 mg/dl (<1.7 mmol/l)
HDL >40 mg/dl (>1.1 mmol/l)

178
What do the results mean?

When finished with the blood glucose check, write down the results and review them to see how
food, activity and stress are affecting the blood glucose. Take a close look at the blood glucose
record to see if the level is too high or too low several days in a row at about the same time. If the
same thing keeps happening, it might be time to change the plan. This takes time.

What about urine checks for glucose?

Urine checks for glucose are not as accurate as blood glucose checks and should only be used
when blood testing is impossible. Urine checks for ketones, however, is important when diabetes is
out of control or when patients are sick. Everyone with diabetes should know how to check urine for
ketones.
NOTES

179
 Peripheral Nerve Blocks and Field Blocks
Indications
 Repair lacerations
 Nail procedures
 Incision and drainage of abscess
 Anesthesia for fracture or dislocation
 Tumor or cyst removal

Field Blocks

Field Block of the ear Field Block of the Skin

Technique for Digit Nerve Blocks

OR

180
 Lumbar Puncture
Procedure and Documentation

Indications
 Suspicion of meningitis
 Suspicion of subarachnoid hemorrhage
 Suspicion of central nervous system diseases such as Guillain-Barré syndrome3
 and carcinomatous meningitis
 Therapeutic relief of pseudotumorcerebri

Contraindications

 Absolute contraindications to lumbar puncture are as follows:

 Unequal pressures between the supratentorial and infratentorial compartments, usually
inferred by characteristic findings on the brain CT scan:
 Midline shift
 Loss of suprachiasmatic and basilar cisterns
 Posterior fossa mass
 Loss of the superior cerebellar cistern
 Loss of the quadrigeminal plate cistern
 Infected skin over the needle entry site
 Relative contraindications to lumbar puncture are as follows:
 Increased intracranial pressure (ICP)
 Coagulopathy
 Brain abscess

181
  Indications for brain CT scan prior to lumbar puncture in patients with suspected meningitis
include the following:
 Patients who are older than 60 years
 Patients who are immunocompromised
 Patients with known CNS lesions
 Patients who have had a seizure within 1 week of presentation
 Patients with abnormal level of consciousness
 Patients with focal findings on neurological examination
 Patients with papilledema seen on physical examination with clinical suspicion of
elevated ICP

Materials

1. Lumbar puncture tray (to include 20 or 22 gauge Quinke needle with stylet, prep solution,
manometer, drapes, tubes, and local anesthetic)
2. Universal precautions materials

Pre-procedure patient education

1. Obtain informed consent
2. Inform patient of possibility of complications (bleeding, persistent headache, infection) and
their treatment
3. Explain the major steps of the procedure, positioning, and post-procedure care

Procedure
1. Assess indications for procedure and obtain informed consent as appropriate
2. Provide necessary analgesia and/or sedation as required
3. Position patient: lateral decubitus position
with “fetal ball” curling up, or seated an and
leaning over a table top; both these positions
will open up the inter spinous spaces
4. Locate landmarks: between spinous
processes at L4-5,
L3-4, or L2-3 levels.
On obese patients,
find the sacral
promontory; the end
of this structure
marks the L5- S1 interspace. Use this reference to locate L4-5 for
the entry point. You will aim the needle towards the navel.
5. Prep and drape the area after identifying landmarks. Use
lidocaine 1% with or without epinephrine to
anesthetize the skin and the deeper tissues
under the insertion site
6. Assemble needle and manometer. Attach the 3-way stopcock to
manometer
7. Insert Quinke needle bevel-up through the skin and advance through the
deeper tissues. A slight pop or give is felt when the dura is punctured.
Angle of insertion is on a slightly cephalad angle, between the vertebra. If
you hit bone, partially withdraw the needle, reposition, and re- advance
182
 8. When CSF flows, attach the 3-way stopcock and manometer. Measure ICP…this should be
20 cm or less. Note that the pressure reading is not reliable if the patient is in the sitting
position
9. If CSF does not flow, or you hit bone, withdraw needle partially, recheck landmarks, and re-
advance
10. Once the ICP has been recorded, remove the 3-way stopcock, and begin filling collection
tubes 1-4 with 2-4 ml of CSF each

Tube 1: Gram’s stain, bacterial and viral cultures

Tube 2: glucose, protein, protein electrophoresis
Tube 3: cell count and differential
Tube 4: reserve tube for any special tests (virology, mycology, cytology…)

11. After tap, remove needle, and place a bandage over the puncture site. Instruct patient to
remain lying down for 1-2 hours before getting up.

**NOTE

 Insertion of the needle bevel-up minimizes dural trauma

 A traumatic “bloody tap” occurs when a spinal venous plexus is penetrated. Often the fluid will
clear as succeeding tubes are filled. Spin down the first tube: if red blood cells have been in
the spinal fluid for some time (for example, subarachnoid hemorrhage), xanthochromia will be
present in the supernatant fluid. If the fluid is clear after it is spun down, the tap was only
traumatic
 In some cases, conscious sedation is helpful in reducing patient anxiety and allowing maximal
spinal flexion.
 Document as a procedure note

Complications, Prevention, and Management

Complications Prevention Management

Bleeding from puncture site post-
None Local pressure
tap
Withdraw needle and perform tap
Bloody spinal fluid None
atinterspace either above or below
Do not perform tap through infected
Infection skin Antibiotics
Use sterile technique
Use pencil-tipped needle if possible; Post-procedure epidural blood
Post-tap persisting headache
insert needle bevel-up patch by anesthesia consultant

NOTES

183
 Catheterization of the Urinary Bladder

Procedure

1. Sterile technique
2. Drape the genital area with sterile drapes or towels.
3. Cleanse the urethral meatus and surrounding area with
antiseptic solution. (retract foreskin)
4. Can insert 2% lidocaine jelly into urethra – leave in place 5
– 10 minutes.
5. Use 16 – 18 French catheter.
6. Introduce catheter into urethral meatus.
7. Follow the anticipated course of the urethra and pass
approximately 3 inches into the bladder.
8. Once urine flows through the catheter the balloon can be
inflated (You did check that it works before the procedure?)
9. Gently pull catheter outward until balloon resting against
bladder neck

NOTES

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 Splinting and Casting
Reasons for Immobilization
The following are conditions that may require immobilization in the form of a splint or a cast:
 Fractures
 Sprains
 Severe soft-tissue injuries
 Reduced joint dislocations
 Inflammatory conditions such as arthritis, tendinopathy, tenosynovitis
 Deep laceration repairs across joints
 Tendon lacerations

Splinting
Used initially when there is swelling present after an injury. Pressure complications such as skin
breakdown or necrosis, compartment syndrome) are minimized when there is not a circumferential
cast. The splint can be easily removed to allow for examination of the injury. Problems with splints
mainly include patient non-compliance because they can be easily removed, too much motion at the
injury site (especially with unstable fractures).

Casting

This is the main treatment for fractures providing more effective immobilization. Problems with casts
especially if improperly applied include skin breakdown, compartment syndrome, neurologic injury,
dermatitis, heat injury, joint stiffness.

Materials and Equipment

 Adhesive tape
 Bandage scissors
 Basin of water at room temperature
 Casting gloves - necessary when using fiberglass
 Elastic bandage – used for splints
 Padding
 Plaster or fiberglass cast material
 Sheets, under pads
 Stockinette

Guidelines

 Use appropriate type and amount of padding

 Use enough padding to pad bony prominences and high pressure areas
 Make sure that the extremity is properly positioned throughout the procedure
 Avoid tension and wrinkles on all padding, plaster, and fiberglass
 Avoid molding and indenting excessively

185
 Applying a Splint
1. Padding: In general, padding 2 inches wide is used for the hands, 2 to 4 inches for upper
extremities, 3 inches for feet, and 4 to 6 inches for lower extremities.

For splinting: Pre-fabricated splints are available, they are easy to cut and mold to the
injured extremity but are very costly and sometimes not available. If using a roll of
fiberglass, the physician should unroll the splint material to the appropriate length to
create the first layer. When the splint edge is reached, the next layer should be folded
back on itself to create the subsequent layer. This process should be repeated until a
splint with the appropriate number of layers has been created. The thickness of the
splint depends on the patient's size, the extremity involved, and the desired strength of
the final product. For an average-size adult, upper extremities should be splinted with
six to 10 sheets of material, whereas lower extremity injuries may require 12 to 15
sheets. Use of more sheets provides more strength, but the splint will weigh more,
produce more heat, and be bulkier. In general, the minimum number of layers
necessary to achieve adequate strength should be used.

2. Splint material should be submerged in water until bubbling from the materials stops. The splint
is removed and excess water squeezed out.
3. The splint is then placed on a hard surface and smoothed to remove any wrinkles and to ensure
even wetness of all layers
4. With the extremity still in its position of function, the wet splint is placed over the padding and
molded to the contours of the extremity
5. Elastic bandage is then wrapped in distal to proximal manner to secure the splint.

186
 Cast Application
1. Measure the stockinette
2. Stockinette should extend at least 2 inches beyond each end of the intended final length of
the splint or cast.
3. Joints should be placed in their proper position of function before, during, and after padding is
applied to avoid areas of excess wrinkling and subsequent pressure. In general, the wrist is
placed in slight extension and ulnar deviation, and the ankle is placed at 90 degrees of flexion.
4. The padding is applied circumferentially around the arm. In general, padding 2 inches wide is
used for the hands, 2 to 4 inches for upper extremities, 3 inches for feet, and 4 to 6 inches for
lower extremities.
5. The fiberglass (or plaster) casting material is applied wrapping circumferentially with each roll
overlapping the previous layer by 50%. Do not apply too tightly and avoid any wrinkling if at all
possible. If too loose then there may be risk of excessive rubbing or skin injuries. Before the
final layer of casting material is applied, fold back the edges of the stockinette to create a
smooth edge.
6. Perform vascular and neurological exam before and after the cast placement.

Cast and Splint Care

Written and verbal education is very important. Patient should be instructed to elevate the injured
extremity to decrease pain and swelling. They should not get the casting material wet or put any
objects down into the cast in the attempt to scratch an itch. They should regularly check for signs of
compartment syndrome and know how to contact the physician should this occur. Avoid the use of
strong opioids in the first two to three days because these medications, while certainly helpful for the

187
pain, can mask serious complications that might be occurring because of the cast placement. Follow
up visits will vary based on the location and severity of the injury. Most will necessitate follow up
within 1-2 weeks. Time in the cast or splint will also vary.

Cast Removal

NOTES

188
 Joint Injections
Diagnostic and Therapeutic Injection
Soft tissue conditions: Bursitis, tendonitis or tendinosis, trigger points, ganglion cysts, neuromas,
entrapment syndromes, fasciitis.

Joint conditions: advanced osteoarthritis, inflammatory arthritis, synovitis, crystalloid arthropathies,

effusion of unknown origin (diagnostic)

Contraindications
Relative contraindications include anatomically inaccessible joints, uncontrolled DM,
anticoagulation therapy, minimal relief with two previous injections, underlying coagulopathy.
These relative contraindications should be evaluated on a case by case basis and apply to
therapeutic injections not to diagnostic joint or soft tissue aspirations.

Absolute contraindications would include drug allergies, infection (bacteremia, septic

arthritis, local cellulitis), acute fracture, prosthetic joints, and tendon sites which have high risk
of rupture. Again, these restrictions do not apply to diagnostic joint or soft tissue aspirations.

Corticosteroid Agents
Agent Potency Duration Dose/site
10 to 25 mg for soft
Hydrocortisone acetate (Cortef) Low Short tissue and small joints
50 mg for large joints
Methylprednisolone acetate (Depo-Medrol) or 2 to 10 mg for soft
triamcinolone acetonide (Aristocort)
Intermediate Intermediate tissue and small joints
10 to 80 mg for large
joints
Dexamethasone sodium phosphate (Decadron) 0.5 to 3 mg for soft
High Long tissue and small joints
2 to 4 mg for large
joints
Betamethasone sodium phosphate and acetate 1 to 3 mg for soft tissue
(Celestone Soluspan) and small joints
High Long
2 to 6 mg for large
joints

Method

Shoulder:

Glenohumeral Joint:

Posterior approach: the patient sits with the arm resting at his/her side.
The sulcus between the head of the humerus and acromion is identified. The

189
needle is inserted 2-3cm inferior and medial to the posterolateral corner of the acromion and
directed anteriorly towards the coracoid process. An 18-gauge needle should go easily into
the joint and there should be little to no resistance felt when pushing on
the plunger.

Anterior approach: The 18-gauge needle is inserted medial to the head

of humerus, lateral to the coracoid process by 1cm and directed
posteriorly at a slight superior and lateral angle.

Subacromial space injection:

The patient sits with their arm resting at
his/her side. The posterior edge of the
acromion is palpated and the needle is
inserted inferior to the posterolateral
acromion and directed laterally into the sub acromial space,
aim for the anterolateral corner of the acromion. If there is any
resistance the needle should be withdrawn and readjusted
aiming more superiorly under the acromion. Avoid injecting
into the rotator cuff.

Acromioclavicular joint:
The patient sits with their arm resting at his/her side. The distal
aspect of the clavicle is palpated to identify the convexity of the AC
joint where the clavicle meets the acromion, then the needle is
inserted from an anterior and superior angle and directed inferiorly
and slightly medial. The needle should pass easily. You will only
use 2ml of steroid as this joint space will not accommodate more
volume than that.

Wrist:

Wrist joint injection:

Dorsal hand is in slight flexion (about 20 degrees) and the
needle is inserted just distal to the radius in the “snuff box”
area. Hold need perpendicular, enter just lateral to the
extensor pollicus longus tendon and distal to the radial
head. If the needle goes in easily about 1-2 cm, then it is
the right place. This injection will disperse into the entire
carpal joint complex because the synovial spaces
interconnect.

DeQuervain’s tenosynovitis:
Abduct the thumb as much as possible to accentuate the
tendon, then insert the needle parallel to the tendon. Inject
at the area of most tenderness. Post-injection splint may
be advisable.

190
 Carpal Tunnel Syndrome:
Rest the dorsi-flexed (30 degrees) wrist over a rolled towel. Insert the needle at the
distal crease of the wrist either lateral or medial to the palmaris longus tendon. Find the
tendon by having the patient flex the middle finger
against resistance and then inject. Do this injection with
minimal pressure, slowly. If there is resistance or if the
patient feels any tingling sensation in the fingers, stop
immediately. If you inject the nerve itself, there will be a
lot of pain after the injection and sometimes surgical
decompression may be needed.

Elbow:

Lateral and medial epicondylitis:

Palpate the area of most tenderness over the lateral or medial
epicondyle. Insert the needle perpendicularly until bone is felt,
then withdraw the needle slightly, 1-2 mm and inject. You can fan
out the injection in several directions. Then massage the site
gently.

Knee:

This joint can be entered either medially or laterally. Have the knee slightly flexed and placed
over a rolled towel. For lateral approach palpate the superior lateral aspect of the patella and
insert the needle 1 cm superior and lateral to this point. Apply gentle pressure on the
contralateral side of the knee to encourage the fluid to pool in the area of aspiration. Direct the

needle under the patella at a 45- degree angle to the mid-joint area.
Aspirate all fluid before doing injecting. The medial approach can be
performed in similar manner
Lateral Approach Medial Approach

Hip:

Greater Trochanteric Bursitis

The needle is inserted perpendicular to the skin and directed

191
 Nasogastric Intubation Insertion
Indications - (known or suspected)

Diagnostic evaluation/treatment UGIB

Low Intermittent Suction– gastric or small bowel obstruction Lavage – poisoning/overdose, antidote
Enteral Feeding

Contraindications

Facial Trauma or basilar skull Fracture Bilateral Nasal Obstruction (oral route) Recent Surgery of:
(nose, pharynx, esophagus, stomach) Patient with Bleeding Diathesis

Precautions & Complications

 Aspiration – aspiration pneumonia, 20-50% increase with

 enteral feedings (duodenum)
 Injury – nasal mucosa, hypopharynx (with weighted tip/metal stylet for feeding tube lung
injury)
 Tracheal Intubation – coughing, choking, difficulty talking or swallowing (less apparent with
small bore feeding tubes)
 Esophageal Perforation – rare

Procedure
1. If possible, explain the procedure to the patient
2. Position the patient as follows:
3. If the patient is awake and alert-in a sitting position in high-fowler’s.
4. If the patient is obtunded or unconscious-head down, preferably in a left side lying position.
5. Place a protective pad/towel on the patient’s chest as well as provide the patient with a basin
to minimize contact with aspirated gastric contents.

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6. Using the NG tube as a measuring device determine the length of the NG tube to be passed
by measuring the length from nose to earlobe and then earlobe to xiphoid process.
7. Add the measurements together and mark this total distance with a small piece of tape.
8. Inspect both of the patient’s nostrils for patency. Have the patient blow nose if able.
9. Lubricate the first 6 inches of the NG tube liberally with a water soluble lubricant. Choose the
largest patent nostril and begin to pass the NG tube through the nostril to the nasopharynx;
direct the tube through the nostril aiming down
and back.
10. Once in the pharynx instruct the patient to swallow
either mimicking the action or by sipping on small
amounts of water. If awake and alert have the
patient place chin to chest to facilitate easier
passage of the tube. Introduce the tube until the
selected mark (indicated by the tape) is reached.
See Figure B.
11. Verify NG tube placement in the stomach by two
of the following: Chest X-ray or aspirating gastric
contents with the irrigation syringe
12. While listening over the epigastrium with a
stethoscope quickly instill a 30cc air bolus with the
irrigation syringe. Air entering the stomach will produce a “whooshing” sound.
13. Ask the patient to hum or talk. Coughing, cyanosis or choking may indicate that the NG tube
has passed through the larynx.
14. Place the open end of the NG tube in a cup of water. Persistent bubbling may indicate that the
NG tube has passed through the larynx.
15. If unable to positively confirm that the NG tube has been placed is in the stomach the tube
must be removed immediately and re-attempted.
16. Once confirmed for placement, secure the NG tube by placing one end of tape on from the
bridge to the tip of the nose and the other end wrapped around the tube itself. If possible the
nose should be clean and prepped prior to securing with tincture of benzoin.
17. Clamp or connect the NG tube as desired. If a Salem sump tube is utilized it important to
remember that the blue pigtail must be kept at the level of the fluid in the patient’s stomach.
This will prevent gastric contents from leaking back through vent lumen.
18. To deter the NG tube from dangling and possible dislodgment:
 Curve and tape the tube to the patient’s cheek to prevent unnecessary tugging on the
nostrils. Attach the tube to the patient’s gown. (Do not tape to the patient’s forehead as
this will put pressure on the nares.
 Wrap a small piece of tape around the tube near the connection creating a tab.
 Loop a rubber band in a slip knot near the connection and pin to the patient’s gown.

NOTES

193
 Suturing Techniques
Suture Products
 Absorbable: Vicryl, PDS, Chromic, and Catgut
 Non-absorbable: Nylon, Silk, and Polypropylene

Needles

 Taper Point
 Blunt Taper Point
 Cutting Edge
 Reverse Cutting Edge
 Taper cut
 Micro Point Spatula Curved
 Micro Point Reverse Cutting

Styles of Sutures
 Simple Interrupted
 Running cutaneous
 Running intradermal
 Vertical Mattress
 Horizontal Mattress

Biopsy Types

 Shave Biopsy
 Punch Biopsy
 Elliptical excision

Instruments
Forceps

Scissors

Needle Drivers

194
 Hemostats

Types of Sutures
Simple Interrupted

Needle should enter the skin surface at a 90-degree angle. The proper needle path to
produce eversion of the wound edge is in the shape of a flask. Use the non-dominant hand to
push down on both sides of the wound, this will cause the tissue in the deep part of the wound
to move toward the center of the wound. The needle exits the skin vertically. When the tissue
relaxes the suture makes a flask shape and then with tying, the suture produces eversion.
Careful: pushing down on the wound with the fingers increases the risk for needle-stick injury,
you can use instruments to push down on the wound edges.

Running Cutaneous

This is just a simple interrupted stitch that you don’t tie off, just continue with the long end,
multiple loops are made straight across the wound, moving down the wound edge about 4-5
mm with each pass. At the end, the suture is tied by looping suture over the needle driver and
reaching back to grasp the final loop across the wound.

Vertical Mattress
The needle starts far from the wound edge on the first pass (4-8 mm) and should pass
vertically through the skin surface. This must be place at the same distance and the same
depth from the wound edge.

195
The needle comes up the other place at the same distance and
the same depth as the first side. Place the needle backward in
the needle driver, now you will make the ‘near’ pass, it will be
within 1-2 mm of the wound edge, using a backhand pass. This
pass should be within the dermis.

Avoid tying the suture too tight here as is results in increased

wound scarring.

Horizontal Mattress

196
The needle is passed from the right side of the wound to the left side of the wound. The entry
and exit sites of the wound generally are 4-8 mm from
the wound edge. Do not tie the suture. The needle is
then placed backward in the needle driver and then the
suture is passed back from the left side to the right side.
The second pass of the suture is 4-8 mm down the
wound edge.

Then the suture is tied, producing skin edge eversion,

tying too tightly produces extra eversion and this can
cause skin pressure necrosis.

NOTES

197
 Oral Case Presentation Guide
Writing a note IS NOT the same as verbally reporting it. It takes practice to do a good verbal
presentation. Use your lab case notes. Below is an example of a written note and then an example
is given of how to give an oral presentation.

MUST HAVE:

 A SUCCINCT HISTORY emphasizing HPI

 A SUCCINCT PHYSICAL EXAMINATION
Always start with vitals, state only most pertinent exam findings, positive and negative, that
support your differential.
 PERTINENT LABS/IMAGING/DIAGNOSTIC TESTS
 ASSESSSMENT: Your DDX which matches the reasoning stated D PLAN

It is key to be brief (1-2 minutes) and deliver it from memory. Focus on the HPI, assessment and
plan using key findings in the exam to support your differential.

Written Note Sample:

Subjective:
Patient info: Amy I. Hurt 3/7/1979
CC: Abdominal pain

HPI:
40 y/o Female, G2P2, with 2-day history of abdominal pain that began 2 hours after a meal.
The pain began at the umbilicus and then moved to the RLQ and does not radiate
anywhere. The pain was intermittent at first but has become constant. It is sometimes
crampy and sometimes sharp. The pain was not relieved by two Advil, but is a little better
when the patient sits curled up and still. The pain is worse with walking. Since the pain began
she has not eaten and drinking has decreased. Constant nausea X 2 days, and has vomited
twice today. Patient normally stools daily but has not for two days, also with decreased urinary
frequency. Pain is now an 8/10, seems to be getting worse, she does not know what is
causing the pain. No priors.

PMH:
Medical: Gout dx age 35
Surgeries: tonsillectomy, age 8
Hospitalizations: only for tonsillectomy and childbirth
Injuries: none

Meds:
Rx: Allopurinol 200 mg QD
OTC: occasional ibuprofen
Supplements: MVI QD (daily multivitamin)

Allergies:
Medication/Food/Environmental: none

198
 SH:
Occupation: KFC manager
Living situation: Married 10 years, lives in house with husband and 2 children
Sleep: restful sleep 8 hours per night
Exercise: walks 3 X per week
Diet: balanced diet, avoids fast food
Substance use: smokes 1-2 cigars per month, 3 alcohol drinks per month, no recreational
drugs, 3 cups coffee per day
Sexual history: monogamous with husband, 3 total partners, no STI’s

Family Hx:
Mother: 72, had breast CA
Father: 77, HTN
Brother: 42 A&W (alive and well)

ROS: (review of systems)

General: + fever for two days, no weight changes, no chills, decreased appetite
CV: no chest pain, tachycardia or palpitations
Resp: no shortness of breath, cough or wheezing
GI: + nausea, + vomiting, mild constipation, no hematochezia (see HPI)
GU/Repro: no dysuria, dark urine, decreased urination, possible hematuria. G2P2, FDLMP 3
weeks ago, no vaginal discharge, no pelvic pain, no dysmenorrhea.
MSK: no back pain

Objective:
Vitals: P: 104 beats/min, R: 14 breaths/min, BP: 132/84, Ht: 63in, Wt: 123lbs., BMI: 21,
Temp: 100.4F, Pulse Ox: 97%

GA: Appears alert and oriented, erect posture, healthy weight, even skin tone, no distress

CV: RRR, S1 and S2 present, no S3 or S4, no thrills, heaves or murmur, PMI 5th ICS MCL

Resp: no chest deformities, no tenderness or masses, thorax is symmetrical in shape and

expansion. LCTA b/l

Abd: smooth, flat, no scars, no lacerations, even skin tone

Bowel sounds markedly decreased in all 4 quadrants, no abdominal or femoral bruits.
Tympanic to percussion in all four quadrants, liver measures 8 cm.
Tender to palpation in RLQ, positive rebound in RLQ and positive Rovsing’s. Negative Psoas
sign, negative obturator sign, negative Murphy’s, negative Lloyd’s. No masses or HSM,
kidneys not palpable, aorta midline and approx. 3 cm. No rectal masses, heme neg.

OPP: T10 FRSR

Assessment:
1. CC: RLQ abdominal pain
a. Appendicitis
b. Ectopic pregnancy
c. Ovarian cyst
d. Cholecystitis
e. Gastroenteritis

199
 f. Nephrolithiasis
g. Gout
h. Somatic dysfunction of T spine

Plan:
1. CBC, CMP, qualitative pregnancy test, UA, surgery consult
2. Abdominal CT with and without contrast
3. MET after acute episode resolved
4. Discussed risks of surgery and side-effects of medication
5. Follow up 2 days after hospital discharge

Now from the written note here is how you might do a verbal
presentation:
I have a 40 y/o female, G2P2, with a 2-day history of RLQ abdominal pain without radiation which
she has not experienced before. It was initially intermittent, now constant, sharp and 8/10 in severity.
It began 2 hours after a normal meal, she has had no PO intake since then due to constant nausea.
She has had 2 episodes of vomiting. The pain worsens with walking and she is most comfortable
lying down curled up. She feels feverish. She denies hematochezia, dysuria, frequency, unusual
vaginal discharge or new sexual partners. FDLMP 3 weeks ago with a normal period. Review of
systems otherwise negative. She is a social smoker and drinker, does drink 3 cups of coffee a day.
She takes 200 mg daily of allopurinol for gout and occasional ibuprofen. She has no allergies.

Exam
BP 132/84, pulse 104, Respirations 14, Temp 100.4 °F, Pulse ox 97%, BMI 21 She is in obvious
significant discomfort. Lungs are clear in all fields with moderate excursion, heart sounds regular,
good S1S2, no S3S4 or murmur. Abdomen without
bowel sounds, very tender to light touch, soft, without mass, with positive RLQ rebound and
Rovsing’s sign. Murphy’s negative, no epigastric or LUQ tenderness. Lloyd’s negative

Assessment
I believe she could have an acute appendicitis, or ectopic pregnancy or an ovarian cyst.

Plan
I would like to get a qualitative HCG (pregnancy test), CBC, ESR (sedimentation rate), CMP
(complete metabolic profile), UA (urine analysis) and abdominal CT with and without contrast. I
would keep her NPO (nothing per oral) and consult a surgeon.

NOTES

200
 Medical History SOAP Note
Patient Information:
SUBJECTIVE

CC:

HPI: (can use OLD CAARTS PPP) **ALWAYS STATE AGE AND GENDER IN THE FIRST LINE OF
YOUR HPI**
Onset/Setting
Location:
Duration:
Character:
Aggravating:
Alleviating:
Associated Symptoms:
Radiation:
Timing: (frequency, duration, fluctuation)
Severity:
Prior Episodes:
Progression:
Perceived cause:

PMH: (include age at diagnosis) Med Problems:

Major Illnesses:
Childhood disease:
Injuries:
Surgeries:
Hospitalizations:
Immunizations:
Screening Tests and past doctor visits:

Medications: (include dose and directions)

Rx: (including birth control/hormone replacement)
OTC:
Supplements: (vitamins, herbs, other):

Allergies: (include reaction)

Medication:
Food:
Environmental:

Social Hx:
Occupation/Past Occupations:
Living situation: (relationship status, children, type of accommodations if appropriate)
Sleep:
Exercise: Diet:
Substance Use: (include type, quantity, frequency and duration)
Tobacco:

201
 Drugs:
Alcohol:
Caffeine:
Sexual hx: (number of total partner, current partners, STI’s, protection)
Exposures: (Environmental, Other)
Spiritual beliefs or other life experiences that impact health decisions:

Family History: (include ages of dx or death where appropriate)

Mother:
Father:
Grandparents: (MGM, MGF, PGM, PGF)
Siblings:
Children:

ROS: (document exactly what you asked, do not put “none”, as you likely didn’t ask every possible
question for that system)
General:
Head:
Eye:
Ears:
Nose:
Throat:
Neck:
Cardiovascular:
Respiratory:
GI:
Urinary:
Reproductive/Genital:
MSK:
Neuro:
Skin Endocrine:
Hematolymph/Immune:
Psychiatric:

OBJECTIVE

PE
Vitals:
General assessment:
Derm:
HEENT:
Heart:
Lungs:
Abdomen:
GU:
MSK:
Neuro:
Osteopathic:

202
ASSESSMENT
1. CC: ____________________
a. (ddx #1)
b. (ddx #2)
c. (ddx #3)
2. (problem list items can go here, there may be more than one, e.g. hyperlipidemia)
3. Somatic Dysfunction of _______________________

PLAN
1. Labs or tests (reasons why)
2. Treatments: meds, physical therapy, home O2…)
3. OMT treatment
4. Patient education
5. Follow up

NOTES

203
 Procedure Note
(To be used whenever doing any procedure in the hospital or clinical setting)

Patient Identification
Name/DOB

Physician (student doctor and the attending)

Procedure performed

Pre-procedure diagnosis Post-procedure diagnosis

(These may be the same if nothing new is diagnosed during or due to the procedure)

Medications used before, during, and after the procedure List all used
without doses

Equipment used
Detailed list (3 cc syringe, 22G needle, 4-0 Nylon suture, needle driver, forceps, hemostat,
scissors, etc.)

Informed consent
Specify verbal &/or written, state major problems that may occur, can state anticipated
benefit. The more detail here, the better, this protects you as the doctor.

Procedure Detailed description of the procedure performed, including aseptic technique

– if applicable. Start to finish. Include estimated blood loss (EBL), if any, if more than
expected this would be included in ‘complications’

Complications List details of any unexpected outcomes and how it was handled (excess
blood loss, laceration of tendon, laceration of artery for example)

Disposition This is where you document what you did with the patient when you were done
with the procedure:

Released? Admitted to floor? Taken to surgery? What is the next action? You can
put wound care/discussing sign of infection here and follow up if outpatient here.

Sign and date note ________________________________________________

204
 Psychiatric Progress Note
Patient Identification: ______________________________________________________________

Subjective (Include chief complaint and historical information given by the patient)

Objective (Mental Status Exam)

Appearance and attitude: __________________________________________________________

Motor Activity: ____________________________________________________________________

Thought and Speech: _____________________________________________________________

Mood and Affect: ________________________________________________________________

Perceptions: ____________________________________________________________________

Orientation: _____________________________________________________________________

Memory: _______________________________________________________________________

General Information: ______________________________________________________________

Calculations: ____________________________________________________________________

Capacity to read and write: _________________________________________________________

Visuospatial ability: _______________________________________________________________

Attention and Concentration: ________________________________________________________

Abstraction: _____________________________________________________________________

Judgment and Insight: _____________________________________________________________

Suicide/Homicide: ________________________________________________________________

Objective (cont.)
Additional objective measures utilized e.g. rating scales. Other physical
examination

Assessment (DSM TR-4) Axis I

Axis II Axis III Axis
IV Axis V

Plan Biological
Psychological Social
Labs/tests Follow-up

Printed name: ____________________________ Signature: _______________________________

205
 Admissions Orders
(ADC VAAN DIMLS)

Admit
to where
medical floor, surgical floor, CCU, ICU…

Diagnosis
working diagnosis = #1 differential

Condition
Stable Fair Serious Critical

Vitals
Vitals every _____ hours for _____ day(s) then every shift

Activity
Bed Rest Bedside Commode Bathroom Privileges: alone or with assistance
Up Ad Lib Fall Precautions

Allergies
Medication (response)

Nursing Procedures (These are examples, tailor them to your individual patient needs)
Neuro checks every ______ hours
Pulse ox every _______
Continuous pulse ox, maintain O2 saturation > 92%
Daily Weight or every _______
Orthostatic VS every 4 hours x4 then every shift
Continuous cardiac monitoring (if in telemetry unit or ICU)
Notify Physician for
Temp > Pulse > BP> or <
Urine output < 30cc over 4 hours
Record pedal pulses every shift

Diet
NPO Age appropriate Salt restricted ADA 1200 kcal ADA 1500 kcal
ADA 1800 kcal Soft diet Clear liquid AHA step 2
Fluid restriction _______ ml/24 hours _______ (fill in)
gluten free, no corn, no nuts __________

I&O’s
when needed: “I&O q shift” for everything, can also specify which to record IV, chest tube, Foley
catheter, NG etc.

Medications
IV ___________ @ _____ ml/hr OR
IV ___________ @ _____ ml/hr until (time or symptoms resolve or show up) then (change IV,
reduce rate to, stop….)
206
 IV medication order (be very specific)
PO medications (be specific) daily or pm ______ Remember their home daily medicatins
(change IV, reduce rate to, stop….)
IV medication order (be very specific)
PO medication (be specific) daily or prn Remember their home daily medications

Example: Tylenol 500 mg 1-2 PO prn temp > 100.5°F

Cefepime 2 gm IVPB q 12 hours (IV piggy back)
Ambien 5 mg PO q HS prn insomnia
Potassium chloride 20 meq every 4 hours IVPB
MOM 30cc PO q 12 hours prn constipation

Labs and Radiology/Procedures

list specifically
Potassium bid, call results to resident
CBC,
CMP every am x 3 days
Troponin I finger stick every am x3 days
EKG
CXR
OMM

Special Orders
(These are just examples, individualize to your patient needs)

Elevate swollen leg while in bed; Cast/splint check q 12 hours, record distal pulse every shift with
skin color and temp; record bowel sounds q 4 hours; call physical therapy in am for initial post op
consult; call speech therapy for consult; Specific hospital protocols that everyone needs to use can
go here DVT protocol (these typically include both meds with specific doses and nursing orders so
they do not need to be written out each time)

NOTES

207
 Pediatric Admission Orders
Date: ___________ Time: ____________ Ht ____ cm Wt _____ kg Allergies: _________________

Attending Pediatric Service: ________________________________________________________

Category Status 1 2 3 4

Patient Status Inpatient Outpatient Observation

Diagnosis: ______________________________________________________________________

Condition: ______________________________________________________________________

Vital signs Routine __________________

Daily weights
Call House Officer or attending physician for:
Temp less than _____ or greater than _____
HR less than _____ or greater than _____
BP less than _____ or greater than _____
RR less than _____ or greater than _____
Pain scores greater than _____ or equal to 4 if unrelieved

Diet
Pediatric Regular Pediatric Soft Full liquids
Clear liquids Advance as tolerated NPO
Breast feed Formula
Tube feeding Other ________________________

Activity
UP ad lib Up with assistance Bathroom privileges Bedrest

I/O
Routine Strict Weigh diapers

Isolation
Contact Airborne Droplet Reverse

Labs
CBC CBC with differential Basic metabolic panel
Comprehensive metabolic panel Blood culture x
Sedimentation Rate C-Reactive Protein In and Out cath UA
Clean Catch Urine C and S by catheterization
Urine C and S by clean catch

208
Radiology
Portable Chest X-ray PA & Lat Chest X-ray
Indication _______________________________
KUB Abdominal series Other __________________________

IV Fluids
D5 ¼ NS D5 ½ NS 0.9% NS ___________________ at _____ ml/hr
add
20 mEq KCL/liter 20 mEq K Acetate/liter ______________________
after voiding

Monitors
Apnea/Bradycardia Continuous pulse oximeter
Pulse oximeter checks every hrs.

Consults
Social Work-Indication:
Child Life-Indication:
Pediatric Nutrition Support Team-Indication:

Pet Therapy
In Playroom In Patient Room

Discharge Planning
respiratory teaching CPR training Home Health
Equip _______________________________

Other:
_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_________________________ _________________________
(Physician Signature) (Physician Print Name)
Pager Number ______________________

NOTES

209
 Routine Labs
CBC (with or without differential)
WBC, RBC, Hgb, HCT, MCH, MCHC, MCV, RDW)

 RBCs (4.7-6.1 x 10 6th)

 Hemoglobin (Hgb) (F=12-16, M=14-18gr/dL)
 Hematocrit (HCT) (F=37-47, M=40-54%)
 MCH (Mean Cellular Hemoglobin) (27-31) = Hemoglobin (g/L) ÷ RBC (millions/microL)
 MCHC (Mean Cellular Hemoglobin Concentration) (33-37%) = hemoglobin (gm/dL) ÷
hematocrit
 MCV (Mean Cell Volume) (F=81-89, M=80-94fL) = (HCT x 1000) ÷ RBC (millions/microL)
 RDW (Red Cell Distribution Width) (11.5-14.5)
 PLATELETS (150-450,000 µL)
 WBCs (4800-10,800 cells/µL)
 Neutrophils (PMNs 46-80%) (usually 5% - 2 lobes, 15-25% - 4 lobes and 40-50% have
3 lobes)
 “Left shift” = predominance of immature cells (bands or stabs) with only one or
two nuclear lobes separated by a thick chromatin band.
 Eosinophils (1-3%)
 Basophils (0-1%)
 Lymphocytes (24-44%)
 Monocytes (3-7%)

Short - hand notation of a CBC

Glucose (Glu; fasting 70-100 mg/dL)

Electrolytes (Sodium, Potassium, Calcium, Magnesium, Phosphate)

CHEM 6, 7, 12, 14, 20 (Chemistry panels, i.e. Chem 20)

 Albumin (protein level, 3.5-5.0 gm/dL)
 Alkaline Phosphatase (AP; differentiate between bone or liver origin, 20-70 U/liter)
 Alanine Aminotransferase (ALT, SGPT, 8-20 U/L)
 Aspartate Aminotransferase (AST, SGOT, 8-20 U/L) (generally parallels changes in SGPT in
liver disease)
 Bilirubin
 TOTAL (<0.2-1.0 mg/dL)

210
  DIRECT (<0.2 mg/dL)
 INDIRECT (<0.8mg/dL)
 Blood Urea Nitrogen (BUN 7-18 mg/dL)
 Calcium (When interpreting a total Ca value, the total protein and albumin values must be
known.)
 Carbon Dioxide (CO; adult= 23-29, child= 20-28 mmol/liter)
 Chloride (CL; 98-106 mEq/liter)
 Cholesterol (adult 130-200 mg/dL)
 Creatinine (CrF 0.6-1.1, M 0.7-1.3 mg/dL)
 Gamma-glutamyl transferase (SGGT; F 8-40, M 9-50 U/L)
 Lactate dehydrogenase (LDH; 45-100 U/L)
 Phosphorus (2.3-4.7 mg/dL)
 Potassium (K;3.5-5.1 mmol/L)
 Sodium (Na;136-145 mmol/L)
 Triglycerides (F=35-135, M=40-160, can vary with age)
 Uric Acid (F3.0-6.5, M4.5-8.2 mg/dL)

Examples of other Common SERUM Laboratory Tests:

 CD4 cell count
 Vitamin levels: Folic Acid, B12
 Coagulation studies: PT, PTT
 Blood typing: ABO blood groups
 HLA; HLA-B27
 Plasma Studies: Hormones, Trace Metals, Drug levels
 Antibodies, Antigens, Complements, AFP
 Amylase, lipase
 C-Peptide
 HDL, LDL, VLDL
 CK, CKMB
 Ferritin, iron stores, ceruloplasmin
 TSH, FSH, LH
 Lactic Acid, ammonia

211
 Urinalysis

 Color
 Specific gravity
 Ketones
 pH
 Protein
 Glucose
 blood
 Leukocyte esterase
 Epithelial cells
 Bilirubin
 Urobilinogen
 Nitrates

 (# cells/ HPF)
 rare/trace <2
 Occasional/1+ 3-5
 Frequent/2+ 5-9
 Many/3+ large amt.
 TNTC/4+ (full field) packed field

What are we looking for (micro)?

 RBC’s, WBC’s, epithelial cells, parasites (trichomonas), yeast, sperm, crystals, other – hair,
thread, mucus
 Casts – hyaline, RBC, WBC, epithelial, waxy, fatty

NOTES

212
 Abbreviations
This list includes accepted abbreviations for COMLEX. You can ask your preceptors in labs if a
certain abbreviation that is not on this list would be an acceptable one. DO NOT make up
abbreviations and try to avoid abbreviations that might lead to medical errors.

Abd abdomen LMP last menstrual period

AIDS acquired immune deficiency syndrome LP lumbar puncture
BMI body mass index Lspine lumbar spine
BP blood pressure m male
BUN blood urea nitrogen meds medications
c/o complaining of MRI magnetic resonance imaging
CABG coronary artery bypass graft MVA motor vehicle accident
CBC complete blood count MI Myocardial infarction
CC chief complaint NKDA non known drug allergies
cc cubic centimeter Neuro neurologic
CCU cardiac care unit NKA no known allergies
CHF congestive heart failure (+) or pos. positive (must use parentheses)
COPD chronic obstructive pulmonary disease RBC red blood cells
CPR Cardiopulmonary resuscitation PT prothrombin time
Cspine cervical spine PTT partial thromboplastin time
CT computerized tomography PMH past medical history
CTA clear to auscultation NSR normal sinus rhythm
CVA cerebrovascular accident ROM range of motion
CXR chest x-ray PSH past surgical history
DM diabetes mellitus OMT osteopathic manipulative treatment
pupils equal, round, reactive to light and
DTR deep tendon reflex PERRLA
accommodation
E extended PE physical exam
ECG / EKG electrocardiogram PO by mouth
ED emergency department ppd pack per day
EMT emergency medical technician R right
ENT ears, nose, throat RRR regular rate and rhythm
EOM extraocular muscles ROT rotated
EOMI extraocular movements intact ROS review of systems
ETOH alcohol R/O rule out
EXT extremities SB side bent
f female RR respiratory rate
F flexed SH social history
FH family history Tspine thoracic spine
GI gastrointestinal (-) or neg negative (must use parentheses)
GU genitourinary T1DM type 1 diabetes
h/o history of TIA transient ischemic attack
HEENT head, eyes, ears, nose, throat U/S ultrasound
HIV human immunodeficiency virus T2DM type 2 diabetes
HTN hypertension URI upper respiratory infection
HVLA high velocity low amplitude U/A urinalysis
hx history y/o year old
JVD jugular venous distension WBC white blood cells
KUB kidney, ureter, bladder WNL within normal limits
L left w/o without

213
 Other Abbreviations
These are abbreviations that you can use in PCM for your SOAP notes, they are not on the official
COMLEX list.
A&O alert and oriented normoactive bowel sounds X four quadrants
ABG arterial blood gas NABS x 4
ac before meals N/V/C/D nausea, vomiting, diarrhea, constipation
ACL anterior cruciate ligament NAD no acute distress
ad lib as desired NC non-contributory
ant. anterior NC/AT normocephalic/atraumatic
AO x3 alert and oriented times three NSAID non-steroidal anti-inflammatory drug
b/l bilateral OD right eye
BID twice daily OS left eye
BIW twice weekly OU both eyes
BP blood pressure oz ounce
BS bowel sounds PCL posterior cruciate ligament
C◦ degrees Celsius PMI point of maximal impulse
Cap(s) capsules PNS peripheral nervous system
cc cubic centimeter post. posterior
cm centimeter prn as needed
CMT cervical motion tenderness pt. patient
CN cranial nerve q every
CNS central nervous system Q 4 hr every four hours
CVAT costovertebral angle tenderness QAM every morning
F◦ degrees Fahrenheit QD once daily
FROM full range of motion QHS every bedtime
ft. foot QID four times daily
g grams QOD every other day
gt, gtts drops, drops QPM every evening
HJR hepatojugular reflux qs sufficient quantity
hr hour QW once per week
HR heartrate RLL right lower lobe
hs at bedtime RLQ right lower quadrant
HSM hepatosplenomegaly RR Respiratory rate
ht height RROM restricted range of motion
IM intramuscularly RSB right sternal border
in. inch RUL right upper lobe
inj injection RUQ right upper quadrant
IU international units Rx prescription
IV intravenously susp suspension
JVP jugular venous pressure Tab(s) tablets
kg kilograms temp temperature
lat. lateral TID three times daily
lb. or lbs. pound or pounds TIW three times per week
LE lower extremity Tmax maximum temperature in 24 hours
LLL left lower lobe TNTC too numerous to count
LLQ left lower quadrant tsp teaspoon
LSB left sternal border UE upper extremity
LUL left upper lobe UTI urinary tract infection
LUQ left upper quadrant VS vital signs
mcg micrograms VSS vital signs stable
med. medial w/ with
mEq milliequivalent w/r/r wheezes/rales/rhonchi
mg milligrams w/a while awake
ml milliliters WD/WN well developed, well nourished
mm millimeter wt weight
MVI multivitamin x times
214
Symbols

215
 USPSTF A and B Recommendations
Topic Description Grade Release Date of
Current
Recommendation
Abdominal aortic The USPSTF recommends one-time screening for abdominal B June 2014*
aneurysm aortic aneurysm by ultrasonography in men ages 65 to 75 years
screening: men who have ever smoked.
Alcohol misuse: The USPSTF recommends that clinicians screen adults age 18 B May 2013*
screening and years or older for alcohol misuse and provide persons engaged in
counseling risky or hazardous drinking with brief behavioral counseling
interventions to reduce alcohol misuse.
Aspirin preventive The USPSTF recommends initiating low-dose aspirin use for the B April 2016*
medication: adults primary prevention of cardiovascular disease and colorectal
aged 50 to 59 years with cancer in adults aged 50 to 59 years who have a 10% or greater
a ≥10% 10- year 10-year cardiovascular risk, are not at increased risk for bleeding,
cardiovascular risk have a life expectancy of at least 10 years, and are willing to take
low-dose aspirin daily for at least 10 years.
Bacteriuria screening: The USPSTF recommends screening for asymptomatic A July 2008
pregnant bacteriuria with urine culture in pregnant women at 12 to 16
women weeks' gestation or at the first prenatal visit, if later.
Blood pressure The USPSTF recommends screening for high blood pressure in A October 2015*
screening: adults adults aged 18 years or older. The USPSTF recommends
obtaining measurements outside of the clinical setting for
diagnostic confirmation before starting treatment.
BRCA risk assessment The USPSTF recommends that primary care providers screen B December 2013*
and genetic counseling/ women who have family members with breast, ovarian, tubal, or
testing peritoneal cancer with one of several screening tools designed to
identify a family history that may be associated with an increased
risk for potentially harmful mutations in breast cancer
susceptibility genes (BRCA1 or BRCA2). Women with positive
screening results should receive genetic counseling and, if
indicated after counseling, BRCA testing.
Breast cancer preventive The USPSTF recommends that clinicians engage in shared, B September 2013*
medications informed decision making with women who are at increased risk
for breast cancer about medications to reduce their risk. For
women who are at increased risk for breast cancer and at low risk
for adverse medication effects, clinicians should offer to prescribe
risk-reducing medications, such as tamoxifen or raloxifene.
Breast cancer screening The USPSTF recommends screening mammography for women, B September 2002†
with or without clinical breast examination, every 1 to 2 years for
women age 40 years and older.
Breastfeeding The USPSTF recommends providing interventions during B October 2016*
interventions pregnancy and after birth to support breastfeeding.
Cervical cancer The USPSTF recommends screening for cervical cancer in A March 2012*
screening women ages 21 to 65 years with cytology (Pap smear) every 3
years or, for women ages 30 to 65 years who want to lengthen
the screening interval, screening with a combination of cytology
and human papillomavirus (HPV) testing every 5 years.
Chlamydia screening: The USPSTF recommends screening for chlamydia in sexually B September 2014*
women active women age 24 years or younger and in older women who
are at increased risk for infection.
Colorectal cancer The USPSTF recommends screening for colorectal cancer A June 2016*
screening starting at age 50 years and continuing until age 75 years.
Dental caries prevention: The USPSTF recommends the application of fluoride B May 2014*
infants and children up to varnish to the primary teeth of all infants and children starting at
age 5 years the age of primary tooth eruption in primary care practices. The
USPSTF recommends primary care clinicians prescribe oral
fluoride supplementation starting at age 6 months for children
whose water supply is fluoride deficient.
216
Depression screening: The USPSTF recommends screening for major depressive B February 2016*
adolescents disorder (MDD) in adolescents aged 12 to 18 years. Screening
should be implemented with adequate systems in place to
ensure accurate diagnosis, effective treatment, and appropriate
follow-up.
Depression screening: The USPSTF recommends screening for depression in the B January 2016*
adults general adult population, including pregnant and postpartum
women. Screening should be implemented with adequate
systems in place to ensure accurate diagnosis, effective
treatment, and appropriate follow-up.
Diabetes screening The USPSTF recommends screening for abnormal blood B October 2015*
glucose as part of cardiovascular risk assessment in adults aged
40 to 70 years who are overweight or obese. Clinicians should
offer or refer patients with abnormal blood glucose to intensive
behavioral counseling interventions to promote a healthful diet
and physical activity.
Falls prevention: older The USPSTF recommends exercise interventions to prevent B April 2018*
adults falls in community-dwelling adults 65 years or older who are at
increased risk for falls.
Folic acid The USPSTF recommends that all women who are planning or A January 2017*
supplementation capable of pregnancy take a daily supplement containing 0.4 to
0.8 mg (400 to 800 µg) of folic acid.
Gestational diabetes The USPSTF recommends screening for gestational diabetes B January 2014
mellitus screening mellitus in asymptomatic pregnant women after 24 weeks of
gestation.
Gonorrhea prophylactic The USPSTF recommends prophylactic ocular topical A July 2011*
medication: newborns medication for all newborns for the prevention of gonococcal
ophthalmia neonatorum.
Gonorrhea screening: The USPSTF recommends screening for gonorrhea in sexually B September 2014*
women active women age 24 years or younger and in older women who
are at increased risk for infection.
Healthy diet and physical The USPSTF recommends offering or referring adults who are B August 2014*
activity counseling to overweight or obese and have additional cardiovascular disease
prevent cardiovascular (CVD) risk factors to intensive behavioral counseling
disease: adults with interventions to promote a healthful diet and physical activity for
cardiovascular risk factors CVD prevention.
Hemoglobinopathies The USPSTF recommends screening for sickle cell disease in A September 2007
screening: newborns newborns.
Hepatitis B screening: The USPSTF recommends screening for hepatitis B virus B May 2014
nonpregnant adolescents infection in persons at high risk for infection.
and adults
Hepatitis B screening: The USPSTF strongly recommends screening for hepatitis B A June 2009
pregnant women virus infection in pregnant women at their first prenatal visit.
Hepatitis C virus infection The USPSTF recommends screening for hepatitis C virus B June 2013
screening: (HCV) infection in persons at high risk for infection. The SPSTF
adults also recommends offering one-time screening for HCV infection
to adults born between 1945 and 1965.
HIV screening: The USPSTF recommends that clinicians screen for HIV A April 2013*
nonpregnant adolescents infection in adolescents and adults ages 15 to 65 years. Younger
and adults adolescents and older adults who are at increased risk should
also be screened.
HIV screening: pregnant The USPSTF recommends that clinicians screen all pregnant A April 2013*
women women for HIV, including those who present in labor who are
untested and whose HIV status is unknown.
Hypothyrodism screening: The USPSTF recommends screening for congenital A March 2008
newborns hypothyroidism in newborns.
Intimate partner violence The USPSTF recommends that clinicians screen women B January 2013
screening: women of of childbearing age for intimate partner violence, such as
childbearing age domestic violence, and provide or refer women who screen
positive to intervention services. This recommendation applies to
women who do not have signs or symptoms of abuse.
217
Lung cancer screening The USPSTF recommends annual screening for lung cancer with B December 2013
low-dose computed tomography in adults ages 55 to 80 years
who have a 30 pack-year smoking history and currently smoke or
have quit within the past 15 years. Screening should be
discontinued once a person has not smoked for 15 years or
develops a health problem that substantially limits life expectancy
or the ability or willingness to have curative lung surgery.
Obesity screening and The USPSTF recommends screening all adults for obesity. B June 2012*
counseling: adults Clinicians should offer or refer patients with a body mass index of
30 kg/m2 or higher to intensive, multicomponent behavioral
interventions.
Obesity screening: The USPSTF recommends that clinicians screen for obesity in B June 2017*
children and adolescents children and adolescents 6 years and older and offer or refer
them to comprehensive, intensive behavioral interventions to
promote improvements in weight status.
Osteoporosis screening: The USPSTF recommends screening for osteoporosis in women B January 2012*
women age 65 years and older and in younger women whose fracture
risk is equal to or greater than that of a 65-year-old white woman
who has no additional risk factors.
Phenylketonuria The USPSTF recommends screening for phenylketonuria B March 2008
screening: newborns in newborns.
Preeclampsia prevention: The USPSTF recommends the use of low-dose aspirin (81 mg/d) B September 2014
aspirin as preventive medication after 12 weeks of gestation in women
who are at high risk for preeclampsia.
Preeclampsia: screening The USPSTF recommends screening for preeclampsia in B April 2017
pregnant women with blood pressure measurements throughout
pregnancy.
Rh incompatibility The USPSTF strongly recommends Rh (D) blood typing A February 2004
screening: first and antibody testing for all pregnant women during their first visit
pregnancy visit for pregnancy-related care.
Rh incompatibility The USPSTF recommends repeated Rh (D) antibody testing for B February 2004
screening: 24–28 all unsensitized Rh (D)-negative women at 24 to 28 weeks'
weeks' gestation gestation, unless the biological father is known to be Rh (D)-
negative.
Sexually transmitted The USPSTF recommends intensive behavioral counseling for all B September 2014*
infections counseling sexually active adolescents and for adults who are at increased
risk for sexually transmitted infections.
Skin cancer behavioral The USPSTF recommends counseling young adults, B March 2018*
counseling adolescents, children, and parents of young children about
minimizing exposure to ultraviolet (UV) radiation for persons aged
6 months to 24 years with fair skin types to reduce their risk of
skin cancer.
Statin preventive The USPSTF recommends that adults without a history of B November 2016*
medication: adults cardiovascular disease (CVD) (i.e., symptomatic coronary artery
ages 40–75 years with no disease or ischemic stroke) use a low- to moderate-dose statin
history of CVD, 1 or more for the prevention of CVD events and mortality when all of the
CVD risk factors, and a following criteria are met: 1) they are ages 40 to 75 years; 2) they
calculated 10-year CVD have 1 or more CVD risk factors (i.e., dyslipidemia, diabetes,
event risk of 10% or hypertension, or smoking); and 3) they have a calculated 10-year
greater risk of a cardiovascular event of 10% or greater. Identification of
dyslipidemia and calculation of 10-year CVD event risk requires
universal lipids screening in adults ages 40 to 75 years.
Tobacco use counseling The USPSTF recommends that clinicians ask all adults about A September 2015*
and interventions: tobacco use, advise them to stop using tobacco, and provide
nonpregnant adults behavioral interventions and U.S. Food and Drug Administration
(FDA)–approved pharmacotherapy for cessation to adults who
use tobacco.
Tobacco use counseling: The USPSTF recommends that clinicians ask all pregnant women A September 2015*
pregnant women about tobacco use, advise them to stop using tobacco, and
provide behavioral interventions for cessation to pregnant women
who use tobacco.
218
Tobacco use The USPSTF recommends that clinicians provide interventions, B August 2013
interventions: children including education or brief counseling, to prevent initiation of
and adolescents tobacco use in school-aged children and adolescents.
Tuberculosis screening: The USPSTF recommends screening for latent tuberculosis B September 2016
adults infection in populations at increased risk.
Syphilis screening: The USPSTF recommends screening for syphilis A June 2016*
nonpregnant persons infection in persons who are at increased risk for infection.
Syphilis screening: The USPSTF recommends that clinicians screen all pregnant A May 2009
pregnant women women for syphilis infection.
Vision screening: children The USPSTF recommends vision screening at least once in all B September 2017*
children ages 3 to 5 years to detect amblyopia or its risk factors.

†The Department of Health and Human Services, under the standards set out in revised Section 2713(a)(5) of the Public Health Service Act and
Section 9(h)(v)(229) of the 2015 Consolidated Appropriations Act, utilizes the 2002 recommendation on breast cancer screening of the U.S. Preventive
Services Task Force. To see the USPSTF 2016 recommendation on breast cancer screening, go to http://www.uspreventiveservicestaskforce.org/
Page/Document/RecommendationStatementFinal/breast-cancer-screening1.
*Previous recommendation was an “A” or “B.”
Current as of: March 2018

Internet Citation: USPSTF A and B Recommendations. U.S. Preventive Services Task Force. April 2018. https://
www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

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 Competency Exam List
This list shows the basic exam skills that you need to know. Your transition from first year to second
year will involve learning when and why to do certain tests as not all tests are indicated in every
situation. It is important to know why you are performing a given skill. Understand what you are
looking for to recognize when it is abnormal and what the information tells you.

This table is organized into columns. The left-hand column shows the exam skills that you perform
always when in that anatomical region. The right-hand column is the list of investigative tests or
special tests. These tests are done when indicated based on a patient’s chief complaint or abnormal
findings on the general exam.

OMM options are presented, you may choose any reasonable lesion investigation for a diagnosis
based on your differential.

Example:
If the chief complaint leads you to do an HEENT exam, you would do an otoscopic ear exam
as part of the “HEENT general” exam. You would perform the gross hearing test if the patient
reports some hearing loss, or you find on the general exam that there is something that might
decrease the hearing such as wax impaction or eardrum perforation. Then, if poor hearing is
found on this exam then you would further evaluate by doing Weber and Rinne testing.

REMINDERS:
 Remember proper draping!
 Always verbalize inspection during SP encounters. Be specific by stating that you are looking
for rashes, bruising, swelling… for example. Don’t just say “I’m going to look around”. Look for
what you would see based on your differential.
 All areas that can be done bilaterally need to be done so.
 If you have just completed an exam involving palpation of feet, axillae etc., please re-wash or
re-sanitize your hands prior to proceeding on to other parts of the exam.

Vitals and General Assessment

General If Indicated…
Palpatory Blood Pressure

Auscultatory Blood Pressure Orthostatic Blood pressure

Heart Rate

Respiratory Rate

Height and Weight

Pulse oximetry

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 Dermatology Exam

General If Indicated…
Inspection:
 Buccal mucosa
 Conjunctiva
 Skin
 Nails
 Hair
Palpation
 Scalp and Hair
 Fingernails
 Toenails
 Skin

HEENT Exam
General If Indicated…
Inspection: Inspection
 TMJ
Palpation: Palpation
 Head and face  Sinuses
 Lymph Nodes  Transillumination
 Thyroid with swallow  Trachea
 TMJ

Otoscopic Ear Exam: Gross Hearing

 Finger Rub or whisper test
 Weber
 Rinne
Insufflation
Eye Vision
 Pupil light reflexes  Peripheral fields
 EOMI  Visual acuity
 Fundoscopic exam
Otoscopic Nose Exam:
Oral Exam:
 Light
 Tongue blade
 “Say Ah”
Osteopathic:

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 PV and Lymph Exam
General If Indicated...
Inspect upper and lower extremities

Palpation
 Edema (grade)
 Skin texture
 Skin turgor
 Skin temperature
 Pulses (grade)
 Lymph nodes
Auscultation (bruits)
 Carotid
 Abdominal Aorta
 Renal arteries
 Iliac arteries
Special Tests:
 Allen test
 Roos
 Adsons
 Ankle Brachial Index
 Homans
 Postural color change

Cardiovascular Exam
General If Indicated…
Inspection precordium:

Palpation front over precordium Palpation

 Heaves  Any area of reported pain
 Thrills  JVP height
 PMI
Pulses Other Pulses
 Carotid  Brachial
Radial  Aorta
 Pedal  Femoral
 Tibialis posterior  Popliteal
 Dorsalis pedis
Auscultation: Diaphragm and Bell: Auscultation
 Aortic post  Carotid arteries: hold breath
 Pulmonic post  Left lateral decubitus at mitral post
 Erb’s point  Leaning forward at aortic post
 Tricuspid post  Valsalva/Squat-Stand over Erb’s
 Mitral post
Osteopathic exam

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 Pulmonary Exam
General If Indicated…
Inspection front and back:

General palpation front and back: Palpation

 Reported area of pain
 Excursion
 Tactile fremitus “99”
Auscultation: “Deep breath, open mouth” Auscultation: (pick one)
 Anterior: 2 areas bilaterally  Egophony “ee”
 Lateral: axillary line 2 bilaterally  Bronchophony “99”
 Superior  Whispered pectoriloquy “123”
 Inferior
 Posterior: 3 areas bilaterally
Percussion
 Posterior diaphragm excursion
 Anterior, Posterior, Lateral
points compared bilaterally
Osteopathic:

Abdominal Exam
General If Indicated…
Inspection

Auscultation: all 4 quadrants Auscultation additional

Aorta
Renal arteries
Palpation Palpation
 Light in 4 quadrants  Kidneys
 Deep in 4 quadrants  Aorta
 Liver  Rebound over area of tenderness
 Spleen  Rovsing’s sign
 Murphy’s sign
 McBurney’s point
 Rectal exam (with FOBT)
Percussion all 4 quadrants Percussion
 Lloyds sign
 Liver span
 Shifting dullness
 Fluid wave
Osteopathic exam

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 Male GU Exam
(Only performed on SPs during PCM IV in the MUTA/GTA week)

General If Indicated…
Inspection:

Palpation
 Penis
 Scrotum and contents (each testicle,
epididymis, spermatic cord)
 Inguinal lymph nodes
 Hernias
Prostate Exam
 Identify posterior surface of the
prostate, lateral lobes, and median
sulcus, note shape, size, and
consistency, nodules, tenderness
Anal Exam
 Inspect
 Fissures
 Hemorrhoids
 Palpate
 Sphincter tone
 Masses
 Tenderness
Special Tests
 FOBT

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 Female GU Exam
(Only performed on SPs during PCM IV in the MUTA/GTA week)

General If Indicated…
Breast Exam
Inspection

Palpation

Pelvic Exam
Inspection
 Mons
 Vulva
 Perineum
 Vagina
 Cervix
Palpation
 Uterus
 Adnexa
 Recto‐vaginal
 Inguinal lymph nodes
Rectal Exam
 Inspect
 Fissures
 Hemorrhoids
 Palpate
 Sphincter tone
 Masses
 Tenderness
 Special test: FOBT
Osteopathic exam:

MSK Exams

NECK General If Indicated….

Inspection TMJ

General palpation Palpation of any MSK area of

pain TMJ
Active OR passive ROM TMJ
Special Tests:
 Compression test
 Spurling’s Maneuver
 Distraction test
Osteopathic

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 SHOULDERS General If Indicated…
Inspection

General palpation Palpation of any MSK area of pain

Active OR passive ROM Shoulder special tests:

 Supraspinatus
 Empty can
 Drop-Arm
 Infraspinatus
 Resisted external rotation
 Subscapularis
 Lift-Off
 Bear hug
 Impingement
 Hawkins (supraspinatus,
long head biceps)
 Neers (subacromial impingement)
 AC Joint
 Crossover
 Labrum
 O’Briens
 Biceps
 Speeds test
 Yergason’s test
 Glenohumeral dislocation
 Apprehension test
Osteopathic  Spencers
 Cervical spine
 Upper thoracic spine
 Radial head

ELBOWS General If Indicated…

Inspection

General palpation Palpation of any MSK area of pain

Active OR passive ROM Elbow ROM

 Varus/Valgus Stress
 Medial/lateral Epicondylitis
Osteopathic

WRIST/HAND General If Indicated…

Inspection

General palpation Palpation of any MSK area of pain

Active OR passive ROM Wrist/Hand Tests

 Finkelstein
 Ulnar collateral ligament
 First carpometacarpal grind
Osteopathic

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 BACK General If Indicated….
Inspection

General palpation Palpation of any MSK area of

pain
Active OR passive ROM Special Test:
 Straight leg raise
Osteopathic

HIPS General If Indicated…

Inspection

General palpation Palpation/resisted muscle testing of any MSK

area of pain
Active OR passive ROM Hips
 Gait
 Trendelenburg
 Thomas
 FABER/FADIR
Osteopathic

KNEES General If Indicated…

Inspection

General palpation Palpation/resisted muscle testing of any MSK

area of pain
Active OR passive ROM Knees
Anterior/posterior Drawers or Lachman’s
Varus/Valgus
Thessaly or McMurray
Apley’s Compression test
Apprehension
Patello-femoral Grind
Palpate for effusion
Lower leg
Thompson
Osteopathic:

ANKLES General If Indicated…

Inspection

General palpation Palpation/resisted muscle testing of any MSK

area of pain
Active OR passive ROM Ankle
 Kleiger
 Squeeze Test
 Talar Tilt
 Drawer
Osteopathic

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 Peripheral Nervous System Exam
General If Indicated…
Inspection:

General palpation:

Strength Sensation:
 Flexors and extensors UE  2‐point discrimination
 Bicep  Toe proprioception
 Tricep  Temperature
 Forearm Flexors
 Forearm Extensors
 Hands
 Flexors and extensors LE
 Hip flexors
 Hip extensors
 Quadriceps
 Dorsiflexors
 Plantar flexors
DTR DTR
 Upper Extremity Upper extremity reinforcement
 Bicep Lower extremity reinforcement
 Brachioradialis Babinski: done when in the periph-
 Tricep ery but reflects CNS lesion
 Lower Extremity  Clonus: done when in the periph-
 Patellar ery but reflects CNS lesion
 Achilles  Hoffmann’s test
Sensation: eyes closed SPECIAL TESTS:
 Soft and sharp  Tinels
 Dermatomes  Phalens
 Peripheral cutaneous  Prayers
- UE and/or LE  Roos
 Vibration
 Distal boney prominence, bilateral
- UE and/or LE
Osteopathic:

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 Central Nervous System Exam
General If Indicated…
Mental Status (LOL AMEN) (AMEN)
LOL: Attention
Level of Consciousness: Digit span: subtract 7 from 100
Alert, lethargic, stuporous, coma- Spelling: WORLD backwards
tose Months/days forward then
Bright, flat, anxious, paranoid… back-
Attentive, cooperative, detached… ward
Orientation: Memory
Person, place and time asked spe- Recent (anterograde)
cifically = A&O x3 vs A&O Remote (retrograde)
Language: Executive function
Articulate Verbal fluency
Fluent Similar
Comprehends commands: simple Proverbs
to harder Non-dominant hemisphere
Naming items Construction
Repetition: repeat this sentence
_________or series of num-
bers
Cranial Nerve Exam
I: Olfactory
II: Optic
III: Oculomotor
IV: Trochlear
V: Trigeminal motor
V: Trigeminal sensory
VI: Abducens
VII: Facial
VIII: Vestibulochoclear
IX: Glossopharyngeal
X: Vagus
XI: Spinal Accessory
XII: Hypoglossal
Cerebellar
 Dysdiadochokinesis:
 rapid alternating movement
 Dysmetria:
 Finger to nose (make pt reach)
 Heel down shin
 Proprioception/Ataxia
 Romberg with pronator drift
(PROTECT Pt.!)
 Balance
 Regular gait
 Tandem
 Walk on toes/heels
Special Tests
o Strait leg raise o Kernig
o Brudzinski o Spurlings
o Distraction o Babinski
o Ankle clonus

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 Special Thanks To
Dr. Joseph Stasio

Dr. Jill Pitcher

Dr. Ann Trawick

Dr Jean Bouquet

Student Doctor Katy Rose

Student Doctor Ryan Masterson

Student Doctor Blaire Strietelmeier

Student Doctor Kristin Lipe

Dr. Tiemdow Phumiruk

Molly Hunsberger

Honorable Mention
Trawick family for pictures and for not killing their wife or mother when she asked for odd or slightly
revealing poses, and to draw on body parts.

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