Neuro:

 Straight Leg Raise Test:

o Patient lies in a supine position with legs extended.
o Examiner passively lifts one leg at a time with the knee extended.
o A positive result is reproduction of radicular pain (sharp, shooting pain) that
radiates below the knee in the distribution of the sciatic nerve.
o Suggests lumbosacral nerve root irritation, typically at L5 or S1.
o Pain confined to the posterior thigh or hamstring tightness without radiating leg
pain is not a true positive.
o A crossed straight leg raise (pain in the affected leg when the contralateral leg is
raised) is highly specific for herniated disc.
 Lumbosacral and Sciatic Radiculopathy:
o Lumbosacral Radiculopathy: Compression or irritation of a nerve root in the
lumbosacral spine. Causes include herniated disc, spinal stenosis, or degenerative
changes.
 Presents with pain, sensory changes, weakness, and decreased reflexes
along a dermatomal pattern.
 Often unilateral, worsened by activity, improved with rest.
o Sciatic Radiculopathy (Sciatica): A form of radiculopathy involving the sciatic
nerve roots (usually L4-S3).
 Pain starts in the lower back or buttock and radiates down the posterior
leg.
 May have associated motor findings like foot drop or decreased ankle
reflex.
 Discriminative Tests for Sensation:
o Performed only if light touch and pain sensation are intact.
o Stereognosis: Ability to identify an object (coin, key) placed in hand by feel
alone.
o Graphesthesia: Ability to identify numbers or letters traced on the palm with a
dull object.
o Two-point Discrimination: Tests ability to distinguish two closely spaced
points; normal <5 mm on fingertips.
o Point Localization: Ability to localize the exact point of a tactile stimulus.
o Extinction: Simultaneous bilateral stimulation; abnormal if patient ignores one
side (suggests parietal lobe lesion).
 PE Findings for Meningeal Irritation:
o Nuchal Rigidity: Involuntary resistance to passive neck flexion while patient is
supine.
o Brudzinski Sign: Passive flexion of the neck results in spontaneous hip and knee
flexion.
o Kernig Sign: With hip flexed and knee extended, patient experiences pain and
resistance.
o Jolt Accentuation: Rapid turning of the head side to side worsens headache.
o Suggestive of meningitis or subarachnoid hemorrhage in appropriate clinical
context.
 Assessing Cranial Nerves (CN I–XII):
o CN I (Olfactory): Test each nostril with a familiar, non-irritating odor.
o CN II (Optic): Visual acuity, visual fields, inspect optic disc with
ophthalmoscope.
o CN III, IV, VI (Oculomotor, Trochlear, Abducens): Inspect eyelids, pupils,
and extraocular movements (6 cardinal directions).
o CN V (Trigeminal): Motor—palpate masseter and temporalis while clenching
jaw. Sensory—test light touch in ophthalmic, maxillary, and mandibular areas.
o CN VII (Facial): Inspect for asymmetry with facial expressions: smile, frown,
close eyes, puff cheeks.
o CN VIII (Vestibulocochlear): Whisper test; Weber (tuning fork lateralization);
Rinne (air vs bone conduction).
o CN IX, X (Glossopharyngeal, Vagus): Listen to voice, watch soft palate rise,
and test gag reflex.
o CN XI (Spinal Accessory): Shrug shoulders and turn head against resistance.
o CN XII (Hypoglossal): Protrude tongue, check for deviation and fasciculations.
 Coordination and Reflex Testing:
o Finger-to-Nose: Assesses coordination and cerebellar function; abnormal
findings include intention tremor and dysmetria.
o Heel-to-Shin: Run heel down opposite shin; abnormalities suggest cerebellar
disease.
o Rapid Alternating Movements: Inability to perform rapidly suggests
dysdiadochokinesia.
o Reflexes:
 Grading scale: 0 = absent, 1+ = diminished, 2+ = normal, 3+ = brisk, 4+
= clonus.
 Hyperreflexia: Suggests upper motor neuron lesion (e.g., stroke, spinal
cord injury).
 Hyporeflexia: Suggests lower motor neuron lesion (e.g., radiculopathy,
neuropathy).
 Babinski sign: Dorsiflexion of big toe indicates corticospinal tract
dysfunction.
 Red Flag Symptoms for Headache:
o Sudden onset (“thunderclap”)
o Age >50 with new headache
o Signs of systemic illness (fever, weight loss)
o Neurologic deficits (visual changes, weakness)
o Cancer, HIV, or immunocompromised status
o Positional or exertional triggers
 Headache Etiologies:
o Infectious: Fever, chills, stiff neck, photophobia, nausea
o Meningeal Irritation: Positive Kernig/Brudzinski, altered mental status, focal
deficits
o Thunderclap HA: Sudden, intense; consider subarachnoid hemorrhage; requires
emergent imaging
 Dermatome Map (Localization):
 o Important in diagnosing radiculopathies and nerve injury.
o Example:
 C6: Thumb
 C7: Middle finger
 L4: Knee
 L5: Dorsum of foot
 S1: Lateral foot
 Signs of Increased Intracranial Pressure (ICP):
o Papilledema: Blurred disc margins on fundus exam
o Headache, nausea/vomiting, worsening with Valsalva
o Altered mental status or level of consciousness
 Hearing Loss (Conductive vs Sensorineural):
o Conductive: Sound transmission impaired (e.g., cerumen, otitis media).
 Weber lateralizes to affected ear.
 Rinne: Bone conduction > air conduction.
o Sensorineural: Damage to inner ear or auditory nerve.
 Weber lateralizes to unaffected ear.
 Rinne: Air conduction > bone conduction but both decreased.
 Weber and Rinne Tests:
o Weber: Place tuning fork on vertex; identifies lateralization.
o Rinne: Place tuning fork on mastoid then near ear canal; compares bone vs air
conduction.
 Definitions:
o Hypertonia: Increased muscle tone; muscles resist passive stretch; seen in upper
motor neuron lesions.
o Hyperreflexia: Exaggerated deep tendon reflexes; often indicates corticospinal
tract involvement.

MSK:

Descriptions and Associated Pathology

 Bouchard Nodes
o Bony enlargements of the proximal interphalangeal (PIP) joints.
o Found in osteoarthritis (OA), not rheumatoid arthritis (RA).
o Often seen alongside Heberden nodes but occur closer to the hand base.
 Heberden Nodes
o Bony overgrowths at distal interphalangeal (DIP) joints.
o Characteristic of OA, usually hard and painless.
o Associated with decreased range of motion and deformity.
 Osler Nodes
o Painful, red, raised lesions typically found on the fingers or toes.
o Indicative of infective endocarditis.
 Genu Varum (Bowlegs)
 o Outward bowing of the legs in relation to the thighs.
o Normal in toddlers but pathologic in older children/adults.
o May result from rickets, skeletal dysplasia, or trauma.
 Phalen’s Test
o Performed by pressing the backs of hands together at 90 degrees.
o Held for up to 60 seconds to reproduce symptoms.
o Positive if numbness or tingling occurs in the median nerve distribution (suggests
carpal tunnel syndrome).
 Swan Neck Deformity
o Hyperextension of the PIP joint with flexion of the DIP joint.
o Common in RA due to ligament and tendon disruption.
 Trendelenburg Sign
o Positive when the pelvis drops on the contralateral side during single-leg stance.
o Indicates weakness of the gluteus medius/minimus on the stance leg side.
o Associated with hip dysplasia, muscular dystrophy.
 Tinel’s Sign
o Light percussion over the median nerve at the wrist.
o Tingling in the fingers (thumb, index, middle) suggests median nerve
compression.

Movements and Special Tests

 Range of Motion Terms:

o Adduction: Moving a limb toward the midline.
o Abduction: Moving a limb away from the midline.
o Flexion: Bending a joint to decrease the angle.
o Extension: Straightening a joint to increase the angle.
 Valgus Stress Test
o Tests the medial collateral ligament (MCL).
o Apply lateral force to the knee while stabilizing the ankle.
o Pain or laxity indicates potential MCL injury.
 Posterior Drawer Test
o Tests integrity of the posterior cruciate ligament (PCL).
o With knee at 90 degrees, push tibia backward.
o Excessive posterior movement indicates PCL tear.
 McMurray’s Test
o Assesses meniscal integrity (medial or lateral).
o Flex and rotate the knee while applying varus or valgus stress.
o A palpable click or pain suggests meniscal tear.
 Lachman Test
o Preferred test for anterior cruciate ligament (ACL).
o Flex knee 20-30 degrees, stabilize femur, and pull tibia forward.
o Increased anterior translation indicates ACL tear.
Definitions and PE Findings

 Rheumatoid Arthritis (RA)

o Autoimmune, chronic inflammatory polyarthritis.
o Symmetrical joint involvement, especially hands, wrists.
o PE: joint swelling, warmth, tenderness, morning stiffness >1 hour, ulnar
deviation.
 Osteoarthritis (OA)
o Degenerative joint disease from cartilage loss.
o Affects weight-bearing joints and DIP/PIP joints.
o PE: bony enlargements (Heberden, Bouchard), stiffness <30 min, crepitus.
 Hip Dysplasia
o Abnormal formation of the hip joint.
o In infants, tested with Ortolani/Barlow maneuvers.
o In older children/adults: limb length discrepancy, limited abduction, positive
Trendelenburg.
 Cauda Equina Syndrome
o Compression of spinal nerve roots in cauda equina.
o Red flags: saddle anesthesia, urinary retention/incontinence, severe bilateral leg
weakness.
o Requires emergent MRI and surgical decompression.

Gait Patterns and Clinical Relevance

 Antalgic Gait
o Pain avoidance gait; shortened stance phase on affected side.
o Seen with joint inflammation, trauma.
 Trendelenburg Gait
o Lateral trunk lean over stance leg.
o Caused by hip abductor weakness (gluteus medius/minimus).
 Parkinsonian Gait
o Stooped posture, shuffling steps, reduced arm swing.
o Associated with basal ganglia disorders (e.g., Parkinson’s disease).
 Spastic Hemiparesis
o One stiff leg swings around in a semicircle (circumduction).
o Seen in stroke patients with upper motor neuron lesions.
 Scissor Gait
o Thighs cross forward with each step.
o Common in spastic cerebral palsy.
 Steppage Gait
o High stepping due to foot drop.
o Seen in peroneal nerve injury or L5 radiculopathy.
Red Flags for Low Back Pain

 Age >50
 History of cancer
 Unexplained weight loss
 Night/rest pain
 Fever or recent infection
 IV drug use
 Neurologic deficits: incontinence, leg weakness

Constitutional Symptoms Suggesting Systemic Illness

 Fever
 Chills
 Fatigue
 Unexplained weight loss
 Night sweats
 May point to infection, malignancy, or autoimmune disease when combined with MSK
symptoms.

Muscle Examination on PE

 Scalene Muscles
o Lateral neck muscles involved in breathing and neck flexion.
 Sternocleidomastoid (SCM)
o Turns head contralaterally and flexes neck.
o Tested by head rotation against resistance.
o Innervated by Cranial Nerve XI.
 Splenius Capitis
o Posterior neck muscle responsible for head extension and rotation.

Older Adult Section

Assessment and Screening

 Dementia Testing on Physical Exam:

o Mini-Cog:
 Combines 3-word recall and clock drawing.
 High sensitivity and specificity for detecting cognitive impairment.
  Impairment suspected if patient recalls fewer than 3 words or draws an
abnormal clock.
o Montreal Cognitive Assessment (MoCA):
 Comprehensive tool assessing memory, attention, language, visuospatial
function, and executive function.
 Score <26 suggests possible cognitive impairment.
 Takes approximately 10 minutes; preferred for mild cognitive changes.
o Mini-Mental State Exam (MMSE) is also used but less sensitive for early
dementia.
 Normal Hearing Loss (Presbycusis):
o Presbycusis is an age-related, bilateral sensorineural hearing loss.
o Loss begins with high-frequency sounds (e.g., consonants such as "s," "f," "t").
o Patients may report difficulty understanding speech, especially in noisy
environments.
o On PE:
 Whisper test may detect asymmetry.
 Weber test localizes to better ear.
 Rinne test shows air > bone conduction bilaterally.
o Referral for formal audiometry if hearing loss interferes with communication or
daily function.
 Normal Blood Pressure Changes with Aging:
o Systolic BP tends to rise due to arterial stiffening.
o Diastolic BP may remain stable or decrease.
o Orthostatic hypotension:
 Defined as a ≥20 mm Hg drop in systolic or ≥10 mm Hg drop in diastolic
BP within 3 minutes of standing.
 Common in older adults due to baroreceptor insensitivity and medications.
 Important to measure BP sitting and standing during PE.
 Ability to Live Alone and Normal Aging:
o Assessment based on:
 Cognitive function (alertness, memory, judgment).
 Functional status (Activities of Daily Living (ADLs): bathing, dressing,
toileting, feeding).
 Instrumental ADLs (IADLs): cooking, managing finances, using the
telephone, transportation.
o Normal aging may involve slower gait or reaction time, but preserved
independence is typical.
o Concerns arise if:
 Significant memory loss.
 Poor hygiene.
 Repeated falls.
 Inability to manage medications or meals.
 Frailty and Physical Exam Findings:
o Defined as a biologic syndrome of decreased reserve and resistance to stressors.
o Criteria (typically 3 or more of the following):
 Unintentional weight loss (>10 lbs in a year).
  Exhaustion (self-reported).
 Weak grip strength (tested with hand dynamometer).
 Slow walking speed (measured over 15 feet).
 Low physical activity (based on self-report or observation).
o Associated findings: muscle wasting, fatigue, decreased endurance, risk of falls.
o Indicates vulnerability to poor outcomes: hospitalization, disability, death.
 Goals of Evaluating Cognitive Function in Older Adults:
o Detect dementia, mild cognitive impairment, or delirium.
o Establish a baseline for future comparison.
o Identify reversible causes of cognitive changes (e.g., depression, B12 deficiency,
thyroid disorders).
o Support safety, independence, and advanced care planning.
 Normal Neuro Exam Findings in Older Adults:
o Some expected changes:
 Slower mental processing speed.
 Slight decrease in short-term memory.
 Decreased or absent ankle reflexes.
 Mild postural or intention tremor.
 Reduced vibratory sense in feet.
o Pathologic if findings interfere with daily function, cause safety concerns, or
indicate focal deficits.
 Presbyopia:
o Age-related decrease in lens elasticity.
o Loss of near vision, typically begins in 40s and progresses.
o PE: patients may hold reading material at arm’s length.
o Corrected with reading glasses or bifocals.
 Cataracts:
o Lens opacification from protein clumping.
o Risk increases with age, smoking, diabetes, and steroid use.
o Symptoms: blurred vision, glare with headlights, faded colors.
o PE: diminished red reflex, visible lens clouding on fundoscopic exam.
o Can cause significant vision impairment but is surgically correctable.
 Risk Factors for Osteopenia/Osteoporosis:
o Non-modifiable:
 Female sex
 Postmenopausal status
 Older age
 Family history
o Modifiable:
 Smoking, alcohol use
 Low calcium/Vitamin D intake
 Physical inactivity
 Use of glucocorticoids, anticonvulsants
o Screening: Dual-energy X-ray absorptiometry (DEXA) starting at age 65 for
women or earlier with risk factors.
 Spinal Structures Supporting Body Weight:
 o Vertebral bodies: provide structural support.
o Intervertebral discs: act as shock absorbers.
o Facet joints: guide movement and add stability.
o Ligaments and paraspinal muscles: maintain posture and assist movement.
o Degenerative changes in any of these may contribute to pain or mobility issues in
older adults.

Pregnancy Section

 Symptoms and PE findings associated with the following:

o Gestational Hypertension
 Defined as new onset of systolic BP ≥140 mm Hg or diastolic BP ≥90 mm
Hg after 20 weeks of gestation.
 No proteinuria or signs of end-organ damage.
 Typically resolves postpartum.
 May progress to preeclampsia.
o Pre-eclampsia
 Same BP criteria as gestational hypertension plus:
 Proteinuria ≥300 mg in 24-hour urine or protein/creatinine ratio
≥0.3.
 Or end-organ signs: low platelets, elevated liver enzymes, renal
insufficiency, pulmonary edema, or cerebral/visual symptoms.
 PE findings:
 Facial edema
 Hypertension
 Hyperreflexia
 Possible clonus or visual disturbances
o Chloasma (Melasma)
 Also called the "mask of pregnancy."
 Brown, symmetric patches across the cheeks and forehead.
 Due to hormonal changes and sun exposure.
 During the second trimester of pregnancy, what would be considered normal for the
following:
o Fundus Height
 Uterus palpable above the symphysis pubis after 12–14 weeks.
 From 20–36 weeks: fundal height in cm ≈ weeks of gestation.
 Deviation >4 cm from expected warrants investigation (e.g., growth
restriction, multiple gestation).
o Fetal Heart Tones
 Audible by Doppler between 10–12 weeks.
 Heard midline lower abdomen in early second trimester.
 Normal fetal heart rate: 110–160 bpm with beat-to-beat variability.
o Uterine Size
 In second trimester, uterus becomes more globular, rises into abdomen.
  Should grow consistently with gestational age.
o Skin Changes
 Linea nigra (midline abdominal pigmentation).
 Striae gravidarum (stretch marks), especially on abdomen, breasts, thighs.
 Increased skin pigmentation on face (chloasma), nipples, areolae.
o Lung Changes (tidal volume, RR, chest wall diameter, O2 consumption and
levels)
 Tidal volume increases, leading to increased alveolar ventilation.
 Respiratory rate remains stable.
 Chest wall diameter increases slightly from diaphragm elevation.
 Oxygen consumption increases due to metabolic demands.
 Results in mild respiratory alkalosis and possible sensation of dyspnea.
o Heart Tone Changes (murmurs)
 Increased blood volume leads to hyperdynamic circulation.
 Systolic ejection murmur is common.
 May also hear venous hum or mammary souffle in late pregnancy.
 Diastolic murmurs are never normal and warrant further evaluation.

Normal PE Findings at Key Infant Ages

 3-Month-Old:
o Good head control.
o Tracks objects visually.
o Smiles responsively.
o Begins to coo and make vowel sounds.
o Moro and rooting reflexes may still be present but start to diminish.
 6-Month-Old:
o Rolls over both ways.
o Reaches for and transfers objects between hands.
o Babbles with consonant sounds.
o Sits with support.
o Primitive reflexes should be disappearing (Moro gone by ~5-6 months).
 12-Month-Old:
o Pulls to stand; may take independent steps.
o Pincer grasp developed.
o Says 1-2 words with meaning.
o Follows simple directions.
o Stranger anxiety often present.

Blood Pressure in Pediatrics

 Routinely measured starting at age 3 years.

 Important to use correct cuff size for accuracy.
 Measure BP in both arms and one leg once to assess for coarctation of the aorta.
Normal Pediatric Heart Rhythms

 Sinus arrhythmia is common:

o Heart rate increases with inspiration and decreases with expiration.
o Considered normal throughout childhood.
 Premature atrial or ventricular contractions may occur and are often benign.
 Tachycardia >220 bpm in infants suggests paroxysmal supraventricular tachycardia
(PSVT).

Tanner Stages

 Tanner stages (Sexual Maturity Rating) describe physical development in adolescence.

 Five stages (Stage 1 = prepubertal; Stage 5 = mature adult development):

For Girls (Breast Development):

o Stage 1: Prepubertal (no glandular tissue).

o Stage 2: Breast bud stage; elevation of breast and papilla.
o Stage 3: Further enlargement of breast and areola.
o Stage 4: Areola and papilla form a secondary mound above breast.
o Stage 5: Mature stage; projection of papilla only.

For Boys (Genital Development):

o Stage 1: Prepubertal.
o Stage 2: Enlargement of scrotum and testes.
o Stage 3: Growth of penis (length), further testicular enlargement.
o Stage 4: Increased penis size (breadth), darkening of scrotal skin.
o Stage 5: Adult genitalia.

For Both (Pubic Hair):

o Stage 1: No pubic hair.

o Stage 2: Sparse growth of long, slightly pigmented hair.
o Stage 3: Hair becomes darker, coarser, curlier, and spreads sparsely.
o Stage 4: Adult-type hair, but smaller area.
o Stage 5: Adult-type and quantity, spread to medial thighs.

Primitive Reflexes
Primitive reflexes are automatic responses present at birth, gradually disappearing as the central
nervous system matures. Persistent or asymmetric reflexes may suggest neurologic problems.

 Rooting Reflex:
o Elicited by stroking the cheek near the mouth.
o Normal response: infant turns head toward stimulus and opens mouth.
o Disappears by 4 months.
 Moro Reflex (Startle):
o Triggered by sudden movement or loud noise.
o Response: arms abduct and extend, then adduct with fingers fanned.
o Disappears by 4–6 months.
o Asymmetry may suggest brachial plexus injury or fractured clavicle.
 Palmar Grasp:
o Stimulus: placing finger in infant’s palm.
o Response: infant grasps the finger tightly.
o Strong up to 1–2 months, then fades by 4–6 months.
 Plantar Grasp:
o Stimulus: pressing thumb against the sole of the foot.
o Response: toes curl downward.
o Disappears by 6–8 months.
 Landau Reflex:
o Infant is held prone in the air.
o Response: head lifts and spine straightens (trunk extends).
o Emerges by 3 months and disappears by 12–24 months.
 Support Reflex (Stepping/Placing Reflex):
o Hold infant upright with feet touching a surface.
o Response: stepping movements seen.
o Disappears by 2 months.
 Asymmetric Tonic Neck Reflex (ATNR):
o Elicited by turning infant’s head to one side.
o Response: extension of arm and leg on face side, flexion of limbs on opposite
side.
o Disappears by 6 months.

Strategies for Pediatric History & PE

 Involve the parent as a knowledgeable informant.

 Build rapport with both child and parent.
 Allow child to stay in parent’s lap when possible.
 Use play, distraction, and praise.
 Save invasive parts of exam (ears, throat) for last.
 Respect developmental level and use age-appropriate communication.
Pediatric Conditions: Definitions and PE Findings

 Fetal Alcohol Syndrome:

o Caused by prenatal alcohol exposure.
o Distinct facial features: smooth philtrum, thin upper lip, small palpebral fissures.
o May also have microcephaly, short stature, and cognitive/developmental delays.
 Down Syndrome (Trisomy 21):
o Genetic condition resulting in characteristic physical features and developmental
delay.
o Features include flat facial profile, hypotonia, upward slanting palpebral fissures,
epicanthal folds.
o Single palmar crease and Brushfield spots may be present.
 Facial Nerve Palsy:
o Unilateral facial paralysis.
o Can be congenital or due to birth trauma, infections like otitis media, or Bell’s
palsy.
o PE: drooping of one side of face, absent nasolabial fold, incomplete eye closure.
 Congenital Hypothyroidism:
o Thyroid hormone deficiency present at birth.
o Early signs: prolonged neonatal jaundice, large anterior fontanelle, macroglossia,
umbilical hernia, and hypotonia.
o If untreated, leads to intellectual disability and growth failure.
 Benign Physiologic Murmur:
o Innocent murmurs include Still’s murmur (vibratory, systolic) and pulmonary
flow murmur.
o Heard best in early childhood.
o Murmurs are soft, short, vary with position, and not associated with symptoms.
 Strabismus:
o Misalignment of the eyes (e.g., esotropia or exotropia).
o Detected via corneal light reflex test or cover-uncover test.
o Early detection crucial to prevent amblyopia.
 Marfan Syndrome:
o Inherited connective tissue disorder (autosomal dominant).
o Features: tall stature, long limbs/fingers (arachnodactyly), joint hypermobility,
scoliosis, and pectus deformities.
o Ophthalmologic findings: lens dislocation.
o Cardiovascular risk: aortic root dilation or dissection.
 Scoliosis:
o Lateral curvature of the spine; often idiopathic in adolescents.
o Screen using Adam’s forward bend test (observe for asymmetry of rib cage).
o Confirm with radiographic Cobb angle measurement.