Osce 1

General Survey/Vital Signs Physical Appearance *Age (appears stated) *Sex (development appropriate to age) *LOC (alert oriented- person, place, time, situation) *Skin colour (even, no lesions) *Facial features (congruent with movement/no distress) Body Structure *Stature (height normal for age/ethnicity) *Nutrition (weight normal range for height/body comp, with even fat distribution) *Symmetry (body parts equal bilat/relatively in proportion to each other) *Posture (comfortable/erect) *Position (relaxed) *Body build (arm span = height, body length = from crown to pubis/pubis to sole) Mobility *Gait (base shoulder width, foot placement accurate, walk smooth/well balanced, associated movements present) *ROM (full mobility at each joint, movement deliberate/accurate/coordinated, with no involuntary movement) Behavior *Facial expression (eye contact, expressions = situation) *Mood/affect (comfortable/cooperative/pleasant) *Speech (articulation clear/coherent/even pace/word choice = education) *Dress (appropriate to weather/age/body) *Personal hygiene (grooming = age/occupation/socioeconomic group, woman’s makeup = age/culture) Weight *Remove shoes/heavy outer clothing Height *Pt shoeless/stand straight/look straight ahead- use measuring pole on balance scale, align head piece with top of head Temperature *Normal 37* - range of 35.8-37.3 (rectal may be higher) Pulse *Radial most common-count for 30 sec and X2 if regular, count 60 sec if irregular *Assess; Rate- adult resting 60-100 bpm * Rhythm- even tempo *Force- rate from 0 (absent) – 3+ (full bounding) 2+ normal * Elasticity- normal feels springy, straight, and resilient Respirations *Adult resting 10-20 rpm *Relaxed, regular, automatic, silent *Do not mention assessment

*Count 30 sec X2 or 60 sec if abnormality suspected Blood Pressure *Normal adult 120/80 *Varies with-age, sex, race, diurnal rhythm, weight, exercise, emotions, stress *Determined by *Cardiac output, peripheral vascular resistance, blood volume, viscosity, elasticity *Pulse pressure = systolic – diastolic *Pt lying/sitting with feet flat on floor bare arm at heart level, palpate radial artery and inflate cuff until pulse obliterated, measure BP by inflating 20-39 mm Hg beyond this point, BELL of stethoscope on brachial artery and inflate cuff, deflate noting points when first and last sounds are heard *Orthostatic vital signs-done when pt c/o hypotension/syncope *Take readings of pulse and BP when pt is supine for baseline, and repeat measurements with pt sitting then standing (slight decrease will occur) *Thigh pressure- when arm pressure exceedingly high compare with leg BP *Normally higher than arm (10-40 mm Hg) *Pt prone, large cuff around lower 1/3 of thigh centered over politeal artery

Emotional Appearance *Age (appears stated) *Unusual hairstyle/adornments *Type of eye contact- brief/prolonged, absent, normal *Cleanliness/grooming- type of clothing-soiled, unkempt, torn, neat/appropriate, socioeconomic status *Face/body- scars/birthmarks/needle marks, tattoos, glasses, facial hair, earrings/per icings, limp, weight/height proportionate *Body frame- robust/frail/slim/obese/athletic Behavior *LOC awake, alert, aware, oriented (lethargic/obtunded) *Activity/movement- akasthesia, hyperactivity, bradykinesia, accessory movements, psychomotor retardation, agitation, restless, tremors, posture *Facial expression appropriate to situation/changes, comfortable eye contact *Attitude- cooperative, hostile, guarded, regressed, suspicious, asocial, open *Speech effortless/fluent/coherent, conversation appropriate- dysphonia/dysarthria Mood * Judge via body language/facial expression/direct questioning “how do you usually feel?”-appropriate to place/situation/change with topics- euthymic, euphoric, anxious, dysthymic, depressed Affect *Subjective assessment of facial expression, tone, personality, direct questioning- “how do you usually feel?” *Dimensions *Range- movement among emotions- full/restricted *Mobility- labile, flat, restricted *Reactivity- ability to react appropriately to situation *Intensity- force of feeling/emotion expressed- increased, flat, blunted, type, appropriateness *If pt expresses feelings of sadness/hopelessness/despair assess for suicidal tendencies- had these thoughts before? Do you have a plan? Lethality of plan? Resources?

Cognitive Appearance *Posture erect *Position relaxed *Body movements voluntary, deliberate, coordinated, even *Dress appropriate to setting, season, age, gender, social group, body type *Grooming/hygiene clean, hair neat, makeup appropriate, men shaven/groomed, nails clean Behavior *LOC awake, alert, aware, oriented *Facial expression appropriate to situation/changes, comfortable eye contact *Speech effortless/fluent/coherent, conversation appropriate *Mood/affect judge via body language/facial expression/direct questioning-appropriate to place/situation/change with topics Cognitive Functions Orientation *Time, place, person, situation *Ask directly “where are you?” “What day of the week is it?/season/year?” “What is your name/age?” Attention span *Give a series of directions (3 steps) and note ability to follow through Immediate memory/new learning *Four unrelated words test Recent memory *Ask about something you can verify *24 hour diet recall/how they got to agency etc Remote memory *Ask birthday/anniversary/historical events significant to pt New learning *Four Unrelated Words Test Say 4 words; brown, tulip, carrot, ankle pt repeats, ask again few minutes later (5, 10, 30 minute intervals) Constructional Ability *Pt writes name and date *Word comprehension Point to objects in room/body parts and ask person to name them *Reading/Writing Ask to read Ask to make up and write a sentence-note coherence, spelling and parts of speech Higher Intellectual Functioning *Measure problem solving/reasoning abilities *Interpret a proverb- a rolling stone gathers no moss *Calculation ability- serial 7’s *Similarities and differences Judgment *Ability to make a logical decision about a situation *Ask about job/family/plans for future-should be realistic

Thought Process/Perceptions Thought process *Way pt thinks should be logical, goal directed, coherent, relevant, and able to complete a thought *Abnormalities- circumstantiality, tangentiality, flight of ideas, loose associations, word salad, preservation, pressured speech, clang, poverty of thought, echolalia, neologisms, thought blocking Thought content *What pt thinks consistent/logical, evaluate thoughts expressed *Abnormalities- thought insertion, thought broadcasting, obsessions/compulsions, suicidal/homicidal ideation Perceptions *Aware of reality *Abnormalities- illusions/hallucinations (no external stimuli) *How do ppl treat you, talk about you, feel being watched/followed Screen for suicidal/homicidal thoughts *Pt expresses feelings of sadness/grief assess risk of harming self/others Ever thought about hurting yourself/do you have a plan ***Note absence of symptoms for suicide/homicide and psychotic content*** MiniMental Status Examination *11 questions *Max score of 30/average is 27/24-30 = no cognitive impairment

Social Roles *Perception of roles- home/work/family *Areas of role strain/conflict *Role changes with life, impact of current health concerns- upon self/family Family Relationship *Family of origin/sibling position *Urban/rural background *Immediate family *Significant other *Type of family unit *Support of family/significant others *Family rules *Conflict resolution *Decision making in family *History of substance use/abuse- self/family *Method of coping skills used Work Relationship *Occupation/source of income *Satisfaction with work *Get along with coworkers *Job concerns Social Relationship *Time spent with peers/family *Behaviors displayed in interactions *Patterns of communication- leader/follower, introvert/extrovert, passive/assertive/aggressive *Ability to maintain long term relationships *Perception of others liking you *Reaction during interview – level of trust/self disclosure *Social activities/use of leisure time/hobbies *Use of community resources Sexuality *Sexual orientation/expression *Comfort with gender identity/role/orientation *Views regarding sexual activity *Discussion/concerns regarding sex *Relationship with same/opposite sex *Body image (verbal/nonverbal) *Appropriate dress (seductive/conservative) *Demonstration of affection to family/others *History of sexual harassment/assault/incest *Risk potential *Sexual activity/level of risk taking *Vulnerability/exploitation/discrimination *Knowledge of contraceptives/STD/safe sex practices *Values

Skin/hair/nails Inspect/Palpate the Skin General Pigmentation *Consistent with ethnicity *Note freckles, moles, birthmarks Widespread Colour Change *Note any pallor, cyanosis, jaundice, erythematic Temperature *Use dorsa of hands to check temp bilaterally- warm, equal bilat Moisture *Perspiration may be present (note excess- diaphoresis) *Assess for dehydration (check mucous membranes as well) Texture *Smooth, firm, even surface Thickness *Uniformly thin over most surface with calluses on areas of high friction Edema *Press area with thumbs (malleolus/tibia) *Grade pitting 1+ - 4+ Mobility/Turgor *Pinch large fold of skin *Mobility = ease of rising *Turgor = ability to return to place when released Vascularity/Bruising *Note cherry angiomas/bruising/tattoos Lesions *With glove palpate-roll between fingers, scrape, note surrounding skin temp, use magnifying glass for closer inspection *If present note; colour, elevation, pattern/shape, size, location/distribution, exudate, blanching Inspect/Palpate Hair *Colour- processed, ethnic, age *Texture *Distribution- vellus all over body, terminal on eyes/scalp *Lesions Separate hair into sections observing the scalp Inspect/Palpate Nails Shape/Contour *Smooth, rounded and clean *Profile- 160* *Base firm to palpation Consistency- smooth, regular, not brittle/splitting, uniform thickness Colour- translucent nail plate, pink nail bed underneath *Capillary refill- depress nail edge to blanch then release colour returns in 1-2 seconds Separate fingers/toes and not skin condition between Teach Skin Self Examination *Examine skin once a month *Using ABCDE rule for suspicious lesions

*Asymmetry, Border irregularity, Colour variation, Diameter > 6mm, *Elevation/Enlargement *Full-length mirror/well lit room/hand held mirror for difficult to see areas

Head/neck/regional lymphatic Inspect/Palpate Skull Size/Shape *Normocephalic-round/symmetric skull/proportionate to body size *Normal protrusions of forehead, parietal bones, occipital bones, mastoid processes *No tenderness to palpation Temporal Area *Palpate temporal artery- grade 2+ *Palpate temoralmandibular joint as pt opens/closes mouth- note smooth movements, pain, limitations Inspect Face Facial Structures *Expression- appropriateness *Symmetry of eyebrows, palpebral fissures, nasolabial folds and sides of mouth *Note abnormal facial structures/swelling/involuntary movements Inspect/Palpate Neck Symmetry *Head positioned midline; erect, still, neck muscles symmetrical ROM *Note any limitations *Touch chin to chest, turn left-right, touch ear: shoulder, extend head backwards, movements smooth and controlled *Test muscle strength (CN XI) by shrug shoulders/turn head against resistance *As pt moves head note any obvious pulsations/swollen glands Lymph Nodes *Normal-movable, discrete, soft, nontender, cervical may be palpable 10 sites *Preauricular, posterior auricular, occipital, submental, submandibular, jugulodigastric, superficial cervical, deep cervical chain, posterior cervical, supraclavicular *Gentle circular motion of finger pads, compare sides symmetrically *Use one hand for submental, hold chin with other *Deep cervical tilt head to other side *Supraclavicular have pt shrug shoulders *If any are palpable *Note location, size, shape, discrete/matted, mobility, consistency and tenderness Trachea *Midline, note any deviation-palpate for tracheal shift *Index finger in sternal notch and slip off to each side-space should be symmetric on each side Thyroid Gland *Usually not palpable *Tangential lighting for any swelling *Give pt glass of water-inspect neck as pt takes a sip/swallows-thyroid tissue should move up as pt swallows *Posterior approach-sit up straight with head slightly forward and to right, use fingers of left hand to push trachea to right, curve right fingers between trachea and sternomastiod and ask pt to take sip of water-thyroid moves up with trachea/larynx, repeat procedure on the left Auscultate Thyroid

*If enlarged, Auscultate with BELL for presence of bruit, normally not present

Nose/mouth/throat Inspect/Palpate Nose External *Symmetric, midline, proportionate to other facial features *Deformity, inflammation, lesions *Injury suspected palpate gently for pain/break in contour *Test patency of each nostril (occlude and sniff) Nasal Cavity *Use speculum/penlight *Push tip of nose upward view with head erect then tilt head back *Inspect mucosa-normal red colour, smooth/moist surface *Note any swelling, discharge, bleeding, foreign bodies *Observe septum for any deviation/perforation/bleeding *Inspect turbinates on lateral walls (middle/inferior) note swelling/polyps Palpate Sinus Areas General *Using thumbs, press over frontal sinuses (below eyebrows) *As well over maxillary sinuses (below cheekbones) *Should feel firm pressure but no pain Transillumination *When sinus inflammation is suspected *Darken examining room *Shine penlight under superior orbital ridge on frontal sinus area, cover with your hand- a diffuse red glow is normal response *Assess maxillary sinuses by asking pt to open mouth/tilt head back and shine penlight on each cheek just under inner corner of eye Inspect Mouth Lips *Inspect for colour, moisture, cracking, lesions *Note inner surface as well Teeth/Gums *Teeth white/straight evenly spaced and clean *Note any diseased, absent, loose, abnormally positioned teeth *Ask to bite down and assess alignment *Gums are pink, assess for swelling, retraction, bleeding Tongue *Pink even colour *Dorsal surface is roughened from papillae *Ventral surface smooth, glistening, venous *Saliva present *Using glove/cotton gauze swing tongue to side to assess lateral aspects for white spots/lesions *Inspect U shaped area from white patches, nodules, and ulcerations Buccal Mucosa *Hold cheek open with tongue blade *Pink, smooth, moist *Assess for colour, nodules, and lesions Palate *Shine light to roof of mouth

*Anterior hard palate while with irregular transverse rugae *Posterior soft palate pinker, smooth, upwardly movable *Torus palatinus-nodular bony ridge down center of hard palate *Observe uvula midline-assess mobility by pt saying “ahh” should rise Inspect Throat *Using light observe oval, rough surfaced tonsils – pink like mucosa *Tonsils graded 1+ visible - 4+ touching each other *View posterior pharyngeal wall by depressing tongue with blade noting colour, exudate, lesions *Stick out tongue (CN XII) - protrude midline with no tremors, loss of movement or deviation

Peripheral vascular/lymphatic Inspect/Palpate Arms *Lift both hands in yours *Inspect then turnover noting colour of skin, nailbeds, temp, texture, turgor, lesions, edema, clubbing, and scars *Check cap refill (1-2 seconds) *Arms should be symmetric in size *Palpate both radial pulses, noting rate, rhythm, elasticity and force (2+) *Palpate ulnar pulses if indicated *Palpate brachial pulses *Check epitrochlear node – shake hands with pt reach other hand under elbow in groove between bicep/triceps- normally not palpable *Perform MODIFIED ALLEN TEST – occlude radial/ulnar arteries while pt makes a fist several times which causes hand to blanch, ask pt to open hand, release pressure of ulnar artery and maintain on radial, normal colour should return in 2-5 seconds Inspect/Palpate Legs General *Inspect legs bilaterally noting skin colour, hair distribution, venous pattern (flat barely visible, note varicosities), size (asymmetric-measure calf at widest point), lesions, and ulcers *Palpate for temperature with dorsa of hands bilaterally *Flex pt’s knee and gently compress gastrocnemius muscle/sharply dorsiflex foot-no tenderness *Palpate inguinal lymph nodes- small 1cm, movable, nontender *Palpate femoral, popliteal, dorsalis pedis and posterior tibial arteries – grade 2+ *Check for pretibial edema- depress for 5 seconds then release, grade 1+ - 4+ Manual Compression Test *Determine competency of valves *Pt standing, place hand on lower part of varicose vein and compress vein with other hand 15- 20 cm higher, competent valves will prevent a wave transmission and distal fingers will feel no change Trendelenburg Test *Determines vein competence when varicose veins present *Pt supine, elevate involved leg 90* until veins empty, place tourniquet high on thigh, help pt stand and watch for venous filling, 30 seconds, remove tourniquet and observe whether or not varicose veins suddenly fill from able – should not Colour Changes *Suspect arterial deficit *Raise legs 30 cm off bed, ask pt to wag feet to drain off venous blood – skin colour reflects only arterial blood, pale but still pink, have pt sit up and dangle legs, compare colour of both feet, note time for colour to return 10 seconds or less, and time for superficial veins to fill 15 seconds Doppler Ultrasonic Stethoscope *Use to detect weak peripheral pulses *Apply coupling gel and place transducer over pulse site swiveled at 45* angle with light pressure, listen for swooshing sound Ankle-Brachial Index (ABI)

*Use Doppler to assess extent of peripheral vascular disease *Apply BP cuff to arm and measure systolic pressure via brachial *Apply BP cuff to calf and measure systolic pressure via posterior tibial *Divide systolic pressure of ankle by that of arm *Ankle should be equal to or slightly greater than brachial thus normal ABI is 1.0 – 1.2

Abdomen Inspect Abdomen Contour *Stand on pts right side and look down on abd *Stoop to gaze across *Determine profile from rib margin to pubic bone- flat, round, scaphoid, protuberant Symmetry *Tangential lighting to highlight any bulges, masses *Symmetric bilaterally *Step to foot to reassess *Ask pt to take deep breath to further highlight any asymmetry Umbilicus *Midline, inverted, no discoloration, inflammation, hernia Skin *Smooth, even *Note striae, moles, lesions, scars (inquire/measure) *Skin turgor Pulsation/Movement *Abdominal Aorta pulsations *Respiratory movement *Waves of peristalsis Hair Distribution *Pattern of pubic hair is diamond in males, inverted triangle in females Demeanor *Comfortable, relaxed, benign facial expression and slow even resps ***Auscultate*** before palpation/percussion***use pillow knees bent/arms @ sides*** Bowel Sounds *Use DIAPHRAGM *Begin in RLQ at ileocecal valve and move clockwise *Note character (gurgling) and frequency (5-30 times per minute) do not bother to count but judge if they are normal, hypoactive or hyperactive *Must listen for 5 minutes to determine absence of bowel sounds Vascular Sounds *Note presence of bruits *Check over aorta, renal/iliac/femoral arteries *Usually no sound is present

Light Palpation General *Palpate tender areas last *Note overall impression of skin surface and superficial musculature, masses etc *Bend pts knees, arms at sides *Begin in RLQ and move clockwise *First four fingers close together depress skin about 1 cm making gentle rotary motions Percuss General Tympany *Percuss lightly in all four quadrants to determine prevailing amount of TYMPANY and dullness Liver Span *Right midclavicular line *Begin in area of lung resonance and Percuss down interspaces until sound changes to DULL, mark this spot (5th ICS) *Then find abdominal tympany and Percuss up to where sound changes to DULL, mark this spot *Measure distance between two marks 6-12 cm (10.5 male, 7 female) Scratch Test *Place stethoscope over liver *Starting at RLQ using fingernail to scratch up towards liver, when sound in stethoscope becomes magnified you are on liver Splenic Dullness *Percuss for dull note from 9-11th ICS behind left midaxillary line *Area normally not wider than 7 cm *Percuss in lowest interspace in left anterior axillary line- tympany should result *Ask pt to take deep breath, tympany should remain through full inspiration Costovertebral Angle Tenderness *Indirect fist percussion *Place one hand over 12th rib at CVA on the back and thump that hand with ulnar edge of other fist *Pt feels thud but no pain Test for Ascites FLUID WAVE TEST *Stand on pts right side *Pt places ulnar edge of hand on midline of abd *Place left hand on pts right flank *With right hand reach across and strike left flank *If Ascites is present you will feel a fluid wave strike left hand SHIFTING DULLNESS *Pt supine (ascitic fluid will settle to flanks and air upward) *Tympany as percuss over top of abd (gas filled) *Percuss down side of abd, if fluid is present note will change from tympany to dullness, mark this spot *Turn pt on right side (fluid will settle there) *Begin percussing upper side of abd and move down, sound will again change from tympany to dull as you reach fluid level but level of dullness is now higher, which indicates a presence of fluid Special Procedures REBOUND TENDERNESS (Blumberg’s Sign) *When pt reports abd pain or when elicit tenderness with palpation *Choose site away from painful area *Hold hand 90* to abd and push down slowly and deeply then lift up quickly *Negative response is no pain on release of pressure INSPIRATORY ARREST (Murphy’s Sign)

*Normally palpating liver causes no pain but with inflammation of gallbladder it will *Hold fingers under liver border, ask pt to take deep breath *Normal response is to complete deep breath with no pain ILIOPSOAS MUSCLE TEST *Acute abd pain/appendicitis is suspected *Pt supine lift RIGHT leg straight up flexing at hip, then push over lower part of right thigh as pt tries to hold leg up *Test negative when pt feels no change OBTURATOR TEST *Appendicitis is suspected *Pt supine, lift RIGHT leg, flex at hip and knees *Hold ankle and rotate leg internally/externally *Negative response is no pain

Thorax/lungs Inspect Posterior Chest Thoracic Cage *Shape/configuration of chest wall-spinous process in straight line, thorax symmetric with downward sloping ribs, scapulae located symmetrically *Symmetric expansion- note respiratory rate, rhythm, quality *Anteriorposterior diameter < transverse diameter 1:2 or 5:7 *Neck/trapezius muscles equal/developed *Note position pt takes to breathe-relaxed, support weight with arms at sides/use of accessory muscles/nasal flaring *Assess skin/lips/nails colour and condition Palpate Posterior Chest General *Using finger palpate entire chest wall/trachea-note areas of tenderness, temp, moisture, lumps, lesions Symmetric Expansion *Place thumbs together at level of T9 slightly pinching skin together, ask pt to take a breath, note thumbs moving apart symmetrically Tactile Fremitus *5 sites- start at lung apices (trapezius) compare side to side moving in Z pattern *Palpable vibration as sound is generated *Use palmar/ulnar base of hand touch pt’s chest as they repeat “99” Percuss Posterior Chest Lung Fields *9 sites (apices, intercostals down thorax, 8/9 laterally) *Determine predominant note over lung fields (resonance) *Start at apices (band across shoulders) compare side to side in Z pattern *Percuss down interspaces Diaphragmatic Excursion *Ask pt to EXHALE and hold it- Percuss down scapular line until sound changes from RESONANT to DULL on each side (may be higher on right because of liver) *INHALE and hold it- Percuss down from this spot and mark when sound becomes DULL *Measure the difference *Normal 3-5 cm (7-8cm in well conditioned athletes)

Auscultate Posterior Chest**Pt breathe deeply thru open mouth, inform if become faint Breath Sounds *9 sites (apices, intercostals down thorax, 8/9 laterally) *Sitting, lean slightly forward, arms across lap, breathe deeply through mouth, instruct to stop if become dizzy *Use DIAPHRAGM listen to one full respiration at each location comparing side to side *Bronchial sounds; harsh/hollow- heard at trachea- inspiration < expiration *Vesicular sounds; rustling- over peripheral lung fields- inspiration > expiration *Bronchovesicular; mixed- over major bronchi (between scapulae/at sternum)- inspiration = expiration Adventitious Sounds *Note sounds superimposed on breath sounds (ie crackles/wheezes/rhonci(gurgles)/friction rub) Voice Sounds *9 sites (apices, intercostals down thorax, 8/9 laterally) *Determine quality of vocal resonance *Pt says “99” while you listen with stethoscope – sounds should be soft, muffled and indistinct Inspect Anterior Chest *Note shape/configuration, facial expression for distress/effortless breathing *Assess LOC *Note skin colour condition *Assess quality of respirations- in range, automatic, effortless, regular, even, no noise, chest expands symmetrically *Note retraction/bulging of interspaces/use of accessory muscles Palpate Anterior Chest General *Using finger palpate entire chest wall-note areas of tenderness, temp, moisture, lumps, lesions Symmetric Expansion *Place thumbs together at xiphoid process slightly pinching skin together, ask pt to take a breath, note thumbs moving apart symmetrically Tactile Fremitus *5 sites- start at lung apices (trapezius) compare side to side moving in Z pattern *Palpable vibration as sound is generated *Use palmar/ulnar base of hand touch pt’s chest as they repeat “99” Percuss Anterior Chest Lung Fields *5 sites (begin supraclavicular, 2 interspaces sites on pecs, one able nipple, 5th site lateral)

Auscultate Anterior Chest Breath Sounds *Begin at apices and move down to 6th rib *Sitting, lean slightly forward, arms across lap, breathe deeply through mouth, instruct to stop if become dizzy *Use DIAPHRAGM listen to one full respiration at each location comparing side to side *Bronchial sounds- heard at trachea *Vesicular sounds- over peripheral lung fields *Bronchovesicular- over major bronchi (between scapulae/at sternum) Adventitious Sounds *Note sounds superimposed on breath sounds (ie crackles/wheezes) Voice Sounds *Determine quality of vocal resonance *Pt says “99” while you listen with stethoscope – sounds should be soft, muffled and indistinct

Measurement of Pulmonary Function Status Forced Expiratory Time *Ask pt to inhale deepest possible breath then blow it all out hard as quickly as possible with mouth open *Listen with stethoscope over the sternum *Normal time is 4 seconds or less Pulse Oximetry *Measures arterial oxygen saturation *Normal range 98% 12 Minute Distance *Cover as much ground as possible in 12 minutes

Breast/regional lymphatic Inspect Breasts General Appearance *Note symmetry of size/shape/contour/retractions/dimpling Skin *Smooth, even colour/texture *Localized areas of redness, bulging, dimpling *Lesions/vascular pattern/striae *Edema-peau d’orange Lymphatic Drainage Areas *Observe axillary/supraclavicular regions *Note bulging, discoloration or edema Nipple *Symmetrically placed *Protrude unilaterally *Areola size/colour/shape *Note dry scaling, fissure, ulceration, bleeding, and discharge *Note presence of supernumerary nipple (distinguish it from mole) Maneuvers to Screen for Retraction *Lift arms slowly above head-breasts should move up symmetrically *Push hands against hips-contract pecs, both breasts will slightly lift *Large pendulous breasts to lean forward, note symmetric free forward movement Inspect/Palpate Axillae *Sitting *Inspect skin-note rash/infection *Support arm so muscles relaxed, move arm through ROM to allow easier access *Reach fingers high into Axillae and move in four directions *Down middle of chest wall *Anterior border of Axillae *Posterior border *Along inner aspect of upper arm *Usually nodes not palpable, may feel small soft central group, note any enlarged

Palpate Breasts *Use friction-free technique- hot, soapy lather/talcum powder *Supine, small pillow under arm of affected side, arm above head *Pads of first three fingers in gentle rotary motion in grid like pattern all over breast, tail of Spence and nipple *Nulliparous woman breast feels-firm, smooth, elastic (may feel inframammary ridge) *After pregnancy-softer and looser *Nipple *Gentle pressure “milk” nipple towards center from areola, repeat in few directions *Note any indurations, subareolar mass *Any discharge present, note colour and consistency *If lump is present note these characteristics *Location-clock face description *Size- width x length x thickness *Shape- oval/round/lobulated/indistinct *Consistency-soft/firm/hard *Mobility- free/fixed *Distinctness- solitary/multiple *Nipple- displaced/retracted *Skin- erythmatous/dimpled/retracted *Tenderness- upon palpation *Lymphadenopathy- lymph nodes palpable Teach Breast Self Exam-4-14 days after menstruation begins Male Breast *Inspect chest wall noting skin surface, any lumps/swelling *Palpate nipple area for lumps/tissue enlargement, should feel even with no nodules *Gynecomastia-feels like smooth, firm, movable disc

Eyes Test Central Vision Acuity Snellen Eye Chart *Well-lit spot at eye level 20 feet away (can be closer but must be charted) *Remove reading glasses only *Pt holds opaque card up to one eye and reads smallest line of chart possible with other, encourage to read next smallest line also *Record results indicating missed/incorrect letters/glasses worn/distance *Normal vision 20/20 – bigger denominator worse vision Near Vision *Pt 40+ years, reports difficulty reading *Test each eye separately, with glasses on *Hand held vision screener with various sizes printing *Hold card 35 cm (14 inches) from eye- normal result 14/14 *Read without hesitancy/moving card Test Visual Fields Bowel Test*** Confrontation Test *Measure of peripheral vision comparing pts vision to your own *Place self eye level with pt 2 feet away *Pt covers one eye and you mimic *Hold pencil/flicking finger out of field and move it in from periphery in several directions, pt says ‘now’ when they see it, you should see it at this time as well *Angles between Anteriorposterior axis of eye and peripheral axis where object is seen • 50* upward • 90* temporal • 70* down • 60* nasal Inspect Extraocular Muscle Function Corneal Light Reflex (Hirschberg Test) *Assess parallel alignment of eye axes *Shine penlight towards pt eyes as they face forward 30 cm away *Note reflection of light on corneas in exactly the same spot in each eye Cover Test *Pt stares straight ahead *With opaque card cover one eye, note uncovered eye-steady fixed gaze *Remove card, if muscle weakness present eye will have drifted to a relaxed position and will jump to reestablish fixation *Repeat with other eye Diagnostic Positions Test *Lead eyes through six cardinal positions of gaze to elicit any muscle weakness with movement – nystagmus (oscillation), lid lag, and parallel movement *Hold head steady and follow movement of finger (12 inches away) with eyes *Take through positions on clock, back to center between each Inspect Extraocular Structures General *Ability to move about room, avoid objects

*Relaxed expression (no squinting) Eyebrows *Present bilaterally *Move symmetrically with expression changes *No scaling/lesions Eyelids/lashes *Upper overlap superior portion of iris and approximate completely with lower lids when closed *Skin intact without redness, swelling, discharge, and lesions *Palpebral fissures horizontal in non-Asians, Asian have upward slant *Eyelashes evenly distributed along margins and curve outward Eyeballs *Aligned normally in socket with no protrusion/sunken Conjunctiva/Sclera *Pt looks up, slide lower lids down with thumbs *Eyeball moist and glossy *Blood vessels present, otherwise clear *Pinkness over lower lids and white over sclera *Note any colour change, swelling, lesions *Eversion of upper lid to inspect conjunctiva associated with eye pain/foreign body Lacrimal Apparatus *Pt looks down, slide outer part of upper lid along bony orbit, inspect for redness/swelling *Note presence of excessive tearing/blockage of nasolacrimal duct by applying pressure against sac just inside of lower orbital rim, should be no response to pressure Inspect Anterior Eyeball Structures Cornea/Lens *Shine light from side across cornea, check for smoothness/clarity/opacities Iris/Pupil *Iris is flat, round regular shape even coloration *Note size (3-5 mm), shape and equality of pupils- round, regular, equal Test Pupillary Light Reflex *Darken room, pt gaze into distance *Estimate pupil size before and after light reflex tested *Advance light in from side and note response *Constriction of affected pupil *Simultaneous constriction of other pupil *Record size of pupils before/after of both eyes ie R 3/1 = L 3/1 Test Accommodation *Focus on distant object-pupils dilate *Shift gaze to near object- pupils constrict/converge *Record response *PERRLA- pupils equal, round, react to light and accommodation Inspect Ocular Fundus *Using ophthalmoscope *Darken room to dilate pupils *Remove yours/pts glasses and accommodate with diopter gauge *Select large round white light *Hold in Right hand up to your Right eye when examining pts Right eye place other hand on pts head *Pt looks straight ahead into distance at fixed object *Begin 25 cm away from pt at angle of 15 lateral – note red reflex *Progress forward until foreheads almost touch, adjusting lens to bring ocular fundus into sharp focus (both have normal vision should be at 0)

*Adjust RED lens for NEARsighted, and BLACK for FARsighted pts *Inspect structures *Optic disc-by tracking a vessel *Located on NASAL side of retina *Creamy yellow-orange/pink *Round/oval *Margins distinct/sharply demarcated *Cup: disc ratio distinctness varies. Physiologic cup is brighter yellow/white than rest of disc, its width is more than one half the disc diameter *Retinal vessels *Follow paired artery/vein into periphery in four quadrants, gradual decrease in diameter into periphery and may cross paths (fine if do not interrupt blood flow or are within 2DD of disc) *Mild vessel twisting normal if congenital and bilateral *Pulsation may be present near disc *Arteries are brighter red and have light reflex *Artery: vein ratio is 2:3 or 4:5 *General background *Light red to dark brown red corresponding with skin colour *View of fundus should be clear, no lesions obstructing retinal structures *Macula *Inspect last as can be very uncomfortable and cause pupillary constriction *1DD in size and is located 2DD temporal to disc *Colour somewhat darker than rest of fundus but is even and homogenous *Note foveal light reflex-tiny white glistening dot reflecting ophthalmoscope light

Ears Inspect/Palpate External Ear Size/Shape *Equal bilaterally *No swelling/thickening Skin *Colour consistent with facial skin *Intact, no lumps/lesions Tenderness *Move pinna and push on tragus- firm, no pain *Palpate mastoid process- no pain External Auditory Meatus *Note size of opening and choose speculum accordingly *No swelling, redness, discharge *Some cerum may be present- gray/yellow to light brown/black, moist/dry Inspect Using Otoscope General *Look at GOOD ear first *Do this before testing hearing as you will note excessive cerum and will not attribute this to hearing loss *Tilt pts head slightly away from you for better view into the sloping canal *Pull pinna up and back to straighten S curve of the canal and do not release until speculum is removed *Hold Otoscope ‘upside down’ and have dorsa of hand braced against pts face *Insert speculum; rotate slightly to visualize the entire eardrum External Canal *Note any redness, swelling, lesions, foreign bodies, discharge (colour/odor) and change speculum before inspecting other ear *If pt has hearing aid note any irritation on canal wall Tympanic Membrane *Shiny/translucent pearl-gray colour *Light reflex is anterior inferior quadrant (5 o’clock in R, 7 o’clock L) *Sections of malleus are visible; umbo, manubrium and short process *Drum is flat and slightly pulled in at center; flutters with Valsalva to note drum mobility *Inspect integrity of membrane- entire circumference for perforations/scarring-should be intact Test Hearing Acuity Voice Test *Place one finger in tragus of opposite ear *Shield lips with head pulled away from pt *Whisper two-syllable words- Monday/baseball/Fourteen Tuning Fork Tests Weber *When hearing better in one ear *Place vibrating fork down midline of skull *Pt reports if can hear equally in both ears Rinne *Compares air conduction to bone conduction *Pace vibrating fork on pts mastoid process and signal when sound disappears

*Quickly invert fork so vibrating near ear canal, pt should still hear sound (2X longer through AC vs. BC) *Repeat with other ear Vestibular Apparatus Romberg Test *Assess vestibular apparatus’s ability to maintain standing balance *Feet together, arms at sides, eyes closed for 20 seconds, no swaying

Heart/neck vessels Neck Vessels Carotid Artery Palpate *Medial to sternomastiod muscle bilaterally one at a time *Feel contour-smooth with rapid upstroke and slower downstroke and amplitude-strength 2+ Auscultate *With BELL *Pt exhales and holds breath *Three positions- angle of jaw, midcervical area, base of neck *For presence of bruit- none should be present Jugular Venous Pulse Inspect *To assess Central Venous Pressure *Pt supine 30-45*, remove pillow, turn head slightly away, use tangential lighting *External vein along sternomastiod (strong pulsation), internal at suprasternal notch Estimate Jugular Venous Pressure *Pt right side *Hold vertical ruler at Angle of Louis and straight edge to point of highest pulsation, <2cm note angle of bed in documentation Hepatojugular Reflux *Pt supine, breathe quietly thru open mouth *Right hand on RUQ just below rib cage *Watch level of jugular pulsation as push in with hand for 30 seconds *Empties venous blood from liver and adds to system- if heart can pump this addition the jugular veins will rise for a few seconds then recede Precordium Inspect Anterior Chest *Tangential lighting *Note any pulsations (apical pulse) 5th ICS MCL *Note any heaves/thrills Palpate Apical Pulse *Point of maximal impulse, palpable in 50% adults *Pt supine, slightly to left *Use one finger pad, small 1 cm X 2 cm *Pt exhales and holds *Occupy one interspace 5th ICS medial to MCL, feel short gentle tap if first half of systole Palpate Precordium *Palmar aspects gently palpate the apex, left sternal border and base, note any pulsations Auscultation- AParTMent 22345 *Right 2nd ICS- AORTIC *Left 2nd ICS- PULMONIC *Left 3rd ICS- ERB’S POINT *Left lower sternal border- TRICUSPID *Left 5th ICS medial MCL- MITRAL *Begin with DIAPHRAGM – * Note rate/rhythm- 60-100 bpm, rhythm regular

*Identify S1 and S2- S1 louder at apex/coincides with carotid, S2 louder at base *Assess S1 and S2 separately-note if each sound is normal, accentuated, diminished or split *Listen for extra heart sounds- switch to BELL, note timing and characteristics *Listen for murmurs- listen with BELL noting timing, grade loudness, pitch, pattern, quality, location, radiation, and posture *After listening with pt supine, turn to LEFT side and listen at APEX with BELL for presence of any diastolic filling sounds *Pt sit up, lean forward and exhale, listen with DIAPHRAGM at base, right and left sides for soft high pitched early diastolic murmur or aortic or pulmonic regurgitation

Musculoskeletal GENERAL Inspection *Note size/contour of joint *Skin/tissues over joint for colour/swelling/masses/deformity Palpation *Palpate each joint *Skin for temp/moisture *Muscles/strength *Bony articulations *Joint capsule *Note any heat/tenderness/stiffness/swelling/masses *Synovial membrane should not be palpable- if thickened it feels doughy Range of Motion *Active- stabilize area proximal to that being moved *If limitation attempt Passive- anchor joint with one hand and slowly move area with other to its limit *If limitation/increase in ROM use a goniometer to measure angle precisely *Joint motion should not produce tenderness, pain or crepitus Muscle Testing *Test strength of prime mover muscle groups for each joint *Repeat ROM but apply opposing force *Should be equal bilaterally and resist opposing force *Grade strength *5- full ROM, full resistance *4-Full ROM, some resistance *3- Full ROM *2- full passive ROM *1- slight contraction *0- no contraction Temporal Mandibular Joint Inspect *Area anterior to ear Palpate *Place tips of finger anterior to ear pt open/closes mouth- note smooth motion of mandible, any crepitus *Pt clenches jaw, palpate contracted temporalis/masseter muscles- compare sides for size, firmness, and strength ROM *Open mouth maximally- 3-6 cm or 3 fingers sideways *Partially open mouth, protrude lower jaw and move side to side- lateral motion 1-2 cm *Stick out lower jaw- protrude without deviation Muscle Strength *Move jaw forward/laterally, open mouth against resistance Cervical Spine Inspect *Alignment of head/neck- spine straight, head erect Palpate

*Spinous processes, sternomastiod, trapezius and paravertebral muscles-firm, no muscle spasm/tenderness ROM *Touch chin: chest- flex 45 *Chin: ceiling- hyper ext 55 *Ear: shoulder- lateral bending 40 *Turn chin: shoulder- rotation 70 Muscle Strength *Repeat against opposing force Shoulder Inspect *Compare shoulders bilaterally from post/anterior *Size/contour *Equality of bony landmarks *No redness, muscular atrophy, deformity, swelling *Check anterior joint capsule and subacromial bursa for swelling Palpate *Both shoulders *Start at clavicle- acromioclavicular joint, scapulae, greater tubercle, subacromial bursa, biceps groove, glenohumeral joint, and axilla *Note muscular spasm, atrophy, swelling, heat, and tenderness ROM *Cup one hand over shoulder to assess for crepitus *Arms forward above head- forward flex 180 *Arms back down and move back- hyper ext 50 *Rotate internally behind back (try to touch scapulae) – internal rot 90 *Touch palms together behind head with elbows flex/rot posteriorly- external rot 90 *Arms at sides bring above head with elbows extended- abd 180 *Bring arms back down and cross in front of body- add 50 Muscle Strength *Shrug shoulders *Flex forward and up *Abduct against resistance Hip Inspect *Pt stand- note symmetric levels of iliac crests, gluteal folds, and equal sized buttocks *Smooth even gait reflects equal leg length and functional hip motion Palpate *Pt supine – should feel stable, symmetric, no tenderness, crepitus ROM *Raise leg with knee extended- flex 90 *Bend knee up to chest, other leg stays straight- flex 120 *Flex knee/hip 90; stabilize holding thigh/ankle, swing foot outward- internal rotation- 40 *Repeat above and swing foot inward- external rotation 45 *Swing leg laterally; stabilize by pushing on opposite asis- abd 40-45 *Swing leg medially, stabilize by pushing on opposite asis- add 20-30 *Standing, swing leg straight behind body, stabilize pelvis- hyper ext 15 Knee Inspect *Sitting with legs dangling

*Skin smooth, even coloring, and no lesions *Assess lower leg alignment- extend in same axis as thigh *Shape/contour- distinct concavities bilaterally to patella- check for signs of fullness/swelling *Assess prepatella bursa, suprapatellar pouch or swelling *Assess quadriceps muscle for atrophy Palpation *Start high on thigh in grasping fashion of quads *Proceed down towards patella, explore suprapatellar pouch- note consistency of tissues; muscles/soft tissue feels solid and joint feels smooth, warm, no tenderness, thickening or nodularity *If swelling is present determine if d/t soft tissue swelling or inc fluid *BULGE SIGN *Small amt fluid *Firmly stroke medial aspect of knee to displace fluids *Tap lateral aspect of knee, watch hollow of medial side, for distinct bulge of fluid wave, none should be present *BALLOTTMENT *Large amt fluid *Left hand compresses suprapatellar pouch to move fluid into knee joint *Right hand pushes patella sharply against femur *If no fluid present patella will already be snug against femur and no change will occur *Continue palpation of tibiofemoral joint, infrapatallar fat pad and patella *Check for crepitus, hold hand on patella as knee is flexed/extended ROM *Pt standing *Bend knee- flex 130-150 *Extend knee- straight line of 0, some hyper ext 15 *Assess knee ROM during ambulation Muscle Strength *Maintain knee flexion while you oppose trying to pull leg forward *Extension demonstrated by pt rising from chair/low squat without using hands for support Test for meniscal tears *McMurray’s Test *History of trauma, giving way, locking, or local knee pain *Pt supine, stand on affected side *Hold heel/thigh, flex knee/hip *Rotate leg in/out to loosen joint *Externally rotate leg and apply inward pressure on knee *Slowly extend knee- normally no pain with extension Ankle/Foot Inspection *Inspect both while ambulating and seated *Compare feet, note position of feet/toes/contour of joints and skin chara *Foot should align with long axis of lower leg (line from midpatella to between first/second toes) *Weight bearing fall on middle of foot from heel to second/third toes *Inspect arch *Toes point straight and lie flat *Ankles are smooth bony prominences *Note location of calluses/bursa reactions *Examine well-worn shoes for signs of wear and accommodation Palpate *Support ankle/grasp heel with fingers and palpate with thumbs

*Explore joint spaces- smooth, depressed, no fullness/swelling/tenderness *Palpate metatarsalphalangeal joints between thumb and dorsum of fingers on plantar surface *Pinching motion to palpate interphalangeal joints on medial/lateral sides of toes ROM *Point toes to floor- plantar flex 45 *Point toes to nose- dorsiflex- 20 *Turn soles of feet out, stabilize ankle – Eversion 20 *Turn soles of feet in, stabilize ankle- inversion 30 *Flex and straighten toes Muscle Strength *Maintain dorsiflexion/plantarflexion against resistance Spine Inspect *Pt standing *Note alignment of spine-straight from head along spinous processes to gluteal cleft *Note equal horizontal positions of shoulders, scapulae, iliac crests, gluteal folds and equal spaces between arm and lateral thorax *Knees and feet should be aligned with trunk and pointing forward *From side not normal convex thoracic curve and concave lumbar curve Palpate *Palpate spinous processes- straight, nontender *Palpate paravertebral muscles- firm, non-tender, no spasm ROM *Bend forward and tough toes- flex 75-90 smooth/symmetric movements, note concave lumbar curve should disappear and back is single convex C shaped curve *Stabilize pelvis *Pt bends sideways bilaterally- lateral bending 35 *Bend backward- hyper ext 30 *Twist shoulders side to side- rotation 30 STRAIGHT LEG RAISING (LaSegue’s Test) *Reproduce back/leg pain and confirm presences of herniated nucleus pulposus *Raise affected leg just short of where pain is produced, then dorsiflex foot *Raise unaffected leg while leaving other leg flat-inquire about involved side MEASURE LEG LENGTH DISCREPANCY *TRUE *Measure between fixed points- anterior iliac spine to medial malleolus, within 1 cm of each other *APPARENT *Measure from non-fixed points- umbilicus to medial malleolus

Neurological CRANIAL NERVES CN 1 Olfactory *Test in pts report loss of smell, head trauma, abnormal mental status, intracranial lesion suspected *Test patency of each nare *Occlude one nostril and provide aromatic substance, pt identifies CN 2 Optic *Test visual acuity (Snellen eye chart) *Test visual field- bowel/confrontation *Use ophthalmoscope to examine ocular fundus and determine size, shape and colour of optic disc CN 3 4 6 – Oculomotor, Trochlear, Abducens *Palpebral fissure equal width *Check pupils for size, regularity, equality, direct and consensual light reflex and accommodation *Assess extraocular movements via cardinal positions of gaze- if nystagmus (oscillation) is present notebilateral, pendular/jerking, amplitude, frequency, plane of movement CN 5 Trigeminal Motor Function *Palpate temporal/massester muscles as pt clenches teeth- equal strength *Try to separate jaw by pushing down on chin-normally cannot Sensory Function *Pt eyes closed test light sensation by touching cotton wisp to forehead, cheeks and chin- pt says NOW when feels touch CN 7 Facial Motor *Note mobility and facial symmetry as pt smiles, frowns, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth and puff cheeks (press pts cheeks in-air escapes equally) Sensory *Test only when suspects facial nerve injury *Test sense of taste by applying cotton applicator with solution of sugar/salt/lemon juice to tonguept identifies taste CN 8 Acoustic (Vestibulocochlear) *Test hearing acuity by *ability to hear normal conversation *Whispered voice test *Weber *Rinne CN 9 10 Glossopharyngeal/Vagus Motor *Depress tongue and note pharyngeal movement as pt says “AHH”, uvula and soft palate rise midline and tonsillar pillars should move medially *Elicit gag reflex Sensory *Test taste on posterior 1/3 of tongue CN 11 Spinal Accessory *Examine sternomastiod/trapezius muscles for equal size *Check equal strength as pt rotates head/shrugs shoulders against resistance CN 12 Hypoglossal *Inspect the tongue- no wasting/tremors *Note forward thrust in midline as pt protrudes tongue

*Say “light, tight, dynamite” speech should be clear and distinct Inspect/Palpate Motor System Muscles *Size- inspect all muscle groups for size/symmetry for age/occupation - compare right and left, if asymmetric measure- within 1 cm *Strength- test muscle groups of extremities/neck/trunk- grade strength 0 no contraction – 5 normal strength *Palmar Drift- hold arms out front palms up 15 seconds, weak arm will drift downward and thumb will rotate inward *Pt extends arm while you try to hold in flexed position vice versa *Sit on edge of bed hold legs in front for 10 seconds- weakness legs will drop *Tone- a normal degree of tension, mild resistance to passive stretch, to test move extremities through passive ROM- get them to go limp and move thru full ROM- observe for spasticity/ridgity *Involuntary movements- normally none should occur- if they are note location, frequency, rate, amplitude and control at will *Observe gait- smooth, coordinated and balanced- no signs of unsteadiness, widened stance, dragging one foot, shuffling or staggering Cerebellar Function Balance Tests *Gait- obs as pt walks 15 feet turns around and comes back- smooth, rhythmic, effortless, opposing arm swing, turn smooth, step length 15 inches from heel: heel *Tandem walk- heel: toe- decrease base of support and accentuate problems with coordination- walk straight and balanced *Romberg test- feet together, arms at sides, eyes closed for 20 seconds without swaying *Shallow knee bend/hop in place- test both legs- able to do so, maintain balance, adequate muscle strength Coordinated/Skilled Movements *Rapid Alternating Movements- pat knees with both hands alternating between palms and dorsa of hands, ask to do it faster- equal turning and rhythmic pace *Touch thumb to each finger of same hand then reverse direction- quickly and accurately *Finger: finger – eyes open, index finger to your finger then to nose as you move finger to different spot- smooth, accurate *Finger: nose- close eyes stretch out arms, touch tip of nose with finger alternating hands and increasing speed- accurate and smooth *Heel: shin- supine place heel on opposite knee and run down shin from knee to anklestraight line down shin Assess Sensory System Spinothalamic Tract *Pain- ability to perceive a pinprick *Break tongue blade lengthwise so there is a dull and rough end *Randomly touch pt body and states “sharp or dull” *2 seconds pass between stimuli to avoid summation *Temperature *Test only when pain sensation is absent *Fill one test tube with warm water and one with cold *Apply each to pt skin in random order and state sensation felt *Light Touch *Apply wisp of cotton to skin at symmetric points all over body *Pt states when sensation is felt Posterior Column Tract *Vibration

*Tuning fork over body prominences- fingers/great toe *Ask pt to indicate when vibration starts and stops *Compare bilaterally *If no vibration felt move proximal *Position (Kinesthesia) *Ability to perceive passive movement of extremities *Pt eyes closed *Hold digit by the sides and move finger/big toe up and down- pt states state which way it was moved *Tactile Discrimination (fine touch) *Stereognosis- eyes closed place familiar object in pts hand- pt explore with fingers and able to recognize object by feeling form, size and weight, test different object in each hand *Graphesthesia- eyes closed use blunt instrument assess pts ability to “read” a number by having it traced on the skin *Two point Discrimination- ability to distinguish the separation of two simultaneous pin points- open paper clip, touch with one or two points, pt states number of sensations felt, decrease distance between points, easiest felt on fingertips (2-8mm) hardest on arms, thighs and back (40-75mm) *Extinction- simultaneously touch same part of body on both sides- ask how many sensations were felt, normally two are felt *Point Location- touch the skin and withdraw stimulus promptly, ask pt to point where they were just touched, compare bilaterally Test Reflexes Deep Tendon Reflexes *Compare right and left sides *Grade reflexes *4+ very brisk, hyperactive *3+ Brisker than normal *2+ normal *1+ diminished *0 no response *If no reflex is elicited try further encouragement of relaxation, use REINFORCEMENT- perform isometric exercise in distal muscle group being tested- upper body tested- clench teeth, lower body tested- lock fingers together and pull *Biceps (C5- C6)- support forearm in yours and apply same thumb to pts biceps tendon, strike thumb with small part of hammer- response is contraction of bicep muscle and flexion of the forearm *Triceps (C7-C8)- pt lets arm go limp as you suspend upper arm, strike triceps tendon directly just above the elbow- response extension of forearm *Brachioradialis (C5-C6)- hold pt thumb and suspend forearms in relaxed position- strike forearm directly 2-3 cm above radial styloid process- response flexion and supination of forearm *Quadriceps (L2-L4)- lower leg dangles freely, place hand above patella to feel for contraction of quadriceps muscle- strike tendon just below patella- response is extension of lower leg *Achilles (L5-S2)- knee flexed/hip externally rotated, hold foot in dorsiflexion, strike Achilles tendon directly- response is plantar flexion against hand *Clonus- test when reflexes are hyperactive, move foot up and down then sharply dorsiflex foot and hold stretch- normal response is no further movement, clonus present you will feel and see rapid rhythmic contractions of calf muscle and movement of foot Superficial Reflexes *Receptors in skin rather than muscles

*Abdominal- upper (T8-T10) lower (T10-T12)- supine with knees slightly bent use handle of reflex hammer to stroke skin moving from side of abd toward midline and upper and lower levels- response is ipsilateral contraction of abd muscles and deviation of umbilicus toward the stroke *Cremaster (L1-L2)- on the male lightly stoke the inner aspect of the thigh- response is elevation of the ipsilateral testicle *Plantar (Babinski) (L2-S2)- with reflex hammer draw a light stroke up the lateral side of the sole of the foot and inward across the ball of the foot like an upside down J-response is plantar flexion of all toes and inversion and flexion of the forefoot

Male Genitalia Inspect/Palpate Penis *Skin wrinkled, hairless, without lesions, dorsal vein may be apparent *Glans smooth, without lesions- uncirmunsribed retract foreskin, compress to note meatus – central, edges pink, smooth and without discharge *Palpate shaft – smooth, semi firm and nontender *Pubic hair at base consistent with development/no pest inhabitants Inspect/Palpate Scrotum *Hold penis out of the way *Note scrotal size, asymmetry normal – left lower than right *Spread rugae out, lift sac to inspect posterior surface- no lesions *Palpate gently each scrotal half- contents should slide easily, testes oval, firm, rubbery, smooth, freely movable, slightly tender and equal bilaterally *Each epididymis feels discrete, softer than testes, smooth and nontender *Palpate each spermatic cord from epididymis to external inguinal ring- smooth, non-tender cord *If mass is found note*Tenderness, location to testes, reduce when supine, can you ausculate bowel sounds over it and can you place fingers over *Use Transillumination- darken room shine flashlight from behind scrotal contents- normal contents will not transilluminate Inspect/Palpate for Hernia *Inspect inguinal area for a bulge as person stands and bears down- none present *Palpate inguinal canal shifting weight to opposite side *Index finger low on scrotal half palpate up length of spermatic cord, invaginating scrotal skin as you go to external ring (triangular slit like opening) *Insert finger into canal and ask pt to bear down- feel no change, repeat on other side *Palpate femoral area for a bulge Palpate Inguinal Lymph Nodes *Palpate horizontal chain along groin to inguinal ligament and vertical chain along upper inner thigh *May feel small <1cm, soft, discrete, movable node Teach Testicular Self Examination (TSE) *T- timing, once a month *S- shower/soapy, warm water relaxes scrotal sac *E- Examine, check for changes and report ASAP

Female Genitalia Preparation/Position *Empty bladder, offer chaperone, ensure privacy, elevate head, explain before doing, stop if any discomfort *Lithotomy position, arms at sides, draped External Genitalia Inspect *Skin colour, hair distribution, labia majora are symmetric/well formed, meet midline in Nulliparous/gaping and shriveled after vaginal delivery, no lesions *With gloved hand, separate labia to inspect *Clitoris-midline *Labia minora- dark pink/moist/symmetric *Urethra slit like/midline *Vaginal orifice- shape *Perineum- smooth *Anus- coarse skin of increased pigmentation Palpation *Assess urethra and Skene’s glands *Dip gloved finger in bowl warm H2O to lubricate *Insert index finger into vagina and gently milk urethra- no pain/dc *Assess Bartholin’s glands- palpate posterior parts of labia majora with index finger in vagina and thumb outside- feel soft and homogenous *Assess support of pelvic musculature *Palpate perineum- thick, smooth, muscular in Nulliparous/thin and ridged in multiparous *Squeeze vaginal opening around finger- tight in null/less tone multiparous *Use index and middle finger to separate orifice, ask pt to strain down, no bulging of vaginal walls/urinary incontinence occur