Physical Examination By Dr

1 Physical Examination Marfori, Francis Anthony V, MD, BSN Definition of Terms

Symptoms Reasons

why

patient/s

see/s

the

physician Unpleasant

unusual subjective sensation which affects the patient’s comfort and productivity E.g.

A group of symptoms and/or signs that, occurring together, constitute a particular disorder E.g. – irritable bowel syndrome •Intermittent pain in the lower abdomen •Abdominal swelling •Irregular bowel movements •Mucus in the feces •Excessive gas •Worsening of symptoms after eating 

– pain

Definition of Terms The seven attributes of a symptom •Location Where is it? Does it radiate? •Quality What is it like? •Quantity or Severity How bad is it? •Timing When did / does it start? How long does it start? How often does it come? Definition of Terms The seven attributes of a symptoms •The Setting in which it occurs, including environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness

•Factors that make it better or worse •Associated manifestations Definition of Terms

Signs Alteration

in function / structure which can be detected by a physical examination

Introduction

Most

patients view physical examination with at least some anxiety

A

thorough examination does more than prevent sickness and prolong the lives of healthy men and women

A privilege – show some respect Introduction 4 fundamentals Inspection Palpation



Auscultation



Percussion



Introduction

Inspection Examination

of patient by way of observing the patient Needs:

lighting

good

pair

of

eyes,

good

evidence of a disease as detected by a physical examination

– color, lesions, pigmentation Introduction Palpation Examination of the body by the sense of touch

E.g.



Objective

– high temperature, flushing, marked weight loss

E.g.

Supplement inspection

E.g. – fremitus, crepitations, chest expansion Introduction Auscultation 

Definition of Terms Syndrome

2 Act of listening to a sound produced by the body Direct – ear; indirect – stethoscope E.g. – heart sounds, breath sounds, vascular sounds, peristaltic sounds, fetal heart sounds 

Introduction Percussion Technique by striking the chest wall and perceiving the character of the sensation as they are perceived by the ear and palpating fingers To detect amount of air, presence of fluid, presence of organomegaly E.g. •Resonance – percussion of lung containing a normal amount of air (normal lung) •Hyperresonance •Flatness – less than normal air (thigh) •Dullness – air has been completely removed (liver) •Tympany – air in an enclosed chamber (gastric air bubble) Introduction

Setting the stage Reflect

on your approach to the patient Decide on the scope of the examination Choose the examination sequence Adjust the lighting and the environment Make the patient comfortable Introduction

Approaching the patient Let

the patient know you are a student May need to spend more time Avoid interpreting your findings Introduction

Scope

of the examination: how complete should it be? Comprehensive? Focused? General Principle: new patient warrants a complete physical examination, regardless of the chief complaint or setting

Introduction

On

Choosing the exam sequence, position and handedness Head to toe (cephalocaudal) •Not from feet, genitalia or rectum to face or mouth •Not from rectum to vagina Examine from the patients right side Sitting, supine patient depending on the area examined Introduction

Adjusting lighting and environment Adjust

the bed the patient to move toward you Tangential lighting for examination of JVP, thyroid gland, apical impulse Ask

Introduction

Promoting the patient’s comfort Show

concern for privacy and comfort Draping the patient: visualize one area of the body at a time Introduction

Hand washing ! ! ! ! ! Introduction Overview of a comprehensive examination General survey Vital signs Skin Head Eyes Ears Nose and sinuses Mouth and pharynx Neck Back Posterior thorax and lungs Breast, axilla and epitrochlear nodes

3 Musculoskeletal system Breasts Anterior thorax and lungs Cardiovascular system Abdomen Rectal examination in men Genitalia and rectal examination in women Legs Neurological examination Mental status  

General Survey Psyche / mental status Apparent state of health Signs of distress Position and posture Movement and paralysis / paresis Gait

Speech Nutritional status Development and stature Temperature Facies Skin General Survey – Psyche / Mental State Degree of consciousness or awareness of a patient to his environment Mood •Anxious •Apathetic •Depressed •Elation •Hostility •Withdrawn Intellect – dull or intelligent Orientation – time, place and person General Survey – Psyche / Mental State Levels of consciousness Coma •Deepest stage, unarousable •Semi-coma – positive response to pinprick Stupor •Marked reduction in mental and physical activity •Sleeping but arousable Delirium

•Confused state with agitation and hallucination Confusion •Mental slowness, inattentiveness •Incoherence in thinking General Survey – Psyche / Mental State General Survey – Psyche / Mental State Examples of disturbances in orientation and emotional states Korsakoff’s syndrome •Disorientation state in chronic alcoholism Grave’s disease (hyperthyroidism) •Mentally quick, unusually alert Myxedema (hypothyroidism) •Alligator look – dull, apathetic, lack of intelligence, swollen face, heavy eyes Catatonia •Statue like, in psychiatric patient General Survey – Apparent State of Health

Judging from the general appearance of the patient In good health Acutely ill / Chronically ill Frail / robust General Survey – Cardiac / Respiratory Distress Types Dyspnea Orthopnea Tachypnea – increase RR Bradypnea Hyperpnea – increase RR and depth Severity

Mild Moderate Severe  

Pain, anxiety or depression

General Survey – Position and Posture

One

holds the body while sitting and standing

Height and build Unusually

short or tall or muscular Body symmetry Look for deformities Slender

General Survey – Position and Posture

4

May reflect an underlying disease Scoliosis

•Abnormal curvature of the spine Lordosis

•Exaggerated anterior curvature Kyphosis

•Exaggerated posterior curvature General Survey – Position and Posture

Certain position  diagnostic clues Pneumonia

or pleuritis – lying on affected side Gall bladder stone – doubling up Cardiac failure – sleeps with head on the forearm Asthmatic / pulmonary edema – sits upright Meningitis – opisthotonus General Survey – Movement and Paralysis Fasciculations Visible twitching movement of a muscle bundle Tremors Involuntary rhythmic tremulous movements of an extremity Intention; at rest; postural Tics Repetitive twitching of small muscle bundles often on face and upper trunk Chorea Rapid, jerky, irregular, unpredictable, involuntary movement of face, extremities or trunk Athetosis Slower, more twisting than chorea Asterexis Positive jerky alterations of flexion and extension at the wrist and interphalangeal joints General Survey - Gait Manner in which a person walks Hemiplegia

1 arm is flexed close to side and immobile; toes dragged Footdrop / enturned / stiffage Like a horse; feet lifted high with knees flexed  brought down violently Gait of sensory ataxia / tabetic 

Wide base gait; patient watches the ground Parkinsonian gait Short shuffling steps Scissors gait Thigh cross forward with each other Waddling gait Pregnant walk 

General Survey - Speech Aphasia / dysphasia - cortical speech center damaged Aphasia – loss of production/comprehension of spoken/written language Dysphasia – error in choice of words Dysarthria Can understand and talks well but has difficulty in articulation Cerebellar dysarthria Poor in comprehension; irregular speech Aphonia / dysphonia – disease of larynx Aphonia – loss of speech Dysphonia – raspy voice Palatal paralysis Nasal speech Parkinsonism Monotonous weak voice Infantilism High pitched voice Hypothyroid Monotonous, halting speech General Survey Configuration

–

Habitus

/

Body

Asthenic (ectomorph) Sthenic (medomorph) Hypersthenic (endomorph) General Survey – Nutritional Status

Types Emaciated Poorly

nourished nourished Well nourished Obese Fairly

General Survey - Development Size and proportion of the general body structure Well developed

5 Fairly developed Poorly developed

 

Giants Acromegalic giants



•Large head, prominent jaw, massive head and feet, large nose Infantile giants •Abnormally large stature retarded sexual development

with

General Survey - Development Dwarves Ateliotic dwarves •Small adults, proportionate Achondroplastic dwarves •Abnormally short, normal size head and trunks Cretin •Short, stocky, mentally retarded, thick lips and tongue, protruding tongue, widest eyes, pale and coarse skin Progeria •Small old man, stunted growth Mitral dwarfism •Patient with congenital heart Renal dwarfism General Survey - Temperature

Normal values Oral:

36.4 – 37.2 degree Celsius 0.3 to 0.5 higher than oral Axillary: 0.3 lower than oral Rectal:

General Survey - Temperature Types of fever Continuous or plateau •Temperature remains consistently elevated Intermittent fever •Elevated temporarily at times but return to normal or subnormal Remittent •Rise and fall but never return to normal Relapsing or Pel-Ebstein •Short febrile periods are interspersed by one or more days of normal temperature Low grade afternoon fever •Usually no higher than 0.5 – 1.0 degree C Tertian fever

•Rise of temp every 3 days, a form of intermittent fever General Survey - Facies Myxedema Hypothyroidism; puffy face, swollen eyelids, dull look, coarse and dry skin Hippocratic facie Face of impending death Nephrotic facie Pale face; edema of lids Cardiac Cyanosis of lips, flaring of alaque nasi Facie of superior vena cava syndrome Duskiness of face, marked prominence of neck veins General Survey - Facies Parkinsonian facie Expressionless Risus sardonicus Sustained exaggerated smile Leonine facie Flattening of the nose, thickened forehead and cheeks Moon facie Round face, (+) acne, hirsutism Thyrotoxic facie Startled look with widened palpebral fissures General Survey - Skin

Temperature Texture Moisture Turgor Color Lesions Vital Signs

Blood pressure Heart rate and rhythm Respiratory rate and rhythm Temperature Skin / Integumentary - Color

Color Increased/loss Pallor

Cyanosis

pigmentation

6 Yellowing/jaundice

Skin / Integumentary - Color Variations in color Brown •Pregnancy Bronze •Hemochromatosis Blue •Heart or lung disease Red •Sunburn, fever, blushing Yellow •Jaundice – liver disease •Carotenemia – increase intake of carrots •Chronic uremic / renal failure – chronic renal failure Decreased color •Albinism •Vetiligo •Tinea versicolor Skin / Integumentary - Moisture

Moisture Dryness Sweating oiliness

Skin / Integumentary – Temperature and Texture

Temperature Use

the back of your fingers temp of any red areas

Note

•Patch – larger than 1 cm; measles rash •Erythema macules

of

red

Skin / Integumentary - Lesions Circumscribed superficial elevation of skin by free fluid on a cavity within skin lesions •Vesicle – up to 1 cm; filled with serous fluid; chicken pox •Bulla – greater than 1 cm; filled with serous fluid; secondary burn •Pustule – filled with pus; acne Skin / Integumentary - Lesions

Secondary of skin surface

•Erosion – loss of surface epidermis; smoothness

Skin / Integumentary – Mobility and Turgor

Mobility and Turgor Lift

confluence

Skin / Integumentary - Lesions Circumscribed; palpable, elevated solid mass •Papule – up to 1 cm; wart, pimple •Plaque – larger than 1cm, often coalescence of papule; neurodermatitis •Nodules – firmer than papule, up to 1 cm, solid; xanthomas •Tumors – larger than 1 cm, depth may be above or beneath skin surface •Weal – papule that is edematous; insect bite

Loss

Texture Roughness/

–

a fold of skin and note the ease with which it lifts up (mobility) and the speed with which it returns into place (turgor) •Decreased mobility in edema •Decreased turgor in dehydration Skin / Integumentary - Lesions Primary Circumscribed; flat; non-palpable •Macule – up to 1cm in diameter; freckles

moist area after rupture of a vesicle •Ulcer – deeper loss of skin surface; may bleed and scar; pressure ulcer •Fissure – linear crack in the skin; athlete’s foot Skin / Integumentary - Lesions

Secondary Materials

on skin surface

•Crust – dried residue of serum, pus or blood; impetigo •Scale – thin flake epidermis; dandruff

of

exfoliated

Skin / Integumentary - Lesions Secondary Miscellaneous

7 •Lichenification

– thickening and roughening of the skin with increased visibility of the skin furrows; atopic dermatitis •Atrophy - thinning of the skin with loss of the normal skin furrows; arterial insufficiency •Excoriation - scratch marks / abrasions •Scar – replacement of damaged tissue by fibrous tissue •Keloid – hypertrophoid scar Skin / Integumentary - Lesions Under the skin / subcutaneous Petechiae – deposit of blood <2mm; pinpoint Purpura – bigger; several mm 1cm Ecchymosis – larger hemorrhagic area larger than 1 cm Herpes zoster – linear, along course of nerves, painful Angular lesions – in ringworms Clusters – herpes simplex

Spoon nails – concave; iron deficient anemia Beause lines – transverse depression in the nail; acute severe illness Onycosis – separation of nail from nail bed; in infection, trauma, malnutrition Paronichia – inflammation of skin around the nails Skin / Integumentary - Nails –

To describe tumors Size

of mass

Shape

Texture

or consistency

Mobility

Tenderness Temperature Location

Head and Neck / ENT

Hair

– quantity, texture, distribution, pattern of hair loss, lice, baldness Fine hair – hyperthyroidism Coarse hair – hypothyroidism Dandruff / flaking of hair

Scalp

– presence of flakes, scales; tenderness and lumps Scaling – psoriasis Dandruff

Skull

Cardiac disease – clubbing of fingers (convex)

hemorrhage bacterial endocarditis

Skin / Integumentary - Tumors

Head and Neck / ENT

Skin / Integumentary - Nails Color / Shape / Lesions

Splinter

Blue nails – Wilson’s nail

subacute

White nails – alcoholic cirrhosis Yellow nails – hemochromatosis

Large

skull

•hydrocephalus Small

skull •microcephalus Pagett’s disease •protrusion of frontal bones Head and Neck / ENT Ear Auricle •Shape – Darwin’s tubercle – extension of the rim upward •Skin color – Tophi – nontender, whitish nodule •Tug test (move up and down)  pain  otitis externa External canal •Note any discharge, foreign body, redness, swelling •Mucosa •Foreign bodies •Wax •E.g. otitis externa – swelling and redness of external mucosa

8 Head and Neck / ENT Ear Use an otoscope (upward and backward, slightly away from the head) Drum – pearly gray white •Retracted drum •Serous otitis media – (+)fluid level + bubbles •Exudative otitis – no more luster  reddish •Perforation Head and Neck / ENT Ear Auditory acuity examination •Deafness: conduction and nerve •Weber test – lateralization; normal – both ears; CHL – lateralizes to impaired ear; NHL – lateralizes to the good ear •Rinne test – air conduction versus bone conduction; CHL – BC>AC or BC=AC; NHL – AC>BC •Schwabach’s test – patient versus physician Head and Neck / ENT

Nose Symmetry,

shape and nasal mucosa, septum Inspect anterior and inferior surface of the nose Note for any deformity Note any swelling, bleeding, exudates in nasal mucosa Note any deviation, inflammation and perforation in nasal septum Note for polyps Head and Neck / ENT

Palpate for sinus tenderness Frontal

and maxillary sinuses Head and Neck / ENT Lips / mouth Ask the patient to remove dentures Put on gloves if the patient has suspicious nodules or ulcers Color: cyanotic Lumps, cracking, scaliness

 

Chelitis Chelosis – secondary to vit B complex deficiency  

Mucus retention – cyst; bluish nodules, non-tender, benign Cancer of the lips – ulcerations Primary syphilis – button-like; nontender 

Head and Neck / ENT Lips Fever blisters / cold sores – herpes simplex virus; recurrent vesicular eruptions of lips and surrounding tissues Chancre – button like nodule formation of lips; syphilis Angular cheilitis – fissure at corner of lips due to lack of vitamin B Mucous retention cyst / mucocele – bluish cyst on lips due to clogging of sebaceous glands Peutz-jeghers syndrome – patchy brown discoloration of lips Carcinoma of lips – lower lips; most common form of oral cancer Head and Neck / ENT

Roof of mouth Torus

palatinus

•any protrusions of roof of mouth Thrush

•milk curd – like lesions on hard palate; due to fungal infections (Candida) Head and Neck / ENT Buccal Mucosa The oral mucosa •Color •ulcers Apthous ulcer (cancer sore) •Reddish with whitish center; very tender Fordyce spots •Non-significant yellowish granules Apthous stomatitis •Whitish ulcer surrounded by a reddish area •Painful 

Head and Neck / ENT Gums and teeth Color of gums, normally pink

9 Enlargement, nodules, swelling, growth, teeth deformities, bleeding Gums •Gingivitis – redness, swelling of gum margins •Periodonitis / pyorrhea – inflammation of deeper tissue around the teeth; common cause of tooth loss in adults •Retracted gums •Epulis – non tender nodules •Acute necrotizing gingivitis (Trench mouth / Vincent’s stomatitis) – painful gingivitis characterized by redness, swelling and ulceration of gingival tissue; formation of grayish membrane •Gingival enlargement – gingival tissue appear heaped up and partially cover the teeth Teeth – growth abnormalities, missing teeth, cavities 

Head and Neck / ENT Tongue Ask the patient to out his tongue, inspect for symmetry (test for hypoglossal nerve, CN XII) Inspect sides and undersurface of tongue, note for reddened areas, nodules, ulcers, smoothness, papillae, color, movement Smooth tongue; no papillae



•due top anemia, B12, iron deficiency

Hairy tongue Geographic •with smooth area, prominent area of papillae Scrotal or fissure tongue •may be normal Abnormal hypoglossal CN •deviation to the side; abnormality of the 12th nerve; towards the affected side Varicosities Head and Neck / ENT  

The pharynx Inspect Viral

the uvula, tonsils, pharynx

phryngitis

•Mild, pinkish color; slightly swollen Streptococcal

/ bacterial pharyngitis •Reddish color, markedly swollen, whitish / yellowish exudates on tonsils Diptheria

•Color is very red, very red •Covered with grayish exudates

up to

the uvula Head and Neck / ENT

Neck Inspect

noting symmetry, masses, scars, Thyroid gland enlargement

any

Abnormalities

•Hypothyroidism •Goiter Head and Neck / ENT Visible lymph nodes •Preauricular •Submental •Supraclavicular •Submaxillary •Superficial cervical •Posterior cervical •Deep cervical chain Head and Neck / ENT

Trachea Inspect

for deviation your finger along one side of trachea and note space bet it and sternocleidomastoid. Compare with the other side. Spaces should be symmetric. Head and Neck / ENT Place

Thyroid gland Inspect

Palpate

for enlargement

•Ask the pt to flex neck sl forward •Place the fingers of both hands on the pts neck so your index finger is just below the cricoid cartilage •Ask the patient to sip and swallow •Note the size, shape and consistency and identify nodules and enlargement •If enlarged, listen over the lateral lobes with a stet to detect a bruit heard in hyperthyroidism Eyes

Visual acuity Use

Snellen eye chart patient 20 ft from the chart Test one eye at a time Position

10 E.g.

20/200 ( at 20 ft. the patient can read print that a normal person can read at 200 ft.) Eyes Normal vision

Macular degeneration Eyes Glaucoma

Cataract

Eyes Diabetic retinopathy Eyes Color blindness Red – Green color blindness test

Color blindness Red

– Green color blindness test

•Normal eye will see number 57 •Red-green deficiencies will

see number 35 Eyes Palpebral fissure Opening formed by upper and lower eyelids N size 8-10mm in height; 26-29 mm in length Narrowing •Enophthalmos – congenital anomaly or fracture of orbit  contents push back •Congenitally small microphthalmic eyes •True phimotic narrowing of vertical and horizontal •Ptosis – drooping Horner’s syndrome – small pupils, ptosis, loss of sweating Oculomotor nerve palsy or paralysis – pupillary dilatation, deviation of eyeball laterally and downward, ptosis Myasthenia gravis – depression of upper eyelids

Eyes

Palpebral fissure Widening •Negroid group with shallow bony orbits •Carotid cavernous fistula – forward displacement of eyeball •Orbital mass •Grave’s disease – hyperthyroidism •Pathologically large eye in high myopia •Bupthalmos – secondary to glaucoma Eyes Eyelids Width of palpebral fissure Edema of the eyelids Color Lesions (blepharitis) Adequacy with which the eyelids close

Eyes Eyelids Swelling •Hordeolum or sty •Chalazion Edema •Blepharitis - swelling •Acute glomerulonehpritis •Systemic trichinosis •Angioneurotic edema – due to allergy from drugs / food •Venous obstruction of the cavernous sinus and orbital Inflammatory sequelae •Ectropion – outward turning of eyelid •Entropion – inward turning •Trichiasis – misdirection of eyelashes inward Eyes Conjunctiva Mucus membrane surrounding the inner lid of the cornea •Bulbar – covers anterior surface of the eyeball •Palpebral Color

11 Vascular pattern against the scleral background Look for any nodules or swelling 

Abnormal findings •Discoloration – anemia; jaundice •Chemosis – edematous swelling of bulbar conjunctiva •Petachia – suabacute bacterial endocarditis 

Eyes

Conjunctiva Abnormal

findings

•Subconjunctival

hemorrhage – subconjunctival hemorrahge, whooping cough •Symblepharon – attachment of eyelids to eyeball; trauma, burns •Degenerative changes Pinguencula – yellowish triangular nodule in bulbar conjunctiva on either side of iris Pterygium – fibrovascular wedge of CT in bulbar Eyes

Conjunctiva Abnormal

findings •Xerophthalmia – dry lusterless conjunctiva; due to vitamin A deficiency •Bitot’s spot - shiny gray triangular spot; due to vitamin A deficiency •Conjunctivitis – redness, tenderness, discharges, crusts Eyes Cornea Pigmentation •Arcus (partial) and annulus (complete) senilis – ring around the cornea •Kayser-Fleischer ring – greenish brown ring around cornea; in Wilson’s disease (copper deposits) Ulcerations – trauma, after Herpes zoster Keratitis – inflammation Hurler’s disease (Gargoylism) – ground glass appearance of cornea Eyes Cornea

Dryness of cornea •Sjogren’s syndrome’ severe malnutrition, vitamin A deficiency Dacryo-Adenitis •inflammation of lacrimal gland due to poor health Epiphora •watering of the eye  increase tears Keratomalacia •Softening of cornea due to vitamin A deficiency Keratoconus •Non inflammatory protrusion of center of corneo due to gradual thinning of apex 

Eyes Pupils Normal size – 3 to 5 mm in diameter Pupillary reaction to light Myosis



•Less than 2mm; morphine addiction Mydriasis



•Greater than 6mm; coma, strong

emotions Hippus •Abnormal rhythmic variations in size of pupil Tonic pupil •Unequal size of pupils Eyes Extraocular muscles Ask the patient to follow your finger Make a wide H, lead the patient’s gaze Detects paralysis in EOM Thorax and Lungs

Inspection Chest

wall

•Normal ratio, in cm, of AP to lateral chest wall diameter 5:7 •Types Barrel chest •Equal diameter Pectus carinatum / chicken or pigeon breast •Protrusion of chest / sternum forward together with costal cartilage; greater AP diameter Pectus excavatum / funnel chest

12 •Lesser AP diameter; depression of chest Thorax and Lungs

Inspection Respiratory

pattern depth and regularity of breathing; normal value 12 – 16 cpm, other books 12 – 20 cpm •Types Tachypnea – rapid, shallow breathing; restrictive lung disease hyperpnea / hyperventilation – rapid, deep breathing; exercise, anxiety Bradypnea – slow breathing; coma Kussmaul’s breathing – deep and fast; increase in depth and rate; diabetic ketoacidosis

•Rate,

Thorax and Lungs

Inspection Respiratory

pattern

•Types

Cheyne-Stokes respiration – period of hyperpnea followed by apnea; cerebrovascular stroke Biot’s respiration / ataxic breathing – very irregular breathing; brain damage at the medulla Sighing respiration – hyperventilation syndrome Obstructive breathing increased respiratory rate  patient lacks sufficient time for full expiration 

Thorax and Lungs

Palpation

Thorax and Lungs Auscultation Listen to the breath sounds •Breath sounds usually louder in upper anterior lung field Types of breath sounds •Vesicular breath sounds Produced by air from trachea to alveoli; long on inspiration, short on expiration •Bronchial breath sounds Auscultating near bigger airways; short on inspiration, long on expiration •Bronchiovesicular breath sounds Near on lower part of lung; long on inspiration, short on expiration 

Thorax and Lungs Auscultation Abnormal breath sounds •Rales – noises produced by air passage thru liquid or thru a narrowed tube by edema or spasm Types: •Rale – passage of air with a fluid in a small bronchiole or alveoli •Fine / repitant rales – heard at the terminal end of inspiration •Coarse rales – crackling, bubbling, gurgling, non-continuous sounds •Rhonchus / rhonci – noise from bigger airways (trachea); fluid / exudate in bigger area •Wheeze – piping or whistling sound on air passage thru an obstructed airway Thorax and Lungs

tender areas of observed findings Assessment of chest expansion Assessment of tactile fremitus Thorax and Lungs Percussion Percuss anterior and lateral chest Heart produces an area of dullness

Auscultation

Percussion sounds •Resonance •Hyperresonance •Dullness •Flatness •Tympany

Thorax and Lungs

Identify

Assessment



Abnormal

breath sounds friction rub – grating, crackling, squeaking sound and heard when pleura rub against each other •Hamman’s sign – crunching sound at anterior chest wall and synchronous with heart beat

•Pleural

Auscultation Vocal

resonance

•Pectoriloquy Hear the words itself; consolidation



13 •Bronchophony

Loud but can not hear proper word •Egophony With nasal or bleating quality; fluid effusion Cardiovascular System Inspection Precordium •Rectangular space overlying heart, great vessels and pericardium •Boundaries nd Upper – 2 rib th Lower – 6 rib Left – midclavicular line Right – parasternal line •Apical beat Represents the brief early pulsation of the left ventricle as it moves anteriorly during conrtraction and touches the chest wall th 5 or 4th ICS left MCL Measures less then 2.5 cm Point of maximum impulse 

Cardiovascular System

Inspection Jugular

veins •Measure of the right atrium •Indicator of cardiac function and right heart hemodynamics •Best estimated from the internal jugular vein, usually on the right •Jugular venous pressure - normal pressure 7 – 8cm water Cardiovascular System Inspection Steps for assessing the JVP •Raise the head slightly on a pillow to relax the sternocleidomastoid muscle •Raise the head of the bed at 30º. Turn the patients head slightly away from the side you are inspecting •Use tangential lighting, identify ext jugular vein then find the internal jugular vein •Identify the highest pulsation in the right internal jugular vein •Extend a card horizontally from this point and a centimeter ruler vertically from the sternal angle. This distance above the angle in cm, is the JVP

Cardiovascular System Cardiovascular System

Palpation Pulsation

usually accompanies dilatation or enlargement Carotid

pulsations •Grading of pulses •+4  0 •If 0 pulse – inadequate circulation; thrombosis •Auscultation Bruit – murmurlike sound of a vascular rather than cardiac origin Cardiovascular System

Percussion Estimates

cardiac border

Auscultation Know

your stethoscope! •The diaphragm: better for picking up high pitched sounds of S1 and S2, murmurs of aortic and mitral regurgitation, pericardial friction rubs. •The bell: more sensitive to low pitched sounds of S3 and S4 and the murmur of mitral stenosis Cardiovascular System

Auscultation S1

– closure of mitral valve; loudest at apex S2 – closure of aortic valve; loudest at base S3 – due to ventricular filling in early diastole S4 – due to contraction of LA in late diastole to propel remaining blood to LV Rate

– fast or slow; rhythm – regular or irregular Cardiovascular System

Auscultation Murmurs

•A

musical sound produced by turbulent flow of blood •Normally a laminar flow of blood in BV  velocity of blood flow progressively

14 increase towards center  velocity reaches critical level  turbulence  vibration  murmurs Cardiovascular System Auscultation Murmurs •Characteristics Location Timing Duration Pitch Intensity •Grade I – need to tune in •Grade II – faint but audible •Grade III – loud •Grade IV – loud and with a thrill, fully placed diaphragm •Grade V – loud and with a thrill, partially placed diaphragm •Grade VI – thrill, diaphragm is away Quality – harsh, blowing, rumbling, cresendo, decresendo, or cresendodecresendo Cardiovascular System Types of murmurs Midsystolic murmurs •Innocent murmurs •Physiologic murmurs •Pathologic murmurs Pulmonic stenosis Aortic stenosis Hypertrophic cardiomyopathy

Types of murmurs

Pansystolic (Holosystolic) murmurs •Mitral regurgitation •Tricuspid regurgitation •Vetricular septal defect Diastolic murmurs •Aortic regurgitation •Mitral stenosis 

Breast and Axilla Female – lies between the 2nd and 6th ribs, between sternal edge and midaxillary line Nipple – located centrally, surrounded by areola Parts of breast Tail Upper inner

Lower inner Upper outer Lower outer  

Breast and Axilla Female breasts Inspection •Size and symmetry •Skin color •Nipple Size and shape Direction to which they point Rashes or ulcerations Discharge Breast and Axilla

Palpation Patient

in supine position fingerpads of 2nd, 3rd, 4th fingers Vertical strip pattern •Examine for consistency •Tenderness •Nodules •Conssitency or elasticity •Induration Health Teachings for Breast SelfExamination Breast and Axilla Use

Axilla Inspection

•Presence

of rash, infection and unusual pigmentation Palpation •Feel for presence of enlarged lymph nodes Abdomen Steps for enhancing abdominal exam Patient should have an empty bladder Make the patient comfortable in a supine position Have the patient keep arms at the sides or folded across the chest Ask the patient to point any areas of pain and examine these areas last Warm your hands and stet, avoid long fingernails Approach slowly and avoid quick unexpected movements Distract the patient with conversation or question Abdomen Inspection

15 Skin



Bluish / yellowish blue discoloration around umbilicus due to retro / intraperitoneal bleeding caused by rupture ectopic pregnancy and hemorrhage •Spider angioma / spider nevi Reddish hyperpigmentation of the chest wall; liver cirrhosis •Stria Rupture of the elastic fibers of skin due to overstretching; bluish, pinkish, silvery white •Veins Caput medussae – cluster of dilated vein radiating to umbilicus due to portal hypertension •Presence of nodules •Scars •Rashes and other lesions Abdomen 







Inspection Contour

Grating sound, inflammation of peritoneal surface of an organ •Placental souffle Soft blowing sound due to blood flow to placenta •Fetal heart beats 

•Color •Cullen sign

of the abdomen

•Described as Distended Flat Scaphoid 

Peristaltic

•Muscle rigidity / guarding •Tenderness Direct Rebound / indirect tenderness Murphy’s sign (acute cholecystitis) versus Murphy’s punch sign Ballotment test Abdomen

Palpation



Pulsations

Abdomen Palpation Light palpation •Identify abdominal tenderness, muscular resistance, superficial organs and masses •Fingers together, flat on the abdominal surface, palpate the abdomen with a light, dipping motion •Feel all quadrants

Deep

movements

Abdomen Auscultation Performed first before palpation and percussion Alters bowel sounds Auscultate for •Bowel sounds Increased bowel sounds or decrease / absent bowel sounds Normal 5-34/minute •Systolic bruits Vascular sounds resembling cardiac murmurs •Venous hum Soft, continuous sound, between the umbilicus and xiphoid process

Auscultation •Friction rub

Genitourinary Tract

Kidney tenderness Murphy’s

Abdomen Auscultate

palpation •Required to delineate abdominal masses •Identify masses and note their location, size, shape, consistency, tenderness •Enlargement of different organs Abdomen Percussion Organs and fluids Normal span of the liver dullness •MCL – 6 – 12cm •MSL – 4 – 8cm Tests for fluids in the abdomen •Shifting dullness •Fluid wave test •Puddle sign – up to 20ml

for

punch sign angle tenderness Kidney punch sign Costovertebral

Male Genitalia Inspection

16 Size of penile shaft – as stomach enlarges, shaft decreases Skin: excoriations Glans: ulcers(balanitis), scars, signs of inflammation Look for nits, lice around the base of the penis Prepuce •Phimosis Prepuce cannot be retracted •Paraphimosis Prepuce is stuck at the glans 





Abnormalities

Female Genitalia - Internal

Assess the support of vaginal walls Separate

the labia the patient to strain down Note for bulging of vaginal walls •Cystocele •rectocele Ask

Female Genitalia - Internal

Use speculum Select

a speculum of appropriate size it with warm water

Lubricate



•Infantilism •Virilism •Elephantiasis •Hermaphroditism

Male Genitalia

Penis Palpate

for any abnormality, tenderness, induration Palpation of the shaft may be omitted in young asymptomatic patients If you retract the foreskin, replace it before proceeding on to examine the scrotum Male Genitalia

The scrotum Lift

the scrotum so you can see the posterior surface •Note any swelling, lumps, •Cryptorchidism (undescedned testes) Palpate each testes and note size, shape, consistency, tenderness •Painless nodule raises the possibility of CA Female Genitalia - External Mons pubis: excoriations, red maculopapules suggest pediculosis pubis The labia minora Clitoris Urethral meatus Vaginal opening Inflammation Ulceration Swelling Nodules

Female Genitalia - Internal

The Cervix Normal

cervix may be round, oval or slitlike Pinkish in non pregnant state Note for polyps Mucupurulent discharges Masses Female Genitalia - Internal

Uterus/ovaries Perform

a bimanual exam the uterus: place your hand midway between umbilicus and symphysis pubis •Note for size, shape, consistency, mobility Palpate the ovaries •Note for size, shape, consistency, mobility •Normal ovaries are somewhat tender •Difficult to feel in obese or poorly relaxed patients Female Genitalia Pregnant Woman Inspect Fundic height •Tape measure •Symphisis pubis 12 – 14 wks AOG •Between SP and umbilicus 16 wks AOG •Umbilicus 20 – 22 wks AOG •Xiphoid process 36 wks AOG Palpate

External genitalia



•Bleeding, presenting parts

17 

Anus for hemorrhoids

Anus, Rectum and Prostate

Pregnant Woman

Side-lying position is satisfactory Patient’s buttocks close to the edge

Palpation

of the examining table near you

Abdomen

Flex the patient’s hip and knees, esp

•Mass or organs •Fetal movements

top leg

5 in 10 minutes •Uterine contractility 5 in 10 minutes, moderate

Drape appropriately, adjust light Glove your hands, spread

Pregnant Woman Palpation Abdomen •Leopold’s Maneuvers L1 – fundic grip; part of the fetus in the upper pole L2 – umbilical grip; fetal back L3 – pelvic grip; presenting part L4

Anus, Rectum and Prostate



Pregnant Woman

Bimanual examination Index

and middle finger •Palpate – cervix – position, shape, consistency, regularity, mobility and tenderness •Palpate – uterus – size, shape, consistency and mobility, tenderness and masses •Palpate – each ovary

Rectovaginal Examination Index

finger – vagina; middle finger – rectum •Retroverted uterus Pregnant Woman

Auscultation Fetal

heart beat 120-160 beats per minute

Normal

Anus, Rectum and Prostate

Least popular May cause

discomfort,

embarrassments

Requires Gentleness Slow

the

buttocks apart

movement of the fingers Calm demeanor Explanation

Inspect perianal area Ulcers Inflammation Hemorrhoids Venereal Perianal

warts abscess

Anus, Rectum and Prostate Anus and rectum Palpation •Insert index finger over the anus Observe •Sphincter tone •Tenderness •Induration •Irregularities or nodules •Insert index finger into the rectum Note for •Nodules •Irregularities •Induration •Prostate gland Anus, Rectum and Prostate Male Palpation – prostate gland •Identify the lateral lobes •Median sulcus •Size •Shape •Consistency – rubbery •Nodules or tenderness - nontender Anus, Rectum and Prostate

After the rectal exam… Gently Wipe

withdraw your fingers the patient’s anus, or give him

tissue Note the color of any fecal matter on your glove

18 Anus, Rectum and Prostate Female Follows male except usual position is lithotomy Note for •Cervix •Retroverted uterus •Vaginal tampon •Tumor Peripheral Vascular System

What pulses? Any

artery that can be pressed against the bone and hear the surface of the body E.g. •Radial •Popliteal •Femoral •Carotid •Brachial Peripheral Vascular System

Factors that affect the pulse Normal – 60 – 100 bpm Age Size

of patient

Emotions Physical

activity Sex – increase in female Peripheral Vascular System

Pulses Compare

both sides – a must quality •Size of fullness – height of pulse •Type of wave Upstroke Downstroke Peak •Rhythm – equidistant •Tension •Vessel wall Determine

Peripheral Vascular System

Pulses Abnormal

rate •Pulses frequens Increase pulse rate Causes: Graves; hyperthyroidism •Pulsus rarus Decrease pulse rate

Causes: infectious diseases Peripheral Vascular System Pulses Abnormal wave •Quick pulse – Celer – rapid rise and fall •Slow pulse – Tardus – prolonged rise and fall •Pulses magnus Pulse is big Rise and fall is rapid: pulsus magnus et celer Causes: aortic insufficiency •Pulsus parvus Small pulse Pulsus parvus et tardus Plateau pulse 

Peripheral Vascular System

Pulses Abnormal

rhythm

•Pulsus regularis •Pulsus irregularis Musculoskeletal System

Temporomandibular joint Inspection

and palpation •Inspect for swelling and redness •Palpate for clicking •Range of motion Opening and closing Protrusion and retraction lateral Musculoskeletal System Shoulder Inspection •Shoulder and shoulder girdle •Scapula •Note: swelling, deformity or muscle atrophy or fasciculations Palpation •Top of the shoulder •Lateral aspect of the shoulder •Anterior shoulder •Landmarks: acromion, acromioclavicular joint, coracoid process •ROM: flexion, extension, abduction, adduction, internal and external rotation

19

Musculoskeletal System

Elbow Inspection

and palpation

•Inspect contours of the elbow •Nodules and swelling •Palpate olecranon process

and epicondyles Tenderness in lateral epicondyles – tennis elbow In medial epicondyles – pitcher’s or golfer’s elbow •ROM: flexion and extension; pronation and supination •Deformities Cubitus valgus – carrying angle above 10 degree Cubitus varus – carrying angle below 10 degree Musculoskeletal System

Wrist Inspection

and palpation

•Swelling, tenderness, deformities •Carpal tunnel syndrome – median

nerve Tests: Tinel’s sign and hyperflexion test; Phalen’s test Musculoskeletal System Hand Inspection and palpation – deformities, abscess, nodes Common deformities •Ulnar drift / deviation •Clawhand deformity – median nerve injury •Carpal spasm / obstetrician’s hand – hypocalcemic tetany •Wrist drop – radial nerve palsy •Dupuytren’s contracture – contraction of middle finger •Heberden’s nodes – distal phalanx, osteoarthritis •Haygarth’s nodes – proximal, rheumatoid arthritis Musculoskeletal System Hip and lower extremities Inspection •Measurement of leg length – ASIS to tip of medial malleolus •Abnormalities of gait; list to one side; asymmetry of buttocks; lateral tilting of the pelvis

•ROM: flexion, extension, abduction, adduction, internal and external rotation •Tests Anvil test – (+) pain  early disease of hip joint Thomas sign of lordosis Trendelenburg’s sign – sagging of unsupported buttock •Fractures Posterior and anterior hip dislocation Musculoskeletal System

Knee Inspection

•Deformities,

swelling, atrophy of muscle •Note for position of patella •Genu valgum, genu varum, genu recurvatum •ROM: flexion and extension •Bulge sign – (+) fluid within knee joint •Tests (next slide) Musculoskeletal System •Tests Abduction stress test – (+) partial tear of the medial collateral ligament Adduction stress test – (+) partial tear of the lateral collateral ligament Anterior drawer sign – (+) tear in the ACL Lachman test – ACL tear Posterior drawer sign – (+) isolated PCL tears McMurray test – (+) medial meniscus and lateral meniscus tear Musculoskeletal System

Ankle and foot Ankle

joint – ROM; pitting edema; joint swelling Foot •Inspection Deformities, nodules, swelling, calluses or corns •Palpation Achilles tendon, metatarsophalangeal Musculoskeletal System •Ankle and foot deformities Talipes calcaneovalgus – eversion and dorsiflexion of foot Talipes equinovarus – club foot Pes cavus – high-arched foot

20 Pes palnus – flat foot Hallux valgus – lateral deviation of the great toe Ram’s horn nail – overgrowth of toenail Bunion Podagra – inflammation of 1st MTP joint – gout Musculoskeletal System  

The spine Inspect

the patient’s posture erect position of the head Neck stiffness signals arthritis, muscle strain Lateral deviation of the head suggest torticollis from contraction of the sternocleidomastoid muscle Assess

Musculoskeletal System Drape

the patient to expose the entire back Patient should be standing upright Inspect from the sides to evaluate the spinal curvature Musculoskeletal System

Palpate

the spinous processes of each vertebra dislocation, arthritis

suggests underlying

fracture, infection,

Musculoskeletal System

Flexion:

ask the patient to bend forward to touch the toes Deformity of the thorax on forward bending in scoliosis Musculoskeletal System

Extension:

place your hand on the post superior iliac spine with fingers pointing toward the midline, ask the patient to bend backward as far as possible Decreased spinal mobility in osteoarthritis and ankylosing spondylitis Musculoskeletal System

Lateral bending Stabilize

the patient to lean to both sides as far away as possible •Pain or tenderness especially with radiation to the leg warrants careful neurologic testing for possible cord or nerve root compression Neurological Examination

Test for cerebral function Test for cerebellar function Test for cranial nerves Test for motor system Test for sensory system Test for reflexes Cerebral Function

How patient is able to communicate Intellectual performance Recent

Spine

Tenderness

Ask

the pelvis by placing your hand on the patients hip

and remote memory

•What did you eat this breakfast? •When is you birthday? Capacity

to calculate •100 minus 7 …… •7 x 7 x 7 ….. Orientation as to the 3ps Cerebral Function Intellectual performance Abstract reasoning •Strike while the iron is hot? General information Similarities and differences •Apple, banana, guava •Ball, moon, coin General behavior and mood dresses Cerebral Function

Specific cerebral function test Cortical

sensory interpretation •Patient recognizes or identifies familiar objects in any special senses •Visual, auditory and tactile agnosia Cortical motor interpretation •Apraxia – inability to carry out purposive or skilled movements in the absence of paralysis, motor and sensory impairment Cerebral Function Test for language or speech Aphasia – impairment of understanding or the use of the language

21 •Brocas motor aphasia Anterior branch of middle cerebral artery Telegraphic speech Can get a lot of information across with few words and with use of fingers •Wernikes sensory aphasia Posterior branch of MCA Comprehension problem Talks excessively without any sense •Global aphasia Both sensory and motor Cannot express and understand Cerebral Function

Other disorders of speech Cerebellar

speech disturbance •Jerky, scanning; due to incoordination of the muscles Rhythm disturbance in speech •Poorly coordinated, irregular speech with unnatural separation of syllables Parkinson’s or basal ganglia disease •Monotonous, weak and barely a whisper Cerebral Function

Other disorders of speech Diffuse

brain disease •Difficulty in pronunciation of polysyllabic words Athetosis •Impaired coordination of tongue muscles Nervous individual Nasal speech Cerebellar System Function for synergy, coordination and balance Findings Dystaxia •Difficulty in controlling voluntary movements Dysarthria •Slurred speech due to impaired articulation Hypotonia •Rag-doll posture, floppiness or loose jointed appearance Coordination

Coordination

of muscle movt requires that 4 areas of the nervous system function in an integrated way Motor system, for muscle strength

Cerebellar

system for rhythmic movement and steady posture Vestibular system for balance Sensory system for position sense Cerebellar System

Tests Finger

to nose test of 8 Rapid alternative movement •Adiadochokinesia – inability perform this test Walk in tandem fashion Point to point or heel to shin test Coordination Figure

to

Rapid alternating movements Dysdiadochokinesis:

•one movt cant be followed quickly by

its opposite and movements are slow, irregular and clumsy •Seen in cerebellar disease

Point to point movement Dysmetria:

•finger may initially overshoot its mark but finally reaches it fairly well •In cerebellar disease

Gait Walk

across the room heel to toe Ataxia •Gait that lacks in coordination, with reeling and instability •May be due to cerebellar disease, loss of position sense, intoxication Walk

Romberg test Test

for position sense stands with feet together eyes open then close eyes for 20-30 s In ataxia due to position sense, patient stands fairly well with eyes open but loses balance when eyes are closed In cerebellar ataxia, patient has difficulty standing when standing whether eyes are open or closed Patient

Motor System

Grade of motor strength

22 Draw

stick figure and put grading normal with full resistance 4/5 raise extremity with slight resistance 3/5 can only be raised against gravity 2/5 gross movement but not against gravity 1/5 flicker of movement 0/5 no movement Motor System 5/5

Presence of incoordination Errors

in rate, force, direction, and range of motion

Tests for gait Tests for presence

movements Motor System

of involuntary movements Sensory System Patient’s eyes are closed Primary form of sensation Superficial •Superficial touch •Superficial pain •Superficial temperature Deep •Vibration sense Pallesthesia – sensibility to vibration Pallhyposthesia – diminish vibration sense Pallanesthesia – absence •Position sense The sensory system

Tests for muscle strength

Pain and temperature (spinothalamic

Status of motor system 6

parts

•Muscle strength •Inspection of muscle substance •Testing for muscle tone •Presence of incoordination •Test for gait •Test for presence of involuntary

muscles – arm forward, let patient resist downward pressure of the examiner Shoulder girdle – arms forward, palms upward, maintain position for a few minutes Hand grip – gripping Extensor pollicis and anterior tibialis – walk on toes Motor System

tract

Tests for muscle strength

“does this feel the same as this?”

Deltoid

Gastrocnemius

– walk on heels Quadriceps femoris muscle – rise from squatting position Motor strength, sensory and cerebellar function – stand on one foot, jump in place Abdominal muscles – rise from sitting position without support Motor System

Inspection for muscle substances Atrophy

Fasciculation

Testing for muscle tone Hypertonic Isotonic

Hypotonic

/ spasticity

/ flaccidity Motor System

Position

and sense(posterior columns)

vibration

Light touch (both pathways) Pain

Use a sharp pin Ask the patient:

“is this sharp or

dull”, Analgesia

(absence of pain) Temperature

Omitted if pain sensation is normal Use 2 tubes with hot and cold water Ask the patient to identify whether its hot or cold Light touch

Use

cotton, touch the skin lightly avoiding pressure

Calloused

skin is insensitive Anesthesia is absence sensation Position sense

Grasp the patient’s big toe

relatively of

touch

23

Demonstrate

Chaddock’s sign – scratch lateral malleolus of ankle Motor System

“up” and down” then with the patient’s eyes closed, ask for a response or “up” or “down” Sensory System



Cortical

Hemiplegia

and discriminatory forms of

sensation Stereognosis – eyes closed, place object on patient’s hand  identify, if not astereognosis Number identification – agraphesthesia Point localization Texture discrimination Deep Tendon Reflexes (DTR)

General

principles for eliciting deep reflexes Strike with a sudden blow Desirable point for blow – tendon Muscle should be slightly stretched by the position of the limb or by pressure of the tendon Limb should be relaxed; reinforcement may be used Deep Tendon Reflexes (DTR) Grading Grade 0 absent Grade 1 + hypoactive Grade 2 ++ physiological Grade 3 +++ hyperactive, brisk Grade 4 ++++ markedly hyperactive with transient clonus Grade 5 +++++ markedly hyperactive with sustain clonus Deep Tendon Reflexes (DTR)

Superficial reflexes Upper

abdominal skin reflex Midabdominal skin reflex Lower abdominal skin reflex Cremasteric reflex Superficial anal reflex Deep Tendon Reflexes (DTR) Abnormal reflexes in pyramidal tract disease Babinski’s sign •Dorsiflexion of great toe •Fanning of all toes •Dorsiflexion of ankle •Flexion of hip and knee Oppenheim’s sign – knuckles at shin

Disease – paralysis of ½ of the body Paraplegia – lower half of the body Quadriplegia – all four extremities Monoplegia – one extremity Diplegia – like parts usually lower extremities Cranial Nerves

CN I – olfactory nerve Sense

of smell

Abnormalities

•Anosmia – absence •Hyperosmia •Parosmia – perverted sense of smell •Cacosmia – smelling of unpleasant odors due to decomposition of tissue; expiration •Olfactory hallucination Cranial Nerves CN II – optic nerve Vision Test for visual acuity •Snellen’s chart •20/200 – patient can read print at 20 feet when a normal eye can read at 200 ft Ophthalmoscopic exam •Orange red-reflex •Optic disc •Retinal vessels •Other retinal parts •Macula Cranial Nerves Test for visual fields •Blind right eye – right optic nerve •Bitemporal hemianopsia – optic chiasma •Left homonymous hemianopsia – right optic tract •Homonymous left upper quadrantic – right parietal lesion of optic radiation Cranial Nerves Color blindness •Use Ishihara’s chart •Scotoma – blind spots on visual fields •Achromatism – colorless •Dichromatism – 2 colors only •Monochromatism – 1 color only

24 •Amblyopia – total blindness •Hemeralopia – day blindness •Nyctalopia – night blindness Cranial Nerves CN III – oculomotor For puppilary constriction Most extraocular movements •Levator palpebral muscle – eyelid movement •Medial rectus – towards nasal •Superior rectus – upward •Inferior rectus – downward •Inferior oblique – upward, outward •Superior oblique – downward, outward Diseases •Oculomotor nerve palsy •Ptosis •External ophthalmoplegia Cranial Nerves

CN IV – trochlear Innervates

superior oblique muscle of

the eye Downward and outward Disease •Divergent squint Cranial Nerves CN V – trigeminal Motor – temporal and masseter muscles (jaw clenching); lateral movement of jaw; mastication Sensory – ophthalmic (corneal reflex); maxillary and mandibular Diseases •Trigeminal nerve neuralgia •Tic doloreaux – severe headache secondary to CN V palsy Cranial Nerves

CN VI – abducens Innervates

lateral rectus muscles of the eye – lateral deviation of the eye Disease •Paralytic strabismus or convergent strabismus – cross-eyed Cranial Nerves

CN VII – facial Motor

•Facial movement •Closing of mouth, eyes •Symmetry or asymmetrical Sensory

•Tastes

Disease

•Bell’s palsy Cranial Nerves

CN VIII – auditory / acoustic Hearing

and balance – deafness and tinnitus Vestibular – vertigo •Caloric test Cranial Nerves Cochlea

CN IX – glossopharyngeal Motor

•pharynx; gag reflex Sensory

•Tastes – posterior 1/3 of tongue Cranial Nerves

CN X – vagus Motor

•Palate, pharynx, larynx Sensory

•Pharynx and larynx Tests

for

•Gag reflex; swallowing; voice Cranial Nerves

CN XI – spinal accessory Innervates

sternomastoid muscle – lateral movement of neck; upper portion of trapezius Tests – lifting of shoulder Cranial Nerves CN XII – hypoglossal Innervates tongue movement

Summary

Sensory •CN I, II and VIII Motor •CN III, IV, VI, XI and XII Both •CN V, CN VII, CN IX and CN X Mental Status Examination Presentation Appearance Activity Attitude examiner/examination Attention Orientation Concentration Memory 

toward

25

Speech Thought content and process Mood – feeling tone of the subject

observed Affect – outward behavior Perceptions Intelligence Insight Judgment