Physical ExaminationMarfori, 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. – 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

Objective evidence of a disease as detected by a physical examination

E.g. – high temperature, flushing, marked weight loss

Definition of Terms Syndrome 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

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: good pair of eyes, good lighting

E.g. – color, lesions, pigmentationIntroduction Palpation Examination of the body by the sense of touch

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Supplement inspection

E.g. – fremitus, crepitations, chest expansionIntroduction Auscultation 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 Ask the patient to move toward you Tangential lighting for examination of JVP, thyroid gland, apical impulse

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

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Head Eyes Ears Nose and sinuses Mouth and pharynx Neck Back Posterior thorax and lungs Breast, axilla and epitrochlear nodes

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 personGeneral 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 StateGeneral 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 patientGeneral 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

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Severity Mild Moderate Severe

Pain, anxiety or depressionGeneral Survey – Position and Posture One holds the body while sitting and standing

Height and build Unusually short or tall Slender or muscular Body symmetry Look for deformities

General Survey – Position and Posture 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

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Nasal speech Parkinsonism Monotonous weak voice Infantilism High pitched voice Hypothyroid Monotonous, halting speech

General Survey – Habitus / Body Configuration Asthenic (ectomorph) Sthenic (medomorph) Hypersthenic (endomorph)

General Survey – Nutritional Status Types Emaciated Poorly nourished Fairly nourished Well nourished Obese

General Survey - Development Size and proportion of the general body structure Well developed Fairly developed Poorly developed

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

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 Rectal: 0.3 to 0.5 higher than oral Axillary: 0.3 lower than oral

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 feverGeneral 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

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Round face, (+) acne, hirsutism Thyrotoxic facie Startled look with widened palpebral fissuresGeneral 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 pigmentation Pallor Cyanosis 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 Note temp of any red areas

Texture Roughness/ smoothness

Skin / Integumentary – Mobility and Turgor Mobility and Turgor Lift 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 dehydrationSkin / Integumentary - Lesions Primary Circumscribed; flat; non-palpable• Macule – up to 1cm in diameter; freckles

• Patch – larger than 1 cm; measles rash

• Erythema – confluence of red macules

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

Skin / Integumentary - Lesions Circumscribed superficial elevation of skin by free fluid on a cavity within skin lesions

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• 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 Loss of skin surface• Erosion – loss of surface epidermis; 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 footSkin / Integumentary - Lesions Secondary Materials on skin surface• Crust – dried residue of serum, pus or blood; impetigo• Scale – thin flake of exfoliated epidermis; dandruff

Skin / Integumentary - Lesions Secondary Miscellaneous• 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

Skin / Integumentary - Nails Color / Shape / Lesions

Cardiac disease – clubbing of fingers (convex)

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 Splinter hemorrhage – subacute bacterial endocarditis

White nails – alcoholic cirrhosis

Yellow nails – hemochromatosis

Blue nails – Wilson’s nail

Skin / Integumentary - Tumors 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

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Head and Neck / ENT Skull 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

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 physicianHead 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 sinusesHead 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; non-tender

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

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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

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 VaricositiesHead and Neck / ENT The pharynx Inspect the uvula, tonsils, pharynx

Viral 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, any masses, scars, Thyroid gland enlargement

Abnormalities • Hypothyroidism

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• 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 Place 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 Thyroid gland Inspect for enlargement Palpate• 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 hyperthyroidismEyes Visual acuity Use Snellen eye chart Position patient 20 ft from the chart Test one eye at a time 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 degenerationEyes Glaucoma

CataractEyes Diabetic retinopathyEyes 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 35Eyes 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 fissureWidening• Negroid group with shallow bony orbits• Carotid cavernous fistula – forward displacement of eyeball

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• 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 EyelidsSwelling • 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 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 bulbarEyes 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

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• 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

• Lesser AP diameter; depression of chest

Thorax and Lungs Inspection Respiratory pattern• Rate, 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

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 Identify tender areas Assessment of observed findings Assessment of chest expansion Assessment of tactile fremitusThorax and Lungs Percussion Percuss anterior and lateral chest Heart produces an area of dullness

Percussion sounds• Resonance

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• Hyperresonance• Dullness• Flatness• Tympany

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 Auscultation Abnormal breath sounds• Pleural 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

Thorax and Lungs Auscultation Vocal resonance• Pectoriloquy Hear the words itself; consolidation • Bronchophony Loud but can not hear proper word• Egophony With nasal or bleating quality; fluid effusionCardiovascular System Inspection Precordium • Rectangular space overlying heart, great vessels and pericardium • Boundaries Upper – 2nd rib Lower – 6th 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 5th 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

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• 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 SystemCardiovascular 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 irregularCardiovascular 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 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 cresendo-decresendo

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

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• 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 Use fingerpads of 2nd, 3rd, 4th

fingers Vertical strip pattern• Examine for consistency• Tenderness• Nodules• Conssitency or elasticity• Induration Health Teachings for Breast Self-Examination Breast and Axilla 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 questionAbdomen Inspection Skin• Color• Cullen sign Bluish / yellowish blue discoloration around umbilicus due to retro / intra-peritoneal 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 lesionsAbdomen Inspection Contour of the abdomen• Described as Distended Flat Scaphoid

Pulsations Peristaltic movements

Abdomen Auscultation

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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

Abdomen Auscultation Auscultate for• Friction rub Grating sound, inflammation of peritoneal surface of an organ• Placental souffle Soft blowing sound due to blood flow to placenta• Fetal heart beats

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

• Muscle rigidity / guarding• Tenderness Direct Rebound / indirect tenderness Murphy’s sign (acute cholecystitis) versus Murphy’s punch sign Ballotment test Abdomen Palpation Deep palpation • Required to delineate abdominal masses• Identify masses and note their location, size, shape, consistency, tenderness

• Enlargement of different organsAbdomen 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

Genitourinary Tract Kidney tenderness Murphy’s punch sign Costovertebral angle tenderness Kidney punch sign

Male Genitalia Inspection 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• 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 scrotumMale Genitalia The scrotum

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

Female Genitalia - Internal Use speculum Select a speculum of appropriate size Lubricate it with warm water

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

Palpate 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 patientsFemale 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

External genitalia• Bleeding, presenting parts Anus for hemorrhoids

Pregnant Woman Palpation Abdomen• Mass or organs• Fetal movements 5 in 10 minutes• Uterine contractility 5 in 10 minutes, moderate

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

Pregnant Woman Bimanual examination Index and middle finger

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• 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 uterusPregnant Woman Auscultation Fetal heart beat Normal 120-160 beats per minute

Anus, Rectum and Prostate Least popular May cause discomfort, embarrassments Requires Gentleness Slow movement of the fingers Calm demeanor Explanation

Anus, Rectum and Prostate Side-lying position is satisfactory Patient’s buttocks close to the edge of the examining table near you Flex the patient’s hip and knees, esp top leg Drape appropriately, adjust light Glove your hands, spread the buttocks apart

Anus, Rectum and Prostate Inspect perianal area Ulcers Inflammation Hemorrhoids Venereal warts Perianal 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 - nontenderAnus, Rectum and Prostate After the rectal exam… Gently withdraw your fingers Wipe the patient’s anus, or give him tissue Note the color of any fecal matter on your glove

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

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• Brachial

Peripheral Vascular System Factors that affect the pulse Normal – 60 – 100 bpm Age Size of patient Emotions Physical activity Sex – increase in femalePeripheral Vascular System Pulses Compare both sides – a must Determine quality• Size of fullness – height of pulse• Type of wave Upstroke Downstroke Peak • Rhythm – equidistant• Tension• Vessel wall

Peripheral Vascular System Pulses Abnormal rate• Pulses frequens Increase pulse rate Causes: Graves; hyperthyroidism • Pulsus rarus Decrease pulse rate Causes: infectious diseasesPeripheral 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

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

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Wrist Inspection and palpation • Swelling, tenderness, deformities• Carpal tunnel syndrome – median nerve Tests: Tinel’s sign and hyperflexion test; Phalen’s testMusculoskeletal 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 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 Assess erect position of the head Neck stiffness signals arthritis, muscle strain

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Lateral deviation of the head suggest torticollis from contraction of the sternocleidomastoid muscle

Musculoskeletal System Spine Drape the patient to expose the entire back Patient should be standing upright Inspect from the sides to evaluate the spinal curvatureMusculoskeletal System Palpate the spinous processes of each vertebra Tenderness suggests fracture, dislocation, underlying infection, arthritis

Musculoskeletal System Flexion: ask the patient to bend forward to touch the toes Deformity of the thorax on forward bending in scoliosisMusculoskeletal 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 pelvis by placing your hand on the patients hip Ask 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 compressionNeurological 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 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 3psCerebral 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• 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

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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 whisperCerebral 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 senseCerebellar System Tests Finger to nose test Figure of 8

Rapid alternative movement• Adiadochokinesia – inability to perform this test Walk in tandem fashion Point to point or heel to shin testCoordination 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 Walk heel to toe Ataxia• Gait that lacks in coordination, with reeling and instability• May be due to cerebellar disease, loss of position sense, intoxication

Romberg test Test for position sense Patient 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

Motor System Grade of motor strength Draw stick figure and put grading 5/5 normal with full resistance 4/5 raise extremity with slight resistance

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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 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 movementsMotor System

Tests for muscle strength Deltoid 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 toesMotor System

Tests for muscle strength 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 / spasticity Isotonic Hypotonic / flaccidity Motor System Presence of incoordination Errors in rate, force, direction, and range of motion Tests for gait

Tests for presence 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 senseThe sensory system Pain and temperature (spinothalamic tract Position and vibration sense(posterior columns) Light touch (both pathways)

Pain Use a sharp pin Ask the patient: “is this sharp or dull”, “does this feel the same as this?” 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 coldLight touch Use cotton, touch the skin lightly avoiding pressure Calloused skin is relatively insensitive Anesthesia is absence of touch sensationPosition sense Grasp the patient’s big toe Demonstrate “up” and down” then with the patient’s eyes closed, ask for a response or “up” or “down”Sensory System

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Cortical 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 usedDeep 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

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

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• Scotoma – blind spots on visual fields• Achromatism – colorless• Dichromatism – 2 colors only • Monochromatism – 1 color only• 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 squintCranial 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 palsyCranial Nerves CN VI – abducens Innervates lateral rectus muscles of the eye – lateral deviation of the eye Disease • Paralytic strabismus or convergent strabismus – cross-eyedCranial Nerves CN VII – facial

Motor• Facial movement • Closing of mouth, eyes• Symmetry or asymmetrical Sensory • Tastes Disease • Bell’s palsyCranial Nerves CN VIII – auditory / acoustic Hearing and balance Cochlea – deafness and tinnitus Vestibular – vertigo• Caloric testCranial Nerves CN IX – glossopharyngeal Motor• pharynx; gag reflex Sensory• Tastes – posterior 1/3 of tongueCranial 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 shoulderCranial 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 XMental Status Examination Presentation Appearance Activity

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Attitude toward examiner/examination Attention Orientation Concentration Memory

Speech Thought content and process Mood – feeling tone of the subject observed Affect – outward behavior Perceptions Intelligence Insight Judgment

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