Physical exam 4 (MSK, neuro)

What does general inspection include?

Swelling, positioning, skin changes, atrophy, deformity, guarding, symmetry, fasciculation

What does general palpation include?

Landmarks, tenderness, crepitus, warmth, spasm, bogginess

Shoulder

Purpose: Visually assess for abnormalities of skin or underlying structures

task: inspection

General inspection

Shoulder

Purpose: Assess underlying structures by touch. identify precise location of abnormalities

Task: Palpation

-General palpation

-Palpates bony landmarks: SC joint, clavicle, AC joint, acromion, greater tubercle of humerus, coracoid process.

Shoulder

Purpose: Evaluation of joint mobility

Task: Range of motion (active)

Flexion/extension

Abduction/adduction

internal/external rotation

Verbalizes option to assess passive ROM

Shoulder

Purpose: Assesses for strength deficit, which can be due to neuromuscular, spinal, or peripheral nerve conditions.

Task: Strength

Flexion/extension

Abduction/adduction

Internal/external rotation

Shoulder

Purpose: Detect rotator cuff impingement, weakness, or tear

Task: special testing

Painful arc test

Neer impingement sign

Hawkins impingement sign

Lift off test

Drop arm test

Empty can test

Shoulder

Purpose: AC joint pain or sprain

Task: Special testing

sulcus sign

Shoulder

Purpose: Biceps tendonitis

task: special testing

Yergason's test

Shoulder

purpose: Anterior instability/subluxation

Task: special testing

Apprehension sign

Elbow

Purpose: Visually assess for abnormalities of skin or underlying structures

Task: inspection

General inspection

Elbow

Purpose: Assess underlying structures by touch. identify precise location of abnormalities

Task: Palpation

General palpation

Palpates bony landmarks: Medial epicondyle, lateral epicondyle, olecranon process, radial head

Elbow

Purpose: Evaluation of joint mobility

Task: Range of motion (active)

Flexion/extension

Pronation/supination

Elbow

Purpose: Assesses for strength deficit, which can be due to neuromuscular, spinal, or peripheral nerve conditions.

Task: strength

Flexion/extension

Pronation/supination

Elbow

Purpose: Detect lateral epicondylitis (Tennis elbow)

Task: Special tests

cozen test

lateral collateral stress test

Elbow

Purpose: Detect medial epicondylitis (Golfer's elbow)

Task: Medial collateral stress test

Wrist and hand

Purpose: Visually assess for abnormalities of skin or underlying structures

Task: Inspection

General inspection

Wrist and hand

Purpose: Assess underlying structures by touch. identify precise location of abnormalities.

task: palpation

General palpation

Palpates bony landmarks: Distal radius and ulna, radial styloid, anatomic snuffbox, carpal bones, metacarpal bones, proximal/middle/distal phalanges, wrist joint, MCPs, PIPs

Wrist and hand

Purpose: Evaluation of joint mobility

Task: Range of motion (active)

Flexion/extension of wrist

Radial/ulnar deviation of wrist

Flexion/extension of fingers

Abduction/adduction of fingers

Flexion/extension of thumb

Abduction/adduction of thumb

Opposition of thumb

Wrist and hand

Purpose: Assesses for strength deficit, which can be due to neuromuscular, spinal, or peripheral nerve conditions

Task: Strength

Flexion/extension of wrist

Grip strength

Extension of fingers

Abduction/adduction of fingers and thumb

Abduction/adduction of thumb

Opposition of thumb

Wrist and hand

Prompt: Specific for deQuervain's tenosynovitis

Task: Special test

FInkelstein test

Wrist and hand

Prompt: Provocative maneuvers to detect carpal tunnel syndrome

Task: special tests

Tinel sign

Phalen sign

Vertebral spine

purpose: Visually assess for abnormalities of skin or underlying structures

Task: Inspection

general inspection

Vertebral spine

Purpose: Assess for abnormalities of spine alignment

Task: Palpation

-General palpation

-Palpates bony landmarks: vertebral spinous processes, facet joints, sacroiliac joint, iliac crests, posterior superior iliac spines, lumbrosacral vertebrae for step-offs or slippage

-Palpates soft tissues: Paravertebral muscles

Vertebral spine

purpose: evaluation of joint mobility

Task: Range of motion (active)

-Flexion/extension of neck

-Lateral bending of neck

-rotation of neck

-flexion/extension of lumbar spine

-lateral bending of lumbar spine

-rotation of lumbar spine

Vertebral spine

Purpose: Assess for strength deficit , which can be due to neuromuscular, spinal, or peripheral nerve conditions

Task: Strength

Neck rotation

Vertebral spine

Purpose: detects cervical radiculopathy

Task: Special testing

Spurling test

Vertebral spine

Purpose: Detects lumbrosacral radiculopatho

Task: Special testing

Straight leg raise

Hip

Purpose: Visually assess for abnormalities of skin or underlying structures

Task: Inspection

General inspection

Hip

Purpose: Abnormalities can be signs of neuromuscular disease. Abnormalities also increase risk of sequelae like chronic low back pain.

task: inspection

Gait

symmetry of heights of iliac crests and of leg length

Hip

Purpose: assess underlying structures by touch. identify precise location of abnormalities

task: Palpation

-General palpation

-Palpates bony landmarks: iliac crest, iliac tubercle, ASIS, greater trochanter, pubic tubercle, PSIS, greater trochanter, ischial tuberosity, SI joint

Hip

purpose: Evaluation of joint mobility

task: range of motion (active)

-flexion/extension

-abduction/adduction

-external/internal rotation

Knee

Purpose: Visually assess for abnormalities of skin or underlying structures

Task: inspection

-general inspection

-varus or valgus deformity

Knee

Purpose: Assess underlying structures by touch. identify precise location of abnormalities

Task: Palpation

-General palpation

-palpates bony and soft tissue landmarks: tibiofemoral joint, medial femoral condyle, adductor tubercle, medial tibial plateau, MCL, lateral femoral condyle, lateral tibial plateau, LCL, patella, patella tendon, tibial tuberosity, prepatellar bursa, anserine bursa, popliteal fossa

Knee

purpose: Evaluation of joint mobility

Task: Range of motion (active)

Flexion/extension of knee

Knee

Purpose: Assesses for strength deficit, which can be due to neuromuscular, spinal, or peripheral nerve conditions

task: Strength

-flexion/extension of knee

Knee

Purpose: Meniscal tears

Task: Special tests

McMurray Test

Knee

Purpose: Integrity of MCL

Task: Special test

Valgus test

Knee

Purpose: Integrity of LCL

task: varus test

Knee

Purpose: ACL integrity

Task: Special test

-Anterior drawer test

-Lachman test

Knee

Purpose: PCL integrity

Task: Special test

-Posterior drawer sign

Ankle/foot

purpose: visually assess for abnormalities of skin or underlying structures

task: inspection

-general inspection

Ankle and foot

Task: assess underlying structures by touch. identify precise location of abnormalities

Task: Palpation

-General palpation

-Palpates bony and soft tissue landmarks: medial malleolus, lateral malleolus, calcaneus, achilles, plantar surface of foot, heads of metatarsals, metatarsophalangeal joints, proximal interphalangeal joints, distal interphalangeal joints.

Ankle and foot

Purpose: Evaluation of joint mobility

Task: range of motion (active)

-ankle/foot: Dorsiflexion, plantarflexion, inversion, eversion

-Toes: flexion, extension, abduction, adduction

Ankle/foot

purpose: assess for strength deficit, which can be due to neuromuscular, spinal, or peripheral nerve conditions

Task: strength

-dorsiflexion, plantarflecion

Ankle and foot

Purpose: Anterior talofibular ligament integrity

task: special test

-anterior drawer test of ankle

Ankle and foot

Purpose: achilles tendon integrity

task: special tests

-Thompson test

Ankle and foot

Purpose: transverse tarsal joint integrity

task: inversion/eversion test of the midfoot

Neuro

Purpose: Assesses cognitive function

Task: Mental status

-Determines LOC

-Determines orientation to person, place, time, event

Neuro

Purpose: Cranial nerve exam assesses integrity of neurologic function in brainstem and cranial nerves can help localize pathology.

Cranial nerve 1

Task: CN I - Olfactory (s)

Assesses smell

Neuro

Purpose: Cranial nerve exam assesses integrity of neurologic function in brainstem and cranial nerves can help localize pathology.

Cranial nerve II

Task: CNII - Optic (s)

-Tests visual acuity with snellen or rosenbaum chart

-Fundoscopic exam

-Visual fields by confrontation

Neuro

Purpose: Cranial nerve exam assesses integrity of neurologic function in brainstem and cranial nerves can help localize pathology.

Cranial nerve III, IV, VI

Task: CN III, IV, VI - Occulomotor, trochlear, and abducens (M&S)

Assess pupils

-Size and shape bilaterally

-Reaction to light, direct and consensual

-Accomodation reaction

Extraocular movements

-Has pt follow finger with eyes, head still, in a slow H

-H pattern brings pt's eyes to extreme fields of gaze

-Assesses for ptosis of upper eyelid

Neuro

Purpose: Cranial nerve exam assesses integrity of neurologic function in brainstem and cranial nerves can help localize pathology.

Cranial nerve V

Task: CN V - Trigeminal (M&S)

Assesses strength of temporal and masseter muscles

-Clench teeth

-move jaw side to side

Assesses sensation bilaterally

-uses light touch to assess ophthalmic, maxillary, and mandibular distributions

-tests corneal reflex bilaterally from outside visual field.

Neuro

Purpose: Cranial nerve exam assesses integrity of neurologic function in brainstem and cranial nerves can help localize pathology.

Cranial nerve VII

Task: CN VII - Facial (M&S)

Assesses facial symmetry and movements

-Raise both eyebrows

-Frown/smile

-Close both eyes tightly

-show upper and lower teeth

-puff out cheeks

Neuro

Purpose: Cranial nerve exam assesses integrity of neurologic function in brainstem and cranial nerves can help localize pathology.

Cranial nerve VIII

Task: CN VIII - Vestibulocochlear (S)

Assesses auditory acuity with whispered voice test (occlude ear not being tested, lips are not visible)

Neuro

Purpose: Cranial nerve exam assesses integrity of neurologic function in brainstem and cranial nerves can help localize pathology.

Cranial nerve IX, X

Task: CN IX, X - Glossopharyngeal, Vagus (M&S)

Notes voice quality. Evaluates for hoarseness

Using good lighting source, visualizes movement of soft palate and pharynx on phonation of "ah" sound.

Stimulates gag reflex (may verbalize)

Neuro

Purpose: Cranial nerve exam assesses integrity of neurologic function in brainstem and cranial nerves can help localize pathology.

Cranial nerve XI

Task: CN XI - Spinal accessory (M&S)

Assess trapezii and sternocleidomastoids strength against resistance

-shoulder shrug

-turn head against resistance

Neuro

Purpose: Cranial nerve exam assesses integrity of neurologic function in brainstem and cranial nerves can help localize pathology.

Cranial nerve XII

Task: CN XII - Hypoglossal (M&S)

Assess tongue motions

-Has pt open mouth. observes for movements of tongue at rest.

-Has pt stick tongue out straight and move tongue from side to side.

Neuro

Purpose: Detects gait abnormalities and postural instability. May indicate nerve damage, MSK pathology, or vestibular dysfunction.

Task: Coordination, Gait, Cerebellar, and other tests

Asks pt to walk across the room, noting balance, posture, swinging of arms, and leg movements.

Neuro

Purpose: Increases the difficulty of walking to detect subtle balance impairments.

Task: Coordination, Gait, Cerebellar, and other tests

Asks pt to tandem walk

Neuro

Purpose: Assesses gastroc/soleus strength and integrity of S1 nerve root

Task: Coordination, Gait, Cerebellar, and other tests

Asks pt to toe walk

Neuro

Purpose: Assesses anterior tibialis strength and integrity of L5 nerve root

Task: Coordination, Gait, Cerebellar, and other tests

Asks pt to heel walk

Neuro

Purpose: Cerebellar function

Task: Coordination, Gait, Cerebellar, and other tests

-Hand flip

-Finger to nose

-Hell down shin

Neuro

Purpose: Detects proprioceptive and/or vestibular deficit

Task: Romberg

Neuro

Purpose: Cortocospinal tract lesion (e.g. stroke)

Task: Coordination, Gait, Cerebellar, and other tests

Pronator drift

Neuro

Purpose: Sharp, dull, and temperature sensation test different afferent neural pathways and small fibers

Task: Sensory

Assesses for pain sensation by scattering sharp and dull stimuli across ankle at medial malleolus (L4), medial aspect of dorsum of foot (L5), lateral malleolus and fifth toe (S1) and plantar surface of foot (L4, L5, S1)

-Compares pain sensation bilaterally

Performs temperature sensation testing if pain sensation is abnormal

Neuro

Purpose: Light touch sensation tests a separate afferent neural pathway and large fibers.

Task: Sensation

Assesses for light touch with a cotton wisp over medial malleolus, medial aspect of dorsum of foot, lateral malleolus, and fifth toe.

-compares light touch sensation bilaterally.

Neuro

Purpose: Loss of vibratory sensation is an early sign of diabetic neuropathy.

Task: Sensory

Assesses for vibratory sensation over interphalangeal joint of the big toe.

Neuro

Purpose: Impaired proprioception increases risk of falls due to gait and postural instability.

Task: Sensory

Assesses proprioception

-Grasps sides of big toe and demonstrate up and down position

-moves the toe into a position and asks pt to identify position of big toe

Neuro

Purpose: Tests ability of sensory and association cortices to analyze and interpret sensory input

Purpose: Discriminative sensation

Assesses stereognosis

Assesses graphesthesia

Neuro

Purpose: Check for integrity of motor system. provides information about upper and lower motor neurons.

task: reflexes

assesses deep tendon reflexes bilaterally with pt relaxed using same force

-Biceps (C5-6)

-Triceps (C6-7)

-Brachioradialis (C5-6)

-Knees (L2-L4)

-Ankles (s1)

Assesses abdominal reflexes

-T8-10 above umbilicus

-T10-12 below umbilicus

Assesses Babinski/plantar response (L5, S1)

Neuro

Purpose: Clonus indicates 4+ DTR

Task: Reflexes

Assesses for clonus bilateral foot

Neuro

Purpose: These tests have high specificity and low sensitivity for meningeal irritation

Task: Meningeal signs

Nuchal rigidity

Brudzinski sign

Kernig sign