Spine & Extremities / Abdomen / Neurologic Exam

GENERAL SURVEY o Report; no, noted abdominal and renal

artery bruit.
Check for
Consciousness, coherence, attitude, nutritional PALPATION
and developmental status. Inquire for any presence of abdominal pain, and
Gross deformities, posture and gait, if there is locate the areas of discomfort by;
ambulatory/non ambulatory o Taking a rapid and deep inspiration,
Febrile non febrile coughing. And areas with discomfort
Cardiac or respiratory distress should be examined last.
Stand on the right side of the patient.
Vital Signs
BP Light Palpation
CR Start from the lower quadrant working upward
RR by pressing the abdomen to a depth of about
Temperature 1cm.
Report; upon doing light palpation there is no
Skin noted tenderness and superficial mass.
Color, texture, temperature, moisture
Mobility, turgor and elasticity Deep palpation
Skin lesions (describe type, distribution) Do a Deep palpation, pushing down 5-8cm (2-
Hair, nails 3in). Same technique as light palpation.
Report; No noted tenderness and no noted deep
ABDOMEN mass upon palpation of the 9 quadrants

Ask for the patient’s name. Palpate for liver, instruct the patient to breathe
Introduce yourself, orient the patient on what are deeply
you going to do. (examine his Abdomen)
Ask the patient to lie down on the bed.
Flex the patient’s knee
Raise the patient’s shirt, enough to expose the
abdomen
Position of examiner (right side of patient).

INSPECTION
Get the Abdominal circumference at the level of
umbilicus, then report. o Report; liver edge is palpable1 cm
Report; Abdomen is flat, no striations, no below the subcostal margin, smooth
prominent veins, no discoloration, no visible consistency, with no nodules and sharp
pulsation and peristalsis. Umbilicus is inverted upon palpation.
with no noted calculi, and Abdomen is
symmetrical. Palpate for the left and right kidneys.

AUSCULATION
Auscultate for the Bowel sounds on the RLQ.
Report;
o Normoactive Bowel Sound
Soft or loud/low pitch
5-30/min occurs every 5-15
seconds
o Hyperactive bowel sounds
>30 or (+) BS every 2 seconds o Report; kidneys are not palpable.
Continous and loud
o Hypoactive bowel sounds
5/min- soft
Check for Bruit of Abdominal Aorta and Renal
Artery

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 Spine & Extremities / Abdomen / Neurologic Exam
Palpation on spleen Test for appendicitis
o Rovsing’s Sign (rebound tenderness)
o Merkle Sign or Jar tenderness
o Obturator Sign

o Report; spleen is not palpable.

PERCUSSION o Psoas sign

Percuss the 9 quadrants.
Report; general tymphanism is noted upon
percussion of the 9 quadrants.

Measuring of the liver span

Begin percussion at RLQ-MCL, percuss upward
till area of dullness is heard (lower boarder of
liver and mark it). From ICS-MCL area of
resonance percuss downward to area of dullness
(upper border of liver and mark)
Test for ascites;
o Fluid wave

Report; patient is negative for

fluid wave
Measure the two markings. 6-12cm (normal
o Shifting dullness
liver span)

Percussion of the Traube’s Space

Landmarks;
Superior border – 6th ICS
Lateral border – Left axillary line
Inferior – left costal margin
Report; general tymphanism is
Report; general tymphanism is noted upon
heard and patient is negative for
percussion of the traube’s space.
shifting dullness.
Kidney punch test.
SPECIAL TEST
Test for cholecystitis –
MURPHY SIGN (+) if with inspiratory arrest

o Report; patient is negative for kidney

punch test.

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 Spine & Extremities / Abdomen / Neurologic Exam
EXTREMITIES AND SPINE Upper Arm
Inspection
Ask for the patient’s name. No noted deformities, bulging, depression upon
Introduce yourself, orient the patient on what are inspection of the upper arm
you going to do.(examine his spine and Palpation
extremities) No noted tenderness, mass, nodules upon
palpation of the upper arm
Metacarpophalangeal joints
Inspection Shoulder joints
No noted deformities, bulging, depression upon Inspection
inspection of the hands No depression, bulging, gross deformities,
Palpation shoulder joints are symmetrical on both sides.
No noted tenderness, mass, nodules upon
palpation of the metacarpophalangeal joints Palpation (4 Landmarks)
ROM 1. Acromion process
Patient able to perform full range of motion of 2. Coracoids process
the hands as to pronation, supination, flexion, 3. Greater tuberosity of humerus
extension, abduction, adduction, and opposition 4. Scapula
of the thumb without difficulty. No noted tenderness, mass, nodules upon
palpation of the four landmarks of shoulder
Forearm ROM
Inspection Patient able to perform full range of motion of
No noted deformities, bulging, depression upon the shoulder as to flexion, extension, adduction,
inspection of the forearm abduction, internal and external rotation without
Palpation (2 Landmarks) difficulty
1. Radial prominence
2. Ulnar prominence Spine
No noted tenderness, mass, nodules upon Inspection
palpation of the of the two landmarks of radius “On the lateral aspect of the body”
and ulna o Note for excessive curvatures of the
ROM spine
Patient able to perform full range of motion as to Ask the patient to bend over
pronation, supination without difficulty. o Note for any deviation of the spine
Palpation
Elbow Joint Ask the patient to bend the neck
Inspection o Palpate the C7, and note for any
No noted deformities, bulging, depression upon tenderness
inspection of the elbow joint; both joints are Palpate for the paravertebral muscles and note
symmetrical for any, tenderness, mass, nodules and spasm.
Palpation (3 Landmarks) ROM
1. Lateral epicondyle Patient able to perform full range of motion of
2. Medial epicondyle the spine as to (neck) flexion, extension, chin to
3. Olecranon process shoulder (lateral rotation), ear to shoulder
No noted tenderness, mass, nodules upon (lateral bending).
palpation of the of the three landmarks
ROM Hip Joint
Patient able to perform full range of motion as to Inspection
Flexion, extension (humeroulnar joint). “Ask the patient to walk:
pronation, supination (humeroradial joint) o Patient have normal gait
without difficulty.
Palpation ( 4 Landmarks with only one palpable)
Measure the muscle circumference at symmetrical 1. Iliac crest
points above and below elbow joint and report. Iliac crest is palpable, no noted tenderness,
mass, nodule upon palpation

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 Spine & Extremities / Abdomen / Neurologic Exam
ROM Palpation ( 2 Landmarks)
Patient able to perform full range of motion of 1. Lateral condyle
the hip joint as to flexion, extension, adduction, 2. Medial condyle
abduction, internal and external rotation. No noted tenderness, and crepitus upon
SPECIAL TEST palpation of the of the two landmarks
Lasegue’s test/Straight leg raising test Palpate for any cyst
o There is no cyst on the anterior part of
the knee and popliteal area
ROM
Patient able to perform full range of motion of
the knee joint as to flexion, extension

Measure the muscle circumference at symmetrical

points above and below knee joint and report.

Patrick’s test Ankle Joint and Foot

Inspection
no noted atrophy, bulging depression upon
inspection of the foot, no toe abnormalities, no
deformities, no cutaneous abnormalities

Palpation (2 Landmarks)
1. Lateral malleolus
2. Medial malleolus
No noted tenderness, mass,nodules upon
palpation of the of the two landmarks
No noted tenderness, mass,nodules upon
palpation of the of thedorsal and plantar surface
Anvil test (no picture available) ROM
o Straighten the leg of the patient and Patient able to perform full range of motion of
strike the calcaneus the ankle as to dorsi flexion, plantar flexion,
Trendelenburg’s test eversion and inversion.

MAESURE THE LENGTH OF THE LIMBS

From asis to the medial malleolus. Then report

Knee Joint
Inspection
No depression, bulging, gross deformities, knee
joints are symmetrical on both sides.

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 Spine & Extremities / Abdomen / Neurologic Exam
NEUROLOGIC EXAMINATION The patient should then close both eyes. Occlude
Ask for the patient’s name. one nostril and test smell in the other with such
Introduce yourself, orient the patient on what are substances as cloves, coffee, soap, or vanilla.
Ask if the patient smells anything and, if so,
you going to do. (you will perform his
what. Test the other side. A person should
neurological exam) normally perceive odor on each side, and can
often identify it.
Instruct the patient to answer all your questions, and
obey your commands; Cranial Nerve II—Optic.
Q; Alam nyo po ba kung nasaan kayo? Visual acuity of each eye.
A: Confrontation test for peripheral visual field
testing
Q: Alam nyo po ba kung umaga, tanghali o gabi
ngayon? Cranial Nerves II and III—Optic and Oculomotor.
A: Inspect the size and shape of the pupils
Q: Sino ang Pangulo ng Pilipinas? Compare one side with the other.
A: Test the pupillary reactions to light; if these are
Q: Sino ang pambansang bayani? abnormal, examine the near response also.
A:
Q: Kung kayo ay may P10, at namasahe sa dyip ng P7.
Magkano nalang ang inyong sukli?
A:
Q; Halimbawa po kayo ay nagluluto, at biglang may Cranial Nerves III, IV, and VI—Oculomotor,
sunog, ano ang inyong gagawin? Trochlear, and Abducens
A: Test the extraocular movements in the six
cardinal directions of gaze, and look for loss of
conjugate movements in any of the six
Paki sunod lang po ang aking mga ipapagawa sa inyo;
directions.
Ituro nyo sakin ang kisame, higaan, upuan, Check convergence of the eyes. Identify any
sahig. nystagmus, noting the direction of gaze in which
Gamit ang inyong kanang kamay, paki kuha ang it appears, the plane in which movements occur
hawak kong gamit. (horizontal, vertical, rotary, or mixed), and the
Gamit naman ang inyong kaliwang kamay, ito direction of the quick and slow components.
Report; EOM are intact
ay ibalik sakin
Paki ulit po ang 3 bagay na aking sasabihin, Cranial Nerve V—Trigeminal
pagkayari ko itong sabihin “ilaw, kwarto at Motor.
kama” While palpating the temporal and masseter
Sabi sa kasabihan “kung may tyaga, merong muscles in turn
nilaga” ano po ang pagkakaintindi nyo ditto? Ask the patient to clench his or her teeth. Note
the strength of muscle contraction.
Ano na nga po yung tatlong bagay kong sinabi Sensory.
sa inyo? After explaining what you plan to do, test the
Report; forehead, cheeks, and jaw on each side for pain
Patient is conscious, coherent, oriented to time sensation.
space and person. Suggested areas are indicated by the circles.
Has audible voice, no dysarthria.
Patient can even follow simple and complex
command.
Can perform simple calculations.
Have good judgment, general knowledge and
abstract thinking.

Cranial Nerves Examination

The patient’s eyes should be closed.
Cranial Nerve I—Olfactory. o Use a safety pin or other suitable sharp
Test the sense of smell by presenting the patient object,* occasionally substituting the
with familiar and nonirritating odors. blunt end for the point as a stimulus.
First be sure that each nasal passage is open by Ask the patient to report whether it is
compressing one side of the nose and asking the “sharp” or “dull” and to compare sides.
patient to sniff through the other.

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 Spine & Extremities / Abdomen / Neurologic Exam
Cranial Nerve VII—Facial. midline, and each side of the posterior
Motor pharynx moves medially, like a curtain.
Inspect the face, both at rest and during The slightly curved uvula seen
conversation with the patient. Note any occasionally in a normal person should
asymmetry (e.g., of the nasolabial folds), and not be mistaken for a uvula deviated by
observe any tics or other abnormal movements. a 10th nerve lesion
Ask the patient to: Gag Reflex
o Raise both eyebrows. Warn the patient that you are going to test the
o Frown. gag reflex.
o Close both eyes tightly so that you Stimulate the back of the throat lightly on each
cannot open them. Test muscular side in turn and note the gag reflex. It may be
strength by trying to open them, as symmetrically diminished or absent in some
illustrated. normal people.

Cranial Nerve XI—Spinal Accessory.

From behind, look for atrophy or fasciculations
in the trapezius muscles, and compare one side
with the other. Ask the patient to shrug both
shoulders upward against your hands. Note the
strength and contraction of the trapezii.

o Show both upper and lower teeth.

o Smile.
o Puff out both cheeks.
Note any weakness or asymmetry.
Sensory;
Taste in anterior 2/3 of the tongue
Ask the patient to turn his or her head to each
side against your hand.
Cranial Nerve VIII – Acoustic
Observe the contraction of the opposite
Assess hearing with whispered voice test
sternomastoid and note the force of the
If hearing loss is present,do test for;
movement against your hand.
o Lateralization ( Weber’s Test)

o Compare air and bone conduction

(Rinnes Test) Cranial Nerve XII—Hypoglossal.
With the patient’s tongue protruded, look for
asymmetry, atrophy, or deviation from the
midline.
Ask the patient to move the tongue from side to
side, and note the symmetry of the movement.

Motor Test
Inspect both upper and lower extremities.
Report; no noted fasciculations, atrophy of muscles on
Cranial Nerves IX and X—Glossopharyngeal and both upper and lower extremities.
Vagus.
Listen to the patient’s voice. Is it hoarse or does
Test for spasticity and rigidity of extremities.
it have a nasal quality?
Is there difficulty in swallowing? With examiners hand, flex and extend patients
Ask the patient to say “ah” or to yawn as you forearm on both sides. Do the same with the
watch the movements of the soft palate and the lower extremities.
pharynx. Report ; muscle tone is normal with no noted spasticity
o The soft palate normally rises and rigidity on both lower and upper extremities.
symmetrically, the uvula remains in the
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 Spine & Extremities / Abdomen / Neurologic Exam
Test for muscle strength in both extremities. Report; the patient have normal gait and stance, able to
Ask the patient to put force against you. do tandem walking without tendency to fall.
Push (patient’s) arms outward, push arms
inward. Deep Tendon Reflexes
Ask patient to flex and extend his forearm while Biceps Reflex (C5 & C6)
examiner is offering force against it
Push patient’s leg, forward and backward.
Ask patient to flex and extend his legs while
examiner is offering force against it
Report; Muscle grade is +5 on both upper and lower
extremities
Cerebellar Test

Do Finger to Nose test. Triceps Reflex (C6 & C7)

Report; Patient is negative for dysmetria of upper

extremities. Knee Jerk reflex (L1,L2,L3)

Do Thigh patting test.

Alternate pronation and supination movement of
the hand to thigh
Make sure to make an audible sound with each
pat
Report; Patient is negative for Dysdiachokenesia

Do Heel to shin test.

Ankle Jerk Reflex (S1)

Report; Patient is negative for dysmetria of lower

extremities.

Test for Gait and Stance. Elicit pathologic signs;

Ask the patient to walk across the room Babinski Sign
Ask the patient to do tandem walking

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 Spine & Extremities / Abdomen / Neurologic Exam

Report; patient have intact position and vibration sense

on both lower and extremities
Test for astereognosis
Place a familiar object in patient’s hand (e.g.
cellphone) and ask what it is?

Report; if patient identifies the object, report that the

patient is negative for astereognosia.

Do Romberg’s Test
Positive Babinski Sign
Report; patient have +2 DTR on both lower and upper
extremities, and patient is negative for babinski sign.
Sensory Examination;
Ask the patient to close his eyes.
Familiarize the patient with the stimulus (Sharp
and blunt)
Do the Two point discrimination on Right arm,
forearm, then Left arm, forearm, and in the
lower extremities (thighs and legs). Report; the patient is negative for Romberg’s Test
Report; Patient has equal sensation on both right and left
extremities and are equal on both sides. Signs of Menigeal Irritation
a. Brudzinski’s Sign.
i. As you flex the neck, watch the
Test for digital position sense
hips and knees in reaction to
Use the fourth digit in position sense (minimally your maneuver. Normally they
represented in the brain) should remain relaxed and
Work from proximal to distal motionless.
Ask the patient to close eye
Separate the digit you are examining
Grasp the digit laterally b. Kernig’s Sign.
i. Flex the patient’s leg at both the
Stabilize the joint proximal to it
hip and the knee, and then
Ask the patient if the finger is moving up/down straighten the knee. Discomfort
or neutral behind the knee during full
extension occurs in many
Testing for loss of vibration sense (pallanesthesia) normal people, but this
maneuver should not produce
pain.

--------------------------- End-----------------------------
REMEMBER: All reports here are based on
NORMAL findings, if you see any abnormalities and
other findings you may report it. This is not a script,
Eyes closed
this is just a guide.
Holding a tuning fork (128 or 256 CPS) by
around the shaft and strike the tines a crisp blow Goodluck!
against the ulnar side of the palm to set the pork -ef
vibrating
Familiarize the patient with the stimulus
Examine the fourth digit
Apply free end of the shaft to the nails or just
proximal to the nailbed
Place your finger against patients finger pad and
serve as control
Check by alternating presence and absence of
vibration
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