RAC checklist

 General observation and respirology:

o Demonstrate surface anatomy of various lobes
o Demonstrate and explain inspection of the chest including symmetry of expansion
o Demonstrate how to palpate for expansion of the chest
o Demonstrate how to palpate the trachea
o Demonstrate percussion of the anterior and posterior chest
o Demonstrate auscultation of the chest
o Demonstrate how to examine for cyanosis and clubbing
 Vital signs and cardiovascular:
o Demonstrate recording of BP by palpation and by auscultation in arms (if manual)
o Demonstrate surface landmarks for normal heart
o Demonstrate and explain inspection and palpation of precordium including apical
impulse and other precordial impulses
o Demonstrate areas of auscultation of the heart
o Demonstrate examination of peripheral pulses (carotid, brachial, radial, dorsalis
pedis)
 Abdomen and lymphatics:
o Demonstrate and explain abdominal inspection
o Demonstrate auscultation and describe bowel sounds
o Demonstrate superficial and deep palpation of the abdomen including assessment
of liver, spleen, and kidneys
o Demonstrate percussion of liver size, splenic enlargement, and palpation of
kidneys
 MSK:
o Shoulders
o Hips
o Knees (including stability of the cruciate ligaments, McMurray’s sign, stability of
the collateral ligaments)
o Ankles: tibio-talar, subtalar, transverse tarsal
 Neurological:
o Pupillary light reflex
o Extraocular movements
o Facial muscles
o Stance and gait
o Tandem gait
o Rapid alternating movements in the upper extremities
o Finger-to-nose testing
o Tone in upper extremities
o Power in upper and lower extremities
o Deep tendon reflexes (brachial, brachioradialis, triceps, knee, ankle)
o Plantar (Babinski) response
 o Light touch sensation

RAC Notes

Physical Exam

Technical note (e.g. how to hold your hands, etc.)

Pathology
Anatomy/ anatomical landmark
What to say

ALWAYS:
Start off by:
 Introduce self “Hi I’m abc. I’m a second year medical student. I’m going to be doing your
physical exam today. Is that alright?”
 Ask for their name
 Wash hands, dry and put on gloves
 Ensure privacy by pulling curtains
End by:
 Offering to tie up the gown

Mouth and Throat

Thyroid
A. Inspection:
 Scars
 Swelling
 Ask patient to swallow water (should see the thyroid cartilage move up)
B. Palpation: Go posterior to the patient, put the thumb behind the ear and index finger along
the jawline. Use third and fourth fingers to palpate.
-Find the thyroid cartilage, go down to find the cricoid cartilage. Inferior to that is the
thyroid isthmus. Lateral to the cricoid cartilage are the thyroid gland lobes
-Push on one side of the thyroid and (on the other side) move fingers in circular motion.
-“There is no enlargement of the thyroid gland”
C. Percussion: none
D. Auscultation: go to the anterior side of the patient, and put your stethoscope on the thyroid
gland. Say “there is no bruit in the superior thyroid artery”
Chest
Anatomical landmarks:
 Going from anterior (mid-clavicular)  lateral (mid-axillary)  posterior (spinous process)
the lungs end at ribs 6  8  10
 Sternal angle is at rib 2
 Lung apexes are 2-4cm above the inner third of clavicle
 Inferior angle of the scapula is at 7th rib
A. Observation
 Scars, nodules, dilated veins
 “The patient is breathing comfortably and not using any accessory respiratory muscles”
 Chest deformities “I see no chest deformities, such as pigeon chest or barrel chest”
 Central cyanosis (blue lips)
 Peripheral cyanosis (blue finger tips)
 Clubbing
-Have the patient put the back-side of their index fingers together. There should be a
diamond shape made by their finger nails.
-Say “the patient does not have clubbing, as is seen by the obtuse angle between their
nail and nail bed”
B. Palpation
 Palpate their chest while looking at their face (for pain). Say “I don’t find any nodules,
masses or tenderness”
 Chest expansion:
-go posterior to the patient, put your hands under their armpits and pull all the skin
back until your thumbs meet one another. Have the patient take a deep breath in.
-Say “there is symmetrical chest expansion of 5cm”

 Trachea
-Put your middle finger on the trachea (inferior to the cricoid cartilage) and then your
index and ring finger on each side of the trachea
-Say “there is no deviation of the trachea”
 -If there was a pleural effusion, the trachea would be deviated to the opposite side of
the pleural effusion
-If there was a collapsed lung, the trachea would be sucked onto the same side as the
collapsed lung.
 Tactile fremitus: say “I am checking for vocal fremitus now. It is symmetrical”
-Put your palm on the three levels of the lungs (superior, middle and inferior) and have
the patient say 99. Do it on one side and then the next (to compare the two sides)
-Also do it on the lateral sides (under the axilla) at 2 levels.
-If there is lung consolidation (e.g. pneumonia), the vocal fremitus would be increased
C. Percussion
 Put your finger in an intercostal space and tap it with the middle finger of your dominant
hand. Do it at 3 levels of the lungs (alternate sides to compare the loudness).
 Say “there is normal, symmetrical resonance”
 There will be hyper-resonance in a patient with a pneumothorax.
 There will be hypo-resonance in a patient with consolidation, pleural effusion, or collapsed
lung.
D. Auscultation
 Listen to three areas of the lungs (alternating sides, to compare the sound). Ask patient to
breathe in deeply.
-Say “there is normal, symmetrical vesicular sounds. No extra sounds such as crackling
or wheezing”
 Vesicular breaths are what is normally heard over the lungs. You can hear the
inspiration and 1/3 of the expiration.
 Bronchial breathing is what’s normally heard over the trachea and main-stem
bronchi. You can hear the inspiration, a pause, and then the expiration. They’re
harsher, louder and higher in pitch.
 Crackles are intermittent, non-musical and brief. Heard in pneumonia, pulmonary
fibrosis and early heart failure.
 Wheezing is longer, sound more musical, high-pitched whistling noise. Often
suggest asthma.
-If there’s consolidation, there will be bronchial breathing.
-Note: Crackles = crepitus = rails.
 Vocal resonance: ask patient to say 99 while auscultating
-Say “now I’m going to check for vocal resonance”.
-Will be louder if there’s consolidation
 Pectoriloquy: ask patient to whisper 99
-Say “now I’m going to check for Pectoriloquy”.
-Will be louder if there’s consolidation
 Egophony: ask patient to say “eeeehhhhhh”
-Say “now I’m going to check for vocal resonance”.
-If there’s consolidation, it will sound like “aaaahhhhh”

1.
Lymph Nodes
Describe: location, size, hard/soft, motile, attached to skin, contour, surface (e.g. smooth or
rough), tender (does it cause pain?)

Looking for cellulitis, obvious rashes,

Palpation: you want to do the circular motion. Don’t press too light; apply some pressure

Head and neck

 Submental, lingual, submandibular, pre-auricular, post-auricular, occipital

 Posterior cervical chain: start at the mastoid and go along the trapezius, down along the
cervical spine
 Anterior cervical chain: along the SCM
 Supra-clavicular: just lateral to where the SCM inserts
Axillary: take the patients hand in one hand to lift up the arm. Then palpate the lymph nodes
with the other hand.
 Anterior axillary lymph nodes: just posterior to the tendon of the pectoralis major
 Posterior axillary lymph nodes: just anterior to the latissimus dorsi (which makes up the
posterior fold)
 Central: smack dab in middle of the armpit

Epitrochlear:
 Epitrochlear lymph node: go to the medial epicondyle (of the humerus) and go 2-3 cm
superior to it. then just a bit lateral to it (btw the biceps and triceps, you’ll find the lymph
node)
Peripheral Pulses
Always use the index and middle finger. Don’t press too hard.
Can describe: rate, rhythm (regular or irregular), volume
-Big change in volume suggests aortic regurgitation.
 Carotid pulse: btw the SCM and the thyroid cartilage
 Brachial: medial to the biceps tendon in the antecubital fossa
 Radial: lateral to the flexor carpi radialis
 Femoral: half-way between the pubis symphysis and the ASIS (inferior to the inguinal
ligament).
 Popliteal: behind the knee, on the lateral side
 -Ask their patient to relax their leg while you pick up the back of their knee (such that the
knee is flexed). Use the middle three fingers on each side of the back of the knee and try
to palpate. You have to press hard.
 Dorsalis pedis: lateral to the extensor hallucis longus tendon.
-Ask the patient to extend their toe (put it up towards their head) to see the tendon.

 Posterior tibial: posterior to the medial malleolus (of the tibia)

 Abdominal aorta: can auscultate just above the umbilicus

 Renal arteries: can auscultate the arteries 2-3 cm above and lateral to the umbilicus.
Blood Pressure
 Say “The patient should have rested for 5 minutes, not have had caffeine or smoked for 30
minutes.”
 How to apply sphygmomanometer:
-The width of the bladder should be 40% of the arm circumference. The length of the
bladder should be 80% of the arm circumference.
-Ensure that the patient is sitting with their feet on the ground.
-The bottom part of the BP cuff should be 2cm above the antecubital fossa, with the
arrow pointing towards the brachial artery.
 Taking BP by palpation: note that this only measures systolic (NOT diastolic bp)
-Lift the patient’s arm to heart level but have it be relaxed.
-Find the radial pulse.
-Inflate the cuff until you can’t feel the radial pulse. Decrease it by 2-3mmHg/ second
-When you feel the pulse again, this is the systolic pressure.
 Taking BP by auscultation:
-First, find the systolic bp by using the palpation method. This will allow you to avoid the
auscultatory gap.
-Inflate the cuff to 30 mmHg above the systolic pressure. Decrease the pressure by 2-3
mm Hg. When you hear the noises again, that’s the systolic pressure. When you stop
hearing it, that’s the diastolic pressure. These are the korotkoff sounds:
Cardio
Some basics:
 S1 = closing of the AV valves (during systole): mitral (aka bicuspid) and tricuspid valves.
 S2 = closing of the aortic and pulmonary valves (during diastole).
 JVP reflects pressure in the right atrium and provides info about volume status

Carotid Artery: keep patient at 45o

A. Inspection: a single outward pulse (goes outward between S1 and S2)
B. Palpation: btw the thyroid cartilage and the SCM.
- Describe intensity and rhythm (regular or not). Should see the upstroke btw S1 and S2.
- In aortic stenosis, there will be pulses parvus et tardus (weak and late upstroke after S2)
C. Percussion: none
D. Auscultation: any bruit found here can be either due to aortic stenosis or carotid stenosis

Jugular vein: keep patient at 45O

A. Inspection:
 How to distinguish it from the carotid artery:
JVP Carotid Artery
Bi-phasic Mono-phasic
Falls when patient becomes more upright Unchanged when patient is upright
Falls w/ inspiration Not affected by inspiration
Can’t be palpated Can be palpated
Can be blocked Can’t be blocked
Hepatojugular reflex: press on liver  increase No affected by liver pressure
JVP

 Measure JVP: when you find the pulsation, measure its vertical distance (in cm) from the sternal angle. It
should be 4cm or less.
 The central venous pressure = JVP + 5cm.
B. Palpation: none
C. Percussion: none
D. Auscultation: none

Heart: keep patient at 45O

A. Inspection
 There are no scars, masses or dilated veins.
 The patient’s chest does not have any deformities (no barrel or pigeon chest)
 Check patient’s carotid pulse and JVP
B. Palpate
 Apical impulse: at the left 5th intercostal space. Should be 1-2cm. Say “normal apical impulse, 1-2cm, not
deviated laterally”
- Left ventricle dilation: there will be heaving (apex will be more lateral and larger. Pulse will be more
intense).
- Left ventricle hypertrophy: pulse will be sustained.
 Now I’m checking for right ventricle hypertrophy:
- use thenar eminences (i.e. base of hand) over the parasternal 3-4th intercostal space (the area of the
tricuspid valve)
- In right ventricle hypertrophy, there will be heaving (pulse will be more intense, larger and more
lateral).
 Now I’m checking for thrills
 - Use the palm side of the MCP (the area btw the palms and the starts of the fingers) over the
pulmonary and aortic valve areas.
- If there’s any thrill, the murmur will automatically be considered above a level 4.
C. Percussion: none
D. Auscultate:
 Say “normal S1 and S2, no extra heart sounds or murmurs)
 Where to auscultate:
 Mitral valve: mid-clavicular 5th intercostal space
 Tricuspid valve: parasternal 3-4th intercostal space.
 Pulmonary valve: 2nd intercostal space (more lateral than tricuspid)
 Aortic valve: 2nd intercostal space on the right side.
 Extra heart sounds:
 S3: after S2. Caused by lots of fluid in the atrium hitting the ventricle wall. Seen in heart failure.
 S4: before S1. Contraction of atrium against a stiff ventricle. Seen in ventricular hypertrophy.
 Position to elicit murmurs and rubs:
 Mitral stenosis: have patient roll onto the left side
 Aortic regurgitation: lean forward and breathe out (b/c it moves the left ventricle closer to the
chest wall). Decrescendo diastolic murmur.
 Pericardial rubs: lean forward and breathe out. Heard during systole and diastole.
E. Special tests
 Check for peripheral edema: add light pressure with your thumb for 5 seconds. Test the dorsum of the foot,
behind the medial malleolus and over the shins. Also look for swelling and size of feet.
Abdomen
NOTE: you must do auscultation before palpation in the abdomen. This is b/c when you palpate, you’re moving
stuff around and so that’s going to cause more noises than what you wouldn’t otherwise hear

To start: have patient lying down with their knees bent a bit (pillows under the knees). Expose the area from the
pubic symphysis to the knees.
A. Inspection
 I do not see any scars suggestive of surgery or lesions.
 Abdomen is symmetrical and the umbilicus is centrally located and inverted.
 There is no caput medusa (Caput medusa is seen in portal HTN)
 No abdomen distension (abdominal distension is seen in ascites)
 Ask the patient to cough while you’re looking at the inguinal ligament and umbilicus.
- If there is a hernia, it will bulge out.
- I see no cough impulse.
B. Auscultate:
 Auscultate for bowel sounds: go half-way between the ASIS and the umbilicus. Here, you can hear the ileocecal
sounds. Should listen for 1 minute
- When there is bowel obstruction, there will be increased bowel noises first. Then it will be followed by
lack of bowel noises.
- “I hear normal bowel sounds”
 Auscultate for bruit in the arteries: I hear no bruit of these arteries
 Abdominal aorta: 2-3 cm superior to umbilicus
 Renal arteries: 2-3 cm superior and lateral to the umbilicus
 Common iliac arteries: 2-3 cm inferior and lateral to the umbilicus
C. Palpation
 Superficial palpation: lay hand flat and only push in with your fingertips. Push your fingertips forwards and
backwards (not in little circles)
- If there is any location in which the patient has pain, leave that quadrant for last.
- You can test either 4 or 9 quadrants. Go clockwise or counter-clockwise.
- Upon superficial palpation, there is no tenderness, masses or guarding
 Tenderness: either the patient flinches (so you must look in the patient’s eyes while you’re
palpating) or the patient tells you it hurts.
 Guarding: involuntarily tensing the abdominal muscles when you palpate. Seen in peritonitis
 Deep palpation: use two hands. Same finger movement as for superficial palpation.
- Upon deep palpation, there is no tenderness, masses or guarding.
 Palpate (and percuss) for organs
 Liver
- Percussion:
 Going from the right lower quadrant and percuss up on the midclavicular line. Goes from
tympanic  dull.
 Going down from below the nipple, percuss. Goes from resonant  dull.
 Measurements: 6-12cm in midclavicular line. 4-8 cm in mid-sternal line.
- Palpate: start from right lower quadrant and move up to the costal margin. Can hook fingers
under the costal margin. Ask the patient to breathe in deep
 Spleen: this is on the left side at ribs 9-11
- Percussion: percuss along the anterior axillary line btw ribs 8-11 while they’re breathing in and
out
 When they breathe in, if they’re healthy, the percussion will remain tympanic.
 If they have splenomegaly, when they breathe in, you’ll hear dullness because the spleen
will hit your finger
- Palpate:
  Put your left hand on the patient’s posterior side and push it anteriorly (to push the spleen
forwards). go from the umbilicus out to the left side until you feel the costal margin.
 Ask patient to lie on their right side with the knees slightly flexed. Have them breathe in and
use your left hand to push on the posterior side. Palpate with right hand while they breathe
in.
 Kidneys: right kidney is lower than left. They’re in the costovertebral angle
- Percussion: none
- Palpate: put your hand in the costovertebral angle (below the 12th rib) and push anteriorly.
Palpate from the anterior side. Usually it’s not palpable.
 Bladder:
- Percussion: go from above the umbilicus down to the pubic symphysis. The bladder will be dull
(instead of tympanic)
- Palpate: palpate from umbilicus to the pubic symphysis.
 Aorta: assess the width of the aorta. Should be less than 3cm.
D. Percussion: percuss either 4 or 9 quadrants and say “normal tympanic percussion”
E. Special tests
 Tests for ascites:
 Shifting dullness: you percuss the abdomen near the umbilicus and then move laterally. If there’s ascites,
the percussion will go from tympanic to dull (b/c there’s fluid on the sides). Then you ask them to lie in the
decubitus position and percuss from lateral to midline.
- Now, it’ll go from tympanic sounds on the lateral sides and dull in the midline because the fluid
has shifted towards the midline.
 Have the patient put their hand (on the pinky finger) down on their midline (from the belly button down).
Use one finger to flick one side of the abdomen while the other hand rests of the opposite side.
- If there’s ascites, you can feel the wave of fluid on the resting hand.
 Murphy’s sign: put your hand on right side just under the costal margin (under where the liver would be) and
ask the patient to take a deep breath in.
- If they suddenly stop breathing because there’s pain, that’s a sign of cholecystitis.
 McBurney’s point: use your hand to put pressure 2/3 of the way from the umbilicus to the ASIS (so it’s closer to
the ASIS).
- Pain = appendicitis
 Rovsig’s sign: put your hand on lower left quadrant and push toward the midline
- Pain = appendicitis
 Psoas sign: put your hand on the patient’s thigh and ask them to try to push up against it
- Pain = appendicitis
 Obturator sign: flex the knee and bring the ankle medial (such that there’s external rotation of the hip)
- Pain = appendicitis
 Costovertebral angle tenderness: punch the patient in the back near the 12th rib
- Pain = pyelonephritis
 At the end, mention that you would want to check the left supraclavicular lymph nodes (because that’s where
GI metastases will drain to), do an inguinal exam (checks for hernias) and do a DRE.
MSK
For MSK, we’re no longer using the inspect, palpate, percuss, auscultate, special tests.
Instead, we use: inspect, palpate, move, special tests.
 Inspect: SEADS
 Symmetry
 Erythema
 Atrophy
 Deformity
 Scars and swelling
 Palpate: TTCER
 Temperature: use the back of your hand to feel the temperature
 Tenderness
 Crepitus: put your hand on the joint and use the other hand to move the joint passively. If you can feel
or hear creaking, that’s crepitus.
 Effusion: use your thumb to press on skin.
 Range of motion
 Move: always test active motion (i.e. by themselves) BEFORE passive. Only do the passive tests if they can’t do
the active tests.
- Joint injury: no passive movement
- Neural or muscular injury: no movement against resistance
 Special tests
 After all of this, say “I’d like to inspect the joints above and below. I’d also like to check sensation, pulse, and
resistance of the affected joint” (ex. If you’re looking at the shoulder, you’d want to check the neck and the
elbow)

 Shoulder
o Inspect: SEADS
o Palpate
- Palpate the following places: sternoclavicular, mid-clavicular, acromioclavicular, acromion, greater
tuberosity, spine of scapula, biceptal groove (medial to greater tuberosity) and tendon of the long head of
the biceps.

o Move:
 Arms above head: arm flexion – 180 degrees – know these degree numers
 Arms extended back – 45 degrees
 Hands out to the side (abduction) – 180 degrees
 Arms crossed in front: adduction
 Hands behind head: abduction and external rotation – 90 degrees
 Hands on lower back: abduction and internal rotation
 o Special tests:
 Jobs test: thumbs up and thumbs down. When they have thumbs down, have them push up against
resistance.
- Pain = supraspinatus tendonitis
 Painful arc: have them abduct their arm all the way above their head
- Pain from 30-120 degrees = supraspinatus tendonitis
 Drop arm test: have patient abduct the arm all the way and then drop the arm slowly.
- Arm drops after 120 degrees = supraspinatus tear
 Have the patient put the back of their hand on their lower back and push out (while you put pressure on
their wrist)
- Pain = subscapularis tendonitis
 Apprehension test: have the patient sit with their elbow flexed and arm up (like they’re about to do a
high-five). Hold their elbow and push it back.
- Fear = anterior shoulder dislocation
 Support the elbow and have the patient supinate against resistance
- Pain near biceps tendon = biceps tendonitis. (remember that the biceps does supination)
o Remember: end it by saying that you’d check the neck and elbow, sensation, brachial and radial pulse and
resistance.

 Hips
o Inspect: SEADS PLUS make them walk and watch their gait.
o Palpate: TTCE
 To hear/feel crepitus of the hips, have the patient stand up and face the examination table. They can
support themselves with their hands on their table, while they extend their leg backwards.
o Move:
 While they’re standing, have them extend their leg backwards (just like you did when you wanted to
hear crepitus)
 Now have them lie down, and raise their leg (hold onto their ankle)
 Move the leg to the sides while holding the opposite side of the hip down (so it doesn’t tilt)
 Adduction
 External rotation: ankle outwardsinwards (see photo)
 Internal rotations: ankle inwards outwards
o Special tests:
 Thomas test: put your hand behind their back (while they’re lying down) and
then have them hug their knee to their chest. There is loss of lumbar lordosis
and no flexion deformity of the knee.
 Faber test: have them make a 4 with their legs (so you flex the knee, abduct
the leg, externally rotate the leg and put it on the other leg) and then press
on the knee and the contralateral hip.
- Hip joint problem = pain in the hip on the same side as the bent knee
(the hip that’s not being pushed down)
o Finish with: want to test the knee, check the iliac and femoral and popliteal pulses.

 Knees
o Inspection: SEADS plus gait
 Deformity: I see no geno valgum or geno varum or geno recurvatum
 Geno Valgum: knees glued together (gum keeping the knees together
= valgum)
 Geno varum: knees are bent outwards (rum opens your knees = varum)
 Geno recurvatum: knees are more posterior than they should be
 Gait
o Antalgic: painful
 o Hemiplegic: circumduction
o Myopathic: proximal muscle weakness: hip drop
o Neuropathic: foot drop
If suspected knee problem for example – mention will check in hips and ankles and other leg as well
Checking for swelling – pushing hand down top of thigh towards knee cap, have one hand stabilize below the
patella – push the swelling down
Check for warmth – use back of your hand – knee is always colder – if the same temp. – it is not normal
o Palpate: TTCE
 Tenderness: palpate suprapaterllar, medial to the patella, lateral to the patella, infrapatellar, tibial
tuberosity, lateral and medial condlyes of the femur
 Crepitus: put your hand on their knee and life the ankle to flex the knee
 Effusion: there are 2 methods to look for effusion around the knee
 Put your thumb and middle finger of each hand above and below the knee and push your hands
together (such that your fingers are making a diamond shape). Then use the index fingers to
palpate the medial side of the patella.
 Use a hand to push the fluid from top to down. Then push along the medial side of the knee
(towards the lateral side). And finally, push on the lateral side. If there’s effusion there will be a
bulge on the medial side.
o Move: bend and extend the knee
o Special tests:
 Anterior drawer test: sit (lightly) on the foot and have their knee bent. Try to pull the calve forward.
- This tests the anterior cruciate ligament (ACL).
 Posterior drawer test: sit (lightly) on the foot and have their knee bent. Push on the calve (trying to push
it towards their butt).
- This tests the posterior cruciate ligament (PCL)
 Valgum test: hold their ankle upwards and push on the lateral thigh inwards (medially)
- This tests the medial collateral ligament.
 Varum test: hold their ankle upwards and push on the medial thigh outwards (laterally) towards the
lateral sides
- This tests the lateral collateral ligament.
 McMurrary test: hold the knee with one hand and the ankle with the other hand.
 Rotate the leg externally, abduct it, flex it and then extend the knee. Clicking, locking or pain =
medial meniscus tear.
 Rotate the leg internally, abduct, flex and extend. Clicking, locking or pain = lateral meniscus
tear.

 Ankle
o Inspect: SEADS
o Palpate: TTCR
 Tenderness:
 Put pressure on the tip and base of the 5th (lateral) metarsal.
 Put pressure on medial and lateral malleolus.
 Put pressure on head of the fibula (lateral knee).
o Movements: dorsiflexion, plantar flexion, inversion, eversion
o Special tests:
 Thomson test: patient lies on the belly and the ankles hang off. You squeee the gastrocnemius and
there should be plantar flexion
- No plantar flexion = Achilles tendon has been ruptured
Neuro
In the neuro exam, you have 6 different categories: cranial nerves (CNs), motor, sensory, reflexes, gait, and
coordination.
Note: hearing: 512Hz. Vibration sensation: 128 Hz

 Cranial Nerves
 CN 1 (olfactory): have them close one nostril at a time and close their eyes and sniff whatever you’re putting
under their nose. Then they guess
 CN 2 (optic):
 Visual acuity: have them cover up one eye at a time and stand a distance away from them and put up
fingers and ask them how many fingers they see.
 Visual field: both you and the patient cover up an eye (e.g. your left eye and the patient’s right eye).
You bring a finger from outside of your visual field and bring it in. They tell you when they see your
finger. You two should see it at the same time. Check 4 quadrants.
 Color vision: I would use an ishihara chart to test color vision
 Pupillary reaction to light: shine a light in their eye and check that there is both direct and consensual
response (contraction of the pupil).
- There is bilateral, symmetrical pupillary constriction of 3-4 mm.
 Fundoscopy
 CN 3 (oculomotor), 4 (trochlear) and 6 (abducens)
 There is no ptosis. The pupils are symmetrical. There is no strabismus.
 There is a direct and consensual pupillary response to light.
 Have them follow your finger. Hold onto their head while you do the H sign. Tell the patient to tell you
if they see one or two images.
- There is no diplopia, strabismus, or nystagmus.
 Have them follow your finger at you move your finger closer (towards their nose). This is testing
accommodation.
 CN 5 (trigeminal):
 Motor:
 Have them clench their teeth and feel the temporalis and masseter muscles.
 Put your hand under their chin and ask them to open their mouth against resistance.
 Sensory: use a cotton ball. First pat their jugular notch with it to tell them “this is what it feels like”.
Then tell the patient to close their eyes and tell you when they feel it. Check forehead, cheeks and
mandible. Ask if the two sides feel the same.
 Reflex: put your finger under their lip (with their mouth open a bit) and use the hammer on your hand.
- If their mouth opens more, that’s hyperreflexia = UMN lesion.
 CN 7 (Facial)
 Say “symmetrical nasolabial folds”
 Ask them to raise their eyebrows and look up with their eyes (not actually moving the head)
 Ask patient to squeeze their eyes tightly shut and try to open them.
 Ask patient to smile
 Ask patient to puff out their cheeks, and then using one hand try to deflate their cheeks
 Say “I would like to test taste on the anterior 2/3 of the tongue”
 Rub fingers on the two sides of the ear and ask patient if they can hear it similarly on both sides (note
that this is b/c the facial nerve controls the stapedius muscle, in the middle ear, which decreases the
movement of the stapes bone)
 CN 8 (vestibulocochlear)
 Close one ear and whisper in the other ear
 Weber test: use the 512Hz tuning fork. Bang it and then put it on their forehead. Ask them if they hear it
louder in one ear vs. the other
- If it’s louder in one ear, there’s either a contralateral sensorineural hearing loss or an ipsilateral
conduction hearing loss.
 Rinne test: use the 512Hz tuning fork. Bang it and put it on the mastoid process. Tell them to tell you
when they can no longer hear it. When they can’t hear it, move it front of their ear and ask them if they
can still hear it now.
  Look for nystagmus.
 CN 9 (glossopharyngeal) and 10 (vagus):
 Speech is normal (no hoarseness, nasal speech, monotone voice).
 Ask patient to swallow. There is no dysphagia.
 Ask patient to open mouth and say “ahhhh”. The uvula is in the middle.
 I would test the gag reflex
 I would test taste and sensation in the posterior 1/3 of the tongue.
 CN 11 (spinal accessory):
 Put your palm on the patient’s cheek and ask them to rotate their head against it. This tests the power of
the sternocleidomastoid
 Have the patient shrug their shoulders against your hand. This tests the power of the trapezius muscle.
 CN 12 (hypoglossal):
 Observation: No atrophy or fasiculations of the tongue.
 Have them stick out their tongue. No deviation of their tongue.
 Have the patient push their tongue against the inside of the cheek while you’re pushing their cheek in.
This tests the power of their tongue.

 Motor: always check muscle bulk, tone and power

Muscle bulk: muscles should be convex and have no fasiculations
Tone:
 Velocity-dependent spasticity: UMN lesion
 Velocity-independent rigidity or cog-wheeling: basal ganglia lesion
Grading of power:
 0: no muscle movement
 1: flickers
 2: moves with gravity (but not against it)
 3: moves against gravity
 4: move against light resistance
 5: moves against normal resistance

 Reflexes
 Sensation: want to check normal touch sensation, proprioception, pin-prick, and vibration (using the 128Hz fork
on a bony prominence. Start distally and if they don’t feel is distal then move more proximal)

Summary: for upper and lower body you do:

1. Motor:
 Muscle bulk: atrophy and fasiculations
 Tone
 Power
2. Reflexes
3. Sensation
 Touch
 Pin-prick
 Vibration
 Joint position

 Upper body
o Motor
 Muscle bulk: I see no atrophy or fasiculations
 Tone:
 Hold their elbow with one hand and their hand with your other hand. Supinate and pronate slowly
and then quickly.
 Rotate their wrist in a circular motion
 Power:
 Have the patient put their elbows out and resist your movement. Push down on their elbow, up, in
and out.
  Have the patient bend their elbows in front of them, with their hands upwards. Have them resist
pulling and pushing the arms close/ far from their body.
 Have them extend their wrists and resist you trying to push and pull the hands.
 Have them abduct the thumb and resist you trying to push it down. This is median nerve.
 Have them extend the thumb and resist you trying to push it in towards the palm. This is the radial
nerve
 Have them spread their fingers apart and try pushing them in. This is the ulnar nerve.
 Pronator drift: have the patient close their eyes, stretch their arms out in front of them with the
hands facing up. If there’s weakness, the hand will pronate and go down.
o Reflexes
 Biceps (C6): hold the patient’s elbow, put finger on their biceps tendon and then tap your finger with the
hammer.
 Triceps (C7): hold the patient’s elbow and tap on the posterior side, just above the elbow.
 Brachioradialis (C6): have the patient relax their arms on their lap with their thumbs pointing up. Hit above
the wrist on the lateral side.

o Sensation
 Use cotton pad to test the following areas:

 Use needle to pin-prick the same areas

 Vibration: put it on the base of the index finger and the radial base of the wrist.
 Joint position: tell the patient to close their eyes and push their thumb tip either up or down. They need to
say if it’s going up or down.
- Make sure you hold the sides of the finger. Otherwise, they’ll just feel the increased pressure on
one side of their finger and know which direction you’re pushing it.

 Lower Body
o Motor
 Muscle bulk: there is no atrophy or fasiculations
 Muscle tone:
 Take their knee and shake it left to right. See how their ankle also wobbles back and forth.
  Have them relax their leg, lift their knee quickly. You should see their foot slide up.
 Muscle power:
 Have them push their thigh up against your hand, abduct and adduct against resistance.
 Have them flex their knees and put your hands on their calves. Have them push against you and pull
towards you.
 Push ankles up and down
 Push toes and extend.
 Check for ankle clonus: hold onto their calf and move their foot up and down (such that the ankle is
extending and flexing) and then sharply and quickly do dorsiflexion.
- If it starts twitching, that’s clonus (UMN lesion)
o Reflexes
 Patellar (L3,4): have them sit up with their legs dangling off the table. Hit just under the knee.
 Achilles (S1): hit at the Achilles tendon.
 Babinski response: scrape along the lateral edge of the foot (using the other side of the reflex hammer) and
then when you get to the base of the toes, go across.
- Toe extension, = UMN lesion

o Sensation
 Touch

 Pin-prick
 Vibration: put it on the big toe and then the medial malleolus.
 Joint position: ask patient to close eyes and move the big toe up and down (hold the sides of the toe, not the
top and bottom)

 Gait
  Gait: observe the stance, pivot, arm swing
 Toe walking: S1
 Heel walking: L4-5
Gait Where is the Problem Main Effect Adaptation and Gait Gait Name
lesion Name
Neuropathic Nerve Distal muscles are weak Foot scrapes on ground Flex hip and knee Steppage gait
(especially dorsiflexion) more and foot slaps on Foot drop gait
the ground
Myopathic Muscle Proximal muscles are Pelvis tilts to the side Trendleberg gait
weak (hip girdle)
Hemiplegic/ Cerebral Weakness of flexors, Foot can’t clear ground Leg makes semi-circle Unilateral =
diplegic hemisphere increased tone of laterally circumduction
extensor muscles gait
Bilateral=
scissoring
Ataxic Either Impaired control of Base is wide
proprioception force and range of limb Leg movements are erratic
(sensory ataxia) or movements and arrhythmic
cerebellum PLUS impaired anti- Trunk goes forward and
(cerebellar ataxia) gravity reflexes back
Parkinsonian Substantia nigra Movements are slow and Gait is slow, steps are small
broken down Reduced arm swing
PLUS impaired anti- Posture is stooped
gravity reflexes Pivot has many small steps

 Tandem gait: walking toes to heel.

 Coordination
 Romberg test: have the patient stand with their feet together. Put your arms in front and behind the patient (so
you can catch them if they fall). Have them close their eyes
- Cerebellar problem: they fall down with their eyes open or closed
- Proprioception problem: they can stand when they have their eyes open. But when they close their eyes,
they’ll fall.
 Finger-to-nose test: move your finger so they have to follow it
- Dysmetria = cerebellar problem
 Heel to shin test: move their foot from completely extended up their leg to the knee.
- Dysmetria = cerebellar problem
 Rapid-alternating hand movements: have the patient tap the back and then palm of hand in the other as fast as
they can
- Slow = Dysdiadochokinesia = cerebellar problem
 Patients w/ cerebellar problems will have scanning speech (break down speech into separate syllables and
spoken w/ varying force)

Mental Status
 Start out with digit span test. Give patient 5 numbers and ask if they can say it right back. If they can, they have
normal attention
- Attention is abnormal in delirium. Normal in early dementia.
 Continue with the rest of mini-mental status exam (MMSE):
 Orientation to time: start from broad and go more specific. Year, month, season, date, day of week
 Orientation to place: start from broad and go more specific. Country, province, city, hospital, floor #
 Remember 3 words: have them repeat it right away and then ask them after 5 minutes
 Spell “world” backwards
 Ask them “what is this called?” and show them pen cap and something else
 Ask them to write a sentence
o