History and physical assessment/examination

Determining scope of assessment- first time patient= comprehensive assessment

Flexible focused & problem-oriented assessment+ more appropriate in most cases(returning
patients or those with urgent care ned)
Adjust scope of physical and history exam to the situation:
Keep these in mind: magnitude and severity of problem, need for thoroughness, clinical
setting (in or outpatient), time available
Comprehensive focused
- New patients - Established patients
- Strengthens patient physician relationship - During routine or urgent care visits
- Personalised knowledge about patient - For focused concerns/ symptoms
- Helps identify/rule out physical causes - Symptom at a specific body part
- Gives baseline for future assessments - Applies examination methods to asses
- Platform for health promotion (education problem thoroughly & carefully
+counselling)
- Develop proficiency in essential skills of
physical examination
Validated exam techniques
BP measurements, central venous pressure from jugular venous pulse, stections of splenic &
hepatic enlargement, pelvic exam with Papanicolaou (Pap) smears
Subjective Objective
Symptoms and history frm chief complaint Physical examination findings or signs
through review of systems - What you detect during exams,lab
- What patient tells you tests and test data

Components of comprehensive health history: date and time very important

1) Identifying data and source of history; reliability
- Age, gender, occupation, marital status
- Source of history: family, friend, clinical record, letter of referral (identify source-
written report may be needed)
- Identifying source= helps asses quality of referral info + further questions to ask
- Reliability varies according to patients trust, mood and memory(document at end of
interview)
2) Chief complaints
- Symptom(s) causing patient to seek care
- Quote patient’s own words as much as possible
3) Present illness
 - Location, quality, quantity, timings(onset, duration, frequency), where it occurred,
factors that aggravate/alleviate symptoms, associated manifestations, any treatment
to date,
- Includes patients’ thoughts and feelings about illness
- Pulls in review of systems (pertinent positives and negatives)
- May include allergies, tobacco & alcohol use (pertinent to present illness)
- Include patient’s response to symptoms & effect of illness on their life
- Each symptom= own paragraph and full description
- Medications (pill, vit supplements, home remedies, borrowed): name, dose, route
and frequency- ask patient to bring in all medication
- Allergies: specific reaction to medications, allergies to foods, insects and
environmental factors
- Tobacco: type, pack-years
- Alcohol and drug use: units/week, frequency & quantity of drug use
4) Past history
- Childhood illnesses: chronic illnesses, scarlet fever, whooping cough, rubella,
rheumatic fever, polio, mumps, chicken pox
- Adult illnesses (with dates)
(1) Medical: asthma, HIV… hospitalisation, number & gender of sexual partners,
risk taking sexual practices
(2) Surgical: dates, indications and types of operations
(3) obs/gyn: obstetric history, menstrual history, methods of contraception,
sexual function
(4) psychiatry: illness, time frame, diagnoses, hospitalisations and treatments
- Health maintenance practices: immunisations, screening tests, lifestyle issues, home
safety
5) Family history
- Age and health or age and cause of death: siblings, parents & grand parents
- Documents presence or absence of specific diseases in family
6) Personal and social history
- Education level, family of origin, current household, personal interests, lifestyle
7) Review of systems
- Documents presence or absence of common symptoms related to each of the major
body systems
Comprehensive health exam: head to toe
General survey:
general health, height, weight, sexual development
motor activity, gait, personal hygiene, facial expressions, manner, reaction to people and
environment, state of awareness/ level of consciousness
vital signs: pulse, BP, resp rate, pain, blood pressure
skin:
obseve skin of face- note dryness temperature- identify lesions (location, distribution,
arrangement, type + color)
inspect & palpate skind and hair- study surface of both hands-
continue skin observation as you abserve other areas
head, eyes, nose and throat (HEENT):
head- scalp,skull, face
eye- note position and alignment of eyes, eyelid and sclera of conjunctiva; with oblique
lighting, inspect cornea, iris + lens; compare pupils and test reaction to light; asses extra
ocular movements; inspect ocular fundi with opthalmoscope
ear- inspect auricles, canals and drums; check acuity; check lateralisation(weber test) and
compare air and bone conduction(rinne test), if acuity low
nose & sinuses- external nose; mucosa, septum and turbinate with light and nasal speculum;
palpate for tenderness of frontal and maxillary sinuses
throat (or mouth and pharynx): lip, oral mucosa, gums, teeth,tongue, palate, tonsils and
pharynx
crania nerve? :easier to inspect t this stage
neck: inspect and palpate cervical lymph nodes, note masses or unusual pulsations in neck,
feel for deviation of trachea, observe sounds and effort of patient’s breathing, inspect and
palpate thyroid gland
back: inspect and palpate spine and back muscles, observe shoulder height for symmetry
posterior thorax and lungs: inspect and palpate spine and upper back muscles, , inspect
palpate and percuss the chest, identify level of diaphragm dullness, listen to breath sounds,
identify any added sounds, listen to transmitted voice sounds (if indicated)
breast, axillae and epitrochlear nodes: inspect breast with arms relaxed then arms pressed
on hips, inspect axillae and feel for axillary nodes, feel for epitrochlear nodes

- If indicated : with patient still seated, examine hands, arms, shoulders, neck and
temporomandibular joints
- Optional: examine upper extremity muscle bulk, tone, strength and reflexes(can be
done later)
Anterior thorax and lungs: inspect palpate and percuss chest. Listen to breath sounds. Listen
to transmitted voice sounds if indicated
Cardiovascular system: observe jugular venous pulsation and measure its pressure, in
relations to sternal angle. Inspect and palpate carotid pulsations. Listen to carotid bruits

- Head elevated at 30deg, adjust as necessary to see jugular venous pulsation

 - Inspect and palpate precordium; note location, diameter,amplitude and duration of
apical impulse
- Listen at each auscultatory area with the diaphragm of stethoscope. Listen at apex
and lower sterna border with the bell.
- Listen for fist and second heart sounds; physiological splitting of second heart
sound; abnormal sounds or murmurs.
Abdomen (patient surpine): inspect, auscultate and percuss. Palpate lightly then deeply

- Assess liver and spleen by percussion then palpation.

- Try to palpate kidneys
- Palpate aorta and its pulsations
- If suspect kidney infection: percuss posteriorly over the costovertebral angles

Lower extremities (supine): examine 3 systems

1) Peripheral vascular system:
i) Palpate femoral pulses (and popliteal, if indicated)
ii) Palpate inguinal lymph nodes
iii) Inspect for lower extremity oedema, discoloration or ulcers
iv) Palpate for pitting oedema
2) Musculoskeletal:
i) Note deformities or enlarged joints
ii) Palpate joints (if indicated), check range of motion and perform necessary
manoeuvres
3) Nervous system:
i) Assess muscle bulk, tone and strength-
ii) assess sensation and reflexes- observe abnormal movements
lower extremities (standing):
1) peripheral vascular system:
i) inspect for varicose veins
2) musculoskeletal system:
i) examine alignment of spine and range of motion
ii) examine alignment of legs and feet
3) genitalia and hernia in men:
i) examine penis and scrotal contents and check hernias
4) nervous system:
i) observe gait and ability to walk heel to toe, walk on toes, walk on heels, hop in
place and do shallow knee bends
ii) do Romberg test and check for pronator drift
nervous system: can be done at end of examination
1) mental status(can be done during interview):
 i) assess orientation, mood, thought process, thought content, abnormal
perceptions, insight and judgement, memory and attention, information and
vocabulary, calculating abilities, abstract thinking, and constructional ability
2) cranial nerves
i) check sense of smell, strength of temporal and masseter muscles
ii) check corneal reflexes, facial movement, gag reflex
iii)check strength of trapezia and sternocleidomastoid muscles
3) motor systems
i) assess muscle bulk, tone and strength of major muscle groups
ii) cerebellar function: rapid alternating movements, point to point movement(F to
N, H to S)),gait
4) sensory systems
i) assess pain, temperature, light touch, vibration and discrimination
ii) compare right with left side and distal with proximal areas, on limbs
5) reflexes
i) biceps, triceps, brachioradialis, patellar, Achilles deep tendon reflexes, plantar
reflexes or Babinski responses

Additional examinations
1) genital and rectal exam in men (start with genital area if patient cannot stand)
i) inspect sacrococcygeal and perianal areas
ii) palpate anal canal, rectum and prostate
2) genital and rectal exam in women
i) examine external genitalia, vagina and cervix (with chaperone, when needed)
ii) obtain pap smear
iii)palpate uterus and adnexa bimanually
iv)perform rectal exam if indicated
3 types of reasoning for clinical problem solving: pattern recognition, development of
schemas and application of relevant basic and clinical science

Identifying problems and making diagnoses:

1) identify abnormal findings
i) make list of patient’s symptoms
ii) signs observed during examination
iii)lab reports available
2) localise abnormal findings anatomically
i) may not be straight forward: asking about associations will help in determining
this
ii) try to be as specific as possible but may have to settle for region/ body system
iii)some signs are constitutional so cannot be localised: fatigue, fever…
3) cluster clinical findings: do symptoms fit into one problem or several?
i) Tease out cluster of observations- analyse cluster at a time
ii) Clinical characteristics that may help: age, timing of symptoms, involvement of
different body systems, multisystem conditions
 iii)Ask series of key questions: what causes and relieves pain? etc
4) search for probable cause of findings
i) pathologic processes: congenital, inflammatory/infectious, immunologic,
neoplastic, metabolic, nutritional, degenerative, vascular, traumatic and toxic
ii) pathophysiological: derangement of biological functions e.g. heart failure,
migraine
iii)psychopathologic e.g. depression headache(expression of a somatic symptom
disorder)
5) cluster clinical data
6) generate hypotheses about causes of problems: draw on full range of knowledge and
experience
i) select most specific and critical findings to support hypothesis
ii) match findings against all conditions that can produce them
iii)eliminate diagnostic possibilities that fail to explain findings
iv)weigh competing possibilities and select most likely diagnosis
v) give special attention to potentially life-threatening conditions
7) test hypotheses and establish working diagnosis
i) is the diagosis clear cut? Treat if yes
ii) if no: further examinations to be done (x-ray, culture…) to confirm/ rule out

8) establish working diagnosis

i) establish definition of the problem- highest level explicitness and certainty data
allows
ii) may be limited to symptom i.e cause unknown
iii)illness can be due to stressful event in life: identify & help pt cope with this event
iv)routinely listing health maintenance helps track many important health concerns:
immunisation, screening tests, instruction regarding nutrition and testicular or
breast, recommendations about exercise or use of seat belts and responses to
important life events
identify and record a treatment plan for each patient problem

- plan flow logically from problems to diagnoses identified

- specify next step for each problem- tests, procedures, subspecialty consultations,
new/changed medications, arranging family meeting
- plan changed and modified after each visit (as appropriate)
- should reference diagnosis, treatments and patient education
- need to discuss assessments with patients before finalising plan
- encourage patient participation where possible- promotes therapy, adherence to
treatment and patient satisfaction
tips for quality patient data: avoiding errors
a) ask open ended questions and listen carefully to patient’s story
b) craft a thorough and systematic sequence to history taking and physical examination
c) keep an open mind toward patient and the clinical data
 d) always include “worst case scenario” and make sure it can be safely eliminated
e) analyse any mistakes in data collection or interpretation
f) confer with colleagues and review pertinent clinical literature to clarify uncertainties
g) apply principles of evaluating clinical evidence to patient info and testing
problems list: good practice to list patients problems in order of seriousness
 The fundamental of skill interviewing
1. ask a series of questions, one at a time
2. offer multiple choices for answers
3. clarify what the patient means
4. encourage with continuers “I’m listening, go on etc”
5. echoing
key skills: non-verbal communication, validation, reassurance, partnering, summarisation,
transitions and empowering the patient

preparation:
- review clinical records
- set goals for interview
- review your clinical behaviour and appearance
- adjust the environment (to make setting as private and comfortable as possible)

sequence of interview:

- greet patient by name + introduce yourself (explain your role if first consultation)
- take notes but do not focus only on paper/computer
- establish agenda- chief complaint/presenting problem(s)
- invite the patient’s story “tell me more about…”
- explore patient’s perspective- illness explains how patient experiences disease
 patient’s feelings- fear and concerns
 patient’s ideas about nature and cause of problem
 effect of problem on patient’s life and function
 patient’s expectations of disease, clinician/healthcare
- identify and respond to emotional cues- 30/40% have anxiety/depression in primary
care practices= NURSE
 name: “that sounds like a scary experience”
 understand/legitimise: “it’s understandable you feel that way”
 respect: “you’ve done better than most people would”
 support: “I will continue to work with you on this”
 explore: “how else were you feeling about it”
- expand and clarify patient’s story – seven attributes of symptoms (OLD
CARTS/OPQRST)
 OLD CARTS: Onset, Location, Duration, Character, Aggravating/Alleviating,
Radiation, Timing
 OPQRST: Onset, Palliating/Provoking factors, Quality, Radiation, Site, Timing
- Sharing treatment plan = shared decision making
 Behaviour change and motivational interview
- Closing interview and visit: let patient know interview is almost over
 - Self-reflection/mindfulness- being non-judgementally attentive to own experience,
thoughts and feelings

cardiovascular

- apex= point of maximal impulse(PMI)

- PMI as big as 2.5cm, >2.5cm = left ventricular hypertrophy (from
hypertension/aortic stenosis)
- Displacement of PMI lateral to midclavicular line/>10cm lateral to midsternal line=
LVH or ventricular dilation from Myocardial infarction
- Patients with COPD PMI is in xiphoid/epigastric area due to RVH
- Heart sounds of S1 nad S2 from closing of heart valves
- 40+YO: diastolic sound at S3 & S4 are pathologic = heart failure/acute myocardial
ischaemia
- S3= abrupt deceleration of inflow across mitral valve
- S4= increased ventricular end diastolic stiffness- decreases compliance

Explanations for heart sounds: closure of valves leaflets, tensing of related structures, leaflet
positions, pressure gradients during systole, acoustic effects of moving columns of blood

- S1(closing of mitral valve) & S2 define duration of systole and diastole

- Right heart sounds usually at lower pressures than those on left
Splitting of heart sounds
- Events on right side of heart usually happen slightly later
- May hear 2 sounds for S2, 1st= aortic valve closure (A2), 2nd= closure pulmonary
valve(P2)
- R heart filling time increased during inspiration= increased R stroke volume and
duration of ventricular ejection
- A2 normally louder, heard throughout precordium
- P2 best heard in 2nd & 3rd left interspace, close to sternum (search for splitting here)
 - S1 also has 2 components- mitral sound louder than tricuspid sound
- Mitral sound heard throughout precordium- louder at apex
- Tricuspid sound louder at lower sternal border
Heart murmurs
- Different pitch and last longer than normal heart sounds
- “innocent” murmurs common in young people + Stenotic valve (narrow so obstructs
blood flow)
- Valve that fails to fully close (aortic regurgitation)- blood leaks back in retrograde
direction
- Important to integrate location and timing with murmur’s shape, maximal intensity,
direction of radiation, grade of intensity, pitch and quality

Electrocardiogram
Look up video of positioning
- Electrical vector approaching lead= +ve/upward deflection
- Electrical vector moving away from lead= -ve/downward deflection
- +ve and -ve balance= isoelectric/straight line
Arterial pulse and blood pressure
Palpable delay between ventricular contraction and peripheral pulse so peripheral pulse
unsuitable for timing events in cardiac cycle
Factors affecting blood pressure:

- Left ventricular SV
- Distensibility of aorta and large arteries
- Peripheral vascular resistance (specially at arteriolar level)
- Vol of blood in arterial system
- Physical activity, emotional state, pain, temp, drugs, time of day

Jugular venous pressure: index for right heart pressure and cardiac function

- Reflects atrial pressure= central venous pressure= R. ventricular end diastolic

pressure
- Best obtained from right internal jugular vein
- Changing pressure in atrium= jugular venous pulsation:
- Atrial contraction= (a)wave before S1, (x) decent during atrial diastole
- As right AP begins to rise, during ventricular systole= (v) wave elevation
- (y) decent= passive emptying into ventricles(early+ mid diastole)

Dominant movement of JVP= inward= x decent (dominant movement in carotid pulse =

outward)
 - JVP falls with loss of blood, decreased venous vascular tone
- JVP increases with right/left heart failure, pulmonary hypertension, tricuspid
stenosis, AV dissociation, increased venous vascular tone, pericardial compression,
tamponade
Oscillation point of JVP: find highest point of oscillation of Internal jugular vein/ point
above which IJV appears collapsed

- Measured in vertical distance above angle of louis- about 5cm away

- JVP cannot be seen with bed at 30deg- level of oscillation above jaw
- Top of IJV easily visible so can measure vertical distance from angle of louis
- Patient upright so veins are not easily discernible above clavicle
- JVP measured at >3cm above angle of louis(>8cm above atrium)= elevated
- Hypovolemic: low JVP so head of bed to be lowered (up to 0deg)
- Hypervolemic: JVP high so elevate bed (up to 90deg)

Procedure
-

Changes over lifespan

Mumurs are not always a sign of disease

- cervical systolic murmur my be normal in children but a concern for atherosclerosis

in adults
- jugular venous hum can be heard up until young adulthood

concerning symptoms with murmurs

- chest pain
- palpitation
- shortness of breath(dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea)
- oedema
 - syncope
examination

- always exclude Angina pectoralis, Myocardial Infarction, dissecting aortic aneurysm

and pulmonary embolus
- acute coronary syndrome: clinical syndromes caused by acute myocardial ischaemia
(unstable angina, non-ST and ST- elevation infarction
- women over 65 more likely to report atypical symptoms: vomiting, fatigue,
paroxysmal nocturnal dyspnoea, upper back, neck and jaw pain
- chest pain with absence of coronary artery disease on angiogram: microvascular
coronary dysfunction, abnormal nocioception
- anterior chest pain, tearing/ripping and radiating to back/neck: acute aortic
dissection
- transient skips and flip-flops: possible premature contractions
- rapid regular beating of sudden onset and offset: supraventricular tachycardia?
- Rapid regular rate<120bpm (gradual start and stop): sinus tachycardia?
- Sudden dyspnoea: pulmonary embolus, spontaneous pneumothorax & anxiety
- Orthopnoea and paroxysmal nocturnal dyspnoea: left ventricular heart failure &
obstructive Lung disease
- Oedema:
cardiac= right/left ventricular dysfunction/pulmonary hypertension
pulmonary= obstructive lung disease
nutritional= hypoalbuminemia
positional
- Dependent oedema appears in feet& lower leg when sitting, in sacrum when bed
ridden. Anasarca= severe generalised oedema(sacrum + abdomen)
- Periorbital puffiness(eyelids)+ tight rings= nephrotic syndrome
- Enlarged waist line= ascites and liver failure

Ideal Cardiovascular Health (All of These)

● Physical activity at goal: ≥150 minutes/week moderate intensity, ≥75 minutes/ week
vigorous intensity, or combination
●Total cholesterol <200 mg/dL (untreated) ● Abstinence from smoking
● BP <120/<80 (untreated) ● Healthy diet
● Fasting glucose <100 mg/dL (untreated)
● Body mass index <25 kg/m2
Screening:
1. Begin routine screening for individual/global risk of cardiovascular diseases and
family history of premature heart disease
2. Calculate 10 year and lifetime CVD risk on online calculator(40-79yo)
3. Track individual risk factors: diabetes, hypertension, dyslipidemias, metabolic
syndrome, smoking, family history and obesity
Hypertension:

- Primary: age, ex, black,obesity, weight gain, excessive salt intake, physical inactivity,
excessive alcohol
- Secondary: sleep apnoea, chronic kidney disease, renal artery stenosis, medication,
troid disease, parathyroid disease, Cushing syndrome, hyperaldosteronism,
pheochromocytoma, coarctation of aorta
Diabetes:

- Screening from 45yo then every 3yrs or if BMI over 25

Dyslipidaemias:

Metabolic syndrome:

Physical examination:
● Describe the chest wall anatomy
and identify the key listening areas.
● Evaluate the jugular venous pulse,
the carotid upstroke, and presence or absence of carotid bruits.
● Palpate and describe the PMI.
● Auscultate S1 and S2 in six positions from the base to the apex.
● Recognize the effect of the P-R interval on the intensity of S1.
● Identify physiologic and paradoxical splitting of S2.

● Auscultate and recognize abnormal sounds in early diastole, including an S3 and OS of

mitral stenosis.
● Auscultate and recognize an S4 later in diastole.
● Distinguish systolic and diastolic murmurs, using manoeuvres when needed.
● Evaluate and interpret a paradoxical pulse.

1. JVP
2. Carotid pulse: valuable info about regurgitation and aortic valve stenosis
- Kinked carotid artery= unilateral pulsatile bulge
- Decreased pulsation: less SV, atherosclerotic narrowing/occlusion
- Small/weak pulse: cardiogenic shock
- Bounding: aortic regurgitation
- Delayed upstroke: aortic stenosis
Pulsus Alternans:

- Loud and soft Korotkoff/doubling of heart sound- accentuated in upright position

- Difference of 10-12mmHg between highest & lowest systolic(during inspiration)=
paradoxical pulse= acute asthma/obstructive pulmonary disease ( pericardial
tamponade, constrictive pericarditis, acute pulmonary embolism)

Arterial pulse abnormality Description Causes

Cardiac examination

Palpate
Heaves & lifts: use palm, hold finger pad flat/obliquely against the chest. Will lift your
fingers if present (enlarged ventricle/atrium, ventricular aneurysm)
Thrills: press ball of hand firmly on chest to check for buzzing/vibration caused by turbulent
flow. If present auscultate for murmur in same area
S1&S2: right hand on chest wall, palpate carotid upstroke with left index and middle fingers
(before and after upstroke)
S3&S4: palpate cardiac apex with light pressure to detect extra movement
Apical pulse(PMI): supine or in left lateral decubitus position. Max exhalation and stop
breathing helps- measure

- Location: patient supine, locate ICS(5th/4th ).

 Horizonal location- from mid sternal line or mid clavicular line(midpoint of
sternoclavicular and acromioclavicular joint)
- Diameter: about 2.5cm in supine patient, occupies only one interspace
 >3cm= left ventricular enlargement, >4cm= left ventricular overload 5x more
likely
- Amplitude: brisk, tapping, diffuse or sustained and duration

Location (interspaces and relation to midclavicular line) and timing(in relation to S1 & S2 is
important

- S1 louder than S2 at apex(M area), S2 louder at base

- Sounds coinciding with upstroke of carotid pulse= systolic and vice versa

Variation of splitting S2(at P area with bell)

- Physiologic= max separation between aortic and pulmonic component at peak

inspiration
- Paradoxical- max separation at peak expiration- aortic stenosis, left bundle-branch
block = aortic valve closure delayed until after pulmonic valve
S3 Gallop

- Occurs early in diastole- normal in young and athletes, sign of congestive heart
failure in elderly
- Sudden deceleration of blood flow from atrium to left ventricle
- S1 quieter, S2 louder, S3 is low frequency sound (auscultate with bell)

S4 Gallop

- Late diastole, just before S1- S1 decreased, S2 increased with intensity

- Increased stiffness of left ventricle
- Coronary heart disease, aortic stenosis, essential hypertension
- Low frequency sound- never heard with atrial fibrillation

Summation (S3,S4) Gallop at 120bpm

- Rapid heartbeat= compression of diastole= merging S3 and S4

Innocent murmurs

- S2 & S2 are normal, diastole is silent

- Short duration and mid-range frequency
- Pregnancy, hyperthyroidism, exercise and anaemia
- Best auscultated in pulmonic area, increase intensity with inspiration
(bell/diaphragm)
Exercise 120bpm(treadmill test)

- Louder S1
- Stress, hyperthyroidism and elevated temperatures
- Mitral area, use diaphragm

Lung examination
I. Inspection
 At 10th rib
Inhale and
exhale

II. Palpation (ask patient to say 99)

Tactile fremitus- palpable vibration of voice through chest wall

- Vibration should be symmetrical and decreases down the chest

- Weak or absent over precordium
Asymmetry: consolidation, emphysema, pneumothorax, pleural effusion
Faint or absent in upper thorax: obstruction of bronchial tree, fluid, obesity

III. percussion

IV. auscultation
-
- normal(vesicular) breath sounds louder and longer on inspiration
- bronchial breath sounds hollow and audible throughout expiration
- adventitious sounds are sounds added on top of breath sounds:
 wheezing: high pitch hissing sound
 Rhonchi: continuous, low pitched, snoring noise
 Crackle: intermittent, high pitch(note volume, pitch, duration, number, timing,
location, persistence, alteration on position change)
Presentation that warrants respiratory exam: dyspnoea, cough, chest pain, wheezing
The nervous system
Concerning signs
1. Headache
 Primary or secondary
 Subarachnoid haemorrhage= worst headache of my life
 Dull, affected by manoeuvres & in same location = mass lesions (tumour)
2. Dizziness/ Vertigo
 Due to palpitations
 Near-syncope from vasovagal stimulation
 Low blood pressure, febrile illness
 Benign positional vertigo
 Meniere’s disease
 Brainstem tumour
 double vision=(diplopia), Difficulty forming words (dysarthria), ataxia= stroke
& transient ischaemic attack (TIA)
3. Syncope/near syncope, loss of consciousness
 Young, emotional stress with flushing, warmth and nausea= vasovagal
syncope (slow on-set, slow off-set)
 Older: cardiac syncope from dysrhythmias more common (sudden onset and
offset)
4. Seizures
 Tonic-clonic motor activity, incontinence & postictal state (tongue biting &
bruising)
 Abnormal feelings, thought processes and sensations?
5. Tremor, involuntary movements
6. Generalised proximal weakness
 Bilateral proximal weakness= myopathy
 Bilateral (distal) weakness= polyneuropathy
 Worsened by effort, alleviated by rest = myasthenia gravis
 Loss of sensation, paraesthesia (peculiar sensation, no obvious stimulus),
dysesthesias (disordered sensations to stimulus) = brain & spinal cord lesions,
peripheral sensory roots and nerves disorders

Cranial nerve Numbe Function

 r
Olfactory I Sensory: smell
Optic II Sensory: vision
Oculomotor III Motor: pupillary constriction, lid elevation, most extraocular
movements

Trochlear IV Motor: downward internal movement of eyes

Trigeminal V Motor: temporal & masseter muscles, lateral pterygoid’s

Sensory: facial (mandibular, maxillary, ophthalmic)
Abducens VI Motor: lateral deviation of eyes

Facial VII Motor: facial expression, closing eyes & mouth

Sensory: taste- anterior 2/3 of tongue

Acoustic VIII Hearing and balance

Glossopharyngeal IX Motor: pharynx

Sensory: posterior eardrum & canal, pharynx, posterior
tongue(taste)

Vagus X Motor: palate, pharynx, larynx

Sensory: pharynx, larynx

Spinal accessory XI Motor: sternomastoid & upper portion trapezius

Hypoglossal XII Motor: tongue

Cranial Test Possible findings

nerve
I Ask to smell and identify something with eyes Lost in frontal lobe lesions
closed
II Assess acuity Blindness
check visual fields Hemianopsia
inspect optic disc Papilledema, optic atrophy
II, III Pupillary reaction to light (if abnormal test Blindness, CNIII paralysis, tonic pupils,
reaction to near effort) Horner’s syndrome
III, IV, VI Assess extraocular movement (head still move Strabismus from nerve paralysis,
eyes) nystagmus, intranuclear
ophthalmoplegia
V Test pain and light touch sensation
 Motor/sensory loss= lesion CN
(1) Oph
V/higher motor pathway
thal
mic
(2) Max
illar
Feel contraction of temporal and masseter
muscles
Check corneal reflexes (touch cornea with
cotton)
VII Raise both eyebrows, frown, close eyes tightly, Weakness from lesion of peripheral
show teeth, smile & puff out cheeks nerve (bell’s palsy), of CNS (stroke)
Facial paralysis
VIII Hearing of whispers, if decreased: Conduction loss- lateralisation to
- Rinne test: compare air and bone affected ear BC > AC
conduction sensorineural loss lateralisation to
- Weber test: test for lateralisation affected ear AC > BC
IX, X Observe Difficulty swallowing Weakened palate/pharynx
listen to voice Hoarseness/nasality
watch soft palate rise with “ah” Palatal paralysis in CVA
test gag reflex on each side Absent reflex often normal
XI Trapezius muscle: assess bulk, involuntary Atrophy, fasciculations, weakness
movements and strength of shoulder shrug Weakness when head turns to
Sternomastoid muscles: asses strength as head opposite side
turns against your hands
XII Listen to patient’s articulation Dysarthria from damaged CN XII/X
Inspect resting tongue Atrophy, fasciculations = ALS, stroke
Inspect protruded tongue Deviation to weak side = contralateral
CVA
MOTOR SYYSTEM

Testing Technique Possible findings

Body positioning Observation body positioning in motion & Hemiplegia = stroke
at rest
Involuntary If present: location, rate, rhythm, quality, Tremors, fasciculation, tics, chorea,
movements amplitude & setting athetosis, oral-facial dyskinesias
Muscle bulk and tone Inspect contours Atrophy of bulk
Assess resistance to passive stretch of Disorders of muscle tone
arms & legs Spasticity, rigidity, flaccidity of tone
Muscle strength
Peripheral radial nerve damage;
central stroke/multiple sclerosis (if
hemiplegia)
Weak grip= cervical radiculopathy;
Elbow flexion(C5,6)- biceps de Quervain’s tenosynovitis; carpal
Elbow extension(C6,7,8)- triceps tunnel syndrome
Wrist extension(C6,7,8)- radial nerve Weak= ulnar nerve disorders
Grip (C7,8, T1) Weak = carpal tunnel syndrome

Finger abduction (C8, T1)- ulnar nerve

Thumb opposition (C8, T1)- median nerve
Trunk: flexion, extension, lateral bending
Hip flexion (L2,3,4)- Iliopsoas
Hip extension (S1)- gluteus maximus
Hip adduction (L2,3,4)- adductors
Abduction (L4, 5, S1) gluteus Medius &
minimus
Knee extension (L2,3,4) quadriceps
Knee flexion (L4,5, S1,2)- hamstrings
Ankle dorsiflexion (L4,5)
Ankle plantar flexion (S1)
Coordination Rapid alternating movements in arms & Clumsy, slow movements =
legs cerebellar disease
Point to point movement (finger to nose,
heel to shin)
Gait: CVA, cerebellar ataxia,
walk away, turn and come back parkinsonism/ loss of position
walk heel to toe sense
walk on toes, heels Ataxia
hop on each foot, 1 leg shallow knee Corticospinal tract injury
bends Proximal hip girdle weakness
stance: increases risk of falls
Romberg test
Pronator drift (arms forward, eyes closed)
+ve= poor position sense
Flexion & pronation at elbow and
downward drift= contralateral
Ask patient to keep arms up and tap them corticospinal tract lesion
downward Weakness, incoordination, poor
position sense
Sensory system

Sharp and dull sensation Test sharp and dull Hemisensory loss pattern=
sensations, compare sides contralateral cortical lesion
Pain Compare proximal and Dermatomal sensory loss=
distal arms and legs herpes zoster, nerve root
Sharp end of pin and dull compression
end Analgesia, hypalgesia,
hyperalgesia
Temperature Test tube with hot and cold Temperature and pain
water usually correlate
Light touch Use fine wisp of cotton Anaesthesia. hyperesthesia
Vibration sense Low pitch tuning fork 128Hz Peripheral neuropathy
Tap and place on distal Increases likelihood of
interphalangeal joint of peripheral neuropathy 16
finger then toe. folds
- What do you feel?
- Tell me when the
vibration stops
If impaired- move to more
bony areas
Position sense Grasp big toe, show “up” & Posterior column disease:
“down” Tabes dorsalis, multiple
Ask to say up or down with sclerosis or B12 deficiency
closed eyes Diabetic neuropathy
Move to ankle if impaired
Also fingers (wrist, elbows)
Discriminative sensation Useful only when touch
and position not/slightly
impaired
Stereognosis: distinguish Astereognosis
heads from tail of coin
Number identification: trace Graphanesthesia= lesion
number on palm sensory cortex
2 point discrimination: Sensory cortex lesion:
touch 2 point at same time, distance between 2 point
alternate 1 point touch increased
Point localisation:
Extinction: stimulate 1/both Sensory cortex lesion:
side, ask where touch was stimulus on side opposite to
felt damage = absent
Reflexes
Dermatome: band of skin innervated by the sensory root of a single nerve spinal nerve
C2= ear C3= front & back neck T4= nipple C6= thumb & half inner arm C8= ring and little
finger L1= Inguinal L4= knee L5 = anterior ankle and foot S5= perianal

Symmetrically diminished reflex- used reinforcement (isometric contraction of other

muscles for up to 10s)

Biceps(C5,C6) Partially flex elbow Hyperreflexia : CNS lesion of

Forearm pronated, palms descending corticospinal
(sitting/surpine) down tract
Place finger on bicep tendon - look for upper motor
Strike finger with hammer neuron findings- weakness,
spasticity/+ve Babinski sign
Hyporeflexia: lesion of
spinal nerve root, spinal
nerve, plexus or peripheral
nerves
- Look for lower
motor unit disease-
weakness, atrophy
and fasciculations
Triceps (C6, C7) Flex arm at elbow, palms
(sitting/supine) toward body
Tap tendon with hammer
Watch for tricep
contraction/extension at
elbow
Brachioradialis/Supinator Rest hand on abdomen/lap,
(C5,C6) forearm partly pronated
Hold wrist, strike radius
with point/flat edge (1-2cm
above wrist)
Watch for flexion and
supination of forearm
Quadriceps/Knee (L1,2,3) Knee flexed
Tap patellar tendon
Watch contraction of quad
& knee extension
Achilles/Ankle (S1) Sitting: Slowed relaxation phase in
 Dorsiflex ankle hypothyroidism
Watch and feel for plantar
flexion at ankle
Supine:
Flex leg at hip & knee,
rotate externally so lower
leg rests on opposite shin
Dorsiflex at ankle the strike

Check for ankle clonus if hyperactive reflexes

- support knee in partially flexed position
- dorsiflex and plantar flex foot a few time
- sharply dorsiflex foot and maintain in that position
- look and feel for rhythmic oscillation between dorsiflexion and plantar flexion
sustained= CNS disease- ankle dorsiflexes and plantarflexes repetitively & rhythmically
sharp downward displacement of patellar= patellar clonus in extended knee
Cutaneous stimulation reflexes
Abdominal reflexes Lightly & briskly stroke each Absent in CNS & PNS
(T9,10,11,12) side of abdomen disorders
Note movement of muscles
and umbilicus toward
stimulus
Plantar response (L5, S1) Stroke lateral aspect of sole, Dorsiflex of big toe=+ve
from heel to ball, curve Babinski response
medially along ball - transiently +ve in
Observe plantar flexion of unconscious state
pic toe from alcohol/drug &
during postictal
period, after seizure
- marked response
can be accompanied
by reflex flexion at
hip & knee

Anal reflex Lightly scratch anus on both Loss= lesion in S2-3-4 reflex
sides arc (cauda equina lesion)
Watch for reflex contraction
of external anal sphincter
(finger in anus helps)

Special test

Meningeal sign Neck mobility/nuchal rigidity: Neck stiffness= Acute bacterial

- check there’s no injury to cervical vertebrae meningitis/subarachnoid
 & cord haemorrhage
- flex neck forward (until chin to chest)

Brudzinski sign:
- watch hips and knees when you flex neck
Flexion of hips and knees= +ve
Kernig sign:
Pain & increased resistance to
- flex leg at hip and knee
knee extension= +ve
- slowly extend leg and straighten knee (irritation/compression of sacral
& lumbar nerve roots=
radicular/sciatic pain extends to
leg when nerve stretched)
Lumbosacral Straight leg raise Herniated disc= Compression
radiculopathy: - quality & distribution of pain spinal nerve root= painful
straight leg raise - effect of foot dorsiflexion radiculopathy with muscle
(less weakness, dermatomal sensory
sensitive/specific in loss
patients with - herniation mostly at L4-
sciatica) 5, L5-S1)
pain radiating in ipsilateral leg=
+ve

pain when contralateral healthy

leg raise= +ve crossed straight-
leg raise sign
Asterixis Sudden brief, nonrhythmic flexion of hands & fingers Suggest metabolic
followed by recovery encephalopathy when mental
Ask patient to stop traffic with both hands function impaired
Watch for 1-2mins Caused by abnormal
diencephalic motor centres that
regulate agonist/antagonist
muscle tone & maintain posture
Winging of scapula Inspect when shoulder muscles seem weak Medial border of scapula juts
Extend hand an push against yours/wall backward= winging
Observe scapula
Stuporous/comatose Take pulse, BP & rectal temperature
patient Establish level of consciousness
Neurologic exam Lethargy, obtundation, stupor,
coma
 Cheyne-stokes, ataxic
Asymmetric if structural
lesion/brain herniation
Deviation to affected side =
hemisperic stroke
Intact brainstem- eyes move left
Very seep coma/lesion in mid-
brain/PONS- eyes do not move
Conduct neurological exam, looking for asymetric Decorticated rigidity,
findings decerebrate rigidity, flaccid
- breathing hemiplegia
- pupils
- ocular movements Flaccid hand= droops to
horizontal
oculocephalic reflex : Flaccid arm= drops more rapidly
hold eyelids open, turn head quickly L & R Flaccid leg= drops more rapidly
flex & extend neck eyes will be turned to right Flaccid leg= falls into extension
& external rotation
note body posture

Test for flaccid paralysis :

- hold wrist vertically, note positions
- drop arms from 12-18 inches above bed
- extend both knees, extend each knee and let
drop to bed
- from 12-18 inches above bed drop both legs