Cerebellar exam - UMED

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1

(Revised 2/2004)

Physical Diagnosis


Second Year


Physical Examination Sequence (Regional Approach)


1.

Introduction (if not previously accomplished) in a friendly manner.

a.

Refer to patient by Mr., Mrs., Miss and last name, clarifying pronunciation, if
necess
ary.

b.

Shake hands.

2.

Explain purpose of exam


to gather additional information on health status by
thorough examination that should take ____ minutes. Explain that questions (from
the patient) are welcome now and at any point throughout the exam.

3.

Assure pat
ient comfort


eg.
Need to use rest room, telephone, etc.

4.

Optimize lighting


favor natural over fluorescent.

5.

Assure privacy


close door, draw curtains.

6.

Wash hands in presence of patient.

7.

Optimize bed position


raise if necessary; put down rails.

8.

Lay out

equipment sequentially:

BP cuff

Otoscope, ear specula, 512 Hz tuning fork

Penlight, tongue blade

Ophthalmoscope,


Snellen chart

Reflex hammer, 128 Hz tuning fork, tongue blade for sensory testing,


10 g
monofilament (used in patients with diabetes melli
tus).

Cup of water for thyroid exam

Ruler (cm)

Glove, lubricant, guaiac card, guaiac solution

9.

Patient properly gowned (most useful approach)

Gown with open side in back



underwear depending on extent of exam

Additional bed sheet available

10.

Height, weight,
temperature previously measured by staff

11.

Assessment of
general appearance

from first contact with patient:

Gender


Apparent age

Body habitus

Any respiratory distress

Presence/extent of pain (1
-
10 scale, as indicated by patient, where 1 = barely
noticeable

and 10 = worst pain imaginable or experienced)


this may have
been previously determined by staff.

Specific identifying features

Level of consciousness if abnormal

Skin if abnormal

Posture, movements if abnormal

Speech

Behavior


2

Hygiene, odors


PROVIDE FE
EDBACK/DIRECTION TO PATIENT DURING EXAM AS TO EXAM
SEQUENCING AND POSSIBLE FINDINGS


PATIENT SEATED in chair with back supported, feet flat on floor (legs not crossed).

EXAMINER FACING PATIENT

12.

Palpate both radial pulses with index finger simultaneously for

a few seconds to
confirm equal pulse volume, then count rate for at least 30 seconds in one radial pulse
(multiply by 2), noting any irregularities. Characterize the rhythm as regular,
regularly irregular, or irregularly irregular. If pulse is irregular
ly irregular, use
stethoscope to count the cardiac apical rate for 30 seconds.

13.

Count respiratory rate unobtrusively while ostensibly measuring pulse rate, observing
chest if patient in sitting position (chest or abdomen if patient in supine position) for
3
0


60 seconds.

a.

Assess for nasal flaring in patients with cardiopulmonary disease.

14.

Measure BP in both arms (need to determine maximal inflation pressure in one arm
only).

a.

Proper patient preparation (comfortable environment, removal of sufficient
clothing,
and appropriate timing relative to stimulant or food intake).

b.

Optimal patient position: seated, back supported in straight
-
back chair, arm
supported by arm
-
rest or examiner so that midpoint of BP cuff at heart level, feet
flat on floor.

(1)

Measure supine BP
if patient unable to sit; be sure midpoint of BP cuff at
heart level.

(2)

Measure supine and standing BP later in exam if sitting BP is elevated.

c.

Appropriate cuff size for arm circumference.

d.

Appropriate cuff placement (bladder center over brachial artery and 2
.5 cm above
elbow crease); cuff should not touch stethoscope.

e.

Determine maximum inflation level (systolic BP by palpation


30 mm Hg).

f.

Determine BP by auscultation, using bell of stethoscope, rapidly inflating cuff to
maximal inflation pressure, deflating
at 2 mm Hg/sec., recording Korotkov I and
V phases, rounded up to nearest 2 mm Hg. (record Korotkov phase IV


muffling


if sounds continue to very low diastolic values).

g.

If blood pressure elevated to
>

140/90 mm Hg (or


130/80 in patients with
diabetes
or chronic kidney disease), recheck BP in supine and standing position.

h.

Thyroid exam: prior to exam explain that thyroid gland will be examined and that
there may be some mild discomfort

(1)

Identify landmarks:

Thyroid cartilage (Adam’s Apple)

Cricothyroid me
mbrane (site of emergency tracheostomy)

Cricoid cartilage (isthmus of thyroid located just below)

(2)

Inspect lower neck for visible gland, enlargement, asymmetry at rest
and during swallow, optimally with H
2
O

PATIENT SEATED

EXAMINER MOVES BEHIND PATIENT


3

(3)

Exami
ne thyroid using posterior approach

(a)

First, palpate both lobes of thyroid simultaneously both at rest
and during swallow

(b)

Then, palpate each lobe individually at rest and during swallow


MOVE PATIENT FROM CHAIR TO EXAM TABLE

15.

Examination of hands, wrists, elb
ows

a.

Inspect dorsum of hands for clubbing cyanosis, joint inflammation; then
inspect palmar side.

b.

MCP squeeze test across MCP finger joints.

c.

Assess range of motion:

(1)

Make a fist (finger flexion)

to examine MCP joints in detail).

(2)

Make a claw (finger flexion t
o examine PIP and DIP joints in detail).

(3)

Prayer sign (finger extension)

(4)

Wrist flexion and extension during passive (examiner
-
assisted) movement.

d.

Elbow extension to 0


and flexion to 145


e.

Palpate for epitrochlear lymph nodes, rheumatoid nodules, or tophi in

appropriate sites.

16.

Palpate in the axillae bilaterally for lymphadenopathy.

17.

Examine shoulder ROM

a.

Place hands behind head

b.

Place hands behind back as high as possible.

18.

Examine neck ROM


touch each ear to shoulder on same side, achieving 30
-

60


of
range.

19.

P
artial neurologic exam in sitting position. (Alternatively, the entire neurologic exam
can be done as a single maneuver at another time in the physical exam.)

Cranial Nerves

a.

Observe for ptosis

b.

Check ocular motility in 6 cardinal directions for weakness and

nystagmus

c.

Test peripheral visual fields by confrontation

d.

Test masseter muscle on both sides
or

test corneal reflexes or test facial sensation

e.

Observe facial symmetry:

Raise eyebrows

Close eyes against resistance

Puff up cheeks

f.

Test sternocleidomastoid st
rength rotating head against resistance in each
direction
or

elevating shoulders against resistance

g.

Protrude tongue in midline. Check strength of R, L tongue protrusion into R,
L cheeks

Motor strength:


Observe for atrophy, involuntary movements

h.

Plantar f
lex feet against resistance

i.

Dorsiflex feet against resistance

j.

Extend knees against resistance

Flex knees against resistance

k.

Flex each hip against resistance


4

(Alternatively, lower extremity motor strength may be assessed by asking the
patient to walk on toe

tips, walk on heels, and do a squat toward the end of the
exam.)

l.

Check bilateral grip strength

Check lumbricals, interossei


abduct and adduct fingers against resistance


m.

Check wrist strength for flexion and extension

o.

Check bilateral biceps flexion st
rength

p.

Check triceps strength

p.

Shrug shoulders against resistance

Cerebellar exam:

q.

Bilateral finger to nose

r.

Bilateral heel to shin

Deep tendon reflexes:

s.

Biceps


Triceps


Brachioradialis


Knees


Ankles


Plantar responses

Sensory exam:

t.

Test vibration at
R, L 1
st

MTP with 128 Hz tuning fork

u.

Test position sense at great toes

20.

HEENT exam

a.

Inspect scalp for skin lesions, trauma, hair pattern

b.

Use penlight or neck of otoscope light (otoscope light may not be sufficiently
bright with some otoscopes):

1)

Assess pupill
ary size, roundness, reactivity to light directly and
consensually

2)

(a)

Inspect sclerae and conjunctivae, depressing lids slightly to see
palpebral conjunctivae

(b)

Use oblique light to visualize cornea and anterior chamber

(c)


Ask patient to close eyes to

determine adequacy of closure.


3)

Examine oropharynx using tongue blade and light:

(a)

Check lips, gums, teeth, beneath tongue, sides of tongue, lateral
walls of cheeks for any abnormalities

(b)

With tongue remaining in mouth (i.e., do not protrude tongue),
place t
ongue blade in middle third of tongue, pressing down
and slightly posteriorly:

1.

Inspect pharynx, tonsillar areas

2.

Check phonation and observe palate for symmetric
elevation; may facilitate by having patient inspire
quickly

(c)

Ask patient to protrude tongue
looking for lateral movemen


c.

Ear exam: explain to patient what will be done during ear exam

(1)

Inspect pinna for skin lesions, especially skin cancers/pre
-
cancers

(2)

Use otoscope with maximal illumination and largest speculum that
will fit in ear; should be cle
an speculum

(3)

Pull pinna with opposite hand up and back with thumb, forefinger

(4)

Insert speculum


otoscope with same
-
side hand under direct vision
and adjust angle as move forward to see drum. Maintain ulnar border

5

of hand firmly applied to patient’s head to

stabilize it against sudden
movement

(5)

Discard speculum in sight of patient

(6)

Test auditory acuity on each side using finger rub at arm’s length; if
abnormal, repeat at 6 inches.

d.

Nasal exam:

(1)

Examine external structures of nose

(2)

Test each side for patency by
compression of other side

(3)

Inspect nasal mucosa, turbinates using otoscope with
new

speculum,
looking straight back and upwards at turbinates

(4)

Discard used speculum in sight of patient

e.

Visual acuity/ophthalmoscopic exam

(1)

Test visual acuity of each eye sepa
rately with pocket screener at 14
inches

(2)

Ophthalmoscopic examination

(a)

Explain exam to patient

(b)

Darken the room, but not total darkness

(c)

Ask patient to focus on a single spot and try not to blink

(d)

Assess red reflex

(e)

Examine retina/optic disc

(f)

Examine macula/savea

by asking patient to look directly into
light

21.

Neck Exam (upright position)

q.

Lymph node palpation bilaterally

(1)

Pre
-
auricular

(2)

Post
-
auricular

(3)

Occipital

(4)

Posterior cervical

(5)

Submandibular

(6)

Submental

(7)

Anterior cervical

(8)

Supraclavicular


caution patient there may be
mild discomfort

(9)

(Axillary
-
epitrochlear
-

done previously)

(10)

(Inguinal
-

done later)

r.

Tracheal exam

(1)

Assess mid
-
line position: palpate with index finger pushed straight
back in sternal notch.

s.

Accessory muscle use


note any accessory muscle use of sternocleidom
astoids or
scalenus medius (just above clavicle in supraclavicular fossa)


22.

Chest exam

a.

Assess symmetry of posterior chest from a central point above the seated
patient

(1)

Note kyphosis, scoliosis


6

b.

Assess diaphragmatic movement: palpate lower posterior rib cage

with
thumbs 1 inch away from and parallel to the spine with fingers parallel to ribs
and ask patient to take deep breath.

c.

Percuss alternate sides of the posterior chest from just above the scapulae
caudad to the point where dullness begins, looking for as
ymmetry

d.

Percuss diaphragmatic movement (normal = 4

5 cm) for both left and right
sides

(1)

Deep inspiration and hold

(2)

Percuss to dullness

(3)

Full exhalation and hold

(4)

Percuss to dullness

(5)

Measure distance between sites of dullness

e.

CVA tenderness


palpate deeply in

bilateral soft tissue below junction of
posterior costal margin and spine

f.

Auscultate posterior chest side
-
to
-
side, 2 breaths/site with mouth open and
deep inspirations (instruct patient by example)

(1)

Apices

(2)

Upper posterior lung zone

(3)

Mid
-
zone medial to scapu
la

(4)

Lower lung zones

g.

Auscultate lateral chest wall in axillae and at lower site toward lung bases (ie,
high axillary low axilla)


PATIENT SEATED

EXAMINER MOVES TO FACE PATIENT AGAIN


Expose chest of male patients

23.

Inspect anterior chest wall for asymmetry,
pectus excavatum, carinatum

a.

Anterior percussion at 2 sites above and below the nipple line in males.

24.

a.

Ask patient to lean forward, exhale fully, and stop breathing while you listen
with diaphragm of stethoscope at lower left sternal border, 4
th

ICS (l
istening
for aortic insufficiency). This lets patient rest to avoid hyperventilation from
auscultation of breath sounds.


b.

Auscultate anterior chest wall over RUL, LUL, RML, and lingula, 2
breaths/site with mouth open and deep inspirations (you will be
auscultating
above and below the nipple line in males).


PATIENT LIES ON BACK, HEAD OF BED at 30


ANGLE (You may need to adjust this
angle up or down to see neck veins; if you suspect the patient does
not

have heart
failure, adjust the angle downward; if y
ou suspect the patient may have heart failure,
adjust the angle upward.)

EXAMINER ON PATIENT’S RIGHT SIDE

25.

Assess jugular venous pulsations and pressure, focusing first on the right internal
jugular; you may use right external jugular if internal jugular no
t visible.

a.

Estimate JVP height in cm


PATIENT SUPINE, BED FLAT


7

EXAMINER ON PATIENT’S RIGHT SIDE

26.

Auscultate carotid arteries for bruits with light pressure on stethoscope at 2 sites
between angle of jaw and base of neck on R and L (ask patient to briefly

stop
breathing during the period of auscultation


remind him/her to breathe again as soon
as you complete auscultation of each artery).

27.

Palpate carotid arteries (turn head slightly to opposite side to facilitate)
for no more
than 5 seconds

to characteriz
e: a) upstroke velocity, b) pulse amplitude and volume,
and c) pulse contour.

28.

Inspect chest:

a.

Symmetry of R and L chest from head or front of bed


MOVE PATIENT TO SUPINE POSITION

29.

Inspect left precordium for visible cardiac impulse(s)

30.

Breast exam


this exa
m always requires a chaperone.

31.

Precordial palpation

a.

Check for precordial thrills with fingers in interspaces:

(1)

R second intercostal space (aortic area)

(2)

L second intercostal space (pulmonic area)

(3)

L third intercostal (Erb’s point)

(4)

L fifth intercostal space (t
ricuspid area)

b.

Place heel of R hand in mid L parasternal region, depressing area 1.0


1.5 cm
to detect upward systolic movement of RVH, grade as absent or as present.

c.

Place distal finger pads at visualized apical impulse or 5
th

ICS, MCL. If
needed, move
about “peri
-
apical impulse” area to find apical impulse. Record
location, size, duration or absence of apical impulse.

(1)

If no apical impulse, consider percussion from anterior axillary line
medially to detect dullness representing L cardiac border.

32.

Auscult
ate precordium

a.

Place diaphragm of stethoscope at over apical impulse. Listen for S
1

and S
2

and their characteristics, listen for extra heart sounds and murmurs. Then
auscultate this site with bell.

b.

Auscultate with diaphragm and bell in tricuspid area

c.

Aus
cultate with diaphragm at Erb’s point and in pulmonic and aortic areas.

d.

If unable to palpate apical impulse, roll patient to left lateral decubitus
position, supporting patient with left elbow, attempt to find PMI again, then
listen with both bell and diap
hragm.

33.

Abdominal examination

a.

Position patient properly:

(1)

Supine

(2)

Arms at sides

(3)

If needed for relaxation, flex hips and knees resting feet on exam table
or bed

(4)

Abdomen must be sufficiently exposed for inspection

b.

Inspect:

(1)

Cutaneous abnormalities

(2)

Visible pulsat
ions, especially in epigastrium


8

(3)

Contour

(4)

Hernias

c.

Auscultate, depressing skin 1 cm with diaphragm

(1)

Bowel sounds (pitch, frequency)


can listen for bowel sounds in same
sites as for bruits

(2)

Bruits:

(a)

Epigastrium (aorta)

(b)

2 inches superior from umbilicus, then 2
inches laterally to
auscultate right and left renal arteries

(c)

Midway between umbilicus and midpoint of inguinal ligaments
on both right and left for iliac arteries

d.

Percuss four quadrants of abdomen briefly for tenderness or unexpected
dullness

e.

Light palpati
on in four quadrants, depressing skin 1 cm

f.

Deep palpation in four quadrants to a depth that patient comfort will allow;
facilitate by palpating more deeply during exhalation, leaving hand still during
inspiration

g.

Examine liver:

(1)

Percuss from 2
nd

interspace
caudad along MCL until reach dullness
(usually 7
th



8
th

ICS) and continue percussing until tympanitic; mark
upper and lower margins and measure total span

(2)

Palpate inferior liver edge:

(a)

Proceed cephalad from R iliac fossa

(b)

Hold palpating hand steady during i
nspiration

(c)

Move cephalad in increments during expiration

(d)

Note tenderness, nodularity, and pulsatility if the liver is
palpated

h.

Examine spleen:

(1)

Percuss continuously during deep inspiration and exhalation at
Castell’s spot in lowest intercostal space at ante
rior axillary line


dullness indicates possibility of splenomegaly

(2)

Palpate from RLQ progressively toward LUQ; hold palpating hand
steady during inspiration; move in increments toward LUQ during
expiration until reaching palpable spleen or L costal margin

(3)

Consider

(in patients especially at risk for splenomegaly, or if
uncertain whether spleen was palpable) moving patient into R lateral
decubitus position and repeating palpation technique to increase
sensitivity of exam

i.

Examine aorta:

(1)

Locate aortic pulse wi
th flat palm in epigastrium

(2)

Orient both hands vertically on either side of midline with distal
fingers at edge of pulsation; apply equal pressure with distal fingers
until aortic pulsations palpated; estimate lateral width between index
fingers

j.

Examine kid
neys:


9

(1)

Left hand under costovertebral angle and right hand under
anterolateral costal margin; move your right hand more deeply during
exhalation; sufficient pressure needs to be exerted as kidney is deep.
Do not need to palpate for left kidney.

34.

Examine bot
h inguinal areas:

a.

Palpate for lymph nodes

b.

Palpate femoral arteries

c.

Compare timing of right radial and right femoral arteries (looking for sign of
coarctation of aorta

d.

Auscultate femoral arteries for bruits

35.

Examine feet:

a.

Check dorsalis pedis pulses

b.

Check po
sterior tibial pulses

c.

Inspect plantar and dorsal surfaces for deformities


look at soles of feet for
callosity or other lesions

d.

Metatarsal squeeze to each foot for tenderness

e.

In patients with diabetes, annually perform a test of protective sensation using

the 10 gm monofilament.

36.

Check for peripheral edema in foot, just above ankle, with 30


60 seconds of
continuous pressure.

37.

Palpate popliteal arteries (both hands, with thumbs meeting at tibial plateau and
finger tips of both hands searching for pulse in p
opliteal fossa.

38.

Inspect thighs, calves for asymmetry

39.

Examine knee and hip:

a.

Passively flex knee, noting any crepitance (R hand supporting foot, L hand
palpating knee)

b.

Passively flex hip to 90

. Holding foot with R hand and steadying thigh with
left hand; th
en slowly rotate lower limb outward; ie, internal rotation, (normal
is medial rotation of 30


and no pain), then rotate outward (external rotation)

c.

Passively extend knee, noting any crepitance

40.

Measure supine blood pressure in R arm now,
if

orthostatic bloo
d pressure
measurement desired,
or

if sitting BP was elevated.


PATIENTS STANDS

EXAMINER STANDS

41.

Measure BP standing,
arm supported
,
if

sitting BP was elevated

42.

Inspect patient standing:

a.

Front

b.

Side (lordosis, kyphosis)

c.

Back

-
straight spine (no scoliosis)

-
no
rmal, symmetric paraspinal muscles

normal shoulder and gluteal bulk and symmetry

level iliac crests

no popliteal swelling

no hindfoot swelling or deformity


10

43.

Ask patient to bend down and touch toes while you observe from behind

44.

Gait: observe patient

a.

Walking
away

b.

Turning

c.

Walking toward you

d.

Doing tandem gait (heel
-
to
-
toe)

e.

If you choose to assess motor strength in this way, you may also do the
following at this time:

(1)

Walk on toes

(2)

Walk on heels

(3)

Do deep knee bend

45.

Romberg exam

46.

Male hernia and genitalia exam

47.

Male re
ctal exam

Or


Female pelvic exam / rectal exam


EXAMINER BRINGS CLOSURE TO THE EXAM:

48.

Assists patient back to bed

49.

Places bed rails in up position; lower bed back to standard position

50.

Attends to patient’s comfort, eg., repositioning bedside table

51.

Asks patien
t if any questions or other needs.