check list.doc

FOUNDATION SKILLSCLINICAL CHECKLISTSReview CopyMay 2006

CONTENTSCLINICAL CHECKLISTSPAGE

1General History Taking2

2Measuring Blood Pressure for Adults7

3Measuring Oral Temperature Using a Mercury Thermometer9

4Measurement of Oral Temperature Using an Electronic Thermometer for adults11

5Measuring Axillary Temperature Using a Mercury Thermometer for adults12

6Measuring Rectal Temperature Using a Mercury Thermometer for adults14

7Measuring Tympanic Temperature for adults16

8Measuring Radial Pulse17

9Measuring Apical Pulse18

10Measuring Peripheral Arterial Pulses and Examination of Peripheral Lymph Nodes19

11Measuring the Respiratory Rate22

12Mental Status Examination (MSE)23

13Neurological Examination of the Sensory Function25

14Neurological Examination of the Motor Function28

15Examination of the Cranial Nerves32

16External Ear Examination and Otoscope38

17Fundus Examination Using Ophthalmoscope40

18Locomotor Examination of Wrist and Hand42

19Locomotor Examination of Elbow and Forearm44

20Locomotor Examination of the Shoulder Joint46

21Locomotor Examination of the Cervical Spine48

22Locomotor Examination of the Dorsolumbar Spine50

23Locomotor Examination of the Hip Joint52

24Locomotor Examination of the Knee Joint55

25Locomotor Examination of the Foot and the Ankle Joints59

26Examination of the Mouth, Salivary Glands & Temporomandibular Joints61

27Examination of the Neck66

28Chest Examination68

29Cardiac Examination71

30Breast Examination75

31Abdominal Examination77

Clinical ChecklistGeneral History Taking

(To be used by the Teacher at the end of the module)

Place a " " in case box if step/task is performed satisfactorily, an X if it is not performed satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines

Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines

Not Observed: Step or task not performed by learner during evaluation by teacher

LEARNER _____________ Date Observed _____________

STEP/TASKCASES

Getting Ready: Approach to the Patient:

1. Introduced himself with a friendly greeting.

2. Gave name and status.

3. Explained the purpose of interview.

4. Maintained good eye contact

5. Listened attentively.

6. Facilitated verbally and non-verbally.

7. Asked for background information about the patient which included:

Name

Age

Marital status and children (plus menstruation and contraception (if female)

Occupation.

Address.

Special habits of medical importance

Presenting complaint:

Began by inviting the patient to provide an account of recent events in his/her own words.

Listened without interruption

Encouraged the patient to continue the story right up to the time of interview.

History of current illness:

Established:

The principal symptom or symptoms that caused the patient to seek medical attention

When it first appeared

STEP/TASKCASES

How it has changed over time.

Asked About:

1. The main problem that made the patient want to see the doctor.

2. The time and mode of onset of the problem.

3. If the problem had changed since it first happened

4. Investigations and their results if done.

5. Treatments that have been undertaken.

6. Other symptoms of the relevant system.

Past medical history:

Asked about:

1. Any previous similar episodes.

2. Any previous investigations.

3. Local endemic diseases (hepatitis, bilharziasis.)

4. Other medical problems or conditions.

5. Any previous serious illnesses.

6. Previous hospital admissions.

7. Previous operations.

8. Previous blood transfusion.

9. Injuries or accidents in the past.

10. Travel abroad.

History of drug intake and allergies:

Asked about

1. Medications actually taken

2. Over-the-counter drugs used by the patient

3. Low-dose aspirin or Vitamins.

4. Oral contraceptive pills or HRT (hormone replacement therapy).

5. Any recent change in medications

6. If the patient usually forgets to take the tablets

7. Any side effects of the medications

8. Any Allergies.

9. Drug abuse or recreational drug use.

Family history:

Asked about:

1. Significant illness in blood relatives

2. Transmissible diseases in all contacts and relatives.

STEP/TASKCASES

SYSTEMIC INQUIRY

Asked about: Cardiac symptoms

1. Chest pain:

a. Site

b. Radiation

c. Character

d. severity

e. Duration

f. Precipitating factors

g. Relieving factors

h. Associated symptoms

2. Dyspnea, orthopnea, paroxysmal nocturnal dyspnea or dyspnea at rest

3. Cough (dry , productive)

4. Haemoptysis ( amount , relation to posture)

5. Palpitation (regular-irregular), (onset-offset).

6. Edema of lower limb (unilateral-bilateral, pitting- or non pitting).

7. Pain in right upper abdomen

8. Cyanosis

9.Symptoms of low cardiac output: syncope,

dizziness or easy fatigability

10. Hoarseness of voice or dysphagia

11. Joint pain or swelling

12. Fever, pain in left upper abdomen or embolic

manifestations

Asked about: Chest symptoms

1. Cough

a. Dry

b. Productive

2. Haemoptysis

3. Dyspnea

4. Chest pain:

a. Site

b. Radiation

c. Character

d. Duration

e. Precipitating factors

f. Relieving factors

g. Associated symptoms

5. Wheezing

6. Hoarseness of voice or dysphagia

7. loss of weight

8. Night fever, night sweating, and anorexia

STEP/TASKCASES

Asked about: GIT symptoms

1. Appetite: increased or decreased

2. Dysphagia.

3. Abdominal pain:

a. Siteb. Radiation

c. Character

d. Duration

e. Precipitating factors

f. Relieving factors

g. Associated symptoms

4. Dyspepsia, vomiting, or heart burn

5. Diarrhea, constipation or tenesmus

6. Weight loss / gain.

7. Hematemsis, melena or fresh bleeding per rectum

8. Yellowish discoloration of skin and mucus membrane

Asked about: Neurological symptoms

1. Weakness or paralysis

2. Abnormal movements

3. Parasthesia

4. Bladder disturbances

5. Headache, vomiting and blurring of vision

6. Cranial nerve affection

a. Anosmia

b. Diminution of vision

c. Diplopia

d. Loss of sensation of the face, difficulty in mastication

e. Inability to close eye or deviation of the mouth

f. Tinnitus, deafness or vertigo

g. Dysphagia, hoarseness of voice and nasal regurgitation

h. Dysarthria

7. Abnormal behavior or disorientation

8. Convulsions

Asked about: Endocrine/ reproductive system:

1. Fatigue.

2. Polyuria.

3. Weight loss or gain.

4. Heat intolerance / insensitivity.

5. Voice change

6. Skin changes &hair changes

7. Goiter.

STEP/TASKCASES

8. Eye changes

9. Menstrual history, amenorrhoea, loss of secondary sexual characteristics.

10. Impotence.

11. Abdominal cramps .

Asked about: Renal and urinary system:

1. Nocturia, frequency, dysuria

2. Urine: color, quantity

3. Haematuria

4. Stones, gravel.

5. Renal pain.

6. Colic

7. Changes in urine flow.

Asked about: Skin Conditions:

1. Itching

2. Lesions

3. Rashes: distribution, time, course.

4. Colorations

5. Hair loss.

6. Ulcers

7. Rayneolds phenomenin (color changes, swelling).

Asked about: Musculoskeletal system:

1. Joint pain, stiffness, swelling, and deformity

2. Relationship of symptoms to rest and exercise.

3. Limitations of movement.

3. Bone pain & vertebral pain.

4. Fracture from slight trauma.

Clinical ChecklistMeasuring Blood Pressure for Adults







STEP/TASKCASES

Preparing the patient:

1. Asked the patient to relax in a supine position,or instructed the patient to support the back; uncross the legs and rest the feet flat on the floor.

2. Waited for 5 minutes.

3. Prepared equipment

4. Measured the radial pulse on both sides

5. Uncovered the selected arm

6. Abducted and supinated the selected arm.

7. Chose the correct cuff size

8. Wrapped the cuff around the mid arm

9. Aligned the cuffed arm to the level of the heart

TAKING THE BLOOD PRESSURE

1. Properly placed the cuff around the upper arm

2. Properly wrapped the cuff snuggly around the inflatable inner bladder centered over the area of the brachial artery

3. Closed the valve

4. Inflated the cuff while palpating the radial pulse till the pulse was no longer felt to determine the pulse obliteration pressure

5. Deflated the cuff

6. Calculated the maximum inflation level (MIL) by adding 20-30 mm Hg to the pulse obliteration pressure.

STEP/TASKCASES

7. Properly placed the earpieces of the stethoscope into ears,with the earpiece angles turned forward toward the nose.

8. Palpated the brachial artery.

9. Applied the bell (or diaphragm in obese arm) of the

stethoscope over the brachial artery, just below the cuff, while avoiding touching the cuff or tubing

10. Closed the valve.

11. Inflated the cuff rapidly to the MIL while focusing eyes to the level of the midrange of the manometer scale.

12. Opened the valve slightly and maintain a constant rate of deflation at approximately 2mm per second.

13. Allowed the cuff to deflate

14. Listened throughout the entire range of deflation until 10mm Hg below the level of the diastolic reading

15. Fully deflated the cuff by opening the valve.

16. Removed the stethoscope earpieces from the ears.

17. Recorded the exact readings in mm Hg.

Clinical ChecklistMeasuring Oral Temperature for Adults:

1. Using a Mercury Thermometer (To be used by the Teacher at the end of the module)






STEP/TASKCASES

Getting Ready:

1. Prepared equipment (thermometer tray, mercury thermometer, disinfectant, cotton balls).

2. Explained the procedure to the patient.

3. Washed the hands.

4. Held the thermometer opposite to the bulb and removed disinfectant by rinsing with cold water.

5. Dried the thermometer by wiping it from the bulb to the stem using a firm twisting motion.

6. Shook the mercury down to 35 C using a snapping wrist motion.

Procedure:

1. Placed the thermometer in the patients posterior sublingual pocket

2. Reminded the patient to keep the lips closed

3. Waited for three to five minutes before removing the thermometer from the patients mouth.

4. Removed any secretions from the thermometer by wiping from the stem to the bulb.

5. Read the thermometer by holding it at eye

level and rotating the stem until the mercury was seen clearly.

STEP/TASKCASES

Post Procedure:

1. Put the thermometer in the disinfectant solution

2. Washed the hands

3. Recorded the results and explain to the patient.

Clinical ChecklistMeasuring Oral Temperature for Adults:

2. Using an Electronic Thermometer







STEP/TASKCASES

Getting Ready:

1- Prepared equipment (electronic thermometer)

2- Explained procedure to the patient

3- Washed the hands

4- Removed the electronic thermometer from the charger and noted the lighted display

5- Made sure that the blue probe is attached

6- Placed the probe cover on the probe

Procedure:

1- Placed the probe with cover in the clients posterior sublingual pocket.

2- Instructed the client to keep his or her lips closed.

3- Observed the digital display until it became stable and the machine emittted a tone

4- Read the results from the display

Post Procedure:

1- Discarded the probe cover

2- Washed the hands

3- Recorded the results and explained to the patient

Clinical ChecklistMeasuring Axillary Temperature for Adults Using a Mercury Thermometer (To be used by the Teacher at the end of the module)






STEP/TASKCASES

Getting ready

1. Prepared equipment (thermometer tray, mercury thermometer, disinfectant, cotton balls).



4. Held the thermometer opposite to the bulb.

5. Removed the disinfectant from the thermometer by rinsing with cold water.

6. Dried the thermometer by wiping it from the bulb to the stem using a firm twisting motion.

7. Shook the mercury down to 35 C using a snapping wrist motion.

The procedure:

1. Asked the patient to lie in a supine or semi-Fowler position.

2. Placed the bulb of the thermometer in the clients clean, dry axilla.

3. Held the arm of the patient firmly to the side with the elbow flexed and the hand in contact with the chest.

4. Waited three to five minutes before removing the thermometer.

STEP/TASKCASES

5. Read the thermometer by holding it at eye-level and rotating the stem until the mercury was clearly seen

Post procedure:

1. Returned thermometer to disinfectant solution.


3. Recorded the findings and explained to the patient.

Clinical Checklist Measuring Rectal Temperature for Adults Using a Mercury Thermometer (To be used by the Teacher at the end of the module)






STEP/TASKCASES

Getting Ready:


2. Explained procedure to patient.

3. Prepared equipment* (thermometer tray, tissue paper, thermometer, and examination gloves)

4. Closed the door and drew the curtains around the bed, made sure to have a nurse present during the procedure.

5. Asked the patient to lie in the lateral position with the knees slightly bent.

6. Put on examination gloves.

7. Shook down the thermometer to 35 C using a snapping wrist motion.

Procedure:

1. Spread the clients buttocks and gently inserted the bulb of the thermometer into the anus in the direction of the patients umbilicus to a depth of 1 inch.

2. Held the clients buttocks closed with one hand while holding the thermometer with the other hand for two to four minutes.

STEP/TASKCASES

3. Removed the thermometer and slid off the sheath or removed the secretions from thermometer by wiping from the stem to the bulb

4. Read the thermometer

5. Cleaned the thermometer properly

Post Procedure:

1. Returned thermometer to disinfectant solution.


3. Recorded the results and explain to the patient

Clinical ChecklistMeasuring Tympanic Temperature







STEP/TASKCASES

Getting Ready:

1. Prepared equipment (electronic tympanic thermometer with charger, disposable probe cover).

2. Explained procedure to the patient.

3. Washed your hands.

4. Removed the probe from the base unit and note the light display.

5. Made sure that the machine is in tympanic mode.

6. Placed the disposable cover on the probe tip.

Procedure:

1. Pressed the scan button while inserting the probe tip into the clients ear canal.

2. Released the scan button.

3. Removed the probe on heaing signal.

4. Read the temperature on the display and recorded it on a notepad.

Post Procedure:

1. Pressed the release button and discarded the probe cover into a waste receptacle.

2. Returned the probe to the charger.

3. Washed hands

4. Recorded the results and explained to the patient.

Clinical ChecklistMeasuring Radial Pulse







STEP/TASKCASES

Getting Ready:

1. Prepared equipment: Watch or clock with a counter for seconds.


3. Assisted the patient to pronate and slightly fix the forearm.


Procedure:

1. Properly located the radial artery.

2. Placed the tips of the index, middle & ring fingers

3. Pushed lightly at first, gradually adding pressure till the pulse was felt.

Post Procedure:


2. Discussed the findings with the patient.

3. Recorded the results as beats / minute and commented on regularity and volume.

Clinical Checklist Measuring Apical Pulse







STEP/TASKCASES

Getting Ready:



3. Assisted the patient to a comfortable position: supine or semi-sitting position.

4. Standed to the right of the patient.

5. Exposed chest well.

6. Washed the hands

Procedure:

1. Inspected by looking tangentially

2. Palpated the apex by palmer surface of the hand.

3. Localized the apex with the tip of the index finger.

4. Auscultated the apex with the bell of the stethoscope.

Post Procedure:

1. Discussed the findings with the patient.

2. Washed hands.

3. Recorded the results as beats / minute

Clinical ChecklistMeasuring Peripheral Arterial Pulses and Examining Peripheral Lymph Nodes







STEP/TASKCASES

Getting Ready

1. Greeted the patient respectfully and with kindness.

2. Expalined the procedure to the patient

3. Asked the patient to sit on the examining table with arms at sides.

4. Washed hands thoroughly and dried them

5. Put on appropriate gloves on both hands.

6. Instructed the patient to remove all clothing covering the examination areas

Measuring Peripheral Arterial pulses:

1. Femoral artery:

Asked the patient to:

Lie supine

Partially flex the knee

Abduct and externally rotate the hip

Used the tips of the fingers Felt the pulse below the mid-inguinal point Compared both sides.

STEP/TASKCASES

2. Popliteal artery:

Asked the patient to lie supine and partially flex the knees

Felt the pulse with the fingers encircling and supporting the knee from both sides.

Alternate method:

Asked the patient to lie prone Used the tips of the fingers with the tips of the thumbs of both hands pressing against the femur Felt along the line of the artery Compared both sides.

3. Posterior tibial artery:

Asked the patient to lie supine

Used the tips of the fingers

Felt the pulse in the groove midway between the medial malleolus and the heel( tendo-achilles) Compared both sides.

4. Dorsalis pedis artery:

Used the tips of the fingers

Felt the pulse lateral to the extensor hallucis longus tendon and proximal to the first metatarsal space. Compared both sides.

5. Brachial artery:

Partially flexed the elbow

Used the thumb

Felt the pulse over the elbow just medial to the biceps tendon.

6. Radial artery: See specific learning guide

STEP/TASKCASES

Examination of Peripheral Lymph Nodes

Lymph Nodes in the Inguinal Region


Fully expose the inguinal region

Lie supine

Flex the contra-lateral knee

Palpated above and below the inguinal ligament

Examined both sides

Lymph Nodes in the Axilla

Examined the patient from the front:

With the patients arm adducted, resting his/her left forearm on the right forearm

Inserted the right hand into the patient's left axilla

Slided the fingers against the chest wall

Palpated the anterior axillary fold

Palpated the lateral axillary wall

Using the tips of the fingers

Using the left hand for the patients left side

Directed the palm laterally against the upper end of the humerus, palpated for the lymph nodes

Palpated the posterior axillary fold from behind

Epitrochlear Lymph Nodes

Placed the patients elbow in a semiflexed position

Put the right palm over the posterior aspect of the patient's right elbow. Did the opposite when examining the left side.

Using the thumb for palpation, rolled the epitrochlear lymph node against the bone in an antro-posterior direction

Clinical Checklist Measuring the Respiratory Rate







STEP/TASKCASES

Getting Ready:


2. Assisted the patient to a comfortable semi-sitting position


Procedure:

1. Did not explain the procedure to the patient, pretended to be measuring the radial pulse, while inspecting and counting the elevations of the chest wall in 30 seconds.

Post Procedure:

1. Washed hands.

2. Recorded the results as breathes/ minute and commented on regularity and difficulty.

Clinical Checklist Mental Status Examination (MSE)







STEP/TASKCASES

Getting Ready:

1. Prepared equipment

2. Assured that the patient can pay attention.

3. Explain procedure to the patient

A. Appearance:

Commented upon the general appearance of the patient

B. Movements:

Observed and commented upon:

Gait

Posture

Coordinated movement

Eye contact

Facial expressions

C. Level of Alertness:

1. Commented upon patient ability to focus on questions and conversation

2. Asked patient to count from 100 backwards

3. Commented on the attention span

D. Awareness of the Environment (Orientation):

1. Asked the patient whether s/he recognizes:

The place where the interview is being conducted

The day, date, and year Any surrounding persons

E. Affect:

1. Commented upon the patient's interaction during the interview: eye contact, excitability, change in voice tone

STEP/TASKCASES

F. Mood:

Asked the patient whether s/he feels happy, sad, depressed or angry?

G. Speech:

1. Commented upon the following:

Ability to produce sounds

Volume of the voice

Speed of speech

Appropriateness and clarity of the answers

H. Thought Content:

1. Asked about hallucinations

2. Aked about delusions

3. Asked about Obsessions

4. Compared the patients thought content with his affect

5. Asked about suicidal or homicidal thoughts

I. Thought Process:

1. Analyzed the patient's way of thinking

2. Described the logics of patients comments and presentation of ideas

3. Described the linkage between thoughts

4. Commented upon irrelevant details and thought blocking

J. Cognition:

1. Memory:

Tested Short-term memory Tested Long-termmemory

2. Tested general fund of knowledge

3. Tested arithmetic ability:

4. Tested abstract thinking:

K. Judgment:

Asked the patient what to do if he smells smoke

L. Insight:

Analyzed the patient's ability to recognize a problem and understand its nature and severity

Clinical ChecklistNeurological Examination of the Sensory Function







STEP/TASKCASES

Getting Ready:

Prepared the needed equipment:

Sharp pin with large head.

Cylindrical pieces of cotton

Pitched tuning fork (128hz)

Paper clipGeneral Considerations:

Explained the procedure to the patient Proper exposure Instructed the patient's to close the eyes

Compared symmetrical areas on the two sides of the body

Compared distal and proximal areas of the extremities

Recorded findings

STEP/TASKCASES

1. Superficial sensation

A. Pain

1. Used a suitable object to test "sharp" or "dull" sensation

2. Asked the patient (is it sharp or dull?) every time

3. Tested all the following areas:

a. Shoulders

b. Inner and outer aspects of the forearms

c. Thumbs and little fingers

d. Front of both thighs

e. Medial and lateral aspect of both calves

f. Little toes

4. Compared both sides

5. Compared from above down (sensory level)

6. Examined around the trunk or limb in levels

B. Touch

1. Used a fine cylindrical piece of cotton or fingers to touch the skin lightly

2. Followed the same steps done for pain.

C. Temperature

1. Applied two test tubes, one cold 10 C (or metallic pen) and one hot 45 C (or side of the examiner hand)

2. Followed the same steps done for pain.

A. Pressure Sense

1. Applied palm pressure by squeezing the muscles of the arm, forearm, thigh and calf.

2. Asked about sense of deep pressure

B. Vibration Sense

1. Stroke the tuning fork (128Hz) and placed it over the patients forehead to teach the patient about the sense of vibration.

2. Applied the vibrating tuning fork over bony prominences

a. Malleoli

b. Patella

c. Iliac crest

d. Styloid process of radius

e. Olecranon process

f. Clavicle

3. Asked the patient to tell you if the vibration is felt.

4. Stopped the fork, reapplied and asked if the

patient still feels a vibration.

STEP/TASKCASES

C. Joint sense

Joint movement:

1. Held the patients toe between your thumb and index fingers and taught the patient the different positions of the toe.

2. Asked patient to close the eyes, moved the toe up and down and asked the patient to differentiate whether the thumb moved

3. If the sense of movement is impaired, moved proximally to test the ankle joint

4. Tested the fingers in a similar fashion

Joint position:

1. Grasped the patient's big toe and showed the patient "up" and "down."

2. With the patient's eyes closed asked the patient to identify the direction the toe moved

3. If sense of position is impaired, moved proximally to test the ankle joint

4. Tested the fingers in a similar fashion

3. Cortical Sensation:

A. Tactile Localization

Asked the patient to localize one point of pin prick

B. Tactile Discrimination

1. Used an opened paper clip to touch the patient's finger pads in two places simultaneously

2. Asked the patient to identify "one" or "two."

3. Decided the minimal distance at which the patient can discriminate

C. Stereogenesis

1. Asked the patient to close eyes

2. Placed a familiar object in the patient's hand

3. Asked the patient to tell what it is

3. D. Praxia

Asked the patient to demonstrate how to use familiar objects

Clinical Checklist Neurological Examination of the Motor Function







STEP/TASKCASES

Getting Ready:

Prepared the needed equipment:

Reflex hammer General Considerations:

Explained the procedure to the patient Asked the patient to expose both upper and lower limbs and most of the trunk

Instructed the patient to close the eyes during the test Compared symmetrical areas Compared distal and proximal areas

Mapped out any areas of loss in detail.

Recorded findings

1. Examination of the muscle state:

1. Commented upon the size of the muscle

2. Commented upon any involuntary movement or fasciculation, symmetry between left and right, and proximal and distal muscles

STEP/TASKCASES

2. Examination of the muscle tone:

1. Flexed and extended the patient's fingers, wrist, elbow, and shoulder.

2. Flexed and extended patient's ankle, knee & hip.

3. Commented upon any decreased or increased tone

3. Examination of the muscle power:

1. Tested strength by having the patient move against resistance

2. Examined the power in the following parts:

Flexion & Extension at the elbow

Extension at the wrist

Grip

Finger abduction

Opposition of the thumb

Flexion , Extension, Adduction and Abduction at the hip

Flexion and Extension at the knee

Dorsiflexion and Plantar flexion at the ankle

2. Properly graded the power:

4. Pronator drift

1. Asked the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed

2. Instructed the patient to keep the arms still and tapped them briskly downward

5. Deep reflexes

1. Insured that the patient is relaxed and positioned properly before starting

2. Used proper force to provoke a response

3. Graded reflex

5. A. The brachioradialis reflex

1. Had the patient rest the forearm

2. Stroke the radius about 1-2 inches above the wrist

3. Watched for flexion and supination of the forearm

STEP/TASKCASES

5. B. The triceps reflex

1. Supported the upper arm and let the patient's forearm hang free

2. Stroke the triceps tendon above the elbow with the broad side of the hammer

3. Flexed the patient's arm at the elbow and held it close to the chest

4. Watched for contraction of the triceps

5. C. The biceps reflex (C5,6)

1. Properly positioned the patient's arm

2. Placed the left index finger firmly on the biceps tendon

3. Stroke the finger with the reflex hammer

5. D. The knee jerk reflex (L2, L3, L4)

1. Asked the patient to allow the leg to hang down

2. Alternatively, Supported the half bent knee on the left arm, while the patient is supine

3. Tapped the tendon of the quadriceps muscle just below the patella with the hammer

5. E. The ankle jerk reflex (S1, S2)

1. Put the ankle over the other leg with slight ankle dorsiflexion and eversion

2. Used the hammer to hit the Achilles tendon

5. E. 1. The ankle clonus (S1, S2)

1. Supported the knee in a partly flexed position

2. Quickly dorsiflexed the foot

6. Superficial reflexes

Used a blunt object such as a key or tongue depressor to elicit superficial reflexes

6. A. The abdominal skin reflex

1. Stroke the abdominal skin rapidly and not too

hard with a needle from the side to the middle

at three levels

6. B. The cremastric reflex

1. Undressed the patient and instructed him to lie down in the supine position

2. Stroke the skin of the upper thigh longitudinally with a needle

STEP/TASKCASES

6. C. The Planter reflex

1. Exposed the patients feet

2. Pressed the lower leg against the table.

3. With a blunt object stroke the lateral edge of the sole of the foot from the heel to the base of big toe, heavily, steadily and slowly

7. Tests for coordination

7. A. Standing

Checked whether the patient stands straight

Checked whether he could remain straight with eyes opened

Checked whether he could remain straight with eyes closed

7. B. Walking: Asked the patient to

Walk across the room, turn and come back

Walk heel-to-toe in a straight line

Walk on his\her toes in a straight line

Walk on his\her heels in a straight line

Hop in place on each foot

Do a shallow knee bend

Rise from a sitting position

7. C. Diadocokinesia

Asked the patient to do pronation and supination as rapidly as possible

7.D. Finger-to-nose test: Asked the patient to:

Stretch one arm out

Close his\her eyes

Bring the index finger to the tip of the nose

7. E. knee-heel test: Asked the patient to:

Close his eyes

Place the heel of one foot on the knee of other leg

Slide the heel down from the knee to the instep of the leg.

Clinical ChecklistExamination of the Cranial Nerves







STEP/TASKCASES

Getting Ready:

Prepared the needed equipment :

1. Reflex Hammer

2. 128 and 512 (or 1024) Hz tuning Forks

3. A Snellen Eye Chart or Pocket Vision Card

4. Pen Light or Otoscope

5. Wooden Handled Cotton Swabs

6. Non-pungent material in a tube (coffee)

7. Paper clips 8. Tongue depressor

9. Sharp & blunt objects

10. Salt, acetic acid & sugarGeneral Consideration:

Always explained the procedure to the patient

Reported findings

Considered left to right symmetry

Considered proximal vs. distal deficits

A. Olfactory nerves

1. Described the procedure to the patient

2. Insured that the nasal airway is patent

3. Told the patient to close both eyes

4. Closed patient's nostril one at a time

5. Ask the patient to sniff a non-pungent material

STEP/TASKCASES

6. Asked the patient to identify if there is a smell and inquired about its nature

7. Did the same for the other nostril

B. Optic nerve

B.1. Visual Acuity

1. Allowed the patient to use glasses or contact lens

2. Positioned the patient 6 meters in front of the Snellen eye chart

3. Hadthe patient cover one eye at a time with a card

4. Asked the patient to identify direction of the opening of the letter "C" from larger to smaller letters

5. Recorded the smallest line the patient reads successfully

6. Repeated with the other eye.

B.2.Test color vision:

1. Used color chart.

2. Asked patient to identify the colors

B.3. Visual Field

1. Stood 50 cm in front of the patient and at the same level

2. Asked the patient to look directly and fix eyes into examiners eyes

3. Covered non-tested eyes

4. Used small object (or index finger) and placed it half distance beyond limits of field of vision

5. Advanced the object (while moving) from outwards inwards

6. Tested the four quadrants

7. Repeated for the other eye

8. Recorded findings

B.4. Pupillary Reflex

1. Dimmed the room lights as necessary

2. Asked the patient to look into the distance

3. Shined a bright light obliquely into each pupil in turn

4. Looked for the change of pupil size in the same eye

5. Looked for the change of pupil size in the other eye

6. Recorded pupil size in mm and any asymmetry

or irregularity

B.5. Convergence Reflex

1. Held finger about 10 cm from the patient's nose

2. Asked the patient to alternatively look into the distance and at the finger

STEP/TASKCASES

3. Observed the pupillary response in each eye

4. Observed convergence in both eyes

B.6. Fundus examination

C. Oculomotor, trochlear and abducent nerves

C.1. Cover test

1. Told the patient to look at a distant fixation point

2. Covered one eye at a time

3. Removed the cover rapidly

4. Noticed any movement of the eye

5. Repeated in the other eye

C.2. Uncover test, and test for nystagmus

1. Stood or sit one to two meters in front of the patient

2. Asked the patient to follow the finger with his\her eyes without moving their head in the six cardinal directions using a cross or "H" pattern

3. Paused during upward and lateral gaze to check for nystagmus

4. Commented on movement and presence of

Nystagmus

D. Trigeminal nerve

D.1. Motor

1. Asked the patient to clench his teeth

2. Palpated the temporalis and massetter muscles bilaterally

3. Moved jaw to the contralateral side against resistance (ptrygoid) and compare both sides

4. Asked the patient to open his/her mouth then against resistance from the hands placed below the chin

5. Noticed any deviation of the mandible

D.2. Sensory

1. Used a suitable sharp object to test the forehead, cheeks, and jaw on both sides

2. Substituted a blunt object occasionally and asked the patient to report "sharp" or "dull"

3. Tested the three divisions for temperature sensation with a tuning fork heated or cooled by water

4. Tested the three divisions for sensation to light touch using a wisp of cotton

STEP/TASKCASES

D.3. Reflexes

D.3.a Corneal Reflex

1. Asked the patient to look up and away

2. From the other side, touched the cornea lightly with a fine wisp of cotton

3. Looked for the normal blink reaction of both eyes

4. Repeated on the other side

D.3.b Jaw jerk

1. Asked patient to hang the jaw freely (while eyes are closed ).

2. Placed the left index finger on the chin of the

patient

3. Tapped the finger by a hammer

4. Looked for jaw closure

E. Facial nerve

E.1. Motor

1. Asked the patient to sit down and relax

2. Inspected the face for symmetry

3. Asked patient to do the following, note any lag,

weakness, or asymmetry:

a. Raise eyebrows

b. Wrinkl forehead

c. Close both eyes tightly against resistance

d. Smil

e. Frown

f. Show teeth

g. Blow his cheeks

E.2. Sensory

1. Taught the patient to respond to the stimuli by moving hands.

2. Asked patient to protrude his tongue while eyes are closed

3. Applied wet salt, vinegar or sugar solution in the anterior part of the tongue

4. Instructed the patient not to withdraw tongue unless he/she identifies the substance

F. Acoustic nerve

F.1. Voice test

1. Stood beside the patient at about 50 cm

2. Whispered at very low voice

3. Asked the patient to repeat what is said

4. Used watch tick or finger friction sound


STEP/TASKCASES

F.2. Rinne test

1. Used a 512 Hz or 1024 Hz tuning fork, and started vibration

2. Placed the base of the tuning fork against the mastoid bone behind the ear till sound disappears.

3. Held the end of the fork near the patient's ear

5. Repeated on the other ear

F.3. Weber test

1. Used a 512 Hz or 1024 Hz tuning fork, and started vibration

2. Placed the base of the tuning fork firmly on top of the patient's head and asked the patient where the sound appears to be coming from

G. Glossopharyngeal and vagus nerves

G.1 Commented on patients voice

G.2 Deglutition

1. Give the patient a cup of water and ask him/her to swallow it

G.3 Palatal reflex

1. Prepared two tongue depressors and torch

2. Placed the torch over one tongue depressor in the right hand

3. Advanced the torch with the tongue depressor in the patients mouth sto see the pharynx clearly

4. With the other tongue depressor in the left hand touched the inferior surface of the uvula, then to its right and its left sides

G.4 Gag reflex

1. Repeated steps 1, 2, and 3 as in palatal reflex

2. With the other tongue depressor in the left hand touched the posterior pharyngeal wall

H. Accessory nerve

1. Stood behind the patient while sitting on a chair

2. Looked for atrophy or asymmetry of the trapezius muscles

3. Placed your hands over both shoulders and asked the patient to elevate shoulders against resistance

4. Placed your hands so that the right hand is pushing the right side of the patient mandible, and the left hand is palpating the patient's right sterno-

mastoid muscle

5. Asked the patient to push against the right hand and test the muscle for contour, power and or atrophy

STEP/TASKCASES

6. Replaced hands, tesedt for the other muscle

7. Reported findings

I. Hypoglossal nerve

1. Observed the tongue as it lies in the mouth

2. Asked the patient to protrude the tongue and observe deviation

3. Placed finger over the patient's cheek, and

Asked him\her to press by his tongue.

Clinical ChecklistExternal Ear Examination and Otoscope







STEP/TASKCASES

Getting Ready:

PreparedTwo seats; Otoscope; Different sizes specula; Antiseptic solution

General consideration:

Explained the procedure to the patient

Inspection:

1. Asked the patient to sit down

2. Sat beside the patient and faced the side to be examined

3. Inspected the auricle

4. Inspected the external auditory canal opening

Palpation:

1. Held the auricle between the thumb and other fingers and pulled gently on it outward, upwards, and backwards

2. Folded the auricle forward to palpate the mastoid process behind the ear

3. Did the same for the other side and compared

Otoscopic examination:

1. Identified and Assembled the otoscope and specula

2. Asked the patient to turn his head toward the opposite shoulder

STEP/TASKCASES

3. Chose the largest speculum that the ear can comfortably take

STEP/TASKCASES

4. Pulled the auricle upwards and laterally in adult, while in children pulled it horizontally back

5. Held the otoscope between thumb and four fingers horizontally

6. Inserted the speculum gently while reassuring the patient

7. Inspected the external canal

8. Slightly moved the otoscope up, down, left and right to view as much of the tympanic membrane (eardrum) as possible

9. Took off the speculum slowly

10. Examined the other ear

11. Clean edthe speculum carefully with an antiseptic solution for each use

12. Reported findings and explained to the patient

Clinical Checklist Fundus Examination Using Ophthalmoscope







STEP/TASKCASES

Getting Ready:

Checked color coding of the lens wheel and various apertures and filters

General Consideration:

Gave patient instructions to keep both eyes open and to control fixation, with permission to blink when needed Removed eye glasses Educated patient about the purpose of test Room lights dimmed to minimize reflections

Procedure:

1. Asked the patient to sit on a chair

2. Used right hand and right eye to examine patients right eye and vice-versa

3. Placed left hand over the patient head to fix it, while the thumb was slightly elevating the eye brow (reverse for the other eye)

4. Asked the patient to look to a point behind the examiner and "pretend" that he/she can still see it even if the examiner obscures it with the head

5. Braced ophthalmoscope against the examiners brow

6. Turned power on by index finge placed on the power wheel

7. Moved in toward patient while decreasing plus

8. Observed vitreous by asking the patient to look up and then straight ahead

9. Located the optic disc

STEP/TASKCASES

10.Asked the patient to look straight to the ophthalmoscope to test the macula

11.Examined the other eye

12.Recorded the findings

Clinical ChecklistLocomotor Examination of Wrist and Hand







STEP/TASKCASES

Getting Ready:

Arranged the room for conducting the examination

1. PREPARAION OF THE PATIENT AND GENERAL CONSIDERATION

1. Explained the procedure to the patient

2. Asked the patient to sit on a comfortable chair and place the patient's forearm on a narrow examination table

3. Ensured the wrist and hand are free of clothing and jewellery


2. Inspection:

1. Began inspection on the dorsal surface of the wrist, with pronation of the forearm and wrist flexion.

2. Examined the condition of the following muscles:

Forearm muscles

Thenar muscles

Hypothenar muscles

Interossei

3. Palpation:

1. Started by examining the unaffected side.

STEP/TASKCASES

2. Palpated for bony landmarks:

Lower end of the radius

Lower end of the ulna

Carpal bones

Metacarpals

Small joints of the thumb and fingers

4. Movement:

1. Active movement: Asked the patient to: Actively move the wrist:

Actively move the fingers:

Actively move the thumb:

2. Passive range of movement:

Held the forearm with the left hand and gently performed the same movements described above for the wrist, fingers, and thumb.


Clinical Checklist

Locomotor Examination of Elbow and Forearm







STEP/TASKCASES

Getting Ready:



2. Asked the patient to sit on a comfortable chair

3. Ensured both upper limbs are free of clothing and jewels4. Compared both sides during examination

2. Inspection:

1. Began inspection on the ventral surface of the elbow

2. Checked for the physiological valgus with the forearm in full extension and supination.

3. Looked for any deformity,scars, asymmetry or any skin changes

4. Looked for the condition of the muscles of the arm and forearm (atrophy or hypertrophy):

5. Looked for any swelling.

3. PALPATION

1. Started by examining the healthy side.


3. Flexed the elbow, commented on the relation between position of the lateral epicondyle, medial epicondyle, and olecranon during flexion.

4. Extended the elbow, and comment on the relation again

5. Reported any tenderness, warmth or swelling

STEP/TASKCASES

4. MOVEMENT

1. Active movements:

Asked the patient to actively move the elbow,Flexion, Extension, Supination, Pronation

2. Passive movements:

Held the arm with the left hand

Gently performed the same movements described above for the elbow joint.


Clinical Checklist Locomotor Examination of the Shoulder Joint







STEP/TASKCASES

Getting Ready:

1. Preparation of the Patient and General Considerations: Explained the procedure to the patient

Asked the patient to sit on a comfortable chair

Examined the shoulder from above, lateral side, from anterior and from posterior aspect

Ensured both upper limbs are free of clothing and jewels Exposed the upper chest

Compared both sides during examination

2. Inspection:

1. Inspected all aspects of the shoulder joint

2. Noted any scars or asymmetry or any skin changes

3. Noted the condition of the muscles surrounding the shoulder joint (atrophy or hypertrophy)

4. Noted any swelling.

3. Palpation:

1. Started by examining the healthy side.


3. Reported any tenderness or warmth or swelling

4. Movement:

1. Stood behind the patient and fixed the scapula

2. Tested for active and passive movements of the gleno-humeral joint

STEP/TASKCASES

3. Flexion:

Asked the patient to :

A) Trace out an arc while moving forward from 0 to 180 (with the elbow straight).B) Move the hand to a position over their head

4. Extension: Asked the patient to reverse direction and trace an arc backwards (with the elbow straight): position the hand behind the back

5. Adduction and internal rotation


Place the hand behind the back

Reach as high up as possible

6. Abduction:

The patient should be able to painlessly lift the arm in a smooth, arc to a position where the hand rests above the head

The normal range is from 0 to 180 degrees

7. Abduction and external rotation:

Asked the patient to place the hand behind the head and reach as far down the spine as possible

Noted the extent of the reach in relation to the cervical spine

9. Circumduction:

Asked the patient to rotate the extended arm at the shoulder joint

10. Repeated all movements without fixation of the scapula and compare

Clinical Checklist Locomotor Examination of the Cervical Spine







STEP/TASKCASES

Getting Ready:

1. Preparation of the Patient and General Considerations:


2. Asked the patient to sit on a comfortable chair

3. Examined the cervical spine from anterior, lateral sides and from posterior

4. Ensured both upper limbs are free of clothing and jewels5. Exposed the upper chest

2. Inspection:

1. Inspected for any deformity:

Look at the patient head from the anterior aspect to detect Scoliosis Checked the head position for torticollis

Checked for Kyphosis

2. Looked for any skin changes (redness, dilated veins, scars, sinuses).

3. Looked for the condition of the muscles of the neck

4. Looked for any swelling.

STEP/TASKCASES

3. Palpation:


Spinous processes: using the thumb, starting in the midline posteriorly.

Mastoid processes

Clavicle: Moved along the clavicle from medial to lateral.

Scapula: using the flat of the hand over the back of the patient lateral to the upper dorsal spine. Palpate the scapula

2. Reported any tenderness, warmth or swelling

3. Palpated the structures surrounding the vertebra

4. Palpated supraclavicular fossa for masses or tenderness

5. Identified the neck triangles. Examined them and compared both sides

4. Movement:

Stood behind the patient, tested for active and passive movements, compared movements on both sides

Nodding:

Asked the patient to flex and extend the head

while fixing the neck

Rotation

With the head looking forward, asked the patient to look to the right and then to the left

Compared the movement in both directions

Lateral bending:

Started while the head was in the neutral position, asked the patient to try to touch the shoulder by the ipsilateral ear, without moving the shoulders

Repeated on the other side

Flexion:

Instructed the patient to try to touch the chest with the chin

Extension:

Asked the patient to move the head backward and to look up

Clinical Checklist Locomotor Examination of the Dorsolumbar Spine







STEP/TASKCASES

Getting Ready:

1. Preparation of the patient and general considerations1. Explained all procedures before conducting the examination

2. Exposed the back and lower limbs. Covered the genitals and the breasts

4. Prepared a firm examination bed

5. Examination was conducted with patient standing, then repeated with the patient lying in bed.

2. Inspection:

1. Inspected the patient's back while standing; commented upon:

Position of the head

Level of the shoulders Position of the scapulae and shape of the thoracic cage

Lateral margin of the flanks

Relative prominence of the iliac crests

Curvatures of the spine for kyphosis, lordosis or scoliosis

2. Inspected the skin and Commented on any swellings

3. Checked the condition of the paravertebral muscles

STEP/TASKCASES

3. Palpation:

1. Palpated using firm compression by your thumb the following points:

Spinous process

Iliac crest

Sacroiliac joint

Anterior superior iliac spine

Ischial tuberosities

Greater trochanter

2. Felt skin temperature and commented on any swellings

4. Movements:

1. Instructed the patient to Actively movme the back, commented upon: Range of movement; Pain and Crepitation

2. Flexion: Asked the patient to bend forward and try to touch the toes while keeping the knees straight

3. Extension: Asked the patient to lean backwards while supporting the pelvis from behind

4. Lateral bending: Asked the patient to bend sideways sliding the hand down the thigh.

5. Rotation: held the pelvis firmly with two hands and asked the patient to rotate the trunk first to the right, then to the left

5. Straight leg raising test:

1. With the patient lying down supine, instructed him/her to lift the straightened leg.

6. Measure the lower limbs for shortening:

1. Apparent length:

Placed the two limbs parallel in line with the trunk, Identified the umbilicus and the medial malleolus and Measured the length between them

2. True length:

Identified the two anterior superior iliac spines, placed the interspinous line horizontally and measured the distance between the anterior superior iliac spine and the medial malleolus

Clinical Checklist Locomotor Examination of the Hip Joint







STEP/TASKCASES

Getting Ready:


1. Preparation of the patient and general consideration

1. Explained all procedures before conducting the examination

2. Exposed the patient from the xiphisternum to the feet. Put some covering over the genitalia and the breast in women

3. Examination was carried out on a firm bed

4. Examination was conducted with patient lying on the back, then lying on the face and then standing and walking

2. Inspection:

1. Inspected both hip joints and pelvis, passed the hand behind the lumbar spine while the patient was lying flat on bed to detect deformities of the spine

2. Inspected the direction of the patella in both limbs.

3. Inspected the skin and muscles

3. Palpation:

1. Identified the bony landmarks:

Greater trochanter

Anterior superior iliac spine

Upper shaft of the femur

Iliac bone, ischial tuberosity, ischial and pubic rami

2. Located any tenderness by palpating anterior, lateral and posterior to the hip joint

3. Felt the skin around the joint

STEP/TASKCASES

4. Movements:

1. Examined the active and passive movements of the joint

2. Placed one hand on the pelvis to detect any abnormal movements during active and passive movment of the hip joint

3. Examined flexion by holding the knee inferiorly and elevating the limb to flex the hip joint

4. Examined adduction: Held the ankle joint and moved the limb internally while it is straight

5. Examined Rotation:

Put the left hand on the knee, holding the ankle with the right hand.

Moved the ankle laterally and then medialyl

Or: placed the limb straight while holding the ankle and rotating it internally and externally

6. Examined Extension: with the patient in the prone position, elevated the hip away from the bed

7. Examined Abduction:

Placed the limb hanging at the edge of the bed and moved the straightened other limb laterally to test abduction

Or: Asked the patient to place the feet on the bed while flexing both hips and knees, and asked him to move the knees laterally

5. Measurements:

1. Apparent length:

Placed the two limbs parallel in line with the trunk, identified the umbilicus and the medial malleolus and measured the length between them

2. True length:

Identified the two anterior superior iliac spines, placed the interspinous line horizontally, measured the distance between the anterior superior iliac spine and the medial malleolus

3. Circumference:

Identified the anterior superior iliac spine, measured an equal length distally from that point (25 cm) and measured the circumference of both limbs at that point

STEP/TASKCASES

8. SPECIAL TESTS

1. Tredenlenberg's test

Asked the patient to stand up

Asked him to stand on one limb

Watched the movement of the pelvis

Elevation of the other side of the pelvis is normal

If the pelvis drops, there is instability of the joint (positive Trendelenberg's test)

2. Thomas test

Clinical ChecklistLocomotor Examination of the Knee Joint







STEP/TASKCASES

Getting Ready:


1. Preparation of the patient and general consideration

1. Explained all procedures before conducting the examination

2. Made sure that both knees are fully exposed.

3. Asked the patient to lie flat and relaxed on his back

2. Inspection:

1. Inspected the patient walking.

2. Inspected the patient standing, for evidence of bowing (varus), knock-kneed (valgus), flexion or hyperextension deformity, swellings, color changes or skin lesions

3. Inspected the quadriceps, hamstring, or calf muscle groups for atrophy or hypertrophy.

3. Palpation:

1. Started by examining the unaffected side.

2. Asked the patient to bend the knee

3. Palpated for bony landmarks with the knee flexed then extended

4. Paipated the patella with one hand.

5. Grasped the ankle or calf with both hands and gently flexed the knee.

Testing for fluid in the knee

1. Slightly flexed the knee to be examined

2. Placed one hand on the supra-patellar pouch

STEP/TASKCASES

3. Gently pushed down and towards the patella forcing any fluid to accumulate in the central

part of the joint

4. Pushed the patella backwards using the index finger of other hand.

5. Examined for small effusion:

Gently stroke upwards along the medial aspect of the patella.

Gently push on the lateral aspect of the joint.

4. Movement:

1. Active movement:

Asked the patient to bend the knee in full flexion, then to extend it fully

2. Passive movement:

Placed the left hand over the patella.

Grasped the ankle with the right hand

Gently flexed then extended the knee


5. Special Tests:

a. McMurry's test

1. Palpated the knee with the contralateral hand with the middle, index, and ring fingers aligned along the medial joint line

2. Grasped the foot with the right hand and fully flexed the knee

3. Gently turned the ankle so that the foot points outward.

4. Directed the knee to point outward (valgus stress).

5. Returned the knee to the fully flexed position, and turned the foot inwards (inversion).

6. Directed the knee to point inward (varus stress).

7. Placed the index, middle, and ring fingers of the hand along the lateral joint line

8. Gently extended and flexed the knee.

STEP/TASKCASES

b. Valgus strain for integrity of the medial collateral ligaments

1. Flexed the knee at about 30 degrees

2. Used the contralateral hand along the lateral aspect of the knee.

3. Placed the other hand on the ankle or calf

4. Pushed the knee steadily inward with one hand while supplying an opposite force with the other

c. Varus strain for integrity of the lateral collateral ligaments

1. Slightly flexed the right knee at about 30 degrees

2. Placed the right hand along the medial aspect of the knee

3. Placed the left hand on the ankle or calf

4. Pushed steadily outward with the contraletral hand while supplying an opposite force with the other hand

d. Anterior drawer test for anterior cruciate ligament

1. Had the patient lie down, with the right knee flexed so that the foot is flat on the table

2. Fixed the foot by sitting on it

3. Grasped below the knee with both hands, with the thumbs meeting along the front of the tibia.

4. Pulled forward, gauging how much the tibia moved forward in relation to the femur

e. Posterior drawer test for posterior cruciate ligament

1. Had the patient lie down, the right knee flexed to 90 degrees, foot flat on the table

2. Fixed the foot by sitting on it

3. Grasped below the knee with both hands, with the thumbs meeting along the front of the tibia

4. Pushed backward, gauging how much the tibia moved in relation to the femur

6. Measurements:

a. Circumference

Identified the upper pole of the patella on both sides

Measured 10 cm up to the thigh to get two identical point on each limb

Used a standard tape to measure the circumference and compared both sides

STEP/TASKCASES

b. Limb length

1. Apparent length:

Placed the two limbs parallel in line with the trunk; identified the umbilicus and the medial malleolus; measured the length between them

2. True length:

Identified the two anterior superior iliac spines; placed the interspinous line horizontally; measured the distance between the anterior superior iliac spine and the medial malleolus

Clinical ChecklistLocomotor Examination of the Foot and the Ankle Joints







STEP/TASKCASES

Getting Ready:

Arrange the room or conducting the examination



2. Examined the patient in both standing and lying down position

3. Asked the patient to take off his/her footwear

2. Inspection:

Inspected all aspects of foot for any deformity, skin changes, the condition of the muscles of the leg and feet or any swellings

3. PALPATION

Palpated for bony landmarks for any tenderness, warmth or swellings

4. MOVEMENT

Asked the patient to lie down and tested for active and passive movements and compared movements to both sides

Examined dorsiflexion of the ankle joint:

Asked the patient to move the ankle joint directly so that the foot faces upward toward the dorsal aspect

Examined plantar flexion of the ankle joint:

Asked the patient to flex the ankle so that the foot is facing directly down toward the planter aspect of the foot

STEP/TASKCASES

Examined inversion of the subtalar joint:

Asked the patient to move the foot so that the sole faces inward

Examined eversion of subtalar joint:

Asked the patient to move the foot so that the sole faces outward

Examined flexion of the toes:

Asked the patient to move the toes towards the foot of the bed.

Examined extension of the toes:

Asked the patient to move the toes toward the proximal aspect

Clinical ChecklistExamination of the Mouth, Salivary Glands & Temporomandibular Joints







STEP/TASKCASES

Getting Ready

1. Greeted the patient respectfully and with kindness.

2. Told the patient you are going to examine the mouth.


4. Washed hands thoroughly and dried them

5. Put on new examination or high-level disinfected surgical gloves on both hands.

6. Prepared a good light (torch) and spatula

PROCEDURE

EXAMINATION OF THE MOUTH

1. Retracted the lip to inspect the buccal mucosa

2. Pushed the cheek outwards to see the buccal side of the gum (for abnormalities)

3. Pushed the tongue away from the inside of the gum and the floor of mouth; then pushed it aside

4. Depressed the tongue to look at fauces (throat), tonsils and pharynx

5. Palpated the structures in the mouth bimanually; one finger inside the mouth and one outside.

6. Examination of the lips:

Inspected the lips and everted the lip fully

Palpated the lips using two fingers

7. Examination of the cheeks:

Retracted the angle of the mouth and illuminated the interior of the mouth using a torch

Inspected the interior of the cheek for pigmentations, ulcers, swellings

Inspected the orifice of the parotid duct.

8. Examination of the teeth:

Inspected the teeth for their shape, color, dental cares and presence of rough or broken edges.

Inspected for pulpless, impacted, non-erupted or missing teeth by counting their number

If the patient wears dentures, asked for its removal before proceeding with the examination, noticed if it is smooth and well fitting.

9. Examination of the gum:

Everted the lips fully to inspect the gums

Looked at the color, the crenated edges, the relation to the necks of the teeth, pigmentation, ulcers, swellings

10. Examination of the tongue:

Inspected the tongue for size, shape, color, surface, mobility

Palpated the tongue

Asked the patient to relax the tongue and not to move it.

Palpated with the index finger of the right hand while pressing the fingers of the left hand firmly into the cheek, in such a way that the cheek intervenes between the teeth. In order to prevent the patient from biting the examiner finger. Palpated the posterior quarter of the tongue, asked the patient to open the mouth widely.

11. Examination of the floor of the mouth :

Asked the patient to open the mouth and to put the tip of the tongue on the roof of the mouth and to bend the head slightly backwards.

Inspected the floor of the mouth and the undersurface of the tongue

Bimanually palpated any visible swelling

12. Examination of the fauces (throat) and palate

Asked the patient to tilt the head slightly backwards and to open the mouth to its fullest extent

Inspected the movement of the palate while instructing the patient to say (AAH)

Depressed the tongue with a spatula and illuminated the throat; inspected the tonsils, pillars of the fauces (throat) and the posterior pharyngeal wall

Palpated the pharynx,

Seated the patient on a stool, and stand on the right side.

Held the head firmly with the left hand, the index finger of which is pushed in between the jaws

Passed the right index finger behind the soft palate to palpate the posterior nares, nasopharynx and back of tongue.

EXAMINATION OF THE SALIVARY GLANDS

1. The parotid gland:

Inspection of the gland

Asked the patient to clinch the teeth

Inspection of the duct

Retracted the cheek with a spatula and looked for the orifice of the Stenson`s duct opposite the second upper molar tooth.

Applied gentle pressure over the gland

Inspection of the face

Noticed any asymmetry and examined for facial paralysis

Tested the movements of the jaw

Palpated the main body of the gland, assess any swelling

Palpation of the duct

Palpated between the index finger inside the mouth and the thumb over the cheek

Palpated by rolling the finger across the duct while the patient clinched the teeth

Relations: Examined the two jaws, the temporomandibular joints, the other salivary glands and the cervical lymph nodes on both sides

2. The submandibular salivary gland

Inspected the submandibular triangle:

Noted any swelling beneath and in front of the angle of the jaw.

Inspected the floor of the mouth:

Noticed redness of the orifice of Wharton's ducts on either sides of the fraenum linguae

Applied steady pressure over the gland and observed discharge

Inserted a dry swab under the tongue and dropped some lemon juice on the dorsum. Removed the swab and looked for the flow of saliva from the two ducts

Bimanual palpation:

Asked the patient to flex the neck and inclined the head slightly to one side

Inserted the index finger into the mouth and insinuated its tip between the alveolus and the side of the tongue just behind the last molar tooth.

Palpated the gland and the duct from behind forwards.

EXAMINATION OF THE JAW AND TEMPEROMANDIBULAR JOINTS

Palpated the body, angle and lower part of the ramus of the mandible from within and from outside the mouth.

Bimanual palpation of the upper portion of the ramus of the mandible and its codyloid and coronoid processes

Asked the patient to open and close the mouth and noted any deformity, dental malocclusion or limitation of movement

Placed the finger over the joint while the patient opened and closed the mouth; notice if there any crepitus or clicking.

Clinical Checklist

Examination of the Neck







STEP/TASKCASES

Getting Ready

1. Greeted the patient



4.Washed hands thoroughly and dry them

5. Put on new examination or high-level disinfected surgical gloves on both hands.

6. Instructed the patient to remove all clothing down to the nipple line.

PROCEDURE

Inspection:

Observed the contour of the neck and notice any abnormalities

Asked the patient to swallow and notice any masses moving with deglutition

Defined the anatomical site of any observed swelling

Noticed any neck pulsations, dilated veins, scars

Asked the patient to recline at 45 degrees and observed neck veins pulsations

STEP/TASKCASES

PALPATION

Advised the patient to sit on a stool

Standed behind the patient

Instructed the patient to relax the neck muscles

Held the head with one hand and flexed it gently to one side while palpating the front of the neck with the other hand

Flexed the patients head towards the side that is being palpated

Asked the patient to resist your movement in order to contract the muscles; continued to palpate the neck while the muscles were being contracted.

Examined the relationship of any masses detected to:

The trachea: movement of the mass with swallowing

The hyoid bone: movement of the mass with protrusion of the tongue

Palpated the cervical lymph nodes

While facing or while standing behind the patient

Examined all the groups systematically (superficial and deep, upper and lower) Palpated beneath the mandible, over the tonsillar L Ns, over the anterior triangles. Above the clavicles and deep to sternoclavicular attachments of the sternomastoid muscles

Palpated both carotid arteries for equality and presence of a thrill

Percussion :

Tapped with the index finger over the manubrium sterni

Auscultation:

Listened over the thyroid gland Listened over both carotid arteries for any bruit or murmur.

Clinical Checklist Chest Examination







STEP/TASKCASES

Getting Ready:

1. Washed hands.

2. Stood to the right of the patients bed

3. Prepared stethoscope with bell (cone) and diaphragm


5. Warmed hands.

6. Put the patient in sitting position first.

7. Ensured good lighting.

Position of the Trachea by Inspection and Palpation:

1. Placed the patients chin in neutral position.

2. Examined from the front.

3. Gently thrusted the index or the middle finger into the suprasternal notch exactly in the midline and try to feel both the sides of the trachea.

Examination of the Chest Anteriorly:

Inspection:

1. Put the patient in supine position.

2. Exposed the chest well.

3. Compared both sides.

4. Examined the chest wall from front, sides (tangentially) and from foot end.

STEP/TASKCASES

Palpation:

1- Gripped the sides of the chest wall with the fingers.

2- Slided them medially and raised a loose skin fold between thumbs.

3- Actively stretched thumbs should meet in the midline.

4- Asked the patients to take deep breath.

5- Asked patient to repeat four-four in Arabic or Nine -Nine in English.

6- Used the palm of the hand.

7- Palpated all areas sequentially (three levels anteriorly; infraclavicular, mammary and inframammary and two areas laterally; upper axilla and lower axilla).

8- Compared the corresponding area of the opposite side.

Percussion:

1- Asked patient to keep his hands to his sides.

2- Placeed the left hand on the right side of the chest wall with the pleximeter parallel to the border being percussed.

3- Stroke the center of the second phalanx of the middle finger (plessor) sharply with the tip of the pad of the right middle finger with the movement coming from the wrist joint

4- Started from resonant to dull area.

5- Percussed deeply in the right third, fourth and fifth intercostal spaces to define the right cardiac border.

6- Percussed deeply downwards from the second right intercostal space in the mid clavicular line.

7- Proceeded downwards till the liver dullness was obtained

8- Asked patient to take deep breath and hold it.

9- Repercussed tidal percussion-

10- Compared both sides.

11-Percussed directly on the clavicle

12- Percussed the lungs lightly.

13- Percussed the infraclavicular area up to the third rib anteriorly in the midclavicular line (MCL).

14- Percussed the supramammary area from the

third rib to the level of the nipples on the MCL.

STEP/TASKCASES

15- Percussed the inframmamary area from the

nipples to the sixth rib anteriorly in the MCL.

16- Asked the patient to put his/her hands over his Head

17- Percussed the axillary area to the fourth rib in the anterior axillary line (AAL).

18- Percussed in the infra axillary area from the fourth rib to the eighth rib in the AAL.

19- Repeated steps 14 and 15 in the mid axillary line (MAL).

20- Repeat steps 14 and 15 in the posterior axillary line (PAL).

Auscultation:

1- Used the bell (cone).

2- Asked the patient to breathe deeply with his/her mouth kept wide open.

3- Applied the chest piece tightly to avoid sounds produced by friction with the hair.

4- Auscultated all areas of the lungs anteriorly and laterally.

5- Always compared both sides.

6- Asked patient to cough during auscultation.

7- Asked the patient to say four four in Arabic repeatedly (VR) or nine nine in English.

8- Auscultated all areas sequentially.

9- Immediately compared the corresponding area of the opposite side.

Examination of the chest posteriorly:

Inspection:

1- Asked the patient to sit.

2- Exposeed the back well.

3- Compared both sides.

4- Examined from behind and standed overlooking the shoulders.

Palpation:

1- Griped the sides of the chest wall with the fingers.

2- Slided fingers medially and raised a loose skin fold between thumbs.

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