[im ward] history taking tool

7/25/2019 [IM Ward] History Taking Tool

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HISTORY AND PHYSICAL EXAMINATION

LTRP + PAAD BATCH 2017 1

Date: Informant:

History Taken By: Reliability:

IDENTIFYING DATA:

Name (First Name, Middle Name, Last Name):

Age: Gender: Civil Status:

Birthdate: (Month, Day, Year): Birth Place:

Present Address:

Nationality: Occupation: Religion:

Number of Times Admitted to this Hospital: Name of Hospital: Date of Current Admission:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:8 Critical Characteristics:

1.

Timing (Onset, Duration, Frequency)

2.

Location

3.

Setting

4. Character or Quality

5. Quantity or Severity

6.

Associated Factors7.

Aggravating or Relieving Factors

8. Patients Perception

If consultation was made: Indicate diagnosis of

the physician (if any), laboratory examinations

requested and results, and medications given.

Medications:

Generic name

Brand name (in parenthesis)

Preparation

Dosage

Response to treatment

PQRSTU of Pain:

P: Precipitating (Provocative)/ Aggravating/

Palliative (Alleviating or Relieving Factors)

Precipitating Factors: What brings out the

symptoms?

Aggravating Factors: What makes the

symptoms worse?

Palliative Factors: What relieves the

symptom?

Q: Quality (Character)/ Type of Symptom/ Quantity

What is the symptom like?

R: Region (Location) and Radiation of Symptoms

Ask if pain is localized, if not, to where does it

radiate

S: Severity/Intensity and its Progression

Mildlittle or no effect to daily

Moderatethere is limitation to daily

activities

Severeunable to perform daily activities

T: Timing

Duration: How long does the symptom last?

Frequency: Continuous or intermittent (recurat intervals)?

U: Understanding Patients Perception of Pain

Describe how the patient understands the

significance of pain

PAST HEALTH HISTORY:

Childhood Diseases[ ] Mumps, [ ] Measles, [ ] Chicken Pox, [ ] German Measles

Immunizations Received:


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Adult Past Illnesses:

A. Medical (Past Illnesses, Hospitalizations and Ambulatory Care not related to the HPI) Dates, describe symptoms felt,

name of hospital, number of days admitted, give the diagnosis, laboratories done/results, complications, medications

given and the disposition upon discharge

B.

Surgeries and Other ProceduresFull details including type, date, results, and complications

C. Accidents and InjuriesType of injury, date, time, disabilities

D. GynecologicDiseases affecting the female reproductive organs

E.

MedicationsPrescribed, over-the-counter medications, and homeopathic remedies; and any adverse reactions

F. Blood TransfusionDate received, indications and transfusion reactions

G. AllergiesNote the allergen and the reaction

H. PsychiatricHistory of violence, suicidal attempts, drug overdose, and substance abuse

FAMILY MEDICAL HISTORY:

Health status, age, if deceased: age and time of death and cause of death of immediate family members:

Father:

Mother:

Siblings:

Children:

Grandparents (Maternal):

Grandparents (Paternal):

Grandchildren:


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Disease with Heredo-Familial Tendency Stroke, Cancer, Hypertension, Diabetes Mellitus, Heart Diseases, Blood Disorders,

Allergies, Arthritis, Obesity, Alcoholism, Psychiatric Illnesses, Seizure Disorder, Kidney Diseases, etc.

Communicable DiseasesTuberculosis, Sexually Transmitted Infections (STI), etc.

Any member of the family member with similar symptoms:

PERSONAL AND SOCIAL HISTORY (PSH) OR FUNCTIONAL ASSESSMENT OR PERSONAL ACTIVITIES OF DAILY LIVING (ADL):

Education Attainment:

Marital StatusHealth condition of spouse:

Occupational History

Nature of Work:

Number of Hours of Exposure to Hazards:

Safety Measures Used (Past and Present):

Interpersonal Relationships and Financial Resources Within and Outside the Family:

Living Conditions:

Source of Water:

Waste Disposal:

Relevant Travel History:

Habits:

Sleep and Rest Pattern:

Nutrition and Elimination:

Smoking History (Passive and Active Smoker):

Number of Sticks Smoked Per Day:

Number of Years of Smoking:

History of Alcohol and Coffee Intake:

Age When He/She Started Drinking Alcohol

Type of Alcohol:

Quantity:

Frequency of Alcohol Intake:

Illicit Drug Use:

Self-Care:Activities:

Exercise:

Sexual History:

Exposure and History of STI:

Number and Variety of Partners:

MENSTRUAL AND OBSTETRICAL HISTORY:

Age at Menarche:


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Regularity, Interval, Duration, and Amount of Flow of the Succeeding Menses:

Premenstrual Symptoms:

Last Menstrual Period (LMP):

Previous Menstrual Period (PRP):

Age and Symptoms at Menopause:

Use of Hormonal Replacement:

Gravity:Parity:

Manner of DeliverySpontaneous, Cesarean Section, Forceps Extraction

Use of Birth Control Methods:

REVIEW OF SYSTEMS:

1. CONSTITUTIONAL SYMPTOMS:

___ Significant Change in Weight

___ Generalized Body Weakness

___ Fatigue

___ Fever

___ Chills

___ Increased Appetite

2. SKIN:

___ Itchiness

___ Excessive dryness or sweating

___ Cyanosis

___ Pallor

___ Jaundice

___ Erythema

3. HEAD:

___ Headache

___ Dizziness

___ Vertigo

4. EYES:

___ Pain

___ Blurring of Vision

___ Double Vision

___ Lacrimation

___ Photophobia

___ Use of Eye glasses

5. EARS:

___ Earache

___ Deafness

___ Tinnitus

___ Ear discharge

6. NOSE AND SINUSES:

___ Changes in Smell

___ Nose Bleeding

___ Nasal Obstruction

___ Nasal Discharge

___ Pain Over Paranasal Sinuses

7. MOUTH AND THROAT:

___ Toothache

___ Gum Bleeding

___ Disturbance in Taste

___ Sore Throat

___ Hoarseness

8. NECK:

___ Pain

___ Limitation of Movement

___ Mass

9. BREAST:

___ Pain

___ Lumps

___ Nipple Discharge

10. RESPIRATORY:

___ Pleuritic Chest Pain

___ Cough

___ Sputum Production

___ Hemoptysis

___ Audible Wheezing

11. CARDIOVASCULAR:

___ Palpitations

___ Syncope

___ Easy Fatigability

12. GASTROINTESTINAL:

___ Abdominal Pain

___ Nausea

___ Vomiting

___ Dysphagia

___ Diarrhea

___ Constipation

___ Hematemesis

___ Melena

___ Hematochezia

___ Regurgitation

13.

GENITOURINARY:___ Dysuria

___ Urinary Frequency

___ Urgency

___ Hematuria

___ Incontinence

___ Genital Pruritus

___ Urethral Discharge

14.

EXTREMITIES:___ Edema

___ Swelling of Joints

___ Stiffness

___ Numbness

___ Intermittent Claudication

___ Limitation of Movement

15.

NERVOUS:___ Loss of Consciousness

___ Focal Weakness

___ Parethesia

___ Speech Disorder

___ Loss of Memory

___ Confusion

16. HEMATOLOGIC:

___ Bleeding Tendency

___ Easy Bruising

17. ENDOCRINE:

___ Intolerance to Heat and Cold

___ Polydipsia


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GENERAL SURVEY:

A.Assess the LEVEL OF CONSCIOUSNESS

Normal: Awake, alert, responds appropriate to verbal, tactile, and painful stimuli

Impaired: Agitated, restless, drowsy, stuporous, lethargic

May obtain Glasgow Coma Scale (GCS)

B.ORIENTATIONto time, place, and person

C.APPEARANCE

Assess the relationship of the biologic age with the chronological age (Does patient look his stated age? Younger or older?)

Manner of dressing and personal hygiene (appropriate, well-kemptneat and clean, unkemptdirty)

D.ATTITUDE AND BEHAVIOUR (cooperative/uncooperative, rational/irrational, friendly/hostile, interested/indifferent)

E.SPEECH AND LANGUAGEAssess the quantity, rate, loudness (tone), fluency, slurring

Possible findings: aphasia/dysphasia, dysphonia, dysarthria

F.MEMORY, MOOD AND AFFECT

Memory (immediate, recent, remote)

Mood (euthymic/normal, dysphoric/sad, euphoric/elated, angry, anxious, apathetic, etc.)

Affect (appropriate or inappropriate)

G.NUTRITIONAL STATUS (underweight, normal weight/well-nourished, overweight, obese)BMI = weight in kg/(height in m)2

H.GAIT AND POSTURE

Ask the patient to stand straight and observe posture (normalerect and straight, abnormalstooping) Ask the patient to walk and observe gait (normal, abnormallimping, shuffling, staggering)

If unable to walk (wheelchair-borne)

I. BODY BUILT (slender, short, tall, lanky, stout)Sthenic Type (Athletic type)

Hypersthenic (short and stocky)

Hyposthenic (thin and developed)

Asthenic (malnourishedmarasmus or kwashiorkor)

J.SIGNS OF DISTRESSCheck for objective evidence of:

Dyspnea (flaring od alae nasi, use of accessory muscles of respiration, intercostal retractions, active contractions of the SCM)

Cyanosis

Agitation or restlessness

Pallor

Cold-clammy respiration

Chest pain

VITAL SIGNS:

A.BLOOD PRESSURE

B.CARDIAC RATE(beats per minute)

Assess rate and rhythm

C.PULSE RATE(beats per minute)

Assess rate, volume, and rhythm

Amplitude (strong or weak)

D.RESPIRATORY RATE (cycles per minute)

E.BODY TEMPERATURE

F.WEIGHT (kg)

G.

HEIGHT (cm)

EXAMINATION OF THE HEAD

A.Inspect and palpate the HAIR:

1.Color (black, brown, gray; natural or dyed?)

2.Quantity (thin, thick or fairly abundant)

3.Distribution (evenly distributed, pattern of hair loss if any, receding hairline)

4.Texture (fine or course)

5.Moisture (dry or oil)

B.Examine the SCALP for skin lesions (scars, scales, masses, etc.) and lice


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C.Inspect and palpate the CRANIUM:

1.Size/Shape (normocephalic, microcephalic, macrocephalic)

2.Symmetry (symmetric, asymmetric)

3.Scalp (describe lesions if present, tenderness)

4.Temporal Arteries (tortuous or not, describe amplitude and equality of pulsations, consistency of the wallssoft or hard?)

Sample Recording of Findings:

Head: Thick, black hair, evenly distributed, course and dry; clean scalp; normocephalic, no mass or tenderness. Temporal arteries are not visible but palpable with

strong, equal puslations, walls not thickened

EXAMINATION OF THE FACE

Inspect the FACE:

1.SKIN

a.Color (fair, brown, black)

b.Lesions (describe type macule, papule, patch, wheals, etc; color changes erythematous, hyperpigmented,

hypopigmented, depigmented, etc; distribution)

2.SHAPE (oval, triangular, round, square, etc.)

3.SYMMETRY (symmetric or asymmetric; describeshallow right nasolabial fold, drooping right angle of mouth, etc)

4.FACIAL EXPRESSION (FACIE) AND INVOLUNTARY FACIAL MOVEMENTSSample Recording of Findings:

Face: Oval, symmetrical, fair-skinned with several hyperpigmented papules scattered over the face, no masses, normal facie, no involuntary movements

EXAMINATION OF EYES

A.EYEBROWS (amount, distribution, lesion)

B.EYELIDS (swelling, edema, erythematous rim, ptosis lesions)

C.PALPEBRAL FISSURES (normal, widened, or narrowed)

D.EYEBALLS

1.Exopthalmos (protruding eyeballs) or Enopthalmos(sunken eyeballs)

2.Lid Lag TestWith your finger or holding a penlight as a target in the midline above the eye level, about 20 inches (50 cm) away, move the target rapidly downward in

the midline, watching for the appearance of white sclera between the iris and the upper eye lid margin.

E.EYELASHES

1.Direction of Growth

2.Matting of Eyelashes

F.

CONJUNCTIVAE AND SCLERAE1.Color of Sclerae (white or icteric)

2.Color of Palpebral Conjunctivae (pinkish, congested, injected, pale)

3.Look for any growth or edema

G.CORNEA (transparency or clarity, scars, abrasions and ulcers of the cornea)

H.IRIS, PUPILS AND LENS

1.Color of IRIS

2.PUPILS

a.Size (measure the diameter of each pupil in mm)

b.Shape

c.Symmetry

d.Reaction to Light

Pupillary Light Reflex (Direct and Indirect/Consensual Response)

Swinging Flashlight Test(Move the light from one pupil to the other, back and forth)

Accomodation Reflex

3.LENS (transparency, opacity)

I. EXTRAOCULAR MOVEMENTS

H Pattern

Observe for Nystagmus

J.OPHTHALMOSCOPIC EXAMINATION

Note for the following:

1.Clarity of the disc outline(Nasal outline may be normally somewhat blurred)

2.Color of the disc(Normally yellowish orange to creamy pink)


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3.Presence of normal white or pigmented rings or crescents around the discs

4.Size of the central physiologic cup (If present, this cup is normally yellowish white)

5.Symmetry of the eyes (In terms of these observations)

K.TESTING VISUAL ACUITY

1.Distant Vision: Snellen Chart at 10 or 20 feet

2.Near Vision: Near Vision Card at 14 inches

Abnormal Response:

20/30-1: The patient missed a letter of the 20/30 line

20/200: Legally blind (At 20 feet the patients reads a line that a normal eye could see at 200 feet)CF (Counting Fingers): If a patient is unable to read the top line, have him count fingers at maximal distance

HM (Hand Motion): If a patient cannot count fingers, ask them to determine direction of hand motion

LP (Light Perception): If a patient cannot perceive hand motion, see if they can perceive a light

NLP (No Light Perception)

L.VISUAL FIELDS

Confrontation

Peripheral Visual Fields (White Pin)

-Wiggling Fingers

-Counting Fingers

Central Visual Fields (Red Pin)

EXAMINATION OF THE EARS:A.

AURICLE

1.Inspect each auricle and surrounding tissues for size, deformities, lumps, or skin lesions

2.If with ear ache, discharge or inflammationare present, move the auricle up and down, press the tragus and press firmly

behind the ear. Note for tenderness.

B.

OTOSCOPIC EXAMINATION

Observe for the following:

1.Patency of the ear canal

2.Identify any discharge

3.Describe the walls of the ear canal. Note any tenderness or swelling.

4.

Inspect the tympanic membrane and note for the following:

a.Color(pearly white or pinkish grey; hyperemic in myringitis)

b.Intact or Perforated

c.

Contour(bulging: fluid in the middle ear; flat: normal; retracted: pulled upward due to a block in the Eustachian tube)

d.Cone of Light (a change in the normal contour suggests middle ear disease)

e.Identify the Malleus (visible or not)

EXAMINATION OF THE NOSE:

A.Inspect the nose forsymmetry and deformity

B.Palpate fortenderness

C.

Test for patency of the nasal cavities

D.Asses theINTERNAL STRUCTURES of the nose using a penlight or otoscope without a speculum

1.

Visualize SEPTUM (Normal: Pink mucosa, straight at the midline and intact; Deviated; Perforated)

2.VisualizeTURBINATES (Normal: Flat and dry with the same pink color as the surrounding mucosa; Congested; Red; Pale; Wet

with mucus)

E.

Assessment of the FRONTAL AND MAXILLARY SINUSES1.Palpate for tenderness

2.Transillumination using a penlight

EXAMINATION OF THE MOUTH AND PHARYNX:

EXAMINATION OF THE ORAL CAVITY

A.LIPS

1.Color

2.Moisture

3.

Lesions (fissures, ulcers)

4.Symmetry


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5.Deformities

B.BUCCAL MUCOSA

1.

Color

2.Pigmentation

3.Ulcers

4.Patches

5.

Nodules

C.GUMS

1.

Color2.Swelling

3.

Bleeding

4.

Retraction

5.Discoloration

6.Recession of the Gingival Margins

7.Pus in the Margins

8.

Presence of lead and bismuth line

D.TEETH

1.Absence of one or more teeth

2.

Presence of carries

3.Discoloration

4.Fillings

5.

Bridges and braces

E.ROOF (PALATE) AND FLOOR OF THE MOUTH

1.Color

2.Deformities

3.Any lesions and masses

4.Odor (alcohol, ammonia, sweetish fruity odor of acetone, musty odor, halitosis)

F.TONGUE

1.Observe for abnormal movements(fasciculations, tremors)

2.Observe for the following:

a.

Size

b.Color

c.Surface

d.

Moisturee.

Symmetry

f.

Lesions

G.SOFT PALATE, UVULA, TONSILLAR PILLARS, TONSIL, AND POSTERIOR PHARYNGEAL WALL

1.Color

2.Symmetry

3.

Any evidence of exudates

4.Swelling

5.Ulcerations

6.Tonsillar enlargement

7.

Induration or tendernessDescription of Normal Findings:

Lips: pinkish, moist, symmetrical, no lesions

Buccal Mucosa and Gums: pink, smooth, no lesionsTeeth: complete set, no dental carries, good oral hygiene

Roof, Floor and Palate: pinkish, no lesion

Uvula in midline, tonsils not enlarged, pharynx is pink, no lesions, no exudates

EXAMINATION OF THE NECK:

INSPECTION AND RANGE OF MOTION

A.Inspect the NECK

1.Symmetry

2.Size (unusually long or short)

3.Deformity, mass and swelling


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B.Observe how the patient carries his head (position: tilted, rotated) and note the tone of the neck muscles

C.Range of Motion

1.Flexion (chin to chest)

2.Extension (look at the ceiling)

3.Lateral Rotation (chin to shoulder)

4.Lateral Flexion/Bending (ear to shoulder)

PALPATION OF THE NECK

A.In front of patient:posterior cervical spine, mastoid process, trapezius and sternocleidomastoid

B.

Behind the patient:thyroid gland, lymph nodesIf a massis palpable, describe its location, consistency, size, and mobility

PALPATION OF TRACHEA

Palpate the trachea for any deviation

PALPATION LYMPH NODES1. Preauricular

2. Posterior auricular

3. Occipital

4. Tonsillar

5. Submandibular

6. Submental

7. Superficial cervical

8.

Posterior Cervical Chain

9. Deep Cervical Chain

10.

Supraclavicular

Describe palpable lymph nodes

A.Size

B.Shape

C.Surface/Texture (smooth, irregular)

D.Delimitation (discrete, matted)

E.Mobility(fixed or movable)

F.Consistency (soft, firm, hard)

G.Tenderness

THYROID GLAND

A.Inspection (normally rise as the person swallows)

B.Palpation

C.

Auscultation (Done if thyroid is visible and palpable)

Use bell of stethoscopeListen for bruit while the patient holds his breath

D.Describe as to:

1.Size

2.Shape

3.Symmetry

4.Consistency

5.Presence of nodules

6.Tenderness

7.Bruit

EXAMINATION OF THE THORAX AND LUNGS

INSPECTION

A.

CHEST WALL1.Skin

a.Color

b.Lesions

c.Dilated Blood Vessels

2.Bony Thorax

a.Shape and Symmetry

b.Deformity (pectus carinatum, pectus excavatum, scoliosis, kyphosis, kyphoscoliosis, gibbus)

c.Muscle Development

B.Observe RESPIRATION

1.Respiratory Rate


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2.Timing of Inspiratory Phase and Expiratory Phase

3.Rhythm and Depth of Respiration

4.Abnormalities in Rate and Rhythm

a.Cheyn-Stokes Respiration

b.Biots Breathing

c.Kussmaul Respiration

d.Paradoxic Respiration

C.Contraction of the ACCESSORY MUSCLES OF RESPIRATION (sternocleidomastoid, intercostal, etc.)

D.

Observe for EQUALITY OF CHEST MOVEMENTPALPATION

A.Identify tender areas

B.Assess further lung expansion

C.Tactile fremitusor voiced sounds

PERCUSSION

AUSCULTATION

A.Determine the characteristics of the different breath

(lung) sounds1.

Vesicular

2.Bronchial

3.

Bronchovesicular

4.Tracheal

B.Listen for and identify any adventitious (added) sounds

(crackles, wheezing)

C.

Listen to the sounds of the patients spoken and

whispered voiceas they are transmitted to the chest

wall

1.Bronchophony (99, 99 or tres tres)

2.

Egophony (eee)

3.Whispered Pectoriloquy (Whisper 99, 99 or tres

tres)


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EXAMINATION OF THE CARDIOVASCULAR SYSTEM

INSEPCTION AND PALPATION OF THE NECK VESSELS

A.Inspect the neck for venous distention (Patient supine. Elevate trunk to about 30 degrees from the horizontal) Turn head slightly

to the left.

If with venous distentionMeasure Jugular Venous Pressure (JVP) and Central Venous Pressure(CVP)

B.Inspect and Palpate the Carotid Arteries

1.Amplitude of pulsation (strong or weak)

2.Rhythm (regular or irregular)

3.Equality of pulsation

4.

Consistency of the walls (soft or rigid)INSPECTION AND PALPATION OF THE PRECORDIUM

A.Observe the precodium

B.Locate theapex beat or apical impulse

1.Location (usually 5thICS or 1-2 cm medial to the LMCL or 7 cm from the midsternal line)

2.Size (1cm x 2cm or


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6.Pitch(high or low pitched)

7.Shape(crescendo, decrescendo, crescendo-decrescendo)

EXAMINATION OF THE VASCULAR SYSTEM

A.

Assess function of the peripheral blood vessel (inspection and palpation) of the upper and lower extremities

1.Size of arms and legs

2.Symmetry

3.Swelling or edema (pitting or non-pitting)

4.

Changes in the skin and soft tissuea.Pigmentation

b.Pallor/Cyanosis

c.Hairloss

d.

Dilated Veins/Varicosities

e.

Lesions (ulcers)

5.Nails

B.Asses the peripheral arterial blood flowby palpating for:

1.Temperature of both upper and lower extremities

2.Peripheral Pulses

a.

Brachial

b.Radial

c.

Femorald.Popliteal

e.

Dorsalis Pedis

3.Describe the Pulses

a.Amplitude

3+ Full or bounding

2+ Normal to strong

1+ Weak or thready

0 Absent

b.Rhythm (regular or irregular)

c.Equality

d.Consistency of the walls (soft, thickened, rigid)

EXAMINATION OF THE ABDOMEN

INSPECTION

A.Describe the abdomen (symmetry, skin, shape, appearance of umbilicus, visible pulsations in the epigastric region)

1.Symmetry

2.Skin (color, lesions, scarslocation,size, shape, shape, cause)

3.Shape (flat, globular, scaphoid, protuberant)

4.Appearance of the umbilicus ( flat, inverted, everted)

B.Observe for abnormal findings (bulging flanks, dilated superficial blood vessels, pulsations outside of the epigastric region,

peristaltic waves, mass)Sample Recording of Findings:

On inspection, the abdomen, is symmetrical; the skin is brown, no lesions and no scar. The shape is flat and the umbilicus is inverted. No bulging flanks and no

localized bulges. No dilated blood vessels, no abnormal pulsations. No visible peristalsis and no mass.

INSPECTION

A.Listen and describe the BOWEL SOUNDS (normoactive, hyperactive, hypoactive, absent)Press the diaphragm firmly on the RLQ and listen for gurgling/bubbling/popping sounds

B.

Auscultate for possible BRUIT

1.Aortic Aneurysm press the diaphragm firmly over the epigastrium

2.Renal Artery Stenosis position the diaphragm slightly above and lateral to the umbilicus (R and L paraumbilical hernia) then press firmly towards themidline and listen

Sample Recording of Findings:

On auscultation, the bowel sounds are normoactive. No bruit heard over the epigastrium, right and left paraumbilical areas.

PERCUSSION

A.Assess DISTRIBUTION OF AIRin the bowel (tympanitic, dull) randomly percuss each of the four quadrants

B.

Measure the LIVER SPAN(normal: 6-12cm)


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C.Measure the SIZE OF SPLEEN

D.Detect PRESENCE OF FLUIDASCITES

1.

Fluid Wave

2.Shifting Dullness

3.Elicit presence of COSTOVERTEBRAL ANGLE TENDERNESS(Kidney punch)

PALPATION

A.Light Palpation

1.Consistency of the abdomen (soft, firm, rigid), (voluntary, involuntary)

2.

Palpable mass (location, size, shape, consistency, tenderness, pulsation, mobility)3.Tenderness (location)

B.Deep Palpation (deep tenderness, deep masses, enlargement of liver, spleen, kidneys)

Single handed technique

Double handed technique

C.Palpation of Specific organs and structures

1.Liver (Hooking technique)

2.Spleen (Middleton technique)

3.Left and Right kidney (Capture technique)

4.Abdominal Masses

a.Location (intrabdominal or intramural mass)

b.Size (Small or big)

c.

Mass with ascites (Ballottement maneuver)

Special Maneuvers

A.

Test for localized peritonitis

Rebound tenderness (+) Result: pain intensifies upon withdrawal of the examining finger

Blumberg sign Rebound tenderness in the RLQ

Rovsing sign Rebound tenderness in the RLQ during LLQ pressure

Jar tenderness or Markles sign (+) Result: exacerbation of abdominal pain

Psoas sign (+) Result: exacerbation of pain the RLQ

Obturator sign (+) Result: exacerbation of pain the RLQ

B.Test for PossibleAcute Cholecystitis

Murphys sign (+) Result: inspiratory arrest 20to a sharp increase in tenderness over the RUQ

C.Test to Identify an Organ or a Mass Obscured by Ascites

Single handed (+) Result: A freely movable mass will rebound upward and is felt with fingers

Bimanual ballottement

THE NEUROLOGIC EVALUATION:

CEREBRAL FUNCTION

A.Assessment of GENERAL CEREBRAL FUNCTION

1.Level of Consciousness (GCS: E__V__M__)

2.General Behavior and Appearance

a.Appropriately groomed

b.

Cooperative, hostile, indifferent

c.Hyperactive, agitated, violent, quiet, immobile

3.Intellectual Performance

a.Orientationto time, place, and person

b.

Memoryi. Immediate memory or retention(repeat a series of 7

digits forward and 5 digits backward)

ii.Recent memory(ask what his last meal was)

iii.Remote memory(ask patients date of birth)

c.Calculation(subtract series of 3s or 7s from 100)

d.Abstract Reasoning or Thinking

e.Emotional Status

B.Assessment of SPECIFIC CEREBRAL FUNCTION

1.Language

a.Fluency (ability to talk spontaneously with or without sense)


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b.Repetition (repeat a simple phrase or sentence or a series of numbers)

c.Comprehension (verbal requestsimilar request but now written)

2.Cortical Sensory Interpretation or Object Recognition (Agnosia)

3.Cortical Motor Integration(Apraxia)Ability to follow a 3-stage command

CRANIAL NERVES

A.CN I: OLFACTORYCheck patency of each nostril

B.CN II: OPTIC NERVE

1.Visual Acuity

2.Opthalmoscopic Examination

3.Examination of Visual FieldsConfrontation Test

C.CN III, IV, VI: OCCULOMOTOR NERVE, TROCHLEAR NERVE, AND ABDUCENS NERVE

1.Direct Light Reflex

2.Indirect or Consensual Light Reflex

3.Convergence or Accommodation Test

4.Levator Palpebrae Muscle (Lid Elevation)Measure the size of the palpebral fissure in mm

5.Extra-ocular Muscle

6 Cardinal Gaze (H Pattern)

Superior Oblique Test (Note if there is symmetry in position of eyeballs)

Nystagmus

D.CN V: TRIGEMINAL NERVE

1.Test for Sensory Function

a.

Facial Sensation (blunt and sharpforehead, cheeks, and jaw)

b.Corneal Reflex

2.Test for Motor Function

a.

Contraction of temporalis and masseter muscle (clench teeth or bite)

b.

Deviation of lower jaw (open and close mouth)

c.Resist force to close mouth (apply pressure on the chin)

3.

Jaw Jerk ReflexOpen mouth, place top of your left index finger on his chin and tap with a reflex hammer

E.CN VII: FACIAL NERVE

1.Taste Sensation(Anterior 2/3 of the tongue)Keep the tongue out until he identifies the test substance used

2.Motor Function(Facial Expression)

Frown/wrinkle forehead

Raise the eyebrow

Close the eyes tightly

Wrinkle the nose

Show teeth and smile

F.CN VIII: VESTIBULOCOCHLEAR NERVE

1.

Auditory Functiona.Gross Hearing Acuity(128 or 256 Hz)Ask if sound is heard equally or better in one ear

b.Webers Test(256 Hz)

c.Rinnes Test(512 Hz)

2.Vestibular Function (Nystagmus present?)

G.CN IX and X: GLOSSOPHARYNGEAL NERVE AND VAGUS NERVE

1.Dysphonia (abnormality in phonation or nasality in voice) or dysarthria (abnormality in articulation or pronunciation of

consonants)

2.Position of Uvula

3.Gag Reflex


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H.CN XI: SPINAL ACCESSORY NERVE

1.Sternocleidomastoid MuscleTurn his head to one side against resistance of examiners hand

2.TrapeziusAsk patient to elevate the shoulders Apply resistance

I. CN XII: HYPOGLOSSAL NERVE

1.Inspect tongue as it lies on the floor of the mouthFasciculations?

2.

Protruded tongueLook for asymmetry, atrophy, or deviation from midline

3.Move tongue from side to side

CEREBELLAR FUNCTIONA.

Finger-Nose-Finger Test

B.Rapid Alternating Movement (RAM)

C.Heel to Shin Test

D.Tandem Walking Test

MOTOR FUNCTION

A.Muscle SizeArm Circumference: 10 cm from the acromion process

Forearm Circumference: 10 cm from the olecranon process

Thigh Circumference: 15 cm from the midinguinal area

Leg Circumference: 15 cm from the fibular head

B.Muscle Tone (Resistance to passive movement)

C.Hypokinetic and Hyperkinetic Movement (Inspect for any involuntary movements: fasciculations, tremors, myoclonus, tics,

chorea, athetosis, dystonia or torsion spasm, ballismus, motor seizures) D.

Muscle Strength (Upper and Lower Extremities)Grade 0 No visible muscle contractions

Grade 1 Flicker or trace of contraction but no joint movement

Grade 2 Active muscle movement with gravity eliminated

Grade 3 Active muscle movement against gravity

Grade 4 Active muscle movement against gravity and minimal to moderate resistance

Grade 5 Active muscle movement against full resistance without evident fatigue

SENSORY FUNCTION

A.Superficial Tactile SensationTouch with a wisp of a cotton

B.Superficial PainAlternate use of the dull and sharp part of a big safety pin

C.Sensitivity to Vibration

Vibrating tuning fork over bony prominences D.

Position SenseDistal phalanx of the fourth digits of the hands and feet moved passively while lightly holding on the sides ( up, down,neutral)

REFLEXES

A.Superficial Reflexes (Corneal, Gag, Abdominal, Cremasteric, Anal)

B.Deep Tendon Reflexes (Biceps, Brachioradialis, Triceps, Patellar or Knee Jerk, Achilles or Ankle jerk) Grading of Stretch Reflexes:

0 = absent

1+ = diminished

2+ = normal

3+ = increased or hyperactive

4+ = hyperactive with clonus

C.Release or Primitive Reflexes(Snout, Grasp, Palmomental, Rooting)

D.Pathological Reflexes (Babinski, Chaddock/Oppenheim/Gordon, Hoffman, Clonus)

STANCE AND GAITA.

Observe for Posture, Balance, Swinging of the arms, Steps (Wide based gait, spasticity, rigidity)Ask patient to walk back and forth several times across the room

B.

Ask patient to turn as he walks(ataxic, shuffling)

C.

Ask patient to walk on toes and on heels(plantar flexors or dorsiflexors weakness)

SIGNS OF MENINGEAL IRRITATION

A.Nuchal rigidity (+) Result: neck resists flexion and patient winces in pain.

B.Brudzinkis sign (+) Result: flexion of the hips and knees

C.Kernigs sign (+) Result: back pain or sciatic pain

[im ward] history taking tool

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