Dr.____________________________ Date:__________ Pt._________________________

VITAL SIGNS

Height:_____ ft.____in., Weight:_______Ibs., Sex: M F

Temperature: oral ____°F, rectal_____°F, axillary_____°F

Pulse: ____Beats/min.

Respiration: _______Breaths/min.

 

Palpatory Blood Pressure: Left:_______mmHg, Right:_______mmHg

Auscultory Blood Pressure: Left:_____/_____mmHg, Right:_____/_____mmHg

Comments:(auscultory gaps / respiration; rate, rhythm, depth, effort / pulse; contour, rhythm, amplitude) _______________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

GENERAL INSPECTION (upper body)

Observe: Head/Face, Hair, Neck, Chest, Back, both arms/hand,, Fingernails.

Comments:______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

SUPERFICIAL PALPATION(upper body)

HEAD AND NECK THORAX UPPER EXTREMITY

Temperature changes:____________________________/__________________________/________________________________

Edema:________________________________________/__________________________/________________________________

Muscular tonus:_________________________________/__________________________/_______________________________

Tenderness/trigger points:____________________________________________________________________________________

Comments:(lesion; size, shape, consistency, tenderness, temperature, location)________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

ARTERIAL PULSES (upper body)

Temporal:__R__L Antecubital:__R__L

Mandibular:__R__L Radial:__R__L

Carotid:__R__L Ulnar:__R__L

Brachial:__R__L

Comments: (pulse; amplitude, symmetry)_____________________________________________________________________________________________

 

THYROID INSPECTION

Swollen Y N Any Fixed Tissue Y N Asymmetrical movement Y N Is it Midline Y N Masses/nodules Y N

Comments: (Consistency, size, shape, tenderness, location) _______________________________________________________________________________________________________________________________

LYMPH NODES

HEAD AND NECK AXILLARY INGUINAL

Sub-occipital:__R__L Pectoral:__R__L Vertical:__R__L

Posterior Auricular:__R__L Subscapular:__R__L Horizontal:__R__L

Anterior Auricular:__R__L Humeral:__R__L

Sub mandibular__R__L Thoracic:__R__L

Sub mental:__R__L

Anterior chain:__R__L Comments:(size, shape, consistency, tenderness, temperature, location)__________

Posterior chain:__R__L ___________________________________________________________________

Deep chain:__R__L ___________________________________________________________________

Supraclavicular__R__L


GENERAL INSPECTION (Back, Chest and Lower Extremity)

 

SUPERFICIAL PALPATION

BACK CHEST LOWER EXTREMITY

Temperature changes:______________________/_______________________________/_________________________________

Edema ______________________/_______________________________/_________________________________

Muscular tonus: ______________________/_______________________________/_________________________________

Tenderness/trigger points:____________________________________________________________________________________

Comments:(lesion; size, shape, consistency, tenderness, temperature, location)_______________________________________________________________

______________________________________________________________________________________________________________________________

ARTERIAL PULSES (Trunk and Lower extremity)

PMI __R__L Posterior Tibial __R__L Comments:(pulse; amplitude, symmetry)__________________________________

Abdominal __R__L Dorsalis Pedis __R__L ___________________________________________________________________

Iliacs __R__L ____________________________________________________________________

Femorals __R__L

Popliteals __R__L


MOUTH AND THROAT EXAMINATION

INSPECTION:

__ External __ Teeth and gums

__ Buccal mucosa __ Soft and hard palate

__ Tongue __ Oral pharynx

__ Wharton's ducts _______Tonsils

__ Stenson's ducts

OTHER PROCEDURES: ___Tongue protrusion ___ Vernet Rideau ___ Gag reflex

OPTIONAL PROCEDURES: ___Palpation Other

Comments: (lesion: size, shape, location):__________________________________________________________________________________________

COMPLETE CRANIAL NERVE EXAM

CRANIAL NERVE I: Nostrils Patent? Y____________ / N______________ Nostrils obstucted ? Y N

R(scents correctly identified)_____________________________________________________________________________

L(scents correctly identified)_____________________________________________________________________________

NOSE EXAMINATION:

Inspection: __________________________________________________________________________________________

Palpation: ___________________________________________________________________________________________

Rhinoscopy:__________________________________________________________________________________________

Comments: ____________________________________________________________________________________________

CRANIAL NERVE II: Snellen: [ With corrective lenses ] R____/____ color _____ L____/____ color ______

Pinhole test: Snellen: [ Without corrective lenses ] R____/____ L____/____

Pinhole test: Snellen: [ Without corrective lenses and pinhole ] R____/____ L____/____

Central and Peripheral Visual fields:__________________________________________________________________________

Direct and Consensual Light reflex: (CNII & CNIII ) ______________________________________________________________

Ophthalmoscopic exam :

Anterior: ________________________________________________________________________________________________

Posterior:_________________________________________________________________________________________________

Comments: _______________________________________________________________________________________________

CRANIAL NERVE Ill. IV. Vl

(Ciliospinal________________________________________________________)

Corneal light reflex:__________________________________________________________________________________________

Cover test:_________________________________________________________________________________________________

Levator Palpebrae___________________________________________________________________________________________

Cardinal fields of Gaze (extraocular muscles):_____________________________________________________________________

Accommodation:____________________________________________________________________________________________

Comments: ________________________________________________________________________________________________

CRANIAL NERVE V

Sensory: Light toucho_________________________________________________________________________________________

Pain (sharp and dull) _________________________________________________________________________________

Temperature________________________________________________________________________________________

Motor: Inspection___________________________________________________________________________________________

Mandibular gait_______________________________________________________________________________________

Palpation___________________________________________________________________________________________

Masseter/Temporalis __________________________________________________________________________________

Pterygoids R__________________________________________L______________________________________________

Deep Tendon Reflex: Jaw jerk __________ Jendrassik maneuver ________

Superficial Reflex: Corneal (present/absent) R_________L_________

Visceral Reflex: Oculocardiac R_________L_________

Comments: ________________________________________________________________________________________________

CRANIAL NERVE VII

Sensory :Tastes (anterior 2/3 tongue) correctly identified: Sour: R________________________L__________________________

Sweet:R________________________L__________________________

Motor: Inspection ________________________________________________________________________________________

wrinkle forehead_____________ close eyes_____________ close eyes against resistance_____________________

smile_____________ frown____________ puff cheeks_____________ pucker___________grimace (platysma)__________

Autonomic function--Lacrimal_________________________________________

Submandibular_____________________________________

Sublingual_________________________________________

Comments: ________________________________________________________________________________________________

CRANIAL NERVE VIII

EAR EXAMINATION:

Inspection: R____________________________________ L_______________________________________

Palpation: R____________________________________ L________________________________________

Otoscopy: R____________________________________ L________________________________________

COCHLEAR DIVISION

Gross hearing:(distance):R_______________ L_________________

Weber's test:______________________________ Bing's test:_______________________________ Schwabach's:__________

Rinne's test: R = _____sec: _____ sec L = _____sec: _____ sec

BONE AIR BONE AIR

VESTIBULAR DIVISION

Nylen Barany R_____________________ L___________________

Comments: ________________________________________________________________________________________________

CRANIAL NERVE IX

Sensory :

Tastes (Posterior 1/3 tongue) correctly identified: R____________________________/_______________________________

L____________________________/_______________________________

Superficial Reflex --Gag (Present/absent) R________ L_________

Visceral Reflex -- Carotid sinus R________ L_________

Autonomic function -- Parotid __________________________________________________________

Comments: ________________________________________________________________________________________________

CRANIAL NERVE X

Motor: Vernet Rideau ____________________________________________________________________________________

Swallow ____________________________________________________________________________________

Speech ____________________________________________________________________________________

Visceral Reflex:Oculocardiac R__________ L__________

Comments: ________________________________________________________________________________________________

CRANIAL NERVE XI

Motor : Sternocleidomastoid R_____ L_____

Upper Trapezius R_____ L_____

Comments: ________________________________________________________________________________________________

CRANIAL NERVE XII

Motor : Inspection __________________________________________________________________________________________

Tongue protrusion ___________________________________________________________________________________

Tongue against cheek R_____ L_____

Comments: ________________________________________________________________________________________________

Muscle Grading Scale

5 = (normal) complete range of motion against gravity and full resistance for 5 seconds

4 = (good) complete range of motion against gravity with some resistance

3 = (fair) complete range of motion against gravity

2 = (poor) complete range of motion with gravity eliminated

1 = (trace) slight muscle contraction, no joint motion

0 = (zero) no evidence of contraction

(Correlative Neuroanatomy & Functional Neurology, 19th ea.. Chusid)

Wexler Deep Tendon Reflex Grading Scale

(NOTE: 0 - 3 may be normal if equal bilateral. Consider the complete clinical picture)

0 = no response with Jendrassik maneuver

1 = hyporeflexia, present but diminished

2 = normal

3 = hyperreflexia (with no clonus)

4 = hyperreflexia with transient clonus

5 = hyperreflexia with sustained clonus

 

SINUS EXAMINATION

Inspection : ________________________________________________________________________________________________

Palpation : _________________________________________________________________________________________________

Transillumination : (Frontal, Maxillary)__________________________________________________________________________

Comments: ________________________________________________________________________________________________


UPPER EXTREMITY RANGES OF MOTION

Apley's Scratch Test ENDFEELS Difference between R & L reaches

Behind the Back: R _______ L_______ ______________ cm Restricted ___R ___L

Behind the Head: R _______ L_______ ______________ cm Restricted ___R ___L

Across Opposite Shoulder: R _______ L_______ ______________ cm Restricted ___R ___L

Comments: ________________________________________________________________________________________________

Active R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel

Unilateral Elevation (Sagittal) (180°) ____ ______ _______________ _____ _______ _____ ________

Unilateral Elevation (Coronal) (180°) ____ ______ _______________ _____ _______ _____ ________

Bilateral Elevation (Sagital) (180°) ____ ______ _______________ _____ _______ _____ ________

Bilateral Elevation (Coronal) (180°) ____ ______ _______________ _____ _______ _____ ________

Extension (45°) ____ ______ _______________ _____ _______ _____ ________

Adduction (45°) ____ ______ _______________ _____ _______ _____ ________

Lateral Rotation (80÷90°) ____ ______ _______________ _____ _______ _____ ________

Medial Rotation (100÷110°) ____ ______ _______________ _____ _______ _____ ________

Elbow Flexion ( 135°) ____ ______ _______________ _____ _______ _____ ________

Elbow Extension (0°) ____ ______ _______________ _____ _______ _____ ________

Forearm Pronation (90°) ____ ______ _______________ _____ _______ _____ ________

Forearm Supination (90°) ____ ______ _______________ _____ _______ _____ ________

Wrist Flexion (90°) ____ ______ _______________ _____ _______ _____ ________

Wrist Extension (70°) ____ ______ _______________ _____ _______ _____ ________

Wrist Ulnar Deviation (30°) ____ ______ _______________ _____ _______ _____ ________

Wrist Radial Deviation (20°) ____ ______ _______________ _____ _______ _____ ________

Hand MCP Flexion (90°) ____ ______ _______________ _____ _______ _____ ________

Hand PIP Flexion ( 100°) ____ ______ _______________ _____ _______ _____ ________

Hand DIP Flexion (90°) ____ ______ _______________ _____ _______ _____ ________

Hand MCP Extension (30°-45° ) ____ ______ _______________ _____ _______ _____ ________

Hand PIP Extension (0°) ____ ______ _______________ _____ _______ _____ ________

Hand DIP Extension (0-10°) ____ ______ _______________ _____ _______ _____ ________

Hand Adduction (20°) ____ ______ _______________ _____ _______ _____ ________

Hand Abduction (20°) ____ ______ _______________ _____ _______ _____ ________

Thumb Flexion (50°) ____ ______ _______________ _____ _______ _____ ________

Thumb Extension (0°) ____ ______ _______________ _____ _______ _____ ________

Thumb Abduction (70°) ____ ______ _______________ _____ _______ _____ ________

Thumb Adduction (0°) ____ ______ _______________ _____ _______ _____ ________

Cornrnents.___________________________________________________________________________________________


LOWER EXTREMITY RANGES OF MOTION

Active Clearance: Able to do: YES____ No____ Keep heels on floor: Yes____ No____

Trendelenberg: Left_____ Right_____ Patrick FABERE: Left_____ Right_____

Active R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel

Hip Flexion ( 120°) ____ _____ _______________ _____ _______ _____ ________

Hip Abduction (45°) ____ _____ _______________ _____ _______ _____ ________

Hip Adduction (20°) ____ _____ _______________ _____ _______ _____ ________

Hip Extension (30°) ____ _____ _______________ _____ _______ _____ ________

Hip Internal Rot. (35°) ____ _____ _______________ _____ _______ _____ ________

Hip External Rot. (45°) ____ _____ _______________ _____ _______ _____ ________

KNEE R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel

Flexion ____ ______ _______________ ____ _______ _____ ________

Extension ____ ______ _______________ _____ _______ _____ ________

Internal Rot. (10°) ____ ______ _______________ _____ _______ _____ ________

External Rot. (10°) ____ ______ _______________ _____ _______ _____ ________

ANKLE R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel

Dorsiflexion (20°) ____ ______ _______________ _____ _______ _____ ________

Plantarflexion (50°) ____ ______ _______________ _____ _______ _____ ________

Inversion ( 15-20°) ____ ______ _______________ _____ _______ _____ ________

Eversion ' (10°) ____ ______ _______________ _____ _______ _____ ________

FOOT/TOES

/MTP R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel

Flexion of Toes ____ ______ _______________ _____ _______ _____ ________

Extension of Toes ____ ______ _______________ _____ _______ _____ ________

Abduction of Toe ____ ______ _______________ _____ _______ _____ ________

Adduction of Toe ____ ______ _______________ _____ _______ _____ ________

Comments: _______________________________________________________________________________________________

MYOTOMES

CERVICAL SPINE THORACIC SPINE

Cl-C3 (neck extensors) _______ Trunk curl up (Beevor's sign) _______

C2-C3 (neck flexors) _______

Right Left

C5 (deltoids) _______ _______ LUMBAR SPINE

(biceps) _______ _______ Right Left

C6 (brachioradialis) _______ _______ L2-L3 (quadriceps) _______ _______

(wrist extensors) _______ _______ L4 (tibialis anterior) _______ _______

C7 (triceps) _______ _______ L5 (extensor digitorum)_______ _______

(wrist flexors) _______ _______ (extensor halluces) _______ _______

(finger extensors) _______ _______ SI (peroneus longus) _______ _______

C8 (finger flexors) _______ _______ L4/L5 (heel walking) __________________

Tl (inspection) _______ _______ L5/S1 (toe walking) __________________

(abduction/adduction)_______ _______

(interlaced fingers) _______ _______

(abductor digiti minim) _______ _______

Comments: ________________________________________________________________________________________________

. Muscle Grading Scale

5 = (normal) complete range of motion against gravity and full resistance for 5 seconds

4 = (good) complete range of motion against gravity with some resistance

3 = (fair) complete range of motion against gravity

2 = (poor) complete range of motion with gravity eliminated

1 = (trace) slight muscle contraction, no joint motion

0 = (zero) no evidence of contraction

(Correlative Neuroanatomy & Functional Neurology, 19th ea.. Chusid)

DEEP TENDON REFLEXES (J_____) = Jendrassik

CN V (jaw jerk) ______ (J_____)

C5 (biceps) R_____(J_____) L_____(J_____) L4 (patellar) R_____(J_____)

C6 (brachioradialis) R_____(J_____) L_____(J_____) L5 (hamstrings) R_____(J_____)

C7 (triceps) R_____(J_____) L_____(J_____ ) S1 (achilles) R_____(J_____)

Comments: ________________________________________________________________________________________________

Wexler Deep Tendon Reflex Grading Scale

(NOTE: 0 - 3 may be normal if equal bilateral. Consider the complete clinical picture)

0 = no response with Jendrassik maneuver ,1 = hyporeflexia, present but diminished ,2 = normal ,3 = hyperreflexia (with no clonus) ,4 = hyperreflexia with transient clonus,

5 = hyperreflexia with sustained clonus

PATHOLOGICAL REFLEXES

UPPER EXTREMITY

Tromner (present/absent) R ____ L ____

Hoffman (present/absent) R ____ L ____

LOWER EXTREMITY

Babinski (present/absent) R ____ L ____ Oppenheim (present/absent) R ____ L ____

Chaddock (present/absent) R ____ L ____ Shaeffer (present/absent) R ____ L ____

Gordon (present/absent) R ____ L ____ Gonda (present/absent) R ____ L ____

Comments: ________________________________________________________________________________________________

SUPERFICIAL REFLEXES

Corneal Reflex (V,VII) (present/absent) R__________ L__________

Umbilical (Abdominal) (present/absent) RUQ __________ RLQ__________ LUQ__________ LLQ__________

(UQ T7-T10, LQ T10-T12)

Cremasteric/Geigel (present/absent) R__________ L__________

Plantar(SI) (present/absent) R __________ L__________

Anal (S2-S4) (present/absent) R__________ L __________

Comments: ________________________________________________________________________________________________


CIRCUMFERENTIAL MENSURATION

UPPER EXTREMITY

Landmark: ______________________________

Distance proximal to landmark: _____________ cm R ________ cm L________ cm