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