Performing A Physical ExamPO 002.01

Physical Examination The evaluation of a patient is conducted in

two parts: The subjective exam The objective exam

The purpose of the assessment is to fully and clearly understand the patient's problems and the physical basis for the symptoms that cause the patient to complain

It is important to do complete physical exams to ensure that the patient is assessed properly and that the treatment plan addresses the patients issues

Subjective Exam The first step of an evaluation when the PTT will

verbally ask the patient questions pertaining to their condition, signs and symptoms to obtain as much information to help determine the best possible treatment plan

Based on the information gathered from the subjective examination, the clinician will determine which tests to perform designed to confirm or refute their hypothesis on the source of a patient’s symptoms

Most of the valuable information will come from the subjective exam so take time to be thorough and ask follow-up questions to patient’s response

Components of Subjective Examination

A good subjective exam should include the all of the following information: Demographic information Chief complaint or history of present illness Past medical history Current medical history Medications Social status Occupational information Previous treatments Red flag questions

Chief Complaintعمده شکایت

This is the reason the patient is seeking medical advice:

Example: A 22-year-old male complains of left knee pain

: دارد طبی مشوره به نیاز مریض که است دلیل این

دارد 22مرد شکایت چپ زانو درد از ساله

History of Present Illness

The acronym “OPQRST” can be used to help remember what questions to ask: O: Onset P: Provocation/Position

What brought symptoms on?, Where is pain located? Q: Quality

Sharp, dull, crushing etc…

R: Radiation Does pain travel?

S: Severity/Symptoms Associated 1/10 scale, What other symptoms occur?

T: Timing/Triggers Occasional, constant, intermittent, only with certain

activities…

Completing the History

• Another acronym to help remember questions for the subjective history is “SAMPLES”:• S: Signs & Symptoms (review of other systems)• A: Allergies/Social History• M: Medications• P: Past Surgeries/Past Medical Problems• L: Last Time Symptoms Occurred• E: Events Leading Up To Injury/Illness• S: Social History (Occupation, Tobacco/Alcohol Use,

home life/support network)

Red Flags Red Flag findings are symptoms or conditions that

may require immediate attention and supersede the PTT being the primary provider of service

Red flag findings are typically indicative of non-mechanical (non-neuromusculoskelteal) conditions or pathologies of visceral origin and patient’s presenting with red flags need to be referred back to the doctor immediately

Red flags can come from both the subjective and objective exam. There are also specific red flags for specific areas of the body

Red Flags: Medical History History of Cancer (personal or familial) Unwarranted general fatigue/malaise Recent Infection, Illness, or Constitutional

symptoms Immunosuppression Injection drug use Altered Vital Signs (BP, HR, PR, body temp) Fever/Night Sweats

Red Flags: Clinical Presentation Unknown etiology with insidious onset Symptoms unaltered by examination or intervention (for

better or worse) Symptoms unaltered or inconsistent with specific positions

or postures Diminishing symptomatic relief value from previously

effective remedies Disproportionate symptoms Symptoms do not fit in typical or recognizable pattern Unexplained symptoms (swelling, paraesthias, weakness,

tone alteration) Significant, unintended weight loss or Gastrointestinal

Disturbances Palpable, growing mass Skin/Nail Changes Cardiovascular Changes (shortness of breath, chest pain,

pulsatile findings) Bowel/Bladder Change or Dysfunction

Red Flags: Abnormal Pain Symptoms Pain despite full passive ROM Pain inconsistent with emotional or

psychological status Nocturnal pain (sleep interruption) Constant and/or poorly localized pain Severe, unremitting, or unusual pain

Red Flags: Neuro Presentation Altered mental status Altered attentiveness (drowsy, lethargic,

sleepy) Blurred vision, altered speech, hearing deficits Difficult swallowing Headache Balance/Coordination Deficits or altered DTRs

Objective Exam The hands on part of the exam where the PTT

will put the patient through several tests based on the information provided in the subjective exam

The tests performed in the objective exam will provide quantifiable (measurable) data that can be used to track patient progress and the effectiveness of the treatment

During the objective exam, the PTT will collect and record the data from the various tests and the patients response to each test

Components of Objective Exam The objective exam consists of:

Inspection Palpation Range-of-Motion (ROM) Muscle strength testing Motor & Sensory testing Special tests

Objective Exam

Inspection: Ask the patient to place one finger on the one

spot that hurts the most This simple request will localize the problem and

narrow the differential diagnosis Look for swelling, bruising, tone, and muscular

atrophy نمائید شروع را تفتیش

درد که نقطه یک باالی را انگشتش که نمائید تقاضا مریض از . دهد قرار مینماید

و ساخته موضعی را مشکل شما ساده درخواست اینمیسازد تر اسان را تفریقی تشخیص

نمایید جستجو را عضلی اتروفی و مصدومه، ساحه تورم،

Objective Exam

• Inspection continued:– Note the patient's body habits and standing posture– Compare the affected area with the unaffected area

on the opposing side of the body– This comparison is important to define subtle

abnormalities and to rate the severity of the problem–) آن ) ادامه تفتیش با شروع

ایستاده – وضعیت و مریض عادات کردن یادداشتشده – متاثر غیر نهایات با شده متاثر نهایات کردن مقایسهمشکل – درجه تعین و دقیق های ابنارملتی تعین جهت مقایسه این

. میباشد مهم

Inspection

Left calf atrophy and Right calf hypertrophy

Left hand muscle wasting from denervation

Inspection Continued . . .

• Watch the patient walk and transfer to and from sit to stand, or turn in bed if applicable

• Analyze the stance and swing phases of gait to identify antalgic gait patterns

• Look for compensations in movement and comparisons of sides during the movements

Objective Exam: Palpation

• The affected area should be palpated for:– Tenderness or pain– Abnormal masses– Temperature changes– Sensation changes

•: گردد جس ذیل موارد برای باید شده متاثر ساحهحساسیت–نارمل – غیر های کتلهحرارت – درجه تغیرت

Objective Exam: Range of Motion (ROM)• Measuring joint motion is important

– Joint mobility is essential to perform activities of daily living

– Losses in ROM can be a clue to the diagnosis– Also determines if therapy/treatment is effective?– Predicts the patient function?

کلید • از عبارت مفصلی حرکت درجه حاد، مریضی درمیباشد تشخیصی

است؟ • موثر معالجه یا تداوی آیامیکند؟ • فعالیت خوب مریض آیا

Range of Motionحرکت دامنه• Measuring joint motion is important

– In some conditions, the degree of ROM provides an index to the severity and progression of the disorder, as well as providing important information concerning the results of treatment

است • اهمیت با ها خیلی مفصلی حرکت کردن اندازهدرجه – مفصلی، عظمی التهاب مثل مزمن های وضعیت در

را مرض پیشرفت و شدت برای شاخص یک مفصلی حرکاتنتایج های نگرانی برای مهم معلومات همچنان میدهد، نشان

میدهد نشان نیز را تداوی

Basic Principles of ROM Measuringحرکت دامنه اندازه عمده اساسات

Joint ROM is an objective measurement The parameters for rating musculoskeletal

disability are based largely on the degree that joint motion is impaired

میباشد هدف مورد گیری اندازه یک مفصلی حرکت اساس به اسکلیتی عضلی معیوبیت میزان های پارامتر

میباشد مفصلی حرکت درجه در کفایه عدم

Basic Principles of ROMحرکت دامنه عمده اساسات• ROM can be estimated visually

however, a goniometer enhances accuracy• A device used in physical therapy

to measure the ROM around a joint in the body

• Usually made of plastic and is often transparent. Occasionally are made of metal

• There are two "arms" of the goniometer: • The stationary arm and the

moveable arm• Each arm is positioned at specific

points on the body and the center of the goniometer is aligned at the joint to be measured

ROM Starting Positionصفر شروع با وضعیت

• Knowing the accepted starting position for each joint is necessary to provide consistent communication between observers

• For most joints, the starting position is somewhere in the middle of the available anatomical range

• If the starting position is not used when taking a measurement, the position used needs to be recorded in the patient’s chart

Joint Starting Position

Neck Sitting, with thoracic & lumbar spine well supported by the back of a chair

Shoulder Supine, knees flexed, arm at side, thumb up

Elbow Supine, arm at side, pad under distal humerus to allow full extension, palm up

Wrist Sitting , arm supported, elbow bent to 900 wrist inline with forearm and palm down

Fingers Sitting , arm supported, elbow bent to 900 wrist inline with forearm and palm down, fingers in line with forearm and wrist

Back Standing with cervical, thoracic, & lumbar spine inline

Hip Supine, leg straight, initially knee is extended, but knee flexion should be allowed as hip ROM is taken

Knee Supine, knee in extension, initially hip in starting position, but as knee flexes, hip also flexes

Ankle Supine or sitting with knee flexed 900 & lower leg over edge of table surface, foot in 00 of inversion/eversion

Strength Testingقدرت یا قوت تست

Strength Testing Physical therapy uses the Oxford Scale to assess

muscle strength

According to the Oxford scale, muscle strength is graded on a scale of 0 to 5

It is important that the same PTT test the patient throughout treatment as the Oxford scale has poor reliability between different testers

Strength testing should be done in the same starting positions as ROM testing

NumericGradeدرجه عدد

DescriptiveGradeدرجه

تشریحی

Descriptionتشریح

5 Normalنارمل Complete range of motion against gravity with full or normal resistance

با ثقل قوه مقابل در مکمل حرکت دامنهمکمل با نارمل مقامت

4 Good خوب Complete range of motion against gravity with some resistance

با ثقل قوه مقابل در مکمل حرکت دامنهمکمل با مقامت از بعضی

3 Fairمناسب Complete range of motion against gravity

ثقل قوه مقابل در مکمل حرکت دامنه2 Poorضعیف Complete range of motion with gravity eliminated

ثقل قوه مقابل در مکمل حرکت دامنهشده محدود

1 Traceکم Muscle contraction but no or very limited joint motion

یا مفصلی حرکت عدم ولی عضله تقلصکم ها خیلی مفصلی حرکت

0 Zeroصفر No evidence of muscle function

نیست موجود عضلی فعالیت شواهدی

Strength Testing Continued Strength testing should be performed on

initial assessment to those muscles that are involved or potentially could be involved because of the specific injury

If the patient experiences pain with testing it should be recorded in addition to the strength grade

If a patient has pain or not with a weaken muscle, it can help determine or confirm a diagnosis

Strength Testing Results

Response to Testing Possible Indications

Strong and Painless This response represents a normal muscle

Strong and Painful This response to suggests a minor lesion of a musculotendinous structure

Weak and Painful This response suggests a partial tear of a musculotendinous structure

Weak and Painless This response to resistance is indicative of a complete tear or neurologic lesion

Strength Testing Guidelines

Place the patient in a position that provides overall support to the body (i.e. sitting or supine)

The area to be tested is placed in the same starting position as for ROM testing

The proximal part of the area being tested should be stabilized to reduce the opportunity for compensatory action by muscles

Strength Testing Guidelines Continued . . . Resistance needs to be applied directly

opposite the "line of pull" of the muscles being tested i.e. If testing the quad muscles, force needs to be

applied to flex the knee as the patient tries to extend

Gradual application of pressure should take place slowly eventually applying resistive force to meet the patient’s maximal effort

Both sides should be assessed to provide a comparison of the patient’s potential strength

Objective Exam: Motor and Sensory Testing

• Nerve root function should be tested if the patient's presenting complaints suggest a neck or back problem (spine)

• Peripheral nerve function should be tested if the disorder is localized to the extremities

مریض • اگر یعنی گردد تست خوب باید عصبی ریشه فعالیت ) دهد ) نشان نخاع کمر یا عنق مشکل و بگوید را شکایات

تشوش • اگر گردد تست خوب باید محیطی عصبی فعالیتباشد داشته موقعیت نهایات در

Motor and Sensory Evaluation The nerves at each level in the spine

correspond with a specific muscle(s) (Myotome) and sensation to a specific area on the body (Dermatome)

Myotome = relationship between the spinal nerves and a muscle

Dermatome = relationship between the spinal nerves and sensation to skin

MyotomesSpinal Level

Corresponding Muscle function

C3-5 Diaphragm (the large muscle between the chest and the belly that we use to breath)

C5 Shoulder abduction and elbow flexion

C6 Elbow flexion and wrist extension

C7 Elbow extension and wrist flexion

C8 Thumb extension

T1 Spreading of the fingers

T1-12 Supplies the chest wall and the abdominal muscles

L2 Hip flexion

L3 Knee extension

L4 Ankle dorsi-flexion and inversion

L5 Great toe extension

S1 Ankle plantar flexion and eversion

S2-5 Supplies the bladder

Dermatomes

Reflex Testing A reflex arc has afferent (sensory) & efferent

(motor) branch

Disruption of any part of path alters reflexes: Upper Motor Neuron (UMN) Lesion

Reflexes more brisk (hyper-reflexia)

Lower Motor Neuron (LMN) Lesion or Peripheral Sensory Lesions Reflexes are reduced or absent (hypo-reflexia)

Reflexive Arc

Reflexes ها ریفلکس A scale used to

describe the strength of deep tendon reflexes0 reflex absent1+ reflex somewhat

diminished; low normal2+ reflex average; normal3+ reflex brisker than

average4+ reflex very brisk,

hyperactive

استفاده • مورد میزانقدرت تشریح برای

های ریفلکس عمیقهوتری

ریفلکس 0 غیابت1 +، کم و پائین ریفلکس

نارمل از کمترمتوسط،+ 2 ریفلکس

نارملحد+ 3 از بیشتر ریفلکس

متوسطها + 4 خیلی ریفلکس

فعال ها خیلی و سریع

Reflex Basics Reflexes generally assessed in 5 places:

3 in the arm (biceps, triceps, brachioradialis) 2 in the leg (patellar & achilles)

Basic Technique for assessing a reflex: Clearly identify tendon of muscle to be tested Position limb so muscle is at rest Strike tendon briskly with reflex hammer Observe for muscle contraction & limb movement

Reflex Basics Continued . . . Reflex Trouble Shooting:

Make sure the patient is relaxed & that you are striking the tendon directly

Hammer must swing freely Reinforcement (distraction) helps if you’re

having problems getting a response When testing legs, ask patient to push their hands

together as you strike the tendon When testing the upper extremities, ask them to

clench teeth

Biceps (C5,6) Identify biceps tendon

Have patient flex elbow against resistance while you palpate tendon

Place arm so it’s bent to 90 degrees

Place one of your fingers on tendon and strike it briskly

Muscle should contract & forearm flex

Triceps (C7, 8) Identify triceps tendon

Have patient extend elbow against resistance while you palpate tendon

Arm can hang down at ninety degrees or have hands on hips

Strike tendon directly or place finger on the tendon & strike it

Triceps muscle contracts & arm extends

Brachioradialis (C5,6) Tendon for

brachioradialis is ~ 10 cm proximal to wrist –you cant see or feel it

Place arm so resting on patient’s thigh, bent at elbow

Strike firmly Muscle will contract

& arm will flex at elbow & supinate

Patellar (L3,4) Patellar tendon

extends below knee cap

It is thick & usually visible & palpable, if not, palpate while patient extends lower leg

Strike firmly on tendon

Muscle will contract & leg extend at knee

Achilles (S1,2) Achilles tendon is a

thick structure connecting calf muscles to the heel

If having trouble finding, palpate as patient pushes their foot into your other hand

Hold foot at 90 degrees

Strike tendon firmly Muscle will contract &

foot plantar-flex (move downward)

Babinski Testing The Babinski reflex occurs when the big toe

moves upward and the other toes fan out after the sole of the foot has been firmly stroked

This reflex is normal in children up to 2 years old. It disappears as the child gets older. It may disappear as early as 12 months

When the Babinski reflex is present in a child older than 2 years or in an adult, it is often a sign of a brain or nervous system disorder (UMN lesion)

Babinski Testing Firmly stroke

bottom of foot, starting laterally & near heel –moving up & across balls of feet (metatarsal heads)

Normal = great toe moving downward

If UMN lesion (or in newborns), great toe will extend & other toes fan out

Myotomes, Dermatomes and Reflexes Overview

Special Testing مخصوص های تست

• Maneuvers developed to assist in the diagnosis of a particular musculoskeletal condition

• The patient's subjective history and results of the rest of the objective exam will guide special test selection

• Special tests will help confirm diagnoses or give clues for potential differential diagnoses

• Test very specific structures or functions

Summary The physical exam consists of the subjective and the

objective exams

The information gathered in the subjective exam will help direct what testing will be done in the objective exam

The objective exam consists of: Inspection Palpation Range-of-Motion (ROM) Muscle strength testing Motor & Sensory testing Special tests

Questions?

Comprehension Check

1. What are the two components of a physical exam?

2. What are the 2 acronyms used to help direct which questions to ask the patient and what do they stand for?

3. Why is it important to inspect the area of injury?

4. What is the starting position for ROM testing for the elbow, shoulder and knee?

5. What does a 3/5 on the Oxford scale mean?

6. What is a normal Babinski test in an adult? And in a child under 2?

Answers1. The two components of a physical exam are:

Subjective exam Objective exam

2. The 2 acronyms for questioning patients are: “OPQRST”: Onset, Provocation/Position,

Quality, Radiation, Severity/Symptoms associated, Timings/triggers

“SAMPLES”: Signs/symptoms, Allergies, Medications, Past surgeries/medical history, Last time symptoms occurred, Events leading to the injury, Social history

Answers3. Inspection is important to look for any

bruising, swelling, deformity, and to compare the injured side to the unaffected side

4. Starting positions: Elbow: Supine, arm at side, pad under distal

humerus to allow full extension, palm up Shoulder: Supine, knees flexed, arm at side,

thumb up Hip: Supine, leg straight, initially knee is

extended, but knee flexion should be allowed as hip ROM is taken

Answers5. A 3/5 on the Oxford scale means complete

range of motion against gravity

6. A normal Babinski in an adult is the great toe moving downward when the sole of the foot is stroked. A normal response in a child under 2 is great toe extension with fanning of the rest of the toes

A 24-year-old man complains of neck pain from a whiplash injury yesterday. Pain radiates to his right thumb. If he has decreased light touch sensation between his thumb and index finger what other exam finding is MOST likely?a) Weakness with wrist flexionb) Weakness with elbow extensionc) Decreased triceps reflexd) Weakness with wrist extensione) Decreased biceps reflex

. 24مرد به درد دارد شکایت دیروز ضربتی جرحه و عنق درد از ساله . حسیت کاهش او اگر میکند انتشار راست شصت انگشت طرف

باشد، داشته شهادت انگشت و شصت انگشت بین در چراغ تماسگردد؟ معاینه باید را ها دریافت دیگر نوع کدام

)a دست بند قبض ضعیفی)b آرنج بسط ضعیفی)c سپس ترای ریفلکس کاهش)d دست بند بسط ضعیفی)e بایسپس ریفلکس کاهش

A 24-year-old man complains of neck pain from a whiplash injury yesterday. Pain radiates to his right thumb. If he has decreased light touch sensation between his thumb and index finger what other exam finding is MOST likely?a) Weakness with wrist flexionb) Weakness with elbow extensionc) Decreased triceps reflexd) Weakness with wrist extension (C6)e) Decreased biceps reflex. 24مرد به درد دارد شکایت دیروز ضربتی جرحه و عنق درد از ساله

. حسیت کاهش او اگر میکند انتشار راست شصت انگشت طرفکدام داشته، شهادت انگشت و شصت انگشت بین در چراغ تماس

گردد؟ معاینه باید را ها دریافت دیگر نوع)a دست بند قبض ضعیفی)b آرنج بسط ضعیفی)c سپس ترای ریفلکس کاهش)d دست بند بسط ضعیفی)e بایسپس ریفلکس کاهش

A 38-year-old orthopedic patient complains of low back pain that radiates to his left leg down to his medial foot. If he has weakness with left ankle plantar flexion and inversion what other exam finding is MOST likely?a) Decreased sensation lateral footb) Weakness with foot eversionc) Decreased patella tendon reflexd) Decreased Achilles tendon reflexe) Weakness with great toe extensionمرد پای 38یک به درد که داشت شکایت کمر سفلی درد از ساله

. تدور در ضعیفی او اگر میکند انتشار او پای انسی قسمت به چپرا ها دریافت دیگر نوع کدام باشد، داشته داخل به چپ پای دادن

گردد؟ معاینه باید)a پا وحشی حسیت کاهش)b خارج به پای تدور ضعیفی)c رضفه وتری ریفلکس کاهش)d آشیل وتر ریفلکس کاهش)e بزرگ انگشت بسط ضعیفی

A 38-year-old orthopedic PA complains of low back pain that radiates to his left leg down to his medial foot. If he has weakness with left foot inversion what other exam finding is MOST likely?a) Decreased sensation lateral footb) Weakness with foot eversionc) Decreased patella tendon reflex (L4)d) Decreased Achilles tendon reflexe) Weakness with great toe extension

مرد پای 38یک به درد که داشت شکایت کمر سفلی درد از ساله . تدور در ضعیفی او اگر میکند انتشار او پای انسی قسمت به چپرا ها دریافت دیگر نوع کدام باشد، داشته داخل به چپ پای دادن

گردد؟ معاینه باید)a پا وحشی حسیت کاهش)b خارج به پای تدور ضعیفی)c رضفه وتری ریفلکس کاهش)d آشیل وتر ریفلکس کاهش)e بزرگ انگشت بسط ضعیفی

Complete range of motion with gravity eliminated BEST describes which strength score?a) 0/5b) 1/5c) 2/5d) 3/5e) 4/5

قدرت درست صورت به ثقل قوه بدون حرکت سویه کردن تکمیلمینماید؟ تشریح را عضلی

a) 0/5b) 1/5c) 2/5d) 3/5e) 4/5

Complete range of motion with gravity eliminated BEST describes which strength score?a) 0/5b) 1/5c) 2/5d) 3/5e) 4/5

قدرت درست صورت به ثقل قوه بدون حرکت سویه کردن تکمیلمینماید؟ تشریح را عضلی

a) 0/5b) 1/5c) 2/5d) 3/5e) 4/5