SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE

DOCTORING

SCREENING HEAD TO TOE PHYSICAL EXAMINATION 2006 -- 2007

The following checklist will be used for evaluating your physical examination skills at SIUSOM. The Chicago Basic Clinical Skills Consortium initially developed this checklist. The consortium was comprised of faculty members from UIC, University of Chicago, Loyola Medical School, Rush Medical College, Chicago Medical School, Northwestern Medical School, and Indiana University Northwest Medical School.

CHECKLIST ITEMS: This checklist is compatible with the physical exam techniques described in the Bates text. The Bates textbook is the foundation on which the Step 2 -- Clinical Skills Exam is based. In preparation for learning the Screening Head to Toe Examination, students should use this checklist and the Bates text as the primary references. An instructional DVD is also available as a secondary reference, which will be made available to each student. Do not assume however, that the video is the only resource needed, as there are a few maneuvers that were inadvertently omitted in the production process.

THE ORDER OF THE CHECKLIST: You are not required to perform the examination in the same order that appears on this checklist (unless the checklist item so states; wash hands before starting examination, auscultation prior to palpation, etc.) The checklist order listed here is one physician's opinion of how the examination should be performed. Should you decide to modify the order, keep in mind that it is important to move the patient from a sitting position to a supine position to a standing position as few times as possible.

ACCEPTABLE TECHNIQUES: Within the curriculum, you will learn many acceptable methods of performing various physical examination maneuvers. However, the standard for the Screening Head to Toe Examination uses the techniques listed in this checklist. Using one standard is the only way to insure a standardized examination for all students, and also assures us that students know at least one correct way to perform each and every maneuver.

Head to Toe Physical Examination 2006-2007

STUDENT CHECKLIST

Please note that references to gender in the checklist items are represented by she/her/herself, but that he/him/himself is also implied.

Wash hands before starting examination. Note: If you do not do so, the patient will ask you to wash your hands. However, you will not receive credit for this item.

VITAL SIGNS

Measure blood pressure accurately in each arm.
Hold up each arm outstretched and perpendicular to heart while measuring blood pressure.
Place cuff snugly in correct anatomical location.

Note: Credit will not be given if any part of the gown is tucked into the cuff. This must be done completely on skin.

Palpate radial pulse (thumb side of wrist) for at least 15 seconds.

Note: Credit is only given if pulse is taken for a full 15 seconds.

Measure the respiratory rate for at least 15 seconds. Credit is only given if rate is measured for a full 15 seconds. Note: Student may place her hand on upper epigastric area and count respirations or may just observe.

HEAD AND SINUSES

Examine the Skull, Hair and Scalp.

Step # 1: Inspect the skull for its general size, shape and contours.

Step # 2: Note the hair texture and quantity.

Step # 3: Examine the scalp for skin lesions. Have patient bend her head slightly forward. Inspect the skin by parting the hair in several places with your fingers. Note scaliness, lumps, or other skin lesions.

Step # 4: Palpate the scalp. Use the palmar aspects of the fingertips. Feel front to back with short sweeping motions. Note lumps or tender areas.

Frontal Sinus - Palpate or percuss for tenderness above each eye.
Maxillary Sinus - Palpate or percuss for tenderness below each eye.

LYMPH NODES AND THYROID

Preauricular nodes - palpate in front of ears.
Posterior auricular nodes - palpate behind ears.
Occipital nodes - palpate at the base of the skull.
Anterior cervical nodes - palpate anterior to and over the sternocleidomastoid muscle.
Posterior cervical nodes - palpate posterior to and under the sternocleidomastoid muscle.
Supraclavicular nodes - palpate above the collarbone - must be done on skin for credit.
Tonsillar lymph nodes - palate at angle of jaw.
Submandibular lymph nodes - palpate between tonsillar and submental nodes.
Submental lymph nodes - palpate directly under the chin.
Prior to palpating the thyroid, observe the thyroid gland by asking patient to swallow. This will give examiner a visual cue as to where the patient's thyroid is located.
Thyroid gland - palpate first without swallowing and then with swallowing.
- Recommended Technique: Examiner stands behind patient. However, this may be done while standing in front of the patient, as well. Note: Be prepared to offer the patient a cup of water in case the patient is having difficulty swallowing.

EYES

Test visual acuity in each eye separately with a pocket visual screening chart by holding the chart 14" from patient's face. It is acceptable for patient to hold the card herself. Note: If patient wears glasses, patient should be allowed to keep them on during this exam.
Test visual fields (four quadrants for each eye by confrontation, each eye separately).

Note: Make sure your fingers are outside of the patient's field of vision before you begin this test. Check with the patient as you test each quadrant to be sure that your fingers cannot be seen at the onset.

Step # 1: Stand approximately 12" from patient.

Step # 2: Ask patient to close her right eye. You should then close your left eye.

Step # 3: Extend your right arm, outside of the patient's and your own field of vision. Ask patient if she can see your hand/fingers. If patient says “yes”, adjust your hand until neither you nor the patient can see your hand/fingers.

Step # 4: Wiggle your fingers while bringing arm in slowly at the diagonals. Ask patient to inform you when your fingers are visible.

Step # 5: With patient's right eye still closed and your left eye still closed, extend your left arm (repeat what was done in step # 3) and wiggle your fingers while bringing arm in slowly at the diagonals. Again, ask patient to inform you as to when your fingers are visible.

Step # 6: Ask patient to close her left eye. You should then close your right eye. Extend your left arm and wiggle your fingers while bringing arm in slowly at the diagonals. Ask patient to inform you when your fingers are visible.

Step # 7: With patient's left eye still closed and your right eye still closed, extend your right arm and wiggle your fingers while bringing arm in slowly at the diagonals. Again, ask patient to inform you as to when your fingers are visible. Both eyes (4 diagonals or quadrants) must be tested for credit. The order of the exam can vary however, all steps must be completed to receive full credit.

Check for convergence by holding your finger in front of patient's face and moving your finger in towards patient's nose. You should start at arm's length and go about 6" from nose.
Test cranial nerves III, IV, and VI by asking patient to hold her head completely still and follow only your finger, looking rightward and leftward, up and out, up and in, down and out, and down and in. If necessary, you may gently hold the patient's head in the proper midline position. You must test the 6 cardinal positions for credit.
Test cranial nerve VII motor function (upper division) by asking patient to force her eyelid closed against resistance. Note: Another method that is accepted is asking the patient to close her eyes as student tries to force the eyelids open.
Test cranial nerve VII motor function (lower division) by asking patient to show the teeth
Observe pupillary responses: Both eyes must be examined for credit.

Note: The Direct Response is tested as you shine penlight into patient's eye while the patient looks into the distance. You will first look at that eye for a direct response to the light. Remove light from eye and let pupil return to normal. Then shine penlight in that same eye, while observing pupil of the opposite eye. The Indirect Response to light (consensual) is tested by looking at the eye not exposed to the direct light.

Inspect each eye separately for the condition of the lid, cornea and conjunctiva.

Step #1: Ask patient to pull down her lower eyelids and look up while you examine the eyes.

Step #2: Ask patient to pull up on her upper eyelids and look down while you examine the eyes.

(By having the patient pull up and down on her own eyelids, you can prevent infection).

Hold ophthalmoscope at proper distance to visualize the posterior structures of the eye.
Hold ophthalmoscope with right hand to look through scope with your right eye when inspecting patient's right eye.
Hold ophthalmoscope with left hand to look through scope with your left eye when inspecting patient's left eye.

EARS

Test auditory acuity by whispering into each ear at a distance of two feet (an alternative method is to create a sound by rubbing your thumb and fingers together at a distance of about 10 cm from each ear, separately).
Inspect the external ear thoroughly, looking in front, and then pull ear forward to look behind the ear.
Examine each internal ear with otoscope by pulling up on patient's ear and inserting the speculum and carefully examining the internal ear.
Perform the Rinne Test - Using the 512 Hz tuning fork.

Step # 1: To create a sound, hold the tuning fork by its base. Strike it gently on the heel of your hand or with the reflex hammer.

Step # 2: Place the tuning fork on the mastoid process (the bony ridge behind the ear) and ask patient to tell you if she can hear (not feel) the sound of the tuning fork. If she can, hold it there until she signals that the sound has faded away.

Step # 3: At that point, move the fork as near to the external ear canal as possible, sweeping away overlying hair, if necessary. Hold one tine of the fork close to her ear. Ask if she can again hear the tuning fork.

Perform the Weber Test - Using the 512 Hz tuning fork.

Step # 1: Activate the fork.

Step # 2: Press the base of the fork firmly on the apex of the skull in the midline. If she cannot hear the fork, press the base on the middle of the forehead.

Step # 3: Ask where she hears it. Normally, it is heard in the midline. Abnormally, it lateralizes to one side, either toward the side of conductive loss or away from the side of sensorineural loss.

NOSE

Test patency of each nasal cavity. Instruct the patient to close one nostril while sniffing through the other. Then, test the other nostril in the same manner.

MOUTH AND THROAT

Inspect the lips, gums, tongue and teeth with the help of a tongue blade and light. You must pull patient's cheeks out with the tongue blade and inspect the teeth and gums on both sides of the mouth. You may ask patient to pull lips up and down to inspect front teeth and gums.
Inspect the posterior pharynx. Using a penlight and a tongue depressor. This facilitates the inspection of the posterior pharynx.
Observe the elevation of the palate by instructing patient to say “ah”.
Test cranial nerve XII by asking patient to protrude the tongue and move it from side to side as you observe.
Test cranial nerve V motor function.

Step#1: Place your hands on both sides of patient's face by the masseter muscles.

Step #2: Ask patient to bite down while palpating the contraction of the masseter muscles.

Demonstrate “Sharp and Dull” to patient, while the patient is watching, using the broken end of a Q-Tip for the sharp and a cotton ball for dull.
Test cranial nerve V sensory function. (Test both sharp and dull in each of the 3 divisions bilaterally.)
Test cranial nerve XI: Check the strength of the Sternomastoids.

Have patient keep her head in the midline as you try to push the chin to one side and then the other. When she resists you, the direction you are pushing points to the muscle you are testing. Watch for bulging.

Test cranial nerve XI: Check strength of Upper Trapezius.

Step #1: Place your hands on the patient's shoulders.

Step #2: Have patient attempt to shrug her shoulders upward against your resistance.

LUNGS AND THORAX - Note: All percussion and auscultation must be done on skin.

Percuss the posterior lung fields bilaterally and symmetrically, over the upper, middle and lower lung fields, comparing the left side and the right side at each of the three levels.
Auscultate the posterior lung fields bilaterally and symmetrically, comparing right and left - three levels. Before auscultating, instruct patient to breathe deeply through an open mouth.
Percuss the anterior lung fields (at least one level) on the upper chest, bilaterally and symmetrically.
Auscultate the anterior lung fields (upper lobes), bilaterally and symmetrically. Before auscultating, instruct patient to breathe deeply through an open mouth.
Auscultate the lateral lung fields (right middle lobe and lingula) bilaterally and symmetrically. Before auscultation, instruct patient to breathe deeply through an open mouth.

BREAST EXAM - Part 1

With the patient in the sitting position, ask patient to lower the gown so that both breasts are visible. Inspect the appearance of the skin, size and dimpling of the breasts, and contour of the breasts.
Instruct patient to raise arms outstretched above the head and examine each breast for dimpling, contour changes, and skin discoloration.
Instruct patient to hold hands against hips and press inward. Inspect again for dimpling.
Palpate the axillary nodes in the following four areas: 1) anterior axillary fold; 2) posterior axillary fold; 3) along the proximal humerus; and 4) deep in the axillary vault.

Note: This examination should be performed on bare skin, not over the gown.

ASK PATIENT TO TAKE THE SUPINE POSITION ON THE EXAMINATION TABLE

BREAST EXAM - Part 2

Instruct patient to lie down supine. Instruct patient to raise the ipsilateral arm above the head.
Use the middle three fingers of your dominant hand to palpate the breast starting at the top of the breast on the side of the sternum. Repeat on the opposite breast.

Note: You must use 3 types of pressure while palpating, starting with a light pressure, then a medium pressure, then a firm pressure on each area covered. Fingers must never lose contact with the skin of the breast.

*Recommended Technique: The “strip” technique - with your fingers never losing contact with the breast, descend from top to bottom and bottom to top in vertical lines until all regions (including the nipple as part of the breast tissue) have been palpated.

HEART - Note: All palpation and auscultation must be done on skin.

NOTE: Regarding the term “palpation” when used during the cardiac examination: this palpation is designed to feel for pulses, thrills, etc. You are not feeling for masses. Therefore, your fingers should not move in a circular motion but rather should remain motionless in the appropriate anatomical location.

Elevate the trunk, head and neck 30 -- 45 degrees so that the jugular venous pulse is visible. If no jugular venous pulse is visible, return patient to the supine position and check again for a visible right jugular vein. Note: Only one pulse in one side of the neck needs to be examined.
Palpate the aortic area (2nd intercostal space on the right). Using only the pads of the fingers, not the fingertips.
Palpate the pulmonic area (2nd and 3rd intercostal spaces on the left). Using only the pads of the fingers, not the fingertips.
Palpate the tricuspid area (4th and 5th intercostal spaces at the left sternal edge. Using only the pads of the fingers, not the fingertips.
Palpate the mitral (cardiac apex) area (5th intercostal space, midclavicular line. Using only the pads of the fingers, not the fingertips.

CARDIAC AUSCULTATION:

NOTE: Although one may also perform cardiac auscultation with the patient sitting upright, the required position for the screening HTT exam is SUPINE.

Auscultate the aortic area using the diaphragm of the stethoscope
Auscultate the pulmonic area using the diaphragm of the stethoscope
Auscultate the tricuspid area using the diaphragm of the stethoscope
Auscultate the mitral (cardiac apex) area using the diaphragm of the stethoscope
Auscultate the aortic area using the bell of the stethoscope
Auscultate the pulmonic area using the bell of the stethoscope
Auscultate the tricuspid area using the bell of the stethoscope
Auscultate the mitral (apical) area using the bell of the stethoscope

PULSES - Note: All pulses must be done on skin

Auscultate each carotid artery. Instruct patient to hold breath before auscultation.
Palpate the carotid pulses ( just medial to and below the angle of the jaw), one at a time, bilaterally.
Auscultate the abdominal aorta.
Auscultate the renal arteries, bilaterally.
Palpate the femoral pulses
Palpate the popliteal pulses, one at a time, bilaterally.

**Recommended method for popliteal pulses: have patient supine or seated. Using both hands to support the weight of the leg, palpate the pulse.

Palpate the posterior tibial pulses bilaterally (at the ankle behind the medial malleolus).
Palpate the dorsalis pedis pulses bilaterally (located on top of foot, midway between the toes and the ankle, along the tendon line.
Test for Peripheral Edema: Check each shin for pitting edema by pressing on the lower anterior tibia, medial malleolus, or dorsum of foot for 3-5 seconds. Note: Must examine both legs. Must be done on skin. Must be done for at least 3 seconds for credit.

ABDOMEN - Note: All auscultation, percussion and palpation must be done on skin.

Adjust the examination table to be flat. Position patient in supine position. Stand on the patient's right side.
Inspect abdomen. Expose (uncover) abdomen to its full boundaries.
Auscultate prior to manipulation or palpation
Auscultate each of the four quadrants of the abdomen.
Percuss liver span prior to any abdominal palpation.
Percuss the liver span from just below right nipple line to just below right rib cage listening for the sound to change.
Palpate the liver edge. Place your hand in the proper location. Ask patient to inhale as you attempt to push up and under right rib cage Then, ask patient to exhale and continue to push up and under liver edge, without causing pain to patient.
Palpate the spleen. Place your hand in the proper location and ask patient to take a deep breath as you push up and in, at the bottom of the left rib cage. Then ask patient to exhale as you continue to push up and in, without causing pain to patient. This can be done either supine or with the patient lying on her right side.
Palpate the left upper quadrant using two pressures (gently then firmly).
Palpate the right upper quadrant using two pressures (gently then firmly).
Palpate the right lower quadrant using two pressures (gently then firmly).
Palpate the left lower quadrant using two pressures (gently then firmly).
Ask to do a rectal/pelvic exam.

MUSCULOSKELETAL

Inspect and palpate both hands (palm and dorsum).
Assess finger extension by asking patient to spread the fingers of both hands
Assess finger flexion by asking patient to make a fist with both hands.
Screen range of motion for both wrists. May be done actively or passively.

Step # 1: Have patient flex and extend each wrist while you observe.

Step # 2: Observe radial and ulnar deviation.

Inspect and palpate both wrists for redness and swelling
Screen range of motion of both elbows. May be done actively or passively.

Step # 1: Have patient extend her arms in pronation and then supination. Observe movement of elbow.

Step # 2: Have patient flex and extend each elbow. Observe movement of elbow.

Inspect and palpate both elbows. Inspect the olecranon areas for bursal or joint swelling, and over the ulnar ridge for nodules.
Shoulder flexion: Stand behind patient and have patient's gown completely untied and open in the back. Observe shoulder flexion by asking patient to bring the arms forward and then raise them overhead.
Shoulder internal rotation: Stand behind patient and have patient's gown completely untied and open in the back. Instruct the patient to place both hands behind the back as high up on the back as possible while you observe from behind.
Shoulder external rotation: Stand behind patient and have patient's gown completely untied and open in the back. Instruct patient to clasp both hands behind the neck and to pull the elbows back while you observe from behind.

ASK PATIENT TO TAKE THE SUPINE POSITION ON THE EXAMINATION TABLE

103. Inspect and palpate both knees:

Step # 1: Note any muscle atrophy, especially of the quadriceps

Step # 2: Examine the fossae above (medial and lateral) and below the knee.

They should all be visible.

Step # 3: Note the shape and size of the patella.

Step # 4: Note any skin lesions, such as psoriasis.

104. Screen range of motion of the knee:

With hand on knee, flex each knee, then extend and raise each knee.

As it rises, view the joint, front and back for swelling.

105. Assess hip flexion.

*Recommended Technique: Grasping the heel and moving the thigh up

toward the thorax, as far as it will go.

NOTE: Do not combine items #104 and #105; must perform each item separately for credit.

106. External and internal hip rotation. * Recommended Technique: Return the thigh to a position perpendicular to the exam table while holding the shin parallel to the exam table. Now, move the ankle medially to assess hip external rotation. Move the ankle laterally to assess hip internal rotation. Return the leg to the table. Repeat these examinations on the other leg.

107. Inspect and palpate both ankles:

When inspecting the ankles, check for swelling or redness in the gastroc-soleus complex and in all surfaces of the ankle joint. Pay close attention to any swelling around the malleoli.

108. Screen range of motion of both ankles:

Step # 1: Observe plantar and dorsal flexion in both ankles.

Step # 2: Observe inversion and eversion in both ankles.

Step # 3: Observe motion in a circle.

109. Inspect the mid foot and toes of both feet.

110. Inspect the plantar surface of both feet.

ASK PATIENT TO STAND

111. Assess neck flexion by instructing patient to place the chin on the chest.

112. Assess neck extension by asking patient to look up at the ceiling.

113. Assess right and left rotation of the neck by asking patient to place the chin on each shoulder.

114. Assess lateral bending of the neck by asking patient to incline each ear toward each shoulder.

115. Observe the alignment of the knees, heels and feet: Ask patient to stand and position yourself behind patient. Have patient's gown completely untied and open in the back. Carefully observe the alignment of the patient's knees, heels and feet.

NOTE: For items 116, 117 and 118, inform the patient that you are going to place your hands on their hips, over the gown, to guard the patient from losing their balance and falling and also as a way to keep the gown from falling off the patient as they perform the maneuvers.

116. Assess thoracolumbar lateral bending by asking patient to bend torso to the right and to the left. Stand behind patient and have patient's gown completely untied and open in the back.

117. Assess lumbar flexion by asking patient to bend forward at the waist and to attempt to touch the toes. Stand behind patient and have patient's gown completely untied and open in the back.

118. Assess lumbar extension by asking patient to bend backwards. Stand behind patient and have patient's gown completely untied and open in the back.

119. Costovertebral Angle Tenderness / Kidney Punch Tenderness: Perform fist percussion of the costovertebral angles by gently punching on the right & left side of patient's back, just below the rib cage. Ask patient if she feels pain.

NEUROLOGICAL

120. Romberg Test:

Step #1: Instruct patient to stand with her arms down at her sides and with her

feet completely together with eyes open. Watch for obvious unsteadiness. If she

remains steady, continue with the test

Step #2: Move closer to the patient. Place your hands on her shoulders. Ask her to close eyes and then reassure the patient that you will not let her fall.

Step # 3: Remove your hands to a few inches away, ready to catch her if necessary. Observe the patient for signs of swaying for at least 15 seconds. Note: Credit is only given if test is conducted for a full 15 seconds.

121. Ask patient to walk away from you while you observe the gait.

122. Ask patient to walk towards or away from you on her toes and observe.

123. Ask patient to walk towards or away from you on heels and observe.

124. Ask patient to walk towards you heel-to-toe (tandem gait) and observe.

125. Pronator Drift Test:

Step # 1: Ask patient to close her eyes and hold arms out in front of her, palms up.

Step # 2: Observe for at least 15 seconds for signs of one of the arms

dropping below the other.

Note: Credit is only given if test is conducted for a full 15 seconds.

ASK PATIENT TO HAVE A SEAT ON THE EXAMINATION TABLE

126. Test patient's grip strength bilaterally by asking patient to squeeze your index finger as you try to pull it out of patient's grip.

127. Test the deltoid muscle strength bilaterally by pushing downward on the

patient's abducted arms.

128. Test the biceps muscle strength bilaterally by positioning patient's elbow

to a 90-degree bend, palm up. Then brace one palm on the biceps,

grasp the wrist and pull.

129. Test the triceps muscle strength bilaterally by positioning patient's elbow to a 90-degree bend, palm up. Then brace one hand on triceps, grasp wrist and push.

130. Test the hip flexor muscle strength bilaterally but separately by having patient either seated on table with legs dangling, or supine. Resist flexion by having patient raise each knee or leg as you push down on thigh.

131. Test the lower leg muscle strength bilaterally by asking the patient to push away your hand (placed on the ankle); then ask patient to pull towards herself. Note: Student should position the knee to a 90 degree bend. Resist flexion by pulling up on lower leg. Resist extension by pushing down on lower leg.

132. Test the biceps reflex bilaterally.

Step # 1: With the elbow slightly flexed and forearm resting in the patient's lap, palm down, palpate the biceps tendon with your thumb and press in to produce moderate tension.

Step # 2: Stretch the tendon by striking your thumbnail. You will find up to 3 motions. Note speed and intensity of each response.

133. Test the brachioradialis reflex bilaterally.

Step # 1: Let patient's arm rest in her lap, elbow bent, forearm halfway between supination and pronation.

Step # 2: Palpate the radial styloid (at the wrist by the base of the thumb) and move 2 inches proximally.

Step # 3: Palpate the tendon over the radius.

Step # 4: Stretch the tendon by striking your finger (or thumb). Watch for flexion and supination of the forearm.

134. Test the triceps reflex bilaterally.

Step # 1: Position yourself posterior to the patient, her arms are still in her lap.

Step # 2: Palpate the triceps tendon just above the olecranon. If you have trouble finding the tendon, press on the tendon as she extends her arm against your resistance. The tendon will tighten and bulge.

Step # 3: Strike the tendon directly, without an interposed finger. (Stay clear of the ulnar groove, just medial to the tendon.) Watch for extension of the forearm or contraction of the muscle.

135. Test the patellar reflex bilaterally.

Step # 1: Position the patient with her legs dangling freely. Then move to one side so that you do not get kicked.

Step # 2: Locate the tendon just inferior to the patella

Step # 3: Tap briskly and observe extension of the knee or contraction of the quadriceps muscle.

136. Test the Achilles (ankle) reflex bilaterally

Step # 1: With the legs still dangling, grasp the foot by the ball,

and slightly dorsiflex it.

Step # 2: Strike the tendon briskly. Watch for the intensity of the plantar flexion and how quickly it relaxes afterward.

137. Test the Babinski reflex bilaterally. .

Step # 1: Use the wooden end of a tongue depressor, or the handle of the reflex hammer. DO NOT USE ANY SHARP OBJECT DURING THIS EXAM.

Step # 2: Hold patient's ankle and gently stroke the plantar surface. Begin by the

heel on the lateral side. Continue upward to the ball, and then curve medially

over the ball to the large toe. Note: This test should not be painful for the

patient. Inform the patient that it may tickle a little or feel slightly

uncomfortable.

138. Test finger-to-nose coordination bilaterally by positioning your finger 2 feet

from patient's face at shoulder level. Then, ask patient to hold her head still.

Have patient touch her index finger to your finger, then to her nose,

alternating back and forth several times. Student should move her finger

several times, in different directions, so patient must accurately alter directions.

139. Test both sharp and dull on each forearm and palm. Instruct patient to close her eyes prior to test.

140. Test both sharp and dull on each thigh, shin and foot with patient's eyes still closed.

141. Test both sharp and dull on the trunk at dermatome T4 (breast region) and dermatome T10 (umbilical region) with patient's eyes still closed.

142. Position Sense Demonstration:

Step # 1: Grasp the large toe or index finger by the sides.

Step # 2: To avoid confusion, demonstrate to the patient, while patient is watching, what is meant by up and down motion of the large toe or index finger. The joint must be completely relaxed.

143. Position Sense Test: Must be done bilaterally.

Step # 1: Ask patient to close the eyes, grasp large toe /index finger by the sides and then move the large toe/index finger in an up or down direction.

Step # 2: Ask patient to tell you “up” or “down” after each motion.

Step # 3: Position sense must be checked on all 4 extremities.

144. Vibratory Sense Demonstration: Use a low pitched 128 Hz tuning fork

Step #1: Demonstrate to patient, while patient is watching you.

Step # 2: Hold tuning fork near its base and activate it by tapping it on heel of your hand or by striking it with reflex hammer. Always press it to a bony prominence.

Step # 3: Ask patient if she can feel the “vibration.”

145. Vibratory Sense Test: Must be done bilaterally.

Step # 1: Ask patient to close eyes or to look away.

Step # 2: Test the vibration sense on each big toe and index finger using the 128 Hz tuning fork.

Step # 3: Ask patient if she feels a “vibration” and then ask the patient to inform you of when the “vibration.”

Step # 4: Vibratory sense must be checked on all 4 extremities.