**“SHIPWRECK'S” GO-BY**       2nd  Edition

                                                                                 Copyright 1996PRIVATE 

written by

**FRANK CARVALHO**

**LT MSC USN**

**PHYSICIAN ASSISTANT**

**[ FORMER-HMC (SW)****DDG-40 ]**

FOR USE BY MEDICAL PERSONNEL IN EXAMINATION PROCEDURES DURING PATIENT EVALUATION.

WHILE NOT ALL INCLUSIVE, THIS GUIDE 

PROVIDES PERTINENT ASSESSMENT

GUIDELINES. 

This Booklet is dedicated:

To the Hospital Corpsman of **past** who served and gave their all for fellow shipmates in need of care. 

To the Hospital Corpsman of **today** to assist them in that task.

To the Hospital Corpsman of the **future** to continue that fine tradition.

********************************************

This booklet is can be downloaded at the following site:

http://www-nshspts.med.navy.mil/nshs/sw/index.htm

Comments or Suggestions are greatly  appreciated.

Please Email Frank Carvalho 

at shpwrck@aol.com or shpwrck@juno.com

**INDEX**

PAGES 

1-5.............History/Subjective/Objective

6.................Skin/Nails/Hair

7.................Head

8-9.............Eyes

10-11.........Ears

12 ..............Nose

13 ..............Throat

14...............Neck

15 ..............Chest and Lungs

16-17..........Heart

18...............Peripheral Vascular system

19...............Gastrointestinal

20...............Genitourinary- Male

21...............Genitourinary- Female

22-23..........Back (low) and Hip Exam with Neuro

24-25..........Knee

26...............Ankle and Foot

27-28..........Shoulder (upper back) with Neuro

29...............Elbow and Hand

30-34..........Mental/Neuro status exam with Cranial                     Nerves/Cerebellar status

35...............The ULTIMATE SOAP NOTE

**HISTORY**

**Subjective**

**All important**: Depending on the chief complaint consider everything, document the essential. 

Consider Abdominal, Genitourinary, Respiratory, Cardiovascular, Neurological, Musculoskeletal, and Psychiatric involvement.

Document presence or absence of fever, chills,  nausea, vomiting, diarrhea, chest pain, shortness of breath and headaches. If you don't ask, they might not tell!

Focus on History of Present Illness

**P**-  What **Provokes** discomfort?

**Q**- What is the**Quality**of the discomfort?

**R**-  Where is the **Region** of the discomfort?

**S**-  What is the **Severity**of the discomfort?

**T**-  What is the**Time** sequence?

What was the mechanism of injury?

What was the pt doing prior to incident?

Are there any associated symptoms?

Are there any aggravating/relieving factors?

Is this a recurrent illness or injury?

Is the patient on any medications?

Note pt's ETOH, caffeine and smoking habits.

Allergies? **ASK FOR YOURSELF!**

**R**EVIEW**O**F**S**YSTEMS: To help you focus your exam, consider a **ROS.**

**General:** First Impression. Nutritional status, weight gain/loss, weakness, fatigue,  hydration  status & overall condition?

**Skin**: Changes in skin/nail/hair texture, appearance and color. Rashes, itching, lumps or infection? Cellulitis, Lymphangitis,  lymphadenopathy?

**Head**: Loss of consciousness? Lightheaded, vertigo,  headaches, symmetry, Hx of Injury, PMH, sinus pain? Visual disturbance?

**Ears**: Acoustic trauma, hearing loss, tinnitus, drainage, pain, infection, discharge, vertigo. Hearing aids? Last Exam?

**Eyes**: Visual changes, diplopia, epiphora, pain, discharge, injection,  light halos, trauma, photophobia, glaucoma, cataracts, 

last eye exam? Iritis, visual acuity,  and Glasses/contacts?

**Nose/Sinuses**: Olfactory changes, stuffiness, drainage, itching, obstruction, hx of trauma, hay fever, nosebleeds, sinus problems. 

**Throat/Mouth**: Hoarseness, dysphagia, enlarged tonsils, bleeding gums, sores, leukoplakia, teeth condition, caries,  tongue changes, dry mouth, hx of sore throat?

**Neck:** Goiter, pain, masses, nodules, adenopathy, thyroid problems, stiffness, creptitus? Hx of Injury?

**Respiratory:**  Cough, dyspnea, pleurisy, sputum (amt, type, color), asthma, bronchitis, COPD, emphysema, effusion, TB, last CXR? Coccidiomycosis, Histoplasmosis and smoking history?

**Cardiac:** HTN, hyperlipidemia, rheumatic fever, murmurs, chest pain/discomfort, orthopnea, dyspnea, edema, last ekg/stress test? CHF, pericarditis. Hx of surgeries/procedures/monitors.

**Peripheral vascular:**Nocturnal pain**,**claudication, varicose veins, thrombophlebitis, leg cramps? CHF? Venous insuffieciency? DVT?

**Gastrointestinal**: Heartburn, dsyphagia, appetite, indigestion, belching, flatulence, hematemesis, stool changes, hemechezia, melena, diarrhea, constipation, nausea, regurgitation, vomiting? Hx of gallbladder, liver, pancreatic disease, PUD?

**Genital** (male) Hernias, sores, lesions, penile discharge, pain , testicular/mass discomfort,  scrotal  mass/discomfort? hx of STD's. Sexual hx, function, problems?

**Genital**(female): Birth control, sexual hx/function, STD's, itching, sores, discharge, dyspareunia, last pap/pelvic exam? Menarche, menopause, LMP, GPA, menstrual regularity, frequency, duration, amt? Dys/amenorrhea,  metromenorrhea and PMS,

**Urinary**: Dysuria, polyuria, frequency, stones, pattern change, incontinence, nocturia, STD, hesitancy, dribbling, hematuria, infections? Flank discomfort?

**Hematologic**: Bleeding, bruising, anemias, petechia, hx of transfusions, sickle cell, thalassemias, G6PD?

**Endocrine**: Thyroid, adrenal, hormonal. Heat/cold intolerance, edema, hirsutism, sweating, excessive thirst, hunger, polyuria, pigment changes?

**Psychiatric**: Anxiety, mood swings, mania, depression, memory loss, insomnia, suicidal ideations, delusions, hallucinations?

**Musculoskeletal**: Myalgia, stiffness, gout, arthritis, backache. Hx of swelling, pain, erythema, tenderness, decreased ROM? Hx of trauma, overuse. 

**Neurologic**: Syncope, vertigo, seizures, blackouts, parasthesias, paralysis, tremors, weakness, involuntary movements, equilibrium, LOC.

**Other Problems and past medical history:**

Consider any other problems which are currently active, comments should include functional impairment, childhood /adult illnesses, Hx of trauma, surgeries, hospitalizations. 

Document environmental exposures and Family History when appropriate.

**OBJECTIVE**

**Always start your objective with a opening statement concerning the patients general appearance and condition.**

Example: Well developed, well nourished male in no acute distress. Pt is alert, orientated x3, cooperative, and shows no gross mental status changes. Pt appears hydrated. Vital signs noted.

Consider listing a minimum of 3-4 Physical exam findings for each complaint. Check the system above and below, and include the possibility of  cutaneous, musculoskeletal and occult findings. Document the absence of critical findings. This Booklet will assist you in that task.

Remember, its not what you find that gets you in trouble.   **IT’S WHAT YOU MISS!**

**SKIN/NAILS/HAIR**

Inspect for color changes: brown, gray, bronze, blue

reddish blue, red, yellow, hypo/hyperpigmentation.

Palpate for**skin** changes: in moisture, temperature,

texture, turgor.

Inspect and palpate **nails**for changes in texture, 

color and shape. Look for infections

Inspect and Palpate**hair**for changes in quantity,

quality, texture and distribution. Look for infections.

**Primary Lesions** include: macules, patch, papule,

plaque, nodule, tumor, wheal, vesicle, bullae, pustule.

**Secondary Lesions** include: Erosion, ulcer, fissure,

crust, scale, lichenification, atrophy, scar, keloid.

**PERTINENT POSITIVES AND NEGATIVES**

? Edema

? Erythema/warmth

? Pruritis/tenderness

? Scaling/Flaking

? Weeping/Discharge (color, amt, type)

? Fluctuance

? Mobile/fixed

? Lymphadenitis/lymphangitis

? Size, color, location, distribution

? Asymmetry, borders, elevation

? Auspwitz sign

? Nikolsky’s sign

? Telangiectasia

**HEAD/FACE**

Inspect for symmetry, lesions, rashes, edema, erythema, twitching, involuntary movements,  evidence of trauma/infection.

Palpate for masses, nodules, lymph nodes, 

salivary glands, Sinus tenderness, temporal artery tenderness, step-off . 

**PERTINENT POSITIVES AND NEGATIVES**

? Edema, ecchymosis

? Erythema, exudate, erosions

? Obvious deformity

? Mastoid tenderness/ Battle sign

? Cranial Nerve compromise (see page 34)

? Cerebellar function  (see page 31)

? Periorbital edema/cellulitis

? TMJ tenderness

? Signs of infection

? Sinus tenderness

**EYES**

Visual Acuity: Gross exam at 14" tests only near vision! Snellen Chart is more reliable.

Document as 20/_ OS,  20/_OD,  20/_OU with and without correction if applicable.,

Inspect the Eyebrows, eyelids, lacrimal apparatus, conjunctiva, sclera, cornea for edema, erythema, injection, abrasion, infection. Note pupils for dilation/constriction.

Inspect for position and alignment of eyes. Orthophoric vs evidence of Strabismus.

**Hirschberg's** test: Look for the light reflection on corneas. Are They Symmetrical?

**Cover/Uncover Test**: Tests for Strabismus.

Exotropia, Esotropia, Hypertropia, Hypotropia?.

**Fields of Confrontation:**Cranial nerve II

Tests for peripheral vision. Evaluate both eyes (8 fields) Are they equal to yours?

**Extra Ocular Movements:** Check the 6 cardinal fields 

of gaze. Check for nystagmus, convergence, lidlag. 

Cranial Nerve III responsible for opening the eye, 

pupillary constriction, most extraocular movements.

Cranial Nerve IV responsible for downward, inward 

movement of eye. (Superior oblique)- SO4.

Cranial Nerve VI responsible for lateral deviation of eye.

(Lateral rectus) LR6.

**Fundoscopic Exam**: Note the Optic disc for sharp margins,

2:1 cup to disc ratio. Is there any evidence of Retinal changes (AV nicking, copper wiring, exudates, wool spots, tapering, banking, neovascularzations.)

Is there any papilledema, retinal detachment, drusen?

**PERRLA**: 

Pupils, Equal, Reactive, Round to Light and Accommodation. Did you really check them all?

**PERTINENT POSITIVES AND NEGATIVES**

? PERRLA/visual acuity

? Injection/erythema/discharge (color, amt, type)

? Ciliary/Limbic Flush, Limbic pallor, Hyphema, Dendrites

? Foreign Body, abrasions, ulcers, invert eyelids

? Anterior chamber depth, IOP

? Preauricular Nodes

? Fluorescent Stain

? Keratoconjunctivitis

**EARS**

Inspect Auricles and External canal for lesions, nodules,

foreign bodies, deformities, erythema, edema , wax, 

ecchymosis, discharge.

Palpate for tenderness and masses. Note preauricular 

and post auricular nodes.

**Auditory Acuity**(conductive vs neuro loss)

Whisper test: (gross exam)

Weber test:  lateralization to which ear?

Rinne test:  is AC>BC?

                             Suspected Hearing Loss

                                               I

                                       Weber Test

         Lateralizes          No lateralization                 Lateralizes

              left                             I                                    right

                I                               I                                      I

            Rinne                       Rinne                               Rinne

           /        \                       /        \                              /        \

      AC>     BC>             AC>       BC>                  AC>         BC>

Neuro R       Cond L      Norm   Bilat =            Neuro L  Cond R

Norm L        Norm R                 Cond Loss      Norm R   Norm L

Tympanogram: Evaluate Eustachian tube function.

Conductive Loss: may be due to wax, foreign body, tympanosclerosis, otitis media, cholesteatoma.

Neuro Loss: may be due to Cranial Nerve VIII dysfunction, cochlear damage, acoustic trauma.

**PERTINENT POSITIVES AND NEGATIVES**

? External ear &canal condition/

? Lymphadenopathy, hematoma, 

? Laceration  with cartilage exposure

? Edema, erythema, abrasions, cerumen

? Drainage (color, amt, type)

? Tenderness (where)

? Foreign body, masses

? **TM** condition (color, intact,  mobile, landmarks)

? Hearing acuity, Tympanogram

? Air Fluid level

? Anterior Cone of Light

? Mastoid tenderness

**NOSE/SINUSES**

Inspect for masses, lesions, edema, erythema, deformity. Visualize the mucosa, note color, consistency, lesions, masses, discharge, exudate, abrasion, lacerations

Palpate for tenderness, Percuss frontal and maxillary sinuses. Have patient bend forward. Note increase in discomfort to sinuses.

Transilluminate with otoscope 

**PERTINENT POSITIVES AND NEGATIVES**

? Symmetry, Patency

? Ecchymosis, edema, exudate

? Bleeding  (ant vs post)

? Drainage (color, amt, type)

? Septal hematoma (fracture)

? Polyps

? Foreign body

? Mucous membrane color

**THROAT**

Inspect lips, gums, teeth, buccal mucosa, tongue, soft/hard palate, ant/post pillars, tonsils, uvula, posterior pharanyx, frenulum, salivary glands. 

**Note** any lesions, masses, edema, erythema, pustules, exudates, ecchymosis, nodules, masses, discharges, ulcerations, color variations.

**PERTINENT POSITIVES AND NEGATIVES**

? Uvula (midline?) Trismus , PTA

? Erythema, edema,  (where?)

? Exudate (color, amt, type, where?)

? Pustules, vesicles (where?)

? Breath  odor (fetid?)

? Adenopathy (which ones?)

? Tonsils (presence/absence)

? Ulcerations, Leukoplakia?

? Abscess (where?)

? Oral Hygiene

? Rash on face/truck

? Heart Murmur, Hepatosplenomegaly

**NECK**

Inspect skin, trachea, thyroid, SCM, anterior/posterior 

triangles. 

**Note** symmetry, lesions, nodules, masses, edema, 

ecchymosis, erythema.

Palpate all landmarks for tenderness, crepitus, spasm, 

nodules, masses, nodes.

**Lymph node** examination: Preauricular, postauricular, 

occipital, tonsillar, submandibular, submental, 

anterior cervical, posterior cervical, supraclavicular.

Assess Range of Motion: Flexion, extension, lateral rotation, lateral bending. (active and passive)

**PERTINENT POSITIVES AND NEGATIVES**

? Masses, edema

? Nodules

? Meningeal signs (kernig, brudzinski)

? Erythema, ecchymosis

? Rigidity, Suppleness

? Tenderness

? Thyroid exam

? Lymphadenopathy

? Range of motion

**CHEST AND LUNG**

Inspect anterior/posterior/lateral. Observe rate, rhythm, depth symmetry of respirations, AP-LAT ratio. Look for retraction/bulging of intercostal spaces, masses, lesions, deformity. Palpate for tenderness.

Auscultate**all**lobes, for pneumo/consolidation, consider AP/LAT CXR. If suspect effusion, include  lateral decubitus view.

Percussion: Listen for dull, tympanic, resonant, hyperresonant, flat sounds.

**PERTINENT POSITIVES AND NEGATIVES**

? Auscultation (all lobes)

? Respiratory expansion

? Diaphragmatic excursion

? Tactile fremitus

? Percussion

? Egophony, bronchophony, whispered pectoriloquy

? Spirometry (before and after)

? FEV1, pulse oximeter

? Pleural rubs

? Wheeze, rhonchi, rales (inspiratory/expiratory)

**HEART**

Inspect for heaves, thrusts, obvious deformity. Note PMI (LMCL at 5th ICS) location and activity.

Palpate valve areas:

(**A**) **AORTIC** --  RUSB at the 2nd ICS

(**P**)  **PULMONIC** -- LUSB at the 2nd ICS

(**M**)**MITRAL** -- LMCL at the 5th ICS

(**T**)  **TRICUSPID** -- LLSB at the 5th ICS

**ERB's Point**  LMSB at the 3rd ICS

Point of Ectopy midway between **P**and **M**

Auscultate valves with:

Diap**h**ragm for **High** Pitched sounds.

examples- S1, S2, regurgitant murmurs

Bel**l**for **Low** Pitched sounds:

examples- S3, S4, stenotic murmurs

Murmurs are graded 1-6, note location, pitch, intensity, shape, quality, timing.

**Systolic** Murmurs  vs  **Diastolic** Murmurs

(**A**)  stenosis                (**A**)  regurgitant

(**P**)  stenosis                 (**P**)  regurgitant

(**M**) regurgitant            (**M**) stenosis

(**T**)  regurgitant            (**T**)  stenosis

**HEART**

**PERTINENT POSITIVES AND NEGATIVES**

? Rate, rhythm, regularity

? S1, S2, S3, S4

? Splits, clicks

? Murmurs

? Friction rub

? Thrills, heaves, thrusts

**EKG**Pertinent Positives and Negatives

? Rate

? Rhythm

? Regularity

? Axis

? PR/QRS interval

? Q's (where), J point changes

? BBB's, hypertrophy, hemiblock

? ST changes

? Sinus, AV, junctional, ventricular origin

? WPW, early repolarization

? Upright T’s in  I, II, V2-6

**PERIPHERAL VASCULAR  SYSTEM**

Inspect, Palpate and **Auscultate**carotids, abdominalaorta, renal, iliac, femorals, popliteal, posterior tibial, dorsal pedis, radial, ulnar, brachial pulses.

Look for edema, symmetry, venous, patterns, varicosities, change in temperature, color, texture differences on all extremities. Include nailbed assessment.

Palpate for sensory changes, varicosities, pulse differences, cord tenderness.

**PERTINENT POSITIVES AND NEGATIVES**

? Jugular  venous distension  (CVP) 

? Hepatojugular reflux

? Retrograde filling test (valvular competency)

? Manual compression (saphenous)

? Allen's test (radial/ulnar patency)

? Adson's test (subclavian)

? Thrombophelbitis/ DVT

? Compartment Syndrome

? Varicosities

? Homan's Sign

**GASTROINTESTINAL**

Inspect abdomen for lesion, masses, distension, 

erythema, edema, ecchymosis, color changes, striae.

Auscultate all four quadrants for bowel sounds, 

listen to aorta, renals, iliac arteries.

Palpate (light/deep) for guarding, rigidity, masses, tenderness.

Percuss entire abdomen, liver and spleen.

**PERTINENT POSITIVES AND NEGATIVES**

? Masses, aneurysms, bruits

? Hepatosplenomegaly

? Rigidity, guarding, rosvings

? Rebound, referred rebound

? Psoas, obturator, cough

? Heelslap, pelvic shake

? Ascites (fluid wave)

? Murphy's, Cullen's, Grey-Turner's sign

**Rectal Exam**

? sphincter tone, hemocult

? fissure, fistula, hemorrhoids

? ulceration, excoriation, infection, lesions

? Prostate:  size, shape, consistency, boggy, hard,         firm, enlarged, nodules, masses, tenderness.

**GENITOURINARY** (MALE)

Inspect**entire**pubic area. note lesions, masses, edema, erythema, ecchymosis, excoriation, lichenification,  discharge, drainage.

Palpate **entire** pubic area for tenderness, masses, nodules, cysts, lymphadenopathy.

**PERTINENT POSITIVES AND NEGATIVES**

? Lesions, rash, erythema  (Where?)

? Masses/ nodules/ cysts (where?)

? Discharge/drainage (color, amt, type)

? Scrotal vs testicular involvement

? Epididymitis vs torsion

? Phren's sign

? Cremasteric Reflex

? Hernias

? Spermatic cord

? Lymphadenopathy (where?)

? Rectal exam

? Prostate exam

**GENITOURINARY (**FEMALE)

Inspect**entire**pubic area. note lesions, masses, edema, erythema, ecchymosis, excoriation, lichenification,  discharge, drainage.

Palpate **entire** pubic area for tenderness, masses, nodules, cysts, lymphadenopathy.

**PERTINENT POSITIVES AND NEGATIVES**

? HCG

?**C**ervical **M**otion **T**enderness (PID)

? Chandelier's Sign

? Discharge/drainage (color, amt, type)

? KOH/NaCl Prep

? Cervical os condition, bleeding

? Rectal

? Ectopic, ovarian cyst, endometriosis

? Adnexal masses, tenderness

? Uterine masses, tenderness

? Vaginal/introitus condition

? Lesion, rashes, erythema, edema 

? Abortion, miscarriage

? Chadwick's sign

? STD workup (TM, chlamydia, RPR, HIV, wet prep),  herpes          titer and hepatitis screen.

**LOW BACK/HIP EXAM WITH NEURO**

Be familiar with all landmarks: iliac crest, ant/posterior iliac spines, sacrum, lumbars, coccyx, paraspinals, latissimus dorsi, greater trochanter, Sacral-iliac  junction, Sciatic notch.

**PERTINENT POSITIVES AND NEGATIVES**

? Edema, ecchymosis, erythema

? Deformity, spasms (where)

? Step off  (spondylolisthesis, bifida)

? Lordosis, scoliosis

? Tenderness (where?)

? SLR/ crossover SLR

? Flip,  Patrick, Yeoman's test

? Hoovers, Milgrams test

? Rectal Exam

? Valsalva, (intrathecal pressure)

? Kernigs test

? Gaenslen's sign (Sacroiliac)

? Pelvic Rock (Sacroiliac)

? Trendelenburg test (hip)

? Ober's Test (ITB)

? Range of Motion, Muscle strength 

? Babinski

Distraction Maneuvers

? Sitting SLR

? Axial Compression

? Pseudo trunk rotation

? Light touch

**NEURO CHECK  L4, L5, S1**

**L4**

Motor-       Inversion of foot 

Sensory-    Medial aspect of foot/calf

Reflex-       Patellar

**L5**

Motor-       Dorsiflexion of big toe

Sensory-    Dorsum of foot and lateral calf

Reflex-       None

**S1**

Motor-       Eversion of foot

Sensory-    Lateral aspect foot and sole

Reflex-      Achilles

**S5**-            Sphincter tone

**If any discrepancies, consider doing sensory specific testing list on page 32.**

**KNEE**

Observe patient presentation, consider mechanism of injury. Palpate all landmarks. Consider hip, ankle involvement. Do neurovascular check (L3, L4, L5,  S1, S2). Consider Sensory Specific testing.

**PERTINENT POSITIVES AND NEGATIVES**

? Edema, erythema, ecchymosis, effusion

? Deformity, stability, masses, tenderness

? Valgus (med collateral)

? Varus  (lat collateral)

? Anterior drawer (anterior cruciate)

? Posterior drawer (posterior cruciate)

? Lachman's  (ACL)

? Posterior Sag  (PCL)

? Apley's compression (meniscus)

? Apley's distraction (collaterals)

? Flick test, Duckwalk, Childress (meniscus)

? McMurray's, Bounce home test (meniscus)

? Ballotment, bulge sign (effusion)

? Patellar grind (PFS, CMP)

? Tinel sign (neuromata)

? ROM, muscle Strength (active/passive)

? Neurovascular check (L4, L5, S1), sensory specific.

IF no history of direct trauma, consider OVERUSE conditions.

? ITB tendonitis

? PES tendonitis

? Quadracep/ patellar tendonitis

? Retinacular tendonitis

? Shinsplints

? Stress fracture

? PFS/CMP

? Osgood Schlatter's

? Bursitis  (inflammatory, septic)

**ANKLE/FOOT**

Observe patient presentation, consider **m**echanism **o**f **i**njury (**MOI**). Palpate all landmarks. Consider knee, hip, back involvement. Do neurovascular check ( L4, L5,  S1). Consider Sensory Specific testing.

Inspect and Palpate all landmarks

**PERTINENT POSITIVES AND NEGATIVES**

? Edema, ecchymosis, erythema, effusion

? Lesions, rashes, masses, nodules.

? Deformity, tenderness, crepitus (where?)

? Neurovascular ( L4, L5, S1 ), sensory specific

? Stability (ATFL, CFL, PTFL, deltoid ligament)

? Talar rock, ant drawer

? Metatarsal squeeze (morton's neuroma)

? Plantar fascia

? Peroneus brevis

? Fx (Jones, Pott's, Talar dome)

? Squeeze test (Achilles)

? Syndesmosis disruption

? Homan's Test (DVT)

? ROM, muscle Strength (active/passive)

? Bursitis, (inflammatory, septic)

**SHOULDER EXAM WITH NEURO**

Observe patient presentation, consider **m**echanism **o**f **i**njury (**MOI**). Palpate all landmarks. Consider neck, elbow involvement. Do neurovascular check ( C5, C6, C7, C8, T1, T2). Consider Sensory Specific testing.

PERTINENT POSITIVES AND NEGATIVES

?  Edema, erythema, ecchymosis, effusion

?  Deformity, tenderness (where?)

?  Drop arm test (rotator cuff)

?  Yeargersons test (bicipital tendon)

?  Apprehension Test (shoulder stability)

?  Apley's Scratch test

?  Winging

?  ROM, muscle strength (active/passive)

?  Bursitis (inflammatory, septic, DJD)

?  Rhomboid vs trapezius spasm

?  Shoulder Girdle, axilla, clavicle status 

?  AC separation

?  Shoulder dislocation

?  Neurovascular check  ( C5, C6, C7, C8, T1, T2).

Do both active and passive ROM testing, Document findings. Note when you are able to reproduce discomfort. This is essential for accurate diagnosis.

**SHOULDER NEURO EXAM**

**C5**

Motor-      Abduct Arm, Bicep flexion

Sensory-    Lateral Arm (Axillary nerve)

Reflex-      Bicep

**C6**

Motor-      Wrist extension, Bicep flexion

Sensory-    Lateral forearm/1st, 2nd digit

                  (musculocutaneous nerve)

Reflex-       Brachioradialis

**C7**

Motor-       Wrist flexors, finger extensors, tricep ext.

Sensory-    Middle finger 

Reflex-       Tricep

**C8**

Motor-     Hand Intrinsics, finger flexors

Sensory-   Medial forearm/ 4th and 5th digits

                 (medial antebrachial cutaneous nerve)

**T1-2**

Motor-      Hand intrinsics, finger abd/adduction

Sensory-   Medial Arm ( med.brach cutaneous  nerve)

**If abnormal findings occur do Sensory Specific, on page 32.**

**ELBOW/HAND**

Observe patient presentation, consider **m**echanism **o**f **i**njury (**MOI**). Palpate all landmarks. Consider neck, Wrist involvement. Do neurovascular  check ( C5, C6, C7, C8, T1, T2). Consider Sensory Specific testing.

**PERTINENT POSITIVES AND NEGATIVES**

?  Edema, erythema, ecchymosis, effusion

?  Deformity, nodules, tenderness (where?)

?  Crepitus

?  Bursitis (inflammatory, septic)

?  ROM, muscle strength (active/passive)

?  Bursitis (inflammatory, septic, DJD)

?  Snuff box tenderness  

?  Tenosynovitis (inflammatory, infectious)

?  Fx, sprain, strain, overuse syndrome

?  Neurovascular check  ( C5, C6, C7, C8, T1, T2).

?  Tendonitis

?  Flexor, extensor, collateral  integrity

?  Fx (volar plate, boxer's, bennett's, colle's, nightstick)

?  Nodules ( DIP Hebeden's, PIP Bouchard's)

?  Cysts (ganglion) 

**Establish tendon, muscle, ligament, neurovascular integrity prior to any attempt at reducing or closing an injury.**

**NEURO/MENTAL STATUS EXAM**

Do all**6**components:

**1st-  Mental Status Exam**

Always check this on all patients: Observation is your best tool,  These can be assessed without provoking the pt. Observe the following:

Level of consciousness

Posture and motor activity

Dress, grooming and personal hygiene

Facial Expression, Speech and Language

Manner and affect Mood

Insight and judgement:

Thought content: Perceptions, interpretation of external stimulus.

Thought Process: Sequence, logic,                   coherence, relevance of thought.

**If anything does not seem right in the routine MS exam then check these cognitive Functions:**

Test for memory (recent, remote)

Test for calculation ability 

Test for orientation x3 (person, place, time)

Test for abstract thinking (proverbs,similarities)

Test for judgement

Test for general knowledge

Test constructional abilities

Test for new learning ability

**2nd CEREBELLAR FUNCTIONS**

1.  Station

2.  Romberg

3.  Pronator sign

4.  Heel to toe walk

5.  Heel to shin drag

6.  Rapid alternating movements (RAM's)

     - flipping hands on thighs

     - index finger to thumb DIP

**3rd    MOTOR TESTING**

Bilaterally check:

 Cranial nerves III, IV, V, VI, VII, IX, X, XI, XII 

 C5 - T1

 L4  - S1

 Dermatomes

**4th    SENSORY TESTING**

Bilaterally check:

 Cranial nerves I, II V, VII, IX, X, 

 C5 - T1

 L4 - S1

 Dermatomes

**Sensory specific tests**

Sharp/dull 

2 point discrimination

Temperature

Vibratory

Pain

Light touch

Proprioception

Stereognosis

Graphesthesia

**5th     REFLEX TESTING**

Bilaterally check:

 Cranial nerves  V,  IX, X, 

**Deep Tendon Reflexes:**

 C5  - Biceps

 C6  - Brachioradialis

 C7  - Triceps

 L4  -  Patellar

 S1  -  Achilles

**Superficial reflexes**:

Abdominal  reflex    - upper  T7 - T10

                                 -  lower  T10 - L1

Cremasteric reflex   -  L1, L2

Superficial Anal reflex -  S2, S3, S4

Bulbocavernosus reflex - sacral sparring

Babinski sign- upper motor neuron lesion

**6th  CRANIAL NERVE EXAM**

I-      **Olfactory**

         Sensory - smell

II-    **Optic**

Sensory - Visual Acuity, Peripheral                                                       vision by confrontation.-- Fundoscopic

III-  **Oculomotor**

 Motor  - EOM, accommodation.(lateral rectus,                                      superior oblique)

IV-    **Trochlear**

 Motor - EOM (superior oblique)

V-     **Trigeminal**

Motor- clench teeth (palpate)

Sensory- bilateral 3 sections of face

Reflex- corneal

VI-   **Abducens**

 Motor- EOM (lateral rectus)

VII   **Facial**

Motor- raise eyebrow, frown, smile, puff                                                cheeks,  show teeth, shut eyes tightly.

Sensory: taste to anterior of tongue

VIII  **Vestibulocochlear**

Sensory-  watch tick, rub fingers,  weber, rinne.

IX/X **Vagus/Glossopharyngeal**

Motor-  Listen to voice, say "AH"

Sensory- Taste to Posterior tongue

Reflex-  gag

XI     **Spinal accessory**

Motor- Turn head, Shrug shoulders

XII    **Hypoglossal**

 Motor- stick out tongue

**The ULTIMATE SOAP note:PRIVATE**

Be sure to include something in each 

section and you've just about covered all bases!

**Subjective:**

Pt's name and  biographical data

Chief complaint

Prior self care/ means of arrival

History of present illness (concise)

Review of systems/ associated problems

Past medical history/ pertinent recent history

Family/ social history/ other complaints

**Objective**:

Physical Exam/ vital signs

Impression: Justify ancillary services

Obtain consent for:

Procedures, IV's, Labs, X-rays (time)

Ancillary service interpretation

Pt condition during/after procedure

**Assessment**: 

Found worst to least critical

**Plan:**

Meds, Labs, X-rays

Follow-up date/ where?

Pt education sheets

Pt condition on discharge

Special thanks to HM2 Eddie Robirds 

for providing the Shipwreck logo. 

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