🩺 Bedside tests and signs

🎯 What you are testing for

Low calcium (and low magnesium). It is one of the two bedside signs of neuromuscular irritability.

🦻 How to do it

1. Have her sit with her face relaxed.
2. Tap lightly over the facial nerve, just in front of the earlobe and below the zygomatic arch.
3. Watch the same side of her face.

🎯 What you are testing for

Low calcium. It is the more specific of the two calcium signs.

🦻 How to do it

1. Put a blood-pressure cuff on her upper arm.
2. Inflate it about 20 mmHg above her systolic pressure.
3. Leave it up for 3 minutes and watch her hand.

🎯 What you are testing for

Protective sensation in the diabetic foot - whether she would feel a stone in her shoe before it became an ulcer.

🦻 How to do it

1. Show her the filament on her arm first so she knows the sensation.
2. Ask her to close her eyes.
3. Press the 10 g monofilament perpendicular to the sole until it buckles, hold about 1 second.
4. Test several sites on each foot; avoid callus and ulcer.

🎯 What you are testing for

Meningeal irritation - meningitis or subarachnoid blood.

🦻 How to do it

1. Lay her flat.
2. Flex one hip to 90 degrees with the knee bent.
3. Then try to straighten the knee.

🎯 What you are testing for

Meningeal irritation - meningitis, the same thing Kernig is looking for.

🦻 How to do it

1. Lay her flat with no pillow.
2. Put a hand behind her head and flex the neck towards her chest.
3. Watch her hips and knees.

🎯 What you are testing for

Upper motor neuron integrity - the corticospinal tract.

🦻 How to do it

1. Use the handle of the reflex hammer, not a sharp point.
2. Stroke up the lateral edge of the sole from heel to ball, then across the ball towards the big toe.

🎯 What you are testing for

Proprioception and the vestibular system - can she stay upright without her eyes helping?

🦻 How to do it

1. Have her stand with feet together and arms at her sides, eyes open, for 20 seconds.
2. Then ask her to close her eyes and hold it for another 20.
3. Stand beside her ready to catch her.

🎯 What you are testing for

Level of consciousness, scored so that a change is measurable rather than a matter of opinion.

🦻 How to do it

1. Score three things: eye opening (1-4), verbal response (1-5), best motor response (1-6).
2. Use the best response she gives.
3. Add them: the range is 3 to 15.

🎯 What you are testing for

Cranial nerves II and III, and rising intracranial pressure.

🦻 How to do it

1. Dim the lights.
2. Bring the penlight in from the side, not straight at her.
3. Check size, shape, equality, the direct and consensual response, and accommodation.

🎯 What you are testing for

Which side hears differently. It cannot tell you the type of loss.

🦻 How to do it

1. Strike a tuning fork and place the base on the midline of the forehead or the top of the head.
2. Ask: where do you hear it?

🎯 What you are testing for

Which type of hearing loss - it compares air conduction with bone conduction.

🦻 How to do it

1. Strike a tuning fork and hold the base on the mastoid bone behind the ear (bone conduction).
2. When she says the sound has gone, move the tines beside the ear canal (air conduction).
3. Ask whether she can hear it again, and for how long.

🎯 What you are testing for

Gross hearing, one ear at a time, with no equipment.

🦻 How to do it

1. Stand about 2 feet behind her so she cannot lip-read.
2. Occlude the ear you are not testing.
3. Whisper a set of letters and numbers after a full exhalation and ask her to repeat them.

🎯 What you are testing for

Distance visual acuity.

🦻 How to do it

1. Stand her 20 feet from the chart.
2. Test each eye separately, then both, with her glasses on if she wears them.
3. Record the smallest line she reads more than half of.

🎯 What you are testing for

The macula - central vision.

🦻 How to do it

1. Hold the grid at normal reading distance, wearing reading glasses.
2. Cover one eye and stare at the central dot.
3. Ask what the surrounding lines look like. Repeat for the other eye.

🎯 What you are testing for

Intraocular pressure - screening for glaucoma.

🦻 How to do it

1. Anaesthetic drop first for applanation; the puff-of-air version needs none.
2. She sits still and looks straight ahead while the instrument touches or puffs the cornea.

🎯 What you are testing for

Peripheral vision - gross visual field loss.

🦻 How to do it

1. Sit about 2 feet away, at eye level.
2. She covers one eye; you cover your opposite one.
3. Bring a wiggling finger in from the periphery and ask her to say when she sees it, comparing her field with yours.

🎯 What you are testing for

Whether the ulnar artery alone can supply the hand - done before a radial ABG or arterial line.

🦻 How to do it

1. Ask her to make a fist.
2. Press on both the radial and ulnar arteries until the hand blanches.
3. Have her open the hand - it should look pale.
4. Release the ulnar side only and keep timing.

🎯 What you are testing for

Historically used to suggest a DVT.

🦻 How to do it

1. Straighten the leg and dorsiflex the foot.
2. Ask about calf pain.

🎯 What you are testing for

Peripheral perfusion.

🦻 How to do it

1. Hold the hand at about heart level.
2. Press the nail bed until it blanches, then release.
3. Count.

🎯 What you are testing for

Volume status and fall risk - whether her pressure holds when she stands.

🦻 How to do it

1. Measure BP and pulse lying, after she has been flat a few minutes.
2. Sit her up, wait 1-3 minutes, measure again.
3. Stand her, wait 1-3 minutes, measure again.
4. Stay with her.

🎯 What you are testing for

Right-sided filling pressure - fluid overload, right heart failure, tamponade.

🦻 How to do it

1. Position the head of the bed at 30-45 degrees.
2. Turn her head slightly away.
3. Use tangential lighting and look at the internal jugular pulsation in the neck.

🎯 What you are testing for

Cardiac tamponade, and severe asthma or COPD.

🦻 How to do it

1. Inflate the cuff above systolic and deflate slowly.
2. Note the pressure where Korotkoff sounds are heard only on expiration.
3. Keep deflating to where they are heard through the whole cycle. Subtract.

🎯 What you are testing for

Arterial supply to the leg - peripheral arterial disease.

🦻 How to do it

1. Take the highest ankle systolic pressure with a Doppler.
2. Take the highest brachial systolic pressure.
3. Divide ankle by brachial.

🎯 What you are testing for

Whether the lung underneath is solid, normal, or full of air or fluid.

🦻 How to do it

1. Place the ulnar edge or ball of your hands on her back.
2. Ask her to say "ninety-nine" each time you move.
3. Compare side to side, top to bottom, in a ladder.

🎯 What you are testing for

Consolidation - solid lung transmits voice better than air-filled lung.

🦻 How to do it

1. Egophony: she says "eeee" while you listen.
2. Bronchophony: she says "ninety-nine" while you listen.
3. Whispered pectoriloquy: she whispers "one-two-three" while you listen.

🎯 What you are testing for

How obstructed her airways are right now - asthma monitoring at home.

🦻 How to do it

1. Stand or sit upright, pointer at zero.
2. Deep breath in, tight seal on the mouthpiece.
3. Blow out as hard and fast as possible.
4. Do it three times and record the best, not the average.

🎯 What you are testing for

Peritoneal irritation - peritonitis, a ruptured appendix.

🦻 How to do it

1. Press slowly and deeply over the area.
2. Release quickly.
3. Ask when it hurt more.

🎯 What you are testing for

Appendicitis.

🦻 How to do it

1. Find the point one third of the way from the right anterior superior iliac spine to the umbilicus.
2. Palpate gently there.

🎯 What you are testing for

Appendicitis, when the picture is not obvious.

🦻 How to do it

1. Rovsing: press on the left lower quadrant.
2. Psoas: she lies on her left side; you extend her right hip.
3. Obturator: flex her right hip and knee, then internally rotate the hip.

🎯 What you are testing for

Acute cholecystitis.

🦻 How to do it

1. Press under the right costal margin at the mid-clavicular line.
2. Ask her to take a deep breath in.

🎯 What you are testing for

Retroperitoneal bleeding - most often severe hemorrhagic pancreatitis.

🦻 How to do it

1. Inspect the abdomen with good light.
2. Look around the umbilicus and at both flanks.

🎯 What you are testing for

Ascites - free fluid in the abdomen.

🦻 How to do it

1. Fluid wave: she (or a second person) presses the ulnar edge of a hand down the midline; you tap one flank and feel the other.
2. Shifting dullness: percuss from resonant to dull with her supine, mark it, roll her to one side and percuss again.

🎯 What you are testing for

Kidney inflammation - pyelonephritis or a stone.

🦻 How to do it

1. She sits up.
2. Place one palm flat over the costovertebral angle - where the twelfth rib meets the spine.
3. Strike the back of that hand once with the ulnar side of your fist.

🎯 What you are testing for

Whether she is emptying her bladder - retention, and BPH.

🦻 How to do it

1. Ask her to void normally, and measure it if you can.
2. Within about 10 minutes, scan the bladder (or catheterize if ordered).

🎯 What you are testing for

Carpal tunnel syndrome - median nerve compression.

🦻 How to do it

1. Have her press the backs of both hands together with the wrists fully flexed, fingers pointing down.
2. Hold for 60 seconds.

🎯 What you are testing for

Carpal tunnel syndrome - the same nerve, a different provocation.

🦻 How to do it

1. Tap lightly over the median nerve on the palmar side of the wrist, at the carpal tunnel.

🎯 What you are testing for

Sciatic nerve root irritation - a herniated lumbar disc.

🦻 How to do it

1. She lies flat.
2. Keep the knee straight and slowly raise the leg by the heel.

🎯 What you are testing for

Compartment syndrome in a limb - after a fracture, a cast, or a crush injury.

🦻 How to do it

1. Check the limb distal to the injury for each in turn:
2. Pain out of proportion, and pain on passive stretch
3. Pressure - the compartment feels tight and full
4. Paraesthesia, then Pallor, then Paralysis, and last Pulselessness

🎯 What you are testing for

Hip abductor weakness, and developmental dysplasia of the hip in an older child.

🦻 How to do it

1. Ask her to stand on one leg.
2. Watch the opposite side of the pelvis.

🎯 What you are testing for

Fetal lie, presentation, position and engagement by feel, before you place the monitor.

🦻 How to do it

1. Have her empty her bladder and lie supine with knees slightly bent, a wedge under the right hip.
2. 1. Fundal grip - what is in the top? Buttocks are soft and irregular; the head is hard and round.
3. 2. Umbilical grip - which side is the smooth firm back, which is the knobbly small parts?
4. 3. Pawlik grip - grasp just above the symphysis: what is presenting, and does it move?
5. 4. Pelvic grip - fingers down towards the pelvis: is it engaged?

🎯 What you are testing for

Whether the membranes have actually ruptured.

🦻 How to do it

1. Nitrazine: touch the paper to the fluid in the vagina.
2. Fern: smear fluid on a slide, let it air-dry, look under the microscope.

🎯 What you are testing for

Fetal growth and dating between about 18 and 36 weeks.

🦻 How to do it

1. Empty bladder, lie supine.
2. Measure in centimeters from the top of the symphysis pubis over the curve of the abdomen to the top of the fundus.

🎯 What you are testing for

Fetal wellbeing - does the heart rate accelerate when the baby moves?

🦻 How to do it

1. Semi-Fowler with a left tilt; external monitors on.
2. Record for 20-40 minutes.

🎯 What you are testing for

How the newborn is adapting, at 1 and 5 minutes.

🦻 How to do it

1. Score 0, 1 or 2 for each of five: Appearance (color), Pulse, Grimace (reflex irritability), Activity (tone), Respiration.
2. Add them - the range is 0 to 10.

🎯 What you are testing for

Developmental dysplasia of the hip in a newborn.

🦻 How to do it

1. Baby relaxed and supine, hips and knees flexed.
2. Ortolani: abduct the hips and lift the femur forward - you are trying to relocate a dislocated hip.
3. Barlow: adduct and press gently back - you are trying to dislocate a loose one.

🎯 What you are testing for

An intact newborn nervous system - and their disappearance on schedule is just as important.

🦻 How to do it

1. Moro: a sudden controlled drop of the head - arms abduct then embrace. Gone by 4-6 months.
2. Rooting: stroke the cheek - head turns towards it. Gone by 3-4 months.
3. Palmar grasp: press the palm - fingers curl. Gone by 3-4 months.
4. Tonic neck (fencing): turn the head - same-side arm extends. Gone by 3-4 months.
5. Stepping: hold upright with feet touching - stepping motion. Gone by 4 weeks.

🎯 What you are testing for

Gestational age from physical and neuromuscular maturity, when dates are uncertain.

🦻 How to do it

1. Score six neuromuscular items (posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear).
2. Score six physical items (skin, lanugo, plantar surface, breast, eye/ear, genitals).
3. Add and read the age off the maturity chart.

🎯 What you are testing for

Age-appropriate baselines - the numbers move a long way between a newborn and a teenager.

🦻 How to do it

1. Count respirations first, while the child is quiet, for a full minute.
2. Then apical pulse for a full minute in a child under 2.
3. Do the blood pressure and temperature last - they are the most upsetting.
4. Use a cuff covering about two thirds of the upper arm.

🎯 What you are testing for

Hydration - though it is a rough guide, not proof.

🦻 How to do it

1. Pinch a fold of skin over the sternum or forehead in an adult, or the abdomen in a child.
2. Release and watch it.

🎯 What you are testing for

Risk of developing a pressure injury.

🦻 How to do it

1. Score six areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
2. Five of them score 1-4; friction/shear scores 1-3.

🎯 What you are testing for

How much body surface is burned - which drives the fluid resuscitation.

🦻 How to do it

1. Count only partial and full thickness burns, never superficial ones.
2. Adult: head 9, each arm 9, each leg 18, front torso 18, back torso 18, perineum 1.
3. Use the client’s palm ≈ 1% for scattered patches.

🎯 What you are testing for

Cognitive screening - a possible dementia, and a baseline to compare against later.

🦻 How to do it

1. Mini-Cog: name 3 words, draw a clock showing a set time, then recall the 3 words.
2. MMSE: 30 questions covering orientation, registration, attention, recall, language and copying.

🎯 What you are testing for

Problem drinking, in four questions.

🦻 How to do it

1. C - have you felt you should cut down?
2. A - have people annoyed you by criticising your drinking?
3. G - have you felt guilty about your drinking?
4. E - have you had a morning drink, an eye-opener?