Physical Examination Checklist
POM I
General
1) Wash hands before beginning examination—in the CLASS center, you
MUST use the hand wipes that are located in or near the sinks (remember
that they are not plumbed)
2) Display a professional demeanor towards the patient during the exam
a) Introduce yourself as a medical student
b) Use the patient’s last name
c) Dress professionally in white coat
3) Appropriate interaction with the patient—sensitivity to privacy, comfort
and dignity
4) Drape the patient appropriately during each segment of the exam
5) Use proper sequencing of the examiniation and proper pacing
6) All palpation and auscultation must be done on bare skin
Vital Signs
1) Take the BP in one arm (NOTE THAT YOU NEED NOT TAKE THE BP
IN BOTH ARMS UNLESS SPECIFICALLY INSTRUCTED TO DO SO)
a) Choose a cuff of appropriate size for the patient
b) Center the bladder of the cuff over the brachial artery
i)
Identify location of the brachial artery by palpation
ii) Lower border of the cuff should be about 2.5 cm above the
antecubital crease
iii) Secure the cuff snugly
c) Position the patient’s arm so that it is slightly flexed at the elbow and
at raised to heart level
d) Estimate the systolic pressure by palpation of the radial artery (Bates,
pp 76)
i)
Wait 15 seconds after deflating the cuff before auscultating the
BP
e) Take the BP, using auscultation
i)
Listen with the stethoscope over the brachial artery
ii) Inflate cuff rapidly to at least 150 mm Hg
iii) Deflate at rate of 2-3 mm Hg per second
iv) Note systolic and diastolic pressures
2) Take the radial pulse for 15 secs if the rhythm is regular (60 secs if rate is
slow or fast)
a) Use the pads of index and middle fingers
b) Compress the radial artery until a maximal pulsation is detected
3) Count the respiratory rate for 1 minute
a) Watch movement of the chest wall
Head
1) Inspect the skull, scalp, hair by parting the hair in at least three places
2) Inspect the face
Ears
1) Inspect the external ear—auricle or pinna
2) Use the otoscope to inspect the internal auditory canal and the eardrum and
middle ear
a) Select the largest available speculum for the otoscope
b) Position the patient’s head to allow best insertion of the otoscope
c) Pull the auricle gently upwards and backwards to straighten the canal
d) Hold the otoscope between thumb and fingers (see Bates, p 156)
e) Insert the speculum gently into the ear canal
i)
Identify the eardrum
ii) Identify the cone of light
iii) Identify the malleus
3) Assess hearing
a) Ask the patient to occlude one ear with a finger and then the examiner
whispers softly from 1 or 2 feet away toward the unoccluded ear
i)
Choose short words (see Bates p 157)
b) Check air and bone conduction
i)
Weber test
(1) place the base of the lightly vibrating tuning fork firmly on
top of the patient’s head
(2) Ask where the patient hears it
ii) Rinne test
(1) Place the base of the lightly vibrating tuning fork on the
mastoid bone
(2) When the patient can no longer hear the sound, quickly
place the fork close to the ear canal and ask whether sound
can still be heard
Eyes
1) Check for visual acuity using a Snellen eye card or eye chart in the exam
room
2) Assess visual fields (Bates, p 145-146)
a) Ask the patient to look with both eyes into your eyes
b) While you return the patient’s gaze, place your hands about 2 feet
apart, lateral to the patient’s ears.
c) Instruct the patient to point to your fingers as soon as they are seen
d) Then slowly move the wiggling fingers of both your hands along the
imaginary bowl and towards the line of gaze until the patient
identifies them
e) Repeat this pattern in the upper and lower temporal quadrants
3) Inspect external eye
a) Stand in front of the patient and survey the eyes for position and
alignment with each other
b) Inspect the eyebrows—quantity and distribution
c) Inspect the eyelids
d) Inspect the region of the lacrimal glands
e) Inspect the conjunctiva and sclera
i)
Ask the patient to look up as you depress both lower lids with
your thumbs (Bates p 147), exposing sclera and conjunctiva
f)
Inspect the cornea and lens, using a penlight shined oblique across the
eye
g) Inspect each iris
h) Inspect the pupils for size, shape and symmetry
4) Assess pupillary reflexes (turn out the room light if necessary)
a) To light—ask the patient to look into the distance and shine a bright
light obliquely into each pupil in turn.
i)
Note direct reaction—pupillary constriction in the same eye
ii) Note indirect reaction—pupillary constriction in the opposite
eye
b) Assess accomodation – ask the patient to look alternately at a pencil
held 10 cm from his eye and into the distance directly behind it.
Observe for pupillary constriction with near effort
5) Assess Extraocular movements
a) From 2 feet in front of the patient, shine a light into the patient’s eyes
and ask the patient to look at it. Inspect the reflections in the corneas,
which should be visible slightly nasal to the center of the pupils
b) Ask the patient to follow your finger or pencil as you sweep through
the six cardinal directions of gaze
i)
To the patient’s extreme right
ii) To the right and upward
iii) To the right and downwards
iv) Without pausing in the middle to the extreme left
v) To the left and upwards
vi) To the left and downwards
6) Ophthalmoscopic exam (See “Steps for using the ophthalmoscope” and
“Steps for examining the opic disc and the retina” in Bates pp 152 and 153
Nose
1) Inspect the anterior and inferior surfaces of the nose
a) Push gently on the tip of the nose to widen the nostrils
b) Use a penlight to view the nasal vestibule
2) Inspect the inside of the nose using an otoscope with the largest available
speculum
a) Tilt the patient’s head back slightly and insert the speculum (Bates p
159)
b) Inspect the inf and mid turbinates and nasal septum
3) Palpate the frontal and maxillary sinuses for tenderness (Bates p 160
Mouth and Pharynx
1) Inspect the lips
2) Inspect the oral mucosa using a good light and a tongue blade
3) Inspect the gums and teeth
4) Inspect the hard palate
5) Inspect the tongue and floor of the mouth
a) Ask the patient to put out his tongue
b) Ask the patient to put his tongue on the roof of his mouth
6) Inspect the pharynx
a) Tongue in normal position, ask the patient to say “ah;” but if pharynx
not well visualized use a tongue blade
b) Inspect the soft palate, tonsils and pharynx
Neck
1) Assess neck ROM (Bates p 504) by asking the patient to perform the
following maneuvers:
a) Flexion: touch the chin to the chest
b) Extension: look up at the ceiling
c) Rotation: turn the head to each side, looking directly over the
shoulder
d) Lateral bending: tilt the head, touching each ear to the corresponding
shoulder
2) Palpate the lymph nodes (See Bates p 163-164 for specific technique)
3) Inspect trachea and feel for any deviation by placing a finger along one side
of the trachea, noting the space, and compare with the opposite side.
4) Inspect the thyroid gland
a) Tip the patient’s head back
b) Locate the cricoid cartilage and inspect the region below for the
thyroid
5) Palpate the thyroid gland (See Bates p 167) – may be performed from
either an anterior or posterior approach
a) Flex the neck slightly forward
b) Place finger of both hands on the patient’s neck with index fingers
just below the cricoid cartilage
c) Feel for the thyroid isthmus
d) Displace the trachea to the right with the fingers of your left hand;
palpate with R fingers for the right lobe of the thyroid
e) Reverse the use of the fingers to feel the left lobe of the thyroid
Posterior thorax – lung exam
1) Examination techniques MUST be performed on bare skin
2) Palpate for tactile fremitus
a) Use either the ball of your palm or the ulnar surface of your hand for
palpation
b) Ask the patient to repeat the words “ninety-nine”
c) You may palpate one side at a time or use both hands simultaneously
to compare sides
d) Palpate in four locations on both sides of the chest and compare
(Bates p 223)
3) Percuss
a) Ask the patient to keep both arms crossed in front of the chest
b) Press the DIP joint of the left middle finger firmly against the chest
wall, avoiding contact with other fingers (Bates p 223)
c) Strike this DIP joint with the tip of the right middle finger, swinging
from the wrist
d) Percuss in seven areas on each side (Bates p 225)
4) Auscultate for breath sounds
a) Instruct the patient to breathe deeply through an open mouth
b) Listen with the diaphragm of the stethoscope in the same seven areas
in which you percussed
Cranial Nerves (Bates, pp 567-571)
1) Olfactory (CN I) – usually not tested
2) Optic (CN II) – you have already tested for visual fields. Visual acuity can
be tested with an eye chart
3) Oculomotor (CN III) – you have already tested pupillary constriction and
the EOM controlled by this nerve
4) Trochlear (CN IV) – you have already tested for downward, inward
movement of the eye
5) Trigeminal (CN V)
a) While palpating the temporal and masseter muscles in turn, ask the
patient to clench her teeth
b) Check the forehead, cheeks and jaw on each side for pain and light
touch
c) Check the corneal reflex with a wisp of cotton
6) Abducens (CN VI) – you have already tested for lateral deviation of the eye
with your extra-ocular movement maneuvers
7) Facial (CN VII)
a) Ask the patient to raise both eyebrows
b) Frown
c) Close both eyes tightly
d) Show both upper and lower teeth
e) Smile
f)
Puff out both cheeks
8) Acoustic (CN VIII) – you have already assessed hearing and performed
Weber and Rinne maneuvers
9) Glossopharyngeal (CN IX) – tested together with CN X
10) Vagus (CN X)
a) Ask the patient to say “ah” and watch the movements of the soft
palate and pharynx
b) Check gag reflex with a tongue blade
11) Spinal Accessory (CN XI)
a) Ask the patient to shrug both shoulders against your hands
b) Ask the patient to turn her head to each side against your hand
12) Hypoglossal (CN XII)
a) Ask the patient to protrude her tongue
b) Ask the patient to push the tongue against the inside of each cheek
Anterior thorax—lung exam
1) Examination techniques MUST be performed on bare skin
2) The patient may be either sitting or supine. The drape should be adjusted
to allow exposure of the area being examined
3) Inspect the shape of the patient’s chest and movement of the chest wall
(NB when moving from the post chest when you have completed
auscultating, it is acceptable to auscultate the ant chest before inspection or
palpation)
4) Palpate for tactile fremitus
a) Use the ball of the palm or ulnar surface of the hand to palpate in 3
areas on each side of the anterior chest (Bates p 231)
5) Percuss the anterior and lateral chest, comparing sides, in 6 areas on each
side (Bates p 231)
a) Displace a woman breast with your left hand or ask her to move her
breast for you
6) Auscultate the anterior chest, comparing sides in the 6 areas on each side
where you percussed.
Posterior thorax
1) The patient should be sitting with the posterior thorax exposed.
2) The doctor assumes a midline position behind the patient
3) Inspect the cervical, thoracic and upper lumbar spine (you will check for
ROM of the thoracic and lumbar spine towards the end of the complete
physical when the patient is standing up)
4) Palpate the spinous processes of each vertebra for tenderness with your
thumb or by thumping with the ulnar surface of your fist (Bates p 503)
5) Assess for costovertebral tenderness
a) Place the ball of one hand in the costovertebral angle and strike it
with the ulnar surface of your fist (Bates p 344)
6) Inspect the shape and movement of the chest wall
a) Place your thumbs at the level of the 10th ribs with your fingers
loosely grasping the rib cage and gently slide them medially.
b) Ask the patient to inhale deeply and observe whether your thumbs
move apart symmetrically
Axillae – examination of the axillae can be performed at the present juncture. It
is sometimes performed at the end of the exam, or as part of a breast exam in a
female
1) Inspect the skin of each axilla (Bates, pp 310-311)
2) Palpation L axilla
a) Ask the patient to relax with the L arm down
b) Support the L wrist or hand with your left hand
c) Cup together the fingers of your right hand and reach as high as you
can toward the apex of the axilla
d) Press your fingers toward the chest wall and slide down to feel
potential LN
e) To palpate for lateral group of LN, feel along the upper humerus
3) Palpation R axilla – reverse your hands and follow the steps above
Cardiovascular
1) The patient should be supine with the upper body raised by elevated the
table to about 30°. The drape should be arranged to expose the precordium.
EXAM TECHNIQUES MUST BE PERFORMED ON BARE SKIN.
2) The examiner should stand tat the patient’s right side
3) Inspect the precordium
a) look for apical impulse
b) look for any other movements
4) Palpate for precordium
a) Use the palmar surfaces of several fingers to locate the PMI—can
switch to one fingertip when located
i)
Displace a woman’s breast upward or laterally, or ask her to do
this for you
ii) Note location of PMI, amplitude and duration
b) Palpate for the RV impulse along the lower left sternal border
5) Auscultation of the heart
a) Listen to the heart with the diaphragm of your stethoscope in the R
2nd ICS, L 2nd ICS, L 3rd or 4th ICS, and the lower left sternal border
(5th ICS) and at the apex (may also start at the apex and proceed to the
base of the heart)
b) Listen to the heart with the bell of your stethoscope in the same five
listening areas
6) Inspect the neck for jugular venous pulsations
a) Turn the patient’s head slightly away from the side you are inspecting
(Bates p 267)
b) Raise or lower the bed until you identify the pulsations
c) Identify the highest point of pulsation
i)
Meausure the vertical distance of this point above the sternal
angle
7) Inspect the neck for carotid pulsations
8) Palpate the carotid pulsation
a) Place your left index and middle fingers (or thumb) on the right
carotid artery
i)
Note amplitude and contour of the pulse wave
ii) Never palpate both carotids simultaneously
b) Use your right fingers or thumb to palpate the left carotid artery
9) Auscultate the carotid arteries for bruits with the bell of the stethoscope
a) Ask the patient to take a deep breath and hold it to eliminate breath
sounds
Abdomen
1) The patient should be in a supine position with arms at side or folded
across the chest
2) The drapes should be arranged to expose the abdoment from above the
xyphoid process to the symphysis pubis.
3) Approach the patient from his right side
4) Inspect the abdomen
5) Ausculate the abdomen as the next step in the exam after inspection
a) Place the diaphragm of the stethoscope gently on the abdomen
b) Listen for bowel sounds
i)
Listening in one spot is sufficient
c) Listen for an aortic bruit on the midline just above the naval
6) Percuss the abdomen lightly in four quadrants
7) Percuss for liver dullness
a) Define the lower edge of liver dullness in the mid-clavicular line,
starting at a level below the umbilicus
b) Define the upper edge of liver dullness in MCL, starting in the area of
lung resonance
i)
Gently displace a woman’s breast as necessary
c) Measure in centimeters with a ruler the vertical span of liver dullness
in the MCL
8) Percuss for splenic dullness
a) Percuss along the L lower chest wall between the lung resonance
above and the costal margin moving laterally (Bates p 341)
i)
Ask the patient to take a deep breath and percuss again in this
area
9) Palpate the abdomen lightly in four quadrants and in the suprapubic and
epigastric areas
a) Use a gentle, light dipping motion (Bates p 335)
10) Palpate the abdomen deeply in all four quadrants
a) Use a firmer dipping motion
11) Palpate for the liver edge
a) Place your R hand on the right abdomen lateral to the rectus muscle,
beginning more than 3 fingerbreadths below the costal margin
b) Ask the patient to take in a deep breath
c) Palpate upwards trying to feel the descending liver edge, using a
rocking motion
i)
May also use the “hooking technique” described in Bates p 340
12) Palpate for a spleen tip
a) Reach over and around the patient with your left hand to support and
press forward the lower left rib cage
b)
Press inward towards the spleen with your right hand, beginning at
least 3 finger breadths below the L costal margin
c) Ask the patient to take in deep breaths, trying to feel the spleen tip as
it comes down to meet your fingertips.
13) Palpates for aorta by pressing deeply with one hand on each side of the
aorta (Bates, p 344)
14) Palpate for the superficial inguinal lymph nodes (Bates, p 452)
15) Palpate for both femoral artery pulses
a) Press deeply below the inguinal ligament (Bates, p 452)
Upper extremity—MSK and Partial Neurological (these maneuvers must be
repeated on both upper extremities
1) Inspect the hands, including each finger, its skin and joints, and nails
a) Palpate any abnormal joints
2) Inspect the wrist
3) Palpate the distal radius and snuff box; palpate the distal ulna
4) Palpate the radial pulse on the flexor surface of the wrist, laterally
a) Compare the pulses in both arms
5) Check ROM of the fingers
a) Ask the patient to make a tight fist with each hand
b) Extend and spread the fingers
c) Ask the patient to spread the fingers apart and back together
d) Ask the patient to move the thumb across the palm and touch the base
of the 5th finger, and then back across the palm and away from the
fingers
e) Have the patient touch the thumb to each of the other fingertips
6) Check ROM of the wrist (Bates p 499)
a) Flexion
b) Extension
c) Ulnar and radial deviation
7) Check ROM of the elbow (Bates p 497)
a) Flexion and extension: ask the patient to bend and straighten the
elbow
b) Pronation and supination: with arms at his side, and elbows flexed,
ask the patient to turn the palms up and then down
8) Palpate for epitrochlear lymph nodes (Bates p 451)
a) Flex the elbow to 90°
b) Palpate in the groove between the biceps and triceps
9) Inspect the shoulder (Bates, p 492)
10) Palpate the shoulder (Bates, p 493)
a) Locate the acromion process and the acromioclavicular joint
b) Locate the greater tubercle of the humerus
c) Locate the coracoid process of the scapula
11) Check ROM of the shoulder (Bates, p 493)
a) Watch for smooth, fluid movement as you stand in front of the patient
and ask:
i)
Raise the arms to shoulder level (abduct) with palms facing
down
ii) Raise the arms to a vertical position above the head with the
palms facing each other
iii) Place both hands behind the neck with elbows out to the side
(external rotation and abduction)
iv) Place both hands behind the small of the back (internal rotation
and adduction)
12) Test Muscle strength in the upper extremity (Bates pp 574-575). You must
compare sides
a) Test grip—ask the patient to squeeze two of your fingers as hard as
possible and not let them go
b) Test finger abduction—position the patient’s hand with palms down
and fingers spread. Try to force the fingers together
c) Test opposition of the thumb—the patient should try to touch the little
finger with the thumb against your resistance
d) Test extension of the wrist by asking the patient to make a fist and
resist you pulling it down
e) Test flexion and extension of the elbow by having the patient pull and
push against your hand
Lower extremity—MSK and Partial Neurological (these maneuvers must be
repeated on both lower extremities
1) The patient may be sitting or lying down and draped so that the external
genitalia are covered with the legs fully exposed during the exam
2) Inspect both feet and ankle—compare sides
3) Palpate the feet and ankles (Bates, p 517)
a) Assess for pedal edema—press firmly with your thumb over the
dorsum of the foot, behind each medial malleolus and over the shins
(Bates, p 455)
b) Palpate the anterior aspect of each ankle joint
c) Palpate the heel, especially the post and inf calcaneus
d) Palpate the MTP joints
e) Palpate the heads of the five metatarsals
4) Palpate for the peripheral pulses of the legs
a) Dorsalis pedis—feel the dorsum of the foot just lateral to the extensor
tendon of the great toe
b) Posterior tibial—feel below the medial malleolus of the ankle
5) Check ROM of the ankle (Bates, p 518)
a) Dorsiflex and plantar flex the foot at the ankle
b) Invert and evert the foot
c) Flex the toes
6) Inspect the knee for alignment and contours
7) Palpate the knee with the knee in flexion (Bates, p 511-513)
a) Identify the medial femoral condyle and the medial tibial plateau
b) Identify the tibial tubercle
c) Identify the lateral femoral condyle and lateral tibial plateau
d) Identify the patellar tendon and ask the patient to extend the leg
e) Palpate the medial collateral and lateral collateral ligaments and
menisci
f)
Feel for swelling above and to the sides of the patella
g) Check the prepatellar, anserine and popliteal bursae (Bates p 513)
8) Check ROM of the knee (Bates p 515)
a) Ask the patient to flex and extend the knee while sitting (or by asking
the patient from a standing position to squat and then stand up again
b) Check internal and external rotation by asking the patient to rotate the
foot medially and laterally
9) Inspect the hip by observing the patient’s gait at some time during the exam
(Bates p 506)
10) Palpate the surface landmarks of the hip
a) Anterior surface: locate the iliac crest, iliac tubercle and anterior
superior iliac spine
b) Posterior surface: locate the posterior superior iliac spine, the greater
trochanter and the ischial tuberosity
11) Check ROM of the hip (Bates, p 509-510)
a) Flexion—with the patient supine, ask him to bend each knee in turn
up to the chest and pull it firmly against the abdomen
b) Abduction—grasp the ankle and abduct the extended leg until you
feel the iliac spine move
c) Adduction—hold one ankle and move the leg medially across the
body and over the opposite extremity
d) Rotation—flex the leg to 90 at hip and knee; stabilize the thigh with
one hand, grasp the ankle with the other and swing the lower leg,
medially and laterally
12) Check muscle strength in the LE (Bates, p 576-578)
a) Test flexion at the hip—place your hand on the patient’s thigh and
asking the patient to raise the leg against your hand
b) Test adduction at the hips—place your hands firmly on the bed
between the patient’s knees. Ask the patient to bring both legs
together
c) Test abduction at the hips—place your hands firmly on the bed
outside the patient’s knees. Ask the patient to spread both legs
against your hands
d) Test extension at the hips—have the patient push the posterior thigh
down against your hand
e) Test extension at the knee—support the knee in flexion and ask the
patient to straighten the leg against your hand
f)
Test flexion at the knee—place the patient’s leg so that the knee is
flexed with the foot resting on the bed. Tell the patient to keep the
foot down as you try to straighten the leg
g) Test dorsiflexion and plantar flexion at the ankle—ask the patient to
pull down and push down against your hand
Neurological – some parts of the neurological exam have been woven into exam
of the head and neck and extremities (i.e. Cranial Nerve exam and motor testing).
The remaining components of the neurological exam are covered here
1) Reflexes (Bates, p 588-591)
a) Biceps reflex (C5, C6) — with patient’s arm partially flexed at the
elbow and palm down, place your thumb or finger firmly on the
biceps tendon and strike with reflex hammer
b) Triceps reflex (C6, C7) – flex the patient’s arm at the elbow with
palm towards the body and pull it across the chest. Strike the triceps
tendon above the elbow
c) Knee (Patellar) reflex (L2, L3, L4) – patient may be either sitting or
supine with knee flexed. Tap the patellar tendon just below the
patella
d) Ankle (Achilles) reflex (S1) – dorsiflex the foot at the ankle and
strike the Achilles tendon
e) Plantar (Babinski) response (L5, S1) – with a key or the tip of the
shaft of a reflex hammer, stroke the lateral aspect of the sole from the
heel to the ball of the foot, curving medially across the ball
2) Sensory (Bates, p 583-584)
a) Pain – Create a sharp from a broken tongue blade
i)
Compare symmetrical areas on the two sides of the body,
including arms, legs and trunk
ii) Compare the distal with the proximal areas of the extremities
iii) Vary the pace of your testing and occasionally substitute the
blunt end for the point, while asking “Is this sharp or dull?” or
“Does this feel the same as this?”
b) Light touch – using a fine wisp of cotton, touch the skin lightly,
avoiding pressure
i)
Ask the patient to respond whenever a touch is felt.
ii) Compare one area with another
c) Vibration – Use a low-pitched tuning fork (128 Hz)
i)
Set the fork vibrating and place it firmly over a DIP of a finger
and of the great toe
ii) Ask what the patient feels
iii) If vibration sense is impaired, move to more proximal bony
prominences
d) Joint position sense
i)
Grasp the patient’s big toe, holding it by its sides and pull it
away from the other toes so as to avoid friction.
ii) Demonstrate “up” and “down”
iii) With patient’s eyes closed ask him to identify up and down
movements
iv) Compare sides
v) Move more proximally if joint position is impaired
vi) Test JPS in the UE by moving a finger joint
3) Cerebellar/Coordination (Bates, p 578-580)
a) Rapid alternating movements
i)
UE – Show patient how to strike one hand on the thigh, first
with the palm, then with the back of the hand. Have the patient
repeat these alternating movements as rapidly as possible.
Repeat with opposite hand
(1) OR Show the patient how to tap the distal joint of the
thumb with the tip of the index finger as rapidly as
possible. Have the patient perform the action. Check the
opposite hand
ii) LE – ask the patient to tap your hand as quickly as possible with
the ball of each foot in turn
b) Point-to-point movements
i)
UE – ask the patient to touch your index finger and then his
nose alternately several times. Move your finger about.
ii) LE – Ask the patient to place one heel on the opposite knee and
then run it down the shin to the big toe. Repeat on the other
side
4) Gait
a) Ask the patient to walk across the room, then turn and come back
b) Walk heel-to-toe in a straight line
c) Walk on toes then on heels
5) Romberg Test
a) The patient should first stand with feet together and eyes open and
then close both eyes for 20-30 secs without support
Back
1) ROM (Bates, p 505)
a) Flexion – with patient standing, ask him to bend forward to touch the
toes
b) Extension – place your hand on the posterior superior iliac spine and
with your fingers pointing towards the midline, ask the patient to
bend backward as far as possible
c) Lateral bending – ask the patient to lean to both sides as far as
possible