CCE I Class Notes Page 1 of 5

SECTION I: VITAL SIGNS

General Survey
Physical Appearance
Age, Gender, Level of Consciousness, Skin Color (relative to ethnicity), Facial Features
No Signs of Acute Distress
Body Structure
Stature, Nutrition, Symmetry, Posture, Position, Body Build/Contour
Mobility
Gait, ROM
No Involuntary Movement
Behavior
Facial Expression, Mood and Affect, Speech, Dress, Personal Hygiene
Vitals- temperature, pulse, respiratory rate, blood pressure
Temperature
Done orally with an digital thermometer
Sheath thermometer in front of patient
Average: 98.6F
Normal range: 96.4F 99.1F
Pulse
Stroke Volume = amount of blood the heart pumps into the aorta with every heartbeat
The arterial walls respond to this force and the resulting pressure wave is what is felt when palpating the
peripheral pulse for the rate and rhythm of the heartbeat.
Conduct a bilateral evaluation of the rate, rhythm, & local amplitude (strength) of the blood flow.
An absent pulse suggests arterial occlusion.
Pulse Rate in beats per minute (bpm)
Count the number of beats in 30 seconds and multiply by 2 (or 15 and 4), unless the rhythm is irregular,
then count for a full minute.
Average: 74-76 bpm
Normal adult range: 60-100 bpm
Pregnant women may have a normal increase of 10-15 bpm
Well-conditioned athletes may be as low as 50 bpm
Pulse Force- amplitude
3+ full bounding
2+ normal
1+ weak, thread
0 absent
Respiratory Rate
Count the number of breaths in 30 seconds and multiply by 2
Normal range: 10-20 cycles per minute
Normal Pulse : Respiratory Rate ratio = 4:1
Blood Pressure
Determined by 5 factors:
1. Cardiac output
2. Peripheral vascular resistance
3. Volume of circulating blood
4. Viscosity
5. Elasticity of vessel walls
Normal: <120/<80 mmHg
Prehypertension: 120-139/80-89mmHg
Stage 1 Hypertension: 140-159/90-99mmHg
Stage 2 Hypertension: > or = 160/100mmHg
Systolic= maximum pressure felt on the artery during left ventricle contraction
Diastolic= elastic recoil; the constant resting pressure between contractions
CCE I Class Notes Page 2 of 5

Perform bilaterally- difference of >10 mmHg systolic or diastolic reassess at the end of the exam and
be ready to refer - major differences could indicate arterial occlusion
Other Measurements
Weight
Standardized balance or electrical standing scale
Shoes and heavy outerwear should be removed
Pockets emptied
Helps to ask patient if they know their weight including any recent gains or losses (unintentional could be
indicative of cancer)
Height
Have patient facing away from scale, looking straight ahead
No shoes or hats
Snellen Eye Chart (Not a Vital)
Basic screening of distant vision
Patient stands with their heels at the 20 foot line
Please cover your right eye with this paper, keep both of your eyes open, and tell me the number of the
lowest line you can read with one eye comfortably. Could you please read me the letters on that line
from left to right/right to left?
o If they succeed: Do you think you can read the next line?
o Do not point to the line that they are reading- you want to make sure their eyes can track
horizontally evenly.
Can you please tell me what color this is?
o Do not say good or bad after they tell you colors- one eye could be color blind while the
other could be just fine.
If the patient can read most of the letters on a line, but missed one or two, write the fraction minus the
number wrong.
If patient has poorer than 20/30 vision, refer to optometrist
For patients unable to read the largest letter, shorten the distance and include it as the first number (i.e.
10/200 would indicate the patient could only read the largest letter (size 200) while standing at a distance
of 10 feet.)
Use the Jaeger card with patients over 40 or those who report a serious problems
o Instruct patient to hold 35 cm/14 in out
Hearing
General Hearing Test
o Tell patient to wiggle the tragus of their opposite ear
o Also to close their eyes
o They should tell you when they can and cannot hear the rubbing fingers - Start/Stop
o Start at 3 ft, come closer 1 ft if they cannot hear
Weber Test
o Use a 512 Hz tuning fork on top of head
o Tests bone conduction
o Will hear better in obstructed ear because it does not have all the air noise
Rinne Test
o Use 512 Hz tuning fork
o Compares air conduction to bone conduction- ratio should be 2:1
o On mastoid process until patient says, Stop - measures bone conduction
o Quickly invert tuning fork & hold ~1cm away from patients earmeasures air conduction
CCE I Class Notes Page 3 of 5

SECTION II: HISTORY TAKING

Why take a complete history?

The history is perhaps the most important aspect of the clinical evaluation.
Past history & history of complaint must be thorough and accurate, as they direct the doctor to specific
physical exam procedures to rule in or rule out suspicions for a preliminary diagnosis
Past History - I SHIP HAM
Immunizations: all up-to-date?
Surgeries: why, when, recover well?
Hospitalizations: why, when?
Illness: everything, even the general flu, how was it treated?
Past Injuries: what, recover well?
Habits: smoker, sit all day, eat well, exercise
Allergies: how are they managed, what allergen/season?
Medications: time, dose, purpose? Need to have record of all meds
o Or Review of Systems
Previous Chiropractic Care
What type of chiropractic?
o Technique, philosophy, open/private room
Who administered the care?
Reason for care?
Frequency
Duration
Response
Family History
Parents, grandparents, siblings
Indicate age and health status of each
o i.e. MGM (87, deceased)
Mother (54, diabetes)
Sister (28, in good health)
Be sure to include any extended family members who have any noteworthy illnesses
o i.e. Paternal Aunt ( 60, in remission)
ABCDEFG
Arthritides: what kind of arthritis?
Blood Disorders: high BP, arteriosclerosis, etc.
Cancer: type? management?
Diabetes: type? medications? management?
Epilepsy
Fatalities: also look for emotional response
Genetic Predispositions: everything else
Occupational History
Habitual postures of ones occupation may provide insight into source of problem.
Review at least the past 10 years of the patients work history.
Review work duties associated with the work.
CCE I Class Notes Page 4 of 5

History of Complaint O(MP3)PPQRSTFID [ADLs]

Onset: when did the pain start?
Mechanism (of injury): What caused the pain, what happened?
Progression: getting better, worse, the same?
Prior History of the Same Type of Complaint: what was Diagnosis, Treatment, recover well?
Prior Care for This Complaint: treatment outcomes?
Palliative: what makes it feel better?
Provocative: what makes it hurt worse?
Quality of Pain: sharp, stabbing, dull, burning, achy, tingling
Radiating Characteristics of Pain: does the pain travel anywhere?
Site: have patient point on their body or poster, is spot same when it originated?
Timing: when does problem affect patient the most- morning, noon, night, exercise, work, etc.
Frequency: constant, periodic, occasional?
Intensity: on a scale from 0-10, currently, at the onset, at its worst, & at its best
Duration: how long after palliative does the pain come back?
Activities of Daily Living: affect on everyday living? What cant you do that you would like to?

SECTION III: SPINAL RANGE OF MOTION AND INCLINOMETRY

Cervical Spine- Flexion/Extension

Patient sits with head in neutral
Place one inclinometer directly on top of the head and the other at T1
Have the patient flex the neck fully
Subtract lower angle from the upper angle to determine true flexion
Repeat with the patient extending
Cervical Spine- Lateral Flexion
Have the patient laterally flex
Cervical Spine- Rotation
Have the patient in a supine position with the head in neutral
Place one inclinometer on the forehead
Determine the angle of rotation
If patient is flexible, move petrometer further to the opposite side of the forehead and zero it out there
Only test using one petrometer/inclinometer
Thoracolumbar Spine- Flexion/Extension
Have the patient stand in a neutral, straight position
Place one inclinometer at T1 and the other at S1
Have the patient flex forward
Subtract the bottom from the top angle to determine the true thoracolumbar flexion
Instruct patient to cross their arms over their chest so their gowns do not fall forward/off
Thoracolumbar Spine- Lateral Flexion
Have the patient lateral bend as far to the right/left as possible
Subtract the bottom inclinometer angle from the top angle to obtain true thoracolumbar lateral flexion.
Trace your middle finger down the side seem of your pant leg.
Thoracolumbar Spine- Rotation
Have the patient bend forward so that the spine is parallel to the floor
Place one inclinometer at T1 and the other at S1 (perpendicular to patient and facing inward)
Have the patient rotate as for to the right/left as possible
Active Range of Motion (AROM)
All motions are actively performed by the patient first (as long as there is no discomfort)
Leave all painful motions for the end
Passive Range of Motion (PROM) / End Feel
For PROM the supine patient is to relax to allow the examiner to move the head in all ranges of motion
assessed with the pain-free AROM
CCE I Class Notes Page 5 of 5

SECTION IV: NEUROLOGIC EVALUATION

Sensory
Test for superficial pain, light touch, and vibration in a few random/distal locations.
Have patient expose their sternum and illustrate the sensation there, with their eyes open.
The patients eyes should be closed when testing.
Compare sensation on random/nonsymmetrical parts of the body (bilaterally)
Pain
Pain is tested with an opened paperclip. The patients ability to perceive dull or sharp is measured.
Let at least 5 seconds elapse between each stimulus to avoid summation.
Testing the Lateral SpinoThalamic Tract
Light Touch
Apply a wisp of cotton to the patients skin in a random order or sites distal to proximal at irregular
intervals.
For upper extremities, use the palmar aspect of the hands.
For lower extremities, use the dorsum of the feet.
Vibration
Use a 128Hz tuning fork
Hands should be raised up, not resting on knees, with dorsum side up.
If the distal test is normal, the assumption is that the proximal levels are intact.
Deep Tendon Reflexes (DTRs)
Wexler Scale
o +4 very brisk, hyperactive with clonus, may indicate UMNL
o +3 brisker than average
o +2 average, normal
o +1 diminished, low normal
o 0 no response
Babinski Test
Positive Babinski sign is normal until the age of 2 years
In adults, a positive test would indicate an UMNL
Patients are still able to laugh, flex toes, and/or pull foot away to be considered normal
Myotome Assessment
Muscle Grading Chart
o +5 normal, complete ROM, against gravity, with full resistance
o +4 good, complete ROM, against gravity, with some resistance
o +3 fair, complete ROM, against gravity
o +2 poor, complete ROM, with gravity eliminated
o +1 trace, slight contractility, no joint motion
o 0 no evidence of contractility
Full resistance needs to be held for 5 seconds
Meet my resistance & Any pain or tightness
Dermatome Assessment
Proximal to distal
Continue off the tips of the fingers or toes
Tell me if there is any change in sensation from right to left.

SECTION V: UPPER EXTREMITY RANGE OF MOTION

Class notes are sufficient- no elaboration necessary.

SECTION VI: LOWER EXTREMITY RANGE OF MOTION

Class notes are sufficient- no elaboration necessary.