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Physical Examination ChecklistPOM I

General1) Wash hands before beginning examination—in the CLASS

center, you MUST use the hand wipes that are located in ornear the sinks (remember that they are not plumbed)

2) Display a professional demeanor towards the patient duringthe exama) Introduce yourself as a medical studentb) Use the patient’s last namec) Dress professionally in white coat

3) Appropriate interaction with the patient—sensitivity toprivacy, comfort and dignity

4) Drape the patient appropriately during each segment of theexam

5) Use proper sequencing of the examiniation and properpacing

6) All palpation and auscultation must be done on bare skin

Vital Signs1) 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 patientb) Center the bladder of the cuff over the brachial artery

i) Identify location of the brachial artery by palpationii) Lower border of the cuff should be about 2.5 cm

above the antecubital creaseiii) Secure the cuff snugly

c) Position the patient’s arm so that it is slightly flexed atthe elbow and at raised to heart leveld) Estimate the systolic pressure by palpation of the radial

artery (Bates, pp 76)i) Wait 15 seconds after deflating the cuff before

auscultating the BPe) Take the BP, using auscultation

i) Listen with the stethoscope over the brachialartery

ii) Inflate cuff rapidly to at least 150 mm Hgiii) Deflate at rate of 2-3 mm Hg per secondiv) Note systolic and diastolic pressures

2) Take the radial pulse for 15 secs if the rhythm is regular (60secs if rate is slow or fast)a) Use the pads of index and middle fingersb) Compress the radial artery until a maximal pulsation is

detected

3) Count the respiratory rate for 1 minutea) Watch movement of the chest wall

Head1) Inspect the skull, scalp, hair by parting the hair in at least

three places2) Inspect the face

Ears1) Inspect the external ear—auricle or pinna2) Use the otoscope to inspect the internal auditory canal and

the eardrum and middle eara) Select the largest available speculum for the otoscopeb) Position the patient’s head to allow best insertion of the

otoscopec) Pull the auricle gently upwards and backwards to

straighten the canald) Hold the otoscope between thumb and fingers (seeBates, p 156)

e) Insert the speculum gently into the ear canali) Identify the eardrumii) Identify the cone of lightiii) Identify the malleus

3) Assess hearinga) Ask the patient to occlude one ear with a finger and

then the examiner whispers softly from 1 or 2 feetaway toward the unoccluded eari) Choose short words (see Bates p 157)

b) Check air and bone conductioni) Weber test

(1) place the base of the lightly vibrating tuningfork firmly on top of the patient’s head

(2) Ask where the patient hears itii) Rinne test

(1) Place the base of the lightly vibrating tunifork on the mastoid bone

(2) When the patient can no longer hear thesound, quickly place the fork close to the ecanal and ask whether sound can still beheard

Eyes1) Check for visual acuity using a Snellen eye card or eye

chart in the exam room2) Assess visual fields (Bates, p 145-146)

a) Ask the patient to look with both eyes into your eyeb) While you return the patient’s gaze, place your han

about 2 feet apart, lateral to the patient’s ears.c) Instruct the patient to point to your fingers as soon

they are seend) Then slowly move the wiggling fingers of both your

hands along the imaginary bowl and towards the lingaze until the patient identifies them

e) Repeat this pattern in the upper and lower temporaquadrants

3) Inspect external eyea) Stand in front of the patient and survey the eyes fo

position and alignment with each otherb) Inspect the eyebrows—quantity and distribution

c) Inspect the eyelidsd) Inspect the region of the lacrimal glandse) Inspect the conjunctiva and sclera

i) Ask the patient to look up as you depress bothlower lids with your thumbs (Bates p 147),exposing sclera and conjunctiva

f) Inspect the cornea and lens, using a penlight shineoblique across the eye

g) Inspect each irish) 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 a

shine a bright light obliquely into each pupil in turni) Note direct reaction—pupillary constriction in t

same eyeii) Note indirect reaction—pupillary constriction in

opposite eyeb) Assess accomodation – ask the patient to look

alternately at a pencil held 10 cm from his eye andthe distance directly behind it. Observe for pupillaconstriction with near effort

5) Assess Extraocular movementsa) From 2 feet in front of the patient, shine a light into

patient’s eyes and ask the patient to look at it. Insthe reflections in the corneas, which should be visibslightly nasal to the center of the pupils

b) Ask the patient to follow your finger or pencil as yosweep through the six cardinal directions of gazei) To the patient’s extreme rightii) To the right and upwardiii) To the right and downwardsiv) Without pausing in the middle to the extreme

v) To the left and upwardsvi) To the left and downwards6) Ophthalmoscopic exam (See “Steps for using the

ophthalmoscope” and “Steps for examining the opic disand the retina” in Bates pp 152 and 153

Nose1) Inspect the anterior and inferior surfaces of the nose

a) Push gently on the tip of the nose to widen the nosb) Use a penlight to view the nasal vestibule

2) Inspect the inside of the nose using an otoscope with thlargest available speculuma) 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

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Mouth and Pharynx1) Inspect the lips2) Inspect the oral mucosa using a good light and a tongue

blade3) Inspect the gums and teeth4) Inspect the hard palate5) Inspect the tongue and floor of the mouth

a) Ask the patient to put out his tongueb) Ask the patient to put his tongue on the roof of his

mouth6) 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

Neck1) Assess neck ROM (Bates p 504) by asking the patient to

perform the following maneuvers:a) Flexion: touch the chin to the chestb) Extension: look up at the ceilingc) Rotation: turn the head to each side, looking directly

over the shoulderd) Lateral bending: tilt the head, touching each ear to the

corresponding shoulder2) Palpate the lymph nodes (See Bates p 163-164 for specifictechnique)

3) Inspect trachea and feel for any deviation by placing afinger along one side of the trachea, noting the space, andcompare with the opposite side.

4) Inspect the thyroid glanda) Tip the patient’s head backb) Locate the cricoid cartilage and inspect the region

below for the thyroid5) Palpate the thyroid gland (See Bates p 167) – may be

performed from either an anterior or posterior approacha) Flex the neck slightly forwardb) Place finger of both hands on the patient’s neck with

index fingers just below the cricoid cartilagec) Feel for the thyroid isthmusd) Displace the trachea to the right with the fingers of 

your left hand; palpate with R fingers for the right lobeof the thyroid

e) Reverse the use of the fingers to feel the left lobe of the thyroid

Cranial Nerves (Bates, pp 567-571)1) Olfactory (CN I) – usually not tested2) Optic (CN II) – you have already tested for visual fields.

Visual acuity can be tested with an eye chart3) Oculomotor (CN III) – you have already tested pupillary

constriction and the EOM controlled by this nerve4) Trochlear (CN IV) – you have already tested for downward,

inward movement of the eye5) Trigeminal (CN V)

a) While palpating the temporal and masseter muscles inturn, ask the patient to clench her teeth

b) Check the forehead, cheeks and jaw on each side forpain and light touchc) Check the corneal reflex with a wisp of cotton

6) Abducens (CN VI) – you have already tested for lateraldeviation of the eye with your extra-ocular movementmaneuvers

7) Facial (CN VII)a) Ask the patient to raise both eyebrowsb) Frownc) Close both eyes tightlyd) Show both upper and lower teethe) Smilef) Puff out both cheeks

8) Acoustic (CN VIII) – you have already assessed hearing andperformed Weber and Rinne maneuvers

9) Glossopharyngeal (CN IX) – tested together with CN X10) Vagus (CN X)

a) Ask the patient to say “ah” and watch the movemeof the soft palate and pharynx

b) Check gag reflex with a tongue blade11) Spinal Accessory (CN XI)

a) Ask the patient to shrug both shoulders against yohands

b) Ask the patient to turn her head to each side againyour hand

12) Hypoglossal (CN XII)a) Ask the patient to protrude her tongueb) Ask the patient to push the tongue against the insi

each cheek

Posterior thorax

1) The patient should be sitting with the posterior thoraxexposed.

2) The doctor assumes a midline position behind the patie3) Inspect the cervical, thoracic and upper lumbar spine (y

will check for ROM of the thoracic and lumbar spine towthe end of the complete physical when the patient isstanding up)

4) Palpate the spinous processes of each vertebra fortenderness with your thumb or by thumping with the ulsurface of your fist (Bates p 503)

5) Assess for costovertebral tendernessa) Place the ball of one hand in the costovertebral ang

and strike it with the ulnar surface of your fist (Bate344)

6) Inspect the shape and movement of the chest walla) Place your thumbs at the level of the 10th ribs with

fingers loosely grasping the rib cage and gently slidthem medially.b) Ask the patient to inhale deeply and observe wheth

your thumbs move apart symmetrically

Posterior thorax – lung exam1) Examination techniques MUST be performed on bare sk2) Palpate for tactile fremitus

a) Use either the ball of your palm or the ulnar surfacyour 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 han

simultaneously to compare sidesd) Palpate in four locations on both sides of the chest

compare (Bates p 223)

3) Percussa) Ask the patient to keep both arms crossed in front

the chestb) Press the DIP joint of the left middle finger firmly

against the chest wall, avoiding contact with otherfingers (Bates p 223)

c) Strike this DIP joint with the tip of the right middlefinger, 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 omouth

b) Listen with the diaphragm of the stethoscope in thesame seven areas in which you percussed

Anterior thorax—lung exam1) Examination techniques MUST be performed on bare sk2) The patient may be either sitting or supine. The drape

should be adjusted to allow exposure of the area beingexamined

3) Inspect the shape of the patient’s chest and movementthe chest wall (NB when moving from the post chest whyou have completed auscultating, it is acceptable toauscultate the ant chest before inspection or palpation)

4) Palpate for tactile fremitusa) Use the ball of the palm or ulnar surface of the han

palpate in 3 areas on each side of the anterior ches(Bates p 231)

5) Percuss the anterior and lateral chest, comparing sides

areas on each side (Bates p 231)

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a) Displace a woman breast with your left hand or ask herto move her breast for you

6) Auscultate the anterior chest, comparing sides in the 6areas on each side where you percussed.

Axillae – examination of the axillae can be performed at thepresent juncture. It is sometimes performed at the end of theexam, or as part of a breast exam in a female1) Inspect the skin of each axilla (Bates, pp 310-311)2) Palpation L axilla

a) Ask the patient to relax with the L arm downb) Support the L wrist or hand with your left handc) Cup together the fingers of your right hand and reach

as high as you can toward the apex of the axillad) Press your fingers toward the chest wall and slide down

to feel potential LNe) To palpate for lateral group of LN, feel along the upper

humerus3) Palpation R axilla – reverse your hands and follow the steps

above

Cardiovascular1) The patient should be supine with the upper body raised by

elevated the table to about 30°. The drape should bearranged to expose the precordium. EXAM TECHNIQUESMUST BE PERFORMED ON BARE SKIN.

2) The examiner should stand tat the patient’s right side3) Inspect the precordium

a) look for apical impulseb) look for any other movements

4) Palpate for precordiuma) Use the palmar surfaces of several fingers to locate the

PMI—can switch to one fingertip when locatedi) Displace a woman’s breast upward or laterally, or

ask her to do this for youii) Note location of PMI, amplitude and duration

b) Palpate for the RV impulse along the lower left sternalborder

5) Auscultation of the heart

a) Listen to the heart with the diaphragm of yourstethoscope in the R 2nd ICS, L 2nd ICS, L 3rd or 4th ICS,and the lower left sternal border (5th ICS) and at theapex (may also start at the apex and proceed to thebase of the heart)

b) Listen to the heart with the bell of your stethoscope inthe same five listening areas

6) Inspect the neck for jugular venous pulsationsa) 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 pulsationsc) Identify the highest point of pulsation

i) Meausure the vertical distance of this point abovethe sternal angle

7) Inspect the neck for carotid pulsations8) 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 waveii) Never palpate both carotids simultaneously

b) Use your right fingers or thumb to palpate the leftcarotid artery

9) Auscultate the carotid arteries for bruits with the bell ofstethoscopea) Ask the patient to take a deep breath and hold it to

eliminate breath sounds

Abdomen1) The patient should be in a supine position with arms at

or folded across the chest2) The drapes should be arranged to expose the abdomen

from above the xyphoid process to the symphysis pubis

3) Approach the patient from his right side4) Inspect the abdomen5) Ausculate the abdomen as the next step in the exam af

inspectiona) Place the diaphragm of the stethoscope gently on t

abdomenb) Listen for bowel sounds

i) Listening in one spot is sufficientc) Listen for an aortic bruit on the midline just above

naval6) Percuss the abdomen lightly in four quadrants7) Percuss for liver dullness

a) Define the lower edge of liver dullness in the mid-clavicular line, starting at a level below the umbilic

b) Define the upper edge of liver dullness in MCL, starin the area of lung resonance

i) Gently displace a woman’s breast as necessarc) Measure in centimeters with a ruler the vertical spaliver dullness in the MCL

8) Percuss for splenic dullnessa) Percuss along the L lower chest wall between the lu

resonance above and the costal margin movinglaterally (Bates p 341)i) Ask the patient to take a deep breath and perc

again in this area9) Palpate the abdomen lightly in four quadrants and in th

suprapubic and epigastric areasa) Use a gentle, light dipping motion (Bates p 335)

10) Palpate the abdomen deeply in all four quadrantsa) Use a firmer dipping motion

11) Palpate for the liver edgea) Place your R hand on the right abdomen lateral to t

rectus muscle, beginning more than 3 fingerbreadt

below the costal marginb) Ask the patient to take in a deep breathc) Palpate upwards trying to feel the descending liver

edge, using a rocking motioni) May also use the “hooking technique” describe

Bates p 34012) Palpate for a spleen tip

a) Reach over and around the patient with your left hto support and press forward the lower left rib cage

b) Press inward towards the spleen with your right habeginning at least 3 finger breadths below the L comargin

c) Ask the patient to take in deep breaths, trying to fethe spleen tip as it comes down to meet your finge

13) Palpates for aorta by pressing deeply with one hand oneach side of the aorta (Bates, p 344)

14) Palpate for the superficial inguinal lymph nodes (Bates,452)15) Palpate for both femoral artery pulses

a) Press deeply below the inguinal ligament (Bates, p

Upper extremity—MSK and Partial Neurological (thesemaneuvers must be repeated on both upper extremities1) Inspect the hands, including each finger, its skin and jo

and nailsa) Palpate any abnormal joints

2) Inspect the wrist3) Palpate the distal radius and snuff box; palpate the dist

ulna4) Palpate the radial pulse on the flexor surface of the wri

laterallya) Compare the pulses in both arms

5) Check ROM of the fingers

a) Ask the patient to make a tight fist with each hand

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 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

fingerse) Have the patient touch the thumb to each of the other fingertips

6) Check ROM of the wrist (Bates p 499)

a) Flexionb) Extensionc) 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 elbowb) Pronation and supination: with arms at his side, and

elbows flexed, ask the patient to turn the palms up andthen 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 triceps9) 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 humerusc) 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 downii) Raise the arms to a vertical position above the

head with the palms facing each otheriii) 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 sidesa) Test grip—ask the patient to squeeze two of your

fingers as hard as possible and not let them gob) Test finger abduction—position the patient’s hand with

palms down and fingers spread. Try to force thefingers together

c) Test opposition of the thumb—the patient should try totouch the little finger with the thumb against yourresistance

d) Test extension of the wrist by asking the patient to

make a fist and resist you pulling it downe) Test flexion and extension of the elbow by having the

patient pull and push against your hand

Lower extremity—MSK and Partial Neurological (thesemaneuvers must be repeated on both lower extremities1) The patient may be sitting or lying down and draped so that

the external genitalia are covered with the legs fullyexposed during the exam

2) Inspect both feet and ankle—compare sides3) Palpate the feet and ankles (Bates, p 517)

a) Assess for pedal edema—press firmly with your thumbover the dorsum of the foot, behind each medialmalleolus and over the shins (Bates, p 455)

b) Palpate the anterior aspect of each ankle jointc) Palpate the heel, especially the post and inf calcaneusd) Palpate the MTP jointse) 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 lateto the extensor tendon of the great toe

b) Posterior tibial—feel below the medial malleolus ofankle

5) Check ROM of the ankle (Bates, p 518)a) Dorsiflex and plantar flex the foot at the ankleb) Invert and evert the footc) Flex the toes

6) Inspect the knee for alignment and contours7) Palpate the knee with the knee in flexion (Bates, p 511-

a) Identify the medial femoral condyle and the mediatibial plateau

b) Identify the tibial tuberclec) Identify the lateral femoral condyle and lateral tibia

plateaud) Identify the patellar tendon and ask the patient to

extend the lege) Palpate the medial collateral and lateral collateral

ligaments and meniscif) Feel for swelling above and to the sides of the pateg) Check the prepatellar, anserine and popliteal bursa

(Bates p 513)8) Check ROM of the knee (Bates p 515)

a) Ask the patient to flex and extend the knee whilesitting (or by asking the patient from a standingposition to squat and then stand up again

b) Check internal and external rotation by asking thepatient to rotate the foot medially and laterally

9) Inspect the hip by observing the patient’s gait at some during the exam (Bates p 506)

10) Palpate the surface landmarks of the hipa) Anterior surface: locate the iliac crest, iliac tubercland anterior superior iliac spine

b) Posterior surface: locate the posterior superior iliacspine, the greater trochanter and the ischial tubero

11) Check ROM of the hip (Bates, p 509-510)a) Flexion—with the patient supine, ask him to bend e

knee in turn up to the chest and pull it firmly againthe abdomen

b) Abduction—grasp the ankle and abduct the extendleg until you feel the iliac spine move

c) Adduction—hold one ankle and move the leg mediaacross the body and over the opposite extremity

d) Rotation—flex the leg to 90° at hip and knee; stabilthe thigh with one hand, grasp the ankle with the oand 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 thepatient’s thigh and asking the patient to raise the leagainst your hand

b) Test adduction at the hips—place your hands firmlythe bed between the patient’s knees. Ask the patieto bring both legs together

c) Test abduction at the hips—place your hands firmlythe bed outside the patient’s knees. Ask the patiespread both legs against your hands

d) Test extension at the hips—have the patient push tposterior thigh down against your hand

e) Test extension at the knee—support the knee in fleand ask the patient to straighten the leg against yohand

f) Test flexion at the knee—place the patient’s leg sothe knee is flexed with the foot resting on the bed.

the patient to keep the foot down as you try tostraighten the leg

g) Test dorsiflexion and plantar flexion at the ankle—the patient to pull down and push down against yohand

Neurological – some parts of the neurological exam have bewoven into exam of the head and neck and extremities (i.e.Cranial Nerve exam and motor testing). The remainingcomponents of the neurological exam are covered here

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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 thumbor finger firmly on the biceps tendon and strike withreflex hammer

b) Triceps reflex (C6, C7) – flex the patient’s arm at theelbow with palm towards the body and pull it across thechest. Strike the triceps tendon above the elbow

c) Knee (Patellar) reflex (L2, L3, L4) – patient may beeither sitting or supine with knee flexed. Tap thepatellar tendon just below the patella

d) Ankle (Achilles) reflex (S1) – dorsiflex the foot at theankle 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 lateralaspect 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 theextremities

iii) Vary the pace of your testing and occasionallysubstitute the blunt end for the point, while asking“Is this sharp or dull?” or “Does this feel the sameas this?”

b) Light touch – using a fine wisp of cotton, touch the skinlightly, avoiding pressurei) Ask the patient to respond whenever a touch is

felt.ii) Compare one area with anotherc) Vibration – Use a low-pitched tuning fork (128 Hz)

i) Set the fork vibrating and place it firmly over a DIPof a finger and of the great toe

ii) Ask what the patient feelsiii) If vibration sense is impaired, move to more

proximal bony prominencesd) Joint position sense

i) Grasp the patient’s big toe, holding it by its sidesand pull it away from the other toes so as to avoidfriction.

ii) Demonstrate “up” and “down”iii) With patient’s eyes closed ask him to identify up

and down movementsiv) Compare sidesv) Move more proximally if joint position is impaired

vi) Test JPS in the UE by moving a finger joint3) Cerebellar/Coordination (Bates, p 578-580)

a) Rapid alternating movementsi) UE – Show patient how to strike one hand on the

thigh, first with the palm, then with the back of thehand. Have the patient repeat these alternatingmovements as rapidly as possible. Repeat withopposite hand(1) OR Show the patient how to tap the distal joint

of the thumb with the tip of the index finger asrapidly as possible. Have the patient performthe action. Check the opposite hand

ii) LE – ask the patient to tap your hand as quickly aspossible with the ball of each foot in turn

b) Point-to-point movementsi) UE – ask the patient to touch your index finger and

then his nose alternately several times. Move yourfinger about.ii) LE – Ask the patient to place one heel on the

opposite knee and then run it down the shin to thebig toe. Repeat on the other side

4) Gaita) Ask the patient to walk across the room, then turn and

come backb) Walk heel-to-toe in a straight linec) Walk on toes then on heels

5) Romberg Testa) The patient should first stand with feet together and

eyes open and then close both eyes for 20-30 secswithout support

Back1) ROM (Bates, p 505)

a) Flexion – with patient standing, ask him to bendforward to touch the toes

b) Extension – place your hand on the posterior superiliac spine and with your fingers pointing towards thmidline, ask the patient to bend backward as far aspossible

c) Lateral bending – ask the patient to lean to both sidas far as possible