Updated SEP16

Physical Exam Checklist

Student: _____________________________ Date: ____________________ Evaluator: ____________________________ Yes No

1. Wash hands VITAL SIGNS

2. Blood pressure done – 1 arm 3. Systolic BP estimated by palpation of brachial or radial arteries with BP cuff 4. BP done correctly (not over clothing, cuff tight, arm correct relaxed position, etc.) 5. Blood pressure taken with the stethoscope over the brachial artery 6. Heart rate – at least 15 seconds checking radial pulse with fingers, not thumb 7. Respiratory rate – inconspicuously watching chest movement (at least 20-30

seconds) 8. Temperature (done correctly – will beep when done if electronic)

HEAD EXAM

9. Palpates scalp 10. Palpates thoroughly (temples, parietal – sides above ears, crown, occipital – back)

EYES

11. Inspects external ocular (eye) structures (lids, conjunctiva, iris cornea, pupils) 12. Gently moves eyelids up and down to obtain better view 13. Checks acuity with Snellen and from proper distance (depending on the chart

used may be 6 feet or 14 inches if Rosenbaum used) 14. Checks acuity both eyes separately 15. Evaluates extraocular movement (big H) 16. Checks convergence and accommodations (follows finger from far to near, looks

from far to near) 17. Visual fields – both eyes independently 18. Visual fields – 4 cardinal directions for each eye (superior and inferior portions of

temporal and nasal visual fields) 19. Visual fields – Examiners hands or object to view introduced in the plane half-way

between patient and examiner 20. Gives clear directions to the patient while doing the visual fields. 21. Pupillary response to light - direct (same eye the light is directed into) 22. Pupillary response – indirect (eye light is not directed into) 23. Swinging flashlight test (start in one eye, quickly move to other eye, wait then fast

back to original eye and wait) 24. Ophthalmologic Examination: Lights are dimmed 25. Holds and positions ophthalmoscope properly, uses index finger or thumb when or

if switching lenses

Updated SEP16

26. Examiner uses R hand R eye to look in R eye Yes No

27. Inspects optic nerve – R eye (comes in at 15o with lens at 0 or moving from the positive towards 0)

28. Traces vessels to all four quadrants – R eye 29. Observes macula – R eye (credit to be given if #28 and look laterally) 30. Examiner uses L hand L eye to look in L eye 31. Inspects optic nerve – L eye (comes in at 15o with lens at 0 or moving from the

positive towards 0) 32. Traces vessels to all four quadrants – L eye 33. Observes macula – L eye (credit to be given if #32 and look laterally)

EARS

34. Inspects externally bilaterally (including behind ears) 35. Palpates auricles bilaterally 36. Auditory acuity tested (eyes closed if finger rub and you can see movement of

hands or arm) 37. Auditory acuity tested correctly (each ear independently, etc.)If hearing problem

Weber and Rinne performed 38. Otoscopic examination bilaterally 39. Otoscopic examination performed without pain 40. Auricles pulled superiorly, posteriorly, and away from patient

NOSE

41. Tests for nasal obstruction 42. Otoscope used with nasal speculum to inspect nasal vault or may use otoscope

ear speculum 43. Nasal speculum examination done without causing pain 44. Palpate frontal sinus for tenderness (medial brow left and right, be sure not too

high) 45. Palpate maxillary sinus for tenderness (correct postion) 46. Palpate ethmoid sinus (bridge of nose) for tenderness

MOUTH 47. Should use light source for inspection 48. Inspect lips, gums, buccal mucosa, teeth 49. Inspect tongue, posterior pharynx 50. Inspect floor of mouth (under tongue) 51. Elevation of palate (“ah”) 52. Examination done with minimal discomfort

NECK EXAM

53. Inspects anterior neck for symmetry 54. Carotid arteries palpated 55. Carotid arteries correctly palpated, singly, lower or upper neck (not mid-neck),

fingers or thumb 56. Auscultation of carotid arteries (lower carotids bilaterally) 57. Auscultation of carotid arteries (upper carotids bilaterally)

Updated SEP16

58. Thyroid gland palpated from behind, chin is slightly flexed (can palpate from front)

59. Hands in proper position (below the cricoid cartilage) 60. Palpates the isthmus and has patient swallow 61. Palpates the lobes and has patient swallow

Yes No LYMPH NODES

62. Preauricular (in front of the ear) 63. Posterior auricular (behind the ear) 64. Occipital (base of skull) 65. Tonsillar (angle of jaw) 66. Submandibular (mid-jaw) 67. Submental (under chin) 68. Posterior cervical (back of neck) 69. Superficial cervical (on top of the sternomastoid muscle) 70. Deep cervical (deep in the sternomastoid muscle) 71. Supraclavicular

LUNG EXAM

72. Observes trachea for midline position 73. Anterior Chest (lying or sitting or at 30o) Inspection: For symmetry, fully exposed 74. Palpation: For tactile fremitus (attempted) 75. Palpation: Alternates from side to side or may use both hands simultaneously 76. Percussion: Anterior chest (attempted) 77. Percussion: Alternates from side to side 78. Percussion: Done correctly (bilaterally, symmetrically, good tone) 79. Auscultation: Bilaterally (attempted) 80. Auscultation: Done correctly (above clavicle, 3-4 places, listens throughout

inspiration and expiration) 81. Auscultation: Patient instructed slow, deep breath, mouth open 82. Auscultation: Alternates from side to side 83. Auscultation: At least 3-4 areas auscultated on each side 84. Posterior Chest Inspection: For symmetry 85. Palpation: Bilateral movement chest wall (hands on sides, try to bring thumbs

together, moderate pressure) 86. Palpation: For tactile fremitus (attempted) 87. Palpation: Alternates from side to side or may use both hands simultaneously 88. Percussion: Check diaphragmatic movement bilaterally 89. Percussion: Posterior lung fields (attempted) 90. Percussion: Alternates from side to side 91. Percussion: Done correctly bilaterally, symmetrically, good tone 92. Auscultation: Bilaterally (attempted) 93. Auscultation: Done correctly (above scapula, 3-4 places, throughout inspiration

and expiration) 94. Auscultation: Patient instructed deep slow breaths, mouth open 95. Auscultation: Alternates from side to side 96. Auscultation: At least 3-4 areas auscultated on each side

Updated SEP16

97. Arms crossed for tactile fremitus, percussion and auscultation 98. Lateral Chest Percussion laterally can be done as part of anterior or posterior 99 Auscultation laterally can be done as part of anterior or posterior 100. Other: Stethoscope placed in examiner’s ears correctly 101. Other: Correct order of inspection (palpation or percussion), auscultation 102. Percussion over costovertebral angle

Yes No HEART EXAM

103. Inspection jugular vein (remember can be done at 0, 15, 30o, will likely move table position)

104. Inspection done correctly; right side, head tilted left, patient elevated 105. Inspection, palpation and auscultation for rest of cardiac examination performed at

30o 106. Inspection of all 4 areas 107. Palpation of aortic area (right second intercostals space just lateral to sternum) 108. Palpation of pulmonic area (left second intercostals space just lateral to sternum) 109. Palpation of right ventricular area (left lower sternal border) 110. Palpation of apical area (about fifth intercostals space mid-clavicular line) 111. If apical impulse not palpable, patient in left lateral decubitus 112. Palpation done with fingerpads in all 4 areas 113. Auscultation with Diaphragm Aortic area 114. Auscultation with Diaphragm Pulmonic area 115. Auscultation with Diaphragm Tricuspid area (left lower sternal border) 116. Auscultation with Diaphragm Mitral area (apical area) 117. Auscultation with Diaphragm Sitting, left lower sternal border, patient fully exhaled 118. Auscultation with bell. Tricuspid area 119. Auscultation with bell. Mitral area 120. Auscultation with bell. Mitral area in the left lateral decubitus position 121. Done correctly – Bell applied light pressure, not heavy (remember newer

stethoscopes diaphragm lightly OK and if not already tested stethoscope in ears properly)

Yes No ABDOMEN

122. Inspection with adequate exposure (lower chest to pelvis) 123. Auscultation: Listens at least 10 secs. (one place or can move to several areas,

must listen for at least 10 secs) 124. Auscultation of the aorta 125. Auscultation of iliac arteries bilaterally 126. Auscultation of renal arteries bilaterally 127. Percussion: L abdomen above below umbilicus 128. Percussion: R abdomen above below umbilicus 129. Percussion: Liver span (measure liver span) 130. Palpation: Lightly, all 4 quadrants 131. Palpation: Deeply, all 4 quadrants 132. Palpation: Liver (attempts to do)

Updated SEP16

133. Palpation: Liver (correctly – palpating deepest full inspiration, 1 hand under one hand palpating or 2 palpating)

134. Palpation: Spleen (attempts to do) 135. Palpation: Spleen (correctly – position, breaths, palpating deepest full inspiration, 1

hand under L side, 1 feeling) 136. Palpation: Spleen (if not palpable, R lateral decubitus) 137. Palpation: For abdominal aorta (to feel both the left and right walls of the aorta) 138. Palpation: Inspects patient’s face during palpation (at least 50% of the time) 139. In correct order: Inspection, auscultation, percussion and palpation 140. Abdominal Examination was done at 0o

NEUROLOGICAL EXAM

Yes No MENTAL STATUS 141. Level of Consciousness 142. Orientation (person, place and time) 143. Language ( fluency, comprehension, repetition) 144. Articulation; dysarthria

Proceed to more complete mental status examination if problems suspected

CRANIAL NERVES 145. I. Sense of smell: formally tests in each nostril individually 146. II Test visual acuity, test visual fields, pupillary response; direct

. and consensual; funduscopic exam 147. III, IV, VI Inspect lids for ptosis, extraocular motion and accommodation 148. V Fine-touch: All 3 divisions bilaterally 149. V Bite down feeling over masseter and temporalis muscles 150. VII Raises eyebrows 151. VII Closes both eyes tightly 152. VII Smiles or puffs up cheeks 153. VIII Auditory acuity 154. IX, X Gag reflex (patient must be told about maneuver do in selected patients and

does not need to be done on practical exam) 155. XI Shoulder shrug bilaterally (instruction for shrug should be upward) 156. XI Patient turns head against resistance bilaterally 157. XII Tongue (sticks out tongue in midline) 158. XII Tongue move left and right

NEUROLOGICAL MOTOR

159. Observation for hypertrophy, atrophy, fasciculations, tremor, dystonia, myoclonus 160. Tone; spasticity, rigidity 161. Pronator drift 162. Strength Proximal upper extremities (shoulders, triceps, biceps) 163. Strength Distal upper extremities (fingers abduction, wrist flexion, extension) 164. Strength Proximal lower extremities; hip flexion, knee extension, knee flexion,

ankle dorsiflexion and plantar flexion)

NEUROLOGICAL SENSORY

Updated SEP16

165. Bilateral vibratory perception in the distal lower extremities (start at first toe interphalangeal joint and move up as needed until vibration perceived)

166. Bilateral vibratory perception in the distal upper extremities (start at DIP and if abnormal progress proximally until vibration perceived)

167. Bilateral position sense done in distal lower extremities (begin at the great toe and if abnormal move proximally until normal )

168. Bilateral position sense done in distal upper extremities (begin at any finger DIP and move proximally until normal)

169. Bilateral pin prick in distal lower extremities (begin at foot and examine in more detail if abnormal)

170. Bilateral pin prick in distal upper extremities (begin at hand and exam in more detail if abnormal)

171. Bilateral temperature done distal lower extremities (begin at foot and exam in more detail if abnormal) Yes No 172. Bilateral temperature done distal upper extremities (begin at hand and exam in more detail if abnormal) 173. Tests graphesthesia or sterognosis

CEREBELLAR

174. Finger-to-nose bilaterally (patient’s arm should be fully extended when touching finger)

175. Heel-to-shin bilaterally (in supine position) 176. Rapid alternating movements bilaterally upper extremity (each side one at a time) 177. Rapid alternating movements bilaterally lower extremity (each side one at a time) 178. Romberg-heels toes together; eyes opened, arms at side or at 90o

with palms up or down. Then ask to close eyes 179. Gait: Heel-to-toe (Tandem) 180. Gait: On toes (part of motor exam done at this time) 181. Gait: On heels (part of motor exam done at this time)

DEEP TENDON REFLEXES

182. Biceps bilateral (elbow flexed at 90o, examiner’s thumb or finger on biceps tendon when striking)

183. Triceps bilateral (elbow flexed, arm at patient’s side or supported by examiner) 184. Brachioradialis bilateral (distal 1/3 of forearm) 185. Patellar bilateral (knee should be flexed at 90o) 186. Achilles bilateral (slightly dorsiflex foot, OK pull leg out from table some) 187. Plantar response (Babinski) bilateral (sharp obj. heel to toes

laterally then ball of foot)

PERIPHERAL VASCULAR 188. Palpation radial pulses bilaterally 189. Palpation radial pulses simultaneously 190. Palpation ulnar pulses bilaterally 191. Palpation brachial pulses bilaterally (medial to biceps tendon)

Updated SEP16

192. Palpation epitrochlear nodes bilaterally (1-1 and ½ inches proximal to elbow in biceps grove)

193. Palpation femoral pulses bilaterally 194. Palpation inguinal lymph nodes bilaterally 195. Auscultation femoral arteries bruits bilaterally 196. Palpation popliteal pulses bilaterally (knee should be flexed and relaxed, may do in

prone position) 197. Inspection lower extremities bilaterally 198. Palpation pitting edema bilateral lower ext. (5 seconds, fair amount of pressure,

distal ankle/top of foot over bone) 199. Palpation posterior tibial pulses bilaterally (medial ankle) 200. Palpation dorsalis pedis pulses bilaterally (top foot, location varies (usually

between 1st and 2nd toes) MUSCULOSKELETAL EXAM SPINE

201. Inspection: from behind - cervical, thoracic, lumbar spine & Paraspinal muscles (states what is inspecting for)

202. Observe normal gait (patient walks bare foot away & towards you) 203. Palpation: of cervical, thoracic, lumbar, sacral vertebrae, SI Joints & Paraspinal

muscles 204. Range of Motion: active ROM (observing from in front for cervical spine and from

behind for lumber spine) 205. Cervical spine: flexion and extension 206. Cervical spine: lateral bending, to left and right side 207. Cervical spine: rotation (patient turns the neck to left and right) 208. Lumbar spine: full flexion 209. Lumbar spine: full extension 210. Lumbar spine: lateral bending, to left and right side 211. Lumbar spine: rotation to left and right, while stabilizing the pelvis 212. Patient’s pelvis is stabilized for rotation movements only-to exclude hip movements 213. Inspection, palpation and ROM with adequate exposure (not over gown)

SHOULDER

214. Inspection (from front & behind, states what is inspecting for) 215. Palpation: Clavicle, A/C joint, acromion, scapula, scapular spine, bicipital groove 216. Palpation of both shoulders done simultaneously for comparison 217. Flexion and Extension (both arms raised in front and behind body) 218. Abduction (both arms raised out to side at 90 degrees, & to full arc)

Updated SEP16

219. Adduction (both arms crossed in front of body across midline) 220. Internal rotation (both hands behind back to opposite scapula) 221. External rotation (both hands behind head) 222. Examination done bilaterally & simultaneously for comparison 223. Inspection, palpation and ROM with full exposure of both shoulders together and

not over the gown.

ELBOW

224. Inspection (states what is inspecting for) 225. Palpation: Medial & lateral epicondyles, olecranon, cubital fossa & Biceps tendon 226. Palpation of both elbows done for comparison 227. Range of Motion: Observe active ROM (or passive if required) 228. Movements done bilaterally for comparison 229. Flexion and Extension to full extent 230. Supination (elbow held/fixed on side of body, flexed to 90 degrees, palm up) 231. Pronation (elbow held/fixed on side of body, flexed to 90 degrees, palm down) 232. Inspection, palpation and ROM with full exposure (not over gown)

WRIST and HAND

233. Inspection dorsal & volar aspects (states what is inspecting for) 234. Palpation of Wrist: distal radius & ulna, carpel bones & anatomical snuffbox,

Carpal tunnel 235. Palpation of Hand: Metacarpals, MCP and IP joints (DIP and PIP), phalanges,

Thenar & hypothenar eminence & palm area 236. Palpation done on both dorsal & volar aspects of wrist & hand 237. Range of Motion: Active ROM with elbow held at 90 degree on side of body 238. Wrist: flexion and extension (with arm held on the side of body) 239. Wrist: radial and ulnar deviation (with arm held on the side of body) 240. Hand: flexion and extension of fingers (makes fist & then fully extends fingers) 241. Hand: abduction and adduction of fingers (spread out& and bring together) 242. Hand: Thumb abduction, adduction, extension, flexion & opposition 243. Examination done bilaterally & simultaneously for comparison

HIP

244. Inspection (states what is inspecting for, e.g. iliac crest, ASIS) 245. Palpation: iliac crest, anterior superior iliac spine and greater trochanter 246. Range of Motion: Measures passive ROM 247. Flexion (full flexion with patient supine, knee flexed) 248. Extension (patient prone on the table, with sacrum stabilized) 249. Abduction (leg away from the body with hip and knee at 0 degrees) 250. Adduction (leg moved across the midline with hip and knee at 0 degrees) 251. Stabilizes patient’s opposite pelvis for abduction/adduction for each leg

Updated SEP16

252. Internal and External rotation (patient supine, hip and knee flexed at 90 degrees) 253. Examination done bilaterally for comparison

KNEE

254. Inspection (states what is inspecting for e.g. quads muscles, patella etc) 255. Palpation: patella, patellar tendon, tibial tuberosity, medial and lateral femoral

condyles, fibular head, medial & lateral joint line, popliteal fossa 256. Palpation done on both knees, one at a time 257. Range of Motion: Measures active and/or passive ROM 258. Flexion (assess full flexion) 259. Extension (assess full extension) 260. Examination done bilaterally for comparison

ANKLE and FOOT

261. Inspection (states what is inspecting for e.g. medial & lateral malleoli) 262. Palpation of Ankle: Lateral and medial malleolus, Achilles Tendon 263. Palpation of Foot: Tarsal bones, metatarsal bones, MTP joints, PIP & DIP joints 264. Range of Motion: Measures active and/or passive ROM 265. Ankle: dorsiflexion and plantar flexion 266. Ankle: inversion and eversion of foot (stabilize the ankle in 90 degree and invert &

evert the heel) 267. Foot: supination and pronation of the forefoot (stabilize the ankle in 90 degree as

well as the heel and then supinate and pronate the forefoot) 268. Toes: flexion and extension 269. Examination done bilaterally for comparison

Steven A. Haist, MD, MS, FACP

Physical Examination Checklist Guidelines

General Comments:

1. The student or resident should perform the physical examination in a logical manner with smooth

transition from one region to another. This does not necessarily mean that you have to complete the entire

neurological examination before proceeding to the musculoskeletal or peripheral vascular examination.

"Logical manner" may include doing the peripheral pulses, neurological examination, and musculoskeletal

examination of the upper extremities distally and proceeding proximally and then move to the lower

extremities. There is no “right” order in which to do the physical examination. Find an order that makes

sense to you and practice it repeatedly. You should minimize the number of movements your patient

needs to make but most importantly it should flow in a logical manner.

2. The student should explain in laymen's terms the various parts of the examination to the patient. The

examiner should warn the patient before any maneuvers which may cause pain or discomfort such as the

gag reflex.

3. During any explanation or discussion with the patient, the student should avoid the use of medical jargon

or, if it is used, provide an explanation of terminology in laymen's terms.

4. During the examination the patient should be asked to move a minimum number of times.

Updated SEP16

5. Also during the examination, the number of movements made by the examiner should be minimized as

well.

6. Most of the examination should be done from the patient's right-hand side or while in front of the patient.

7. It is very important to be concerned with the comfort and privacy of the patient. The door should remain

closed except when it is opened slightly during the fundoscopic examination. The patient should be

draped except during inspection, and then the amount of time of exposure should be limited. For a female

patient, the anterior chest should be observed as part of the breast examination as well as for inspection of

the anterior chest examination and cardiac examination. Inspection of the breast, anterior chest and

cardiac area can be done simultaneously. If the breast exam is not to be done, inspection would best be

accomplished with the patient in a supine position. If the breast examination is to be done, it should be

done with the patient sitting up. Later inspection for the point of maximal impulse rate should be done

with the patient at 30 degrees.

A. Preliminary

1. The examiner should always wash his/her hands before performing any part of the physical

examination. It is best to do this in front of the patient. Remember also to warm your stethoscope

before use.

B. Vital Signs

2-5. Blood Pressure: Blood pressure should be taken in both arms at least once. In any patient who has

not been seen before, their blood pressure is unknown, and it could range anywhere from > 200

systolic to < 100 systolic. Systolic blood pressure should be estimated the first time a patient's

blood pressure is taken. This will help to avoid errors caused by an auscultatory gap (silent period

between systolic and diastolic blood pressure). This is done by palpating the brachial or radial

arteries; after the pulse is palpated inflate the blood pressure cuff until the pulse is no longer felt.

Read the pressure on the manometer at this time. This is an estimate of the systolic blood pressure.

The blood pressure cuff should be placed with the center of the bladder over the artery, 2.5 cm

above the antecubital crease. The cuff should fit snugly and should never be placed over clothing

or the hospital gown. Use of the proper size cuff is important. The width of the inflatable bladder

of the cuff should be 40% of the upper arm circumference and the length of the bladder should be

80% of the upper arm circumference. The arm of the patient should be in a relaxed position with

the arm slightly flexed. The brachial artery should be at the level of the right atrium. If the arm is

elevated above the head, this will falsely lower the blood pressure, and if the arm is below the level

of the right heart the blood pressure will be falsely elevated. The blood pressure cuff should be

inflated to approximately 20-30 mmHg above the estimated systolic blood pressure palpated as

described above. The blood pressure cuff should be deflated about 2-3 mmHg per second. The

bell or diaphragm of the stethoscope should be placed over the brachial artery. The first audible

sound will be the systolic blood pressure, and the last audible sound will be the diastolic pressure.

The bell of the stethoscope is used because the last sounds in the diastolic pressure, or Korotkoff

sounds, are low-pitched and are best heard with the bell of the stethoscope. However many use the

diaphragm and this will be accepted. The cuff should not be inflated multiple times; this will create

venous pooling and may artificially lower the systolic pressure and elevate the diastolic pressure.

6. Heart rate: The patient's heart rate should be checked by palpating the radial pulse for at least 15

seconds with your fingers. Multiplying this number by 4 if you have palpated for 15 seconds will

give you the heart rate for one minute. If the heart rate is rapid or irregular you may need to count

the heart rate for one minute or you may need to auscultate the heart for a more accurate heart rate,

since not all beats will generate a palpable pulse. If the heart rate is irregular, you should palpate

longer than 15 seconds.

Updated SEP16

7. Respiratory rate: The patient can vary his/her respirations and either breathe slowly or quickly if

they know their respirations are being counted. Thus counting of respirations should be done

inconspicuously. It can be done as part of the chest examination when you are behind the patient

or during the vital signs, or you may continue to palpate the radial pulse once you have determined

the heart rate and inconspicuously watch for chest wall movement out of the corner of your eye.

The respiratory rate is normally 12-20 times per minute.

8. Temperature: You should be able to take a temperature on a patient with an electronic

thermometer. The proper cover should be used, and you should be able to give the patient

instructions on what to do (place the instrument under their tongue and hold it there). The

temperature should be recorded in degrees Celsius or Fahrenheit, and note made of the route

(axillary, oral, rectally, or central temperature).

C. Head

9-10. The examiner should thoroughly inspect the patient's scalp and palpate for symmetry and any

tenderness.

D. Eyes

11-12 As with any part of the examination, you should begin examination of the eyes with inspection.

You inspect the external ocular structures, including the lids, conjunctiva, iris, cornea, and pupils.

You should gently move the lower eyelid down and ask the patient to look up and gently move the

upper eyelid upward and ask the patient to look down to obtain a more thorough view of the

conjunctiva.

13-14. The patient's visual acuity should be formally evaluated. This can be done by a Snellen card held

at approximately 14 inches (you can attach a 14 inch string to help determine the distance) from

the patient's nose. The patient should be instructed to cover the left eye and read the smallest line

they possibly can read with the right eye. You should verify the information they provide. The

right eye should then be covered and the patient should be asked again to read the smallest line

they can. You can have the patient read the smallest line backwards with the left eye. This will

help eliminate memory as the reason why correct answers were given. If you do not have a

Snellen card, you can ask the patient to read any print. If you use printed words, it is best to have

them say the letters backwards. If the patient cannot see large print, then you can check their

ability to count fingers, or note hand motion, or observe light.

15-16. Evaluation of extraocular movements involves having the patient's head stationery and following

the examiner's finger laterally until they are in an extreme lateral gaze (medial gaze for contra-

lateral eye); then the examiner should move their finger superiorly to note the maximal superior

lateral gaze (maximal superior medial gaze for contralateral eye), then inferiorly to note the same.

The examiner should move their finger to the opposite side of the patient across the mid-line for

extreme medial gaze for the one eye (maximal lateral gaze for the other eye), then to maximal

superior medial gaze for the first eye (maximal superior lateral gaze for the eye on the same side as

the finger), then inferior medial gaze for the first eye (maximal superior lateral gaze for the eye on

the same side as the finger). Note that when the right eye is in maximal lateral gaze, the left eye

should be in maximal medial gaze, and etc. During extraocular movements the examiner should

pause in far lateral gaze and upward movement to check for nystagmus. Once extraocular

movements are evaluated, the examiner should take their finger from about 12 inches away from

the patient, ask the patient to stare at the finger and follow it. The examiner should move their

Updated SEP16

finger to the tip of the patient's nose, checking for convergence. For accommodation ask the

patient to focus on a distant object and then rapidly focus on an object in front of their nose. The

patient should be told to tell you if they experience double vision (diplopia) at any time during the

EOM exam.

17-20 Visual fields by confrontation should be evaluated. Each eye should be done independently. The

patient and examiner should cover opposite eyes, then stare at each other's eyes (patient's right eye

to examiner's left eye; patient's left eye to examiner's right eye). The examiner should place one

hand in the plane between the patient and the examiner and, either through hand movement or

counting fingers, check the patient's vision in four quadrants. For instance, for the examiner's right

eye looking at the patient's left eye, you would check in four directions: temporally inferior and

superior quadrants, and nasal inferior and superior quadrants. Repeat the process with the patient's

right eye. You are using yourself for a control and should be able to note any gross defects. You

will note that both you and the patient can see your hand fully extended laterally, and actually you

and the patient can see laterally much farther than your hand extends.

21-23. A pen-light should be used to check pupillary response. First, the pen-light should be placed in

front of the patient, noting where the reflection of light is

reflected back from both pupils. It should be a symmetrical position. If it is not symmetrical, this

may indicate disconjugate gaze. Then the bright light should be directed into one pupil, and you

should note constriction of that pupil and constriction of the other pupil. To adequately do this,

you can shine the light in the left eye and note if the left eye constricts. Take the light away and

shine it back in the left eye while looking in the right eye and noting if the right eye constricts. An

acceptable alternative would be when you shine the light in the left eye and watch the left eye

constrict; as you take the light away, you can watch the right eye dilate. You can do the same

process on the other side.

The swinging flashlight test is done to detect optic nerve disease. A bright light is placed in front

of one eye and moved quickly to the other eye, then one or two seconds later moved quickly back

to the first eye. The pupils should remain constricted when the light is taken from one eye quickly

to the other.

24-33. The ophthalmologic examination: The lights in the room should be dimmed or lights turned off

and the door slightly ajar. The examiner should hold the ophthalmoscope in their right hand using

their right eye to examine the patient's right eye, and using their left hand looking with their left

eye to examine the patient's left eye. The ophthalmoscope contains a series of optic lenses which

will change the distance of the point of focus. You will use your index finger of the hand holding

the ophthalmoscope to change the lenses. To examine the anterior structures such as the cornea

and anterior chamber you will be in the positive diopters. As you move from the positives toward

zero and then into the negative numbers your focal point will be deeper and deeper in the eye. In a

patient who is nearsighted or with myopia the globe is elongated and will require more negative

diopters to see the fundus; whereas in a patient who is farsighted or with hyperopia the globe of the

eye is shortened and you will focus in on the fundus with more positive diopters (black or green).

This is assuming that the examiner has normal vision. If the examiner also has myopia or

hyperopia, this will change the focal point for any given diopter. It is probably best to start with

the ophthalmoscope on a positive 10-20 diopters. You will ask the patient to look straight ahead,

and you will approach the patient from about 15 degrees lateral from directly in front of the

patient. If you are to examine the patient's right eye, you will be holding the ophthalmoscope with

your right hand and looking with your right eye, and your left hand will be positioned on the

patient's forehead. You will start the examination from about 2 feet away, and you should be

looking for a red reflex. Once this is found, you will come up closer to the patient until you are

Updated SEP16

about .5 to 1.5 inches away. Then you will change the diopter slowly from positive 10 to 20

toward 0 and as you go deeper into the eye into negative diopters. Coming in lateral 15 degrees

should bring you directly to the optic disc. If you initially see blood vessels, you can follow the

blood vessels toward the disc. They flow like rivers toward the disc. Once you see the disc, you

should note its color and note what percent of the physiologic cup involves the disc.

The cup-to-disc ratio should be less than 0.3. You should note the size of the arterioles as

compared to the veins. They should be 2/3 to 4/5 the size of veins. You should look in all four

directions for any peripheral lesions such as hemorrhages or exudates. Once this is done, you can

go back to the disc and either look directly lateral for the macula and fovea which should be 2 to

2.5 disc diameters lateral, or you can also ask the patient to directly look at the light, and

this will bring the macula and fovea into view. The same process should be done in the other eye.

E. Ears

34. The ears need to be closely inspected, including behind the ears.

35. Palpate the ears between two fingers for any masses or tenderness. Palpate the mastoid bone for

tenderness as may be seen in otitis media and the tragus for pain on movement which may be seen

in otitis externa.

36-37. Auditory acuity needs to be tested in both ears independently. This is done by having the patient

cover their other ear and then lightly rubbing your fingers from 3 ft. and ask the patient to tell you

when they hear your fingers rubbing, and moving your fingers closer to the patient. The patient's

eyes need to be closed if you use the finger rub to test acuity, since they may see your arm or

clothing moving. You could also cover your mouth and whisper numbers or letters from 3 ft. and

move closer to the patient and have the patient repeat what you are saying. If an abnormality of

hearing is noted perform the Weber test. Using a 512 hz tuning fork lightly tap it on your knuckles

and place it firmly on the patient’s head or forehead in the midline. Ask the patient if he/she hears

the sound better on one side or if it is heard better in the middle. Normally the sound should be

heard equally on both sides. Then perform the Rinne test. This is to compare air conduction to

bone conduction and should be done in both ears. Place the base of the vibrating tuning fork on

the mastoid bone at the level of the ear canal and ask the patient to tell you when you can no

longer hear it. Then place the fork by the ear canal with the U of the fork facing forward. The

patient should be able to hear the tuning fork (normal for air conduction to be greater than bone

conduction)

38-40. Otoscopic examination needs to be done bilaterally. If there is a complaint of ear pain always

begin with the nonpainful ear. You should always be visualizing the opening to the ear canal

before and while advancing the speculum. This will avoid causing undue pain. The auricle is

pulled posteriorly, superiorly and away from the patient to straighten out the canal. This will help

facilitate visualization of tympanic membrane.

F. Nose

41. Check for nasal obstruction by pressing on each ala nasi and asking the patient to breathe in.

42. Palpation of the frontal sinuses is done by putting pressure with your thumb at the medial edge of

the eyebrow. The pressure is directed superiorly and medially. Your thumb will be between the

eyebrow and the bridge of the nose. Frontal sinuses may be hypoplastic, and this may be the only

Updated SEP16

area in which the frontal sinuses could be palpated. Some individuals do have rather large frontal

sinuses which could be palpated an inch or greater above the eyebrow in the frontal bone region.

43. Palpation of maxillary sinus. This is done by putting pressure with your thumb over the medial

maxilla and directing pressure superiorly and centrally. Your thumb will be lateral to the

ipsilateral nares by 1 to 1 ½ inches.

44. Palpation of the ethmoid sinus is done by putting pressure between two fingers at the bridge of the

nose and the pressure is directed inferiorly and centrally.

45-46. The otoscope with a nasal speculum can be used to inspect the nasal vault. You should use the

largest ear speculum available; ideally you should use a nasal speculum. Again, be sure to

visualize the opening before and while advancing the speculum. Placing the finger on the tip of

the nose and lightly push on the tip and having the patient extend their neck will help facilitate the

exam.

G. Mouth

47. A light source should be used for inspection of the mouth.

48. A tongue blade should be used to inspect the lips, gums, buccal mucosa, and teeth. A tongue blade

should be used to help separate the lips from the gums and buccal mucosa, and the buccal mucosa

from the teeth. This should be done with minimal discomfort.

49. The tongue should be inspected as well as the posterior pharynx. The patient should be asked to

protrude their tongue so the posterior tongue can be visualized. Inspection of the posterior

pharynx can be facilitated by having the patient say, "Ah" and with use of a tongue blade.

50. The floor of the mouth should be inspected. This is one of the most common places to find cancer

in the oral cavity. Have the patient lift up their tongue and look under the tongue.

51. The patient should be asked to say "ah" to help elevate the palate.

52. The entire examination should be done with minimal discomfort.

Other: Also, in a patient who smokes or drinks, the tongue, buccal mucosa, gums, and floor of the

mouth should be palpated. Be sure to wear a glove.

H. Neck

53. The anterior neck should be inspected for symmetry.

54-55. The carotid arteries need to be palpated bilaterally. This is done by palpating each carotid artery

individually (and not simultaneously) in the lower neck. Simultaneous palpation of both carotids

may result in bradycardia and syncope. You palpate in the lower neck to avoid palpating the

carotid sinus which could result in stimulation of the vagus nerve and result in bradycardia (a slow

heart rate). The carotids can be palpated superiorly one at a time as well as inferiorly. You may

use your fingers or thumbs to palpate.

56-57. You should auscultate the carotid arteries in both the inferior and superior regions. It is easiest to

do this with the bell of the stethoscope. However, the carotid arteries can be auscultated with the

bell or the diaphragm. The reason for auscultating superiorly as well as inferiorly is to hear any

bruits secondary to stenosis of the more distal part of the carotid artery.

58-61. Palpation of the thyroid can be done from in front of or behind the patient. The posterior approach

is preferred. The chin is slightly extended and hands should be in their proper position, which is

below the cricoid cartilage. Cricoid cartilage is found by finding the Adam's apple and then going

inferiorly, there is a hard cartilage which is the cricoid cartilage and just below that is the cricoid

membrane. Just below the cricoid membrane should be the isthmus of the thyroid. The isthmus is

palpated by having your fingers of both hands almost touch in the midline just below the cricoid

membrane and asking the patient to swallow. Then you need to palpate the lobes of the thyroid

gland which runs superior and inferior to the isthmus lateral to the midline. You should move your

Updated SEP16

fingers away from the midline and then ask the patient to swallow. Swallowing should cause the

isthmus and the lobes of the thyroid gland to move superiorly. This examination can be facilitated

by having the patient drink water through a straw and hold the water in their mouth and then

swallow on command by the examiner. It is difficult for many patients to repeatedly swallow

without having anything in their mouth.

I. Lymph Nodes--Head and Neck

62-71. There are 10 lymph node groups. Lymph nodes should be palpated with the finger pads in a rotary

fashion. When the examiner is palpating lymph nodes, the examiner should always make note of

the size of the lymph nodes, whether they are hard, rubbery, or soft, and whether they are tender or

non-tender.

62. Periauricular are located in front of the ear.

63. Posterior auricular are behind the ear.

64. Occipital are at the base of the skull.

65. Tonsillar are just inferior to the angle of the jaw.

66. Submandibular are just inferior to the mid-jaw.

67. Submental are under the chin.

68. Posterior cervical are along the trapezius muscle.

69. Superficial cervical are on the top of the sternomastoid muscle.

70. Deep cervical are deep in the sternomastoid muscle.

71. Supraclavicular are in the supraclavicular fossa.

.

J. Anterior Chest

--Anterior Chest (lying or sitting) The anterior chest should be examined with the patient lying or sitting

(or at 30 - 60). Often times the posterior chest is examined first and is begun after examination

of the thyroid while standing behind the patient.

72. Inspection of trachea for midline position. This may be noted during neck exam but should be

recorded as part of lung examination.

73. Inspection: there should always be adequate exposure. You are looking for symmetry, scars, and

it is also a good time to inspect the skin on the back for any lesions such as skin cancer.

74-75. Palpation: Palpation for tactile fremitus is done using the bony part of the hand (ulnar aspect of

the palm or the ball of the hand, just distal to the wrist) and asking the patient to say "ninety-nine".

You are feeling for vibrations. You alternate from side to side, so you can compare each side and

you can compare each side by doing both sides at the same time using the left and right hand.

76-78. Percussion: Anterior chest

Should be percussed starting above the clavicles and alternating from side to side. Again, this part

of the examination is done comparing the left and right sides. The examiner's non-dominant hand

is placed between two ribs overlying lung tissue with the majority of the pressure exerted at the

DIP joint. The tone elicited by percussion is obtained by striking your second or third digit at a

90-degree angle from your dominant hand to the DIP joint over the non-dominant hand. The

examiner's wrist should be fairly limp so that once it strikes the DIP joint it will freely bounce off

and not deaden the sound. It is very important that this is accomplished by striking the DIP at a

right angle. The examiner may want to strike the DIP joint two or three times in each location.

Realize that over the anterior chest the left lower anterior chest will have dullness to percussion

because of the heart. The examiner is listening for good tone which is bilaterally symmetrical.

79-83. Auscultation: The stethoscope is placed in the ears correctly and this part of the examination is

also done comparing right and left sides. The examiner should ask the patient to take slow, deep

breaths with their mouth open, and the examiner needs to listen throughout the respiratory cycle.

Updated SEP16

The examiner should listen above the clavicle on both sides and alternate from side to side moving

inferiorly. The examiner should listen in 3-4 areas on each side of the anterior chest.

K. --Posterior Chest

84. The examiner often does the posterior chest before the anterior chest. Inspection needs to be

adequate. Again, the examiner is looking for scars, any skin lesions, and symmetry.

85-87. Palpation: There are two parts to palpation of the posterior chest, including checking for bilateral

movement of the chest wall, and tactile fremitus. Tactile fremitus was described above under

Anterior Chest; again, you alternate from side to side. Movement of the chest wall requires the

examiner to place both hands on the lower part of the chest laterally, (not below the chest) firmly

placing their fingers on the patient's lateral chest and then putting pressure with the fingers and

then the hands before trying to touch the thumbs together off the chest wall. Once the examiner's

hands are as close together as they can get, place the

thumbs on the chest wall and ask the patient to take a deep breath. As the chest expands, the

examiner's thumbs will move apart. If the examiner does not have a firm hold of the chest wall on

both sides, there will not be much space created between the thumbs with full inhalation or not

much space created between the thumbs with full inhalation or not much movement of the hands

as the chest wall expands into the loose area between the examiner's hands.

88-91. Percussion: Percussion of the posterior chest is similar to the anterior chest. One comment should

be made regarding placement of fingers. When the hands are placed on the chest wall in the same

direction as the ribs, meaning if the spine runs north-south on the east side of the chest, your

fingers are running northwest to southeast and on the west side of the chest they are running

northeast to southwest. Percussion of the diaphragms is done bilaterally. During tidal breathing

(normal breathing) you percuss from mid-lung or the lower 1/3 inferiorly. You note the point

where the tone changes from tympanic to dull. This is the position of the diaphragm during tidal

breathing (point A). Ask the patient to take a deep breath. Start percussing from the point of

dullness inferiorly. When it becomes dull again then you are at the position of the diaphragms

during maximal inhalation (point B). The distance between point A and point B is the distance the

diaphragm moves between tidal breathing and full inspiration.

92-96. Auscultation: Auscultation of the posterior chest is similar to the anterior chest.

97. Arms should be crossed for tactile fremitus, percussion and auscultation. When palpating for

tactile fremitus, percussing, and auscultating in the upper- to mid-posterior chest, the patient

should be instructed to cross their arms so as to pull apart the scapula and offer more of the

posterior lung fields for examination.

Lateral Chest

98-99. Percussion and auscultation of lateral lung fields should be done as part of the anterior or posterior

chest or separately. The same technique should be used as for percussing and auscultating the

anterior and posterior chest.

100. The correct order for examination of the chest should be inspection, then palpation or percussion in

either order, and finally auscultation.

101. The stethoscope should be placed in the examiner's ears correctly. The ear canals are directed

anteriorly and if the stethoscope is placed incorrectly sound will not be transmitted as well from

the chest to the examiner's tympanic membrane.

102. Percussion over costovertebral angle: The examiner places the non-dominant hand over the

inferior rib cage posteriorly with palm against the chest, makes a fist with the dominant hand and

strikes with the ulnar aspect of the fist against the dorsal of their hand. Direct percussion is also

acceptable. The examiner will strike the same area with the ulnar aspect of their fist. This is done

Updated SEP16

to detect inflammation around the kidney often seen with pyelonephritis. If there is inflammation,

this maneuver will elicit marked pain.

Other: If there is any asymmetry by palpation for tactile fremitus or percussion of lung fields, or if

respiratory crackles or rhonchii are heard, the examiner should then proceed with other procedures

to possibly detect consolidation of the lung. These maneuvers may include egophony, whispered

pectroliloquy, and vocal fremitus.

BREAST--FEMALE

--Inspection

Inspection of the female breast is done to help direct palpation and provides the examiner an

opportunity to inspect the skin of the female patient for abnormalities such as scars, or skin lesions.

This is the only time that both breasts should be exposed during the examination of the female

patient. This part of the examination

should only take 10-15 seconds. The patient should be instructed to have arms at their side, and the

examiner should compare both sides, looking for symmetry of the shape of the breasts, any nipple

discharge, fissures, excoriation, nipple inversion, edema or asymetric venous engorgement,

dimpling or flattening of the skin. Then the patient should be instructed to place their hands on

their hips and push in at their hips. Next the patient should be instructed to clasp their hands behind

their head. These last two maneuvers are done to give the examiner a different "view" of the

breasts. Oftentimes there may be an underlying lesion which may cause asymmetry on inspection

with one maneuver and not another.

For the patient with large, pendulous breasts, the breasts in all three of the above positions may not

look any different. In this case, another position for inspection would be to support the patient's

arms and have them lean forward while looking at the superior aspects of the breasts. With this

maneuver, the breasts are suspended by gravity.

-Palpation

The patient should be lying down with her ipsilateral hand above and under her head. To facilitate

the examination, a folded or rolled-up sheet or towel should be placed under the ipsilateral

shoulder. There should be adequate exposure of the breast which the examiner is palpating. The

examiner should only expose this breast and not the contralateral side. The examiner should

palpate with the finger pads on two or three fingers in a rotary fashion. The examiner should start

at the nipple and palpate in a circular fashion in spirals around the breast. The spirals will

progressively get larger. The examiner must make sure the entire breast is palpated and that the

circles created by palpation is accomplished in a spiral fashion should overlap so that all the

underlying breast tissue is palpated. The upper outer quadrant should be palpated very thoroughly

for two reasons. Proportionally, breast cancer occurs with greater frequency in the upper outer

quadrant, and the shape of the breast is like a teardrop with the tail extending from the upper outer

quadrant up toward the axillae. The examiner should palpate the areola and nipple. Nipple

compression should be done by using the second digits on both fingers starting at the areolar edge

and pushing downward medially and then upward (milking the nipple). The color of any discharge

should be noted. The patient should be instructed on breast self-examination during the breast

examination.

Breast - Male

The male breast should be inspected in a similar fashion as the female breast. Palpation of all four

quadrants of the breast should occur. Also, the areolae and nipples should be palpated.

Updated SEP16

Axillary Nodes

There are five axillary nodes that should be palpated. These lymph node groups are the central

(deep in the midline of the axillae), the humeral (lateral along the arm), subscapular (along the

posterior axillary fold), pectoral (along anterior axillary fold), and infraclavicular (below the

clavicle).

When palpating the central, humeral, subscapular, and pectoral group with the patient sitting,

support their right arm with your right arm (their left arm with your left arm) and use the finger

pads of your other hand to palpate. For the central

group you will place your palm in the patient's axillae, have them relax while you are supporting

their arm, and firmly press or move your fingers superiorly. If you are not causing some

discomfort, you are not high enough in the axillae. In a rotary fashion palpate with your finger

pads moving inferiorly. For the humeral group, you will turn the palmar surface of your hand

away from the patient and

press it against the humerus, then have the patient relax their arm and drop it toward their side and

then again move your fingers superiorly. Again, if you are not causing some discomfort, you are

not up high enough. Palpate in a rotary fashion using your finger pads moving down the humerus.

For the pectoral and subscapular groups, it is best to have the arm away from the chest wall; this

will help to better define the axillary folds , the landmarks to be used for this part of the

examination . In a rotary fashion, palpate medially along the axillary folds. For the infraclavicular

group, it is best to palpate superior from the clavicle down to where you were palpating breast

tissue, again in a rotary fashion with the finger pads. Landmarks that can be used are the triangular

area defined by the anterior axillary line, the clavicle and the line that runs from the junction of the

clavicle and sternum through the nipple.

The axillary lymph nodes can be palpated with the patient lying down. The examination should be

done in a similar fashion with your hand against the chest wall or against the humerus; the patient's

arm should be relaxed and placed toward their side. Again, the patient's arm will be away from the

chest wall to help define the axillary folds for the subscapular and pectoral groups.

L. Cardiac

103-104. Inspection of jugular venous pressure should be done with the patient lying with their head tilted

to the left side. The patient should be elevated to the point where jugular venous distention is seen

in the mid-neck. In a patient with a markedly elevated jugular venous distention, they may

actually need to be sitting upright, or in a patient with a low-normal jugular venous pressure this

may need to be at 0o to see the distention in the mid-neck.

105. The rest of the cardiac examination, including inspection, palpation and auscultation should be

done with the patient in a supine position at 30o. The exam should not be done with the patient

sitting or lying flat.

106. Inspection of all four cardiac areas should be done, looking for abnormal impulses and the point of

maximal impulse. You will look at the right and left second intercostal space, left lower sternal

border, and in the fifth intercostal space in the mid-clavicular line. If the apical impulse is

displaced, it may be more lateral and inferior to the 5th intercostal space in the midclavicular line.

107-110. Palpation of the aortic area (right second intercostal space), palpation of the pulmonic area (left

second intercostal space), palpation of the right ventricular area (left lower sternal border), and

palpation of the mitral area (about the fifth intercostal space in the mid-clavicular line), all should

be done with the finger pads (not finger tips) placed lightly over these areas.

111. If the apical impulse is not palpable with the patient lying flat, the patient should be rolled over

into the left lateral decubitus position and supported with the examiner's non-dominant arm, and

Updated SEP16

palpation of the apical area performed with the dominant hand. Realize that if the apical impulse

is palpated in this position and it is lateral to the mid-clavicular line, it may not necessarily indicate

left

ventricular hypertrophy because the left lateral decubitus position, may displace the heart laterally.

112. Palpation of the heart is done with the finger pads of two or three fingers.

--Ausculation with Diaphragm

113-116. The diaphragm of the stethoscope is used to listen to medium- to high-pitched sounds. You

should auscultate with the diaphragm over the aortic area (right second intercostal space), over the

pulmonic area (left second intercostal space), the tricuspid area (left lower sternal border), and the

mitral area (apical area--about fifth intercostal space in the mid-clavicular line). You should listen

through several heartbeats in each area. You should also listen in the third and fourth left

intercostal spaces (not on checklist).

117. At some point you should auscultate with the diaphragm at the left lower sternal border with the

patient sitting and fully exhaled. This is the optimal position to listen for aortic insufficiency.

--Auscultation with Bell

118-121. The bell of the stethoscope is used to hear low-pitched sounds, including right-sided S3's and

S4's, left-sided S3's, S4's, mitral stenosis, and Korotkoff sounds. You should listen with the bell of

the stethoscope in the tricuspid area (left lower sternal border) for right-sided S3's and S4's and in

the mitral area for left-sided S3's, S4's and mitral stenosis. For the examiner to optimally hear

mitral stenosis, the patient should be placed in the left lateral decubitus position and the examiner

should listen with the bell of the stethoscope over the mitral area.

Listening to the patient in the left lateral decubitus position will increase the intensity of all sounds

from the apical area, including left-sided S3's and S4's, mitral stenosis, mitral regurgitation, S1

(closure of the mitral valve), and an opening snap.

When using the bell of the stethoscope, it should be applied to the chest wall with only slight

pressure. Heavy pressure will actually cause the bell to function as a diaphragm because the skin

will be pulled taut and the skin over the bell will in essence become a diaphragm, and you will not

hear low-pitched sounds as well as if the bell is just lightly applied.

M. Abdomen

122. There should be adequate exposure of the abdomen for proper inspection. The patient should be

exposed from the inferior chest to the anterior iliac spines bilaterally.

123. Auscultation for bowel sounds with the diaphragm. You should listen for at least 10-15 seconds

and note the pitch and frequency of bowel sounds. If you do not hear any bowel sounds, you

should listen for a full two minutes before you can state that the patient does not have any bowel

sounds. Bowel sounds should occur from every other second to every 12 seconds.

124-126. Auscultation for bruits should be done with the bell. Listen for an aortic bruit in the epigastrum,

in both upper quadrants for renal bruits and below the umbilicus on both sides for the iliac arteries

(auscultation of both inguinal areas for femoral bruits can be done now and recorded as part of

peripheral vascular system)

127-128. Percussion: the left and right abdomen should be percussed above and below the umbilicus.

Most examiners will percuss 8 or more areas.

129. Percussion of liver span: in the right mid-clavicular line start percussing in an area of tympany

below the umbilicus. Percuss upward until you find the lower border of the liver noted when your

percussion note becomes dull. Next locate the upper border of liver dullness by beginning

percussion above the liver in area of resonance over the lungs. Percuss downward in the

Updated SEP16

midclavicular line until your percussion note becomes dull. This is the upper border of the liver.

Note the distance between the lower border of the liver and the upper border. This is your liver

span. Normally in adults it is 6-12 cm when done in the midclavicular line.

130-131. Palpation: For palpation of the abdomen, the patient should be relaxed, comfortable, with arms

down to their side. To avoid guarding or to make it easier to palpate the abdomen, the patient can

have hips and knees flexed while resting their feet on the table. If the patient has a particular

complaint, for example pain in the left lower quadrant, that should be the last area you palpate.

Palpation should always begin with lightly palpating in all four quadrants; (minimally acceptable

is palpation in four areas), generally you will palpate about nine areas in a systematic fashion. For

instance, right upper quadrant, mid-epigastric area, left upper quadrant, mid-left quadrant, left

lower quadrant, suprapubic area, right lower quadrant, right mid-abdomen, and periumbilical area.

You will proceed to deeply palpate the same areas. You may actually use both hands with deep

palpating.

132-133. Palpation of the liver: the examiner's left hand should be placed under the

right lower rib cage, and the right hand placed several centimeters below where you percussed the

lower edge of the liver. You apply pressure with your left hand against the patient's lower right rib

cage. You should ask the patient to breathe in and out deeply, and as the patient breathes in your

fingertips of the right hand should be maximally exerting pressure superiorly and deep into the

abdomen. You are trying to feel the liver edge come down and meet your fingers as the patient is

taking a deep breath. If you do not feel the liver edge, then as the patient exhales you will move

your fingers 1-2 centimeters superiorly and begin the same process again. It is acceptable during

palpation of the liver to use both hands. You use the fingers of one hand to palpate and the other

hand is used to apply pressure to the dorsum of the other hand. Thus the hand you are using to

palpate does not need to be used to apply pressure.

134-136 Palpation of the spleen: You will put your left hand over the patient and underneath the left

lower rib cage, placing your right hand on the patient's left lower abdomen, just left (patient’s left)

of the umbilicus, pointing toward the left

axillae. Have the patient breathe in and out deeply, and as the patient breathes in deeply you will

maximally put pressure with your fingers superiorly and laterally and deep to the abdomen.

Again, the spleen will descend with deep inspiration and you are trying to feel the spleen tip. With

each breath your line of palpation will move along an oblique line from just left of the umbilicus

toward the anterior axillary line through the nipple. If the spleen is not palpated, you will start the

same process again, 1-2 centimeters superior to where your fingers were before. You will

continue this process until you are palpating underneath the left anterior lower costal margin or

you palpate the spleen. If the spleen is not palpated in this position, the patient should be

positioned in the right lateral decubitus position, repeating the above process.

It should be noted the spleen can also be percussed. A normal spleen will create dullness to

percussion in the mid-axillary line over the 7th, 8th, and 9th ribs. If you get dullness to percussion

in the anterior axillary line over the same region, this would indicate an enlarged spleen. Realize

that it is difficult to tell the difference between dullness of the posterior flank from the spleen.

137. Palpation for abdominal aorta: Your aorta runs parallel to the spine, just left

of the mid-line. You should press firmly and deeply with the fingertips of one hand right of the

mid-line feeling for aortic pulsation. If you do not feel it, then move your fingers closer to the

mid-line and proceed in this fashion until you feel the pulsation from the "right side" of the aorta.

Then you will do the same thing beginning in the mid-left abdomen and feeling for the pulsation.

If pulsation is not felt, you will move your fingers closer toward the spine, again pushing deeply.

You will move your fingers each time about ½ to 1 cm closer to the mid-line until you feel the

Updated SEP16

pulsation from the "left side" of the aorta. A normal adult aorta should be between 2 and 3 cm

wide. Realize in patients that are very thin, it is very easy to palpate their aorta. In patients that

are obese or have voluntary guarding, it may be very difficult, even if the aorta is enlarged.

138. During palpation, you should be inspecting the patient's face, looking for any

indication that the patient may be feeling discomfort or pain during palpatation

139. There is a correct order for examining the abdomen, and this order is:

inspection, auscultation, percussion, and palpation. Some students or residents ask why you have

to percuss before palpating. The main reason for this is that if you percuss the liver and/or spleen,

you know the lower edge of these organs and will know approximately where you need to start

palpating otherwise the examiner may start palpating over the enlarged organ.

140. The entire abdominal examination should be done with the patient supine at 0.

N. Neurologic Examination

General comment: When doing the screening neurologic examination, you will only do certain

maneuvers proximally and distally, such as testing motor strength. Distal will refer to the ankles and

wrists and distal to the ankles and wrists and proximal will refer to proximal to knees and elbows.

The neurological exam often includes a brief mental status exam much of which may be observed during

the history. But in documenting your exam and in interviewing or evaluating your patient you should

make note of:

141. Level of consciousness: alert is awake and aware of self and environment, lethargy is drowsy but

responsive when spoken to in a loud voice, obtundation is requiring to be shaken to respond and

confused, stuporresponds to painful stimuli, verbal responses slow or absent, lapses into

unresponsiveness when stimulus stops, coma is unarousable

142. Orientation: Awareness of personal identity, place and time requires both memory and attention to

respond properly

143. Language: Observe the patient’s fluency, of speech which refers to the rate, flow, melody of

speech, content and use of words. Observe their comprehension and ability to follow simple

commands. Usually by this time you have given the patient instructions and have observed their

ability to comprehend but if not start with a one stage command such as to point to their nose and

then ask a two stage command like point to your nose and then your knee. Evaluate repetition by

asking the patients to repeat a phrase such as “No ifs ands or buts”

144. Articulation: Observe for dysarthria which is problem with the motor control needed to form

words. Words may be nasal, slurred or indistinct. Causes include motor lesions of the peripheral

or central nervous system, parkinsonism and cerebellar disease.

If problems are identified you should move on to a more complete mental status examination.

--Cranial nerves

145-158. Cranial nerves II, III, IV, VI, VIII, IX, and X have previously been described under Eyes, Ears,

and Mouth.

145. Cranial nerve I: Sense of smell can be formally tested or it is perfectly acceptable to inquire

regarding the patient's ability to smell. If you test smell, each side of the nose should be tested

separately. If the patient can identify by sight the object you are asking them to smell, you need to

have them close their eyes.

146. Cranial nerve II: See eye exam for details, test visual acuity, visual fields, funduscopic exam,

papillary response

147. Cranial Nerve III, IV, VI : Se eye exam inspect for ptosis, extraocular motoion and convergenece

and accommodation

148-.149 Cranial nerve V: Cranial nerve V has both motor function and sensory function. There are

three divisions to the sensory function: the ophthalmic, maxillary, and mandibular divisions. You

Updated SEP16

need to check all three divisions bilaterally. You should test fine touch. The motor function of V

is tested, while having the patient bite down with their teeth, and palpating the masseter and

temporal muscles. Both side should be palpated simultaneously and should feel the same. The

temporalis muscle is posterior and slightly superior to the temple. The Masseter muscle is just

anterior and superior to the angle of the jaw and anterior and inferior from the ear lobe.

Corneal reflex involves a sensory or afferent limb (cranial nerve V) and a motor or efferent limb

(cranial nerve VII). . This is not a required component of the exam in an awake and responsive

patient.

150-152. Cranial nerve VII: Cranial nerve VII is primarily motor-controlling facial movements. Ask the

patient to raise their eyebrows, wrinkle their forehead, close their eyes tightly, smile and puff up

their cheeks. You should note symmetry of these movements.

153. Cranial Nerve VIII: See ear exam, should test auditory acuity

154 Cranial nerves IX and X: Gag reflex. The patient should be told prior to your gagging them what

you are about to do. A tongue blade can be used and is touched to either the posterior aspect of the

tongue on one side or to the posterior pharynx.

155-156. Cranial nerve XI: Patient should be instructed to shrug their shoulders, raise their shoulders

superiorly parallel to their body against resistance (against the examiner's hands which are placed

on the patient's shoulders), and also turn their head against resistance (against the examiner's

hand). You should be comparing the left side and the right side.

157-158. Cranial nerve XII: The patient should be instructed to stick their tongue out and move their

tongue from side to side. You can also ask the patient to put their tongue in their mouth and push

it against their buccal mucosa, and you can feel the strength of the tongue through the outside of

the cheek with your fingers. You will then compare the left and right sides.

--Motor

159-164. You need to check proximal and distal upper extremities bilaterally and proximal and distal

lower extremities bilaterally. A substitute for proximal lower extremity would be hopping in place

as part of the cerebellar examination, and a substitute for distal lower extremity strength would be

walking on toes as part of the cerebellar examination.

Motor strength should be graded on a 0-to-5 scale:

0 no response

1 contraction of the muscle

2 active movement of the body part with elimination of gravity/

patient lying in bed moving their arm in the plane of the bed

3 active movement against gravity but not against resistance

4 active movement against gravity and some resistance

5 active movement against full resistance without obvious fatigue

Examiners often indicate "+" or "-" with the above numbers.

Begin by observing the muscles for hypertrophy, atrophy, fasciculations, tremor, dystonia or

myclonus. Note tone looking for rigidity or spasticity or flaccidity. To check tone note the

muscles resistance to passive stretch. Try to relax the patient. Take one hand in yours and with

the other holding the elbow flex and extend the patient’s fingers, wrist ,elbow and put the shoulder

through a passive range of motion on both sides and note resistance to movement. Check for

pronator drift by asking the patient to extend both arms forward with palms up for 20-30 seconds.

Then tap the arms briskly downward, normally the arms should return smoothly to the horizontal

position.

--Sensory

Updated SEP16

165-173. You must check position sense or vibratory sense (sensations located in the posterior columns),

and you must also check pin-prick or temperature, which are located in the spinothalamic tract. It

should be noted that neurofibers carrying the sensation of touch take one of two pathways,

including fine touch in the posterior column (discriminating) and crude touch in the anterior

spinothalamic tract (non-discriminating--without accurate localization).

165-168. Position sense and vibratory sense must be done correctly. For position sense to

be done accurately, you check position sense of upper extremities and lower

extremities bilaterally using a digit. You hold this digit from the sides and not

on the palmar and dorsal surfaces (plantar and dorsal surfaces). If you hold the

toe from the plantar and dorsal surfaces, rather than from the sides or hold the

finger from palmar and dorsal surfaces, rather than from the sides, the patient will

be able to exert pressure downward or upward and know which direction you are

holding the digit. You should hold the digit from the side and have the

patient close their eyes. Then you will move the digit upward, downward, and in the middle and

ask the patient where the toe or finger is in relation to neutral. You need to do a digit of an upper

extremity and lower extremity bilaterally. A substitute for position sense for lower extremity is the

Romberg with eyes closed (checks cerebellar function and position sense with eyes closed). For

position sense distal upper extremity a substitute is doing the finger-to-nose with the examiner's

finger stationery and asking patient to close their eyes. If position sense is not intact distally move

proximally until it is.

Vibratory sense: You must use a tuning fork of 128 Hz. You need to check vibratory sense

quantitatively rather than just qualitatively. You should check vibratory sense on a finger

(preferably over the DIP, PIP is acceptable, MCP is too proximal) and a toe bilaterally. You

should hit the tuning fork on the examining table or on the floor, and while holding it at the base

apply it over a distal joint of a finger or toe. You should put pressure on the toe with the base of

the tuning fork. You can ask the patient to describe how it feels or do the same maneuver over

their forehead and chest so they will know what it should feel like. You should ask the patient to

tell you when the vibratory feeling stops vibrating. By holding the base of the tuning fork, you can

tell when the vibration almost stops. When applying the fork to the patient's distal extremity you

will still barely be able to feel the vibration when they will say it stops. The examiner should not

suddenly stop the tuning fork from vibrating (qualitative). Screening for loss of vibratory sense

quantitatively may alert you to peripheral neuropathy from such causes as diabetes or alcoholism.

If vibratory sense is lost distally move proximally until it is felt.

169-172. Pin-prick and temperature: these need to be done in the distal and proximal upper extremities

and distal and proximal lower extremities bilaterally. It is best to either use a safety pin which you

will clean off with alcohol and then discard the safety pin (it should never be used on two

patients), or break a cotton Q-tip or tongue blade and use a sharp piece of wood to check for sharp

sensation. With pin-prick you should lightly poke the sharp object into the skin distally and

compare left and right hands and feet. You should then also test each extremity distally and

proximally and ask the patient whether it feels the same.

173. Discrimination should be tested with either stereognosis bilaterally or graphesthesia bilaterally.

Stereognosis is identifying objects such as coins (or any other common object) and asking the

patient what coin is placed in their hand and asking them to place the "head" of the coin face up.

Graphesthesia is writing numbers in the patient's hand and asking them to identify them. Both

stereognosis and graphesthesia should be done with the patient's eyes closed.

Updated SEP16

--Cerebellar

174. Finger-to-nose: The patient should be instructed to touch the tip of their nose with the tip of the

finger on their right hand and then touch the tip of your finger which should be held 12 inches

away from the patient. Once the patient has touched your finger, ask them to repeat the movement

and you move your finger. You should move your finger to at least all four quadrants in front of

the patient. Once this is done, you should ask the patient to repeat the same movements with their

other hand. Remember, once you have checked the four quadrants, you can hold your fingers

stationery in front of the patient and ask them to touch your finger two more times, then close their

eyes and continue the process, and this will substitute for position sense of the upper extremity.

175. Heel-to-shin: Should be done with the patient in the supine position. The patient should be

instructed to put their heel of one leg on the shin of their contralateral leg and bring it up to their

knee. Then the process is repeated on the other side.

176-177. Rapid alternating movements need to be done in upper and lower extremities bilaterally. The

patient can be asked to put the palm of their hand on their thigh, turn it over, and pat the dorsum of

their hand on their thigh and rapidly repeat this motion, (the hand should be taken off their thigh

when doing the above and not just rolling it over) or they can be told to touch their thumb to their

little finger and then to the fourth digit, third digit, second digit, and then repeat this. They should

be told to do this as fast as they can. Any rapid and alternating movement is acceptable. They

should do each side independently. It is not acceptable to do both sides at the same time. They

should do the same thing with their lower extremities by tapping their foot against the floor or

against the examiner's hand. They should then repeat this with the other foot. Again, both feet

should not be done at the same time.

178. Romberg: The patient should be told to put their heels and toes together with their eyes open and

stand there for 5-10 seconds. They should be able to keep their balance. You may have the

patient's arms to their sides or out in front of them with their palms up or palms down. If you have

their arms outstretched with palms up, you may be able to detect an ulnar drift. Remember, their

hands may be at their sides. If you have the patient close their eyes in this procedure, you are also

checking position sense as well as cerebellar function. You may lightly tap the patient from the

side or from front and back to check their balance with their eyes open or closed. Remember, all

you have to do is have the patient stand with their toes and heels together, arms at their sides and

stand in one position for 5-10 seconds.

179-181. Part of the cerebellar function would include having the patient walk putting one heel in front of

their toes and then repeating this motion with the other foot and walking in this fashion. Also, you

should check their gait with them walking on their toes, and then walking on their heels. Realize

when they are walking on their toes that this could also check motor function distally.

--Reflexes

182-185. Reflexes should be checked bilaterally, and you should be comparing the reflex elicited on the

left and right sides. The patient's extremity from which the reflex is being elicited should be

relaxed. If it is a sub-optimal reflex, you should distract the patient. This could be done, for

instance, when doing the patellar reflex by having the patient squeeze their hands together.

182. Biceps reflex: The patient's arm should be in their lap with the elbow at 90 degrees, and the palm

should be turned toward the floor. As noted above, the arm should be relaxed. The examiner

should take the thumb of their non-dominant hand and place it over the biceps tendon of the

patient. The examiner should hit their thumb with the pointed end of the reflex hammer. It is

important that the reflex hammer is held very loosely, and striking motion should be done with a

limp wrist. To hold the reflex hammer loosely, you can hold it loosely between the 2nd digit’s PIP

Updated SEP16

and MCP (along the radial/palmar aspect). If you repeatedly hit the biceps tendon, be sure you

wait at least 5 seconds between striking it again to give the muscle time to repolarize; if you

continue to hit it with a short interval in between you can extinguish the reflex. You will compare

the left and right sides.

183. Triceps reflex: This can be checked by having the patient's arm in a similar position for the biceps

reflex and striking the tendon. A second acceptable position is abduct the shoulder to 90 degrees,

have the patient flex the elbow at 90 degrees so that the forearm is hanging toward the ground

parallel to body. The examiner will need to support the arm in this position with the examiner's

non-dominant hand and have the patient relax. You can palpate the triceps tendon with one finger

of your dominant hand and strike this tendon with the pointed end of the reflex hammer. You will

repeat this on the other side and compare the left and right sides.

184. Brachioradialis reflex: This reflex is elicited by having the patient's arm in their lap with the ulnar

aspect of their palm on their thigh turned 30-40 (radial aspect off the thigh). You will strike the

radial aspect of the forearm in the distal one-third over the radius (1-2 inches above the wrist) with

either end of the reflex hammer (using the long end may be easier on this reflex). You should look

for flexion and supination of the forearm. You compare the left and right brachioradialis reflexes.

185. Patellar reflex: This reflex is elicited by striking the patellar tendon, which is located just distal to

the patella, with the pointed end of the reflex hammer. The knee should be flexed at 90 degrees,

and the patient should be in a relaxed position. It is advisable not to stand in front of the patient

when you are doing this, because if they have a fairly active reflex you may get kicked. Again,

this should be done bilaterally, comparing the left and right sides.

186. Achilles reflex: This reflex should be checked with the patient sitting, knee and hips flexed at 90°

and the examiner should take their non-dominant hand and apply a mild amount of pressure on the

distal foot, dorsiflexing the patient's foot. You should strike the Achilles tendon with the reflex

hammer (either end); a normal response would be for the patient's foot to plantar flex. Again, the

knee should be flexed at 90 degrees. If the leg is extended, the reflex may be diminished. The

reflex should be elicited bilaterally, comparing the left and right sides.

Reflexes are graded on a 0-to-4 scale, 0 being "no response", 2 being "normal response", 3 being

"hyperactive but considered normal". A 4-plus response is hyperactive and may indicate disease.

There is often clonus associated with a reflex graded a 4. You should be familiar with the nerve

roots tested by each reflex--biceps reflex C-5, C-6; brachioradialis reflex C-5, C-6; triceps reflex

C-6, C-7; patellar reflex L-2, L-3, L-4; and ankle reflex L-5, S-1, S-2.

It should be noted reflexes can also be tested with the patient lying flat in bed and the examiner

moving the patient's arms or legs to approximate the above-mentioned positions.

187. Plantar response: This is done to detect upper motor neuron disease. The knee should be extended

to 0 (and ideally the hip should be extended to 0). This is done by taking an object such as the

metal end of the reflex hammer and starting at the lateral aspect of the heel on the bottom of the

foot dragging with a fair amount of pressure proximally along the lateral aspect of the foot to the

ball of the foot, proximal to the 5th toe, then making an arc and bringing it just proximal to the

great toe along the ball of the foot. A normal response would be for the toes to flex. An abnormal

response or Babinski response is for the great toe to dorsiflex and for the toes to fan out.

O. Peripheral Vascular Examination

188-200. General comment: It is acceptable to palpate larger arteries such as the carotid, brachial or

femoral pulses, with your thumb. Peripheral pulses such as the ulnar, radial, dorsalis pedis, and

posterior tibial pulses should be palpated with the finger pads of one or two fingers. All pulses

should be palpated bilaterally and compared.

Updated SEP16

188-189. Radial pulses are palpated bilaterally and also should be palpated simultaneously. The radial

pulse should be palpated with the patient's wrist at 0 (neutral position). You should palpate on the

radial side of the flexor surface of the wrist with the fingertips of one or two fingers lightly. If no

pulse is felt, you may apply more pressure. The pulse is most easily palpated between the radial

styloid process and the most lateral flexor tendon on the radial side of the forearm about one to two

inches proximal to the distal radius.

190. Palpation of the ulnar pulses bilaterally: The ulnar pulse is not as easily palpable as the radial

pulse and is located just lateral to the first tendon on the ulnar side of the forearm near the wrist

about one to two inches proximal to the distal ulnar.

191. Palpation of the brachial pulses bilaterally: The brachial pulse is best palpated just medial to the

insertion of the biceps tendon or along the biceps groove.

192. Palpation of epitrochlear nodes bilaterally: The epitrochlear nodes are palpated in a similar

fashion as described previously (with the finger pads of two or three fingers moving in a rotary

fashion). The patient's elbow should be flexed at about 90 degrees. The epitrochlear nodes are

located 1-2 inches proximal to the medial epicondyle in the biceps groove.

193. Palpation of the femoral pulses bilaterally: The femoral artery should be palpated bilaterally. The

examiner should place pressure with the finger pads of two or three fingers just below the inguinal

ligament between the pubic symphysis and the anterior superior iliac spine.

194. Palpation for inguinal lymph nodes bilaterally: There are two lymph node groups: the horizontal

and vertical inguinal lymph nodes. The horizontal group is palpated along the inguinal ligament

near the femoral artery, and the vertical group is located near the femoral artery and the vein

inferior to the inguinal ligament and run the direction of the leg.

195. You should auscultate with the bell or diaphragm for femoral bruits over the femoral arteries.

196. Palpation of the popliteal pulses bilaterally: The popliteal pulse is palpated with the patient's knee

flexed at about 90 degrees with the leg relaxed. The patient should be lying supine with their heel

resting on the examination table and with the knee flexed. The examiner should place fingers of

both hands into the popliteal fossae and palpate deeply in the middle of the fossae. Both thumbs

may be placed on the anterior portion of the patella or distal thigh. The examiner should exert

pressure and keep increasing the amount of pressure until the pulse is palpable. This examination

can also be done with the patient in the prone position with the leg flexed at 90 degrees, the leg

supported by the examiner's arm or shoulder. The examiner's fingers or thumbs of both hands can

be placed deep in the fossae. Pressure is applied in the mid-line again, increasing the amount of

pressure until the pulse is palpable.

197. The lower extremities from mid-thigh distally should be examined. The examiner should note any

scars, skin lesions, changes in pigmentation, hair distribution, varicosities, and any erythema or

ulcers.

198. Palpation for pitting edema: This should be done bilaterally, either on the distal ankle medially or

on the dorsum of the foot. The examiner should exert a fair amount of pressure with their thumb

for at least 5 seconds over either one of the two described areas and then release your thumb. An

indentation will be left if there is any pitting edema. This can be best detected by visualization or

by running your fingers over the same area and feeling for any indentation in the skin. The second

method is more sensitive for detecting trace to 1+ pitting edema.

199. Palpation of posterior tibial pulses bilaterally: Posterior tibial pulses are located just behind the

medial malleolus of the ankle. It is best to have the patient's foot resting or relaxed.

200. The dorsalis pedis pulse should be palpated bilaterally. In most patients, the dorsalis pedis pulse is

palpated in the mid-foot between the first and second extensor tendons. In some individuals (about

10%) this pulse may be located more laterally. About 10% of patients do not have a dorsalis pedis

pulse.

Updated SEP16

Pulses are graded on a 0-to-4 scale, with 0 being nonpalpable, 2-3 being normal, and 4 being

bounding pulses.

P. Musculoskeletal Exam

Much of the musculoskeletal exam is included in the neurological exam. During muscle strength

testing joints can be observed for symmetry or abnormalities such as swelling, redness, or

deformity. During palpation warmth, tenderness and effusions need to be noted. Active range of

motion is generally acceptable for screening of joints if there are no complaints or joint

abnormalities on observation. Active range of motion involves the patient actively moving the

joint, and passive range of motion involves the examiner moving the joint. Active range of

motion should be done first. If complaints or limitations are encountered, then Passive range of

motion is performed. The student should check for symmetrical range of movement, and if the

range of motion is not symmetrical, or it is symmetrically decreased, the student should note the

degrees each joint moves.

Spine:

201-202.The examiner should inspect the cervical, thoracic, and lumbar spine along with Paraspinal

muscle. There should be adequate exposure. (Normal gait should be observed and this can be

done during the neurological exam).

203. Palpation of the cervical, thoracic, lumbar, sacral vertebrae, SI joint and Paraspinal muscles should

be done. This can be done by using fingertips of two fingers over the spine, in vertical fashion,

starting from C1 to the sacral spine.

204-207. Cervical spine: The examiner should either be behind the patient watching these motions or,

preferably the examination can be done from in front of the patient. The patient should be

instructed to fully flex and extend their neck. The patient should be instructed to tilt their head as

far to one side and then the other side for lateral movement, and then with their head in a stationary

position the patient should be directed to turn their head all the way to one side and then the other

to check rotary movement.

208-213. Lumbar spine: Again, this should be done with the examiner standing behind the patient. The

patient should be instructed to completely flex at the waist as far as they can easily with their knees

straight and then extend backwards in the same manner. The patient should be instructed to have

their feet no wider than their shoulders. With the patient in the neutral position, the patient is then

asked to tilt their shoulders laterally toward the floor, first one side and then the other. Then the

patient should be instructed to keep their legs and hips stationery, and the examiner should hold

the patient's hips and instruct the patient to turn their shoulders all the way around to one side and

then the other for rotary movement.

214-223. Shoulders: The examiner should inspect and palpate the shoulders before checking the range of

motions. The patient should begin with their arms down to their sides with their palms against

their hips. Have the patient raise the arms in front and then overhead to assess flexion. Raising

the arm(s) backward and upward will assess extension. Have the patient then raise their arms out

and to the side 90 degrees. This will test abduction. Raising the hands further over their head to

180 degrees in an arching motion measures the full abduction and arc. Moving the arm back to 90

degrees abduction and then across the front of the chest will assess adduction. For internal and

external rotation, the patient could have their arm at 90 degrees abduction and their elbow flexed

forward at 90 degrees with their palm facing the floor and fingers pointing forward. Then have the

Updated SEP16

patient rotate their arm upward to the ceiling for external rotation or rotate downward to the floor

for internal rotation. For Functional range, the patient should then be instructed to place their

hands behind their head/neck with their elbows out to the sides. This will test external rotation of

the shoulders. The patient should then be instructed to reach their hands behind the small of their

back and try to touch the opposite shoulder blade, which will check internal rotation of the

shoulders

224-232. Elbows: The examiner needs to inspect and palpate the elbow structures before assessing range

of motion. The examiner will have the patient fully flex and fully extend their forearms. With the

elbow held against the body and flexed at 90 degrees, have the patient turn the forearm so that the

palm is facing upwards towards the ceiling. This is supination. Then, also with the elbow flexed at

90 degrees, have the patient turn the palm downwards towards the floor. This is pronation.

233-243. Wrists and Hands: The wrists, hands and fingers will need to be inspected and palpated before

checking the range of motion. The examiner will have the patient fully flex and fully extend at the

wrist. With the wrist at 0 (neutral position) and the palm facing upward (supinated), the patient

will be instructed to deviate the wrists ulnar and radially. The examiner should palpate all of the

metacarpophalangeal (MCP) joints and palpate all of the interphalangeal joints…proximal

interphalangeal (PIP) and distal interphalangeal (DIP) joints. Then have the patient fully flex and

extend the fingers by making a tight fist and then fully opening it up. Abduction and adduction of

the fingers can be assessed by spreading the fingers out widely and then bringing them back

together. Assess thumb abduction (raise thumb straight up towards the ceiling from supinated

palm), adduction (back down towards side of hand), extension (taking thumb away laterally-

radially), flexion (taking thumb across the palm – ulnar) and opposition (cross thumb over to touch

pulp of little or other fingers) with the palm turned upward.

244-253. Hips: The examiner should inspect and palpate the hips before the examining the range of

motion. The examiner should feel for the iliac crest, anterior superior iliac spine and greater

trochanter. With the patient supine and knee flexed, the hip should be fully flexed (bent to the

chest). Extension (moving the leg backward at the hip) can be assessed with the patient prone.

Abduction is done with the patient supine and with the knee and hip at 0 degrees and moving the

leg outward, away from the body. Adduction is done with the knee and hip at 0 degrees, then

moving the leg back and across the midline. Stabilize the patient’s opposite hip by pressing down

on the opposite iliac crest during these movements. External and internal rotation is done with the

hip flexed to 90 degrees and knee flexed at 90 degrees. In this position with the patient supine, the

patient’s foot is moved medially toward the other leg for external rotation and laterally for internal

rotation. The rotation is done on the axis through the femur.

255-260. Knees: The examiner should inspect and palpate the knees before checking the range of motion.

The knee should be fully flexed with patient supine. Then the knee should be extended to 0

degrees and then check for any hyperextension (usually another 5-10 degrees) by asking the

patient to push on the hand placed under the knee.

261-269. Ankles and Feet: The examiner should inspect and palpate the ankles before checking the

range of motion. Ankles should be fully dorsi-flexed and plantar-flexed. Inversion and eversion

of the foot at the subtalar joint is accomplished by stabilizing the ankle in full dorsiflexion with

your non-dominant hand (by grasping the leg at the lateral and medial malleolus) and inverting and

everting the foot by the heel (turning the foot inward and outward). Supination and Pronation of

the forefoot at the (transverse) mid-tarsal joint is accomplished by stabilizing the ankle in full

Updated SEP16

dorsiflexion and the foot at the heel with your non-dominant hand. Having stabilized the ankle and

heel grasp the forefoot with your dominant hand, turn the forefoot inward for supination and

outward for pronation ( or ask the patient to move forefoot actively in those directions)

.

Feet: Palpation of the metatarsals and MTP and IP joints should be done by applying pressure

between your thumb and fingers over the metatarsals and all MTP & IP joints. Toes are also

flexed and extended.

Adapted from the work of Dr. Steven Haist University of Kentucky

and from Bates Guide to the Physical Exam

Techniques and Interpersonal Skills by Standardized Patient

STRONGLY STRONGLY

DISAGREE NEUTRAL AGREE

60% 70% 80% 90% 100%

Q. TECHNIQUE

1. The student or resident performed the examination

in a logical manner with smooth 1 2 3 4 5

transition from one region to another.

2. The student or resident explained various 1 2 3 4 5

procedures to the patient.

3. The student or resident did not use medical 1 2 3 4 5

jargon or, if so, an explanation of

the unfamiliar

terminology was given.

4. The student or resident minimized patient 1 2 3 4 5

movement and the number of patient

position changes.

5. The amount of movement and position 1 2 3 4 5

changes by the student was minimized

during the examination.

6. When the patient was supine, the 1 2 3 4 5

examination was done from the

patient's right side.

R.: INTERPERSONAL SKILLS

1. The student or resident was concerned with the 1 2 3 4 5

comfort and privacy of the patient

(including appropriate draping).

2. The student or resident demonstrated a 1 2 3 4 5

professional (verbal and nonverbal)

demeanor during the examination.

4. I was comfortable being examined by 1 2 3 4 5

Updated SEP16

this student or resident.

5. I would go to this student or resident as a physician 1 2 3 4 5

in the future.