Physical Examination (1) Place the base of the lightly vibrating tuning

fork on the mastoid bone

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