intro to clinical medicine physical exam checklist

Incorrect W/O Prompt & ND Incorrect W/ Prompt

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/ W/O Prompt Total W/ Prompt Total

ICM II Head to Toe Exam Checklist (Revised 01.13.14)

Please print names clearly.

Student SP Initials

Patient Sitting on Examination Table

W/O Prompt Not Done W/ Prompt

Correct Incorrect Correct Incorrect

1. Introduce self to patient and shake the patient's hand.

2. Wash hands before and at the end of the examination (soap and

water).

3. Student must stand on the right side of patient when appropriate for

PE maneuvers.

Vital Signs



4. Palpate radial pulse for at least 15 seconds.

5. Measure the respiratory rate for at least 15 seconds.

6. Place cuff snugly in correct anatomical location (position the "Artery"

marker on cuff over brachial artery).

7. Measure blood pressure in each arm, while holding arm at heart level

and using stethoscope correctly (position of ear buds).

Head



8. Palpate and observe scalp (fingertips must touch and examine the

scalp).

Nodes and Thyroid

(2-3 circular palpations must be done with three fingers of each hand over each node)

9. Palpate the preauricular lymph nodes.



10. Palpate posterior auricular lymph nodes.

11. Palpate occipital lymph nodes.

12. Palpate the tonsillar lymph nodes.

Checklist adapted with permission from The University of Chicago Pritzker School of Medicine


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Nodes and Thyroid continued (2-3 circular palpations must be done with three fingers of each hand over each node)

13. Palpate the submaxillary lymph nodes.



14. Palpate the submental lymph nodes.

15. Palpate the posterior cervical nodes (palpate in three spots behind the

sternomastoid muscle).

16. Palpate the supraclavicular nodes.

17. Palpate the anterior cervical nodes (palpate in three spots in front of the

sternomastoid muscle).

18. Ask the patient to swallow while you observe the thyroid gland.

19. Palpate the laryngeal cartilages (thyroid cartilage) to locate the

thyroid gland.

20. Palpate the thyroid gland twice: once while the patient is swallowing

and once without swallowing.

Eyes

21. Inspect each eye separately for the condition of the lid, cornea, and

conjunctiva (when holding the bottom lid ask patient to look up, when

holding top lid ask patient to look down). 22. Test visual acuity (cranial nerve II) in each eye separately with a pocket

visual screening chart held at the distance most comfortable for the patient

and asking patient to read smallest line possible. 23. Observe pupillary responses: the direct response and the indirect

response to light (consensual) in each eye. Lights must be dimmed.



24. Test the cranial nerves III, IV, and VI by asking the patient to look right, up

and down, and left, up and down in the shape of an 'H.' Instruct patient

not to move the head.

25. Check for convergence.

26. Test cranial nerve VII motor function by asking the patient to force

his/her eyelids closed against resistance (upper division).

27. Position your hands approximately 3 feet from the patient at the

same eye level. Test visual fields (four quadrants for each eye by finger

counting, each eye separately).

28. Position the patient for ophthalmoscopy at a height comfortable for you.

29. Hold ophthalmoscope at proper distance to visualize the posterior

structures of the eye.

30. Hold ophthalmoscope with right hand to look through scope with your

right eye when inspecting patient's right eye, and with left hand to look

through scope with your left eye when inspecting patient's left eye (Not

necessary with panoptic scope).


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Ears



31. Inspect the external ears (bend pinna to observe backside of ear)

bilaterally.

32. Examine each ear with the otoscope.

33. Conduct Rinne test with 512 tuning fork.

34. Conduct Weber test.

35. Test auditory acuity (cochlear nucleus of cranial nerve VIII) by whispering into each ear from two feet (or create a sound by rubbing your thumb and fingers together 10

cm from each ear, separately, and out of sight from the patient).

Nose and Sinuses

36. Test the openness of the nasal passages bilaterally. Instruct the patient

to close one nostril while sniffing through the other.



37. Inspect the nasal passages bilaterally using the otoscope.

38. Palpate firmly for frontal sinus tenderness above each eye.

39. Palpate firmly for maxillary sinus tenderness below each eye.

Mouth and Throat

40. Inspect the lips, gums, tongue, and teeth with the help of a tongue blade

and light.



41. Instruct the patient to breathe only through the mouth, to facilitate the

inspection of the posterior pharynx.

42. Inspect the posterior pharynx with a light.

43. Observe with penlight the elevation of the palate (cranial nerve IX and X)

after instructing the patient to say "ah."

44. Inspect the opening of Stensen's duct (parotid) and the submandibular

gland duct.

45. Test cranial nerve XII by asking the patient to stick out his/her tongue and

move it from side to side as you observe

46. Test cranial nerve V motor function by first positioning hands on masseter

muscles and then asking patient to bite down.

47. Test cranial nerve VII motor function by asking the patient to show the

teeth (lower division).

48. Test cranial nerve XI by asking the patient to rotate or turn his/her head against resistance.

49. Test cranial nerve XI by asking the patient to shrug the shoulders against

resistance.


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Lungs and Thorax

50. Inspect the posterior thorax for scars or asymmetry.



51. Percuss the posterior lung fields bilaterally, symmetrically and alternately,

over the upper, middle and lower lung fields, comparing the left side and

the right side at each of three levels. 52. Fist percuss your hand with palm placed on the costovertebral angle

bilaterally (kidney tenderness). Ask the patient if he/she feels pain.

53. Instruct the patient to breathe through an open mouth before you

begin auscultation. Use stethoscope correctly (position of ear buds).

54. Auscultate the posterior lung fields bilaterally, symmetrically and

alternately, comparing right and left.

55. Inspect the anterior chest for scars or asymmetry.

56. Percuss the anterior lung fields in one area on the upper chest, bilaterally,

symmetrically, and alternately.

57. Auscultate the anterior lung fields, bilaterally, symmetrically, and alternately.

Heart



58. Elevate the trunk, head, and neck to 30 degrees (by raising the back of

the examining table), have the patient turn his/her head to the left, and

shine your penlight obliquely across the right neck so that the jugular venous pulsations are visible.


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Heart continued



59. Expose the apical area and inspect for an observable apical impulse.

60. Place finger pads* on the aortic area to feel for a thrill or pulsation.

61. Place finger pads* on the pulmonic area to feel for a thrill or pulsation.

62. Place the palm on the tricuspid area to feel for a thrill or a heave.

63. Place finger pads* on the apical area and feel for location

and strength of the apical impulse.

64. Student must use stethoscope correctly (position of ear buds).

65. With diaphragm of stethoscope auscultate the aortic area.

66. With diaphragm of stethoscope auscultate the pulmonic area.

67. With diaphragm of stethoscope auscultate the tricuspid area.

68. With diaphragm of stethoscope auscultate the mitral area.

69. Using bell of stethoscope auscultate the aortic area.

70. Using bell of stethoscope auscultate the pulmonic area.

71. Using bell of stethoscope auscultate the tricuspid area.

72. Using bell of stethoscope auscultate the mitral area.

* Does not need to be specifically finger pads, student can use palm of hand.

Pulses and Testing for Peripheral Edema


Correct Incorrect Correct Incorrect 73. Instruct the patient to hold breath as you auscultate each carotid artery

(use bell of stethoscope). Student must use stethoscope correctly

(position of ear buds). 74. Palpate the carotid pulses bilaterally, one at a time.

75. Palpate the femoral pulses bilaterally, one at a time.

76. Palpate the popliteal pulses bilaterally, one at a time.

77. Palpate the dorsalis pedis pulses bilaterally (top of foot).

78. Palpate the posterior tibial pulses bilaterally (at the ankle behind the medial malleolus).

79. Check each shin for pitting edema by pressing on the lower tibia for 3 - 5

seconds. Must be done on bone.


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Abdomen



80. Have patient lie back, adjust examining table to be flat, and expose the

entire abdomen for examination.

81. Inspect the abdomen for contour, markings, venous markings and

changes with respiration.

82. Student must use stethoscope correctly (position of ear buds).

83. Auscultate each of the four quadrants of the abdomen.

84. Percuss the abdomen in 4 quadrants.

85. Palpate the left upper quadrant with light and deep pressures.

86. Palpate the left lower quadrant with light and deep pressures.

87. Palpate the right lower quadrant with light and deep pressures.

88. Palpate the right upper quadrant with light and deep pressures.

89. The student placed his/her dominant hand on top of non-dominant hand

for all abdominal palpations in all four quadrants.

90. Palpate the spleen: Place your hands on the left upper abdomen. Instruct the

patient to inhale as you begin palpating. Instruct the patient to exhale as you

deepen your palpation.

91. Percuss the liver span. Stand at the patient's right side.

92. Palpate the liver: Place your hands on the right upper abdomen. Then ask

the patient to inhale as you palpate. Instruct the patient to exhale as you

deepen your palpation then inhale again while maintaining your palpation.

Stand at the patient's right side.

Musculoskeletal

93. Assess hip flexion on each leg moving the thigh up toward the trunk,

can be active or passive.



94. Return the thigh to a position perpendicular to the exam table while holding the

shin parallel to the exam table. Move the ankle medially to assess the hip

external rotation, and laterally to assess the hip internal rotation. Both legs. 95. Flex and extend each knee.

96. Inspect the midfoot, toes, and plantar surfaces of both feet.

97. Plantarflex and dorsiflex the ankles.

98. Inspect palms and backs of both hands.

99. Assess finger extension by asking the patient to spread the fingers, both

hands, palms down.

100. Assess finger flexion by asking the patient to make a fist with each hand

(palms can be up or down).


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Musculoskeletal continued



101. Inspect both fists and wrists while you supinate and pronate the forearms.

102. Flex and extend each wrist.

103. Inspect, then flex and extend each elbow.

104. Shoulder flexion: Observe shoulder flexion by asking the patient to bring

the arms forward and raise them overhead, then ask patient to return

arms to lap. 105. Shoulder external rotation: Instruct the patient (seated or standing) to

clasp both hands behind the extended neck and to pull the elbows

back. 106. Shoulder internal rotation: Instruct the patient (seated or standing) to

place both hands behind the back as high up on the back as possible.

Observe entire range of motion from behind with patient's gown open. 107. Examination of spine: Assess neck flexion by instructing the patient to

place the chin on the chest.

108. Assess neck extension by asking the patient to look up at the ceiling.

109. Observe right and left rotation of the neck.

110. Assess lateral bending of the neck by asking the patient to incline ear

toward each shoulder.

111. Assess thoracolumbar lateral flexion by asking the patient to stand and

bend the torso to the right and to the left.

112. Observe lumbar flexion by asking the patient to bend forward at the

waist and to attempt to touch the toes.

113. Observe lumbar extension by asking the patient to bend backwards.

114. Examiner to stand behind the patient to observe thoracolumbar motion,

lumbar flexion and extension, and alignment of spine, knees, heels and

feet. Patient gown open for checklist numbers 111-114.

A complete neurologic exam would begin with the cranial nerve exam, which is described above.

Begin by having patient return to the exam table to sit.

Mental Status: Assessed during history.

Cranial nerves: completed above (except for sensory V below).

Neurological: Motor

115. Pronator Drift Test: Ask the patient to close eyes and hold arms out in front

of chest, palms facing ceiling. Observe for forearm pronation for 5-7 seconds.



116. Test the patient's wrist extension strength bilaterally.

117. Test the deltoid muscle strength bilaterally.

118. Test the biceps muscle strength bilaterally, one arm at a time.

119. Test the triceps muscle strength bilaterally, one arm at a time.


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Neurological: Motor continued


Correct Incorrect Correct Incorrect 120. Test the hip flexor muscle strength bilaterally, one leg at a time.

121. Test the knee extensor and knee flexor muscle strength bilaterally, one

leg at a time.

Neurological: Sensation

122. Demonstrate to the patient the difference between sharp and dull (on a

proximal area such as an asymptomatic forearm) with a broken cotton

tipped swab. 123. Instruct the patient to close eyes in preparation for testing sharp touch

(broken end of wooden cotton tipped applicator) and dull touch

(cotton tipped end of applicator). 124. Describe first, then test cranial nerve V sensory function forehead (V1),

cheek (V2) and jaw line (V3).



125. Test sensation on front or back of trunk, including once for light touch and once

to discriminate between sharp and dull sensation.

126. Test sensation bilaterally on upper or lower arms, including once for light touch

and once to discriminate between sharp and dull sensation.

127. Test sensation bilaterally on upper or lower legs, including once for light touch

and once to discriminate between sharp and dull sensation.

128. Demonstrate to patient while patient is watching what vibration feels like with the 128 Hz tuning fork on a bony part of the wrist.

129. Ask the patient to close eyes and then test vibration sense on each great

toe with the 128 Hz tuning fork. Test vibratory sensation on lateral malleolus

if not sensed on great toe. 130. Position sense: Grasp the great toe by the sides. Demonstrate to the patient,

while he/she is watching, what is meant by up and down motion of the toes.

131. Position sense: Ask the patient to close eyes while you slightly move the

toe in an up or down direction, bilaterally. Ask the patient to tell you "up"

or "down" after each motion.

Neurological: Reflexes

W/O Prompt

Not Done

W/ Prompt

Correct Incorrect Correct Incorrect 132. Test the biceps reflex bilaterally.

133. Test the brachioradialis reflex bilaterally.

134. Test the triceps reflex bilaterally.

135. Test the patellar reflex bilaterally.

136. Test the Achilles reflex bilaterally, while supporting the patient's foot.

137. Test the Plantar reflex bilaterally (for Babinski's sign), with a tongue blade.


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Neurological: Coordination

138. Test upper extremity coordination bilaterally with the finger-to-nose test

(patient's arm should extend fully).



139. Test for dysdiadokokinesia by having the patient alternately slap the front

and back of hands against the thigh (have patient mimic you).

140. Test for lower extremity coordination bilaterally with the heel-to-knee-to-shin

test.

141. Test for dorsal column signs with the Romberg Test: Begin by instructing the

patient to stand up and put feet together, arms at the sides and then

close eyes. Observe the patient for falling for 5-7 seconds. 142. Ask the patient to walk across the room, pivot and return while you

observe the gait.

143. Ask the patient to walk away from you on tip toe and observe.

144. Ask the patient to walk toward you on heels and observe.

145. Ask the patient to walk heel-to-toe and observe.

Closure

146. Invite the patient to return to the exam table. Tell the patient you have

completed the exam. Shake the patient's hand and thank him/her for

his/her time. 147. The student did not use gloves for any portion of the exam (instead had

skin-on-skin contact throughout all exam items).

Last Updated: 01/13/14 9:26 a.m.



intro to clinical medicine physical exam checklist

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