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Physical Exam Guide

1) HEENT
Inspection • Inspect for asymmetry, deformity, scars, lumps, involuntary movements, hair loss, or edema Palpation • Palpate the head and neck for tenderness, deformity, and masses Temporomandibular Joint • Place fingers in front of the tragus of both ears • Ask patient to open and close their mouth • Note any tenderness, crepitus, or loss of ROM Superficial Lymph Nodes • Systematically palpate the following: Occipital, Postauricular, Preauricular, Tonsillar, Submandibular, Submental, Anterior Cervical, Supraclavicular Thyroid Gland • • • • • • • Inspect for obvious enlargement Position self behind patient Palpate cricoid cartilage (landmark) Move downward two or three rings Palpate for the thyroid isthmus Move laterally to both thyroid lobes While palpating, ask the patient to swallow- provide a cup of water if possible

External Eye • Inspect for ptosis, exophthalmos (noted in patient’s R-eye), lesions, deformity, or asymmetry • Pull down lower lid while asking patient to look up to inspect conjunctiva and sclera • Spread lids while asking patient to look in 4 directions to inspect bulbar surface • Repeat on other side • Wash hands before and after this portion of the exam Eye Movement • Inspect corneal reflections

• Stand 3-6 feet in front of patient • Have patient hold head still and follow examiners finger with eyes in 6 cardinal directions • Check convergence External Ear • Inspect ears and surrounding area • Palpate the mastoid processes • Gently move each ear and asks about discomfort Otoscopic Exam • • • • Hold otoscope properly Pull ear upward and backward Insert otoscope to proper depth Examine canal and middle ear Nose Exam • Insert otoscope avoiding the septum • Start inspection at the "floor" and move upward • Repeat on other side Mouth and Throat Exam • • • • • • • • Use otoscope or other bright light Ask patient to open their mouth Inspect the anterior structures Inspect the tongue and under Inspect the posterior oropharynx Ask the patient to say "Ah." Considerable tooth decay noted Missing teeth in the front Palpation of the Mouth • • • • • Use a gloved finger inside the mouth Use other hand for counter pressure on outside Palpate anterior structures Palpate floor of mouth Pull tongue out using gauze and palpates Special Considerations: Deep Cervical lymph nodes • Hook fingers around the anterior edge of the SCM muscle .

• Ask patient to tilt head forward and toward side being examined • Move muscle backward while palpating structures underneath • Repeat on other side Special Considerations: Facial Tenderness • Press under both eyebrows • Press over both maxillary sinuses • Tenderness noted in frontal sinuses bilaterally Special Considerations: Upper Eyelid Eversion • • • • • • Ask patient to look down Gently grasp upper eyelashes and pull out and down Place cotton applicator above lid edge Turn eyelid over Inspect conjunctiva Ask patient to blink to flip eyelid back Special Considerations: Pneumatic Otoscopy • • • • • Proper grip with bulb Perform standard exam Pull ear down and back on a pediatric patient Gently presse bulb Observe tympanic membrane for movement Special Considerations: Sinus Transillumination • • • • • Room must be dark Place bright light (otoscope) over maxillary sinus Ask patient to open mouth Compare "glow" on both sides Maxiallary sinus congestion noted on the patients R-side 2) CHEST General • Patient in gown or loosely dressed • ALWAYS examine sequentially from side to side Pulmonary Inspection • Identify the oblique and horizontal fissures • Look for asymmetry and deformity of the chest wall and trachea .

and effort of breathing • Look for and stated significance of increased A/P diameter Pulmonary Palpation • Palpate the anterior.• Observe rate. posterior. rhythm. depth. wheezes. and lateral chest • Identify areas of tenderness Special Considerations • Chest expansion • Tactile fremitus Pulmonary Percussion • Place distal middle finger against chest and tapping smartly with opposite middle finger produced a good percussion "note" • Percuss a minimum 6 anterior points • Percuss a minimum 4 posterior points • Percuss a minimum 1 lateral point bilaterally • Identify lobes of each lung bilaterally • CTA bilaterally Special Considerations • Diaphragmatic excursion Pulmonary Auscultation • • • • • Auscultate a minimum 6 anterior points Auscultate a minimum 4 posterior points Auscultate a minimum 1 lateral point bilaterally Identify lobes of each lung bilaterally Be able to articulate a description of: rales/crackles. rhonchi. abnormal I/E ratio Special Considerations • Egophony Peak Flow Monitoring • Use correct technique with Peak Flow Meter • Repeat 3 times and record highest reading Special Considerations .

• Tactile fremitus Special Considerations • Chest expansion • Even and non-labored bilaterally Special Considerations • Diaphragmatic excursion Special Considerations • Egophony 3) CARDIOVASCULAR Preparation • Position and gown patient • ALWAYS stand to patient's right side Inspection • Inspect ankles for signs of edema (NO edema noted) • Identify carotid and jugular pulse (JVP normal) Pulse and Blood Pressure • Note vital sign values (HR• Measure pulse and blood pressure if no values are reported or if values are abnormal Special Consideration: Irregular Pulse • Measure up to a minute Carotid Pulsations • Observe pulsations in neck • Palpate one side at a time • Note amplitude and contour Special Consideration: Auscultation for Bruits • Place diaphragm or bell over each carotid artery • Ask patient to hold their breath momentarily .

The Precordium • Observe for precordial movement • Identify apical pulse visually • Palpate apical pulse/PMI • Palpate for extra movement Auscultation with the Diaphragm • • • • Auscultate aortic area (R 2nd IS) Auscultate pulmonic area (L 2nd IS) Auscultate tricuspid (L sternal border) Auscultate mitral area (PMI) Auscultation with the Bell • Auscultate mitral area (PMI) • Auscultate other areas as time permits Special Consideration: Jugular Venous Pressure • • • • • Position on exam table starting with head elevated 30 degrees Use tangential lighting Identify jugular venous pulse (distinct from carotid pulse) Adjust bed angle as needed Measure distance of pulse above sternal angle Special Consideration: S3 and Mitral Murmurs • Roll patient on left side • Palpate to locate PMI • Auscultate in the mitral area (PMI) with the bell Special Consideration: Aortic Insufficiency • Position patient sitting and leaning forward • Ask patient to exhale • Auscultate the L 3rd and 4th IS with the diaphragm 4) ABDOMINAL General • Position patient and drape • Use the correct terminology for locations on the abdomen .

or rashes • Look for pulsations or peristalsis • Observe the abdominal contour Auscultation • Listen until bowel sounds are heard or for a full minute • Report sounds as increased. striae.• Ask patient to point to areas of pain and examine that area last Inspection • Look for scars. or normal Auscultation for Bruits • Auscultate for aorta • Auscultate for renal arteries • Auscultate for iliac arteries Percussion • • • • Percuss in all 4 quadrants Outline areas of dullness and tympany Percuss liver span in midclavicular line Percuss for splenic dullness at the last interspace in the left anterior axillary line Light Palpation • Lightly palpate in all 4 quadrants and the midline • Observe for signs of discomfort Deep Palpation • Deeply palpate in all 4 quadrants and the midline • Identify organ enlargement or other masses if present Liver and Aorta • Palpate for the liver • Palpate for the aorta and determines width Palpation of the Spleen • • • • Position yourself on patient's right Lift patient's left flank Palpate at left costal margin Ask patient to take a deep breath . decreased. lesions. hernias. vascular changes.

• Finish palpation Special Considerations: Rebound Tenderness • • • • Warn patient Slowly press abdomen on the side of reported pain Quickly release pressure Observe for signs of discomfort Special Considerations: Liver Scratch Test • Place diaphragm of stethoscope over upper margin of liver • Lightly scratch the skin below the anticipated lower edge of the liver • Methodically scratch higher until sound is magnified by the mass of the liver Special Considerations: Costovertebral Tenderness • • • • • • Warn patient Place hand over CV angle Hit smartly with other hand Observe for signs of discomfort Repeat on other side NONE noted Special Considerations: Shifting Dullness • • • • Percuss level of dullness Ask patient to roll on side Percuss new level of dullness Repeat on other side Special Considerations: Leg Signs for Appendicitis • Ask patient to raise right leg against resistance (Psoas Sign) • Raise and internally rotate right leg with knee flexed (Obturator Sign) 5) MUSCULOSKELETAL General: Preparation. atrophy ALWAYS compare each joint and muscle group bilaterally Palpate each joint and muscle group in sequence Isolate each axis when testing ROM Identify 6 cardinal signs of musculoskeletal disease: pain. Palpation • • • • • • Patient in gown or loosely dressed ALWAYS begin each joint exam with inspection for asymmetry. deformity. redness. swelling. Inspection. . warmth.

internal rotation. the grooves between the epicondyles and the olecranon • Assese range of motion for flexion. adduction. external rotation Special Considerations: Shoulder • Drop arm test • Impingement sign Elbow • Palpate: medial and lateral epicondyles of the humerus. A/C joint. flexion. long head of biceps • Measure ROM in 6 axes (active and passive): abduction. isolating each axis of motion • Thumb abduction and opposition Special Considerations: Wrist and Hand • Identify and test for tenderness in anatomical snuffbox • Profundus and Superficialis Tendon tests Back • Palpate over each spinous process and paraspinous muscle group • Palpate sacroiliac joint • Measure ROM (active) in 6 axes Special Considerations: Back . supination and pronation Wrist and Hand • Palpate interphalangeal joints • Perform ROM (active and passive) of wrist. the olecranon. thumb. extension.deformity. loss of function Neck • Palpate over each spinous process and paraspinous muscle groups • Measure ROM in 6 axes Shoulder • Palpate: clavicle. extension. and fingers. corocoid process. glenohumeral joint. scapula.

plantar surface. calcaneus. popliteal fossa Special Considerations: Knee • • • • Collateral Ligament Testing Lachman's Test Drawer Test Major and minor effusion tests Ankle and Foot • Inspect all surfaces of the foot • Palpate: tibiotalar joint. head of fibula. metatarsal heads • ROM: Dorsiflex and plantarflex at the the tibiotalar joint. patella with movement. inguinal ligament. medial and lateral joint lines. External Rotation) Test Bilaterally Knee • Palpate: distal femur and muscles. patella and tendon. metatarsophalangeal joints. ischial tuberosity • Measure ROM (active) in 6 axes Special Considerations: Hip • "FABER" (Flexion. tibial tubercle. invert and evert distally Strength Testing Against Resistance • • • • • • Abduct shoulder Flex and extend elbow Spread fingers Flex hips Flex and extend knee Dorsiflex and plantarflex ankle Special Considerations Be able to identify the significance of a positive finding
 of any of these tests Crossarm adduction test (drop arm) . achilles tendon. invert and evert proximally. pubic tubercle • Palpate: greater trochanter.• Straight Leg Raises Bilaterally Hip • Palpate: Anterior superior iliac spine. ABduction.

vagus): articulation.Rotator cuff impingement Snuffbox tenderness Flexor digitorum superficialis and profundus Straight leg raise FABER test Collateral ligament testing Lachman's test & Drawer tests Test for knee effusion Ballotable knee 6) NEURO Cranial Nerve Examination • CN II (optic): visual fields. puff cheeks. shut eyes while examiner attempts to pry them open • CN VIII (auditory): finger rubs • CN IX and X (glossopharyngeal. Abducens): extraocular movements. VI (Oculomotor. "ah" and note palate movement • CN XI (accessory): shoulder shrug and neck strength against resistance • CN XII (hypoglossal): stick out the tongue and move side to side Special Considerations: CNVIII • Use tuning fork is decreased hearing (Weber test) Motor Exam: compare side to side • • • • • • • • • • • Observe for bulk and abnormal movements Testing tone: passively flex and extend elbows Strength Testing against resistance Abduct shoulder Flex and extend elbow Spread fingers Thumb opposition to pinkie Flex hips Flex and extend knee Dorsiflex and plantarflex ankle Weakness noted on patient’s R-side Coordination and Gait: Cerebellar Function . pupillary reaction and accommodation • CN III. frown. raise eyebrows. IV. Trochlear. convergence • CN V (trigeminal): sensory (sharp) and motor (clenches teeth while examiner palpates masseter and temporalis) • CN VII (facial): smile.

lesions. deformity. or asymmetry • Inspect conjunctiva and sclera . exophthalmia.• • • • • • • • Finger to nose testing Heel to shin testing (normal) Rapid alternating movements Romberg Testing (unsteady) Gait: walking and turning Tandem gait Walking on heels and toes Abnormal gait Reflex Examination: Tendon reflexes • • • • • • • Biceps Triceps Brachioradialis Knee Ankle Babinski All reflexes were normal Special Considerations: Reflexes • Test for clonus by quickly dorsiflexing the foot on both sides Sensory Examination • Vibratory sensation bilaterally on index finger and great toe • Subjective light touch tested symmetrically on upper and lower extremities • Problems with 2pt discrimination in bilateral UE Special Considerations: Sensory Examination • • • • Position sense or proprioception bilaterally on index finger and great toe Two point discrimination Graphesthesia Stereognosis Visual Acuity • Use proper technique with Rosenbaum Card • Use proper technique with Snellen Eye Chart Inspection of External Eye • Observe for ptosis.

diopter. 4 quadrants. and right while inspecting bulbar surface • Wash hands before and after this portion of the exam Visual Field • Position and instruct patient • Screen by confrontation. left.• Ask patient to look up. and neglect Extra Ocular Movements • • • • Position self and patient Instruct patient Demonstrate 6 sided cross or "H" pattern Check convergence Corneal Reflections • Check corneal reflections with penlight Pupillary Reaction • • • • Approach from temporal angle Test bilaterally Check for direct and consensual responses Accommodation response Standard Ophthalmoscope • • • • • Adjust aperture. down. and light intensity Dim room light Use right hand/right eye/index finger technique Instruct patient to fixate on a point and elicits a red reflex Follow inward thru the pupil to locate optic disc and allows time to focus PanOptic Ophthalmoscope • • • • • • Focus instrument by observing object across the room (10 feet away) Adjust rheostat to maximum light intensity Follow red reflex into pupil until eye cup contacts brow Compress eye cup halfway to maximize view Adjust focus as necessary Repeat bilaterally .

Corneal Reflex • Use a cotton tip applicator • Gently and lightly contact the cornea and observe patient's reflex Special Considerations Be able to identify the significance of a positive finding
 of any of these tests Corneal Reflex Using the Equipment Standard Ophthalmoscope PanOptic Ophthalmoscope .