Routine Adult Physical Examination Checklist Student__________________________________ Instructor_____________________________ ____1.

Examiner washes hands at beginning and end of exam. ____2. Examiner introduces self to patient. Positioning – patient sitting facing examiner. General/Vital signs ____3. Note general appearance. ____4. Check pulse in radial artery for 15 seconds. (x4 = HR/minute) ____5. Compare both radial pulses. ____6. Obtain blood pressure in one arm. Head ____7. Inspect scalp and hair. Eyes ____8. Inspect external eye (conjunctiva, eyelids, sclera). ____9. Check extraocular movements (6 positions). ____10. Check visual fields by confrontation. ____11. Determine pupil reaction to light (direct, consensual). ____12. Perform ophthalmoscopy exam (dim lights, positions patient correctly), holds ophthalmoscope with correct hand (i.e. right for right eye) and index finger to switch lenses. Verbalizes structures examined. Ears ____13. Perform hearing test using rubbed fingers or whispered number or tuning fork. ____14. Inspect external ear. ____15. Perform otoscope exam bilaterally. Nose/Mouth/Sinuses ____16. Inspect nasal septum and turbinate with otoscope. ____17. Palpate frontal and maxillary sinuses.

Have patients phonate and protrude tongue. Inspect mouth with tongue blade: tongue. Positioning – patient supine. Auscultate carotids (ask patient to hold breath). Cardiovascular ____30. Instruct patient to roll in left lateral position. Positioning – examiner moves behind patient. pharynx. Inspect and palpate precordium identifying PMI and palpating valve areas and left sternal border. Palpate spine. ____27. ____19. Ask to swallow. Instruct patient to exhale and lean forward. Percuss costovertebral angles with fist. Neck/Shoulder/Back ____20. . Palpate one carotid at a time. ____36. ____28. Auscultate anterior lung fields. ____37. palpate apex and auscultate apex with bell. Auscultate PMI/apex with bell. Inspect neck veins with patient at 30 degree angle. Auscultate each valve area with diaphragm. ____33. forward. ____34. Palpate lymph nodes in head and neck region (verbalize node groups). to sides. Percuss anterior lung fields. ____29. mucosa. duct openings. ____26. Percuss posteriorly and laterally. examiner at patient’s right side. Positioning – examiner moves to front of sitting patient. Instruct patient to breathe through open mouth and auscultate posteriorly and laterally. ____23. Palpate thyroid lobes and isthmus. ____21. ____31. ____35. ____32. back. Check symmetry of chest expansion with deep inspiration. Check neck range of motion. ____24. Chest ____25. observe palate and uvula with swallow. tonsillar fossa.____18. ____22. auscultate heart with diaphragm at left sternal border third to fourth ICS) (maneuver to determine presence of aortic insufficiency).

Neurological/Musculoskeletal Exam ____50. ____53. ____51. wrinkle forehead. ____46. triceps. Auscultate for bruits. Inspect and palpate legs. ____55. Palpate femoral pulses and listen for femoral bruits. ____54. Inspect. Percuss liver dullness (measure span in midclavicular line) ____42. . Test finger-to-nose. knee. ____43. Palpate and estimate aortic pulsation. ____40. ____48. Palpate liver edge in inspiration using proper hand position. Palpate four quadrants superficially. ____52. head to side. ____45. ____41. Palpate four quadrants deeply. close eyes. Perform reflexes – biceps. Check dorsalis pedis and posterior tibial pulses. ____56. ____57. brachioradialis.Breasts (may be deferred) Abdomen ____38. shoulder shrug. Palpate spleen in deep inspiration using proper hand position. close eyes. ankle. Cranial nerve exam not done in HEENT: facial sensation. Test vibration (128 cps) and position sense in lower extremities. Auscultate for bowel sounds. ____49. show teeth. Check range of motion and strength of lower extremities. ____44. checking for pretibial and ankle edema. Test sensation to pinprick in lower extremities. Lower extremities ____47. clench jaw and palpate temporal and mandibular muscles. Test plantar reflex bilaterally. Check range of motion and strength of upper extremities. ____39.

____59. Observe toe-to-heel walking. ____60. ____61. Perform Romberg test.____58. Test heel-to-shin. . ____62. Perform pronator drift. Check gait.

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