Sanitize hands
Introduce yourself as a medical student
Use the patient’s last name
Observe general appearance
Take BP
Take radial pulse and temp
Auscultate trachea (listen for
number of respirations per
minute)
General survey of the skin:
look for nevi, rashes, dry skin,
scars, tattoos, other abnormal
growths
Inspects nails, hands, arms,
and joints
Palpate radial pulses on the
wrists at the same time
(patient’s hands forward
raised)
Examine hair, scalp, and face
Check facial symmetry
Inspect the external ear and
auricle (gently pull the auricle
upward and downward)
Inspect puncta, conjunctivae,
and sclerae
I will be taking your
blood pressure
I will be taking you radial
pulse, at the same time
your temperature
I’ll just check your
respiratory rate
Now, I’m going to
examine the skin
Palpating the radial pulses
on the wrists
Examining the head, just
tell me if you feel any
pain
I will be checking your
face motor function.
Test eyebrow elevation,
forehead wrinkling, eye
closure, smiling, cheek
puff
I will be examining your
ears
I will be examining your
eyes. Can you please look
up, look down, and look
The patient is conscious,
coherent, and alert; properly
oriented to time, place, and
person; dressed appropriately;
and shows no signs distress.
BP
PR
Temp
RR
The skin is fair in color, warm
to touch, with good turgor.
There is no redness and pallor.
Scars are noted on the left arm
and shoulder. No lesions, ulcers
or rashes noted.
The patient has normal capillary
refill
Radial pulses are symmetrical
Hair is evenly distributed, there
are no signs of alopecia; no
scars or lesions and no
tenderness noted. The skull is
normocephalic.
The patient’s facial and
trigeminal nerves are intact.
The eyebrows are symmetrical
with even hair distribution.
The cartilage is firm. there is no
tenderness on movement and no
piercings noted.
The conjunctiva is pinkish, non-
icteric sclera; the puncta has no
discharge and are not

Assess pupillary reflex
Assess extra-ocular
movements (CN III, IV, VI)
Inspect lips and oral cavity
Ask patient to protrude tongue,
then move side to side
Inspect tonsils, position and
symmetry of palate and uvula
with phonation (“ahh”)
Palpate cervical lymph nodes
Inspect trachea
Inspect and palpate thyroid
gland
Palpate spinous processes of
each vertebrae
Percuss lungs posteriorly
SUPINE POSITION
Percuss lungs anteriorly
Measure jugular venous
pressure
at me.
I will be checking your
eyes some more. Please
look forward.
Now please look at the
pen and follow it with
your eyes.
Can you look forward and
follow the penlight just by
using your eyes while not
moving your head.
I will be checking your
lips. Look directly at me.
Can you open your
mouth.
Please stick your tongue
out and move it side to
side
Please stick your tongue
out again and say “aah”.
I will be palpating your
lymph nodes. Just tell me
if you feel any pain.
Can you tilt your head up
for me. I’ll be palpating
your trachea.
Can you swallow for me
and tell me if you feel any
pain upon swallowing.
I will be palpating your
spine, just tell me if you
feel any pain.
Posteriorly: Can you cross
your arms for me. I will
be percussing your lungs
from the back.
Anteriorly: Can you lie
down for me. I will be
percussing your lungs
from the front.
I will now ask you to look
to the left.
obstructed.
Pupils are equally round and
reactive to light and
accommodation.
The patient’s oculomotor,
trochlear and abducens nerves
are intact bilaterally. No
nystagmus noted.
The lips are moist with no
cracks and no scars or lesions.
The oral cavity is pinkish with
no lesions or ulcerations and has
good dentition.
The hypoglossal nerve is intact.
The uvula is at the midline and
rises upon phonation; tonsils are
not enlarged nor inflamed.
Lymph nodes are nonpalpable
and nontender.
The trachea is at the midline.
The thyroid gland is nontender,
not enlarged and rises upon
deglutition
The spine is at the midline; the
spinous processes are
nontender.
Lungs are resonant on
percussion posteriorly.
Lungs are resonant on
percussion anteriorly.
The jugular venous pressure is
6-8 cm H2O
Auscultate carotid arteries for
bruits (use bell of the steth)
Inspect and palpate for point of I will be pulling down the
maximal impulse
Auscultate heart sounds in all
valvular areas using diaphragm stethoscope, take a deep
and bell of stethoscope
Inspect abdomen
Auscultate abdomen
Percusses abdomen lightly on
all 4 quadrants
Checks for hepatomegaly
Checks for splenomegaly
SITTING POSITION
Assesses for costovertebral
angle tenderness (back; strike
with the ulnar surface of the
fist)
Inspects legs, feet, and joints
Palpates for pitting edema
Palpates dorsalis pedis, then
posterior tibialis pulses on both your pulses on both legs.
legs
Checks biceps and patellar
reflexes
Checks gait
No carotid bruits heard.
Point of maximal impulse is at
drape just over your navel the 5th ICS, left midclavicular
and I will be checking for line.
your point of maximal
impulse.
Whenever you feel the There are normal heart sounds
with S1 best heard at the apex
breath. and S2 more audible at the base.
No heaves or thrills noted.
I will now check your No scars or lesions noted. Navel
abdomen. is at the midline.
Can you take deep breaths The patient has normal bowel
for me. Inhale through sounds and no aortic bruits
your nose then exhale heard.
through your mouth.
I will be pressing on some The abdomen is tympanitic
parts of your abdomen. upon percussion.
Please inform me if you
feel pain.
I will be percussing your The liver span is 6-12cm in the
liver. right midclavicular line.
Take a deep breath while The liver is nontender and not
I’m palpating your liver. enlarged.
I will be percussing your The spleen is not enlarged.
spleen. Take a deep
breath.
If you feel any pain just There is no costovertebral
say so. tenderness noted.
I will be inspecting your There is no discoloration and no
lower extremities. ulcers noted in the lower
extremities.
If you feel any pain just The lower extremities are non-
say so. edematous.
I will now be checking The pulses are present
bilaterally.
Please relax your arms The patient is normoreflexic
and legs. with a grade of 2+.
Walk normally. No dysmetria and no
Walk on heels. dysdiadochokinesia. The
Walk on toes. patient’s cerebellar function is
Along a straight line, heel intact and the gait is normal.
to toe.