History of Present Illness (HPI

)
You are expected to take the History of Present Illness including the questions covered in Lab 1.

Head-to-Toe Physical Examination – Covering All Labs
HENT AND NECK Skin
Inspect the skin of the face and neck for color, moisture, temperature, texture, mobility, turgor, and lesions. State to patient “I am inspecting the skin of your face and neck”

Head
1. Inspect the hair and scalp. State to patient “I am inspecting your hair and scalp.” 2. Palpate the skull for tenderness or deformities.

Ears
1. Inspect each auricle for size, symmetry, deformity, tenderness, or lesions. State to patient “I am inspecting the outside of your ear.” 2. a. Inspect the external ear canal with the otoscope for discharge, swelling, or redness b. Examine the tympanic membranes with the otoscope (use a disposable speculum). Inspect the color, contour, and cone of light. State to patient “I am inspecting the inside of your ear.” 3. Test auditory acuity one ear at a time by using the whisper test or by rubbing your fingers together. 4. Perform the Weber test: place a 512 Hz tuning fork (correct one required) firmly on top of the patient’s head. Ask them where they hear the sound: on one or both sides? 5. Perform the Rinne test: place a 512 Hz tuning fork on the mastoid bone, behind the ear. When the patient can no longer hear the sound, quickly place the tuning fork close to the external ear canal and ask if they can now hear the sound. Perform this test on both ears.

Nose
1. Inspect the nose for symmetry and deformity. State to patient “I am inspecting your nose.” 2. Test the patency of each nostril. Have patient occlude one nostril, ask the patient to inhale through the open nostril and then repeat on the other side. 3. Examine the each nostril with the otoscope and the largest ear speculum (replace the speculum if used on the ears). Observe the nasal mucosa over the septum and turbinates for deformities, color and swelling. State, “ I am examining the inside of your nose” 4. Palpate for sinus tenderness by pressing on the frontal and maxillary sinuses.

Mouth and Pharynx (Wear gloves when examining the mouth and tongue)
1. Inspect the lips for color, moisture, masses, ulcers, scaling. State, “I am inspecting your lips.” 2. For all of step 2 you must use the light and examine the patient’s entire mouth and throat, including having the patient lift their tongue, pull the cheeks aside by using your finger or a tongue blade. State, “I am inspecting your mouth and throat.” a. Using a light source (penlight, otoscope), inspect the oral mucosa, hard palate, floor of mouth, and gums for color, ulcers, and nodules.
UTHSCSA Head to Toe Physical Examination for Medical Students, last edit April 7, 2011

Identify the parotid duct openings and the submandibular gland duct openings. c. 5. Assess visual acuity of each eye with a hand held visual acuity card held 14 inches from the patient. 2. symmetry. Submandibular f. eyelids. and lesions. Test for direct and consensual pupillary reaction to light. 3. deformity. and thyroid enlargement. d. Inspect the position and alignment of the eyes.” 2. Posterior cervical i. Ask the patient to follow your finger with their eyes as you move through the six areas. Occipital b. Inspect the symmetry. Posterior auricular c. 2011 . last edit April 7. Inspect and gently palpate the floor of the mouth. Examine the dorsum. swelling. mobility. Preauricular d. Tonsillar e. Inspect the neck for symmetry. Superficial cervical h. Palpate the tongue for induration or masses. 6. ------------------------------------------------------------------------------------------------------------------------------------------ EXTERNAL EYE EXAMINATION 1. Now I am looking at the conjunctiva and your cornea. and undersurface of the tongue.b. 3. consistency. 4. nodules. You must have the patient swallow (can use a sip of water) to aid your examination. swelling (must pull eyelids down) • Cornea and lens for opacities. Inspect the teeth for color. “ah” Neck 1. Verbally identify each set of nodes as you palpate: a. Palpate the thyroid gland from the front or from behind the patient. and the iris with oblique lighting (from the side of the eye while you are in front of the patient) • Inspect the pupils for size. Note color. masses. Each eye should be tested separately (cover non-tested eye). Inspect the following and state what you are doing: “I am looking at your eyebrows. shape. Submental g. Observe the movement of the soft palate and uvula when the patient says. and tenderness. or absence of teeth. tonsils. shape and symmetry. Test extraocular muscle function in each eye through the six cardinal fields of gaze. delimitation. color. UTHSCSA Head to Toe Physical Examination for Medical Students. and pharynx. Inspect the anterior and posterior pillars. State to patient “I am inspecting your pupils. and texture of the extended tongue.” • Eyebrows for hair quantity and distribution and condition of the skin • Eyelids and lacrimal apparatus for color. Supraclavicular 2. 5. State to patient “I am inspecting your neck.” 4. sides. lesions • Conjunctiva and sclera for color. Deep cervical chain j. Palpate the following lymph nodes noting size.

Rosende in his fall lecture. 5. VITAL SIGNS 1. Auscultate the lungs with the diaphragm of the stethoscope. “I am inspecting the front of your chest. Measure heart rate with finger pads (not thumb) in one radial artery for 15 seconds. 3. then middle fields. then lower lung fields (top to bottom) 6. Reveal to standardized patient that you measured respiratory rate after doing so in a hidden manner. stethoscope positioned correctly (bell or diaphragm is okay). State. Test visual fields by confrontation method – patient and student cover one eye and test at least 4 quadrants using waving fingers or having the patient count fingers. --------------------------------------------------------------------------------------------------------------------------------------------- CHEST AND LUNG EXAM Posterior Thorax 1. Percuss the posterior chest wall comparing sides sequentially and bilaterally: start with the upper fields. as the patient (1) breathes deeply (2) through an open mouth. 2. Use either the method described in Bates or by Dr. Percuss and measure diaphragm excursion from full expiration to full inspiration on both sides 7. Measure respiratory rate for 15 seconds. Palpate the anterior chest in the upper fields only 3. Anterior Thorax (the patient may be seated or supine) 1. Compare sides sequentially and bilaterally in upper. Inspect (state. 3. Measure blood pressure in one arm. or lateral edge of hands on pinky side) and having patient say “99” or “toy boat”. 4. 7. middle. and lower lung fields.6. “I am inspecting the back of your chest. but you are not required to report blood pressure. Arm should be at heart level. Compare sides sequentially and bilaterally in upper. Do not have to report heart rate. Palpate the posterior chest for masses or tenderness using moderately firm pressure. and lower lung fields 8. Test chest expansion (respiratory excursion) with hands wrapped around the lower portion of the ribs with thumbs pointing upward. last edit April 7.” 2. It is good practice. Do not have to report respiratory rate.”) anterior chest 2. Inspect posterior chest for lesions or swelling. Auscultate the anterior lung fields in the upper lobes on the chest wall (must at least listen under the collar bones and above the breasts) UTHSCSA Head to Toe Physical Examination for Medical Students. 2011 . Auscultate for E-to-A change (egophony) by asking the patient to say “E” while auscultating the posterior lung fields with the diaphragm of the stethoscope. Test for convergence. cuff positioned correctly. Palpate for tactile fremitus using bony portion of hand (palmar side of knuckles. comparing symmetric areas. middle.

NOTE: Assess only one artery at a time. Place the patient in the left lateral decubitus position if necessary to locate the pulse. 10. 2011 . left second interspace (pulmonic). you will be counted incorrect. pulmonic. ------------------------------------------------------------------------------------------------------------------------------------------- CARDIAC EXAM Neck 1. auscultate the entire precordium (area in front of heart) from the base to the apex to identify the first (S1) and second heart sounds (S2). left lower sternal border (tricuspid) and apical (mitral) areas for thrills. Auscultate under the right breast or mid-axillary line over the right middle lobe with the diaphragm of the stethoscope. last edit April 7. Using the diaphragm. 10th ed. left lower sternal border (tricuspid) and apex (mitral). UTHSCSA Head to Toe Physical Examination for Medical Students. Palpate the popliteal pulse (behind knee in tibial side of knee crease) in both legs using the pads of your first and second fingers. Palpate the posterior tibial pulse (behind lower edge of interior side of ankle) in both legs using the pads of your first and second fingers. 11. auscultate the apex (mitral area) and left lower sternal border (tricuspid) for extra heart sounds (S3. 3. Using the bell placed lightly to the chest. 2. You must have patient hold his/her breath during this maneuver. S4). 8. 6. Heart 1. If table is flat or >45 degree angle. Measure the distance in cm above the sternal angle.4.” PERIPHERAL VASCULATURE: 5. 3. palpate the aortic. Palpate the apical impulse (also known as the PMI – point of maximal impulse) using your finger pads. but we prefer you use the pads of your fingers). Palpate the femoral pulse (in the groin crease) in both legs using the pads of your first and second fingers. State to patient “I am listening for extra heart sounds with the bell of my stethoscope.). Palpate the dorsalis pedis pulse (on middle of top of foot) in both legs using the pads of your first and second fingers. Auscultate both carotid arteries for bruits (can use diaphragm or bell). 9. Using the ball of the hand. Perform the Allen test for patency of the radial and ulnar arteries in one arm 7. Palpate right and left radial pulses using the pads of your first and second fingers. Measure the JVP with two rulers (or a ruler and a flat object) – one ruler upright at sternal angle and the flat object parallel to the floor (see Bates page 351. Identify the right internal jugular vein with the head of the exam table raised to 30 degrees. Palpate the brachial pulses in both arms using the pads of your first and second fingers. You should auscultate in all 4 areas sequentially – right second interspace (aortic). You do not need to report this finding. Palpate the carotid pulse in both carotid arteries using the pads of your first and second fingers (Bates says thumb is okay. It is fine to position the patient in the left lateral decubitus position for this maneuver. never occlude both sides at the same time. This area must be exposed during the examination. 4. 2.

2011 . Lightly palpate all four quadrants. Palpate each groin for the superficial inguinal nodes (Bates page 476). Deeply palpate all four quadrants. BACK Percuss the costovertebral angle (CVA) on both flanks with your fist to examine for tenderness (Bates pg 446).” 13. PERIPHERAL LYMPH NODES Examine both sides of the body. Inspect the abdomen – contour. 10th ed). Do not perform the “hooking technique”. noting any muscular resistance or tenderness. or pulsations 8. This area must be exposed during the examination. Palpate for pitting edema on both legs using firm pressure over the dorsum of the feet and/or anterior lower legs (shin area). You must hold pressure for at least five seconds. palpate both axillae for axillary nodes (note in Bates pages 392 and 475 the areas of central. Auscultate for an aortic bruit 4. Palpate the aortic pulse in the abdomen 9. 3. Percuss lightly in all four quadrants to assess the distribution of tympani and dullness 5. 2. anterior. Assess the vertical liver span by percussing the right lower anterior chest in the midclavicular line and upper abdominal quadrant to identify the liver borders. Inspect for edema in the foot and lower leg. before palpation/percussion. 7. Auscultate the abdomen for bowel sounds. posterior and lateral) This area must be exposed. start in the quadrant farthest away from the area of pain. Palpate for the spleen with the patient in the supine position and/or while lying on his/her right side (Bates pages 444-445. symmetry. If the patient complains of pain. ------------------------------------------------------------------------------------------------------------------------------------------ ABDOMEN 1. Palpate each upper extremity for epitrochlear nodes (Bates page 475) 3. noting any tenderness. ---------------------------------------------------------------------------------------------- UTHSCSA Head to Toe Physical Examination for Medical Students. 10. 6. State to patient “I am looking for swelling in your feet and legs. last edit April 7. 2.12. State to patient “I am inspecting your abdomen. masses.” You must have the abdomen fully exposed. (You may wear gloves to examine the axillae and groin) 1. Identify where you have located the edges of the liver. With the patient’s arms down and relaxed. 10th ed). Palpate for the lower edge of the liver with deep palpation (Bates pages 441. lesions.

pronation. State to patient “I am inspecting your hands and fingers. State to patient “I am inspecting your spine. Examine the wrists including: • Inspection of palmar and dorsal surfaces. last edit April 7.” • • Palpation of olecranon process and epicondyles Active range of motion (AROM) including flexion.” • Palpation of distal radius and ulna on lateral and medial surfaces. and sacroiliac joints • Active range of motion (AROM) of the neck including flexion. extension. abduction.MUSCULOSKELETAL 1. • Examine the hips including: Observation of gait (may include with examination of the spine). internal rotation. • Palpation of trochanteric bursa bilaterally (patient lying on their side or back). adduction • Active range of motion of the thumb including flexion. and medial and lateral aspects of each PIP joint and DIP joint • Active range of motion (AROM) of the fingers including flexion. Examine the shoulders including: • Inspection. and joint palpation of MCP joints. State to patient “I am inspecting your shoulders. coracoid process. abduction. external rotation. if necessary. you must palpate both sides and front and back of wrists • Active range of motion (AROM) including flexion. • Active range of motion (AROM—the patient moves their own limb) including forward flexion. lateral bending 2. extension. State to patient “I am inspecting your elbows. lateral bending • AROM of the spine including flexion. so that the patient moves at the waist only). opposition MUSCULOSKELETAL—LOWER EXTREMITIES AND SPINE 1.” • Palpation of acromioclavicular joint. Examine the hands and fingers: • Inspection of the dorsal and palmar surfaces of the hands and fingers. Examine the elbows including: • Inspection of extensor surface of ulna and olecranon process. extension. groove of joint on dorsal surface and the carpal bones. subacromial bursa/ supraspinatous insertion (pg. Examine the spine including: • Inspection of posture and spinal curvature from behind. rotation (hold patient’s hips stable. 593 top picture). area exposed (can perform hip extension at the same time) UTHSCSA Head to Toe Physical Examination for Medical Students. State to patient “I am inspecting your wrists. 592). radial and ulnar deviation 4. supination 3. 2011 . extension.” • General palpation of anatomic snuffbox and metacarpals. and biceps tendon (pg. extension. extension. abduction and adduction 2. adduction.” Only correct if you expose the entire spine and stand behind the patient for this. • Palpation of spinous processes of each vertebra. the paravertebral muscles. rotation. extension.

2. abduction. month. extension (if not done in prior step). city.• Passive range of motion (PROM—you move the patient’s leg – this is different from all the other joints you have examined!). Examine the feet including: • • • Inspection for deformities and swelling state to patient “I am inspecting your feet”.e. current events. penny). Remote memory: Ask patient for 1-2 historical events relevant to his/her past (i.. today’s appointment time). Ask patient to subtract serial 7s.e. Orientation to place: Do you know where you are right now? Ask for the name of hospital. year. femoral condyles. adduction. Examine the ankles including: • • • Inspection for deformities and swelling state to patient “I am inspecting your ankles”. 3. Palpation (anterior ankle. With the patient supine move the hip through flexion. favorite music/TV programs. 6. 5. medial and lateral collateral ligaments. heel. and flexion of toes --------------------------------------------------------------------------------------------------------------------------------------------- NERVOUS SYSTEM-MENTAL STATUS MENTAL STATUS.apple. AROM including inversion and eversion of foot. internal rotation 3. • AROM including flexion and extension 4. name 5 large cities in the US) 9. day of week.. Alternatively. external rotation. state to patient “I am inspecting your knees. 4. or county. or season. Achilles tendon). the weather. Tell the patient you will ask him/her to tell you these 3 words again in a few minutes.must have these questions memorized 1. Orientation to person: Ask for the patient’s full name. name of schools attended). Recent memory: Ask patient to tell you events about the day (i. (Give the patient 3 simple nouns to recall: for example. name of president.e. Orientation to time: Ask patient for the date.. 8. state. AROM including dorsiflexion and plantar flexion at ankle 5. Ask patient to name three objects and immediately repeat them. Calculating ability: Ask patient to solve simple arithmetic problems. floor. Stop after 5 answers. and joint lines.” • Palpation with knee in flexion of the patellar tendon. Information and Vocabulary: Ask about patient’s work. 7. • Examine the knees including: Inspection of contour and swelling. hobbies. birth date. table. last edit April 7. jobs held. ask patient to spell WORLD backwards. Ask specific facts (i. UTHSCSA Head to Toe Physical Examination for Medical Students. Palpation (metatarsophalangeal joints. 2011 . vice president. plantar fascia).

Ask patient to repeat the names of the three objects above in #4. (2) strength of eyelid closure (student must try to open the patient’s closed eyes). Example-“Please draw a clock showing the time 2:30. CN I – Test for ability to smell.10.check visual acuity on each eye. CN VII – Test face muscles: (1) wrinkling forehead. check visual fields 3. 5. CN III. 4. CN IX. test one nostril at a time. tissue or other soft object. CRANIAL NERVES 1. last edit April 7. and (3) smiling and/or puffing cheeks (must do 1. IV. State. 11. “I am listening to/have listened to your voice. CN XII (Hypoglossal) – Test by having patient stick tongue straight out NERVOUS SYSTEM—MOTOR SYSTEM AND REFLEXES Motor System – Upper Extremity 1. 2011 . 2. 2. X – • Observe movement of the soft palate and uvula when the patient says “ah” (do not have to use a tongue blade IF you can see the movement) • Listen to patient’s voice. VI -Check extraocular muscle function in each eye through 6 cardinal fields of gaze. State.” 5. CN II. CN XI (Spinal Accessory) – • Test strength of trapezius with shrugging shoulders against firm pressure • Test strength of sternocleidomastoid by turning head each direction against firm pressure 6. Inspect muscle bulk and tone of the arms and hands. bilateral cheeks. Have the patient follow your finger while it makes a large “H” in front of the patient’s face (approximately 1420 inches away). “I am inspecting the muscle bulk of your arms and hands. 2. bilaterally on chin.” 12. CN VIII– • Test auditory acuity (one ear at a time) using the whisper test or rubbing fingers together. Abstract thinking: Ask patient to explain a proverb or similarities. CN V – • Test sensation on face with the patient’s eyes closed: bilateral at forehead. and 3) 3. CN III (Optic and Oculomotor) . Should compare two sides at the same time and use light touch with finger.” UTHSCSA Head to Toe Physical Examination for Medical Students. Constructional ability: Ask patient to draw a clock complete with numbers and hands and set to a specific time. Use a different scent for each nostril if possible. • Test jaw clenching by palpating at jaw for muscle contraction.Test for direct and consensual pupillary reaction to light (must use light source-penlight or otoscope) 4.

S2—hamstrings) knee extension (L2. State. C7.L5.L3. C7. C8) biceps (C5. S1—gluteus medius and mimimus) hip adduction(L2. T1) thumb opposition (C8. Test muscle strength bilaterally. T1) finger abduction (C8. L4—quadriceps) ankle dorsiflexion (mainly L4. Plantar response : use gentle pressure with end of reflex hammer or dull tongue depressor to gently stroke the lateral aspect of the sole from the heel to the ball of the foot . C8. C6) wrist flexors (C6. T1. “I am inspecting the muscle bulk of your legs and feet. Test the following on both sides of the body: (Please do not strike the patient’s tendon more than 3 times to elicit the response. If you elicit the response with the first attempt. note the number of times it does so.) • • • • • Biceps Brachioradialis Triceps Knee Ankle 2.L4—iliopsoas) hip extension (S1—gluteus maximus) hip abduction (L4. C8. C7. L5. L4—adductors) knee flexion (L4. Test for ankle clonus: Push foot up (dorsiflex ankle) sharply once and hold to see if foot pushes back down. NERVOUS SYSTEM—SENSORY SYSTEM AND CEREBELLAR FUNCTION Sensory System UTHSCSA Head to Toe Physical Examination for Medical Students. including (Bates pages 680-83): • • • • • • • • deltoids (C5. S1. median nerve) Motor System – Lower Extremity 1. making sure to isolate the muscle(s) to be tested. 2011 . L5) ankle plantarflexion (S1) Deep Tendon Reflexes 1. C8. curving medially across the ball (Bates pg. radial nerve) wrist extensors (C6. radial nerve) finger grip (C7. 702) 3. C6) triceps (C6. move on with the exam. if it does. making sure to isolate the muscle(s) to be tested. last edit April 7.” 2. L3. Inspect muscle bulk and tone of the legs and feet.2. including (Bates pages 684-686): • • • • • • • • hip flexion (L2. L3. Test muscle strength bilaterally.

of the upper and lower extremities. Compare symmetric areas on both sides of the upper and lower extremities.use broken end of cotton swab.holding the DIP 6. “Can you feel this equally on both sides?” • • • • • • Both shoulders (C4) Inner and outer aspects of forearms (C6 and T1) Thumbs and little fingers (C6 and C8) Fronts of both thighs (L2) Medial and lateral aspects of both calves (L4 and L5) Little toes (S1) 3. Sensation—temperature: With patient’s eyes closed. say. test sensation to pain (sharp object. One finger on each hand. 687). not top and bottom) of the following: • • Both big toes. 2011 . Be clear with your verbal instructions to the patient. Compare symmetric areas on both sides of the upper and lower extremities. Sensation—pain: With patient’s eyes closed.1. say. testing one side at a time. Test vibratory sensation with the 128 Hz tuning fork over • • the DIP of one finger on each hand the interphalangeal joints of both big toes 5. Sensation—light touch: With patient’s eyes closed. Test position sense (by holding the sides of the joint. Test both hands UTHSCSA Head to Toe Physical Examination for Medical Students. last edit April 7. test temperature sensation using your tuning fork (cool sensation). Rapid alternating movements: Have patient alternate striking palm and back of hands on thighs as quickly as they can (p. Be clear with your verbal instructions to the patient. Test discriminative sensation in one hand by • stereognosis • number identification (graphesthesia) Cerebellar Function / Coordination 1. • Both upper arms • • • Both lower arms Fronts of both thighs Both lateral calves 4. “Can you feel this equally on both sides?” • • • • • • Both shoulders (C4) Inner and outer aspects of forearms (C6 and T1) Thumbs and little fingers (C6 and C8) Fronts of both thighs (L2) Medial and lateral aspects of both calves (L4 and L5) Little toes (S1) 2. please do not use safety pins with standardized patients). Ask the patient to tell you when they feel a cool touch. Compare symmetric areas. test sensation to light touch (cotton ball).

Point-to-point testing by “finger to nose”. have them open eyes. 3.2. 5. toe walk 4. have the patient hold their arms out straight with palms up and close their eyes. last edit April 7. Romberg: Have patient stand for at least 20 seconds with arms at their sides. heel walk. if they start to lose balance). tandem walk (heel to toe). and eyes closed (be prepared to stop the test. Gait – • • • • normal walking. 2011 . Have them hold this position for at least 20 seconds to observe any movement or pronator drift UTHSCSA Head to Toe Physical Examination for Medical Students. Test for pronator drift: Have patient stand or sit (if you are worried about their balance). feet together. Test both sides.