Always use proper introduction and hand hygiene techniques, offer patient a chaperone, and make sure the patient is comfortable and gives permission for the next tasks. Explain to the patient what you will be doing, and as much as possible, what you are learning/finding as you go along. Some parts of the examination are combined in these checklists (e.g., the skin examination can be done separately, as may occur in a Dermatology office, or as part of the “inspection” in each section of the physical examination. Note to the examiner and patient what you are doing, especially if it may not be clear (For example, “I am inspecting your chest for any scars or other findings on your skin.”) In addition, you may be asked to do a part of an examination (e.g. the Eye Exam), which is otherwise embedded in another checklist (Head and Neck).
The Set the Stage section is important for any parts or combinations of the examination. If you are proceeding from one part of the examination to the next, you (obviously) do not need to “reset” the stage. The same goes for the “Thank patient and exit” statement. Do not do this until you are actually done!
As you proceed through the curriculum and develop new skills and maneuvers (e.g. cardiac murmur accentuation techniques, skillful measurement of the JVP, assessment of tactile fremitus), other skills and parts of the examination will be added to these lists (in FMS 511–513, and then in your clerkships).
Note
The Set the Stage and Summary and Close checklists are common to all examinations and are not repeated in each checklist.
Use at start of any examination or combination of examinations.
Student knocks on the door and asks permission to come into the room.
- Student addresses and greets patient, asks how patient wishes to be addressed.
- Student introduces self with first name, last name, and title (medical student).
- Washes/sanitizes hands.
- Student asks for permission to proceed with the examination.
- Student thanks patient for willingness to cooperate.
Student assesses patient needs including time constraints, request for a chaperone, need for interpreter as appropriate, or other requirements.
Summary and Close of the Examination
Use at the end of any examination or combination of examinations.
This is the last part of the examination/station.
- Student thanks the patient.
- Washes hands
- Let patient know they may get dressed and that student will leave the room to discuss with the preceptor.
Vital Signs Examination
Student seeks permission to expose patient as necessary.
Student observes general appearance of patient.
Student assesses pulse in both radial arteries, making a note of rate and rhythm to the examiner.
Student measures blood pressure in both arms, using stethoscope.
Orthostatic Blood Pressure (Optional in year 1)
Student measures blood pressure and pulse after positional changes
Student measures respiratory rate, noting this to examiner.
Skin and Nails Examination
Student seeks permission to expose patient as necessary.
Student examines hands and fingernails.
Student examines the remainder of the skin, exposing it where necessary, throughout the remainder of the physical exam.
Head and Neck Examination
Student seeks permission to expose patient as necessary.
Examine the Head and Face
- Student seeks permission to and performs general inspection of patient’s head and scalp.
- Observe, inspect, and palpate head, face, hair, scalp, skull. Palpate lymph nodes, parotid and other salivary gland regions.
Student asks patient to bite down while palpating masseter muscles, touch facial skin bilaterally on forehead, cheeks, mandibular regions (CN V)
Student asks patient to raise eyebrows, squeeze eyes shut, and show teeth (CN VII).
Examine the Eyes
Student tests visual acuity using hand-held card.
Student tests visual fields to confrontation.
Student examines external eye structures: lids, lashes, conjunctiva, sclera, cornea, anterior chamber, and iris.
Student tests extraocular movements (CN III, IV, VI).
Student tests corneal light reflection and compare size and shape of pupils.
Student tests pupils for direct and consensual reaction to light and to accommodation (CN II, III).
Student uses ophthalmoscope appropriately and describes red reflex, blood vessels, retinal background (color), optic cup and disc, and macula.
Examine the Ears
Student inspects auricle and mastoid, palpate helix and tragus for tenderness.
Student uses otoscope to examine external canal and tympanic membrane, describing appearance and landmarks
After requesting that patient close eyes, student tests hearing by rubbing fingertips a few centimeters from both ears, one at a time.
Examine the Nose and Mouth
Student inspects the external nose.
Student uses otoscope to examine the nares, nasal cavities, septum, and turbinates.
- Student inspects the lips, mucosa, tongue, floor of mouth, palate, tonsils, and oropharynx.
- Student inspects the teeth and gums.
Student asks patient to phonate and inspects palate and uvula (CN IX and X).
Student asks patient to extend and move tongue (CN XII).
Examine the Neck and Thyroid
Student examines the neck for asymmetry.
Student examines neck range of motion.
Student asks patient to shrug shoulders and rotate neck bilaterally against resistance (CN XI).
Student palpates lymph nodes in anterior and posterior cervical triangles, submandibular, supraclavicular, and infraclavicular areas.
Student inspects the thyroid gland by standing behind or in front of patient and palpates the thyroid gland.
Chest and Respiratory Examination
Student seeks permission to expose patient as necessary.
- Student seeks permission to and performs general inspection of patient’s chest.
- Student observes respiratory effort, inspects anterior and posterior thorax for scars, deformity, and symmetry.
Student assesses radial pulse and respiratory rate if not done previously, noting this to the examiner.
Student notes tracheal position.
Student places hands on posterior chest and asks patient to breathe in to expand the chest.
Student percusses the lung fields.
Student auscultates the lungs on the anterior, lateral, and posterior aspects of the chest.
Cardiovascular Examination
Student seeks permission to expose patient as necessary.
Student seeks permission to and performs general inspection of patient’s chest and precordium.
Student inspects and assesses hands: temperature, capillary refill time (later, clubbing).
Student assesses radial pulse and respiratory rate while doing so, making a note of this to the examiner.
Student assesses carotid pulse (one at a time).
Student inspects eyes for conjunctival pallor (later, xanthelasma, corneal arcus).
Student inspects mouth for perioral cyanosis.
Student auscultates each heart valve in appropriate location. Student notes heart rate and rhythm.
- Student palpates for apex heartbeat (point of maximal impulse).
- Later, student also palpates for heaves and thrills.
Student assesses bilateral carotid (if not done earlier), brachial, femoral, posterior tibialis, and dorsalis pedis pulses (remember to seek permission for femoral and to remove socks for pulses on feet).
Inspect for sacral edema and for peripheral (ankle/leg) edema.
Abdominal Examination
- Student seeks permission to expose patient as necessary.
- Student stands on right-hand side of patient’s body.
Student seeks permission to and observes abdomen for shape, distention, scars, masses, and visible enlargement of liver or spleen.
- Student listens with diaphragm of stethoscope to all 4 quadrants, noting bowel sounds.
- Student listens for bruits centrally and over renal arteries.
Student percusses the abdomen in all quadrants. Student percusses liver span.
- Student palpates all quadrants superficially, then deeply (think about what is in each area).
- Student palpates liver and spleen, identifies liver edge with inspiration.
- Student palpates region of the abdominal aorta.
Student seeks permission and palpates inguinal areas for lymph nodes, femoral pulses.
Student performs percussion of costovertebral angles for tenderness.
Basic Neurological Examination
Student seeks permission to expose patient as necessary.
Student grossly evaluates mental status (e.g., asking patient to name a person, the place, and date)
- Student assesses gait by asking patient to stand from seated position, and asks patient to walk across room, turn, and walk back.
- Student asks patient to stand in one place with eyes closed (assuring that student can catch/support patient in case of a fall) [Romberg].
- Student assesses tandem gait as a test of balance if appropriate (heel-to-toe walking).
- Student assesses heel walk and toe walk.
Student inspects skull and palpates along spinous processes.
- Assure no injury to cervical vertebrae or spine.
- Student assesses for Brudzinski’s sign.
- Student assesses for Kernig’s sign.
- Student assesses straight-leg raise.
Student assesses cranial nerves:
- Smell (or describes): CN I
- Visual acuity and visual fields: CN II
- Pupillary response to light: CN II + III
- Extra-ocular movements: CN III, IV, VI
- Facial sensation and motor; also, corneal reflex: CN V (know how to do and to describe)
- Facial expression, closing eyes: CN VII
- Hearing: CN VIII
- Gag, palate rise: CN IX, X
- Neck turn/shoulder shrug: CN XII
- Tongue protrusion/movement: CN XII
Student examines extremities for symmetry, muscle bulk, and tone.
- Student tests upper extremity strength: shoulder abduction, elbow. flexion/extension, wrist flexion/extension, grip strength, and finger abduction.
- Student tests upper extremity (pronator) drift.
Student tests lower extremity strength: hip flexion, knee flexion/extension, and foot dorsi/plantar flexion.
Student tests sensation to light touch, vibration (using tuning fork, over 1 bony prominence per extremity, e.g., an MCP joint), and proprioception.
Student tests cerebellar function with either finger to nose to finger, or heel to shin, or rapid alternating finger movements.
- Student tests deep tendon reflexes bilaterally: biceps, triceps, brachioradialis, patellar, Achilles.
- Student tests plantar response (Babinski).
Note
Remember that motor tests (for strength, tone, bulk/atrophy) are part of the neurological examination. The musculoskeletal examination examines bones and joints separately.
Guidance for the Neurological Examination
Click here for more details on the Neurological Examination.
Basic Musculoskeletal Examination
Student seeks permission to expose patient as necessary.
Student examines extremities for deformity, asymmetry, atrophy.
Student palpates extremities, muscle groups, and joints for tenderness, warmth, tightness (spasm), and anatomic landmarks.
Student tests range of motion in appropriate joints, measure when possible (goniometry).
Student uses maneuvers as appropriate for testing of ligaments, tendons, and cartilage.
Mental Status and Health Examination
Student seeks permission to assess patient both alone and, if possible, again with family/peer support.
Student observes level of consciousness, posture and motor behavior, dress, grooming, personal hygiene, and behavior, including eye contact.
Student observes mood (subjective) and affect (objective).
Student observes verbal speech (rate, volume, fluency) and written language (appropriate/inappropriate for educational level).
Student observes thoughts for content and perceptions, insight, and judgment.
Student observes orientation, attention, remote memory, and recent memory; executive function, uses screening tool as appropriate.
Note
The following examinations are taught in more detail in year 2 of the Art and Practice of Medicine.
Breast Examination
Student seeks permission to expose patient as necessary.
Student inspects the breasts for asymmetry, nipple inversion, skin changes.
Student palpates the four axillary lymph node groups on both sides.
- Student positions patient supine, gown lowered on one side, with ipsilateral hand above or behind head.
- Student palpates breast tissue using circular movements and three different levels of pressure, in vertical strip pattern, avoiding jumping of fingers.
Female Genitalia and Rectum Examination
- Student seeks permission to conduct examination and to expose patient as necessary.
- Ask patient to remove undergarments if they have not done so.
Student performs abdominal examination; supine portion of breast examination is also performed here if breast and pelvic examinations are being performed together.
Student performs percussion of costovertebral angles for tenderness.
- Student, chaperone assist with positioning of patient in lithotomy position, maintaining patient’s drape from waist down, opening footrests with leg support still in place, and helping patient place heels in footrests with appropriate width in between.
- Standing at patient’s side, asks patient to move so that end of table does not interfere with bimanual/speculum examination.
- Student sits on rolling stool and moves into position for examination. With explanation, student lifts drape to knees and folds it back; indents drape to allow patient to see student.
- Student, wearing gloves and with explanation, inspects external genitalia, including areas hidden by skin folds.
- If swelling or lesion is noted, student palpates for consistency, tenderness.
- Student chooses appropriate speculum, assistant/student applies gel.
- Student conducts speculum examination with care, using explanations throughout.
- Student visualizes cervix between speculum blades.
- Student notes cervical discharge and samples, if necessary.
- Student uses cervical broom or spatula/brush for endocervical cell and transformation zone sampling (PAP smear).
- Student examines vaginal mucosa as speculum is removed.
- Student examines for rectocele/cystocele by asking patient to bear down with speculum partially inserted.
- Student stands, explains next step; applies lubricant to fingers.
- Student uses appropriate technique to palpate vaginal walls and to note cervical position, size, consistency, mobility, and tenderness.
- Student palpates uterus (non-dominant hand above drape, on lower abdomen).
- Student examines adnexa with appropriate hand placement.
- Student re-gloves.
Student explains purpose of examination. - Student examines rectum with index finger in vagina, middle finger in rectum, abdominal hand visible to patient.
- Student examines retroverted uterine wall/size through rectal wall.
- Student examines rectal vault/walls
Male Genitalia, Rectum, and Prostate Examination
Student seeks permission to conduct examination and to expose patient as necessary. Ask patient to remove undergarments if they have not done so. Decide if the examination will be done on the examination table or standing up.
- Student gently palpates testes for consistency, size. If appropriate, student uses transillumination to distinguish hydrocele from testicular tissue.
- Student palpate and identifies any discrete abnormalities in the collection of tissues known as the spermatic cord (vas deferens, testicular artery/vein, ilio-inguinal nerve, lymphatics, and fatty tissue), from the epididymis to the inguinal canal.
- Evaluation for inguinal hernia
- With patient standing, student asks patient to bear down (Valsalva) or cough (patient should turn head first) while student observes inguinal region.
- Examining right inguinal region, place index finger of right hand along spermatic cord, inverting scrotal skin to trace cord to its emergence from the external ring of the inguinal canal.
- Student asks patient to repeat maneuvers that increase intra-abdominal pressure and notes any bulging tissue.
- Student repeats examination on left side, using reversed hand positioning.
- (Standing) Student instructs patient to turn around and rest chest on examination table. Student remains seated. If patient cannot stand, the examination may be performed with the patient lying on the examination table. Student helps patient to lie on side, with knees tucked under chest, and back as close to edge of table as possible.
- Student separates buttocks and examines peri-anal area.
- Student provides patient with tissues/box for self-cleaning at end of examination.
- Student applies lubricant to index finger of examination hand.
- Student informs patient of each step of examination, asking questions, and making patient feel comfortable.
- Student places well-lubricated finger against anus.
- Student asks patient to bear down (Valsalva), while student pushes finger gently into anal canal, noting resistance.
- Student rotates finger to left, right, then directly back toward self and along sacrum.
- Student’s finger should be directed anteriorly (toward patient’s umbilicus), resting on prostate gland.
- Student palpates prostate gland through rectal wall.
- Student assesses rectal tone (can be done earlier in examination)
- Student examines stool on finger at end of examination. In clinic, as appropriate: student uses stool guaiac card to test stool smear.
- Student allows patient to clean up and dress with some privacy.
- Student removes glove using appropriate method, which inverts it on removal.
References
- Bates’ Visual Guide to Physical Examination, 5th edition.
- Bickley, L.,Bates’ Guide to Physical Examination and History Taking, 12th edition.
- Goldberg C, University of California San Diego School of Medicine Practical Guide to Clinical Medicine, https://meded.ucsd.edu/clinicalmed; last accessed April 24, 2018.