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 State to patient “I am inspecting your neck. consistency. and tenderness. Examine the dorsum. Verbally identify each set of nodes as you palpate: a. and texture of the extended tongue. Occipital b.b. 2. swelling. Tonsillar e. tonsils. Supraclavicular 2. 3. Identify the parotid duct openings and the submandibular gland duct openings.” • Eyebrows for hair quantity and distribution and condition of the skin • Eyelids and lacrimal apparatus for color. Test for direct and consensual pupillary reaction to light. symmetry. Ask the patient to follow your finger with their eyes as you move through the six areas. Inspect the position and alignment of the eyes. delimitation. lesions • Conjunctiva and sclera for color. shape and symmetry. Posterior cervical i. last edit April 7. Inspect and gently palpate the floor of the mouth. Inspect the teeth for color. Submandibular f. Now I am looking at the conjunctiva and your cornea. d. Test extraocular muscle function in each eye through the six cardinal fields of gaze. State to patient “I am inspecting your pupils. Inspect the following and state what you are doing: “I am looking at your eyebrows. Posterior auricular c. or absence of teeth. 6. UTHSCSA Head to Toe Physical Examination for Medical Students. mobility.” 4. “ah” Neck 1. 4. You must have the patient swallow (can use a sip of water) to aid your examination. nodules. Palpate the tongue for induration or masses. masses. 5. and pharynx. Note color. Observe the movement of the soft palate and uvula when the patient says. Palpate the following lymph nodes noting size. Assess visual acuity of each eye with a hand held visual acuity card held 14 inches from the patient. shape. Preauricular d. swelling (must pull eyelids down) • Cornea and lens for opacities. Inspect the anterior and posterior pillars. Each eye should be tested separately (cover non-tested eye). 5. 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. 3. Submental g. and undersurface of the tongue. Superficial cervical h. Inspect the neck for symmetry. eyelids. ------------------------------------------------------------------------------------------------------------------------------------------ EXTERNAL EYE EXAMINATION 1. 2011 . Inspect the symmetry. sides. Palpate the thyroid gland from the front or from behind the patient. c.” 2. deformity. and lesions. and thyroid enlargement. color. Deep cervical chain j. It is good practice. 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. Measure respiratory rate for 15 seconds. middle. 2. but you are not required to report blood pressure. 4. or lateral edge of hands on pinky side) and having patient say “99” or “toy boat”. Do not have to report respiratory rate. Inspect (state. cuff positioned correctly. Percuss the posterior chest wall comparing sides sequentially and bilaterally: start with the upper fields. Do not have to report heart rate. 3. then lower lung fields (top to bottom) 6. as the patient (1) breathes deeply (2) through an open mouth. and lower lung fields 8. Palpate the posterior chest for masses or tenderness using moderately firm pressure. Anterior Thorax (the patient may be seated or supine) 1. VITAL SIGNS 1. Palpate the anterior chest in the upper fields only 3. last edit April 7. Rosende in his fall lecture.” 2. Measure blood pressure in one arm. 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. 5. Test for convergence. Compare sides sequentially and bilaterally in upper. Palpate for tactile fremitus using bony portion of hand (palmar side of knuckles. Percuss and measure diaphragm excursion from full expiration to full inspiration on both sides 7. “I am inspecting the back of your chest. then middle fields. Test chest expansion (respiratory excursion) with hands wrapped around the lower portion of the ribs with thumbs pointing upward.6. 7. comparing symmetric areas. middle. 2011 . State. Compare sides sequentially and bilaterally in upper. Auscultate the lungs with the diaphragm of the stethoscope. Reveal to standardized patient that you measured respiratory rate after doing so in a hidden manner. 3. Use either the method described in Bates or by Dr. stethoscope positioned correctly (bell or diaphragm is okay). --------------------------------------------------------------------------------------------------------------------------------------------- CHEST AND LUNG EXAM Posterior Thorax 1. Measure heart rate with finger pads (not thumb) in one radial artery for 15 seconds. Inspect posterior chest for lesions or swelling. and lower lung fields. 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.”) anterior chest 2. “I am inspecting the front of your chest. Arm should be at heart level. Palpate the popliteal pulse (behind knee in tibial side of knee crease) in both legs using the pads of your first and second fingers. 4. ------------------------------------------------------------------------------------------------------------------------------------------- CARDIAC EXAM Neck 1. 2. 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. last edit April 7. Palpate the brachial pulses in both arms using the pads of your first and second fingers. Palpate right and left radial pulses using the pads of your first and second fingers. 3.4. State to patient “I am listening for extra heart sounds with the bell of my stethoscope. but we prefer you use the pads of your fingers). Using the diaphragm. Auscultate under the right breast or mid-axillary line over the right middle lobe with the diaphragm of the stethoscope. left lower sternal border (tricuspid) and apex (mitral). 11. 3. Palpate the femoral pulse (in the groin crease) in both legs using the pads of your first and second fingers. never occlude both sides at the same time. You do not need to report this finding. Using the ball of the hand. S4). If table is flat or >45 degree angle. NOTE: Assess only one artery at a time. Using the bell placed lightly to the chest. Perform the Allen test for patency of the radial and ulnar arteries in one arm 7. You must have patient hold his/her breath during this maneuver. Palpate the dorsalis pedis pulse (on middle of top of foot) in both legs using the pads of your first and second fingers. left second interspace (pulmonic). Palpate the apical impulse (also known as the PMI – point of maximal impulse) using your finger pads. It is fine to position the patient in the left lateral decubitus position for this maneuver. 8.). 2. 10. You should auscultate in all 4 areas sequentially – right second interspace (aortic). 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. Measure the distance in cm above the sternal angle. UTHSCSA Head to Toe Physical Examination for Medical Students. 9. 2011 . you will be counted incorrect. Heart 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). Auscultate both carotid arteries for bruits (can use diaphragm or bell). auscultate the apex (mitral area) and left lower sternal border (tricuspid) for extra heart sounds (S3. Identify the right internal jugular vein with the head of the exam table raised to 30 degrees. 10th ed. Place the patient in the left lateral decubitus position if necessary to locate the pulse. left lower sternal border (tricuspid) and apical (mitral) areas for thrills. This area must be exposed during the examination. pulmonic. 6. Palpate the carotid pulse in both carotid arteries using the pads of your first and second fingers (Bates says thumb is okay. palpate the aortic.” PERIPHERAL VASCULATURE: 5. Lightly palpate all four quadrants. noting any muscular resistance or tenderness. last edit April 7. ------------------------------------------------------------------------------------------------------------------------------------------ ABDOMEN 1. 2. 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. Palpate for the lower edge of the liver with deep palpation (Bates pages 441. PERIPHERAL LYMPH NODES Examine both sides of the body.” You must have the abdomen fully exposed. 10. Inspect the abdomen – contour.12. lesions. BACK Percuss the costovertebral angle (CVA) on both flanks with your fist to examine for tenderness (Bates pg 446). State to patient “I am inspecting your abdomen. Auscultate the abdomen for bowel sounds. If the patient complains of pain. Palpate the aortic pulse in the abdomen 9. 6. (You may wear gloves to examine the axillae and groin) 1. State to patient “I am looking for swelling in your feet and legs. palpate both axillae for axillary nodes (note in Bates pages 392 and 475 the areas of central. Do not perform the “hooking technique”. Palpate for the spleen with the patient in the supine position and/or while lying on his/her right side (Bates pages 444-445. start in the quadrant farthest away from the area of pain. 2011 . Percuss lightly in all four quadrants to assess the distribution of tympani and dullness 5. Auscultate for an aortic bruit 4. Palpate each upper extremity for epitrochlear nodes (Bates page 475) 3. anterior. Identify where you have located the edges of the liver. symmetry. This area must be exposed during the examination. 3. Deeply palpate all four quadrants. noting any tenderness. Palpate each groin for the superficial inguinal nodes (Bates page 476). 2.” 13. or pulsations 8. Inspect for edema in the foot and lower leg. Palpate for pitting edema on both legs using firm pressure over the dorsum of the feet and/or anterior lower legs (shin area). 10th ed). 7. With the patient’s arms down and relaxed. 10th ed). masses. posterior and lateral) This area must be exposed. before palpation/percussion. You must hold pressure for at least five seconds. ---------------------------------------------------------------------------------------------- UTHSCSA Head to Toe Physical Examination for Medical Students. ” • Palpation of distal radius and ulna on lateral and medial surfaces. 2011 . 592). extension. adduction. abduction. extension. rotation. • Active range of motion (AROM—the patient moves their own limb) including forward flexion. State to patient “I am inspecting your spine. groove of joint on dorsal surface and the carpal bones. abduction and adduction 2. and sacroiliac joints • Active range of motion (AROM) of the neck including flexion. State to patient “I am inspecting your elbows. Examine the elbows including: • Inspection of extensor surface of ulna and olecranon process.MUSCULOSKELETAL 1. extension. 593 top picture). supination 3. internal rotation. area exposed (can perform hip extension at the same time) UTHSCSA Head to Toe Physical Examination for Medical Students. radial and ulnar deviation 4. abduction. and biceps tendon (pg. and medial and lateral aspects of each PIP joint and DIP joint • Active range of motion (AROM) of the fingers including flexion. Examine the spine including: • Inspection of posture and spinal curvature from behind.” Only correct if you expose the entire spine and stand behind the patient for this. • Palpation of trochanteric bursa bilaterally (patient lying on their side or back). last edit April 7. State to patient “I am inspecting your wrists. • Palpation of spinous processes of each vertebra. opposition MUSCULOSKELETAL—LOWER EXTREMITIES AND SPINE 1. if necessary. rotation (hold patient’s hips stable. external rotation. extension. the paravertebral muscles.” • • Palpation of olecranon process and epicondyles Active range of motion (AROM) including flexion. subacromial bursa/ supraspinatous insertion (pg. and joint palpation of MCP joints. Examine the shoulders including: • Inspection. extension. State to patient “I am inspecting your hands and fingers. lateral bending • AROM of the spine including flexion. • Examine the hips including: Observation of gait (may include with examination of the spine). pronation. so that the patient moves at the waist only). Examine the wrists including: • Inspection of palmar and dorsal surfaces. extension. extension.” • General palpation of anatomic snuffbox and metacarpals. you must palpate both sides and front and back of wrists • Active range of motion (AROM) including flexion. lateral bending 2. adduction • Active range of motion of the thumb including flexion. State to patient “I am inspecting your shoulders. coracoid process. Examine the hands and fingers: • Inspection of the dorsal and palmar surfaces of the hands and fingers.” • Palpation of acromioclavicular joint. table. Information and Vocabulary: Ask about patient’s work. Ask patient to name three objects and immediately repeat them. favorite music/TV programs. external rotation. month.e. the weather. AROM including dorsiflexion and plantar flexion at ankle 5. or season.” • Palpation with knee in flexion of the patellar tendon. Ask specific facts (i. Recent memory: Ask patient to tell you events about the day (i. state. Stop after 5 answers.. (Give the patient 3 simple nouns to recall: for example. birth date. and flexion of toes --------------------------------------------------------------------------------------------------------------------------------------------- NERVOUS SYSTEM-MENTAL STATUS MENTAL STATUS. 8. internal rotation 3. UTHSCSA Head to Toe Physical Examination for Medical Students. year. last edit April 7. 5. 4. medial and lateral collateral ligaments. hobbies. name of president. 3. vice president. Orientation to place: Do you know where you are right now? Ask for the name of hospital. femoral condyles. extension (if not done in prior step). state to patient “I am inspecting your knees. Examine the feet including: • • • Inspection for deformities and swelling state to patient “I am inspecting your feet”. today’s appointment time)..must have these questions memorized 1. 2.apple. floor. Calculating ability: Ask patient to solve simple arithmetic problems. heel. Achilles tendon). Palpation (metatarsophalangeal joints. name 5 large cities in the US) 9. Orientation to time: Ask patient for the date. day of week. ask patient to spell WORLD backwards. • Examine the knees including: Inspection of contour and swelling. plantar fascia). With the patient supine move the hip through flexion. or county. city. Palpation (anterior ankle.e. AROM including inversion and eversion of foot. Tell the patient you will ask him/her to tell you these 3 words again in a few minutes. and joint lines. 7. Orientation to person: Ask for the patient’s full name.e. Alternatively. 6. penny). jobs held.• Passive range of motion (PROM—you move the patient’s leg – this is different from all the other joints you have examined!). name of schools attended). Ask patient to subtract serial 7s.. current events. 2011 . Remote memory: Ask patient for 1-2 historical events relevant to his/her past (i. abduction. adduction. • AROM including flexion and extension 4. Examine the ankles including: • • • Inspection for deformities and swelling state to patient “I am inspecting your ankles”. 2. Constructional ability: Ask patient to draw a clock complete with numbers and hands and set to a specific time. CN III.” 5. check visual fields 3. 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. “I am listening to/have listened to your voice. Abstract thinking: Ask patient to explain a proverb or similarities.check visual acuity on each eye. Have the patient follow your finger while it makes a large “H” in front of the patient’s face (approximately 1420 inches away). (2) strength of eyelid closure (student must try to open the patient’s closed eyes). Use a different scent for each nostril if possible. CRANIAL NERVES 1. CN VIII– • Test auditory acuity (one ear at a time) using the whisper test or rubbing fingers together. CN II. State. tissue or other soft object. Inspect muscle bulk and tone of the arms and hands. • Test jaw clenching by palpating at jaw for muscle contraction. and (3) smiling and/or puffing cheeks (must do 1. CN III (Optic and Oculomotor) . CN V – • Test sensation on face with the patient’s eyes closed: bilateral at forehead.Test for direct and consensual pupillary reaction to light (must use light source-penlight or otoscope) 4. bilateral cheeks. CN I – Test for ability to smell. VI -Check extraocular muscle function in each eye through 6 cardinal fields of gaze. last edit April 7. State. test one nostril at a time. and 3) 3. CN VII – Test face muscles: (1) wrinkling forehead. Ask patient to repeat the names of the three objects above in #4.” UTHSCSA Head to Toe Physical Examination for Medical Students. CN XII (Hypoglossal) – Test by having patient stick tongue straight out NERVOUS SYSTEM—MOTOR SYSTEM AND REFLEXES Motor System – Upper Extremity 1. 4. “I am inspecting the muscle bulk of your arms and hands. Should compare two sides at the same time and use light touch with finger. 11. 2. bilaterally on chin. CN IX. IV. 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. 2011 . 2.10. 5. Example-“Please draw a clock showing the time 2:30.” 12. T1) thumb opposition (C8. median nerve) Motor System – Lower Extremity 1. T1) finger abduction (C8. note the number of times it does so. C8. C7. move on with the exam. 2011 . Inspect muscle bulk and tone of the legs and feet. C7. radial nerve) finger grip (C7. 702) 3. S2—hamstrings) knee extension (L2. C6) wrist flexors (C6. including (Bates pages 684-686): • • • • • • • • hip flexion (L2.L3. if it does.) • • • • • Biceps Brachioradialis Triceps Knee Ankle 2. L4—adductors) knee flexion (L4.2. including (Bates pages 680-83): • • • • • • • • deltoids (C5.L5. last edit April 7.” 2. C8. L5) ankle plantarflexion (S1) Deep Tendon Reflexes 1. C8. C8) biceps (C5. State.L4—iliopsoas) hip extension (S1—gluteus maximus) hip abduction (L4. S1—gluteus medius and mimimus) hip adduction(L2. L3. “I am inspecting the muscle bulk of your legs and feet. curving medially across the ball (Bates pg. L4—quadriceps) ankle dorsiflexion (mainly L4. L3. Test for ankle clonus: Push foot up (dorsiflex ankle) sharply once and hold to see if foot pushes back down. making sure to isolate the muscle(s) to be tested. L5. making sure to isolate the muscle(s) to be tested. radial nerve) wrist extensors (C6. 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. S1. C7. If you elicit the response with the first attempt. 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 . Test muscle strength bilaterally. T1. Test muscle strength bilaterally. NERVOUS SYSTEM—SENSORY SYSTEM AND CEREBELLAR FUNCTION Sensory System UTHSCSA Head to Toe Physical Examination for Medical Students. C6) triceps (C6. “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. “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. 687). Be clear with your verbal instructions to the patient. please do not use safety pins with standardized patients). One finger on each hand. test sensation to light touch (cotton ball). Test discriminative sensation in one hand by • stereognosis • number identification (graphesthesia) Cerebellar Function / Coordination 1. Sensation—temperature: With patient’s eyes closed. Test position sense (by holding the sides of the joint. Sensation—light touch: With patient’s eyes closed. testing one side at a time. Compare symmetric areas. Rapid alternating movements: Have patient alternate striking palm and back of hands on thighs as quickly as they can (p.holding the DIP 6.use broken end of cotton swab. of the upper and lower extremities. Sensation—pain: With patient’s eyes closed. 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. not top and bottom) of the following: • • Both big toes. Test both hands UTHSCSA Head to Toe Physical Examination for Medical Students. test temperature sensation using your tuning fork (cool sensation).1. last edit April 7. Compare symmetric areas on both sides of the upper and lower extremities. Compare symmetric areas on both sides of the upper and lower extremities. 2011 . • Both upper arms • • • Both lower arms Fronts of both thighs Both lateral calves 4. test sensation to pain (sharp object. say. Be clear with your verbal instructions to the patient. say. Ask the patient to tell you when they feel a cool touch. Test for pronator drift: Have patient stand or sit (if you are worried about their balance). 5. toe walk 4. Romberg: Have patient stand for at least 20 seconds with arms at their sides. have them open eyes. tandem walk (heel to toe). if they start to lose balance). have the patient hold their arms out straight with palms up and close their eyes. and eyes closed (be prepared to stop the test. Gait – • • • • normal walking. Test both sides. Point-to-point testing by “finger to nose”. last edit April 7. feet together. 3.2. heel walk. 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. 2011 .