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General Assessment
- Seated on exam table
- Proper draping
- Introduce self to patient
- Wash hands before touching patient
- Verbalize a general assessment: Well dressed, well nourished, no acute distress, hygiene, posture, gait (limp, balance, discomfort, fear of falling), speech, grooming, facial expressions, anxiety or depression, body habitus (slender, muscular, stocky, emaciated, plump, obese, fat distribution over the trunk or torso or hips), motor activity (fast and frequent, slowed activity, tremors, involuntary movements, paralysis), laces, hair and dress style, piercings
- Vitals: BP, P, RR in both arms
- Inspect skin and nails with verbalization: head, face, neck, upper extremities, nails (chewed, long, dirty, trimmed)
- Palpate skin: turgor, texture, temp, moisture, lesions, pallor, edema, moles (ABCDE)
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Head & Eyes
- Verbalize inspection of facial features: facial features, expression, contours, asymmetry, tics, spasms, edema, masses, eyebrows, eyelids
- Test for facial muscle function (CN VII): Raise eyebrows, close eyes, smile, frown and puff cheeks
- Inspect & Palpate hair, scalp, skull: tenderness, hair distribution
- Palpate facial bones: tenderness, abnormalities, including globes of eyes
- Sinus palpation: frontal & maxillary
- Palpate TMJ ROM: crepitus, pain
- Palpate masseter muscles strength (CN V): clench teeth, feel muscle
- Test face for light touch & pain (CN V): sharp dull, Q-tip and cotton wisp
- Test visual acuity (CN II): eye chart, note corrected or uncorrected
- Visual fields: Fish bowl, 3 fields
- Test extraocular movements (CN III, IV, VI): Giant H, bring it in close, make em x-eyed
- Test accommodation (near reaction): Look at my finger and far away
- Inspect sclera, conjunctiva, iris, pupil with verbalization: pull down lower lids and have pt look up, pupil (size, shape, symmetry, anisocoria)
- Assess depth of anterior chamber: from side
- Check corneal light reflex and verbalize: shine light on middle of nose
- Test direct pupillary light reflex (CN III): constriction
- Test consensual pupillary light reflex: constriction
- Ophthalmoscopic exam (lights dim): look at spot on wall
- Verbalize red reflex & fundus landmarks: optical disk, retina, macula, fovea, follow blood vessels in 4 quadrants
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Ears, Nose, & Throat
- Inspect external ear and verbalize: auricles
- Check hearing (CN VIII): whisper test, Plug one ear moves fingers away “tell me when you can hear anymore”
- Weber verbalize: lateralization, equal
- Rinne verbalize: bone conduction from mastoid, AC > BC
- Palpate external ear: press tragus and mastoid
- Otoscopic exam with verbalization of TM appearance: TM pearly gray with bony landmarks and cone of light intact bilaterally
- Inspect external nose with verbalization: color, size, position, shape, nares for discharge
- Palpate nose: tenderness
- Test nasal patency bilaterally: plug nose
- Sense of smell (CN I): close eyes, one side at a time
- Nasal speculum exam with verbalization: middle and inferior turbinates, mucosa (color, swelling, bleeding, exudate), septum (deviation, inflammation, perforation), abnormalities (ulcers, polyps), discharge (clear, mucopurulent, purulent)
- Inspect mouth with verbalization: lips, teeth gums, buccal mucosa, tongue, floor, hard and soft palate, oropharynx, tonsils (symmetrical, 1+, 2+, 3+, 4+), Wharton’s ducts (submandibular), Stensen’s ducts (parotid, lateral 2nd molar), sublingual glands
- Say “Ah” (CN X): movement of uvula
- Test tongue (CN XII): protrusion & side-to-side
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Neck
- Inspect neck: verbalization, muscle symmetry, trachea (swallow water, midline, no tugging), triangles landmarks, fullness at base of neck, masses, webbing, excess skin folds, unusual shortness, asymmetry, carotid artery prominence, jugular vein distension, deformities
- Neck ROM: Flex, extend, rotate, and lateral flexion
- Check lateral neck rotation against resistance (CN XI): against hand
- Check shoulder shrug against resistance (CN XI): against hand
- Palpate lymph nodes: preauricular, postauricular, occipital, tonsillar, submandibular, submental, anterior cervical, posterior cervical, deep cervical and supraclavicular lymph nodes
- Palpate cervical spine and trapezius: tenderness, muscle symmetry
- Palpate carotid arteries bilaterally: one at a time, strength and regularity
- Auscultate carotids bilaterally for bruits: one at a time
- Palpate tracheal position: alignment, location of landmarks
- Palpate thyroid gland: Find thyroid, swallow water to feel for isthmus, Turn to one side and then the other to feel lobes; feel size, shape, configuration, consistency, tenderness, nodules, auscultate enlarged gland
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Upper Extremities
- Inspect UE with verbalization: Symmetrical with no obvious deformity
- Palpate shoulders & verbalize landmarks: SC, clavicle, AC, subacromial bursa, biceps groove, deltoid and scapula
- Palpate elbows & verbalize landmarks: Medial and lateral condyles and radial head
- Palpate wrists & verbalize landmarks: palpating carpals, scaphoid (anatomical snuff box)
- Palpate hands/fingers & verbalize landmarks: MCP, fingers are PIP (proximal interphalangeal joint) and DIP, thumb is IP
- Check shoulder ROM (flex, ext, abduct, adduct, int rot, ext rot): cross arms, arms behind ears, arms behind your back, lift arms up, put arms back
- Strength test shoulder abduction & adduction: winging up and down
- Check elbow ROM (flex, ext, pronate, supinate): curl, straight, hold your soup, dump your soup
- Strength test elbow flexion & extension: Boxers guard “push toward me, pull toward yourself”
- Check wrist ROM (flex, ext, ulnar & radial dev.): flex (motorcycle) extend down, thumb radial, ulnar pinky
- Strength test wrist flexion & extension: keep fist clenched in boxer guard, push and pull
- Test grip strength: grasp fingers of examiner
- Extend & spread fingers against resistance: push fingers together two at a time
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Pulmonary/Chest
- Inspect body habitus with verbalization: Remove gown, have pt sit upright, transverse diameter vs anteroposterior diameter, skin wdp, no deformities
- Comment on breathing pattern and chest symmetry: “breathing is symmetrical and non-labored”,
- Palpate posterior and lateral thorax, with verbalization: palpate superior to inferior and posterior lateral chest wall “do you have any tenderness?”, feel for crepitus (air in subcutaneous tissue), friction rub (grating vibration)
- Palpate for thoracic expansion: thumbs mid line and watch breathe
- Palpate for posterior tactile fremitus (“99”, “1,2,3”): Two times medially and one time laterally, ↓ due to edema/emphysema, ↑ due to consolidation/solid mass
- Percuss posterior & lateral lung fields: 5 medial and 2 lateral lung fields, hyperresonance = hyperinflation, dullness = fluid or solid
- Percuss diaphragmatic excursion: deep breath and blow all your air out and hold
- Fist percussion of spine and CVA’s: Costal Vertebral Angle
- Auscultate for breath sounds post. & laterally: 5 medial and 2 lateral lung fields; stridor, wheezes, crackles/rales, rhonchi; vesicular in most lung fields (soft, low pitched, inspiration > expiration in asthma), bronchovesicular over main bronchus and R upper posterior lung (medium pitch, inspiration = expiration), bronchotracheal (loud, high pitched, expiration slightly > inspiration)
- Inspect anterior chest, with verbalization: “symmetrical with no deformity”
- Palpate anterior chest: Superior to inferior squeeze chest wall
- Palpate for anterior tactile fremitus: “99”, two times medially and one time laterally
- Percuss anterior chest: 4 medial and two lateral fields
- Auscultate anterior chest for breath sounds: 12 fields, breathe thru mouth
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Cardiac
- Auscultation should include aortic, pulmonic, tricuspid, and mitral areas
- Patient supine 30°
- Measure JVP: Right angle to GROUND, measure chest to angle
- Inspect chest wall for PMI and verbalize: Look at precordium for point of maximal impulse
- Palpate precordium and verbalize: lifts, heaves, thrills,
- Palpate axillary lymph nodes: Tea Cup
- Auscultate 5 key areas with diaphragm: R 2nd intercostal (aortic) L 2nd (pulmonic), L 3rd intercostal (2nd pulmonic), L 4th intercostal (tricuspid), Apex for Mitral; listen for S1, S2, S1—S2, S2—S1, and murmurs.
- Auscultate 5 key areas with bell: R 2nd intercostal (aortic) L 2nd (pulmonic), L 3rd intercostal (2nd pulmonic), L 4th intercostal (tricuspid), Apex for Mitral; listen for S1, S2, S1—S2, S2—S1, and murmurs.
- Auscultate apex in LLD: Roll on Left Side, same field
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Abdominal
- Inspect abdomen with verbalization: “skin, pulsation, raise your head”
- Auscultate abdomen: four quadrants
- Auscultate aorta for bruits: listen once for all
- Auscultate renal, iliac, and femoral a. for bruits: listen once for all
- Percuss all four quadrants of abdomen: tympany
- Percuss for liver size in RUQ: mark
- Percuss for splenic dullness: “breathe in” percuss, should be absent of dull sound
- Palpate four quadrants lightly: Light wave
- Palpate four quadrants deeply: Deep wave
- Palpate for liver in RUQ: press deep
- Palpate for spleen in LUQ: press deep
- Palpate for kidneys with verbalization: do the kidney sandwich, “I don’t feel the kidney”
- Palpate abdomen aorta for size: walk fingers out, 2cm
- Palpation of inguinal lymph nodes and femoral pulses: listen for bruits
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Lower Extremities and Back
- Patient Supine:
- Inspect hips, legs & feet with verbalization: skin wdp, symmetrical with no deformities
- Palpate hips, knees, ankles, feet for bony landmarks: iliac crest, malleolus,
- Palpate popliteal fossa: tenderness
- Palpate calf and Achilles tendon: tenderness
- Palpate ankle/foot: edema
- Palpate posterior tibial pulse: strength
- Palpate dorsalis pedis pulse: strength
- Check hip ROM: flexion, abduction, adduction, internal & external rotation
- Patient Seated:
- Strength test hip flexion and extension: “push up against my hand w knee, pull back w knee”
- Strength test knee flexion & extension: hold ankle push and pull
- Check ankle ROM: dorsiflexion, plantar flexion, inversion, and eversion
- Strength test ankle: dorsiflex & plantar flexion
- Check toe: flexion and extension
- Patient Standing, Back to Clinician:
- Inspect spinal curvature with verbalization: “spine is midline”
- Palpate or percuss spine: tenderness
- Inspect spine ROM: flexion, extension, lateral bending, & rotation, hold pts hips
- Observe patient’s gait, with verbalization: Walk TURN AROUND AND COME BACK
- Observe patient Heel-to-Toe walking: Walk and come back
- Patient Standing, Facing Clinician:
- Romberg test (feet together, eyes closed): Eyes open, then closed, Watch for 30 seconds; (open cerebellar problem, closed proprioception problem)
- Pronator Drift: Eyes closed, arms out, palms up, wait 20 seconds, push down gently on forearms
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Neurological
- Patient seated:
- Verbalize behavior, orientation, and level of consciousness: “pt is conscious, alert and oriented to ppte and exhibits appropriate behavior”
- Check patient’s recall (3 objects): watch, ball, pen
- Check remote memory (3 past events): last 4/5 presidents
- Check calculations: serial 7’s (100, 93, 86, 79, 72, 65)
- Finger-to-nose testing bilaterally: finger to nose stable, move, then stable fast, then close eyes
- Heel-to-shin testing bilaterally: run heel down shin to toe
- Light touch and pain sensory testing, upper and lower extremities (sharp/dull):
- Rapid Alternating Movements Upper and Lower: Patty cake and feet tapping
- Vibration: Tuning fork on big toe and thumb, Vibrate, wait a few seconds, dampen
- Position sense (lower extremity): Close eye move toe up and down
- Stereognosis or graphesthesia: key in hand, draw number on palm w closed eyes
- 2 Point Discrimination: Paperclip thumb, middle and pinky
- Biceps DTR’s: hammer strikes thumb
- Triceps DTR’s: Marionette position
- Brachioradialis DTR’s: radial forearm
- Knee DTR’s: hammer
- Achilles DTR’s: hammer
- Plantar reflex bilaterally (Babinski): toes extend
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