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 patients 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 patients 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.
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b. Inspect the teeth for color, deformity, or absence of teeth. c. Inspect the symmetry, color, and texture of the extended tongue. Examine the dorsum, sides, and undersurface of the tongue. d. Inspect the anterior and posterior pillars, tonsils, and pharynx. Note color, symmetry, and lesions. 3. Identify the parotid duct openings and the submandibular gland duct openings. 4. Palpate the tongue for induration or masses. 5. Inspect and gently palpate the floor of the mouth. 6. Observe the movement of the soft palate and uvula when the patient says, ah

Neck
1. Inspect the neck for symmetry, masses, and thyroid enlargement. State to patient I am inspecting your neck. 2. Palpate the following lymph nodes noting size, shape, delimitation, mobility, consistency, and tenderness. Verbally identify each set of nodes as you palpate: a. Occipital b. Posterior auricular c. Preauricular d. Tonsillar e. Submandibular f. Submental g. Superficial cervical h. Posterior cervical i. Deep cervical chain j. Supraclavicular 2. Palpate the thyroid gland from the front or from behind the patient. You must have the patient swallow (can use a sip of water) to aid your examination. ------------------------------------------------------------------------------------------------------------------------------------------

EXTERNAL EYE EXAMINATION

1. Assess visual acuity of each eye with a hand held visual acuity card held 14 inches from the patient. Each eye should be tested separately (cover non-tested eye). 2. Inspect the position and alignment of the eyes. 3. Inspect the following and state what you are doing: I am looking at your eyebrows, eyelids. Now I am looking at the conjunctiva and your cornea. Eyebrows for hair quantity and distribution and condition of the skin Eyelids and lacrimal apparatus for color, swelling, lesions Conjunctiva and sclera for color, nodules, swelling (must pull eyelids down) Cornea and lens for opacities, 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, shape and symmetry. State to patient I am inspecting your pupils. 4. Test for direct and consensual pupillary reaction to light. 5. Test extraocular muscle function in each eye through the six cardinal fields of gaze. Ask the patient to follow your finger with their eyes as you move through the six areas.
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6. Test for convergence. 7. 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. Use either the method described in Bates or by Dr. Rosende in his fall lecture.

VITAL SIGNS
1. Measure blood pressure in one arm. Arm should be at heart level, cuff positioned correctly, stethoscope positioned correctly (bell or diaphragm is okay). It is good practice, but you are not required to report blood pressure. 2. Measure heart rate with finger pads (not thumb) in one radial artery for 15 seconds. Do not have to report heart rate. 3. Measure respiratory rate for 15 seconds. Reveal to standardized patient that you measured respiratory rate after doing so in a hidden manner. Do not have to report respiratory rate. ---------------------------------------------------------------------------------------------------------------------------------------------

CHEST AND LUNG EXAM Posterior Thorax

1. Inspect posterior chest for lesions or swelling. State, I am inspecting the back of your chest. 2. Palpate the posterior chest for masses or tenderness using moderately firm pressure. 3. Test chest expansion (respiratory excursion) with hands wrapped around the lower portion of the ribs with thumbs pointing upward. 4. Palpate for tactile fremitus using bony portion of hand (palmar side of knuckles, or lateral edge of hands on pinky side) and having patient say 99 or toy boat, comparing symmetric areas. 5. Percuss the posterior chest wall comparing sides sequentially and bilaterally: start with the upper fields, then middle fields, then lower lung fields (top to bottom) 6. Percuss and measure diaphragm excursion from full expiration to full inspiration on both sides 7. Auscultate the lungs with the diaphragm of the stethoscope, as the patient (1) breathes deeply (2) through an open mouth. Compare sides sequentially and bilaterally in upper, middle, and lower lung fields 8. 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. Compare sides sequentially and bilaterally in upper, middle, and lower lung fields.

Anterior Thorax (the patient may be seated or supine)

1. Inspect (state, I am inspecting the front of your chest.) anterior chest 2. Palpate the anterior chest in the upper fields only 3. 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)
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4. Auscultate under the right breast or mid-axillary line over the right middle lobe with the diaphragm of the stethoscope. -------------------------------------------------------------------------------------------------------------------------------------------

CARDIAC EXAM Neck

1. Identify the right internal jugular vein with the head of the exam table raised to 30 degrees. If table is flat or >45 degree angle, you will be counted incorrect. 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, 10th ed.). Measure the distance in cm above the sternal angle. You do not need to report this finding. 2. Palpate the carotid pulse in both carotid arteries using the pads of your first and second fingers (Bates says thumb is okay, but we prefer you use the pads of your fingers). NOTE: Assess only one artery at a time; never occlude both sides at the same time. 3. Auscultate both carotid arteries for bruits (can use diaphragm or bell). You must have patient hold his/her breath during this maneuver.

Heart
1. Palpate the apical impulse (also known as the PMI point of maximal impulse) using your finger pads. Place the patient in the left lateral decubitus position if necessary to locate the pulse. 2. Using the ball of the hand, palpate the aortic, pulmonic, left lower sternal border (tricuspid) and apical (mitral) areas for thrills. 3. Using the diaphragm, 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). You should auscultate in all 4 areas sequentially right second interspace (aortic), left second interspace (pulmonic), left lower sternal border (tricuspid) and apex (mitral). 4. Using the bell placed lightly to the chest, auscultate the apex (mitral area) and left lower sternal border (tricuspid) for extra heart sounds (S3, S4). It is fine to position the patient in the left lateral decubitus position for this maneuver. State to patient I am listening for extra heart sounds with the bell of my stethoscope.

PERIPHERAL VASCULATURE:
5. Palpate right and left radial pulses using the pads of your first and second fingers. 6. Perform the Allen test for patency of the radial and ulnar arteries in one arm 7. Palpate the brachial pulses in both arms using the pads of your first and second fingers. 8. Palpate the femoral pulse (in the groin crease) in both legs using the pads of your first and second fingers. This area must be exposed during the examination. 9. Palpate the popliteal pulse (behind knee in tibial side of knee crease) in both legs using the pads of your first and second fingers. 10. Palpate the dorsalis pedis pulse (on middle of top of foot) in both legs using the pads of your first and second fingers. 11. 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.

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12. Inspect for edema in the foot and lower leg. State to patient I am looking for swelling in your feet and legs. 13. 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. ------------------------------------------------------------------------------------------------------------------------------------------

ABDOMEN
1. Inspect the abdomen contour, symmetry, lesions. State to patient I am inspecting your abdomen. You must have the abdomen fully exposed. 2. Auscultate the abdomen for bowel sounds, before palpation/percussion. 3. Auscultate for an aortic bruit 4. Percuss lightly in all four quadrants to assess the distribution of tympani and dullness 5. 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. Identify where you have located the edges of the liver. 6. Lightly palpate all four quadrants, noting any muscular resistance or tenderness. If the patient complains of pain, start in the quadrant farthest away from the area of pain. 7. Deeply palpate all four quadrants, noting any tenderness, masses, or pulsations 8. Palpate the aortic pulse in the abdomen 9. Palpate for the lower edge of the liver with deep palpation (Bates pages 441, 10th ed). Do not perform the hooking technique. 10. Palpate for the spleen with the patient in the supine position and/or while lying on his/her right side (Bates pages 444-445, 10th ed).

PERIPHERAL LYMPH NODES

Examine both sides of the body. (You may wear gloves to examine the axillae and groin) 1. With the patients arms down and relaxed, palpate both axillae for axillary nodes (note in Bates pages 392 and 475 the areas of central, anterior, posterior and lateral) This area must be exposed. 2. Palpate each upper extremity for epitrochlear nodes (Bates page 475)

3. Palpate each groin for the superficial inguinal nodes (Bates page 476). This area must be exposed during the examination.

BACK
Percuss the costovertebral angle (CVA) on both flanks with your fist to examine for tenderness (Bates pg 446).

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MUSCULOSKELETAL
1. Examine the shoulders including: Inspection; State to patient I am inspecting your shoulders. Palpation of acromioclavicular joint, coracoid process, subacromial bursa/ supraspinatous insertion (pg. 593 top picture), and biceps tendon (pg. 592). Active range of motion (AROMthe patient moves their own limb) including forward flexion, extension, external rotation, internal rotation, abduction and adduction 2. Examine the elbows including: Inspection of extensor surface of ulna and olecranon process; State to patient I am inspecting your elbows. Palpation of olecranon process and epicondyles Active range of motion (AROM) including flexion, extension, pronation, supination

3. Examine the wrists including: Inspection of palmar and dorsal surfaces; State to patient I am inspecting your wrists. Palpation of distal radius and ulna on lateral and medial surfaces, groove of joint on dorsal surface and the carpal bones, you must palpate both sides and front and back of wrists Active range of motion (AROM) including flexion, extension, radial and ulnar deviation

4. Examine the hands and fingers: Inspection of the dorsal and palmar surfaces of the hands and fingers; State to patient I am inspecting your hands and fingers. General palpation of anatomic snuffbox and metacarpals; and joint palpation of MCP joints, and medial and lateral aspects of each PIP joint and DIP joint Active range of motion (AROM) of the fingers including flexion, extension, abduction, adduction Active range of motion of the thumb including flexion, extension, abduction, adduction, opposition MUSCULOSKELETALLOWER EXTREMITIES AND SPINE 1. Examine the spine including: Inspection of posture and spinal curvature from behind, State to patient I am inspecting your spine. 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, and sacroiliac joints Active range of motion (AROM) of the neck including flexion, extension, rotation, lateral bending AROM of the spine including flexion, extension, rotation (hold patients hips stable, if necessary, so that the patient moves at the waist only), lateral bending 2. Examine the hips including: Observation of gait (may include with examination of the spine), Palpation of trochanteric bursa bilaterally (patient lying on their side or back), area exposed (can perform hip extension at the same time)

UTHSCSA Head to Toe Physical Examination for Medical Students, last edit April 7, 2011

 Passive range of motion (PROMyou move the patients leg this is different from all the other joints you have examined!); With the patient supine move the hip through flexion, extension (if not done in prior step), abduction, adduction, external rotation, internal rotation 3. Examine the knees including: Inspection of contour and swelling, state to patient I am inspecting your knees. Palpation with knee in flexion of the patellar tendon, femoral condyles, medial and lateral collateral ligaments, and joint lines, AROM including flexion and extension

4. Examine the ankles including: Inspection for deformities and swelling state to patient I am inspecting your ankles, Palpation (anterior ankle, Achilles tendon), AROM including dorsiflexion and plantar flexion at ankle

5. Examine the feet including: Inspection for deformities and swelling state to patient I am inspecting your feet, Palpation (metatarsophalangeal joints, heel, plantar fascia), AROM including inversion and eversion of foot, and flexion of toes

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NERVOUS SYSTEM-MENTAL STATUS MENTAL STATUS- must have these questions memorized
1. Orientation to person: Ask for the patients full name. 2. Orientation to place: Do you know where you are right now? Ask for the name of hospital, floor, city, state, or county. 3. Orientation to time: Ask patient for the date, month, year, day of week, or season. 4. Ask patient to name three objects and immediately repeat them. (Give the patient 3 simple nouns to recall: for example- apple, table, penny). Tell the patient you will ask him/her to tell you these 3 words again in a few minutes. 5. Remote memory: Ask patient for 1-2 historical events relevant to his/her past (i.e., jobs held, birth date, name of schools attended). 6. Recent memory: Ask patient to tell you events about the day (i.e., the weather, todays appointment time). 7. Ask patient to subtract serial 7s. Stop after 5 answers. Alternatively, ask patient to spell WORLD backwards. 8. Information and Vocabulary: Ask about patients work, hobbies, favorite music/TV programs, current events. Ask specific facts (i.e., name of president, vice president, name 5 large cities in the US) 9. Calculating ability: Ask patient to solve simple arithmetic problems.
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10. Abstract thinking: Ask patient to explain a proverb or similarities. 11. Constructional ability: Ask patient to draw a clock complete with numbers and hands and set to a specific time. Example-Please draw a clock showing the time 2:30. 12. Ask patient to repeat the names of the three objects above in #4.

CRANIAL NERVES
1. CN I Test for ability to smell, test one nostril at a time. Use a different scent for each nostril if possible. 2. CN II- check visual acuity on each eye, check visual fields 3. CN III (Optic and Oculomotor) - Test for direct and consensual pupillary reaction to light (must use light source-penlight or otoscope) 4. CN III, IV, VI -Check extraocular muscle function in each eye through 6 cardinal fields of gaze. Have the patient follow your finger while it makes a large H in front of the patients face (approximately 1420 inches away). 5. CN V Test sensation on face with the patients eyes closed: bilateral at forehead, bilateral cheeks, bilaterally on chin. Should compare two sides at the same time and use light touch with finger, tissue or other soft object. Test jaw clenching by palpating at jaw for muscle contraction. 2. CN VII Test face muscles: (1) wrinkling forehead, (2) strength of eyelid closure (student must try to open the patients closed eyes), and (3) smiling and/or puffing cheeks (must do 1, 2, and 3) 3. CN VIII Test auditory acuity (one ear at a time) using the whisper test or rubbing fingers together. 4. CN IX, 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 patients voice. State, I am listening to/have listened to your voice. 5. 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. CN XII (Hypoglossal) Test by having patient stick tongue straight out

NERVOUS SYSTEMMOTOR SYSTEM AND REFLEXES Motor System Upper Extremity

1. Inspect muscle bulk and tone of the arms and hands. State, I am inspecting the muscle bulk of your arms and hands.

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2. Test muscle strength bilaterally, making sure to isolate the muscle(s) to be tested, including (Bates pages 680-83): deltoids (C5, C6) triceps (C6, C7, C8) biceps (C5, C6) wrist flexors (C6, C7, C8, radial nerve) wrist extensors (C6, C7, C8, radial nerve) finger grip (C7, C8, T1) finger abduction (C8, T1) thumb opposition (C8, T1, median nerve)

Motor System Lower Extremity

1. Inspect muscle bulk and tone of the legs and feet. State, I am inspecting the muscle bulk of your legs and feet. 2. Test muscle strength bilaterally, making sure to isolate the muscle(s) to be tested, including (Bates pages 684-686): hip flexion (L2,L3,L4iliopsoas) hip extension (S1gluteus maximus) hip abduction (L4,L5, S1gluteus medius and mimimus) hip adduction(L2, L3, L4adductors) knee flexion (L4, L5, S1, S2hamstrings) knee extension (L2, L3, L4quadriceps) ankle dorsiflexion (mainly L4, L5) ankle plantarflexion (S1)

Deep Tendon Reflexes

1. Test the following on both sides of the body: (Please do not strike the patients tendon more than 3 times to elicit the response. If you elicit the response with the first attempt, move on with the exam.) Biceps Brachioradialis Triceps Knee Ankle

2. 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 , curving medially across the ball (Bates pg. 702) 3. Test for ankle clonus: Push foot up (dorsiflex ankle) sharply once and hold to see if foot pushes back down; if it does, note the number of times it does so.

NERVOUS SYSTEMSENSORY SYSTEM AND CEREBELLAR FUNCTION Sensory System

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1.

Sensationlight touch: With patients eyes closed, test sensation to light touch (cotton ball). Compare symmetric areas on both sides of the upper and lower extremities. Be clear with your verbal instructions to the patient; say, 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. Sensationpain: With patients eyes closed, test sensation to pain (sharp object- use broken end of cotton swab, please do not use safety pins with standardized patients). Compare symmetric areas on both sides of the upper and lower extremities. Be clear with your verbal instructions to the patient; say, 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. Sensationtemperature: With patients eyes closed, test temperature sensation using your tuning fork (cool sensation). Compare symmetric areas, testing one side at a time, of the upper and lower extremities. Ask the patient to tell you when they feel a cool touch. Both upper arms Both lower arms Fronts of both thighs Both lateral calves

4. 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. Test position sense (by holding the sides of the joint, not top and bottom) of the following: Both big toes, One finger on each hand- holding the DIP

6. Test discriminative sensation in one hand by stereognosis number identification (graphesthesia)

Cerebellar Function / Coordination

1. Rapid alternating movements: Have patient alternate striking palm and back of hands on thighs as quickly as they can (p. 687). Test both hands

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2. Point-to-point testing by finger to nose. Test both sides. 3. Gait normal walking, tandem walk (heel to toe), heel walk, toe walk

4. Romberg: Have patient stand for at least 20 seconds with arms at their sides, feet together, and eyes closed (be prepared to stop the test, have them open eyes, if they start to lose balance). 5. Test for pronator drift: Have patient stand or sit (if you are worried about their balance), have the patient hold their arms out straight with palms up and close their eyes. 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, last edit April 7, 2011