Clinical Skills Physical Exam Checklist- 2008-09 (98 items)

A. General (8 items)

 

___ Wash hands before and after examining patient

___ Observe patient’s general appearance and behavior; notes signs of illness/distress

___ Put patient at ease, acknowledge distress, attend to comfort, respect modesty

___ Draping and disrobing: Inform and seek patient permission, cooperation

___ Explain exam maneuvers clearly, transition smoothly; allow patient to accommodate

___ Record/Ask patient for height/weight to assess body mass index (BMI)

 

Assess Mood and Thought:

___ Assess mood (predominant emotional state) and affect (emotional expression)

___ Assess thought content and behavior.

 

B. Vital Signs (4 items)

 

Blood pressure-

___ Locate and palpate the brachial artery

___ Measure with proper arm positioning/stethoscope placement

 

Pulse

___ Check radial artery or other pulse for at least 15 seconds

 

Respiratory rate

___ Check respiratory rate for at least 30 seconds

 

C. Skin exam (1 item)

 

___ Assess exposed skin

 

D. Head exam (12 items)

 

___ Scalp/face: Inspects for cranio-facial shape/symmetry/deformity

 

Eyes

___ Inspect sclera and conjunctiva

___ Perform visual acuity exam using Snellen Chart- with corrective lenses if applicable.

___ Test visual fields. Ask how many fingers on each side (not total- bilaterally

___ Have patient follow finger from center to left to right to center to up and to down.

___ Perform fundus exam using ophthalmoscope- bilaterally

___ Check pupils and assesses for consensual response-bilaterally

 

Ears

___ Inspect external ears bilaterally

___ Inspect ear canals and tympanic membranes bilaterally using otoscope

 

Nose

___ Inspect in nares bilaterally using otoscope

 

Oro-pharynx

___ Assess uvula, hard and soft palate, posterior pharynx and tonsils

___ Assess dentition and gums

 

Neck exam

___ Inspect for asymmetry

___ Palpate lymph nodes in all chains- bilaterally

___ Palpate for thyroid gland

 

E. Cranial nerves (7 items)

 

___ Touch quickly V1, V2, and V3 on each side of face

___ Ask patient to close eyes tightly, then open widely (observing forehead wrinkling).

___ Ask patient to show teeth

___ Rub fingers in each ear to assess hearing

___ Observe elevation of palate

___ Ask patient to protrude tongue

___ Test shoulder shrug strength bilaterally

 

F.  Lung exam (7 items)

 

Inspection (while taking pulse)

___ Assess for normal inspiratory-expiratory ratio- views posterior chest with deep inspiration

___ Assess appearance of respiratory effort– accessory musculature usage, purse lips, costal retractions, deformity/asymmetry;

 

Percussion

___ Percuss for dullness or hyperresonance in side-to-side pattern

___ Percuss for diaphragmatic excursion to check symmetry (identify level of diaphragms)

 

Palpation

___ Palpate for tactile fremitus with patient saying “ninety-nine”

 

Auscultation

___ Listen for breath sounds in side-to side pattern; Identifies abnormal sounds (e.g. wheezes, rhonchi, crackles);

___ Auscultate throughout chest (posteriorly-4 positions vertically and 2 laterally each side; anteriorly- 1 position each side).

 

 

 

 

 

G. Cardiovascular exam (9 items)

 

___ Position patient supine at approximately 30 degrees

___ Assess proximal/distal pulses (radial, dorsalis pedis, posterior tibial)-bilaterally

___ Assess for edema (pre-tibial or pedal) in lower extremities-bilaterally

 

Assess carotid pulses

___ Auscultate first with stethoscope over both carotid arteries

___ Palpate (not simultaneously) both carotid arteries

 

Assess JVP

___ Identify venous pulsations, measures on right side using either external or internal jugular vein

 

Identify PMI

___ If female patient, ask permission and drapes left side of chest to preserve modesty

___ Inspect, palpate to identify PMI- positions patient in left lateral position as needed

 

Auscultation

___ Auscultate with diaphragm in at least the four primary positions identifying S1 and S2- use of bell optional

 

H. Abdominal exam (11 items)

 

___ Positioning: Student on right side, places patient in supine position, and adequately exposes abdomen

 

Inspection

___ Inspect for any gross abnormalities (above/tangentially)

 

Auscultation

___ Auscultate prior to percussion or palpation

___ Auscultate for bowel sounds for 10-15 seconds

___ Auscultate for aortic, renal and iliac artery bruits bilaterally

 

Percussion

___ Percuss in all four quadrants

 

Palpation

___ Palpate lightly in all 9 regions

___ Palpate deeply in all 9 regions

___ Palpate for spleen (optional- may add right lateral decubitus position)

___ Palpate for liver

 

Assess for organomegaly

___ Assess liver span (percussion or scratch test)

 

I. Extremities and Musculoskeletal exam (10 items)

 

Knees (inspection/palpation/range of motion)-bilateral exam

___ Observe for any deformity

___ Observe for effusion of the knee medially and laterally

___ Check for temperature elevation in both knees

___ Assess for effusion by bulge sign

___ Flex and extend knee to evaluate range of motion

___ Palpate knee joint looking for any areas of tenderness

 

Hands (inspection/palpation/range of motion) - bilateral exam

___ Observe DIP, PIP and MCP and wrist for deformity, inflammation

___ Assess fingernails and checks for clubbing

___ Ask patient to make a finger curl

___ Flex and extend wrist

 

 

J. Neurologic: Mental Status (7 items)

 

___ Observe level of consciousness: Awake and Alert?

___ Assess orientation: Asks patient: name, day, date, time, place and situation

___ Assess attention: Asks patient to recite days of week forward and backwards

 

Assess Speech/ Aphasia:

___ Ask patient to name three objects

___ Ask patient to repeat, “ The sky is blue in Baltimore”.

___ Ask patient to point to the ceiling and point to the way out of the room.

___ Notes speech quality (e.g. clear/coherent; slurred, rambling)

 

K. Neurologic: Motor (5 items)- All bilateral assessments

 

___ Check for pronator drift bilaterally

___ Check proximal arm strength at deltoid: arms in „chicken wing position- test one side at a   time

___ Check finger extensor strength bilaterally

___ Check hip flexor strength bilaterally

___ Check dorsiflexion of foot strength bilaterally

 

 

 

 

 

 

 

 

L.Neurologic: Sensation (4 items )- All bilateral assessments

 

___ Test fine touch: mid-arm, distal phalanx of index finger, mid-thigh, distal phalanx of great toe- (ask patient to close eyes)

___ Test pin prick sensation: mid-arm, distal phalanx of index finger, mid-thigh and distal phalanx of great toe

___ Test vibration of PIP joint of great toe bilaterally, counting to 10 (use 128 or 256 Hz tuning fork)

___ Assess proprioception moving great toe up or down

 

J. Neurologic: Reflexes (3 items) - All bilateral assessments

 

___ Strike tendon on one of biceps or brachioradialis bilaterally

___ Strike tendon on one of patella or ankle tendon bilaterally

___ Assess Babinski reflex, warning patient first of possible discomfort. 

 

L. Neurologic:  Coordination/Gait (7 items)

 

___ Perform finger to nose testing both sides using two points for each side- bilateral

___ Rapidly tap 5 times on thigh with each hand (rhythm and regularity)-bilateral

___ Ask patient to stand and walk distance of 10 feet (if possible)

___ Ask patient to stand with feet together, then close eyes (provide contact guard)

___ Ask patient to walk with one foot in front of the other (tandem walk).

___ Ask patient to stand on heels then stand on toes.

___ Alternate: heel to shin test-bilateral (may omit if performs all of walking/gait tasks)