Vital Signs

1. Lying down, measure hr and respiratory rate

a. Radial pulse
2. Estimate bp
a. Radial pulse
3. Measure orthostatic bp
4. Sit up, measure bp and hr
5. Measure temp

Laying down

Abdominal Exam
1. Lying down flat
2. Gown pulled up beneath chest & down to hip bone
3. ORDER: inspect, auscultate, percuss, palpate
4. INSPECT
5. Auscultate 4 quadrants
6. Percuss 4 quadrants
7. Palpate 4 quadrants (lightly, then deeply)
8. Rebound tenderness 2 lower quadrants
9. Palpate liver
a. Start at lower abdomen, work up
b. Left hand under patient’s rib cage
c. Cupped right hand underneath ribs
d. Take deep breaths (feel during inspiration)
10. Palpate spleen
a. Start at lower abdomen, work up
b. Left hand under patient’s rib cage
c. Take deep breaths
d. Re-examine w/ patient rolling to right side
11. Examine Murphy’s sign
a. To the right of midline, right edge of rectus muscle
b. Take deep breaths
c. Positive sign  during expiration

Cardio Exam
1. LYING AT 30 DEGREES
2. inspect jugular venous pulsation
a. Tilt head slightly to left
3. PUT BED BACK TO 0 DEGREES
4. DRAPING
5. palpate cardiac apical impulse
a. 5th intercostal space
6. auscultate with diaphragm
a. aortic
b. pulmonary
 c. tricuspid
d. mitral
7. auscultate with bell
a. tricuspid
b. mitral
8. palpate radial pulse
a. both sides separately
b. both sides simultaneously
9. palpate ulnar pulse (both sides)
10. palpate brachial pulse (both sides)
11. INSPECT
12. DRAPING
13. Palpate femoral pulse and check for inguinal lymph nodes (both sides)
a. Ask for hip bone location
b. Bend knee outward
14. Palpate popliteal pulse (both sides)
a. Underneath knee
15. Palpate posterior tibial pulse (both sides)
a. Behind ankle bones
16. Palpate dorsalis pedis (both sides)
a. Top of feet
17. Examine for edema (both sides)
a. Test over distal tibia and dorsal surface of feet

Neurological exam
1. Heel-to-shin coordination (both sides)
a. LAY DOWN
b. Put feet on top of other leg (heel touching shin)
c. Move up and down the shin
2. Babinski (both sides)  part of sensory test
a. LAY DOWN
b. Use sharp edge of reflex hammer
c. Upward, opposite C

Musculoskeletal exam
1. DRAPING
2. Straight leg raise
a. ACTIVE and PASSIVE (both sides)
3. Test hip (both sides)
a. PASSIVE
b. Straight leg abduction, adduction
c. BEND LEG up (90 degrees) internal and external rotation
4. Knee
a. ACITVE and PASSIVE
b. Passive hand on knee, crepitus
c. STRAIGHT LEG AGAIN
 d. PALPATE medial and lateral joint line tenderness
e. PALPATE patella
f. MILK patella

Sitting up

Lung and Thorax Exam

1. Sit up
2. TAKE SLOW, DEEP BREATHS THROUGH MOUTH
3. ASK TO UNTIE TOP OF GOWN
4. Auscultate upper, anterior (both sides)
a. Above clavicle
b. Underneath clavicle
5. INSPECT BACK
6. Auscultate posterior (both sides)
a. Both sides alternating
b. At least 3-4 areas each side
7. Auscultate lateral (both sides)
a. 2 areas each side
8. check chest expansion
a. hand on lower back spread, thumbs touching
b. take deep breath
9. percuss posterior
a. ARMS CROSSED
b. Both sides alternating
c. 3-4 areas each side

Abdomen
1. SIT UP
2. Kidney punch

Head and Neck

1. Palpate frontal sinuses for tenderness
a. Right above medial eyebrows
b. Push upwards, sufficient pressure
2. Palate maxillary sinuses for tenderness
a. Medial to cheekbones, below eyes
b. Push upwards, sufficient pressure
3. INSPECT anterior neck
4. AUSCULTATE carotid arteries (both sides)
a. Ask patient to HOLD BREATH
5. PALPATE carotid pulse
a. ONE SIDE AT A TIME
6. HAVE A GLASS OF WATER READY
7. Palpate thyroid gland (isthmus)
a. TELL PATIENT you gonna palpate from behind
 b. Ask patient to EXTEND NECK slightly
8. Palpate thyroid gland (lobes)
a. Position hands below cricoid cartilage
b. Ask patient to drink water 1-2 times
9. Palpate LYMPH NODES
a. auricular (3)
i. in front of ear
ii. behind ear
iii. occipital
b. mandibular (3)
i. tonsillar (angle of jaw)
ii. submandibular (mid-jaw)
iii. submental (under chin)
c. sternomastoid (3)
i. posterior side of SCM muscle
ii. on top of SCM muscle
iii. deep in SCM muscle
d. supraclavicular (1)
10. INSPECT ears (both sides)
11. OTOSCOPE
a. Check light
b. Put one new otoscope speculum
12. INSPECT nasal vault and septum (both sides)
a. NEW speculum
b. Ask patient to TIP HEAD BACK
c. Push nose slightly up using thumb
13. TAKE TONGUE DEPRESSOR
a. NEW speculum
14. INSPECT
a. Lips
b. Gums (push lips away using depressor)
c. Buccal mucose (push mouth to side using depressor)
d. Teeth
e. Roof of mouth
f. Tongue
g. Underneath tongue (ask patient to)
h. Pharynx (back of throat)  ask patient to say “AHH”
15. Examine auditory canals and tympanic membranes (both sides)
a. NEW speculum
b. Pull auricles slightly superiorly, posteriorly, away from patient
16. Test auditory acuity (both sides)
a. COVER other ear
b. Whisper a word

Eye Exam
1. INSPECT (both sides)
a. Eyelids
 b. Gently move eyelids up and down
c. Conjunctiva, iris, cornea, pupils
2. Check visual acuity
a. SNELLEN chart
b. 1 feet away
c. check BOTH EYES TOGETHER
d. check INDIVIDUALLY, cover other eye
3. check eye movement
a. ask patient to follow with just the eye!
b. 6 directions
c. BIG H
4. Check convergence
a. Tell patient it checks for both ocular movements and pupillary constriction
5. Test visual field (both sides)
a. MIRROR IMAGE
b. Ask patient to cover right eye
c. Ask patient to focus on you!
d. You use your left hand to cover left eye (mirror image!)
e. Move hands in an X pattern
i. Top right to center
ii. Bottom right to center
f. SWITCH HANDS (cover left eye with right hand now!)
i. Top left to center
ii. Bottom left to center
g. DO OTHER EYE
6. Check pupillary response to light (both sides)
a. DIM LIGHT
b. Explain to patient!
c. Direct response (both eyes)
d. Indirect response (both eyes)
e. Swinging flashlight method
7. Ophthalmoscope (both sides)
a. Check light, focus of ophthalmoscope
b. DIM LIGHT
c. USE RIGHT HAND TO EXAMINE RIGHT EYE, and LEFT HAND TO EXAMINE
LEFT EYE
d. Tell patient you’re examining RETINA, BLOOD VESSELS, OPTIC DISC AND
CUP

Neurological Exam
Motor (strength) (both sides)
1. Test elbow flexion and extension (both sides)
a. Against resistance
2. Test hand grip (both sides)
a. Against resistance
b. Opposite handshakes
3. Test finger abduction (both sides)
 a. Patient’s fingers spread
b. Keep them spread apart against resistance
4. Test finger (both sides)
a. Patient makes fist
b. Open up hand against resistance
5. Test hip flexion (both sides)
a. Raise thigh against resistance (hand just above knee)
6. Test hip extension (both sides)
a. Lift up patient’s leg
b. Ask patient to push thigh down against resistance
7. Test knee flexion and extension (both sides)
a. Against resistance
8. Test ankle dorsiflexion and plantarflexion (both sides)
a. Against resistance
Motor (reflexes) (both sides)
1. Hand/wrist (both sides)
a. 2 inches above wrist, radial side
2. Biceps/brachioradialis (both sides)
a. Radial side, above elbow notch
b. Hammer on finger that covers the notch
3. Triceps (both sides)
a. Ask patient to put weight of arm on you, hanging off
b. Above elbow, look for notch
4. Patellar (both sides)
5. Achilles (both sides)
a. Put hand underneath feet to feel
6. Babinski  can be combined with laying down part of coordination
Sensory (proprioception) (both sides)
1. Test lower and upper extremity (both sides)
2. 1 location on each side
3. patient’s EYES CLOSED
4. EXPLAIN to patient!
5. hold patient’s finger on sides and move up and down
a. right and left finger
b. right and left toe
Sensory (pain and temperature) (both sides)
1. take a swab and break it in half
2. use one soft and one sharp end
3. patient’s EYES CLOSED
4. EXPLAIN to patient!
5. Test sensation (both sides)
a. Hand (placed on knee)
b. Forearm
c. Leg
d. Foot
Sensory (light touch) (both sides)
1. Use cleanex soft tissue
 2. Patient’s EYES CLOSED
3. EXPLAIN to patient!
a. TOUCH AND COMPARE to other side!
b. Face
i. All 3 divisions of cranial nerve
ii. TELL PATIENT!!!
c. Hand
d. Forearm
e. Leg
f. Foot
Sensory (other) (both sides)
1. Test discriminative sensation
a. Patient’s EYES CLOSED
b. EXPLAIN to patient! (both sides)
i. Draw a letter on hand and identify
Cranial Nerves (both sides)
1. CN V Sensory
a. Already did with light touch!
2. CN V Motor (both sides)
a. Place hands on masseter
b. Ask patient to bite down and feel
3. CN VII, upper (both sides)
a. Raise eyebrows
b. Close both eyes tightly, then try to open them (EXPLAIN TO PATIENT)
4. CN VII, lower (both sides)
a. Puff up cheeks OR smile
5. CN XI (both sides)
a. Shrug shoulders against resistance
b. Turn head against resistance
6. CN XII
a. Protrude tongue
b. Move tongue left and right
Coordination (both sides)
3. SIT UP
4. Finger-to-nose coordination (both sides)
a. Ask patient to touch your index finger and own nose
b. Move index finger around
5. Rapid alternating movement
a. Ask patient to place hands on thigh
b. Rapid switching up and down of hands

Standing

Musculoskeletal exam
1. UNTIE TOP OF GOWN
2. INSPECT back
 3. Percuss along spine, top to bottom (fist)
4. TIE UP GOWN
5. Spine range of motion
a. Bend forward, backwards (support!)
b. Lean to each side
c. Hands on hips, turn to each side
6. Neck range of motion
a. Head forward, backwards
b. Turn to each side
c. Ears to shoulders
7. Shoulder range of motion
a. ACTIVE and PASSIVE (both sides)
b. Raise arms over head, bring back to back
c. Move hands behind back
d. While PASSIVE, hand on shoulder, test for CREPITUS
8. Elbow range of motion
a. Flex, extend
b. Pronation, supination
c. PALPATE (both sides) medial and lateral epicondyles for tenderness
9. Wrist range of motion
a. Flex, extend
b. Make first, spread fingers
c. PALPATE (both sides) wrist bones, snuffbox
d. PALPATE (both sides) each finger joint

Neurological exam
1. Ask patient to WALK ACROSS ROOM AND BACK
a. Normal gait
b. Heel-to-toe (walking on a rope)
c. Tiptoes
d. Walking on heels
2. Romberg maneuver and pronator drift
a. EXPLAIN to patient!
b. Feet together, EYE OPEN, arms out parallel to ground, palms up
c. CLOSE EYES for 20 seconds