AICM-PE Study Guide

165 Point Physical Examination Study Guide
Professionalism/Patient Centered Care Competency 1. Students appearance and manner are appropriate and professional; Student introduces himself/herself and establishes rapport. 2. Student shows concern for patients comfort and assures privacy during the examination. 3. Student informs patient of upcoming procedures and prepares the patient for use of instruments; instructions to the patient are clear. 4. Exam sequence is logical and progresses from one region to another without undue changes in patient positioning. 5. Student examines patient using serial exposure appropriate to the steps of the examination. 6. Student balances need for palpation/percussion/auscultation to elicit information with gentle examination technique.
Procedure and Tips

Introduce yourself with your name, position, and role. Ask patients name. Unless, they ask to be called by their first name, refer to the patient by their last name. Explain that you will be performing a head to toe physical exam which will require you to expose and touch certain parts of the patients body. Warn the patient that they may experience some discomfort during parts of the exam. Make sure the patient acknowledges and consents to the exam. Answer any questions that they may have. Cover the patients legs with the provided drape after washing hands.
SECTION A GENERAL INSPECTION / VITAL SIGNS
165 Point Physical Examination Study Guide Exam performed with patient sitting
1. Wash hands before starting examination. 2. Measure blood pressure in one upper limb by placing cuff snugly in correct anatomical position.
Wash hands with soap and water or alternatively an
ethanol based waterless hand sanitizer.

Drape the patients legs. Position patient at a comfortable distance from the BP Bates 10th ed.
p.115-117 Bates 11th ed. p.119-123
cuff. Support patients arm from below at the level of the heart. Ensure the artery marker is over the medial aspect of the arm just medial to the biceps tendon. Place cuff snugly with enough space in the antecubital fossa to ensure the bell is not underneath the cuff. Inflate the sphygmomanometer to at least 200 mmHg. Deflate slowly at 2-4 mmHg/second.
3. Measure respiratory rate for at least 30 seconds.
Measure respiratory rate by placing your fingers over
Bates 10th ed.

p.119
4. Palpate radial pulse for at least 15 seconds.
the radial artery and placing the patients arm across their chest. Observe and feel the rise and fall of the chest as the patient breathes. Attempt to not make it obvious that you are observing respirations. Palpate for the pulse in one wrist with the pads of your index and middle fingers lateral to the flexor carpi radialis tendon.
Bates 11th ed.

p.126
Modified technique
Bates 10 ed. p.119, 482 Bates 11th ed. p.126, 500

th
5. Palpate radial pulses simultaneously for symmetry.
Palpate long enough to detect a few cardiac cycles (2
Bates 10th ed. Bates 11th ed.

p.500 p.482
seconds minimum).
SECTION B HANDS / UPPER LIMBS
6. Inspect and palpate both hands (dorsal and palmar). 7. Inspect nails and nail beds. Check clubbing and capillary refill.
Palpate both hands simultaneously. Ensure you
Bates 10th ed.

p.603-605
palpate the fingers and thumbs as well. Ask the patient to report any tenderness.
Check for clubbing in at least 2 fingers using the
Bates 11th ed. p.

629-631
Bates 10th ed.

p.164,170, 193
Schamroth technique. Check capillary refill by pressing over the nails in at least two separate fingers in each hand. Hold pressure for 2 seconds and then release. Alternate technique required for patients with nail polish and artificial nails, but not acceptable for this exam.
Bates 11th ed.

p.172, 179, 202
Modified technique
8. Inspect and palpate both arms and forearms with clothing removed.
Expose the arms before inspection. Inspect one arm at a time. Palpate one arm at a time by palpating
Bates 10th ed.

p.481
Bates 11th ed.

p.499
Modified technique
circumferentially with both hands. 9. Palpate epitrochlear nodes.

Support the patients abducted arm with 90 degree
Bates 10th ed.

p.475, 483
flexion at the elbow. Locate the medial epicondyle of the humerus as a landmark with your fifth digit. Ask the patient to flex their biceps to help identify the groove between the biceps and triceps. Palpate with your second, third and fourth digits between the groove of the biceps and triceps muscles. Palpate in small round circles.
Bates 11th ed.

p.493, 501
10. Palpate axillary nodes (use proper technique to palpate axillary nodes).
Ask the patient for permission to adequately expose
Bates 10th ed.

p.407-408
the axilla. Take the patients arm out of the gown and wrap the gown behind the patient. To assess the patients left axilla, hold their left wrist or hand with your left hand and examine the axilla with your right hand. Lift the patients arm with one hand and place your other hand within the axilla to feel for the central (deep) lymph nodes. Lower the patients arm before palpating in a circular motion. Elevate the patients arm slightly and reposition your hands inferiorly to feel central nodes again along their chain. Lower the patients arm before palpating in a circular motion. Elevate the patients arm and reposition your hand to feel for the pectoral (anterior) lymph nodes with your thumb positioned anterior to the pectoralis for support. Palpate the nodes, then lift the arm slightly and reposition to palpate a little lower along the chain of nodes in the anterior area. Elevate the patients arm and reposition your hand to feel for the lateral nodes along the upper humerus. Lower the patients arm before palpating in a circular
Bates 11th ed.

p.424-425
11. Wash hands after palpating axillary nodes.

SECTION C HEAD
motion. Lift the arm to reposition more distally on the humerus along the chain of nodes, lower the arm and palpate again. Elevate the patients arm and reposition your hand to feel for the subscapular (posterior) nodes. Step to the side or behind the patient to facilitate easier palpation. Lower the patients arm before palpating in a circular motion. Repeat for the right axilla. Wash hands with soap and water or alternatively an ethanol based waterless hand sanitizer.
Bates 10th ed.
p.205 Bates 11th ed. p.215
12. Inspect and palpate scalp Observe the general size and contour of the head. thoroughly. Part the hair in 4 places and look for scaling, lumps, nevi, dandruff, or other lesions. Palpate the head by pressing gently with fingertips first followed by pressing down with your palms. Palpate the frontal and occipital region simultaneously, followed by the parietal areas simultaneously. Note any deformities, depressions, lumps, or tenderness. 13. Assess hair for texture Observe quantity, distribution, and patterns of loss, if and consistency. any. Feel two separate parts of hair for texture and consistency (can be performed simultaneously).
SECTION D - EYES
Bates 10th ed.

p.205
Bates 11th ed.

p.215
14. Assess visual acuity (near or far) bilaterally.
Using a pocket-sized eye chart, place the chart 14
Bates 10th ed.
15. Screen for peripheral visual field deficits.
p.211-212 inches from the patients eyes (You may also use a 6ft th Bates 11 ed. chart). p.221-222 Ask the patient to cover one eye with two fingers and instruct them to Read the lowest line you can. The examiner should be standing next to the patient and reading the line along with them (without verbalizing the letters) to ensure the line was read accurately and to note the degree of visual acuity. Have the patient switch eyes and repeat the first three steps but instruct patient to read the lowest possible line backwards. Bates 10th ed. Stand directly in front of the patient and ensure that p.212-213 you are at the same eye level. th Bates 11 ed. Have the patient maintain continuous eye contact p.222-223 throughout exam. Modified technique Hold your arms out diagonally at the edge of your visual field and at a position that is equidistant between you and the patient. Tell the patient that you will be wiggling two fingers and they should point to the fingers they see wiggling. Proceed to wiggle fingers on one hand then the next to screen for any deficits. Switch your arm position to the other diagonal direction and repeat the previous step.
16. Test visual fields in each eye separately in 4 quadrants.
Stand directly in front of the patient and ensure that
Bates 10th ed.

p.212-213
17. Inspect external ocular structures (lids, cornea, conjunctiva).
18. Assess conjunctiva and sclera.
you are at the same eye level. Maintain continuous eye contact throughout exam. Ask the patient to cover one eye with two fingers, while you mirror this action covering your corresponding eye. Instruct the patient that you will be wiggling two fingers and they should say Now as soon as the fingers are seen. Leading with two wiggling fingers, test the following visual fields: temporal, superior, inferior. When testing the nasal field, switch hands covering your eye and use the opposite arm to test this field, instruct your patient to continue covering the same eye. Repeat the above steps to test the patients other eye. Stand in front of the patient and survey the eyes for position and alignment. Inspect the cornea, noting any haziness. Inspect the conjunctiva. Note the position of the lids in relation to the eyeballs and note the width of the palpebral fissures. Have the patient close their eyes and observe the lids for any edema or discoloration. Ask the patient to look up as you depress both lower lids with your thumbs exposing the palpebral conjunctiva. Note the color of the conjunctiva. Ask the patient to look down as you raise both upper eyelids with your thumbs exposing the sclera. Note the color of the sclera.
Bates 11th ed.

p.222-223
Bates 10th ed.

p.205-206, 213214 Bates 11th ed. p.215-216, 223224
Bates 10th ed.

p.214
Bates 11th ed.

p.224
19. Observe pupillary response to light (direct).
Ask the patient to look at the red dot on the wall
Bates 10th ed.

20. Observe pupillary response to light (consensual).
21. Evaluate extraocular muscle function (the H-test).
behind you. Shine a bright light obliquely into each pupil in turn. Observe the pupillary constriction of each eye individually. Ask the patient to look at the red dot on the wall behind you. Shine a bright light obliquely into each eye in turn. Observe the pupillary constriction of the contralateral eye individually. To test the six extra-ocular movements, ask the patient to follow your finger without moving their head as you sweep twice through the six cardinal directions of gaze. At a comfortable distance from the patient, make a
Bates 10th ed.

Bates 10th ed.

p.211,216-217
Bates 11th ed.

p.221,226-227
22. Check for convergence.
23. Check for near reaction / accommodation.
24. Lights dimmed before direct ophthalmoscopy. 25. Ophthalmoscope held properly and index finger used to switch lenses.
26. Hold ophthalmoscope with right hand to inspect patients right eye.
wide H with your finger. Lead the patients gaze: To the extreme right until the sclera of their abducting eye disappears. From this position, move your finger upward and downward. Move your finger to the extreme left until the sclera of the abducting eye disappears. From this position, move your finger upward and downward. With the tip of your finger at the patients eye level, ask the patient to follow your finger as you move it in toward the bridge of their nose. As you move your finger toward the nose, observe the adduction of the eye and simultaneous pupillary constriction. Perform this test twice to observe each eye individually. Position your finger about 10 cm from the patients eyes with the tip of your finger at the patients eye level. Ask the patient to look alternately at the tip of your finger and into the distance at a red dot on the wall behind you. Perform this test twice to observe the pupillary constriction of each eye individually. Turn on a lamp in the exam room. Turn off the main light source of the room. Turn on the ophthalmoscope light and turn the lens disc until you see the large round beam of white light. Turn the lens disc to the 0 diopter. Keep your index finger on the lens disc so that you can turn the disc to focus the lens when you examine the fundus and anterior structures of the eye. Ask the patient to turn their position to the right with the direction of their legs corresponding to the right corner of the examining table. Ask the patient to adjust their posture so that you are on the same eye level. Hold the ophthalmoscope firmly braced against the medial aspect of the bony orbit of your right eye to inspect the patients right eye.
Bates 10th ed.

p.210,218
Bates 11th ed.

p.220,228
Bates 10th ed.

p.210,216
Bates 11th ed.

p.220,226
Bates 10th ed.

p.218-222 Bates 11th ed. p.228-232
Bates 10th ed.

p.218-222
Bates 11th ed.

p.228-232
27. Inspect optic nerve.
Position yourself about 15 inches from patient by
Bates 10th ed.

p.218-222
placing your left arm on the patients right shoulder. From an angle of 15 degrees lateral to the patients line of vision, shine the beam of light on the pupil and
Bates 11th ed.

p.228-232
look for the red reflex. To steady yourself before you examine the fundus, place the thumb of your left hand on the patients right eyebrow. Keeping the light beam focused on the red reflex, move in with the ophthalmoscope approaching at a 15 degree angle toward the pupil until you are within 1 inch of the patients eye. Locate the optic disc and bring it into focus by adjusting the diopters of the lens. Inspect the optic disc noting its color, the clarity of its margins, and size of the cup.
28. Trace vessels in four quadrants.
Follow the vessels peripherally in each of four
Bates 10th ed.

p.218-222
29. Inspect anterior structures with ophthalmoscope.
30. Ophthalmoscope held at proper distance to visualize structures of the eye. 31. Hold ophthalmoscope with left hand to inspect patients left eye.
directions. As you search the retina, move your head and the ophthalmoscope as a unit, using the patients pupil as an imaginary fulcrum. This will help you keep your light in the pupil. After inspecting the fundus, look for opacities in the vitreous or lens. Rotate the lens disc toward the positive diopters until it reads approximately +10. Positive diopters converge light and help you focus on near objects such as the structures anterior to the retina. Approximately 1 inch from the patients eye. Almost touching the patients eyelashes.
Bates 11th ed.

p.228-232
Bates 10th ed.

Bates 10th ed.

p.219
Bates 11th ed.

p.229
If necessary, ask the patient to turn their position to the
Bates 10th ed.

p.218-222
32. Inspect optic nerve.
left with the direction of their legs corresponding to the left corner of the examining table. Ask the patient to adjust their posture so that you are on the same eye level Hold the ophthalmoscope firmly braced against the medial aspect of the bony orbit of your left eye to inspect the patients left eye. See task #27
Bates 11th ed.

p.228-232
Bates 10th ed.

p.218-222 Bates 11th ed. p.228-232
33. Trace vessels in four quadrants. 34. Inspect anterior structures with ophthalmoscope.
See task #28
Bates 10th ed.

p.218-222
Bates 11th ed.

p.228-232
See task # 29
Bates 10th ed.

p.218-222
Bates 11th ed.
165 Point Physical Examination Study Guide p.228-232 SECTION E - EARS
35. Observe auricles and post auricular regions bilaterally.
Turn the main lights on and turn off the lamp. Inspect
Bates 10th ed.

p.225
36. Palpate auricles bilaterally.
the anterior auricle and surrounding tissue for deformities, lumps, discharge, inflammation or skin lesions. Inspect the posterior auricular region and the posterior auricle. Palpate the auricle, press on the tragus, and press firmly behind the ear on the mastoid process.
Bates 11th ed
p.235
Bates 10th ed.

p.225
Bates 11th ed.

p.235
37. Test auditory acuity.
Occlude one of the patients ears by pressing on the
Bates 10th ed.

p.226
38. Examine ears bilaterally with otoscope.
tragus. Ask the patient to close their eyes and tell you what they hear. Tap your fingers together in front of the non-occluded ear and assess the patients response. Test the patients opposite ear using the first two steps but this time rub your fingers together in front of the non-occluded ear and assess the patients response. Now perform the whispered voice test. Ask the patient to close their eyes and repeat what they hear. Occlude the non-test ear by pressing on the tragus. Whisper 1,2,3 next to the non-occluded ear and assess the patients response. Repeat the first three steps for the opposite ear but this time whisper A,B,C and assess the patients response. Attach a large speculum to the tip of the otoscope. Ask the patient to position themselves so that you can perform the exam comfortably. To straighten the ear canal, grasp the auricle with your thumb and index finger and pull it upward, backward, and slightly away from the head. Hold the otoscope handle between your thumb and fingers. Stabilize the instrument prior to insertion. Hold the otoscope in your right hand to inspect the patients right ear. Hold the otoscope in your left hand to inspect the
Bates 11th ed.

p.236-237
Bates 10th ed.

p.225-226
Bates 11th ed.

p.235-236
patients left ear. Insert the speculum gently into the ear canal. Inspect the canal and tympanic membrane. Repeat the above steps on the opposite ear.
39. Stabilize otoscope upon insertion to avoid injury.
Stabilize the instrument by bracing the ulnar side of
Bates 10th ed.

p.225-226 Bates 11th ed. p.235-236
your hand against the zygomatic arch of the patients face. This method of stabilization allows your hand and instrument to follow any unexpected movements by the patient.
SECTION F NOSE
(CN I asked here __________ )
Ask the patient if they have experienced any change in
Bates 10th ed.

p.673
smell or taste. See #143

Ask the patient to occlude one nostril and breathe in. Repeat for the other nostril.
Bates 11th ed.

p.702-703
Modified technique
40. Test for patency of both nasal passages.

p.240 p.229
41. Palpate for frontal sinus tenderness.
Using the pads of your thumbs, palpate with moderate
Bates 10th ed.

p.229-231
pressure bilaterally and simultaneously over the frontal sinuses by pressing up underneath the medial, superior border of the orbit.
Bates 11th ed.

p.239-241
42. Palpate for maxillary sinus tenderness.
Using the pads of your thumbs, palpate with moderate
Bates 10th ed.

p.229-231
pressure bilaterally and simultaneously over the maxillary sinuses.
Bates 11th ed.

p.239-241
43. Inspect nasal vaults and stabilize to avoid injury.
Holding the otoscope between your thumb and index
Bates 10th ed.

p.230 Bates 11th ed. p.240-241
fingers. Ask the patient to tilt their head back. Stabilize on the patients cheek with the ulnar side of the hand and advance the speculum into the lateral side of one nostril and visualize while sweeping lateral to medial. Avoid contact with the nasal septum. Repeat for the other nostril.
SECTION G THROAT
44. Inspect lips, gums, tongue, teeth.
Use a tongue depressor and a light source to visualize
Bates 10th ed.
p.234 the structures of the mouth. th Bates 11 ed. Have the patient relax their lips and inspect the outside p.264-265 of the mouth. Have the patient relax and open their mouth and use the tongue depressor to lift and move the lips and cheeks to expose the top gums, bottom front gums, left bottom gums, left buccal mucosa, left upper gums, right lower gums, right buccal mucosa and right upper gums. Use a light source to illuminate these structures while inspecting.
45. Inspect the floor of the mouth and base of tongue. 46. Inspect posterior pharynx and hard palate.
Ask the patient to elevate their tongue to look at the

p.246 p.235
floor of the mouth.

Ask the patient to open their mouth wide. Illuminate the pharynx and hard palate with the light

p.247 p.236
48. Examine patient without causing discomfort. 47. Test Cranial Nerve IX and X.
source. Use of a tongue depressor may be necessary to aid in visualization of posterior pharynx. Asking the patient to tilt their head back may aid in visualization of hard palate. Hold the tongue depressor with a steady hand and displace tissue gently to avoid discomfort or injury. With mouth open, illuminate posterior pharynx, and ask the patient to say ah. Observe for symmetrical elevation of the palate with the uvula remaining midline while asking the patient to say ah.
Bates 10th ed.

p.676-677
Bates 11th ed.

p.706-707
Use of a tongue depressor may be necessary to aid in
visualization of posterior pharynx.
SECTION H NECK
Palpate lymph nodes:
Using the pads of at least two fingers palpate the
Bates 10th ed.
p.238-239 nodes in a circular motion. th Bates 11 ed. When appropriate, palpate along the lymphatic chain p.249-251 in a continuous fashion. Avoid skipping sections of the chain.
49. Occipital nodes
Palpate each side separately. If necessary, have the
50. Posterior auricular nodes 51. Preauricular nodes 52. Tonsillar nodes 53. Submandibular nodes 54. Submental nodes 55. Anterior cervical nodes (superficial and deep)
o o
patient flex their neck and turn slightly towards the side being examined. Palpate superficial to the mastoid process. Palpate anterior to the tragus. Palpate under the angle of the mandible. Palpate under the mandible midway between the angle of the mandible and the tip of the mandible. Palpate in the midline with one hand behind the tip of the mandible. Superficial: Palpate both sides simultaneously along the chain anterior and superficial to the sternocleidomastoid. Deep: Palpate each side separately along the chain anterior and deep to the sternocleidomastoid
56. Posterior cervical nodes
Palpate bilaterally simultaneously starting at the
57. Supraclavicular nodes
58. Inspect thyroid with and without swallowing. 59. Palpate thyroid without swallowing.
occipital protuberance and moving inferiorly along the anterior edge of the trapezius. Palpate just lateral to the insertion of the clavicular head of the sternocleidomastoid, superior to the clavicle. Inspect from in front of the patient. Offer the patient a cup of water and ask patient to swallow a small amount while inspecting.
Standing from behind the patient, find the cricoid
Bates 10th ed.

p.240-242 Bates 11th ed. p.251-253
Bates 10th ed.

p.240-242
cartilage and palpate below this level with the second, third and fourth finger pads.
Bates 11th ed.
Palpate one side at a time with
165 Point Physical Examination Study Guide p.251-253 displacement of the
contralateral side towards the side being examined.

Palpate in small circular motions. Palpation should not displace the trachea from midline. Alternative technique: in front of the patient, place your
60. Palpate thyroid with swallowing.
5th digits at the sternoclavicular joints as a landmark and place the 2nd, 3rd, and 4th digits below the level of the cricoid cartilage. Palpate one side at a time while displacing the contralateral side towards the side being palpated. Offer the patient a cup of water and instruct the patient to take a small amount of water in their mouth but not to swallow yet. Displace the left lobe of the gland towards the midline, ask the patient to swallow the water and palpate the right side. Repeat for palpation of the left side.
Exam performed with patient sitting on left or right of bed
Bates 10th ed.

p.242
Bates 11th ed.

p.253
SECTION I BACK
61. Inspect back for lesions/deformity.
Observe for any bruising, lesions, muscle spasm,
Bates 10th ed.

p.611-613 Bates 11th ed. p.637-639
62. Palpate spinous processes of thoracic and lumbar vertebrae. 63. Perform fist percussion of: thoracic, lumbar, and sacral vertebrae; sacroiliac joints bilaterally; and costovertebral angles.
deformities, or abnormal curvature. Look from different perspectives including directly behind and from each side of the patient. Palpate the spinous process of each vertebra with your thumb looking for tenderness or step offs.
Place the open palm of one of your hands over the
Bates 10th ed.

p.612
Bates 11th ed.

p.638
Bates 10th ed.

p.612
correct anatomical location to be percussed. Use the ulnar surface of your fist to gently thump on the dorsal aspect of your palm over each area.
Bates 11th ed.

p.638
Modified technique
SECTION J LUNGS POSTERIOR
64. Inspect chest posteriorly.
Make sure the back is appropriately exposed. Ask the patient to inhale deeply as you inspect chest
Bates 10th ed.

p.296-298
expansion from the back. 65. Palpate chest expansion, symmetry.

Place both hands at the approximate level of 10th rib
Bates 11th ed.

p.306
Bates 10th ed.

p.298
on the back with your fingers loosely grasping and parallel to the lateral rib cage. Your thumbs should hover over the patients back
Bates 11th ed.

p.307
without touching to better observe separation. Ask the patient to inhale deeply and observe the distance between your thumbs relative to the midline spine to check for symmetrical chest expansion.
Modified technique
66. Percuss posterior lung fields bilaterally and symmetrically.
Bates 10th ed. Lay your hand flat on the patients back. p.299-302 Use the tip of your middle finger in your dominant hand Bates 11th ed. to percuss on the middle phalanx of the extended
middle finger of your other hand with quick, sharp but relaxed wrist motion. Percuss in 3 areas on each side symmetrically using the ladder or zig-zag technique to cover the posterior lung fields. Avoid percussing over the scapula.
p.308-310
Modified technique
67. Instruct patient to breathe Ensure the patient follows these directions by asking deeply through an open them to take a deep breath through an open mouth mouth. each time they feel your stethoscope touching their back. 68. Auscultate posterior lung fields bilaterally and symmetrically
Using the diaphragm of your stethoscope, auscultate
Bates 10th ed.

Bates 10th ed.

p.302-303
the same 6 areas symmetrically using the ladder or zig-zag technique. Keep the diaphragm in position for one full inhalation and exhalation cycle for all lung auscultations.
Bates 11th ed.

p.311-313
Modified technique
ANTERIOR AND LATERAL LUNG FIELDS
69. Inspect chest anteriorly.
Expose the anterior chest by pulling the gown down
Bates 10th ed.

p.305
below the xiphoid process. Ask the patient to inhale deeply as you inspect.
Bates 11th ed.

p.315
70. Percuss anterior lung fields bilaterally and symmetrically.
Percuss using the same technique as the posterior
Bates 10th ed.

p.307-308
lung fields. See # 66 Percuss 6 areas, 3 on each side. From the top, 1st area percussed is along the parasternal line. 2nd area to percuss is along the mid clavicular line and 3rd area percussed is along the anterior axillary line (for females ask patient to displace their breast in and up). Try to avoid the heart border on the left.
Bates 11th ed.

p.317
Modified technique
71. Percuss lateral lung fields bilaterally and symmetrically.
Percuss one area along the mid axillary line on each
Bates 10th ed.

p.307
side symmetrically between approximately the 5th and 6th rib.

Auscultate symmetrically using the ladder or zig-zag
Bates 11th ed.

p.317
Modified technique
72. Auscultate anterior lung fields bilaterally and symmetrically.
Bates 10th ed.

p.308
method. Auscultate with the diaphragm in the same areas as in percussion.
Bates 11th ed.

p.318
Modified technique
73. Auscultate lateral lung fields bilaterally and symmetrically.

SECTION K HEART
Auscultate one area along the mid axillary line on each
Bates 10th ed.

Modified technique
side symmetrically. Auscultate with the diaphragm.

Exam performed with exam table at a 30 to 45 degree angle
74. Inspect precordium for visible apical impulse / heaves.
Raise the head of the exam table to between 30 to
Bates 10th ed.
75. Examine Jugular Venous Pulse/Pressure (JVP)
p.355-356, 32445 and have the patient recline while you extend the 325 foot rest. Bates 11th ed. Observe the precordium from the right side of the p.370, 334 patient for a few cardiac cycles. On the right side of the patient, look over to inspect the chest and apical impulse. Bates 10th ed. Ask the patient to lift their head up and turn it toward p.334-336 their left to examine the right jugular venous pulse/ th Bates 11 ed. pressure (JVP). p.361-366
Look for the internal jugular vein between the two
heads of the sternocleidomastoid muscle-typically next to the medial head just above clavicle. Point to the internal jugular vein pulsations and verbalize that this is where you would measure the jugular venous pressure (JVP) and evaluate the jugular venous pulse. 76. Palpate carotids bilaterally.
Place the stethoscope in your ears. Feel for the carotid pulsation with the finger pads of Bates 10th ed.
p.352-353
your index and middle fingers.
Bates 11th ed.

p.367-368
77. Auscultate carotids bilaterally.
Palpate:
Place the diaphragm of your stethoscope on top of your fingers as you slide them out to ensure you stay in the same location. Ask the patient to inhale deeply and hold their breath. Listen for any bruits for 3-4 heartbeats. Ask the patient to resume normal breathing. Repeat on the other side. * High grade occlusions with low pitched bruits are best heard with the bell. Consider in elderly patients of your 2nd, 3rd and 4th fingers. Slide your fingers to the right of the sternum along the 2nd rib into the parasternal area. Slide your fingers below the 2nd rib to locate the 2nd ICS. Lay your fingers flat until the distal interphalangeal joint is on the patients chest. Your middle finger should be in the intercostal space. Keep your fingers in that location for 3-4 heartbeats. angle of Louis to the patients left.
Bates 10th ed.

p.353
Bates 11th ed.

p.368
78. Aortic area (2nd ICS right).
Locate the sternal angle / angle of Louis with the pads
Bates 10th ed.

p.356, 361
Bates 11th ed.

p.371, 375
Modified technique
79. Pulmonic area (2nd ICS left).
See # 78, but slide your fingers from the sterna angle/
Bates 10th ed.

p.356, 361 Bates 11th ed. p.371, 375
Modified technique
80. Right ventricular area (4 ICS, LLSB). Picture 81. Right ventricular heave (left parasternal area)
th
Slide your fingers down the 3 rib, 3 ICS, 4 rib and
rd
rd
th
Bates 10th ed.

p.356, 357
into the 4 ICS. Place the middle finger into the 4th ICS in the left parasternal border and keep it there for 3-4 beats.
Slide your fingers slightly laterally from the 4th ICS. Keep them there for 3-4 beats.
th
Bates 11th ed.

p.371
Modified technique
Bates 10th ed.

p.356,359360,378 Bates 11th ed.
165 Point Physical Examination Study Guide p.371, 374-375

Modified technique
82. Mitral (apical) area (5 ICS left MCL).
th
Slide your fingers over the 5 rib and into the 5 ICS
th
th
Bates 10th ed.

p.356-359
and lateral to the mid clavicular line. Place your middle finger into the 5th ICS. Keep your fingers there for 3-4 beats. It may be necessary to ask your patient to displace their breast during this procedure
See #78 Place the diaphragm of the stethoscope in the right
Bates 11th ed.

p.371-374
Modified technique
Auscultate:
83. Aortic area.
Bates 10th ed. Bates 11th ed. p.

376-377 p.356,361-363
84. Pulmonic area.
85. Tricuspid area.
86. Mitral (apical) area.
87. Ask patient to roll to left lateral decubitus position.
88. Relocate apex.
parasternal area next to the sternal angle. Auscultate for 3-4 beats. See #79 Place the diaphragm of the stethoscope in the left parasternal area next to the sternal angle. Auscultate for 3-4 beats. See #80 Place the diaphragm of the stethoscope in the area of 4th ICS. Auscultate for 3-4 beats. See # 81 Place the diaphragm of the stethoscope in the area of 5th ICS in the mid-clavicular line. Auscultate for 3-4 beats. Do not remove the stethoscope from your ears. Ask the patient to turn towards the left side and place left arm underneath their head. For female patient, ask her to lift breast upwards and inwards. Ensure your patient does not fall off the bed during this maneuver. Make sure that you feel the impulse in the lateral decubitus position. If the impulse shifts, relocate it. You may need the assistance of a stool to reach over your patient.
Bates 10th ed.

p.356,361-363
Bates 11th ed.

p.376-377
Bates 10th ed.

p.356,361-363
Bates 11th ed. p.

376-377
Bates 10th ed.

p.356,361-363 Bates 11th ed. p.371, 376-377
Bates 10th ed.

p.363
Bates 11th ed.

p.372
Bates 10th ed.

89. Auscultate apex with diaphragm.
Place the bell over your fingers as you slide them out
Bates 10th ed.

p.363
90. Auscultate apex with bell.

SECTION L - ABDOMEN
to ensure that you stay in the same location. Place the diaphragm over your fingers as you slide them out. Place your fingers over the stethoscope as you slide it out. Switch the stethoscope to the bell. Place the bell over your fingers as you slide them out.
Bates 11th ed.

p.378
Bates 10th ed.

Exam performed with table fully reclined
91. Inspect abdomen and instruct patient to relax
Standing to the right of the patient, expose the
Bates 10th ed.

p.434-436
abdomen from the xiphoid process to ASIS.
abdomen (bend knees, arms at sides).
Ask the patient to bend their knees and place their
Bates 11th ed.

p.452-454
92. Watch patients face while examining abdomen.
arms to the side. Inspect for abnormalities of the skin, umbilicus, and contour of the abdomen. This must be done throughout abdominal exam whenever palpating the abdomen.
Bates 10th ed.

p.434
Bates 11th ed.

p.452
93. Auscultate before manipulation or palpation.
Maneuvering the bowel can alter the frequency of
Bates 10th ed.

bowel sounds.
Auscultate for bruits and bowel sounds: 94. Auscultate for bowel sounds. 95. Aorta
Use the diaphragm for this section. Listen for bowel sounds in one quadrant and note Bates 10th ed.
frequency (5-34 per minute) and character.

Measure the distance halfway between the xiphoid
Bates 10th ed.

p.436-437 Bates 11th ed. p.454-455
Modified technique
and ASIS. Auscultate and listen for bruits.
96. Left upper quadrant to include LEFT renal artery.
Move laterally from midline to the left side of the

p.454-455
Modified technique
abdomen making sure to not auscultate over the ribs. Auscultate and listen for bruits.
Move laterally from midline to the right side of the
p.436-437
97. Right upper quadrant to include RIGHT renal artery.
Bates 10th ed.

p.436-437
abdomen making sure to not auscultate over the ribs. Auscultate and listen for bruits.
Bates 11th ed.

p.454-455
Modified technique
Palpate superficially: check sequence in Video and match it to checklist
98. Right lower quadrant.
Keeping your hand and forearm in a horizontal plane
Bates 10th ed.

p.437-438
99. Right upper quadrant. 100. Epigastrium. 101. Left upper quadrant.
with fingers together and flat on the patients abdominal surface, palpate the abdomen. Use a light, gentle dipping motion. When moving your hand to next region, raise it just off the skin, moving smoothly to feel all quadrants. See #98 Keep your fingers together and flat on abdominal surface, but point towards the xiphoid process. See #98
Bates 11th ed.

p.455-456
Modified technique
102. Left lower quadrant.

Palpate deeply:
See #98 Use the palmar surface of your fingers of one hand to Bates 10th ed.
103. Right lower quadrant.
p.438 palpate the five quadrants. th Bates 11 ed. Use the other hand to apply pressure on the dorsum of p.456 the hand in contact with the patients abdomen. Modified technique
104. Right upper quadrant. 105. Epigastrium to include aorta. 106. Left upper quadrant. 107. Left lower quadrant. 108. Percuss liver span.
See # 103 In this region, place your hand so that your fingers
face in the direction of the xiphoid process. See # 103

See # 103 In the mid clavicular line, start at a level below the
Bates 10th ed.

p.439-440 Bates 11th ed. p.457-458
109. Use proper technique to palpate liver edge.
110. Use proper technique to palpate tip of spleen.
umbilicus and percuss upward toward the liver edge. Identify the lower border of dullness and have your patient mark this level with their finger. Ask the patient to displace their right breast to the right and make sure to remain in the mid clavicular line. Starting at the nipple line, lightly percuss downwards towards liver edge dullness. Measure the distance between the two points of dullness in centimeters. Normal liver span measures 6-12 cm. Place your left hand behind the patient at the level of the 11th and 12th ribs and press anteriorly. Your right hand should be placed lateral to the rectus muscle with the fingers located below the lower border of liver dullness and pointing up toward the head. Ask your patient to inhale and try to feel for the liver edge with your fingertips as it comes down with inhalation. Lighten the pressure of your right hand to allow the liver to slip under your finger pads (if palpable). With your left hand, reach over and around the patient to support and press anteriorly under the lower left ribcage (you may need a stool to facilitate this maneuver). Place your right hand below the left costal margin. Press in toward the spleen as the patient inspires. Then ask the patient to roll onto their right side with
Bates 10th ed.

p.441-442
Bates 11th ed.

p.459-460
Modified technique
Bates 10th ed.

p.443-445 Bates 11th ed. p.461-463
Modified technique
their legs slightly flexed at the hips and knees. Place your left hand over and around the patient to support and apply pressure anteriorly under the left ribcage Using your right hand, press toward the spleen with inspiration.
SECTION M LOWER LIMBS Palpate pulses bilaterally:
111. Femoral.
Using the pads of your fingertips, press below inguinal

p.502
Modified technique
ligament midway between ASIS and the pubic symphysis. 112. Palpate inguinal lymph nodes.
Trace the lymph node chain. Medial to femoral vein and below the inguinal ligament
p.484
Bates 10th ed.

p.476 Bates 11th ed. p.494, 502
is the vertical group. The horizontal group is just under the inguinal ligament. Washing your hands with soap and water or ethanol based waterless gel after this examination is recommended.
113. Inspect bilaterally with outer clothes removed.
Make sure to move the drape past patients mid-thigh
Bates 10th ed.

p.483
to obtain adequate exposure. Inspect each leg individually while raising it off the table so you can inspect all 4 sides.
Carefully inspect heels when raising the leg up. Spread toes individually and inspect between them.
Bates 11th ed.

p.501
114. Inspect feet including toes, heels and soles.
Bates 10th ed.

p.483
Bates 11th ed.

p.501
115. Dorsalis pedis.
Place the pads of two fingertips on the dorsum of the
Bates 10th ed.

p.485
patients foot (not ankle) just lateral to extensor tendon. Palpate for several beats bilaterally.
Bates 11th ed
p.504
116. Posterior tibial.
Curve your fingers and place the pads of your
Bates 10th ed.

p.485 Bates 11th ed p.504
fingertips behind and slightly below the medial malleolus to locate the posterior tibial pulse. Palpate for several beats bilaterally.
117. Check for peripheral pitting edema.
Press the pad of your thumb into the dorsum of the
Bates 10th ed.

p.487 Bates 11th ed p.505
patients foot for at least two seconds. While watching your patients face for pain, release pressure and look and sweep your thumbs over the area to feel for pitting. Repeat test mid way up patients lower leg medial to the anterior border of the tibia and press firmly against the medial surface of the tibia.
SECTION N LOWER LIMB MUSCULOSKELETAL
118. Test Hip flexion.
With your patient lying in supine, ask them to lift each
Bates 10th ed.

p.684
leg without bending their knee while you apply resistance against their thigh (distal femur).
Bates 11th ed
p.713
119. Test knee flexion.
Patient is recumbent during this exam. Ask the patient to bend their knee. Place your hand behind their gastrocnemius and ask
Bates 10th ed.

p.685
Bates 11th ed
p.714
them to pull back against your resistance to test hamstring strength.
120. Test knee extension.
Place your hands against the patients lower shin and
Bates 10th ed.

p.684-685
asks the patient to push against your resistance to test quadriceps muscle strength. Repeat bilaterally.
Bates 11th ed.

p.714
121. Test foot plantar flexion.
Ask the patient to push against your hands. Resist patients motion.
Bates 10th ed.

p.685-686
Bates 11th ed.

p.715
122. Test foot dorsiflexion.
While hand is placed on the dorsum of foot ask the
Bates 10th ed.

p.685-686
patient to pull up. Resist patients motion.
Bates 11th ed.

p.715
SECTION O SENSORY STATUS (LIGHT TOUCH, PINPRICK, PROPRIOCEPTION, VIBRATION)
123. Test vibration sense in great toes and index fingers
Use the 128 Hz tuning fork and test with patients eyes
Bates 10th ed.

p.692
open. Tap the tuning fork on the heel of your hand and place it over the interphalangeal joint of the patients big toe. Ask what the patient feels. Repeat on the DIP of the patients middle finger.
Bates 11th ed.

p.721
124. Test position sense in great toe and index fingers bilaterally (eyes closed).
Grasp the patients big toe by holding it by its sides
Bates 10th ed.

p.692-693
between your thumb and index finger. Pull away the other toes to prevent extraneous tactile stimuli. Demonstrate up and down movements, then ask patient to close eyes and ask for a response.
Bates 11th ed.

p.721-722
Repeat at least twice on each side. In similar sense test position in index finger.
125. Test light touch and pin prick on upper extremities
Explain process to patient and ask to close eyes. Touch patient with a wooden broken q-tip and ask for
Bates 10th ed.

p.692
comparisons Sharp or dull.

Follow dermatomal distribution: both shoulders (C4),
Bates 11th ed.

p.721
Modified technique
126. Test light touch and pinprick lower extremities
inner and outer aspects of forearms (C6 and T1), thumbs and little finger (C6 and C8). As above in following locations: fronts of both thighs (L2), medial and lateral aspects of both calves (L4 and L5), little toes (S1).
Exam performed with patient in sitting position
Bates 10th ed.

p.692
Bates 11th ed.

p.721
Modified technique
SECTION P UPPER LIMB
127. Test for upper limb strength.
Ask the patient to hold their arms up and flex their
Bates 10th ed.

p.680-681
128. Test distal strength on dorsiflexed wrist.
129. Test patients grip bilaterally.
elbows towards their body. Tell the patient resist my movements. Examiner first presses down on patients upper arm at their elbows and then pushes upwards from below the patients elbows. Examiner then places the palms of their hands on the patients biceps and attempts to push the patients arms outwards. Examiner then places their hands behind the elbows just proximal to the joint and tries to push the arms towards the midline of the patients body. Examiner then attempts to pull the patients arms away from their body by pulling at the mid forearms. Examiner then attempts to push the patients arms in towards their body by pushing on their forearms. Ask the patient to make a fist. With the patients wrist dorsiflexed, the examiner puts pressure on dorsal aspect of patients hand and asks the patient to extend their wrist further against resistance. Hold out fingers crossed and ask patients to squeeze your fingers. Please squeeze my fingers as hard as you can.
Bates 11th ed.

p.710-711
Modified technique
Bates 10th ed.

p.681-682 Bates 11th ed. p.711
Bates 10th ed.

p.682
Bates 11th ed.

p.712
Modified technique
130. Test strength of finger abduction.
Ask patient to hold both hands out and spread their
Bates 10th ed.

Modified technique
fingers apart. Instruct patient to resist your movement. Attempt to adduct each set of fingers against resistance.
131. Test thenar strength (thumb opposition).
Ask the patient to touch their thumb to the pad of their
Bates 10th ed.

Modified technique
2nd digit forming a ring and attempt to break the connection.
132. Test for pronator drift. (30 sec) (not combined with Romberg).
SECTION Q REFLEXES
Ask the patient to hold their extended arms out in front
Bates 10th ed.

p.689-690 Bates 11th ed. p.718-719
with their palms facing up for 30 sec. The examiner should be watching for pronation of hands indicating UMN lesion/spasticity.
Patients arm should be partially flexed at the elbow
133. Test biceps reflex.
Bates 10th ed.
p.696-697 with palm down. Bates 11th ed. Place your thumb or finger on biceps tendon and strike p.726 your finger with the pointed end of the hammer. If you have difficulty eliciting the reflex, ask patient to turn away and to clench their teeth just before you strike the tendon. Look for flexion at elbow and contraction of biceps.
134. Test brachioradialis reflex
Ask the patient to rest their hand on their lap with their
Bates 10th ed.

p.698
forearm partially pronated. Locate radial styloid and strike radius with flat edge of hammer about 1-2 above the wrist. Look for flexion at elbow, extension of thumb, supination of forearm.
Bates 11th ed.

p.727
135. Test triceps reflex.
Flex patients arm at elbow with palm toward their

p.727 p.698
body. Strike tendon just proximal to olecranon with the pointed end of hammer. Look for extension of elbow and contraction of triceps.
136. Test patellar reflex.
Briskly tap the patellar tendon just below the patella. Note contraction of quadriceps and extension of knee.
Bates 10th ed.

137. Test achilles reflex.
Dorsiflex patients foot at ankle slightly and persuade
Bates 10th ed.

p.699-700
patient to relax. Strike the tendon and watch and feel for plantar flexion and contraction of the gastrocnemius.
Bates 11th ed.

p.728-729
138. Test plantar reflex.
Warn the patient before performing this task that it
Bates 10th ed.

p.701-702
may cause some discomfort but it will only be brief. With the end of the reflex hammer, stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball of the foot. Hold the ankle if necessary.
Bates 11th ed.

p.730-731
SECTION R CEREBELLAR FUNCTION
139. Test rapid alternating movements hands.
Show patient how to strike one hand on thigh, turn
Bates 10th ed.

p.687
140. Test rapid alternating movements feet.
141. Test finger-to-nose bilaterally (for dysmetria and tremor).
142. Test heel-to-shin bilaterally. (for dysmetria and tremor) Observe tandem gait (done with patient standing).
over, and strike again on same place of thigh. Urge patient to repeat these as rapidly as possible. Repeat with other hand. Ask patient to tap your hand with the ball of both feet individually as fast as possible. Washing your hands with soap and water or ethanol based waterless gel after this examination is recommended. Ask patient to touch your index finger and then his or her nose alternately. Move your finger so that the patient has to alter directions and extend arm fully to reach. Test both sides with both arms. Ask patient to place one heel on opposite knee and slide it down their shin to their big toe.
Bates 11th ed.

p.716
Bates 10th ed.

Bates 10th ed.

p.688
Bates 11th ed.

p.717
Bates 10th ed.

p.688
Bates 11th ed.

p.717
SEE # 155
Bates 10th ed.

SECTION S CRANIAL NERVES
143. Test CN-I: (Sense of smell); Adequate to ask patient if he/she has experienced a change in smell and/or taste. Test CN-II (Done during EENT exam). a. Visual acuity. b. Visual fields. c. Ophthalmoscopic (disc, blood vessels, retina). Test CN-III, IV, VI (Done during EENT exam). a. Pupillary reaction to light.
See NOSE section #40
Bates 10th ed.

p.673 Bates 11th ed. p.702-703
Modified technique
See # 14 See # 15, 16 See # 27 See # 21 See # 19, 20
b. Extraocular movements. 144. Test CN-V (Sensory): Light touch on cornea (offer to test).
See # 21, 22 Only offer to test, but do not test.
Bates 10th ed.

p.675-676
Bates 11th ed.

p.705
145. Test CN-V (Sensory): Light touch on face.
Instruct patient to close his/her eyes and ask the
Bates 10th ed.

p.675
patient to tell you when they feel your touch. Test for all three branches of the trigeminal nerve.
Bates 11th ed.

p.705
146. Test CN-V (Motor): Test contraction of masseter, temporalis and pterygoid muscles.
Ask patient to bite down and palpate temporalis and

p.704 p.674
masseter muscles bilaterally. Then ask patient to move jaw from side to side.
147. Test CN-VII (Motor): Raise eyebrows and forced eyelid closing. 148. Test CN-VII (Motor): Show teeth, puff out cheeks, and smile.
Ask patient to raise their eyebrows. Ask patient to close their eyes tightly and instruct them

p.706 p.676
not to let you open them.

Ask patient to show teeth, smile and puff out cheeks.
Bates 10th ed.

p.676
Bates 11th ed.

p.706
Test CN-VIII (Hearing done See # 37 with EENT exam). Test CN-IX and X: Observe See # 46 elevation of palate vocalizing ah (EENT exam). 149. Test CN-XI: Rotation of Place your open palm on one side of the patients face
Bates 10th ed.
patients head against resistance. 150. Test CN-XI: Shoulder shrug against resistance. 151. Test CN-XII: Observe midline protrusion of tongue (do with EENT exam).
SECTION T GAIT
and ask the patient to turn his/her hand. Repeat on the other side.
165 Point Physical Examination Study Guide p.677 head against your Bates 11th ed. p.707
Place your hands on patients shoulders and ask
Bates 10th ed.

patient to shrug his/her shoulders against your resistance.

Ask patient to stick his/her tongue out and move it side
Bates 10th ed.

p.677-678 Bates 11th ed. p.707-708
to side.
Exam performed with patient standing
152. Observe stance and gait. 153. Have patient walk on toes.
Ask patient to walk in a straight line. Examine gait and observe posture, balance and arm
Bates 10th ed.

p.688
movement.
Ask patient to walk on tip toes Position yourself so that you can observe the heels are
Bates 11th ed.

p.717
Bates 10th ed.

p.688
rising off the floor symmetrically.
Bates 11th ed.

p.717
154. Have patient walk on heels.
Ask patient to walk on their heels. Position yourself so that you can observe the toes
Bates 10th ed.

p.688
raising off the floor symmetrically
Bates 11th ed.

p.717
155. Observe tandem gait (heel-to-toe).
Ask patient to walk heel-to-toe by looking straight
Bates 10th ed.

ahead and then placing one foot in front of the other, with heel of one foot touching toes of the other Observe stability Stand near patient to assist if they lose balance.
156. Perform Romberg test. (30 seconds). pic
Ask patient to stand with feet together and arms by
Bates 10th ed.

p.689
their side. Ask them to close both eyes for 30 to 60 seconds without support. Note ability to maintain upright posture.
Bates 11th ed.

p.718
SECTION U SPINE
157. Test flexion by having Ask patient to bend down and touch their toes while patient bend at waist to touch watching smoothness and symmetry of movement, toes. range of motion, and curve of lumbar area.
Bates 10th ed.

p.615
Bates 11th ed.

p.641
159. Test extension by having patient bend backwards.
While supporting patients hips ask to bend back as far Bates 10th ed.
as possible.
160. Have patient bend sideways and rotate at hips.
While supporting both of the patients hips ask them to
Bates 10th ed.

p.616
place your hands on the side of thighs and slide them down your leg as far as you can and twist to look back at the wall on [both sides].
Bates 11th ed.

p.642
Modified technique
158 Perform screening test for scoliosis.
Inspect patients spine while having them bend all the
Bates 10th ed.

p.613, 615, 846847 Bates 11th ed. p.639, 641, 868869
way down, and then half way up. Ask patient to stand up straight and place fingertips (palms down) over shoulders and then iliac crests looking for symmetry.
161. Test flexion, extension, and rotation of neck.
Ask patient to bring chin to their chest, look up at the
Bates 10th ed.

p.615
ceiling, look over each shoulder individually, and bring your ear to your shoulder. Ask patient to rotate their head in one direction, then the other direction in a circular motion.
Bates 11th ed.

p.641
SECTION V MENTAL STATUS
162. Level of alertness and orientation: time, place, person.
Ask the patient their full name. Ask the patient where they are: expect room, building,
Bates 10th ed.

p.141,151-152
163. Attention and Calculation: Serial 7s. 164. Registration and Recall, Memory: immediate and remote.
city and state ask for each if not given p.157-158 Ask the patient the todays date: expect day number, month and year Ask patient to name the day of the week and approximate time of day as well as the day of the week and approximate time of the day. Bates 10th ed. Ask the patient to count backwards from 100 by 7 p.141,152 starting at 100. th
Bates 11 ed.
p.158
Bates 11th ed.
Ask the patient to repeat three words, for example
Bates 10th ed.
165. Language, fluency and abstract thinking. Repeat the following phrase No ifs, ands or buts. Dont count your chickens before theyre hatched.
p.141,153 apple, table penny and repeat them out loud to check th Bates 11 ed. for registration. p.159 Tell the patient to remember those three things as they will be asked about them shortly. Allow two separate tests to pass between registration before asking the patient if they can recall and repeat those three things. Bates 10th ed. Ask the patient to repeat the first phrase to assess p.141,148,153 fluency. Bates 11th ed. Ask the patient to interpret the second phrase (a p.154,159 proverb) to assess abstract thinking.

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165 Point Physical Examination Study Guide

Procedure and Tips

SECTION A GENERAL INSPECTION / VITAL SIGNS

Wash hands with soap and water or alternatively an

ethanol based waterless hand sanitizer.

3. Measure respiratory rate for at least 30 seconds.

Measure respiratory rate by placing your fingers over

Bates 10th ed.

4. Palpate radial pulse for at least 15 seconds.

Bates 11th ed.

Bates 10 ed. p.119, 482 Bates 11th ed. p.126, 500

5. Palpate radial pulses simultaneously for symmetry.

Palpate long enough to detect a few cardiac cycles (2

Bates 10th ed. Bates 11th ed.

SECTION B HANDS / UPPER LIMBS

Palpate both hands simultaneously. Ensure you

Bates 10th ed.

Bates 11th ed. p.

Bates 10th ed.

Bates 11th ed.

165 Point Physical Examination Study Guide

Bates 10th ed.

Bates 11th ed.

circumferentially with both hands. 9. Palpate epitrochlear nodes.

Bates 10th ed.

Bates 11th ed.

Ask the patient for permission to adequately expose

Bates 10th ed.

Bates 11th ed.

165 Point Physical Examination Study Guide

11. Wash hands after palpating axillary nodes.

Bates 10th ed.

Bates 11th ed.

14. Assess visual acuity (near or far) bilaterally.

Using a pocket-sized eye chart, place the chart 14

Bates 10th ed.

15. Screen for peripheral visual field deficits.

165 Point Physical Examination Study Guide

16. Test visual fields in each eye separately in 4 quadrants.

Stand directly in front of the patient and ensure that

Bates 10th ed.

17. Inspect external ocular structures (lids, cornea, conjunctiva).

18. Assess conjunctiva and sclera.

Bates 11th ed.

Bates 10th ed.

Bates 10th ed.

Bates 11th ed.

19. Observe pupillary response to light (direct).

Ask the patient to look at the red dot on the wall

Bates 10th ed.

20. Observe pupillary response to light (consensual).

21. Evaluate extraocular muscle function (the H-test).

Bates 10th ed.

Bates 10th ed.

Bates 11th ed.

165 Point Physical Examination Study Guide

22. Check for convergence.

23. Check for near reaction / accommodation.

Bates 10th ed.

Bates 11th ed.

Bates 10th ed.

Bates 11th ed.

Bates 10th ed.

Bates 10th ed.