During ICM 5, we get tested on 251 things we need to be able to do on a physical exam, which we perform by memory within 1 hour in front of an evaluator. We must perform 85% of the 251 correctly in order to pass the class. The list here is a simplification of that checklist.
Except for the Lungs, Heart, and Abdomen, there is no required order in which we must do the physical exams. The following is simply the order in which I personally like to do the exams.
- Wash Hands
- HR/RR — do together
- Temperature (Don’t Do)
- Palpate Scalp
- Inspect neck for symmetry
- Palpate Thyroid glands, tell patient to swallow
- Lymph Nodes — Preauricular, Posterior auricular, Occipital (base of skull), Tonsillar (angle of jaw), Submandibular (mid-jaw), Submental (under chin), Posterior cervical (back of neck), Superficial cervical (top of SCM), Deep cervical (deep to SCM), Supraclavicular (don’t palpate over shirt!)
- Inspect — look for conjunctivitis
- Visual Acuity
- Test the occulomotor muscles by doing the H. Also test for nystagmus.
- Test for Convergence.
- Test for Accomodation. patient looks at a finger further away and a finger nearer.
- Visual Field — test all four quadrants and remember to cover your eye as well as pt’s
- Pupillary response to light — direct and indirect (swing test).
- Ophthalmic Examination — look for both fundus and macula (by going towards center)
- Palpation — feel ears.
- Auditory Acuity — remember to cover your ear as well as pt’s
- Otoscopic Examination — remember to pull ear back.
- Test for Nasal Obstruction. tell patient to press on one nostril and breathe
- Test sense of smell — tell patient to close their eye, then test each nostril!!
- Look inside nose w/ Otoscope
- Palpation of sinuses — Frontal, Maxillary, Ethmoid (bridge of nose) — look for any tenderness. Just press hard, don’t do circular massages!
- Inspection — use wooden tongue depressor. lips, gums, buccal mucosa, teeth, tongue, pharynx, floor of mouth
- Uvula — say ahh to lift palate
LUNG — Patient sits up
- Inspect Trachea, Anterior Chest
- Palpate Anterior tactile fremitus @ top, middle, and lower chest
- Percussion Anterior, starting above clavical, and do lateral too!
- Auscultation Anterior, with deep breath with mouth open! Remember to do lateral!
- Inspect Posterior
- Palpation Posterior – tactile fremitus @ top, middle, and lower chest. tell patient to cross arms!
- Palpation Posterior – Bilateral movement of chest wall
- Percussion Posterior, tell patient to cross arms!! and do lateral too!
- Percussion for diaphragmatic movement
- Auscultation Posterior, with deep breath with mouth open! Remember to do lateral!
- Percussion of costovertebral angle on both sides over kidneys). WARN PATIENTS!! ASK FOR TENDERNESS!!
HEART — 30 degrees!! No Percussion!!
- Inspect Jugular Venous Pulse, and then measure
- Palpate upper and lower carotids
- Auscultate upper and lower carotids
- Palpate APTM with finger tips
- Auscultate APTM w/ diaphragm
- Auscultate TM w/ bell to hear S3 and S4 on right and left sides of heart
- Tell patient to sit up and exhale and auscultate T for aortic insufficiency/regurg
- Tell patient to get in left lateral decubitus and auscultate M for mitral stenosis
ABDOMEN — 0 degrees!! Palpation last!!! Always look at patient for any tenderness. “let me know if there’s any tenderness.”
- Auscultate the four quadrants for at least 10 sec.
- Auscultate aorta, renal arteries, iliac arteries
- Percuss four quadrants
- Percuss liver span
- Palpate 4 quadrants — light, then deep
- Palpate liver
- Palpate spleen
- Palpate abdominal aorta
- DONE — Smell test
- DONE — visual acuity
- DONE — H/Convergence
- DONE — H/ Convergence
- Fine touch on forehead, cheekbone, and jaw. Bite down, feel masseter and temporalis
- DONE — H/Convergence
- Raise eyebrows, close eyes tightly, smile/puff cheeks
- DONE — Auditory acuity
- DONT DO
- DONT DO
- Shoulder shrug. Patient turns head against resistance.
- Stick out tongue at midline, left, and right.
MENTAL STATUS: do while examining for tone in the patient’s arms
- What’s your name?
- Where are you?
- What day is it?
- Can you repeat “lovely yellow linoleum”?
- Can you repeat “no ifs ands or buts”
- Strength: shoulder, triceps, biceps, wrist, fingers
- Strength: hip, knee, ankle, plantar.
- Pronator drift test. eyes closed!! stand by wall ready to catch!
NEUROLOGICAL SENSORY — do for both upper and lower extremities
- Vibratory Sense
- Position Sense
- Sharp/Dull Sense
- Temperature Sense
- Graphesthesia or Sterognosia — eyes closed!!
- Finger-to-nose and Heel-to-shin
- Rapid Alternating Movements: upper and lower extremities
- Romberg — heals/toes together. Eyes open, then eyes closed. Arms can be on side.
- 3 Gaits — heal-to-toe, on toes, on heel
DEEP TENDON REFLEX
- Biceps, Triceps, Brachioradialis
- Patella, Achilles
- Radial pulses
- Ulnar pulses
- Brachial pulses
- Epitrochlear nodes (around elbow)
- Popliteal pulse — patient lying down!
- Inspection of lower extremities
- Palpate for Edema
- Tibial pulse
- Dorsalis pedis
SPINE (Don’t Do)
SHOULDER (Don’t Do)
ELBOW (Don’t Do)
WRIST/HAND (Don’t Do)
- Palpate iliac crest and greater trochanter
- Passive Flexion/Extension of hips (standing, holding on table)
- Passive Abduction/Adduction of hips (stabilize opposite pelvis)
- Passive Internal/External Rotation (knee flexed at 90 degrees)
- Palpate patella, popliteal fossa, medial/lateral joints
- Palpate ankle: Achilles tendon, lateral/medial malleolus
- Palpate foot: joints
- Ankle: Dorsiflexion/plantar flexion, Inversion/eversion
- Foot: Inversion/eversion
- Toes: flexion/extension