The Human Physical Exam -  from head to toe

Here it is: the list of things your doctor is looking for during your physical exam (in fact, for every line of this exam there exists a specialty, a subspecialty, and a whole library of texts, journals and atlases. But this is where it starts:  

 General Inspection: 

 1. Skin color
 2. Facial expression
 3. Mobility 

1. Use of assertive devices
2. Gait
3. Sitting, rising from chair
4. Taking off coat

 4. Dress and Posture
 5. Speech pattern, disorders, foreign language
 6. Difficulty hearing, assistive devices
 7. Stature and build
 8. Musculoskeletal deformities
 9. Vision problems, assistive devices,
10. Eye contact with examiner
11. Orientation, mental alertness
12. Nutritional state
13. Respiratory problems
14. Significant others accompanying patient

Measurements:

 1. Height
 2. Weight
 3. Distance vision: Snellen chart
 4. Vital signs:

1. Temperature
2. Pulse
3. Respirations
4. Blood pressure in both arms
   
   

Patient seated, in gown

Patient is seated on examining table; examiner stands in front of patient.

Head and face

1. Inspect skin characteristics
2. Inspect symmetry and external characteristics of eyes and ears
3. Inspect configuration pf skull
4. Inspect and palpate scalp and hair for texture, distribution, and quantity of hair
5. Palpate facial bones
6. Palpate temporomandibular joint  while patient opens and closes mouth
7. Palpate pre-sinus regions; if tender transilluminate
8. Inspect ability to clench teeth, squeeze eyes tightly shut, wrinkle forehead, smile, stick out  tongue, puff out cheeks (cranial nerves - CN - V, VII)
9. Test light sensation of forehead, cheeks, chin, (CN V)

Eyes

1. External examination

1. Inspect eyelids, lashes, lacrima, palpebral folds
2. Determine alignment of eyebrows
3. Inspect sclera, conjunctiva, iris
4. palpate lacrimal apparatus

2. Near vision screening: Rosenbaum chart (CN II)
3. Eye function

1. Test pupillary response to light and accommodation
2. Perform cover-uncover test and light reflex
3. Test extraocular eye movements (CN III, IV, VI)
4. Assess visual fields (CN II) 
5. Test corneal reflex (CN V)

4. Ophthalmologic examination

1. Test red reflex 
2. Inspect lens 
3. Inspect disc, cup margins, vessels, retinal surface, vitreous humor
   

Ears

1. Inspect alignment 
2. Inspect surface characteristics 
3. Palpate auricle
4. Assess hearing with whisper test  or ticking watch (CN VIII)
5. Perform otoscopic examination

1. Inspect canals
2. Inspect tympanic membranes for landmarks, deformities, inflammation

6. Perform Rinne and Weber tests

Nose

1. Note structure, position of septum
2. Determine patency of each nostril
3. Inspect mucosa, septum, and turbinates with nasal speculum
4. Assess olfactory function: test sense of smell (CN I)

Mouth and Pharynx

1. Inspect lips, buccal mucosa, gums, hard and soft palates, floor of mouth for color and surface characteristics
2. Inspect oropharynx: note anteroposterior pillars, uvula, tonsils, posterior pharynx, mouth    odor
3. Inspect teeth for color, number, surface characteristics
4. Inspect tongue for color, characteristics, symmetry, movement (CN XII)
Test gag reflex and "ah" reflex (CN IX, X)
5. Perform taste test (CN VII)

Neck 

1. Inspect for symmetry and smoothness of neck and thyroid
2. Inspect for jugular venous distension
3. Inspect and palpate range of motion; test resistance against examiner's hand
4. Test shoulder shrug (CN IX)
5. Palpate carotid pulses 
6. Palpate tracheal position
7. Palpate thyroid
8. Palpate lymph nodes: pre- and postauricular, occipital, tonsilar, submaxillary, submental,  superficial cervical chain, posterior cervical, deep cervical, supra-clavicular
9. Auscultate carotid arteries and thyroid

Upper extremities

1. Observe and palpate hands, arms, and shoulders

1. Skin and nail characteristics
2. Muscle mass
3. Musculoskeletal deformities
4. Joint range of motion: fingers, wrists, elbows, shoulders

2. Assess pulses: radial, brachial
3. Palpate epitrochlear nodes

Patient seated, back exposed

Patient is seated on the examining table. Gown is pulled down to the waist for males so he entire chest and back are exposed; back is exposed but breasts are covered for females. Examiner stands behind the patient.

Back and posterior chest

1. Inspect skin and thoracic configuration
2. Inspect symmetry of shoulders, musculoskeletal development
3. Inspect and palpate scapula and spine
4. Palpate and percuss postvertebral angle

Lungs

1. Inspect respiration: excursion, depth, rhythm, pattern
2. Palpate for expansion and tactile fremitus
3. Palpate scapular and subscapular nodes
4. Percuss posterior chest and lateral walls systematically for resonance
5. Percuss for diaphragmatic excursion
6. Auscultate systematically for breath sounds: note characteristics and adventitious sounds

Patient seated, chest exposed

Examiner moves around to front of the patient. The gown is lowered in females to expose anterior chest. 

Anterior chest, lungs, and heart

1. Inspect skin, musculoskeletal development, symmetry
2. Inspect respirations: patient posture, respiratory effort
3. Inspect for pulsations or heaving
4. Inspect chest wall for stability, crepitence, tenderness
5. Palpate precordium for thrills, heaves, pulsations
6. Palpate left chest to locate apical impulse 
7. Palpate for tactile fremitus
8. Palpate nodes: infraclavicular , axillary
9. Percuss systematically for resonance
10. Auscultate systematically for breath sounds
11. Auscultate systematically for heart sounds: aortic area, pulmonic area, and second pulmonic area, apical area

Female breasts

1. Inspect in the following positions: the patient's arms extended over the head, pushing hands on hips, hands pushed together in front of chest, patient leaning forward
2. Palpate breasts in all four quadrants, tail of Spence, over areolae; if breasts are large perform bimanual palpation
3. Palpate nipple; compress breasts to observe for discharge

Male breasts

1. Inspect breasts and nipples for symmetry, enlargement, surface characteristics
2. Palpate breast tissue

Patient reclining 45 degrees

Assist the patient to a reclining position at a 45-degreee angle. Examiner stands to right side of patient.

1. Inspect chest in recumbent position 
2. Inspect jugular venous pulsations and measure jugular venous pressure

Patient Supine, Chest exposed

Assist the patient into a supine position. If the patient cannot tolerate lying flat, maintain head elevation at a 30-degree angle. Uncover the chest while keeping abdomen and lower extremities draped. 

Female breasts

1 .Inspect in recumbent position
2. Palpate systematically with patient's arm over head and arm at side

Heart 

1. Palpate chest wall for thrills, heaves, pulsations
2. Auscultate systematically; you can turn patient slightly to left side and repeat auscultation; use both diaphragm and bell of stethoscope

Patient supine, abdomen exposed

Patient remains supine. Cover he chest withy the patient's gown. Arrange draping to expose the abdomen from pubis to epigastrium.

Abdomen

1. Inspect skin characteristics, contour, pulsations, movement
2. Auscultate all quadrants for bowel sounds
3. Auscultate aorta, renal arteries, femoral arteries for bruits, venous hums
4. Percuss all quadrants for tone
5. Percuss liver borders and estimate span
6. Percuss left midaxillary line for splenic dullness
7. Lightly palpate all quadrants
8. Palpate right costal margin for liver border
9. Deeply palpate all quadrants
10. Palpate left costal margin for spleen
11. Palpate for right and left kidneys
12. Palpate midline for aortic pulsation
13. Test abdominal; reflexes
14. Have patient raise head as you inspect abdominal muscles

Inguinal area 

Palpate for lymph nodes, pulses, hernias

External genitalia, males, females...(I'll spare you that part of the exam)

Patient supine, legs exposed

Patient remains supine. Arrange drapes to cover abdomen and pubis and to expose lower extremities 

Feet and legs

1. Inspect for skin characteristics, hair distribution, muscle mass, musculoskeletal configuration
2. Palpate for temperature, texture, edema, pulses, (dorsalis pedis, posterior tibial, popliteal)
3. Test range of motion and strength of toes, feet ankles, knees

Hips

1. Palpate hips for stability
2. Test range of motion and strength of hips

Patient sitting, lap draped

Assist the patient  to a sitting position. Patient should have gown and drape across lap. 

Musculoskeletal

1. Observe patient moving from lying to sitting position
2. Note coordination, use of muscles, ease of movement

Neurologic

1. test sensory function: dull and sharp sensation of forehead, paranasal sinus area, lower arms, hands, feet
2. Test vibratory sensation of wrists and ankles
3. Test two-point discrimination of palms, thighs, back
4. Test stereognosis, graphesthesia
5. Test  fine motor function, coordination and position sense of upper extremities

1. Touch nose with alternating index fingers
2. Rapidly alternate fingers to thumb
3. Rapidly move index finger between own nose and examiner's finger

6. Test fine motor function, coordination, and position sense of lower extremities

1. Run heel down tibia of opposite leg
2. Alternately and rapidly cross leg over knee

7. Test deep tendon reflexes and compare bilaterally; biceps, triceps, brachioradial, patellar, Achilles
8. Test Babinski reflex bilaterally

Patient standing

Assist patient to a standing position. Examiner stands next to patient.

Spine

1. Inspect and palpate spine as patient bends ogfer at waist
2. Test range of motion: hyperextension, lateral bending, rotation of upper trunk

Neurologic

1. Observe gait
2. Test proprioception and cerebellar function

1. Romberg test
2. Walk heel to toe
3. Stand on one foot then the other with eyes closed
4. Hop on one foot the the other with eyes closed
5. Hop in [place on one foot then the other
6. Do deep knee bends
   

Abdominal/genital

Test for inguinal and femoral hernias

....Ok, enough already :-)

Point here folks is to look at all the various modes of observation other professional observers utilize in their work.

[From Mosby's guide to the Physical Exam.  Used with pending permission]