PRE-CLINICAL CLERKSHIP, YEAR 1, 2007/2008 Physical Examination Sessions Eight and Nine Flow of the Head-to-Toe Exam Cheryl

A. Walters, M.D. 1. Learning Objectives To develop a flow for the head-to-toe exam.

2. Checklist for Flow of the Head-to-Toe Exam Wash hands Observe general appearance Palpate radial pulse Measure blood pressure in both arms Inspect and palpate head Assess visual acuity bilaterally Test visual fields by confrontation Test eye alignment bilaterally (convergence and accommodation) Evaluate extraocular muscle function in 6 directions bilaterally Observe direct and consensual pupillary reflexes bilaterally Inspect external eye structures (eyelid, lacrimal apparatus, conjunctiva, sclera, cornea, pupil, iris, depth of anterior chamber) Funduscopic exam Test auditory acuity bilaterally Weber Rinne Inspect auricles and posterior auricular areas bilaterally Otoscopic exam Inspect nose Inspect and palpate oral cavity Neck range of motion Inspect and palpate salivary glands and neck nodes Inspect and palpate thyroid Examine the chest with patient sitting: Inspect and palpate position of trachea in suprasternal notch Percuss posterior chest Percuss for spine tenderness Percuss for CVA tenderness Auscultate lungs posteriorly Percuss upper lobes anteriorly Percuss laterally over RML (lingula optional) Auscultate upper lobes anteriorly Auscultate RML (lingula optional) Examine the heart with patient supine at 30 to 45 degrees: Measure the height of JVD at a right angle to the reference point of the angle of Louis Palpate carotid artery upstroke bilaterally Auscultate for carotid artery bruits Inspect anterior chest and breasts Palpate aortic area, pulmonic area, Erbs point, tricuspid area, PMI Auscultate using diaphragm of stethoscope aortic, pulmonic, Erbs point, tricuspid, mitral areas Auscultate using bell of stethoscope - tricuspid area

Examine the heart with patient in left lateral decubitus position: Palpate to relocate apex, PMI Auscultate using bell of stethoscope mitral area Examine the heart with patient sitting: Auscultate using diaphragm of stethoscope all areas Auscultate with patient leaning forward, using diaphragm of stethoscope base (aortic area, pulmonic area) Palpate for axillary lymph nodes with patient sitting Palpate breasts with patient supine Examine the abdomen with patient supine: Inspect the abdomen Listen in all 4 quadrants for presence of bowel sounds or vascular bruits (renal and iliac arteries) Listen for femoral artery bruits Percuss all 4 quadrants of the abdomen and flanks Percuss the liver for size (along MCL) and presence or absence of tenderness Percuss the spleen at Castells point Palpate the abdomen lightly in all 4 quadrants Palpate the liver edge on inspiration in the MCL Palpate for splenomegaly using the single-handed technique [If the splenic percussion sign is negative, splenomegaly has been effectively ruled out and there is no need to palpate.] Deep palpation for the width of the aorta Palpate the inguinal nodes Palpate the femoral artery pulses Inspect extremities and joints Palpate posterior tibial and dorsalis pedis pulses (popliteal optional) Mental status alertness, orientation, attention (months forward and backward), immediate registration and delayed recall of 3 objects for 4 minutes timed. Naming of watch parts. CN V facial sensation to light touch CN VII facial symmetry during emotional smile CN IX, X palate elevation, voice CN XI head turning and shoulder shrug against resistance CN XII tongue protrusion Sensory exam light touch in hands and feet. Pinprick or temperature testing in feet bilaterally. Vibration and joint position in feet bilaterally. Motor exam pronator drift. Rapid hand and foot tapping. Upper and lower extremity tone. Strength in several proximal and distal muscles in the upper and lower extremities bilaterally. Reflexes bilateral biceps, brachioradialis, patellar, Achilles tendon, plantar Coordination and gait finger to nose and heel to shin tests bilaterally. Gait and tandem gait. Joint range of motion upper and lower extremities Spine range of motion