HAPE EXAM CHECKLIST

Students Name _________________________________________________________ Evaluators Name _______________________________________________________ Patients Name ___________________________________________________________ The Student:
Dressed professionally (in lab coat) Introduces self and title to patient Washed his/her hands just before the physical exam Seemed confident in his/her abilities throughout the exam Performed the PE exam smoothly Maintained a respectful demeanor Avoided jargon, used non-medical language Demonstrated empathy

VITAL SIGNS
ASK ABOUT HEIGHT Ask patient his/her most recent recorded height

ASK ABOUT WEIGHT

Ask patient his/her most recent recorded weight

ASK FOR THE TEMPERATURE ASK FOR THE BLOOD PRESSURE

REPEAT BLOOD PRESSURE ( if Abnormal) (deferred, must be mentioned) RADIAL PULSE ( how long to measure pulse) at least 15 seconds ASK FOR RESPIRATORY RATE

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SKIN
INSPECTION and PALPATION: The skin areas that are being inspected must be visible

Color Moisture Temperature using the backs of the fingers Texture Mobility and turgor by lifting a fold of skin and note the ease with which it lifts up (mobility) and the speed with which it returns into place (turgor) Note the location, distribution, arrangement, type, and color of any lesions Note color, shape, and any lesions of the nails Note quantity, distribution, and texture of any hair

HEAD
INSPECTION and PALPATION: face and skin
Note patients facial expression and contours, asymmetry, involuntary movements, skin color and texture, facial hair distribution, presence of edema, or lesions

INSPECTION and PALPATION: hair and scalp

Observe thoroughly by parting hair Note presence of scaliness, lumps, hair distribution, or lesions

EYES
R L

INSPECTION: surrounding eye structures

Note quantity and distribution of eyebrows Note eyelid position in relation to the eyeballs Note direction of eyelashes and presence of lesions Note lacrimal apparatus for redness and swelling Raise both eyebrows

INSPECTION: external eye structures

Note color and vascular pattern of the conjunctivae and sclera Note cornea, lens, and iris for any opacities Note pupil size, shape, and symmetry

ASSESS VISUAL ACUITY (CN II - 111)

Test each eye individually by having patient cover opposite Test both eyes together ASSESS COLOR VISION Have patient identify at least 3 different colors

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ASSESS VISUAL FIELDS (CN II - 111)

Ask patient to look with both eyes into the examiners eyes Ask patient to indicate when they see the examiners fingers come into view, starting in a position lateral to his/her ears and from behind the patients head Assess upper temporal fields, starting from a position behind the patients head Assess lower temporal fields, starting from a position behind the patients head

ASSESS EXTRAOCULAR MUSCLES (CN III, IV, and VI - 113)

Test all 6 cardinal positions Hold position at patients extreme lateral gaze to check for nystagmus Assess for lid lag CONVERGENCE

Have patient follow an object with their eyes to within 5 8 cm of the nose ASSESS PUPILLARY ACCOMODATION: constriction and convergence (CN III, IV, and VI - 113)
Have the patient focus on an object at a distance and then bring it in toward the center of his/her nose

ASSESS PUPILLARY REACTION TO LIGHT: direct and consensual (CN II and III - 112)
Shine a light into the patients eye assessing pupillary constriction while checking the opposite eye for the same reaction; repeat assessment in the opposite eye

PERFORM FUNDUSCOPIC EXAM (CN II - 111)

Dim lights before ophthalmoscopic examination (give credit for student saying they would) Adjust obturator by switching lenses (or have finger ready to make adjustments)

INSPECTION: internal eye structures Note red reflex Note any lens opacities Note size of the vessels and character of arteriovenous crossings (AV nicking) Note color and size of the optic disc and physiologic cup Note retina for any lesions Ask patient to look directly at light - note the fovea and macula for any abnormalities

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EARS
R L

INSPECTION: auricle (external ear) and back of ears

Note presence of deformities, lumps, or lesions

PALPATION: auricle
Pull the auricle up when palpating Ask patient if s/he feels any tenderness

PALPATION: tragus
Apply pressure on the tragus Ask patient if s/he feels any tenderness

PALPATION: mastoid process

Apply pressure on the mastoid process Ask patient if s/he feels any tenderness

INSPECTION: ear canal

Insert speculum, note any discharge, foreign objects, cerumen, redness of the skin, and/or swelling

INSPECTION: tympanic membrane (eardrum)

Advance the speculum without causing pain to the patient Note color of tympanic membrane, while visualizing the cone of light and its landmarks TEST AUDITORY ACUITY (CN VIII 116) Occlude one ear while testing the opposite ear with whisper test, OR Ask patient when s/he stops hearing the fingers rubbing as they are moved away from the patients ear Place base of vibrating tuning fork on top of patients head and ask where the patient hears it: on right, left, or both sides equally

WEBER TEST (CN VIII 116) RINNE TEST (CN VIII 116) Place base of vibrating tuning fork behind the ear
When the patient acknowledges s/he can hear the sound, ask them to report when it stops, then place the fork close to the ear canal; then ask the patient if the sound can be heard again

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NOSE AND SINUSES

R L

INSPECTION: external surfaces

Use a penlight or otoscope to view nasal vestibule Note any asymmetry or deformity of nares Test for nasal obstruction: press each ala nasi in turn while having patient inhale Test smell (CN I 110)

INSPECTION: internal nose structures

Use otoscope when inspecting inside the nose Note the nasal mucosa and septum for any abnormalities

PALPATION: sinuses
Palpate frontal sinuses for tenderness Palpate maxillary sinuses for tenderness

MOUTH AND PHARYNX

R L

INSPECTION: external mouth structures

Note color and moisture of lips, and presence of any lesions Note presence of swelling, ulcers or lesions

INSPECTION AND PALPATION: internal mouth structures

Use flashlight when inspecting inside the mouth Note color of bucca mucosa (sides inside mouth,) gums, gum margins and presence of ulcers, white patches, or lesions Ask patient to protrude tongue, note the color and texture of the surface (CN XII 120) Ask patient to lift tip of tongue to roof of mouth, note the color and presence of any lesions on the undersurface Note sides of tongue for white patches or lesions using a square gauze to grasp tip of tongue and gently pull it to each side if necessary Test for the gag response (give credit for student saying they would) (CN IX 117) Sensory: test taste on posterior 1/3 of tongue (give credit for student saying they would) (CN IX 117) Test strength of the lingualis muscle (have patient push with their tongue against the inside of their cheek while the examiner pushes on the outside of their cheek) CN XII 120) Note condition and absence of teeth Use gloves when touching any mouth structures

INSPECTION: pharynx (back of mouth)

Note color of the soft and hard palate, presence of ulceration, exudates, or lesions Note color of the anterior and posterior pillars, presence of exudates, or lesions Note presence or absence of tonsils, tonsillar enlargement, presence of exudates

REQUEST PATIENT TO SAY AH (CN X 118)

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Observe elevation of uvula and soft palate, using tongue blade if necessary

NECK AND THYROID

R L

INSPECTION: trachea and thyroid gland

Request patient to sip some water and swallow during inspection observing the upwards movement of the thyroid gland and noting its contour and symmetry (CN IX 117)

Note any trachea deviation from midline

PALPATION: tracheal position PALPATION; thyroid PALPATION: nodes Pre-auricular lymph nodes - Located in front of the ear

Post-auricular lymph nodes - Located behind the ear, superficial to the mastoid
process Occipital lymph nodes - Located at the base of the skull posteriorly

Tonsillar lymph nodes - Located at the angle of the mandible Submandibular lymph nodes - Located midway down the base of the jaw Submental lymph nodes - Located under the chin Superficial cervical lymph nodes - Located superficial to the sternomastoid Posterior cervical lymph nodes - Located along the anterior edge of the
trapezius

Deep cervical lymph nodes - Located deep to the sternomastoid Supraclavicular lymph nodes - Located in the angle formed by the clavicle and
the sternomastoid

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LUNGS AND THORAX

R L INSPECTION: general

Note rate, rhythm and effort of breathing

Note shape, A/P-lateral diameter, deformities, asymmetry, abnormal retraction of intercostals spaces, and tracheal position INSPECTION AND PALPATION: respiratory expansion Place thumbs along each costal margin (bottom of rib cage) anteriorly (on front), or posteriorly (on back) at the level of and parallel to the 10th rib, to form a loose skin fold Ask patient to inhale deeply while observing the extent and symmetry of respiratory movement PALPATION: posterior and anterior chest Apply pressure to posterior and anterior chest in the upper and lower lung fields Apply pressure to lateral lung fields PALPATION: assessment of tactile fremitus - posterior lung fields Ask patient to fold arms across chest Ask patient to say ninety-nine while placing ball or ulnar surface of hand on the 4 posterior lung field positions PERCUSSION: diaphragmatic excursion Locate and measure the level at quiet respiration Locate and measure the upper level by having the patient fully exhale and percuss upwards from the quiet respiration mark Locate and measure the lower level by having the patient fully inhale and percuss downwards from the quiet respiration mark PERCUSSION: posterior lung fields Ask patient to fold arms across chest Percuss the 7 locations on the posterior lung fields from the apices to the lung bases, to include the lateral lung fields Compare locations bilaterally when percussing AUSCULTATION: posterior lung fields Ask patient to fold arms across chest Auscultate the 7 locations on the posterior lung fields from the apices to the lung bases, to include the lateral lung fields Compare locations bilaterally when auscultating PALPATION: assessment of tactile fremitus - anterior lung fields Ask patient to place hands on hips Ask patient to say ninety-nine while placing ball or ulnar surface of hand on the 3 anterior lung field positions R

PERCUSSION: anterior lung fields Ask patient to place hands on hips Percuss the 6 locations on the anterior lung fields from the apices to the lung bases Compare locations bilaterally when percussing

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A* P** AUSCULTATION: anterior lung fields Ask patient to place hands on hips Auscultate the 6 locations on the anterior lung fields from the apices to the lung bases
Compare locations bilaterally when auscultating AUSCULTATION: transmitted voice sounds the student must perform one of the following assessments: - bronchophony (ask patient to say ninety-nine ) - egophony (ask patient to say ee) - whispered pectoriloquy (ask patient to whisper one, two, three or ninety-nine) Compare locations bilaterally when auscultating

*Anterior **Posterior

HEART
R L INSPECTION: precordium Note any lifts, heaves, pulsations, or visible PMI (point of maximum impulse) PALPATION: carotid arteries Palpate the carotid arteries Palpate carotid arteries separately not together PALPATION: precordium and PMI Use the palm of the hand to palpate over the heart Left sternal border Use fingertips to localize the apical impulse or PMI

AUSCULTATION: carotid arteries Auscultate the carotid arteries Use the bell to auscultate D* B** AUSCULTATION: 2nd right intercostal space (ICS) right sternal border (aortic sounds) AUSCULTATION: 2nd left ICS left sternal border (pulmonic sounds) AUSCULTATION: 3rd left ICS left sternal border (tricuspid sounds) AUSCULTATION: 4th left ICS left sternal border (tricuspid sounds) AUSCULTATION: 5th left ICS left midclavicular line (mitral sounds) AUSCULTATION: left sternal border and at apex (to accentuate mitral murmurs mitral regurgitation) Have patient lean forward, exhale completely, and then hold breath

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Auscultate with the diaphragm

*Diaphragm -- **Bell

PATIENT LYING DOWN INSPECTION: precordium D* B** Note any lifts, heaves, pulsations, or visible PMI PALPATION: precordium and PMI Use the palm of the hand to palpate over the heart Left sternal border Use fingertips to localize the apical impulse or PMI AUSCULTATION: 2nd right intercostal space (ICS) right sternal border (aortic sounds) AUSCULTATION: 2nd left ICS left sternal border (pulmonic sounds) AUSCULTATION: 3rd left ICS left sternal border (tricuspid sounds) AUSCULTATION: 4th left ICS left sternal border (tricuspid sounds)

AUSCULTATION: 5th left ICS left midclavicular line (mitral sounds)

AUSCULTATION: apical impulse (to accentuate left-sided S3 and S4 and mitral murmurs mitral stenosis) Ask patient to roll onto left side, locate PMI Auscultate with the bell

*Diaphragm -- **Bell

ABDOMEN
R L POSITIONING OF PATIENT Patient lying down Full exposure of abdomen from above the xiphoid process to the symphysis pubis INSPECTION: general abdomen Inspect from above and at table level Note scars, striae, dilated veins, lesions, contour of the abdomen, peristalsis, umbilicus contour and location, signs of inflammation or hernia, or pulsations AUSCULTATION PREFORMED PRIOR TO PERCUSSION OR PALPATION AUSCULTATION: general abdomen Auscultate all four quadrants

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 R L

AUSCULTATION: renal arteries (check for bruits) AUSCULTATION: iliac arteries (check for bruits) AUSCULTATION AND PALPATION: aorta Auscultate first, slightly to the left of the midline in the upper abdomen Then palpate, using two hands pressing firmly in the same area PALPATION AND AUSCULTATION: femoral arteries Palpate femoral pulses (first) Auscultate arteries for bruits PERCUSSION: general abdomen Percuss all four quadrants of the abdomen PERCUSSION: gastric air bubble

PERCUSSION: bladder

PERCUSSION: upper and lower liver borders For the upper border start at a level above the nipple and percuss downwards along the right midclavicular line For the lower border start below the level of the umbilicus and percuss upwards along the right midclavicular line Measure in centimeters the distance between the two points PERCUSSION: spleen Percuss starting at the left lower rib cage from midclavicular line toward the left midaxillary line Percuss starting below the umbilicus diagonally to midaxillary line KNEES BENT FOR PALPATION LIGHT PALPATION: general abdomen With fingers together and flat, palpate all four quadrants of the abdomen DEEP PALPATION: general abdomen Use two hands, one on top of the other palpate all four quadrants of the abdomen Exerting pressure when patient exhales PALPATION: liver Place one or both hands (hooking technique) on the right side of the abdomen below the rib cage and press in and upwards with fingers Ask patient to take a deep breath while pressing in and up

PALPATION: spleen With left hand, press forward the lower left rib cage and with right hand below the left costal margin, press in toward the spleen Ask the patient to take a deep breath PALPATION: kidneys Displace the kidney anteriorly, using one hand to press behind the patient, while pressing in deeply in the upper quadrant with the other hand at the peak of inspiration Ask the patient to take a deep breath

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PALPATION: CVA tenderness Place ball of one hand in the costovertebral angle and strike it with the surface of the fist of the other hand

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MUSCULOSKELETAL
R L
INSPECTION, PALPATION AND ROM: temporomandibular joint (TMJ joint)

Note and swelling or redness Palpate the TMJ joint by placing tip of index fingers in front of tragus of each ear and ask patient to open and close mouth Have patient demonstrate opening and closing, jutting the jaw forward, and side-to-side motion
INSPECTION, PALPATION AND ROM: shoulder

Note any swelling, joint deformity, or muscle atrophy or fasciculations (fine tremor of the muscles) Palpate the bony landmarks (acromion process, acromioclavicular joint, coracoid process) Flexion Extension Abduction Adduction Internal rotation External rotation Test strength and contraction of the trapezii (ask the patient to shrug both shoulders upward against the examiners hands) (CN XI - 119)
INSPECTION, PALPATION AND ROM: elbow

Note any swelling, or nodules Palpate the groves (between the epicondyles and olecranon) Flexion Extension Pronation (turn palms down) Supination (turn palms up)

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INSPECTION, PALPATION AND ROM: wrist and hands

Note any swelling, joint deformity, or deviations Palpate the wrist (at the distal radius and ulna on the lateral and medial surfaces) and the anatomic snuffbox Palpate the MCP (metacarpal) joints Palpate the PIP (proximal interphalangeal) joints Palpate the DIP (distal interphalangeal) joints Wrist flexion Wrist extension Ulnar deviation Radial deviation Fingers flexion Fingers extension Fingers abduction Fingers adduction Thumb flexion Thumb extension Thumb abduction Thumb adduction Thumb opposition
INSPECTION, PALPATION AND ROM: neck

Note any spinal curvatures Palpate spinous processes of each vertebra Flexion Extension Rotation Lateral bending Test the strength of the sternocleidomastoid (have the patient turn their hand and push their cheek against the examiners hand while they palpate the opposite SCM muscle, then repeat on the other side) (119)
INSPECTION, PALPATION AND ROM: spine

With patient standing, feet together, exposing entire back, note any spinal curvatures Palpate spinous processes of each vertebra Flexion Extension Rotation Lateral bending

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R L

INSPECTION, PALPATION AND ROM: hip

Inspect gait and anterior and posterior surfaces of the hip for any areas of muscle atrophy or bruising Ask patient to place heel of the leg being examined on the opposite knee, palpate the inguinal ligament (extending from the anterior superior iliac spine to the pubic tubercle) With patient resting on one side and the hip flexed and internally rotated, palpate the trochanteric bursa (lying over the greater trochanter) Flexion Extension Abduction Adduction

Rotation
INSPECTION, PALPATION AND ROM: knee

Note any swelling With knee in 90 flexion, palpate the patellar tendon, and menisci With knee extended, palpate bursae Flexion Extension Internal rotation External rotation Abduction (valgus) stress test assesses the medial collateral ligament (MCL) Adduction (varus) stress test assesses the lateral collateral ligament (LCL) Anterior drawer test assesses the anterior cruciate ligament (ACL)

Posterior drawer test assesses the posterior cruciate ligament (PCL)

INSPECTION, PALPATION AND ROM: ankle and foot

Note any swelling, deformities, nodules, calluses, or corns Palpate the anterior of each ankle joint and the Achilles tendon Palpate the heel and the plantar fascia Palpate the MTP (metatarsophalangeal) joints by compressing the forefoot between the thumb and fingers and then the heads of the joints and the grooves between them Ankle flexion Ankle extension Foot inversion

Foot eversion

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MENTAL STATUS
INSPECTION: general appearance Note attitude, affect, appearance, attention span, behavior, cognitive functions, dress, development, expressions, facies, grooming, hygiene, level of consciousness, mood, motor activity, speech, thought content, and thought process ORIENTATION: person, place, and time Can you tell me who I am? Can you tell me specifically where we are? Can you tell me what day it is?

DEEP TENDON REFLEXES

R L DEEP TENDON REFLEXES Biceps reflex Triceps reflex Supinator or brachioradialis reflex Knee reflex Ankle reflex Plantar response (Babinski) Abdominal reflexes (testing upper and lower abdomen)

Student Signature_______________________

Proctor____________________________

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