Foundations Of Clinical Practice Elements Of A Complete Physical Exam

Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM I. General Assessment and Vital Signs A. Major Objective 1. The student will demonstrate the ability to perform a general evaluation and vital signs. B. Specific Objectives: General Survey 1. The student will observe the general state of health, level of nourishment, sexual development, ethnicity, level of alertness, level of apparent distress and degree of cooperation with the evaluation when evaluating a patient. Observe the patient and note the following: a. general appearance of their health: healthy, acutely ill, chronically ill b. level of nourishment: cachectic, thin, well-nourished, obese c. sexual development: appropriate sexual development for age d. apparent ethnicity: Caucasian, African-American, Hispanic, etc e. level of alertness: unresponsive, lethargic, confused, alert f. level of distress: no distress, mild, moderate, severe distress g. cooperation: uncooperative or cooperative with the examiner 2. The student will observe and any other important features, behaviors, odors, etc. that are apparent upon examining a patient. Observe the patient and note the following: a. distinct odors: tobacco, alcohol, ketones (smells like fingernail polish remover) b. general hygiene and dress and grooming c. unusual behaviors, tics or postures C. Specific Objectives: Vital Signs 1. The student will demonstrate the ability to measure the blood pressure properly when examining a patient. Take the Blood Pressure a. chose the appropriate sized cuff b. prepare the patient c. describe the Korotkoff sounds d. measure the blood pressure: arm and thigh e. describe the blood pressure classification: optimal, normal , HTN(3-stages) 2. The student will demonstrate the ability to properly determine the rate and rhythm of the pulse. Take the Pulse a. take the radial and apical pulse b. describe the rate and rhythm of the pulse 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) 3. The student will demonstrate the ability to determine the temperature of a patient and note variations of same depending upon the site where it is taken (rectal, vs. oral). Take the temperature a. measure the temperature with a thermometer and an electronic device b. describe the temperature variances by site of measurement c. describe the normal temperature and diurnal variation thereof 4. The student will demonstrate the ability to properly determine the rate and quality of the respirations of a patient. Evaluate the respirations a. measure the respiratory rate b. describe the rhythm of the respiration c. describe the quality of respirations: regular, labored, deep, shallow d. measure oxygen saturation using an oximeter 5. The student will demonstrate the ability to determine the level of pain

reported by a patient using the Analog Pain Scale or Happy/Sad Cartoon faces. Describe the Pain Level a. quantify the level of pain using the analog pain scale b. quantify pain using standard pain level cartoon face scale II. The Musculoskeletal System A. Major Objectives The student will demonstrate the ability to evaluate the musculoskeletal system when evaluating a patient. B. Specific Objectives: The Spine 1. The student will demonstrate the ability to identify and palpate important spinal landmarks and to evaluate the range of motion of the various spinal segments of a patient. Identify and palpate the following landmarks a. cervical and lumbar lordosis, thoracic kyphosis b. cervical vertebral #7 c. sacro-iliac joints d. thoraco-lumbar junction e. costo-vertebral angle f. iliac crest and anterior/posterior iliac spines g. scapulae h. count the vertebral bodies 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) Demonstrate Range of Motion of the spine a. cervical spine: flexion, extension, rotation, lateral bending b. thoracic spine: flexion, extension, rotation, lateral bending c. lumbar spine: flexion, extension, rotation, lateral bending C. Specific Objectives: The Upper Extremity 1. The student will identify the important topographical anatomy by palpation of the upper extremity of a patient. Identify and Palpate the Landmarks of the upper extremity a. shoulder: acromion, coracoid process, acromioclavicular joint, clavicle, humerus, sternoclavicular and glenohumeral joints b. elbow: epicondyles, olecranon process, ulnar nerve c. wrist and hand: palmar and dorsal surfaces d. thenar and hypothenar eminences e. distal radius and carpal tunnel f. ulna g anatomic snuffbox h. metacarpals and metacarpo-phalangeal joints, proximal and distal interphalangeal joints i. Major Muscles: deltoids, pectoralis major/minor, latissimus dorsi, biceps, triceps forearm extensors and flexors, serratus anterior, supra and infraspinatus muscles, and the intrinsic musculature of the hands j. Major Arteries: brachial, ulnar and radial 3. The student will demonstrate the normal function and range of motion of the joints of the upper extremity of a patient. Demonstrate normal range of motion and function/muscle testing of following: a. shoulder: abduction, adduction, flexion, extension, internal and external rotation b. elbow: flexion and extension., pronation and supination of the forearm c. wrist: flexion and extension and radial and ulnar deviation d. digits: flexion and extension, abduction/adduction, grip and pinch D. Specific Objectives: The Lower Extremity

1. The student will identify the important topographical anatomy by palpation of the lower extremity of a patient. 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) Identify and palpate the following landmarks of the lower extremity: a. Hip: greater trochanter/trochanteric bursa b. Knee: popliteal fossa, patella, medial and lateral joint lines, distal femur, proximal tibia, attachments of quadriceps, patella, hamstrings, and adductors c. tibia, fibula, ankle joint, medical and lateral malleoli d. calcaneous, metatarsals, and phalanges e. deltoid and anterior talofibular ligaments and tarsal tunnel f. Major Muscles: gluteals, hamstrings, quadriceps, adductors, abductors, ankle dorsi and plantar flexors g. common peroneal nerve at lateral knee region 3. The student will demonstrate the normal function and range of motion of the joints of the lower extremity of a patient. Demonstrate normal range of motion and function/ muscle testing of the following: a. Hip flexion, extension, abduction, adduction, internal and external rotation b. Knee flexion, extension, extension lag, external tibial rotation at full extension (�screw home� motion) c. Ankle: flexion, extension, inversion, eversion d. Digits: flexion and extension III. The Nervous System A. Major Objectives The student will demonstrate the ability to perform a screening neurological evaluation of a patient. B. Specific Objectives: The Mental Status Examination 1. The student will evaluate the mental status of a patient. Perform a mental status examination a. Assess Appearance b. Assess Behavior c. Assess Mood d. Assess Thoughts and Perceptions d. Assess Cognitive Function with the Folstein Mini-Mental Status Test C. Specific Objectives: The Cranial Nerves 1. The student will demonstrate the ability to perform an examination of the twelve cranial nerves: 1. I-assess sense of smell 2. II- assess visual fields, visual acuity, the pupillary reflex and the fundoscopic exam 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) 3. III, IV, VI � assess extra ocular movement and pupillary function 4. V- assess facial sensation (3 divisions), motor function 5. VII- assess motor function 6. VIII-assess hearing , vestibular function 7. IX, X-assess motor function of palate, larynx and pharynx 8. XI � assess motor function of sternocleidomastoid muscles 9. XII- assess motor function of the tongue D. Specific Objectives: The Motor and Sensory Examination

1. The student will perform motor examination of the trunk and extremities of a patient. Perform the following examinations: a. Perform a motor examination of the extremities b. Perform an examination of muscular tone. The student will perform sensory examination of the trunk and extremities of a patient. Perform the following examinations: a. Perform a sensory examination: gross, fine touch and temperature sensation b. Perform an examination of the deep tendon reflexes E. Specific Objectives: The Examination of Gait, Balance and Coordination 1. The student will perform a examination of gait, balance and coordination of a patient. Perform the following examinations: a. Perform an examination of gait: usual gait, heel-toe b. Perform a Romberg test c. Perform a heel-shin test, finger-nose test, test of rapid alternating movements. IV. The Thorax A. Major Objectives 1. When examining a patient, the students will demonstrate the ability to perform a proper evaluation of cardiovascular and pulmonary systems. B. Specific Objectives: Thorax 1. The students will describe the topographical anatomy of the thorax of a patient. 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) Identify and Palpate the following structures a. Supra sternal notch b. The manubrium, sternum, xiphoid and angle of Louis c. Clavicle, sternoclavicular joint and scapulae d. Lines: midclavicular, midsternal, anterior/middle/posterior axillary, scapular and vertebral e. Shape of the thorax f. Costovertebral angle g. The ribs and intercostals spaces by number C. Specific Objectives: The Lungs 1. The students will inspect the respiratory motions of a patient Inspect the following a. the symmetry and degree of lung expansion 2. The students will palpate the chest for symmetry of expansion and for fremitus on a patient. Demonstrate the following a. assess the symmetry and degree of lung expansion by palpation b evaluate for normal fremitus c. palpate the thorax for irregularities or tenderness 3. The student will demonstrate the correct technique of percussing the chest of a patient and be able to describe the various types of percussion notes. Demonstrate the following a. Percuss the chest symmetrically b. Identify the limits of diaphragmatic excursion by percussion c. Describe the following percussion notes: hyper-resonance, resonance, tympany, dullness, flatness 5. The student will demonstrate the correct techniques for auscultation of the lungs and be able to describe the characteristics of normal breath sounds.

Demonstrate the following: a. auscultate the lungs symmetrically (4 anteriorly, 2 laterally, 6 posteriorly) b. describe the normal breath sounds (tracheal, bronchial, vesicular) 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) D. Specific Objectives: The Heart 1. The student will measure the jugular venous pressure of a patient according to the criteria established by the CSC. Demonstrate the following: a. examine the jugular venous pulse and estimate the right atrial pressure 2. The student will demonstrate the proper techniques of precordial palpation and location of the PMI on a patient. Demonstrate the following a. palpate the aortic area (right 2nd intercostal space), pulmonic area (left 2nd intercostal space, the right ventricular area (lower left sternal border and subxiphoid area, and the PMI at the apex 3. The student will demonstrate the proper technique of auscultation of the heart, with the diaphragm and bell of the stethoscope in the upright and supine positions on a patient. Demonstrate the following a. auscultate the heart with the diaphragm and bell in the 4 standard positions in the sitting and supine positions b. describe the normal heart sounds as the relate to the cardiac cycle E. Specific Objectives: The Vasculature/ Hematologic system 1. The student will perform an examination of the major arteries of the neck, upper and lower extremities when examining a patient. Palpate the following arteries: a. carotid b. radial c. aorta d. femoral e. dorsalis pedis and tibialis posterior V. The Abdomen A. Major Objectives 1. The student will demonstrate the ability to perform a complete examination of the abdomen of a patient. B. Specific Objectives 1. The student will describe the topographical anatomy of the abdomen, identify anatomic regions and identify any distinguishing abnormalities such as surgical scars, hernia, etc. on a patient. 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) Describe and Identify the following: a. xiphoid process, umbilicus, inguinal ligaments, costal margins b. right/left upper and lower quadrants c. epigastric, umbilical and suprapubic areas 2. The student will demonstrate the ability to properly auscultate the abdomen of a patient. 4. The student will demonstrate the ability to perform a general percussive examination of the abdomen as well as a specific percussive examination of the liver span on a patient. 5. The student will demonstrate the ability to lightly and deeply palpate the

major anatomic regions of the abdomen of a patient. 6. The student will demonstrate the ability to palpate the inferior borders of the liver, spleen of a patient. VI. The Male Genitourinary Tract A. Major Objective The student will demonstrate the ability to perform an evaluation of the of the genitourinary function of a male patient. B. Specific Objectives: Male Genitalia 1. The student will inspect the genitalia of a male patient. Inspect the following: a. skin of the penis and scrotum, glans penis (retract foreskin), shaft of the penis, inguinal regions 4. The student will demonstrate the ability to palpate the genitalia of a male patient. Palpate the following: a. shaft of the penis and the glans penis, testes, epididymi and spermatic chords 5. The student will demonstrate the ability to evaluate for an inguinal hernia of a male patient.. Inspect and Palpate the following: a. inspect the inguinal regions for bulges or swelling b. palpate the inguinal canals 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) C. Specific Objectives: The Prostate and Rectal Examination 1. The student will demonstrated the ability to perform a rectal examination and prostate examination of a male patient. Demonstrate the following skills a. inspection the perianal region b. palpate the anus, assess anal tone c. identify prostate including lobes and palpate these d. perform a rectal �sweep� to evaluate for masses e. demonstrate how to do a guiac test VII. The Female Genitourinary Tract and Breast A. Major Objectives 1. The student will demonstrate the ability to perform a gynecologic and breast evaluation of a female patient. B. Specific Objectives: Female Genitourinary tract 1. The student will demonstrate the technique involved in performing a pelvic examination and pap test on a female patient. Demonstrate the following a. explain the examination that you are about to perform b. demonstrate the ability to comfortably position and drape patient c. perform pelvic in proper sequence, as follows: - inspect the perineum, inguinal area, urethra and vulva - palpate the inguinal area (nodes, pulse), labia major, and minora - insert the speculum and inspect the vaginal mucosa, and cervix -perform a pap test -withdraw the speculum and perform a bimanual examination of the uterus, and adnexae C. Specific Objectives: The Breasts 1. The student will demonstrate the ability to perform a breast examination. Perform a breast exam a. explain the examination that you are about to perform

b. position and drape the patient properly c. identify the breast boundaries d. inspect the breasts for symmetry, dimpling, discharge, and inflammation e. examine the breasts using the vertical strip pattern or radial pattern f. examine the lymph nodes of the axillae 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) VIII. Evaluation of the Head and Neck A. Major Objective: When examining a patient the student will demonstrate the ability to perform a detailed examination of the structures of the head and neck, including an evaluation of the specific sensory functions associated with these structures. B. Specific Objectives: The Head 1. The student will describe the topographical anatomy of the head of a patient according to the criteria established by the CSC. Identify and Palpate the Following Landmarks: a. mandible, maxilla, orbits, occipital bones, submandibular gland, parotid gland, temporal arteries C. Specific Objectives: The Eye 1. The student will describe the external structures of the eye of a patient Describe the external structures of the eye a. medial and lateral canthus b. sclera, limbus, cornea c. iris, pupil 3. The student will demonstrate the ability to evaluate the visual fields, extra ocular movements and the pupillary light and near reactions of the eyes of a patient. Demonstrate the following skills a. assess visual acuity using a Snellen Chart b. assess ocular motility c. assess ocular symmetry d. assess visual fields by confrontation d. assess the pupillary light reaction e. perform a �swinging flashlight� test f. assess the Near Reaction (convergence and accommodation) 4. The student will demonstrate the ability to describe the basic operation of the ophthalmoscope and to demonstrate the technique involved in examining the fundus of the eye of a patient. Demonstrate the following skills: a. describe the basic functions of the ophthalmoscope as follows: -turn on the light and adjust brightness -adjust the diopters -actuate small and large light aperture, slit lamp and red free light filter b. find the �red reflex� 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) c. identify the optic disk and surrounding vessels d. describe normal relationship of cup to disc, vein to arteriole D. Specific Objectives: The Ear 1. The student will describe the external structures of the ear of a patient. Identify and Palpate the following Landmarks a. Auricle(external ear): Helix/antihelix, tragus, lobule

b. External ear canal 3. The student will demonstrate the ability to use an otoscope to examine the external ear canal and tympanic membrane and to identify appropriate landmarks when examining the ear of a patient. Demonstrate the following skills a. Describe the basic operation of the otoscope b. Demonstrate proper technique for examination of the internal ear with the otoscope c. Identify and describe the: malleus, cone of light, pars flaccida and tensa of the tympanic membrane 4. The student will demonstrate the ability to perform a basic hearing assessment, including the use of the tuning fork (Weber and Rhinne tests), when examining a patient. Demonstrate the following skills a. Assess hearing grossly by whispering or rubbing fingers by each ear b. Perform a Rhinne test and interpret this c. Perform a Weber test and interpret this E. Specific Objectives: The Nose 1. The student will identify the approximate topographical location of the paranasal sinuses on a patient. Identify and Palpate the following a. The bridge, tip, ala nasi, naris, and the junction of the nasal bone and nasal cartilage b. Identify and palpate/percuss the frontal and maxillary sinuses 3. The student will demonstrate the ability to examine the internal nasal structures and to transilluminate the maxillary sinuses of a patient. Demonstrate the following techniques a. examine the internal nose and identify the septum and turbinates b. demonstrate the proper technique to transilluminate the maxillary sinuses 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) F. Specific Objectives: The Mouth 1. The student will demonstrate the ability to perform and examination the structures of the mouth and pharynx of a patient. Identify the following structures a. The gingival margin, alveolar and labial mucosa and labial frenulum b. The papilla and opening of Stenson�s duct c. The posterior and anterior pillars and tonsils d. The soft and hard palate, pharynx and uvula. e. The incisor , canine teeth and molars. G. Specific Objectives: The Neck 1. The student will identify the topographical anatomy of the neck of a patient. Identify and Palpate the following a. The sternocleidomastoid muscle, and it�s clavicular and sternal insertions. b. The trapezious muscle c. The hyoid bone, trachea, thyroid cartilage and cricoid cartilage and crico- thyroid ligament d. The anterior and posterior triangles e. The thyroid gland 3. The student will demonstrate the ability to identify and examine the major groups of lymph nodes in the neck of a patient. Identify and Palpate the following a. The superficial lymph nodes: preauricular, occipital, tonsillar, submandibular, submental, posterior cervical, supraclavicular and

superficial cervical 4. The student will demonstrate the ability to properly examine the thyroid gland of a patient. Demonstrate the following a. Examine the thyroid gland IX. The Skin, A. Major Objectives 1. The student will demonstrate the ability to perform a general evaluation of the skin and it�s appendages of a patient. B. Specific Objectives 1. The student will perform an examination of the skin and it�s appendages on a patient. 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM Foundations of Clinical Practice ELEMENTS OF A COMPLETE PHYSICAL EXAM (continued) Perform an examination of the skin and appendages: a. Inspect � rash - mole -tattoos - piercing/jewelry b. Nails c. Hair 2007 Foundations of Clinical Practice, University of New Mexico School of Medicine, Albuquerque, NM