Review of Systems ..........................................................................................................................

2
General Appearance, Vital Signs and HEENT .................................................................................. 4
Cervical Spine Exam ........................................................................................................................ 9
Thoracic Spine Exam ..................................................................................................................... 11
Lumbar Spine Exam ....................................................................................................................... 13
Shoulder Exam .............................................................................................................................. 16
Elbow Exam ................................................................................................................................... 18
Wrist and Hand Exam.................................................................................................................... 20
Hip Exam ....................................................................................................................................... 22
Knee Exam ..................................................................................................................................... 24
Ankle & Foot Exam ........................................................................................................................ 27
Cardiovascular Exam ..................................................................................................................... 29
Pulmonary Exam ........................................................................................................................... 32
Abdominal Exam ........................................................................................................................... 34
Sample Focused Note DMSK-shoulder pain ................................................................................. 37
Sample Documentation of a Normal Physical Exam ..................................................................... 39
Samples of Abnormal PE Write-Up ............................................................................................... 41
 Review of Systems
Constitutional/General: Fevers/chills/sweats? Wt loss/gain? Fatigue? Difficulty
sleeping? Chronic pain?

Eyes: Chronic or past eye disorders? Decrease/change in vision or blurriness? Eye pain?
double vision (diplopia)? Eye discharge (d/c)? Red eye (conjunctivitis)?

Ears/nose/mouth/throat: Pain? Sores or masses around or in mouth? Changes in

Hearing? Ear pain or d/c? Nasal d/c, postnasal drip? Change in voice/hoarseness?
tooth pain or problems? Sense of lump/mass (globus) in throat when
swallowing?

Cardiovascular (CV):
Chronic CV disorders? Chest pain(CP) or pressure? Shortness of breath (dyspnea)
at rest or with exertion? Shortness of breath when lying down (orthopnea)?
lower extremity edema?, Sudden loss of consciousness (syncope)?
sense of rapid heartbeat (palpitations)? Calf/leg pain with ambulation
(claudication) relieved by rest? Ulcers on legs/feet or difficulty healing?

Pulmonary (Pulm):
Chronic or past pulm disorders? (Asthma, copd, etc), Shortness of breath
(dyspnea) at rest or with exertion? Chest pain with inspiration? Cough?
bloody sputum (hemoptysis), wheezing, snoring or stopping breathing
while sleeping (sleep apnea symptoms)?

Gastrointestinal: (GI): Chronic or past GI disorders? Heartburn (GERD)? Abd pain?

difficulty swallowing (dysphagia), painful swallowing (odynophagia)?
nausea or vomiting? Abdominal swelling or distention? Ascites? Vomiting
blood (hematemesis)? Black/tarry stools (melena)? Constipation,
diarrhea or change in bowel habits?

Genitourinary (GU):
Chronic or past GU disorders? Blood in urine (hematuria)? Urination at night
(nocturia)? Incontinence? Pain with urination (dysuria)? Urgency? Frequency?
Decreased force of stream?
For men: Erectile dysfunction (ED), Penile d/c or pain? Testicular pain/swelling
or mass? Penile ulcers/growths? Hx of STI’s?

Integument (Skin/hair):
Hx of prior skin problems? Hair loss? Rash? Growths? non healing lesions?
changing moles (color, shape, size or new onset itching)?
Musculoskelatol (MS):
Known MS disease? Joint pain or swelling? Joint stiffness? Muscle aches
(myalgias)? Low back pain?

Neurologic (neuro):
Known disease? Sudden loss of neurological function? Abrupt loss/change in
level of consciousness? Hx seizures? Numbness or sensory changes
(paresthesias)? Weakness? Dizziness? Balance problems? Headaches?

Psychiatric (psych):
Known mental health disorder (anxiety, depression, bipolar, etc), feelings
of sadness or depression or anxiety? Hx of alcohol or substance abuse?
Memory problems? Confusion?

Endocrine:
Known endocrine disorder (DM, thyroid problems etc), increased hunger
(polyphagia),increased thirst (polydipsia), increased urination (polyuria)?
fatigue, weight loss/gain?

Hematology/lymphatic:
Chronic or past hematologic or oncologic disease? (leukemia, prior dvt/pe, etc)
fever, chills, sweats or wt loss? Abnormal bleeding or bruising? New
lymphadenopathy?

Ob/gyn/breast:
Chronic or past disease? Menstrual history? Method of contraception? Past
pregnancies, Hx abortion/miscarriage? Vaginal discharge? Breast mass, pain or
d/c?
 General Appearance, Vital Signs and HEENT
General Appearance
❑ Observe the Apparent State of Health (Is the patient acutely or chronically ill, frail, or fit and
robust?)
❑ Assess the Level of Consciousness (Is the patient awake, alert, and responsive to you and
others in the environment? If not, promptly assess the level of consciousness.)
❑ Observe for Signs of Distress
• Does the patient show evidence of cardiac or respiratory distress such as clutching
of the chest, pallor, diaphoresis, or labored breathing, wheezing, and coughing?
• Does the patient show evidence of pain such as wincing sweating, protectiveness of
a painful area, facial grimacing, or an unusual posture favoring one limb or body
area?
• Does the patient show evidence of anxiety or depression such as anxious facial
expressions, fidgety movements, cold and moist palms, inexpressive or flat affect,
poor eye contact, or psychomotor slowing?
❑ Observe the skin for color such as pallor, cyanosis, and jaundice
❑ Observe the skin for rashes, bruises, scars, plaques or nevi.
❑ Observe the patient’s dress, grooming, and personal hygiene for how the patient is
dressed? Is the clothing appropriate for the temperature and weather? Is it clean and
appropriate to the setting? Note the patient’s hair, fingernails, and use of cosmetics. They
may be clues to the patient’s personality, mood, lifestyle, and self-regard. Do personal
hygiene and grooming seem appropriate to the patient’s age, lifestyle, occupation, and
stage of life?
❑ Observe the facial expression at rest, during conversation about specific topics, during the
physical examination, and in interaction with others. Watch for eye contact. Is it natural?
Sustained and unblinking? Averted quickly? Absent?
❑ Assess for odors of the body and breath, odors can be important diagnostic clues, like the
fruity odor of diabetes or the scent of alcohol.
❑ Observe the patient’s posture, gait, and motor activity, what is the patient’s preferred
posture? Is the patient restless or quiet? How often does the patient change position? Is
there any involuntary motor activity? Are some body parts immobile? Which ones? Does
the patient walk smoothly, with comfort, self-confidence, and balance, or is there a limp or
discomfort, fear of falling, loss of balance, or any movement disorder?
Vital Signs
Heart Rate
❑ Count the number of pulses at radial artery over 30 seconds and multiply by 2 or 15 seconds
and multiply x 4.
❑ Assess rhythm (i.e., regular or irregular)
❑ Note strength and intensity of the pulse (i.e., normal, weak or bounding).

Respiratory Rate
❑ Count the number of respiratory cycles that occur in 30 seconds and multiply x 2.
❑ Note the rhythm, depth, and effort of breathing.

Blood Pressure (after patient has been sitting quietly for at least 5 minutes)
❑ Use a blood pressure cuff (sphygmomanometer) of the appropriate size.
❑ Center the inflatable bladder over the brachial artery, with lower border of the cuff about
2.5 cm above the antecubital crease. Secure the cuff snugly.
❑ Position the patient’s arm so that it is slightly flexed at the elbow. Support the patient’s
arm so that the brachial artery, at the antecubital crease, is at heart level.
❑ Place the diaphragm or bell over the brachial artery.
❑ Inflate the cuff to 30 mm Hg above the approximate systolic pressure (or 160 mm Hg).
Deflate it slowly, at a rate of 2-3 mm Hg per second.
o Note systolic pressure (pressure at which the first 2 consecutive beats are heard).
❑ Continue to lower the pressure slowly until the sounds disappear.
o Note diastolic pressure (pressure at which sounds disappear).
❑ Record both the systolic and diastolic readings to the nearest 2 mm Hg.
❑ Take blood pressure in opposite arm (if appropriate).
❑ Provide patient with pulse, respiratory rate and blood pressure readings, as well as normal
values for each.

“Mrs. Scott is a young, healthy-appearing woman, well-groomed, fit, and cheerful. Height is
5′4″, weight 135 lbs, BMI 24, BP 120/80, right and left arms, HR 72 and regular, RR 16,
temperature 37.5°C.”

OR

“Mr. Jones is an elderly man who looks pale and chronically ill. He is alert, with good eye contact
but unable to speak more than two or three words at a time due to shortness of breath. He has
intercostal muscle retraction when breathing and sits upright in bed. He is thin, with diffuse
muscle wasting. Height is 6′2″, weight 175 lbs, BP 160/95, right arm, HR 108 and irregular, RR
32 and labored, temperature 101.2°F.”

HEENT Exam
Head
❑ Inspect hair for quantity, distribution, texture, pattern of loss
❑ Inspect scalp and face for asymmetry, involuntary movements, edema or masses

Eyes
❑ Inspect general appearance of eyes including lids, lashes, conjunctiva, and sclera
❑ Test extraocular movements (CN III, IV, VI) in an H pattern while stabilizing head
❑ Test for convergence by moving finger toward bridge of nose
❑ Test pupillary near reaction for accommodation
❑ Evaluate upper and lower visual fields by confrontation (CN II) in each eye
❑ Assess visual acuity in each eye individually using an eye chart (20 feet away) or eye card
(14 inches away) with glasses if patient wears them
❑ Determine pupil size bilaterally and compare for equality
❑ Test pupillary reaction to light (CN II, III) directly and consensually
❑ Perform a fundoscopic exam to evaluate blood vessels for narrowing, AV nicking,
hemorrhages, or exudates
❑ Evaluate the optic discs

Ears
❑ Inspect external appearance of ears including auricle, tragus, helix, and lobule
❑ Palpate the tragus and auricles bilaterally
❑ Test gross hearing using the finger rub (CN VIII)
❑ Perform an otoscopic exam

If gross hearing test is abnormal, then perform the following optional tests:
❑ Perform Weber test (CN VIII) by placing a vibrating tuning fork in the midline of the
forehead and assess for laterality
❑ Perform Rinne test (CN VIII) by placing the base of a vibrating tuning fork on the mastoid
and then next to the ear canal; assess whether air conduction is greater than bone
conduction

Nose and Paranasal Sinuses

❑ Inspect the nose for asymmetry or deformity
❑ Inspect nasal mucosa and septum with otoscope to assess for deviation, inflammation, or
perforation
❑ Palpate the frontal and maxillary sinuses to assess for tenderness

If the patient reports difficulty smelling, perform the following test:

❑ Test olfactory nerve (CN I): While the patient closes one nostril with a finger, have them
identify a smell (ex. coffee beans, cinnamon). Repeat for other side.

Mouth
❑ Inspect oral mucosa, gums, and dentition using a penlight or otoscope
❑ Inspect undersurface and sides of tongue and floor of mouth
❑ Inspect posterior pharynx, tonsils, and uvula (use tongue depressor if needed)

Neck
❑ Inspect neck for asymmetry, atrophy, swelling, masses or scars
❑ Palpate preauricular, posterior auricular, and occipital lymph nodes
❑ Palpate tonsillar, submandibular, and submental lymph nodes
❑ Palpate superficial cervical, posterior cervical, deep cervical lymph nodes
❑ Palpate supraclavicular lymph nodes
❑ Examine thyroid gland using a posterior approach while patient swallows

Closure
❑ Summarize information gathered in physical exam
❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)

Sample Documentation of a HEENT examination:

HEENT: Head—The skull is normocephalic/atraumatic (NC/AT). Hair with average texture.

Eyes—Visual acuity 20/20 bilaterally. Sclera white, conjunctiva pink. Pupils are 4 mm
constricting to 2 mm, equally round and reactive to light and accommodations. Disc margins
sharp; no hemorrhages or exudates, no arteriolar narrowing. Ears—Acuity good to whispered
voice. Tympanic membranes (TMs) with good cone of light. Weber midline. AC > BC. Nose—
Nasal mucosa pink, septum midline; no sinus tenderness. Throat (or Mouth)—Oral mucosa pink,
dentition good, pharynx without exudates.

Neck—Trachea midline. Neck supple; thyroid isthmus palpable, lobes not felt.

Lymph Nodes—No cervical, axillary, epitrochlear, inguinal adenopathy.

OR

Head—The skull is normocephalic/atraumatic. Frontal balding. Eyes— Visual acuity 20/100

bilaterally. Sclera white; conjunctiva injected. Pupils constrict 3 mm to 2 mm, equally round and
reactive to light and accommodation. Disc margins sharp; no hemorrhages or exudates.
Arteriolar-to-venous ratio (AV ratio) 2:4; no AV nicking. Ears—Acuity diminished to whispered
voice; intact to spoken voice. TMs clear. Nose—Mucosa swollen with erythema and clear
drainage. Septum midline. Tender over maxillary sinuses. Throat—Oral mucosa pink, dental
caries in lower molars, pharynx erythematous, no exudates.

Neck—Trachea midline. Neck supple; thyroid isthmus midline, lobes palpable but not enlarged.
Lymph Nodes—Submandibular and anterior cervical lymph nodes tender, 1 × 1 cm, rubbery and
mobile; no posterior cervical, epitrochlear, axillary, or inguinal lymphadenopathy.
 Cervical Spine Exam
General Approach

❑ Inspect for asymmetry, inflammation (redness, warmth, swelling, tenderness).

❑ If applicable, check temperature differences using the back of your hand.
❑ Palpate for tenderness or discontinuity of bone (crepitus is a palpable crunching sensation
that is often felt in the presence of roughened articular cartilage surfaces).
❑ Test range of motion (check active ROM first; if patient unable, check passive ROM).
❑ Compare sides (right and left).
❑ Assess muscles, bones, nerves and vasculature.
❑ In the presence of an injury always test the joint above and the joint below.
❑ Use proper draping technique during entire exam.

Cervical Spine: patient sitting

❑ Inspect the cervical spine

❑ Palpate cervical spinous processes and paraspinous muscles for tenderness
❑ Test ROM: flexion, extension, lateral flexion, and rotation

If you are concerned about a cervical radiculopathy, perform the following test:

❑ Spurling’s Test: Slightly extend the neck, rotate towards the affected side, and compress the
patient’s head downward. A positive test results in reproducible radicular symptoms.

Closure

❑ Summarize information gathered in physical exam

❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)

* You should learn how to find all the different pulses, however, you generally only need to test
for pulses at the level of and distal to an injury to assess vascular patency. If you suspect limb
ischemia / claudication, you should assess all the pulses and perform ABIs (ankle brachial
indices).

* You perform a strength and sensation assessment at the level of and distal to an injury or
musculoskeletal complaint.
Assess Scale for Grading Reflexes
4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension)
3+ Brisker than average; possibly but not necessarily indicative of disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 No responses superficial sensation of upper and lower extremities.

Scale for Grading Muscle Strength

0—No muscular contraction detected

1—A barely detectable flicker or trace of contraction
2—Active movement of the body part with gravity eliminated
3—Active movement against gravity
4—Active movement against gravity and some resistance
5—Active movement against full resistance without evident fatigue. This is normal strength.

Recommended Grading of Pulses

3+ Bounding
2+ Brisk, expected (normal)
1+ Diminished, weaker than expected
0 Absent, unable to palpate
 Thoracic Spine Exam
General Approach
❑ Inspect for asymmetry, inflammation (redness, warmth, swelling, tenderness).
❑ If applicable, check temperature differences using the back of your hand.
❑ Palpate for tenderness or discontinuity of bone (crepitus is a palpable crunching sensation
that is often felt in the presence of roughened articular cartilage surfaces).
❑ Test range of motion (check active ROM first; if patient unable, check passive ROM).
❑ Compare sides (right and left).
❑ Assess muscles, bones, nerves and vasculature.
❑ In the presence of an injury always test the joint above and the joint below.
❑ Use proper draping technique during entire exam.

Thoracic Spine: patient sitting

❑ Inspect back for kyphosis, excessive lordosis, or scoliosis
❑ Palpate thoracic spinous processes and paravertebral muscles for tenderness
❑ Percuss the spine for tenderness
❑ Test active ROM: flexion (assess for scoliosis on forward bending)

Closure
❑ Summarize information gathered in physical exam
❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)

* You should learn how to find all the different pulses, however, you generally only need to test
for pulses at the level of and distal to an injury to assess vascular patency. If you suspect limb
ischemia / claudication, you should assess all the pulses and perform ABIs (ankle brachial
indices).

* You perform a strength and sensation assessment at the level of and distal to an injury or
musculoskeletal complaint.

Assess Scale for Grading Reflexes

4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension)
3+ Brisker than average; possibly but not necessarily indicative of disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 No responses superficial sensation of upper and lower extremities.

Scale for Grading Muscle Strength

0—No muscular contraction detected

1—A barely detectable flicker or trace of contraction
2—Active movement of the body part with gravity eliminated
3—Active movement against gravity
4—Active movement against gravity and some resistance
5—Active movement against full resistance without evident fatigue. This is normal strength.

Recommended Grading of Pulses

3+ Bounding
2+ Brisk, expected (normal)
1+ Diminished, weaker than expected
0 Absent, unable to palpate
 Lumbar Spine Exam
General Approach
❑ Inspect for asymmetry, inflammation (redness, warmth, swelling, tenderness).
❑ If applicable, check temperature differences using the back of your hand.
❑ Palpate for tenderness or discontinuity of bone (crepitus is a palpable crunching sensation
that is often felt in the presence of roughened articular cartilage surfaces).
❑ Test range of motion (check active ROM first; if patient unable, check passive ROM).
❑ Compare sides (right and left).
❑ Assess muscles, bones, nerves and vasculature.
❑ In the presence of an injury always test the joint above and the joint below.
❑ Use proper draping technique during entire exam.

Lumbar-sacral Spine: patient standing

❑ Inspect the lumbar-sacral spine asymmetry, inflammation (redness, warmth, swelling,

tenderness), deformity, scoliosis or abnormal hair growth.
❑ Inspect for leg length discrepancies by placing hands on both iliac crests and compare
height.
❑ Palpate for areas of tenderness: Spinous processes, Paraspinous muscles, Sacroiliac joints,
Tip of coccyx.
❑ Percuss the spine for tenderness.
❑ Test active ROM: forward flexion (normally 80 to 90°), look for asymmetry of the back
suggestive of scoliosis, extension (20 to 30°), lateral bending (20 to 30° in each direction),
rotation (30 to 40° in each direction).

Strength Testing:

❑ Evaluate gait before heel and toe walking

❑ Heel walking (anterior tibial muscles; L4),
❑ Toe walking (gastroc-soleus muscles; S1),
❑ Resisted great toe dorsiflexion (L5).

A focused neurologic exam should be performed in patients with lower back pain to include:

❑ Deep tendon reflexes (knee jerk – L4 nerve root; ankle jerk – S1 nerve root).
❑ Straight-leg raise – this test is performed by lifting the leg, with the knee extended, in the
sitting (or supine) position.
❑ Ankle clonus may be elicited by sudden passive ankle dorsiflexion and result in repetitive
uncontrolled ankle twitches.
❑ Consider rectal exam (to check for decreased sphincter tone and perianal sensation) when
cauda equina syndrome is suspected.

Closure
❑ Summarize information gathered in physical exam
❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)

* You should learn how to find all the different pulses, however, you generally only need to test
for pulses at the level of and distal to an injury to assess vascular patency. If you suspect limb
ischemia / claudication, you should assess all the pulses and perform ABIs (ankle brachial
indices).

* You perform a strength and sensation assessment at the level of and distal to an injury or
musculoskeletal complaint.

Assess Scale for Grading Reflexes

4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension)
3+ Brisker than average; possibly but not necessarily indicative of disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 No responses superficial sensation of upper and lower extremities.

Scale for Grading Muscle Strength

0—No muscular contraction detected

1—A barely detectable flicker or trace of contraction
2—Active movement of the body part with gravity eliminated
3—Active movement against gravity
4—Active movement against gravity and some resistance
5—Active movement against full resistance without evident fatigue. This is normal strength.

Recommended Grading of Pulses

3+ Bounding
2+ Brisk, expected (normal)
1+ Diminished, weaker than expected
0 Absent, unable to palpate

Sample documentation for a patient with a lumbar spine complaint

“Back is symmetric without scoliosis, exaggerated kyphosis or lordosis appreciated. Tenderness

to percussion over low LS spine. Right paraspinous tenderness to palpation also noted in same
region. ROM for LS spine is normal to forward flexion, extension, lateral flexion and rotation, but
gait markedly antalgic, with decreased weight placed on the right leg. Unable to walk well on
toes due to pain/weakness. MS 3/5 at ankles with plantarflexion, but 5/5 at hips and knees.
Ankle jerk reflex absent on right. DTR’s otherwise 2+ at both patella and left ankle. Sensation to
light touch decreased over lateral aspect of right lower leg. Intact and symmetric otherwise.
Hips with full and non-tender ROM. SLR is positive on right at 30 degrees with reproduction of
patient’s pain in right lateral foot.”
 Shoulder Exam
General Approach
❑ Inspect for asymmetry, inflammation (redness, warmth, swelling, tenderness).
❑ If applicable, check temperature differences using the back of your hand.
❑ Palpate for tenderness or discontinuity of bone (crepitus is a palpable crunching sensation
that is often felt in the presence of roughened articular cartilage surfaces).
❑ Test range of motion (check active ROM first; if patient unable, check passive ROM).
❑ Compare sides (right and left).
❑ Assess muscles, bones, nerves and vasculature.
❑ In the presence of an injury always test the joint above and the joint below.
❑ Use proper draping technique during entire exam.

Shoulder
❑ Inspect the shoulders with arms resting at sides for asymmetry, erythema, masses, effusions,
atrophy, or swelling
❑ Palpate the sternoclavicular and acromioclavicular joints, the greater tuberosity, and the
biceps tendon in the intertubercular groove
❑ Test active ROM: flexion (to 180°), extension, internal rotation, external rotation, abduction
(test passive ROM if unable to perform active)

If there is pain with ROM or concern for rotator cuff injury, perform the following tests:

❑ Empty Can Test (supraspinatus): Elevate the arms to 90°, angled outwards 30° from the
midline, and internally rotate the arms with the thumbs pointing down (as if emptying a can).
Have the patient resist as you place downward pressure.
❑ Lift-off Test (subscapularis): Have the patient place the back of the hand on his/her back
pocket and push out against resistance.
❑ Infraspinatus & Teres Minor: Flex elbows to 90 degrees with thumbs turned up and elbows at
sides. Have the patient externally rotate against resistance.

Upper Extremity Neuro Exam

Assess muscle strength*:
❑ Deltoid abduction at shoulder (C5)
Assess sensation*:

❑ Light touch over deltoid, proximal forearm, and hand

Closure
❑ Summarize information gathered in physical exam
❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)
* You should learn how to find all the different pulses, however, you generally only need to test
for pulses at the level of and distal to an injury to assess vascular patency. If you suspect limb
ischemia / claudication, you should assess all the pulses and perform ABIs (ankle brachial
indices).

* You perform a strength and sensation assessment at the level of and distal to an injury or
musculoskeletal complaint.

“Shoulder: No bony deformities, inflammation, or tenderness in rotator cuff, biceps tendon, or

acromioclavicular joint. Full ROM and strength in shoulder upon adduction, abduction, internal
and external rotation. Scapular winging, impingement sign, scratch test (internal rotation), joint
laxity, drop arm test were negative”.
 Elbow Exam
General Approach
❑ Inspect for asymmetry, inflammation (redness, warmth, swelling, tenderness).
❑ If applicable, check temperature differences using the back of your hand.
❑ Palpate for tenderness or discontinuity of bone (crepitus is a palpable crunching sensation
that is often felt in the presence of roughened articular cartilage surfaces).
❑ Test range of motion (check active ROM first; if patient unable, check passive ROM).
❑ Compare sides (right and left).
❑ Assess muscles, bones, nerves and vasculature.
❑ In the presence of an injury always test the joint above and the joint below.
❑ Use proper draping technique during entire exam.

Elbow
❑ Inspect elbows in both flexed and extended positions
❑ Palpate the olecranon process and the medial and lateral epicondyles for tenderness,
warmth, or effusion
❑ Palpate the radiohumeral joint for synovial enlargement
❑ Palpate the brachial pulses*
❑ Test active ROM: flexion, extension, supination, pronation (test passive ROM if unable to
perform active)

If you are concerned for cubital tunnel syndrome, perform the following test:

❑ Tinel’s Test: Tap your fingers over the ulnar nerve as it passes just posterior to the medial
epicondyle. A positive test results in aching and numbness.
If you are concerned for ulnar collateral ligament injury, perform the following test:
❑ Valgus stress test of the elbow: with the elbow in extension and the forearm in supination,
one hand stabilizes the radial aspect of the elbow, while the other hand applies a radial
directed force from the wrist

Upper Extremity Neuro Exam

Assess muscle strength*:
❑ Deltoid abduction at shoulder (C5)
❑ Elbow flexion (biceps, C5-C6) and elbow extension (triceps, C6-C8)
❑ Wrist extension (C6-C8), wrist flexion (C7), and grip (C7-T1)
Assess sensation*:

❑ Light touch over deltoid, proximal forearm, and hand

Closure
❑ Summarize information gathered in physical exam
❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)

* You should learn how to find all the different pulses, however, you generally only need to test
for pulses at the level of and distal to an injury to assess vascular patency. If you suspect limb
ischemia / claudication, you should assess all the pulses and perform ABIs (ankle brachial
indices).

* You perform a strength and sensation assessment at the level of and distal to an injury or
musculoskeletal complaint.

“Elbow: No bony deformities, inflammation, or tenderness in olecranon, medial, lateral

epicondyle elbow. Full ROM upon flexion and extension. Cubital tunnel (Tinel’s), milking
maneuver were negative.”
 Wrist and Hand Exam
General Approach

❑ Inspect for asymmetry, inflammation (redness, warmth, swelling, tenderness).

❑ If applicable, check temperature differences using the back of your hand.
❑ Palpate for tenderness or discontinuity of bone (crepitus is a palpable crunching sensation
that is often felt in the presence of roughened articular cartilage surfaces).

❑ Test range of motion (check active ROM first; if patient unable, check passive ROM).
❑ Compare sides (right and left).
❑ Assess muscles, bones, nerves and vasculature.
❑ In the presence of an injury always test the joint above and the joint below.
❑ Use proper draping technique during entire exam.

Wrist

❑ Inspect wrists for symmetry, swelling, deformity, or redness

❑ Palpate the radial styloid, ulnar styloid, carpal bones (including scaphoid & anatomic
snuffbox), and the carpal tunnel
❑ Palpate the radial and ulnar pulses*
❑ Test active ROM: dorsiflexion, palmarflexion, radial and ulnar deviation (test passive ROM if
unable to perform active)

If you are concerned for carpel tunnel syndrome, then perform the following tests:

❑ Tinel’s Test: Positive if tapping lightly over the course of the median nerve in the carpal
tunnel elicits aching and numbness.
❑ Phalen’s Test: Ask the patient to hold wrists together, flexed, for 15 seconds. Positive if
elicits numbness and tingling.

Hands

❑ Inspect hands for symmetry, swelling, deformity, or redness

❑ Palpate the DIP, PIP, and MCP joints
❑ Check capillary refill in each hand
❑ Test active finger ROM (including thumb): flexion, extension, abduction, adduction (test
passive ROM if unable to perform active)
❑ Test active thumb ROM: opposition
 If you have a digital injury (laceration or fracture), you need to assess distal tendon function

❑ Assess flexor and extensor tendon function through flexion and extension against resistance
at the MCP, PCP, and DIP using stabilization of the joint proximal to the joint being tested

Upper Extremity Neuro Exam

Assess muscle strength*:

❑ Elbow flexion (biceps, C5-C6) and elbow extension (triceps, C6-C8)

❑ Wrist extension (C6-C8), wrist flexion (C7), and grip (C7-T1)
❑ Interossei adduction and abduction (C7, T1), and thumb adduction (C8, T1)
Assess sensation*:

❑ Light touch over deltoid, proximal forearm, and hand

Closure

❑ Summarize information gathered in physical exam

❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)

* You should learn how to find all the different pulses, however, you generally only need to test
for pulses at the level of and distal to an injury to assess vascular patency. If you suspect limb
ischemia / claudication, you should assess all the pulses and perform ABIs (ankle brachial
indices).

* You perform a strength and sensation assessment at the level of and distal to an injury or
musculoskeletal complaint.

“Right/Left hand dominant. No bony deformities, inflammation, or tenderness of bony

prominences. No anatomical snuff box tenderness; Full ROM in DIP, PIP, MCP, & carpal joints &
with supination and pronation. Phalen’s & Tinel’s tests were negative”.
Hip Exam
General Approach

❑ Inspect for asymmetry, inflammation (redness, warmth, swelling, tenderness).

❑ If applicable, check temperature differences using the back of your hand.
❑ Palpate for tenderness or discontinuity of bone (crepitus is a palpable crunching sensation
that is often felt in the presence of roughened articular cartilage surfaces).
❑ Test range of motion (check active ROM first; if patient unable, check passive ROM).
❑ Compare sides (right and left).
❑ Assess muscles, bones, nerves and vasculature.
❑ In the presence of an injury always test the joint above and the joint below.
❑ Use proper draping technique during entire exam.

Hip: patient supine

❑ Inspect the hips

❑ Palpate the iliac crest, anterior-superior iliac spine, and greater trochanter
❑ Test passive ROM: flexion, external rotation, internal rotation, abduction

If you have concern for sciatica, perform the following test:

❑ Straight Leg Raise: Raise the patient’s relaxed and straightened leg from the ankle, flexing
the hip, then dorsiflex the foot. A positive test results in pain that radiates into the
ipsilateral leg.

Lower Extremity Neuro Exam

Assess muscle strength*:

❑ Hip flexion (L2-3)

❑ Knee extension (L3-4) and knee flexion (S1)
Assess sensation*:

❑ Light touch over the thigh, calf, and foot

Closure

❑ Summarize information gathered in physical exam

❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)
* You should learn how to find all the different pulses, however, you generally only need to test
for pulses at the level of and distal to an injury to assess vascular patency. If you suspect limb
ischemia / claudication, you should assess all the pulses and perform ABIs (ankle brachial
indices).

* You perform a strength and sensation assessment at the level of and distal to an injury or
musculoskeletal complaint.

“Hip: No bony deformities, inflammation, or tenderness in hip joint. Full active ROM upon
flexion & extension, internal & external rotation, abduction, & adduction. Full strength in hip
flexors/extensors, adductors/abductors. Crossed straight leg-raising sign negative (sitting and
supine).”
 Knee Exam
General Approach
❑ Inspect for asymmetry, inflammation (redness, warmth, swelling, tenderness).
❑ If applicable, check temperature differences using the back of your hand.
❑ Palpate for tenderness or discontinuity of bone (crepitus is a palpable crunching sensation
that is often felt in the presence of roughened articular cartilage surfaces).
❑ Test range of motion (check active ROM first; if patient unable, check passive ROM).
❑ Compare sides (right and left).
❑ Assess muscles, bones, nerves and vasculature.
❑ In the presence of an injury always test the joint above and the joint below.
❑ Use proper draping technique during entire exam.

Knee: patient supine

❑ Inspect the knees for swelling, mass, deformity, atrophy
❑ Palpate for a knee effusion using the bulge sign (try to milk any fluid laterally and assess for
the presence of a bulge)
❑ Palpate the medial and lateral femoral condyles, the medial and lateral joint lines (including
the medial and lateral collateral ligaments), the patella and patellar tendon, and the
popliteal fossa
❑ Palpate the popliteal pulses*
❑ Test active ROM: flexion, extension

If you have concern for MCL or LCL injury, perform the following tests:
❑ Valgus Stress Test (MCL): Flex the knee approximately 25°. Place one hand against the
lateral knee to stabilize femur and the other hand around the medial ankle. Push medially
against the knee pull laterally at the ankle to open the medial joint space.
❑ Varus Stress Test (LCL): Flex the knee approximately 25°. Place one hand against the medial
surface of the knee and the other around the lateral ankle. Push laterally against the knee
and pull medially at the ankle to open the lateral joint space.

If you have concern for ACL injury, perform one of the following tests:
❑ Anterior Drawer Test: With the knee flexed to 90°, cup your hands around the knee with the
thumbs on the medial and lateral joint line. Stabilize the foot by leaning on it. Draw the tibia
forward and observe if it slides forward from under the femur. More than 3 mm of side-to-
side difference is abnormal.
❑ Lachman’s Test: Place the knee in 30° of flexion. Grasp the distal femur on the lateral side
with one hand and the proximal tibia on the medial side with the other. Pull the tibia
forward and the femur back simultaneously and assess for any forward excursion.

If you have concern for PCL injury, perform the following test:
❑ Posterior Drawer Test: Cup your hands around the knee with the thumbs on the medial and
lateral joint line. Push the tibia posteriorly and observe if it slides backward under the
femur.
 If you have concerns for a Meniscus injury, perform the following test:
❑ McMurray's Test: When examining the right knee, place your left hand so that your middle,
index, and ring fingers are aligned along the medial joint line. Grasp the foot with your right
hand and fully flex the knee. Gently turn the ankle so that the foot is pointed outward
(everted). Then direct the knee so that it is pointed outward as well (valgus stress). While
holding the foot in this everted position, gently extend and flex the knee. If there is medial
meniscal injury, you will feel a "click" with the hand on the knee as it is extended. This may
also elicit pain. Now, return the knee to the fully flexed position, and turn the foot inwards
(inversion). Then direct the knee so that it is pointed inward as well (varus stress). Place the
index, middle, and ring fingers of your left hand along the lateral joint line. Gently extend
and flex the knee. If the lateral meniscus has been injured, you may feel a "click" with the
hand palpating the joint line. You may also elicit pain.

If you have concern for a large knee effusion, perform the following tests:
❑ Ballottment: Compress suprapatellar pouch and push patella sharply against femur. A
positive test results when fluid is visibly returning to the suprapatellar pouch.

Lower Extremity Neuro Exam

Assess muscle strength*:

❑ Hip flexion (L2-3)

❑ Knee extension (L3-4) and knee flexion (S1)
❑ Ankle dorsiflexion (L4-5), ankle plantar-flexion (S1)
Assess sensation*:
❑ Light touch over the thigh, calf, and foot

Closure
❑ Summarize information gathered in physical exam
❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)

* You should learn how to find all the different pulses, however, you generally only need to test
for pulses at the level of and distal to an injury to assess vascular patency. If you suspect limb
ischemia / claudication, you should assess all the pulses and perform ABIs (ankle brachial
indices).

* You perform a strength and sensation assessment at the level of and distal to an injury or
musculoskeletal complaint.

“Knees: Rt knee without visible swelling, deformity or muscular atrophy. Full and non-tender
active ROM. Left knee with notable effusion with positive bulge sign. Patella is ballotable.
Tenderness to palpation is noted along the lateral joint line. Pt is not able to fully flex or extend
the knee actively or passively due to the effusion. There is tenderness with varus strain, but the
joint does not open laterally. Valgus, anterior and posterior drawer and Lachman’s maneuvers
are unremarkable. Marked clicking and tenderness noted with McMurray testing along the
lateral meniscus region. The left hip and left ankle are non-tender with full ROM.”
 Ankle & Foot Exam
General Approach

❑ Inspect for asymmetry, inflammation (redness, warmth, swelling, tenderness).

❑ If applicable, check temperature differences using the back of your hand.
❑ Palpate for tenderness or discontinuity of bone (crepitus is a palpable crunching sensation
that is often felt in the presence of roughened articular cartilage surfaces).
❑ Test range of motion (check active ROM first; if patient unable, check passive ROM).
❑ Compare sides (right and left).
❑ Assess muscles, bones, nerves and vasculature.
❑ In the presence of an injury always test the joint above and the joint below.
❑ Use proper draping technique during entire exam.

Ankle & Foot: Patient sitting

❑ Inspect lower extremities for color, temperature, edema, deformity, asymmetry, nodules,
calluses, corns, and structure of the longitudinal arch
❑ Palpate the medial and lateral malleoli, Achilles tendon, and heel
❑ Palpate the dorsalis pedis and posterior tibial pulses*
❑ Check capillary refill in each foot
❑ Test active ROM: dorsiflexion, plantar-flexion, inversion, eversion (test passive ROM if
unable to perform active)
❑ Assess flexor and extensor tendon function distally in the presence of a digital injury

If you have concern for a ligamentous injury to the ankle, perform the following test:
❑ Varus Stress Test (lateral ligaments): Stabilize the distal leg with one hand, place the other
hand under the calcaneus, and maximally invert it. An abnormal test results in lateral
gapping and rocking of the talus.
❑ Valgus Stress Test (deltoid ligament): Stabilize the distal leg with one hand, place the other
hand under the calcaneus, and maximally evert it. An abnormal test results in medial
gapping and rocking of the talus.
❑ Anterior Drawer Test: to assess the stability of the anterior tibiotalar joint, stabilize the
distal part of the lower leg with one hand and hold the heel using the other hand with the
palm facing up. The sole of the patient’s foot should be in 10° of plantar flexion. Apply
anterior force to the heel. Any subluxation of the talus on the distal tibia is abnormal.

Lower Extremity Neuro Exam

Assess muscle strength*:

❑ Ankle dorsiflexion (L4-5), ankle plantar-flexion (S1)

Assess sensation*:
❑ Light touch over the thigh, calf, and foot

Closure

❑ Summarize information gathered in physical exam

❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)

* You should learn how to find all the different pulses, however, you generally only need to test
for pulses at the level of and distal to an injury to assess vascular patency. If you suspect limb
ischemia / claudication, you should assess all the pulses and perform ABIs (ankle brachial
indices).

* You perform a strength and sensation assessment at the level of and distal to an injury or
musculoskeletal complaint.
 Cardiovascular Exam
General
❑ Assess general appearance of the patient, including signs of distress
❑ Assess level of consciousness and orientation
❑ Inspect skin color, texture, and lesions (Example splinter hemorrhages, Janeway lesions,
Osler’s nodes)
❑ Inspect lips and mucous membranes (cyanosis, pallor)
❑ Inspect nails (Example: clubbing, splinter hemorrhages)

Anterior Exam: patient laying supine at 30°

❑ Inspect for jugular venous distension
• Examine both sides of the neck
• Turn the patient’s head slightly to the left, since the PE is conducted from the
patient’s right side
• Identify the external jugular vein, find the internal jugular venous pulsations
• If necessary, raise or lower the HOB until you can see the oscillation point of the
internal jugular venous pulsations in the lower half of the neck.
• Look for the oscillation point along the sternomastoid muscle between the clavicle
and the angle of the jaw, or just posterior to the sternomastoid
• Internal jugular pulsations are rarely palpable, whereas the carotid pulse is almost
always palpable
• Internal jugular pulsations are eliminated by light pressure on the vein just above
the clavicle... ...whereas the carotid pulse is not eliminated by the pressure
• The level of internal jugular pulsations changes with position
• The level of internal jugular pulsations usually falls with inspiration… …whereas the
carotid pulse is not affected by inspiration.
❑ If necessary place the patient back at 30° supine
❑ Assess the carotid pulse by palpating (to assess the amplitude and contour of the carotid
upstroke) and auscultating (to assess for the presence or absence of bruits from turbulent
blood flow)
• Inspect and palpate both the right and left carotid arteries and compare
• Do not press on both carotid arteries at once
• Place your index and middle fingers, or your thumb, on the right carotid artery in the
lower third of the neck
• Press just inside the medial border of a well-relaxed sternomastoid muscle, roughly
at the level of the cricoid cartilage, slowly increase pressure until you feel a maximal
pulsation. Then slowly decrease pressure until you best sense the arterial pressure
wave and contour
• Try to assess the amplitude of the pulse. It correlates reasonably well with the pulse
pressure, and the speed of the downstroke.
• Listen over one artery at a time with the diaphragm of your stethoscope
• Ask the patient to hold breathing for a moment, breath sounds do not obscure the
sound of turbulent flow.
❑ Inspect Precordium for scars, (examples: thoracotomy, pacemakers)
❑ Inspect chest wall configuration (barrel chest, pectus excavatum)
❑ Palpate for the apical impulse/PMI noting diameter, location, amplitude, duration
❑ Palpate for heaves, lifts and thrills using the palm and/or finger pads held flat or obliquely
against the chest wall
❑ Auscultate all 4 cardiac areas
• Aortic area (2nd ICS, right sternal edge) using the diaphragm of the stethoscope.
Note cardiac rate and rhythm. Identify S1 and S2
• Pulmonic area (2nd ICS, left sternal edge) using the diaphragm. Identify S1 and S2,
inspiratory splitting of S2
• Tricuspid area (4th ICS, left sternal edge) Use the diaphragm and the bell.
• Mitral area (5th left intercostal space [ICS], midclavicular line [MCL]) Use the
diaphragm and the bell

Provocative maneuver for exploring Mitral Stenosis

❑ Have the patient move into the left lateral decubitus position
❑ Auscultate the mitral area using the bell of the stethoscope with light pressure and firm
pressure for S3, S4 or if you suspect mitral stenosis

Provocative maneuver for exploring Aortic Regurgitation

❑ Have the patient sit up and lean forward
❑ Ask the patient to exhale completely and hold his breath
❑ Using the diaphragm, listen at the Left 2 nd interspace and move down the left sternal border
to the apex.

Vascular Exam (Please note: if distal pulses are intact, you do not have to assess proximal
pulses, you can assume they are intact. You should compare pulse quality from side to side.)

If you suspect arterial or venous disease (Examples: leg ulcers. Asymmetry, color changes),
you may need to assess pulses distal working your way proximal.
❑ Palpate the brachial pulses
❑ Palpate the radial and ulnar pulses
❑ Palpate the femoral pulses
❑ Palpate the popliteal pulses
❑ Palpate the posterior tibial and dorsalis pedis pulses
❑ Check capillary refill time
❑ Examine lower extremities for edema

Closure
❑ Summarize information gathered in physical exam
❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Appropriate Hand Hygiene
This is a sample of the documentation for cardiovascular exam, it is not meant to be all
inclusive.
Cardiovascular: No chest wall deformities or scars. No JVD. Carotid upstroke brisk. No carotid
bruits. Chest is non-tender, no thrills or heaves noted. PMI felt 5th Left ICS MCL. RRR, S1, S2
noted. No murmurs, rubs or gallops. Capillary refill 2 seconds. Posterior tibial pulses 2+ and
symmetric. No edema noted in the extremities.
 Pulmonary Exam
Opening
❑ Wash your hands (foam in)
❑ Introduce yourself to the patient
❑ Identify the patient by last name and DOB
❑ Determine how the patient prefers to be addressed
❑ Explain your role in the health care team
❑ Negotiate an agenda for the encounter

General
❑ Assess general appearance of the patient, including signs of respiratory distress, including
ability to converse without dyspnea
❑ Assess level of consciousness and orientation
❑ Inspect skin and lips for general appearance, color (cyanosis), texture, and lesions
❑ Inspect the nails (look for clubbing)

Anterior Examination: patient sitting

❑ Inspect the chest wall for symmetry, any bony deformities,
❑ Observe the rate, rhythm, depth, and effort of breathing
❑ Listen for audible sounds of breathing that may indicate distress
❑ Count the respiratory rate (breaths per minute)
❑ Inspect the neck. Look for the use of accessory muscles suggesting respiratory difficulty
❑ Palpate in the sternal notch assessing for a midline trachea

Posterior Examination: patient sitting

❑ Inspect the posterior thorax observing contour, symmetry, and deformities
❑ Palpate the chest wall for tenderness
❑ Assess for chest expansion (place your thumbs close to the patient’s spine at the level of the
10th ribs and spread your fingers lightly across the lateral thorax, ask the patient to inhale
and exhale deeply watching the divergence of your thumbs feeling for the range and
symmetry)
❑ Percuss the posterior lung fields at 3 levels bilaterally as well as the mid-axillary line. Use a
ladderlike pattern (Listen to the intensity, pitch, and duration of your percussion notes and
note the sense of vibration)
❑ Auscultate the posterior lung fields using the diaphragm of the stethoscope. Begin at the
apices and proceed downward, moving systematically from side‐to‐side in a ladder
pattern—comparing breath sounds in symmetrical areas (at 3 levels as well as the mid-
axillary line). Listen to the duration, pitch, and intensity of the inspiratory and expiratory
sounds.
Provocative Maneuvers when your patient has abnormal breath sounds
If abnormal breath sounds are heard, perform the following tests on the posterior lung fields at
6 levels as well as the mid-axillary line. Use a ladderlike pattern:

❑ Bronchophony: Listen with the stethoscope (diaphragm) as the patient says “ninety-nine”.
Normally the sounds transmitted through the chest wall are muffled and indistinct.
❑ Egophony: Listen with the stethoscope as the patient says “ee”. Normally spoken “ee”
heard as “ee”. In the setting of consolidation, “ee” becomes “ay”
❑ Whispered Pectoriloquy: Listen with the stethoscope as the patient whispers “ninety-nine”.
Normally whispered words faint and indistinct.
❑ Tactile Fremitus: Place the ball or ulnar surface of your hand on the posterior chest and ask
the patient to say “ninety-nine”, “toy boat”, or “one-one-one”.

Tactile Fremitus & Transmitted Voice Sounds

Consolidation Increased over the involved area
Atelectasis Usually absent
Pleural Effusion Decreased to absent
Pneumothorax Decreased to absent
COPD Decreased
Asthma Decreased

Anterior Exam:
❑ Inspect shape and movement of the anterior chest wall
❑ Palpate the anterior chest wall for tenderness
❑ Percuss the anterior lung fields at 2 levels. Use a ladderlike pattern.
❑ Auscultate the anterior lung fields at 2 levels. Use a ladderlike pattern.

Closure
❑ Summarize information gathered in physical exam
❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)

Sample documentation for the Pulmonary exam*

Thorax symmetric with moderate kyphosis and increased anteroposterior (AP) diameter,
decreased expansion. Lungs are hyperresonant. Breath sounds distant with delayed expiratory
phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, egophony, or
whispered pectoriloquy.

*this is a sample, it is not meant to all-inclusive

 Abdominal Exam
General approach
❑ Stand on the patient’s right side, if possible.
❑ Position patient supine, completely flat: arms at side and knees flexed (thus relaxing
abdominal muscles).
❑ Use proper draping technique during entire exam.
❑ Warm hands and stethoscope.
❑ Examine any areas of tenderness last.

Patient lying flat: arms at sides, knees flexed

❑ Inspect abdomen for contour, scars, asymmetry, masses, pulsations, striae, and ecchymosis
❑ Auscultate for bowel sounds before percussion (start in one quadrant and if unable to
auscultate, listen over the other quadrants)
❑ Percuss four quadrants for tympany
❑ Percuss the liver span in the right mid-clavicular line
❑ Palpate lightly four quadrants assessing for areas for tenderness, guarding, or rigidity (observe
the patient’s face for visible signs of pain/discomfort)
❑ Palpate deeply four quadrants for masses
❑ Palpate the liver edge
❑ Palpate the spleen
❑ Palpate the inguinal ligament for hernia or lymph nodes
❑ Palpate the femoral pulses

If you are concerned about secondary causes for hypertension:

❑ Auscultate for aortic and renal artery bruits

If you are attempting to distinguish an Abdominal Mass from a Mass in the Abdominal Wall,
have the patient tense the abdominal wall muscles.
❑ Ask the patient either to raise the head and shoulders, raise the legs about 2-3 inches off
the examination bed OR to strain down. Feel for the mass again. A mass in the abdominal
wall remains palpable; an intra-abdominal mass is obscured by muscular contraction.

If the patient has concerning symptoms/signs of ascites, perform the following test:

❑ Shifting Dullness: Percuss the border of tympany and dullness with the patient supine. After
having the patient turn onto one side, percuss and mark the borders again. If the border
between tympany and dullness changes, this is a positive test.
 If the patient presents with RUQ pain or you have concern for cholecystitis, perform the
following test:

❑ Murphy’s Sign: Place your left thumb or fingers of the right hand under the right costal
margin and ask the patient to take a deep breath. A positive test results when a sharp
increase in tenderness suddenly stops inspiratory effort.

If the patient presents with RLQ pain or you have concern for appendicitis, perform the
following tests:

❑ McBurney’s Point: Palpate for tenderness at a point 2/3 the distance from the umbilicus to
the anterior superior iliac spine.
❑ Rovsing’s Sign: Press deeply and evenly in the left lower quadrant and quickly withdraw
your fingers. A positive test results when there is pain in the RLQ.

If you have concerns about peritonitis, perform the following tests:

❑ Rigidity is an involuntary reflex contraction of the abdominal wall that persists over several
examinations.
❑ Rebound Tenderness. Ask the patient “Which hurts more, when I press or let go?” Press
down with your fingers firmly and slowly, then withdraw your hand quickly. The maneuver
is positive if withdrawal produces pain.
❑ Percussion tenderness. Percuss gently to check for percussion tenderness.
❑ Obturator Sign: Flex the patient’s right hip with the knee bent and rotate the leg internally.
A positive test results when there is pain with internal rotation.
❑ Psoas Sign: Place the patient on their left side and extend the right hip. A positive test
results in pain with hip extension.

If the patient is over the age of 50, screen for abdominal aortic aneurysm
❑ Palpate for an abdominal aortic aneurysm (AAA) - Press firmly deep in the upper abdomen,
slightly to the left of the midline, and identify the aortic pulsations. Assess the width of the
aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta. In
patients over age 50, a normal aorta is not more than 3 cm wide (average, 2.5 cm). This
measurement does not include the thickness of the abdominal wall. The ease of feeling
aortic pulsations varies greatly with the thickness of the abdominal wall and with the
anteroposterior diameter of the abdomen.

While these will be addressed in other sessions, please note: Perform a rectal examination and,
in women, a pelvic examination in any patient with lower abdominal pain or pelvic pain. These
maneuvers may not help you to discriminate between a normal and an inflamed appendix, but
they may help to identify an inflamed appendix atypically located within the pelvic cavity or
other causes of the abdominal pain.
Patient sitting up on the exam table

❑ Fist percussion for costovertebral angle (CVA) tenderness

Closure

❑ Summarize information gathered in physical exam

❑ Inquire if patient has questions or concerns
❑ State appreciation to patient
❑ Shake hands (if appropriate)
❑ Wash your hands (foam out)

Sample Documentation

“Abdomen is protuberant with active bowel sounds. It is soft and nontender; no palpable
masses or hepatosplenomegaly. Liver span is 7 cm in the right mid-clavicular line; edge is
smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No
costovertebral angle (CVA) tenderness.”

OR

“Abdomen is flat. No bowel sounds heard. It is firm and board like, with increased tenderness,
guarding, and rebound throughout the abdomen. Positive Obturator sign noted. Liver percusses
to 7 cm in the midclavicular line; edge not felt. Spleen and kidneys not felt. No palpable masses.
No CVA tenderness.”
 Sample Focused Note DMSK-shoulder pain
Informant: SC 53 yo male; BD 9/27/64
Student name: Jan Owens
Date of encounter: 6/15/2017

CC: “My right shoulder is killing me”

HPI: Sam Carson is a 53 yo male carpenter with sudden onset right shoulder pain. The patient
first noted aching pain in the shoulder 2 nights ago while trying to sleep on that side. He
remembers noting a sudden “tearing” pain in the shoulder earlier that day while doing
overhead work at a construction site. Pain is 5/10 at rest, but increases to 9/10 if he attempts
to lift the right arm overhead or behind his back. He has also noted some weakness on that
side, particularly with overhead movement. The pain is preventing him from sleeping on his
right side. The pain does not radiate. Advil helps to ease the pain. He injured the same shoulder
10 years ago while skiing and wonders if this could be related. He is concerned that he will not
be able to work if the pain and weakness do not dissipate. He denies any other muscle or joint
pain, stiffness, or history of arthritis or gout in the past.

PMH/PSH:
No significant illnesses, hospitalizations or surgeries in the past. Patient does recall having right
shoulder pain for a few weeks after a skiing accident 20 years ago.
Immunizations: Last tdap 2014.
Ob/MH: Not relevant.
Screening studies: colonoscopy 2013-negative.

ALLERGIES:
NKDA.
Latex-“Swelling of throat”

MEDS:
None except advil 600mg 3x/day for present illness

SOCIAL/FUNCTIONAL HISTORY:
Habits: tobacco- 2 ppd x 25yr. No etoh/illicit drug use.
Widowed. 3 children. Carpenter.
No regular exercise. Low fat diet.

FAMILY HISTORY:
Adopted. Family history unknown. Children-A&W

PE:
VS: T-98.6 RR-12 P-60 BP 120/80
Gen: Mid aged male who in mild distress, holding right arm close to his body.
Shoulders: symmetric without visible swelling, deformity or muscular atrophy. Left shoulder
non-tender to palpation. Full active ROM. Right shoulder: tender to palpation at subacromial
bursae region. Active ROM full for flexion and extension, but active abduction is limited to 60
degrees due to pain. Full but painful abduction possible passively. Active internal and external
rotation of the right shoulder is painful. Positive empty can and lift off tests. No pain or
weakness with external rotation against resistance. Normal sensation and peripheral pulses in
the upper extremities. Neck with full and painless active ROM. Right elbow non-tender, with full
ROM.

LABS: xray of right shoulder- unremarkable.

SUMMARY STATEMENT:
53 yo previously healthy male carpenter with acute onset right shoulder pain and weakness
after prolonged overhead work. PMH significant for prior right shoulder trauma in the past.
Pertinent PE findings include tenderness to palpation in subacromial bursa region of the right
shoulder with limited active abduction and internal rotation due to pain.

DIAGNOSTIC IMPRESSION WITH JUSTIFICATION:

Right shoulder pain- Probable supraspinatus/subscapularis tear vs rotator cuff tendonitis.
Supporting data: Hx of shoulder pain in subacromial bursa region following overhead work,
which is worse at night. PE with positive empty can and lift off tests.

Plan (not expected for second year students): Ice, rest, NSAID’s, no overhead work for now.
Consider MRI, steroid injection, referral to PT or referral to orthopedics.
 Sample Documentation of a Normal Physical Exam (example only)
General: well-developed, well-nourished middle-aged female in no apparent distress.
VS: BP 120/80 P- 60 RR-14 T-98.6 Pulse ox 96% on room air
HEENT: (extended write up)
Head: AT/NC (atraumatic/normocephalic)
Eyes: Visual acuity 20/20 OD, 20/20 OS and 20/20 OU. Conjunctivae pink, sclera white. Visual
field full and symmetric. Extraocular motion intact (EOMI). Pupils equal, round and reactive to
light and accommodation (PERRLA). constricting from 4mm to 2mm. Fundi with sharp disc
margins.
Ears: ear canals patent, tympanic membranes pearly gray with good light reflex. Acuity good to
whisper/finger rub.
Nose: nasal mucosa pink, septum midline, sinuses non-tender
Oropharynx: dentition good, oral mucosa pink, pharynx without exudates. Uvula midline

More commonly you will see the above abbreviated and grouped as HEENT:
HEENT: Head: AT/NC. Eyes: PERRLA EOMI. Fundoscopic: Sharp disc margins, without
hemorrhages. Ears: TM’s clear with good light reflex. Nose/sinuses: Non-deviated septum, no
sinus tenderness Mouth/throat: no oral lesions or cyanosis. Moist mucosa. Pharynx without
exudates. (Typically, a brief exam of the neck for lymphadenopathy is included with HEENT
documentation--- ie “Neck supple without mass or lymphadenopathy”

Neck: neck supple with full ROM, thyroid without enlargement or palpable nodules. No
adenopathy in occipital, pre- auricular, posterior auricular, submandibular, superficial cervical,
posterior cervical or supraclavicular nodes. No carotid bruits or JVD (these may be included in
the cardiac exam instead).

Cardiac: S1, S2. Regular rate and rhythm (RRR) without murmur click or rub. No lifts, thrills or
heaves noted. PMI non displaced or enlarged at 5th left ICS. Carotid upstroke brisk, no bruits.
JVP measures 3cm above the sternal angle. (If normal we usually just say, “no JVD”). Peripheral
pulses symmetric and 2+. Capillary refill <3 seconds. No peripheral edema noted.

Pulmonary/thorax: Thorax symmetric with good expansion. No chest wall deformities noted.
No chest wall tenderness to palpation. Lung fields resonant to percussion. Lungs sounds clear to
auscultation (If PE suggests pneumonia or pleural effusion—i.e. if bronchophony or rhonchi are
noted on exam or if dullness is noted to percussion, the write up should include comments on
egophony, bronchophony, whispered pectoriloquy and tactile fremitus)

Abdomen: Flat and without visible scars. Bowel sounds normoactive. Soft, non-tender, no
palpable masses. No organomegaly with liver edge palpable 1 cm below the right costal margin.
Spleen edge non palpable. No rebound or rigidity noted. Percussion reveals liver span 6 cm in
right mid-clavicular line. No CVA tenderness.
Neuro: (Should include MS (mental status), CN (cranial nerves), Motor (including
tone/strength) DTR’s, Sensory (soft touch/sharp/vibratory/position) and Cerebellar /Gait
assessment
Alert and oriented to person, place and time. CN II-X11 intact. Good muscle tone with strength
5/5 throughout. Cerebellar-Rapid Alternating Movements (RAM), finger to nose, heel to shin
intact. Gait with normal base. Romberg-maintains balance with eyes closed. No pronator drift.
Sensation to sharp, light touch, vibration and position intact. DTR’s 2+ with plantar reflexes
downgoing.

Extremities: Extremities are warm and without edema. No varicosities or stasis changes. Calves
are supple and nontender. No femoral or abdominal bruits Brachial, radial, femoral, popliteal,
dorsalis pedis (DP) and posterior tibial (PT) pulses are 2+ and symmetric.

GU (Male): Circumcised male. No penile discharge or lesions. No scrotal swelling or varicoceles

noted. Testes descended bilaterally, smooth, without masses or tenderness Epididymis
nontender. No inguinal or femoral hernias. No perirectal lesions or fissures. External sphincter
tone intact. Rectal vault without masses. Prostate smooth and nontender with palpable median
sulcus.

GU (Female): No inguinal adenopathy. External genitalia without erythema, lesions or masses.

Vaginal mucosa pink. Cervix parous, pink and without discharge. Uterus anterior, midline,
smooth and non-enlarged. No adnexal tenderness. Pap smear obtained. Rectovaginal wall
intact. Rectal vault without masses. Stool heme negative.

Back: Back is symmetric without scoliosis, exaggerated kyphosis or lordosis appreciated. No

tenderness noted over cervical, thoracic or lumbar spine to percussion and no paraspinous
muscle tenderness noted to palpation. ROM for LS spine is normal on forward flexion,
extension, lateral flexion and rotation. Hips with full and painless ROM. Muscle strength is 5/5
at hips, knees and ankles with no problems heel or toe walking. Sensation is symmetric and
intact to light touch. DTR’s are 2+ at patella and ankle bilaterally. SLR is negative bilaterally.
Gait is normal.
 Samples of Abnormal PE Write-Up
Knees: (Sample for lateral meniscus injury)
Right knee without visible swelling, deformity or muscular atrophy. Full and non-tender active ROM.
Left knee with notable effusion with positive bulge sign. Patella is ballotable. Tenderness to palpation is
noted along the lateral joint line. Patient is not able to fully flex or extend the knee actively or passively
due to the effusion. There is tenderness with varus strain, but the joint does not open laterally. Valgus,
ant/posterior drawer and lachman’s maneuvers are unremarkable. Marked clicking and tenderness
noted with McMurray testing along the lateral meniscus region. Sensation and peripheral pulses are
normal. The left hip and left ankle are non tender with full ROM.

Shoulders: (Sample for right rotator cuff injury)

Shoulders symmetric without visible swelling, deformity or muscular atrophy. Left shoulder non-tender
to palpation. Full active ROM. Right shoulder: tender to palpation at subacromian bursa region. Active
ROM full for flexion and extension, but active abduction is limited to 60 degrees due to pain. Full but
painful abduction possible passively. Active internal rotation of the right shoulder is painful. Positive
empty can and lift off tests. No pain or weakness with external rotation against resistance. Sensation
and peripheral pulses normal in upper extremities. Neck with full and painless active ROM. Right elbow
non-tender, with full ROM.

Back: (sample for herniated disc involving LS spine region)

Back is symmetric without scoliosis, exaggerated kyphosis or lordosis appreciated. Tenderness to
percussion over low LS spine. Right paraspinous tenderness to palpation also noted in same region.
ROM for LS spine is normal to forward flexion, extension, lateral flexion and rotation, but gait markedly
antalgic, with decreased weight placed on the right leg. Unable to walk well on toes due to
pain/weakness. MS 3/5 at ankles with plantarflexion, but 5/5 at hips and knees. Ankle jerk reflex absent
on right. DTR’s otherwise 2+ at both patella and left ankle. Sensation to light touch decreased over
lateral aspect of right lower leg. Intact and symmetric otherwise. Hips with full and non tender ROM. SLR
is positive on right at 30 degrees with reproduction of patient’s pain in right lateral foot.

Sample write up for HEENT case (sinusitis):

HEENT: TM’s clear with good light reflex bilaterally. Hearing grossly intact. Copious thick nasal
secretions. Non deviated septum. Positive left frontal sinus tenderness to palpation. No pharyngeal
exudate or erythema. Marked postnasal drip noted. No enlarged cervical lymph nodes appreciated.

Sample write up for appendicitis:

Abdomen: Abdomen: Non distended. No visible scars. Bowel sounds hypoactive. Abdomen is rigid with
greatest tenderness in RLQ. Positive guarding and rebound tenderness at McBurney’s point. No palpable
mass or organomegaly noted. Liver percusses at 7cm midclavicular line. There is percussive tenderness
at RLQ. +Rovsings, obturator and psoas testing.