1.

Introduction
• Good morning maám, I’m _____________, a 3rd year medical student. I’ll be attending
you today.
• May I know your name and age maám?
• So maám (name), I want to I inform you that I’ll be asking some series of questions
today and some of those might be too personal. Are you alright with that?

2. General Data
• May ask for your:
▪ Date of birth
▪ Place of Birth
▪ Current address
▪ Religion
▪ Civil Status

3. Chief complaint
• May I ask what is the reason for you to seek consult maám?

4. History of present illness

• How long have you been experiencing the (symptoms)?
• IS it sudden or progressive?
• Does it suddenly disappear or is it continuous?
• *if pain* Can you tell me at what part is it radiating?
• How can you describe the (symptom)?
• What did you do when you first experienced the (symptom)?
• Are there any other symptoms accompanying the main reason for you consult?
• What did you do to alleviate the symptom?
• Have you noticed any triggers that could make your symptom worst?
• Did you take any medication?
▪ If yes
o What is the dosage?
o When do you usually take the medicine?
o For how long have you’ve taken the medicine?
• Have you experience this symptom before? Did you seek consult? Did you take
anything? What did you do to make it better?

5. Obstetrics History
• How many children do you have?
• May I know the date of birth
• Does the child have a normal delivery?
• Where did you had your delivery?
• Male or female?
• May I know the birth date of your child?

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 • May I know the weight of your child?
• Are all your child living?
• Have experience abortion?

(PEDIA)

6. Birth History (if perogy)

• Prenatal History
▪ When was your first pre-natal check-up?
▪ When was your last day of menstruation?
▪ Compute age of gestation
▪ What medical conditions do you have? (asthma, hypertension, diabetes)
▪ Did you have any previous hospitalization?
▪ Have you had any previous illnesses or infection during pregnancy?
▪ What vaccine have you got? (doses and when)
▪ Do you drink alcohol, smoke?
▪ Have you taken any contraceptives?
▪ Do you have any medications? (dose, frequency, when start)
▪ Do you take any vitamins?
▪ Did you have any bleedings during pregnancy?
▪ Did you have any threatened abortion?

• Natal History
▪ Did you experience labor?
▪ How long was your labor?
▪ How painful was your labor? (number scale)
▪ Did you use any analgesia?
▪ How was the baby?
▪ How assisted your birth?
▪ What type of delivery is your baby?
▪ Are there any complications?
▪ What is the birth weight?
▪ APGAR score
▪ AOG (term, preterm, post term)
▪ Birth rank

• Postnatal History
▪ How was the baby after birth?
▪ Any jaundice, convulsion, resuscitation, pallor, dyspnoea?
▪ Any congenital defects?
▪ Did the baby have a newborn screening? What is the result?
▪ Did the baby have eye ointment?
▪ Did the baby receive vitamin k?
▪ How many days are you in the hospital?
▪ Any medications given?

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 ▪ What are the immunization given to the baby? (dose and when)
▪ Any noted allergies?
▪ Is the baby breastfed? (pure, mixed)
▪ When did you start bottle-feeding the baby?
▪ When did you start introducing solid food?
▪ Any vitamins taken?

• Developmental history
▪ Holds head steady while sitting?
▪ Sits with /without support?
▪ Rolls back to stomach.
▪ Pulls self to stand. Stand with support?
▪ Walks with handheld.
▪ Stand alone? Walks alone? Crawls? Runs? Hops on foot?
▪ Tooth eruption?
▪ Reaches for objects.
▪ Transfer objects from hand to hand?
▪ Holds bottle?
▪ Imitates cross?
▪ Write alphabet?
▪ Attempts to use a spoon.
▪ Feeds self?
▪ Social smile?
▪ Coo?
▪ Babble?
▪ Stranger anxiety?
▪ Stares momentarily at spot where object disappeared?
▪ Object permanence?
▪ Pretend play?

• Psychosocial history
▪ How long does the baby sleep during the night and day?
▪ Does the baby have normal bowel movement? (color and consistency of stool)
▪ Does the baby thumb sack, nail biting, tantrums?

7. Menstrual History
• At what age did you have your first menstruation?
• Is it regular or irregular?
• What is the interval between your periods?
• How many pads do you usually use per day?
• Have you experience dysmenorrhea?
• When having your period? Do you experience any other symptoms with it?
• When was your last day of menstruation?

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 • Have you had your menopausal?

8. Sexual History
• When was your first sexual intercourse?
• Are sexually active?
• How many sexual partners do you have?
• DO you experience pain while having intercourse?
• Do you have any history of sexually transmitted diseases?
• Have you undergone pap smear?

9. Contraceptive History
• Do you use any contraceptives? (include ligations and complications)

10. Past medical history

• Do you have any other medical conditions?
▪ Hypertension?
▪ Diabetes?
▪ Asthma?
▪ Allergies?
• Did you have any immunization for the past weeks or months?
• Can you recall what immunizations you had?

11. Family History

• Does any of your family has a medical condition?
• Does a heredofamilial disease runs in your family? (mother father siblings lolo lola)

12. Personal and social History

• May I know the age of your husband, your kids?
• How long have you been married?
• What do you do for a living? Also, for the husband? If available, children also
• Are the children working?
• Who are you living with? How many are you in a household?
• In a what type of house are you living? Do you own the house or rent?
• How do you usually do in your house?
• Do you do exercise?
• How many hours is your usual sleep?
• Do you drink alcohol, smoke?
• Do you use illicit drugs?

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 13. Environmental History
• DO you consider your home safe for your family’s health?
• What is your source of water?
• Where do you usually get your foods?
• Are exposed to any paints or tiners?

14. Review of System

Recent weight change, Change in appetite, Overall weakness, Lack of energy

General
(Fatigue), Fever, Chills, Sweats, Lack of enjoyment in life (Anhedonia)
Rashes, Lumps, Sores, Itching, Dryness, Changes in color, Changes in hair or nails,
Skin
Changes in size or color of moles
Head Headache, Head injury, Dizziness, Lightheadedness
Change in vision, glasses or contact lenses, Nearsightedness or Farsightedness,
Pain, Redness, Excessive tearing, Double or blurred vision, Spots, Specks, flashing
Eyes
lights or shimmering light (scintillating scotoma), Glaucoma, Cataracts, Spots in
visual fields (floaters), Double vision (diplopia), Last eye check up
Change in hearing, Tinnitus, Vertigo, Earaches, Infection, Discharge, Use of
Ears
hearing aids
Frequent colds, Nasal stuffiness, Clogged Nose, Discharge, Itching, Hay fever
Nose and sinuses
(Allergic rhinitis), Nosebleeds, Sinus problems
Condition of teeth and gums, Bleeding gums, Dry mouth, Sore throat, Dentures,
Throat (Mouth
Painful tooth, Sore tongue, Dry mouth, Hoarseness, Decreased or change of
and Pharynx)
sense in taste, Difficultly in speech, Last dental examination
Neck Swollen glands, Goiter, Lumps, Pain, or Stiffness in the neck
Breast Lumps, Pain, Discomfort, Nipple discharge, Self-examination practices
Cough, Colds, Shortness of breath (dyspnea), Wheezing, Pain with a deep breath
Respiratory (pleuritic pain), Asthma, Bronchitis, Emphysema, Pneumonia, Tuberculosis, Last
chest x-ray
Chest pain or Discomfort, Heart trouble, High blood pressure, Rheumatic fever,
Heart murmurs, Palpitations, Shortness of breath, need to use pillows at night to
Cardiovascular ease breathing (orthopnea), Need to sit up at night to ease breathing
(paroxysmal nocturnal dyspnea), Swelling in the hands, ankles, or feet (edema),
Results of past electrocardiograms or other cardiovascular tests
Constipation, Diarrhea, Abdominal pain, Food intolerance, Trouble swallowing
(dysphagia), Heartburn (reflux), Nausea, Bowel movements, Vomiting color,
consistency, after taste, odor, and quantity, Stool appearance, color, consistency,
Gastrointestinal quantity, and size, Jaundice, Liver or Gallbladder trouble, Hepatitis, Pain with
defecation, Rectal bleeding or black or tarry stools (melena), Rectal pain
(proctalgia), rectal discharge or rectal itching (pruritis ani), Hemorrhoids,
Excessive belching (eructation) or passing of gas (flatulence)
Varicose veins, Intermittent leg pain with exertion (claudication), Leg cramps,
Peripheral
Past clots in the veins, swelling in calves, legs, or feet, Color change in fingertips
vascular
or toes during cold weather, Swelling with redness or tenderness
Urination frequency, quantity, and color, Polyuria, Nocturia, Urgency, Burning or
Urinary pain during urination (dysuria), Blood in the urine (hematuria), Urinary
infections, Kidney or flank pain, Kidney stones, Ureteral colic, Suprapubic pain,

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 Incontinence, In Males: Reduced caliber or force of the urinary stream,
Hesitancy, Dribbling
Male: History of sexually transmitted infections and their treatments, Sexual
habits, Interest, Function, Condom use, Satisfaction, Contraceptives, Discharge
from or Sores on the penis, Testicular pain or masses, Scrotal pain or swelling,
Change in ejaculation (bloody, retrograde, premature), Difficulty in getting an
erection (Impotence or Erectile dysfunction), Concerns about HIV infection
Female: Dysmenorrhea, Bleeding between periods or after intercourse,
Premenstrual tension, menopausal symptoms, postmenopausal bleeding, Heavy
Genital
periods (menometrorrhagia), Lack of periods (amenorrhea), Hot flashes If the
patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal
use during pregnancy (linked to cervical carcinoma), Sexually transmitted
infections and treatments, Complications of pregnancy, Contraceptives, Vaginal
pain, Discharge, Itching, Sores or lesions, Lumps, Sexual preference, Interest,
Function, Satisfaction, any problems, including Dyspareunia, Concerns about HIV
infection
Muscle or joint pain, Stiffness, Arthritis, Gout, Backache, Location of affected
joints or muscles, Swelling, Redness, Pain, Tenderness, Stiffness, Weakness,
Limitation or difficulty of motion or activity, Aching or cramping pain in the
Musculoskeletal
calves with walking, Timing of symptoms, Duration, History of trauma, Neck or
low back pain, Joint pain with systemic symptoms such as fever, Chills, Rash,
Anorexia, Weight loss, Bleeding or Bruising tendencies
Nervousness, Tension, Mood, Depression, Memory change, Suicidal ideation,
Suicide plans or attempts, Psychotherapy or Psychiatric admissions,
Psychiatric
Unwelcoming thoughts (intrusive thoughts), Loss of good judgement or insight,
Seeing or hearing things that don't exist (hallucination), Past counselling
Changes in mood, attention, or speech; changes in orientation, memory, insight,
or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness,
Neurologic
paralysis, numbness, or loss of sensation, tingling or “pins and needles,” tremors
or other involuntary movements, seizures.
Anemia, Bruising or Bleeding, Past transfusions, Transfusion reactions, Frequent
Hematologic or unusual infections, Swelling, Lumps, Bumps (Lymphadenopathy, Enlarging
glands)
Thyroid trouble or abnormal growth, Heat or cold intolerance, Excessive
Endocrine sweating, Excessive thirst or hunger, Polyuria, Change in glove or shoe size, Loss
of sexual drive (Libido), Salt craving

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 15. Physical Examination
• General
▪ Check the patient’s level of consciousness
o Alertness
✓ Is the patient awake, alert, or interactive?
o Lethargy
✓ Is the patient having loud voice when answering
✓ Is the patient drowsy but open eyes or looking at you?
✓ Does the patient response or falls asleep?
o Obtundation
✓ Does the patient open eyes and looks at you when shaken
gently but the responds slow and confused?
✓ Is the alertness and interest in environment are decreased?
o Stupor
✓ Does the Patient arouse from sleep only after painful stimuli?
✓ Verbal responses are slow or absent?
✓ Patient lapses into unresponsiveness when stimulus stops?
✓ Patient has minimal awareness of self or environment?
o Coma
✓ Does the patient remain unarousable with eyes closed even
with repeated painful stimuli?
✓ No evident response to inner need or external stimuli is shown?
▪ Check for the signs of distress
o If the patient cardiac/respiratory distress, pain, and anxiety/depression?
▪ Check for skin discoloration or any obvious lesion
▪ Check for the grooming, hygiene, and odors
▪ Check for the facial expression
▪ Check for posture, gait, and motor activity
• Vital signs
▪ Blood pressure

Systolic Diastolic
Normal <120 <80
Prehypertension 120-139 80-89
Stage 1 hypertension 140-159 90-99
Stage 2 hypertension ≥160 ≥100
If diabetes or renal disease <130 <80

▪ Heart rate
o 60-100 beats per minute
o Count for 15 seconds then multiply by 4
▪ Respiratory rate
o 14-20 breathe per minute

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 ▪ Temperature
▪ Weight (kg)
▪ Height
▪ BMI
o Weight (kg) / Height (m2)
o 1 meter = 3.3 foot
o 1 meter = 39.37 in

Example: “Mrs. Scott is a young, healthy-appearing woman, well-groomed, fit, and in good spirits.
Height is 5′4″, weight 135 lbs., BP 120/80, HR 72 and regular, RR 16, temperature 37.5°C.”

• Mental Status
▪ Check for appearance and behavior
▪ Speech and language
o Word comprehension
✓ Ask patient to follow a command: “point to your nose”, “point
to your mouth”
o Repetition
✓ Ask patients to repeat a phrase: “No ifs, ands, or buts”
o Naming
✓ Ask patient to name an object
o Reading comprehension
✓ Ask patient to read a paragraph
o Writing
✓ Ask patient to write a sentence
▪ Mood
o Ask if the patient feels happy, sad, depressed, indifferent.
o Ask if any suicidal thoughts
▪ Thoughts and perceptions
o Thought process
✓ Assess the organization and formulation of thoughts of the
patient.
✓ Is it coherent?
o Thought content
✓ Ask about unusual or unpleasant thoughts
o Perception
✓ Ask about any unusual seeing or hearing
o Insight and Judgement asses
✓ Ask patient’s thought about the illness and patient’s judgement
in making decisions or plans
▪ Cognition function
o Orientation
✓ Asses the orientation to time, place, and person

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 o Attention
✓ Digit span
o Ability to repeat a series of numbers forward and
backward
✓ Serial 7s
o Ability to subtract 7 repeatedly
✓ Spelling backward
o Ability to spell a 5-letter word
o Remote memory
✓ Ask patient for birthdays, anniversary, school, jobs
o Recent memory
✓ Ask patient today’s event
o New learning ability
✓ Ability to repeat 3 or 4 words after few minutes
▪ Higher cognitive functions
o Information and vocabulary
o Calculating abilities
o Abstract thinking
✓ Ask patient to describe the similarities of things
o Constructional ability
✓ Ask patient to follow figures, draw a clock

Example: “The patient is alert, well-groomed, and cheerful. Speech is fluent and words are clear.
Thought processes are coherent, insight is good. The patient is oriented to person, place, and time.
Serial 7s accurate; recent and remote memory intact. Calculations intact.”

• HEENT
▪ Head
o Hair
✓ Quantity
✓ Distribution
✓ Texture
o Scalp
✓ Are there lumps or lesions?
o Skull
✓ Check for size or contours
o Face
✓ Check for symmetry and facial expression
o Skin
✓ Color
o Check for cyanosis, jaundice, carotenemia
✓ Moisture
o Dry or oily
✓ Temperature
o Cool or warm

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 ✓ Texture
o Smooth or rough
✓ Mobility
o Can be moved or decreased if edema
✓ Turgor
o Fold the skin of the patient, check the speed when it
returns to place
✓ Lesions
o Distribution
➢ Generalized or localized
o patterns and shapes
➢ linear, clustered, or dermatomal
o Type
➢ Macule, papule, pustule, bulla, or tumor
o Color
➢ Red, white, brown, or black

Example: “Color pink. Skin warm and moist. Nails without clubbing or cyanosis. No suspicious nevi, rash,
petechiae, or ecchymoses. The skull is normocephalic/atraumatic (NC/AT). Hair with average texture.

▪ Eyes
o Inspect
✓ Position and alignment
✓ Eyebrows, eyelids
✓ Lacrimal apparatus
✓ Conjunctiva and sclera
o Examine
✓ Pupils
o Size, shape, and symmetry
o Reaction to light, direct or consensual
o Near reaction: Pupillary constriction
➢ Shift object to the center of the eyes
o Assess
✓ Corneal reflections
✓ Six cardinal directions
o “Asterisk”
o Inspect with ophthalmoscope
✓ Fundi
o Red reflex
o Optic disc
➢ Check for color. Normal: Round yellowish
orange
➢ Check for sharpness or clarity
➢ Check for the size, venous pulsation
o Arteries, veins, and AV crossings

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 o Adjacent retina
➢ Check for any hemorrhages, exudates, cotton-
wool patches
o Macular area
➢ Check for macular degeneration
o Anterior structures
➢ Check for floaters, cataracts

Example: Visual acuity 20/20 bilaterally. Sclera white; conjunctiva pink. Pupils constrict 4 mm to 2 mm,
equally round and reactive to light and accommodations. Disc margins sharp; no hemorrhages or
exudates; no arteriolar narrowing.

▪ Ears
o Inspect auricles for keloids, epidermoid cyst
o Suspected otitis:
✓ Move auricle up and own, and press on tragus: there should be
pain
o Eardrum and canal
✓ Inspect through a speculum
o Pull auricle up, back, and slightly out
o Check for canal swelling or erythema
o Check for bulging drum
o Hearing
✓ Assess auditory acuity to whispered or spoken voice
o If diminished, use tuning fork
➢ Weber test (lateralization)
❖ Place vibrating and tuning fork on
vertex of skull
➢ Rinne test (air and bone conduction)
❖ Place vibrating and tuning fork on
mastoid bone, then remove

Example: Acuity good to whispered voice. Tympanic membranes (TMs) with good cone of light. Weber
midline. AC > BC.

▪ Nose
o Inspect external nose
o Inspect using speculum
✓ Nasal mucosa
o Check for color and swelling
✓ Nasal septum
o Check for position and integrity
o Palpate the frontal and maxillary sinuses

Example: Nasal mucosa pink, septum midline; no sinus tenderness.

▪ Throat (or Mouth)

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 o Inspect
✓ Lips
✓ Oral mucosa
✓ Gums
✓ Teeth
✓ Roof of the mouth
✓ Tongue
o Papillae
o Symmetry
o Any lesion
✓ Floor of the mouth
✓ Pharynx
o Color or any exudate
o Presence and size of tonsils
o Symmetry of soft palpate
➢ Ask patient to say “ah”

Example: Oral mucosa pink; dentition good; pharynx without exudates.

▪ Neck
o Inspect
✓ Check for scars, masses
o Palpate lymph nodes
o Inspect and palpate the position of trachea
o Thyroid gland
✓ Inspect at rest and as patient swallows water
✓ Palpate from behind at rest and as patient swallows water

Example: Trachea midline. Neck supple; thyroid isthmus palpable, lobes not felt. No cervical, axillary,
epitrochlear, inguinal adenopathy

• Chest and Lungs

▪ Thorax
o Inspect
✓ Check rate, rhythm, depth, and effort of breathing
✓ Check for inspiratory retraction and contraction of
supraclavicular areas and sternomastoid, respectively.
o Observe shape of chest
o Listen for breathing
✓ Rate and rhythm
✓ Stridor and wheezes
▪ Posterior chest
o Inspect
✓ Check for deformities or asymmetry
✓ Anormal inspiratory retraction
✓ Impairment or unilateral lag

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o Palpate
✓ Tender areas
✓ Assessment of visible abnormalities
✓ Chest expansion
✓ Tactile fremitus as the patient says “aa” or “blue moon”
o Percuss
✓ Chest areas illustrated, compare one side wit the other at each
level

✓ Level of diaphragmatic dullness on each side and estimate

diaphragmatic descent after full inspiration

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o Listen to the chest using stethoscope
✓ Evaluate breath sounds
✓ Note for adventitious sounds
o Observe
✓ Quality of breath sound
✓ Timing in respiratory cycle
✓ Location on chest wall.

o Assess transmitted voice sounds, bronchial breath sounds heard on

abnormal places
✓ Ask patient to say “ninety-nine” and “ee” and whisper “ninety-
nine” or “one-two-three”

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 ▪ Anterior Chest
o Inspect
✓ Deformities or asymmetry
✓ Intercostal retraction
✓ Impaired or lagging respiratory movement
o Palpate chest
✓ Tender areas
✓ Assessment of visible abnormalities
✓ Respiratory expansion
✓ Tactile fremitus
o Percuss chest

o Listen to the chest

✓ Breath sounds
✓ Adventitious sounds
✓ Transmitted voice sounds

Examples: “Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular, no rales,
wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally”

• CVS
▪ Heart rate and Blood pressure
o Measure radial or apical pulse
o Measure BP
▪ Jugular veins
o Identify pulsation and their highest point in the neck
✓ Start with head of the bed at 30 degrees
o Measure jugular venous pressure
✓ Vertical distance between this highest point and the sternal
angle, normally <3 to 4 cm

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▪ Carotid Pulse
o Asses the amplitude and contour of carotid upstroke
o Check for variations in pulse amplitude
o Listen for bruits
▪ Heart

o Inspect and palpate the anterior chest for heaves lifts, or thrills
o Palpate
✓ Identify apical impulse
o Check for location, diameter, amplitude, duration
✓ Feel for right ventricular impulse in left parasternal and
epigastric areas
✓ Palpate left and right second interspace close to sternum

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o Auscultation
✓ Listen by inching the stethoscope from base to apex
✓ Use diaphragm for relatively high-pitched sounds
✓ Listen at each area for:
o S1
o S2
o Extra sound in systole and diastole
o Systolic and diastolic murmurs

o Identify if murmurs are present

✓ Check for timing in cardiac cycle
o Helpful to palpate the carotid
✓ Check fir maximal intensity, radiation, pitch, quality
✓ Check for intensity on a 6-point scale
o Listen at the apex with patient turned towards left side
for low pitched sounds
o Listen down left sternal border to the apex as patient
sits, leaning forward, with breath held after exhalation

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 o Special techniques
✓ Pulsus alternans
o Feel pulse for alternation in amplitude. Lower pressure
of blood pressure cuff slowly to systolic level while you
listen with stethoscope over brachial artery.
✓ Paradoxical pulse
o Lower pressure of blood pressure cuff slowly and note
two pressure levels:
➢ Where Korotkoff sounds are first heard
➢ Where they first persist through the respiratory
cycle. These levels are normally not more than 3
to 4 mm Hg apart
✓ Aids to identify systolic murmurs
o Valsalva maneuver
➢ Ask patient to strain down
➢ Suspected MVP, AS from HC
o Squatting and standing
➢ Suspected MVP and AS from HC

Example: “The jugular venous pulse (JVP) is 3 cm above the sternal angle with the head of the bed
elevated to 30 degrees. Carotid upstrokes are brisk, without bruits. The point of maximal impulse (PMI)
is tapping, 7 cm lateral to the midsternal line in the 5th intercostal space. Crisp S1 and S2. At the base,
S2 is greater than S1 and physiologically split, with A2 > P2. At the apex, S1 is greater than S2 and
constant. No murmurs or extra sounds.”

• Breast

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 ▪ Female
o Inspect in four positions
✓ Note for size, symmetry, contour, appearance of the skin
o Inspect the nipples
✓ Compare size, shape, and direction
✓ Note any rashes, ulcerations, or discharge
o Palpate breast
✓ Breast tissue should be flattened, and patient is supine
o Palpate in rectangular area from clavicle to the inframammary fold, and
from the midsternal line to the posterior axillary line and well into the
axilla for the tail of Spence
✓ Note for consistency, tenderness, and nodules
o Vertical strip pattern (currently the best validated technique) or a
circular or wedge pattern. Palpate in small, concentric circles.
✓ Lateral portion of the breast
o Ask the patient to roll onto the opposite hip, place her
hand on her forehead, but keep shoulders pressed
against the bed or examining table
✓ Medial portion of the breast
o Ask the patient to lie with her shoulders flat against the
bed or examining table, place her hand at her neck, and
lift her elbow until it is even with her shoulder
o Palate each nipple and inspect along the incision lines of mastectomy
▪ Male
o Inspect and palpate the nipple and areola
▪ Axillae
o Inspect
✓ Note rashes, infection, and pigmentation
✓ Palpate the axillary nodes, including the central, pectoral,
lateral, and subscapular groups
▪ Special techniques
o Breast discharge
✓ Compress the areola in spoke like pattern around the nipple

Example: “Breasts symmetric and smooth, without masses. Nipples without discharge.”

• Abdomen
▪ Inspect
o Check for the skin, umbilicus
o Check for contours
✓ Shape, symmetry, enlarge organs or masses
✓ Check for peristaltic waves and any pulsations
▪ Auscultate
o Check the bowel sounds, bruits, and friction rubs

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▪ Percuss
o Check for patterns of tympany and dullness
▪ Palpate
o Check all quadrants:
✓ Lightly guarding, rebound, and tenderness
✓ Deeply for masses or tenderness
▪ Liver
o Percuss
✓ Check the span of liver dullness in midclavicular line
✓ Feel the liver edge as the patient breathes in
✓ Measure its distance from the costal margin in the MCL
✓ Note any tenderness or masses
▪ Spleen
o Percuss
✓ Patient should be supine, lying on the right side with legs flexed
at hips and knees
o Percuss across left lower anterior chest, noting change
from tympany to dullness
▪ Kidneys
o Palpate each kidney
✓ Check for costovertebral angle tenderness
▪ Aorta
o Palpate for pulsation

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Example: “Abdomen is protuberant with active bowel sounds. It is soft and nontender, no palpable
masses or hepatosplenomegaly. Liver span is 7 cm and in the right MCL; edge is smooth and palpable 1
cm below the right costal margin. Spleen and kidneys not felt. No CVA tenderness.”

• Peripheral Vascular exam

▪ Arms
o Inspect
✓ Check for size, symmetry, and any swelling
✓ Check for venous pattern
✓ Check color and texture of skin and nails
o Nails
➢ Color
➢ Shape
➢ Lesions
o Palpate and grade pulses
✓ Radial
✓ Brachial

o Feel for the epitrochlear nodes

Abd

▪ Abdomen
o Palpate and estimate the width of the abdominal aorta between two
fingers
▪ Legs
o Inspect for size and symmetry, nay swelling in the thigh or calf
o Check for venous pattern. Color, and texture of skin, hair distribution
and temperature.
o Palpate inguinal lymph nodes
✓ Horizontal group
✓ Vertical group
o Palpate and grade the pulses
✓ Femoral
✓ popliteal
✓ Dorsalis pedis
✓ Posterior tibialis
o Check for pitting edema
o Palpate for calves
o Ask patient to stand and reinspect the venous pattern

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 o Special techniques
✓ Allen test
o Evaluate arterial supply to the hand
➢ Ask patient to make a tight fist and occlude
both radial and ulnar arteries with thumb
➢ Ask patient to open hand
➢ Release pressure over one artery. Palms should
flush with 3 to 5 seconds
➢ Repeat, releasing other artery
✓ Postural color changes of chronic arterial insufficiency
o Raise both legs to 60 degrees for about 1 minute. Then
ask patient to sit up with legs dangling down. Note time
required for (1) return of pinkness (normally 10
seconds) and (2) filling of veins on feet and ankles
(normally about 15 seconds).

Example: “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.”

Radial Brachial Femoral Popliteal Dorsalis Posterior

Pedis Tibialis
RT 2+ 2+ 2+ 2+ 2+ 2+
LT 2+ 2+ 2+ 2+ 2+ 2+

• Genitalia exam
▪ Male
o Penis
✓ Inspect
o the development of penis, skin, hair, prepuce, glans,
and urethral meatus
✓ Palpate
o Any lesion
o Shaft
o Scrotum and contents
✓ Inspect
o Check for contours and skin
✓ Palpate
o Check testis for lumps and tenderness
o Check epididymis, spermatic cord, and adjacent areas
o Hernia
✓ Inspect for inguinal and femoral areas as patient strains down
✓ Palpate external inguinal ring through scrotal skin and ask
patient to strain down

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Example: “Circumcised male. No penile discharge or lesions. No scrotal swelling or dis coloration. Testes
descended bilaterally, smooth, without masses. Epididymis nontender. No inguinal or femoral hernias”

▪ Female
o External
✓ Observe pubic hair to assess sexual maturity
✓ Examine the labia minora, clitoris, urethral orifice, introitus
✓ Milk the urethra for discharge
o Internal
✓ Locate cervix with gloved and water-lubricated index finger
✓ Assess support of vaginal outlet by asking patient to strain
down.
✓ Enlarge the introitus by pressing its posterior margin downward.
✓ Insert a water-lubricated speculum of suitable size. Start with
speculum held obliquely, then rotate to horizontal position for
full insertion
✓ Inspect
o Observe for position, color, and epithelial surfaces
o Check for any discharge or bleeding
o Check for any ulcers, nodules, or masses
o Check the vaginal mucosa as you withdraw
➢ Endocervical broom or brush with scrapper to
collect squamous and columnar cells
➢ Cotton-tipped applicator moistened with water
for pregnant woman
✓ Palpate
o Check the cervix and fornices
o Uterus
o Right and left ovaries
✓ Asses the strength of pelvic muscles
o Ask patient to tighten her muscles around the fingers as
hard and long as she can
✓ Rectovaginal examination
o Palpate retroverted uterus, uterosacral ligaments, cul-
de-sac, and ovaries pr screen for colorectal cancer in
women 50 years or older
✓ Special techniques
o Palpate for a bulge in femoral canal and labia majora up
to just lateral to the pubic tubercle
➢ Ask patient to strain down.

Example: “No inguinal adenopathy. External genitalia without erythema, lesions, or masses. Vaginal
mucosa pink. Cervix parous, pink, and without discharge. Uterus anterior, midline, smooth, and not
enlarged. No adnexal tenderness. Pap smear obtained. Rectovaginal wall intact. Rectal vault without
masses. Stool brown and Hemoccult negative.

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 • Anus, rectal, and prostate exam
▪ Male
o Position the patient on his side, or standing leaning forward over the
examining table and hips flexed
o Inspect
✓ Check the sacrococcygeal are and perianal area
o Palpate
✓ Palpate the anal canal and rectum with a lubricated and gloved
finger
o Feel the walls of the rectum and prostate glands
o Feel above the prostate for irregularities or tenderness

▪ Female
o Position the patient in lithotomy position or lying on her side
o Inspect the anus
o Palpate the anal canal and rectum

Example: “No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses.
Prostate smooth and nontender with palpable median sulcus. (Or in a female, uterine cervix nontender.)
Stool brown and Hemoccult negative.”

• Musculoskeletal exam
▪ Temporomandibular joint
o Inspect for swelling or redness
o Palpate as the patient opens and closes the mouth
o Palpate the muscle of mastification
✓ Masseters
✓ Temporal muscles
✓ Pterygoid muscles
▪ Shoulders
o Insect the contour of the shoulders and shoulder girdles from front and
back

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o Palpate
✓ Clavicle from the sternoclavicular joint to the acromioclavicular
joint
✓ Bicipital tendon
✓ Subacromial and subdeltoid bursae after lifting arm posteriorly

o Asses the range of motion

✓ Flexion
o Raise your arm in front of you and overhead
✓ Extension
o Move your arms behind you
✓ Abduction
o Raise your arms out to the side and overhead
✓ External and internal rotation

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o Perform maneuver to assess the “SITS” muscles and tendons of rotator
cuff
✓ Supraspinatus, infraspinatus, teres minor, subscapularis, and
bicipital tendon
✓ “Empty can test” for supraspinatus strength

✓ Infraspinatus strength

✓ Forearm supination

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 ✓ “Drop arm” test

▪ Elbows
o Inspect and Palpate
✓ Olecranon process
✓ Medial and lateral epicondyles
✓ Extensor surface of the ulna
✓ Grooves between the epicondyles and the olecranon
o Ask patient to:
✓ Flex and extend elbows
✓ Turn palms up and down

▪ Wrist and Hands

o Inspect
✓ Check the movement of the wrist, hands, and fingers
✓ Check the contours of wrist, hands, and fingers
✓ Contours of palms
o Palpate
✓ Check the wrist joint
✓ Distal and radius and ulna

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 ✓ “Anatomic snuffbox” (hollow low space distal to the radial
styloid bone)
✓ Metacarpophalangeal joint
✓ Proximal and distal interphalangeal joint
o Assess range of motion
✓ Wrist
o Flexion, extension, adduction, and abduction
✓ Fingers
o Flexions, extensions, abduction, and adduction
✓ Thumbs

o Perform maneuvers
✓ Hand grip strength
✓ Thumb movement

✓ Carpal tunnel testing

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 ✓ Thumb adduction
✓ Tinel’s sign

✓ Phalen’s sign

▪ Spine
o Inspect from the side and back
✓ Note any abnormal curvatures
✓ Look for asymmetric heights of shoulder, iliac cresta or buttocks
o Identify and palpate
✓ Spinous process of each vertebra. Sacroiliac joints.
Paravertebral muscles, sciatic nerve

o Test the range of motion in the neck and spine

✓ Flexion, rotation, extension, and lateral bending

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▪ Hips
o Inspect gait
✓ Stance and swing

✓ Width of base
o Palpate
✓ Along the inguinal ligament
✓ Trochanteric bursa on greater trochanter of the femur
✓ Ischiogluteal bursa, superficial to the ischial tuberosity

o Check range of motion

✓ Flexion

✓ Extension

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 ✓ Abduction and adduction
✓ Internal and external rotation

▪ Knees
o Inspect
✓ Gait for knee extension at heel strike, flexion during all other
phases of swing and stance
✓ Alignment of knee
✓ Contours of knee
o Inspect and palpate
✓ Tibiofemoral joint with knee flexed
o Joint line
➢ Place thumbs on either side of patellar tendon
o Medial and lateral meniscus
o Medial and lateral collateral ligaments
✓ Patellofemoral compartment
o Check the patella
o Palpate the patellar tendon and ask patient to extend
the leg
o Press the patella against the underlying femur
o Push patella distally and ask patient to tighten knee
against table
✓ Suprapatellar pouch, infrapatellar spaces medial tibial condyle,
and popliteal surface
o Assess any effusion
✓ Bulge sign
o Compress the suprapatellar pouch, stroke downward on
medial surface, apply pressure to force fluid to lateral
surface, and then tap knee behind lateral margin of
patella

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 ✓ Balloon sign
o Compress suprapatellar pouch with one hand; with
thumb and finger of other hand, feel for fluid entering
the spaces next to the patella
✓ Ballotte the patella
o Push the patella sharply against the femur; watch for
fluid returning to the suprapatellar space.
o Assess the range of motion
✓ McMurray test: Medial meniscus and lateral meniscus
o With the patient supine, grasp the heel and flex the
knee. Cup your other hand over the knee joint with
fingers and thumb along the medial joint line. From the
heel, externally rotate the lower leg, then push on the
lateral side to apply a valgus stress on the medial side of
the joint. Slowly extend the lower leg in external
rotation

✓ Medial collateral ligament

o With knee slightly flexed, push medially against lateral
surface of knee with one hand and pull laterally at the
ankle with the other hand

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✓ Lateral collateral ligament
o With knee slightly flexed, push laterally along medial
surface of knee with one hand and pull medially at the
ankle with the other hand

✓ Anterior cruciate ligament

o With knee flexed, place thumbs on medial and lateral
joint line and place fingers on hamstring insertions. Pull
tibia forward, observe if tibia slides forward “like a
drawer.” Compare to opposite knee

o Lachmann test -Grasp the distal femur with one hand

and the proximal tibia with the other (place the thumb
on the joint line). Move the femur forward and the tibia
back.

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 ✓ Posterior cruciate ligament: Posterior drawer sign
o Position patient and hands as in the ACL test. Push the
tibia posteriorly and observe for posterior movement,
like a drawer sliding posteriorly

▪ Ankles and feet

o Inspect ankles and feet
o Palpate
✓ Ankle joint
✓ Ankle ligaments
o Medial-deltoid, lateral-anterior, posterior talofibular,
and calcaneofibular
✓ Achilles’ tendon
✓ Compress the metatarsophalangeal joins then palpate each
joint between the thumb and forefinger

o Assess range of motion

✓ Dorsiflex and plantar flex the ankle
✓ Stabilize the ankle and inert and evert the heel

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 ✓ Stabilize the heel and invert and evert the forefoot

✓ Move proximal phalanx of each toe up and down

Example: “Full range of motion in all joints. No evidence of swelling or deformity.”

• Nervous system exam

o Cranial nerves
✓ CN I (Olfactory)
o Test sense of smell
✓ CN II (Optic)
o Assess visual acuity
o Check visual fields inspect optic discs
✓ CN II, III (Optic and Oculomotor)
o Test pupillary reactions to light
✓ CN III, IV, VI (Oculomotor, trochlear, and abducens)
o Asses extraocular movements

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 ✓ CN V (Trigeminal)
o Test pain and light touch sensation on face
➢ Ophthalmic, maxillary, and mandibular zone
o Feel the contraction of temporal and masseter muscles
o Check for corneal reflex
✓ CN VII (Facial)
➢ Ask patient to raise both eyebrows, frown, close
eyes tightly, show teeth, smile, and puff out
cheeks
✓ CN VIII (Acoustic)
o Asses hearing of whispered voice
o If decreased:
➢ Weber’s test (lateralization)
➢ Rinne test (Compare air and bone conduction)
✓ CN IX, X (Glossopharyngeal and Vagus)
o Observe any difficulty in swallowing
o Listen to the voice
o Watch soft plate rise with “ah”
o Test gag reflex on each side
✓ CN XI (Spinal accessory)
o Trapezius muscle
➢ Assess muscles for bulk, involuntary
movements, and strength of shoulder shrug
o Sternomastoid muscle
➢ Assess strength as head turns against your hand
✓ CN XII (Hypoglossal)
✓ Listen to patient’s articulation
✓ Inspect the resting tongue
✓ Inspect the protruded tongue
o Motor system
✓ Body position
o Observe body position during movement and at rest
✓ Involuntary movements
o Observe location, quality, rate, rhythm, amplitude, and
setting
✓ Muscle bulk and tone
o Inspect muscle contours
o Assess resistance to passive stretch of arms and legs

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✓ Muscle strength
o Test and grade the major muscle groups

o Elbow flexion (C5, C6) - Biceps

o Elbow extension (C6, C7, C8) - Triceps
o Wrist extension (C6, C7, C8) – radial nerve
o Grip (C7, C8, T1)
o Finger abduction (C8, T1) – ulnar nerve

o Thumb opposition (C8, T1) – median nerve

o Trunk – flexion, extension, lateral bending

o Hip flexion (L2, L3, L4) – iliopsoas

o Hip extension (S1) – gluteus maximus

o Hip adduction (L2, L3, L4) - adductors
o Hip abduction (L4, L5, S1) – gluteus medius and minimus
o Knee extension (L2, L3, L4) – quadriceps
o Knee flexion (L4, L5, S1, S2) - hamstring

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 o Ankle dorsiflexion (L4, L5)
o Ankle plantar flexion (S1)
✓ Coordination
o Check rapid alternating movements in arms and legs
o Point-to-point movement s in arm and legs-finger to
nose, heel to shin
o Gait
➢ Ask patient to walk away, turn, and come back
➢ Walk hell to toe
➢ Walk on toes, then on heels
➢ Hop in place on each foot, do one-legged
shallow knee bends. Substitute rising form a
chair and climbing on stool for hops and bends
o Stance
➢ Romberg test
❖ Ask patient to stand with feet together
and eyes open, then close for 20-30
seconds
➢ Look for a pronator drifts as patient holds arm
forward, with eyes closed, for 20-30 seconds
➢ Ask patient to keep arms up and tap them
downward
o Sensory system
✓ Use an object like a broken cotton swab to test sharp and dull
sensation
✓ Compare symmetric areas on the two sides of the body.
✓ Compare proximal and distal areas of arms and legs for pain,
temperature, and touch sensation. Scatter stimuli to sample
most dermatomes and major peripheral nerves.
✓ Map for any abnormal response
✓ Assess response to the following stimuli with patient eyes
closed
o Pain.
➢ Use the sharp end of a pin or other suitable
tool. The dull end serves as a control.
o Temperature (if indicated).
➢ Use test tubes with hot and cold water, or other
objects of suit able temperature.
o Light touch.
➢ Use a fine wisp of cotton
✓ Check for vibration and position senses. If responses are
abnormal, test more proximally
o Vibration and position.

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 ➢ Vibration: Use a 128-Hz tuning fork, held on a
bony prominence. Vibration and position
senses, both carried in the posterior columns,
often correlate.
➢ Position. Holding patient’s finger or big toe by
its sides, move it up or down
✓ Assess discriminative sensations
o Stereognosis.
➢ Ask for identification of a common object
placed in patient’s hand.
o Number identification (graphesthesia)
➢ Draw a number on patient’s palm with blunt
end of a pen and ask the patient to identify the
number
o Two-point discrimination.
➢ Use two pins of the sides of a paper clip to find
minimal distance on pad of patient’s finger at
which two points can be distinguished (normally
<5 mm)
o Point localization.
➢ Touch skin briefly, and ask patient to open both
eyes and identify the place touched
o Extinction.
➢ Simultaneously touch opposite, corresponding
areas of the body; ask whether the patient feels
one touch or two.
o Reflexes

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o Cutaneous stimulation reflexes

o Special Techniques
✓ Meningeal Signs
o Brudzinski’s sign
➢ With patient supine, flex head and neck toward
chest. Note resistance or pain, and watch for
flexion of hips and knees
o Kernig’s sign
➢ Flex one of patient’s legs at hip and knee, then
straighten knee. Note resistance or pain

✓ Lumbosacral Radiculopathy
o Straight-leg raise
➢ With patient supine, raise relaxed and
straightened leg, flexing the leg at the hip. Then
dorsiflex the foot.

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 ✓ Asterixis.
o Ask patient to hold both arms forward, with hands
cocked up and fingers spread. Watch for 1 to 2 minutes.
✓ Winging of the Scapula
o Ask patient to push against the wall of your hand with a
partially straightened arm. Inspect scapula. It should
stay close to the chest wall

✓ The Stuporous or Comatose Patient

o Assess ABCs (airway, breathing, and circulation).
o Take pulse, blood pressure, and rectal temperature.
o Establish level of consciousness with escalating stimuli.
However, don’t dilate pupils, and don’t flex patient’s
neck if any suspicion of cervical cord injury
o Neurological examination
✓ Observe breathing pattern, pupils, and ocular movement
✓ Check for oculocephalic reflex (doll’s eye movements)
o Hold upper eyelids open, turn head quickly to each side,
and then flex and extend patient’s neck
o Note for posture

✓ Test for flaccid paralysis

o Hold forearms vertically; note wrist positions.
o From 12 to 18 inches above bed, drop each arm.
o Support both knees in a somewhat flexed position, and
then extend each knee and let leg drop to the bed.
o From a similar starting position, release both legs

Example: “Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and
time. Detailed cognitive testing deferred. Cranial Nerves: I—not tested; II through XII intact. Motor:

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Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar: Rapid alternating movements (RAMs),
finger-to-nose (F→N), heel-to-shin (H→ S) intact. Gait with nor mal base. Romberg—maintains balance
with eyes closed. No pronator drifts. Sensory: Pinprick, light touch, position, and vibration intact.
Reflexes: 2+ and symmetric with plantar reflexes down going.”

Biceps Triceps Brachial Knee Ankle PI

RT 2+ 2+ 2+ 2+ 2+
LT 2+ 2+ 2+ 2+ 2+

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