Richie’s Physical Diagnosis Checklist for Practical Exams

I wrote this for medical students who are undergoing their physical diagnosis class. Here is a checklist to follow to ace your practicals

First Greet Your Patient; assess general mental status and patient’s immediate condition.
Note any respiratory distress, cyanosis or facial expressions.

Vital Signs - (Blood Pressure Cuff)

___ Take radial pulse
___ Take Blood Pressure via palpation
___ Take Blood Pressure via auscultation
___ Note respiration rate and quality.
___ Take temperature/weight/height *** If Available***

***HEENT EXAM*** (patient sitting up, gauzepad or cotton ball)

Head

___ Inspect cranium (look for asymmetry, edema)
___ Inspect Scalp (Look for lesions, masses, bleeding)
___ Inspect/Palpate Hair (looking for hair quality indicative of hormone disorders)
___ Palpate Cranium (bleeding, fractures, and masses)
___ Inspect Face (note any bleeding, facial muscle weakness, lesions)
___ Auscultation for bruits in temporal area (ask patient to hold breath)

___ Have patient smile then frown
___ Have patient grit teeth and clench down
___ Have patient wrinkle their forehead
___ Have patient move face/neck against resistance bilaterally
___ Test sensation on 6 parts of face with cotton ball

Neck

___ Inspect both sides of neck (lesions, masses, weakness,etc..)
___ Inspect trachea, make sure it is midline.
___ Auscultate for carotid Bruits bilaterally (ask patient to hold breath)
___ Palpate both sides of neck for masses
___ Palpate Lymphnodes (Look for adenopathy in Occiptal, Poterior Auricular,
Posterior Triangle, Anterior Triangle, Submandibular, Sublingual, Submental
nodes)
___ Palpate Thyroid from anterior approach (Look for absence or enlargement)
___ Ask patient to breath in and

Eyes (Visual Acuity Card, Penlight, Ophthalmoscope)

___ Assess Visual Acuity using card in each eye (CN II)
___ Assess Visual Fields using fingers for each eye
___ Assess eye alignment with penlight by shining in reflective pupils
___ Test Extraocular motor function using diagnostic positions of gaze (CN III,IV,VI)
___ Check pupillary consensual response to light using penlight
___ Test for convergence by having patient follow your finger to nose
___ Inspect external eye structures (lift/depress to see conjunctiva)
___ Have patient keep eyes closed against resistance (test CN VII)
___ Perform Finger to Nose test
___ Fundoscopic examination with coaxial scope. (Remember, 30 degree angle, match
eye to scope hand. Look for diabetic retinopathy, abnormal cup/disc ratio,
Macular degeneration…)

Ears (Tuning Fork, Otoscope)

___ Inspect External Ear structure bilaterally (signs of otitis externa, mastoiditis..etc..)
___ Palpate External Ear Structures bilaterally
___ Evaluate auditory acuity using either tuning fork or whispering in each ear
___ Perform Weber/Rinne test if previous whisper test doesn’t work *** (optional)
___ Do otoscopic examination of both ears, being sure to straighten the ear canal.
(Note any TM bulging or retraction, TM injection, cerumen impaction or
inflammation of the external ear canal)

Nose (Otoscope)

___ Inspect the nose
___ Palpate the nasal skeleton
___ Palpate Frontal, Ethmoid and Maxillary sinuses
___ Using otoscope, shine light in nostrils and inspect nasal septum and turbinates
bilaterally (note any inflammation, discharge, swelling)

Mouth (Tongue Depressor, Gloves, Gauze Pad)

___ Inspect the inner surface and outer surface of lips and facial muscles of expression
(lesions, cyanosis, weakness, etc.)
___ Have patient open mouth and inspect Teeth using a tongue depressor.
___ Inspect Gingiva
___ Inspect Buccal mucosa
___ Inspect Stensen’s and Wharton’s Ducts bilaterally for blockages (stones)
___ Inspect Hard Palate
___ Inspect Soft Palate
___ Inspect Tongue
___ Have patient stick out tongue noting any deviation from midline (CN XII)
___ Inspect Floor of mouth by having patient raise tongue up.
___ Inspect Tonsils (if present)
___ Inspect Posterior Pharyngeal Wall( looking for sinus drainage, inflammation,
exudates)
___ Have patient open mouth and say “Ah” to test uvula and elevation of oropharynx
___ Test Gag Reflex by putting tongue depressor a smidge further back on tongue
___ With Gloved hands, pinch cheeks together (to keep patient from biting your finger)
and palpate the buccal mucosa, and floor of mouth (look for masses or bleeding)
___ With Gauze Pad, palpate the lateral margins of the tongue

CHEST EXAMS

Posterior Chest (Stethoscope)

___ Inspect the back on both sides
___ Auscultate back for breath sounds in 6 areas (note crackles,wheezes,etc..)
___ Evaluate Diaphragmatic Excursion using both hands
___ Palpate back for tactile fremitus
___ Percuss back bilaterally

Anterior Chest (Stethoscope)

___ Inspect chest bilaterally, noting abnormal movements or retractions
___ Note abnormalities, if any, in patient’s posture
___ Auscultate breath sounds in 4 places (L/R upper quadrant and subaxillary points)
___ Palpate PMI (point of maximal impulse)
___ Auscultate heart sounds in 5 areas (note any murmurs, ejection clicks, etc…)
___ Have patient lean forward, hold breath and Auscultate at cardiac base for murmur
___ Have patient lay on left side, Auscultate with bell cardiac apex

Abdomen Exam (Stethoscope)

___ Inspect Abdomen for abnormalities
___ Inspect for Hernias
___ Auscultate for bowel sounds
___ Auscultate for Renal, Iliac and Aortic bruits
___ Palpate Abdomen lightly in all four quadrants
___ Palpate Abdomen deeply in all four quadrants
___ Percuss out borders of liver and spleen
___ Test for rebound tenderness
___ Palpate the Liver
___ Palpate for the spleen
___ Palpate the abdominal aorta(it’s deep)
___ Test for fluid wave

Assess Pulses in Extremities

___ Carotid pulse
___ Radial Pulse
___ Dorsalis Pedis Pulse
___ Brachial Pulse

EXTREMITIES (reflex hammer, paperclip, coin)

Testing reflexes with reflex hammer

___ Biceps Reflex
___ Triceps Reflex
___ Brachioradialis Reflex
___ Patellar Reflex
___ Ankle Reflex

Shoulder

___ Inspect shoulder
___ Palpate shoulder joints bilaterally
___ Test Range of Motion of shoulders

Arms/ Elbows

___ Inspect both elbows
___ Inspect both arms
___ Test range of motion in elbows
___ Squeeze arms to assess muscular tone
___ Test muscle strength of arms against resistance both ways

Wrist and Hands (Cotton, paper clip, tuning fork, coin)

___ Inspect both hands and wrists
___ Inspect nails
___ Palpate Interphalangeal Joints
___ Palpate Metacarpophalangeal Joints
___ Test light touch with cotton
___ Test vibration sense on bone prominences with tuning fork
___ Test proprioception by moving pt’s finger up and down with eyes shut
___ Test Two point discrimination
___ Assess Rapid alternating movements with fingers
___ Test Finger and wrist strength against resistance

Hips

___ Inspect Hips
___ Test Range of motion

Thigh/Legs

___ Inspect Legs
___ Assess muscle tone in leg muscles
___ Have patient slide foot down shin to assess cerebellar function

Knees

___ Inspect both sides of both knees
___ Palpate Knees
___ Palpate Patella on both sides
___ Test Range of Motion in knees
___ Test leg strength against resistance both ways

Feet/Ankles

___ Inspect Feet and Ankles
___ Test Range of Motion in Feet and ankles
___ Palpate the Achilles tendon
___ Palpate Metatarsals both sides
___ Palpate Metatarsophalangeal joints on both sides
___ Palpate Ankle joints bilaterally
___ Test light touch on both feet
___ Test Vibration sense with tuning fork bilaterally
___ Test proprioception moving toe up and down
___ Test foot strength against resistance bilaterally.

Gait Analysis (have patient stand)

___ Inspect Spine
___ Palpate Spine
___ Have patient bend down and then slowly raise up for scoliosis screen
___ Have patient walk normally across room
___ Have patient walk on heels
___ Have patient walk on toes
___ Do Romberg test to evaluate if patient falls over with eyes closed.

Tell patient how patient they are and then smile for the camera because you are DONE!