Combined Head-to-Toe Physical Examination

01 Introduction & Preparation

Merged from four sheets — General Survey, Neurological, MSK, and Abdominal all open with the same block. Run it once.

• 1Introduces self to patient — includes first and last name
• 2Identifies the patient with two patient identifiers (name and DOB)
• 3Explains purpose of examination
• 4Asks patient if he/she emptied his/her bladder prior to examinationAbdominal sheet only — but harmless to include in every run-through.
• 5Asks patient to undress for proper visualization (shirt, shoes, socks)
• 6Student verbalizes they would ensure proper lighting
• 7Verbalizes and/or demonstrates washing of the hands prior to examination
• 8Demonstrates professionalism throughout the examinationGraded continuously; also appears at the close.

02 General Survey

General Survey / Vital Signs sheet.

• 9Inspects for general health status, body habitus, physical deformities
• 10Inspects facial expression and observes for signs of distress
• 11Inspects if stated age matches apparent age
• 12Inspects grooming and hygiene

03 Level of Consciousness & Orientation

The General Survey sheet names these in one line; the Neurological sheet grades the full definitions. The Neuro version is used here — it satisfies both.

• 13Verbalizes intent to evaluate level of consciousness"I will evaluate the patient for the following levels of consciousness."
• 14Verbalizes and defines each LOC level, then selects the appropriate oneAlert — opens eyes, responds fully and appropriately to stimuli · Lethargic — opens eyes to loud voice, back to sleep after appropriately answering questions · Obtunded — eyes open to tactile stimulus, slow and confused responses · Stupor — responds only to painful/noxious stimulus · Coma — unconscious
• 15Verbalizes intent to evaluate orientation"I will evaluate the patient for the following levels of orientation."
• 16Verbalizes questions for person, place, time, and event = AOx4
• 17Verbalizes and defines each orientation level, then selects the appropriate oneOriented — answers all questions correctly · Confused — one or more answers incorrect · Inappropriate — manner of response is inappropriate · Incomprehensible — mumbling or moaning, speech cannot be understood · Coma — non-responsive

04 Vital Signs

General Survey / Vital Signs sheet. The full peripheral pulse set has been moved down to §17 so pulses are palpated once.

Height, weight, temperature

• 18Verbalizes they would obtain height, weight, and calculate BMI
• 19Verbalizes they would obtain a temperature and pulse oximetry

Heart rate

• 20Locates the radial artery to check the heart rate
• 21Assesses pulse with the pads of the index and middle fingers
• 22Verbalizes the calculation used to assess the pulse — must verbalize 30 seconds × 2

Respiratory rate

• 23Ensures adequate exposure of the chest
• 24Maintains position as if counting pulse rate
• 25Verbalizes the calculation used to assess the respiratory rate

Blood pressure

• 26Positions patient properly — seated, back supported, feet on floor, legs uncrossed
• 27Assesses for appropriate cuff size — must verbalize
• 28Locates the brachial artery
• 29Properly positions BP cuff 2.5 cm above antecubital fossa, artery line properly placed
• 30Supports the arm with the brachial artery at or slightly above heart level
• 31Determines the palpable radial pulse obliteration pressure and verbalizes the readingInflate while palpating the radial artery until the pulse is no longer palpable.
• 32Deflates cuff completely and waits 15–30 seconds
• 33Re-inflates cuff to 30 mmHg above palpable systolic pressure
• 34Assesses for onset of Korotkoff sounds to determine systolic blood pressure
• 35Deflates cuff slowly
• 36Assesses for cessation of Korotkoff sounds to determine diastolic blood pressure
• 37Repeats measurement on the opposite arm
• 38Verbalizes that if orthostatic measurement were indicated, they would also assess blood pressure supine and standing, waiting 1–3 minutes between positions

05 Skin, Hair & Nails

Skin, Hair and Nails sheet. This is itself a top-down sweep, so it stays intact and sits here — before you start working region by region. Items that also appear on HENT, Eye, Lung, or Peripheral Vascular sheets are tagged; perform them once, here.

• 39also HENTInspects and palpates the hair and scalp — must part hair in multiple locations"I am inspecting the hair for color, distribution and quantity. I am inspecting the scalp for hygiene, lesions, dandruff, nits or lice. I am palpating the hair for texture…"
• 40also EyeInspects the eyebrows and eyelashes for color, distribution and quantity
• 41also HENTInspects the skin of the head, face and neck
• 42Inspects the upper back
• 43Inspects the shoulders, axillae, and upper extremities
• 44Inspects the hands and fingers — all surfaces and between digits
• 45also Lungs · PVInspects and palpates the fingernailsCovers the lung sheet's "nail beds for cyanosis and clubbing" and the PV sheet's "inspect the nail beds."
• 46Inspects the chest
• 47Inspects the abdomen
• 48Inspects the anterior, medial and lateral thighs and lower legs
• 49Inspects the feet and toes — all surfaces and between digits
• 50Inspects and palpates the toenails
• 51Inspects the lower back and posterior legs
• 52Verbalizes examination of the buttocks, breasts, and genitalia"For a full-body examination, the buttocks, breasts, and genitalia would also be assessed."
• 53Palpates skin temperature using the dorsal surface of the hands, bilaterally over upper and lower extremities, anterior and posterior"I am palpating the skin for temperature and evaluating for symmetry in the extremities."
• 54Palpates skin for texture, mobility and turgor, bilaterally over upper and lower extremities, anterior and posterior"I am palpating the skin to assess texture, mobility and turgor."

06 Head, Face & Scalp CN V · VII

HENT sheet, with CN V trigeminal and CN VII facial testing from the Neurological sheet folded in — masseter, temporalis, facial sensation and facial expression all belong to the face exam.

• 55Inspects face for symmetry, edema, masses, and hair growth"I am inspecting the face for symmetry, edema, masses, or hair growth."
• 56Inspects head for position, size, shape, symmetry, contour, and deformity"I am inspecting the head/skull for position, size, shape, symmetry, contour, or deformity."
• 57done at 39Palpates hair texture — restate here if HENT is being graded separately"I am palpating the hair for texture."
• 58Palpates the scalp for mobility, tenderness and masses"I am palpating the scalp for mobility, tenderness or masses."
• 59Palpates the parotid glands bilaterally for tenderness and edema"I am palpating the parotid glands for tenderness or edema."

Cranial nerve V — Trigeminal

• 60CN VCorrectly states cranial nerve number and name — V, Trigeminal
• 61Asks patient to clench teeth while palpating the temporalis muscle
• 62Asks patient to clench teeth while palpating the masseter muscle
• 63Tests light touch with a cotton ball over all three divisions and names each — V1 ophthalmic, V2 maxillary, V3 mandibular

Cranial nerve VII — Facial

• 64CN VIICorrectly states cranial nerve number and name — VII, Facial
• 65Assesses for facial asymmetryPairs with item 55 — you are already looking at the face.
• 66Instructs patient to raise both eyebrows — resistance not required
• 67Instructs patient to close eyes, then keep eyes closed against resistance
• 68Asks and observes patient to smile and show teeth
• 69Instructs patient to puff out cheeks, then percusses cheeks lightly

07 Eyes CN II · III · IV · VI

Eye sheet, with the CN II, III, IV and VI naming and verbalizations placed at the maneuver that tests them. All techniques bilateral.

• 70Inspects the eyebrows, eyelashes and eyelids — symmetry, erythema, lesions"I am inspecting the eyebrows, eyelashes, and eyelids noting any asymmetry, erythema, or lesions."
• 71Inspects the eyelids for position and closure"I am inspecting the eyelids for position and closure."
• 72Inspects the area over the lacrimal apparatus for edema and lesions"I am inspecting over the lacrimal apparatus for edema and lesions."
• 73Palpates the area over the lacrimal apparatus for tenderness"I am palpating over the lacrimal apparatus for tenderness."
• 74Inspects the bulbar and palpebral conjunctivae — injection, lesions"I am inspecting the bulbar and palpebral conjunctivae, noting any areas of injection or lesions."
• 75Inspects the sclera — color, injection, or blood"I am inspecting the sclera for color, injection, or blood."

Cranial nerve II — Optic

• 76CN IICorrectly states cranial nerve number and name — II, Optic
• 77Verbalizes the four tests for this nerve"To evaluate cranial nerve II, I would test the following: visual acuity, pupillary light reflex, visual fields, and the ophthalmoscopic exam."
• 78Tests visual acuity of each eye using an eye chart — one at a time, then togetherMust be done before shining any light into the eyes.
• 79Verbalizes that vision is tested with and without corrective lenses if used by the patient"I would test the patient's vision with and without corrective lenses if present."
• 80Measures pupil size and inspects for symmetry"I am measuring pupil size and inspecting for symmetry."
• 81Tests visual fields by confrontation — monocular technique, standing level with the patient, 4 points per eye. Do not rush.

• 82Tests corneal light reflex — penlight held at midline, 2 feet away"I am assessing the corneal light reflex for symmetry."

Cranial nerves III, IV and VI — Oculomotor, Trochlear, Abducens

• 83CN III · IV · VICorrectly states cranial nerve numbers and names — III Oculomotor, IV Trochlear, VI Abducens
• 84Verbalizes the test for these three nerves"I would test extraocular movements in the six cardinal gazes to evaluate cranial nerves III, IV, and VI."
• 85Tests extraocular movements in the six cardinal directions of gaze (H pattern), pausing at extreme gazes to check for nystagmus

• 86Tests convergence by moving an object toward the bridge of the nose
• 87Uses oblique lighting to inspect the cornea and lens for opacities and assess anterior chamber depth"I will use oblique lighting to inspect the cornea and lens for opacities, and assess the depth of the anterior chamber — noting any crescent shadows in the medial aspects."
• 88CN II · IIITests direct and consensual pupillary light reaction — places hand over the bridge of the nose to block light
• 89CN IIIVerbalizes that pupillary constriction for CN III was tested with the pupillary light reflex and examined for PERRL

Fundoscopic exam — completes CN II

• 90Verbalizes proper lighting"I would dim the room light before fundoscopic examination."
• 91Adjusts light beam and diopter setting before beginning examination
• 92Uses right hand and right eye for the patient's right eye; left hand and left eye for the left eye
• 93Assesses the eye for the presence of red reflex
• 94Assesses retina — moves into proper position and verbalizes the structures observed, adjusting the diopter wheel to focus"I am assessing the optic disc and margins; the cup to disc ratio; the retinal arteries and veins; and the condition of the retina."
• 95Assesses fovea and macula — asks the patient to look into the light"I am assessing the fovea and macula."
• 96Assesses anterior structures before backing away from the patient"I am adjusting the diopter to focus on the anterior structures."

08 Ears CN VIII

HENT sheet with CN VIII vestibulocochlear folded in — the whisper test appears on both sheets and is performed once, here.

• 97Inspects the auricle for deformities, discharge, and lesions"I am inspecting the auricle for deformities, discharge, or lesions."
• 98Palpates the auricle, tragus, and mastoid for tenderness"I am palpating the auricle, tragus, or mastoid for tenderness."

Otoscopic exam — bilateral

• 99Chooses appropriate size speculum for the patient
• 100Pulls auricle upward, outward, and back to straighten the ear canal
• 101Verbalizes structures assessed in the ear canal"I am noting the condition of the external canal, noting the amount of cerumen, the presence of any inflammation, edema, or foreign bodies."
• 102Notes the color and contour of the tympanic membrane"I am noting the color and contour of the tympanic membrane as 'pearly gray.'"
• 103Identifies the light reflex and landmarks of the tympanic membrane"I am visualizing the landmarks of the tympanic membrane including malleus, umbo, pars tensa, pars flaccida and the light reflex (cone of light)."

Cranial nerve VIII — Vestibulocochlear

• 104CN VIIICorrectly states cranial nerve number and name — VIII, Vestibulocochlear
• 105Verbalizes intent to assess for patent ear canals first, with an otoscopeAlready done at items 99–103 — say it out loud here so the CN VIII sequence is complete.
• 106Performs the whispered hearing test bilaterally while standing two feet away
• 107Verbalizes the follow-up if the gross hearing test is abnormal"If this test was abnormal, I would perform a Rinne and Weber test for bone vs. air conduction."
• 108Verbalizes that vestibular function is assessed during the Romberg testRomberg itself is performed later, at item 390 — this is just the attribution.

09 Nose & Sinuses CN I

HENT sheet with CN I olfactory folded in — both sheets test nasal patency, so it happens once. Do the CN I scent testing while you already have the patient occluding nostrils.

• 109Inspects the nose for deformities"I am inspecting the nose for deformities."

Cranial nerve I — Olfactory

• 110CN ICorrectly states cranial nerve number and name — I, Olfactory
• 111Evaluates nasal patency bilaterally — occludes one nostril and has the patient sniff through the other
• 112Asks patient to close eyes and occludes the nostril not being tested
• 113Tests one nostril at a time using one scent for each nostril

• 114Palpates the nose for tenderness
• 115Uses otoscope with appropriate size speculum to inspect the nares"I am inspecting the condition of the nasal mucosa, the turbinates for polyps, and the nasal septum for septal deviation or perforations."
• 116Palpates the frontal and maxillary sinuses

10 Oral Cavity & Pharynx CN IX · X · XII

HENT sheet with CN IX glossopharyngeal, CN X vagus and CN XII hypoglossal folded in. The gag reflex, "say AHH" and tongue testing are done here, once, with the nerve named as you do them.

• 117Uses penlight and tongue depressor for the examination, and gloves for palpating the tongue
• 118Inspects the nasolabial fold, lips, buccal mucosa, gingiva, floor of mouth, and teeth"I am inspecting the nasolabial fold, lips, buccal mucosa, gingiva, floor of mouth, and teeth."
• 119Inspects Wharton's and Stensen's ductsHeads up — the HENT sheet labels these the other way around. Standard anatomy: Stensen's = parotid duct (opposite the upper 2nd molar), Wharton's = submandibular duct (floor of mouth). Verbalize whichever pairing your facilitator is grading.
• 120Notes inflammation, lesions, and condition of dentition"I am noting any inflammation or lesions and condition of dentition."
• 121Inspects the palate and oropharynx for inflammation and lesions"I am inspecting the palate and oropharynx for inflammation or lesions."
• 122Inspects the posterior pharynx, noting the condition of the tonsils"I am inspecting the posterior pharynx noting the condition of the tonsils."

Cranial nerves IX and X — Glossopharyngeal and Vagus

• 123CN IX · XCorrectly states cranial nerve numbers and names — IX Glossopharyngeal, X Vagus
• 124Asks the patient to "say AHH" while observing and listening"I am noting the phonation and symmetrical rise and fall of the soft palate and uvula."
• 125Verbalizes performance of the gag reflexYou have the tongue depressor in hand from item 117 — this is its natural moment.
• 126Observes the patient swallow — mouth need not be open, but watch the anterior neck"I am observing the patient swallow and watching the anterior neck, which evaluates cranial nerve X, the vagus."

Cranial nerve XII — Hypoglossal

• 127CN XIICorrectly states cranial nerve number and name — XII, Hypoglossal
• 128Asks the patient to "stick out tongue" and notes color, texture, and whether it is midline"I am noting the color and texture of the tongue and assessing if it is midline."
• 129Asks the patient to move the tongue side to side, then push against the inside of each cheek while palpating externally for strength — evaluates symmetry, deviation, atrophy, and fasciculations

• 130Uses gauze to hold the tongue and palpates all sides for induration and masses with the opposite gloved hand

11 Neck CN XI

HENT sheet with CN XI spinal accessory folded in — trapezius and sternocleidomastoid are neck muscles, and your hands are already there.

• 131also CardiacInspects the anterior neck for masses, asymmetry, thyromegaly, or jugular vein distention"I am inspecting the anterior neck for masses, asymmetry, thyromegaly, or jugular vein distention."
• 132Inspects and palpates the position of the trachea"I am inspecting and palpating the position of the trachea."
• 133Inspects the area over the thyroid gland and isthmus for edema and masses — asks patient to swallow while observing anteriorly"I am inspecting the area over the thyroid gland and isthmus for edema and masses."
• 134Stands facing the patient and palpates the isthmus and each thyroid lobe for size, shape and consistency
• 135Stands behind the patient and palpates the isthmus and each thyroid lobe, displacing the trachea laterally to reach each lobe
• 136Asks the patient to swallow while palpating the thyroid isthmus from behind

Cranial nerve XI — Spinal Accessory

• 137CN XICorrectly states cranial nerve number and name — XI, Spinal Accessory
• 138Tests strength of the trapezius and sternocleidomastoid muscles bilaterally against resistanceYou are already standing behind the patient from item 135.

12 Lymph Nodes — Head & Neck

HENT sheet. Epitrochlear and inguinal nodes are on the Peripheral Vascular sheet and are palpated later, at §16.

• 139Verbalizes the names of the lymph nodes as they are palpated
• 140Palpates lymph nodes using the pads of the fingers in a circular motion
• 141Preauricular
• 142Posterior auricular
• 143Occipital
• 144Tonsillar
• 145Submandibular
• 146Submental
• 147Superficial cervical chain
• 148Posterior cervical chain
• 149Deep cervical chain — one side at a time, displacing the sternocleidomastoid muscle
• 150Supraclavicular — ask the patient to take a deep breath during palpation

13 Thorax & Lungs

Lungs and Thorax sheet. Performed seated, before you recline the patient for the cardiac exam.

Inspection

• 151Inspects for the shape and movement of the thorax and any unilateral lag in movement
• 152Inspects for rate, rhythm, and effort of respiration
• 153Inspects for deformities, asymmetry, abnormal retractions, lesions, and areas of ecchymosis
• 154Inspects for use of accessory muscles
• 155Inspects lips for cyanosis
• 156done at 45Inspects bilateral nail beds for cyanosis and clubbing
• 157Inspects anterior-posterior (AP) diameter

Palpation

• 158Palpates posterior chest wall for tenderness or deformities
• 159Palpates lateral chest wall for tenderness or deformities
• 160Palpates anterior chest wall for tenderness or deformities
• 161Palpates thoracic expansion for symmetry of respiratory effort — posteriorly
• 162Palpates tactile fremitus bilaterally — posteriorly, laterally, and anteriorly

Percussion

• 163Percusses posterior chest wall, alternating sides
• 164Percusses lateral chest wall, alternating sides
• 165Percusses upper lobes, anterior chest wall, alternating sides
• 166Measures diaphragmatic excursion in centimeters (4–6 cm)Distance between the level of dullness on full expiration and on full inspiration.

Auscultation

• 167Asks patient to breathe through the mouth during auscultation
• 168Asks the patient to cross arms for the posterior examination
• 169Verbalizes and demonstrates performing one full cycle of inhalation and expiration at each point
• 170Auscultates posterior chest wall, alternating sides bilaterally in a ladder pattern
• 171Auscultates lateral chest wall, alternating sides bilaterally in a ladder pattern
• 172Auscultates upper lobes, anterior chest wall, alternating sides bilaterally in a ladder pattern
• 173Verbalizes whether breath sounds are appropriate for the area auscultated — vesicular, bronchovesicular, bronchial, tracheal
• 174Verbalizes listening for crackles, rhonchi, wheezes, and pleural rubs
• 175Verbalizes the follow-up if adventitious sounds are present"I will perform one of three tests, egophony, bronchophony, and/or whispered pectoriloquy."

14 Cardiovascular

Cardiovascular sheet. Its introduction and hand-hygiene items were folded into §1; the jugular/carotid inspection overlaps §11.

• 176Places the patient supine with the head elevated 30 degrees
• 177Stands on the correct side of the patient for handedness
• 178Obtains appropriate history questions and interprets vitals
• 179also §11Visualizes/identifies the carotid and jugular pulses

Inspection

• 180Inspects the precordium for abnormal wall motion and apical impulse using tangential lighting

Carotid pulse

• 181Inspects the carotid pulses in the neckIndication: carotid upstroke, its amplitude and contour, and the presence of thrills.
• 182Asks the patient to hold their breath for ten seconds; auscultates the carotids with the diaphragm and bell
• 183With the head of the bed still at 30°, palpates each carotid artery in the lower one-third of the neck using index and middle fingers — bilaterally, one carotid at a time

Palpation of the precordium for heaves and lifts — finger pads

• 1842nd intercostal space, right sternal border — Aortic
• 1852nd intercostal space, left sternal border — Pulmonic
• 1863rd intercostal space, left sternal border — Erb's point
• 1874th intercostal space, left sternal border — Tricuspid
• 1885th intercostal space, left midclavicular line — Mitral
• 189Notes the size and intensity of the apical impulse by palpation, using the palmar surface of several fingers — should be described as a light tap
• 190Notes the location of the point of maximal impulse (PMI)

Palpation of the precordium for thrills — ball of the hand

• 1912nd ICS, right sternal border — Aortic
• 1922nd ICS, left sternal border — Pulmonic
• 1933rd ICS, left sternal border — Erb's point
• 1944th ICS, left sternal border — Tricuspid
• 1955th ICS, left midclavicular line — Mitral

Auscultation of the precordium — diaphragm and bell

• 1962nd ICS, right sternal border — Aortic
• 1972nd ICS, left sternal border — Pulmonic
• 1983rd ICS, left sternal border — Erb's point
• 1994th ICS, left sternal border — Tricuspid
• 2005th ICS, left midclavicular line — Mitral
• 201Verbalizes what is being listened for — rate, rhythm, intensities of S1 and S2, systole, diastole, any extra sounds, any murmurs

15 Abdomen

Abdominal sheet. Its nine-item introduction was folded into §1; the two positioning items remain here because they are abdomen-specific.

• 202Places patient supine, knees flexed, arms at sides or across chest
• 203Verbalizes they would expose the patient from xiphoid to symphysis pubis

Inspection

• 204Inspects the abdomen — striae, rash, dilated veins, telangiectasia
• 205Inspection performed prior to auscultation, percussion, and palpation

Auscultation

• 206Auscultates in all 4 quadrants for 1 minute
• 207Verbalizes the follow-up for absent bowel sounds"If bowel sounds are absent in a quadrant, then I will auscultate for 3–5 minutes in that quadrant."
• 208Bruits with the diaphragm — abdominal aorta
• 209Bruits with the diaphragm — renal arteries, bilaterally
• 210Bruits with the diaphragm — iliac arteries, bilaterally
• 211Bruits with the diaphragm — femoral arteries, bilaterallyCredit given if the student verbalizes "under clothing" but performs over clothing.
• 212Bruits with the bell, checking for low-pitched bruits — abdominal aorta
• 213Bruits with the bell — renal arteries, bilaterally
• 214Bruits with the bell — iliac arteries, bilaterally
• 215Bruits with the bell — femoral arteries, bilaterally
• 216Auscultates before palpation or percussion

Percussion

• 217Observes and notes the patient's facial expression during percussion
• 218Leaves the tender or painful area for last
• 219Percusses 4 quadrants "for tympany or dullness"
• 220Percusses liver span at the midclavicular line
• 221Measures liver span in centimeters — 6–12 cm at the MCL
• 222Percusses the spleen — Traube's space or the splenic percussion sign; choose one
• 223Percusses before palpation

Palpation

• 224Observes and notes the patient's facial expression during palpation
• 225Palpates lightly in 4 quadrants (1 cm)
• 226Palpates deeply in 4 quadrants (3–4 cm)
• 227Palpates the liver edge as the patient breathes in, or uses the hooking technique; choose one
• 228Palpates for the spleen
• 229Palpates the size of the abdominal aorta and states it should be less than 3.0 cm wide
• 230also §17Palpates for inguinal nodesThe PV sheet grades vertical and horizontal inguinal chains separately — see items 248–249. Palpate once.
• 231Attempts to palpate the right kidney using the capture technique
• 232Attempts to palpate the left kidney using the capture technique from the patient's left side
• 233Assesses CVA tenderness, bilaterally

16 Peripheral Vascular

Peripheral Vascular sheet, with the carotid, ulnar, brachial and radial pulses from the Vital Signs sheet's "complete peripheral vascular exam" line merged in so the full set is in one place.

Inspection

• 234Inspects for size, symmetry, and edema of the extremitiesIndication for 234–238: size, symmetry, swelling, venous pattern, skin color, skin texture, temperature of feet and legs, hair growth, ulcerations, and nail beds — upper and lower extremities.
• 235Inspects for venous pattern and hair growth
• 236Inspects skin color for erythema, cyanosis, and jaundice
• 237Inspects for pigmentation changes and ulcerations
• 238done at 45Inspects the nail beds

Pulses — bilaterally, assessing amplitude, rate, rhythm and quality

• 239done at 183CarotidPalpated during the cardiac exam — one side at a time.
• 240Brachial
• 241done at 20Radial
• 242from Vitals sheetUlnar
• 243Femoral
• 244Popliteal
• 245Posterior tibialis
• 246Dorsalis pedis

Lymph nodes — bilaterally

• 247Epitrochlear
• 248Vertical inguinal
• 249Horizontal inguinal

Capillary refill — bilaterally

• 250Palpates the nail beds of the upper extremities for capillary refill
• 251Palpates the nail beds of the lower extremities for capillary refill
• 252Notes that color typically returns within 2–3 seconds

17 Musculoskeletal

MSK checksheet. Its six-item introduction was folded into §1. This sheet is already a top-down joint sequence, so it runs intact.

• 253Inspection — verbalizes an introductory phrase before or during the examination"For every joint, I will be inspecting for symmetry, signs of inflammation, deformities or malalignment of bones, conditions of surrounding tissues, bony landmarks, and ease of range of motion."
• 254Palpation — verbalizes an introductory phrase before or during the examination"For every joint, I will be palpating for clicking, popping, tenderness, symmetry, signs of inflammation, deformities or malalignment of bones, conditions of surrounding tissues and muscles, and ease of range of motion."

Temporomandibular joint

• 255Inspects the TMJ — sitting or standing
• 256Palpates the TMJ during range of motion
• 257Has the patient open and close the jaw
• 258Has the patient perform protrusion and retraction
• 259Has the patient perform lateral movement, right and left, bilaterally

Cervical spine

• 260Inspects the cervical spine, paravertebral muscles, trapezius, shoulder posture and scapular position from posterior and from the lateral sides, patient standing
• 261Palpates the cervical spine, paravertebral muscles, trapezius and spinous processes from the posterior
• 262ROM — flexion
• 263ROM — hyperextension
• 264ROM — lateral bending, right and left
• 265ROM — rotation, right and left

Thoracic and lumbar spine

• 266Inspects the pelvis from posterior and from the right or left side for symmetry of the iliac crests and posterior superior iliac spines, patient standing
• 267Inspects the thoracic and lumbar spine from the posterior and from the right or left side
• 268Palpates the thoracic and lumbar spinous processes, paraspinal muscles, and lumbosacral junction from the posterior
• 269ROM — flexion
• 270ROM — hyperextension
• 271ROM — lateral bending, right and left
• 272ROM — rotation, right and left

Shoulder

• 273Inspects the shoulders bilaterally — standing or sitting
• 274Locates and palpates the sternoclavicular joint, bilaterally
• 275Locates and palpates the clavicle, bilaterally
• 276Locates and palpates the acromioclavicular joint, bilaterally
• 277Locates and palpates the coracoid process, bilaterally
• 278Locates and palpates the greater tubercle of the humerus, bilaterally
• 279Locates and palpates the bicipital groove and tendon, bilaterally
• 280ROM — flexion
• 281ROM — extension
• 282ROM — abduction
• 283ROM — adduction
• 284ROM — internal rotation
• 285ROM — external rotation

Elbow

• 286Inspects the elbow in flexion at 70°, supported by your hand, bilaterally
• 287Palpates the elbows, bilaterally
• 288Palpates the olecranon processes, medial epicondyles, and lateral epicondyles, bilaterally
• 289Palpates the biceps brachii, triceps brachii, and ulnar nerves, bilaterally
• 290ROM — flexion
• 291ROM — extension
• 292ROM — pronation, elbow isolated and flexed to 90°Hold the arm to the side supporting one at a time, or pin the elbow to the waist.
• 293ROM — supination, elbow isolated and flexed to 90°

Wrists, hands and fingers

• 294Inspects the dorsal and ventral aspects of the wrists, bilaterally
• 295Palpates the distal radius, distal ulna, radial styloid, and ulnar styloid, bilaterally
• 296Inspects the dorsal and palmar aspects of the hands, bilaterally
• 297Palpates the carpals, metacarpals, MCP joints, IP joints, PIP joints and DIP joints on the dorsal and palmar aspects, bilaterally
• 298Wrist ROM — flexion
• 299Wrist ROM — extension
• 300Wrist ROM — radial deviation
• 301Wrist ROM — ulnar deviation
• 302Finger flexion — patient makes a fist with the thumb across the knuckles
• 303Finger extension — patient opens the fist
• 304Finger abduction — patient spreads the fingers apart
• 305Finger adduction — patient brings the fingers back together
• 306Thumb flexion — thumb across the palm to the base of the 5th fingerCredit if combined with finger flexion, but only if the thumb is across the fist.
• 307Thumb extension — thumb away from the fingers, farthest from the 5th digitCredit if combined with finger extension, but only if the thumb is farthest from the 5th digit.
• 308Thumb abduction — thumb moves anteriorly away from the palm, hand neutral and palm up
• 309Thumb adduction — thumb returns from abduction
• 310Thumb opposition — thumb to the tip of the 5th digit

Hip

• 311Inspects the anterior hip joint, bilaterally — supine or standingPosterior and lateral views were completed with the spine exam.
• 312Palpates the iliac crest, bilaterally
• 313Palpates the anterior superior iliac spine, bilaterally
• 314Palpates the sacroiliac joints, bilaterally
• 315Palpates the greater trochanter, bilaterally
• 316ROM — flexionSupine preferred; may be combined with knee flexion while standing after lumbar ROM, with support.
• 317ROM — extension, standing or lateral decubitus
• 318ROM — adduction, supine (or actively standing with support)
• 319ROM — abduction, supine (or actively standing with support)
• 320ROM — internal rotation, supine
• 321ROM — external rotation, supine

Knee

• 322Inspects the knee in flexion and extension, bilaterally — supine or seated
• 323Palpates the patella and patellar tendon, bilaterally, with the knee in extension
• 324Palpates the medial and lateral condyles, bilaterally
• 325Palpates the tibial tuberosity, bilaterally
• 326Palpates the medial and lateral tibial plateaus and the medial and lateral joint lines, bilaterally, knee flexed
• 327ROM — flexion, supine or standing with hip flexion
• 328ROM — extension, supine or seated

Ankles, feet and toes

• 329Inspects the dorsal and ventral aspects of the ankles, bilaterally
• 330Inspects the dorsal and plantar aspects of the feet, bilaterally
• 331Palpates the anterior talofibular, calcaneofibular, and posterior talofibular ligaments, bilaterally
• 332Palpates the Achilles tendon, bilaterally
• 333Palpates the medial and lateral malleoli, bilaterally
• 334Palpates the tarsals, tarsometatarsal joints, metatarsals, interphalangeal joints and metatarsophalangeal joints, bilaterally
• 335ROM — dorsiflexion, stabilizing the leg
• 336ROM — plantarflexion, stabilizing the leg
• 337ROM — inversion, stabilizing the leg
• 338ROM — eversion, stabilizing the leg
• 339ROM — flexion of toes, stabilizing the ankle
• 340ROM — extension of toes, stabilizing the ankle

18 Motor & Muscle Strength

Neurological sheet. Every strength item is shaded — the sheet requires you to verbalize the motion and its nerve roots while providing resistance. Muscles are listed for reference only and do not need to be verbalized.

• 341Inspects upper and lower extremities for muscle bulk
• 342Examines muscle tone (baseline muscle tension) — cursory passive ROM of all four extremities; may stand for the upper extremities
• 343Verbalizes the 0–5 muscle strength scale, defining each grade, then selects the appropriate one0 no muscular contraction detected · 1 barely detectable flicker or trace of contraction · 2 active movement 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 (normal)

Cervical spine innervation C5–T1

• 344Shoulder abduction — C5, C6 deltoid
• 345Shoulder adduction — C5–T1 pectoralis major
• 346Elbow flexion — C5, C6 biceps brachii, brachioradialis
• 347Elbow extension — C6, C7, C8 triceps brachii
• 348Wrist extension — C6, C7, C8 extensor carpi radialis longus and brevis, extensor carpi ulnaris
• 349Wrist flexion — C6, C7, C8 flexor carpi radialis, flexor carpi ulnaris
• 350Hand grip strength — C7, C8, T1
• 351Opposition of thumb — C8, T1
• 352Finger abduction — C8, T1 first dorsal interosseous, abductor digiti minimi

Lumbar spine innervation L2–S1

• 353Hip abduction — L4, L5, S1 gluteus medius and minimus
• 354Hip adduction — L2, L3, L4 adductors
• 355Hip flexion — L2, L3, L4 iliopsoas; if seated, do not hold the table
• 356Hip extension — S1 gluteus maximus; if seated, do not hold the table
• 357Knee flexion — L5, S1, S2 hamstrings
• 358Knee extension — L2, L3, L4 quadriceps
• 359Ankle dorsiflexion — L4, L5 tibialis anterior
• 360Ankle plantar flexion — S1 gastrocnemius and soleus

19 Reflexes

Neurological sheet. You must name the reflex and its nerve roots aloud for each.

• 361Verbalizes the reflex grading scale, defining each grade4+ very brisk, hyperactive, with clonus · 3+ brisker than average, possibly but not necessarily indicative of disease · 2+ average, normal · 1+ somewhat diminished, low normal · 0 no response
• 362Biceps reflex — C5, C6 — bilaterally
• 363Triceps reflex — C6, C7 — bilaterally
• 364Brachioradialis reflex — C5, C6 — bilaterally
• 365Patellar reflex — L2, L3, L4 — bilaterally
• 366Ankle reflex — S1 — bilaterally
• 367Abdominal reflexes — T8, T9, T10 above the umbilicus; T10, T11, T12 below
• 368Plantar reflex (Babinski) — L5, S1 — bilaterallyDown-going toe is normal.

20 Sensory

Neurological sheet. Any area of the dermatome will suffice, but the root must be verbalized. May run proximal to distal, alternating pain and light touch.

Pain (sharp vs dull) and light touch — bilaterally

• 369C3 — anterior, lateral and posterior mid-neck
• 370C5 — anterolateral arm (regimental badge)
• 371C6 — lateral wrist and thumb, or 1st digit
• 372C7 — middle finger, 3rd digit
• 373C8 — little finger, 5th digit
• 374T4 — nipple line; verbalizes would assess under garments
• 375T10 — umbilicus
• 376L1 — inguinal area; verbalizes would assess under garments
• 377L4 — lateral thigh, over the knee, or down the medial lower leg
• 378L5 — lateral calf or hallux
• 379S1 — lateral foot or 5th digit

Discriminative (fine touch) — facilitator chooses ONE

• 380Stereognosis — a different object for each hand (coin, pen, paperclip)
• 381Graphesthesia — a different number in each hand, right-side-up for the patient, no lifting while drawing
• 382Two-point discrimination — palmar surface of the index fingertip and plantar surface of the hallux, once in each location bilaterally
• 383Extinction — touch one lower extremity and ask which was touched, repeat on the opposite side, then touch both simultaneously and ask; repeat for upper extremities

Position and vibration sense

• 384Upper extremity joint position sense, bilaterally — distal phalanx of the index finger, grasping the sides
• 385Lower extremity joint position sense, bilaterally — distal phalanx of the great toe, grasping the sides
• 386Upper extremity vibration sense, bilaterally — over the DIP joint of the index finger
• 387Lower extremity vibration sense, bilaterally — over the IP joint of the great toe

21 Balance, Coordination & Gait

Neurological sheet — cerebellar, posterior columns, equilibrium and vestibular function. This is also where the CN VIII vestibular component named at item 108 is satisfied.

• 388Observes posture and stance
• 389Observes regular and tandem gait, including symmetry, balance and length of stride
• 390Performs the Romberg test — feet close together, eyes closed; verbalizes they would watch for 30–60 seconds and observes for significant sway or loss of balanceYou do not have to observe for the full 30 seconds, but you must verbalize the time.
• 391Performs pronator drift — both arms extended forward, palms up, eyes closed, then briskly tap the arms downward (may be done simultaneously bilaterally)
• 392Completes one coordination test, chosen by the facilitatorRapid alternating hand movements (wrist-flipping with alternating supination and pronation) · finger-to-thumb tapping · toe-tapping · heel-to-shin · finger-to-nose

22 Closing

The deferred-exam verbalizations from the Skin and Abdominal sheets, plus the professionalism item that all four introduction blocks carry.

• 393Verbalizes the deferred examinations"I will then perform a rectal exam and the appropriate genitalia exam."The skin sheet phrases this as buttocks, breasts and genitalia — item 52. Cover both sets if you are running the full combined exam.
• 394Exhibits professionalism throughout the examination