BCM Physical Exam Standards

Updated July 2012

Contents / Page
Vitals / 2
Head, eyes, ears, nose, throat / 2
Neck / 3
Lungs / 3
Cardiovascular / 4
Peripheral vascular / 4
Abdomen / 5
Neurologic
  • Cranial nerves
  • Motor
  • Sensation
  • Reflexes
  • Coordination
  • Mental status exam
/ 5
7
8
8
9
9
Musculoskeletal
  • Shoulder
  • Knee
/ 10
11

Vitals:

  • Checked radial pulse at least 15 seconds-
  • Places pads of index finger (or index plus other fingers) over radial pulse on either hand. Counts for at least 15 seconds
  • Checked respirations for at least 15 seconds –
  • Student observes patient for at least an additional 15 seconds in order to observe the respiratory rate. Student does not state he/she is measuring the respiratory rate, and may continue to hold the arm and palpate the radial artery.
  • Placed cuff on arm, tubing forward over brachial artery
  • The student asks the patient to extend arm and places cuff above elbow, tight enough to prevent slipping down arm. Cuff should be placed so that artery marker or center of the bladder is over the brachial artery. If cuff has no artery marker, tubing should be placed over brachial artery. Readjustment once is acceptable.
  • Supported arm so it was relaxed
  • The student supports the patient's arm at heart level (on his/her arm, shoulder, or chair/desktop) so that the patient's arm remains stable when relaxed.
  • Measured blood pressure
  • Student estimates systolic BP by palpating radial artery with pads of fingers and then inflating blood pressure cuff until pulse disappears. Student reads this pressure and deflates the cuff.
  • Student applies the stethoscope firmly over the antecubital fossa. Student then inflates the cuff to a pressure of 30 mm Hg higher than the palpated systolic pressure. Student listens for Korotkoff sounds while deflating cuff at 2-3 mm Hg/sec. Student may repeat step 2 as long as they do not tell the patient the BP reading and completely deflates the cuff before re-inflating it or does the other arm. (Student may be seated or standing)
  • Repored pulse, respiratory rate and blood pressure:
  • Student may tell the pulse, respiratory rate, and blood pressure directly after their measurement, or all at the same time.

HEENT:

  • Inspected my head
  • Student feels both sides and the top of the head and parts the hair to examine the scalp
  • Checked my frontal and maxillary sinuses for tenderness
  • Student presses up on both sides of the frontal sinuses from under the bony brows, avoiding pressure on the eyes; then presses on both sides of upper cheekbones. Must do both sides and press under brows and on upper cheekbones for full credit.
  • Examined my eyes
  • Student spreads the upper and lower lids of one eye to examine the surface of the eye then does the same on the other side.
  • Examined my eyes with the ophthalmoscope
  • The student decreases the room light before beginning eye exam and asks the patient to gaze at a specific distant point. The student examines the right eye and the left eye of the patient. Student should begin by holding the ophthalmoscope 12-18 inches away from the patient's eye and approach to within 2-3 inches of the patient's eye. The light should shine on the pupil, and student must have finger or thumb on diopter.Student holds the ophthalmoscope in the left hand using student’s left eye while examining patient’s left eye and holds ophthalmoscope in right hand using student’s right eye while examining patient’s right eye. Left eye – left hand – left eye. Right eye – right hand – right eye. This takes practice!
  • Examined my ear
  • Prior to looking in the patient's ear, the student inspects outer ear. Student grasps the patient's auricle and gently pulls it upward and backwards, slightly away from the patient's head. Student braces the hand holding the otoscope against the side of the patient's face, and angles the speculum into the ear canal, directing it somewhat downward and forward, and viewing tympanic membranes. Student repeats for opposite ear. Patient should not feel pain.
  • Looked in my nose
  • With tip still on otoscope, student gently tilts the patient's head back slightly and with his/her thumb or finger, places gentle pressure on the tip of the patient's nose to widen the nostrils. Bracing the hand holding the otoscope against the side of patient’s face, inserts the otoscope into the patient's nose (avoiding contact with the septum) to examine the internal structures. Both nostrils should be visualized through the otoscope to receive full credit. Patient should not feel pain.
  • Looked in my throat and mouth
  • Student asks you to open your mouth widely and illuminates the inside of mouth with light source; pushes your tongue down with a tongue blade if needed. Also asks you to lift your tongue in order to examine the floor of your mouth.

Neck:

  • Inspected and palpated my thyroid
  • Student inspects the region below the cricoid cartilage for the thyroid gland. Then standing behind you, asks you to flex neck slightly forward to relax the sternocleidomastoid muscle as needed. The student places both hands in the center of the base of the patient's neck. The student should feel along the base of the neck, palpating the thyroid gland. The student may ask that you swallow to feel the thyroid gland better.
  • Palpated for lymph nodes along the sternoclavicular muscles (preauricular, anterior and posterior cervical chain)
  • Using the pads of the 2nd and 3rd fingers, student palpates gently in preauricular area, anterior cervical chain (anterior and superficial to the sternocleidomastoid muscle) and posterior cervical chain (along the trapezius and posterior edge of sternocleidomastoid muscle) from the jawline to the base of the neck. Gently flexes patient’s neck slightly forward as needed to maintain a relaxed position.

Lungs:

  • Examined symmetry of chest excursion
  • Student places his/her hands on the patient's back below the shoulder blades and asks the patient to breathe through his/her mouth. Student observes breathing for at least three full cycles of inspiration and expiration. Done Incorrectly - If the student does not observe for three full cycles of inspiration and expiration.
  • Percussed alternate sides of the posterior lung fields.
  • While standing behind the patient, student uses one or two fingertips of one hand to strike single finger of second hand on posterior chest wall. Student must percuss alternating left and right sides at three different levels bilaterally (for a total of six locations) of the posterior chest. (One side and then the other at each level.) Done Incorrectly - If the student does not percuss in six places, does percussion through patient gown, or percusses up and down instead of side to side.
  • Auscultated alternate sides of my posterior and anterior lung fields with a stethoscope
  • Student must listen for a total of twelve breaths, any combination, on the posterior and anterior. Done Incorrectly - If the student listens through your gown,does not listen to 12 places for full breaths, doesn't listen on both the front and the back, listens up and down rather than side to side.
  • Posterior - While standing behind patient, student (1) listens with a diaphragm of stethoscope placed firmly on patient's back so it does not move with patient breathing, and (2) asks patient to breathe deeply (full cycles of inspiration and expiration). Student must listen to one side and then the other at each level side to side.
  • Anterior - Student (1) listens with diaphragm of stethoscope placed firmly on patient's chest so it does not move with patient breathing, and (2) asks patient to breathe deeply (full cycles of inspiration and expiration). Student must listen on left and right sides, side to side.

Cardiovascular:

  • Palpated and auscultated carotid pulse (either order acceptable)
  • Student places pads of fingers on carotid pulse.
  • Student places bell of stethoscope on neck areas over pulse on each side while asking patient to stop breathing. (Patient may be sitting or reclining).
  • Inspected neck veins
  • Student elevates the head of the exam table to a 30-degree angle and, with patient reclining, looks at the patient's jugular veins on both sides of the neck.
  • Inspected and examined chest with patient supine
  • Prior to beginning palpation and with patient supine, the student uncovers the patient's chest, stands on right side of the patient and states that he/she is looking at or inspecting the precordium/chest.
  • Felt for point of maximal impulse (PMI)
  • Prior to beginning auscultation and with patient supine, the student stands on the right side of the patient, uncovers the patient's chest, and places the finger pads of his/her right hand in the area below the left nipple and feels for the point of maximal impulse (PMI). Student may reposition hand as needed.
  • Auscultated over heart valves
  • With patient supine, student stands on right side of the patient and places diaphragm of stethoscope securely (so that it does not move or slip during breathing). Student must state which valve is being examined. Both bell and diaphragm should be used over mitral and tricuspid valves. (Student should inform patient if they are using cardioscopes or other stethoscopes where physical manipulation of bell is not necessary). Done Incorrectly - If the student listens to the heart through the patient's gown or does not use both bell and diaphragm for mitral and tricuspid valves.
  • Listened to right second intercostal space (aortic valve) with diaphragm
  • Listened to left second intercostal space (pulmonic valve) with diaphragm
  • Listened to left lower sternal border (tricuspid valve) with bell and diaphragm
  • Listened to apex, below left nipple (mitral valve) with bell and diaphragm

Peripheral vascular:

  • Inspected nail beds
  • Examined legs for edema (bilaterally)
  • Student looks at both legs from mid-shin downward, uncovering them if not already uncovered. Student feels for texture of skin and pitting edema by pressing firmly but gently on the top of the foot or the tibial plateau for several seconds. Repeats for opposite leg. (Patient may be sitting or reclining)
  • Palpated peripheral pulses (radial, brachial, dorsalis pedis, posterior tibial)
  • Student palpates all four pulses bilaterally. The radial pulse is palpated on the thumb-side of the forearm in the groove between the radius and the flexor ligaments. The brachial pulse is palpated in the arm medial to the brachial tendon. The dorsalis pedis pulse is palpated across the top of the foot, and the posterior tibial pulse is palpated on the medial side posterior to the ankle.

Abdomen:

  • Place patient in supine position
  • Appropriately drape patient during the exam and exposed abdomen from xyphoid to pubis (there are drapes in SP rooms)
  • Inspected abdomen: Verbalize this action. This must be done prior to palpation or percussion.
  • Ask about any abdominal pain
  • Auscultated abdomen: All four quadrants. This must be done prior to palpation or percussion.
  • Palpated my abdomen lightly and deeply in 4 quadrants.
  • Watched my face during exam for signs of discomfort. Light palpation is done before deep palpation. Student should begin palpation away from any areas of pain, palpating the most tender areas last.
  • Palpated liver edge
  • Beginning below the right costal margin and moving upward, student presses fingers against the abdomen and then asks patient to take a deep breath while pressing in under the right rib cage during inspiration. Alternatively, the student may use the "hooking technique" by placing both hands side by side on the right abdomen below the border of liver dullness. While pressing in with the fingers and up toward the costal margin, student asks the patient to take a deep breath.
  • Percussed liver span
  • Student uses one or two fingertips of one hand to strike single finger of second hand on abdomen below right rib cage. Begins at pelvic brim and advances upward along the right midclavicular line one or two finger breadths at a time to level of nipple. Percusses over interspaces (not ribs) when over rib cage.
  • Palpated spleen edge
  • With one hand, the student reaches over and around patient to support and press forward the rib cage and adjacent soft tissue. Beginning below the left costal margin and moving upward, student presses the fingers of his/her opposite hand against the abdomen. Asks patient to take a deep breath and presses in and under left rib cage during inspiration.
  • Percussed for CVA tenderness

Neurologic exam:

Cranial nerves:

Important: Name each nerve as you are testing it.

  • Tested my visual acuity (CN II)
  • The student holds a Snellen pocket vision card about 14 inches from the patient in good light and asks them to read the lowest line they are able to read with one eye and then with the other. They may ask the patient to close one eye, cover one eye, or may cover the patient's eye themselves. If a line other than the lowest line is read then the student should ask the patient to try the next line down. This must be done before any other eye exam with the ophthalmoscope for full credit. The student should not ask the SP to remove their glasses.
  • Tested my visual fields (CN II)
  • The student faces the patient "nose to nose" separated by about 2-3 feet and asks the patient to close one eye and look at his or her nose. The student then closes his/her opposite eye and shows a number of fingers on each hand in opposite visual quadrants (i.e. upper right and lower left). The student asks the patient to say how many fingers he/she sees. The student then moves their hands to the other visual quadrants (i.e. lower right and upper left) and does the same thing again. Student may wiggle a finger on one hand and ask the patient to point to the finger which is moving instead of showing a number of fingers. This should be performed in all four quadrants as well.
  • Fundoscopic exam: examined my eyes with the ophthalmoscope (CN II)
  • The student decreases the room light before beginning eye exam and asks the patient to gaze at a specific distant point. The student examines the right eye and the left eye of the patient. Student should begin by holding the ophthalmoscope 12-18 inches away from the patient's eye and approach to within 2-3 inches of the patient's eye. The light should shine on the pupil, and student must have finger or thumb on diopter.Student holds the ophthalmoscope in the left hand using student’s left eye while examining patient’s left eye and holds ophthalmoscope in right hand using student’s right eye while examining patient’s right eye. Left eye – left hand – left eye. Right eye – right hand – right eye. This takes practice!
  • Tested my pupillary response (direct) (CN II, III)
  • The student decreases the room light before beginning the eye exam, and asks patient to look into the distance while he/she shines a bright light (usually from a penlight) into the patient's pupil for 1-2 seconds. The student should then repeat the test on the other pupil. Student must wait a few seconds between eyes.
  • Asked me to look horizontally to left and right and vertically up and down (CN III, IV, VI)
  • Student asks the patient to hold their head steady and follow student's finger with his/her eyes as student traces an "H" or star pattern 8-12 inches from the patient's eyes. The student then brings finger in to test convergence. Student should move their finger slowly and not so far in any direction that it becomes blurry or hard to see. Done Incorrectly - If done too quickly, making the SP dizzy, or does not cross midline.
  • Touched my forehead, cheeks, and jaws (light touch only) (CN V)
  • Student touches the patient's skin with a piece of cotton/gauze on both sides (one side at a time) of each of the following: the forehead, the cheeks, and the jaw. Student asks patient if the sensation on each pair of the three sides is the same, the student must test corresponding sides at a time (example: right forehead then left forehead). Students can substitute their fingers for the cotton/gauze when testing this cranial nerve as long as they lightly touch the skin and do not scrape/swipe against it.
  • Tested my muscles of mastication (CN V) (must do both)
  • Student places his/her hands on the masseter or temporalis muscles and asks patient to bite down or clench teeth while the student feels the masseter or temporalis muscles bilaterally. Students must use both hands (one on each side) and feel the difference between relaxed and clenched muscles.
  • The student tries to open closed jaw by placing his/her hands on the chin and forehead or chin and upper lip/cheeks.
  • Asked me to close my eyes tightly and close my mouth tightly (CN VII)
  • Student asks patient to close eyes and then the mouth so tightly that the student cannot open them with fingers. Student must complete both tests for full credit.
  • Tested my gross hearing (CN VIII)
  • The student does one of two tests: (1) The student asks patient to close his/her eyes or stands out of patient's line of sight and rubs his/her fingers together, gradually increasing the distance from the patient's ear. The student asks the patient to say when the rubbing sound is no longer heard (or if the student reaches their natural wingspan they will stop). The student then repeats the procedure in opposite ear OR (2) The student asks patient to close his/her eyes or stands out of the patient's line of sight and rubs his/her fingers together about 6 to 8 inches away from one of the patient's ear and asks the patient whether or not they hear anything, and if so, from which side it is coming. The student then repeats the procedure in opposite ear.
  • Asked me to say "ahhh" shining light in the patient's mouth to check uvula elevation (CN IX, X)
  • Asked me to shrug shoulders and turn head against force (CN XI) (must do both)
  • Student asks patient to shrug his/her shoulders then pushes down on the trapezius muscles above the shoulders one at a time.
  • Student asks the patient to turn his/her head to the side and resist having the neck turned back to the midline. This is then repeated for the other side.
  • Asked me to stick out tongue (CN XII)

Motor