Foundations of Patient Care: University of California, San Francisco School of Medicine

Foundations of Patient
Care
University of California, San Francisco
School of Medicine
Physical Exam Skills

Student Guide (Class of 2019)
Dear First-Year Medical Students,
Welcome to UCSF and to the Foundations of Patient Care (FPC)

course! As one of your FPC Course Directors, I could not be more
excited about the journey on which you are about to embark! As a
physician trained in medicine, pediatrics and palliative care, I have
practiced inpatient medicine at UCSF and the San Francisco VA
Medical Center over the past 12 years and know how critical and
transformative these next few years of medical school will be. My
colleagues and I have a remarkable course planned, and want you to
have all the tools you need to succeed and thrive during these
formative years at UCSF.
Heather Nye, MD PhD
FPC is a longitudinal clinical skills course. It is the only course lasting
throughout the entire first two years of medical school. Our goal is to
Co-Director, Foundations of
support you in developing necessary skills for entering clerkships and
Patient Care
the life-long learning skills you need to be a physician. Successful
Director FPC 2
completion of the FPC course allows for advancement to clerkships.
Your performance will be summarized in your Medical Student
Associate Professor of
Performance Evaluation (MSPE or Dean’s Letter). In FPC you will
Medicine
learn to build a patient history, perform a physical exam, communicate
with patients, families, and clinical teams, apply clinical reasoning to
determine likely diagnoses, write notes in the medical chart, and do
oral case presentations.
As part of the FPC curriculum, you will have several guides, an

advisory college mentor, small group facilitators, peer-mentors, and
faculty. Many students build supportive relationships in FPC small
groups, physical exam (PE) skills, and preceptorships that last
throughout medical school and beyond. Students often look back
during their clerkship years and fully appreciate the important skills
learned during FPC.
My colleagues and I are here to challenge and support you during

these critical first two years of medical school. On behalf of the entire
FPC Team, our warmest wishes to you as you embark on this exciting
learning adventure!
Sincerely,
Heather Nye, MD PhD
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Table of contents
Faculty & Staff Contact Information ………………………………………………………....1
Dates for Physical Exam (PE) Skills Groups ………………………………………………..2
Overview of Curriculum………………………………………………………………………...3
UCSF Peer Physical Exam Policy…………………………………………………………...11
Foundational PE Exam Checklist.……………………………………………………………14
Complete PE Exam Checklist………………………………………………………………..15
Short Sheets: Sessions 1 – 10……………………………………………………………….17
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Faculty & Staff Contact Information
FPC FACULTY AND STAFF

CONTACT INFORMATION
FACULTY
FPC-1 Course Director

Heather Whelan, MD (415) 221-4810 heather.whelan@ucsf.edu
Department of Medicine x5282
FPC Co-Directors
Amin Azzam, MD, MA (415) 476-7836 amin.azzam@ucsf.edu

Department of Psychiatry
Dan Ciccarone, MD, MPH (415) 514-0275 ciccaron@fcm.ucsf.edu

Department of Family &
Community Medicine
Meg McNamara, MD (415) 206-4332 mcnamara@peds.ucsf.edu

Department of Pediatrics
Heather Nye, MD, PhD (415) 221-4810 Heather.Nye@ucsf.edu

Department of Medicine X3287
Co-Director for PE Skills
Heather Nye, MD, PhD (415) 221-4810 heather.nye@ucsf.edu

Department of Medicine x3287
STAFF
Course Coordinator
(415) 502-5155 Joshua.Stein@ucsf.ed
(FPC Year 1) Josh Stein
Course Coordinator
(FPC Year 2) TBD
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PE Skills CALENDAR
PE Skills Small Group Sessions generally run from 1-3pm or 3-5pm on TUES/THURS
**Class Lecture (Tues 9/8, 10am) Intro to PE Skills Curriculum & Observation**
PE Skills Sessions
Session 1: Intro, Instruments, Interactions, Inspection, VS & Skin

TUES 9/8 THURS 9/10
Session 2: HEENT & Neck Exams

TUES 9/15 THURS 9/17
Session 3: Cardiovascular & Pulmonary Exams

Session 4: Musculoskeletal Exam (Upper & Lower Extremity) 1-3pm ONLY

Session 5: Abdominal & Back Exams

Session 6: Neurologic Exam & Foundational Exam Review

Session 7: Observed Foundational Exam 8am-5pm

TUES 10/20
Session 8: Oral Exam & Dental Review 1-3pm ONLY

Session 9: Cardiology Exam Revisited

Session 10: Pulmonary Exam Revisited

TUES 2/2/16 THURS 2/4/16
**Adult PE Review (Exam, Self-assessment)**

• Tuesday, March 1, 2016
• Wednesday, March 2, 2016
• Thursday, March 3, 2016
Session 11: Scopes Session 8am-5pm

TUES 4/5/16
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Overview and Curriculum
Welcome to the FPC Physical Examination Skills Curriculum!
One of the distinguishing features of any excellent clinician is a strong command of the artful
and evidence-based physical exam. We hope you are looking forward to learning this complex
and valuable skillset. It’s important to recognize that the art takes a lifetime to perfect, and is
largely dependent on practice, feedback, and accumulation of experience. Learning a directed,
accurate & thoughtful physical examination takes a great deal of patience and time, with
attention to the four below skill domains.
Overall Philosophy
Physical examination skills can be divided into four domains: motor, professional, cognitive, and
hypothesis-driven.
I. Motor skills encompass the pure mechanical performance of the exam (how to move the
patient, where to place hands/instrument) and appropriate use of equipment.
II. Professional skills include demonstration of respect for the examinee (introductions,
hand-washing, attention to patient comfort and proper draping) as well as appropriate
interpersonal interaction (clear verbal instructions, expressions of empathy).
III. Cognitive skills involve integration of anatomy, pathophysiology and evidence-based
medicine to aid in clinical reasoning and diagnosis.
IV. Hypothesis driven physical exam refers to conducting specific portions of the exam that
are relevant to your differential diagnosis based on information gleaned in the patient
interview.
We will start by focusing primarily on the motor and professional skills that underlie every good
physical examination. The cognitive aspects will grow with time and will naturally develop into
hypothesis-driven approaches as you gain increasing knowledge of medical conditions,
associated physical findings, and comfort with basic PE maneuvers.
The Curriculum
The PE Curriculum in FPC is outlined in the figures below. It includes formal teaching
sessions and integrated practice opportunities as well as evaluations.
Formal teaching
• FPC PE Skills Sessions

During fall of first year, students participate in a series of weekly two-hour sessions. During
these, small groups of 6-8 students are introduced to basic PE maneuvers and engage in
peer practice with direct observation and feedback from instructors. This ‘crash course’ is
intended to serve as an introduction to physical exam, patient interaction, oral presentations
& note writing. The sessions are important for early consolidation and reinforcement of PE
skills. Later in the first year, there are additional FPC PE Skills sessions: Cardiovascular
Exam Revisited & Pulmonary Exam Revisited, Oral Health and a Scopes Session (oto- &
ophthalmocope use).
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• Professional Educators (Kanbar)

In the second year of FPC, students have the opportunity to learn the breast, pelvic &
genitourinary exams through sessions in the Kanbar Center with professional educators.
• Additional teaching
Other components of the PE curriculum are taught in the Essential Core, such as the
comprehensive neurological and mental status exams during the Brain Mind and Behavior
block in the spring.
Practice Opportunities
There are both scripted (with standardized patients) and real patient settings in which students
can practice physical exam throughout the first year.
• Integrated Exercises (Kanbar)

Block-specific cases (aligned with EC content) where students engage with a standardized
patient from a scripted case in the Kanbar Center and practice interviewing, a focused
physical exam and clinical reasoning skills.
• Kanbar Practice Sessions

We aim to schedule periodic Kanbar time staffed by instructor volunteers for additional
optional practice and feedback opportunities.
• Preceptorships
Students have several preceptor sessions over the 1st and 2nd years (primary care,
emergency departments or other settings). This early exposure to the clinical setting serves
as another venue for honing interview and physical exam skills.
• Adult PE Review (Kanbar)

Near the end of both 1st and 2nd years, students perform a full head-to-toe physical exam on
a peer partner under direct observation from an instructor, who then gives formative
feedback in advance of the final examination (mini-OSCE or OSCE).
• Exams (Kanbar)
FPC examinations final examination for years 1 and 2 (mini-OSCE and OSCE, respectively)
involve clinical cases with standardized patients, where students perform interviews &
exams and apply information to answer clinical questions. While serving as instruments for
assessing student progress, these events are highly rated as some of the most valuable
learning experiences for students.
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Learning Tools
Short Sheets
These are session-specific brief handouts with a collection of relevant diagrams and
figures, learning points, and a suggested schedule for each PE Skills session. Please
consider this your syllabus, bring it to your small groups and use it as your guide. There
will be a quiz at the beginning of each session which is based on the information in the
short sheet.
Text
The Bates’ Guide to Physical Exam & History Taking, 11th Edition, is our recommended
text. The Inkling Ipad and web versions have excellent and integrated platforms. This text
will provide additional detail and anatomical context for each PE Skills session, explicit
instructions on PE maneuvers, accompanying videos, cases, and quizzes that will augment
your learning.
Applications
UCSF partnered Bandwdth Educational Publishing to produce two amazing ipad/iphone
apps for learning the musculoskeletal and neurological physical examinations.The apps are
available to UCSF students and faculty free of charge through the below website:
http://meded.ucsf.edu/tel/physicalexam-tutor-iOS-apps
Websites / videos
There is no one perfect video for learning the physical exam. Each shows slightly different
approaches for different components of the exam. It is important to be aware of these
variations in exam techniques—so we invite you to view more than one video for each
session, particularly if you’d like a second ‘view’ of a specific maneuver.
1. Bates Visual Guide to Physical Examination and OSCE Clinical Skills Videos through the
UCSF Library/Collaborative Learning Environment site. These include videos of all parts of
the physical exam and require logging on via MyAccess.
www.library.ucsf.edu/db/bates-visual-guide-physical-examination-online
2. University of Virginia School of Medicine

http://www.med-ed.virginia.edu/courses/pom1/videos/index.cfm
3. University of Florida College of Medicine (Online PE Teaching Assistant, OPETA)

http://depmedicina.med.up.pt/opeta/index.html
4. University of Wisconsin School of Medicine and Public Health

http://videos.med.wisc.edu/modules/18
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5. University of California, San Diego’s ‘Practical Guide to Clinical Medicine’ is a website that
is more advanced, but has excellent written explanations and photos of exam maneuvers,
anatomy, and various pathology.
http://meded.ucsd.edu/clinicalmed/
PE Skills Sessions: Nuts & Bolts
• Your PE Skills small group (different from your FPC & EC small groups) will consist of 6-8
students and meet weekly with one or two instructors for guided practice.
• The exam will be demonstrated briefly by your instructors. Note: students are expected to
prepare for the session. Bring your short-sheets.
• Most of the time will be spent practicing the exam on a partner under the supervision of an
instructor. These are intended to be cumulative practice sessions: each week review what
you have learned in sessions up to that point.
• Near the close of each session, all students will practice written and oral presentation of
exam findings. One or two students will present to the group.
• Advance Preparation:
1. Equipment: Please come to each session with stethoscope, reflex hammer, and
penlight. Bring blood pressure cuff and oto/ophthalmoscope if you have one.
2. Reading and Viewing: You must read the short sheets and physical exam videos prior
to your session. PLEASE BE PREPARED, YOU WILL BE TESTED.
3. Dress: Please come properly dressed to be examined. Gowns and drapes will be used
as in real clinical scenarios.
4. Hygiene/Other Precautions: HAND WASHING IS ESSENTIAL before you examine
someone. Long fingernails are not conducive to a comfortable exam for either you or
your patient, so trim your nails ahead of time.
Assessment & Evaluation
Your skills will be evaluated in several different ways. Remedial work will be required for
students whose performance on any of these evaluations does not demonstrate a level of
expected competence.
PE Skills Session instructor. S/he will give you regular, formative feedback on your physical
exam skills during weekly sessions.
Quizzes: There will be a PreparE quiz prior to each PE Skills Session. These will be based on
information in the session short sheet and will count for 20% of your final PE assessment
grade (Observed Foundational Exam).
Preceptor. Your preceptor will also offer formative feedback on your exam skills observed in the
clinical setting. S/he creates a summative evaluation on all of your clinical skills over the
duration of your experience.
Observed Foundational Exam Immediately following the initial PE Skills Sessions, you will be
formally evaluated on your ability to perform a “full” foundational physical exam according to
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the checklist and without notes on a partner in 20-30 minutes. This exam will not include the
female breast and pelvic, or male genitourinary exams.
Peer Exams and Professional Behavior
The process of learning how to look at and touch parts of the body that are normally kept private
often bring up anxiety. This feeling may reflect what patients experience. When examined
by a physician, patients may experience feelings of uneasiness or embarrassment, but are
usually able to cope because the physician is trusted to treat the body “professionally.”
What is “professionally?” This implies gentleness, respect, competence, a nonjudgmental
attitude, maintenance of confidentiality, and the absence of sexualization of the encounter.
An important task of FPC is to help develop your ability to treat patients and each other
professionally. Some specific suggestions that may be helpful in learning this include:
• Talk openly and honestly about possible anxiety and embarrassment
• Be empathetic and considerate of other people’s thoughts and feelings: a comment or joke
made to relieve your anxiety or bolster your confidence could be experienced as insulting or
anxiety-producing for one of your colleagues
• Practice a nonjudgmental demeanor by refraining from making sexual comments or
innuendoes about each other
• Take time in your small group sessions to share feelings, identify any special concerns in
your group, and take responsibility as a group for developing plans for how to manage the
learning experience optimally.
No student will be required to be examined by a classmate if this results in severe

discomfort or distress. PLEASE SEE UCSF PEER EXAMINATION POLICY
If you feel significantly uncomfortable in your group, please contact your instructor to discuss
your concerns. If there are difficulties that your instructor is unable to assist with, do not
hesitate to contact Dr. Nye at heather.nye@ucsf.edu or Josh Stein at Joshua.Stein@ucsf.edu.
We will guarantee your confidentiality and safety.
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FAQs
Q. What’s the best way to organize a full physical exam?

A. Top to bottom: Most practitioners examine the different regions of the body in sequence,
starting from the top with the head and proceeding down to the feet. Not only is this a standard
method of examination, but it also helps you develop a systematic way to do the exam every
time, so that you don’t forget important parts of it.
As you grow more seasoned in your technique and clinical knowledge over the year, you will
begin to abbreviate parts of the exam and tailor maneuvers performed in a hypothesis-driven
fashion.
Within each body region, the same sequence is generally followed:
a. Inspection: information gained through all senses, not just the eyes!
b. Palpation: information gained through touch
c. Percussion: striking one finger against another to produce vibration/sound
d. Auscultation: listening (most often with a stethoscope)
Two exceptions to above:

a. Not every body region is examined using all four modalities (for example, we don’t
generally percuss the heart)
b. Auscultation is performed first when examining the abdomen
Q. Is there one right way to perform a physical exam?

A. No! There are as many ways to perform the physical exam as there are practitioners.
We will be teaching a certain sequence based on consensus and input from several UCSF
clinicians. It will not necessarily be the exact exam that your preceptor or other providers
use. It’s important to be comfortable with variation when you observe different instructors who
have adopted certain techniques over others. You too will develop preferences with your exam
techniques moving forward.
• As long as your exam follows a consistent, thorough and sensible sequence, the order in
which you proceed is of less importance.
• You will need to examine hundreds of normal patients, to learn the full range of normal—and
you cannot fully appreciate what “abnormal” is until then.
Q. How much of the physical exam do I need to do on a patient?

A. The answer is “as much as necessary” (which is hard to know as a beginning medical
student). How do you learn how much is necessary?
Experienced practitioners target their physical exam to help them decide what their patient’s
possible diagnoses are. They begin to formulate a list of possible diagnoses while they are
taking the patient’s medical history. But, since you are just starting, you will and probably
should err in the direction of doing “too much” rather than “too little” on your exam. It is useful to
learn and practice everything now, in order to develop good exam skills. The “artistic” and
focused physical exam will come with time.
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UCSF Peer Examination Policy
UCSF School of Medicine

Student Peer Examination Policy
for Clinical Skills Learning
Peer Exams, Briefly:
• Peer Examination is an effective and valuable model for clinical skills building in medical
education that is utilized in most medical schools
• Peer Exams may be awkward or uncomfortable for some
• Peer Exams will not include the inguinal region, genitals, breast, or rectum
• Students may opt out of peer examination and choose alternative learning strategies by
notifying course directors in advance. This choice carries no adverse consequences.
Each student, despite learning method, must achieve the same expected level of
competence in clinical skills performance.
Background
Physical examination (PE) of patients is one of the most intimate interactions that health care
providers will engage in throughout their careers. Educators have considered multiple
methods for early students to learn and practice PE, ultrasound, and surface anatomy skills.
Student peer examination will remain as one learning strategy here at UCSF SOM.
Peer practice allows students to learn with each other in a safe and relaxed space as fellow
students practice new and unfamiliar maneuvers. Despite its efficacy, peer examinations
also may elicit discomfort for some students. This guide, originally drafted by a medical
student, will provide context and guidance for addressing questions that may arise
during PE Skills, Surface Anatomy or Ultrasound sessions.
Small Groups & Peer Partnering
Co-ed groups are assigned at the beginning of the academic year with an even number of men
and women to allow pairs by gender. Students are free to choose their own partners. Every
group develops its own partnering “style”. Some change partners each session, others stay
with the same partners throughout the course.
Anxiety and Discomfort
It is understandable for students to experience a certain amount of discomfort with peer exams,
while finding it a valuable learning experience. Given this context, course directors and
small group instructors are dedicated to creating the most comfortable experience possible.
Examinations WILL NEVER INCLUDE sensitive areas such as the inguinal region, genitals,
breast, or rectum. Professional educators serve as patients during learning sessions for
these regions during the second year.
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Easing Anxiety
To encourage respect and professionalism within PE groups, sessions should begin and
conclude with a group “check-in” reflecting on the session learning process. This time is
meant for students to share concerns and comments, and bring forward suggestions to
improve comfort levels within the group.
Please be aware that while one student may feel completely comfortable with peer exams, their
partner may not. Students must be sensitive to this possibility while beginning each session
– check in with their partner to see if there is any part of the examination in which they would
rather not participate. Instructors will help with finding another “patient” from the group for
that part of the exam.
Students will never be required to participate in any peer exam that makes them so
uncomfortable that it interferes with their learning.
Unexpected & Unusual Findings
When performing peer exams, there is the potential for unexpected findings (e.g. heart murmur,
thyroid nodule, skin lesion). This can be distressing for both examinee and examining
student. Should it occur, we ask students to remember their commitment to confidentiality,
and discretely ask the “patient” if they are aware of any related medical condition. If the
finding is indeed new, an instructor should be called over and asked for guidance. The
finding should NOT be shared with other students.
If an instructor confirms the finding, he/she will recommend that the student follow-up with their
personal health care provider. Instructors are not asked or expected to provide medical
advice beyond this guidance.
Physical findings for known or existing conditions may also be noted on exams. This could
include scars, scoliosis, tattoos, irregular heartbeat, etc. We ask students to be discrete and
respectful of their partner’s privacy. While they may ask if the finding is known, they should
refrain from discussing it openly.
OPTING OUT: What to do
Should a student decide they would rather not be examined for a particular session, they should
notify the course director in advance (preferred), or notify their instructor, who can then
make any necessary partnering changes in the group. This will NOT affect the student’s
grade nor have any untoward consequences for their group.
If sessions cause significant distress—and this discomfort interferes with learning, alternative
arrangements can be made. (i.e. changing groups, formation of same-gender groups,
alternative learning models, working with a standardized patient,…etc). This process can be
initiated by contacting anyone listed on “chain of contacts.”
Each person on this list is available to help think through situations, advise on solutions, and put
wheels in motion for changes with utmost confidentiality and care.
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Chain of Contacts for Concerns

Your PE, Ultrasound, or Surface
Anatomy Small Group
Instructor(s)
FPC-1 Course Coordinator Josh Stein Joshua.Stein@ucsf.edu
FPC/CMC Director for PE Skills Heather Nye Heather.Nye@ucsf.edu
Anatomy Director Kim Topp Kimberly.Topp@ucsf.edu
Ultrasound Directors Emma Webb Emily.Webb@ucsf.edu
Nate Teissman Nathan.Teismann@ucsf.edu
Overall Course/Block Director See course materials
Dean of Student Affairs Maxine Papadakis PapadakM@ucsf.edu
Dean of Curricular Affairs Susan Masters susan.masters@ucsf.edu
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2015-16 FOUNDATIONAL Physical Exam Checklist FINAL
This examination is suggested as an initial head-to-toe screening exam
in undifferentiated patients. It is by no means comprehensive. With PULMONARY
specific complaints and information from a history, a more targeted  Inspect thorax
approach to the PE is expected. Clinical reasoning should guide which  Percuss chest posteriorly
parts of the exam will be most useful in differentiating possible  Auscultate anterior and posterior lung fields
diagnoses. ‘BUILD-OUT’ exam learning will supplement this
FOUNDATIONAL exam and focus on diagnostic clues associated with CARDIOVASCULAR
common presentations. Shaded items can be considered in  palpate carotid arteries
Foundational Exam.  Jugular Venous Distention
 Palpate precordium for point of maximal impulse (PMI)
DOCTOR-PATIENT INTERACTIONS  Auscultate cardiac sounds in 5 listening areas with diaphragm
 Introduce yourself to the patient  Auscultate with bell at apex
 Communicate with clear, easy-to-understand instructions  Palpate radial, dorsalis pedis and/or posterior tibial arteries
 Use appropriate draping techniques for privacy and comfort  Palpate for lower extremity edema
 Wash hands before starting the examination
ABDOMEN
GENERAL– VS/Mental Status  Inspect the abdomen
 Note general appearance & behavior (comfortable, look  Auscultate the abdomen
ill/well))  Palpate the abdomen in four quadrants
 Weight, height, body mass index (record if available)  Percuss liver span
 Temperature
 Count radial pulse MUSCULOSKELETAL
 Count respiratory rate  Inspect upper and lower extremities (tone & bulk, alignment
 Measure blood pressure and symmetry, nails)
 Assess level of consciousness  Inspect joints (effusion, swelling, deformity)
 Orientation to person, place, time Further testing if abnormalities or MSK complaint; should include
palpation and ROM of affected joint and contralateral partner
SKIN
 Inspect skin throughout exam NEUROLOGIC
 Test pupillary response to light (CN II, III)
HEAD AND FACE  Test extraocular movements (CN III, IV, VI)
 Inspect lids, sclerae, conjunctivae  Inspect tongue, asking patient to protrude (CN XII)
 Examine ear canal and tympanic membrane with otoscope  Speech (fluency? comprehension?)
 Inspect mouth, including lips, gums, teeth  Deep tendon reflexes (biceps, patellar, ankle)
 Inspect tonsillar pillars, soft palate, posterior pharynx  Sensation to light touch or pinprick (feet)
 Strength upper and lower extremities
Neck  Gait
 Palpate neck lymph nodes: cervical, supraclavicular
 Palpate thyroid
H.Nye 8/18/15 Adapted from Gowda et al 2014 Acad Med
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2014-15 COMPLETE PE CHECKLIST MS1 (pre-BMB) italicized = not required, more comprehensive or advanced maneuvers for MS2 & above
NECK
DOCTOR-PATIENT INTERACTIONS  Inspect and palpate for tracheal deviation
 Introduce yourself to the patient  Check range of motion of the neck
Throughout the exam  Auscultate carotid arteries with bell of the stethoscope
 Communicate with clear, easy-to-understand instructions  Palpate lymph nodes **submandibular, submental, anterior cervical,
 Place hands on the examinee respectfully and reassuringly posterior cervical, pre- and posterior auricular, occipital,
 Use appropriate draping to preserve privacy and comfort supraclavicular**
 Palpate carotids separately
GENERAL APPEARANCE - VITAL SIGNS  Inspect thyroid gland while patient swallows
 Wash hands before starting the examination  Palpate thyroid while patient swallows
 Inspect and describe gen appearance (comfortable, ill, well, etc.)
 Count radial pulse PULMONARY
 Count respiratory rate  Palpate posteriorly for symmetrical chest expansion
 Measure blood pressure  Check for tactile fremitus (performed only if abnormality on
percussion or auscultation)
SKIN  Percuss posterior lung fields
 Inspect skin during all parts of the exam  Auscultate posterior, lateral, and anterior lung fields
 Palpate and describe any lesions
o
CARDIOVASCULAR (patient supine, head elevated to 30 )
HEAD AND FACE  Inspect the neck for venous pulsations and estimate JVD
 Inspect head and face, including hair and scalp  Check for hepatojugular reflux
 Inspect anterior chest and precordium
EYES  Palpate precordium for apical impulse, lifts, heaves and/or thrills
 Inspect lids, lashes, brows, sclerae, conjunctivae  Auscultate precordium in aortic, pulmonic, triscuspid and mitral
 Test pupillary response to light (CN II, III) areas with the diaphragm of the stethoscope; repeat with bell
 Test extraocular movements (CN III, IV, VI)  Listen for radiation of murmurs, if present, to carotids or axilla
 Visualize the retina (optic disc, cup, vessels, macula)  Check for lower extremity edema
 Check pulses **carotid, radial, brachial, aortic popliteal, posterior
EARS, NOSE AND MOUTH tibial, dorsalis pedis **
 Examine the external ear
 Screen hearing with the whisper test or fingers rubbing ABDOMEN (supine with patient’s legs bent)
 Examine ear canal and tympanic membrane with otoscope  Drape patient appropriately to preserve privacy and comfort
 Percuss or palpate for sinus tenderness  Inspect the abdomen
 Assess patency of nares  Auscultate the abdomen
 Inspect nose, septum, and turbinates  Percuss the abdomen in four quadrants
 Inspect mouth, including lips, gums, teeth, tongue, floor of the  Percuss the liver span
mouth, and posterior pharynx  Palpate the abdomen in four quadrants, lightly then more deeply,
 Inspect tongue, asking patient to protrude (CN XII) starting away from any area of tenderness
 Inspect palate & uvula symmetry while patient says ‘aaa’ (CN X)  Palpate for the liver and spleen
 Palpate the mouth with gloved fingers (if any abnormalities noted or  Palpate the aorta
the patient uses tobacco)
8.20.2015 Nye
15
2014-15 COMPLETE PE CHECKLIST MS1 (pre-BMB) italicized = not required, more comprehensive or advanced maneuvers for MS2 & above
MSK
 Inspect upper (shoulder, elbow, wrist, fingers) & lower (hip, knee, NEUROLOGIC
ankle) extremities for tone & bulk, alignment and symmetry Comprehensive Neuro exam will be learned in BMB block. The Essential exam
 Inspect joints (effusion, swelling, deformity) is below. Can be performed separately or integrated by region.
BACK (sitting or standing) Mental Status

 Inspect back for curvature, asymmetry, masses  Orientation (place & date)
 Palpate spinous processes and paraspinal musculature  Language: Naming (two objects)
 Percuss for costovertebral angle tenderness  Language: Comprehension (3-step command)
 Test range of forward flexion of back (touch toes while standing)  Language: Fluency (speaking in full sentences)
 Language: Repetition (no “ifs, ands or buts”)
UPPER EXTREMITIES (sitting or standing)
 Palpate acromioclavicular joint, clavicle, spine of scapula, deltoid Cranial Nerves (may be tested during head & neck exam)
 Test range of motion of the shoulders (standing)  II Check visual fields (4 quadrants, both eyes open)
 Perform the “empty can” and “drop arm” tests on a shoulder  II, III Check pupillary response to light (direct & consensual)
 Palpate lateral and medial epicondyles of the elbows  III, IV, VI Check extraocular movements (letter H)
 Test range of motion of the elbows, wrist and fingers  VII Facial motor (eyelid closure, wrinkle forehead, show teeth)
LOWER EXTREMITIES (sitting, standing, supine) Motor

 Assess hip strength observing patient stand from seated position  Tone: Muscle tone (upper/lower extremity)
 Palpate iliac crest, and greater trochanter  Strength: Finger extension
 Test ROM of hips (flexion, extension, internal & external rotation,  Strength: Ankle flexion
abduction & adduction)  Strength: Pronator Drift (extend arms, palms up, eyes closed)
 Palpate joint line of the knee, the MCL and LCL ligaments  Strength: Finger and toe taps (done one extremity at a time)
 Test range of motion of knees (flexion and extension)
 Perform a Lachman test Reflexes
 Perform varus and valgus stress tests  Biceps, triceps, brachioradialis, patellar, Achilles
 Inspect and palpate ankles and feet
 Test ankle range of motion Sensory
 Light touch (check distal extremities; include double simultaneous
stimulation with eyes closed)
 Romberg (stand with feet together and close eyes)
Coordination and gait

 Finger-to-nose test (check accuracy fully extending)
 Observe stance and gait (including tandem, heel and toe walking)
8.20.2015 Nye
16
PE Skills Session 1: Introduction, Instruments, Interactions, Inspection, Integument & VS H. Nye 2015
Recommended 15 minutes: meet & greet, icebreakers, logistics
Schedule 15 minutes: instrument review, percussion practice, introduction to patient, draping
10 minutes: demo pulse, resp rate, blood pressure
60 minutes: practice, feedback
10 minutes: practice oral/written presentations and check out
Exam/Topic: Key Information:
Intro MEET & GREET
• Introductions: As instructor, supportive role, not focused on evaluation
• Ice Breaker: students share (what are they excited about, something personal, something non-medical)
• Briefly describe PE Skills Sessions, peer practice model, agree upon procedures for changing clothes, abnormal findings
• Discuss group format, practice partners, possible awkwardness, instructor contact info and PE director (heather.nye@ucsf.edu) if help needed
• Pairing and preferences: M/M, F/F, M/F, or change around each week
• Appoint time-keeper and write schedule on the board
• Oral presentations for all upcoming sessions
• Field questions and concerns
Instruments
Stethoscope: for listening to lungs, heart, abdomen, vasculature
• How to wear: putting the earpieces in correctly, turning the head from bell to diaphragm and back, test with a tap
• Diaphragm vs. Bell: bell for lower pitched sounds (bruits, some murmurs) and diaphragm for higher pitched sounds, the Littmann ‘tunable’ or
‘floating’ diaphragm, which changes listening frequency based on pressure placed on stethoscope head
Your clinic should Reflex Hammer: for eliciting deep tendon reflexes (part of neuro exam)
also have a • Styles: Taylor/‘tomahawk’ vs. ‘Queen’s Square’ vs. ‘Buck’
measuring tape, • Use: Holding lightly between fingers, and allowing swing to be enhanced by weight of hammer head
scale, and Otoscope/Ophthalmoscope: viewing tympanic membrane and retina. To be reviewed in HEENT session
apparatus to Penlight: all-purpose pocket light-source for pupillary response, looking in the mouth, nose, etc. No need for expense here.
measure height Hands: Sensation/ Palpation Different parts of hand are better at feeling certain things
- Fingertips: fine discrimination for delineating size, firmness, texture of soft tissue (ie: lymph node exam, palpation of liver edge)
- Dorsal hand: temperature discrimination
- Palm or ulnar surface of hand: vibration sensation
Percussion Creating resonant tones/vibrations from striking various parts of the body with ‘human hammer’. Can give clues to nature of
tissue make-up: liquid, air-filled, solid/dense.
Method: i. Press skin surface firmly with distal portion of contact finger (plexor=middle finger of nondominant hand). Avoid contact with other fingers
ii. Strike the DIP joint of the surface finger with the middle finger of dominant hand (pleximeter)
Descriptors: tympanic, resonant, dull, flat, loud, soft PRACTICE!! Use tables, boxes, books to practice your ‘swing’ and create some tones!
Doctor-Patient • Remind students to wash hands before examinations—they MUST use the hand sanitizer or the sinks in the restrooms
Interactions • Encourage students to practice professional demeanor towards each other as patients
-Introduce self (full name) as a medical student (year), and what is planned for the encounter (History, PE, etc.)
Getting Started -Sensitivity to patient privacy, comfort and dignity
-Appropriate use of gowning and draping during each segment of the exam
-Encourage examining student to give clear instructions to patient and speak out findings when appropriate
17
PE Skills Session 1: Introduction, Instruments, Interactions, Inspection, Integument & VS H. Nye 2015
Inspection/ • Have students practice describing the patient’s general appearance: use vision, hearing, smell, observations
Observation -- State of development, nutrition and hydration, body habitus, cleanliness (unkempt, disheveled, or neat)
General -- Degree of wellness or illness, in distress or calm, in pain or comfortable **can sometimes comment on mental status here**
Appearance
• Height, Weight, Waist Circumference (measured just below belly button, >35 inches women, >40 men, portends increased risk for diabetes, hypertension, and
2
cardiovascular disease), Body Mass Index (BMI, kg/m )
• Temperature *normal = 37 C, 98.6 F fever T > 38.5 C, 101.5 F *

Vital Signs
- Discuss methods of recording temperature and indications for each method (oral, axillary, rectal...etc—not to be practiced)
• Pulse * adult normal range 60-100 beats per minute *
*Note: For children,
normal values vary - Demonstrate taking the pulse over the radial artery using the pads of the index and middle fingers
considerably - Count pulse for 15 seconds and multiply by 4 for beats per minute count for longer (30 sec-1 min) if irregularities in pulse
depending on age* • Respiratory Rate * normal adult rate 8-16 breaths per minute *
- Count the respiratory rate by observing / listening / feeling respiratory movements for one minute
- Make observations unobtrusively, so that patient will not focus attention on his or her respirations
- Observe/Note the presence or absence of the use of accessory muscles of respiration
• Blood Pressure * normal adult range ~100-140/50-80 mmHg *
- Appropriate cuff size & placement (center bladder of cuff over brachial artery), snug fit
BMI
- Lower border of the cuff should be about 2.5 cm above the antecubital crease
<18.5 underwt - Position the patient’s arm so that it is slightly flexed at the elbow and at raised to heart level (arm supported by clinician or table)
18.5-25 normal
25-30 overwt By palpation: Estimate the systolic pressure by palpation of the radial artery to not miss the ‘auscultatory gap’ and record falsely low SBP
>30 obese - Inflate the cuff while simultaneously palpating the radial pulse until you no longer feel the pulse.
- Pump ~20 mmHg above this point, then slowly deflate cuff. When you can feel the pulse again, this is the true systolic pressure.
- Deflate the cuff completely and wait ~15 sec before attempting to pump it up again.
By auscultation: Listen with the stethoscope over the brachial artery (just medial to the biceps tendon)
Skin Exam - Inflate cuff rapidly to 20-30 mm Hg greater than SBP determined by palpation, deflate slowly, 2-3 mm Hg per second
(Dermatology - Record the pressure at which the Korotkoff sounds are first heard (systolic pressure) and when the sounds disappear (diastolic pressure)
-Discuss normal values and orthostatic vital signs
session to
follow) • Throughout entire exam, closely examine skin of all parts of the body for skin markings, rashes & clues to illness/ medical history document
1) Color (pink, pale, jaundiced, red or “erythematous”, patches)
2) Texture (smooth, dry, rough, moist, nodules, scales)
3) Scars, tattoos, piercings, unusual moles or markings (ie: striae), rashes or open lesions (scabs, excoriations, lacerations)
4) Other: Tone and elasticity, warm, cool or neutral, presence or absence of hair
Videos http://depmedicina.med.up.pt/opeta/vital/VS_main.html
http://www.med-ed.virginia.edu/courses/pom1/pexams/VSandChestExam/
GOWNING & DRAPING, Full Body Skin Exam: www.meddean.luc.edu/lumen/MedEd/MEDICINE/pulmonar/pdself/menu_videos.htm
Documentation Vitals: Temp 98F, HR 72, BP 126/74, RR 12
General Appearance: well developed well nourished (WDWN), no apparent distress (NAD), interactive
Skin: dry, no rashes, midline well-healed vertical abdominal scar of 5cm
18
PE Skills Session 2: Head, Eyes, Ears, Nose, Throat & Neck (HEENT)
Short Sheet H. Nye 2015
Recommended 5 minutes: check-in, schedule review TIPS: Review appropriate doctor-patient

15 minutes: demo neck exam
Schedule interactions and handwashing!!
35 minutes: practice
15 minutes: demo other portion of exam practice oral/written presentations and check Always make note of skin findings in each
35 minutes: practice 15 minutes: Observe and feedback full HEENT exam part of exam (scars, tattoos, discoloration)
TOPIC/EXAM KEY TECHNIQUES: SURFACE ANATOMY/NOTES:
Instruments & Otoscope: To view the tympanic membrane and the ear canal as well as nasal cavities
Pupil
Other Tools Note—use of ophthalmoscope will be covered in Scopes Session in April 2016 Cornea Sclera (white)
Penlight: used for looking at eye structures, in mouth, or eliciting a pupillary response (clear covering) Conjunctiva (clear
Tongue Blade: can assist with lowering the tongue to view posterior pharynx & retract mucosa Iris covering)
Water cup: Used while palpating the thyroid, patient swallows during exam to raise gland superiorly
HEENT
Head:
• Inspect: Examine head for shape, size, symmetry; face for skin changes, signs of fatigue, mucous
drainage. Check hair and scalp for abnormalities.
• Palpate: skull, scalp, facial bones, and temporal arteries if there is history to indicate necessity
• Percuss: Tap or press firmly upon the paranasal sinuses (clinical utility of maneuver is controversial)
Eyes:
• Inspect
1) Structures: lids, lashes, pupils, iris, sclera Symmetry? Swelling? Redness? Discharge? Flaking?
2) Conjunctiva: redness may signify conjunctivitis or inflammation Sclera: anicteric vs. icteric. Retract lids
sequentially and use penlight, have patient move eyes in all directions to view maximal surface of the eye
3) Pupillary response: shine a light in one eye, note constriction of pupil in both eyes (direct and consensual
response), repeat by shining light in other eye (CN II, III)
4) Eye movements: make a ‘H’ with finger, have patient hold head still while eyes follow finger (CN III,IV,VI),
Ears:
also test accommodation with moving finger toward nose and having patient follow
• Inspect , Palpate
There are many 1) External ear auricle (or pinna)= helix, tragus, antitragus, meatus, lobule (ear lobe)
different ways to 2) Ear canal, tympanic membrane (TM) (window to middle ear) -- Using the Otoscope
hold the otoscope— o Turning light source on, bright light usually best for viewing, speculum (large or small)
see what feels best o Hold with handle pointing down OR up (scope upside down) OR as a pencil, pointing to forehead
to you.
o Scope can be held with same hand as the ear you are examining (In right hand when examining right
ear…etc) or can simply be kept in dominant hand.
o Anchor hand on patients forehead with pinky and/or ring finger for stability prior to inserting
speculum into ear canal
o Pull auricle up and back with free hand to straighten ear canal
o Go slowly and gently—asking for feedback from patient as you advance scope
o Once speculum inside canal, angle anteriorly to optimize view of TM
• Assess hearing by whisper test or rubbing two fingers together (tuning forks may be used, below)
19
• Advanced hearing maneuvers with tuning forks learned during Scopes Session in April 2016
Nose: • Inspect size, structure, and position; assess nares size and symmetry as well as any discharge
• Assess patency of each nostril, sniff test
• Visualize the nasal septum, turbinates, and middle meatus using a penlight or your otoscope
--Look for edema, erythema, mucous, blood
‘Throat’:
Inspect: mouth oropharynx
Mouth and
-Lips, oral mucosa, the gums and teeth -soft palate, uvula, tonsils, posterior wall
Pharynx
-oral cavity, tongue, floor of mouth, hard palate -with tongue in normal position, ask patient to say
-tongue blade can help retract buccal mucosa “ah” as in ‘job’ or “aaaa” as in ‘stab’ (CN IX)
-tongue strength: extend, move side to side -Can use tongue blade to depress tongue
(CN XII) -Careful not to GAG patient!
Palpation: to detect early oral cancers, gloved palpation of oral cavity should be performed on patients with
risk factors (smoking, tobacco use) or symptoms
NECK extremely sensitive area, talk through exam with patient & place hand respectfully on shoulder
• Inspect for obvious swelling, fullness, masses, symmetry, midline trachea; inspect while patient
swallows and observe for thyroid fullness or asymmetry
• Auscultate for bruits in either carotid artery with bell of stethoscope
• Palpate
1) Tracheal deviation: place thumbs on each side at suprasternal notch noting the space, and
compare with the opposite side
2) Lymph nodes (submandibular, submental, anterior and posterior cervical, pre- and post-auricular,
occipital, supraclavicular) Correct technique: use flats of fingertips in a gentle, circular motion
3) Carotid pulses: check them one at a time, listen for bruits in advance
4) Thyroid : --Identify hyoid bone and cricoid cartilage and inspect region below for the thyroid
--Ask examinee to take water in mouth and hold it without swallowing
--Position yourself either anteriorly or posteriorly
rd th
Anterior approach: place both index fingers just below cricoid cartilage, Place 3 & 4 fingers on either
side, ask the examinee to swallow
Posterior approach: reach around patient’s neck w/ both 3rd fingers, place them just below cricoid
rd th
cartilage; Place index fingers superolaterally & 3 & 4 fingers inferolaterally (approximating the contour of
the thyroid) and ask the examinee to swallow
• Assess Neck ROM: Have patient perform below maneuvers while assessing for pain, limitations
of movements, or other symptoms
 Flexion: touch chin to chest
 Extension: look up at ceiling
 Rotation: turn head to each side, looking directly over shoulder
 Lateral flexion: tilt head, touching each ear to corresponding shoulder
20
Video Links &

Other HEENT: http://www.med-ed.virginia.edu/courses/pom1/pexams/HEENT/
Resources
http://depmedicina.med.up.pt/opeta/musculo/MS_ch2.html
Documentation HEENT: Head symmetric, no masses noted. Lids, lashes, sclerae, and conjunctivae clear. No discharge. Pupils equal, round and reactive to light
(PERRL). Extraocular movements intact. (EOMI) Tympanic membranes (TMs) clear and without erythema; nasal septum not deviated, turbinates
without edema, erythema, or purulence. Oral mucous membranes moist (MMM); oropharynx clear.
Neck: supple. Trachea midline. No lymphadenopathy or masses. No spinal tenderness. Full range of motion (ROM). Thyroid: no masses palpated.
21
PE Skills Session 3: Cardiovascular and Pulmonary Exams
Recommended 10 minutes: check-in, appoint time-keeper and write schedule on board TIPS: Review appropriate doctor-patient
Schedule 5 minutes: review last week (Patient-Doctor Interactions, Observation, VS, Skin) Interactions, gowning and handwashing!!
15 minutes: demo this week (Chest, Cardiovascular)  Exam should be on BARE SKIN, always DRAPE
50 minutes: practice cumulative exam, observe and feedback with individual students appropriately
10 minutes: practice oral/written presentations and check out Compare lungs side to side
TOPIC/EXAM KEY TECHNIQUES: SURFACE ANATOMY:
Chest/Lung 1) Inspect Anterior Thorax: Posterior Thorax:
Exam a) Size, shape (A-P diameter), symmetry, scars suggestive of prior surgery/injury
b) chest movement with breathing for symmetry & use of accessory muscles
Posterior thorax 2) Palpate
a) thoracic expansion with deep breathing
i) Place both hands on patient’s lower post thorax with thumbs touching during
breath, can pinch a skin fold between thumbs of each hand. Observe for
asymmetry in movement of hands/thumbs with breathing
Draping hints: b) tactile fremitus (advanced maneuver)
For anterior i) Use either the ball of your palm or the ulnar surface of your hand
exam, you can > Ask the patient to repeat the words “ninety-nine”
expose one > palpate both sides simultaneously to compare sides in four areas
shoulder or 3) Percuss: Ask the patient to keep both arms crossed in front of the chest, percuss
hemi-thorax at a posteriorly in 4-5 places each side (see diagram)
time. For i) Press the DIP joint of the left middle finger firmly against the chest wall, avoiding
listening to contact with other fingers
lungs/heart on a ii) Strike DIP joint with the tip of the right middle finger, swinging from the wrist
female, ask if iii) Percuss from side to side, comparing as you go along
she can displace iv) Estimate diaphragmatic excursion by percussion
breast away 4) Auscultate for breath sounds
from exam area a) Instruct the patient to breathe deeply through an open mouth
for improved b) Listen with the diaphragm of the stethoscope in the same areas in which you
exposure (e.g. percussed + anteriorly (see diagram)
during mitral i) Always auscultate side to side, comparing the sounds you hear
listening) ii) Posteriorly, practitioners generally listen in four paired positions medially (not
over the scapulae) and in two paired positions laterally.
iii) Grow accustomed to normal lung sounds in different areas before focusing on
adventitious (abnormal) lung sounds, which will be covered later
areas for percussion and auscultation

Anterior thorax 1) Inspect the shape of the patient’s chest and movement of the chest wall BREATH SOUNDS: normally ‘vesicular’ BS heard over
2) Auscultate the anterior chest, comparing sides (this will allow you to listen to the right more peripheral lung, while ‘bronchial’ BS heard more
middle lobe and the lingula) centrally, over larger airways
22
PE Skills Session 3: Cardiovascular and Pulmonary Exams
Cardiovascular 1) Drape the patient to expose the precordium Suprasternal
manubrium
2) Examiner should stand at the patient’s right side--ideal position, patient laying supine with notch
Heart and head at 30 degrees Body of
Sternal angle
Precordium 3) Inspect precordium for apical impulse and any other movements sternum
4) Palpate precordium for thrills, heaves or lifts and the point of maximal impulse (PMI) using
palmar surface of hand
i. Ask for permission to displace a woman’s breast upward or laterally, or you may A
ask her to do this for you
ii. Note location of PMI, amplitude and duration—normally apical area over left ventricle
5) Auscultation of the heart (2245 Apt. M -- see figure)
nd
a. Listen to the heart with the diaphragm of your stethoscope in the R 2 ICS (Aortic valve),
nd th th
L 2 ICS (pulmonary valve), L 4 ICS (tricuspid valve) and the left lower sternal border (5 ICS) P
and at the apex (at the mid-clavicular line)(mitral valve)axilla
b. Also listen to the heart with the bell of your stethoscope for lower pitched sounds (some T
murmurs, extra heart sounds, or rubs) in the same five listening areas
c. You may progress through listening areas by starting at the base (aortic/pulmonic area)
and moving caudally OR by starting at the apex (mitral area) and proceeding cephalad M
Listening Areas:
Vascular Exam • Inspection of the jugular venous distention (JVD) is an advanced maneuver and will be 2245  refers to the intercostal spaces
covered later, but may be discussed if time permits APT. M  aortic, pulmonary, tricuspid, and mitral valves
• Auscultation: listen for bruits (caused by turbulent flow in narrowed arterial lumen) with
bell over aorta, carotid & renal arteries
FIRST PRACTICE LISTENING FOR S1 and S2 during cardiac
• Palpate the radial, brachial, aortic, popliteal, dorsalis pedis, and posterior tibial arteries
auscultation to determine systole vs. diastole. Taking the
(If not already done during neck exam, also palpate carotid pulses if no bruits heard.)
carotid pulse simultaneously can be helpful in determining
a) Compare from side to side (except for the aorta); noting any differences.
where you are in the cardiac cycle
b) Amplitude of pulses are graded from 0 (not palpable) to 2 (expected) to 4 (bounding)
LATER, listen for extra heart sounds and murmurs
Video Links http://www.med-ed.virginia.edu/courses/pom1/pexams/VSandChestExam/
http://www.med-ed.virginia.edu/courses/pom1/pexams/CardioExam/
http://depmedicina.med.up.pt/opeta/cardio/CV_main.html
http://depmedicina.med.up.pt/opeta/chest/CH_main.html
Documentation Chest: Symmetrical expansion b/l, clear to auscultation bilaterally (CTAB)

CV: regular rate and rhythm (RRR), normal S1 S2 , no murmurs/rubs/gallops, PMI non-displaced, 2+ peripheral pulses b/l
Presentation On Exam, lungs are clear to auscultation bilaterally, PMI at midclavicular line, not sustained or displaced. Heart – regular rhythm without extra heart
sounds. Pulses symmetrical and 2+ throughout; no edema.
23
PE Skills Session 4: MSK Lower Extremities
Recommended 1:10-1:20 check-in TIPS: Review doctor-patient interactions and handwashing!!
Schedule 1:20-1:30 demo this week (hip, knee, ankle)  Please be sure to go through FULL ROM with each joint
1:30-2:50 practice – include full head-to-toe PE  Always compare an affected joint to its contralateral partner
2:50-3:00 practice oral/written presentations and check out Practice all maneuvers learned to date
Musculo- 1) Inspection: (always compare joints in pairs) General Questions for All Joint Problems:
skeletal a) Muscle wasting vs. hypertrophy - Where is pain?
Exam b) Ecchymosis, joint effusion / swelling, and erythema. - Onset of pain, sudden or gradual?
General 2) Palpation: bones, tendons, ligaments, and bursae for tenderness. - Nature of pain (stabbing, burning, sharp, constant, intermittent)
3) ROM: Document range of motion in each plane in which the joint moves. - Ever had this before? - How long? Improving or worsening?
Approach
Finding pain on active range of motion but not passive range of motion can - Swelling, numbness, redness, or loss of function?
be helpful to discern a muscular or tendinous etiology from a bony etiology. - Aggravating factors? - Arthritis at other joints?
4) Special testing: for each joint, there are special tests to specify the injury - Exercise, work & hobby history?
(tendonitis or joint instability) - Mechanism of injury (if known trauma)?
Exam: Key Techniques: Always compare an affected joint to its contralateral partner
LOWER A. Inspect and palpate:
Extremities: 1. Patient gait, rise from chair, and movement onto the exam table
Hip 2. Iliac Crest
3. Anterior-Superior Iliac Spine
4. Great Trochanter
5. Quadriceps muscles bulk and tone
6. Assess for pelvic stability
B. Active and passive range of motion & strength testing of italicized
o
1. Flexion (knee bent 120 , leg straight 90°) greater trochanter
o
2. Extension (with patient lying on side, lying prone or standing, 20 )
3. Internal (40°) and External (45°) Rotation with knee flexed to 90°
4. Abduction (45°) and Adduction (30°)
Knee
A. Observe: alignment and contours of knees while patient standing
B. Inspect and Palpate:
1. Observe for swelling, redness, and asymmetry of the joint
2. Palpate sup, ant and lat to patella to assess for effusion–ballottement
3. Palpate posterior to knee in popliteal space for fullness
4. Hold hand over knee with active/passive flexion to assess for crepitus
Questions specific for the knee joint:
5. Tibial tuberosity
-Any difficulty ascending or descending staircases?
6. Tibial plateau
-Is there pain with the first few steps after being seated for a
7. Medial & lateral femoral condyles
prolonged time? (suggestive for patellofemoral syndrome, one of the
8. MCL, LCL and joint lines
most common causes of knee complaints.)
9. Fibula
10. Patella and patellar tendon
o o
The anterior C. Check ROM: flexion (160 ) and extension (0-15 )
24
PE Skills Session 4: MSK Lower Extremities
drawer test is D. Special Tests:
o
done with the 1. Valgus Stress Test (MCL) - flex knee to 30
o
patient supine 2. Varus Stress Test (LCL) – flex knee to 30
and the knee 3. Lachman Test (ACL)
flexed 90 degrees. 4. Anterior Drawer Test (ACL)
This test is less 5. Posterior Drawer Test (PCL)
sensitive and Lachman test is the most reliable test to help in diagnosing a rupture of the
specific for an ACL ACL. The patient lies supine with the knee flexed 20 to 30 degrees and with
rupture than the the heel on the examination table. The examiner grasps the femur with one
Lachman test hand just above the knee, to reduce motion of the upper leg and to relax the
hamstring muscles. The other hand tugs forward on the lower leg briskly and
should feel a discrete endpoint. Absence of a discrete endpoint, or increased
anterior translocation of the tibia when compared with the contralateral side,
constitutes a positive test
Ankle/Foot A. Inspect: looing for obvious swelling,

deformities, redness, bruising, scars
indicating prior trauma or surgery,
ulcerations, skin & nail changes suggestive
of tinea or other disease processes DEEP TENDON REFLEXES
B. Palpate: Lower Upper Grades
1. Medial & lateral malleoli (ankle) Patellar Biceps 0, 1+ (absent, diminished)
2. Achilles tendon Ankle (Achilles) Triceps 2+ (normal)
3. Midfoot, arch Brachioradialis 3+, 4+ (brisk, hyperactive)
4. metatarsal / phalangeal joint (MTPs) Reflex TIPS:
th
5. 5 metatarsal (common site for avulsion, -Hold hammer loosely, let swing of hammer provide tapping force
Jones’ & stress fractures) -ensure patient muscles relaxed, isolate tendon
6. Ankle temp, PT & DP pulses, edema -passively dorsiflex foot to enhance ankle reflex
C. ROM: passive and active
1. tibiotalar joint: dorsi and plantar flexion
2. talonavicular joint: inversion & eversion
D. Ottawa Rules Foot xrays are indicated if pain
in the midfoot zone and any of the following: 1)
th
bone tenderness at 5 MT base, 2) of navicular,
or 3) inability to bear weight after injury
Video Links http://www.med-ed.virginia.edu/courses/pom1/pexams/LowExtrExam/
Documentation Hips with full ROM, nontender, Knees symmetrical b/l without scars; no joint tenderness to palpation of joint line, MCL and LCL intact, full ROM ,
normal gait and stance
25
PE Skills Session 4: Musculoskeletal Exam: Upper Extremities
Recommended 1:10-1:15 check-in TIPS:
Schedule 1:15-1:30 demo this week Review appropriate doctor-patient interactions and handwashing!!
1:30-2:15 practice  Exam should be on BARE SKIN
2:15-2:50 review and practice entire exam Practice all maneuvers learned to date!
(VS, Gen Appearance, HEENT, Neck, Pulmonary, CV, Abd, Back)
2:50-3:00 practice oral/written presentations and check out
Exam: Key Techniques: Notes:
Musculoskeletal 1) Inspection: (always compare joints in pairs) General Questions for All Joint Problems:
Exam a) Expose entire joint and surrounding tissues - Where is pain?
b) Muscle wasting vs. hypertrophy vs. bony deformity - Onset of pain, sudden or gradual?
General Approach c) Ecchymosis, joint effusion, swelling, or erythema? - Nature of pain (stabbing, burning, sharp, constant, intermittent)
2) Palpation: bones, tendons, ligaments, and bursae for tenderness - Ever had this before?
and/or warmth. Palpate muscles for bulk and tone - How long? Improving or worsening?
3) ROM: Document range of motion in each plane in which the joint - Swelling, numbness, redness, or loss of function?
moves. Finding pain on active range of motion but not passive range - Aggravating factors?
of motion can be helpful to discern a muscular or tendinous etiology - Arthritis at other joints?
from a bony etiology. - Exercise, work & hobby (sports, etc.) history?
4) Special testing: for each joint, there are special tests to specify the - Trauma? Mechanism of injury?
injury (tendonitis or joint instability)
5) Neuro: Muscle bulk, tone & strength should be assessed and deep
tendon reflexes of the each limb tested during MSK or neuro exam
UPPER A. Inspect, and palpate the following:
Extremities 1. Sternoclavicular joint 5. Acromion
Shoulder: 2. Clavicle 6. Bicipital groove
3. Coracoid process 7. Spine of the scapula
**note: Pain 4. Acromioclavicular joint 8. Deltoid muscle
with active ROM only, 9. Superspinatus & infraspinatus muscles
suggests tendon/
muscular injury, while B. Active and passive range of motion (ROM) testing, followed by
pain with passive ROM strength testing (movement against resistance) of italicized
seen with joint o
1. Forward flexion (180 ) Palms down, arms lifted upwards in front
inflammation. Pain of body (like sleep-walking) until above head
with both active and o
2. Extension (45 ) arms move from sides to behind body
passive ROM suggests o
3. Abduction (180 ) arms move upwards & outwards at sides of General Questions for Shoulder Pain:
subacromial bursitis or
adhesive capsulitis body, palms down (like jumping jack) until hands meet above head -Examinee’s age? Work? Hobbies? Old sports injuries? Handedness?
(“frozen shoulder”)** 4. Adduction (arm across chest) -Lifting above head? (Rotator cuff problems are more common in patients
5. External rotation hands behind head, elbows out = full ext rot’n > 50y – and in baseball pitchers.)
6. Internal rotation (‘Apply Scratch Test’ one thumb behind back, -Past med history: shoulder pain can also be caused by cancer metastatic
touching opposite shoulder blade~ T7 level) to bone, referred pain from heart disease; or by gallstones.
26
PE Skills Session 4: Musculoskeletal Exam: Upper Extremities
C. Special tests for rotator cuff injury: humerus
1. Impingement: pain with lateral arm abduction (also Neer or
Hawkins maneuvers)
2. Drop arm : if +, significant tear in supraspinatus tendon
3. Empty Can: if +, more likely supraspinatus injury, if -, possibly
subacromial bursitis
Elbow:
A. Inspect and palpate
‘Tennis Elbow’, 1) Medial & Lateral Epicondyles
(lateral epicondylitis) 2) Olecranon process
tenderness to 3) Radial Head
palpation at lat 4) Brachial artery
epicondyle or over B Check ROM & strength (of italicized)
radiohumeral joint 1) Flexion & extension
2) Pronation and supination
Wrist and Hand:
A. Inspect hands, including each finger, skin, joints, and nails,
interosseous muscles, hypothenar and thenar eminences
(deformities, contractures, swelling, atrophy, nodules, etc.)
B. Palpate wrists, distal radius and distal ulna, radial artery
C. Check ROM of the wrist (flexion, extension)
D. Check ROM of the fingers
1) make a tight fist with each hand
2) Extend and spread fingers radius ulna
3) spread fingers apart and back together
4) move thumb across palm and touch base of 5th finger, Test for CARPAL TUNNEL (median nerve compression)
and then back across palm and away from fingers - Tinel’s Sign: tap lightly over the volar aspect of wristpositive if tingling
5) touch the thumb to each of the other fingertips -Phalen’s sign: hold wrists in flexion for 60 seconds (or asking patient to
Deep Tendon E. Other maneuvers (Carpal Tunnel, etc.)  push the back of his/her hands together)positive if worsened tingling
Reflexes
**may also be done 1. Biceps FINKELSTEIN’s Test (for de Quervain’s tenosynovitis)
during separate neuro 2. Triceps Ask patient to grab thumb with same hand against palm and then move
exam** 3. Brachioradialis wrist toward the midline in ulnar deviationpositive if painful
Video Links http://www.fammed.wisc.edu/our-department/media/623/shoulder-exam (shoulder)

http://www.med-ed.virginia.edu/courses/pom1/videos/shoulder.cfm (Shoulder exam)
http://www.med-ed.virginia.edu/courses/pom1/videos/upextremities.cfm (Upper Extremities)
Documentation & Shoulders symmetrical; no joint tenderness, full ROM, no impingement sign, negative drop arm and empty can tests
Presentation Elbow and wrist with normal range of motion, no joint swelling or pain
27
PE Skills Session 5: Abdomen & Back
Recommended 5 minutes: check-in TIPS:

Schedule 10 minutes: review previous weeks (HEENT, Neck, CV, Pulm, Skin) Review appropriate doctor-patient interactions and handwashing!!
15 minutes: demo this week (Abdomen, Back)  Exam should be on BARE SKIN
70 minutes: practice Gowns open in back with drape on legs to ant superior iliac spine
10 minutes: practice oral/written presentations and check out Patient should lie supine with knees slightly bent for abd exam
Exam: Key Techniques: Notes:
Abdomen 1) The patient should be supine with arms at side and knees bent Great time to introduce the quadrants and organs located in each, noting
2) Expose abdomen from above the xyphoid process to the symphysis pubis. that it will be covered extensively in anatomy and the GI portion of M&N
3) Approach the patient from his/her right side
Draping hints: RUQ: liver and gall bladder
• Inspect
Ask patient to LUQ: spleen and stomach
a. general contour (scaphoid, flat, rounded, protuberant, distended, etc)
pull gown up RLQ: cecum and appendix
b. skin (for scars, striae, dilated veins, rashes, etc.)
and then push LLQ: sigmoid colon
c. umbilicus
their underwear Areas: Epigastric: pancreas, stomach and common bile duct
d. presence of any swellings, vascularity, pulsations, or peristalsis
down to the Periumbilical: small intestine
e. Inspect the abdominal muscles when the examinee raises their head to
level superior Suprapubic/Pelvic: bladder and uterus
detect masses or a hernia.
iliac spine
NOTE CHANGE IN ORDER OF EXAM
(hips). This is
• Auscultate (avoid bowel manipulation by palpating last)
where your
a. Place the diaphragm of the stethoscope gently on the abdomen
drape will start
b. Listen for bowel sounds
i. Listening in one spot is sufficient
ii. auscultate for the presence vs. absence of bowel sounds
iii. determine if normoactive, hypoactive, or hyperactive AND high or
low pitched
c. Listen for an aortic bruit on the midline just above the naval
• Percuss in four quadrants
a. Note differences between air-filled bowel and underlying organs
b. Discuss tympany vs. dullness
c. Percuss for liver span (normal is 8-12 cm)
Define the upper and lower edges of the liver in the mid-clavicular line,
starting at a level below the umbilicus
d. REMIND students to start LOW in the abdomen, at the pelvic brim and
proceed toward the patient’s head
e. Since retroperitoneal organs are not easily examined, kidneys are
evaluated indirectly with percussion at the costovertebral angles Percussion: IT TAKES PRACTICE! Press firmly with contact finger (plexor)
(learned as part of BACK exam) and use loose wrist action and brisk force with striking finger (pleximeter)
• Palpate in four quadrants
a. Always begin palpation AWAY from any painful area Review & reiterate proper palpation technique
b. Lightly in all four quadrants, the suprapubic and epigastric areas Palpation: Knees should be bent to relax stomach muscles. Hands warm.
Used tips of fingers with circular motion. First lightly, then more deeply.
28
PE Skills Session 5: Abdomen & Back
c. Deeply in all four quadrants, using a firmer dipping motion
d. Assess for masses, rebound tenderness, guarding, rigid vs. soft
e. Palpate for the liver edge, start at the pelvic brim
Alternate Technique: demonstrate “hooking technique”
i. Ask the patient to take in a deep breath
ii. Palpate upwards to feel the descending liver edge, use a rocking motion
f. Palpate for a spleen
i. Place L hand underneath the L costovertebral angle and press upward.
ii. With R hand, attempt to detect the spleen below the R costal margin.
Back g. Palpate for aorta, press deeply with one hand on each side of the aorta
BACK
C • Inspection and Palpation: assess for shape, symmetry, alignment,
contours/ curvature deformities. Palpate spinous processes for
tenderness and paraspinal muscles and trapezius for bulk, tone &
tenderness
T 1. Cervical (C): C7 (most prominent), T1 also prominent, just below C7
2. Thoracic (T): Normal Curvature vs scloliosis (lateral curvature), kyphosis or
lordosis (anterior-posterior curvatures). T7 is at lower level of scapula
3. Lumbosacral (L) : Iliac Crests (at L4)
4. Paraspinal muscles (spasm? tight? supple? symmetric?)
• Costovertebral Angle (CVA) Tenderness. Examination of the kidney is

best performed indirectly, by direct and gentle percussion of the
costovertebral angles with the fist Rebound Tenderness:
L During palpation, press deeply in one place, then let go quickly. Ask the
patient, “Which hurts more, when I press or when I let go?” If more pain
• Perform active range of motion testing of the back:
1. Flexion (have patient touch toes from a standing position) is elicited during the release of your pressing, rebound tenderness is
2. Extension (hands on hips, have patient lean backwards) present.
S 3. Lateral bending
4. Rotation Peritonitis (inflammation of the abdominal cavity lining) is much more
likely if rebound tenderness is present along with rigidity on physical
exam. Can be caused by numerous thing, including appendicitis,
cholecystitis, and bowel perforation.
Video Link http://depmedicina.med.up.pt/opeta/abdo/AB_main.html

http://videos.med.wisc.edu/videos/40412 (back)
Documentation Soft, non-tender, non-distended, BS present, tympanic to percussion, no guarding or rebound, no hepatosplenomegaly (HSM)
Presentation On exam, the abdomen is soft, non-tender, non-distended; bowel sounds present; liver span 8cm
29
PE Skills Session 6: The Essential Neurological Exam & Other Neurologic Evaluation Maneuvers
Essential Exam The neurological exam is comprised of the following major components: TIPS:  parts of neuro exam may be integrated into MSK (reflexes,
(screening) A. Mental Status E. Sensory Exam muscle strength) or HEENT (cranial nerves)
General B. Cranial Nerves F. Coordination remainder of comprehensive neuro exam (learned in BMB) should be
Approach C. Motor Exam G. Gait performed if abnormalities detected in screening exam
D. Reflexes
Exam: Screening Essentials: TIPS
Mental Status Assess orientation by asking the patient tell you the location and the date. Naming, show items convenient to you (ie: pen, book, wristwatch)
(MS) During conversation, listen for fluency. Have the patient name two 3-step command “Take this paper, fold it in half & put it on the table”
objects, repeat a sentence and follow a three-step command. Repeat a sentence: “No ifs, ands, or buts”
Cranial Nerves -------------------------------------------- --------------------------------------------
(CNs) Check visual fields (II), pupil size and reactivity (II, III), extraocular movements Visual fields, (both eyes open), stand at eye level with hands equidistant
(III,IV,VI), and facial strength (VII). smile between examiner and patient. Test by placing one finger out in the
**may be done as periphery and asking the patient when s/he sees it move. (for more subtle
deficits, hold up 1, 2 or 3 still fingers in periphery, ask what is seen)
part of the HEENT
Facial strength Ask patient to wrinkle the forehead, close eyes tightly,
& neck exam**
puff out the cheeks, and smile. Note differences between the upper third and
lower two-thirds of the face (central vs. peripheral lesion)
Close eyes tightly Wrinkle forehead
Motor Exam Visual fields --------------------------------------------

Screen for motor function by checking pronator drift, finger taps and foot taps.
 Function
Assess extremity tone and check strength of finger extensors and toe extensors
 Tone (extensor hallucis longus).
 Strength Muscle Strength grading '0 – 5 / 5':
0 - no movement --------------------------------------------
1 - flicker of contraction Pronator drift, patient holds arms forward, fully extended and supinated
2 - movement with gravity (“like holding a pizza”), ask to maintain posture for~10 sec with eyes
*may do during eliminated (i.e., requires support) closed. Normal=arms stay in same position. Asymmetry during 10 sec
MSK exam* 3 - barely moves against gravity (ie: pronation in one arm), may indicate problem with motor function.
4 - between 3 and 5
5 - full power Pronator drift finger and foot tap, very sensitive test for integration of motor function—
The patient repetitively taps index finger against thumb or taps each foot
Other motor/
on floor. Look for rapid and even rhythm.
function
Testing larger muscle group strength can be helpful in identifying proximal Tone UE: Grasp arm above the wrist. Gentle shake the arm and rapidly
Large muscle
weakness: shoulder abduction, elbow extension, wrist extension, finger extend it while stabilizing at the elbow. LE: With patient supine, raise
groups abduction, hip flexion, knee flexion, ankle dorsiflexion knee quickly and observe foot. The heel should slide along the bed as
Ask the patient to get up from a chair, walk 10 feet, turn, and return to the knee easily flexes rather than lifting off the bed. Grasp leg above ankle
Timed Get up chair. Most older adults can complete this test in 10 seconds. >20 sec is and gently shake it side to side. Spastic= resistance to passive stretch in
and Go abnormal and correlates with increased risk of falls one direction Rigid = resistance to stretch in both directions
30
PE Skills Session 6: The Essential Neurological Exam & Other Neurologic Evaluation Maneuvers
Reflexes Check the biceps (C5,6), patellar (L4) and Achilles or ‘ankle’ (S1) reflexes. Strength Extend or flex body part against resistance. More sensitive if
(DTRs) Reflex grades: 0 absent 1+ diminished 2+ normal muscle isolated and tested one side at a time. Have patient straighten
Ankle reflex 3+ heightened or ‘brisk’ 4+ clonus fingers out with palm down. Support hand above the metacarpal joints,
*may do during the use your own fingers from the other hand to resist extension. For toe
MSK exam* extension, stabilize foot with one hand, use the other to oppose the great
toe extension.
Best tested in a sitting position, feet off the floor & patient completely
relaxed. Identify target tendon with finger. Hold reflex hammer loosely
between finger and thumb and allow it to swing freely, so the weight of
the head briskly taps the tendon. For Achilles testing, passively dorsiflex
Sensory Exam Biceps reflex foot to better appreciate a plantar flexion response.
Romberg Check whether the patient can feel light touch on each distal extremity and --------------------------------------------
whether she can detect double simultaneous stimulation using light touch on Light touch Brush finger tips lightly over a distal point on each extremity.
the hands. Perform the Romberg maneuver. Ask: Does patient feel? Same or different on both sides?
Double simultaneous stimulation—screens for loss of cortical function.
Patient’s closes eyes, touch one or both hands and have patient identify
the point(s) of stimulation (instruct to say “left,” right,” or “both”). With
parietal lobe lesion, patient will be unable to identify the stimulus on the
contralateral side when simultaneously touched.
Romberg maneuver—test of proprioceptive sensation. The patient stands
with feet close enough together to maintain balance with eyes open,
Finger to nose then closes eye. Abnormal = loss of balance when eyes closed.
Coordination --------------------------------------------
--------------------------------------------
Observe patient at rest and during spontaneous movement. Test finger-to-
Finger-to-nose—Patient touches index finger to his/her nose, then your
nose.
finger, back and forth. Note accuracy and not speed. Be sure patient’s
--------------------------------------------
arm is stretched toward full extension. Observe for tremor near target
If the patient is safe upright, ALWAYS test the gait! Observe base, stride,
Gait --------------------------------------------
posture, arm swing, turn and heel-to-toe (tandem) walking. Toe and
Gait--Describe what you see as patient walks freely and relaxed, as
heel walking will test both strength and function of lower leg muscles
(see “Get up and though strolling on the sidewalk. Observe base, posture, balance,
symmetry of leg movements in walking, arm movements.
Go” test above)
Toe and heel walking are good tests of gastrocnemius/soleus and
tibialis/peroneus function, respectively. Heel-to-toe walking (tandem
tandem gait gait) can bring out subtle abnormalities in posture and balance.
Video Links http://vimeo.com/album/2234882/video/55797563 (UCSF Essential Neurological Exam)
Documentation Alert and oriented x 3, language fluent and cogent, CN II-XII intact, motor strength 5/5 in upper & lower ext, normal muscle bulk and tone. DTR 2+
throughout (bilateral biceps, patellar, and ankle) and no sensory deficits to light touch, negative Romberg. Normal finger-to-nose, no tremors. Gait normal
with normal tandem walking.
31
Foundations of Patient Care (FPC) FPC Foundational Exam Heather Nye, MD, PhD
UCSF School of Medicine October 20, 2015
Suggested Schedule: TIPS:
Arrive to the Kanbar Center on time! You will have a brief orientation to the center prior to the exam. Also- please come • Study your short sheets and checklist to
prepared to change into a gown and be draped. When it is your time to perform the exam, you will wear a white coat prepare. Make sure you can perform the
over your gown, to limit the time spent on role switching (patient to examiner and vice versa). Please bring your Foundational Exam in less than 30
stethoscope and wear your name tag. minutes.
• Check final student schedule & pairings on
iRocket for exact time and exam room
number. Arrive on-time and ready to start.
OVERVIEW
I. FORMAT OF THE OBSERVED FOUNDATIONAL EXAM AND SIGN UP
You and a partner from your PE practice group will sign up for a specific one-hour time slot with a faculty observer. Check your schedule for conflicts before signing up.
Sign-up sheets are posted on the CLE. The faculty observer will likely NOT be your PE Skills group instructor. Each student will have up to 30 minutes to perform a brief head
to toe exam on a partner and to receive feedback. Aim for 20 minutes to allow time for feedback. Partners will then switch places for the second half of the hour. The exam
we are asking you to perform is delineated on the foundational exam checklist attached to your calendar. This checklist does NOT include every detailed maneuver that you
may have learned (e.g., checking for diaphragmatic excursion during the lung exam), but represents an example of a basic screening examination. There will be more
maneuvers studied more extensively in the coming months, and therefore optional (in italics). Please memorize the foundational exam and practice it until your physical
exam is fluid and comfortable.
II. EVALUATION
The purpose of this exercise is to ensure that you have learned the mechanics of how to perform a basic physical exam. Your faculty observer will be checking to see that
you perform the mechanics of the exam properly. Although some of you may be anxious about having to demonstrate your skills in this way, the opportunity to have one-
on-one observation and feedback is really a luxury, so try to have fun practicing. Students in past years have been grateful to have such a chance to solidify their skills. If
your faculty observer feels that you have not performed as well as s/he thinks is adequate, s/he will refer you to Dr. Heather Nye for additional help. Very few students
have needed this in the past. Remedial help consists of getting tutoring on the parts of the exam with which you are having trouble, and then repeating the exam with Dr.
Nye or her designate as your observer.
III. PRACTICE
Your weekly cumulative exam practice during PE Skills Sessions will be the best preparation for the Observed Exam. Be sure to take advantage of this time to consolidate
the multiple components of the exam as you have learned them and practice them in a logical and predictable order.
We encourage you to also practice with a peer or willing friend or family member, taking care to also focus on the professional aspects of your exam (i.e., hand washing,
attention to patient comfort, draping, communication).
Resources:
1. PE Skills Short Sheets and videos for Sessions 1 – 6 & Foundational Exam Check list
2. Review any relevant chapters of Bates necessary to consolidate your learning.
3. Final Student Schedule attached to iRocket Calendar session.
This session addresses the following UCSF School of Medicine Medical Student Competencies: Patient Care, Practice-Based Learning & Improvement
32
Foundations of Patient Care (FPC) FPC PE Skills: Oral Health Susan Hyde, DDS, MPH, PhD
UCSF School of Medicine 10/27/2015 OR 10/29/2015: 1:00 – 3:00PM Heather Nye, MD, PhD
Suggested Schedule: TIPS:

 HEENOT; O represents an oral exam
PLEASE SEE IROCKET/CLE COURSE PAGE FOR SCHEDULE as part of the Head, Eye, Ear, Nose
and Throat physical examination
Overview and Learning Objectives
Oral health contributes to and reflects systemic health and is therefore the responsibility of all health care professionals. Poor oral health has been
associated with many systemic diseases including cardiovascular, diabetes, and pneumonia. This session is designed to teach primary care providers to
assess a patient’s oral health status, provide patients with basic preventive oral health care and effectively communicate with dentists about a
patient’s oral health. The learning objectives of this session are to:
• Discuss the relationship between oral health, systemic health and global health.
• Review basic dental and oral anatomy and physiology.
• Understand and be able to assess the risks and protective factors for dental caries.
• Perform an oral examination that screens for disease, dysfunction, and discomfort.
• Write a descriptive referral of findings to a dentist.
• Perform a preventive fluoride varnish application.
Order of Importance
1. Watch the oral health articulate presenter
2. Watch preforming an oral examination and applying fluoride varnish demonstration videos
3. View additional resources: Caries Risk Assessment Form, Common Oral Pathology Lesions, and Clinic Referral Guide
Topic/Exam Notes
Tooth 20 primary teeth, 32 permanent teeth
Enamel
Anatomy Tooth Structure Dentin
• Enamel: hard outer mineral matrix that protects the tooth Pulp
• Dentin: softer than enamel, gives tooth its color
• Pulp: contains nerves and blood vessels
This session addresses the following UCSF School of Medicine Medical Student Competencies: Patient Care, Medical Knowledge
33
Foundations of Patient Care (FPC) FPC PE Skills: Oral Health Susan Hyde, DDS, MPH, PhD
UCSF School of Medicine 10/27/2015 OR 10/29/2015: 1:00 – 3:00PM Heather Nye, MD, PhD
Basic Oral Supplies Caries can appear as dark stains or as white spots on teeth.
Examination • Gauze, gloves and penlight
Extraoral
• Palpate the lymph nodes in the area of the oral cavity
• Exam the lip and vermillion border
Intraoral
• Examine the maxillary and mandibular vestibule, right and left Oral Pathologies can have many different presentations and
buccal mucosa and the gingiva occur on intra and extra oral tissues.
• Examine the dorsum and lateral borders of the tongue
• Examine and palpate the floor of the mouth
• Examine the palate of the mouth
• Examine the facial and occlusal surfaces of both maxillary and
mandibular teeth
Fluoride Supplies Fluoride primarily works topically to remineralize enamel,

Varnish • Fluoride varnish, gauze, gloves and penlight making it stronger and more resistant to caries.
Application
• Ask your patient to hold the fluoride varnish
• Dry the teeth and apply the varnish liberally to all surfaces of the
teeth one quadrant at a time
Post-Op Instructions
• After application the patient should not eat or drink (except
water) for 60 minutes
• The patient should not brush their teeth until the following
morning
Resources:
1) Link to Resource: National Institute of Dental and Craniofacial Research’s guide to performing an oral
examination: http://www.nidcr.nih.gov/oralhealth/Topics/OralCancer/DetectingOralCancer.htm
2) Link to other
This session addresses the following UCSF School of Medicine Medical Student Competencies: Patient Care, Medical Knowledge
34
PE Skills Session 9: Cardiovascular Exam Revisited
Short Sheet 2015 H. Nye
Recommended 5 minutes: check-in, appoint time-keeper and write schedule on board TIPS: Review appropriate doctor-patient
Schedule 15 minutes: demo cardiovascular exam, review important elements of history Interactions, gowning and handwashing!!
45 minutes: practice  Cardiac exam should be on BARE SKIN
40 minutes: cases / simulated heart sounds  BEGIN TO INCORPORATE HISTORY & DIFFERENTIAL
5 minutes: review and check out DIAGNOSIS BUILDING INTO PHYSICAL EXAM
TOPIC/EXAM KEY TECHNIQUES: SURFACE ANATOMY:
History  exercise capacity (how many blocks or flights of stairs patient can walk, changes?)
 risk factors for coronary disease (male, smoking, DM, HTN, hyperlipidemia, obesity,
age >55 men, >65 women, +family history for premature CAD= MI in female relative
<55years, male relative <45 years)
 family history of cardiac disease (MI, CHF, sudden death, angioplasty/cardiac surgery, pacer)
 cardiac symptoms (CP, SOB, Edema, palpitations, orthopnea, syncope…etc.)
Vascular Exam A. Inspection of the jugular venous distention (JVD) The right internal jugular (IJ) is in straight-line
JVD communication with the right atrium. The IJ can therefore function as a manometer, with
distention indicating elevation of Central Venous Pressure (CVP) ~ RA pressure. The external
jugular vein is more easily seen and has been shown to be a reliable surrogate for JVD.
1. Patient at 30-45 degree incline, head turned slightly to left, examine from right side
2. Identify right IJ venous pulsations (bi- or tri-phasic vs. monophasic carotid)
3. Measure height of right IJ from top of sternal angle and add 4-5cm (height to RA)
4. Normal JVP is <8-9 cm, DDx if elevated: CHF (rt or left), volume overload, tricuspid
stenosis, pulm stenosis, pulmonary htn, constrictive pericarditis, tamponade)
5. Abnormal pulsations: large a, ‘cannon’ a, Kussmaul=JVP rise with inspiration
6. Hepatojugular Reflux
-Apply pressure over the RUQ for at least 10 seconds (some suggest to 1 minute).
-An increase in JVP of >3 cm for >10 second is a positive HJR test= right heart failure
B. Palpate the carotid pulse
1. Listen for bruit first, palpate only ONE carotid artery at a time
2. Assess amplitude, contour, variations (beat to beat or with respirations)
3. Weak & Delayed? (AS) Bounding? Water Hammer? (AI) Pulsus Alternans? (LV dysfunction)
Heart and A. Inspect precordium for apical impulse and any other movements Cardiac listening areas
35
PE Skills Session 9: Cardiovascular Exam Revisited
Precordium B. Palpate precordium for the point of maximal impulse (PMI) using palmar surface of hand Suprasternal
manubrium
1. Displace a woman’s breast upward or laterally, or ask her to do this for you notch
Murmur Grades
2. Note location of PMI, amplitude and duration, HAVE PT LEAN TO LEFT SIDE to augment Body of
Sternal angle
1/6 very faint, only
C. Auscultation of the heart (2245 APT. M -- see figure) sternum
heard with optimal
nd
conditions 1. Listen to the heart with the diaphragm of your stethoscope in the R 2 ICS (Aortic valve), L
2/6 quiet, but heard nd th th
2 ICS (Pulmonary valve), L 4 ICS (Tricuspid valve) and the left lower sternal border (5 ICS) and
immediately
3/6 mod. loud
at the apex (Mitral valve)axilla A
4/6 loud (+thrill) 2. Listen to the heart with the bell of your stethoscope in the same five listening areas
5/6 very loud, heard 3. Focus on S1 and S2, systole (between S1 & S2) & diastole (after S2)
with scope partly off 4. Attempt to hear physiologic split S2 (listening in pulmonic area) with deep respirations
chest (+thrill)
6/6 very loud, heard
P
with scope off chest
(+thrill) T
M
CHF findings
5. Extra heart sounds? (S3, S4, rub)

6. Murmurs
D. Special Maneuvers pt laying to left: augments S3, PMI, some diastolic murmurs (MS)
Pt sitting up and breathing out: may augment AI
The Periphery A. Inspect Cyanosis? Clubbing? Distorted/swollen limbs
B. Palpate 1. Cool or warm?
2. Edema? (Sacrum, Lower extremities, Pitting?)
3. Arterial pulses: radial, brachial, aortic, popliteal, dorsalis pedis & posterior tibial
*Compare from side to side, noting any differences.
*Amplitude of pulses are graded from 0 (not palpable) to 2 (normal) to 4 (bounding)
TIPS / TRICKS -Timing: systole or diastole? -Quality (rumbling, sharp)

Describing a
-Area -Changes in intensity
murmur
-Intensity -Relationship to S1 & S2 (holosystolic, mid-systolic)
-Pitch (high or low) -Radiation (axilla, carotids)
Video Links http://www.youtube.com/watch?v=SFrsv6U-0KU (OPETA CV, special maneuvers)
http://www.med-ed.virginia.edu/courses/pom1/pexams/CardioExam/
Documentation CV: regular rate and rhythm (RRR), normal S1 S2 , 3/6 holosystolic ejection murmur (SEM) at apex, radiating to axilla. +S3. No thrill. PMI non-displaced, + 2
peripheral pulses b/l , normal carotid upstroke without bruits, JVP elevated to ~10cm, ++hepatojugular reflux. 2+ LEE bilaterally
36
PE Skills Session 10: Pulmonary Exam Revisited
Recommended 5 minutes: check-in, appoint time-keeper and write schedule on board TIPS: Recall appropriate doctor-patient
Schedule 15 minutes: review lung fields, exam (demo prn) & important elements of history interactions, gowning and handwashing!
80 minutes: practice exam cases / lung sounds, evidence based PE, clinical prediction rule  Exam should be on BARE SKIN
10 minutes: Review sounds and check out Compare lungs side to side
TOPIC/EXAM KEY TECHNIQUES: FIGURES:
Common Symptoms: Shortness of breath (dyspnea), cough (productive vs. non-productive), chest pain Chest SHAPE
Symptoms / Normal Barrel P. Excavatum
Signs / History Specific historical elements: Frequency of ‘colds’ or respiratory illnesses? Seasonal variation?
What helped in the past? Fevers? Sick Contacts? Smoking history? Asthma? Allergies?
Change in environment (work, housing)? Potential occupational exposures (work history)?
Prior Hospitalizations? Intubations?
Chest/Lung -Vital Signs (Tachycardic? Tachypneic? Hyper/Hypotensive? O2 Saturation?)

Exam -Skin Color (Pale? Red? Cyanotic?)
-Speaking (Complete sentences? One word sentences?)
Inspection -Posture (Tripod? Able to move from chair to table?)
-Shape of chest (barrel?COPD, P. excavatum, kyphosis, scoliosis?restrictive lung disease)
-Work of breathing (Accessory muscle use? Retractions? Abdominal breathing?)
-Pattern of breathing (Normal? Tachypneic? Kussmaul? Cheyne-Stokes?)
-Audible respiratory sounds (Stridor? Wheeze?)
-Signs of upper respiratory illness? (Rhinorrhea? Conjunctivitis?)
Tripod
Posterior thorax 1) Palpate
a) thoracic expansion with deep breathing
i) Place both hands on patient’s lower post thorax with thumbs touching during
breath, can pinch a skin fold between thumbs of each hand
b) tactile fremitus (increasedconsolidation, decreasedeffusion or pneumothorax)
i) Use either the ball of your palm or the ulnar surface of your hand
> Ask the patient to repeat the words “ninety-nine”
> palpate both sides simultaneously to compare sides in four areas
2) Percuss Ask the patient to keep both arms crossed in front of the chest
i) Percuss from side to side, comparing as you go along
ii) Estimate diaphragmatic excursion by percussion
3) Auscultate for breath sounds
a) Instruct the patient to breathe SLOWLY and DEEPLY through an open mouth
b) Listen with stethoscope diaphragm in the same areas percussed
i) Auscultate side to side, comparing sounds from one side to the other.
ii) Listen in four paired positions medially and in two paired positions laterally.
Anterior thorax Auscultate breath sounds in three paired positions anteriorly and at the mid-axillary line
Surface Anatomy
bilaterally, comparing sides (this will allow you to listen to the RML and the lingula)
37
PE Skills Session 10: Pulmonary Exam Revisited
Air Movement Normal, decreased or absent
Ratio of insp/exp phase (usually 1:1 or 1:2), 1:3 or 1:4 in obstructive pulmonary disease
Normal Lung Vesicular – soft, breathy, heard over most of lungs, esp periphery (alveoli, sm airways)
Sounds Bronchial—loud, high-pitched, heard over central lung fields, gap b/w insp and exp sounds
Bronchovesicular—medium intensity and pitch, heard over central chest—abnormal if heard
elsewhere
Adventitious Crackles (Rales) (wet, dry, fine, course) discontinuous, nonmusical, most common on
Lung Sounds inspiration. Small ‘pop’s, small airways opening with fluid/pus in alveoli
Rhonchi (course, fine) low-pitched, continuous, musical sounds often from larger airway
secretions, ‘snoring’-like quality
Wheeze continuous, high-pitched, continuous whistling or musical sounds, most often during
expiration, but also on inspiration, air flowing through narrowed airways due to secretions,
swelling, or foreign body
Rub- dry, leathery sound that can indicate pleural inflammation (insp & expir)
Egophony increased resonance of voice sounds over areas of consolidation or fibrosis
( transmission of high-frequency noise), high pitched, nasal/bleating quality
E-to-A changes E sounds like A (nasal quality) over areas of consolidation COPD
Evidence-Based Compiled data from several studies, likelihood ratios (LR) for pneumonia given the presence or
Medicine absence of individual symptoms, historical features, or exam findings NS=not significant
(EBM):
Pulmonary Hx Hx/Sxs LR+ LR- PE findings LR+ LR-
& Exam Dyspnea 1.4 NS in 2 studies 0.67 RR>25 1.5-3.4 0.78-0.82
Sputum 1.3 0.55 dullness to percuss. 2.2-4.3 0.79-0.93
pneumonia Fever 1.7-2.1 0.59-0.71 crackles 1.6-2.7 0.62-0.87
Cough 1.8 NS in 2 studies 0.31 rhonchi 3.5 0.90
Adapted from Rhinorrhea 0.78 NS in 1 study 2.4 bronchial breath sounds 1.4-1.5 0.76-0.85
*Metlay JP, et al. Hx asthma 0.10 0.85 egophony 2.0-8.6 0.76-0.96
-------------------------------------------------------------------------------------------------------------------
http://www.med-ed.virginia.edu/courses/pom1/pexams/VSandChestExam/
http://stanfordmedicine25.stanford.edu/the25/pulmonary.html (focus on percussion)
Video Links http://depts.washington.edu/physdx/pulmonary/index.html (UW pulm exam, EBM)
--------------------
Chest: Symmetrical expansion b/l, no increased work of breathing, normal & equal
Documentation percussion in posterior fields, 5cm diaphragmatic excursion. Bibasilar crackles on inspiration.
No wheeze, rhonchi, or egophony. COPD Risk Factors Age
Smoking Severe lung infections as child
*Metlay J,
Kapoor W,Fine MJ. Does this patient have community-acquired pneumonia? JAMA 1997; 278: 1440-5. Occupational exposure Family history of lung disease
38

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Foundations of Patient

Physical Exam Skills

Welcome to UCSF and to the Foundations of Patient Care (FPC)

As part of the FPC curriculum, you will have several guides, an

My colleagues and I are here to challenge and support you during

Heather Nye, MD PhD

Faculty & Staff Contact Information ………………………………………………………....1

Dates for Physical Exam (PE) Skills Groups ………………………………………………..2

UCSF Peer Physical Exam Policy…………………………………………………………...11

Foundational PE Exam Checklist.……………………………………………………………14

Complete PE Exam Checklist………………………………………………………………..15

Short Sheets: Sessions 1 – 10……………………………………………………………….17

FPC FACULTY AND STAFF

FPC-1 Course Director

Amin Azzam, MD, MA (415) 476-7836 amin.azzam@ucsf.edu

Dan Ciccarone, MD, MPH (415) 514-0275 ciccaron@fcm.ucsf.edu

Meg McNamara, MD (415) 206-4332 mcnamara@peds.ucsf.edu

Heather Nye, MD, PhD (415) 221-4810 Heather.Nye@ucsf.edu

Co-Director for PE Skills

Heather Nye, MD, PhD (415) 221-4810 heather.nye@ucsf.edu

Session 1: Intro, Instruments, Interactions, Inspection, VS & Skin

Session 2: HEENT & Neck Exams

Session 3: Cardiovascular & Pulmonary Exams

Session 4: Musculoskeletal Exam (Upper & Lower Extremity) 1-3pm ONLY

Session 5: Abdominal & Back Exams

Session 6: Neurologic Exam & Foundational Exam Review

Session 7: Observed Foundational Exam 8am-5pm

Session 8: Oral Exam & Dental Review 1-3pm ONLY

Session 9: Cardiology Exam Revisited

Session 10: Pulmonary Exam Revisited

**Adult PE Review (Exam, Self-assessment)**

Session 11: Scopes Session 8am-5pm

Welcome to the FPC Physical Examination Skills Curriculum!

• FPC PE Skills Sessions

• Professional Educators (Kanbar)

• Integrated Exercises (Kanbar)

• Kanbar Practice Sessions

• Adult PE Review (Kanbar)

2. University of Virginia School of Medicine

3. University of Florida College of Medicine (Online PE Teaching Assistant, OPETA)

4. University of Wisconsin School of Medicine and Public Health

PE Skills Sessions: Nuts & Bolts

Assessment & Evaluation

Peer Exams and Professional Behavior

No student will be required to be examined by a classmate if this results in severe

Q. What’s the best way to organize a full physical exam?

Two exceptions to above:

Q. Is there one right way to perform a physical exam?

Q. How much of the physical exam do I need to do on a patient?

UCSF School of Medicine

Peer Exams, Briefly:

Small Groups & Peer Partnering

Anxiety and Discomfort

Unexpected & Unusual Findings

OPTING OUT: What to do

Chain of Contacts for Concerns

BACK (sitting or standing) Mental Status

Adult PE Review (Exam, Self-assessment)

• Temperature normal = 37 C, 98.6 F fever T > 38.5 C, 101.5 F