[FIRST] SCREENING PE DEMO RUBRICS:

1. Observe general appearance

2. Vital signs (BP → CR → RR → Temperature)
3. Perform general survey of the skin
4. Inspect nails, hands, arms and joints
5. Palpate radial pulses simultaneously on both arms
6. Examine hair, scalp and face
7. Check facial asymmetry (CN VII)
8. Inspect external ears
9. Inspect puncta, conjunctiva, sclera
10. Assess pupillary reflex
11. Asses extraocular movements (CN III, IV, VI)
12. Inspect lips and oral cavity
13. Ask px to protrude tongue and move from side to side (CN XII)
14. Inspect tonsils, position and symmetry of palate and uvula with phonation (CN IX, X)
15. Palpate cervical lymph nodes
16. Inspect trachea
17. Inspect and palpate thyroid gland
18. Palpate spinous processes of each vertebrae
19. Percuss lungs posteriorly and anteriorly
20. Auscultate lungs posteriorly and anteriorly
21. Measure JVP
22. Auscultate carotid arteries for bruit
23. Inspect and palpate for PMI
24. Auscultate heart sounds in all valvular areas using diaphragm and bell of steth
25. Inspect abdomen
26. Auscultate abdomen
27. Percuss abdomen lightly on all 4 quadrants
28. Check for hepatomegaly
29. Check for splenomegaly
30. Palpate abdomen lightly then deeply in all quadrants
31. Assess for costovertebral angle tenderness
32. Inspect legs feet and joints
33. Palpate for pitting edema
34. Palpate dorsalis pedis, then posterior tibialis pulses on both legs
35. Check bicep and patellar reflexes
36. Check gait
 CBL 1: NECK PAIN
CBL Guide questions:
1. Describe the physical examination.
• Reference: Sample medical record (PE part)

2. Give at least 2 differential diagnoses.

• References: Chapter 51, The Patient History: an Evidence-based approach to ddx,
2nd ed
• Table 16-2 (Pain in the neck), p. 669 in Bates’ Guide to PE and Hx taking

3. What are the bases for your differentials?

4. What is the patient’s problem list?
• Reference: Sample medical record

CBL 2: BACK PAIN

CBL Guide questions:
1. Describe the physical examination.
• Reference: Sample medical record (PE part)

2. Give at least 2 differential diagnoses.

• References: Chapter 54, The Patient History: an Evidence-based approach to ddx,
2nd ed
• Table 16-1 (Low back pain), p. 668 in Bates’ Guide to PE and Hx taking

3. What are the bases for your differentials?

4. What is the patient’s problem list?
• Reference: Sample medical record