Saint Louis University

Medicine I
Comprehensive PE Checklist

General
1) Wash or sanitize hands before beginning examination.
2) Display a professional demeanor towards the patient during the exam
a) Introduce yourself as a medical student
b) Use the patient’s last name
c) Dress professionally in white coat
3) Appropriate interaction with the patient—sensitivity to privacy, comfort and dignity
4) Explain to the patient the procedures to be done.
5) Drape the patient appropriately during each segment of the exam
6) Use proper sequencing of the examination and proper pacing
7) All palpation and auscultation must be done on bare skin
8) Thank the patient after doing the examination.

NOTE: ITEMS IN RED ARE PART OF THE SCREENING PE. THE REST ARE DONE WHEN THE NEED
FOR THESE PE MANEUVERS ARISES.

I. GENERAL SURVEY
Skills Done US ND
1. Observe general appearance. Watch for signs of distress
2. Assess level of consciousness, coherence, orientation

II. ANTHROPOMETRICS AND VITAL SIGNS

Skills Done US ND
3. Obtain height and weight, waist circumference
4. Position the patient in comfortable sitting position. Arms abducted, slightly
flexed at the elbow and raised at heart level
5. Take temperature.
6. On the other extremity: Deflate the cuff then center the bladder of the
cuff over the brachial artery. Wrap the cuff around the arm snugly fitting
7. Estimate the systolic pressure by palpation of the radial artery. Rapidly
inflate the cuff until 80 mmHg then inflate by 10 mmHg increments until
radial pulse disappears. Deflate cuff at a rate of 2 mmHg per second noting
when the radial pulses reappears (palpated systolic pressure). Afterwhich,
deflate cuff promptly and completely.
8. Take the BP, using auscultation. Place the bell of stethoscope over
brachial artery.
9. Inflate cuff until 30 mmHg above the palpated systolic pressure then
deflate it slowly at a rate of 2-3 mm Hg per sec.
10. Note systolic (Korotkoff 1) and diastolic pressure (Korotkoff 5).

11. Take the radial pulse for 1 minute. Use pads of index finger and middle
fingers, compressing the radial artery until maximal pulsation is detected.
12. With fingers still on patient’s wrist, count respiratory rate in 1 minute by
watching movement of the chest wall. Another way is to auscultate over the
trachea, listening for the number of respirations per minute.

III. SKIN
Skills Done US ND
13. Perform general survey of skin – looking for nevi, rashes, dry skin, scars,
tattoos, other abnormal growths, etc.

IV. UPPER EXTREMITIES

Skills Done US ND
14. Inspect nails, hands, arms and joints.
15. Palpate radial pulses on the wrists at the same time.
16. Check range of motion of joints.

V. EXAMINATION OF THE HEAD, EYES, EARS, NOSE, THROAT, NECK

Skills Done US ND

17. HEAD: Examine the hair, scalp, skull and face

FACE
18. Check facial sensation to light touch and temperature (CN V);

Motor component: corneal reflex or jaw clench (motor component)

19. Check facial symmetry (CN VII): Test eyebrow elevation, forehead
wrinkling, eye closure, smiling, cheek puff

EARS
20. Inspect the external ear or auricle.
21. Inspect auditory canal with otoscope, selecting the largest available
speculum
22. Position patient’s head to allow best insertion of the otoscope
23. Pull the auricle gently upwards and backwards to straighten the canal
24. Hold otoscope between thumb and fingers
25. Insert the speculum gently into the ear canal and do inspection of the
auditory canal, cone of light, tympanic membrane
26. Assess hearing (auditory acuity – CN VIII): Ask the patient to occlude
one ear with a finger and then examiner whispers softly or rubs fingers 1 to
2 feet away towards the un-occluded ear
27. IF ACUITY IS DIMINISHED, check air and bone conduction:
Weber test (CN VIII): Test for lateralization
Place the lightly vibrating tuning fork firmly on top of the patient’s head
28. Ask where the patient hears it
29. Rinne test (CN VIII): Compare air conduction and bone conduction
Place the base of a lightly vibrating tuning fork on the mastoid bone
30. When the patient can no longer hear the sound, quickly place the fork
close to the ear canal and ask whether sound can still be heard.

EYES
31. Check visual acuity using a Snellen eye chart (CN II). Position the patient
20 feet from the chart. You may also use a Jaeger chart. Patient holds the
card 12 inches away.
32. Ask patient to cover one eye with a card and read the smallest line of
print
33. Repeat procedure on the other eye
34. Assess visual fields (CN II). Ask the patient to look with booth eyes into
your eyes
35. While you return the patient’s gaze, place your hands about 2 feet apart,
lateral to the patient’s ear.
36. Instruct the patient to point to your fingers as soon as they are seen.
37. Slowly move your wiggling fingers of both your hands along the
imaginary bowl and toward the line of gaze until the patient identifies them
38.Repeat this pattern in the upper and lower temporal quadrants
39. Inspect external eyes: Stand in front of the patient and survey eyes for
position and alignment
40. Inspect the eyebrows and eyelids
41. Inspect the region of the puncta, conjunctiva and sclera. Ask the patient
to look up as you depress both lower lids with your thumb
42. Inspect the cornea and lens, using a penlight shined obliquely across the
eye
43. Inspect iris, pupils for size and shape and symmetry (CN III, IV, VI)
44.Assess pupillary reflexes (CN III, IV, VI). Ask the patient to look into the
distance and shine a bright light obliquely into each pupil in turn
45. Assess Extraocular movements (CN III, IV, VI): From 2 feet directly in
front of the patient, shine a light into the patient’s eye and ask the patient to
look at it. Inspect the reflection in the corneas,
46.Ask the patient to follow your finger or pencil as you sweep through the
six cardinal directions of gaze
47.Ophthalmoscopic Exam (CN II): Turn the lens disc to the 0 diopter
48. Hold ophthalmoscope in your right hand to examine the patient’s right
eye, and hold it in the left hand to examine the left eye.
49. Instruct the patient to look slightly up and over your shoulder
50. Place yourself about 15 inches away from the patient. Shine light on
pupil and look for red-orange reflex. Then examine optic disc, retinal vessels,
retina and macula
NOSE AND PARANASAL SINUSES

51. Inspect the anterior and inferior surfaces of the nose. Push gently on the
tip of the nose to widen the nostrils.
52.Inspect the inside of the nose using an otoscope with the largest available
speculum. Tilt the patient’s head back slightly and insert the speculum
53. Inspect the nasal septum, inferior and middle turbinates
54. Palpate the frontal and maxillary sinuses
55. Assess sense of smell (CN I): Ask patient to identify odorant (e.g.
toothpaste, coffee) with eyes closed

MOUTH AND PHARYNX

56. Inspect the lips
57. Inspect oral mucosa and tonsillopharyngeal wall using good light and
tongue blade
58. Inspect gums, teeth, hard palate
59. Inspect the tongue and floor of the mouth. Ask patient to put out his
tongue then to move it side to side (CN XII)
60. Ask the patient to put his tongue on the roof of the mouth.
61. Inspect the pharynx. Tongue in normal position. Ask the patient to say
“ah” and inspect soft palate, tonsils and pharynx. May use tongue blade.
Check position and symmetry of palate and uvula at rest and with phonation
(“aah”) (CN IX, X)

NECK
62. Palpate the lymph nodes in the following sequence: Preauricular ;
posterior auricular; occipital; tonsillar; submandibular; submental;
superficial cervical; deep cervical chain; supraclavicular
63. Inspect trachea and feel for any deviation by placing your finger along
one side of the trachea and note the space between it and sternomastoid.
Compare with the other side.
64. Inspect the thyroid gland. Tip the patient’s head back a bit and inspect
the region below the cricoid cartilage
65. Palpate the thyroid gland; Flex the neck slightly forward. Place the
fingers of both hands on the patient’s neck with index finger just below the
cricoids cartilage. Ask patient to swallow
66. Ask patient to shrug shoulders and rotate head to each side against
resistance (CN XI)

VI. EXAMINATION OF THORAX AND LUNGS

Skills Done US ND
Posterior Thorax
67. The patient should be sitting with the posterior thorax exposed.
68. The doctor assumes a midline position behind the patient
69. Inspect the cervical, thoracic and upper lumbar spine (you will check for
ROM of the thoracic and lumbar spine towards the end of the complete
physical when the patient is standing up)
70. Palpate the spinous processes of each vertebra for tenderness with your
thumb or by thumping with the ulnar surface of your fist
Inspect the shape and movement of the chest wall
71. Place your thumbs at the level of the 10th ribs with your fingers loosely
grasping the rib cage and gently slide them medially.
72. Ask the patient to inhale deeply and observe whether your thumbs move
apart symmetrically
Palpate for tactile fremitus
73. Use either the ball of your palm or the ulnar surface of your hand for
palpation
74. Ask the patient to repeat the words “ninety-nine. You may palpate one
side at a time or use both hands simultaneously to
compare sides
75. Palpate in four locations on both sides of the chest and compare
Percussion
76. Ask the patient to keep both arms crossed in front of the chest
77.Press the DIP joint of the left middle finger firmly against the chest wall,
avoiding contact with other fingers. Strike this DIP joint with the tip of the
right middle finger, swinging from the wrist
78. Percuss in seven areas on each side (Bates p 310)
79. Auscultate for breath sounds
Instruct the patient to breathe deeply through an open mouth
80. Listen with the diaphragm of the stethoscope in the same seven areas in
which you percussed.

Anterior Thorax
81. The patient may be either sitting or supine. The drape should be
adjusted to allow exposure of the area being examined
82. Inspect the shape of the patient’s chest and movement of the chest wall
83. Palpate for tactile fremitus
Use the ball of the palm or ulnar surface of the hand to palpate in 3 areas
on each side of the anterior chest
84. Percuss the anterior and lateral chest, comparing sides, in 6 areas on
each side
85. Auscultate the anterior chest, comparing sides in the 6 areas on each
side where you percussed

VII. EXAMINATION OF THE CARDIOVASCULAR SYSTEM

Skills
86.The patient should be supine with the upper body raised by elevated the
table to about 30°. The drape should be arranged to expose the precordium.
The examiner should stand at the patient’s right side

87. Observe the jugular venous pulsations and measure jugular venous
pressure in relation to the sternal angle.

88. Inspect and palpate the carotid pulsations. Listen for carotid bruits using
bell of stethoscope.

89. Inspect the precordium

a) look for apical impulse
b) look for any other movements
90. Palpate for precordium
Use the palmar surfaces of several fingers to locate the PMI—can switch
to one fingertip when located
i) Displace a woman’s breast upward or laterally, or ask her to do
this for you
ii) Note location of PMI, amplitude and duration
91. Palpate for the RV impulse along the lower left sternal border
92. Auscultation of the heart
Listen to the heart with the diaphragm of your stethoscope in the R 2nd
ICS, L 2nd ICS, L 3rd or 4th ICS, and the lower left sternal border (5th ICS) and
at the apex (may also start at the apex and proceed to the base)
93. Listen to the heart with the bell of your stethoscope in the same five
listening areas

VIII. EXAMINATION OF THE ABDOMEN

Skills
94. The patient should be in a supine position with arms at side or folded
across the chest
95. The drapes should be arranged to expose the abdomen from above the
xyphoid process to the symphysis pubis.
96. Approach the patient from his right side
97. Inspect the abdomen
98. Auscultate the abdomen as the next step in the exam after inspection
a) Place the diaphragm of the stethoscope gently on the abdomen
b) Listen for bowel sound. Listening in one spot is sufficient
c) Listen for an aortic bruit on the midline just above the navel
99. Percuss the abdomen lightly in four quadrants
100. Percuss for liver dullness
d) Define the lower edge of liver dullness in the mid-clavicular line,
starting at a level below the umbilicus
101. Define the upper edge of liver dullness in MCL, starting in the area of
lung resonance (Gently displace a woman’s breast as necessary)
102.Measure in centimeters with a ruler the vertical span of liver dullness in
the MCL
103.Percuss for splenic dullness
Percuss along the L lower chest wall between the lung resonance above
and the costal margin moving laterally. Ask the patient to take a deep breath
and percuss again in this area
104. Palpate the abdomen lightly in four quadrants and in the suprapubic
and epigastric areas. Use a gentle, light dipping motion
105. Palpate the abdomen deeply in all four quadrants
Use a firmer dipping motion
106.Palpate for the liver edge
a. Place your R hand on the right abdomen lateral to the rectus muscle,
beginning more than 3 fingerbreadths below the costal margin
b. Ask the patient to take in a deep breath
107. Palpate upwards trying to feel the descending liver edge, using a
rocking motion. May also use the “hooking technique”
108.Palpate for a spleen tip
a. Reach over and around the patient with your left hand to support and
press forward the lower left rib cage
109. Press inward towards the spleen with your right hand, beginning at
least 3 finger breadths below the L costal margin
Ask the patient to take in deep breaths, trying to feel the spleen tip as it
comes down to meet your fingertips
Assess for costovertebral tenderness
110. Place the ball of one hand in the costovertebral angle and strike it with
the ulnar surface of your fist

IX. EXAMINATION OF THE LOWER EXTREMITIES

Skills Done US ND
111. Inspect legs, feet and joints. Look for lower extremity edema,
discoloration, ulcers, deformities or enlarged joints.
112. Palpate for pitting edema.
Peripheral Vascular System:
113. Palpate the dorsalis pedis and posterior tibialis pulses on the feet at the
same time.
114. With the patient standing: Inspect for varicose veins
115. Palpate the joints, check their range of motion
116. Motor examination: Assess extremity strength. Repeat on upper
extremities.
117. Sensory examination: Ask whether patient can feel light touch and
temperature of a cool object in each distal extremity; check double
simultaneous stimulation using light touch on hands
118. Check biceps and patellar reflexes
119. Check coordination and cerebellar functions: Rapid alternating
movements of the hands; finger-to-nose and heel-knee-shin maneuvers
120. Check gait. Observe patient while walking normally, on the heels and
toes, and along straight line