MS1: MS3:

Model:

PCM 1: OSCE #2, AY 2010-11, February 22 & 24

Case prompter instructions: Please circle the appropriate answer that best reflects the student’s knowledge/practice of each of the following physical exam skill steps. “1” If the student did the step satisfactorily, “0.5” If the student did the step, but the technique was NOT satisfactory, “0” If the student omitted the step.

1 0.5 0 1. WASH HANDS

HEAD & NECK

1 0.5 0 2. Locate and identify the parotid glands. Student should point to area behind and superficial to mandible, below the zygomatic arch and in front of the ear.

1 0.5 0 3. Locate and identify the submandibular salivary glands. Student should point to area deep to or at the inner surface of the mandible

4. Locate and identify the Papillae of the ducts of the submandibular glands. 1 0.5 0 Wharton’s duct, located in the mouth at the base of the tongue, on both sides of the midline lingual frenulum. Student should ask pt to curl up their tongue or touch the tongue to the roof of the mouth to demonstrate these ducts at the base of the tongue

1 0.5 0 5. Locate and identify the opening of the Parotid glands. Stenson’s duct, located in the mouth at the 2nd upper molar on the buccal mucosa by a small papilla

1 0.5 0 6. Locate and examine the trapezius muscles. (Tests CN XI = Spinal Accessory Nerve) Student places their hands on patient’s trapezius muscles and then asks the patient to shrug both shoulders upward against the student’s hands. The strength and symmetry of contraction is assessed.

1 0.5 0 7. Locate and examine the sternocleidomastoid muscles. (Also tests CN XI = Spinal Accessory Nerve) Technique should be to ask patient to turn head to each side against 1st year student’s hand. As the patient turns head to each side, observe the contraction of the opposite sternocleidomastoid. The right sternocleidomastoid contracts and turns patient’s head to patient’s left.

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1 0.5 0 8. Locate and identify the borders of the anterior triangles (each side of the neck is divided into 2 triangles, by the diagonally running sternocleidomastoid muscle) Anterior triangle borders= mandible, sternocleidomastoid muscle, and midline of neck

9. Locate and identify the external jugular vein by performing a Valsalva 1 0.5 0 maneuver The external jugular vein is identified behind the clavicular head of the sternocleidomastoid or roughly about the middle third of the clavicle and then passes diagonally over the surface of the sternocleidomastoid and up behind the angle of the mandible. A Valsalva maneuver is a forced expiration against a closed glottis (ask the patient to “strain” or “beardown” as is they are trying to have a bowel movement). Student may need to lay the patient supine or at 30 or 45 degrees to best demonstrate this step.

1 0.5 0 10. Locate and identify the location of the thyroid gland Student may ask the patient to take a sip of water to facilitate this step. Student places finger pads of both hands so that the index fingers are just below the cricoid cartilage. Ask the patient to swallow and the student attempts to feel the thyroid rising under their fingerpads. Student’s fingers should be a little lateral to midline. The thyroid has 2 lateral lobes and a midline isthmus and is usually located between the levels of the C5 and T1 vertebrae.

1 0.5 0 11. Locate and identify the structures that make up the external ear Cartilaginous ear- auricle- pinna. Outermost rim- helix, antihelix is internal to helix, and the tragus lies in front of the external auditory meatus. The ear lobule has no cartilage.

1 0.5 0 12. Locate and examine the tympanic membrane with an otoscope Student makes sure the otoscope light works, and uses an ear speculum for the exam. Student should stand close to the patient and warn the patient before they start. Student gently pulls the ear upward and backward to straighten the canal for easy visualization. This maneuver assists in visualization in majority of patients (UP, OUT, and BACK)

13. Locate and identify the Pre & post auricular lymph nodes 1 0.5 0 Preauricular= parotid lymph nodes would be in front of the ear Post-auricular= mastoid lymph nodes would be behind the ear and superficial to the mastoid process.

1 0.5 0 14. Locate and identify the Occipital lymph nodes At the base of the skull, posteriorly

Page 2 of 18 1 0.5 0 15. Locate and identify the Submental lymph nodes A few centimeters behind the tip of the mandible (chin)

1 0.5 0 16. Locate and identify the Superficial cervical lymph nodes These are superficial to the surface of the sternocleidomastoid muscles.

1 0.5 0 17. Locate and identify the posterior cervical lymph nodes These are located along the anterior border of the trapezius muscles.

1 0.5 0 18. Locate and identify the supraclavicular lymph nodes These are part of the deep cervical lymph nodes, located in the angle formed by the clavicle and the clavicular head of the SCM.

THORAX/LUNG 1 0.5 0 19. Locate and identify the sternal angle of Louis. -the boney ridge joining the manubrium to the body of the sternum The 2nd costal cartilages are adjacent to the sternal angel.

1 0.5 0 20. Identify and locate the second intercostals space. Inferior to the 2nd costal cartilage, which is lateral to the sternal notch. This is important in helping doctors count ribs and ICS to name a location on the chest wall along with the vertical axis.

1 0.5 0 21. Locate and identify the midsternal line. A vertical line that runs through the middle of the sternum and xiphoid process.

1 0.5 0 22. Locate and identify the midclavicular line. A vertical line running through the midpoint of the clavicle and inferiorly.

1 0.5 0 23. Locate and identify the anterior axillary line. A vertical line running inferiorly from the anterior axillary muscle fold

24. Locate and identify the posterior axillary line. 1 0.5 0 A vertical line running inferiorly from the posterior axillary muscle fold. (The purpose of all the above is to help the student describe and locate findings vertically and horizontally around the thorax. Please stress this point.)

25. Locate and identify the surface markings of the lungs, fissures, and lobes. 1 0.5 0 LUNGS: Anteriorly, the apex of each lung rises about 2 – 4 cm above the inner third of the clavicle. The lower border of the lung crosses the 6th rib at the midclavicular line. Laterally: the lower lung border crosses the 8th rib at the midaxillary line.

Page 3 of 18 Posteriorly: the lower border of the lung lies at about the level of T 10. During normal breathing, the lower border of the lung may descend about 5-6 cm as the diaphragm contracts. FISSURES and LOBES: Each lung is roughly divided in half by an oblique major fissure. This fissure can be approximated by a line from T3 spinous process posteriorly and then runs obliquely down and around the chest to the 6th rib in the midclavicular line. Posteriorly, above this line are the upper lobes, and below is the lower lobe. The right lung also is further divided by a horizontal = minor fissure. Anteriorly, this fissure runs from about the 4th rib and then travels roughly horizontally around the chest wall to the 5th rib in the midaxillary line. Above this fissure is RUL, and below is RML. Key teaching points: (1) The right middle lobe does not have a posterior projection. To exam the RML, you need to auscultate/percuss in the lateral and anterior chest. (2) Most of the upper lobes are best auscultated anteriorly.

1 0.5 0 26. Test for respiratory expansion Technique: First, the student should inspect the chest wall for symmetric expansion. Second, the student places their hands on the lower posterior chest wall with their thumbs at about the level of the 10th rib and parallel to the 10th rib. As the student grasps the lower chest wall, they should slide their thumbs medially so that they raise a vertical skin fold medial to their thumbs and lateral to the patient’s spine. Student should then ask the SP to take a deep breath. As the patient breathes, the student’s hands and thumbs should move laterally and equally about 2 –5 inches as the chest expands. The skin fold the student created should also decrease in size as the chest wall expands. If the student starts too close to the midline over the spine, there is usually not enough loose skin available to create a skin fold.

1 0.5 0 27. Take the patient’s respiratory rate (Ask the student for the RR/minute). Ideally the student should count for 30 seconds to one minute. To only count for 15 seconds may be too short.

1 0.5 0 28. Test for tactile fremitus Purpose for examining for tactile fremitus: detects palpable vibrations transmitted through the broncho- pulmonary tree to the chest wall. In a normal patient, both right and left lungs have normal and equal/ symmetric vibrations, which the examiner appreciates. Increased, decreased, or absent tactile fremitus of one lung as compared to the other is abnormal. Admittedly this is a “rough” assessment tool at best, but as a scouting technique it directs the examiner’s attention to possible abnormalities and to areas where the examiner wants to pay particular attention later on in the rest of the lung exam. Technique: Ideally, the student should ask the patient to grab their opposite shoulder with their hands so as to move the scapulae laterally and increase the examinable area of the posterior lung fields. -Must be done on skin, not over a gown or an article of clothing

Page 4 of 18 -Student should place either the dorsal surface of their fingers or the ulnar surface of their hands and fifth fingers or the “ball” of their hand (metacarpal phalangeal joints of fingers 2-5) on patient’s posterior chest, beginning at the top of the chest first. Any of these three positions helps optimize the examiner’s appreciation of vibration through the bones of their hands/fingers. -Student then asks the patient to repeat a phrase such as “ninety-nine” or “one- one-one” each time the patient feels the student’s hands in a new location when they examine the patient for tactile fremitus. -If the student cannot appreciate the fremitus at first, they should ask the patient to speak louder or in a deeper voice. -The student should examine for tactile fremitus in at least three locations posteriorly (upper, middle, and lower chest wall) and then one area laterally (remember the right middle lobe has no posterior projection.) Bates also recommends 3 areas anteriorly: upper and lower parasternal areas and then in anterior axillary line

1 0.5 0 29. Demonstrate the technique of percussion Purpose of percussion: to determine if the tissues 5-7 cm deep to/underlying the percussed site are air filled (normal lung), fluid filled (pleural effusion), or solid (tumor/mass). Technique of percussion: -Ideally, the student should ask the patient to grab their opposite shoulders with their hands so as to move the scapulae laterally and increase the examinable area of the lung fields. -Must be done on skin, not over a gown or an article of clothing. -Student places the end of (from the DIP joint to the tip of the finger) their index or middle finger firmly against the patient’s posterior chest, ideally in an intercostal space and not over a rib. -No other part of the student’s hand should be resting on the patient’s posterior chest. If they rest more of their finger or hand against the posterior chest, the student dampens the percussed sound. -Using the other hand’s index and/or middle finger, the student quickly strikes at the finger on the chest and also withdraws the percussing finger quickly. If the percussing finger is left on the chest, this will also dampen the percussed sound. -The action of percussion works best if the percussing hand’s wrist is already close to the chest wall and the act of percussing comes from flexion at the wrist. (Flexion of the percussing finger alone does not provide enough strength to create a percussed sound.) Also, if the percussing hand is far from the patient’s chest, it is very difficult to accurately strike the finger on the chest. -The student should always start at the top of the lungs and should always compare right side to left at a given level. How many areas that need to be percussed is debatable. Bates recommends 7 different areas posteriorly and 3 anteriorly. It is probably sufficient for the student to assess the upper, middle, and lower posterior chest wall and then lateral chest wall and also 3 areas anteriorly.

Page 5 of 18 1 0.5 0 30. State the five percussion notes and their characteristics

Adapted from Bates: 8th Ed. Page 225 Intensity Pitch Duration Location Flatness Soft High Short Thigh Dullness Medium Medium Medium Liver Resonance Loud Low Long Normal lung Hyperresonance Very loud Lower Longer None normally Tympany Loud High* * Gastric air bubble or puffed out cheek * Distinguished mainly by its musical timbre

1 0.5 0 31. Ask the student to identify TWO types of normal breath sounds. Bates describes four different breath sounds: Tracheal- heard over the trachea Bronchial- heard normally over the manubrium Bronchovesicular- heard normally between the scapula Vesicular- heard normally throughout the rest of the lungs

1 0.5 0 32. Test for the technique of auscultation. Student should ask the patient to grab their shoulders (to move the scapulae laterally). Exam is done on skin, NOT gown. Student listens with the DIAPHRAGM of stethoscope, begins at apices, compares right to left at each level, asks patient to breath though their mouth, student should NOT move stethoscope to next position until the complete respiratory cycle is done (inspiration and all of expiration). Student should auscultate upper, mid, lower and lateral lung fields and then 2 or 3 areas anteriorly.

1 0.5 0 33. Ask the student to explain how to test for vocal fremitus (listening for transmitted voice sounds) and give ONE example. While auscultating ask patient to repeat or whisper “ninety-nine” or say “EEEEE”. Each time student moves their stethoscope. Example: bronchophony- ninety-nine is heard louder and clearer than expected, egophony- “EEE” is heard as a nasal “ayy”, and whispered pectoriloquy- whispered “ninety-nine” is heard louder and clearer than expected. These transmitted voice sounds are all abnormal and are indications of airless or consolidated lungs.

Page 6 of 18 HEART 1 0.5 0 34. Identify and locate the apex and base of the heart Answer = base is the junction between the heart and the great vessels; lies just below sternal angle Identify and locate the apex of the heart Answer = apex is the tip of the LV; normally found in midclavicular line, about 5th intercostal space

1 0.5 0 35. Identify and locate the “aortic area” Answer = right 2nd intercostal space

1 0.5 0 36. Identify and locate the “pulmonic area” Answer = left 2nd intercostal space

1 0.5 0 37. Identify and locate the surface projection on the precordium of the right atrium Answer = right heart border, from right 2nd ICS (intercostal space) to about 3rd or 4th Right ICS

1 0.5 0 38. Identify and locate the surface projection on the precordium of the right ventricle Answer = RV occupies most of the anterior cardiac surface; RV is a wedge-like structure behind and to the left of the sternum with the inferior border just below the junction of the sternum and xiphoid process, the RV narrows superiorly and meets the pulmonary artery at left 3rd ICS near the sternum

1 0.5 0 39. Identify and locate the surface projection on the precordium of the left ventricle Answer = LV is the left lateral border of the anterior cardiac surface

1 0.5 0 40. Name the Four principal factors that influence arterial blood pressure. LV stroke volume Distensibility of Aorta and large arteries Peripheral Vascular Resistance Blood volume

1 0.5 0 41. Locate and count and describe the patient’s radial pulse Technique = student should use finger pads (not tips), and describe beats/min, rhythm

1 0.5 0 42. Locate and count and describe the patient’s carotid pulse Technique = student should only check for ONE carotid pulse at a time; should have fingerpads in lower half to lower third of neck, usually medical to sternocleidomastoid muscle, about at the level of the cricoid cartilage.

Page 7 of 18 1 0.5 0 43. Ask the student to demonstrate how to determine the correct BP cuff size for their patient, and demonstrate. Answer = width of cuff should be about 40% of the circumference of patient’s arm. Length of bladder (not entire cuff) should be about 80% of circumference of patient’s arm.

1 0.5 0 44. Ask the student what happens to BP if one uses a BP cuff that is too small for a patient. Answer = BP reading is falsely elevated when the BP cuff is too small

1 0.5 0 45. First describe the technique then correctly measure the patient’s BP by palpation in one arm Technique = appropriate size cuff is place on SKIN (not over gown) about 2-3 cm above antecubital fossa. Find radial pulse, then blow up cuff until pulse disappears and blow up about 20 mm Hg. Higher, then slowly release the air in the cuff (about 3 mm Hg per second). Return of the pulse = estimate of SYSTOLIC BP. (Student must tell you their reading)

1 0.5 0 46. Correctly measure (auscultate) BP in one extremity Technique = as above, except include that patient’s arm is relaxed and the brachial artery is elevated to about heart level by the student while the patient is sitting. Student should only blow up the cuff about 20 – 30 mm Hg above their BP by palpation. Air should be released from the cuff slowly (about 3 mmHg per second). Student tells you patient’s BP.

1 0.5 0 47. Ask student to describe what the maximal height of the internal jugular vein represents. Answer = reflection or indication of right atrial pressure, which reflects hydration or volume status of patient.

48. Identify the point of maximal height of the internal jugular vein on the 1 0.5 0 patient and measure the JVP. Technique = student is on patient’s right side, student should have pt. lay back and should adjust the exam table between 30 – 45 degrees, and should be able to point out the height of the right internal jugular neck vein, turn patient's head slightly to their left. To measure, student places a ruler on sternal angle and uses a horizontal surface from the point of maximal height of the right int. jugular vein. Student adds 5 cm to their measurement to get the patient’s JVP.

Page 8 of 18 1 0.5 0 49. Palpate the precordium in 5 areas, identify the PMI (apical impulse) Technique = exam done on skin (not over a gown), patient lying flat, student on patient’s right side-student tries to inspect for PMI (student may ask patient t roll 45 degrees to left and may also ask patient to exhale fully and hold breath student looks for, palpates for PMI). -student uses palmar surface of hand, gently placing ball of hand (metacarpal- phalangeal joints on the precordium) -5 locations on the precordium are palpated (any order is acceptable) -apex (PMI) -left parasternal area (left 3rd to 5th intercostal space) -epigastrium-left 2nd ICS (Pulmonic area) -right 2nd ICS (aortic area)

1 0.5 0 50. Correctly percuss for left cardiac border and identify left cardiac border Technique = Patient is supine, percussion is done on skin (not over a gown), student on patient’s right side -percussion begins laterally in 4th or 5th ICS in about anterior axillary line and student percusses lateral to medical along an ICS, until dullness is heard -then student percusses in ICS above or below -student may ask patient to hold their breath (to prevent respiratory movement)or ask patient to exhale completely and hold their breath while they percuss. This maneuver brings the heart closest to the chest wall. -student should correctly identify left cardiac border as resonance changes to dullness

1 0.5 0 51. Correctly auscultate the heart in 5 locations Technique = patient is supine or at most 30 degrees, exam is done on skin (not over a gown) student on patient’s right side, -student first uses bell of stethoscope and then repeats exam with bell -5 locations on the precordium are auscultated: -apex -left sternal border -epigastrium -left 2nd ICS -right 2nd ICS

52. Locate and identify the area on the precordium where splitting of S2 is best 1 0.5 0 auscultated Answer = left 2nd intercostal space (pulmonic area)

Page 9 of 18 ABDOMEN Patient should be supine for the abdomen exam. -Student should pull out the ledge for the patient’s legs. -Student should help to make sure the patient is appropriately draped, but ideally let the… -Patient lifts up their gown to expose the abdomen and have the sheet draped across the pelvis. -Patient’s arms should be at their side, NOT above their heads. -Student should be on patient’s right side. This is the classic position for the abdomen exam.

1 0.5 0 53. Identify and locate the rectus abdominis muscle Student may ask patient to raise their head and shoulders from the supine position. These muscles run about 7-10 cm lateral to and parallel to the linea alba. The lateral border of the rectus abdominis muscle is known as the linea semilunaris. The rectus abdominis muscle arises from the pubic crest and inserts onto the anterior surface of ribs 5-7 and the xiphoid process.

1 0.5 0 54. Identify and locate the umbilicus Normally at about L3 to L5. Granted, the umbilicus’ position depends on patient’s weight, size, etc.

1 0.5 0 55. Identify and locate the inguinal ligament The inguinal ligament extends from the pubic tubercle to the anterior superior iliac spine. The inguinal ligament separates the abdomen above from the thigh below.

1 0.5 0 56. Identify and locate the surface markings of the four abdominal quadrants (RUQ, LUQ, RLQ, LLQ) The four quadrants of the abdomen are defined by a vertical line running through the umbilicus and a horizontal line running through the umbilicus. Remember, “right” and “left” are defined as the patient’s “right” and “left”.

1 0.5 0 57. Identify and locate the surface markings of the colon The colon is approximately 5 feet in length. The colon begins in the RLQ as the cecum and then turns into the ascending colon as it ascends to hepatic flexure (just under the liver) at about the 9th intercostal space. The transverse colon is the longest and most mobile part of the colon. It runs from the hepatic flexure in the RUQ to the splenic flexure in the LUQ. The colon then turns into the descending colon and at the level of the pelvic brim becomes the sigmoid colon and finally terminates in the rectum and anus.

1 0.5 0 58. Identify and locate the surface markings of the spleen The normal spleen is just inferior to the diaphragm in the LUQ at the level of the 9th-11th ribs, POSTERIOR to the left midaxillary line.

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1 0.5 0 59. Identify and locate the surface markings of the kidneys The kidneys are bean shaped organs, about 11 cm long, 5-6 cm wide, 3 cm thick, and about 4-5 cm from the midline at the level of about T12 through the first lumbar vertebrae. The kidneys are posterior/retroperitoneal organs. Their upper poles are protected by the 11th and 12th ribs posteriorly. The inferior poles may be 3-4 cm above the iliac crests. The right kidney is slightly lower than the left kidney.

1 0.5 0 60. Identify and locate the abdominal aorta The abdominal aorta begins as a direct continuation of the thoracic aorta at the level of T12 to L1 where the thoracic aorta passes through the diaphragm at the aortic hiatus in the midline. The abdominal aorta descends in front of the bodies of the first four lumbar vertebrae in the midline or slightly to the left of the midline. At L4, the aorta bifurcates (remember the umbilicus is L3-L5) into common iliac arteries. The total length of the abdominal aorta is about 10 cm and normally its diameter is about 2.5 cm.

1 0.5 0 61. Identify and locate the femoral arteries The femoral artery is a continuation of the external iliac artery as it runs posterior to the inguinal ligament at about the midpoint of the inguinal ligament. 1 0.5 0 62. Auscultate abdomen in four quadrants In the abdominal exam, auscultation always comes before palpation since any contact with bowel can increase the bowel’s motility. Gently place the diaphragm of the stethoscope on the abdominal wall. Normally there are 5-34 bowel sounds per minute.

1 0.5 0 63. Palpate for horizontal and vertical superficial inguinal lymph nodes The horizontal superficial inguinal lymph nodes are INFERIOR to the inguinal ligament. These drain the superficial portions of the lower abdomen and buttock, the external genitalia (but not the testes,) the anal canal, the perineal area, and the lower vagina.

The vertical superficial inguinal lymph nodes cluster near the upper part of the saphenous vein. The student palpates medial and parallel to the femoral artery below the inguinal ligament. These lymph nodes drain the distal leg.

1 0.5 0 64. Palpate the abdomen superficially The student places a hand flat on the abdomen and while keeping the fingers together, uses gentle, light dipping motions to palpate. ALL FOUR QUADRANTS must be palpated.

Page 11 of 18 1 0.5 0 65. Palpate the abdomen deeply The student may use a 2 handed technique, exerting pressure from the top hand and palpating with the bottom hand. Again, ALL FOUR QUADRANTS must be palpated deeply.

1 0.5 0 66. Palpate for the liver edge and spleen With their right hand at about the level of the umbilicus and lateral to the rectus abdominus muscle, the student presses gently up and in while asking the patient to take a deep breath. If the liver edge is not palpated, the student repositions their right hand closer to the costal margin and repeats the step to try to feel the liver edge pass beneath their fingers as the SP takes a deep breath. Again, if the liver edge is not felt, the student then places their right hand just under the costal margin and repeats the step. The student may place their left hand behind the lower ribs and lift up while attempting to palpate the liver edge with the right hand. A common mistake is to start with the right hand too high, at the level of the costal margin. If the liver edge is below the costal margin, the student may never feel the edge if they start “too high”. Normally a spleen tip is not felt. The same examination approach is used for the spleen. The student should place their right hand at about the level of the umbilicus, lateral to the rectus abdominis muscle and gently press up and in as the patient takes a deep breath. The student may place their left hand behind the lower ribs and lift up. This technique is repeated as the student’s right hand is eventually placed next to the costal margin.

1 0.5 0 67. Percuss for the liver span The goal of this step is to measure the vertical span of the liver in the right mid- clavicular line. The student must percuss both above the liver (in the lung area) and below the liver to hear the different percussion notes of air in the lungs and bowels as opposed to the solid percussion note of the liver. In the abdomen, the student should start at the level of the umbilicus and then percuss up toward the liver. The student should not percuss over the gown. A normal adult liver span is 6-12 cm in the right midclavicular line.

1 0.5 0 68. Palpate for the kidneys In most normal adults, the kidneys are not palpable. In a very thin and relaxed person, you may feel the lower pole of the right kidney. The student is trying to “trap” the lower pole of the kidney between their hands as the patient takes a deep breath. To palpate for the right kidney, the student places their right hand below the costal margin in the RUQ, lateral to the rectus abdominus muscle but parallel to it, and place their left hand BELOW and parallel to the 12th rib. (The left hand is between the lower end of the rib cage and the iliac crest – note that this is a LOWER position than the step when the liver edge is being palpated) While the left hand is lifting up, the patient is asked to take a deep breath and at the peak of

Page 12 of 18 inspiration, the student presses deeply into the right upper quadrant just below the costal margin and attempts to “capture” the right kidney between their two hands. Then the patient can breathe out and the student slowly releases the pressure from their right hand, feeling at the same time for the kidney to slide back into its expiratory position higher up. If the kidney is “trapped” the patient is aware of a capture and release sensation. The right kidney is normally lower than the left. The left kidney is rarely palpable, but the same technique is used. Or the student may move to the patient’s left side and use their left hand to feel deep while their right hand lifts up from behind the patient.

1 0.5 0 69. With patient in right lateral decubitus position, palpate for the spleen Remember, a spleen tip is not normally felt. If the spleen is palpable, it is usually 3x its normal size. As the spleen enlarges, it enlarges diagonally, toward the RLQ. (It enlarges anteriorly, downward, and medially). Also, remember that the spleen is normally posterior to the midaxillary line. By having the patient lay on their right side, gravity may bring the spleen forward and to the right into a palpable location. Again the student may place their left hand behind the left lower ribs and then they gently press up and in as the patient takes a deep breath.

MUSCULOSKELETAL HAND/WRIST 1 0.5 0 70. Inspect and palpate nails, palms, skin, and joints of each hand and wrist - Students should look for nail changes, cyanosis, rashes or skin lesions, bony or muscular abnormalities, joint swelling or erythema

Inspect and demonstrate the passive and active range of motion of the following joints:

1 0.5 0 71. Hands – Distal Interphalangeal, Proximal Interphalangeal, Metacarpophalangeal joints Flexion/Extension Abduction/Adduction – in relation to the 3rd finger

72. Wrist – do not ask measurements of ROM, only demonstrations 1 0.5 0 Flexion (90°) Extension (70°) Radial (20°)/Ulnar (55°) deviation Supination/Pronation (90° each)

Locate, inspect and palpate the following structures:

1 0.5 0 73. Thenar and hypothenar eminences

Page 13 of 18 1 0.5 0 74. Radial and Ulnar styloids

1 0.5 0 75. “Anatomical Snuff Box” Hollowed depression just distal to the radial styloid process formed by the abductor pollicis longus and extensor pollicis longus of the thumb where the scaphoid bone may be palpable

76. Extensor Carpi Ulnaris Tendon 1 0.5 0 Felt best just distal to ulnar styloid with wrist in ulnar deviation

ELBOW 1 0.5 0 77. Inspect and palpate skin and elbow joint for landmarks and deformities

78. Inspect and demonstrate the passive and active range of motion of the elbow 1 0.5 0 Elbow Flexion (160°) Extension (0°) Pronation (80°) Supination (80°)

Locate, inspect and palpate the following structures 1 0.5 0 79. Medial and Lateral Epicondyles Bony protuberances located on the distal aspect of the humerus -Common extensor origin (lateral epicondyle), common flexor origin (medial epicondyle)

1 0.5 0 80. Olecranon, radial head and elbow joint

SHOULDER 1 0.5 0 81. Inspect and palpate skin, shoulder, and periscapular regions

82. Inspect and demonstrate the passive and active range of motion of the 1 0.5 0 shoulder (glenohumeral) joint: Shoulder Flexion (160°) Abduction (160°) Internal Rotation -Place hand behind back with elbow in flexion, and elevate thumb as much as possible External Rotation -Done at 0° abduction -Also can do at 90° abduction (younger patients)

Page 14 of 18 Locate, inspect and palpate the following structures: 1 0.5 0 83. Sternoclavicular Joint The junction of the clavicle with the sternum

1 0.5 0 84. Clavicle

85. Acromioclavicular Joint 1 0.5 0 Located on the superior aspect of the shoulder as a small depression where the clavicle meets the acromion

1 0.5 0 86. Spine of the Scapula This is the bony landmark palpated on the back of the scapula

1 0.5 0 87. Coracoid Process Palpated inferior to the AC joint on the anterior aspect of the shoulder and is often tender to palpation

1 0.5 0 88. Greater/Lesser Tuberosities/Biceps Tendon -palpated at the proximal aspect of the humerus anteriorly

CERVICAL SPINE 1 0.5 0 89. Inspect the posterior neck including skin

90. Inspect and demonstrate the range of motion of the cervical spine 1 0.5 0 Flexion – chin to chest Extension – look up at ceiling Lateral Rotation – turn chin towards shoulder Side bending – tilt ear to shoulder (no shrugging)

1 0.5 0 91. Inspect and palpate the cervical spinous processes and paraspinal muscles and upper trapezius

1 0.5 0 92. Locate the spinous process of C7 – This spinous process moves with lateral rotation of the neck

THORACIC AND LUMBAR SPINE 1 0.5 0 93. Inspect the thoracic and lumbar spine including skin

94. Inspect and demonstrate the range of motion of the thoracic and lumbar 1 0.5 0 spine Flexion Extension Rotation Side Bending

Page 15 of 18 1 0.5 0 95. Palpate the ribs, musculature and spinous processes

HIP/PELVIS 1 0.5 0 96. Observe gait as part of lower extremity evaluation.

97. Inspect and evaluate skin and the hip and pelvis for landmarks and 1 0.5 0 deformities:

1 0.5 0 98. Inspect and demonstrate the range of motion of the hip (femoralacetabular) joint: Hip Flexion (>90°) Extension Abduction/Adduction check supine with hip flexed/extended, seated, and prone (prone is the most accurate) Internal Rotation/External Rotation When supine, external rotation is noted by direction of knee (when knee is external, hip is in external) and internal rotation is noted by “internal” location of the knee. From seated position: stabilize the femur with one hand above the knee, grasp the ankle with the other hand and push the ankle toward the midline (external rotation of the hip) and pull the ankle away from the midline (internal rotation of the hip)

Locate, inspect and palpate the following structures: 1 0.5 0 99. Greater Trochanter of the Femur and Trochanteric Bursa the bony prominence on the lateral aspect of the hip

1 0.5 0 100. Palpate anterior superior (ASIS) and posterior superior iliac spines (PSIS), and sacroiliac (SI) joints.

KNEE AND LEG: 1 0.5 0 101. Inspect and evaluate skin and the knee and leg for landmarks and deformities: -Evaluate for varus (bow-legged) or valgus (knock-kneed) alignment

102. Inspect and demonstrate the range of motion of the knee (patellofemoral) 1 0.5 0 joint: Knee Flexion (100° - 150°) Extension (0° - (-)10°) Knee range of motion can also be described (10-0-150, where 10 represents the amount of hyperextension)

Page 16 of 18 Locate, inspect and palpate the following structures: 1 0.5 0 103. Quadriceps Tendon palpated from the superior aspect of the patella to the quadriceps muscles

1 0.5 0 104. Patella

1 0.5 0 105. Patellar Tendon (Ligament) palpated from the inferior aspect of the patella to the tibial tuberosity

106. Tibial Tubercle 1 0.5 0 bony prominence on the tibia directly inferior to the patella where patellar tendon attaches

1 0.5 0 107. Medial Collateral Ligament on the inside of the knee connecting the femur to the tibia

108. Lateral Collateral Ligament 1 0.5 0 on the outside of the knee connecting the femur to the fibula, best palpated in “figure four” position

1 0.5 0 109. Iliotibial Band (distal tendon, felt in lateral knee)

1 0.5 0 110. Medial and Lateral Femoral Condyles the most distal bony prominences palpated on the medial and lateral aspects of femur.

1 0.5 0 111. Tibia Palpate tibial plateau, proximal medial tibia (pes anserine bursa) as well as tibia shaft

1 0.5 0 112. Fibula Palpate fibular head (biceps femoris tendon attachment)and fibular shaft

1 0.5 0 113. Joint line Palpate soft area just medial and lateral to patellar tendon between tibia and femur and proceed posteriorly

ANKLE/FOOT: 1 0.5 0 114. Inspect and evaluate skin and the ankle and foot for landmarks and deformities

Page 17 of 18 1 0.5 0 115. Inspect and demonstrate the passive and active range of motion of the following joints: Ankle (Tibiotalar) Joint Dorsiflex and plantarflex the foot at the ankle Sagittal plane motion

1 0.5 0 116. Talocalcaneal Joint (Subtalar) Stabilize the ankle with one hand, grasp the heel with the other and abduct and adduct the calcaneus (talar tilt) -Coronal plane motion

1 0.5 0 117. Transverse Tarsal Joint Stabilize the heel and invert and evert the forefoot

Locate, inspect and palpate the following structures: 1 0.5 0 118. Achilles Tendon large tendinous band palpated as it inserts at the calcaneus at the posterior aspect of the ankle

1 0.5 0 119. Medial and Lateral Malleoli -bony prominences at the medial and lateral aspects of the ankle

1 0.5 0 120. Base of the Fifth metatarsal, first metatarsophalyngeal joint

121. Plantar fascia 1 0.5 0 -Broad ligament on plantar aspect of foot that originates at medial calcaneus

1 0.5 0 122. WASH YOUR HANDS WHEN FINISHED.

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