Complete Physical Exam Benchmarks

The Physical Exam Benchmarks are the maneuvers that we expect all students to be able to perform on a patient or on an Objective Structured Clinical Encounter (OSCE). On an OSCE,  you would only be expected to perform maneuvers that you have covered to date in FCM. By the time you reach clerkships, you should be able to perform them all.
BENCHMARKS FOR HEAD & NECK EXAM
  • Inspect the head and the scalp

Eyes

  • Measure visual acuity
  • Inspect the external eye
  • Observe corneal light reflex
  • Assess size and reactivity of pupils
  • Assess the red reflex
  • Perform direct ophthalmoscopy

 Ears

  • Assess hearing
  • Inspect and palpate the auricle and mastoid
  • Perform otoscopy

Nose

  • Inspect the external nose for symmetry & discharge

Mouth

  • Inspect the oral cavity, including the teeth and gums
  • Palpate salivary glands
  • Palpate temporomandibular joints (TMJ)

Neck

  • Inspect the neck for symmetry and masses
  • Palpate the cervical lymph nodes
  • Palpate the thyroid gland
  • Auscultate the carotid artery
  • Palpate the carotid pulse

Perform hypothesis-driven exam maneuvers:

  • To differentiate conductive and sensorineural hearing loss, perform the Weber and Rinne tests.
  • If you suspect sinusitis, palpate the sinuses.
  • If you suspect allergic or infectious rhinitis or sinusitis, Inspect the nasal mucosa.
BENCHMARKS FOR THE CHEST EXAM

Inspection

  • Observe respiratory effort and note any signs of respiratory distress
  • Observe respiratory excursion
  • Inspect the skin as you perform the chest exam

Percussion

  • Percuss the chest posteriorly, comparing right and left sides from the apex to interscapular area to the base
  • Percuss the spine and costovertebral angles

Auscultation

Use the diaphragm of the stethoscope placed firmly on bare skin, comparing left to right:

  • Posteriorly, from the apex to the interscapular area to base
  • Laterally, in the midaxillary line
  • Anteriorly, over the upper lobes and right middle lobe

Recognize and interpret common findings on the chest exam

  • Inspection:
    • o Asymmetric chest expansion
    • o Nasal flaring
    • o Accessory muscle use
    • o Intercostal retraction
    • o Paradoxical movement of the abdomen
  • Percussion:
    • o Dullness
    • o Hyperresonance
    • o CVA and vertebral tenderness
  • Auscultation:
    • o Decreased breath sounds
    • o Bronchial breath sounds, crackles, wheezes, pleural rub, stridor

Perform hypothesis-driven exam maneuvers

  • To differentiate consolidation from pleural effusion or pneumothorax, assess for tactile fremitus
  • If you suspect consolidation, assess for egophany
BENCHMARKS FOR THE CV EXAM

Inspection

  • Inspect the anterior chest and neck for skin lesions as you perform the exam
  • Inspect the precordium for abnormal movement

Palpation

  • Palpate the carotid arteries, one at a time, observing strength & symmetry
  • Palpate the apical impulse and interpret your findings

Auscultation

  • Listen at each of the primary listening areas with firm pressure on the diaphragm:
    • Right 2nd intercostal space (R upper sternal border)
    • Left 2nd intercostal space (L upper sternal border)
    • Left lower sternal border (along the sternum at the 5th intercostal space)
    • Cardiac apex (midclavicular line in the 4th – 5th intercostal space)
  • Listen light pressure on the diaphragm or with the bell at the cardiac apex
  • Listen for bruits over each carotid artery

Peripheral Circulation & Edema

Note the presence and severity of leg edema.  Palpate each of the following pulses on each side:

  • Radial
  • Femoral
  • Dorsalis pedis
  • Posterior tibialis

Recognize and interpret common findings on the cardiovascular exam, including.

  • Three systolic murmurs (aortic stenosis, mitral regurgitation, innocent murmur)
  • Two diastolic murmurs (aortic regurgitation, mitral stenosis)
  • Physiologic and abnormal splitting of S2
  • S3 and S4

Perform hypothesis driven exam maneuvers: 

  • If you suspect abnormal volume status, measure jugular venous pressure
  • If you suspect ventricular hypertrophy or valvular heart disease, assess the apical impulse
BENCHMARKS FOR THE ABDOMINAL EXAM

Inspection

  • Observe your patient for increased discomfort with movement.
  • Inspect the abdominal contour, observing for distention or masses.
  • Inspect the skin as you examine the abdomen, noting scars and skin lesions

Auscultation

  •  Listen in one place with the diaphragm of the stethoscope until you hear bowel sounds.

Percussion

  • Percuss all four quadrants, observing for tenderness and tympany
  • Percuss the upper and lower liver margins in the R mid-clavicular line

Palpation

  • Palpate all 4 quadrants for tenderness or masses
  • Palpate the lower liver edge
  • Palpate for an enlarged spleen

Recognize and interpret common findings on the abdominal exam

Auscultation: Absent bowel sounds, tinkling bowel sounds

Percussion: Percussion tenderness

Palpation: Rigidity, guarding, abnormal liver edge, splenomegaly

Perform hypothesis driven exam maneuvers:

  • If you suspect renovascular hypertension, listen for renal artery bruits.
  • If you suspect appendicitis, assess for McBurney’s point tenderness
  • If you suspect cholecystitis, assess for Murphy’s sign
  • If you suspect ascites, test for a fluid wave and shifting dullness
  • If you suspect aortic aneurysm, assess the diameter of the abdominal aorta using palpation.
BENCHMARKS FOR THE NEUROLOGIC EXAM

Inspection – Assess mental status

  • Level of consciousness
  • Orientation
  • Speech

Assess cranial nerves II-XII

  • Test visual acuity and visual fields for each eye alone (CN II)
  • Test pupillary reaction (CN II and III)
  • Test extra-ocular movements (CN III, IV, VI), observing for nystagmus (CN VIII)
  • Test facial sensation & muscles of mastication (CN V)
  • Test muscles of facial expression (CN VII)
  • Test hearing (CN VIII)
  • Test palatal rise to phonation (CN IX and X)
  • Test sternocleidomastoid & upper trapezius muscle strength (CN XI)
  • Test tongue protrusion (CN XII)

Assess motor function

  • Evaluate strength and bulk of:
    • o Upper extremity muscle groups: Shoulder abductors, arm flexors and extensors, wrist flexors and extensors, finger flexors, finger abductors
    • o Lower extremity muscle groups: Hip flexors, extensors, abductors and adductors; knee flexors and extensors, foot dorsiflexors and plantar flexors
  • Assess for pronator drift

Assess reflexes

  • Upper extremity: Biceps, triceps, and brachioradialis
  • Lower extremity: Patellar, Achilles and plantar

Assess sensation

  • Compare light touch on the bilateral arms and legs
  • If your patient reports sensory changes, assess multiple sensory modalities. Modify your choice of the four sensory modalities to match the patient’s sensory complaints: pin prick, vibration, joint position sense, or light touch.

Assess cerebellar function

  • Finger to nose test
  • Heel to shin test
  • Gait
  • Romberg test (tests sensation and cerebellar function)

Perform hypothesis-driven exam maneuvers

  • If you suspect a disorder causing rigidity or spasticity, assess muscle tone
  • If you suspect cognitive impairment, perform the Mini-Cog
  • If you suspect a disorder of the eye or visual pathways, test visual fields.
  • If your patient reports sensory changes, assess multiple sensory modalities
BENCHMARKS FOR THE MUSCULOSKELETAL EXAM

The essential approach to examining the musculoskeletal system is the same no matter what joint or limb is being examined.  The affected and contralateral side should both be examined carefully, observing for side-to-side differences.

Inspect

  • Observe alignment and relative sizes of the areas of interest, at rest and in motion
  • Observe any erythema, swelling, ecchymosis, deformity, or skin lesions

 Palpate

Use a systematic approach to palpation, assessing these structures for each a regional exam.

  • Joint
  • Soft tissue
  • Bursae
  • Tendons
  • Muscles
  • Ligaments
  • Bony Prominences

 Range of motion

  • Active range of motion – the patient moves the joint
  • Passive range of motion – the examiner moves the joint

Strength testing

  • Of muscles that move the joint, and in some cases, muscles that move the joint above or below it.

 Stability and special tests, as directed by the differential diagnosis

For all orthopedic exams, there are many potential special tests that could be performed.  In general, the sensitivity and specificity of these tests is highly variable based on examiner skill.  These may include:

  • Joint specific maneuvers to test stability of major structures.
  • Hypothesis driven maneuvers to support or argue against diagnoses on your differential.
BENCHMARKS FOR LUMBAR SPINE EXAM

Benchmarks for a problem focused exam of a patient with low back pain include:

Inspect: From the back and the side, observing spine curvature, muscle bulk, and symmetry of hip and shoulder height

Palpate: Observing for tenderness, spasm, and asymmetry:

  • Vertebrae from L1 to the sacrum
  • Paravertebral muscles bilaterally
  • Sacroiliac joints

Range of motion: Assess flexion, extension, lateral rotation, side bending

Neurovascular testing: To assess for compression of nerve roots or spinal cord, test

  • Lower extremity strength
  • Lower extremity reflexes
  • Lower extremity sensation

Stability and special tests as directed by the differential: 

  • If you suspect lumbosacral radiculopathy, perform straight leg raise
BENCHMARKS FOR SHOULDER EXAM

Benchmarks for a problem focused exam of a patient with shoulder pain include:

Inspection

  • Anterior, lateral and posterior shoulder

Palpation

  • Palpate systematically, noting warmth, deformity, swelling and tenderness:
  • Sternoclavicular joint
  • Clavicle
  • Acromioclavicular (AC) joint
  • Biceps tendon in the bicipital groove
  • Subacromial space and rotator cuff:
    • Supraspinatus tendon
    • Infraspinatus tendon
    • Teres minor
    • Subscapularis insertion
  • Scapula
  • Coracoid process

Range of motion  

  • Flexion, also called forward elevation
  • Abduction
  • Internal and external rotation

Strength Testing  

  • Flexion/forward elevation and extension
  • Abduction and adduction
  • Internal and external rotation

Stability and Special Tests (as directed by DDx)

If you suspect rotator cuff dysfunction: 

  • Perform targeted strength testing of rotator cuff muscles:
    • Empty can test
    • Lift off test
  • Assess for bursitis or impingement
    • Neer test
    • Hawkins test
BENCHMARKS FOR KNEE EXAM

Benchmarks for a problem focused exam of a patient with knee pain include:

Inspection

  • Inspect the knees in the standing position, observing alignment and leg length
  • Observe gait
  • Inspect the knees in the seated or supine position, observing for deformity, swelling, erythema, and ecchymoses

Palpation

  • Palpate systematically, noting warmth, deformity, swelling and tenderness:
  • Patella, quadriceps tendon and prepatellar bursa
  • Proximal tibia
  • Proximal fibula
  • Medial & lateral femoral epicondyles
  • Popliteal fossa
  • Medial and lateral joint lines

Range of motion

  • Extension
  • Flexion

Strength testing

  • Knee extension
  • Knee flexion

Stability and special tests as directed by the DDx:

  • Test medial and lateral collateral ligament (MCL and LCL) stability with varus and valgus stress
  • Test anterior cruciate ligament (ACL) stability with:
    • Anterior drawer test OR
    • Lachman Test
  • Test posterior cruciate ligament (PCL) stability with posterior drawer test
  • Test for meniscal injury with McMurray’s test
  • Evaluate for knee effusion if indicated by history and exam

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