Adult Advanced Physical Examination 1 (PE1)
Week 1
Session Description
The purpose of this first session of PE1 is to allow the student to practice unfamiliar techniques
of physical examination in a non-threatening environment. During the session, each student will
perform a comprehensive head-to-toe examination on another student. The faculty preceptor is
expected to 1) provide guidance to the students as they perform techniques and to 2) answer
any questions that may arise. Additionally, faculty preceptors may choose to demonstrate
unfamiliar techniques.
Learning Objectives
At the completion of this session, each student will:
1. Name the components of a comprehensive physical examination.
2. Perform a comprehensive physical examination using a coordinated approach.
3. Accurately assess the following components of the patient’s general appearance:
a. Apparent state of heath/presence of any signs of distress.
b. Level of consciousness.
c. Dress, grooming, and personal hygiene.
d. Facial expression.
e. Odors of body and breath (if present).
4. Correctly obtain and interpret a patient’s height, weight, and body mass index (BMI).
5. Correctly obtain and interpret a patient’s blood pressure.
6. Correctly obtain and interpret a patient’s heart rate and rhythm.
7. Correctly obtain and interpret a patient’s respiratory rate.
8. List 3 different ways to obtain a patient’s body temperature and interpret the
measurement.
Required Reading
Bates’ (10th edition) Chapter 1: Overview: Physical Examination and History Taking.
Bates’ (10th edition) Chapter 2: Clinical Reasoning, Assessment, and Recording Your Findings.
Bates’ (10th edition) Chapter 3: Interviewing and the Health History.
Bates’ (10th edition) Chapter 4: Beginning the Physical Examination: General Survey, Vital
Signs, and Pain.
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Adult Advanced Physical Examination 1 (PE1)
Week 2
Session Description
During this second session of PE1, each student will obtain a comprehensive history and
perform a comprehensive head-to-toe examination on an assigned hospitalized patient. Special
attention should be given to the techniques that can be utilized to obtain the patient’s history.
The facilitator of the group should rotate among the students and in the process, observe each
of the students as they perform components of the comprehensive history and physical
examination and provide feedback. Once each student has had an opportunity to perform a
comprehensive history and physical examination, the students should reconvene as a small
group with their faculty preceptor to discuss the patients that they have seen and to discuss the
assigned reading for the session. Also during this time, one or more students should be given
the opportunity to orally present the patient that they have examined. Since this is the first time
that the student will be orally presenting a patient, the faculty member likely will need to provide
significant guidance. At the end of the session, students are expected to record their
observations in a standard fashion and to enter data related to the patient seen in the electronic
learning log. The written report should be handed to the faculty preceptor by no later than the
next meeting time. Included in your write-up should be an assessment and plan section that
includes a problem list and a differential diagnosis that integrates the history and physical
examination information that you have obtained.
Learning Objectives
At the completion of this session, each student will:
1.
Name the components of a comprehensive history and physical examination.
2.
Introduce yourself to the patient in an appropriate and respectful manner.
3. Explore the patient’s story in a non-directive and patient-centered way using facilitative
responses such as active listening.
4. Elicit the patient’s perspective.
5. Use transition statements between the different parts of the history and between the
history and physical examination.
6. Use alternate approaches for gathering data when an interview is difficult.
7. Show concern for the patient’s comfort.
8. Convey an attitude of interest and respect for the patient.
Required Reading
Bates’ (10th edition) Chapter 1: Overview: Physical Examination and History Taking.
Bates’ (10th edition) Chapter 3: Interviewing and the Health History.
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Adult Advanced Physical Examination 1 (PE1)
Week 3
Session Description
During the third session of PE1, each student will obtain a comprehensive history and perform a
comprehensive head-to-toe examination on a hospitalized patient. Special attention should be
paid to the head, eyes, ears, nose, throat (HEENT) and neck examinations. As the facilitator
rotates among the students, he/she should observe each of the students perform components
of the comprehensive history and physical examination and offer feedback. Once each student
has had an opportunity to perform a comprehensive history and physical examination, the
students should reconvene as a small group with their faculty preceptor to discuss the patients
that they have seen and to discuss the assigned reading for the session. During this time, one
or more students should be given an opportunity to orally present the patient that they have
examined. The student(s) who present this week should be different than the one(s) who
presented during the previous week. At the end of the session, students are expected to record
his/her observations in a standard fashion and to enter data related to the patient seen in the
electronic learning log. The written report should be handed to the faculty preceptor by no later
than the next meeting time. As in the previous session, included in your write-up should be an
assessment and plan section that includes a problem list and a differential diagnosis that
integrates the history and physical examination information that you have obtained.
Learning Objectives
At the completion of this session, each student will:
1. Describe the following types of facies: acromegaly, myxedema, Cushing’s syndrome,
nephrotic syndrome, and Parkinson’s disease.
2. Name the lesions of the visual pathways and describe their corresponding visual field
defects.
3. Describe ptosis, exophthalmos, sty, and xanthelasma.
4. List the differential diagnosis of the red eye.
5. Describe Argyll Robertson pupil and Horner’s syndrome.
6. Identify papilledema, optic atrophy, a-v nicking, deep retinal hemorrhages (dot or blot
hemorrhages), soft exudates (cotton wool spots), and neovascularization.
7. Identify and differentiate acute otitis media, serous effusion, bullous myringitis, and otitis
externa.
8. Evaluate air and bone conduction using Weber and Rinne tests.
9. Correctly perform the techniques of examining the sinuses.
10. Identify and describe the following lip lesions: herpes simplex, angular chelitis,
angioedema, and carcinoma.
11. Locate and correctly examine the thyroid gland and identify diffuse enlargement,
multinodular goiter, and a single nodule.
12. Name the locations of all superficial lymph nodes.
Required Reading
Bates’ (10th edition) Chapter 7: The Head and Neck.
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Adult Advanced Physical Examination 1 (PE1)
Week 4
Session Description
During the fourth and final session of PE1, each student will obtain a comprehensive history and
perform a comprehensive head-to-toe examination on a hospitalized patient. Special attention
should be given to the examination of the thorax and lungs. The facilitator of the group should
rotate among the students in order observe each of the students perform components of the
comprehensive history and physical examination and provide feedback. Once each student has
had an opportunity to perform a comprehensive history and physical examination, the students
should reconvene as a small group with their faculty preceptor to discuss the patients that they
have seen and to discuss the assigned reading for the session. During this time, one or more
students should be given opportunity to orally present the patient that they have examined. It is
expected that by the end of this session, each student will have been given an opportunity to
present. At the end of the session, students are expected to record his/her observations in a
standard fashion and to enter data related to the patient seen in the electronic learning log. The
written report should be handed to the faculty preceptor by no later than one week following the
final session. Included in your write-up should be an assessment and plan section that includes
a problem list and a differential diagnosis that integrates the history and physical examination
information that you have obtained.
Learning Objectives
At the completion of this session, each student will:
1. Properly perform the following techniques of examining the thorax and lungs:
a. Inspection.
b. Palpation.
i. Test chest expansion.
ii. Feel for tactile fremitus.
c. Percussion.
d. Auscultation.
2. Describe and identify the following types of breath sounds: vesicular, bronchovesicular,
bronchial, tracheal.
3. Describe and identify the following transmitted voice sounds: egophony, bronchophony,
and whispered pectoriloquy.
4. Describe and identify the following adventitious breath sounds and the accompanying
pathophysiologic state that are responsible for causing each sound: crackles (or rales),
wheezes, rhonchi.
Required Reading
Bates’ (10th edition) Chapter 8: The Thorax and Lungs.
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Example of a Written Adult History and Physical
Source of History: Patient
Chief Complaint: “My chest was hurting”
History of Present Illness: Ms. B is a 64 year old postmenopausal woman with hypertension and
type II diabetes mellitus on oral hypoglycemics who presented to the ED with the complaint of 6
hours of chest pain. She reports that the pain started early this morning, about 10 minutes after
eating some cereal and tea. The pain was severe and steady, getting slightly worse over the
period of 4-6 hours. She describes the pain as burning in nature, in the center of her chest and
“at the top of [her] belly.” The pain did not radiate. She reports feeling slightly short of breath
after the pain had been there about 1-2 hours. She denies any orthopnea, dyspnea on exertion,
palpitations, lightheadedness, diaphoresis, cough, fever, and hemoptysis. She also denies any
nausea, vomiting, diarrhea, change in stool, blood in stool, abdominal pain, and dysphagia. She
does have occasional heartburn, but this pain was different. She tried some Tums and some
ginger ale, both of which did nothing for the pain. At its onset, the pain was 6/10 intensity. At its
worst, the pain was 10/10. She reports that nothing made the pain worse and she did not eat
anything after the cereal. She has never had this pain before. Because of the severity of the
pain, she decided to come to the ED for evaluation.
Past Medical/Surgical History:
Hypertension
Type II Diabetes Mellitus on oral hypoglycemics
s/p total abdominal hysterectomy with bilateral salpingo-oophorectomy for fibroids, 25 years ago
s/p cholecystectomy
GERD
Osteoporosis
Chicken pox as a child
Medications:
Hydrochlorothiazide 25mg by mouth once daily
Metformin 850mg by mouth 3 times daily
Glyburide 10mg by mouth twice daily
Lisinopril 20mg by mouth once daily
Alendronate 70mg by mouth once weekly
Aspirin 81 mg by mouth once daily
Acetaminophen 325 mg by mouth occasionally for “aches and pains”
Tums by mouth as needed for heartburn
The patient denies use of any herbal supplements or other over-the-counter medications.
Allergies:
Penicillin -- “I don’t remember the reaction, I had it when I was a child”
Occasional allergic symptoms to dust
No food allergies
Immunizations:
Reports that she received all of her childhood immunizations
Pneumonia vaccine (last year)
Flu shot (3 weeks ago)
Tetanus vaccine (4 years ago)
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Health Care Maintenance:
Colonoscopy 2005: “normal”
Mammogram 5/09: “normal”
Pap smear 4/09: “normal,” with no history of abnormal Pap smears
DEXA scan 5/08: stable osteoporosis
Social History:
The pt lives with her husband of 42 years on Mount Washington. She has 3 grown children. She
has not worked outside the home since getting married. She denies cigarettes, alcohol, or
recreational drug use, past or present. She denies any violence, past or present. She is
mutually monogamous with her husband although she does note that her libido is down and she
has not been sexually active in >1 year. Her husband has been her only sexual partner. She
likes to garden and goes for a walk with her husband nightly when the weather is good. She
tries to stick to her diabetic diet, but she enjoys ice cream.
Obstetrical/Gynecological History:
G4P3013 with 1 spontaneous miscarriage. TAH/BSO 25 years ago secondary to menorrhagia
and fibroids. No hot flashes. No problems with labor/pregnancy.
Family History:
Mother: alive at 87 years with HTN
Father: deceased at 74 years from MI, CVA
Brother: deceased from MVA at 32 years old
Brother: 70 years of age with HTN, DM
Sister: 68 years of age with depression, “borderline” DM, HTN
Son: healthy, 40 years old
Son: healthy, 38 years old
Daughter: HTN, 36 years old
No coronary artery disease, cancer, alcoholism, kidney disease, anemia, lung disease, arthritis.
ROS:
General: Denies wt loss, fever, weakness
Skin: Denies rashes, lumps, or bruises
HEENT: Occasional HA relieved with acetaminophen; Wears corrective glasses; Slight hearing
loss, especially in crowded rooms; Denies any eye pain, redness, blurred vision, ear pain, sinus
infections, mouth ulcers, throat pain, nose pain, nasal drainage, bloody nose, or hoarse voice;
Last dental exam was 6mos ago; Last eye exam was last year.
Neck: Denies any lumps, pain
Breasts: Denies any lumps, nipple discharge, or abnormal mammograms
Cardiovascular: see HPI
Pulmonary: see HPI
Gastrointestinal: see HPI
Genitourinary: Occasional urinary incontinence when she sneezes or coughs; Denies
hematuria, dysuria, or frequency
Gynecological: Denies vaginal irritation, dryness, or lesions
Psychiatric: Denies depression, anxiety
Neurologic: Denies any numbness or tingling, seizures, or dizziness
Endocrine: Denies any thyroid issues, heat or cold intolerance
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Physical Examination:
Vital signs: BP 154/98, repeat 148/90; HR 62; T 36.9 degrees Celsius measured orally; RR 14
respirations/minute; O2 saturation = 98% on room air
General: In no apparent distress, appears stated age
Head: Atraumatic, normocephalic
Eyes: No conjunctival injection; pupils equally round and reactive to light and accommodation;
no afferent papillary defect; Extra-ocular movements intact; fundoscopic examination reveals
normal optic discs
Ears: TMs within normal limits; ear canals with small amount of cerumen bilaterally
Sinuses: No maxillary or frontal sinus tenderness
Nares: Nasal mucosa pink without injection; no septal deviation
Mouth: Oral mucosa moist without lesions; posterior pharynx pink without injection; tonsils
normal in size without exudates
Neck: Supple; no thyromegaly, carotid bruits, or masses; no JVD
Cardio: Regular rhythm; normal S1/S2; +3/6 systolic murmur best heard over the left sternal
border with no radiation; PMI slightly displaced to left
Thorax: Bilaterally clear to auscultation and percussion; good air entry; normal lung expansion.
Breasts: Symmetric; no palpable masses or expressible nipple discharge
Abdomen: Normoactive bowel sounds with no bruits; soft, nontender, nondistended, no rebound
or guarding; liver span 10 cm, not felt below costal margin; no splenomegaly or palpable
masses
Back: No CVA tenderness, scoliosis, or vertebral tenderness
Extremities: Trace edema bilaterally around ankles; full ROM bilaterally in both upper and lower
extremities; dorsalis pedis and posterior tibial pulses +2 bilaterally
Neurologic: Awake, alert, and oriented x 3; cranial nerves II-XII grossly intact; DTRs 2+
bilaterally; strength +5/5 throughout; vibratory, light touch, and pain sensation grossly intact;
finger-to-nose and rapid alternating movements within normal limits; downgoing toes bilaterally;
normal gait; Romberg negative
Derm: No lesions or rashes
Lymph: No cervical, axillary, or inguinal lymphadenopathy
Laboratory and Data:
EKG: normal sinus rhythm, rate 62, 2mm ST-elevation in V2-V6, avL, I
Assessment and Plan:
Ms. B. is a 64 year old postmenopausal woman with HTN and type II DM who presents with a 46 hour history of substernal chest pain.
1. Chest Pain: One of the most concerning differential diagnoses for this patient is an acute
coronary syndrome as she has 3 cardiac risk factors and her pain is somewhat typical for
angina pectoris (substernal in nature). Although her pain was brought on after eating and not
after exertion, women and diabetics (both describing this patient), tend to present more
commonly with atypical presentations for angina pectoris. Other possibilities for her chest pain
complaints include gastritis, GERD, pneumonia, peptic ulcer disease, and pneumothorax. She
does have a history of reflux, yet this pain did not go away with Tums and is unlike her prior
pain. She has some shortness of breath, but no cough with productive sputum, fever, or chills,
making pneumonia less likely. Her examination argues against both pneumonia and
pneumothorax. I will workup the patient’s chest pain by obtaining serial troponin levels (x3) to
evaluate for myocardial infarction and a chest x-ray to evaluate for pneumonia and
pneumothorax. I will also perform guaiac testing of her stool as gastritis may cause occult blood
in her stool. If all of these are negative, I will obtain an exercise stress test with nuclear imaging.
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For now, I will admit the patient to a telemetry bed and will monitor for any arrhythmias. I will
continue the patient on aspirin and her proton pump inhibitor and will consider nitroglycerin for
treatment of her chest pain. The patient’s blood pressure is above goal (<130/80). Thus, the
patient will likely need to have her antihypertensive regimen adjusted before she leaves the
hospital. Finally, I will check her cholesterol level and treat appropriately (goal LDL is < 100
given her diabetes).
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