Phase II Physical Exam Rubric

Question 1

General Assessment

Answer 1

Level of distress
State age
Nutritional status
Clothing

Question 2

Vitals

Answer 2

Heart rate (Measure and assess rate, rhythm, and quality)
Blood pressure (one arm only)
Respiratory rate (measure and assess character)

Question 3

HEENT (Inspect)

Answer 3

External inspection of eyes (verbalize orbital area, conjuctiva, sclera, iris, or pupils)
Pupillary rxn to light
Inspect mouth and oral cavity (verbalize on one)
Inspect posterior pharynx (verbalize on one)

Question 4

HEENT (Palpate)

Answer 4

Palpate lymph nodes (anterior cervical and supraclavicular for size, shape, symmetry, consistency, mobility, and tenderness)
Palpate thyroid (size, shape, symmetry, nodules, and tenderness)

Question 5

Cardiac (Inspect and Auscultate)

Answer 5

Auscultate aorta, pulmonic, tricuspid, and apex (sitting or supine)
Auscultate with bell at apex at 5th interspace midclavicular line (supine)

Question 6

Cardiac (Palpate)

Answer 6

Inspect and palpate precordium to assess apical PMI
Palpate radial and posterior tibial or dorsalis pedis pulses bilaterally
Assess lower extremity edema bilaterally

Question 7

Pulmonary

Answer 7

Inspect thorax - front, back, ribs (verbalize size, shape, or symmetry AND use of accessory muscles or presence of retractions)
Percuss chest posteriorly (minimum 3 regions bilaterally)
Auscultate chest anteriorly and posteriorly bilaterally (2 ant; 3 post)

Question 8

Abdominal

Answer 8

Expose abdomen from sternum to pubis and inspect skin, size, shape, contour (supine)
Auscultate abdomen (all four quadrants; 5-10 sec each)
Palpate abdomen (all four quadrants; light then deep)
Palpate liver

Question 9

MSK (Upper and Lower)

Answer 9

Inspect extremities and verbalize for alignment, symmetry, gross deformity, muscle hypertrophy OR muscle atrophy
Inspect joints for swelling, redness, OR deformities for both the knees and hands (bilaterally)

Question 10

Skin, Hair, Nails

Answer 10

Inspect skin and verbalize for color, lesions, moisture

Question 11

Neurologic

Answer 11

Brief mental status: Orientation (self, date, and location) and level of consciousness
Assess speech (verbalize fluency, volume, rate)
Cranial nerves 2-12
Motor (one upper, one lower, bilaterally)
Gait (normal, tandem, heel walking, or toe walking gait)
Deep tendon reflexes - biceps and patellar (bilaterally)
Sensory - light touch or pinprick feet while pt looks away

Question 12

Neuro (CN 2-12)

Answer 12

2 - Pupillary light reflex (2nd time)
3,4,6 - Extraocular movements
5 - sensation of face
7 - eye + mouth movements
9,10 - Say "ah"
11 - Shrug shoulders + turn head against resistance
12 - Protrude tongue