History and Physical Exam Skills List

Note: As the OSCE is the culmination of your communication and physical diagnosis
training all of your advanced skills (both communication and physical diagnosis) are fair
game. You will be responsible for knowing and being prepared to demonstrate specialty
maneuvers if they are appropriate to the case. You will not however be responsible for
the items that are marked as "not in PD sessions with SPs (e.g. temperature, femoral
pulses.)

OPENING VISIT
Greets patient and introduces self by first and last name
Uses patient's formal name (Mrs. Smith, Ms. Smith, Mr. Smith)
Demonstrates interest and respect
Attends to comfort and privacy of patient
o Asks permission to do the exam
o Explains what he/she is doing during the exam, as he/she is doing it
o Uses gown and drape to maintain patient privacy

RELATIONSHIP BUILDING MAINTAINED THROUGHOUT THE INTERVIEW

Student greets and shows interest in patient as person
Non-verbal: Maintains eye contact and uses non-verbal skills to demonstrate interest and
respect
Uses tone, pace, eye contact and posture to show care and concern
Responds to empathic cues with an empathic statement, avoids redirecting
Responds in non-judgmental way to patient's story, uses words that reflect caring and concern
Uses encouragers that demonstrate listening actively (uh-hum, nodding)
Use pleasant tone of voice and pacing
Actively listens throughout the interview using verbal and non-verbal techniques

INFORMATION GATHERING: GATHERS HPI OR REASON FOR VISIT/PHONE CALL

Allows the patient to complete opening statement without interruption in eliciting chief
concern/reason for visit: "What brings you here today?"
Starts with open-ended questions-"How can I help you today?"
Uses facilitation statements-"Tell me more."
Follows with focused questions, "Can you tell me more about that concern?"
Uses language patient can understand when getting more details of patient's history
Clarifies details as necessary with more specific, focused questions or close ended yes/no
questions
Gathers history of present illness or history of reason for visit
Establish/explain/negotiate agenda/focus of visit-asking "anything else" to elicit full set of
concerns
Asks about pain uses pain score
Asks all clarifying questions about HPI location, duration, quality, severity, timing, context,
modifying factors
Encourages patient to maintain story line in chronological order
Elicits patient perspective/beliefs/concerns about cause of problem
Summarize information when appropriate
Summarizes HPI and gives patient opportunity to correct or add information
Makes natural transitions to next part of interview

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INFORMATION GATHERING: PAST MEDICAL HISTORY
Asks about Past Medical History if not seen in chart
Elicits information on:
Hospitalizations
Surgeries
Serious illnesses
Psychiatric illnesses
Complementary and integrative medicine
Pregnancies
Exposures
Immunizations
Allergies
Medications

INFORMATION GATHERING: FAMILY AND SOCIAL HISTORY

Present ages and state of health, or age at death and cause for family major medical and
psychiatric problems
Asks about life events, circumstances, other people that might affect patient's health
Asks family history of breast, ovarian, colon, prostatic cancers, hypertension, heart disease,
diabetes, alcoholism, depression, abuse
Asks patient about suicidal or homicidal intent, possession of gun
Asks about patient's current living situation
Asks the question Do you think any of your problems are caused by exposures or hazards in
your home, community or workplace?
Patient's health habits-smoking, drugs, ETOH, exercise, nutrition, sexual orientation and practices
Ask patient about sexual history and orientation
Asks about patient's current stresses and sources of support
Asks for patients last year of education (literacy)
Assesses occupational or environmental risks
Makes appropriate transition to end of interview or physical exam

REVIEW OF SYSTEMS
This list is not necessarily complete but is sufficient for practice and PD
General: fevers/chills, weight loss or gain, fatigue, weakness, recent episodes of pain
Skin: rash, itching, sores, lumps, mole changes, color changes, dryness, hair loss
Head and neck: headaches, facial pain, numbness or weakness, vertigo, rhinorrhea, epistaxis,
nasal congestion, hearing impairment, ear pain, tinnitus, visual loss, glasses or contacts use,
blurry vision or double vision, eye pain. Neck pain, sore throat, neck stiffness, lymphadenopathy,
goiter
Endocrine: heat or cold intolerance, increased or decreased energy, weight gain or loss,
fatigue/weakness
Pulmonary: wheezing, dyspnea, hemoptysis, chest pain with breathing, cough, dry or with
sputum, cyanosis,
Cardio: chest pain, palpitations, syncope, orthopnea, change in exercise tolerance, paroxysmal
nocturnal dyspnea, edema,
GI: Sore throat, sore tongue, heartburn, flatulence, nausea, vomiting, abdominal pain, anorexia,
hematemesis or coffee ground emesis, dysphagia or odynophagia, change in bowel function,
diarrhea or constipation, jaundice, melena
GU: difficulty urinating, dysuria, flank pain, urgency, polyuria, nocturia, hematuria
Musculoskeletal: joint pain (multiple, knee, shoulder, jaw), joint swelling, back pain, neck pain,
stiffness, difficulty walking or moving (use pain score), arthritis

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 Neuro: Headaches, paresthesias, numbness; dizziness, syncope, weakness, tremor,
incoordination, change in normal activities, seizures
Psychiatric: insomnia, memory problems, difficulty thinking or concentrating, unexplainably sad,
worried, or afraid, depressed mood, hallucinations, history of depression or
addiction. Functional status: problems with Activities of Daily Living (Taking care of finances or
paying bills; preparing meals; getting around in the house; getting dressed; washing, bathing, or
showering; going to the bathroom)

PHYSICAL EXAM
Knocks, shakes hands and introduces self
Washes hands before examining the patient.
Attends to comfort and privacy of patient
o Asks permission to do the exam
o Explains what he/she is doing during the exam, as he/she does it
o Uses gown and drape to maintain patient privacy
Examines or listens with stethoscope on the skin (not through the gown)
Asks about area of pain before examination
Tells the patient what he/she is doing while they are doing it

GENERAL EXAM, SKIN AND VITALS

Uses observation skills throughout the exam (patient distress level, hygiene, etc.)
Examine skin with each portion of the exam (lesions, color changes, sores, hair loss, etc.)
Examine hands, lower legs, feet and nails (clubbing, palmar erythema, asterixis, thenar wasting,
nail abnormalities, edema, hair loss)
Obtain blood pressure
Obtain heart rate (radial)
Obtain respiratory rate
Obtain pain score
Obtain temperature (not in PD sessions)

HEAD and NECK EXAM

Observation of skin and head
Palpate sinuses and examine nasal passages with the otoscope
Examine and palpate the mouth, tongue, teeth, and gums
Examine the eyes for pallor or icterus and eyelids for drooping
Use the ophthalmoscope to visualize the fundus
For rest of eyes - see cranial nerves in neuro
Examine the tympanic membrane with the otoscope
Test for bone conduction with the Rhinne and lateralization with the Weber test
Screen for hearing loss with finger rub
Palpate the boundaries of the thyroid, size and texture and palpate during swallowing
Palpate for lymph nodes in the following areas: Preauricular, postauricular, occipital, tonisllar,
Submandibular, Submental, Superficial cervical, Posterior cervical, Supraclavicular, Axillary

CARDIOPULMONARY
Observe the shape of chest and observe for respiratory difficulties and use of accessory muscles
Palpate spine and ribs posteriorly. Palpate for areas of tenderness and chest expansion
Percuss both lungs posteriorly
Auscultate with the stethoscope under the gown to the lungs posteriorly, anteriorly, and
laterally (all lobes) for breath sounds -
Vesicular, bronchiovesicular, bronchial, tracheal
Crackles (rales), wet crackles (rhonchi), wheezes,
Auscultate for transmitted voice sounds
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 Egophony using e and
Bronchophony using 99
Whispered pectoriloquy
Assess for CVA tenderness
Auscultate with the stethoscope under the gown to the heart in the 4 main listening areas using
the diaphragm
Aortic (2nd R IC space)
Pulmonic (2nd L IC space)
Tricuspid (lower L sternal border)
Mitral (Apex)
Identify and measure the JVP patient at 30 degrees (not tested on SPs)
Auscultate the heart while palpating the carotid pulse for S1
Listen for bruits in the carotid arteries
Position the patient in the left lateral decubitus position and palpate the PMI
Listen over the PMI (Apex) with the bell of th stethoscope
Listen for the splitting of S2
Listen for S3 and S4 and common murmurs (systolic - flow, mitral regurgitation, aortic stenosis,
mitral valve prolapse. Diastolic - aortic insufficiency)
Observe fingers and toes for discoloration and nail abnormalities. Measure capillary refill
Palpate peripheral pulses (brachial, radial, popliteal, posterior tibialis, dorsalis pedis)
Palpate axillary region for lymphadenopathy
Palpate lower legs and feet for edema

ABDOMINAL EXAM
Observation of the abdomen and skin - symmetry, contour, striae, hernias, scars, signs of trauma,
distension, bulging flanks, ascites, caput medusa, aortic pulsations
Position the patient in a supine position with proper coverage with gown and drape
Ask about areas of pain and examine from the right
Auscultate with the stethoscope under the gown to the abdomen in all 4 quadrants for bowel
sounds
Percuss the abdomen in all 4 quadrants
Percuss for liver span
Lightly palpate the abdomen in all 4 quadrants
Deeply palpate the abdomen, using two hands (area of pain last)
Palpate the liver edge using two hands or hook technique
Palpate the abdominal aorta
Palpate the bladder, or the suprapubic area for tenderness
Auscultate for renal bruits
Palpate the femoral arteries (not tested on SPs)
Auscultate the femoral arteries (not tested on SPs)

Specialty maneuvers
Rebound tenderness (ask where it hurt and which hurt more: pressing or letting go?)
Assess for ascites (shifting dullness and fluid wave tests)
Check for asterixis
Check for jaundice
Check for lower extremity edema
Assess for guarding and rigidity
Check for Rovsings sign
Check for psoas sign
Check for obturator sign
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 Check for Murphys sign
Check for ventral hernia
The abdominal exam is incomplete without an examination of the rectum and stool. It will not be done in
this session.

MUSCULOSKELETAL EXAM
Active Range of Motion - observer for symmetry
Upper extremities - sitting or standing
Abduct arms to 180 with palms inward (shoulder abduction)
Raise arms forward to 180 with palms down (shoulder flexion)
With arms at sides, bend arms at elbows (elbow flexion)
Place palms behind neck (shoulder external rotation)
Place dorsum of hands behind lower back (internal rotation
Lower extremities - supine
Abduct each leg to 45 (hip abduction)
Raise each leg to 130 (hip flexion)
With legs raised, bend legs at knees (knee flexion)
With knee bent, rotate each leg inward (hip internal rotation)
With knee bent, rotate each leg outward (hip external rotation)
Spine - standing
Bend forward with chin to chest and fingers to toes (trunk flexion)
Bend backward to look at ceiling (trunk extension)
Rotate head and shoulders to either side (trunk rotation)
Tilt head and shoulders to either side (trunk lateral flexion)
Palpate spinous processes and sacroiliac joints
Inspect and palpate the following joints: test for pain, swelling
o Hands and fingers, wrists, elbows, shoulders, hips, knees, ankles, toes
Test for strength - extension and flexion
o Hands and fingers, wrists, elbows, shoulders, hips, knees, ankles, toes

Special Maneuvers:
Hand: Tinels and Phalens tests
Knee - Mc Murray test, Valgus and Varus stress test, anterior and posterior drawer sign,
Lachman Test
Shoulder: Crossover test, Neers impingement sign, Hawkins impingement sign, strength and
drop arm sign

NEUROLOGICAL EXAM
o Test orientation to person, place, time
o Observe patients appearance, behavior, mood and speech
o Ask patient to recall 3 words (ball, tree, flag) after distraction (ask what they had for
breakfast)
o Test cranial nerves
Smell (CN I) [Remember, you are not testing CN I (smell)]
Pupillary responses (CN II, III) using ophthalmoscope
Visual acuity (CN II) using eye chart
Visual fields (CN II)
Extraocular movements (CN III, IV, VI) using H test
Facial sensation (CN V)
Jaw strength (CN V)
Facial expressions (raise eyebrows, shut eyes, smile, puff cheeks) (CN VII)
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 Hearing acuity (CN VIII) using finger rub test
Gag reflex (CN IX, X) (you do NOT have to do this for this session)
Swallowing (CN IX, X)
Palate elevation while saying ahhh (CN X)
Shrug shoulders (CN XI)
Rotate head against hand (CN XI)
Tongue symmetry (CN XII)
o Test sensation to light touch in upper and lower extremities
o Test sensation to sharp touch in upper and lower extremities
o Test sensation to vibration fingers and toes using tuning fork
o Test proprioception in fingers and toes
o Test strength at shoulders, wrists, fingers, hips, knees, ankles (you do NOT need to
repeat this from the MSK exam)
o Test deep tendon reflexes (biceps, triceps, patella, Achilles)
o Test for the Babinski reflex
o Test for coordination using finger-to-nose, rapid alternating movement tests
o Test for balance using Romberg test
o Test for gait
Walk normally to door
Walk heel-to-toe back to table
Walk on toes to door
Walk on heels to table

INTERVIEW CLOSE
Checks patient understanding by using teach back/tell back
Makes appropriate transition to end of interview, or to move to physical exam, or to talk with
preceptor
Closed interview before standing up
Closes interview with appropriate parting statement
Confirms follow up

COMMUNICATIONS IN MEDICINE

SKILLS SPECIFIC FOR PATIENT EDUCATION WITH DISCUSSION OF RISK

Asks patient if familiar with diagnosis or risk assessment
Gives information clearly and concisely, avoids medical jargon
Gathers information about patient's knowledge, health beliefs, and level of understanding about
risk
Tailors education to patient's literacy level and cultural background
Discusses risk in terms of specific behaviors (e.g. getting more tests)
Utilizes appropriate written material
Uses teach back/Make sure patient understands details by checking for understanding
Inquires if anyone else needs to be at next visit

SKILLS SPECIFIC TO HEALTH BEHAVIOR CHANGE: USES 5A MODEL:

Asks: "Do you smoke?" "Have you thought about quitting?"
Advises: e.g. "I want to let you know it is dangerous to your health to continue smoking. I want
you to know that the long term effects of smoking could be very serious."
Assesses: "What is patient's readiness for change? Is patient: pre-contemplative, contemplative,
ready for action, relapsed?

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 Assists: Offers patient a variety of methods to quit when/if ready, offers partnership to help
process of quitting. Makes empathic statements if patient is not ready, leaves the door open.
Advises no smoking around family members.
Arranges: Makes any necessary arrangements to facilitate process. Offers pamphlets, Quit line
numbers, website.
Motivates contemplators by stating the advantages and disadvantages of starting new behavior,
or uses readiness ruler to assess confidence and importance.
Gathers information by giving information in small amounts.
Checks patient understanding by using teach back/tell back
Encourages shared decision making
Checks patient's ability to follow plan.

SKILLS SPECIFIC TO NEW/SEXUAL CONCERNS-UNDERSTANDS THE PATIENT'S PERSPECTIVE

Elicits patient's perspective regarding current concern
Acknowledges patient's perspective
Elicits fears, concerns, beliefs without imposing provider's beliefs
Shares information by giving patient information and checking for understanding-does patient
know difference between HIV and AIDS
Explains using words the patient can understand particularly when educating the patient about
risk
Adjusts information on risk to patient's readiness for change in sexual behavior
Uses teach back/Make sure patient understands details by checking for understanding
Reaches agreement on plan and checks patient's ability to follow plan.
Offers partnership, works with patient to address concerns

SKILLS SPECIFIC TO DIAGNOSIS OF ANXIETY OR DEPRESSION

Shares information by explaining using words patient can understand
Avoids using medical jargon
Reaches agreement in new/changed plan by including patient in choices and decisions to extent
he/she desires
Includes patient in choices and decisions to extent he/she desires

ORAL PRESENTATION
Uses the Oral Presentation Format
Includes relevant information from HPI, PMH, PSHx, FMHx, Soc Hx, ROS, Vitals, Lymph Nodes and
thyroid exam when presenting
Includes a prioritized problem list with appropriate justification and discussion
Demonstrates logical organization
Avoids inappropriate labels or comments

Compiled Skills List - Rev 7.5.17