|
|
| Line 1: |
Line 1: |
| {{familytree/start}} | | {{familytree/start}} |
| {{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:'''<br> | | {{familytree | | | A01 | | A01=}} |
| ----
| | {{familytree | |,|-|^|-|.| |}} |
| '''General appearance'''<br>
| | {{familytree | B01 | | B02 | |B01=|B02=}} |
| ❑ Cachectic<br>
| | {{familytree | |!| | | |!| | |}} |
| ❑ Diaphoretic<br>
| | {{familytree | C01 | | C02 | |C01=|C02=}} |
| ❑ Obese<br>
| | {{familytree | | | |,|-|^|-|.| |}} |
| ❑ Thin<br>
| | {{familytree | | | D01 | | D02 | |D01=|D02=}} |
| ❑ Well-appearing or ill-appearing
| | {{familytree | | | |!| | | |!| | | |}} |
| ----
| | {{familytree | | | E01 | | E02 |E01=|E02=}} |
| '''Vitals'''<br>
| |
| ----
| |
| ❑ [[Temperature]]<br>
| |
| :❑ [[Fever]] <br>
| |
| :❑ [[Hypothermia]] <br>
| |
| ❑ [[Pulse]]<br>
| |
| :❑ Rate <br>
| |
| ::❑ [[Tachycardia]] <br>
| |
| ::❑ [[Bradycardia]] <br>
| |
| :❑ Rhythm <br>
| |
| ::❑ Regular <br>
| |
| ::❑ Irregularly irregular <br>
| |
| :❑ Strength <br>
| |
| ::❑ Weak <br>
| |
| ::❑ Bounding <br>
| |
| ::❑ Alternating in strength ([[pulsus alternans]]) <br>
| |
| :❑ [[Paradoxical pulse]] <br>
| |
| :❑ Symmetry <br>
| |
| ::❑ Asymmetric <br>
| |
| ❑ [[Respiration]]<br>
| |
| :❑ [[Tachypnea]] <br>
| |
| :❑ [[Bradypnea]] <br>
| |
| :❑ [[Kussmaul respirations]] <br>
| |
| ❑ [[Blood pressure]]<br>
| |
| :❑ [[Hypotension]] <br>
| |
| :❑ [[Hypertension]] <br>
| |
| :❑ [[Wide pulse pressure]] <br>
| |
| :❑ [[Narrow pulse pressure]] <br>
| |
| ❑ [[Pulse oximetry]]<br>
| |
| ----
| |
| '''Skin'''<br>
| |
| ----
| |
| ❑ Inspection <br>
| |
| :❑ [[Cyanosis]] <br>
| |
| :❑ [[Jaundice]] <br>
| |
| :❑ [[Rash]] <br>
| |
| :❑ [[Pallor]] <br>
| |
| :❑ [[Skin lesion|Lesions]] <br>
| |
| ❑ Palpation (e.g., induration, subcutaneous nodules, tightening)<br>
| |
| ----
| |
| '''Head, Ear, Eye, Nose & Throat'''<br>
| |
| ----
| |
| ❑ [[Head]]<br>
| |
| :❑ Abnormalities of the head/hair <br>
| |
| :❑ Evidence of [[trauma]] <br>
| |
| ❑ [[Eye]]<br>
| |
| :❑ [[Icterus|Icteric sclera]] <br>
| |
| :❑ [[Nystagmus]] <br>
| |
| :❑ [[Eye examination#Testing Extra-Ocular Movements:|Abnormal extra-ocular movements]] <br>
| |
| :❑ [[Eye examination#Assessing Pupillary Response to Light:|Pupils not reactive to light]] <br>
| |
| :❑ [[Eye examination#Using the Opthalmoscope|Abnormal findings on ophthalmoscopic exam]] <br>
| |
| ❑ [[Ear]] <br>
| |
| :❑ Reduced hearing acuity<br>
| |
| :❑ Positive [[Weber test]]<br>
| |
| :❑ Positive [[Rinne test]]<br>
| |
| :❑ [[Exudate]] from the ear canal <br>
| |
| :❑ [[Tenderness]] on movement of the pinnae <br>
| |
| ❑ Nose <br>
| |
| :❑ Inflamed [[nares]]<br>
| |
| :❑ [[Epistaxis]] <br>
| |
| :❑ [[Purulent]] exudate from the nares <br>
| |
| :❑ [[Tenderness]] to percussion of the sinuses <br>
| |
| :❑ [[Nasal congestion|Congested nares]]<br>
| |
| ❑ [[Throat]]<br>
| |
| :❑ Erythematous <br>
| |
| :❑ [[Exudate]] <br>
| |
| :❑ [[Petechiae]] <br>
| |
| :❑ Tonsillar inflammation <br>
| |
| ----
| |
| '''Neck'''<br>
| |
| ----
| |
| :❑ Masses, overall appearance, symmetry, tracheal position, crepitus<br>
| |
| :❑ Elevated [[jugular venous pressure]]<br>
| |
| :❑ [[Carotid bruits]] <br>
| |
| :❑ [[Lymph nodes]] <br>
| |
| :❑ [[Thyromegaly]] <br>
| |
| :❑ [[Hepatojugular reflux]] <br>
| |
| ---- | |
| '''Respiratory examination'''<br>
| |
| ----
| |
| ❑ Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement, [[wheezing]], asymmetric chest movement)<br>
| |
| ❑ Percussion (e.g., dullness, hyperresonance)<br>
| |
| ❑ Palpation (e.g., tactile fremitus)<br>
| |
| ❑ Auscultation ([[rales]], reduced [[breath sounds]], [[egophony]])<br>
| |
| ----
| |
| '''Cardiovascular examination'''<br>
| |
| ----
| |
| ❑ Palpation (location, size, [[thrill]]s, [[heave]])<br>
| |
| ❑ Auscultation (abnormal sounds, murmurs, [[pericardial friction rub]])<br>
| |
| :❑ [[Heart sounds]]
| |
| ::❑ [[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] <br>
| |
| ::❑ [[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]] <br>
| |
| ::❑ [[Heart sounds#Third heart sound S3|S3]] <br>
| |
| ::❑ [[Heart sounds#Fourth heart sound S4|S4]] <br>
| |
| ::❑ [[Heart sounds#Summation Gallop|Gallops]] <br>
| |
| :❑ [[Murmur]]
| |
| ::❑ [[Systolic murmur]] best heard at the base (describe the murmur)<br>
| |
| ::❑ [[Systolic murmur]] best heard at the apex (describe the murmur)<br>
| |
| ::❑ [[Diastolic murmur]] (describe the murmur)<br> ❑ Carotid arteries (e.g., pulse amplitude, bruits)<br>
| |
| ❑ Abdominal aorta (e.g., size, bruits)<br>
| |
| ❑ Femoral arteries (e.g., pulse amplitude, bruits)<br>
| |
| ❑ Pedal pulses (e.g., pulse amplitude)<br>
| |
| ----
| |
| '''Abdominal examination'''<br>
| |
| ----
| |
| ❑ Inspection <br>
| |
| :❑ [[Abdominal distention]] <br>
| |
| ❑ Palpation<br>
| |
| :❑ Presence of [[abdominal mass]], [[abdominal tenderness]], [[rebound tenderness]], renal angle tenderness<br>
| |
| :❑ Examination of the liver and spleen<br>
| |
| ::❑ [[Hepatomegaly]] <br>
| |
| ::❑ [[Splenomegaly]] <br>
| |
| :❑ Examination for the presence or absence of hernias<br>
| |
| :❑ Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses<br>
| |
| ❑ [[Genitourinary exam]], if relevant <br>
| |
| ❑ Percussion<br>
| |
| :❑ Dullness (fluid thrill, [[ascites]])<br>
| |
| ❑ Auscultation<br>
| |
| :❑ Aortic bruits<br>
| |
| ----
| |
| '''Extremities'''<br>
| |
| ----
| |
| ❑ Gait and station<br>
| |
| ❑ Inspection/palpation <br>
| |
| :❑ Digits and nails (e.g., [[clubbing]], [[cyanosis]], inflammatory conditions, petechiae, ischemia, infections, nodes)<br>
| |
| :❑ Defects, tenderness, masses or effusions<br>
| |
| :❑ Range of motion with notation of any pain, crepitation or contracture<br>
| |
| :❑ Muscle strength and tone (e.g., flaccid, cogwheel, spastic)<br>
| |
| ----
| |
| '''Neurological examination'''<br>
| |
| ----
| |
| ❑ [[Glasgow coma scale]] of___ <br>
| |
| ❑ Test cranial nerves with notation of any deficits<br>
| |
| ❑ Deep tendon reflexes with notation of any pathologic reflexes (e.g., Babinksi)<br>
| |
| :❑ [[Clonus]] <br>
| |
| :❑ [[Hyperactive reflexes]] <br>
| |
| ❑ Sensation (e.g., by touch, pin, vibration, proprioception)<br>
| |
| ----
| |
| '''Psychiatric evaluation'''<br>
| |
| ----
| |
| ❑ Description of patient’s judgment and insight<br>
| |
| ❑ Brief mental status<br>
| |
| :❑ Orientation to time, place, and person<br>
| |
| :❑ Recent and remote memory<br>
| |
| :❑ Mood and affect<br>
| |
| </div>}}
| |
| {{familytree/end}} | | {{familytree/end}} |