Resident survival guide examine the patient

Appearance of the Patient
❑ This section should give a general description of what a patient with the disease you are describing may look like. You may include a physical description such as obese, thin, cachectic, well appearing, ill appearing, diaphoretic etc

Vitals
❑ Temperature

❑ Fever

❑ Hypothermia

❑ Pulse

❑ Rate

❑ Tachycardia

❑ Bradycardia

❑ Rhythm

❑ Regular

❑ Irregularly irregular

❑ Strength

❑ Weak

❑ Bounding

❑ Alternating in strength (pulsus alternans)

❑ Paradoxical pulse

❑ Symmetry

❑ Asymmetric

❑ Blood pressure
❑ Hypotension
❑ Hypertension
❑ Wide pulse pressure
❑ Narrow pulse pressure

❑ Respiratory rate
❑ Tachypnea
❑ Bradypnea
❑ Kussmaul respirations

Skin
❑ Cyanosis
❑ Jaundice
❑ Rash
❑ Pallor
❑ Lesions

Head
❑ Abnormalities of the head/hair
❑ Evidence of trauma

Eyes
❑ Icteric sclera
❑ Nystagmus
❑ Abnormal extra-ocular movements
❑ Pupils not reactive to light
❑ Abnormal findings on ophthalmoscopic exam

Ears
❑ Reduced hearing acuity
❑ Positive Weber test
❑ Positive Rinne test
❑ Exudate from the ear canal
❑ Tenderness on movement of the pinnae

Nose
❑ Inflamed nares
❑ Epistaxis
❑ Purulent exudate from the nares
❑ Tenderness to percussion of the sinuses
❑ Congested nares

Throat
❑ Erythematous
❑ Exudate
❑ Petechiae
❑ Tonsillar inflammation

Neck
❑ Elevated jugular venous pressure
❑ Carotid bruits
❑ Lymph nodes
❑ Thyromegaly
❑ Hepatojugular reflux

Lungs
❑ Pulmonary edema and rales
❑ Wheezing
❑ Reduced breath sounds
❑ Rales
❑ Egophony
❑ Asymmetric chest movement

Heart
❑ Heave
❑ Thrill
❑ Pericardial friction rub
❑ Heart sounds

❑ S1

❑ S2

❑ S3

❑ S4

❑ Gallops
❑ Murmur

❑ Systolic murmur best heard at the base (describe the murmur)

❑ Systolic murmur best heard at the apex (describe the murmur)

❑ Diastolic murmur (describe the murmur)

Abdomen
❑ Abdominal distention
❑ Abdominal tenderness
❑ Rebound tenderness
❑ Abdominal mass
❑ Abdominal guarding
❑ Hepatomegaly
❑ Splenomegaly
❑ Genitourinary exam if relevant

Extremities
❑ Clubbing
❑ Cyanosis
❑ Edema

Neurologic
❑ Altered mental status
❑ Glasgow coma scale of___
❑ Clonus
❑ Hyperactive reflexes
❑ Deficits in cranial nerves ___

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