Sandbox/22

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 ❑ Cyanosis ❑ Jaundice ❑ Rash ❑ Pallor ❑ Lesions ❑ Inspection (e.g., rashes, lesions, ulcers) ❑ 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