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