Examine the patient
Vitals
❑ Temperature
❑ Pulse
❑ Respiration
❑ Blood pressure
❑ Pulse oximetry
General appearance
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Head, Ear, Eye, Nose & Throat
❑ Head
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❑ Eye
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❑ Ear
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❑ Neck
- ❑ Masses, overall appearance, symmetry, tracheal position, crepitus
- ❑ Jugular vein distention
- ❑ Thyroid
❑ Throat
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Respiratory examination
❑ Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
❑ Percussion (e.g., dullness, hyperresonance)
❑ Palpation (e.g., tactile fremitus)
❑ Auscultation (crepitus)
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Cardiovascular examination
❑ Palpation (location, size, thrills)
❑ Auscultation (abnormal sounds and murmurs)
❑ 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)
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Abdominal examination
❑ Inspection e.g., asymmetry with notation of
❑ Palpation
- ❑ Presence of masses or tenderness
- ❑ Examination of the liver and spleen
- ❑ Examination for the presence or absence of hernias
- ❑ Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
❑ Percussion
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❑ Auscultation
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Extremities
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Neurological examination
❑ Test cranial nerves with notation of any deficits
❑ Deep tendon reflexes with notation of any pathologic reflexes (e.g., Babinksi)
❑ Sensation (e.g., by touch, pin, vibration, proprioception)
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Skin
❑ Inspection (e.g., rashes, lesions, ulcers)
❑ Palpation (e.g., induration, subcutaneous nodules, tightening)
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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
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