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 ___