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

❑ A fever is often present

❑ Hypothermia may be present

❑ Pulse

❑ Rate

❑ Tachycardia may be present

❑ Bradycardia may be present

❑ Rhythm

❑ The pulse is regular

❑ The pules is irregularly irregular

❑ Strength

❑ The pulse may be weak

❑ The pulse may be bounding

❑ The pulse may be alternating in strength (pulsus alternans)

❑ A paradoxical pulse may be present

❑ Symmetry

❑ The pulses may be asymmetric

❑ Blood pressure
❑ Hypotension may be present
❑ Hypertension may be present
❑ A wide pulse pressure may be present
❑ A narrow pulse pressure may be present

❑ Respiratory rate
❑ Tachypnea may be present
❑ Bradypnea may be present
❑ Kussmaul respirations may be present

Skin
❑ Cyanosis may be present
❑ Jaundice may be present
❑ A rash may be present
❑ Pallor may be present
❑ Lesions may be present

Head
❑ Abnormalities of the head/hair may include ___
❑ There may be evidence of trauma

Eyes
❑ Icteric sclera may be present
❑ Nystagmus may be present
❑ Extra-ocular movements may be abnormal
❑ Pupils may not react to light
❑ Ophthalmoscopic exam may be abnormal with findings of ___

Ears
❑ Hearing acuity may be reduced
❑ Weber test may be positive
❑ Rinne test may be positive
❑ There may be exudate from the ear canal
❑ There may be tenderness on movement of the pinnae

Nose
❑ Nares may be inflamed
❑ There may be epistaxis
❑ There may be purulent exudate from the nares
❑ There may be tenderness to percussion of the sinuses
❑ The nares may be congested

Throat
❑ The throat may be erythematous
❑ There may be exudate in the throat
❑ There may be petechiae seen in the throat
❑ There may be tonsillar inflammation

Neck
❑ Jugular venous pressure may be elevated
❑ Carotid bruits may be present
❑ Lymph nodes may be present
❑ Thyromegaly may be present
❑ Hepatojugular reflux may be present

Lungs
❑ Pulmonary edema and rales may be present
❑ Wheezing may be present
❑ Consolidation may be present with reduced breath sounds auscultated
❑ Rales may be present
❑ Egophony may be present
❑ Chest movement may be assymetric

Heart
❑ A heave may be present
❑ A thrill may be present
❑ A friction rub may be pressent

❑ Auscultation

❑ S1
❑ S2
❑ S3
❑ S4
❑ Gallops
❑ A systolic murmur best heard at the base may be present
❑ A systolic murmur best heard at the apex may be present
❑ A diastolic murmur may be present

Abdomen
❑ Abdominal distention may be present
❑ Abdominal tenderness may be present
❑ Rebound may be present
❑ An acute abdomen may be present
❑ An abdominal mass may be present
❑ Guarding may be present
❑ Hepatomegaly may be present
❑ Splenomegaly may be present
❑ Genitourinary exam if relevant

Extremities
❑ Clubbing may be present
❑ Cyanosis may be present
❑ Edema may be present

Neurologic
❑ Mental status may be altered
❑ Glasgow coma scale is ___
❑ Clonus may be present
❑ Hyperactive reflexes may be present
❑ There are deficits in cranial nerves ___