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