- Vital signs: Temperature, pulse, blood pressure (both arms), respiratory rate. These observations need not be repeated under their respective subheadings.
- General appearance: state of orientation; development, state of nutrition, degree of discomfort, cooperativeness, other conspicuous general characteristics of appearance (including dress, neatness, behavior, gait and posture).
- Skin: color, temperature, texture, moisture, eruptions, ecchymoses or petechiae, hair distribution, nails. Significant scars.
- Head and face: Conformation, symmetry, abnormal movements, signs of injury, tenderness.
- Eyes: extraocular movements, sclerae, conjunctivae, pupils, (size, equality, regularity, reaction to light and accommodation), gross vision and visual fields.
- Ears: pinna, external canal, tympanic membrane, gross hearing, mastoids.
- Nose: obstruction, discharge, septal perforation or deviation. Sinus tenderness.
- Mouth: breath, mucous membranes, teeth, tongue, tonsils, faucial pillars, postnasal drip.
- Neck; stiffness, masses, venous distention, abnormal pulsations, thyroid, position of trachea; carotid bruits.
- Lymph nodes: size, consistency, tenderness, and mobility of cervical, supraclavicular, axillary, inguinal. (All nodes may be described here, or the regional nodes may be described with appropriate areas as examined.)
- Thorax: configuration, AP diameter, symmetry, and amplitude of motion.
Breasts: masses, tenderness, discharge from nipples, areolae.
- Lungs:
Inspection: respiratory excursion, rhythm, symmetry.
Palpation: fremitus (tactile).
Percussion: resonance, lung borders and descent.
Auscultation: breath sounds, spoken and whispered voice sounds (vocal fremitus), rales, friction rubs.
- Heart:
Inspection: Precordial movements, precordial bulging.
Palpation: apex impulse and PMI, thrills, shocks.
Percussion: Heart borders, sternum.
Auscultation: rhythm, heart sounds, murmurs (include left lateral position and sitting in full expiration), friction rubs, extracardiac.
- Abdomen:
Inspection: contour, engorged veins, protrusions, umbilicus, visible peristalsis.
Percussion: Hepatic, splenic, bladder dullness, gaseous distention, shifting dullness.
Auscultation: peristaltic sounds, vascular bruits.
Palpation: tenderness, rebound tenderness, rigidity, fluid wave, liver, spleen, kidney masses, hernias. If liver or spleen are palpable, note character or edge. Costovertebral tenderness.
- Spine: Vertebral curvatures, mobility, tenderness.
- Extremities:
Joints: swelling, effusion, deformities, tenderness, increased warmth, mobility. Clubbing, cyanosis, edema. Calf tenderness, Homan's sign. Character and equality of radial, femoral, posterior tibial and dorsalis pedis pulses; sclerosis of arterial walls; abnormal venous structures (varicosities, telangiectases).
- Neurological: A limited or screening neurological examination is part of every routine physical examination. When positive findings make a more complete study necessary, the complete examination is done. Mental status; gait and station, abnormal movement; cerebellar signs; cranial nerves; muscle strength, atrophy, fasciculations; sensation: touch, pain, vibration, position sense; reflexes: (biceps, triceps, Hoffman, abdominals, cremasterics, knee jerks, ankle jerks, plantar); meningeal irritation (nuchal rigidity, Kernig's sign).
- Genitalia:
- Male: penis, scrotum, testes, epididymis, spermatic cord. Discharge, inguinal canals.
- Female: speculum examination of vagina and cervix, palpation of uterus and adnexa. Pap smears, culture when indicated.
- Rectal: External hemorrhoids, fissures.
Digital: Sphincter, hemorrhoids, prostate, seminal vesicles (or uterus and cervix), Feces (description of gross appearance) and test for occult blood.
* Summary
Concise summary of relevant points in history and physical examination.
* Formulation
This is intended to alert the reader to the basis on which the diagnoses were made and the direction in which the work-up will process.
It is a statement of what the leading diagnoses are, which diagnoses you favor and why, how you will differentiate between the likely diagnoses and a general approach to therapy, if there is a presumptive diagnosis.
Plans for further investigation and management: __________________________________________________________________________________________________________________