Resident survival guide examine the patient

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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 ___


 
 
 
 
 
 
 
Examine the patient:

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