The Complete Physical Examination (And What Should Be Included)

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CONSTITUTIONAL

Measurement of any three of the following seven vital signs:

bulletsitting or standing blood pressure
bulletsupine blood pressure
bulletpulse rate and regularity
bulletrespiratory rate
bullettemperature
bulletheight
bulletweight

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GENERAL APPEARANCE

Development, nutrition, body habitus, deformities, attention to grooming, etc.

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HEENT (HEAD, EYES, EARS, NOSE, AND THROAT)

bulletEyes
bulletInspection of conjunctivae and lids.
bulletExamination of pupils and irises (e.g., reaction to light and accommodation, size and symmetry).
bulletOphthalmoscopic examination of optic discs (e.g., size, cup-to-disc ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages).
bulletEars, Nose, TNuth and Throat
bulletExternal inspection of ears and nose (e.g., overall appearance, scars, lesions, masses).
bulletOtoscopic examination of external auditory canals and tympanic membranes
bulletAssessment of hearing (e.g., whispered voice, finger rub, tuning fork)
bulletInspection of nasal mucosa, septum and turbinates
bulletInspection of lips, teeth and gums
bulletExamination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

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NECK

bulletExamination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
bulletExamination of thyroid (e.g., enlargement, tenderness, mass)

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RESPIRATORY

bulletAssessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
bulletPercussion of chest (e.g., dullness, flatness, hyperresonance)
bulletPalpation of chest (e.g., tactile fremitus)
bulletAuscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

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CARDIOVASCULAR

bulletPalpation of heart (e.g., location, size, thrills)
bulletAuscultation of heart with notation of abnormal sounds and murmurs
bulletExamination of:
bulletcarotid arteries (e.g., pulse amplitude, bruits)
bulletabdominal aorta (e.g., size, bruits)
bulletfemoral arteries (e.g., pulse amplitude, bruits)
bulletpedal pulses (e.g., pulse amplitude)
bulletextremities for edema and/or varicosities

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CHEST

bulletInspection of breasts (e.g., symmetry, nipple discharge)
bulletPalpation of breasts and axillae (e.g., masses or lumps, tenderness)

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GASTROINTESTINAL

bulletExamination of abdomen with notation of presence of masses or tenderness
bulletExamination of liver and spleen
bulletExamination for presence or absence of hernia
bulletExamination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
bulletObtain stool sample for occult blood test when indicated

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GENITOURINARY

MALE:

bulletExamination of the scrotal contents (e.g., hydrocele, spermatocele, tenderness of cord, testicular mass)
bulletExamination of the penis
bulletDigital rectal examination of prostate gland (e.g., size, symmetry, nodularity, tenderness)

FEMALE:

bulletPelvic examination (with or without specimen collection for smears and cultures), including:
bulletExamination of external genitalia (e.g., general appearance, hair distribution, lesions) and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
bulletExamination of urethra (e.g., masses, tenderness, scarring)
bulletExamination of bladder (e.g., fullness, masses, tenderness)
bulletCervix (e.g., general appearance, lesions, discharge)
bulletUterus (e.g., size, contour, position, TNbility, tenderness, consistency, descent or support)
bulletAdnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)

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LYMPHATIC

Palpation of lymph nodes in two or more areas:

bulletNeck
bulletAxillae
bulletGroin
bulletOther

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MUSCULOSKELETAL

bulletExamination of gait and station
bulletInspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)
bulletExamination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity.
bulletThe examination of a given area includes:
bulletInspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
bulletAssessment of range of motion with notation of any pain, crepitation or contracture
bulletAssessment of stability with notation of any dislocation (luxation), subluxation or laxity
bulletAssessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

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SKIN

bulletInspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
bulletPalpation of skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)

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NEUROLOGIC

bulletTest cranial nerves with notation of any deficits
bulletExamination of deep tendon reflexes with notation of pathological reflexes (e.g., Babinski)
bulletExamination of sensation (e.g., by touch, pin, vibration, proprioception)

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PSYCHIATRIC

bulletDescription of patient's judgment and insight
bulletBrief assessment of mental status including:
bulletorientation to time, place and person
bulletrecent and remote memory
bulletmood and affect (e.g., depression, anxiety, agitation)

 

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