Vital Signs: Height, weight, temp, pulse (radial & apical if irregular), respiratory rate, blood pressure (sitting & standing in both arms, and one leg if patient is hypertensive)

General Appearance:

Skin: Texture, turgor, color, lesions, hair, nails

Lymphatics: Cervical, supraclavicular, axillary, epitrochlear, inguinal

HEENT:

Head: Shape, trauma, tenderness, masses

Ears: External ear & mastoids, otoscopic, hearing loss

Nose: Mucosa, obstruction, sinuses

Eyes: Appearance, pupil reactions, visual acuity, EOM, visual fields, funduscopic

Oral: Lips, mucosa, gums, tongue, pharynx, teeth Cavity

Neck: ROM, thyroid, trachea, masses

Breasts: Masses, tenderness, skin retraction, galactorrhea, gynecomastia

Chest: Breathing pattern, thorax shape & motion, percussion, breath sounds, adventitious sounds, fremitus, diaphragm motion, local tenderness

Cardiovascular:

Neck vein distention, carotid pulse contour, deep venous waves, precordial motion. PMI (record in cm. from MCL).

Auscultation (includes S1,S2,S3,S4, O.S., clicks, rubs and murmurs

Peripheral Pulses:

O=absent, 1 + barely palpable, 2+ definitely reduced, 3+ slightly reduced, 4+ normal, 5+ aneurysmal, B=bruit

Radial Ulnar Carotid Femoral Popliteal Post Tibial Dorsalis Aorta

Abdomen: Configuration, scars (use diagram), tenderness (superficial, deep, rebound), guarding, rigidity, liver, spleen, kidneys, masses, bowel sounds, bruits, signs of free fluid

Back: ROM, spine tenderness or deformity, CVA tenderness

Genitalia: Males: Pubic hair, testes and epididymus, penis, anal area, prostate, rectal lesions

Females: Pubic hair, external genitalia, BUS, vagina, support, cervix, body of uterus, adenxa, rectum

Extremities: Deformity, ROM, joint exam, edema, trophic skin changes, clubbing, veins

 Neurological: Mental status, language function, cranial nerves, motor functions (tone, strength, atrophy), sensation (pin prick, touch, position, vibration, deep pain, stereognosis), cerebellar function (Rhomberg, F N, H 5), gait.

Reflexes: (Scale: 0=absent, 1 +=reduced, 2+=normal, 3+= increased, 4+=clonus)

Triceps Biceps Brachioradialis Hoffman Knee Ankle Babinski

R

L

Assessment(s):

In each assessment give a brief statement of the patient’s diagnosis, or if you do not know a diagnosis a brief statement of the patient’s symptom, one at a time as a list.

Following each brief statement you should discuss what you are thinking. I.e. you should explain how you reached this diagnosis, and discuss other diagnoses you have considered in your differential.

Example Number One:

Assessment:

1) Acute Myocardial Infarction. This patient has symptoms of chest pain that came on with exertion, lab findings and EKG finding consistent with an acute MI.

2) Hypertension. This has been a long-standing problem for this patient. The patient has been followed regularly for this, and is compliant with his medications.

3) Hypercholesterolemia. This problem has not been dealt with in an optimal manner in this patient. The patient has not taken cholesterol-lowering medications because he judged the side effects of all of the medications to be worse than having high cholesterol. And dietary control has not been successful for this patient.

You can see in this example that I am ‘sure’ of the patient’s main diagnosis of acute myocardial infarction. That is not always the case. Another example of an assessment list may be as follows.

Example Number Two:

1) Chest Pain. I believe the patient may have a musculoskeletal reason for this chest pain, as when I press on the patient’s sternal area I am able to reproduce this chest pain. This patient does not have EKG changes or lab data consistent with an MI. Pulmonary Embolus is a consideration, but this patient has no risk factors for a PE. There is no family history of a hypercoagulable state, and there has been no recent long-term immobility.

2) Essential Hypertension. Long standing problem. Patient is compliant with medications and monitoring.

3) Hypercholesterolemia. Patient declines dietary recommendations and suggestions to deal with this problem.

Plan:

This is what you plan to do to either further look into a patient’s complaint or what you plan to do to treat the patient. The plan can be numbered; in which case you may choose to have the numbers correspond to the appropriate assessment.

Example Number One (this might correspond to Example Number One under assessment):

1) MI. Admit to ICU. Standard orders for MI will be started, including thrombolytics.

2) Hypertension. Continue present medications.

3) Hypercholesterolemia. I will have to discuss with this patient further the ramifications of untreated hypercholesterolemia in light of his apparent MI.

Example Number Two (this corresponds to Example Number Two under assessment).

1) Chest Pain. I am quite certain that this patient is having musculoskeletal chest pain. But, I cannot rule out the possibility of him having a cardiac problem. The EKG was not done when the patient was having chest pain.

And, although this patient does not have EKG findings consistent with an MI, and although he does not have lab data suggestive of an MI, and even though he has pain reproducible with pressure on the sternum he does say that he has had sternal pain for quite some time off and on and that sometimes his chest pain is felt deeper than the sternum, I am not completely ruling out the possibility of cardiac ischemia. I am also keeping in mind that there is some family history of heart disease. With all of this in mind, admit to the hospital for observation. And, if further chest pain develops, a stat EKG will be ordered. And, cardiac enzymes will be followed with the patient in the hospital.

2) Hypertension. Continue present medications.

3) Hyperlipidemia. I will have to discuss further with this patient his decision to not treat his elevated cholesterol.