PHYSICAL EXAM CHECK LIST

GENERAL LUNGS ( ) Gravid: NEURO

( ) AAOx4, ( ) NAD ( ) CTAB Fundal height:_______ Speech: ( )nml ( )slur ( )pressur
( ) WDWN Wheezes: ( ) inspir., ( ) expir. ( ) Vtx, ( ) Breech, ( ) Transv. CN II-->XII: ( ) intact
( ) non-toxic ( ) Good air movement ( ) Positive fetal movements Cerebellum: ( ) intact
( ) cooperative Egophany: ( )-, ( )+ Surgical scar: Romberg: ( ) nml, ( ) abnormal
( ) anxious Tachyphremitis: ( )-, ( )+ Location _________,Size ____ DTRs:
( ) disheveled Percussion: ( ) dullness Murphy's sign: ( )+, ( )- triceps __/3+, brachrad __/3+
Eye contact: ( ) Rales, ( ) Rhonchi: Liver span: ( ) nml, _____cm patellar __/3+, Achilles __/3+
( ) good, ( ) poor ( ) Pannus, ( ) Striae ( ) symmetric, ( ) R>L, ( ) L>R
UPPER EXTREMITIES Hernia: ( ) present, ( ) absent
HEENT Shoulder: ( ) umbilical, ( ) midline SKIN
( ) Normal Abduct: ( ) full, ( ) limit ____ o ( ) inguinal, ( ) direct ( ) Scars, location ____________
Scalp: Adduct: ( ) full, ( ) limit ____ o ( ) good turgor pressure
( ) atraumatic, ( ) normocephal Int rot: ( ) full, ( ) limit ____ o LOWER EXTREMITIES Rash: Location______________
Eyes: Ext rot: ( ) full, ( ) limit ____ o Hip: ( ) FROM ( ) macular, ( ) papular
( ) PERRLA, ( ) EOMI Pron: ( ) full, ( ) limit ____ o Knee: ( ) FROM, ( ) maculopapular
Nystagmus: ( ) No, ( )R, ( )L Supin: ( ) full, ( ) limit ____ o Crepitis: R( )+, ( )-, L( )+, ( )- locat: ( )diffus ( )local, ( )discret
Convergence: ( ) nml, ( ) abn Elbow: ( ) FROM ( ) limit ____ o Ligaments: ( ) intact, _________ blanchable: ( ) blanch, ( ) non-
Sclera: ( ) clear, ( ) injected ( ) Lat epicond, ( ) Med epicond McMurray R( )+, ( )-, L( )+, ( )-
Fundi: ( ) WNL, ( ) papilledema Wrists: Ankle: ( ) FROM PSYCH
Cornea: ( ) Flourescene - ( ) FROM Achiles: ( ) intact Affect: ( ) good, ( ) flat
Ears: Tinel’s R: ( )-, ( )+; L:( )-, ( )+ Homan's: ( )-, ( )+ MSE:
Tympanic membranes: Phalen’s R: ( )-, ( )+; L:( )-, ( )+ Motor : ___/5 ( ) short-term memory
R: ( ) clear, ( ) eryth, ( ) bulge Finkel R: ( )-, ( )+; L: ( )-, ( )+ SLR: ( ) -, ( ) + ( ) long-term memory
L: ( ) clear, ( ) eryth, ( ) bulge Cogwheeling ( )Y, ( )N Edema: ( ) concentration
External canals: ( ) neurovascularly intact ( )-, ( )__+ pitting ( ) __+ non- ( ) judgement
R: ( ) nml, ( ) eryth, ( ) D/C ( ) no CCE, ( ) cap. refill < 2 sec Gait: ( )nml, or limp on ( )R ( )L
L: ( ) nml, ( ) eryth, ( ) D/C ( ) no paresthesias WOUND
Hearing: ( ) nml, ( ) abn ( ) pulses 2+ PELVIS ( ) No eryth or exudate
Nose: ( ) patent bilaterally Fingers: ( ) FROM, Grip ___/5 ( ) normal female genitalia
( ) deviated septum Vagina: ( ) moist, ( ) no lesions ( ) Pap smear done
( ) swollen MM CHEST WALL ( ) atrophic
Color: ( )pink, ( )boggy mucosa ( ) WNL, ( ) scaphoid Adnexa: ( ) normal
Mouth: ( ) tender to palpation R mass ___cm,
( ) poor dentition location_________________ ( ) non-, ( ) tender
( ) aphthous ulcers left mass ___cm
( ) moist MM BACK ( ) non-, ( ) tender
( ) tongue midline Flex: ( )___ o ( ) toe touch ___ in Cervix: motion tender: ( ) -, ( ) +
Oropharynx: Ext: ( )___ o ( ) toe touch ___ in ___cm dilated, ( )D/C, ( )blood
( ) no eryth, ( ) no exudate Lat bend: ____ degrees
Tonsils: Lat rot: ____ degrees RECTAL
( ) non-enlarged Paraspinous musles: ( ) NT ( ) no masses
( ) hypertrophied ( ) Thoracic ( )R, ( )L, ( )B Sphincter: ( ) good tone
( ) plaques ( ) Lumber ( )R, ( )L, ( )B Fissure ( ) none, ( ) present
( ) Scoliosis ___ degrees Hemorrhoids:
NECK ( ) No CVAT ( ) none, ( ) exter., ( ) internal
( ) supple, ( ) FROM Prostate:
Lymph nodes: ABDOMEN ( ) non-enlarged, ( ) no masses
( ) no LN ( ) SNTND BS+ 0 HSM 0 Mass ( ) hypertrophied
( ) preauricular Firmness: Soft ( ), Rigid ( ) ( ) calcification
( ) superficial cervical Tenderness: ( ) rubbery mass
( ) deep cervical ( ) Non-tender location____________________
( ) supraclavicular Magnitude: Stool guaic: ( )+, ( )-
( ) No JVD ( )min., ( )mild, ( )mod., ( )very
( ) No hepatojular reflux Location: ( ) diffuse, ( ) focal GENITALS
Bruits: ( ) none ( )R, ( )L, ( )B ( )RUQ, ( )RLQ, ( )LUQ, ( )LLQ Penis:
Thyroid: ( ) epiga, ( ) umbil, ( ) suprapu ( ) circumcised, ( ) non-circ
Size: ( ) thyromeg, ( ) none Guarding: ( )Y, ( )N ( ) warts, ( ) lesions
Masses: Rebound: ( )Y, ( )N Testes:
( ) no masses Distended: ( ) Non, ( )tympany Size: ( ) nml, ( ) large, ( ) sml
( ) nodules ( )R, ( )L, ( )B Obese: ( ) tender, ( ) non-tender
Trapezius: ( )morb ( )obes ( )flat ( )scap ( ) hydrocele, ( )R, ( )L
( ) non-tender, ( ) tender BS: Epididy: ( ) non-, ( ) tender
Magnitud: ( )nml, ( )-, ( )hyper
LYMPH NODES Location: ( ) all Q’s, other____
( ) tender, ( ) non-tender Masses:
( ) supraclavic, ( ) jugulodigast ( ) No masses, ( ) No HSM
( ) axillary, ( ) inguinal HSM ____cm below costal
____cm total liver span
HEART ( ) Mass
( ) RRR w/ murmer Location _______________
Murmer: Bruits: ( ) None, ( ) R, ( ) L
( ) no rubs, ( ) no gallops AAA: ( ) None, _____cm
( ) MPI WNL