Basic Exam

PROFESSIONALISM
Wash hands
Introduce him/herself appropriately
GENERAL INSPECTION/VITAL SIGNS
Reviews and rechecks abnormal vital signs
HEENT
Inspects eyes (retracts lids, etc.)
Observes pupillary response to light (direct and
consensual)
Inspects tongue, mouth and posterior pharynx
NECK
Palpates lymph nodes in the following areas: Ears,
Anterior cervical chain, Posterior cervical chain,
and Supraclavicular
Palpates thyroid (ask patient to swallow)
Auscultates carotids bilaterally
Assess for JVD
THORAX
Auscultates lung fields bilaterally and
symmetrically
Asks patient to breathe through open mouth
HEART
Auscultates all 4 areas (aortic, pulmonic, mitral,
tricuspid)
ABDOMEN
Auscultate bowel sounds a before manipulation or
palpation
Palpate all 4 quadrants
Assess for hepatomegaly
Assess for splenomegaly
EXTREMITIES
Inspects hands and feet for clubbing, cyanosis,
and edema
Check distal pulses (radial, dorsalis pedis and
posterior tibial)
Palpates axillary and inguinal lymph nodes
bilaterally
NEUROLOGIC
Reflexes (test bilaterally): Biceps, Triceps,
Brachioradialis, Patellar, Achilles, and Plantar.
Lung and Thorax
Observe the rate, rhythm, depth, and effort of
breathing
Palpate the thorax
Check for chest expansion
Check tactile fremitus bilaterally and
symmetrically
Percuss the lung fields bilaterally and
symmetrically
Percuss for diaphragmatic excursion
Auscultate lung fields bilaterally and
symmetrically
Check for bronchophony, whispered pectoriloquy
and egophony
Cardiovascular
Assess for jugular venous distension (JVD)
Assess for extremity edema
Palpate the carotid artery one at a time
Palpate chest wall for point of maximum impulse
Palpate extremity pulses (radial, dorsalis pedis
and posterior tibial)
Auscultate the carotid arteries one at a time
Auscultate all 4 areas (aortic, pulmonic, mitral,
tricuspid using both the diaphragm and bell)

Abdominal Exam
Look for scars, distension, striae, pulsations, or
masses
Listen for bowel sounds
Listen for bruits over renal, inguinal, and femoral
arteries and over the aorta
Percuss the abdomen over all four quadrants
Percuss liver and Traubes space
Percuss over the costovertebral angle
Palpate all 4 quadrants (first with 1 hand and then
with both)
Check for rebound and guarding
Palpate pulsation of aorta checking for width
Palpate the liver and spleen
SPECIAL TESTS
Murphy's sign: Pt exhales, place hand below liver
and ask patient to inhale.
Psoas sign: pain w/ extension of thigh when lying
on side with knees extended
Obturator sign: pain w/ flexion and internal
rotation of the hip
Rovsings sign: Palpate LLQ = pain in RLQ
Checks for fluid wave and shifting dullness
Neurological Exam
MENTAL STATUS EXAM
Assess level of consciousness
Check orientation to person, place and time
Assess speech (dysarthria or dysphasia)
Check attention (serial 7s)
Check memory (3 object recall, recent and remote
memory)
Check construction ability (copy figure)
Check judgement
CRANIAL NERVES
CN2: Assess visual acuity.
CN2: Test visual fields by confrontation.
CN3,4,6: Evaluate extraocular muscle function in 6
directions.
CN5: Check sensation to touch on face: upper,
middle and lower.
CN5: Palpate clenched masseter muscles.
CN7: Test upper (e.g. raises eyebrows) and lower
(e.g. smile).
CN8: Check hearing.
CN9,10: Check gag.
CN11: Test head rotation against resistance or
shoulder shrug
CN12: Observe midline protrusion of tongue.
MOTOR
Check strength in the upper extremities
(shoulders, elbows, wrists and hands)
Check strength in the lower extremities (hips,
knees, ankles, toes)
REFLEXES
Biceps, Triceps, Brachioradialis, Patellar, Achilles &
Plantar
SENSORY
Tests light touch and sharp vs. dull on hands and
feet Tests position sense and vibration sense on
feet
CEREBELLAR
Test rapid alternating movements-hands
Test finger to-nose bilaterally
Test heel-to shin (knee to ankle)
Perform Romberg test
Observe gait
Observe tandem gait (heel to toe)

Chief Complaint: health problem/complaint in patients own words.

History of Present Illness (HPI): chronological order of time/place of symptom(s) onset, duration,
frequency, location, quality, quantity/severity, aggravating/alleviating factors, associated symptoms, self-
treatment, relevant laboratory values, pertinent negatives.

Past Medical History:

General Health: date, type, outcome, complications of Childhood Illnesses (measles, mumps, rubella,
whopping cough, chicken pox, rheumatic fever, scarlet fever, polio);
Adult Illnesses; Accidents/Injuries; hospitalizations not already listed;
Immunizations (DPT, MMR, polio, hepatitis B, H. influenza, S. pneumonia, varicella.);
Screening Tests (hematocrit, urinalysis, tuberculin skin test, pap smear, mammogram, occult stool blood,
cholesterol, dental visits).
Past Surgical History: date(s), type, reason, outcome, transfusions, complications.
Medications: name, dose, frequency, duration, reason taking, compliance, availability.
Allergies: medications/substances causing reactions (rash, swelling, agitation, etc.).
Family History: age, health/death of parents, siblings, spouse, children;
Ask About: diabetes, heart disease, hypertension, stroke, cancer, bleeding disorders, asthma, arthritis,
tuberculosis, epilepsy, mental illness, symptoms of presenting illness.

Social History: birthplace, education, employment, religion, marriage/divorce, living accommodations,

people at home, ambulation status/ability, hobbies, diet, exercise.
Tobacco, Alcohol, Drugs: type, amount, frequency, duration, reactions, treatment.

Gyn: first menstrual period, regular? duration, vaginal discharge, vaginal pain, STI, problems with sexual
activity.

Location
Associated Manifestations
Negatives
Onset
Precipitating/ Palliative factors
Quality and Quantity
Radiation and Risk factors
Severity and Setting
Timing

Reflexes
0 no response
1+ diminished
2+ normal
3+ increased
4+ hyperactive
Review of Systems:
General: weight change, fatigue, weakness, fever, chills, night sweats
Skin: skin, hair, nail changes, itching, rashes, sores, lumps, moles
Head: trauma, headache location/frequency, nausea, vomiting, visual changes
Eyes: glasses/contacts, blurriness, diplopia, tearing, itching, acute vision loss
Ears: hearing loss, tinnitus, vertigo, discharge, earache
Nose: rhinorrhea, stuffiness, sneezing, itching, allergy, epistaxis
Mouth: bleeding gums, hoarseness, sore throat, swollen neck
Breasts: skin changes, masses/lumps, pain, discharge, self-exams
Cardiac: HTN, murmurs, angina, palpitations, dyspnea, orthopnea, edema, last ECG
Respiratory: SOB, wheeze, cough, sputum, hemoptysis, pneumonia, asthma, last CXR
GI: appetite, N/V, indigestion, dysphagia, BM changes, melena, pain, jaundice, hepatitis
Urinary: frequency, hesitancy, urgency, polyuria, dysuria, hematuria, nocturia, stones
Genital, male: discharge, sores, testicular pain, hernias
Genital, female: menarche, period regularity, dysmenorrhea, FDLMP, itching, sores, discharge,
grava/para/abortus, birth control, STD history, sex interest, sexual problems
Vascular: leg edema, claudication, varicose veins, thromboses/emboli
MSK: muscle weakness, pain, joint stiffness, ROM instability, redness, arthritis, gout
Neuro: loss of sensation, numbness, tingling, tremors, weakness, syncope, seizures
Hematologic: anemia, easy bruising/bleeding, petechiae, purpura, transfusions
Endocrine: heat/cold intolerance, sweating, polyuria, polydipsia, thyroid, diabetes
Psych: mood, anxiety, depression, tension, memory, suicidal ideation
Physical Exam
General: sex, race, state of health, development, dress, hygiene, affect
Vitals: blood pressure/auscultatory gap, pulse, respirations, pain, temp, height, weight
Skin: skin scars, rashes, bruises, tattoos, hair consistency, nail pitting, stippling
Head: size, shape, trauma
Eyes: pupil size, shape, reactivity, conjunctival injection, scleral icterus, fundal papilledema, hemorrhages,
lids, extraocular movements, visual fields and acuity
Ears: shape/symmetry, tenderness, discharge, external canal/tympanic membrane inflammation, gross
auditory acuity via Rinne and Weber tests
Nose: symmetry, tenderness, discharge, mucosa/turbinate inflammation, frontal/maxillary sinus
tenderness, dullness to percussion of sinuses
Mouth/Throat: hygiene, dentures, erythema, exudate, tonsillar enlargement
Neck: masses, range of motion, spine/trachea deviation, thyroid size, JVD

Breasts: skin changes, symmetry, tenderness, masses, dimpling, discharge

Heart: rate, rhythm, murmurs, rubs, gallops, clicks, precordial movements, Allen test, PMI, heaves,
hepato- or abdominojugular reflex/reflux, jugular venous pressure

Lungs: chest symmetry with respirations, wheezes, crackles, vocal fremitus, whispered pectoriloquy
(Scooby Doo or toy boat), percussion, diaphragmatic excursion

Abdomen: shape, scars, bowel sounds, consistency (soft/firm), tenderness, rebound masses, guarding,
spleen size, liver span, percussion (tympany, shifting dullness), costovertebral angle (CVA) tenderness via
Lloyd punch, Murphy sign, Psoas sign, Obturator sign, Rovsing sign

GU, male: rashes, ulcers, scars, nodules, induration, discharge, scrotal masses, hernias
GU, female: external genitalia, vaginal mucosa/cervix, inflammation, discharge, bleeding, ulcers, nodules,
masses, internal vaginal support, bimanual and rectovaginal palpation of cervix, uterus, ovariesRectal:
sphincter tone, prostate consistency, masses, occult stool blood

MSK: muscle atrophy, weakness, joint ROM, instability, redness, swelling, tenderness, spine deviation,
gait, Heberden and Bouchard nodes, somatic dysfunction (osteopathic) MSK, knee: anterior/posterior
drawer test, varus/valgus stress test, McMurray sign, Apley grind, ballottement, patellar tracking,
Thompson test (Achilles)MSK, back: straight leg raise, seated straight leg raise (malingering)MSK, wrist:
Phalen sign, Tinel sign, DeQuervain test

Vascular: carotid, radial, femoral, popliteal, posterior tibial, dorsalis pedis pulses, carotid bruits, jugular
venous distension (JVD), edema, varicose, veins, Homan & Pratt signs Lymphatic: cervical,
supra/infraclavicular, axillary, trochlear, inguinal adenopathy

Neurologic: cranial nerves, sensation, strength (5/5), reflexes (+2/4), cerebellum (rapid alternating
movements, finger-to-nose, pronator drift, heel-to-shin), gait (tandem walk on heels L5 or toes S1,
Romberg test), Kernig and Brudzinski signs, asterixis test
Labs: hematology, chemistry, urinalysis, cultures, ECG, x-rays, CT/MRI scan, etc.

Code Status: determine if patient has a living will, DNR, or advance directives.

Assessment/Plan: differential diagnosis, supporting history and exam, medication changes, lab tests,
procedures, consults, etc. Smoking Cessation: 1-800-QUIT-NOW