Summary of Physical Exam and History

History:

CC: Chief complaint: One sentence on why the patient is here

HOPI: History of present illness: use CODIERS-chief complaint, onset, duration, intensity, exacerbations, remissions of symptoms

PMH: Past medical history, include surgeries and major hospitalizations

FamHx: Family history of illnesses in blood relatives.

SocHx: social and personal history, occupation, level of education, health maintenance items, alcohol, drug, tobacco use, sexual history.

ROS: Review of systems-basic questions about each body system. Common reviews include fever/chills, cough, headache, chest pain, shortness of breath, nausea/vomiting, diarrhea, constipation, painful or frequent urination.

Physical Examination:

General: Overall appearance, height, build, sexual development, gait, dress, hygiene, expressions, and level of consciousness.

Skin: Identify lesions and their locations, distribution, arrangement, type and color. Inspect the nails and hair. Study patient’s hands.

Vital signs: pulse, respiratory rate, blood pressure, temperature

HEENT (Head, eyes, ears, nose, throat): Examine the scalp, hair, skull, and face. Measure visual acuity and screen visual fields. Note patient’s eye alignment and position, and eyelid position. Inspect sclera and conjunctiva, compare pupils and test reactivity to light. Assess extraocular movements and inspect the fundi with ophthalmoscope. Inspect the auricles, canals, and drums. Check auditory acuity, Weber and Rinne Test for bone-air conduction comparison. Check external nose, nasal mucosa, septum, and turbinates. Palpate for tenderness of frontal and maxillary sinuses. Inspect lips, oral mucosa, gums, teeth, tongue palate, tonsils, and pharynx. Inspect and palpate cervical lymph nodes, tracheal deviation, and thyroid gland.

Lungs: Inspect, palpate, and percuss the chest. Identify the level of the diaphragmatic dullness on each side. Listen to breath sounds and transmitted voice sounds.

Breasts: Inspect breasts with arms relaxed, then elevated. Palpate the breasts in supine position. Inspect and palpate the axillary lymph nodes.

Heart: Inspect and palpate the carotid pulsations in the neck, listen for bruits (“brew-ees”); observe heart, note the location, diameter, amplitude, and duration of the apical impulse. Auscultate at the apex and lower sternal border with the bell and diaphragm of the stethoscope for any murmurs, gallops or rubs.

Abdomen: Inspect, auscultate, and percuss the abdomen. Palpate lightly then deeply. Assess the liver and spleen by percussion and then palpation. Observe any hernias with straining.

Genital and Rectal: Inspect the perianal and sacrococcygeal areas. Palpate the anal canal, rectum, and prostate gland; palpate the scrotum for hernias in men. Examine the external genitalia, vagina, and cervix in females. Obtain Pap smears. Palpate the uterus and ovaries.

Musculoskeletal: Inspect and palpate hands, arms, shoulders, elbows, neck, temporomandibular joint, hips, legs, knees, ankles, and feet. Note any swelling, discoloration, or edema. Palpate lower extremity pulses and upper extremity pulses. Note any enlarged or deformed joints, check joint range of motion, observe muscle bulk and any abnormal movements. Check for alignment of the spine. Observe patient’s gait, ability to heel and toe walk, hop in place, and shallow knee bends. Romberg test for proprioceptive disturbances of balance.

Neurologic: Mental status exam: during interview, assess pt's mood, thought processes, thought contents, abnormal perceptions, insight, and judgement, memory and attention, calculating abilities, and abstract thinking. Assess all 12 cranials through scent, eye movements, facial movements and sensation, and tongue movements. Have the patient say “no ifs, ands or buts about it” to assess facial symmetry. Assess muscle strength (passive and active), reflexes, cerebellar test of rapid alternating movements and point-to-point movements. Assess sensory system through pain, light touch, position, vibration, and discrimination. Compare right and left sides.

*Remember to wash your hands, tell the patient what you are doing, and document your findings.

Compiled by Eric J Prenger, MD; Edited by Elise Sadoun, M4. 2006 edition. See Bates’ Guide to Physical Examination