Constitutional
Measurement of any three vital signs
General
appearance of patient
Eyes
Inspection of conjunctivae and lids
Examination of pupils and irises
Ophthalmoscopic examination of optic discs
Ears, Nose, Mouth, and Throat
External
inspection of ears and nose
Otoscopic examination of external auditory canals and tympanic
membranes
Assessment of hearing
Inspection of nasal mucosa, septum and turbinate's
Inspection of lips, teeth, and gums
Examination of oropharynx: oral mucosa, salivary glands, hard and
soft palates, tongue, tonsils, and posterior pharynx
Neck
Examination of
Neck
Examination of Thyroid
Respiratory
Assessment
of respiratory effort
Percussion of chest
Palpitation of chest
Auscultation of lungs
Cardiovascular
Palpitation of heart
Auscultation of
heart with notation of abnormal sounds and murmurs
Examination of carotid arteries
Examination of abdominal aorta
Examination of femoral arteries
Examination of pedal pulses
Examination of extremities for edema and/or varicosities
Chest/Breasts
Inspection of breasts
Palpation of breasts and axillae
Gastrointestinal
Examination
of abdomen
Examination of liver and spleen
Examination for presence or absence of hernia
Examine anus, perineum, and rectum
Obtain stool sample for
occult blood test when indicated
Genitourinary (M)
Examine the scrotal contents
Examination of penis
Digital rectal
examination of prostate gland
Genitourinary (F)
Examination of external genitalia and vagina
Examination of urethra
Examination of bladder
Cervix
Uterus
Adnexa/parametria
Lymphatic
Palpation of lymph nodes in Neck
Palpation of lymph nodes in Axillae
Palpation
of lymph nodes in Groin
Palpation
of lymph nodes in other areas
Musculoskeletal
Examination of gait and station
Inspection and/or
palpation of digits and nails
Musculoskeletal - Head & Neck
Head & Neck - Inspection and/or palpation
Head & Neck -
Assessment of range of motion
Head & Neck - Assessment of stability
Head & Neck -
Assessment of muscle strength and tone
Musculoskeletal - Spine, Ribs, & Pelvis
Spine,
Ribs, & Pelvis - Inspection and/or palpation
Spine, Ribs, & Pelvis - Assessment of range of motion
Spine, Ribs, & Pelvis - Assessment of stability
Spine, Ribs, & Pelvis - Assessment of muscle strength and tone
Musculoskeletal - Left Upper Extremity
Left Upper Extremity - Inspection and/or palpation
Left Upper Extremity -
Assessment of range of motion
Left Upper Extremity - Assessment of stability
Left Upper Extremity
- Assessment of muscle strength and tone
Musculoskeletal - Right Upper Extremity
Right Upper Extremity - Inspection and/or palpation
Right Upper Extremity
- Assessment of range of motion
Right Upper Extremity -
Assessment of stability
Right Upper
Extremity - Assessment of muscle strength and tone
Musculoskeletal - Left Lower Extremity
Left Lower Extremity - Inspection and/or palpation
Left Lower Extremity -
Assessment of range of motion
Left Lower Extremity - Assessment of stability
Left Lower Extremity
- Assessment of muscle strength and tone
Musculoskeletal - Right Lower Extremity
Right Lower Extremity - Inspection and/or palpation
Right Lower Extremity
- Assessment of range of motion
Right Lower Extremity -
Assessment of stability
Right Lower
Extremity - Assessment of muscle strength and tone
Skin
Inspection of skin and subcutaneous tissue
Palpation of skin and subcutaneous tissue
Neurological
Test
cranial nerves
Examination of deep tendon reflexes
Examination of sensation
Psychiatric
Description of patients judgement and insight
Brief assessment of mental status including orientation to time,
place, and person
Brief
assessment of mental status including recent and remote memory
Brief
assessment of mental status including mood and affect