Sandbox/22

Examine the patient: Vitals ❑ Temperature ❑ Pulse ❑ Respiration ❑ Blood pressure ❑ Pulse oximetry General appearance ❑ ❑ ❑ ❑ Head, Ear, Eye, Nose & Throat ❑ Head ❑ ❑ ❑ Eye ❑ ❑ ❑ Ear ❑ ❑ ❑ Neck ❑ Masses, overall appearance, symmetry, tracheal position, crepitus ❑ Jugular vein distention ❑ Thyroid ❑ Throat ❑ ❑ Respiratory examination ❑ Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement) ❑ Percussion (e.g., dullness, hyperresonance) ❑ Palpation (e.g., tactile fremitus) ❑ Auscultation (crepitus) ❑ ❑ Cardiovascular examination ❑ Palpation (location, size, thrills) ❑ Auscultation (abnormal sounds and murmurs) ❑ Carotid arteries (e.g., pulse amplitude, bruits) ❑ Abdominal aorta (e.g., size, bruits) ❑ Femoral arteries (e.g., pulse amplitude, bruits) ❑ Pedal pulses (e.g., pulse amplitude) Abdominal examination ❑ Inspection e.g., asymmetry with notation of ❑ Palpation ❑ Presence of masses or tenderness ❑ Examination of the liver and spleen ❑ Examination for the presence or absence of hernias ❑ Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses ❑ Percussion ❑ ❑ ❑ ❑ Auscultation ❑ ❑ ❑ ❑ ❑ Extremities ❑ Gait and station ❑ Inspection/palpation ❑ Digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) ❑ Defects, tenderness, masses or effusions ❑ Range of motion with notation of any pain, crepitation or contracture ❑ Muscle strength and tone (e.g., flaccid, cogwheel, spastic) Neurological examination ❑ Test cranial nerves with notation of any deficits ❑ Deep tendon reflexes with notation of any pathologic reflexes (e.g., Babinksi) ❑ Sensation (e.g., by touch, pin, vibration, proprioception) Skin ❑ Inspection (e.g., rashes, lesions, ulcers) ❑ Palpation (e.g., induration, subcutaneous nodules, tightening) Psychiatric evaluation ❑ Description of patient’s judgment and insight ❑ Brief mental status ❑ Orientation to time, place, and person ❑ Recent and remote memory ❑ Mood and affect