CV GI GU Musculoskeletal Neurological Endocrine Hematology Mental Health

Total for History [-1 point for each pertinent missing component of the history (e.g., components of a section) (-) 1-5 points for complete omission of a pertinent section of the history]

Physical Examination (PE)

Washes hands before beginning the examination Vital Signs (VS) addressed with patient Temp, Pulse, Respiration, BP, Pain, BMI

PE (in context of complaint)

General • Presentation Skin • Inspection, Palpation Head • Inspection, Palpation Eyes • Accessory structures, Vision acuity, Peripheral vision, Alignment, EOMs, Visual fields, Pupil, FundusscopicENT/Mouth • Hearing, External, Otoscope, Pneumatic Otoscopy, Sinus, Nose, Mouth, Rinne/Weber

Neck • ROM, Lymph nodes, Thyroid, JVP, Carotids Cardiac/Vascular • Inspection, Palpation, Auscultation, Peripheral Pulses X4 limbs, Capillary refill, Peripheral edema

Respiratory • Inspection, Palpation (including infraclavicular and supraclavicular nodes), Percussion, Auscultation

Breasts (as indicated) • Inspection, Palpation of breasts and axillary nodes (Tanner Stage as appropriate)

GI • Inspection, Auscultation, Percussion, Palpation • Rectal Exam (as indicated) • Special Maneuvers as indicated (e.g., Rebound Tenderness, Roving's Sign,