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GENERAL PHYSICAL EXAMINATION & CVS
GENERAL PHYSICAL EXAMINATION
General appearance
Young ( ) / Old ( ) Healthy ( ) /ill ( ) /anxious looking ( )
Physique
Normal ( ) Unusually tall ( ) Short ( ) Obese ( ) Thin ( ) Wasted ( ) Puffy ( )
Consciousness
Alert ( ) Oriented ( ) Confused ( ) Drowsy ( ) Unconscious ( )
Posture or Attitude
Comfortable ( )
Dyspnic
While lying
in bed ( )
Lying propped
up ( )
Sitting up or
bending forward ( )
Supraclavicular ( )\intercostal ( ) Indrawing ( )
In pain ( )
lying still ( )
Writhing in
bed ( )
Any specific odor from patient
Fruity (acetone) ( ) Fetor Hepaticus ( )
Vital Signs
Pulse - Rate........ (per minute) Rhythm...........
BP ............... (mmHg) Palpatory.......... Auscultatory...........
Temperature ( ) F / C
Respiratory rate ................
Hands
Shape.................. Short metacarpals ( ) Syn ( )/Poly ( ) Dactyly
Tremors ( ) ............. Carpal spasm ( )
Size......... normal ( ) OR Broad ( ) Tattoo marks ( )
Nails
Pallor ( ) Clubbing ( ) Pitting
of nails ( ) Cyanosis ( )
Splinter hemorrhages ( )
Beau's lines ( ) Oncholysis ( )
Meas lines ( ) Jaundice ( )
Koilonychia ( )
Leukonychia ( ) Terry's nails ( )
Fingers
Oslers nodes ( ) Bouchard's
nodes ( ) Heberdons's
nodes ( )
Joint swelling ( )
Arachnodactyly ( )
Xanthomas ( ) Ulcers at
the finger end ( )
Gouty tophi ( )
Palms
Pallor ( ) Palmer erythema (
) Sweating ( )
Scratch marks ( )
Duputyren's contracture ( )
Asterixis ( ) Bruising (
) Simian crease ( )
Janeway's lesions ( )
Face
General appearance- sallow appearance ( ) Moon like face
( ) Pink puffer ( )
Blue bloater ( )
Expressionless face ( ) Peaches
& cream appearance ( )
Pallor ( )
Periorbital puffiness ( ) Loss
of outer 1/3 of eye brows ( )
Proptosis ( )
Ptosis ( ) Xanthelasmas ( )
Yellowness of lower conjunctiva ( )
Pallor of lower conjunctiva ( )
Yellowness of sclera ( ) Rash ( )
Bluish tinged sclera ( ) Hirsutism ( )
Alopecia ( )
Baldness ( )
Any vesicles ( )
Spider nevi ( ) Enlarged parotid gland ( )
Any abnormal pigmentation of the lips ( ) / Face ( )
Cheilosis (Lips) ( )
Angular stomatitis ( )
Tongue
Abnormally large tongue ( )
Dryness ( ) Pallor ( )/
Cyanosis ( )
Any abnormal pigmentation ( )
Loss of papillae ( ) Redness ( )
<on dorsal surface>
Yellowness ( ) <undersurface>
Neck
Thyroid
Inspection
..............................
Palpation
..............................
Percussion (retrosternal
thyroid) ..............................
Auscultation
..............................
Pamberton's
sign ..............................
Neck vessels
Level of JVP
.............................., Venous pulsations ( )
Dancing
carotids ( ) Carotid shudder ( ) Carotid bruit ( )
Lymph nodes
Submental (
) Submendibular ( )
Parotid ( )
Pre auricular
( ) Post auricular ( )
Ant /Post cervical ( )
Occipital (
)
Supraclavicular ( )
Scalene nodes ( )
Lymphnode
Features:
No .......... Site .......... Size .......... Consistency ..........
Mobility.......... Matted .......... Discrete ..........
Adherent to Skin .......... (Adherent to underlying structures) ..........
Tenderness ..........
Discharge .......... /Sinuses ..........
Breast examination
Right
Symmetry .......... Localswelling ..........
( describe features of a mass) see the box below
Left
Symmetry .......... Localswelling ..........
( describe features of a mass) see the box below
Skin-dimpling or Teathering ( ) right ( ) left
Nipples-Retracted ( ) ( )
Discharge ( ) ( )
Axillary tail ................... .....................
Regional lymph nodes
Axillary ................... .....................
Supraclavicular ................ .....................
Axilla
Axillary hair ..................
Lymph nodes Ant ( ) Post ( ) Lat ( ) Med ( )
Apical ( ) Central ( )
Groin
Pubic hair .....................
Inguinal lymph nodes ( )
Testicular atrophy ( )
Presacral edema ( )
Hernial orifices...............
Shin
Ulceration ( ) Abnormal
pigmentation ( ) Loss of
hair ( )
Feet
Clubbing ( ) Koilonychia ( ) Cyanosis ( )
Loss of hair ( ) Edema ( ) Interdigital clefts---Athelet's foot ( )
Features of a mass
Site.............. Size .......... Shape ............
Consistency------ Cystic ( ) Soft ( ) Firm ( ) Hard ( )
Surface----- Smooth ( ) Irregular ( ) Nodular ( )
Edge ......... Tenderness ( ) Movement with respiration ( ) Mobile ( )/
Fix ( ) limits ...........
Bimanuallypalpable ( ) Thrill ( ) Transillumination ( ) Pulsatile ( )
Skin fixation ( ) Fluctuation ( ) |
CARDIOVASCULAR SYSTEM
Pulse
Rate ........... Rhythm ........... Vol ........... Character ...........
Condition of vessel wall ...........
Comparison with other pulses...........
Radio radial delay ( ) Radiofemoral delay ( )
Other features
Dancing carotids ( ) Pistol shots ( ) Capillary pulsations ( )
Digital throbbing ( ) Auscultation of major arteries any bruit ( )
INSPECTION
a) Chest deformity Pectus
excavatum ( ) Pectus carinatum ( )
Scoliosis ( )
b) Scar on chest-sternal ( )
Lateral Thoracotomy scar ( )
c) Pulsations
Apex beat ( ) Pulsations--- Along left para
sternal border ( )
In-- pulmonary area ( ) Suprasternal notch ( ) Epigastrium ( )
d) Prominent veins ( )
PALPATION
1) Apex beat ........... a) site
........... b) character ...........
Tapping ( )
Heaving ( ) Illsustained ( )/well sustained ( )
Normal ( )
2) Right ventricular heave ( )
3) Left ventricular heave ( )
4) Palpable heart sound ( )
5) Thrill ( )
6) Palpable pericardial rub ( )
7) Epigastric thud ( )
PERCUSSION
Area of cardiac dullness increased ( ) or
Decreased ( )
AUSCULTATION
Heart sounds
a) Intensity s1 ........... , s2
...........
b) Splitting of s2 ( )
c) 3rd & 4th heart sounds
...........
d) Gallop s3, s4 ...........
Other sounds
Opening snap ( )
Ejection systolic clicks ( )
Mid systolic click ( )
Prosthetic valve ( )
Murmers
Timing ...........
Grade ........... Site of
max. intensity ........... Radiation ...........
Character ...........
Pitch ...........
Effect of respiration ........... Effect of
posture ...........
Pericardial rub ( )
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