Constitutional:
VITAL SIGNS: Height, weight, blood pressure, pulse rate, respiratory rate, and temperature.
GENERAL APPEARANCE: Development, nutrition, growth, body habitus, attention to grooming, etc.
Ear, Nose, Mouth, and Throat:
EAR: Overall appearance of auricles, auditory canal (swelling, drainage, etc.), tympanic membrane (erythema, blood, mobility, etc.), and assessment of hearing acuity.
NOSE: Examination of external nose, nasal mucosa, sinuses, septum, and turbinates for swelling, redness, polyps, blood, rhinorrhea, deviation, perforation, etc.
MOUTH: Examination of lips, teeth, tongue, gums, etc. for dental caries, gingivitis, periodontal disease, tooth loss, cyanosis, etc.
THROAT: Examination of oropharynx for lesions, symmetry, erythema, tonsillitis, etc.
Respiratory:
Examination should include inspection of chest (shape, symmetry, expansion, use of accessory muscles, and intercostal retractions), percussion of chest (dullness, hyperresonance), palpation of chest (tenderness, masses, tactile fremitus), and auscultation of lungs (equality of breath sounds, rubs, rales, rhonchi, and wheezes).
Cardiovascular:
Examination should include palpation of heart (location, forcefulness of the point of maximal impact, thrills, etc.), auscultation of heart (murmurs, abnormal sounds), assessment of pulse amplitude and presence of bruits in various arteries (carotid, femoral, popliteal, etc.), assessment of jugular veins (distention, A, V, or
cannon A waves), palpation of pedal and other pulses, and measurement of ankle-brachial index.
Breasts (Chest):
The breasts may be inspected for contour, symmetry, nipple discharge, gynecomastia, and palpated for lumps/masses and tenderness.
Gastrointestinal:
The abdomen should be inspected for obesity, distention, and scarring, followed by auscultation in all four quadrants for bowel sounds. Percussion may be performed to detect abdominal tenderness, ascites, or tympani. Palpation is performed to assess for tenderness, guarding, rebound, and other signs of peritoneal irritation, enlargement of the spleen or liver, masses, and pulsatile enlargement of the aorta (abdominal aortic aneurysm). Digital examination of the rectum may be performed to detect hemorrhoids or rectal masses, assess rectal tone, obtain stool for Hemocult determination, and examine the prostate.
Genitourinary (Male):
External examination of the penis may be performed to detect lesions or discharge. The testicles may be examined for symmetry, tenderness, masses, hydrocele, or varicocele. The prostate may be assessed for enlargement, tenderness, or masses during digital rectal examination. The bladder may be palpated to assess for distention or tenderness.
Genitourinary (Female):
The external genitalia and vagina may be examined for general appearance, estrogen effect, lesions, or discharge. The cervix may be inspected for lesions or discharge using a speculum, at which time specimens may be obtained for microscopy and culture. Bimanual examination of the internal GU organs is performed to detect cervical motion tenderness as well as uterine and/or ovarian enlargement, tenderness, or masses. The bladder may be palpated to assess for distention or tenderness.
Musculoskeletal:
The spine may be examined for tenderness, range of motion, step-offs, scoliosis, or other deformity. Muscles may be examined for strength, tenderness, swelling, or spasm. Joints may be examined for range of motion, tenderness, warmth, discoloration (erythema/ecchymosis), swelling, and instability. Other bones should be palpated for tenderness, deformity, and crepitus as appropriate.
Neurologic:
The patient should have his mental status assessed (mini-mental status exam) for higher cognitive function (including level of consciousness). Glasgow Coma Scale is a useful adjunct to assess the current mental status and progression of trauma victims. Cranial nerves II through XII are routinely assessed as part of the neurologic examination.
CN II Visual acuity and fields
CN III, IV, and VI Extraocular movements, pupillary reflex (III) CN V Facial sensation and corneal reflex CN VII Facial symmetry and strength CN VIII Hearing
CN IX Gag reflex and reflex palatal movement
CN X Voluntary movement of soft palate or vocal cord function CN XI Shoulder shrug strength
CN XII Tongue protrusion (midline)
CN I (olfactory) is difficult to assess in the field since this requires testing of smell. Cerebellar function is tested by having the patient perform actions requiring coordination such as finger/nose or rapid alternating movements. Motor assessment includes strength and symmetry of major muscle groups. Standard deep tendon reflexes tested include the knee, ankle, and biceps. Sensation testing may include light touch, pinprick, vibration, and proprioception. Gait testing is another good measure of central nervous system function.
Psychiatric:
If psychiatric examination is indicated, it should include a number of elements, including a description
of speech (rate, volume, pressured, etc.), assessment of thought process (rate and content), association (loose, tangential, intact, etc.), abnormal or psychotic thoughts (hallucinations, delusions, suicidal or homicidal ideation, etc.), and mood/affect (depression, anxiety, agitation, etc.). Other psychiatric components that may be assessed as part of overall examination include orientation, memory, concentration, and attention span.
Lymphatic:
Evaluation may include palpation for enlarged nodes in the neck, axillae, and groin.
Integumentary:
Examination may include quantity, texture, and distribution of hair, as well as assessment of skin for rashes, lesions, moles, birthmarks, and hyperhidrosis etc.
1. Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278:652-7.
PART 3: GENERAL SYMPTOMS Symptom: Acute Abdominal Pain
COL (Ret) Peter McNally, MC, USA
Introduction: Acute abdominal pain is an internal response to a mechanical or chemical stimulus. The pain can be separated into three categories: visceral (dull and poorly characterized), somatoparietal (more intense and precisely localized) and referred (pain felt remote from the origin). The most important elements in the evaluation of acute abdominal pain are the history and physical examination. Attention to the chronology and description of the pain can often suggest the origin of acute abdominal pain. Acute abdominal pain caused by blunt or penetrating trauma is covered on the SOF Medical CD-ROM.