General Appearance
Apparent age, state of health, nutritional status, alertness, and evidence of discomfort.
Vital Signs
Temperature, blood pressure, pulse rate and rhythm (regular or irregular), and respiratory rate and pattern.
Skin
Texture, moisture and temperature; eruptions, scars, masses, nevi, telangiectasia; abnormalities of hair and nails.
Lymph nodes
Size, consistency, mobility and tenderness in occipital, cervical, post-auricular, submandibular, supra-clavicular, epitrochlear, axillary and inguinal regions.
Head
Size, symmetry, evidence of trauma, tenderness (including sinuses), masses, and condition of scalp.
Eyes
Eyebrows, lids, conjunctival inflammation and scleral icterus; corneal opacities and abrasions; pupillary size, equality and reaction to light and accommodation; extraocular movements and exophthalmos; fundi for discs, vessels, macula, exudates and hemorrhages; gross visual acuity and fields.
Ears
Auricles, auditory canals, tympanic membranes and gross hearing.
Nose
Deformities and septal deviation; obstruction, mucous membrane inflammation, polyps, bleeding and discharge.
Mouth
Lip color, lesions and pigmentations; condition of teeth; gingival color, inflammation, and bleeding; tongue color, moisture, tremor and coating; buccal mucosa inflammation and eruptions; soft palate; odor of breath. If patient wears dentures, remove them.
Throat
Mucosal color, exudates and lesions; tonsil size, symmetry and exudates; post-nasal discharge.
Neck
Range of motion; pain and tenderness; tracheal position, thyroid size, symmetry and consistency; carotid impulse strength and bruits.
Back
Range of motion; pain and tenderness over spine, muscles and costovertebral angle; symmetry.
Thorax
Shape and symmetry in excursion; intercostal retractions; rib tenderness and chest wall masses.
Lungs
Percussion, auscultation, bronchophony, egophony, pectoriloquy and fremitus.
Breasts
Size, shape, symmetry, tenderness and masses.
Heart
Precordial movement, apical impulse, rate and rhythm; heart sounds, murmurs, rubs and gallops.
Abdomen
Shape, tenderness, bowel sounds and bruits; size of liver, spleen, and kidneys; masses .
Extremities
Deformities, tenderness, localized swelling, peripheral pulses and edema, cyanosis, clubbing, temperature, varicose veins, and hair loss.
Musculoskeletal
Joint mobility, tenderness, effusion, erythema and deformity.
Neurologic
Screening exam in non-neurologic cases, otherwise full exam. Mental status; cranial nerves; peripheral strength, tone and sensation; deep tendon reflexes; Rhomberg and gait.