Examination

Conduct of Exam
Process/Skills
Inspection – looking

Palpation – touching

Percussion – tapping and listening

Auscultation - listening
Documentation
Describes what is seen and observed
Describes what is felt and the patient’s reaction
Describes what is heard in specific terms
Describes what is heard usually with a stethoscope
The following body areas are recognized: 
Head, including the face
Swelling
Features
Shape
Normocephalic

Neck
Masses
Nodules
Tenderness
Thyroid
Chest, including breast and axillae
Masses
Lumps
Tenderness
Nipple discharge
Symmetry
Abdomen
Tenderness
Guarding
Bowel sounds
Masses
Liver
Spleen


Genitalia, groin, buttocks
Tenderness
Masses
Swelling


Back, including spine
Tenderness
Masses
Nodules

Each extremity
Clubbing
Cyanosis
Edema
Pulses (pedal)
Reflexes
The following organ systems are recognized:
Constitutional
Vital signs
General appearance



Eyes
Conjunctivae
Lids
Pupils
PERRLA
EOMI
Ear, Nose, Mouth and Throat
Tympanic membrane
OP
Masses
Lesions


Cardiovascular
Murmurs
Gallops
Rubs
Bruits

Respiratory
Rails
Rattles
Crackles
Congestion

Gastrointestinal
Tenderness
Guarding
Masses
Hernia
Occult blood test

Genitourinary
Tenderness
Lesions
Discharge
Masses

Musculoskeletal
Clubbing
Cyanosis
Gait
Kyphosis

Integumentary (Skin)
Color
Texture
Turgor
Temperature

Neurologic
Details of responses
Babinski
Reflexes
Cranial nerves

Psychiatric
Alert and oriented
Responsiveness
Name
Date

Hematologic/Lymphatic/Immunology
Tenderness
Swelling
Bruises