| REPORTING COMMON FINDINGS OF DISEASE IN WRITE-UPS and OCPs | |
| General appearance |
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| Current health |
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| Skin, hair and nails | |
| Temperature & perfusion |
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| Skin | For skin lesions, report location and type of lesion
Additional descriptors:
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| Nails | Clubbing
Pitting |
| Hair: | Alopecia
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| Eyes | |
| Visual acuity | Decreased visual acuity. Note the acuity in each eye.
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| Visual fields | Visual field defect. Note the quadrant(s) affected, using the terms superior, inferior, nasal, and temporal to describe them.
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| Eyelids | Ptosis
Stye Skin lesions (see skin above) |
| External eye | Conjunctival injection
Conjunctival pallor Ciliary flush Scleral icterus Arcus senilis |
| Pupils | Asymmetric corneal light reflection
Absent red reflex Asymmetricpupils Decreased reaction to light
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| Ears | |
| External ear & EAC | Swelling, tenderness or discharge |
| Tympanic membrane | Erythema or bulging
Presence of middle ear effusion |
| Hearing | Decreased hearing. Note method of testing. |
| Weber test | Note ear in which the sound is heard best
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| Rinne test | Note whether air conduction or bone conduction is louder
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| Nose and sinuses | |
| Internal nose | Palloror injection of mucosa
Nasal polyps Ulcers. Note size and location. Discharge |
| Sinuses | Sinus tenderness
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| Oral cavity | |
| Oral mucosa | Plaque
Ulcers Masses |
| Posterior pharynx | Erythema
Exudate Tonsillar enlargement |
| Dentition and gingivae | Caries
Gingival erythema or swelling |
| Base of tongue & submandibular area | Ulceration or mass (suggesting malignancy)
Lymph node enlargement |
| Parotid glands | Swelling |
| Temporomandibular | Tenderness or crepitus |
| Neck and thyroid exam | |
| Lymph nodes | Enlargement. Note size, tenderness, mobility, consistency and location of enlarged node(s)
2.5 cm firm, non-tender, fixed node, L posterior cervical triangle |
| Thyroid | Nodules: 1.5 cm palpable nodule, non-tender in R lobe
Enlargement: Thyroid diffusely enlarged, non-tender, without palpable nodules |
| Chest exam | |
| Inspection | Evidence of respiratory distress: tachypnea, accessory muscle use, retractions
Decreased chest expansion |
| Palpation | Asymmetric tactile fremitus
Decreased tactile fremitus ½ way up the R posterior chest Vertebral, rib, CVA or chest wall tenderness |
| Percussion | Dullness or hyperresonance to percussion.
Hyperresonant to percussion entire L chest |
| Auscultation | Adventitious sounds: fine crackles, coarse crackles, wheezes, stridor, rubs.
Coarse crackles present in the R lower lung field Decreased breath sounds Decreased breath sounds L lower lung field |
| Cardiovascular exam | |
| Inspection | Abnormal jugular venous pressure: elevated or flat
JVP 13 cm H20 |
| Palpation | Abnormal apical impulse: enlarged, sustained, and/or laterally displaced.
Apical impulse palpable lateral to the MCL in the 5th ICS |
| Auscultation | Abnormal rate or rhythm
Presence of an S3 or S4 gallop Report five characteristics of any murmur: loudness, timing, quality location & radiation 2/6 harsh early systolic murmur loudest @ RUSB, and radiating to the R carotid |
| Pulses | Asymmetric or absent pulses
2+ and symmetric carotid, radial and femoral pulses. Absent dorsalis pedis and posterior tibial pulses bilaterally. Bruits |
| Edema | Note the proximal extent of the edema and the presence of pitting or weeping;
Often graded from absent to 4+ (scale is subjective) 3+ pitting edema in bilateral lower extremities, up to mid-thigh |
| Abdominal exam | |
| Inspection | Scars. Describe size and location.
Distension |
| Auscultation | Abnormal bowel sounds: Hyperactive or absent. Bruits
R epigastric bruit present |
| Percussion & palpation | Tenderness. Note location and presence or absence of guarding.
RUQ tender to palpation, with involuntary guarding. Abnormal liver size or consistency |
| Neurologic exam | |
| Mental status | Abnormal level of consciousness: lethargic, obtunded or comatose
Abnormal orientation Oriented x 2 (to self and place only) Abnormal recall Recalls 1/3 items at 5 minutes. Clock drawing abnormal. |
| Cranial nerves | Note the abnormal nerve(s) and how each abnormality was detected.
CN II-XII are intact, except for R CN VI. Pt is unable to abduct R eye. |
| Motor: | Abnormal strength.
Strength 5/5 in all major muscle groups except 4-/5 in R hip flexors Grading strength 0 = no movement 1 = flicker of movement or slight twitch 2 = moves with gravity eliminated 3 = moves against gravity but not against resistance 4 = moves against resistance but less than full power Abnormal bulk: Bulk is normal in UE and LLE. Atrophy of R calf and foot muscles noted Abnormal tone: Increased tone in the LUE |
| Reflexes: | Abnormal Babinski reflex
Asymmetric or changing reflexes. Compare side to side and grade 0-4.
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| Sensation | Describe the location of abnormal sensation and modalities tested
Positive Romberg |
| Cerebellar | Describe the abnormal test
Finger to nose test abnormal with bilateral dysmetria |