Constitutional


* All elements must be documented.

• Measurement of any three of the following seven vital signs:
  1. Sitting or standing blood pressure
  2. Supine blood pressure
  3. Pulse rate and regularity
  4. Respiration
  5. Temperature
  6. Height
  7. Weight (may be measured and recorded by ancillary staff)
• General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Eyes

• Inspection of conjunctivae and lids (e.g., xanthelasma)

Ears, Nose,
Mouth and Throat

• Inspection of teeth, gums and palate
• Inspection of oral mucosa with notation of presence of pallor or cyanosis

• Examination of jugular veins (e.g., distension; a, v or cannon a waves)
• Examination of thyroid (e.g., enlargement, tenderness, mass)

• Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
• Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

Cardiovascular



* All elements must be documented.

• Palpation of heart (e.g., location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4)
• Auscultation of heart including sounds, abnormal sounds and murmurs
• Measurement of blood pressure in two or more extremities when indicated (e.g., aortic dissection, coarctation)

Examination of:

• Carotid arteries (e.g., waveform, pulse amplitude, bruits, apical-carotid delay)
• Abdominal aorta (e.g., size, bruits)
• Femoral arteries (e.g., pulse amplitude, bruits)
• Pedal pulses (e.g., pulse amplitude)
• Extremities for peripheral edema and/or varicosities

Gastrointestinal
(Abdomen)


* All elements must be documented.

• Examination of abdomen with notation of presence of masses or tenderness
• Examination of liver and spleen
• Obtain stool sample for occult blood from patients who are being considered for thrombolytic or anticoagulant therapy

Musculoskeletal

• Examination of the back with notation of kyphosis or scoliosis
• Examination of gait with notation of ability to undergo exercise testing and/or participation in exercise programs
• Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements

Extremities

• Inspection and palpation of digits and nails (e.g., clubbing, cyanosis, inflammation, petechiae, ischemia, infections, Osler's nodes)

Skin

• Inspection and/or palpation of skin and subcutaneous tissue (e.g., stasis dermatitis, ulcers, scars, xanthomas)

Neurological/

* All elements must be documented.

Brief assessment of mental status including

• Orientation to time, place and person
• Mood and affect (e.g., depression, anxiety, agitation)