Eyes, ears, nose and throat physical examination

• • Lips cyanosis
  • Both, or at least one nasal meatus patent
  • At least one paranasal sinus tender on percussion
  • Throat
  • Dental hygiene
  • Serous fluid behind tympanic membrane on otoscopic exam
  • Pus behind the tympanic membrane or tympanic membrane ruptured (possibly with pus in the meatus and middle ear seen) on otoscopy exam
  • Gross discharge (or on otoscopy) seen from ear
  • During otoscopy external auditory meatus is tender
  • Erythematous tympanic membrane on otoscopic exam
  • Outward bulging of the tympanic membrane on otoscopic exam

Constitutional and vital signs physical examination

• • BMI
  • Temperature, i.e. 100.4 F
  • Pulse rate (not always equals the heart rate)
  • Systolic blood pressure
  • Diastolic blood pressure
  • Respiratory rate
  • Arterial O2 (oxygen) saturation (SaO2 %) on room oxygen (Fio2 21%).
  • Supplied air O2 % (FiO2 %), Room air: 21%, Nasal cannula: 1L/min 24%, 2L/min 28%, 3L/min 32%, 4L/min 36%, 5L/min 40%, 6L/min 44% *
  • Patient’s gender

Constitutional & general review of system

• Unplanned or unexplained weight loss
• Unplanned or unexplained weight gain
• History of chills
• Fevers as temporal artery or ear temp>100.4 F
• History of generalized fatigue
• History of decreased or depressed mood
• Is patient able to walk by himself
• Has this patient presented from nursing home or long-term care facility
• Has this patient been hospitalized for at least 2 days within the preceding 90 days
• Is patient fasting (at least 6 hours NPO)
• Did patient recently have close contact with somebody sick (i.e., common cold, upper respiratory tract infection, pneumonia)
• Respiratory or cardiac arrest recently
• Has patient been in the hospital for at least 48 hours
• History of hypotension (i.e., septic shock, bleeding or during general anesthesia) recently
• Use of new detergents, cosmetics, soaps, etc.
• Recent consumption of new meals, new foods

Eyes, ears, nose and throat review of system

• Recent history of acute loss of visual acuity
• Recent history of acute blindness
• Recent history of double vision
• Recent history of yellow sclerae
• History of eyes itchiness
• Recent history of sneezing
• History of postnasal drainage
• History of pain around the perinasal sinuses
• Eyes itchiness, sneezing, postnasal drainage, if present, related to a given time of the year
• Hoarseness
• Pain of larynx with talking/coughing
• History of ear pain
• History of hearing loss
• History of ear discharge

Cardiovascular review of system

• Exercise tolerance due to dyspnea
• Exertional dyspnea progression.
• Orthopnea by history
• Paroxysmal nocturnal dyspnea (PND) by history
• Any chest pains or discomforts that are triggered or exacerbated by physical activity or emotional excitement? Any history of recent chest pains that have been there too short to say what are they triggered or exacerbated by
• Has any chest pain or discomfort or the one triggered or exacerbated by physical activity or emotional excitement been recently more severe
• Has any chest pain or discomfort or the one triggered or exacerbated by physical activity or emotional excitement been recently more frequent
• Has the chest pain or discomfort episodes (if present) which are triggered or exacerbated by physical activity or emotional excitement been longer
• What is the quality of the chest pain or discomfort
• How long does the chest pain or discomfort last, once it is triggered / since it is started (if this is new pain)
• Where is the chest pain or chest discomfort radiating
• Where these chest pain or discomfort episodes, are felt
• Has the chest pain or discomfort been resolving after nitroglycerine use
• Has the chest pain been resolving after rest
• Subjective sensation of irregular or overly fast heartbeats
• When irregular heartbeats are present patient feels lightheadedness at the same time
• When irregular heartbeats are present patient feels chest pain or chest discomfort at the same time
• When irregular heartbeats episodes are present patient feels weak
• When irregular heartbeats are present patient feels headaches at the same time
• When irregular heartbeats are present patient sweats at the same time
• Symptoms of DVT (deep vein thrombosis) or SVT (superficial vein thrombosis), on any extremity (unilateral or asymmetric extremity edema, engorged superficial veins especially when asymmetric, unexplained erythema or warmth of the extremity)

Respiratory review of system

• Resting dyspnea severity
• Resting dyspnea progression.
• Episodes of dyspnea associated with severe anxiety
• Episodes of dyspnea associated with tingling of fingertips and around the mouth
• Episodes of dyspnea associated with lightheadedness
• Episodes of dyspnea resolve when breathing with plastic or paper bag (re-breather) used
• Mucous production with cough or suction from endotracheal tube
• Mucus production increased within last days
• Mucus features best described as
• Mucus color changed over last days
• Cough severity
• Wheezing. Currently or recently.
• Wheezing. Episodes in the past
• Amount of hemoptysis
• Pleuritic (i.e., with cough or with relation to breath phase) or positional (i.e. not felt or diminished with leaning forward) chest pain
• Pleuritic chest pain onset and progression
• Snoring
• Daytime sleepiness

Skin review of system

• History of dry skin
• History of excessive sweating
• History of jaundice
• History of hirsutism
• History of skin macules
• History of skin papules
• History of skin pustules
• History of skin petechiae or hemorrhaging changes
• History of urticaria (hives)
• History of episodes of cutaneous flushing
• History of recent zoster or cold sores (herpetic) rash
• History of facial venous telangiectasia
• History of skin itchiness (besides the perineal and perianal areas)
• History of perineal itchiness
• History of perianal area itchiness

Gastrointestinal review of system

• History of nausea
• History of vomiting
• Dry retching (separate from vomiting if any present)
• Heartburn, as a symptom of gastroesophageal reflux
• History of any red (hematemesis) or black (coffee ground) vomitus
• History of any red (hematochezia) or black (melena) stool
• Count of loose stools (diarrhea)
• History of chronic loose stools (diarrhea)
• History of constipation
• Most recent stool
• History of vague and not localized abdominal discomfort (not pain), sometimes described as generalized fullness, distention or pressure
• History of flatulence
• Severity of the abdominal pain
• Abdominal pain distribution
• If there is abdominal pain, besides when after pain medicines, does the abdominal pain go away by itself (i.e., when patient is in a specific position, or after vomiting, or bowel movement) for at least some short time ?
• Pain in the anal area
• Stool incontinence or underwear stool soiling
• Itching in the anal area
• Abdominal pain progression
• History of pain in the right upper quadrant
• History of pain in the left upper quadrant
• History of pain in the right lower quadrant
• History of pain in the left lower quadrant
• History of pain in the right or left flank
• History of pain in the periumbilical area
• History of abdominal pain in the epigastric area – midline
• History of pain in the right or left inguinal area
• History of pain below the umbilicus / lower abdomen or pelvic pain
• Does the abdominal pain have the tendency to recur around the same time of the period cycle, (i.e. always 1 to 3 days before menstruation)
• Does the abdominal pain have the tendency to recur around immediately before or during the menstruation
• Is abdominal pain radiating to the back
• Is abdominal pain relieving or decreasing when patient is leaning forward
• Is abdominal pain radiating to the perineum
• Fasting is aggravating, triggering or increasing the abdominal pain or discomfort
• Alcohol is aggravating, could have been a trigger (even remote – if patient had it couple of days ago) or increased the abdominal pain
• Food or meals are aggravating, triggering or increasing the abdominal pain or discomfort
• Lying down is aggravating, triggering or increasing the abdominal pain
• Straining or cough is aggravating, triggering or increasing the abdominal pain
• Has food intake significantly decreased
• Early satiety present
• Has fluid intake significantly decreased
• Has patient been on a diet deprived of electrolytes (i.e. drinking huge amount of coffee and eating biscuits only)
• History of pain with swallowing
• History of issues when swallowing solids
• History of issues when swallowing fluids
• History of aspiration (i.e. choking, cough immediately afterward)
• Regurgitation of food bolus during sleep

Genitourinary review of system

• History of discomfort, pain, or “burning” with urination (dysuria)
• History of overly frequent urination
• Bloody urine (gross hematuria)
• Is nocturia (night time urination) present
• Does the urination make the pain or pressure of lower abdomen (if present) less severe or it goes away for at least a short time after urination
• Is there a weak stream during urination
• Is there a need to strain to urinate
• Urinary urgency
• Producing less (relatively to fluid intake) urine than usually
• Polyuria (as large amounts of urine)
• Polydipsia
• Presence of urinary incontinence with increased intraabdominal pressure (laughing, coughing, sneezing)
• Subjective sensation of inability to empty bladder completely (immediately, or shortly after urination patient has a feeling of urination urge or bladder pressure, frequency)
• Presence of constant or close to constant leaking of drops or larger amounts of urine
• History of vaginal spotting or bleeding (in females)
• History of abnormal vaginal discharge (in females)
• History of vaginal soreness (in females)
• History of urethral discharge
• History of blood in semen (in males)
• History of scrotal / testicular pain (in males)
• History of menorrhagia (heavy periods) – in females
• History of metrorrhagia (irregular periods) – in females
• Most recent period – in females
• Amenorrhea (in female).
• Pain during sex (dyspareunia) in females
• Perineal or prostate pain during ejaculation in males
• Is there history of childbirth

Neurological review of system

• Is there a history of a localized sensory deficit, paresthesias or pain along skin dermatomes (i.e., L5 lateral leg, S1 posterior leg) over lower extremities
• Is there a history of a localized motor deficit of lower extremities
• Is there a history of a localized sensory deficit, paresthesias or pain along skin dermatomes over upper extremities or neck
• Is there a history of a localized motor deficit of upper extremities or neck
• Is there a history of a localized sensory deficit, paresthesias or pain along skin dermatomes on trunk or face
• History of a generalized muscle weakness
• History of seizures
• Aphasia (motor or sensory) by history
• Loss of consciousness or presyncopal event
• Loss of consciousness or presyncopal event prodromal symptoms
• Palpitations just before the loss of consciousness or before or during the presyncopal event
• Chest pain just before the loss of consciousness or before or during the presyncopal event
• Headache just before the loss of consciousness or before or during the presyncopal event
• Seizures during the loss of consciousness
• Loss of consciousness and / or loss of sphincter control
• Patient was drowsy or went to sleep after the episode of loss of consciousness
• Orthostatic lightheadedness
• Dizziness when changing head’s position
• Dizziness with exertion
• Frontal headache
• Headache
• Other (i.e. in the back of the head) headache
• This headache’s episode maximal intensity

Endocrine review of system

• Heat intolerance
• Cold intolerance
• Salt craving

Musculoskeletal review of system

• History of currently felt low back pain
• What is the severity of the low back pain
• Is low back pain resolving or improving with flexed spine position (patient may elect to be in flexed position)
• Is Valsalva’s (straining, sneezing, or coughing) triggering or making the low back pain worse
• Is low back pain resolving or improving during night / prolonged rest
• Is exercise improving or worsening the low back pain
• Localized bone or joint pain (other than low back pain), without obvious trigger i.e. trauma
• History of generalized bones’ pains
• History of generalized muscles’ pains
• Localized spine pain
• Height loss
• History of recent trauma to the chest or T spine
• History of recent head trauma

Past medical history

• History of COPD
• History of Asthma
• History of recurrent bronchopulmonary infections
• Risk factors for thrombosis
• History of CHF (left ventricle failure) – with low or preserved ejection fraction
• History of CAD (coronary artery disease)
• History of atrial fibrillation (or atrial flutter)
• History of HTN (hypertension)
• History of diabetes mellitus type 1
• History of diabetes mellitus type 2
• History of poorly controlled diabetes mellitus (type 1 or type 2)
• History of renal colic or kidney stones
• History of peptic ulcer disease
• History of sexually transmitted diseases (excluding HIV)
• History of hypothyroidism on thyroxine supplementation currently
• History of chronic kidney disease (CKD)
• History of benign prostatic hypertrophy (BPH)
• History of abdominal or pelvic surgery
• History of ovarian cysts
• History of Chron’s disease
• History of colitis ulcerosa
• History of recent viral or unknown gastroenteritis
• History of liver cirrhosis or ascites
• History of esophageal varices or other symptoms of portal hypertension
• History of peritonitis
• History of gall stones
• History of diverticulosis or diverticulitis
• History of depression
• History of substance abuse
• History of psychiatric issues, other than depression
• History of aspiration
• History of recent pneumonia
• History of recent common respiratory infection (i.e. common cold)
• History of recent hospital stay within the previous couple of weeks
• History of tonsillectomy
• History of recent dental procedure
• History of immunodeficiency (i.e. AIDS) or neutropenia
• Patient has history of malignant neoplastic disease
• Contact with healthcare
• Does patient have currently open wounds
• Has patient attended hospital or hemodialysis clinic within last 30 days

Medications/Therapy/Allergies

• Currently on anticoagulation due to thrombosis/stroke prophylaxis
• Bronchodilators therapy for dyspnea tried
• Diuretics therapy for dyspnea tried
• History of recent heavy or overt diuretics therapy
• Allergic to iodine-containing IV dye
• Has patient received any wound care within last 30 days
• Has patient been using any oral antibiotics recently
• Have been using or had access to opiates, i.e. Heroin, Morphine, Codeine, Hydrocodone, Oxycodone, Hydromorphone, Buprenorphine, Fentanyl, Methadone
• Has patient been using any IV (intravenous) antibiotics recently
• Has been using ACE-I (angiotensin converting enzyme inhibitors) or ARBs (angiotensin II receptor blockers) recently
• Has been using NSAIDS recently
• Has been exposed to iodine contrast recently
• Have been using or had access to tricyclic antidepressants (TCAs) i.e. Amitriptyline, Clomipramine, Desipramine, Doxepin
• Have been using or had access to anticholinergic medicines – i.e. Atropine, Diphenhydramine, Hydroxyzine, Tolterodine, Bupropion, Spiriva, Doxepin
• Have been using or had access to serotoninergic medicines or herbs – i.e. Tramadol, Sumatriptan, Fluoxetine, Citalopram, Paroxetine, Venlafaxine, Duloxetine, Rizatriptan, Imipramine, St. John’s wort, Linezolid
• Have been using or had access to benzodiazepines
• Have been using or had access to lithium
• Have used new medicine or medicine with known history of allergy to it
• Have patient used any medicines that can cause neutropenia besides chemotherapeutics (i.e. sulfasalazine, clozapine, methimazole, propylthiouracil, NSAIDs, cocaine or heroin with the addition of levamisole, acetazolamide, procainamide, flecainide, ticlopidine, enalapril, captopril, propranolol, bactrim, macrolides, vancomycin, cephalosporins, carbamazepine, phenytoin, thiazides, furosemide, or spironolactone)
• Has any recent chemotherapy been administered (within last 30 days)

Family history

• History of COPD in 1st degree relatives
• How many people of 1st degree relatives have asthma
• History of Coronary Artery Diseases (CAD) in 1st degree relatives, who were diagnosed when they were younger than 60
• History of blood clots (SVT/DVT/PE) in 1st degree relatives
• History of Chron’s disease in a 1st or 2nd degree relative
• History of colitis ulcerosa in a 1st or 2nd degree relative
• Family history of multiple endocrine neoplasia type 2 (MEN-2)
• Family history of von Hippel-Lindau (VHL)
• Family history of neurofibromatosis type 1 (NF-1)
• History of early (diagnosed before the age of 60 years old) colon cancer, or condition predisposing to colon cancer (i.e. Familial adenomatous polyposis – FAP) in a 1st or 2nd degree relative

Social history

• History of smoking
• History of alcohol (ETOH) abuse
• History of recent IV drugs or other illegal substances abuse
• History of dust or toxic inhalants exposure
• History of tuberculosis exposure (i.e. in prison, homeless)
• Is there a history of risky sexual behaviors

Eyes physical examination

• Anisocoria (unequal pupils)
• Pupils
• Conjunctivas
• Visual acuity
• Blindness

Neck physical examination

• Neck supple
• Thyroid gland enlarged
• Bruit heard when thyroid gland is auscultated
• Thyroid irregularities or nodules palpated

Respiratory physical examination

• Crackles/rales on inspiration
• Rhonchi
• Wheezing on expiration
• Decreased breath sounds
• Using accessory respiratory muscles
• Prolonged expiratory phase

Cardiovascular physical examination

• Regular rhythm
• Jugular venous pressure (appreciated at patient lying supine with head of the bed 30 degrees elevation)
• Is patient preferring to sit up, as breathing is easier
• Is holosystolic or early systolic (possibly decrescendo) murmur present and heard at the apex (patient should be in left lateral decubitus position to best appreciate this murmur)
• Is holosystolic or early systolic (possibly decrescendo) murmur from apex – if present – radiating to either left axilla or neck
• Is there holosystolic or early systolic (possibly decrescendo) murmur present at 2nd or 3rd left intercostal space at the left sternal border (can be slightly shifted towards the apex)
• Does the holosystolic or early systolic (possibly decrescendo) murmur present at the 2nd or 3rd left intercostal space – if present – increases after inspiration and one or two cardiac beats (Carvallo’s sign)
• Is holosystolic or early systolic murmur present (with the palpable thrill or not) at the left lower sternal border
• Is holosystolic or early systolic murmur present (with the palpable thrill or not) at the left lower sternal border – if present – radiating to the right lower sternal border
• Is midsystolic ejection murmur (with the palpable thrill or not) heard at the right 2nd intercostal space at the right sternal border
• Is midsystolic ejection murmur (with the palpable thrill or not) heard at the right 2nd intercostal space at the right sternal border – if present – radiating to the neck and bilaterally to carotid arteries
• Is early diastolic murmur heard at the right 2nd intercostal space or at the left sternal border (patient should be sitting up leaning forward to best appreciate this murmur)
• Is early diastolic murmur heard at the right 2nd intercostal space or at the left sternal border – if present – radiating to the apex
• Is murmur heard at the left 2nd interspace during systole and diastole continuously (can be radiating to left clavicle) and sometimes with an accompanying thrill
• Pericardial friction heard
• Right heart S3 gallop present
• Right heart S4 gallop present
• Left heart S3 gallop present
• Left heart S4 gallop present
• Edema on lower extremities/dependent body areas.
• Asymmetric edema on lower extremities.
• Tenderness along veins on lower extremities.
• Other signs associated with vein thrombosis? (redness, warmness, and engorged superficial veins)
• Pedal pulses on lower extremities.
• Femoral pulses.
• Are the blood pressures taken bilaterally on popliteal arteries (cuff placed on thigh) higher by 10 mmHg or more than the blood pressures on brachial arteries (both blood pressures taken with patient supine)
• Bruits over carotid arteries
• Bruits over renal arteries

Gastrointestinal physical examination

• Midline epigastric tenderness
• Lower abdomen, suprapubic, midline tenderness
• Periumbilical region tenderness
• Right upper quadrant tenderness
• Left upper quadrant tenderness
• Right or left lower quadrant tenderness
• Rebound tenderness (Blumberg’s sign)
• Abdominal guarding
• Murphy’s sign
• Is bladder enlarged on palpation
• Is bladder small on palpation or too small to be palpated (due to its size) at all?
• Tenderness in the area of right or left inguinal ligament
• Palpated bulge in the area of right or left inguinal ligament (sometimes patient needs to be standing or needs to cough lightly during the examination to better appreciate the bulge):
• Hemorrhoids are apparent during rectal exam
• Rectal fissure is apparent during rectal exam
• Is there black/red content on rectal exam
• Is hepatomegaly apparent on abdominal exam
• Is liver irregular on palpation

Genitourinary physical examination

• Is the testis tender
• Is the testis enlarged
• Is the testis irregular
• Goldflam’s sign (also known as costovertebral angle tenderness (CVAT), or Murphy’s punch sign)
• Is prostate tender on rectal exam
• Prostate is enlarged on rectal exam
• Is prostate hardened on rectal exam
• Is prostate irregular on rectal exam

• Skin physical examination

  • Skin moisture
  • Jaundice
  • Skin petechiae or hemorrhaging changes
  • Exfoliation
  • Urticaria
  • Presence of condylomata lata
  • Zoster or cold sores (herpetic) rash present
  • Presence of facial venous telangiectasia
  • Skin macules on exam
  • Skin papules on exam
  • Skin pustules on exam
   

Neurologic physical examination

• • Is neuro exam revealing localized sensory deficit, paresthesias or pain along skin dermatomes (i.e. L5 lateral leg, S1 posterior leg) over lower extremities
  • Is neuro exam revealing localized motor deficit of lower extremities
  • Is neuro exam revealing localized sensory deficit, paresthesias or pain along skin dermatomes over upper extremities or neck
  • Is neuro exam revealing localized motor deficit of upper extremities or neck
  • Is neuro exam revealing localized sensory deficit, paresthesias or pain along skin dermatomes on trunk or face
  • Is neuro exam revealing localized motor deficit on trunk or face
  • Generalized or affecting multiple muscle groups weakness on exam
  • Aphasia (motor or sensory) on exam
  • Presence of meningeal signs on exam (i.e. Brudzinski’s, Kernig’s)
  • Romberg’s sign
  • Babinski’s or plantar reflex (foot’s sole stimulation causes upward response – extension of the toes)
  • Feet or ankle clonus (more than 4 beats of reflex after abrupt dorsiflexion of foot)
  • General hyperreflexia on deep tendon reflexes examination
  • Straight leg raise (Lasegue’s sign)
  • Crossed straight leg (the leg of the unnafected by low back pain radiation)
  • Is weak ankle dorsiflection, lack or weak ankle jerk (Achilles deep tendon reflex) or calf wasting present on one or both legs
  • Is there a lack or weak knee jerk on both or one leg

Musculoskeletal physical examination

• Is there a lack of normal lumbar lordosis
• Is there paraspinal muscles or facets tenderness
• Is there limited spine lateral or anterior flexion
• Is there any tenderness on percussion of C spine vertebrae
• Is there any tenderness on percussion of T spine vertebrae
• Is there any tenderness on percussion of L spine vertebrae
• Is there any tenderness on percussion of S spine vertebrae

Psychiatric physical examination

• Verbal contact with patient
• Patient’s orientation
• Can patient be awaken
• Drowsiness description
• If patient can be awaken, what is the minimal necessary stimulus to wake patient up
• Agitation

Blood work

• Serum creatinine in mg/dl.
• Hemoglobin level g/dl
• Positive anti PLA2R antibodies (anti phospholipase 2 receptor antibodies) .
• Positive anti THSD7A antibodies ( anti thrombospondin type 1 domain-containing 7A) .
• Albumin level g/dl
• BNP (brain natriuretic protein) level in pg/ml

Urine test

• Protein excretion in urine (proteinuria) in mg/day
• Total daily albumin excretion in urine in mg/day (albuminuria).
• Features of infection or inflammation on urinalysis (elevated leukocyte esterase, nitrates, more than 5 white blood cells in visual field, pyuria, cloudy urine)
• Hematuria on urinalysis (more than 2 red blood cells in visual field, red urine)

Arterial blood gas analysis

• pCO2 on ABG in mmHg
• Hypercapnia presence on ABG / VBG

Imaging

• Presence of focal infiltrate on chest x-ray
• Normal appearance of chest x-ray
• Hydronephrosis on abdominal / pelvic CT scan (no IV contrast necessary).
• Diverticulitis evident on an abdominal / pelvic CT scan
• evident on abdominal / pelvic CT scan
• Peri-nephric stranding on abdominal / pelvic CT scan (no IV contrast necessary).
• Hydronephrosis on retroperitoneal ultrasound.
• Elevated (for example > 100cc) of post void volume in bladder
• Thickened wall of bladder on utlrasound
• Presence of pleural effusion(s) on chest x-ray
• Presence of pneumothorax on chest x-ray
• Presence of bilateral infiltrates / edema on chest x-ray

Biopsy

• Features of membranous nephropathy on kidney biopsy

Clinical evaluation

• • Colon malignancy present (found on colonoscopy).
  • Prostate malignancy present
  • Breast malignancy present