History/Physical Examination

eTABLE 3-3 FOCUSED ASSESSMENTS

Visual System Respiratory System
Use this checklist to make sure that the key assessment steps have Use this checklist to make sure that the key assessment steps have
been done. been done.

Subjective Subjective
Ask the patient about any of the following and note responses. Ask the patient about any of the following and note responses.
Changes in vision (e.g., acuity, blurred) Y N Shortness of breath Y N
Eye redness, itching, discomfort Y N Wheezing Y N
Drainage from eyes Y N Sputum production (color, quantity) Y N
Pain with breathing Y N
Objective: Physical Examination Cough Y N
Inspect
Eyes for any discoloration or drainage Objective: Diagnostic
Conjunctiva and sclera for color and vascularity Check the following laboratory results for critical values.
Lens for clarity Arterial blood gases
Eyelid for ptosis Chest x-ray
Assess Hct, Hgb
Vision based on patients looking at nurse or Snellen chart
Extraocular movements Objective: Physical Examination
Peripheral vision Observe
PERRLA Respirations for rate, quality, and pattern
PERRLA, Pupils equal, round, reactive to light and accommodation. Inspect
Skin and nails for integrity and color
Integumentary System Neck for position of trachea
Use this checklist to make sure that the key assessment steps have Shape, symmetry, and movement of chest wall
been done. Palpate
Chest and back for masses
Subjective Auscultate
Ask the patient about any of the following and note responses. Lung (breath) sounds
Hair loss (unusual or rapid) Y N
Changes in skin (e.g., lesions, bruising) Y N
Nail discoloration Y N

Objective: Diagnostic
Check the following for results and critical values.
Biopsy results
Albumin

Objective: Physical Examination

Inspect
Skin for color, integrity, scars, lesions, signs of breakdown
Facial and body hair for distribution, color, quantity, hygiene
Nails for shape, contour, color, thickness, cleanliness
Dressings if present
Palpate
Skin for temperature, texture, moisture, thickness, turgor,
mobility

Continued

Copyright 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc.
eTABLE 3-3 FOCUSED ASSESSMENTScontd
Hematologic System Gastrointestinal System
Use this checklist to make sure that the key assessment steps have Use this checklist to make sure that the key assessment steps have
been done. been done.

Subjective Subjective
Ask the patient about any of the following and note responses. Ask the patient about any of the following and note responses.
Unusual bleeding or bruising Y N Loss of appetite Y N
Black, tarry stool Y N Abdominal pain Y N
Blood in vomitus Y N Changes in stools. If so, color, blood, consistency, frequency, Y N
Swelling in neck, armpits, or groin Y N etc.
Dark-colored urine Y N Nausea, vomiting Y N
Fatigue Y N Painful swallowing Y N
Heart palpitations Y N
Objective: Diagnostic
Objective: Diagnostic Check the following laboratory results for critical values.
Check the following laboratory results for critical values. Endoscopy: colonoscopy, sigmoidoscopy,
CBC esophagogastroduodenoscopy
White blood cell count with differential CT scan
Clotting: PT, INR, aPTT, platelets Radiologic series: upper GI, lower GI
Hgb, Hct Stool for occult blood or ova and parasites
Liver function tests
Objective: Physical Examination
Inspect Objective: Physical Examination
Skin for lesions or color changes Inspect
Auscultate Skin for color, lesions, scars, petechiae, etc.
BP for alteration or orthostasis Abdominal contour for symmetry and distention
Palpate Anus and rectum for intact skin, hemorrhoids
Pulse for tachycardia Auscultate*
Liver and spleen for enlargement Bowel sounds
Lymph nodes for lymphadenopathy Palpate
aPTT, Activated partial thromboplastin time; INR, international normalized ratio; Abdominal quadrants using light touch
PT, prothrombin time. Abdominal quadrants using a deep technique
*NOTE: Do auscultation before palpation.
Cardiovascular System
Use this checklist to make certain that the key assessment steps Urinary System
have been done. Use this checklist to make sure that the key assessment steps have
been done.
Subjective
Ask the patient about any of the following and note responses. Subjective
Chest pain Y N Ask the patient about any of the following and note responses.
Palpitations Y N Painful urination Y N
Shortness of breath (especially when lying down or at rest) Y N Changes in color of urine (blood, cloudy) Y N
Edema in legs or any part of body Y N Change in characteristics or urination (diminished, excessive) Y N
Leg pain during exercise Y N Problems with frequent nighttime urination (nocturia) Y N
Excess urination at night Y N
Objective: Diagnostic
Objective: Diagnostic Check the following laboratory results for critical values.
Check the following for critical values or changes. Blood urea nitrogen
Cardiac biomarkers (troponin, CK-MB) Serum creatinine
Hematocrit and hemoglobin Urinalysis
Electrocardiogram Urine culture and sensitivity

Objective: Physical Examination Objective: Physical Examination

Inspect and Palpate Inspect
Anterior chest wall for pulsations and heaves Abdomen
Pulses for symmetry, quality, and rhythm Urinary meatus for inflammation or discharge
Auscultate Palpate
Blood pressure Abdomen for bladder distention, masses, or tenderness
Heart for rate, rhythm, and sounds Percuss
CK-MB, Creatine kinaseMB. Costovertebral angle for tenderness
Auscultate
Renal arteries for bruits

Copyright 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc.
 36.e7

eTABLE 3-3 FOCUSED ASSESSMENTScontd

Endocrine System Neurologic System
Use this checklist to ensure that the key assessment steps have Use this checklist to make sure the key assessment steps have
been done. been done.

Subjective Subjective
Ask the patient about any of the following and note responses. Ask the patient about any of the following and note responses.
Excessive or increased thirst Y N Blackouts/loss of memory Y N
Excessive or decreased urination Y N Weakness, numbness, tingling in arms or legs Y N
Excessive hunger Y N Headaches, especially new onset Y N
Intolerance to heat or cold Y N Loss of balance/coordination Y N
Excessive sweating Y N Orientation to person, place, and time Y N
Recent weight gain or loss Y N
Objective: Diagnostic
Objective: Diagnostic Check the following laboratory results for critical values.
Check the following laboratory results for critical values. Lumbar puncture
Potassium CT or MRI of brain
Glucose EEG
Sodium
Glycosylated hemoglobin (Hb A1C) Objective: Physical Examination
Thyroid studies: TSH, T3, T4 Inspect/Observe
General level of consciousness/orientation
Objective: Physical Examination Oropharynx for gag reflex and soft palate movement
Inspect/Measure Peripheral sensation of light touch and pinprick (face, hands,
Body temperature feet)
Height and weight Smell with an alcohol wipe
Alertness and emotional state Eyes for extraocular movements, PERRLA, peripheral vision,
Skin for changes in color and texture nystagmus
Hair for changes in color, texture, and distribution Gait for smoothness and coordination
Auscultate Palpate
Heart rate, blood pressure Strength of neck, shoulders, arms, and legs full and
Palpate symmetric
Extremities for edema Percuss
Skin for texture and temperature Reflexes
Neck for thyroid size, shape PERRLA, Pupils equal, round, and reactive to light and accommodation.
T3, Triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating hormone.
Musculoskeletal System
Reproductive System Use this checklist to make sure that the key assessment steps have
Use this checklist to ensure that the key assessment steps have been done.
been done.
Subjective
Subjective Ask the patient about any of the following and note responses.
Ask the patient about any of the following and note responses. Joint pain or stiffness Y N
Vaginal discharge/itching, unusual bleeding Y N Muscle weakness Y N
Penile pain, lesions, discharge Y N Bone pain Y N
Medications: oral contraceptives, antihypertensives, Y N
psychotropics, hormones Objective: Diagnostic
Self-examinations (breast or testicular examination) and Y N Check the results of the following diagnostic studies.
results X-ray results
Clinical examinations of reproductive systems (breast, pelvis, Y N Bone scans
testicular, prostate) and results Erythrocyte sedimentation rate
Pain in the abdomen, pelvis, or genitalia Y N
Objective: Physical Examination
Objective: Diagnostic Inspect and Palpate
Check the following for results and critical values. Skeleton and extremities (and compare sides) for alignment,
Serum hCG contour, symmetry, size, and gross deformities
Serum PSA Joints for range of motion, tenderness or pain, heat, crepitus,
Culture and sensitivity test results and swelling
Hormone levels (testosterone, progesterone, estrogen) if Muscles (and compare sides) for size, symmetry, tone, and
done tenderness or pain
Screen for STIs (e.g., chlamydia, gonorrhea) Bones for tenderness or pain
Laboratory reports: wet mounts, dark-field microscopy
X-ray of pelvis or breasts
Ultrasound of prostate

Objective: Physical Examination

Inspect
External genitalia for redness, swelling, drainage
Breasts for swelling, dimpling, retraction, drainage
Palpate
Breast tissue for masses or inflammation
hCG, Human chorionic gonadotropin; PSA, prostate-specific antigen.

Copyright 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc.