PD1 Complete Checklist

Entering
Knock and enter the room; shake hands while identifying self
Ask the patients name and reason for coming in today
Elicit a complete HPI
a. Onset
b. Palliative/Provocative
c. Quantity, quality
d. Radiation
e. Severity
f. Time
Elicit patients perspective/beliefs of problem
What do you think this might be?
Elicit a past medical, family, and social history
Summarize HPI for the patient
Review of Systems
1. Constitutional ROS
Any current pain, past episodes of pain
Weight loss/gain
Fevers/chills
Tiredness
2. ROS skin
Recent dryness, itchiness
Unexplained sores, rashes, lumps, mole changes
Yellowing of the skin
3. ROS Head and Neck
Headaches
Hair loss
Eye pain, blurry or double vision
Contacts or glasses
Ear pain, hearing loss, ringing
Runny nose or nose bleeds
Swollen glands, or sinus changes
Sore throat, pain or stiffness of neck
Heat or cold intolerance
Weakness, fatigue or extra energy
4. ROS cardio/pulmonary
Shortness of breath, difficulty breathing
Pain/ noise with breathing
Cough? (Ask about blood in the sputum)
Night sweats, or shortness of breath at night
Rapid heart beats, change in exercise tolerance
Swelling of feet
Dizziness
5. ROS abdominal
Abdominal pain

 Difficulty swallowing, digesting

Heartburn
Nausea or vomiting (vomiting of blood or black coffee grounds)
Diarrhea or constipation (or black stools)
6. ROS urinary
Urgency or increased frequency, difficulty with urination
Urination at night, blood in the urine
Pain with urination or lower back pain
7. ROS musculoskeletal
Difficulty walking or moving
History of arthritis, injuries or falls
Swollen joints (multiple painful joints?)
Pain in the: jaw, neck, hands, shoulder, low back, knee
Morning stiffness
8. ROS neuro/psych
Episodes of fainting, numbness, or weakness
Episodes of convulsions, tingling in fingers or toes
For Depression/MI:
o Sleep
o Trouble concentrating or remembering
o Feeling not like yourself
o Seeing/hearing things that other people dont see or hear
Transition to the physical exam
Wash hands before examining the patient
Attend to patient privacy and comfort (draping, step, table adjustment)
Explain what is being done during the exam
1. Observe the patient appearance, behavior, mood, speech, distress level,
2. Observation of skin this should be done along with each piece of the exam so the
SPs will not have this on the check list
3. Obtain Blood pressure, heart rate, respiratory rate
4. Eyes:
Observe eyelids, sclera and conjunctiva, skin of the head
Pupillary response to light (Light shining), accommodation (H test), visual
fields (Finger in corners). then hold finger for extra-ocular eye movement
Visual acuity with eye chart
Test finger to nose (rapid alternating movements)
5. Ears:
Hearing loss (finger rub)
Examine the tympanic membrane with the otoscope
6. Examine the mouth, tongue, teeth and gums
Tongue movement
Swallowing and rise of the palate
7. Test cranial nerves nerves that were not done earlier
Facial sensation and jaw movements
Facial muscle movements

 Lift shoulders against resistance

8. Palpate thyroid (boundaries, size and texture; touch from behind) and LN (preauricular, submandibular, submental, superficial cervical, posterior cervical,
supraclavicular)
9. Check carotid pulse for regularity
10. Chest and back
Observe shape of the chest, breathing and coloring
Palpate spine and ribs for tenderness, test for CVA (costovertebral angle
tenderness)
Auscultate/percuss the lungs bilaterally (posterior, lateral, anterior)
11. Listen to heart sounds in 4 places aortic, pulmonic, tricuspid, mitral
12. NOTE: Should have person lying down now
Feel and auscultate the PMI (left lateral decubitus position)
Check with a light for the JVP at 30 degrees
Auscultate/percuss/light and deep palpate all 4 quadrants of abdomen
Percuss/palpate the liver at the midclavicular line to determine size
Palpate the suprapubic area for tenderness
13. NOTE: Have the patient sit up
14. Inspect and palpate joints fingers, hands, elbows, shoulders, toes, ankles, knees
15. Test sharp and light touch in fingers bilaterally
16. Test for motor strength arms and legs
17. Observe range of motion of (do not do passive)
Shoulder (arms abducted to shoulder and above head straight arms)
active
Hip (knee to chest)
18. Test deep tendon reflexes biceps, triceps, patellar and Achilles
19. Toes/ feet
Test sharp and light touch in toes bilaterally
Check for peripheral pulses (dorsalis pedis and posterior tibialis)
Test vibratory sense in toes bilaterally
20. Once standing:
Observe range of Neck and spine (do this standing) - neck flexion, forward
back and side to side for spine
Watch the patient walk across the room and back
Test position sense (stand feet together with eyes open, then closed)
Transition to leaving closing statement
Ask if they had any questions