Vitals
• Pulse
Rate
Rhythm
Volume
Character
Peripheral pulses
Radio-radial delay
Radio-femoral delay
Vessel wall thickening
• BP
• Respiratory Rate
Rate
Type: Thoraco-abdominal or abdomino-thoracic
Use of accessory muscles
• Temperature
General examination:
[PICCLE]
• P- Pallor
• I- Icterus
• C- Cyanosis
• C- Clubbing
• L- Lymphadenopathy
• E- Edema
How to Present Examination Findings
On General Physical Examination, his/her pulse rate is 68 beats/min, regularly regular, of normal volume and character. All peripheral pulses are palpable with no radio-radial delay, radio-femoral delay or vessel wall thickening.
His/her blood pressure is 128/76 mmHg, measured from the right arm in sitting position by the auscultatory method.
His/her respiratory rate is 18/min, thoraco-abdominal/abdomino-thoracic in type, without use of accessory muscles of respiration.
His/her axillary temperature is 98.6°F.
There is no pallor, icterus, cyanosis, clubbing, edema or lymphadenopathy.
Pallor Present
Pallor is present. It is assessed at the lower palpebral conjunctiva, tongue, nail beds, palms and palmar creases. The pallor appears mild/moderate/severe. There is/is no associated glossitis, angular cheilitis, koilonychia, pedal edema or flow murmur suggestive of anemia. The patient is further evaluated for signs and causes of anemia.
Icterus Present
Icterus is present. Yellowish discoloration is noted over the sclera and mucous membranes. There is/is no associated scratch marks, hepatomegaly, splenomegaly, ascites, spider nevi, palmar erythema or other stigmata of chronic liver disease. The patient is further evaluated for the etiology of jaundice.
Cyanosis Present
Cyanosis is present. It is noted over the lips, tongue and nail beds and is central/peripheral in nature. There is/is no associated clubbing, raised jugular venous pressure, pedal edema, tachypnea or signs of respiratory distress. The patient is further evaluated for underlying cardiac or respiratory causes.
Clubbing Present
Clubbing is present. It is bilateral/unilateral and Grade I/II/III/IV. There is loss of the normal nail bed angle, increased fluctuation of the nail bed and a positive Schamroth’s window test. There is/is no associated cyanosis, lymphadenopathy or features suggestive of pulmonary, cardiac, gastrointestinal or endocrine disease.
Lymphadenopathy Present
Lymphadenopathy is present. The enlarged lymph nodes involve the ______ group (cervical/axillary/inguinal, etc.). They are approximately ____ × ____ cm in size, single/multiple, discrete/matted, soft/firm/hard in consistency, mobile/fixed and non-tender/tender, with normal/abnormal overlying skin. There is/is no generalized lymphadenopathy or hepatosplenomegaly. The patient is further evaluated for infective, malignant or other systemic causes.
Edema Present
Edema is present. It is bilateral/unilateral, pitting/non-pitting and involves the feet, legs and/or sacral region. It extends up to the level of ______ and is Grade I/II/III/IV. There is/is no associated raised jugular venous pressure, ascites, hepatomegaly or signs of venous insufficiency. The patient is further evaluated for cardiac, renal, hepatic, endocrine or other causes of edema.
(For history taking and systemic examination, check this page)
