Extended

General

• Appearance: Well-nourished, well-developed, distress level
• Orientation: Person, place, time
• Mood/Affect: Appropriate, cooperative
• Posture & Gait: Normal, steady, no ataxia
• Coordination: No dysmetria, normal movement

Skin

• Temperature: Warm, cool, normal
• Moisture: Dry, diaphoretic
• Turgor: Normal, decreased (dehydration)
• Rashes, Lesions, Ulcers: Location, description
• Bruising/Petechiae: None, noted (location)
• Nails: Clubbing, cyanosis, pitting
• Hair: Normal distribution, alopecia, hirsutism

Head

• Shape: Normocephalic, atraumatic
• Scalp: Lesions, tenderness, masses
• Temporal Arteries: Tenderness, thickening

Eyes

• Pupils: PERRLA
• Extraocular Movements: EOMI, nystagmus
• Visual Fields: Full, deficits
• Conjunctiva: Pale, injected, clear
• Sclera: Anicteric, icteric
• Eyelids: Ptosis, swelling, erythema
• Fundoscopic Exam: Disc margins sharp, no papilledema, hemorrhages

Ears

• External: No deformities, masses
• Canals: Clear, cerumen, discharge
• Tympanic Membranes: Intact, erythema, bulging, retraction
• Hearing: Normal, Weber midline, Rinne AC>BC

Nose

• Septum: Midline, deviation
• Mucosa: Pink, pale, inflamed
• Discharge: None, clear, purulent
• Sinuses: Nontender, tender (frontal, maxillary)

Mouth/Throat

• Lips: Moist, dry, cracked
• Mucosa: Pink, moist, lesions
• Gums: Healthy, bleeding, recession
• Teeth: Intact, caries, malalignment
• Tongue: Midline, fasciculations, lesions
• Oropharynx: Clear, erythema, exudates
• Tonsils: Present, hypertrophy, cryptic debris
• Uvula: Midline, symmetric elevation

Lymph Nodes

• No palpable lymphadenopathy
• If present: Location (preauricular, postauricular, occipital, submandibular, submental, anterior/posterior cervical, supraclavicular, axillary, epitrochlear, inguinal, popliteal), size, tenderness, mobility

Neck

• Supple, full ROM
• Trachea: Midline, deviation
• Thyroid: Normal, enlargement, nodules
• JVD: Present, absent
• Bruits: Present, absent

Chest/Lungs

• Symmetry: Equal expansion
• Respiratory Effort: Normal, labored
• Breath Sounds: Clear, wheezes, crackles, rhonchi

Heart

• Rate/Rhythm: Regular, irregular
• S1/S2: Normal, split
• Murmurs: None, location, grade
• Rubs/Gallops: None, present
• PMI: Normal location, displaced
• Pulses: Symmetric, diminished, bounding

Abdomen

• Contour: Flat, distended
• Tenderness: None, location
• Guarding/Rebound: None, present
• Masses: None, present
• Bowel Sounds: Normoactive, hypoactive, hyperactive
• Hepatosplenomegaly: Absent, present
• Bruits: None, present
• Hernias: None, present

Breast Exam

Inspection

• Symmetry: Equal, asymmetry noted.
• Skin Changes: No rashes, dimpling, retraction, ulceration, peau d’orange.
• Nipple Abnormalities: No inversion, discharge, scaling, crusting.
• Masses/Deformities: None, visible lump noted (location, size).

Palpation

• Breast Tissue: No masses, tenderness, or thickening.
• Mass Characteristics (if present):
  • Location: Quadrant, clock position.
  • Size: Measured in cm.
  • Shape: Round, irregular.
  • Consistency: Soft, firm, hard.
  • Mobility: Mobile, fixed.
  • Tenderness: Present, absent.
• Axillary Lymph Nodes: No palpable lymphadenopathy.
  • If present: Size, mobility, tenderness.
• Supraclavicular/Infraclavicular Nodes: No palpable lymphadenopathy.

Special Tests

• Skin Retraction Test: Negative, positive.
• Axillary Compression Test: No abnormal findings.
• Nipple Discharge Test: None, spontaneous/bilateral/unilateral, bloody/clear/milky/green.

Prostate Exam (Digital Rectal Exam - DRE)

Inspection

• Perianal Area: Normal, no lesions, skin tags, hemorrhoids, fistulas, fissures.

Palpation

• Prostate Gland:
  • Size: Normal, enlarged (mild, moderate, severe).
  • Consistency: Soft, firm, rubbery, hard.
  • Texture: Smooth, nodular, irregular.
  • Tenderness: None, mild, moderate, severe.
  • Symmetry: Symmetric, asymmetric.
  • Median Sulcus: Present, obliterated.

Findings

• Benign Prostatic Hyperplasia (BPH) Signs: Enlarged, smooth, rubbery.
• Prostatitis Signs: Tender, boggy, swollen.
• Prostate Cancer Suspicion: Hard, irregular, nodular, loss of median sulcus.

Rectal Exam

Inspection

• Perianal Skin: Normal, no rashes, excoriations, masses.
• Anus: No hemorrhoids, fissures, fistulas, skin tags, warts.
• Lesions: None, ulcerated, raised, bleeding.

Palpation

• Sphincter Tone: Normal, increased (spasticity), decreased (hypotonia).
• Rectal Wall: No masses, polyps, nodularity, tenderness.
• Tenderness: None, present (specify location).
• Stool Examination: No gross blood, mucus, melena, normal brown stool.

Special Tests

• Guaiac Test (if indicated): Negative, positive for occult blood.