Usc Chart Review Worksheet Sample (Page 3 of 3) in pdf

SPECIALTY PHYSICAL EXAM CRITERIA (1997 GUIDELINES)

CARDIOLOGY

ENMT

EYES

GENITOURINARY

LYMPHATIC

Constitutional: *3 of: sit/std BP,

Constitutional: *3 of: sit/std BP, sup

Eyes:

Constitutional: *3 of: sit/std BP,

sup BP, pulse rate, respir, temp,

BP, pulse rate, respir, temp, height,

*visual acuity

sup BP, pulse rate, respir, temp,

height, weight

weight

*visual field

height, weight

*General appearance

*ocular motility

*General appearance

Eyes: *conjuunctivae/lids

Eyes: *Ocular motility

*bulbar & conjunctivae

Neck:

*neck

*thyroid

Head & Face: *palpation face

ENMT:*teeth, gums, palate

ENMT: *aud canal/lymph membrane

*pupils * iris

Resp:

*effort

*auscult lungs

Eyes: *conjunctivae / lids

*oral mucosa

*hearing assess

*cornea

Cardio: *auscultation heart

ENMT: *ext aud canal /tymp memb

Neck: *jugular veins

*thyroid

*external ear/ nose

*anterior chambers

*periph vascular syst/palpation

*nasal mucosa, septum, turb

Resp: *effort, *auscultation/lungs

*nasal mucosa/septum/turb

*lenses

GI:

*abdomen

*liver/spleen

*teeth, gums

Cardio: *palpation *auscult heart

*lips/teeth/gums

*measure intraocular pressure

*stool sample

*hernia

*oropharynx

*measure BP in 2+ extremity

*oropharynx

*optic discs

GU:

Male: *anus/perineum

Neck: *neck

*carotid arteries

*pharynge / pyriform

*posterior segments

*scrotum

*epidiymides

*thyroid

*abd aorta

*larynx

*Ocular Adnexae

*testes

*urethral meatus

Resp: *effort

*femoral arteries

*nasopharynx

*penis

*DRE: prostate

*auscult lungs

*pedal pulses

Head & Face:

Neuro/Psych:

*seminal vesicles

Cardio: *auscult heart

*extemities

*inspect head & face

Mental Status Exam:

*sphincter tone/ hemorrhoid

*periph vascular sys/palpate

GI:

*abdomen

*liver/spleen

*palpation/percussion

*orientation

*rectal masses

GI:

*abdomen

*stool sample

*salivary gland

*mood & affect

Female: 7 of the following

*liver/spleen

Musc: *back

*gait

*assess facial strength

*genitalia

*urethral meatus

Lymph: *palpation lymph nodes

*strength / tone

Neck: *neck

*thyroid

*urethra

*bladder

Extremities: *digits & nails

Extrem: *inspect/palp digits & nails

Resp: *inspect chest

*vagina

*cervix

Skin: *inspect/palp skin & subcut

Skin:

*inspect/palp skin & subcut

*auscultation lungs

*uterus

*adnexa/parametri

Neuro/Psych:

MSE:

Tissue

Cardio: *auscult heart

*anus/perineum

*orientation

Neuro/Psych:

MSE:

*periph vasc syst/palpation

Lymph: *lymph nodes

*mood / affect

*orientation

Neuro/Psych:

MSE:

Skin: *inspect/palp skin & subcut

*mood / affect

*orientation

*mood & affect

Neuro/Psych:

MSE:

Lymph: *palpation lymph nodes

*orientation

*mood / affect

MUSCULOSKELETAL

NEUROLOGICAL

PSYCHIATRIC

SKIN

RESPIRATORY

Constitutional: *3 of: sit/std BP,

Constitutional: *3 of: sit/std BP, sup

Constitutional: *3 of: sit/std BP,

sup BP, pulse rate, respir, temp,

BP, pulse rate, respir, temp, height,

sup BP, pulse rate, respir, temp,

height, weight *General appearance

weight

height, weight *General appearance

height, weight

Cardio: *peripheral vascular

*General appearance

Eyes: *conjunctivae / lids

*General appearance

system/palpate

Eyes: *optic discs

Musc *strength/tone w/ notation of

ENMT: *lips/teeth/gums

ENMT: *teeth & gums

Lymph: *palpation lymph nodes

Cardio: *carotid arteries

abnormal movements/atrophy

*oropharynx

Musc: *gait/station

*auscultation

* gait / station

Neck: *thyroid

*nasal mucosa, septum, turb

Exam 4 of 6:jts/b one/musc/tendon

*periph vasc syst/palpation

Psych: *speech

Cardio:*periph vascular sys/palpate

Neck: *neck

*thyroid

1) head/ neck 2) spine, ribs,

Musc: *gait / station

*thought process

GI:

*anus

*jugular veins

pelvis 3)rt upper 4)lt upper

*muscle strength

*association

*liver/spleen

Resp: *chest

*effort

5) rt lower 6) lt lower

*muscle tone

*abnormal / psychotic thoughts

Lymph: *palpation lymph nodes

*percussion

*percussion/palpation

Neuro:*orientation time/place/person

*judgement / insight

Skin:

*palpation scalp

*palpation chest

*ROM

*stability

*recent & remote memory

COMPLETE MSE:

*inspect/palpation 4 of:

*auscult lungs

*muscle strength & tone

*attention span & concentration

*orientation

1)head 2) neck 3) chest

Cardio: *auscult heart

Skin:

*Inspect skin/subc tissue

*language function

*recent & remote memory

breast 4) abd 5) genitalia

*periph vascular sys/palpate

Exam 4 of 6: 1)head & neck

*fund of knowledge

*attention span / concentration

6) back 7) RUE 8)LUE

GI:

*abdomen

*liver/spleen

2) trunk 3) rt upper 4) lt upper

*cranial nerves 2-12

*language function

9) RLE 10) LLE

Lymph: *palpation lymph nodes

5) rt lower 6) lt lower

*sensation

*fund of knowledge

*eccorine/apocrine glands

Extremities: *digits & nails

Neuro/Psych:

*coordination

*deep tendon reflexes

*mood & affect

Extremities: *digits & nails

Skin: *inspect/palp skin & subcut

*deep tendon reflex

*sensation

* coordination

Neuro/Psych:

MSE:

Neuro/Psych:

MSE:

MSE: *orientation *mood / affect

*orientation

*mood / affect

*orientation

*mood / affect

FOCUSED 1-5 bullets

EXPANDED

6+ bullets

DETAILED: 2 bullets from 6 areas.

COMPREHENSIVE: all bullets in 9+ organ systems/body areas OR 2

systems OR 12+ bullets in 2 areas/

bullets from each of 9 body areas/organ systems.

systems

Usc Chart Review Worksheet Sample Page 3

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