COMPREHENSIVE PE ROS

Therese Marie Grace G. Adlawan

Comprehensive PE:

General Survey and Vital Signs

Record the vital signs taken at the time of your examination rather than earlier in the day. (Common
abbreviations for blood pressure, heart rate, and respiratory rate are self-explanatory.) “Mrs. Scott is a
young, healthy-appearing woman, well-groomed, fit, and cheerful. Height is 5′4″, weight 135 lbs, BMI
24, BP 120/80, right and left arms, HR 72 and regular, RR 16, temperature 37.5ÅãC.”
OR
“Mr. Jones is an elderly man who looks pale and chronically ill. He is alert, with good eye contact but
unable to speak more than two or three words at a time due to shortness of breath. He has intercostal
muscle retraction when breathing and sits upright in bed. He is thin, with diffuse muscle wasting. Height
is 6′2″, weight 175 lbs, BP 160/95, right arm, HR 108 and irregular, RR 32 and labored, temperature
101.2ÅãF.”

Behavior and Mental Status

“Mental Status: The patient is alert, well-groomed, and cheerful. Speech is fluent and words are clear.
Thought processes are coherent, insight is good. The patient is oriented to person, place, and time. Serial
7s accurate; recent and remote memory intact. Calculations intact.”
OR
“Mental Status: The patient appears sad and fatigued; clothes are wrinkled. Speech is slow and words are
mumbled. Thought processes are coherent, but insight into current life reverses is limited. The patient is
oriented to person, place, and time. Digit span, serial 7s, and calculations accurate, but responses
delayed. Clock drawing is good.”

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Therese Marie Grace G. Adlawan

Skin:

Note that initially you may use sentences to describe your findings; later you will use phrases. The
examples below contain phrases appropriate for most write-ups. Use specific terms to describe skin
lesions and rashes, including:
■ Number—solitary or multiple; estimate of total number
■ Size—measured in millimeters or centimeters
■ Color—including erythematous if blanching; if nonblanching, vascular-like cherry angiomas
and vascular malformations, petechiae, or purpura
■ Shape—circular, oval, annular, nummular, or polygonal
■ Texture—smooth, fleshy, verrucous or warty, keratotic; greasy if scaling
■ Primary lesion—flat, a macule or patch; raised, a papule or plaque; or fluid filled, a vesicle or bulla (may
also be erosions, ulcers, nodules, ecchymoses, petechiae, and palpable purpura)
■ Location—including measured distance from other landmarks
■ Configuration—grouped, annular, linear

The Head, Eyes, Ears, Nose, and Throat (HEENT)

HEENT: Head—The skull is normocephalic/atraumatic (NC/AT).

Hair with average texture.
Eyes—Visual acuity 20/20 bilaterally. Sclera white, conjunctiva pink.
Pupils are 4 mm constricting to 2 mm, equally round and reactive to light and accommodations. Disc
margins sharp; no hemorrhages or exudates, no arteriolar narrowing.
Ears—Acuity good to whispered voice. Tympanic membranes
(TMs) with good cone of light. Weber midline. AC > BC.
Nose— Nasal mucosa
pink, septum midline; no sinus tenderness.
Throat (or Mouth)— Oral mucosa pink, dentition good, pharynx without exudates.
Neck—Trachea midline. Neck supple; thyroid isthmus palpable, lobes not felt.
Lymph Nodes—No cervical, axillary, epitrochlear, inguinal adenopathy. OR
Head—The skull is normocephalic/atraumatic. Frontal balding.
Eyes—Visual acuity 20/100 bilaterally. Sclera white; conjunctiva injected. Pupils constrict
3 mm to 2 mm, equally round and reactive to light and accommodation. Disc
margins sharp; no hemorrhages or exudates. Arteriolar-to-venous ratio (AV
ratio) 2:4; no AV nicking.
Ears—Acuity diminished to whispered voice; intact to spoken voice. TMs clear. Nose—Mucosa
swollen with erythema and clear drainage.
Septum midline. Tender over maxillary sinuses.
Throat—Oral mucosa pink, dental caries in lower molars, pharynx erythematous, no exudates.
Neck—Trachea midline.
Neck supple; thyroid isthmus midline, lobes palpable but not enlarged.
Lymph Nodes—Submandibular and anterior cervical lymph nodes tender, 1 cm Å~ 1 cm, rubbery
and mobile; no posterior cervical, epitrochlear, axillary, or inguinal lymphadenopathy.

Thorax and Lungs

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Therese Marie Grace G. Adlawan

“Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no crackles,
wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally.”
OR
“Thorax symmetric with moderate kyphosis and increased AP diameter, decreased expansion. Lungs are
hyperresonant. Breath sounds distant with delayed expiratory phase and scattered expiratory wheezes.
Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy. Diaphragms descend 2 cm
bilaterally.”

Cardiovascular Examination
“The JVP is 3 cm above the sternal angle with the head of bed elevated to 30°.
Carotid upstrokes are brisk, without bruits. The PMI is tapping, 1 cm lateral to the midclavicular line in
the 5th intercostal space. Crisp S1 and S2. At the base, S2 is louder than S1 with physiologic split of A2 > P2.
At the apex, S1 is louder than S2. There are no murmurs or extra sounds.”
OR
“The JVP is 5 cm above the sternal angle with the head of bed elevated to 50°. Carotid upstrokes are
brisk; a bruit is heard over the left carotid artery. The PMI is diffuse, 3 cm in diameter, palpated at the
anterior axillary line in the 5th and 6th intercostal spaces. S 1 and S2 are soft. S3 is present at the apex.
High-pitched harsh 2/6 holosystolic murmur best heard at the apex, radiating to the axilla.”

Breasts and Axillae Examination

“Breasts symmetric and smooth without nodules or masses. Nipples without discharge “
OR
“Breasts pendulous with diffuse fibrocystic changes. Single firm 1 Å~ 1 cm mass, mobile and nontender,
with overlying peau d’orange appearance in right breast, upper outer quadrant at 11 o’clock, 2 cm from
the nipple.”

Abdominal Examination
“Abdomen is protuberant with active bowel sounds. It is soft and nontender; no palpable masses or
hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm
below the right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness.”
OR
“Abdomen is flat. No bowel sounds heard. It is firm and boardlike, with increased tenderness, guarding,
and rebound in the right midquadrant. Liver percusses to 7 cm in the midclavicular line; edge not felt.
Spleen and kidneys not felt. No palpable masses. No CVA tenderness.

Peripheral Vascular System

“Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and
nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis (DP), and
posterior tibial (PT) pulses are 2+ and symmetric.”
OR
“Extremities are pale below the midcalf, with notable hair loss. Rubor noted when legs dependent but no
edema or ulceration. Bilateral femoral bruits; no abdominal bruits heard. Brachial and radial pulses 2+;
femoral, popliteal, DP and PT pulses 1+.” (Alternatively, pulses can be recorded as below.)
Radial Brachial Femoral Popliteal
Dorsalis
Pedis
Posterior
Tibial

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Male Genitalia Examination

“Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended
bilaterally, smooth, without masses. Epididymis is nontender. No inguinal or femoral hernias.”
OR
“Uncircumcised male; prepuce easily retractible. No penile discharge or lesions. No scrotal swelling or
discoloration. Testes descended bilaterally; right testicle smooth; 1 Å~ 1 cm firm nodule on left lateral
testicle. It is fixed and nontender. Epididymis nontender. No inguinal or femoral hernias.”

Female Genitalia
“No inguinal adenopathy. External genitalia without erythema, lesions, or masses. Vaginal mucosa
pink. Cervix parous, pink, and without discharge. Uterus anterior, midline, smooth, and not enlarged.
No adnexal tenderness. Pap smear obtained. Rectovaginal wall intact. Rectal vault without masses.
Stool brown and negative for fecal blood.”
OR
“Bilateral shotty inguinal adenopathy. External genitalia without erythema or lesions. Vaginal mucosa and
cervix coated with thin white homogeneous discharge with mild fishy odor. After swabbing cervix, no
discharge visible in
the cervical os. Uterus midline; no adnexal masses. Rectal vault without masses. Stool brown and
negative for fecal blood. pH of vaginal discharge >4.5”

Anus, Rectum, and Prostate Examination

“No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate
smooth and nontender with palpable median sulcus. (Or in a female, uterine cervix nontender.) Stool
brown; no fecal blood.”
OR
“Perirectal area inflamed; no ulcerations, warts, or discharge. Unable to examine external sphincter,
rectal vault, or prostate because of spasm of external sphincter and marked inflammation and
tenderness of anal canal.”
OR
“No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Left lateral
prostate lobe with 1 Å~ 1 cm firm, hard nodule; right lateral lobe smooth; median sulcus obscured. Stool
brown; no fecal blood.”

Musculoskeletal System
“Full range of motion in all joints of the upper and lower extremities. No evidence of swelling or
deformity.”
OR
“Full range of motion in all joints. Hand with Heberden nodes at the DIP joints, Bouchard nodes at PIP
joints. Mild pain with flexion, extension, and rotation of both hips. Full range of motion in the knees, with
moderate crepitus; no effusion but bony enlargement along the tibiofemoral joint line bilaterally. Both
feet with hallux valgus at the first MTP joints.”
OR
“Right knee with moderate effusion and tenderness over medial meniscus along the joint line. Moderate
laxity of ACL on Lachman test; PCL, MCL, and LCL intact—no posterior drawer sign or tenderness with
varus or valgus stress. Patellar tendon intact—patient able to extend lower extremity. All other joints
with good range of motion; no other deformity or swelling.”

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The Nervous System

“Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place,
and time. Detailed cognitive testing deferred.
Cranial
Nerves:
I—not tested;
II through XII intact.
Motor: Good muscle bulk and tone. Strength 5/5 throughout.
Cerebellar—Rapid alternating movements (RAMs), finger-to-nose (F→N), heel-to-shin (H→S)
intact. Gait with normal base. Romberg—maintains balance with eyes closed. No pronator drift.
Sensory: Pinprick, light touch, position, and vibration intact.
Reflexes: 2 and symmetric with plantar reflexes downgoing.”
OR
“Mental Status: The patient is alert and tries to answer questions but has difficulty
finding words. Cranial Nerves: I—not tested; II—visual acuity intact; visual fields full; III, IV, VI—
extraocular movements intact; V motor— temporal and masseter strength intact, corneal reflexes
present; VII motor prominent right facial droop and flattening of right nasolabial fold, left facial
movements intact, sensory— taste not tested; VIII—hearing intact bilaterally to whispered voice;
IX, X—gag intact;
XI—strength of sternocleidomastoid and trapezius muscles 5/5;
XII—tongue midline. Motor: strength in right biceps, triceps, iliopsoas, gluteals, quadriceps, hamstring,
and ankle flexor and extensor muscles 3/5 with good bulk but increased tone and spasticity; strength in
comparable muscle groups on the left 5/5 with good bulk and tone. Gait—unable to test.
Cerebellar— unable to test on right due to right arm and leg weakness; RAMs, F→N, H→S
intact on left.
Romberg—unable to test due to right leg weakness. Right pronator drift present. Sensory:
decreased sensation to pinprick over right face, arm,
and leg; intact on the left. Stereognosis and two-point discrimination not tested. Reflexes (can
record in two ways):

Review Of Systems:

General: Usual weight, recent weight change, clothing that fits more tightly or loosely than before;
weakness, fatigue, or fever.

Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or
color of moles.

Head, Eyes, Ears, Nose, Throat (HEENT):

Head: Headache, head injury, dizziness, lightheadedness.
Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double
or blurred vision, spots, specks, flashing lights, glaucoma, cataracts.
Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is
decreased, use or nonuse of hearing aids.

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Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay
fever, nosebleeds, sinus trouble.
Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums, dentures, if any,
and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness, no
ulcers, gingival redness, ulceration, salivation
Neck: “Swollen glands,” goiter, lumps, pain, or stiffness in the neck.
Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices.

Respiratory: Cough, sputum (color, quantity; presence of blood or hemoptysis), shortness of breath
(dyspnea), wheezing, pain with a deep breath (pleuritic pain), last chest x-ray. You may wish to include
asthma, bronchitis, emphysema, pneumonia, and tuberculosis.

Cardiovascular: “Heart trouble”; high blood pressure; rheumatic fever; heart murmurs; chest pain or
discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea);
need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea); swelling in the hands, ankles, or
feet (edema); results of past electrocardiograms or other cardiovascular tests.

Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and
size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids,
constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice,
liver, or gallbladder trouble; hepatitis.
Peripheral vascular: Intermittent leg pain with exertion (claudication); leg cramps; varicose veins; past
clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather;
swelling with redness or tenderness.
Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, blood in the
urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain,
incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.
Genital:
Male: Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or
swelling, history of sexually transmitted infections and their treatments. Sexual habits, interest, function,
satisfaction, birth control methods, condom use, and problems. Concerns about HIV infection.
Female: Age at menarche, regularity, frequency, and duration of periods, amount of bleeding;
bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual
tension. Age at menopause, menopausal symptoms, postmenopausal bleeding. If the patient was born
before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy (linked to cervical
carcinoma). Vaginal discharge, itching, sores, lumps, sexually transmitted infections and treatments.
Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced),
complications of pregnancy, birth-control methods. Sexual preference, interest, function, satisfaction, any
problems, including dyspareunia. Concerns about HIV infection.

Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe location of
affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of
motion or activity;
include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low
back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or
weakness.

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Psychiatric: Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide
plans or attempts. Past counseling, psychotherapy, or psychiatric admissions.

Neurologic: Changes in mood, attention, or speech; changes in orientation, memory, insight, or

judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness or loss of
sensation, tingling or “pins and needles,” tremors or other involuntary movements, seizures.

Hematologic: Anemia, easy bruising or bleeding, past transfusions, transfusion reactions.

Endocrine: “Thyroid trouble,” heat or cold intolerance, excessive sweating,excessive thirst or hunger,
polyuria, c hange in glove or shoe size.

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