1. Medical examination and history taking
Medical
history
 Chief complaint
 History of the present illness
 Systems review
 Allergies
o Medications
 Past medical history
o Surgical history
 Family history
 Social history
 Psychiatric history
 Progress notes
 Mnemonics
o SAMPLE
o OPQRST
o SOAP
Physical
examination
General/IPPA
 Inspection
 Auscultation
 Palpation
 Percussion
Vital signs
 Temperature
 Heart rate
 Blood pressure
 Respiratory rate
HEENT Oral mucosa · TM · Eyes (Ophthalmoscopy, Swinging-flashlight test) · Hearing (Weber, Rinne)
Respiratory
 Respiratory signs and symptoms
o Respiratory sounds
o Cyanosis
o Clubbing
Cardiovascular
 Precordial examination
 Peripheral vascular examination

2.  Cardiovascular signs and symptoms
o Heart sounds
 Other
o Jugular venous pressure
o Abdominojugular test
o Carotid bruit
o Ankle brachial pressure index
Abdominal
Digestive Liver span · Rectal · Murphy's sign · Bowel sounds
Urinary Murphy's punch sign
Extremities/Joint
Back (Straight leg raise) · Knee (McMurray test) · Hip · Wrist (Tinel sign, Phalen maneuver) · Shoulder (Adson's
sign) · GALS screen
Neurological
 Mental state
o Mini–mental state examination
 Cranial nerve examination
Neonatal
 Apgar score
 Ballard Maturational Assessment
Gynecological
 Well-woman examination
 Vaginal examination
 Breast examination
 Cervical motion tenderness
L/I Labs (Electrolytes, ABG, LFT) · Medical imaging (EKG, CXR, CT, MRI)
A/P Medical diagnosis · Differential diagnosis