Adult-Gerontology Acute Care

Core Competencies is the knowledge base every other domain draws on. On the ANCC AGACNP-BC examination it accounts for 36 of 150 scored questions (24%) and tests three linked capabilities: knowledge of advanced pathophysiology, knowledge of advanced pharmacology (including age-related changes in drug handling), and skill in advanced physical assessment. The AACN ACNPC-AG examination does not list a separate core domain; it tests the same material inside its body-system Clinical Judgment categories, so a murmur, an anion gap, or a Beers Criteria drug can appear in a cardiovascular, renal, or multisystem item. This section also covers the focused assessments the acute care NP must perform for obstetric and gynecologic emergencies, pain, and abuse or neglect.

Advanced physical assessment is the foundation of acute care NP practice. The AGACNP performs comprehensive and focused examinations across the adult-gerontology continuum and integrates the findings into a differential diagnosis that directs testing and treatment. Exam items usually give a cluster of findings and ask for the most likely diagnosis or the next step, so the emphasis here is on what each finding means.

Health History Collection

The comprehensive history includes chief complaint, history of present illness (HPI), past medical history, surgical history, family history, social history, and review of systems. In acute care the history is often taken under time pressure and may require collateral sources (family, EMS, prior records, pharmacy) when the patient cannot communicate.

Hpiframework:Oldcarts

For acute presentations, fix the timeline precisely: symptom duration changes the differential and the urgency (for example, time last known well determines stroke reperfusion eligibility).

Past medical history: chronic conditions, hospitalizations, and prior acute events.

Allergies: record the specific reaction; distinguish true allergy (urticaria, angioedema, bronchospasm, anaphylaxis) from intolerance or expected adverse effect (nausea with opioids).

Medications: prescription, over-the-counter, supplements, and herbal products, with doses and administration times; timing affects drug-level interpretation and interactions.

Family history: conditions with genetic predisposition relevant to the complaint; for cardiovascular disease, malignancy, diabetes, and thromboembolic disorders record the affected relative and age at diagnosis.

Social history: tobacco in pack-years, alcohol quantity, illicit drug use, occupational exposures, and living situation.

Functional status: establishes the baseline so that an acute decline (new inability to walk, new incontinence, new confusion) is recognized as a presenting sign.

Pack-years = packs smoked per day × years smoked

Example: 1.5 packs/day for 20 years = 30 pack-years. Current USPSTF lung cancer screening uses ≥20 pack-years in adults 50–80 years who currently smoke or quit within the past 15 years.

General Survey and Vital Signs

The general survey begins at first contact: overall appearance, level of consciousness, nutritional status, hygiene, and apparent distress. Document body habitus, gait if ambulatory, assistive devices, affect, behavior, and quality of interaction. "Looks sick" is a legitimate finding that should raise the level of concern.

Parameter	AbnormalFinding	WhattoConsider
Temperature	Fever;	Fever:infectionorinflammation Hypothermia:sepsis(apoorprognosticsign) environmental . ,
	hypothermia	exposure hypothyroidism adrenalinsufficiency hypoglycemia , , ,
Heartrate	Tachycardia;	Dysrhythmia volume status pain anxiety fever drug effect (beta-blockers mask , , , , ,
	bradycardia	compensatorytachycardia)
Respiratory	Tachypnea	Mostsensitiveearlysignofdeterioration:respiratorycompromise metabolicacidosis ,
rate		(Kussmaulbreathing) sepsis PE , ,
Blood	Hypotension;	OrthostaticdropofSBP≥20orDBP≥10mmHgwithin3minutesofstandingindicatesvolume
pressure	orthostasis	depletionorautonomicdysfunction;apulserise≥30/minsupportshypovolemia
Pulse	Widened	Aorticregurgitation increasedintracranialpressure(Cushingresponse) hyperthyroidism , , ,
pressure		sepsis(vasodilation)
Pulse	Narrowed	Reducedstrokevolumeorvasoconstriction:hypovolemicorcardiogenicshock cardiac ,
pressure		tamponade severeaorticstenosis ,
SpO2	Loworunreliable	InterpretwithFiO2 position perfusion anddyshemoglobinemias;obtainABGwhenoximetryis , , ,
		unreliable

MAP ≈ (SBP + 2 × DBP) ÷ 3 Pulse pressure = SBP − DBP

MAP below 65 mmHg indicates inadequate organ perfusion and is the usual resuscitation floor in shock. Example: 90/50 mmHg gives MAP

Blood pressure technique: the cuff bladder should encircle about 80% of the arm with a width about 40% of arm circumference; a cuff that is too small overestimates pressure. Support the arm at heart level.

Pulse oximetry pitfalls. Carbon monoxide poisoning gives a falsely normal SpO2 (carboxyhemoglobin reads as oxyhemoglobin); methemoglobinemia drives SpO2 toward about 85% regardless of true saturation; poor perfusion, vasopressors, hypothermia, motion, and nail polish degrade the signal; oximeters can overestimate saturation in patients with darker skin pigmentation (occult hypoxemia). Use co-oximetry on an arterial sample when a dyshemoglobinemia is suspected.

Head, Eyes, Ears, Nose, Throat, and Neck

Head: inspect for lesions, masses, and trauma (Battle sign, raccoon eyes suggest basilar skull fracture); palpate for tenderness, depressions, or asymmetry. In a patient over 50 with new headache, assess temporal artery prominence and tenderness (giant cell arteritis: jaw claudication, visual symptoms, elevated ESR/CRP; start glucocorticoids promptly to prevent vision loss).

Eyes: visual acuity; pupil size, shape, symmetry, and reactivity (PERRLA: pupils equal, round, reactive to light and accommodation); extraocular movements for restriction or nystagmus. Fundoscopy detects papilledema (increased intracranial pressure), hypertensive retinopathy, and diabetic changes. Also note subconjunctival hemorrhage, scleral icterus (usually visible when bilirubin exceeds about 2.5–3 mg/dL), and conjunctival pallor (anemia).

Ears: otoscopy for tympanic membrane integrity, effusion, and infection (hemotympanum after head trauma); gross hearing assessment identifies deficits that require accommodation during care.

Nose: septal position, mucosa, and discharge character; identify the epistaxis source (anterior, usually Kiesselbach plexus, versus posterior) because it determines management.

Throat: oropharyngeal mucosa, tonsillar size and exudate, uvula position (deviation suggests peritonsillar abscess), and dentition. Evaluate swallowing in patients with neurologic complaints or aspiration risk.

Neck: palpate anterior and posterior cervical and supraclavicular nodes (a left supraclavicular node suggests abdominal malignancy) and the thyroid; auscultate the carotids for bruits suggesting stenosis.

Jugular Venous Pressure

Jugular venous distension estimates right atrial pressure and volume status. With the head of the bed at 30–45°, measure the vertical height of the internal jugular pulsation above the sternal angle; adding 5 cm approximates central venous pressure. A height greater than 3 cm above the sternal angle (CVP above about 8 cm H2O) is elevated. Hepatojugular reflux (sustained rise with abdominal pressure) supports right heart failure or volume overload. Kussmaul sign, a paradoxical rise in JVP with inspiration, suggests constrictive pericarditis, restrictive cardiomyopathy, or right ventricular infarction.

Cardiovascular Examination

Inspect the chest wall for visible pulsations, scars (sternotomy), and devices. Palpate the precordium for the point of maximal impulse (PMI), normally in the 5th intercostal space at the midclavicular line and no larger than about 2.5 cm. A laterally displaced or enlarged PMI suggests left ventricular enlargement; a parasternal lift suggests right ventricular enlargement; a palpable thrill indicates a significant murmur (grade 4 or higher).

Heartsoundsands2Splitting

Sound	Mechanism/Timing	ClinicalSignifci ance
S1	Mitralandtricuspidclosure;startofsystole;	Loud in mitral stenosis and short PR; soft in first-degree AV block
	loudestatapex	andsevereMR
S2	Aortic(A2)andpulmonic(P2)closure;endof	LoudP2inpulmonaryhypertension;softA2insevereaortic
	systole;loudestatbase	stenosis
Physiologic	Widenswithinspiration(morevenousreturn	Normal
splitS2	delaysP2)
WidesplitS2	Splitinbothphases stillwidensoninspiration ,	DelayedRVemptying:rightbundlebranchblock pulmonic ,
		stenosis
FixedsplitS2	Doesnotvarywithrespiration	Atrialseptaldefect
Paradoxical	Splitonexpiration narrowsoninspiration(A2 ,	Leftbundlebranchblock severeaorticstenosis ,
splitS2	delayedpastP2)
S3	Earlydiastole;rapidfillingintoadilated ,	Ventricularsystolicdysfunctionorvolumeoverloadinadults;can
	noncompliant or overloaded ventricle; low- ,	benormalinyoungadultsandpregnancy
	pitched(bell)
S4	Latediastole;atrialcontractionintoastiff	Reducedcompliance:hypertensiveheartdisease CAD/ischemia , ,
Pericardial frictionrub	ventricle; low-pitched (bell) Scratchy uptothreecomponents;bestsitting , upandleaningforward	hypertrophiccardiomyopathy aorticstenosis Cannotoccurin , . atrialfibrillation 1 Pericarditis;persistswhenbreathisheld(apleuralrubstops)

Characterize every murmur by timing, location, radiation, intensity, pitch, and quality. Intensity is graded on a six-point scale. Systolic murmurs occur between S1 and S2; diastolic murmurs are always pathological.

Grade	Description
1/6	Veryfaint;heardonlywithconcentration
2/6	Quietbutheardimmediately
3/6	Moderatelyloud;nothrill
4/6	Loud withapalpablethrill ,
5/6	Veryloud;heardwiththestethoscopepartlyoffthechest;thrill
6/6	Heardwiththestethoscopeentirelyoffthechest;thrill

Lesion	Timing/Quality	BestHeard/Radiation	KeyFeaturesandManeuvers
Aorticstenosis	Midsystolic crescendo-	Right2ndICS;radiatesto	Delayed weakcarotidupstroke(pulsusparvus ,
	decrescendo harsh ,	carotids	ettardus);softorparadoxicallysplitS2;S4 .
			SofterwithValsalvaandhandgrip
Hypertrophic	Midsystolic harsh ,	Leftlowersternalborder;little	LouderwithValsalvaandstanding(less
cardiomyopathy		carotidradiation	preload);softerwithsquatting handgrip and , ,
			legraise
Mitralregurgitation	Holosystolic blowing ,	Apex;radiatestoaxilla	Louderwithhandgrip(increasedafterload) .
			AcuteMRafterMI(papillarymusclerupture)
			causesflashpulmonaryedema
Mitralvalve	Midsystolicclick then ,	Apex	Valsalvaandstandingmovetheclickearlier
prolapse	latesystolicmurmur		andlengthenthemurmur;squattingdelaysit
Tricuspid	Holosystolic blowing ,	Leftlowersternalborder	Louderwithinspiration(Carvallosign);
regurgitation			prominentjugularvwaves pulsatileliver ,
Ventricularseptal	Holosystolic harsh ,	Leftlowersternalborder	Post-MI VSD presents with a new loud murmur
defect			andshock
Aorticregurgitation	Earlydiastolic	Leftsternalborder(Erb'spoint);	Widepulsepressure boundingpulses;louder ,
	decrescendo high , -	patientsitting leaningforward , ,	withhandgrip AcuteAR(endocarditis . ,
	pitched blowing ,	breathheldinexpiration	dissection)isanemergency
Mitralstenosis	Opening snap then low- ,	Apexwithbell patientinleft ,	LoudS1;usuallyrheumatic;atrialfibrillation
	pitcheddiastolicrumble	lateraldecubitus	andleftatrialenlargementcommon

Right-sided murmurs (tricuspid, pulmonic) get louder with inspiration; left-sided murmurs get louder with expiration. Almost every murmur softens with Valsalva or standing because preload falls; the two exceptions, which get louder, are hypertrophic cardiomyopathy and mitral valve prolapse.

Peripheral Vascular Examination

Palpate radial, brachial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses bilaterally. Assess capillary refill (normally under 2–3 seconds), skin temperature, color, and hair distribution. Distinguish pitting from nonpitting edema (lymphedema, myxedema) and note distribution (bilateral dependent edema suggests systemic causes; unilateral edema suggests DVT, cellulitis, or venous obstruction). An ankle-brachial index of 0.90 or less indicates peripheral artery disease; above 1.40 indicates noncompressible, calcified vessels.

Grade	PulseAmplitude	PittingEdema(approximate)
0	Absent	None
1+	Diminished barelypalpable ,	About2mmpit;reboundsalmostimmediately
2+	Normal	About4mm;reboundswithinabout15seconds
3+	Increased full ,	About6mm;reboundswithinabout1minute
4+	Bounding	About8mm;reboundtakesseveralminutes

Acute limb ischemia (the 6 P's): pain (out of proportion), pallor, pulselessness, paresthesia, paralysis, and poikilothermia (cold limb). Sensory loss and motor weakness indicate a threatened limb requiring emergent anticoagulation and vascular surgery consultation.

Pulmonary Examination

Inspection: respiratory rate and effort, accessory muscle use, chest wall symmetry, and breathing pattern. Tachypnea, sternocleidomastoid use, intercostal retractions, and paradoxical abdominal movement (inward abdominal motion on inspiration, a sign of diaphragmatic fatigue) indicate respiratory distress. A barrel chest (increased anteroposterior diameter) suggests COPD.

Palpation: chest wall tenderness, subcutaneous emphysema (crepitus: pneumothorax, esophageal rupture), tactile fremitus, and symmetry of expansion (asymmetric expansion localizes unilateral disease). Percussion: resonance is normal lung; hyperresonance suggests pneumothorax or emphysema; dullness indicates consolidation, effusion, or mass. Diaphragmatic excursion (normally about 3–5 cm) evaluates respiratory muscle function.

Auscultation: vesicular sounds predominate in the periphery, bronchovesicular sounds near the mainstem bronchi, and bronchial sounds over the trachea. Bronchial breath sounds in the periphery mean consolidated lung is transmitting central airway sounds. Egophony (spoken "E" heard as "A"), bronchophony, and whispered pectoriloquy also indicate consolidation.

Sound	Description	Signifi cance
Finecrackles Coarsecrackles	Brief high -pitched late inspiratory ("Velcro") , , Louder lower-pitched bubbling , ,	Interstitiallungdisease earlypulmonaryedema atelectasis1 , , Airwaysecretions pneumonia moreadvancedpulmonaryedema , ,

Adventitioussounds(Continued)

Sound	Description	Signifi cance
Wheezes	Continuous musical usually , ,	Airwaynarrowingfrombronchospasm inflammation orobstruction;a"silent , ,
	expiratory	chest"insevereasthmasignalsminimalairflow
Rhonchi	Low-pitched snoring; often clear ,	Secretionsinlargerairways
	withcough
Stridor	High -pitched inspiratory , ,	Upper airway obstruction (angioedema epiglottitis foreign body post- , , ,
	loudestovertheneck	extubationedema);requiresurgentevaluation
Pleuralfriction	Gratingsoundinbothinspiration	Pleuralinflammation(pneumonia PE);stopswhenthebreathisheld unlikea , ,
rub	andexpiration	pericardialrub

Condition	Trachea	Percussion	Tactile Fremitus	BreathSounds/VoiceSounds
Consolidation(lobar	Midline	Dull	Increased	Bronchialbreathsounds crackles; ,
pneumonia)				egophony bronchophony whispered , ,
				pectoriloquy
Pleuraleffusion(large)	Shiftedaway	Stonydull	Decreasedor	Decreasedorabsent;egophonymaybe
			absent	heardattheupperborder
Pneumothorax	Shiftedawayif	Hyperresonant	Decreasedor	Decreasedorabsent
	tension		absent
COPD/emphysema	Midline	Hyperresonant;low	Decreased	Distantbreathsounds prolonged ,
		diaphragms		expiration wheezes ,
Atelectasis(lobar ,	Shiftedtoward	Dull	Decreased	Decreasedorabsent
obstructedbronchus)	theaffectedside

Abdominal Examination

Examine in the order inspection, auscultation, percussion, palpation, because palpation can alter bowel sounds. Inspect for distension, asymmetry, visible peristalsis, pulsations, scars, and hernias. Striae indicate prior distension; caput medusae (dilated periumbilical veins) suggests portal hypertension.

Auscultation: normal bowel sounds occur about 5–35 times per minute. Hyperactive sounds suggest early obstruction or gastroenteritis (high-pitched tinkling rushes suggest obstruction); absent sounds after 2 minutes of listening suggest ileus or late obstruction. Listen for bruits over the aorta and renal arteries. Percussion: tympany predominates over gas-filled bowel; shifting dullness and a fluid wave indicate ascites. Normal liver span is 6–12 cm in the right midclavicular line.

Palpation: light palpation identifies superficial tenderness and guarding; deep palpation assesses organomegaly and masses. Involuntary guarding and rigidity indicate peritonitis. Palpate the spleen starting in the right lower quadrant and moving toward the left upper quadrant so a massively enlarged spleen is not missed; a palpable spleen is generally enlarged at least threefold. Costovertebral angle tenderness suggests pyelonephritis or nephrolithiasis.

Sign	Technique/Finding	Suggests
Murphysign	InspiratoryarrestwithsharppainduringdeepRUQ	Acutecholecystitis
	palpationunderthecostalmargin
McBurneypoint	Tenderness about one-third of the distance from the	Appendicitis
tenderness	rightanteriorsuperioriliacspinetotheumbilicus
Rovsingsign	RLQpainduringLLQpalpation	Appendicitis
Psoassign	RLQpainwithrighthipextension(patientonleftside)	Retrocecalappendicitis;psoasabscess
	orflexionagainstresistance
Obturatorsign	RLQorpelvicpainwithinternalrotationoftheflexed	Pelvicappendicitis;pelvicabscess
	righthip
Rebound	Painonsuddenreleaseofpressure	Peritonealinflammation
tenderness
Cullensign	Periumbilicalecchymosis	Intra-abdominal or retroperitoneal hemorrhage:
		hemorrhagicpancreatitis rupturedectopicpregnancy ,
GreyTurnersign	Flankecchymosis	Retroperitonealhemorrhage:hemorrhagicpancreatitis ,
		rupturedabdominalaorticaneurysm
Kehrsign	Leftshoulderpainreferredfromdiaphragmatic	Splenicrupture hemoperitoneum ,
	irritation
CVAtenderness	Painwithpercussionoverthecostovertebralangle	Pyelonephritis nephrolithiasis ,

Neurological Examination

Mental status assessment includes level of consciousness, orientation, attention, memory, language, and executive function. The Glasgow Coma Scale quantifies consciousness from 3 to 15; serial scores detect deterioration. A total of 8 or less defines severe brain injury and generally indicates a need for airway protection. Record the best response in each category and the components (for example, E2 V2 M4 = 8), and note "T" for an intubated patient's verbal score.

Score	EyeOpening(E)	VerbalResponse(V)	MotorResponse(M)
6	—	—	Obeyscommands
5	—	Oriented	Localizestopain
4	Spontaneous	Confused	Withdrawsfrompain
3	Tovoice	Inappropriatewords	Abnormalflexion(decorticate)
2	Topain	Incomprehensiblesounds	Extension(decerebrate)
1	None	None	None

I Olfactory

Smell

Familiar scent, each nostril

Anosmia (frontal trauma, neurodegenerative disease)

II Optic

Vision

Acuity, confrontation fields,

Field cut; relative afferent pupillary defect;

fundoscopy; afferent limb of

papilledema

pupillary reflex

III Oculomotor

Most EOMs, eyelid elevation,

EOMs, pupils, lid

"Down and out" eye, ptosis, dilated pupil

pupil constriction

(compressive lesion: uncal herniation, posterior communicating aneurysm)

IV Trochlear

Superior oblique (down and in)

EOMs

Vertical diplopia, worse looking down (stairs)

V Trigeminal

Facial sensation; muscles of

Sensation in V1–V3, jaw

Facial numbness, weak bite

mastication

clench; corneal reflex (afferent)

VI Abducens

Lateral rectus (abduction)

EOMs

Failure of abduction; horizontal diplopia; false localizing sign of raised ICP

VII Facial

Facial expression; taste anterior

Raise brows, close eyes

Peripheral (LMN) lesion: whole half of face

two-thirds; corneal reflex

tightly, smile

(Bell palsy). Central (UMN) lesion: lower

(efferent)

face only, forehead spared

VIII

Hearing and balance

Whisper, Weber/Rinne, head

Hearing loss, vertigo, nystagmus

Vestibulocochlear

impulse

IX

Palate sensation, gag (afferent)

Gag, palate elevation

Diminished gag, dysphagia

Glossopharyngeal X Vagus

Palate elevation, gag (efferent),

Say "ah"; voice quality

Uvula deviates away from the lesion;

phonation

hoarseness

XI Accessory

Sternocleidomastoid and

Shoulder shrug, head turn

Weak shrug or head turn

trapezius

against resistance

XII Hypoglossal

Tongue movement

Protrude tongue

Tongue deviates toward the side of the lesion

Motor examination assesses bulk, tone, and strength and documents the pattern (proximal versus distal, unilateral versus bilateral). Pronator drift is a sensitive screen for subtle upper motor neuron weakness.

Feature	UpperMotorNeuron	LowerMotorNeuron
Location	Brainorspinalcord(corticospinaltract)	Anteriorhorncell nerveroot peripheralnerve , ,
Tone Reflexes Babinskisign Atrophy	Increased(spasticity);maybeflaccidacutely(spinalshock) Hyperreflexia clonus , Present(upgoingtoe) Minimal(disuseonly)	Decreased(flaccidity) Hyporeflexiaorareflexia Absent Marked	1

Uppervslowermotorneuronlesions(Continued)

Feature	UpperMotorNeuron	LowerMotorNeuron
Fasciculations	Absent	Present
Examples	Stroke spinalcordcompression multiplesclerosis , ,	Guillain-Barré syndrome radiculopathy peripheral neuropathy , ,

Grade	Muscle Strength (0–5)	Grade	Deep Tendon Refel xes (0–4+)
0	Nocontraction	0	Absent
1	Flickerortracecontraction	1+	Diminished
2	Activemovementwithgravityeliminated	2+	Normal
3	Activemovementagainstgravity	3+	Briskerthanaverage;spread
4	Againstgravityandsomeresistance	4+	Verybriskwithclonus
5	Normalstrengthagainstfullresistance	—	—

Reflexes tested: biceps (C5–C6), brachioradialis (C6), triceps (C7), patellar (L4), and Achilles (S1), always bilaterally.

Babinski response: dorsiflexion of the great toe with fanning of the other toes on plantar stimulation indicates upper motor neuron dysfunction in adults.

Sensory: light touch, pain, temperature (spinothalamic), and proprioception and vibration (dorsal columns); document dermatomal or stocking-glove patterns.

Coordination: finger-to-nose, heel-to-shin, and rapid alternating movements test cerebellar function.

Romberg test: worsening balance with eyes closed indicates loss of proprioception (dorsal column or large-fiber neuropathy), not cerebellar disease.

Gait: initiation, stride length, arm swing, turning, and balance (shuffling, festinating gait in Parkinson disease; wide- based gait in cerebellar disease).

Musculoskeletal Examination

Examine joints systematically: inspect for swelling, erythema, deformity, and atrophy; palpate for warmth, tenderness, crepitus, and effusion; compare active and passive range of motion with the opposite side and document limitations and pain. A single hot, swollen joint requires arthrocentesis to exclude septic arthritis. The spine examination inspects cervical, thoracic, and lumbar alignment and posture, palpates spinous processes and paraspinal muscles, and assesses flexion, extension, lateral bending, and rotation.

Test	Technique	PositiveFindingSuggests
Straightleg	Passivehipflexionwithknee	Painradiatingbelowthekneeatlessthan60°suggestslumbarnerveroot
raise	extended patientsupine ,	compression(L5/S1radiculopathy);crossedSLRismorespecific
Emptycan (Jobe) Droparm	Armsabducted90° thumbsdown , , resistdownwardpressure Patientslowlylowersthearmfrom 90°abduction	Supraspinatusweaknessortear Armdrops:significantrotatorcufftear

Musculoskeletalspecialtests(Continued)

Test	Technique	PositiveFindingSuggests
Resistedexternal/internal	Elbowatside flexed90° ,	External:infraspinatus/teresminor Internal: .
rotation		subscapularis
FABER(Patrick)	Flexion abduction externalrotationof , ,	Sacroiliacjointpathology(posteriorpain)orhipjoint
	the hip (figure-4)	pathology(groinpain)
Trendelenburgsign	Standononeleg	Oppositepelvisdrops:hipabductor(gluteusmedius)
		weakness
McMurray	Rotatethetibiawhileextendingtheflexed	Painfulclick:meniscaltear(jointlinetenderness
	knee	supports)
Lachman	Knee flexed 20–30° pull tibia forward ,	Increasedtranslation softendpoint:ACLtear(most ,
		sensitivetest)
Anterior/posteriordrawer	Kneeflexed90° pullorpushtibia ,	Anterior:ACLtear Posterior:PCLtear .
Valgus/varusstress	Stressthekneeat0°and30°	Valguslaxity:MCL Varuslaxity:LCL .
Phalen/Tinel	Wristflexionfor60seconds/tapover	Carpaltunnelsyndrome
	mediannerve

Integumentary Examination

Assess skin color, temperature, moisture, turgor, and lesions. Describe lesions by morphology, size, shape, border, color, distribution (localized, generalized, dermatomal, flexural, sun-exposed), configuration, and arrangement (linear, annular, grouped, target).

PrimaryLesion	Defi nition	Example
Macule	Flat colorchange <1cm , ,	Freckle petechia ,
Patch	Flat colorchange ≥1cm , ,	Vitiligo
Papule	Raised solid <1cm , ,	Nevus wart ,
Plaque	Raised flat-topped ≥1 cm , ,	Psoriasis
Nodule	Solid deeper ≥1cm , ,	Lipoma erythemanodosum ,
Vesicle/bulla	Clear-fluid blister <1 cm / ≥1 cm	Herpeszoster/bullouspemphigoid burns ,
Pustule	Pus-filled raised lesion	Folliculitis acne ,
Wheal	Transient edematous pruriticplaque , ,	Urticaria

Secondarychanges(Continued)

Change	Defi nition
Ulcer	Lossofepidermisanddermis;healswithscarring
Fissure	Linearcrackintothedermis
Lichenification	Thickenedskinwithaccentuatedmarkingsfromchronicrubbing
Atrophy	Thinningofskinwithlossofmarkings(chronictopicalsteroids aging) ,

For pigmented lesions, apply the ABCDE criteria for melanoma: asymmetry, border irregularity, color variation, diameter greater than 6 mm, and evolution (change over time).

Stage	Description
Stage1	Intactskinwithnonblanchableerythema(mayappearaspersistentcolorchangeindarkerskin)
Stage2	Partial -thickness skin loss with exposed dermis; pink moist wound bed or intact/ruptured serum-filled
	blister;nosloughoreschar
Stage3	Full -thickness skin loss; adipose tissue visible; slough eschar undermining or tunneling may be present; , , ,
	fascia muscle tendon andbonenotexposed , , ,
Stage4	Full -thickness skin and tissue loss with exposed or directly palpable fascia muscle tendon ligament , , , ,
	cartilage orbone ,
Unstageable	Full -thickness loss with the base obscured by slough or eschar; depth cannot be determined until debrided
	(stabledryescharonheelsisleftinplace)
Deeptissuepressure	Intact or nonintact skin with persistent nonblanchable deep red , maroon , or purple discoloration or a blood -
injury	filledblisteroverdeeptissuedamage

Pressure injuries are never reverse-staged: a healing stage 4 injury is documented as a "healing stage 4," not a stage 2. Mucosal membrane pressure injuries (from tubes and devices) are not staged.

Finding	Appearance	AssociatedConditions
Clubbing	Lossofthenormalanglebetweennailand	Chronichypoxia lungmalignancy bronchiectasis cyanotic , , ,	heart
	nailfold;bulbousfingertip	disease inflammatoryboweldisease cirrhosis , ,
Splinter	Thin red -brown longitudinal lines	Infectiveendocarditis(alsotrauma)
hemorrhages
Terrynails	Mostlywhitenailwithanarrowdistalpink	Hepaticfailure/cirrhosis;alsoheartfailureanddiabetes
Meeslines Beaulines	orbrownband Transversewhitebands Transversegroovesordepressions	Arsenicorotherheavymetalpoisoning severeillness , Temporaryarrestofnailmatrixgrowth(severeillness , chemotherapy)	1

Nailfindingsinsystemicdisease(Continued)

Finding	Appearance	AssociatedConditions
Koilonychia	Spoon-shaped concave nails ,	Irondeficiencyanemia
Pitting	Smallpunctatedepressions	Psoriasis

Changes in hair distribution may indicate endocrine disorders; note alopecia patterns and hirsutism. Mucous membranes reflect hydration and systemic disease; oral candidiasis suggests immunocompromise (HIV, diabetes, inhaled or systemic corticosteroids) or recent antibiotic use.

MAP ≈ (SBP + 2 × DBP) ÷ 3; below 65 mmHg means

Consolidation: dull, increased fremitus, bronchial sounds,

inadequate perfusion.

egophony; effusion: dull, decreased fremitus, trachea shifted away.

Fixed split S2 = ASD; paradoxical split = LBBB or severe AS.

GCS ≤8 generally warrants airway protection; UMN = spastic,

S3 = volume overload/systolic dysfunction; S4 = stiff

hyperreflexic, Babinski.

ventricle, absent in AF.

Pressure injuries are never reverse-staged; eschar obscuring

HCM and MVP murmurs are the only ones louder with

the base = unstageable.

Valsalva or standing.