20
Diagnosis
Table 3. Initial Assessment — Review of Systems and
Physical Examination
Review of Systems Physical Examination
A complete review of systems with
special attention to the areas listed
below:
• General: unexplained weight loss or
gain, night sweats, fever, changes in
body habitus
• Skin: skin discoloration, rash, ulcers,
or lesions
• Lymph nodes: localized or
generalized enlargement of lymph
nodes
• Eyes: vision change or loss
• Mouth: gum disease, ulcers, oral
lesions or pain
• Cardiopulmonary: chest pain,
palpitations, wheezing, dyspnea,
orthopnea
• Gastrointestinal: odynophagia,
dysphagia, diarrhea, nausea, pain
• Endocrinolog y: symptoms of
hyperglycemia, thyroid disease,
hypogonadism
• Neurologic and psychiatric:
persistent and severe headaches,
memory loss, loss of concentration,
depression, apathy, anxiety, mania,
mood swings, lower extremity
paresthesias, pain, or numbness,
paralysis or weakness, cognitive
difficulties, dizziness, seizures, sleep
disorders
• Genitourinary: dysuria, urethral
or vaginal discharge or lesions,
hematuria
• Orthopedic: hip pain, joint pain,
fractures, diagnosis of or risk factors
for osteopenia/osteoporosis
• Anorectal: anal discharge, rectal
bleeding, rectal itching, pain or
fullness in anal area
• Developmental milestones: for
infants and young children assess for
motor or speech delays
A complete physical examination should
be performed, with special attention to the
following areas:
• Vital signs: including height and weight
• General: including body habitus, evidence
of obesity, wasting, lipodystrophy,
assessment of frailty, and ambulatory ability
• Skin: seborrheic dermatitis, ecchymoses,
purpura, petechiae, Kaposi sarcoma, herpes
simplex or zoster, psoriasis, molluscum
contagiosum, onychomycosis, folliculitis,
condylomata, cutaneous fungal infections,
acanthosis
• Lymph nodes: generalized or localized
lymphadenopathy
• Eye: retinal exudates or cotton wool spots,
hemorrhages, pallor, icterus
• Oropharynx: oral hairy leukoplakia,
candidiasis (thrush, palatal erythema,
angular cheilosis), aphthous ulcers,
gingivitis, periodontal disease, Kaposi
sarcoma, tonsillar or parotid gland
enlargement
• Cardiovascular: heart exam, peripheral
pulses, presence/absence of edema or bruits
• Chest: lung examination
• Breast: nodules, nipple discharge
• Abdomen: hepatomegaly, splenomegaly,
masses, tenderness
• Genitourinary: ulcers, warts, chancres,
rashes; g ynecologic exam including
bimanual exam, discharge; testicular exam;
evaluation for hernia.
• Anorectal: ulcers, warts, fissures, internal
or external hemorrhoids, masses, Kaposi
sarcoma; prostate exam when appropriate
• Neuropsychiatric: depression, mania,
anxiety, signs of personality disorder,
difficulties in concentration, attention,
and memory, signs of dementia, speech
problems, gait abnormalities, focal deficits
(motor or sensory), lower extremity
vibratory sensation, deep tendon reflexes
