PATIENT ASSESSMENT
Gen: Wn/wd ______ CAOx3, NAD, (+) ambulation, (+) independence, (-) evidence of abuse
Head: NC/AT, (-) Facial asymmetry (to smile, eyelash burying, cheek puffing, eyebrow raising), (-) nasolabial
flattening, (-) microcephaly/macrocephaly, temporal artery tenderness, scalp swelling/lesions/tenderness,
acute abnormalities to external appearance of face, (-) facial asymmetry
Eyes: PERRLA (3 mm). EOMI. Visual fields intact by confrontation. (-) ptosis, scleral icterus, xanthelasma,
exophthalmos/enophthalmos, conjunctival erythema/hemorrhage, drainage, nystagmus, foreign body, eyelid
swelling/erythema/hordeolum, lid lag. Fundi – (+) red reflex; disc flat with sharp margins; vessels present, (-)
crossing defects, retinal hemorrhages.
Ear: Hearing intact to whisper, finger rub. (-) erythema, edema, or tenderness to pinna, tragus, ear canal; (-)
ear canal swelling, exudates, foreign body, cerumen; TM pinkish grey, clear, (-) discharge, erythema
perforation, bulging, effusion. Hearing intact to whispered voice.
Nose: Nasal mucosa pink and moist. Nares patent. (-) septal deviation, lesions, swelling, asymmetry, bruising,
swelling, discharge, flaring, foreign body
Mouth: Oral mucosa pink/moist with good dentition; normal-appearing tongue. Midline tongue, pharynx,
uvula. (-) tongue lesions/asymmetry; (-) missing, loose, decayed, or abnormally positioned teeth, intraoral
lesions, tonsillar edema/exudate, buccal nodules/lesions.
Throat: Pharynx normal in appearance, (-) tonsillar swelling, exudates, erythema
Neck: Supple, FROM, (-) LAD, masses, thyromegaly/focal lump, inspiratory stridor, tracheal deviation, carotid
bruit; carotid pulses 2+ b/L
Respiratory: Symmetric Chest expansion, eupnea. Lung fields CTA , (-) r/r/w; (-) hyperresonance/dullness to
percussion, accessory muscle use
CV: Heart RRR, (-) m/r/g; PMI dime-sized, non-displaced at 5th intercostal space at midclavicular line, (-) S1/S2
loudness/softness, S3/S4 extrasystolic sounds
Abd: Soft, symmetric, NT/ND to palpation/percussion, BS (+) x4, (-) visible/palpable masses, visible
lesions/scars, hepatosplenomegaly, abdominal aortic pulse bruit/deviation,
Genital: Normal-appearing external genitalia, (-) lesions, swelling, masses, tenderness. Pink/moist vagina, (-)
lesions, discharge. NT cervix, (-) lesions/erosions. Anteflexed uterus, NT, normal in size. Ovaries NT, (-)
palpable masses, enlargement.
Rectal: Rectal sphincter tone normal, (-) external masses/lesions. Normal-appearing stool, (-) gross blood. (-)
guaiac
Neuro: GCS 4/5/6. Patient is AAOx3, (-) confusion, disorientation, somnolence, lethargy; CN II-XII grossly
intact; Sensorium intact to soft touch and vibration. Motor: Normal tone, (-) rigidity, cogwheeling, flaccidity,
Strength +5/5 biceps, triceps, wrist flexors/extensors, finger grip, finger abductors, hip flexors, quadriceps,
plantar flexors/extensors; (-) absence of pronator drift; (-) tremor, chorea, hemiallismus, athetosis, dystonia,
asterixis, myoclonus, fasciculations, tics, seizures; Biceps, triceps, brachioradialis, patellar, Achilles Plantar
Reflexes (+2/4); Babinski response downgoing ; (-) Pronator drift; Cerebellar: Normal finger-to-nose test,
heel-to-shin, fast finger movements, rapid alternating movements; Gait: Regular walking. Gait normal, (-)
hemiparesis, ataxia, shuffling, steppage, spasticity, antalgia.
Spine: (-) Neck/back deformity, external skin changes, signs of trauma; Curvature of cervical, thoracic, lumbar
WNL. Equal height bony features of shoulders. Upright posture. Gait – smooth, steady, WNL, (-) tenderness
to spinous processes, (-) paraspinal muscle tenderness/spasm. (-) Straight leg raise test B/L, (-) abnormal
sensation in upper or lower extremities, (-) clonus, unequal grip strength, unequal dorsi/plantar flexion.
Extremities: Atraumatic with FROM upper/lower extremities, (-) tenderness, deformity, swelling,
erythema. Palpable pulses. (+5/5) strength b/l, (-) abnormal tendon function. Capillary refill <3 seconds all
extremities.
Psychiatric: Appearance well-groomed, appropriately dressed for climate; cooperative, good eye contact,
good attitude (-) psychomotor agitation/retardation, (-) bizarre mannerisms/gestures/facial
expressions. Language – Speaks native language with fluency, (-) muting, dysphonia, dysarthria,
dysphasia. Euthymic mood, (-) dysphoria, euphoria, hostility; Normal and appropriate affect, (-) constriction,
flattening, expansiveness, lability; Speech – Normal clarity, rate, volume, intonations (-) pressure, accent,
stuttering, lisp, fast/slow speech, increased/decreased latency, (-) Circumstantial, tangential, linear, flight of
ideas, “word salad”; (-) auditory/visual hallucinations, (-) delusions, (-) suicidal/homicidal ideation, (-)
derealization/depersonalization. Patient AAOx3 to person, place, time, situation. Good concentration,
memory, general fund of knowledge, abstract thining. Good insight, judgment, impulse control.