Introduction, privacy, explain, assemble supplies, safety, verify allergies and ID, infection control, washes hands General: relative to age, state of
health, skin color, physical deformities, hygiene, dress, body structure/posture, personal hygiene/grooming, cooperative/combative, affect,
cooperation, appropriateness of speech, A&O, posture, gait, use of assistive devices, ROM, vitals, height, weight; breathing effort Neuro/HEENT:
LOC, A&O, inspect head for scars, lumps, rashes, hair loss, facial symmetry, movements, lesions; CN V, VIII, IX, X, XI, XII, inspect eyes for
symmetry, deformities, movement, visual acuity, relation to ears CN III, IV, VI; PERRLA CN III; inspect visible nasal structures, neck and ear canal,
note swelling, redness, drainage, scars, deformities; inspect oral mucosa, oropharynx, mouth, teeth; assess recent memory and cognitive
function; ear palpation; whisper test, temporal pulses; SHN: color and uniformity of color, pallor, moisture, edema, rashes, varicosities, scars,
piercings, tattoos, lesions; palpate for skin turgor and hydration status; inspect nails for contour, color, and signs of clubbing; inspect hair for
condition and luster; note any wounds, lesions or other alterations in skin Resp: RR, rhythm, depth, effort; inspect chest for retractions, use of
accessory muscles, asymmetry, deformity, or increased AP diameter; palpate anterior chest (clavicles, sternal notch, ribs, intercostal spaces);
palpate position and tenderness of spine, expansion and symmetry of chest; palpate posterior chest (6 sites x 2); palpate posterior tactile
fremitus; percuss posterior chest; auscultate anterior 4X2 and posterior 6X2 Cardio: Inspect precordium for heaves and lifts; inspect neck
symmetry, carotid pulses, and JVD; palpate 7 peripheral pulse points and verbalize femoral pulse points; compare peripheral pules for equality
and strength; palpate for edema; auscultate apical pulse at PMI for 1 min; determine regularity of rate and rhythm; auscultate APETM using
diaphragm and then APETM using the bell; identify correct location of heart sounds and note abnormalities; auscultate carotids for bruits; cap
refill Abd: inspect for symmetry, contour, color, scars, umbilical hernia, odor, orientation, piercings; auscultate 4 quadrants; percuss 4
quadrants; palpate 4 quadrants for firm, tender, and mass (light and deep) Musc: Inspect arms and legs for deformity, asymmetry, and tone;
assess muscle strength of upper and lower extremities; assess ROM of at least 8 joints (no neck); Romberg test, deep tendon reflex, cap refill 1
question per system I. occlude and assess each nare (nose) II. Snellen chart (eye) III. darken room, light in eyes, pupil response, pupil size
(eye) IV. follow finger to tip of nose (eye) V. clench teeth together, jaw strength (face) VI. look toward ear(eye), 6 fields of gaze, nystagmus or
twitch(eye) VII. puff cheeks, raise eyebrows, smile, frown, kissy face, symmetry (face) VIII. hearing, whisper test (ear) IX. swallowing, say AHHH
and watch uvula (tongue) X. swallowing, say AHHH and watch uvula (tongue) XI. raise shoulders, turn head, use resistance for both (spinal)
XII. stick out tongue, move side to side, swallow (tongue) Scalp, hair head, face, expression symmetry, sinuses, visual fields, eye muscles/nerves,
external eye structures, sclera, cornea, conjunctivae, pupil size and reaction, ear palpation, ear tenderness, inspect ears, whisper test, temporal
pulses, inside nose, nose symmetry, teeth, buccal mucosa, gums, tongue, palate, uvula, tonsils present or not, say ahhhh with tongue out, all
cranial nerve checks, neck symmetry and pulsations, lymph nodes, ROM, swallowing •RR inspection, palpation, percussion, tactile fremitus,
spinous process, breath sounds 6-8 spots, knee reflexes, spine and scapula •chest and precordium, palpation, percussion, auscultate breath
sounds, heart sounds, apical pulse for 1 min, precordium thrills, use bell for murmurs, APETMinspect, auscultate bowel sounds, vascular
sounds over aorta and renal arteries, percuss and palpate quadrants, check liver and spleen, use light palpation, aorta pulsationsymmetry,
skin, palpate pulses bilaterally- popliteal, posterior tibial, dorsalis pedis, ROM, strength, cap refill symmetry, skin, radial pulses, ROM, strength,
cap refill
General Survey: No gross deformities, erect posture, and easy
gait. Uniformly symmetrical tone and bulk bilaterally. All joints
symmetrical and without redness, tenderness, or swelling. All
joints full range of motion without discomfort. Uniform muscle
strength 5/5 in all joints bilaterally. A & O X 4. Immediate, recent
and remote memory intact. Ability to calculate and use abstract
thinking intact. Pleasant and cooperative. CN I-XII intact. 20/20
vision. No ptosis. Symmetrical. PERRLA. Conjunctivae clear. sclera
white. No tenderness, redness, lesions. Responds appropriately.
Passed whisper test. Gait easy and smooth without lateral lean.
Negative Romberg. Able to perform finger to nose test, rapid
alternating movements, and heel to shin without difficulty. DTRs
2+ X 5 bilaterally. Negative Babinski. GCS 15. Nose symmetric.
Nares present. Mucosa pink, no lesions or mucous. No septal
deviation or perforation. Sinuses not tender to palpation. Can
clench teeth. Mucosa and gingivae pink, no lesions. Teeth
present. Cavity fillings present. Tongue smooth, pink no lesions,
protrudes midline with no tremor. Uvula rises midline on
phonation. Gag reflex present. Tonsils present. Neck full ROM
with no pain. Symmetric, no palpable lymph nodes. Trachea
midline. Thyroid not palpable. Chest: Skin warm and dry with pink
undertones. No lesions or masses observed. No visible pulsations,
heaves, or lifts. Quiet precordium with soft tapping sensation
over PMI. Carotids with regular rate and rhythm. S1 and S2
auscultated in sitting, supine, and LL recumbent positions. No
extra heart sounds or murmurs auscultated. Apical pulse= 68. No
bruits of carotid arteries auscultated. Apical=carotid in rate,
rhythm, and amplitude. Peripheral: Pulse 68. BP 120/80. Skin
warm and dry with pink undertones generalized over upper and
lower extremities. No JVD observed at 45 degree angle. No visible
pulsations in the neck bilaterally. Nails rounded with pink beds.
No abdominal pulsations visible. No visible varicosities with hair
present on proximal phalange of toe bilaterally. Capillary refill < 3
seconds. Temporal, brachial, radial, femoral, popliteal, dorsalis
pedis, and posterior tibial all with regular rate and rhythm, 2+
and equal bilaterally. No palpable lymph nodes. Peripheral veins
without tenderness upon palpation. No edema palpated.
Respiratory rate: 18. Skin pink with no visible lesions noted.
Mucous membranes pink and moist. Good hygiene noted.
Thorax symmetrical with AP < transverse (or lateral) diameter.
No retractions noted. Respirations regular, unlabored at 16
breaths per minute. Skin warm and dry over entire thorax.
Denies tenderness on general palpation of the thorax. Thoracic
expansion equal bilaterally posteriorly. Tactile fremitus equal
bilaterally with decreasing intensity inferiorly. Skin warm and dry
over entire thorax. Denies tenderness on general palpation of the
thorax. Thoracic expansion equal bilaterally posteriorly.
Resonance percussed equal bilaterally both A & P. Breath sounds
clear and equal throughout lung fields. No adventitious sounds
heard. Abdominal Assessment done. Abdomen symmetrical,
round, pink, smooth, and free of lesions, scars, or piercings. No
visible bulges, masses, pulsations, or peristaltic waves. Bowel
sounds active in all 4 quadrants . Aortic, renal, iliac, and femoral
bruits absent. Tympany percussed over all 4 quadrants, with
dullness over liver and spleen. Abdomen soft, smooth, and
nontender, without masses or hepatosplenomegaly. No palpable
aortic pulsations present. No rebound tenderness elicited. Joints:
hip, knee, ankle, wrist, shoulders, elbows, fingers, toes. Pulses:
temporal, radial, popliteal, posterior tibial, dorsalis pedis, carotid,
apical