General Survey:
The patient appears stated age, alert & oriented times 3 to time and place
INTEGUMENTARY
o Can I see your hands; the hands are warm, there is no tenting, capillary refill is
less than 3 seconds, nail bed is less than a 160 degrees or no clubbing, no lesions,
no ulcers, and skin is consistent with the background ethnicity of the patient.
HEAD/NECK – check the head
o Now, I’m going look at your face; everything looks bilaterally symmetric. Can
you raise your eye brows and can you close your eyes tight, smile, and puff your
cheeks cranial nerve 7 is intact bilaterally. I’m going to ask you to close your eyes
and I’m going touch something on your face then tell me when you feel it. Now,
you can open your eyes and can you clench your jaw really tight; any pain or
tenderness? Now, try to resist your jaw while I’m pressing it down. Cranial nerve
5 motor and sensory are intact.
o The neck is symmetric and trachea is midline.
Now, I’m assessing the carotid pulse for strength and it is 2+ bilaterally; (auscultate for bruits)
can you take a deep breath exhales and holds; no bruits are present
Now, I’m going to assess the RANGE OF MOTION of head and neck; can you bent your head
forward, back, and side to side, now shrug your shoulders. Ok good, and now for the resistance
(chin and shoulders) cranial nerve 11 is intact w full active 5 of 5 with and without resistance.
EARS/NOSE/THROAT
I’m going to inspect your ears; the ears are bilaterally symmetric. I’m checking for the patency
of the auditory meatus; and its patent bilaterally. Can you tell you if you feel any tenderness or
pain while I’m palpating the auricle, tragus, and mastoid process? Now, I’m going to press on
your right tragus and whisper something on your left ear, then tell me what you hear? Cranial
nerve 8 is intact bilaterally.
NOSE
Now, I’m moving to the nose; the nose is midline and proportional to the patient facial features,
no lesions, no deviation and the nasal mucosa is intact; nares are bilaterally symmetric; can you
occlude one nare and close your eyes? I’m going to put something under your nose then tell me
what you smell? Ok good and can you close your other nare and keep your eyes close. Tell me
what you smell? Ok good, nares are patent; Cranial nerve 1 is intact.
MOUTH
Now, I’m going to assess your mouth. Lips are symmetric, and no lesions, no cracks. can you
open your mouth please? Buccal mucosa pink and moist and tongue is pink and moist as well as
the hard and soft palate, teeth and gums are in good condition.
Can you say ahh? The uvula and soft palate rise in midline; cranial nerve 9 is intact.
Can you stick out your tongue? No tremors, no deviation, and tongue is midline; cranial nerve 12
is intact.
For cranial never 10; Is assessing for gag reflex; I would depress the tongue and touch the
posterior pharynx (back of the throat)
EYES/VISION
Now, I’m moving on to your eyes, the external features such as; eyebrows, eyelids, the canthus,
and palpebral fissure are all bilaterally symmetric. Can you look at me? The sclera is white and
conjunctiva is pink. Now, can you focus on my pen light and just follow it (testing the 6 cardinal
position of gaze) cranial nerve 3,4, and 6 are intact.
Can you cover one eye? (for confrontation test) I’m going to test your peripheral vision, just tell
me when you see my fingers; cranial nerve 2 is intact.
Look straight at me and I’m going to shine light on your eyes; can you look straight at the wall
and as I bring the pen towards you look at it; ok PERRLA is intact; Pupil Equal Round, React to
Light, and they Accommodate.
RESPIRATORY
(POSTERIOR/LATERAL/ANTERIOR)
Now, I’m going to inspect the posterior chest there is no lesion, no ulcers; (palpating) the spinous
processes- do you feel any pain or any tenderness? no deviations noted; posterior muscle is
symmetric.
Now, I’m going to listen to breath sounds from the apices C7 to lung bases T10; and at the axilla
7 to 8 ribs… 9levels; Posterior chest sounds are clear.
RESPIRATORY/ANTERIOR
Now, I’m moving to your anterior chest, no lesions, no ulcers, and skin is intact. I’m going to
listen for your breath sounds from your apices in sub-clavicular area down to 6 ribs… 4 levels;
anterior chest sound is clear.
CARDIOVASCULAR
Now, I’m moving to your anterior chest, no lesions, no ulcers, and skin is intact. I’m going to
listen for your breath sounds from your apices in sub-clavicular area down to 4 ribs; anterior
chest sound is clear.
And now, I’m going to listen for heart sounds; I’m gonna start at aortic at the Right 2nd ICS w/c
is at the right sternum, then pulmonic at the left 2nd ICS, for tricuspid is at the left 4th ICS, and
for mitral is at the left 5th ICS mid clavicular line.
And now, I’m going to listen for murmurs with my bell at the same location; aortic right 2nd ICS
w/c is at the sternum, then pulmonic left 2nd ICS, then tricuspid left 4 ICS, then mitral left 5 ICS
mid clavicular line; at the mitral I will also palpate for the apical impulse and take the apical rate.
ABDOMINAL
Now, I’m going to inspect the stomach; stomach is flat, no pulsation, skin is intact, and the
umbilicus is midline.
Now, I’m going to listen for bowel sounds starting from RLQ to the RUQ, then going to LUQ,
then to LLQ; bowel sounds are normal (if no active bowel sounds listen for 5mins per quadrant)
Now, I’m going to listen for bruit w/ my bell at the aorta, renal arteries, and iliac arteries; no
bruits are heard.
Now, I’m going to palpate w/ 1cm or ½ inch; do you feel any tenderness, pain or discomfort?
PERIPHERAL VASCULAR
(LOWER AND UPPER EXTREMITIES)
Now, I’m moving to the lower extremities; the legs are bilaterally symmetric, hair is evenly
distributed; legs are warm, no edema, no lesions, or ulcers. No, signs of pallor, erythema, or
cyanosis. And capillary refill is less than 3 seconds
Now, I’m going to check the pulses of the popliteal, posterior tibial, and dorsalis pedis;
peripheral pulses are present bilaterally 2+
MUSCULOSKELETAL
Now, I’m going to assess the range of motion of the lower extremities; Now, I’m going to assess
the muscle strength against resistance; full active range of motion 5 out of 5 with and without
resistance.
LYMPHATIC
Checking the neck for lumps and pulsations; no lymph nodes palpated
RANGE OF MOTION ON THE UPPER EXTREMITIES
Now, I’m moving to range of motion of the upper extremities; full active range of motion 5 of 5
with and without resistance.
RAM
Can you follow my hands we’re going to do the rapid alternating movements; ok good;
cerebellar of the upper extremities is intact.
Now, can I check your brachial pulses and radials pulses; your brachial and radial pulse are
present 2+ bilaterally
ROMBERG TEST
Now, I’m going to assess for Romberg sign (for 20 sec) I’m gonna have you close your eyes
with your hands down and straight on the side. Ok negative Romberg sign
STEREOGNOSIS
Now, can you close your eyes and I’m going to put something on your hand and tell me what it
is? (both hands) ok good; stereognosis is intact bilaterally.
NEUROLOGICAL
Now, can you walk 10 feet, turn, then walk back heel to toe, then walk away on your tippy toes
and return on heels; Gait is smooth and balanced.