|
General Survey: Identify Age - race - sex - Ht. - Wt. - appearance, hygiene &
grooming & build (appears stated age) LOC - Orientation X 4: to person, place,
time, situation - speech - understanding - memory - mood - general knowledge.
HEAD,
FACE
□Inspect
& palpate head for shape, symmetry, lumps.
□Note
hair color, texture, distribution.
□Palpate
temporal artery.
□Palpate
& percuss frontal & maxillary sinuses.
□Check
nasal patency and with pen light. Ask about smell (CN 1).
□Palpate
masseters - clenched teeth -(CN 5, 7)
□Test
light facial sensation (CN 7).
EYES
□Inspect
eyelids and external structures.
□size,
shape and symmetry of eyebrows, eyelids, eyelashes.
□Inspect
conjunctiva, sclera
for color variations,
PERRLA.
□Pupillary
reaction to light.
□Check
6 cardinal fields (CN 3, 4, 6).
□Visual
fields & extraocular muscle function.
□Check
vision (CN 2)
EAR
□Inspect
& palpate ear (note size, shape, skin condition, tenderness)
□Inspect
for ear drainage.
□Hearing
voice test (CN 8).
JAW,
MOUTH
□Palpate
temporomandibular joint, inspect teeth, gums, tongue, palate, and uvula.
□Check
tonsil fossa
□Say
“ah” (CN 9, 10), swallow reflex intact.
□Pt.
Protrudes tongue (CN 12).
NECK
□Inspect
& palpate neck. Note trachea midline.
□Check
neck ROM.
□Palpate
thyroid lightly.
□Palpate
carotids (separately).
□Auscultate
for bruits.
□Assess
apical carotid pulse.
□Palpate
cervical lymph nodes (identify all chains).
□Shrug
shoulders (States CN 11).
□Assess
skin turgor.
Pinch up skin on upper chest area.
UPPER
EXTREMITIES
□Inspect
arms skin color, hair distribution,
□Assess
nails texture, contour & color, capillary refill.
□Assess
ROM and strength (hand grips).
□Palpate
& assess radial pulses (rate, rhythm, & amplitude).
□Assess
radial apical pulse.
□Assess
capillary refill nails.
□Assess
deep tendon reflexes (biceps, triceps).
CHEST
(Lungs)
□Inspect
post., lat. & ant. chest.
□Observe
rate and rhythm of respirations.
□Check
expansion at T9-T10.
□Assess
tactile fremitis.
□Percuss
side to side (resonance).
□Auscultate
anterior – apex to base, side to side for adventitious sounds.
□Auscultate
posterior – apex to base, side to side for adventitious sounds.
□Note
Adventitious sounds: rales also called crackes (may indicate pulmonary edema,
pneumonia), or when suctioning is needed) wheezes, or rhonchi (moaning).
□Note
spinal curvatures.
□Palpate
axillary lymph nodes. Ask about breast self-exam (females).
HEART
□Inspect
for pulsations & palpate at PMI.
□Auscultate
at Aortic, Pulmonic, Tricuspid, Mitral
(A+ To Me).
□Auscultate
apical-radial, & apical-carotid (amplitude, rhythm, rate).
□Identify
S1, S2. Listen for murmurs, clicks. Listen for S3, S4 gallups.
ABDOMEN
□Inspect
color, contour, pulsations. Note scars
□Auscultate
bowel sounds over 4 quadrants
□Auscultate
aortic sounds.
□Check
for ascites.
□Lightly
palpate 1cm. over 4 quadrants.
□Percuss
4 quadrants (tympany).
□Check
for hernias (umbilical).
□Assess
superficial reflex.
LOWER
EXTREMITIES
□Assess
skin of legs, hair distribution.
□Assess
ROM and strength.
□Assess
deep tendon reflexes (patellar, achilles).
□Palpate
& assess posterior tibial, and dorsalis pedis pulses.
□Assess
Homan’s sign.
□Check
for edema.
□Assess
babinski reflex.
□Assess
ankle ROM and strength.
□Inspect
toes & capillary refill.
□Check
skin sensation (evaluate based on dermatome levels).
PERFORMANCE SYNOPSIS
□Overall
Performance.
□Performed
exam in organized manner.
□Communicated
appropriately.
□Protected
the patient from harm and injury.
|
