General Survey: Age - race - sex - Ht. - Wt. - appearance, hygiene & grooming & build (appears stated age)

Mental Status: LOC - Orientation X 4: to person, place, time, situation - speech - understanding - memory - mood - general knowledge.

SKIN, HAIR, NAILS: History (HX), Inspect & palpate color, temperature, odor, moisture, texture, turgor, lesions, edema, vascularity, hair & scalp, nail color - smoothness, thickness, & cap. refill.

MUSCULOSKELETAL: HX, Observe gait/posture/stability. Inspect & palpate. Note loss of height, abnormal curvatures of spine. Note temperature, color, swelling, symmetry. Compare Rt. & Lt. (atrophy, contractures, fasciculations, tremors, spasms, tenderness, crepitation, deformities, tilt, ankylosing joints).

Assess joint ROM & strength: Temporomandibular, cervical spine, shoulder, elbow, wrists, fingers, hips, knees, ankles, toes, lumbar spine.

FUNCTIONAL ASSESSMENT: ADL's (bathing, dressing, toileting, & eating),

& IADL's (housekeeping, shopping, cooking; nutritional status; social relationships, & resources; self-concept & coping; home environment.

HEAD, NECK & REGIONAL LYMPHATICS: HX, Inspect & palpate. Check skull, face (expression, eyebrows, eyes, lips) neck, lymph nodes, trachea. Note shape, size, symmetry, edema, abnormalities, involuntary movements (tics or tremors), skin condition & color.

EENT: Inspect & palpate for shape, size, symmetry, visual fields, extraocular muscle function (6 cardinal fields [CN 2,3,4,6]). EYES: External structures (eyelids, lashes, eyeballs, lacrimal ducts, conjunctiva, sclera). Pupillary reaction (PERRLA [CN 3 & 4]). EARS: External ear structures, hearing voice test. NOSE: Check externally for deviated nasal septum. Palpate sinuses. MOUTH: Inspect lips, mouth, teeth & gums, tongue, buccal mucosa, palate, throat [CN 5].

BREASTS: Ask about breast self-exam. Teach breast self-exam prn. PALPATE axillary lymph nodes.

LUNGS & THORAX: Anterior & Posterior chest: Inspect contour (abnormal: funnel, pigeon, or barrel chest, scoliosis, kyphosis) & expansion at T9-T10. Note skin condition, facial expression, quality & pattern of respirations; Assess tactile fremitis; Palpate for tenderness, temp, moisture, lumps, masses, lesions, Percuss chest (resonance), Auscultate (bronchial or tracheal, brochovesicular, vesicular). Note Adventitious sounds (crackles or rales, wheezes or rhonchi); note landmarks & lung lobe descriptions (LUL, RUL, LLL, RLL).

ABDOMEN: INSPECT color, contour, symmetry, umbilicus, skin. Note smoothness, scars, striae, etc, pulsations & hair distribution. Auscultate bowel sounds and vascular sounds in all 4 quadrants. Note character & frequency (usually irregualr high-pitched gurgling = normoactive). Abnormal = hyperactive, hypoactive, absent (listen 5 minutes to confirm absence). Vascular sounds (no bruits, no hums) of aorta. Percuss (tympany) in 4 quadrants. Palpate 1cm. in 4 quadrants; liver - perform "ascites wave".

NUTRITIONAL: HX of food allergies, change in appetite, usual & present weight; prescribed or special diet. Obtain HX of dietary habits. Note changes in weight, appetite, taste, bowel habits; chewing abilities & swallowing. Identify eating patterns, favorite foods; caffeine, tobacco, alcohol or drug use; exercise or activity; nutritional supplements; recent nausea, vomiting, diarrhea. Lab: Hgb, Hct. Cholesterol, Triglycerides.

GU : PRN: Obtain HX of frequency, urgency & nocturia; hesitancy, straining; Kidney disease, stones, flank pain, UTI's; Observe urine color (yellow, amber, dark, turbid or cloudy, bloody), odor (characteristic, ammonia-like, sweet, fetid); hernias; Inspect prn: Males - penis & scrotum, testes (freely movable, slightly tender); Females - labia, vaginal orifice, perineum & urethra; In both sexes. Note if any discharges present prn: for color, odor, consistency; pubic hair pattern lesions, redness, swelling; pubic lice or nits, condylomata or warts.

RECTAL: HX of bowel habits & changes, rectal bleeding. itching, pain, burning, hemorrhoids. Note dietary & laxative habits, daily fluid intake; note BM's prn: amount, color, consistency, & any unusual odor. When bathing patient, inspect perianal area for hemorroids, lesions, redness, swelling, discharge.

HEART & NECK VESSELS: Palpate & Auscultate carotid arteries (amplitude & equality, bruits). Inspect jugular pulses. Palpate apical pulse @ 4th-5th ICS at PMI. Auscultate heart sounds @ 2nd Rt. ICS = A2, 2nd Lt. ICS = P2, Lt. lower sternal border = T1, 5th ICS @ Lt. midclav. line = M1; Note rate & rhythm ; Identify S1 ,S2, splits, murmurs; Listen for S3, S4 gallups (S1 @ M1, S2 @ A2 or P2)

Explanation of abbreviations

• ICS refers to Intercostal space
• S1 is the first heart sound.
• S2 is the second heart sound.
• A2 refers to the aortic area where the second heart sound is heard.
• P2 refers to the pulmonic area where the second heart sound is also heard.
• T1 refers to the tricspid area where the first heart sound is heard.
• M1 refers to the mitral area where the first heart sound is also heard.

& LYMPHATICS: Examine lymph nodes, cap refill; arms, hands & legs color, hair distribution, venous pattern, temp. Palpate all pulses & note rate, rhythm, & force. Check epitrochlear node in AC fossa; Homan's sign; Check for edema for 5 seconds.

NEUROLOGICAL SYSTEM: HX, assess LOC, Test cranial nerves, muscular coordination (hand grips), superficial pain, light touch, & dermatome levels (down the sides of the legs beginning at the waste); - Babinski sign; Glascow coma score.