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Wash hands Check name date of birth -wrist band Head & Face Inspection: Orientation Where are you?, date, who is the president? Skin- is clear clean and dry without any lesions, wounds Head no mases or indentation Hair no infestation Symmetry all facial features, eyes, ears are symmetric, no abnormal drooping or twitching of the face, eyes and ears at the same level CN VII frown, smile, wrinkle forehead, puff cheeks Palpation Frontal and maxillary sinuses Any pain? Eyes and surrounding external structures Any pain? No swelling in the eye lids Facial lymph nodes Temporal arteries 2+ regular TMJ movement and strength (CN:V) Open mouth no grading or clicking sensation
External ears any pain? Light touch over forehead cheeks & chin w. cotton wisp Assessment of the eye Conjunctiva is pink, sclera white and shiny, without redness, or jaundice, eyes are equal, no strabismus or anisocoria Visual acuity CN: II Snellen chart Confrontation/visual fields cover the opposite eye Extraocular muscle X pattern ask if he sees double vision PERRLA (lights off) pupils are equal reactive to light and accommodation Red reflex (lights off) Fundoscopic exam (lights off) Assessment of the nose Inspect and palpate external nasal structures CN:I smell Inspect nares turbinates and nasal septum w. light Asses NO discharges, crusting, flaring, polyps w light
Lymph nodes warmth, size, tenderness, consistency Thyroid w. swallow Neck Auscultation Carotid arteries w. bell Move behind the pt Inspect palpate head hair scalp no mases, lesions, wounds Chest anterior: Skin warm clean & dry Shape Anterior / posterior diameter 1: 2 ratio. The chest is symmetric bilaterally and the chest movements are symmetric with no retraction & without use of the accessory muscles The respiration Rate, depths and regularity are within normal limits. Palpation anterior: for any subcutaneous air trapping Chest expansion Normal Ribs Tactile fremitus – 99 my side of the hand vibrations are symmetrical from side to side Percussion anterior: Quality and symmetry the sound is resonant & symmetric Auscultation of anterior: Pull out stethoscope Symmetrical comparison of anterior chest walls;
Characteristics of breath sounds No abnormal sounds, no crackles or wheezing Egophony the pt say E loud & I put the stethoscope on the back- I can hear E Whispered pectoriloquy the pt whisper 99 as I put the stethoscope on the back- I cannot hear anything which is a normal finding Chest Inspection of posterior/lateral aspect: Symmetric movement Absence of retraction, do not use the accessory muscles Rate, depth, regularity, are within normal limits Palpation of posterior/lateral aspect: Chest expansion, Ribs Tactile fremitus – 99 my side of the hand vibrations are symmetrical from side to side Percussion of posterior/lateral aspect: Quality and symmetry sounds are resonant & symmetric Diaphragmatic excursion (bilaterally) Take a deep in & hold it Percuss from the top down Mark the area tell the pt to exhale, take a deep breath and exhale & hold. Start from down to top percuss from dull to resonance and mark the area of diaphragmatic excursion.
Auscultation of: use both diaphragm and bell Pt Seated First Rate and rhythm Within normal limits Characteristics of S1 and S2 – Normal location, intensity, timing, splitting No murmurs, clicks, S3 or S4 Pulmonic area Aortic area Erb’s point Tricuspid area Mitral area Have pt move to lateral recumbent position Repeat all above areas of auscultation Have pt move to supine position Repeat all above areas of auscultation Inspect for Jugular vein Distention Abdomen Pt to move to supine position Inspection of: Shape, contour, NO scars, contour is rounded and the abdomen is symmetrical ; Umbilicus is inverted with no drainage ulceration or piercing; Surface motion, hernia, aortic pulsations Eyes level with abdomen Ask pt to lift head – hernia present Auscultation of: Bowel sounds – presence in all 4 quadrants & they were normal NO Friction rub over liver or spleen NO Bruits: Auscultate for renal, iliac, femoral, & abdominal aorta ( 2 inch above the umbilicus) renal (the same level w. Abdominal aorta one inch left &right) iliac (one inch down from the umbilicus and one inch to the side)
Percussion of: Tone in each quadrant Gastric air bubble Left side start under breast Liver span (upper & lower borders) Spleen Palpation of abdomen is soft non tender no mases Aortic & femoral pulsation Light palpation for organ size, position, tenderness Deep for organ size, position and rebound tenderness Liver & spleen Palpate for bladder distention or tenderness Integumentary/ Peripheral Vascular/Neuro/MS Lower Extremities Inspection – Skin warm to touch, clean, no lesions or discoloration hair distributed symmetrical in both sides, no varicose veins Femoral pulses Normal strength 2+, regular, and rate within the normal limits Popliteal pulses & lymph nodes Normal strength 2+, regular, and rate within the normal limits, no enlarged lymph nodes Posterior tibial pulses Normal strength 2+, regular, and rate within the normal limits Dorsalis Pedis pulses Normal strength 2+, regular, and rate within the normal limits
Capillary Refill of fingers 2 seconds, finger nails are pink which is normal with no Clubbing Palpation Joints no nodules, no tenderness, or heat NO Epitrochlear lymph nodes Muscle strength Rapid alternation movement finger to thumb Finger to nose & finger to provider’s finger Stereognosis Recognizing the object in his hand Percussion of Biceps Triceps Brachioradialis Ask pt to stand Inspection - Posture , gait Scoliosis test open eyes lean forward Romberg’s test – pt stand with eye close
CVA Tenderness as part of the abdominal exam between the ribs left palm on the back of the patient hit with the fist of right hand
