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Wash Hands Inspect general appearance Count Radial Pulse. Compare Intro and Vital Signs amplitude Respiratory rate. Is breathing easy or labored? Blood pressure Examine Hair and Scalp for consistency, symmetry, bumps Examine face for involuntary movements, edema, and masses Test CN V with touch and mastication muscles Test CN VII with facial expressions Examine the skin for lesions, color, and pigmentation Measure visual acuity with pocket card. Test each eye separately Inspect lids, conjunctivae, sclera, and pupils. Test pupilary response and accomodation Text extraocular movements CN III, IV, VI Perform retinoscopy: cornea, lens, optic disc, vessels, and retina Test peripheral fields by confronation

Review of Systems

Oral or Written Report

NORMAL Vitals Pulse 60-100 and regular Respiratory rate (RR) 8-16/min BP: 120/80 Temp. 37 degrees Body Mass Index (BMI) 24 Pt was relaxed and responsive, vital signs were stable

Current or change in weight Any recent change in appetite Energy level, Weakness, Fatigue. Fever


Any unusual headaches Head injury New bumps Changes in the thickness of your hair Loss of Hair

NORMAL Head Facial expressions were symmetric w/o fasciculation, edema, or masses


NORMAL Eye Sclera white (anicteric), conjunctivae clear Pupils equally round (note how many mm in diameter) and reactive to light and accommodation (PERRLA) directly and Recent change in vision consensually Blurring of vision Full peripheral vision Double vision Extraocular movements intact (EOMI) w/o Red or painful eyes nystagmus History of glaucoma or cataracts Vision with Snellen card 20/30 in each eye. Most recent eye examination On fundoscopic exam: and results. Sharp disc margins Clear arteries & veins w/o AV nicking or arteriole narrowing Clear fundus no exudates or hemorrhage NORMAL Ears no pain on manipulation of helix or tragus bilaterally. Both external canals without lesions or discharge. Both tympanic membranes pearly white in color with normal cone of light and handle of malleus well visualized. NORMAL Nose external nose normal without lesions or asymmetry. Nasal mucosa pink bilaterally without lesions Septum midline. Inferior turbinates pink without lesions or exudates bilaterally. NORMAL Mouth and Throat Mucosa pink. No oral lesions, no carries, no teeth missing. Tongue normal in color, protrudes symmetrically w/o fasciculation Tonsils absent, posterior pharynx without erythema or exudates. Symmetrical palatal elevation, uvula in midline

Examine external and internal ears with otoscope Compare L and R ears with soft sounds: fingers, wispers Test CN VIII with Weber and Renee Inspect nose, septum, Ears, Nose, and Mouthturbinates with otoscope Observe mouth, lips, gums, teeth, floor of the mouth Test CN XII protude tongue symmetrically Test CN X say "ah" symmetrical uvula lift Test CN IX via gag reflex

EARS Recent change in hearing Pain in or drainage from ears Ringing in the ears Dizziness with or without changes in head position. NOSE Increase in frequency of colds or nasal drainage Nosebleeds History of sinus infections. MOUTH AND THROAT Sores of tongue or mouth Dental problems and dental care history Bleeding of gums Hoarseness or voice change


Palpate thyroid Palpate lymph nodes: Submental, Submandibular, Preauricular, Post Auricular, Tonsillar, Occipital, Anterior Cervical, Supraclavicular Test range of motion of neck Test CN XI SCM and Trapezius

Stiffness or injury New lumps or swelling

NORMAL Neck Full range of motion. No nodules or masses. Thyroid smooth, non-tender, normal in size and consistency.

Cranial Nerves


NORMAL CN CN 2-12 grossly intact eom intact w/o nystagmus tongue protrudes symmetrically Strength symmetric 5/5, bilaterally; Reflexes 2+ and symmetric bilaterally

Chest and Lungs


History of asthma Bronchitis Pneumonia Pleurisy Tuberculosis New cough or coughing blood Sputum Wheezing or shortness of breath. Palpate PMI location and History of high blood pressure heaves and thrills Heart disease Ascultate: Heart murmur Apex (mitral, S1 accent) Palpitations Lower Left Sternum (tricuspid, Chest pain or pressure S1 accent with S1 splitting) Shortness of breath on exertion Top Left Sternum (pulmonic, or while lying down S2 accent with S2 splitting on Ankle swelling inhale) History of electrocardiogram, Top Right Sternum (Aortic, S2 chest x-ray, or other diagnostic accent) tests Auscultate the apex with the Pain in legs with walking (how bell far) Palpate the symmetry of the Sensitivity or color change in carotids fingers or toes with cold Auscultate the carotids with temperatures the bell Varicose veins or history of Check capillary refill phlebitis Inspect back Observe chest symmetry with deep breath Percuss and ascultate the posterior lung fields Auscultate the anterior lung fields

NORMAL Pulmonary Unlabored breathing without the use of accessory muscles Symmetrical excursion Lung fields clear to A & P bilaterally No wheezes/rales/rhonchi

NORMAL Cardiac PMI 5th ICS @ MCL Normal S1, S2 Regular rate and rhythm No murmurs, gallops or rubs Carotids: normal upstroke and equal amplitude Ext: no edema. Capillary refill < 5 sec. Pulses: Carotid, radial, femoral, Dorsalis Pedis, Posterior tibialis (less important screen brachial and Popliteal) 2+ Bilaterally symmetric, no bruits


Inspect abdomen Auscultate the abdomen for bowel sounds, then abdominal and renal bruits Percuss liver span Palpate liver and spleen option Traubes point Lightly pound vertebral spinal angle

NORMAL Abdomen Healthy, flat, scaphoid, or protuberant abdomen Difficulty swallowing No visible skin changes (e.g. scars, Change in appetite lesions, discolorations) Nausea, vomiting Normoactive Bowel sounds (NABS) Diarrhea No bruit or rubs Abdominal pain Non distended Vomiting blood or blood in stool Nontender to percussion and to light Constipation or recent change in and deep palpation. bowel habits or appearance of Liver nontender, palpated/percussed stool 8cm at Midclavicular line (MCL) History of jaundice or liver No spleen palpable History of Gallbladder problems Pulses: Indigestion or new food Aorta 3cm, no pulsatile mass. intolerance No renal bruit No tenderness at the costal spinal angle

NORMAL Musculoskeletal No joint deformity, swelling or masses, EXTREMITIES or tenderness to palpation. Dorsalis pedis and posterior Muscle weakness, pain, ROM in Hands, Wrists, elbows and tibial pulses bilaterally. (Option tenderness, or stiffness shoulders, hips, knees, ankles. of popliteal) Pain or swelling in joints Muscle strength 5/5 bilaterally Examine for Edema in the pre- History of arthritis, gout, or back symmetric tibial area pain. Reflexes 2+ bilaterally symmetric Extremities and Skin Examine ROM in the Pulses: shoulders, elbows, and wrists SKIN Dorsalis pedis L, R 2+ Examine ROM in the knees Recent changes in texture or Posterior tibial L, R 2+ (*2+ is normal) and hips appearance of hair, skin, or nails Option: strength tests New rashes, lumps, sores NORMAL Skin, hair and nails Option: reflexes History of treatment for skin Skin: condition. Warm and dry. No rashes. Several 1cm SKs. No hair loss. No nail changes.