Cpe Physical Examination

Front 1

What are the steps for the head to toe assessment?

Back 1

1. Interpret vital signs including O2 Saturation if needed.
2. Perform Pain/Subjective data assessment.
3. Perform neurological mental status. Orientation X3
4. Perform pulmonary assessment. 4-6 anterior, 8-10 posterior, 1 lateral.
5. Perform cardiac assessment. Auscultate apical pulse noting S1, S2, rhythm, murmur.
6. Perform abdominal assessment. Inspect. Auscultate each quadrant, palpate.
7. Upper extremities: Assess radial pulses for rate, rhythm, strength, and symmetry. Temp, color, cap refill
8. Lower extremities: Assess pedal pulses, edema, temp, color, strength
9. Skin

Front 2

Focused Pain Assessment

Back 2

Observe for behavioral cues: facial expressions, movement, etc.
P: Provokes/Relieves
Q: Quality
R: Radiates
S: Severity
T: Timing/Duration
U: Understanding (Patient's)

Front 3

Focused Head & Neck

Back 3

1. Inspect face for symmetry, shape, appearance.
2. Inspect/palpate cranium for m/l/t, symmetry - UNIVERSAL PCS.
3. Inspect/palpate lymph nodes. Pre/post auricular, occipital, Submadibular, sublingual, submental, Ant/Post cervical chain, supraclavicular.
4. Inspect/palpate position of trachea
5. Inspect/palpate thyroid.

Front 4

Focused Eye

Back 4

1. Inspect for symmetry
2. Inspect external structures (conjunctiva, sclera) UNIVERSAL PCS
3. Direct/Consensual pupillary light reflex and corneal light reflex.
4. Inspect for convergence, accomodation.
5. 6 cardinal fields of gaze
6. Red reflex with opthalmoscope.