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53 Cards in this Set
- Front
- Back
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At beginning and end
of the exam examiner? |
washes hands at beginning and end of exam.
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Head?
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*Normocephalic?
*sinus tenderness tics Edema Bruits |
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Eyes?
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Visual Acuity (near, far)
*PERRLA Conjunctiva (pink, clear) without discharge Sclera white Extraocular movements intact Visual field =s examiners (confrontation) Opthalmoscopic findings no lid lag Ptosis Fasciculations Nystagmus |
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Ears?
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Outer ear abnormality
TM membrane pearly gray; moderate of dry Cerumen (Otoscopic findings) No tragal tenderness Able to hear finger rub from 2 feet away |
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Nose?
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Septum midline;
*Patent *pink, moist mucosa; *boggy turbinate on the right *discharge no polyps |
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Normal findings for Skin, hair and nails?
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Pink, soft, moist, turgor with instant recoil, no lesions or tenderness.
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Normal findings for head
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Normocephalic
head erect and midline; scalp pink, freely movable without lesions or tenderness. Temporal arteries soft, nontender, no bruits |
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Normal findings for opthalmoscopic findings?
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corneal light reflex equal bilaterally, red reflex present, discs cream colored with well defined border bilaterally; no crossing changes noted; cornea, lens and vitreius clear; retina pink, no hemorrhages or exudates; macula yellow
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Snellen findings
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20/20 without glasses
top # vision bottom # distance from chart |
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Describe TM?
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TM gray, translucent, light reflex and bony landmardks present; no perforations
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Mouth
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mouth and throat
buccal mucosa pink and moist, *uvula midline with elevation of soft palate *pharynx without erythema; hoarseness no lesions Tounge midline without fasiculation good dentition gingivitis |
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Ab mouth findings?
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Several interdental papillae red and slightly swollen; tongue midline with a small 3x4 mm, shallow white ulcer on an erythematous ase, located on the under surface near the tip. Its slightly tender but not indurated. Tonsils absent. Pharynx negative/ no exudates or postnasal drip
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Neck?
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Trachea midline. thyroid barely palpable, no adenopathy
no tracheal tug, thyroid and cartilages move with swallowing, thyroid lateral borders palpalbe, no enlargement or nodules noted, FROM with appropriate strength |
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Chest, Lungs
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Symmeteric without deformities;
Good excursion resonant percussion (throughout) in all lung fields tactile fremitius symmetric; CTAB |
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Chest, Lungs with rhonchi
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Scattered rhonchi bilaterally that clear completely with cough leaving vesicular breath sounds all fields. No crackles or wheezes audible
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Chest assessment
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Shape and size of chest
AP vs Trransverse diameter symmetry of movements with respiration venous patterns tenderness over the ribs bony prominences presence of retractions use of accessory muscles diaphragmatic excursion |
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Heart
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anatomic loction of apical impulse
pulsations HR, rhythm palpation findings; thrills, heaves, or lifts auscultation findings char of S1,S2 Murmus, gallops, rubs JVD |
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S1/S2 document
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location
intensity pitch timing splitting systole diastole |
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How do you document mumurs?
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timing
location radiation intensity pitch quality variation with respiration |
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How do you asess BV?
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assess for bruits, the temp, color, hair distribution, skin texture, muscle atrophy, nail beds of lower extremities
Presenceof edema, swelliing, vein distension, varicosities, circumference of extremities Homans sign tenderness of lower extremities or aling superficial vein |
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Inspection findings in the abdomen?
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Shape
contour visible aorta pulsations surface motion venous patternscars hernias separation of muscles peristalsis |
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Auscultation findings with the absomen?
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presence and character of bowel sounds
friction rub over the liver or spleen |
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Palpation findings in the abdomen?
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masses (their location, size, contour consistency) tenderness muscle resistance
Aorta organs feces |
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Percussion findings in the abdomen?
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tone in each quad
areas of different percussion notes CVA tenderness vertebral tenderness paraverterbral tenderness liver span |
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How do document JVD?
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JVP at the level of the sternal angle, with the pt elevated at 45 degree. Carotid pulses normal and symmetrical
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Breasts?
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large, pendulous, *symmetrical.
*No masses. *Nipples erect and without discharge |
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Abdomen documentation?
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Obese, but symmetrical. Well healed right lower uadrant scar. BS normal. Except for a slightly tender sigmoid colon, no masses or tenderness. Liver, spleen, and kidneys not felt. Liver span 7 cm in the rt MCL. No CVA tenderness.
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How do you assess the heart?
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1. Inspect neck veins.
2. Auscult carotids at upper and lower extents. 3. Palpate one carotid at a time. 4. Inspect and palpate precordium. 5. Auscult each valve area with diaphragm. 6. Auscult each valve area with bell. 7. Ask patient to roll in left lateral position; palpates apex. 8. Auscult with bell at apex. |
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How do you assess the abdomen?
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1. Inspect.
2. Auscult epigastrium, 4 quadrants. 3. Palpate 4 quadrants (superficial and deep). 4. Palpate liver edge in deep inspiration. 5. Percuss liver dullness (measure span in midclavicular line). 6. Palpate spleen in deep inspiration. 7. Percuss for splenic dullness. 8. Palpate and measure aortic pulsation. 9. Palpate inguinal nodes. 10. Palpate and auscult femoral pulses. |
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Ab contours?
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Flat, rounded, protuberant, distended or scaphoid
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Protuberant Abdomen
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How does a scaphoid abdomen look?
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For breasts, you want to document?
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Lumps tenderness, nipple discharge, SBE/ Mammogram
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Anosmia
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not able to smell
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scotomata
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blind spot
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EOMI?
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extraocular move
ts intact |
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Genitalia documentation?
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Vulva normal. On straining, a mild cystocele appears. Vagina negative. Parous cervix without redness or tenderness. Uterus anterior, midline, smooth , not enlarged. Adnexa are difficult to delineate because of obesity and poor relaxation, but there is no tenderness. Pap smears taken. Rectovaginal examination confirms above
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Rectal documentation?
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Negative. Brown stool, negative for occcult blood
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Which pulses do you document
What's the normal grade for a pulse? |
Radial, femoral, popliteal. dorsalis pedis, posterior tibial
4+ normal |
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PV documentation
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Radial, femoral, popliteal DP, Pt 4+, 2+ edema of ft and ankles with 1+ edema extending up to just below the knees. Moderate varicosities of the saphenous veins bilaterally from mid-thigh to ankles, with venous stars on both lower legs. No stasis pigmentation or ulcers. No calf tenderness.
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Musculoskeletal doc?
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No joint deformities. ROM including hands, wrists, elbows, shoulders, spine, hips, knees, ankles are normal
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Motor doc?
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No atrophy, fasiculations, tremors. Gait heel-to-toe, heel and toe walking, knee bends, hops well done. Romberg negative. Grip and arms strong
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Sensory doc?
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Pain, vibration, light touch and stereognosis screened and intact
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Normal grade for reflexes?
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2+
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What are the areas of the body are reflexes tested?
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Biceps, Triceps, Supinator/ Brachioradialis, abdomen, knee, ankle, plantar (downward arrow- downgoing)
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MS doc?
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Alert, cooperative, thought coherent. Oriented.
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Anus and rectum abnorm?
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hemorrhoids, fissures, skin tags, pilonidal dimpling, hair tufts inflammation, excoriation
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Anus and Rectum doc?
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Perian area appearance
Rectal wall contour, tenderness sphincter tone and control Prostate size, contour consistency, mobility color and consistency of stool |
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Musculoskeletal Sys assessment?
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Posture, alignment of extremities and spine, symmetry of body parts
symmetry of muscle mass, tone fasciculation, spasms ROM appearance of joints:presence of deformities, tenderness, crepitus, swelling, muscle strength |
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Neuro Gait?
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posture, rhythm sequence of stride and arm movements
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Neuro balance?
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Balance, coordination with rapid alternating motions
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Neuro sensory function?
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presence and symmetry of response to pain, touch, vibration, temprature stimuli, monofilament test
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Neuro reflexes?
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Superficial and deep: symmetry, grade, plantar reflex, ankle clonus
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