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27 Cards in this Set
- Front
- Back
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1 Wash hands
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2 General inspection
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This is a x's year old well-developed well-nourished xx in no acute distress.
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3 AOx3
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"What is your name? Where are you? What is the date, including the year?" Alert and oriented times 3
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4 Vitals: Blood pressure, Heart rate, respiration rate, temperature
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Verbalize actual values
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5 Head observation/ palpation: Observe hair distribution/shape, feel for any obvious deformities or tenderness, look in 8-10 spots for flaking/lice (and behind ears!)
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"Do you feel any tenderness?" Normocephalic, atraumatic, non-tender. Normal hair distribution for gender/age.
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6. Sinuses: Palpate frontal, maxillary
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"Do you feel any tenderness?" Sinus' non-tender to palation.
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Step 7. Lymph
Palpate with pads of fingers: pre & post auricular, tonsillar, submandibular, submental, anterior & posterior cervical chains, supraclavicular, infraclavicular, occipital |
No lymphadenopathy
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8. Thyroid
Palpate from patient for symmetry, nodules, and tenderness. Have patient swallow. Also push thyroid to the right with left hand, and feel for nodules with right hand. Repeat on the other side. |
Palpable, symmetric, not enlarged, non-nodular.
OR non-palpable |
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9 Adnexa of eye Inspection: Look for swelling, discharge, color, symmetry, nodules, tearing, shape, ptosis (drooping), scleral icterus (yellow)
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Adnexa of eye without edema, ptosis, or erythema. Sclera is non-icteric and conjunctiva are non-injected.
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10 Red reflex Turn lights off, Approach eye 15 degrees off of midline, shine light in eye, using OPHTHALMOSCOPE!
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Positive red reflex bilaterally **If you do red reflex first, you can save time by avoiding changing your equipment multiple times
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11 PERRLA Using OTOSCOPE, briefly shine a light in right eye, look for constriction/dilation. Shine light in right eye, look for consensual reflex in left eye. Observe both pupils dilating and constricting together. Place finger 10cm in front of Pt.
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"For accommodation, please look at my finger, and then look at wall behind my finger."
"Pupils equal, round and reactive to light and accommodation." |
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12 EOMI Move fingers in "bow-tie" shape. Then quickly straight across in both directions (check for nystagmus). For convergence, move your finger toward the bridge of patient's nose.
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"Without moving your head, please follow my finger with your eyes." Extraocular movements intact without nystagmus, convergence symmetric.
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13 Ear palpation Palpate pinna by pulling down, tragus, and mastoid process.
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"Do you feel any tenderness?" Non-tender to palpation
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14 Otoscopy Using OTOSCOPE in RIGHT hand for RIGHT EAR (using pinky for stabilization, and with LEFT hand pull pinna up and out), check to make sure external canal is patent (open), cone of light is visible, and tympanic membrane is not bulging, retracted, injected or blocked. Inspect EAC for lesions, rashes, and obstructions.
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External canal patent, positive cone of light, tympanic membrane intact, no injection/ retraction/ bulging. Some cerumin noted (if earwax.)
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15 Nose inspection With thumb, lift end of nose upward. Shine light in both sides, check to make sure septum is midline. Look through otoscope to check mucosa color, bogginess of turbinates, presence of exudates/crusts.
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Septum midline. mucosoal color pink. turbinates non-boggy, exudates/crusts not present
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16 inspect mouth and posterior oropharynx Using light from otoscope, check to see if uvula is midline, with patient's mouth wide open. Grade tonsils (how far are they toward uvula), what color is posterior oropharynx?
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"Open your mouth, stick your tongue out and say 'Ahhh'." uvula midline, tonsilar grade (0-4+), posterior oropharynx pink without injection, exudates, or cobblestoning.
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17. Observation of face, neck, chest, and hands. Notice if Pt. is breathing in a position to avoid pain, or if extra muscles are used during breathing. Is any clubbing or cyanosis seen? feel hands for temperature. On 2 fingers each hand, press over fingernail to check capillary refill (should be less than 2 seconds). On lower extremity, press finger on each tibia and run finger along to check for depression (measure if applicable). Repeat on top of each foot. Check capillary refill on 2 toes in each foot.
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"Please pull back your gown a bit." Normal thoracic shape and motion with respiration, no accessory muscle use, antalgic position, clubbing or cyanosis noted. Hands are warm and dry. No lower extremity edema. Capillary refill less than 2 seconds upper and lower extremities.
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18. ascultate carotid arteries Place stethoscope just anterior to SCM, listen.Patient needs to hold breath!
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"Please take a breath in and hold it." after auscultating, say "Now exhale." No bruits
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19 ascultate heat valves Place stethoscope firmly to skin and listen for murmurs, rubs, gallops, or extra sounds in 4 places: Aoritc area (Right 2nd ICS), Pulmonic area (Left 2nd ICS), Tricuspid area (lower left sternal border), Mitral area (5th ICS, mid-clavicular line)
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regular rate and rhythm without murmurs, rubs, gallops or extra heart sounds.
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20 Auscultate lungs Place stethoscope firmly to skin and listen: Apex (just superior to clavicle), and 2 places bilaterally on anterior side), 4 places bilaterally on the posterior side, last one should be more lateral. Listen for crackling, wheezing.
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"Each time I place my stethoscope on you, please take a deep breath in and out through your mouth" Clear to auscultation anterior and posterior lung fields.
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21 auscultate abdomen Patient must be gowned and supine on exam table, with knees bent. Have patient pull gown up to mid-chest, and unbutton and fold over pants. Stand on right side of patient. Observe skin for surgeries, moles, stretch marks, etc. Place stethoscope on abdomen in all 4 quadrants and listen for bowel sounds ( no more than 2 minutes).
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"Bowel sounds in all 4 quadrants
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22 palpate abdomen Palpate abdomen in all 4 quadrants: light to deep palpation with flat part of hand
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"Do you feel any tenderness?" non-tender to palpation
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23 palpate liver/spleen Liver: place left hand along patient's back to push liver forward, press right hand with knife edge underneath right costal margin. Have patient take deep breath. Spleen: same thing only on left side, right hand will be angled differently. Probably won't feel either of these.
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"No hepatosplenomegaly."
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24 gait Have patient walk normally, on toes, on heels, and tandem (heel to toe). May need to demonstrate tandem walk for patient.
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"Gait is smooth and well-coordinated."
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25 muscle strength Bilaterally (except for hip- do 1 at a time) test: Neck (flexion, extension, lateral rotation), Shoulder (flexion, extension, abduction, adduction, internal, external rotation), Elbow (flexion, extension), Wrists (flexion, extension), Grip strength x3, Hip (flexion, extension, abduction, adduction), Knee (flexion, extension), Ankle (flexion, extension)
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"Please try to resist the pressure I place on you" muscle strength 5/5 in all major muscle groups."
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DTRs Using reflex hammer, test: C5 (biceps), C6 (brachioradialis), C7 (triceps), L4 (patellar), S1 (achilles)
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"Deep tendon reflexes +2 and symmetric."
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