Mood and affect Patient appears Speech: articulation, pattern, content and appropriate, native language Hearing Personal hygiene Measurements and Vital Signs Weight 140 Height 5’ 7” BMI Radial pulse: rate rhythm Respirations: rate depth Blood pressure (indicate if sitting or lying) Temperature (if indicated) 8
Pain assessment Skin Hands and nails Color and pigmentation Temperature Moisture Texture Turgor Presence of lesions? Head and Face Scalp Hair Cranium Face (cranial nerve VII) Temporal artery and temporomandibular joint Maxillary sinuses and frontal sinuses Eyes Visual fields (cranial nerve II) Extraocular muscles, corneal light reflex, and cardinal positions of gaze (cranial nerves III, IV, VI) External structures Conjunctivae, sclerae, and corneas Pupils 9
Describe the purpose of an Opthalmascope for assessing the eyes Ears External ear Any tenderness? Purpose of the otoscope Test hearing (cranial nerve VIII) and conduct the voice test Explain the Weber and Rinne tests Nose External nose Patency of nostrils Describe the purpose of the speculum evaluate nasal mucosa, septum, and turbinates Mouth and Throat Lips and buccal mucosa Teeth and gums Tongue, hard palate, and soft palate Tonsils Uvula (cranial nerves IX, X) Tongue (cranial nerve 10
XII) Neck Symmetry, lumps, and pulsations Cervical lymph nodes Carotid pulse (bruits if indicated) Trachea ROM (cranial nerve XI) Thyroid gland Chest and Lungs: Posterior and Lateral Thoracic cage configuration Skin characteristics Symmetric expansion Tactile fremitus Lumps or tenderness Spinous process Percussion over lung fields CVA tenderness Breath sounds Adventitious sounds Chest and Lungs: Anterior Respirations and skin characteristics Tactile fremitus, lumps, and Tenderness Percuss lung fields Breath sounds 11
Upper Extremities ROM and muscle strength Epitrochlear nodes Discuss the process for assessing breasts and axilla Neck Vessels Jugular venous pulse Presence of jugular venous distension Heart Precordium: pulsations and heave Apical impulse and PMI Precordium and thrills Apical rate and rhythm Heart sounds Abdomen Contour, symmetry, skin characteristics, umbilicus, and pulsations Bowel sounds Vascular sounds Percussion Liver span in right MCL Spleen Light and deep palpation 12
Palpation of liver, spleen, kidneys, and aorta Inguinal Area Femoral pulse Inguinal nodes Lower Extremities Symmetry, skin characteristics, and hair distribution Pulses: Popliteal posterior tibial dorsalis pedis Temperature and pretibial edema Toes ROM and Muscle Strength Ankles and feet Neurologic Sensation: face arms hands legs feet Position sense Stereognosis Cerebellar function (finger to nose) Cerebellar function (heel to shin) 13
Deep tendon reflexes: biceps triceps brachioradialis patellar achilles Babinski reflex Musculoskeletal Walk across room heel to toe Walk on tiptoes, then walk on heels Romberg sign Shallow knee bend ROM of spine 14
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- Spring '16
- Shelley Ashby