Term
| Inspect patient general appearance |
|
Definition
| patient appears stated age, no obvious physical deformities, clothing appropriate for season |
|
|
Term
| Inspect for mood and nutritional status |
|
Definition
calm, pleasant, cooperative
well-nourished |
|
|
Term
| inspect overall skin appearance |
|
Definition
| pink, no lesions, color appriopriate for ethnic background, and cleanliness |
|
|
Term
| palpate skin for moisture, temperature, texture, turgor, and edema |
|
Definition
| skin warm, dry, smooth in texture, turgor elastic without tenting, no edema present |
|
|
Term
| inspect and palpate nails |
|
Definition
| hygiene clean and neat, no clubbing, capillary refill less than 3 seconds |
|
|
Term
| Inspect facial symmetry, inspect hair and scalp |
|
Definition
| Facial structure is symmetrical, hair normal distribution, scalp pink and smooth without pests, flaking, or lesions |
|
|
Term
| Palpate cranium and temporal artery |
|
Definition
| Head normocephalic, no tenderness, temporal pulse palpable bilaterally |
|
|
Term
|
Definition
| TMJ moves freely with tenderness or crepitus |
|
|
Term
| Palpate frontal and maxillary sinuses |
|
Definition
| no tenderness bilaterally |
|
|
Term
| Assess CN 5 trigeminal- motor strength and light touch three facial branches |
|
Definition
| no facial drooping, fasiculation, palpate temporal and masseter for strong muscle contraction, senses light touch to forehead cheek and chin |
|
|
Term
|
Definition
| raise the eyebrows,squeeze the eyes shut, wrinkle the forehead, frown, smile,show teeth, purse lips, puff out cheeks |
|
|
Term
| Inspect eye lid, lashes, and brows |
|
Definition
| no ptosis, lid lag, discharge or crusting. Even lash and brow hair distribution |
|
|
Term
| inspect conjunctiva and sclera |
|
Definition
| pink moist conjunctiva, white sclera |
|
|
Term
| Inspection of direct and consensual response of pupil and response to light- Accomodation-- CN 3 occulomotor |
|
Definition
| constriction same side as light and simultaneous constriction of opposite pupil--- PERRLA (pupil equal round reactive to light and accomodation) |
|
|
Term
| Inspect pupil condition (size and shape)Visual Acquity- Rosenbaum chart for Function Vision- CN 2 Optic |
|
Definition
| Pupil is 4mm, tell the patient to hold the chart as far out as they can and read the farthest line, pt reports vision 20/20 |
|
|
Term
| Assess Cranial Nerves 3 Occulomotor, 4 Trochlear, 6 Abducens |
|
Definition
| down/ medial CN 4 Trochlear, lateral CN 6 abducens, everything else is CN 3 Occulomotor, no nystagmus |
|
|
Term
| Perform Ophthalmoscope exam |
|
Definition
| red reflex identified using RRR or LLL |
|
|
Term
|
Definition
| skin color even and consistent, alignment symmetrical, no lesions present |
|
|
Term
| palpate bilateral ear auricle, lobe, tragus, and mastoid process |
|
Definition
| ask the patient about tenderness |
|
|
Term
perform Otoscope exam of ear canal.
Pull patient ear up and back |
|
Definition
| TM pearly gray, cone of light present, no cerumen present |
|
|
Term
| Assess functional hearing Whisper Test CN 8 Acoustic |
|
Definition
| masks opposing ear- whisper 1,2,3 -hearing intact |
|
|
Term
| Perform Weber test, Rinne Test |
|
Definition
| BC equal bilaterally, AC> BC |
|
|
Term
|
Definition
| midline, no nasal flaring, test patency of nares |
|
|
Term
|
Definition
| nasal mucosa pink, no polyps, no drainage, turbinates and septum intact |
|
|
Term
| inspect mouth with light and tongue blade |
|
Definition
| lips,mucosa gums and palates pink. floor of mouth intact, moist, smooth. Pharynx pink, tongue pink and rough, teeth white and intact |
|
|
Term
| inspect and grade tonsils |
|
Definition
| 1+ pink with no discharge present |
|
|
Term
| assess position of uvula when patient says ahh |
|
Definition
| uvula is symmetrical and midline |
|
|
Term
|
Definition
| tongue symmetrical upon extension |
|
|
Term
|
Definition
| symmetrical and no lumps or pulsations |
|
|
Term
|
Definition
|
|
Term
|
Definition
| non-palpable, no masses present |
|
|
Term
|
Definition
| ( pre-auricular, post-auricular, occipital, posterior cervical chain, tonsilar, sub-mandibular, sub-mental, anterior cervical chain, supraclavicular)(non-palpable and non-tender) |
|
|
Term
|
Definition
| shoulder shrug- neck strength against resistance |
|
|
Term
| inspect anterior, posterior, lateral chest wall |
|
Definition
| shoulders and muscles appear symmetrical, AP diameter 2:1, normal configuration of thoracic cage |
|
|
Term
| Assess respiratory effort |
|
Definition
| no dyspnea, no retractions or accessory muscle use |
|
|
Term
| palpate posterior chest wall for tender areas- flat hands |
|
Definition
| no tenderness, no crepitus, lumps or masses present |
|
|
Term
| palpate thoracic expansion-posterior |
|
Definition
| butterfly hands- expansion equal bilaterally |
|
|
Term
Palpate for tactile fremitus posterior only
"every time I put my hands on your back , can you say 99?" |
|
Definition
| sides of hands- vibrations are symmetrical bilaterally |
|
|
Term
| Percussion posterior only from apex to base- 5 places minimum |
|
Definition
|
|
Term
| percussion of costovertebral angle |
|
Definition
|
|
Term
| Auscultation of breath sounds posterior only from apex to base, minimum of 5 sides |
|
Definition
| Bronchovesicular sounds midline, vesicular sounds in the lung periphery, clear lung sounds in all lobes, no wheezes, crackles, or rhonchi |
|
|
Term
| Auscultate voice sounds Egophony, Whispered Pectoriloquoy, Bronchophony- 2 places minmum |
|
Definition
Egophony- ee-ee-ee does not change to aa-aa-aa sound.
Whispered Pectilogy- whisper 1,2,3- sounds should be muffled
Bronchophony- say 99 in a clear voice- sound should be muffled. |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| no visible pulsations presnet |
|
|
Term
|
Definition
| no visible pulsations presnet |
|
|
Term
|
Definition
| no visible pulsations presnet |
|
|
Term
|
Definition
| no visible pulsations presnet |
|
|
Term
|
Definition
| no visible pulsations presnet |
|
|
Term
|
Definition
| no visible pulsations presnet |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| auscultate carotid artery with bell |
|
Definition
|
|
Term
| auscultate carotid artery with bell |
|
Definition
|
|
Term
| auscultate carotid artery with bell |
|
Definition
|
|
Term
| auscultate carotid artery with bell |
|
Definition
|
|
Term
| auscultate carotid artery with bell |
|
Definition
|
|
Term
| auscultate carotid artery with bell |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Palpation of precordium for heave or thrill |
|
Definition
| no heave, thrill, and PMI is located at the 5th ICS Left midclavicular line |
|
|
Term
| Palpation of precordium for heave or thrill |
|
Definition
| no heave, thrill, and PMI is located at the 5th ICS Left midclavicular line |
|
|
Term
| Palpation of precordium for heave or thrill |
|
Definition
| no heave, thrill, and PMI is located at the 5th ICS Left midclavicular line |
|
|
Term
| Palpation of precordium for heave or thrill |
|
Definition
| no heave, thrill, and PMI is located at the 5th ICS Left midclavicular line |
|
|
Term
| Palpation of precordium for heave or thrill |
|
Definition
| no heave, thrill, and PMI is located at the 5th ICS Left midclavicular line |
|
|
Term
| Palpation of precordium for heave or thrill |
|
Definition
| no heave, thrill, and PMI is located at the 5th ICS Left midclavicular line |
|
|
Term
| Auscultate valves with my diaphragm then my bell |
|
Definition
Aortic- right 2nd ICS sternal border
Pulmonic- left 2nd ICS sternal border
ERB's - left 3rd ICS sternal border
Tricuspid- left 4th ICS sternal border
Mitral-left 5th ICS midclavicular line |
|
|
Term
| Auscultate valves with my diaphragm then my bell |
|
Definition
Aortic- right 2nd ICS sternal border
Pulmonic- left 2nd ICS sternal border
ERB's - left 3rd ICS sternal border
Tricuspid- left 4th ICS sternal border
Mitral-left 5th ICS midclavicular line |
|
|
Term
| Auscultate valves with my diaphragm then my bell |
|
Definition
Aortic- right 2nd ICS sternal border
Pulmonic- left 2nd ICS sternal border
ERB's - left 3rd ICS sternal border
Tricuspid- left 4th ICS sternal border
Mitral-left 5th ICS midclavicular line |
|
|
Term
| Auscultate valves with my diaphragm then my bell |
|
Definition
Aortic- right 2nd ICS sternal border
Pulmonic- left 2nd ICS sternal border
ERB's - left 3rd ICS sternal border
Tricuspid- left 4th ICS sternal border
Mitral-left 5th ICS midclavicular line |
|
|
Term
| Auscultate valves with my diaphragm then my bell |
|
Definition
Aortic- right 2nd ICS sternal border
Pulmonic- left 2nd ICS sternal border
ERB's - left 3rd ICS sternal border
Tricuspid- left 4th ICS sternal border
Mitral-left 5th ICS midclavicular line |
|
|
Term
| Auscultate valves with my diaphragm then my bell |
|
Definition
Aortic- right 2nd ICS sternal border
Pulmonic- left 2nd ICS sternal border
ERB's - left 3rd ICS sternal border
Tricuspid- left 4th ICS sternal border
Mitral-left 5th ICS midclavicular line |
|
|
Term
|
Definition
| Identify presence of S1 S2, regular rhythm in one area |
|
|
Term
|
Definition
| Identify presence of S1 S2, regular rhythm in one area |
|
|
Term
|
Definition
| Identify presence of S1 S2, regular rhythm in one area |
|
|
Term
|
Definition
| Identify presence of S1 S2, regular rhythm in one area |
|
|
Term
|
Definition
| Identify presence of S1 S2, regular rhythm in one area |
|
|
Term
|
Definition
| Identify presence of S1 S2, regular rhythm in one area |
|
|
Term
| Left LATERAL position--- Auscultate PMI |
|
Definition
| Left 5th ICS midclavicular line |
|
|
Term
| Left LATERAL position--- Auscultate PMI |
|
Definition
| Left 5th ICS midclavicular line |
|
|
Term
| Left LATERAL position--- Auscultate PMI |
|
Definition
| Left 5th ICS midclavicular line |
|
|
Term
| Left LATERAL position--- Auscultate PMI |
|
Definition
| Left 5th ICS midclavicular line |
|
|
Term
| Left LATERAL position--- Auscultate PMI |
|
Definition
| Left 5th ICS midclavicular line |
|
|
Term
| Left LATERAL position--- Auscultate PMI |
|
Definition
| Left 5th ICS midclavicular line |
|
|
Term
|
Definition
radial, brachial, dorsalis pedis, posterior tibialis, popliteal
All pulses 3+ |
|
|
Term
|
Definition
radial, brachial, dorsalis pedis, posterior tibialis, popliteal
All pulses 3+ |
|
|
Term
|
Definition
radial, brachial, dorsalis pedis, posterior tibialis, popliteal
All pulses 3+ |
|
|
Term
|
Definition
radial, brachial, dorsalis pedis, posterior tibialis, popliteal
All pulses 3+ |
|
|
Term
|
Definition
radial, brachial, dorsalis pedis, posterior tibialis, popliteal
All pulses 3+ |
|
|
Term
|
Definition
radial, brachial, dorsalis pedis, posterior tibialis, popliteal
All pulses 3+ |
|
|
Term
| Palpate lower extremities for edema |
|
Definition
| no edema bilateral lower extremities |
|
|
Term
| Palpate lower extremities for edema |
|
Definition
| no edema bilateral lower extremities |
|
|
Term
| Palpate lower extremities for edema |
|
Definition
| no edema bilateral lower extremities |
|
|
Term
| Palpate lower extremities for edema |
|
Definition
| no edema bilateral lower extremities |
|
|
Term
| Palpate lower extremities for edema |
|
Definition
| no edema bilateral lower extremities |
|
|
Term
| Palpate lower extremities for edema |
|
Definition
| no edema bilateral lower extremities |
|
|
Term
| inspect abdomen and describe location of liver, spleen, gallbladder, appendix, ascending colon, transverse colon, descending colon,bladder |
|
Definition
abdomen flat, non-distended
Liver- RUQ
Spleen LUQ
Gallbladder- RUQ
Appendix-RLQ
Ascending colon-RLQ to RUQ
transverse colon RUQ to LUQ
Descending colon LUQ to LLQ
bladder is in the suprapubic region |
|
|
Term
| inspect abdomen and describe location of liver, spleen, gallbladder, appendix, ascending colon, transverse colon, descending colon,bladder |
|
Definition
abdomen flat, non-distended
Liver- RUQ
Spleen LUQ
Gallbladder- RUQ
Appendix-RLQ
Ascending colon-RLQ to RUQ
transverse colon RUQ to LUQ
Descending colon LUQ to LLQ
bladder is in the suprapubic region |
|
|
Term
| inspect abdomen and describe location of liver, spleen, gallbladder, appendix, ascending colon, transverse colon, descending colon,bladder |
|
Definition
abdomen flat, non-distended
Liver- RUQ
Spleen LUQ
Gallbladder- RUQ
Appendix-RLQ
Ascending colon-RLQ to RUQ
transverse colon RUQ to LUQ
Descending colon LUQ to LLQ
bladder is in the suprapubic region |
|
|
Term
| inspect abdomen and describe location of liver, spleen, gallbladder, appendix, ascending colon, transverse colon, descending colon,bladder |
|
Definition
abdomen flat, non-distended
Liver- RUQ
Spleen LUQ
Gallbladder- RUQ
Appendix-RLQ
Ascending colon-RLQ to RUQ
transverse colon RUQ to LUQ
Descending colon LUQ to LLQ
bladder is in the suprapubic region |
|
|
Term
| inspect abdomen and describe location of liver, spleen, gallbladder, appendix, ascending colon, transverse colon, descending colon,bladder |
|
Definition
abdomen flat, non-distended
Liver- RUQ
Spleen LUQ
Gallbladder- RUQ
Appendix-RLQ
Ascending colon-RLQ to RUQ
transverse colon RUQ to LUQ
Descending colon LUQ to LLQ
bladder is in the suprapubic region |
|
|
Term
| inspect abdomen and describe location of liver, spleen, gallbladder, appendix, ascending colon, transverse colon, descending colon,bladder |
|
Definition
abdomen flat, non-distended
Liver- RUQ
Spleen LUQ
Gallbladder- RUQ
Appendix-RLQ
Ascending colon-RLQ to RUQ
transverse colon RUQ to LUQ
Descending colon LUQ to LLQ
bladder is in the suprapubic region |
|
|
Term
| auscultate bowel sounds in all 4 quadrants |
|
Definition
| bowel sound present in all four quadrants |
|
|
Term
| auscultate bowel sounds in all 4 quadrants |
|
Definition
| bowel sound present in all four quadrants |
|
|
Term
| auscultate bowel sounds in all 4 quadrants |
|
Definition
| bowel sound present in all four quadrants |
|
|
Term
| auscultate bowel sounds in all 4 quadrants |
|
Definition
| bowel sound present in all four quadrants |
|
|
Term
| auscultate bowel sounds in all 4 quadrants |
|
Definition
| bowel sound present in all four quadrants |
|
|
Term
| auscultate bowel sounds in all 4 quadrants |
|
Definition
| bowel sound present in all four quadrants |
|
|
Term
| auscultate aorta and renal arteries with my BELL |
|
Definition
|
|
Term
| auscultate aorta and renal arteries with my BELL |
|
Definition
|
|
Term
| auscultate aorta and renal arteries with my BELL |
|
Definition
|
|
Term
| auscultate aorta and renal arteries with my BELL |
|
Definition
|
|
Term
| auscultate aorta and renal arteries with my BELL |
|
Definition
|
|
Term
| auscultate aorta and renal arteries with my BELL |
|
Definition
|
|
Term
| Light palpation in all 4 quadrants |
|
Definition
| Abdomen is soft, non-tender, no rigidity, muscle guarding, or masses present |
|
|
Term
| Light palpation in all 4 quadrants |
|
Definition
| Abdomen is soft, non-tender, no rigidity, muscle guarding, or masses present |
|
|
Term
| Light palpation in all 4 quadrants |
|
Definition
| Abdomen is soft, non-tender, no rigidity, muscle guarding, or masses present |
|
|
Term
| Light palpation in all 4 quadrants |
|
Definition
| Abdomen is soft, non-tender, no rigidity, muscle guarding, or masses present |
|
|
Term
| Light palpation in all 4 quadrants |
|
Definition
| Abdomen is soft, non-tender, no rigidity, muscle guarding, or masses present |
|
|
Term
| Light palpation in all 4 quadrants |
|
Definition
| Abdomen is soft, non-tender, no rigidity, muscle guarding, or masses present |
|
|
Term
| Deep Palpation Abdomen- liver, spleen, kidneys |
|
Definition
| liver border is palpable, spleen non-palpable, kidneys are non-palpable, no tenderness or masses |
|
|
Term
| Deep Palpation Abdomen- liver, spleen, kidneys |
|
Definition
| liver border is palpable, spleen non-palpable, kidneys are non-palpable, no tenderness or masses |
|
|
Term
| Deep Palpation Abdomen- liver, spleen, kidneys |
|
Definition
| liver border is palpable, spleen non-palpable, kidneys are non-palpable, no tenderness or masses |
|
|
Term
| Deep Palpation Abdomen- liver, spleen, kidneys |
|
Definition
| liver border is palpable, spleen non-palpable, kidneys are non-palpable, no tenderness or masses |
|
|
Term
| Deep Palpation Abdomen- liver, spleen, kidneys |
|
Definition
| liver border is palpable, spleen non-palpable, kidneys are non-palpable, no tenderness or masses |
|
|
Term
| Deep Palpation Abdomen- liver, spleen, kidneys |
|
Definition
| liver border is palpable, spleen non-palpable, kidneys are non-palpable, no tenderness or masses |
|
|
Term
|
Definition
| aorta palpable, smooth, approx. 2.5 cm in size slightly left of midline |
|
|
Term
|
Definition
| aorta palpable, smooth, approx. 2.5 cm in size slightly left of midline |
|
|
Term
|
Definition
| aorta palpable, smooth, approx. 2.5 cm in size slightly left of midline |
|
|
Term
|
Definition
| aorta palpable, smooth, approx. 2.5 cm in size slightly left of midline |
|
|
Term
|
Definition
| aorta palpable, smooth, approx. 2.5 cm in size slightly left of midline |
|
|
Term
|
Definition
| aorta palpable, smooth, approx. 2.5 cm in size slightly left of midline |
|
|
Term
| percuss abdomen in all 4 quadrants |
|
Definition
| describe as tympanic and dull over organs |
|
|
Term
| percuss abdomen in all 4 quadrants |
|
Definition
| describe as tympanic and dull over organs |
|
|
Term
| percuss abdomen in all 4 quadrants |
|
Definition
| describe as tympanic and dull over organs |
|
|
Term
| percuss abdomen in all 4 quadrants |
|
Definition
| describe as tympanic and dull over organs |
|
|
Term
| percuss abdomen in all 4 quadrants |
|
Definition
| describe as tympanic and dull over organs |
|
|
Term
| percuss abdomen in all 4 quadrants |
|
Definition
| describe as tympanic and dull over organs |
|
|
Term
| percuss liver margin at right MCL |
|
Definition
| liver border below ribs at MCL |
|
|
Term
| percuss liver margin at right MCL |
|
Definition
| liver border below ribs at MCL |
|
|
Term
| percuss liver margin at right MCL |
|
Definition
| liver border below ribs at MCL |
|
|
Term
| percuss liver margin at right MCL |
|
Definition
| liver border below ribs at MCL |
|
|
Term
| percuss liver margin at right MCL |
|
Definition
| liver border below ribs at MCL |
|
|
Term
| percuss liver margin at right MCL |
|
Definition
| liver border below ribs at MCL |
|
|
Term
| percuss spleen Left MAL 10th ICS |
|
Definition
|
|
Term
| percuss spleen Left MAL 10th ICS |
|
Definition
|
|
Term
| percuss spleen Left MAL 10th ICS |
|
Definition
|
|
Term
| percuss spleen Left MAL 10th ICS |
|
Definition
|
|
Term
| percuss spleen Left MAL 10th ICS |
|
Definition
|
|
Term
| percuss spleen Left MAL 10th ICS |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| no visible pulsations presnet |
|
|
Term
|
Definition
|
|
Term
| auscultate carotid artery with bell |
|
Definition
|
|
Term
|
Definition
|
|
Term
| Palpation of precordium for heave or thrill |
|
Definition
| no heave, thrill, and PMI is located at the 5th ICS Left midclavicular line |
|
|
Term
| Auscultate valves with my diaphragm then my bell |
|
Definition
Aortic- right 2nd ICS sternal border
Pulmonic- left 2nd ICS sternal border
ERB's - left 3rd ICS sternal border
Tricuspid- left 4th ICS sternal border
Mitral-left 5th ICS midclavicular line |
|
|
Term
|
Definition
| Identify presence of S1 S2, regular rhythm in one area |
|
|
Term
| Left LATERAL position--- Auscultate PMI |
|
Definition
| Left 5th ICS midclavicular line |
|
|
Term
|
Definition
radial, brachial, dorsalis pedis, posterior tibialis, popliteal
All pulses 3+ |
|
|
Term
| Palpate lower extremities for edema |
|
Definition
| no edema bilateral lower extremities |
|
|
Term
| inspect abdomen and describe location of liver, spleen, gallbladder, appendix, ascending colon, transverse colon, descending colon,bladder |
|
Definition
abdomen flat, non-distended
Liver- RUQ
Spleen LUQ
Gallbladder- RUQ
Appendix-RLQ
Ascending colon-RLQ to RUQ
transverse colon RUQ to LUQ
Descending colon LUQ to LLQ
bladder is in the suprapubic region |
|
|
Term
| auscultate bowel sounds in all 4 quadrants |
|
Definition
| bowel sound present in all four quadrants |
|
|
Term
| auscultate aorta and renal arteries with my BELL |
|
Definition
|
|
Term
| Light palpation in all 4 quadrants |
|
Definition
| Abdomen is soft, non-tender, no rigidity, muscle guarding, or masses present |
|
|
Term
| Deep Palpation Abdomen- liver, spleen, kidneys |
|
Definition
| liver border is palpable, spleen non-palpable, kidneys are non-palpable, no tenderness or masses |
|
|
Term
|
Definition
| aorta palpable, smooth, approx. 2.5 cm in size slightly left of midline |
|
|
Term
| percuss abdomen in all 4 quadrants |
|
Definition
| describe as tympanic and dull over organs |
|
|
Term
| percuss liver margin at right MCL |
|
Definition
| liver border below ribs at MCL |
|
|
Term
| percuss spleen Left MAL 10th ICS |
|
Definition
|
|
