Head to toe - verbage

Question 1

Vital signs - Temp

Answer 1

36.5-37.7 Celsius

96-99.9 F

Question 2

Vital signs - HR

Answer 2

NL 60-100

Regular Rate/Rhythm 2+ amp bilaterally

Question 3

Vital signs - RR

Answer 3

NL 12-20

Regular rate w/ Bilateral rise and fall of the chest and a moderate depth

Question 4

Vital signs - BP

Answer 4

120/80 or below

Question 5

Vital signs - Pain

Answer 5

Are you experiencing any pain? 0-10

Is this normal for you?

Question 6

Neuro - LOC

Answer 6

AVPU/GCS - fully awake and alert

Question 7

Neuro - Orientation A/O?

Answer 7

Person - Full name
Place - Tell me where you are right now?
Time - What is todays date/time?
Situation - What are we doing today?

Question 8

Head

Answer 8

Normocephalic, symmetric, and proportionate head

W/out lesions, soft/boggy spots, or infestations.

Question 9

CN VII

Answer 9

Smile, wrinkle forhead, Close eyes, puff out cheeks

Cranial nerve intact and equal bilaterally.

Question 10

Eye inspection

Answer 10

Are you experiencing any tenderness?

Eye structures are w/out redness, edema, or drainage.

Question 11

CN III

Answer 11

Pupillary rxn to light
Accomodation

PERRLA - eyes converge and pupils constrict bilaterally.
CN III is intact

Question 12

Ears

Answer 12

Please let me know if you experience any tenderness or pain.

No drainage, TTP, or lesions noted.
Ears are symmetrical and inline with outer canthas.

Drainage - color, consistency, odor, or blood?

Question 13

Nose

Answer 13

• Experiencing any drainage in the last week?
• Bridge is firm, stable, w/out TTP or masses.
• Patency is noiseless and easy bilaterally
• Internal nose is pink/moist w/out drainage or redness.
• Septum is midline w/out perforation.

Question 14

Drainage characteristics?

Answer 14

Color, consistency, blood?

Question 15

Mouth exam includes?

Answer 15

Buccal cavity
Teeth
Tongue
Uvula
Tonsils
CN IX and X

Question 16

Buccal cavity

Answer 16

Buccal cavity is pink, moist, w/out lesions.

Question 17

Teeth

Answer 17

• Have you had any teeth removed?

- Teeth are pearly white w/out decay and are firmly attached to gum line.

Question 18

Tongue

Answer 18

Is moderate in size, pink, moist and without lesions or edema.

Question 19

Uvula

Answer 19

Is pink, moist, without lesions and is midline in the oropharnx.

Question 20

Tonsils

Answer 20

Are 1+ w/out exudate, lesions, or swelling.

Question 21

CN IX and X

Answer 21

Open mouth and say AHH

• Uvula and soft palate rise and fall symmetrically in the midline.
• CN IX and X are intact

Question 22

Neck

Answer 22

No bruits present upon auscultation bilaterally.

Carotids regular rate/rhythm w/ 2+ amplitude and no thrills felt upon palpation bilaterally.

Question 23

How to listen to Chest

Answer 23

Breath in/out through mouth
Listening during in/exp
Avoiding bone/breast

Question 24

Listen to anterior chest sites

Answer 24

Begin above clavicles/2nd ICS
End at the Xiphoid process/6th ICS
— No adventitious sounds heard upon auscultation bilaterally.

Question 25

Listen to lateral chest sites

Answer 25

Right - 3 sites and Left 2 sites Right 2nd ICS MAL, 4th ICS AAL, and 6th ICS PAL Left 2nd ICS MAL and 6th ICS PAL. --- No adventitious sounds heard upon auscultation bilaterally.

Question 26

Listen to posterior chest sites

Answer 26

Begin at C7 and end at T10 | --- No adventitious sounds heard upon auscultation bilaterally.

Question 27

CV exam includes

Answer 27

``` Heart sounds Peripheral pulses at radial and pedal. Condition/Color of skin Cap refill - 4 extremities Peripheral edema - 4 extremities. ```

Question 28

CV system heart sounds

Answer 28

Diaphragm and bell - Aortic 2-3 ICS RSB - Pulmonic 2-3 ICS LSB - S2 sound. - Erbs point 3-4 ICS LSB - Tricuspid 4-5 ICS LSB - Mitral 4-5 ICS MCL - apical impulse - or S1 sound.

Question 29

Peripheral pulses

Answer 29

Bilateral Radial and Pedal pulses are regular rate/rhythm w/ 2+ amplitude

Question 30

Skin condition/color

Answer 30

No bruises, rashes, redness are noted. | Skin is even, warm, dry and appropriate for ethnicity.

Question 31

Capillary refill and nail beds

Answer 31

Nail beds are appropriate color and cap refill is <2s in upper and lower extremities.

Question 32

Peripheral edema

Answer 32

Palpate UE at hands and LE at tibial plateau/ankles.

Question 33

Abdomen exam includes

Answer 33

Inspection Auscultation Light palpation

Question 34

Abdomen inspection includes

Answer 34

Contour Shape Pulsations Skin condition

Question 35

ABD contour

Answer 35

Flat or rounded evenly and symmetrically

Question 36

ABD shape

Answer 36

Symmetric w/out bulging

Question 37

ABD skin

Answer 37

Smooth and even color appropriate for ethnicity w/out bruises, pulsations, or redness.

Question 38

Bowel sounds

Answer 38

I will listen for 1 min per quadrant starting in the LRQ for a maximum of 5m in total. Normoactive bowel sounds are 5-30

Question 39

ABD light palpation

Answer 39

Are you experiencing any pain or discomfort in you abdomen, Palpate lightly starting in LRQ moving clockwise Upon palpation there was no guarding, masses, TTP or pulsations felt.

Question 40

Musculoskeletal exam includes

Answer 40

Muscle size, tone, strength Joint redness, edema, TTP Gait/posture ROM of UE and LE

Question 41

MSK ROM joints to assess

Answer 41

UE - shoulder, elbow, wrist, hand/fingers | LE - Hip, Knee, Ankle

Question 42

Muscle size

Answer 42

Muscle size is appropriate for person and equal bilaterally.

Question 43

Muscle tone

Answer 43

Muscle tone is w/out flaccidity, rigidity, or spasticity.

Question 44

Muscle strength

Answer 44

Push/pull hands/feet | Muscle strength is 5+ and equal bilaterally.

Question 45

Joint exam

Answer 45

Joints are w/out redness, edema, warmth, or TTP

Question 46

Posture

Answer 46

Is erect and symmetric w/out misalignment such as scoliosis, lordosis, or kyphosis

Question 47

Gait

Answer 47

Please take a few steps. | Patients gait is smooth and steady w/ toes pointed forward. Posture is erect and arms swing in opposition.

Question 48

ROM - shoulder

Answer 48

``` Flex/Extend Hyperextension Abduction/Adduction Internal/External rotation Circumduction ```

Question 49

ROM - elbow

Answer 49

Flex/Extend Pronation Supination

Question 50

ROM - wrist

Answer 50

Flex/Extend Hyperextension Radial deviation Ulnar deviation

Question 51

ROM - hand/fingers

Answer 51

Flex/Extend Hyperextension Abduct/Adduct Opposition

Question 52

ROM - hips

Answer 52

``` Flex/Extend Hyperextension Abduction/Adduction Internal/External Circumduction ```

Question 53

ROM - knees

Answer 53

Flex/Extend

Question 54

ROM - ankles

Answer 54

Dorsiflexion Plantarflexion Inversion/Eversion Abduct/Adduct