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Prepare equipment:
- Steth
- Pen light
- Snellen chart
- Tuning fork
- Otoscope
- Alcohol swabs
- Tongue depressor
- Hammer
- Paper/pencil
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Introduce self
- Head to toe assessment
- May take a while
- Would you like to empty your bladder?
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Orientation
- What is your name?
- Where are you?
- What is month and year?
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Memory
Four words, repeat back after assessment.
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Pain
- Any pain anywhere?
- 1-10 scale
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Eyes
- Wear contacts or glasses, any vision problems?
- Snellen eye exam
- Pupil size on chart
- PERRLA
- Check consensual
- Accommodation
- Cardinal gazes
- Sclera & conjunctiva
-
Ears
- Any problems hearing, earache, ringing, discharge?
- Hearing test
- Otoscope
- Weber (top of head)
- Rinnes
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Nose
- Any problems with nose, drainage, smelling?
- Look inside nose
- Occlude nostrils
- Smell test
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Mouth
(with gloves & tongue depressor)
- Any problems with teeth, gums, mouth, swallowing?
- Inspect teeth, gums, under tongue, uvula
- Move tongue - up down side
- Gag reflex
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Axillary lymph nodes
Using gloves
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Other lymph nodes
- Occipital
- Post auricular
- Pre auricular
- Submandibular
- Submental
- Cervical chain
- Subclavicular
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Upper extremities
- Skin temp
- Muscle tone
- Skin coloration
- Skin turgor
- Bilateral hand squeezes
- Radial pulses bilaterally and rate
- Capillary refills
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Lungs
(clean steth)
Any problems breathing, wheezing, shortness of breath, cough?
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Heart
- Any heart problems, chest pain, palpitations, SOB?
- 2nd right - Aortic
- 2nd left - Pulmonic
- 4th left - Tricuspid
- 5th midclavicular - PALPATE APICAL first
- Listen to mitral valve
- Listen to Apical for 1 minute
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Breast exams
- Ater menstrual
- In the shower and after shower
- Raise arm
- Report any changes to Dr.
-
Posterior lungs
& Lateral lungs
Note any skin problems or tattoos
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CVA tenderness
Bilaterally
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Abdomen
- Any stomach problems or pain, constipation, diarrhea?
- Last bowel movement
- Inspect stomach first (any pulsations?)
- Bowl sounds
- Last quadrant listen for 1 minute and count sounds
- Palpate lightly
- Palpate deeply
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Liver & Spleen
- Liver (right)
- Spleen (left)
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Lower extremities
- Any leg problems walking, cramps?
- Skin temp
- Muscle tone
- Skin coloration
- Edema on ankle and feet
- Calf tenderness
- Wiggle toes
- Foot pushes bilaterally
- Dorsalis pedis pulses bilaterally (rate)
- Capillary refill
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Lower extremity reflexes
- Patellar
- Achilles
- Babinski (lateral to medial)
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Last menstrual?
Any discharge, itching, urinary problems?
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Any questions or problems?
Wash hands.
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