1. General Approach to client
    • Introduce self
    • Ask name, age, marital status, current meds, allergies, tobacco, alcohol, drug use

    • ask reason for exam
    • wash hands
  2. Skin Assessment
    History: changes in skin, dryness, sores, or rashes

    • Inspect & Palpate- color & temp
    • Turgor- for hydration
    • cap refill
  3. Head Assesment

    Cotton wisp, gloves
    History- headaches, dizziness, head trauma

    Gloves- Examine hair, scalp: inspect and palpate for lesions, masses, lice

    • Test CNVII- Facial- ask to make faces
    • Test CNV- Trigeminal- cotton wisp on face, clench jaw to feel mastoid
  4. Neurological Assessment

    need hammer
    History: any dizziness, seizures, stroke, pain

    • cerebral:
    • place, time, full name, first car
    • mental reasoning ( meaning of finding a needle in a haystack)

    • cerebellar:
    • coor. of fine motorskills (fingers to thumb)
    • balance (stand one foot, then the other)
    • CN VIII- vestibulocochlear- romberg test (pt stands, eyes open, then eyes closed, note swaying)

    sensory perception: dull & sharp of hammer

    • Test deep tendon reflexes (bilaterally)
    • -biceps, triceps, supinator, petallar, achilles, plantar

    Grade outloud 1+ - 4+
  5. Nose Assessment

    need pen light, 2 smells
    History: nasal discharge, sinus pain, allergies

    • Inspect & Palpate external nose
    • Palpate frontal and maxillary sinuses
    • Internal exam (penlight): not color of mucosa, check patency of nares

    Test CNI- olfactory- sniff test (have pt id smell one nostril closed)
  6. Eye Assessment

    gloves, penlight, fundoscope
    History: blurred vision, corrective lenses, surgeries

    Test CNII-Optic (snellen eye chart)

    Inspect conjunctiva (clear) & sclera (white) palpate lacrimal puncta (gloves)

    Test Visual field CNII (cover same eye move finger into view)

    Test CN III,IV,VI (6 cardinal fields of gaze) draw star

    Test CN III (shine light in one eye, dilation in other)

    Test CN III (acomodation) bring finger to nose

    Observe for coordination (shine light btwn eyes, look for equal light reflection)

    Red reflex (use fundoscope, red reflex & optic nerve visible)
  7. Ear Assessment

    need otoscope, tuning fork
    History: any vertigo, hearing loss, ear pain

    Inspect & palpate external hear (tenderness when moved up and out)

    • Inspect canal (using otoscope)
    • otoscopic exam of T.M.

    Test CNVIII (Weber) tuning fork forehead

    Test CNVIII (Rinne) tuning fork, mastoid to in front of ear (AC 2x BC *say)

    Romberg: pt standing closes eyes (note swaying)
  8. Mouth/Throat Assessment

    need toungue blade, cup o water, salt & sugar
    History: Any lesions, sore throat, difficulty swallowing, wisdom teeth

    Inspect oral mucosa, tonsils, palate, pharynx, roof, sides and under tongue

    inspect parotid & sublingual meatus (tongue blade; look under tongue & back of throat)

    count teeth & observe condition (32)

    • CN IX, X- mvmt of uvula (ahhh)
    • CN VII, IX- discriminate test (salt, rinse, sugar)
    • CN IX, X, XII- tests swallowing (water)
    • CN XII- tongue strength, push against cheek
  9. Neck Assessment

    need cup of water
    History: any stiffness, loss of ROM, pain, thyroid problems

    ROM, test m. strength (turn head, resistance)

    Test CN XI- shoulder shrug w/ resistance

    Palpate lymph nodes *say (Submental, submaxillary, tonsillar, preauricular, posteriorauricular, occipital, superficial cervical, posterior cervical, deep cervical, supraclavicular, infraclavicular)

    Palpate carotid pulse (one at a time)

    Palpate Trachea, thyroid (drink water) *say "no bruits"
  10. Thorax Assessment

    need stethoscope
    Social History: asthma, smoke, SOB, chest pain?

    Family History: TB, Bronchitis, lung cancer?

    Observe respiratory rate and effort

    APL diameter (AP<L) (2:1)

    Observe symmetrical expansion (hands on back)

    Palpation: A, P & L chest surfaces (pulsations, bulges)

    A, P & L tactile fermitus (symmetrical when pt. says "99")

    Percussion: anterior, posterior and lateral lung fields

    Auscultation: anterior, posterior and lateral lung
  11. Musculoskeltal Assessment
    History: Arthritis, sore joints, skeletal deformities, surgery?

    Observe gait when walking in

    Inspection: upper & lower extremities (symmetry, tone)

    Palpate- upper & lower extremities (tone, lumps, bumps) lymph nodes (central axillary, brachial axillary, subscapular, epitrochlear)

    • Joint ROM and m. strength w/ resistance (arms over head, behind head, out to side)
    • fingers, wrists, elbows, shoulders
    • hips, knees, ankles
    • adduction, abduction, leg forward, leg backward, knee to chest

    Homan's sign- dorsiflex foot
  12. Cardiac Assessment

    need stethoscope
    Social History: chest pain, SOB, heartburn

    Family History: diabetes, heart disease, hypertension

    • Inspect precordium (pulsations)
    • Palpate for thrills and PMI (5th ICS)

    • Ausculatation (bell & diaphram) *say
    • Aortic: 2nd ICS RSB S2>S1
    • Pulmonic: 2nd ICS LSB S2>S1
    • Erb's: 3rd ICS LSB S2=S1
    • Tricuspid: 5th ICS LSB S2<S1
    • Mitral: 5th ICS LMCL S2<S1

    *say i would then listen again in sitting position

    Count apical HR (1 min)

    Palpate pulses: brachial, radial, dorsalis pedis, posterior tibialis, show femoral
  13. Abdominal Assessment

    need stethoscope, pt pee first!
    History: nausea, vomitting, changes in BM, last BM?

    Inspection: contour, skin, pulsations

    Auscultation: Bowel sounds and abdominal aorta (bell 2 in above umbilicus)

    Percussion: 4 quad (mostly tympany)

    Palpation: light and deep, liver (RUQ) spleen (LUQ non palpable) kidneys

    CVA tenderness
Card Set