Basic Screening Exam Flashcards

What are you looking for?

1
Q

Introduction

A
  1. State name, purpose.
  2. Verify patient identity.
  3. Wash hand.
  4. Clean stethoscope.
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2
Q

General Appearance

A
  1. Habitus, posture
  2. Level of comfort
  3. Signs of distress
  4. Affect
  5. Voice quality
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3
Q

Vital Signs

A
  1. Verify SpO2, weight, temp.
  2. Palpate pulse bilaterally.
  3. Measure pulse, BP and RR.
  4. Orthostatic blood pressure as indicated.
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4
Q

Mental Status

A

Chekc for level of consciousness, psychosis, disorientation

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5
Q

Head

A
  1. Inspect face, skull, face, hair and scalp

2. Palpate skull

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6
Q

Head (inspecting face)

A

Asymmetry, involuntary movement, rashes, lesions, hirsutism

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7
Q

Head (inspecting skull)

A

Size, shape and deformity

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8
Q

Head (inspecting hair and scalp)

A

Alopecia, texture, nits, rashes, lesions

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9
Q

Head (palpate skull)

A

Deformities, tenderness

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10
Q

Eyes

A
  1. Visual acuity
  2. Inspect conjunctivae
  3. Inspect sclerae
  4. Inspect pupil
  5. Observe pupillary reaction to light
  6. Test ocular movements
  7. Fundoscopy
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11
Q

Eyes (visual acuity)

A

Check vision changes, eye chart 14” away.
Cover (cup) one eye, read lowest visible line.
Cover (cup) other eye, read lowest visible line backwards.
With both eyes, read lowest visible line.

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12
Q

Eyes (inspect conjunctivae)

A

Color, masses, discharge

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13
Q

Eyes (inspect sclerae)

A

Icterus (yellow-tinge, jaundice)

Lesions

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14
Q

Eyes (inspect pupil)

A

Size, shape, symmetry

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15
Q

Eyes (pupillary reaction)

A

Direct and consensual response to light

CN II and III

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16
Q

Eyes (extraocular movements)

A

Asymmetry, nystagmus
CN III, IV and VI
Follow light with eyes only, no head movement
Start center and move in “H” pattern

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17
Q

Eyes (fundoscopy)

A

Red reflex, optic disc for papilledema, retina for vessels, fovea, macula

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18
Q

Ears

A
  1. Inspect anterior, posterior auricle
  2. Inspect auditory canal
  3. Inspect tympanic membrane
  4. Test gross hearing (WHISPER TEST)
19
Q

Ears (inspect auricle)

A

Deformities, swelling and lesions

20
Q

Ears (inspect auditory canal)

A

Erythema, swelling, discharge, cerumen, foreign bodies

21
Q

Ears (inspect tympanic membrane)

A

Color, scarring, perforation, bulging, retraction, effusion

22
Q

Ears (whisper test)

A

Symmetry, hearing loss

23
Q

Nose

A

Inspect internal nares

24
Q

Nose (inspect internal nares)

A

Bleeding, discharge, swelling, lesions, polyps, septal perforation

25
Q

Mouth and Throat

A
  1. Lips
  2. Oral mucosa
  3. Teeth
  4. Gingiva
  5. Tongue
  6. Palate
  7. Tonsils
  8. Uvula
  9. Pharynx
26
Q

Mouth and Throat (lips, oral mucosa)

A

Cyanosis, pallor, lesions, moisture

27
Q

Mouth and Throat (teeth)

A

Loose, missing, caries

28
Q

Mouth and Throat (gingiva)

A

Recession, swelling, bleeding masses

29
Q

Mouth and Throat (tongue)

A

4 sides

Color, texture, lesions, leukoplakia

30
Q

Mouth and Throat (palate)

A

Lesions, deformities

31
Q

Mouth and Throat (tonsils)

A

Presence, enlargement, erythema, exudate

32
Q

Mouth and Throat (uvula)

A

Erythema, deviation

33
Q

Mouth and Throat (pharynx)

A

Erythema, swelling

34
Q

Neck and Lymph Nodes

A
  1. Inspect anterior neck
  2. Inspect thyroid; swallow (isthmus and lobes)
  3. Lymph nodes (anterior/posterior/supraclavicular/axillary)
  4. RANGE OF MOTION
35
Q

Neck and Lymph Nodes (anterior neck)

A

Erythema, swelling, symmetry

36
Q

Neck and Lymph Nodes (thyroid; isthmus and lobes)

A

Size, symmetry, nodules

Size, shape, consistency, nodules, tenderness

37
Q

Neck and Lymph Nodes (lymph nodes)

A

Size, shape, mobility, consistency, tenderness

38
Q

Neck and Lymph Nodes (ROM)

A

Pain, decreased ROM

39
Q

Respiratory

A

Posterior and Anterior

  1. Inspect skin
  2. Quiet v. deep respiration
  3. Auscultation
40
Q

Respiratory (inspect skin)

A

Rashes, lesions, scars

41
Q

Respiratory (quiet, deep respiration)

A

Symmetry of chest wall movement, accessory muscle use

42
Q

Respiratory (auscultation)

A

Serpentine order
Pitch, intensity, duration of breath sounds with inspiration and expiration, adventitious breath sounds including: crackles, rhonchi, wheezing, rubs

43
Q

Cardiovascular

A

Supine
Auscultation with diaphragm
Carotid artery

44
Q

Cardiovascular (auscultation)

A

Aortic area, pulmonic arch, left sternal border (2), tricuspid/mitral