Basic Screening Exam Flashcards
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Introduction
- State name, purpose.
- Verify patient identity.
- Wash hand.
- Clean stethoscope.
General Appearance
- Habitus, posture
- Level of comfort
- Signs of distress
- Affect
- Voice quality
Vital Signs
- Verify SpO2, weight, temp.
- Palpate pulse bilaterally.
- Measure pulse, BP and RR.
- Orthostatic blood pressure as indicated.
Mental Status
Chekc for level of consciousness, psychosis, disorientation
Head
- Inspect face, skull, face, hair and scalp
2. Palpate skull
Head (inspecting face)
Asymmetry, involuntary movement, rashes, lesions, hirsutism
Head (inspecting skull)
Size, shape and deformity
Head (inspecting hair and scalp)
Alopecia, texture, nits, rashes, lesions
Head (palpate skull)
Deformities, tenderness
Eyes
- Visual acuity
- Inspect conjunctivae
- Inspect sclerae
- Inspect pupil
- Observe pupillary reaction to light
- Test ocular movements
- Fundoscopy
Eyes (visual acuity)
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.
Eyes (inspect conjunctivae)
Color, masses, discharge
Eyes (inspect sclerae)
Icterus (yellow-tinge, jaundice)
Lesions
Eyes (inspect pupil)
Size, shape, symmetry
Eyes (pupillary reaction)
Direct and consensual response to light
CN II and III
Eyes (extraocular movements)
Asymmetry, nystagmus
CN III, IV and VI
Follow light with eyes only, no head movement
Start center and move in “H” pattern
Eyes (fundoscopy)
Red reflex, optic disc for papilledema, retina for vessels, fovea, macula