Documentation head to toe Flashcards
1
Q
vitals
A
T, BP, P, R
2
Q
General
A
General
3
Q
HEENT
A
nc/at (normocephalic, atraumatic), PERRLA (pupils equal, round, reactive to light and accommodation), EOMI (extraocular m’s intact), TM’s clear b/l, nares patent, throat 0 injected, 0 exudate
4
Q
neck
A
supple s LAD (lympadenopathy), JVD, bruits, thyromegaly
5
Q
lungs
A
CTAB s w/c/r
6
Q
abdominal
A
soft, NT/ND (non-tender, non-distended), nml BS x 4, 0 R/R/G (rebound, rigidity, guarding), 0 HSM, 0 murphys/lloyds
7
Q
ext
A
pulses +2/4 bilaterally (radial, dp and pt), no PTE (pretibial edema), 0 C/C/E (clubbing, cyanosis, edema)
8
Q
MS
A
5/5 stregnth UE/LE b/l
9
Q
neuro
A
A&Ox3, CN 2-12 intact grossly b/l, biceps/triceps/brachiorad DTRs +2/4 b/l, nml gait
10
Q
psych
A
affect, mood congruent and appropriate
11
Q
osteo
A
+TTA R T2-4, tender point lateral C3 on right
