Head to toe - verbage Flashcards
Vital signs - Temp
36.5-37.7 Celsius
96-99.9 F
Vital signs - HR
NL 60-100
Regular Rate/Rhythm 2+ amp bilaterally
Vital signs - RR
NL 12-20
Regular rate w/ Bilateral rise and fall of the chest and a moderate depth
Vital signs - BP
120/80 or below
Vital signs - Pain
Are you experiencing any pain? 0-10
Is this normal for you?
Neuro - LOC
AVPU/GCS - fully awake and alert
Neuro - Orientation A/O?
Person - Full name
Place - Tell me where you are right now?
Time - What is todays date/time?
Situation - What are we doing today?
Head
Normocephalic, symmetric, and proportionate head
W/out lesions, soft/boggy spots, or infestations.
CN VII
Smile, wrinkle forhead, Close eyes, puff out cheeks
Cranial nerve intact and equal bilaterally.
Eye inspection
Are you experiencing any tenderness?
Eye structures are w/out redness, edema, or drainage.
CN III
Pupillary rxn to light
Accomodation
PERRLA - eyes converge and pupils constrict bilaterally.
CN III is intact
Ears
Please let me know if you experience any tenderness or pain.
No drainage, TTP, or lesions noted.
Ears are symmetrical and inline with outer canthas.
Drainage - color, consistency, odor, or blood?
Nose
- Experiencing any drainage in the last week?
- Bridge is firm, stable, w/out TTP or masses.
- Patency is noiseless and easy bilaterally
- Internal nose is pink/moist w/out drainage or redness.
- Septum is midline w/out perforation.
Drainage characteristics?
Color, consistency, blood?
Mouth exam includes?
Buccal cavity Teeth Tongue Uvula Tonsils CN IX and X
Buccal cavity
Buccal cavity is pink, moist, w/out lesions.
Teeth
- Have you had any teeth removed?
- Teeth are pearly white w/out decay and are firmly attached to gum line.
Tongue
Is moderate in size, pink, moist and without lesions or edema.
Uvula
Is pink, moist, without lesions and is midline in the oropharnx.
Tonsils
Are 1+ w/out exudate, lesions, or swelling.
CN IX and X
Open mouth and say AHH
- Uvula and soft palate rise and fall symmetrically in the midline.
- CN IX and X are intact
Neck
No bruits present upon auscultation bilaterally.
Carotids regular rate/rhythm w/ 2+ amplitude and no thrills felt upon palpation bilaterally.
How to listen to Chest
Breath in/out through mouth
Listening during in/exp
Avoiding bone/breast
Listen to anterior chest sites
Begin above clavicles/2nd ICS
End at the Xiphoid process/6th ICS
— No adventitious sounds heard upon auscultation bilaterally.
Listen to lateral chest sites
Right - 3 sites and Left 2 sites
Right 2nd ICS MAL, 4th ICS AAL, and 6th ICS PAL
Left 2nd ICS MAL and 6th ICS PAL.
— No adventitious sounds heard upon auscultation bilaterally.
Listen to posterior chest sites
Begin at C7 and end at T10
— No adventitious sounds heard upon auscultation bilaterally.
CV exam includes
Heart sounds Peripheral pulses at radial and pedal. Condition/Color of skin Cap refill - 4 extremities Peripheral edema - 4 extremities.
CV system heart sounds
Diaphragm and bell
- Aortic 2-3 ICS RSB
- Pulmonic 2-3 ICS LSB - S2 sound.
- Erbs point 3-4 ICS LSB
- Tricuspid 4-5 ICS LSB
- Mitral 4-5 ICS MCL - apical impulse - or S1 sound.
Peripheral pulses
Bilateral Radial and Pedal pulses are regular rate/rhythm w/ 2+ amplitude
Skin condition/color
No bruises, rashes, redness are noted.
Skin is even, warm, dry and appropriate for ethnicity.
Capillary refill and nail beds
Nail beds are appropriate color and cap refill is <2s in upper and lower extremities.
Peripheral edema
Palpate UE at hands and LE at tibial plateau/ankles.
Abdomen exam includes
Inspection
Auscultation
Light palpation
Abdomen inspection includes
Contour
Shape
Pulsations
Skin condition
ABD contour
Flat or rounded evenly and symmetrically
ABD shape
Symmetric w/out bulging
ABD skin
Smooth and even color appropriate for ethnicity w/out bruises, pulsations, or redness.
Bowel sounds
I will listen for 1 min per quadrant starting in the LRQ for a maximum of 5m in total.
Normoactive bowel sounds are 5-30
ABD light palpation
Are you experiencing any pain or discomfort in you abdomen,
Palpate lightly starting in LRQ moving clockwise
Upon palpation there was no guarding, masses, TTP or pulsations felt.
Musculoskeletal exam includes
Muscle size, tone, strength
Joint redness, edema, TTP
Gait/posture
ROM of UE and LE
MSK ROM joints to assess
UE - shoulder, elbow, wrist, hand/fingers
LE - Hip, Knee, Ankle
Muscle size
Muscle size is appropriate for person and equal bilaterally.
Muscle tone
Muscle tone is w/out flaccidity, rigidity, or spasticity.
Muscle strength
Push/pull hands/feet
Muscle strength is 5+ and equal bilaterally.
Joint exam
Joints are w/out redness, edema, warmth, or TTP
Posture
Is erect and symmetric w/out misalignment such as scoliosis, lordosis, or kyphosis
Gait
Please take a few steps.
Patients gait is smooth and steady w/ toes pointed forward. Posture is erect and arms swing in opposition.
ROM - shoulder
Flex/Extend Hyperextension Abduction/Adduction Internal/External rotation Circumduction
ROM - elbow
Flex/Extend
Pronation
Supination
ROM - wrist
Flex/Extend
Hyperextension
Radial deviation
Ulnar deviation
ROM - hand/fingers
Flex/Extend
Hyperextension
Abduct/Adduct
Opposition
ROM - hips
Flex/Extend Hyperextension Abduction/Adduction Internal/External Circumduction
ROM - knees
Flex/Extend
ROM - ankles
Dorsiflexion
Plantarflexion
Inversion/Eversion
Abduct/Adduct
