ICM - General Assessment, Vitals, Skin, HEENT Flashcards
General Assessment: General state of health, signs of distress, facial expression, stature, build, posture, grooming/ hygiene, speech, mobility, mental alertness, etc.
“I am inspecting for general state of health, signs of distress, etc….” “Patient is well developed, well nourished, alert and appropriate and in no acute distress….”
Height, Weight, Temperature
“I have noted your height, weight, and temperature documented on your chart. “
Blood pressure
“Now I will take your vital signs. Do you know what your last blood pressure was…?” “Blood pressure is __/__”
Respirations
“Respirations are __ per minute and unlabored. No retractions are noted.”
Pulse
“Pulse is regular and strong.”
Inspect: skin color and lesions for location, distribution, grouping, and color
“I am checking exposed skin for color, lesions for location, size…..”
Palpate: Turgor, Texture, Temperature
“Skin turgor and texture are normal (as you palpate skin); skin is warm & dry….”
Inspect: facial features • Make note of any asymmetry Inspect: hair, scalp, and skull
“The head is normocephalic and atraumatic, face is symmetrical, without lesions…..”
Palpate: hair, scalp, skull
“Symmetrical hair distribution, hair is coarse, curly with male pattern baldness.” (if appropriate)
Test facial muscle function: (CN VII)
“Squeeze eyes shut, wrinkle forehead, smile, puff out cheeks…..”
Light touch: forehead, cheeks, chin (CN V, sensory)
“Close your eyes. Say ‘now’ each time you feel me touch your face.”
Palpate: facial bones & sinuses
“Do you have any sinus tenderness?”
Palpate TMJ & test TMJ ROM
“Open your mouth, move jaw from side to side”
Palpate masseter muscles: (CN V, motor)
“Clench teeth”
Inspect: external eyes: conjunctiva, sclera, iris, cornea, lids
“I am inspecting the eyes for symmetry, exophthalmos, ptosis, edema, icterus, lesions…”
Visual acuity (CN II) - Snellen or hand-held (Rosenbaum)
“I would normally test vision using Snellen or hand held eye chart….”
Corneal reflex (CN V – sensory and CN VII – motor)
“I would normally check the corneal reflex, lightly touching the cornea, which when tested would cause the patient to blink.”
Direct pupillary light reflex (CN III)
“Pupils equal, round, and reactive to light.”
Consensual pupillary light reflex (CN III)
Evaluate in six cardinal positions, using H pattern. “Extraocular movements are intact bilaterally, without nystagmus.”
Accommodation (CN III)
“Eyes converge and pupils accommodate to near vision.”
Perform: Ophthalmoscopic examination bilaterally - Obtain red reflex - Inspect cornea and lens
“Red reflex is present.”
Funduscopic exam: inspect disc, cup margins, vessels, retina and macula/fovea
“Disc margins are sharp” “AV ratio is 2:3 without nicking or spasms.” “There are no hemorrhages or exudates.”
Check hearing:(CN VIII)
Whisper or rub fingers close to patient’s ears. “Tell me when you hear my fingers rubbing together”
Inspect: auricle and surrounding tissue for deformity, masses, lesions
“I am inspecting the ears for masses or lesions…”
