Lab Notes Head 2 Toe Flashcards
General Survey - 13
Posture, Appearance, Skin color, Nutritional status, Mobility-4, Obvious physical deformities
Speech, Hearing, Personal Hygiene
Appears stated age, level of consciousness, mood and affect, A and O x4
Skin - 7
Color, Moisture, Temperature, Thickness,
Turgor, Edema, Lesions, Bruising
Intro, always - 6
Knock Provide for privacy Introduce self Check 2 forms ID Hand Hygiene Explain what is about to happen
Cranial Nerve 5 tests - 2
Muscles to close, open jaw
Touch 3 places, 2 sides, sharp/dull/light
Cranial nerve 7 tests - 6
Raise eyebrows, close eyes tight while I try to open,
Smile, Show teeth, frown, puff out cheeks,
Eyes inspect no light - 10
Pupil shape and size,
Brows/eyelids/lashes similar and symmetric,
Lens clear, Sclera white, Iris round, Conjuctiva clear and moist,
Accommodation near/far, Peripheral vision wiggly fingers (12),
Extra Ocular vision (6), vision test (2)
Eyes inspect with light - 3
Light on side - scratches/cloudy lens
Light on pupil - normal and consensual, Corneal light reflect
Eyes palpate - 3
Lacrimal sacs, eyelids, eyeballs
Ears inspect/palpate - 5 + 2
Palpate inner/external/tragus/pinna/mastoid process,
Go behind and whisper 2 syllable, each ear
Nose/sinus inspect/palpate - 5
Patentcy, Inspect/Palpate entire lateral surface, Light meatus midline straight intact and pink mucosa/turbinates, Palpate frontal and maxillary sinuses, Test cranial nerve 1 olfactory
Mouth inspect and palpate - 10
Symmetric lips color/moisture/lesions/cracked,
Light gums top/bottom/left/right/soft/hard palate,
Teeth free of decay, Tongue moist/papilla, Say ah uvula rises,
Say ah tonsil area posterior pharynx, Swallow, tongue against cheek,
Stick out tongue midline/left/right, 3 swabs sugar/salt/sour
Neck inspect, palpate, auscultate - 6
Inspect symmetric/swelling/masses/pulsations,
JVD light laying down,
Palpate trachea midline/symmetric, palpate thyroid swallow,
Palpate/auscultate carotid,
ROM/strength shrug/look up/chin to chest/left/right/ear to shoulder/head in circle
Lymphatics palpate
Front of ear, back of ear, mastoid, back to occipital, down to back of neck, supraclavicular, up neck, up to tonsils, under jaw, one finger submental
Pulmonary inspect
Anterior/Posterior Chest, shape, deformities, abnormal inspiratory retractions, impairment of movement
Pulmonary Palpate
Anterior/Posterior chest/trunk tender, deformities
Pulmonary Percuss/Auscultate
Anterior Lung field trachea, supra-clavicular, pattern down
Posterior along spine pattern down below scapula
Lateral high under armpits, C shape down
Pulmonary Chest Expansion
Both hands on back, thumbs touching, big breath, pull apart bilaterally equal
Cardiovascular - 4
Inspect chest
Palpate chest and 5 locations
Auscultate Aortic, Pulmonic, Erbs, Tricuspid, Mitral, Apical pulse
Do with Bell, diaphragm
Abdominal - 9
Inspect abdomen: skin, umbilicus, contours, presence of peristaltic waves, pulsations (eyes level with abdomen)
Auscultate for bowel sounds in 4 quadrants - diaphragm
Percuss 4 quadrants
Palpate 4 quadrants - lightly, then deeply (with knees bent!)
Bilateral sensory function - 3
Dull, sharp for arms, legs
Cotton for arms, legs
Stereognosis - small item in hand, eyes closed, each hand
Coordination - 5
Gait normal, heel/toe, toes, heels Finger to nose rapid Heel to shin Romberg Reflexes biceps, triceps, brachioradialis, patellar, achilles, babinski
General Survey 1
Posture
Appearance
Mobility x4
A and O x4
General Survey 2
Speech
Hearing
Level of consciousness
Mood and affect
General Survey 3
Appears stated age Skin color Nutritional status Personal hygiene Obvious deformities
Order - 22
Intro, general survey, skin, Head/hair, CN 5/7, face,
eyes no light, eyes light, eyes palpate, nose, mouth, ears,
Throat, Lymphatics, pulmonary, cardiac, abdomen, arms, legs,
bilateral sensation,
Coordination, lumbar spine
Lumbar spine - 7
Inspect alignment
ROM flex, extend, lateral L/R, rotate L/R
Bilateral upper extremities - 8
Inspect/palpate shoulders, elbows, wrists, hands/fingers
ROM shoulders flex, extend, abduct, adduct, int/ext rotate
ROM elbows flex, extend, pronate, supinate
ROM wrist flex, extend, ulnar deviation, radial deviation, rotation
ROM hand close/open fist, abduct/adduct fingers, flex/extend thumb
Epitrochelear lymph nodes
Brachial and radial pulse
Finger cap refill
Bilateral lower extremities - 7
Inspect/palpate hips, knees, ankles, feet/toes
ROM Hips flex, extend, abduct, adduct, int/ext rotation
ROM knees flex, extend
ROM Ankles dorsiflex, plantar flex, invert, evert, rotate
ROM toes flex, extend
Femoral, popliteal, posterior tibial, dorsalis pedis pulses
Toe cap refill
