Lab Notes Head 2 Toe

Question 1

General Survey - 13

Answer 1

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

Question 2

Skin - 7

Answer 2

Color, Moisture, Temperature, Thickness,

Turgor, Edema, Lesions, Bruising

Question 3

Intro, always - 6

Answer 3

Knock
Provide for privacy
Introduce self
Check 2 forms ID
Hand Hygiene
Explain what is about to happen

Question 4

Cranial Nerve 5 tests - 2

Answer 4

Muscles to close, open jaw

Touch 3 places, 2 sides, sharp/dull/light

Question 5

Cranial nerve 7 tests - 6

Answer 5

Raise eyebrows, close eyes tight while I try to open,

Smile, Show teeth, frown, puff out cheeks,

Question 6

Eyes inspect no light - 10

Answer 6

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)

Question 7

Eyes inspect with light - 3

Answer 7

Light on side - scratches/cloudy lens

Light on pupil - normal and consensual, Corneal light reflect

Question 8

Eyes palpate - 3

Answer 8

Lacrimal sacs, eyelids, eyeballs

Question 9

Ears inspect/palpate - 5 + 2

Answer 9

Palpate inner/external/tragus/pinna/mastoid process,

Go behind and whisper 2 syllable, each ear

Question 10

Nose/sinus inspect/palpate - 5

Answer 10

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

Question 11

Mouth inspect and palpate - 10

Answer 11

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

Question 12

Neck inspect, palpate, auscultate - 6

Answer 12

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

Question 13

Lymphatics palpate

Answer 13

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

Question 14

Pulmonary inspect

Answer 14

Anterior/Posterior Chest, shape, deformities, abnormal inspiratory retractions, impairment of movement

Question 15

Pulmonary Palpate

Answer 15

Anterior/Posterior chest/trunk tender, deformities

Question 16

Pulmonary Percuss/Auscultate

Answer 16

Anterior Lung field trachea, supra-clavicular, pattern down
Posterior along spine pattern down below scapula
Lateral high under armpits, C shape down

Question 17

Pulmonary Chest Expansion

Answer 17

Both hands on back, thumbs touching, big breath, pull apart bilaterally equal

Question 18

Cardiovascular - 4

Answer 18

Inspect chest
Palpate chest and 5 locations
Auscultate Aortic, Pulmonic, Erbs, Tricuspid, Mitral, Apical pulse
Do with Bell, diaphragm

Question 19

Abdominal - 9

Answer 19

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!)

Question 20

Bilateral sensory function - 3

Answer 20

Dull, sharp for arms, legs
Cotton for arms, legs
Stereognosis - small item in hand, eyes closed, each hand

Question 21

Coordination - 5

Answer 21

Gait normal, heel/toe, toes, heels
Finger to nose rapid
Heel to shin
Romberg
Reflexes biceps, triceps, brachioradialis, patellar, achilles, babinski

Question 22

General Survey 1

Answer 22

Posture
Appearance
Mobility x4
A and O x4

Question 23

General Survey 2

Answer 23

Speech
Hearing
Level of consciousness
Mood and affect

Question 24

General Survey 3

Answer 24

Appears stated age
Skin color
Nutritional status
Personal hygiene
Obvious deformities

Question 25

Order - 22

Answer 25

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

Question 26

Lumbar spine - 7

Answer 26

Inspect alignment

ROM flex, extend, lateral L/R, rotate L/R

Question 26

Bilateral upper extremities - 8

Answer 26

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

Question 26

Bilateral lower extremities - 7

Answer 26

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