Physical

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  1. Prepare equipment:
    • Steth
    • Pen light
    • Snellen chart
    • Tuning fork
    • Otoscope
    • Alcohol swabs
    • Tongue depressor
    • Hammer
    • Paper/pencil
  2. Enter room
    WASH HANDS
  3. Introduce self
    • Head to toe assessment
    • May take a while
    • Would you like to empty your bladder?
  4. Orientation
    • What is your name?
    • Where are you?
    • What is month and year?
  5. Memory
    Four words, repeat back after assessment.
  6. Pain
    • Any pain anywhere?
    • 1-10 scale
  7. Eyes
    • Wear contacts or glasses, any vision problems?
    • Snellen eye exam
    • Pupil size on chart
    • PERRLA
    • Check consensual
    • Accommodation
    • Cardinal gazes
    • Sclera & conjunctiva
  8. Ears
    • Any problems hearing, earache, ringing, discharge?
    • Hearing test
    • Otoscope
    • Weber (top of head)
    • Rinnes
  9. Nose
    • Any problems with nose, drainage, smelling?
    • Look inside nose
    • Occlude nostrils
    • Smell test
  10. Mouth
    (with gloves & tongue depressor)
    • Any problems with teeth, gums, mouth, swallowing?
    • Inspect teeth, gums, under tongue, uvula
    • Move tongue - up down side
    • Gag reflex
  11. Axillary lymph nodes
    Using gloves
  12. Other lymph nodes
    • Occipital
    • Post auricular
    • Pre auricular
    • Submandibular
    • Submental
    • Cervical chain
    • Subclavicular
  13. Shoulder shrug
  14. Carotid pulses
    • Bilaterally
    • Rate (3+)
  15. Upper extremities
    • Skin temp
    • Muscle tone
    • Skin coloration
    • Skin turgor
    • Bilateral hand squeezes
    • Radial pulses bilaterally and rate
    • Capillary refills
  16. Upper extremity reflexes
    • Bilaterally:
    • Tricep
    • Bicep
  17. Lungs
    (clean steth)
    Any problems breathing, wheezing, shortness of breath, cough?
  18. Heart
    • Any heart problems, chest pain, palpitations, SOB?
    • 2nd right - Aortic
    • 2nd left - Pulmonic
    • 4th left - Tricuspid
    • 5th midclavicular - PALPATE APICAL first
    • Listen to mitral valve
    • Listen to Apical for 1 minute
  19. Breast exams
    • Ater menstrual
    • In the shower and after shower
    • Raise arm
    • Report any changes to Dr.
  20. Posterior lungs
    & Lateral lungs
    Note any skin problems or tattoos
  21. Spine
    Bend over
  22. CVA tenderness
    Bilaterally
  23. Abdomen
    • Any stomach problems or pain, constipation, diarrhea?
    • Last bowel movement
    • Inspect stomach first (any pulsations?)
    • Bowl sounds
    • Last quadrant listen for 1 minute and count sounds

    • Palpate lightly
    • Palpate deeply
  24. Liver & Spleen
    • Liver (right)
    • Spleen (left)
  25. Lower extremities
    • Any leg problems walking, cramps?
    • Skin temp
    • Muscle tone
    • Skin coloration
    • Edema on ankle and feet
    • Calf tenderness
    • Wiggle toes
    • Foot pushes bilaterally
    • Dorsalis pedis pulses bilaterally (rate)
    • Capillary refill
  26. Lower extremity reflexes
    • Patellar
    • Achilles
    • Babinski (lateral to medial)
  27. Last menstrual?
    Any discharge, itching, urinary problems?
  28. Memory
    Relay four words.
  29. Any questions or problems?
    Wash hands.

Card Set Information

Author:
jtafoya
ID:
133914
Filename:
Physical
Updated:
2012-02-09 04:25:47
Tags:
Physical
Folders:

Description:
Physical
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