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- Wash hands, introduce self, identify patient.
- Reason for your visit today?
- Do you have any pain today?
- Diabetes, hypertension, heart disease, sickle cell, cancer, seizures?
- Accidents or hospitalizations in the past or other medical specialists being seen today?
- Changes to family history? (mom diabetic)
- Observe appearance (symetry, facial ticks) and movement [Facial/7]
- Ask to the patient to clench teeth. [Trigeminal/5]
- Ask the patient to smile, puff out cheeks, close eyes tightly. [Facial/7]
- How are you feeling today emotionally?
- Ask what you're holding in your hand (a pen for example) [Observe thought process and perceptions]
- Main meal yesterday? Who's speech begins "Four score and seven years ago..."?
- Assess bilateral pupils for symetric size.
- Assess using Glascow Coma scale
- Eye opening: spontaneous=4
- Motor response: obey verbal command=6
- Verbal response: place, date, president=5
- Fully alert, normal=15, coma: <=7
- Inspect and palpate the cranium
PATIENT TO STAND
- Check visual acuity with Snellen Eye Chart [Optic/2]
- Romberg test (feet together, arms at side, close eyes for about 20 seconds) for equilibrium [Acoustic/8]
- See (smooth, rhythmic) gait for 15-20' and return [Acoustic/8]
- Inspect eyes (position, appearance, conjunctiva, sclera, iris)
- Assess six ocular movements and pupil reaction [Oculomotor/3, Trochlear4, Abducens/6]
- While patient looks upward lightly touch the lateral sclera of the eye with sterile gauze to elicit blink [Trigeminal/5]
- Check accommodation - Focus on close pen (pupils constrict), then focus on distant object (pupils dialate)
- Check pupil response to light [Oculomotor/3 Optic/2]
- Inspect ears (position, size, shape, lesions, discoloration).
- Whispered words heard bilaterally [Acoustic/8]
- Inspect mouth (lips, teeth, mucous membranes, gums, tongue
- Ask the patient to protrude tongue at midline, then move it side to side and up and down [Hypoglossal/12]
- 1) Touch tongue to roof of mouth 2) swallowing, 3) Phonation (hoarsness) [Glossopharygeal/9 & Vagus/10]
- Taste at anterior 2/3 of tongue [Facial/7] Taste on the posterior 1/3 of the tongue [Glossopharyngeal/9]
- Inspect nose (skin, shape)
- Ask the patient to close eyes and identify different aromas [Olfactory/1]
- Palpate for tender areas and visible abnormalities
- Ask patient to shrug shoulders against resistance from your hands and turn head to side against resistance from your hand (both sides) [Spinal/11]
- Ask John to take off shirt
- Verbalize inspection of the skin for generalized color, color variation, and scars.
- Palpate for texture, temperature, moisture, turgor, and edema.
- Assess and verbalize Braden Score using chart
- Verbalize inspection of the thorax. Symmetry, Anteroposterior to Transverse diameter should be 1:2 to 5:7
- Palpate posterior chest for respiratory excursion - thumbs adjacent to spine, deep breath. thumbs seperate 1.2-2"
- Palapet posterior for "faintly perceptible vibrations - tactile fremitus" with Pt "nine" at 10 zig-zag positions
- Auscultate the: anterior chest (8 areas), posterior chest (10 areas), lateral chest (5 areas each side). Should hear Bronchial, Bronchovesicular and vesicular, but not rales (crackles), Ronchi (growling), or wheezing
- Inspect chest for visibility of the PMI and any abnormal pulsations while the client is lying down.
- Verbalize inspection of midsternal line landmark.
- Verbalize inspection of midclavicular line landmark.
- Verbalize inspection of anterior axillary line landmark.
- Palpate and auscultate the aortic area.
- Palpate and auscultate the pulmonic area
- Palpate and auscultate Erbs point.
- Palpate and auscultate the tricuspid area
- Palpate and auscultate the mitral area. Count rate for a full minute. Evaluate rhythm.
- Inspect ABD for color, venous pattern, skin integrity, contour, symmetry, and surface motion.
- Auscultate the 4 quadrants of the abdomen. Evaluate bowel sounds.
- Lightly palpate all four quadrants for tenderness and consistency.
- Evaluate the abdomen for rebound tenderness.
- Percuss the abdomen and evaluate for tympany and dullness.
- EXTRA CREDIT: Ausculate the 2 Femoral, 2 Iliac, 2 Renal and Aortic arteries for Bruits.
- Inspect color of urine.
- Palpate the bladder for distention.
- John can put his shirt back on
- Demonstrate inspection of Jugular veins at 45 degrees.
- Demonstrate inspection and palpation of right carotid artery.
- Demonstrate inspection and palpation of left carotid artery.
- Auscultate right carotid artery
- Auscultate left carotid artery
- Evaluate rate, rhythm, symmetry and strength of carotid arteries (with written documentation)
- Demonstrate inspection and palpation of right brachial artery.
- Demonstrate inspection and palpation of left brachial artery
- Evaluate rhythm, symmetry and strength of brachial arteries (with written documentation).
- Demonstrate inspection and palpation of right radial artery.
- Demonstrate inspection and palpation of left radial artery.
- Evaluate rate, rhythm, symmetry and strength of radial arteries (with written documentation).
- Evaluate capillary refill of the upper extremities.
- Evaluate capillary refill of the feet.
- Demonstrate inspection and palpation of right posterior tibial artery (medial!!!).
- Evaluate rhythm, symmetry and strength of posterior tibial arteries (with written documentation).
- Evaluate rate, rhythm, symmetry and strength of pedal (dorsalis pedis) arteries (with written documentation).
- Evaluate Homans sign bilaterally.
- Inspect upper and lower extremities for ROM, swelling, deformities, and pain.
- Palpate upper and lower extremities for tenderness, visible abnormalities, warmth and strength.
and write documentation