general

grooming, hygiene, dress, LOC

mental status

speech, orientation, memory, emotional state, judgement, calculation

cranial nerves

1-12

motor

general, muscle mass, tone, involuntary movements, strength

cerebellar function

touch finger to noserun each heel down opposite shinrapidly pat kneesstand erect with feet together

reflexes

demonstrate assessing triceps, biceps, brachioradialis, patellar, achilles, Babinski

sensory (eyes closed during all tests)

parietal lobe, lateral spinal-thalmic tract, ventral spinal-thalmic tract, posterior column

neuro checks for patients with head injuries

assess LOC, obtain VS, check PERRLA, assess strength of hand grip and movement of extremities, determine ability to sense touch/pain in extremities

integument - skin

color, moisture, temperature, texture, turgor, edema, lesions, suspicious moles, pressure ulcers, vascularity (verbalize)

integument - nails

color, shape, angle, mobility, lesions (inspect or verbalize)

head

inspect and palpate, size in proportion to body, contour or shape, sutures, position, hair, scalp

face

symmetry of features, placement, expression at rest

eyes

external eye structures, gross visual screening, visual fields, extraocular movement, PERRLA, instrument inspection

ears

inspect and palpate, external ear structures, gross hearing screening, instrument inspection

nose

inspect and palpate, percussion of sinuses, external structures, internal structures, paranasal sinuses, smell

mouth

inspect, palpate only if lesions or high risk, lips, membranes and gums, teeth, tongue, throat, taste

neck

inspect and palpate, auscultate carotid arteries, lymph nodes, trachea, symmetry of neck angles, integument characteristics, cessels, trapeius and sternocleidomastoid muscles

heart and great vessels

inspect, palpate, auscultate

lungs

inspect, palpate, auscultate, thoracic integument characteristics, respiratory characteristics, auscultation of breath sounds, adventitious breath sounds, voice transmission tests, equipment

abdomen

inspect, auscultate, palpate light and deep, GI, GU

musculoskeletal

inspect and palpate, general, motor strength, ROM, neurovascular checks for orthopedic patients