Verify name and DOB!!!! Whats the year and president?? Where are you??

GENERAL SURVEY: Dressed appropriately for age? Speech? Hygiene? State of health?
Deformities? Mood and cooperation?? Nutritional status??
PT STAND UP!!
Gait & posture, assistive devices??
Romberg.
AP ratio! Normal is 2 to 1.
ROM of hips and spine. (Bend back and forward, put legs out to sides)
ASK TO SIT DOWN
Palpate scalp & hair. Masses? Scars and lumps? Tenderness? Any hair loss??
Observe the face for shape and symmetry. Smile, frown, puff face, close eyes tight, kissy
face.
Inspect nose (septum midline?), ears, conjunctiva (pink?), sclera (white?), eyelashes,
eyebrows, and
Skin (Scars? Redness? Edema? Tattoos? Piercings?)
Whisper test!
Palpate the sinuses.
Snellen & PERRLA.
6
fields of gaze.
Peripheral vision test. Remember to cover the eye.
Cotton ball on forehead, cheek, and jaw.
Clench the jaw & try to force it open. Palpate the jaw.
Stick out the tongue and say ahh (Make sure soft palate rises) Make the pt swallow
Inspect neck for symmetry and scars. Palpate carotids. Look
for pulsation.
Shrug shoulders against resistance and turn head. Palpate shoulder joint.
ROM of Arms (circles, up & down, & across) Elbows (flex & extend, sup & pro), Wrist
(circles, up & down, invert & evert) Fingers (open & close, fist) Inspect for clubbing and
Cap refill. Cotton ball on arm. Check brachial and radial pulses. Test for strength. (push
and pull and squeeze 2 fingers) Make sure to inspect skin. Check patellar reflex. ROM of
Knee (extend and make circles) Palpate knee joint.
WALK AROUND TO BACK
CVA tenderness and symmetrical expansion with breathing. Palpate spine.
Tactile fremitus (8 spots). Percuss lung fields (6 spots). Auscultate breath
sound.
Try to count resps at this time!!!
Inspect skin
WALK AROUND TO FRONT
Inspect skin. Resps if not already done. Tactile fremitus. Percuss lung fields.
Auscultate lungs and heart sounds (diaphragm and bell). Are they regular?
Ask to lean forward and listen for murmurs. PT LIE DOWN!!!! Check for JVD.
Palpate apical pulse.
Auscultate carotids and apical.
Looks for lifts.

Next is tummy!! Inspect skin. Make sure no distention or herniation. Auscultate for aortic
bruits. Auscultate all 4 quads. Percuss all 4 quads. Palpate all 4 for tenderness & masses.
VERBALIZE FEMORAL AND POPLITEAL PULSES! Palpate hip joint. Palpate for edema.
Check tibial and dorsalis pulses. Palpate ankle joint. ROM of Legs (raise legs, push feet
against hands, make circles with feet, spread toes),
Check light touch of legs.