- Wash hands
- Introduce self and review role for visit
- BP, PTR
- Cranium for size, contour, color, lesions
- Inspect eyebrows, eyelids, and eyelashes
- Palpate sinuses and TMJ
- CN VII (facial expression)
- CN II (confrontation test - peripheral vision)
- CN III, IV, & VI (positions of gaze)
- PERRLA
- Inspect and palpate external ear
- CN VIII (whisper test)
- Inspect and palpate external nose
- Nostril patency and CN I (fragrance test)
- Inspect lips, buccal mucosa, gums, tongue, and palates
- CN V (clench teeth, palpate face)
- Tap teeth
- CN XII (protrude tongue - "light, tight, dynamite")
- CN IX and X (depress tongue and say "ah")
- Neck ROM
- Auscultate carotid pulses
- CN XI (shrug shoulders against resistance)
- Inspect and palpate chest and lungs - back then front
- Palpate spinous processes for paraverbal muscles for tenderness and symmetry
- Auscultate over all lung fields and verbalize normal vs abnormal breath sounds
- Percuss over all lung fields
- Palpate pericardium for pulsations, thrills, and/or heaves
- Auscultate five heart fields, sitting then lying (diaphragm & bell)
- Auscultate heart at apex in lt. lateral position
- Inspect abdomen skin, contour, symmetry, & umbilicus
- Auscultate abdomen with diaphragm, all four quadrants
- Auscultate abdominal aorta with bell for bruit
- Percuss all four quadrants of abdomen
- Palpate abdomen; light then deep
- Inspect skin and nails; capillary refill
- Palpate skin for temperature; skin turgor
- Compare symmetrical parts
- Palpate radial, brachial, & pedal pulses, bilaterally
- Test sensations of extremities w/ cotton ball - tell pt to close eyes
- Test upper & lower extremity ROM and muscle tone using resistance
- Elicit reflexes for biceps, triceps, patellar, and achilles
- Observe gait and balance; heel-toe walk
- Romberg's sign & rapid alternating movements
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