Professional Documents
Culture Documents
Head
Change gloves.
Nose
Eyes
Face
Face is symmetrical. Skin color is even, no unusual moles. Hair distribution of eyelashes and
eyebrows is even and symmetrical.
(Palpate forehead, sinuses)
“Do you have any tenderness or discomfort?”
There are no signs of edema on the face.
Ears
Mouth
“Please stick out your tongue and move it from side to side. Touch the roof of your mouth with
the tip of your tongue”
Frenulum and cranial nerve 12 (hypoglossal) are intact.
Shoulders
Neck
Thorax
I’m going to inspect the chest. Skin color is even. No lesions or moles.
(palpate) No lumps or edema.
(pinch the skin- skin Turgor)
No tenting.
Heart
Lungs
Anterior:
(auscultate with diaphragm)
“please take deep breath in with your nose and out with your mouth”
trachea- bronchial sounds, louder on expiration
above clavicles- vesicular sounds, louder on inspiration
2nd, 3rd,4th intercostal space (compare side to side)- broncho-vesicular sound, equal on
inspiration and expiration.
Posterior:
Beginning from T3 near spine – broncho-vesicular
The periphery – vesicular (auscultate in six different areas)
(place hands on either side of patients back with thumbs close together)
“please take a deep breath”
Lungs expand equally bilaterally
Abdomen
“ Do you have any trouble voiding? When was your last bowel movement?”
“When was your last period”
“Do you perform routine breast exam/ testicular exam?”
(palpate abdomen)
“do you feel any discomfort?”
Upper extremities
“squeeze my hands”
No neurological deficit, full range of motion / Atrophy, neurological deficit
Lower extremities
“push your feet down like you are pressing on gas pedal”
No neurological deficit / Atrophy, neurological deficit
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