VS: Tm: HR: RR: SpO2: @ _____, BP: Wt. BMI:
GENERAL: WD/WN, -yo, AAF, AAO x 3, well groomed, good hygiene, cooperative with exam, good eye contact. No distress.
SKIN: No pallor, jaundice, rash, or lesions. No decubiti ulcers. Warm, cool, dry, diaphoretic. Thick or thin, smooth or coarse texture. Good turgor. Nails dystrophic, discoloration, ridging, irregularities, or pitting. No clubbing, capillary refill <2 secs.
HEENT: NCAT, facial symmetry, no TMJ tenderness, depression, elevation, protrusion, retrusion, and right to left excursions of the jaw normal without limitation. No scalp tenderness. Temporal arteries: 2+ without bruit, bilaterally. Periorbital structures – eyebrows, eyelids, eyelashes are intact. PERRLA, EOMI with conjugate gaze, no nystagmus, lid lag, or strabismus. Conjunctivae injected/pallor, no scleral icterus, irides black, intact, corneae clear. VA - OU: 20/20 or grossly intact, VF by confrontation - OU: appears full with no apparent field defects. Funduscopic: red-reflex present, no lenticular opacity, disc margins sharp without hemorrhages, or exudates; no arteriolar narrowing or A-V nicking, macula not visualized. Gross hearing intact - AU; External ear canals patent. TMs intact with sharp cone of light & w/o effusions. Nares patent, mucosa pink, turbinates not enlarged, septum is in midline/DNS to R/L, no nasal d/c, lesions, or polyps; no maxillary or frontal sinus tenderness. Oropharynx pink and moist, w/o exudates or lesions. Tongue protrudes in midline w/o lesions; teeth in good repair/upper and lower denture plates.
NECK: supple, trachea midline, no JVD, no cervical lymphnodes felt, no midline swelling or thyromegaly. Carotid pulses: 2+ w/o bruit. AROM: full
RESPIRATORY: Chest wall symmetrical with equal excursion on inspiration and expiration. No labored respirations. No Anterior chest wall/Posterior chest wall tenderness bilaterally. TVF equal, lungs resonant, diaphragmatic excursions R & L., CTAB/bronchovesicular, rhonchi/wheezes/crackles (adventitous sounds), bronchophony, egophony, or whispered pectoriloquy (voice sounds).
CARDIOVASCULAR: PMI in 5th ICS medial to MCL; RRR88, S1,S2 no S3,S4, m/r/g. (murmur: intensity, timing, pitch, quality, PMI, radiation)
BREASTS: no erythema, edema, lesions, nipple d/c or masses felt. No axillary LAD bilat.
GASTROINTESTINAL: Scaphoid/protuberant, scars. BS (+), no bruit, soft NT/ND, tympanites, liver span 7 cm in R. MCL. No splenic dullnes. No HSM, no CVA tenderness, upper margin of UB not felt. Hernial orifices intact. Genitalia without abnormalities, no lesions, Rectal: no perineal or perirectal lesions, no external hemorrhoids, fissures. DRE: sphincter tone good, no palpable masses, prostate smooth, symmetrical w/o nodules, NT. Brown stool in rectal vault. No gross blood, guaiac: negative.
GENITOURINARY: normal genitalia, no uretheral discharge, no scrotal or testicular tenderness or masses felt. Perineal sensation intact.
MUSCULOSKELETAL: no erythema, edema, deformity, no joint effusions, AROM/PROM full.
NEUROLOGICAL:
MENTAL STATUS:
Level of consciousness (alert, confused, lethargic, obtunded, comatose).
General appearance including posture, dress, grooming, personal hygiene, facial expression, body language, eye contact.
GCS: EVM.
Orientation in person, place, and time.
Attention: digit span.
Memory: Recent (recall 3 objects at 5 min), Long term events of past like birthday, presidents.
Language: Listening, comprehension, naming, repetition, reading, writing.
Speech: spontaneous, coherent, rate, fluency, and good volume OR aphasia (expressive/receptive), dysarthria. Voice quality. Labial (p,p,p) (b,b,b); lingual (t,t,t) (l,l,l); glottal (guh,guh,guh) (kuh,kuh,kuh. F test: number of words beginning with F in 60 sec (>12 if high school education).
Mood and affect: Pt. notes feeling “good”/”not to well”/”rough”/”sad”, broad range/restricted/blunt, and congruent.
Thought processes: organized, sequential and goal-directed
Thought content: no compulsive, obsessive, phobias, anxiety, suicidal, homicidal ideation or intent, and no hallucinations, illusion, or delusions, No feelings of unreality, depersonalization.
Higher cortical function: General knowledge, vocabulary, year, month, season, week, day, date; or presidents.
Calculations–serial 7’s, 3’s, or simple calculations.
Right and left confusion. Finger agnosia. (touch left ear with right thumb). Agraphia (write name and sentence).
Ideomotor apraxia – unable to pretend combing hair.
Abstract reasoning/concrete reasoning: proverb interpretation
Judgment (scenario: fire in moving theater, letter on side walk, etc)
Insight (how the Pt. perceives his/her condition)
Non-dominant hemisphere functions: left sided neglect, anosognosia, construction tasks (intersecting pentagons, bisecting lines). visuspatial tasks: right/left (draw clock face). Repeat with opposite side.
Frontal release signs: perseveration (alternating sequence of silhouette of squares and triangles); Luria manual sequencing task. Motor impersistence. Go-no-go test, abulia.
CRANIAL NERVES: Visual acuity: 20/20, grossly intact. Fundi: disc margin. Visual fields: Full in all quadrants. Pupils equal, round, reacting to light. No afferent pupillary defect noted. Extraocular muscles intact. No facial sensory loss. Good strength of jaw clenching. Facial movements symmetrical. Audible finger rub bilaterally. Palate and uvula elevates in midline symmetrically when Pt. says “Aah”. Strength of shoulder shrug, 5/5 bilaterally. Head movement side-to-side and against resistance. Tongue protrusion midline and Pt. able to move it from side-to-side.
MOTOR EXAMINATION: muscle bulk and tone normal. No myoclonus, fasiculations, tremors, or other adventitial movements. Strength was 5/5 in upper extremities and lower extremities - bilaterally.
COORDINATION AND GAIT: intact finger to nose, point-to-point movements, heel to shin, and rapid alternating movements. Or (no dysmetria, no dysdiadochokinesia). Gait, tandem walk, toe walking, heel walking, monopedal stance, Ø Romberg's si, or pronator drift.
SENSORY: sensation intact to fine touch, pinprick, temperature, vibration, proprioception. Point localization. No extinction to double simultaneous stimulation. Monofilament: 10/10 both feet. Sensation is normal to light touch, and pinprick in lower extremities bilaterally.
REFLEXES: Bilaterally symmetric and grade 2+ throughout biceps, triceps, brachioradialis, knee and ankle.
MENINGEAL SIGNS: Ø Brudzinski's and Kernig's si (meningeal si)
Geriatric overall assessment: SPICES
S: sleep d/o
P: problems with eating or feeding
I: Incontinence
C: Confusion (what is baseline MS)
E: Evidence of falls
S: skin breakdown (decubiti)
ADL/IADL