Vital SignsHeight | Weight | Pulse (60-100) | Respirations (12-20) | Temperature (97.8-99.1) | Blood Pressure (120-139/80-89) | Pain (scale of 0-10) |
IntegumentaryInspect: color, moisture, hair, rashes, lesions, pallor, edema | Palpate: temperature, turgor, lesions, edema, texture |
ScalpInspect: shape, symmetry | Palpate: tenderness, deformity |
NailsInspect: shape, color | Capillary refill (< 3 sec) |
HeadInspect: symmetry, shape, size, uniformity |
| | NeckInspect: symmetry, lesions, scars | Palpate: tenderness, lymph nodes, thyroid gland, TMG |
EyesInspect: interior and exterior, visual fields, acuity, reflexes |
EarsInspect: color, shape, symmetry, interior inspection | Palpate: tenderness, deformity |
NoseInspect: shape, symmetry, interior inspection | Palpate: frontal sinus, maxillary sinuses |
Mouth and ThroatInspect: interior and exterior |
| | Thorax and Lungs (anterior and posterior)Inspection: respiration quality, symmetry, deformity, tracheal location | Palpation: tenderness, fremitus, chest expansion | Percussion: percussive tones, diaphragmatic excursion | Auscultation: breath sounds and quality |
Heart and Great VesselsInspection: jugular venous pulse | Palpate: pulses, PMI | Auscultate: heart sounds (S1, S2) |
Peripheral Vascular SystemInspect: color, edema | Palpate: temperature, edema |
AbdomenInspect: discomfort, uniformity, color, symmetry, scars, hernia, peristalsis, pulsations | Auscultate: bowel sounds, bruits | Percussion: four quadrants, liver, spleen, renal tenderness | Palpation: light to deep, liver, spleen, aorta, rebound tenderness, fluid wave |
| | MusculoskeletalInspection: asymmetry, deformity, atrophy | Palpation: major joints, tenderness, deformity, ROM |
NeurologicalInspect: mental status, cranial nerves, coordination, movement, senses | Palpate: motor strength, muscle tone, reflexes, senses |
GenitourinaryInspect: general appearance, lesions, scars | Palpate: breast exam, testicular exam, prostate exam, vaginal exam, pap smear |
LymphaticPalpate: assess lymph node locations |
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