Section

Details to Include

General Survey

– Appearance: Describe the patient’s general appearance (e.g., hygiene, posture, grooming). – Behavior: Note demeanor, mood, and level of consciousness. – Vital Signs: Include temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.

Integumentary

– Inspection: Describe skin color, texture, moisture, and any lesions, scars, or rashes. – Palpation: Note skin temperature, turgor, and edema (if present).

HEENT

– Head: Describe scalp, hair, and any abnormalities (e.g., lumps, tenderness). – Eyes: Note symmetry, conjunctiva, sclera, visual acuity, and pupil response (PERRLA). – Ears: Assess external ears, hearing, and any discharge. – Nose: Inspect nasal mucosa, septum, and patency of nostrils. – Throat: Examine oral mucosa, teeth, gums, and throat for abnormalities.

Neck

– Inspection: Assess for symmetry, swelling, or masses. – Palpation: Check for thyroid enlargement or tenderness. – Range of Motion (ROM): Evaluate neck mobility.

Lymph Nodes

– Palpation: Note size, tenderness, and mobility of cervical, axillary, and inguinal lymph nodes.

Thorax and Lungs

– Inspection: Observe chest symmetry, shape, and effort of breathing. – Auscultation: Document breath sounds (e.g., clear, wheezes, crackles).

Cardiovascular

– Inspection: Note any visible pulsations or jugular vein distention (JVD). – Palpation: Assess peripheral pulses (radial, brachial, dorsalis pedis, posterior tibial). – Auscultation: Listen to heart sounds (S1, S2, murmurs).

Abdomen

– Inspection: Observe shape, contour, and skin condition. – Auscultation: Note bowel sounds in all four quadrants. – Palpation: Describe any tenderness, masses, or organomegaly.

Genitourinary

– Inspection and Palpation: Note bladder distension, tenderness, or abnormalities. – Subjective Data: Include patient-reported urinary frequency, urgency, or incontinence.

Extremities & Peripheral Vascular

– Inspection: Evaluate for symmetry, swelling, or deformities. – Palpation: Assess temperature, capillary refill, and pulses. – ROM and Strength: Test joint range of motion and muscle strength.

Neurological

– Mental Status: Assess level of consciousness, orientation (person, place, time), and cognition. – Cranial Nerves: Evaluate cranial nerve function as applicable. – Motor Function: Test strength, tone, and coordination. – Sensory Function: Check for sensation to touch, pain, or temperature. – Reflexes: Document deep tendon reflexes.