Physical Exam

general survey, derm, behavioral health

apparent state of health

general judgement

fit, acute/chronic illness, well-nourished/emaciated, well-developed/frail

level of consciousness

awake, alert, responsive

grooming

appropriately dressed for weather

groomed, no odor

apparent state of discomfort

patient is not in discomfort or in cardiac or respiratory distress

posture

gait and posture are normal

dermatology

skin, hair, nails

IPPA

inspect

palpate

percussion

auscultation

inspect skin where?

head/scalp, neck, back, abdomen, shoulders to fingers, chest, hips to toes

skin is __

normal temp., normal color, no lesions or rashes, no moisture or unusual texture

hair is __

normal thickness, no hair loss or abnormal patterns

nails are __

normal shape, pink, good condition, no discoloration

BH - appearance and behavior

most from GS

consciousness level

hygiene

facial/emotional expression

speech, language

slow/fast, articulation, flow, volume

thought

able to organize thoughts, process and understand what I’m saying, relevant content

mood

normal, appropriate to current discussion

perception

aware of surroundings

insight - aware of situation

judgement - able to make decisions