TO #2 - General Survery & HEENT

1. General Survey:

• Age, Gender, Race

• “Pt is a 23 yo, female, caucasian”

2. Alert and Oriented

• Can you tell me where you are? What time is it?

• “Patient is alert and oriented x 3”

3. Apparent State of Health

• “Appears stated age, does not appear ill, frail, or feeble”

4. Signs of Distress

• “Patient shows no signs of cardiac or respiratory distress. Not pale or diaphoretic. Not clutching chest or wheezing. No signs of pain, no wincing or guarding. No signs of emotional distress, does not appear anxious or restless”

5. Facial expression/Eye contact

• “Patient maintains comfortable eye contact and facial expressions are appropriate to situation.”

6. Mood/Affect

• “Patient appears comfortable, and is cooperative with examiner. Not labile or flat. Is not euphoric, angry, or crying”

7. Dress/Grooming/Hygiene

• “Appropriate dress for season. Buttoned and zipped. Proper fitting of clothes. No body or breath odor.”

8. Speech

• “Speech is clear and distinct, pace is moderate. Word choice if effortless and appropriate”

9. Posture and Body Movement

• “Patient is relaxed, and comfortable. Not stiff/tense, shoulders and not slumped and does not appear restless”

10. Gait

• “Patient gait is smooth, even, and well balanced. No stumbling or limping and no assistive device used.”

11. Inspect/Palpate Head/Hair

• “Patients skull is smooth and appropriate size for body. Hair is brown and thick, evenly distributed, and clean with no odor or parasites.”

12. Face & Neck: Inspect/palpate Skin

• “Face is symmetrical, skin is tan, warm and dry, not diaphoretic, no edema, clean without odor, no tenderness lesions or rashes.”

13. Eyes

• “Patient ears are symmetrical, skin intact; properly aligned with outer canthus of the eye”

14. Mouth

• “Lips are pink, moist without lesions, gums are pink without swelling or bleeding, teeth are white without missing or decayed, or loose teeth.”

15. Tongue

• “Tongue is pink and moist, without lesions. Cranial nerve 12 hypoglossal is intact”

• Ask patient to stick out tongue

16. Pharynx

• “Throat is pink, tonsils 1+ without exudate, cranial nerve 9 glossopharyngeal and 10 vagus are intact”

• I would elicit gag reflex by touching my tongue depressor to the back of the throat

Complete Order: Of survery

1. General Survey

2. Orientation

3. Apparent State of Health

4. Signs of Distress

5. Facial expression/Eye contact

6. Mood/Affect

7. Dress/Grooming/Hygiene

8. Speech

9. Posture

10. Gait

Complete Order: Skills

1. Inspect/palpate Head/hair

2. Face & neck

3. Eyes

4. Ears

5. Mouth

6. Tongue

7. Pharynx