General Survey
Verbalize areas of assessment
physical appearance, body structure J.A. is a 29 year old Caucasian female
who appears well-nourished and is of medium build. Appears stated age. Skin
is intact, fair and even skin tone with scattered macules, no lesions noted.
Appears clean and well-groomed with no notable odor. Clothing clean and
well-fitting.
behavior Alert and oriented x 3. Cooperative and maintains eye contact.
Speech is clear and articulate.
mobility Erect posture and steady gait with smooth and coordinated
movements.
Eyes
Inspect eyebrows, eyelashes, eyelids, orbital area, conjunctiva Eyebrows
and eyelashes present bilaterally, no scaling, lesions, or ptosis noted.
Inspect sclera, cornea, anterior chamber (in oblique lighting), verbalize
clarity, texture Sclera white, bulbar conjunctiva clear and white, papebral
conjunctiva clear and pink. Cornea, anterior chamber, iris and pupil are
smooth and clear bilaterally, no opacities noted.
Inspect, palpate lacrimal puncta Lacrimal puncta have no tenderness or
discharge.
CN II, III (optic, oculomotor)
 Assess pupils (direct and consensual response, accommodation-
PERRLA) PERRLA bilaterally, direct and consensual, eyes move
symmetrically.
 Assess peripheral visual fields Peripheral vision equal bilaterally.
 Ophthalmoscope exam (red reflex), elicit bilaterally Red reflex elicited
bilaterally.
CN III, IV, VI: (oculomotor, trochlear, abducens)
 Assess corneal light reflex Corneal light reflex symmetrical.
 Assess six cardinal fields of gaze, convergence Cardinal fields of
gaze show end-point nystagmus on lateral fields bilaterally.
Head/Face
Inspect skull/scalp/hair/skin & Palpate head and scalp Head is
normocephalic. Scalp is non-tender, clean with no dandruff, lesions, masses
or parasites noted. Hair is blonde, evenly distributed, and of moderate
thickness.
Palpate temporal pulses Temporal pulses 2+ and equal bilaterally.
Inspect structures/general features& Inspect skin, facial hair Facial features
are symmetrical. Skin has fair and even tone, smooth with scattered macules,
well-hydrated. Facial features are symmetrical.
Assess Cranial V: (trigeminal), facial sensation, light touch (forehead,
check, and jaw), jaw
movement (clench teeth) & Assess Cranial VII: facial, expressions (raise
eyebrows, frown, close eyes tightly, puff cheeks) CN V and VII are intact.
Palpate TMJ (describe movement) TMJ has full ROM with no popping, no
pain reported on movement.
Ears
Inspect external ears Ears are symmetrical with no lesions.
Palpate pre-/post-auricular nodes, tragus, auricles, mastoid Pre- and post-
auricular nodes are non-palpable. No tenderness noted over pinna, tragus, or
mastoid process.
Straighten ear canal, positioning client appropriately to inspect structures
Stabilize head appropriately, bracing otoscope
Describe cerumen, hair, canal Ear canals are pink with small amount of
yellowish-brown cerumen and small amount of hair.
Describe inspection of tympanic membrane: characteristics, color,
landmarks, cone of light Tympanic membranes are pearly gray and cone of
light is visualized in the anterior inferior portion bilaterally.
Cranial VIII: (acoustic) (hearing tests)
 Weber Weber test shows tone is heard midline without lateralization.
 Rinne Rinne test shows AC>BC bilaterally.
 Whisper Whisper test heard at 2 ft. bilaterally.
Nose and Sinus
Assess skin, external structures Nose is symmetrical, no abnormalities or skin
lesions.
Palpate paranasal sinuses Sinuses non-tender bilaterally.
Assess patency (each nares) Nares patent bilaterally.
Describe internal cavities (use nasal speculum) Mucosa is pink with minimal
hair, no discharge, lesions, or polyps. Inferior turbinates visualized. No septal
deviation.
Demonstrate appropriate use of instrument
Abdomen **(out of order do after heart)**
Inspect the abdomen Abdomen flat and symmetrical, skin smooth with no
lesions, striae, or scars.
Auscultate epigastrium for bruits, and all 4 quadrants for bowel sounds
Bowel sounds present in all four quadrants. No bruits noted.
Percuss all 4 quadrants Percussion produces tympany in all four quadrants.
Palpate lightly and deeply all 4 quadrants Abdomen soft, no masses or
tenderness.
Demonstrate appropriate pattern
Mouth and Pharynx
Inspect lips, teeth/occlusion, gums, buccal mucosa Lips pink, smooth, and
moist. Oral mucosa and gingivae pink with no masses or lesions. No odor to
breath. Teeth all present and in good repair, no malocclusion. Buccal mucosa
pink and moist.
Assess dorsal, ventral tongue Dorsal tongue surface pink and smooth, ventral
tongue surface pink with veins present.
CN XII (hypoglossal)
Assess tongue for fasiculations, deviation Tongue has full ROM, CN XII
intact.
Describe hard and soft palates Hard palate pinkish-white, soft palate pinkish-
orange.
Describe oropharynx/tonsillar area Oropharynx mucosa pink, no lesions or
exudate. Tonsils 2+, no exudate noted.
CN X (vagus)
Assess uvula movement on phonation Uvula raises midline on phonation.
Demonstrate appropriate use of instruments
Neck
Inspect skin, structures, symmetry Neck supple and symmetrical
Assess range-of-motion (ROM)
Flexion, extension, lateral bending & rotation full ROM, no pain or
tenderness noted
CN XI (spinal accessory)
shrug and turn against resistance Spinal accessory intact, strength equal
bilaterally.
CN IX, X (glossopharyngeal, vagus)
swallow structures rise upon swallowing
Assess trachea trachea midline
Inspect/palpate thyroid Thyroid non-palpable
Palpate lymph nodes (verbalize identification as you examine) Lymph nodes
non-tender and non-palpable. No masses noted.
occipital, tonsillar, superficial & deep cervical, posterior cervical
supraclavicial, submandibular, & submental
Palpate carotids in 3 places bilaterally Carotids 2+ and equal bilaterally.
Auscultate for carotids for bruits No bruits noted.
Thorax
Inspect skin and describe Skin pink and without lesions.
Describe respiratory movement (retractions, use of accessory muscles,
symmetry) Respirations 18 per minute, even and unlabored. Anterior/posterior
thorax symmetrical with chest movement even and regular, chest expansion
symmetrical.
Describe anteroposterior/lateral diameter AP ratio 1:2.
Palpate thorax for tenderness & crepitus No tenderness or crepitus on
palpation, no masses noted.
Palpate fremitus Tactile fremitus equal bilaterally.
Percuss thorax (apex to base) Resonant to percussion over lung fields.
Instruct client on breathing
Auscultate using systematic pattern Clear, vesicular breath sounds heard over
peripheral fields.
Bronchophony (patient says ‘99’) Bronchophony produces muffled sounds.
No adventitious sounds.
Percuss costal vertebral angle No CVA tenderness.
Heart
Describe inspection of anterior precordium: skin, lifts, heaves, & thrusts No
heaves, lifts or pulsations noted; skin warm and well-hydrated.
Palpate the anterior precordium: pulsations, lifts, thrusts, thrills, & PMI
Apical pulse palpable at 5th ICS at left MCL, no thrills noted
Auscultate apical rate, verbalizes rate and rhythm rate 72, regular rhythm
Auscultate across the precordium using diaphragm and bell
aortic, pulmonic, erbs point, triscupid, & mitral S1 and S2 heard in all
areas.
Demonstrates appropriate technique and pattern
Verbalizes rhythm, location, intensity of S1, S2 with diaphragm; S2 > S1 at
aortic and pulmonic. S1 = S2 at Erbs point. S1 > S2 at mitral and tricuspid.
Verbalizes presence or absence of murmurs with bell No murmurs or extra
sounds noted.
Lower Extremities
Inspect skin, nails Even skin tone, smooth with scattered macules; nail beds
pink with no clubbing noted
Inspect size, shape, symmetry, condition of legs, feet Limbs symmetrical in
size with moderate muscle mass and tone bilaterally.
Palpate nails for capillary refill Capillary refill < 1sec
Palpate joints & muscle mass Non-tender to palpation over muscles and
joints. No masses or deformities noted.
Palpate popliteal, posterior tibial, and dorsalis pedis pulses Popliteal,
posterior tibial, and dorsalis pedis pulses 2+, regular and equal bilaterally.
Palpate for temperature of extremities
Assess ROM Full ROM.
Hip – Internal & external rotation, flexion, extension, adduction & abduction
Knee – Flexion & extension
Ankle & foot – dorsiflex & plantar flex toes, invert & evert ankle, rotate ankles
inward & outward Able to dorsiflex and plantar flex against resistance.
Assess strength Strength 5/5 bilaterally.
Hips Knees Ankles
Percuss patellar DTR Patellar DTR elicited 2+ bilaterally.
Upper Extremities
Inspect skin, nails Even skin tone, smooth with scattered macules; nail beds
pink with no clubbing noted.
Inspect size, shape, symmetry of upper limbs, hands Limbs symmetrical in
size with moderate muscle mass and tone bilaterally.
Palpate nails for capillary refill Capillary refill < 1 sec
Palpate joints & muscle mass Non-tender to palpation over muscles and
joints; No masses or deformities noted bilaterally.
Palpate radial, brachial pulses Brachial and radial pulses 2+ bilaterally.
Palpate for temperature of extremities
Assess ROM
Shoulder – adduction, abduction, internal & external rotation
Elbow – Flexion, extension, supination & pronation
Wrist – Flexion, extension, lateral movement
Fingers – Flexion, extension, adduction & abduction
Assess strength Strength 5/5 bilaterally.
Shoulder Elbow Wrist Finger
Hand grip Hand grips are strong bilaterally.
Percuss for biceps DTR Brachial DTR elicited 2+ bilaterally.
Spine
Inspect thoracic-lumbosacral spine in straight and forward bend position in
2 views (posterior & lateral) C curve in forward bent position, posterior and
lateral view; Double S curve in lateral standing position.
Describe symmetry landmarks Spine midline, no deviations noted in standing
or forward bent positions, posterior and lateral views. Shoulders, scapula, and
iliac crests symmetrical.
Palpate vertebra
Assess ROM
Flexion, extension, rotation & lateral bending
Summary
J.A. is a well-nourished female with VS: BP 116/76, P 88, R 14, T 98.2.
Heart sounds regular with S1 and S2 heard in all areas. Chest movement even
and respirations regular, clear, vesicular breath sounds heard over peripheral
fields. Abdomen is flat and symmetrical, bowel sounds present in all four
quadrants.