NEUROLOGICAL

● How are you feeling today? Simi expressions match with mood.
● Comments and speech pattern, can able to understand and response clear, and
understandable articulation.
● LEVEL OF CONSCIOUSNESS, patient is awake, aware, alert, and responsive.
● Two neurological history questions:
Do you have any seizures?
Do you have any history of frequent or unusual headaches?
● I’m also assessing the orientation sphere such as person, place, and time. Okay,
Can you please tell me your full name? Do you know where you are? Do you know the date
today? Patient is alert and oriented to person, place, and time.
● Short-term memory question: Can you tell me what to show in the entrance when you
come here?
● Long-term memory question: When is your birthdate? Her short-term and long-term memory is
intact.
● Now, I will assess your pupils for its shape, size, equal, reaction to light, and accommodation.
First, I will check the shape and size of your pupils, okay it’s round and 3mm. Then, I’m going to
shine a light in each eye, is that okay with you? Please look straight ahead while I’m moving a
penlight back and forth in front of your eyes. Reaction to light, normal. If you can follow my pen,
that would be great. Left and right, up and down and away from you. Pupils 3 mm Equal, Round,
Reactive to Light and Accommodation.
● Can you please squeeze my fingers for a grip strength. Motor functions are strong, equal
bilaterally to upper extremities.

● Now, I will assess your lower extremities bilaterally: dorsiflexion and plantar flexion against
resistance. Can you please move your feet up against my hand. Can you bend your feet down
please against the resistance. Thank you. Motor functions strong, equal bilaterally to lower
extremities.
 ● Perform hand hygiene.
● Now I will do the dull and sharp in upper extremities by using the tongue depressor and
cut this into half, this is sharp part and the dull part (let the patient feel). Please close your eyes,
and tell me whether it’s sharp or dull, okay. Now we will do the same thing in lower extremities,
please close your eyes and tell me whether it’s sharp or dull part. Able to indicate and intact
sensation bilaterally to dull and sharp

MUSCULOSKELETAL
● .Two musculoskeletal history questions:
Do you have any muscle weakness?
Do you have any traumas like fractures, sprains and dislocations?
● Now, I will assess youre gait. Can you walk from here to the other side? Well-balance upright
coordinated rhythmic.
● Then I will also check the Passive Range of Motion, I will do flexion of your arms,
extension, supination, and pronation.
● Apply resistance just proximal to the wrist, and instruct the patient to flex the elbow against your
resistance and then extend the elbow against your resistance.

● Check muscle strength by asking the patient to maintain knee flexion while you oppose by trying
to pull the leg forward. The patient demonstrates muscle extension by successfully rising from a
seated position in a low chair or rising from a squat without using the hands for support.
Muscle strength hundred percent in both upper and lower extremities.
RESPIRATORY
● Two relevant respiratory health history questions:
Have you ever been diagnosed with a respiratory condition like asthma, COPD,
pneumonia, or allergies?
Do you have any chest pain when breathing?
● Chest inspection: Now, I will inspect your anterior chest and posterior chest.
Normal chest shape with no visible deformities, bilaterally symmetrical and
elliptical in cross section.
● Then I will assess your ratio or anterior/posterior diameter to transverse diameter, looking
at the anterior, posterior and tell the patient to raise his/her arms to assess.
Anteroposterior-transverse ratio is 1 is to 2 (1:2).
● Your quality and pattern of breathing. Quiet, rhythmic, and effortless respirations. No sinuses
and no use of accessories muscles.
● Skin colour is consistent, no presence of cyanosis/pallor noted.
● I will also inspect your nail beds for clubbing, may I see your fingernails please. Thank you.
Nail beds are free of cyanosis or unusual pallor. The nails are of normal configuration.
● Chest expansion: Now I will do chest expansion. I will start on your anterior chest. I will place my
hands on the anterolateral wall with the thumbs along the coastal margins and pointing toward
the xiphoid process. Take a nice deep breath in and out. Again please. Thank you. Now, to your
posterior chest as well. I will place my hands on the posterolateral chest wall with thumbs at
level of T9 or T10. Sliding my hands medially to pinch up a small fold of skin between my
thumbs. Take a nice deep breath in and out. Again please. Thank you. Full and symmetrical chest
expansion bilaterally.

● I will palpate your anterior chest, and then your posterior chest as well.
No lumps, masses or tenderness to palpation anteriorly and posteriorly.
● Auscultation: anterior, posterior, and lateral chest

● Now, I will do the auscultation, can you breath through your mouth please which
makes easier for me to listen to your lung sounds. Okay, I will start on your anterior
bare chest. Now I will start to auscultate in your supraclavicular down to your 6th
rib comparing each location bilaterally. *each auscultation tell the patient to take a
nice deep breath in and out. (auscultate using clean stethoscope).

● Now, I will auscultate on your posterior bare chest. I will go on your back. I will
start to auscultate from C7 down to T10. *each auscultation tell the patient to take
a nice deep breath in and out. (Auscultate posterior chest using stethoscope)

● I will auscultate your lateral bare chest bilaterally, can you able to raise your left
hand please? Thank you. I will start to auscultate at the axilla and down to the 7 th or 8 th rib . Thank
you. You can now lower down your arm. Now, can you able to raise your right hand please. Thank you.
I will also start to auscultate here at the axilla and then down to 7th or 8th rib. Okay thank you. You
can now lower down your arm.

Anterior, posterior, and lateral bare chest vesicular breath sounds: clear over lung
fields, equal bilaterally. No adventitious sounds are hear
CARDIOVASCULAR
● Two history cardiovascular questions:
Do you have any cardiovascular seizure in the past?
Have you or someone in your family has any cardiovascular disease?
● Now I will check your temperature. Using my two hands at the same time, touch to both of your
arms directly on skin. Same to legs and feet using the back of the hand. Skin temperature is
warm to touch bilaterally.
● Now I’m going to check your capillary refill on your fingers and toes bilaterally. Can you able to
touch your point fingers together. Capillary refill bilaterally less than three (3) seconds, no
clubbing noted.
● Now, I’m palpating for edema in your upper and lower extremities bilaterally. No edema present
bilaterally.
● I will assess radial pulses bilaterally. Radial pulses are strong, regular, equal bilaterally.
● Now I will assess your brachial pulses bilaterally. Brachial pulses are strong, regular, equal
bilaterally.
● I will assess your posterior tibialis pulses bilaterally. Posterior Tibialis pulses are strong, regular,
equal bilaterally.
● Now I will assess dorsalis pedis pulses bilaterally. Dorsalis pedis pulses are strong, regular, equal
bilaterally.
● PERFORM HAND HYGIENE. Don’t forget after touching patient’s feet.
● Now I will assess and gently palpate precordium for presence of cardiac implants,
thrills, heaves, lifts or pulsations. No presence of cardiac implants, thrills, heaves, lifts or
pulsations.
● Now I will palpate the aortic valve in your right sternum in second intercostal space, and
auscultate for S1 S2 using the diaphragm of my stethoscope. II will flip my bell and listen for S3
and S4.
● Next I’m going to palpate your pulmonic valve into your left sternum in second
intercostal space and ausculate for S1 S2. I will flip my bell and listen for S3 and S4.
● Then I will palpate you tricuspid valve as well in your fifth intercostal space and auscultate for S1
S2. I will flip my bell and listen for S3 and S4.
● Then I will palpate your mitral valve in your fifth intercostal space in midclavicular
line and auscultate for S1 S2. I will flip my bell and listen for S3 and S4. Findings: S1 S2 heard in all sites
and no murmurs heard in S3 and S4.

GASTROINTESTINAL
● Two relevant gastrointestinal history questions:
Do you experience any difficulty swallowing?
Are there any foods you cannot eat? (If yes) What happens if you eat then?
● When was the last time you had ever bowel movement? What are the characteristics of your
stool?
● Are there any changes in your bowel?
 ● Any changes in your appetite?
● Now, I will assess your oral mucosa, can you please open your mouth for me. Thank
You. Oral mucosa is pink and moist.
● Next is skin turgor. I will gently grasp a fold of skin in your back forearm or sternal
Area. Skin with normal turgor snaps rapidly back to its normal position.
● Next, in the side of the bed, I will inspect your abdomen for contour in my eye level.
The contour of the abdomen is flat.
● Now, I’m going to the foot of the bed and I will inspect the symmetry of the abdomen.
Abdomen is symmetrical bilaterally, presence of stretch marks noted due to pregnancy.
● Then, I will auscultate first before palpation so that I don’t disturb the bowel
movement/peristalsis. I will now auscultate in all four (4) quadrants using my diaphragm, RLQ
->RUQ ->LUQ ->LLQ —and change into my bell and auscultate the vascular sounds to hear any
bruit. Normal, active sounds in all four quadrants. No bruit heard.
● Now, I’m lightly palpating the abdomen in all four quadrants.m Abdomen soft to touch with no
masses, swelling, pain, and rigidity.

GENITOURINARY
● Two genitourinary history questions:
Have you had any kidney stones?
Are you sexually active?
● When was the last time you voided?
● Is there any changes from normal voiding patterns or any changes in characteristics of
your urine?
● Is it okay to palpate your bladder if it is descended. Thank you.
● . Are you using any contraceptive methods?

INTEGUMENTARY
● Integumentary health history:
Do you have any rashes, eczema, skin allergies, or skin disease?
Do you have any excessive bruising?
● Now I am assessing for any skin abnormalities:
Intact skin with no obvious lesions, (3) moles noted on anterior and posterior chest, birthmark
on posterior chest (manay Ella).
● Skin tone is UNIFORM.
● . Now I’m assessing your elbow, shoulder blade, coccyx, behind the knee, and then in
the toes: No redness, and no skin breakdown.

SLEEPING PATTERN
What does a typical night’s sleep look like? How many hours do you sleep each night? Do you
use a sleep aid.