Head
NCAT- normocephalic atraumatic
General
Answering appropriately, normal attention, calm cooperative
Eyes
conjunctiva normal, normal eyelids, sclera white
Ear
external ear normal
Nose
nares clear
Throat
mucous membrane moist, handling secretions
Neck
supple
Respiratory
unlabored (effortless), CTA bilaterally (clear to ausculation), upper airway patent (open passage of air)
Cardiovascular
regular rate and rhythm, nor murmurs, gallops rubs, and strong peripheral pulses
Gastrointestinal
soft, nontender, nondistended (not swollen)
Genitourinary
deferred
Back
No CVAT (Costovertebral angle tenderness)
Rectal
deferred
Muscuskeletal
Full ROM, nontender extremities
Skin
normal color, warm, dry
Psychiatric
normal mood, normal affect (appropiate display of emotions)
Neurologic
CN’s grossly intact (normal cranial nerve function), Alert and oriented x3, NO focal neurological deficit, symmetric extremities (both sides of limbs correspond in fucntion, size and shape)
