1
Q
NAD
A
Mild/moderate/severe distress (due to pain)
2
Q
Well developed, well nourished
A
Cachectic/emaciated/malnourished
3
Q
Alert
A
Somnolent, obtunded, unresponsive
4
Q
AT/NC
A
- Any signs of trauma
- Sinus tenderness
- Angioedema
5
Q
PERRL
A
Anisocoria (unequal pupils)
6
Q
EOMI
A
EOM entrapment
7
Q
Sclera are anicteric
A
Scleral icterus
8
Q
Normal conjunctiva
A
- Pale conjunctiva
- Conjunctival injection
9
Q
Clear anterior chamber, sharp disc margins
A
- Retinal detachment
- Papilledema
- Hyphema
10
Q
Normal cornea
A
- Corneal abrasion/ulcerations
- Fluorescein uptake
11
Q
Normal TM
A
- TM erythema
- TM bulging
- TM dullness
- TM obscured by cerumen
12
Q
Normal nares
A
- Epistaxis
- Rhinorrhea
- Septal hematome
- Boggy turbinates
- Nasal deformity
13
Q
Moist mucous membrane, OP normal
A
- DMM
- Dental caries
- Edentulous
- Pharyngeal erythema
- Tonsillar exudate
- Tonsillar hypertrophy
- PTA
14
Q
Supple neck and C-spine
A
- JVD
- Carotid bruit
- Cervical lymphadenopathy
- Vertebral point vs. paraspinal tenderness
15
Q
Regular rate and rhythm, heart sounds normal
A
- Tachycardia (HR > 100) OR bradycardia (HR < 60)
- Irregularly irregular rhythm
- Murmur
- Extrasystoles
- Pleural rub
- Gallop
16
Q
Grading scale for perfusion (what is normal?)
A
0 = absent 1+ = barely palpable 2+ = easily palpable (normal) 3+ = full 4+ = bounding/aneurysmal
17
Q
No respiratory distress
A
- Mild/moderate/severe respiratory distress
- Tachypnea
- Accessory muscle use
18
Q
CTAB
A
- Diminished breath sounds
- Wheezes
- Rales
- Rhonchi
19
Q
S and NT abdomen
A
- Mild/mod/severe tenderness to palpation (TTP)
- Voluntary guarding
- Rebound tenderness
- Rigidity (involuntary guarding)
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