1.

Common Hospital Abbreviations

a. Universal Abbreviations:
3HEAMSC
a.d.
a.s.
a.u.
ac
ad. Lib.
AF
amp
AOG
BID
BMI
BSE
BTL
BUN
Bx
C&S
CA
CBC
CBR c TP
CBR s TP
CBW
CP
CPT
CRT
CVA
CXR
D&C
D/C
D50W
D5LR
D5NSS
D5W
DAT
DBE
DOE
Dx
EBF
EBM
EOF
FBC-CDU
FBS
FDTW
FHT
Fr
Fx
g
GCS
GIT
gtt
GUT
h.s.
H/A

HASMINE

HBR
HGB
I/O
IBW
ICP
IM
IVF

3-hour early morning sputum collection

right ear ("auris dextra")
left ear ("auris sinistra")
both ears ("auris uterque")
before meals ("ante cibum")
as desired ("ad libitum")
absolute figures
ampule
age of gestation
twice a day ("bis in die")
body mass index
breast self-examination
Bilateral Tubal Ligation
blood urea nitrogen
biopsy
culture and sensitivity
carcinoma; cancer
complete blood count
complete bed rest with toilet privileges
complete bed rest without toilet privileges
cooled boiled water
cardiopulmonary
chest physiotherapy
capillary refill time
cerebrovascular accident
chest x-ray
dilatation and curettage
discontinue; discharged
50% dextrose in water
5% dextrose in lactated ringer's solution
5% dextrose in normal saline solution
5% dextrose in water
diet as tolerated
deep breathing exercises
dyspnea on exertion
Diagnosis
exclusive breastfeeding
expressed breast milk
encourage oral fluids
Foley Bag Catheter - Close Drainage Unit
fasting blood sugar
full diet to watcher
fetal heart rate
French
Fracture
Gauge
Glasgow Coma Scale
gastrointestinal tract
Drops
genito-urinary tract
at bedtime ("hora somni")
Headache
health teachings, anticipatory guidance, safety, security & spiritual,
medications, incision care, nutrition, environment
high back rest
Hemoglobin
intake and output
ideal body weight
intracranial pressure
Intramuscular
intravenous fluid

2
IVTT
KPS
KSS
KUB
KVO
LBM
LLQ
LMP
LOC
LOF
LUQ

METHODS

MGH
MHBR
MI
ML
MSCC
MVA
NABS
NBS
NCCF
neb
NGT
NIL
NOD
NPO-PM
NPO-PS
NSS
NSVD
o.d.
o.s.
o.u.
OD
OGT
OGTT
ORS
OTC
PB
pc

PERRLA

PL148
PLR
PLT
PNSS
po
post-BT
PRN
PTA
PTB
PTC
PUD
PUFT
Px
q 2H
q 4H
qH
QID
RLQ
ROD
RTC
RUQ
Rx

intravenous through tubing

kidney punch sign
keep set sterile
kidneys, ureters, bladder
keep vein open
loose bowel movement
left lower quadrant
last menstrual period
level of consciousness
limit oral fluids
left upper quadrant
medications, environment, treatments & visit to physician, health
teachings, observable signs & symptoms, diet, spiritual
may go home
moderate high back rest
myocardial infarction
main line
mid-stream clean catch
motor vehicle accident
normoactive bowel sounds
newborn screening
no chocolate-colored foods
Nebule
nasogastric tube
not in labor
nurse on duty
nothing by mouth - post-midnight
nothing by mouth - post-supper
normal saline solution
normal spontaneous vaginal delivery
right eye ("oculus dexter")
left eye ("oculus siniste")
both eyes ("oculus uterque")
once a day ("omni die")
orogastric tube
Oral Glucose Tolerance Test
oral rehydration solution
over the counter
Piggyback
after meals ("post-cibum")
pupils are equally round and responsive to light and
accommodation
plasmalyte 148
lactated ringer's solution
Platelet
0.9% sodium chloride solution
by mouth ("per os")
post - blood transfusion
as needed ("pro re nata")
prior to admission
pulmonary tuberculosis
prior to consultation
Peptic Ulcer Disease
pregnant uterus full-term
Patient
every two hours
every four hours
every hour
four times a day ("quater in die")
right lower quadrant
resident on-duty
round the clock
right upper quadrant
Prescription

3
S.O.S.
S/E - OPEH
S/P
S/S
SBR
SOB
SQ
ss.
Sx
T.S.

TAHBSO

TBSA
TID
TPN
TPR
TSB
TSE
TTS
ttt
TURP
TWC
U/A
U/S
URTI
UTI
UTZ
V/S
WCR

if needed ("si opus sit")

stool exam - ova, parasite, Entamoeba histolytica
status post
signs and symptoms
strict bed rest
shortness of breath
Subcutaneous
one-half ("semis")
Surgery
to start
Total Abdominal Hysterectomy with Bilateral SalpingoOophorectomy
total burn surface area
three times a day ("ter in die")
total parenteral nutrition
temperature, pulse & respiration
tepid sponge bath
testicular self-examination
turn to sides
Treatment
transurethral resection of the prostate
terminate when consumed
Urinalysis
ultrasound; ultrasonography
upper respiratory tract infection
urinary tract infection
ultrasound; ultrasonography
vital signs
wheel chair ride

b. Other Abbreviations (some may be used in CVGH only):

AP
FMIOD/FMIIC
FMROD/FMRIC
MIOD/MIIC
MROD/MRIC
OBIOD/OBIIC
OBROD/OBRIC
OIOD/OIIC
OROD/ORIC
PGI
SIOD/SIIC
SROD/SRIC
S.O.

attending physician
family medicine intern on-duty/family medicine intern in-charge
family medicine resident on-duty/family medicine resident in-charge
medical intern on-duty/medical intern in-charge
medical resident on-duty/medical resident in-charge
OB intern on-duty/OB intern in-charge
OB resident on-duty/OB resident in-charge
Ophtha intern on-duty/Ophtha intern in-charge
Ophtha resident on-duty/Ophtha resident in-charge
post-graduate intern
surgical intern on-duty/surgical intern in-charge
surgical resident on-duty/surgical resident in-charge
significant other

2. Common Conversion Factors

The 10 golden rules of drug administration
1. Administer the right drug
2. Administer the drug to the right patient
3. Administer the right dose
4. Administer the drug by the right route
5. Administer the drug on the right time
6. Take a complete patient drug history
7. Find out if the patient has any drug allergies
8. Be aware of potential drug to drug to food
interactions
9. Teach your patient about the drugs he is
receiving

10. Document each drug you administer

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Dosage calculations
a. Conversion between systems of measurement

COMMON APPROXIMATE EQUIVALENTS FOR LIQUID MEASUREMENT

METRIC
1ml
5ml
15ml
30ml
240ml
500ml
1000ml

APOTHECARY
15m (minim)
1 dr
1 oz (ounce)
8oz
1pt (pint)
1 qt

HOUSEHOLD
1 tsp
1 tbsp
2 tbsp
1 measuring cup
1qt

METRIC AND APOTHECARY APPROXIMATE EQUIVALENTS FOR SOLID MEASUREMENT

METRIC (GRAMS)
1g
0.6g
0.5g
0.3g
0.2g
0.1g
0.06g
0.05g
0.03g

METRIC (MILLIGRAMS)
1000mg
600mg
500mg
300-325mg
200mg
100mg
60-65mg
50mg
30mg
0.4mg

COMMON CONVERSION FACTORS

(LIQUIDS)
APOTHECA
HOUSEHOLD
METRIC
RY
1 drop
1 minim (Mx)
0.06 ml
15 to 16 gtts
15 to 16 Mx
1 ml
1 tsp
1 fluid dram
4 to 5 ml
1 tbsp
fl. oz.
15 to 16 ml
2 tbsp
1 fl. oz.
30 to 32 ml
1 cup
6 fl. oz.
180 ml
1 glass
8 fl. oz.
237, 240 or 250 ml
1 pint
16 fl. oz.
473, 480 or 500 ml
1 quart
32 fl. oz.
946 ml or 960 ml or 1 L
1 gallon
128 fl. oz.
3765, 3840 or 4000 ml
COMMON CONVERSION FACTORS (SOLIDS)
HOUSEHOL
D
1 grain (gr)

APOTHECA
RY
1 gr

15.4 gr
1 oz.
1 lb
2.2 lbs

15 gr
480 gr
1.33 lbs
2.7 lbs

METRI
C
0.06 or
0.065 g
1g
28.35 g
454 g
1 kg

APOTHECARY
15gr
10gr
7.5gr
5gr
3gr
1.5gr
1gr
3/4gr
1/2gr
1/150gr

5
METRIC CONVERSIONS
1 milliliter
1000 milliliters
100 centiliters
10 deciliters
10 liters
100 liters
1000 liters
1000 micrograms
1000 milligrams
100 centigrams
10 decigrams
10 grams
100 grams
1000 grams

1 cubic meter
1 liter
1 liter
1 liter
1 dekaliter
1 hectoliter
1 kiloliter
1 milligram
1 gram
1 gram
1 gram
1 dekagram
1 hectogram
1 kilogram

TEMPERATURE CONVERSIONS
F = [(1.8)(C)] + 32
C = (F 32) (0.555)

6
b. Calculation of Dosages
Guidelines:
1. Check whether all measures are in the same system. Convert if necessary.
2. Write the problem in equation form using the appropriate formula and labeling all parts, and
complete the necessary calculations.
3. Check the accuracy of your answer for reasonableness, and have someone else verify your
calculations.
Basic formula:
Desired dose x quantity on hand
OR
D xQ

On-hand dose

OH

Example 1:
The physician orders aspirin gr 10q4h PRN for fever over 101F. On hand are aspirin gr 5 tabs.
1. Check to see if all measurements are in the same system. No conversion is necessary. Both
measures are in grains.
2. Use the formula and label all parts.
D

10gr

OH

X 1 tab

10gr

5 gr

X 1 tab

2X1 tab = 2 tabs

5gr

Check for reasonableness.

Example 2: The order reads Ampicillin 0.5g. The unit dose packet reads 250 mg/cap.
1. Check to see if all measurements are in the same system.
Convert grams to milligrams.
1g=1000mg
0.5g X 1000mg= 500mg
1g
2. Use the formula and label all parts.
D
X
Q
500mg X 1 tab
500mg X 1 cap
2X1 cap = 2 caps

OH

250mg

250mg

Example 3: The preoperative order reads Demerol 60mg IM on call. The narcotics locker contains
ampoules labeled meperidine (Demerol) 100mg/2ml.
1. Verify that all measures are in the same system. No conversion is necessary.
2. Set up the problem as a proportion and label all terms:
Dose on hand
=
Desired quantity
Known quantity
Unknown quantity
100mg
2ml

60mg
x ml

100mg (xml)
100ml

60mg (2ml)
100ml

120ml
100
1.2ml

3. CVGH Medication Ticket System (also include parts of a medication ticket)

COLOR

DEPARTMENT

Red
Orange
Pink
Yellow
Blue
White

Surgery
EENT
Family Medicine
Pediatrics
Internal Medicine
OB/Gyne

MEDICATION
TIMING
OD
BID
TID
QID; q4H
PRN
As specified

OUTLINE FOR PHYSICAL EXAMINATION (Head-to-Toe)

> Review of Regional Body Landmarks (anterior & posterior)
I. ASSESSMENT OF THE SKIN, HAIR NAILS
A. Anatomy & Physiology Overview
B. Preparing the Client
C. Equipment
D. Skin Assessment
1. Inspection
a. Color & Pigmentation
> Common Skin Variations:
Freckles
Vitiligo
Striae
Seborrheic keratosis
Scar
Mole
Cutaneous tags
Cutaneous horn
Cherry angiomas
> Abnormal Findings:
Albinism
Erythema
Pallor
Cyanosis (central & peripheral)
Jaundice
Acanthosis nigricans
b. Lesions
> Primary Skin Lesions
Macule
Patch
Papule
Plaque
Nodule
Tumor
Vesicle
Bulla
Wheal
Pustule
Cyst
> Secondary Skin Lesions
Erosion
Ulcer
Scar (Cicatrix)
Fissure
Scales
Crust
Keloid
Atrophy
Lichenification

8
> Vascular Skin Lesions
Petechia
Ecchymosis
Hematoma
Cherry Angioma
Spider Angioma
Telangiectasis (Venous Star)
> Configuration of Skin Lesions
Linear
Annular
Zosteriform
Discrete
Polycyclic
Confluent
> Pressure Ulcer Staging
Stage 1
Stage 2
Stage 3
Stage 4
> Types of Wounds
Abrasion
Incision
Laceration
Puncture
Avulsion
Amputation
> REEDA Assessment of Skin Lesions
Redness
Ecchymosis
Edema
Discharge/Drainage
- Sanguineous
- Serous
- Serosanguineous
- Purulent
Approximation
2. Palpation
a. Moisture
b. Temperature
c. Texture
d. Thickness
e. Mobility & Turgor
f. Edema
E. Scalp & Hair Assessment
1. Inspection
a. Color
b. Distribution
2. Inspection & Palpation
a. Condition (cleanliness, dryness or oiliness, parasites & lesions)
> Common Hair Variations
Male Pattern Baldness
> Abnormal Findings:
Alopecia
Patchy Hair Loss
Pediculosis Capitis
Tinea Capitis
Hirsutism
F. Nail Assessment
1. Inspection
a. Color
b. Shape
> Abnormal Finding:
Clubbing

9
2. Inspection & Palpation
a. Condition (nail grooming & cleanliness; texture; nail markings; nail plate attachment to
nail bed)
> Abnormal Findings:
Beaus Lines
Spoon Nails
Pitted Nails
Paronychia
II. ASSESSMENT OF THE HEAD & FACE
A. Anatomy & Physiology Overview & Landmarks
B. Head Assessment
1. Inspection
a. Configuration & Symmetry
2. Palpation
a. Consistency
C. Assessment of the Face
1. Inspection
a. Facial symmetry
b. Involuntary movements
2. Palpation
a. Temporomandibular joint (TMJ)
D. Abnormalities of the Head & Face
Acromegaly
Cushings syndrome
Pagets disease
Bells palsy
Parkinsons disease
Cachexia
III. Eye Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of External Eye Structures
1. Eyeballs (symmetry, protrusion & sinking)
> Abnormal Findings:
Exophthalmos
Sunken eyeballs
2. Eyebrows (color, symmetry, distribution)
3. Eyelids (position & appearance of eyelids & eyelashes; color changes; blinking)
> Abnormal Findings:
Ectropion
Entropion
Chalazion
Hordeolum
Blepharitis
Ptosis
Lagophthalmos
Eye trauma
4. Bulbar Conjunctivae & Sclerae (clarity, color, texture)
> Abnormal Findings:
Conjunctivitis (Pink Eye)
Pinguecula
Subconjunctival Hemorrhage
Episcleritis
5. Palpebral Conjunctivae (swelling, lesions, foreign bodies, trauma, discharges)
> Abnormal Findings:
Pallor (pale palpebral conjunctivae)
6. Lacrimal Apparatus (swelling, redness, drainage, tenderness)
> Abnormal Finding:
Dacryocystitis
7. Cornea & Lens (appearance)
> Abnormal Findings:
Arcus senilis

10
Corneal scar
Pterygium
Cataract

8. Iris (shape & color)

> Abnormal Findings:
Hyphemia
Hypopyon
9. Pupils (shape, size, direct & consensual reaction to light, accommodation)
> Abnormal Findings:
Miosis
Anisocoria
Mydriasis
D. Assessment of Extraocular Muscle Function
1. Corneal Light Reflex Test
2. Cover Test
3. Cardinal Gaze (Positions test)
4. Abnormal Findings
Strabismus (Tropia)
Esotropia
Exotropia
Pseudostrabismus (normal pediatric variation)
Nystagmus
E. Assessment of Vision
1. Color Vision
2. Visual Acuity: Distant Vision
> Abnormal Findings:
Astigmatism
Myopia
Amblyopia
3. Visual Acuity: Near Vision
> Abnormal Finding:
Presbyopia
4. Peripheral Vision (Confrontation Test)
IV. Ear Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of External Ear Structures
1. Symmetry (size)
2. Auricle position (alignment of pinna with lateral canthus of eyes, configuration of earlobe)
> Normal Variations in Configuration of Ear Lobe:
Attached Ear Lobe
Soldered Ear Lobe
> Abnormal Finding:
Low-set Ears
3. External Ear (lesions, discolorations, discharge, tenderness)
> Normal Variation:
Darwins tubercle
4. External Canal (presence of foreign body or discharges; tenderness on manipulation; amount,
color, consistency & odor of cerumen; color & consistency of ear canal walls
& tympanic membrane)
5. Abnormalities of the External Ear & Ear Canal
Tophi
Postauricular Cyst
Malignant Lesion
Otitis Externa
Foreign Body
Impacted Cerumen
Exostosis
6. Common Abnormalities of the Tympanic Membrane
Acute Otitis Media
Serous Otitis Media
Perforated Tympanic Membrane

11
D. Assessment of Hearing
1. Whisper Test
2. Watch Tick Test
3. Weber Test
> Abnormal Findings:
Conductive Hearing Loss
Sensorineural Hearing Loss
4. Rinne Test
> Abnormal Findings:
Conductive Hearing Loss
Sensorineural Hearing Loss
V. Assessment of the Nose & Sinuses
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of Nasal Structures
1. External portion (nasal color, shape, consistency, tenderness)
2. Patency
3. Internal portion (mucosa, nasal septum & nasal passages; note position of septum, color,
consistency, lesions, perforations & presence of discharges/exudate)
D. Assessment of Sinuses (frontal & maxillary)
1. Percusion & Palpation (tenderness, crepitus)
2. Transillumination
E. Abnormalities of the Nose
Epistaxis
Deviated Septum
Perforated Septum
Nasal polyp
VI. Assessment of the Mouth & Pharynx
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment Proper
1. Lips (consistency, color)
> Abnormal Findings:
Circumoral pallor
Bluish (cyanotic) lips
Reddish lips
Cheilosis
Herpes simplex
Cleft lip
2. Teeth & Gums (color, condition & alignment of teeth; color & consistency of gums)
> Abnormal Findings:
Dental caries
Malocclusion
Gingivitis
Receding Gums
Gingival Hyperplasia
3. Buccal mucosa (color & consistency; Stensons ducts)
> Abnormal Findings:
Aphthous Ulcer (Canker Sore)
Kopliks Spots
4. Tongue (color, moisture, size, texture, fasciculation, midline protrusion, lesions & induration;
ventral surface, frenulum, area under tongue, Whartons ducts & sides of tongue)
> Abnormal Findings:
Fissured Tongue
Black, Hairy Tongue
Smooth, reddish, shiny tongue w/o papillae (Beefy Red Tongue)
Leukoplakia
Candida Albicans Infection (Thrush)
Carcinoma of Tongue
5. Palate (color & integrity of soft & hard palate)
> Normal Variation:

12
Torus

palatinus

> Abnormal Finding:

Cleft Palate
6. Breath Odor
> Abnormal Findings:
Fruity or Acetone Breath
Ammonia Odor
Foul Odor
Sulfur Odor (Fetor hepaticus)
7. Uvula (characteristics & positioning)
8. Tonsils (color, size & presence of swelling, exudate or lesions; grading of tonsils)
> Abnormal Findings:
Tonsillitis
9. Oropharynx/Posterior Pharyngeal Wall (color & presence of exudate or lesions)
10. Gag reflex
VII. Neck Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment Proper
1. Symmetry (position, movement of neck structures as client swallows)
2. ROM (range of motion)
3. Trachea (position)
4. Thyroid gland (symmetry of key landmarks; consistency, tenderness, presence of nodules,
enlargement & bruits)
5. Lymph nodes (includes the ff.: preauricular, postauricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical chain,
& supraclavicular; size, shape, delimitation, mobility, consistency, tenderness,
& location of palpable lymph nodes)
6. Abnormal Finding
Thyroid Enlargement
VIII. Breast Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment Proper
1. Shape
2. Symmetry
3. Nipples (size, direction, dryness, lesions, bleeding, discharge, retraction, dimpling & presence
of supernumerary nipples; color, size, shape, texture & presence of Montgomery
tubercles on areolas)
4. Masses (location, size in cm, shape, mobility, consistency, tenderness, & condition of skin
over mass)
5. Discharges
6. Lymph nodes (characteristics of palpable axillary lymph nodes & epitrochlear node)
7. Abnormal Findings
Peau d Orange
Pagets Disease (crusty, red, scaly nipples)
Gynecomastia
IX. Assessment of the Chest & Lungs
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment Proper
1. Configuration (anterior & posterior thorax for shape, symmetry, anteroposterior to
transverse diameter, position of scapulae, sternum & slope of ribs)
2. Retractions & Bulging (on sternum & intercostal spaces)
3. Depth, Rhythm & Quality of Respiration (breathing characteristics, rhythm, depth,
use of accessory muscles, clients positioning)
4. Tenderness & Sensation (warmth, pain & other sensations)
5. Crepitus (crackling sensation)
6. Fremitus (symmetry & intensity of vibration)
7. Chest expansion

13
8. Percussion tone
9. Diaphragmatic excursion
10. Breath sounds (presence & location & bronchial, bronchovesicular & vesicular breath
sounds)
11. Adventitious sounds (presence & location of crackles, wheezes, & pleural friction rub)
12. Voice sounds (bronchophony, egophony & whispered pectoriloquy)
X. Heart, Neck Vessel & Peripheral Vascular Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of the Heart (Precordium)
1. Heaves (visible pulsations)
2. Apical Impulse (location & amplitude)
3. Abnormal Pulsations (presence of thrills & other unusual pulsations)
4. Rate & Rhythm of Apical Pulse
5. Pulse Deficit
6. S1 Sound (where heard best)
7. S2 Sound (where heard best)
8. Extra Heart Sounds (location & timing)
9. Murmurs (timing, intensity, pitch, quality, shape or pattern, location, transmission,
ventilation & position)
D. Assessment of Neck Vessels
1. Jugular Vein Distention (also assess for hepatojugular reflux)
2. Jugular Venous Pressure
3. Bruits (carotid arteries)
E. Assessment of Peripheral Vasculature
1. Arm/Leg Edema
2. Nail Beds & Capillary Refill Time (CRT)
3. Allen Test
4. Varicosities
5. Homans sign
6. Rate & Strength/Amplitude of Peripheral Pulses (temporal, carotid, brachial, radial,
femoral, popliteal, posterior tibialis,
& dorsalis pedis pulses)
XI. Abdominal Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment Proper
1. Contour
> Abnormal Finding:
Ascites
2. Symmetry (protrusions, bulging or lumps w/ client supine & w/ head raised)
3. Striae
4. Umbilicus (color, location & contour)
5. Aortic pulsations
6. Peristaltic waves
7. Bowel sounds (note character & frequency)
8. Vascular sounds & friction rubs (bruits, venous hums, friction rub over liver & spleen)
9. Percussion tone
10. Liver span
11. Liver palpation (consistency, tenderness, enlargement, presence of nodules)
12. Spleen (percussion tone, tenderness, consistency, enlargement, presence of nodules)
13. Massess palpated (if palpable: location, size in cm, shape, consistency, demarcation,
pulsatility, tenderness, mobility)
14. Kidneys (tenderness on blunt percussion, enlargement, consistency & presence of nodules)
15. Urinary Bladder (tenderness & consistency)
16. Girth
17. Shifting dullness
18. Fluid wave test
19. Rebound tenderness
20. Psoas sign
21. Obturator sign

14
D. Abnormal Findings
Umbilical Hernia
Epigastric Hernia
Diastasis Recti
Incisional Hernia
Hepatomegaly
Splenomegaly
Abdominal Aortic Aneurysm
XII. Rectal Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Selected Positions for Anorectal Examination
C. Equipment
D. Assessment Proper
1. Perianal Area (lumps, ulcers, lesions, rashes, redness, fissures & thickening of epithelium;
presence of bulging, lesions & hemorrhoids as client performs Valsalva
maneuver)
2. Sacrococcygeal area (signs of swelling, redness, dimpling & hair)
3. Anus (tenderness, nodules, hardness & external sphincter tone)
4. Rectum (mucosa: tenderness, irregularities, nodules & hardness; stool: color & blood)
5. Abnormalities of the Anus & Rectum
External hemorrhoid
Perianal abscess
Anal fissure
Anorectal fistula
Rectal prolapse
Pilonidal cyst
XIII. Assessment of the Male Genitalia & Prostate
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of the Penis
1. Base & pubic hair (pubic hair growth pattern; presence of excoriation, erythema or
infestation)
2. Shaft (rashes, lesions, lumps; hardened & tender areas)
3. Foreskin & Glans (size & shape, lesions or redness of glans; color, location, integrity &
retraction of foreskin for uncircumcised client)
4. Urethral opening & discharge (location of urinary meatus; color, consistency, character &
odor of discharges)
5. Abnormalities of the Penis
Syphilitic chancre
Herpes progenitalis
Genital warts
Phimosis
Paraphimosis
Hypospadias
Epispadias
D. Assessment of the Scrotum
1. Size, shape & position (swelling, lumps or bulges)
2. Scrotal skin (color & integrity, lesions or rashes)
3. Testicles & Nearby Structures (size, shape, consistency, nodules & tenderness of each
testis & epididymis; nodules, swelling or tenderness of
each spermatic cord & vas deferens; auscultation &
transillumination if abnormal masse or swelling is noted)
4. Abnormalities of the Scrotum
Hydrocele
Scrotal hernia
Testicular tumor
Cryptochidism
Epididymitis
Orchitis
Small testes
Torsion of spermatic cord

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Varicocele
Spermatocele

E. Assessment of the Inguinal Area

1. Hernias (bulges or masses on inguinal & femoral canal)
2. Lymph nodes (if palpable: size, consistency, mobility or tenderness)
3. Abnormal Findings
F. Assessment of the Prostate
1. Palpation (size, shape, consistency & presence of nodules or tenderness)
2. Abnormal Findings
Benign Prostatic Hypertrophy (BPH)
Cancer of the Prostate
XIV. Assessment of the Female Genitalia
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of the External Genitalia
1. Mons Pubis (distribution of pubic hair & signs of infestation)
2. Inguinal lymph nodes (if palpable: size, consistency, mobility or tenderness)
3. Labia majora & perineum (color & presence lesions, swelling & excoriation)
4. Labia minora, clitoris & vaginal opening (position, symmetry, color & presence of lesions,
excoriation, swelling, & discharge)
5. Urethra (presence of discharges)
6. Bartholins glands (swelling, tenderness, & discharge)
D. Assessment of the Internal Genitalia
1. Vaginal mucosa (color, presence of lesions &/or irregularities)
2. Cervix (color, size, position, surface & appearance of cerval os; presence of lesions &
discharges)
E. Abnormal Findings
Abscess of Bartholins Glands
Genital Warts
Syphilitic Chancre
Genital Herpes Simplex
Cystocele
Rectocele
Uterine Prolapse
XV. Musculoskeletal Assessment (Back & Extremities)
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment Proper
1. Gait (base of support, weight-bearing stability, foot position, stride & strength & cadence of stride,
arm swing)
2. Posture/Stature (curvature of cervical, thoracic & lumbar spine)
> Abnormal Findings:
Kyphosis
Lordosis
Scoliosis
3. Symmetry
4. Range of Motion (ROM of cervical spine, thoracic & lumbar spine, shoulders, arms, elbows,
wrists, hands & fingers, hips, knees, ankles & feet)
5. Crepitus
6. Fasciculations
7. Bony deformities
> Abnormal Findings:
Boutonnire & Swan Neck deformities (chronic rheumatoid arthritis)
Bouchards & Heberdens nodes (osteoarthritis)
8. Muscle Strength
D. Special Tests
1. Phalens test
2. Tinels test
3. Lasgues test
4. Bulge knee test
5. Ballottement knee test
6. McMurrays test

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XVI. Neurologic Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of Mental Status/Cerebral Function
1. Levels of consciousness
> Alert
> Lethargic
> Somnolent
> Obtunded
> Stuporous
> Comatose
2. Glasgow Coma Scale (GCS)
3. Mood & Affect
4. Dress, Hygiene & Grooming
5. Facial Expressions
6. Speech (tone, clarity, pace of speech)
7. Vocabulary
8. Thought Processes (clarity, content)
9. Orientation (person, place, time)
10. Attention (ability to focus & stay attentive, ability to follow directions)
11. Memory (remote & recent)
12. Fund of Information (general knowledge)
13. Abstract Reasoning (proverb interpretation)
14. Judgment (sound answer based on hypothetical situations)
15. Visual Perceptual & Constructional Ability (ability to copy simple figures)
D. Assessment of Motor/Cerebellar Function
1. Rapid alternating movements
2. Finger-thumb test
3. Finger-nose test
4. Heel-to-shin test
5. Button-unbutton shirt
6. Tandem walk
7. Romberg test
8. Involuntary movements (fasciculations, tics, tremors)
E. Assessment of Sensory Function
1. Light touch sensation
2. Discrimination bet. sharp/dull sensations
3. Temperature sensation
4. Vibratory sensation
5. Two-point discrimination
6. Stereognosis
7. Graphesthesia
8. Kinesthesia
F. Assessment of Cranial Nerve Function
1. CN I (Olfactory)
2. CN II (Optic)
3. CN III, IV, & VI (Oculomotor, Trochlear, Abducens)
4. CN V (Trigeminal)
5. CN VII (Facial)
6. CN VIII (Vestibulocochlear)
7. CN IX (Glossopharyngeal)
8. CN X (Vagus)
9. CN XI (Spinal Accessory)
10. CN XII (Hypoglossal)
G. Assessment of Deep Tendon Reflexes
1. Biceps
2. Triceps
3. Brachioradialis
4. Patellar
5. Achilles
H. Assessment of Superficial Reflexes
1. Abdominal
2. Cremasteric

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3. Plantar
I. Assessment of Pathologic Reflexes
1. Brudzinkis sign (test for meningeal irritation)
2. Kernigs sign (test for meningeal irritation)

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