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Test
General Survey (7 pts) - 🧠 ANSWER ✔✔1. Pt appears to be as stated age.
2. Pt sits comfortably with arms relaxed, posture is erect.
3. Pt does not appear to be in distress, no grimacing or labored breathing
throughout the exam.
4. Pt maintains eye contact, expressions are appropriate to the situation,
articulation is clear and understandable.
5. Pt is comfortable and cooperative throughout the exam.
, 6. Pt is well-groomed with no distinguishable body odor.
7. Pt's height and weight are proportional, body fat distribution is even.
Vital Signs (7 pts) - 🧠 ANSWER ✔✔1. Pt's temperature was ____ F
obtained temporally.
2. Pt's blood pressure was _____ systolic over ____ diastolic on his right
upper arm, sitting, using the two step method.
3. Pt's heart rate was ______ bpm obtained apically with a regular rate and
rhythm.
4. Pt's RR was _____ breaths per minute, easy and unlabored.
5. Pt's O2 sat was 99% on room air.
6. Pt states that pain is a 0 on a 0-10 scale.
7. Pt is alert and oriented to person, place, time and situation.
HEENT (6 pts) - 🧠 ANSWER ✔✔1. Pt's near and far vision is intact, pt was
able to read my badge at 14 inches away and read a paper sign on the
curtain 6 feet away.
2. Pt was not wearing glasses and does not use contacts.
3. Pt's pupils were equal, round, and reactive to light.