Skin, Hair & Nails Script

I am inspecting the arms. The skin is intact and even. Vascularity is consistent and regular. There is no bruising present. The skin is smooth, dry and free of lesions. The nail beds are pink. The nails are rounded, clean and even. The nail angle is 160 degrees with no signs of clubbing. The nails are not weak or brittle. Capillary refill time is less than 2 seconds. I am palpating the radial pulse. It is normal and at an even rate. I am palpating the brachial pulse. It is normal and at an even rate. I am palpating the arms bilaterally with the backs of my hands for temperature. The temperature is normal. There is no excess moisture or dryness. I am palpating for edema. There is no edema. I am inspecting the legs. The skin is intact and even. Vascularity is consistent and regular. There is no bruising present. The skin is smooth, dry and free of lesions. The nail beds are pink. The nails are rounded, clean and even. Nails are not weak or brittle. There is no leg hair. I am palpating the femoral pulse. It is normal and at an even rate. I am palpating the popliteal pulse. It is normal and at an even rate. I am palpating the posterior tibial pulse. It is normal and at an even rate. I am palpating te dorsalis pedia pulse. It is normal and at an even rate. I am palpating the legs bilaterally with the backs of my hands for temperature. The temperature is normal. There is no excess moisture or dryness. I am palpating for edema. There is no edema. There are no varicosities. Capillary refill time is less than 2 seconds. I am assessing blood pressure. The blood pressure is ___/___.

Head, Neck, Mouth & Throat Script I am inspecting the scalp. It is smooth and free of lesions. I am inspecting the cranium. The cranium is normocephalic and rounded. The hair is thick, not dry or oily, and free of flakes and nits. The face is symmetrical and facial expression is appropriate for the situation. The nose is symmetrical and free of lesions. Please occlude one nostril and breathe in. Please repeat for the other nostril. The nostrils are patent. I am examining the nose with a light. The nasal mucosa is pink and free of lesions and exudates. I am visualizing the turbinates. They are pink and free of lesions and exudates. I am visualizing the septum, which is intact. I am palpating the frontal and maxillary sinuses. There is no inflammation or tenderness. The lips are pink, not dry or cracked, and free of lesions. The mouth is symmetrical. The buccal mucosa is pink, moist and free of lesions. The gums are pink, moist, firm and free of lesions. The teeth are intact and white with no debris. The floor of the mouth is pink, moist and free of lesions. The palate is pink, moist and free of lesions. The tonsils are not swollen and cannot be seen. The oropharynx is pink and free of lesions. The uvula is present. Please stick your tongue out. The tongue is pink, midline, and free of lesions or discoloration. Please say ah. The uvula is mobile. I am palpating the neck. It is symmetrical and free of lumps. I am palpating the lymph nodes. Preauricular, posterior auricular, occipital, submental, submandibular, jugulodigastric, superficial cervical, posterior cervical, deep cervical chain, supraclavicular. Lymph nodes are not swollen, no tenderness and are movable. I am palpating the trachea. The trachea is midline. I am inspecting the thyroid gland. There is no visible enlargement of nodules. I am palpating the thyroid gland. There are no palpable nodules. I am assessing the blood pressure. It is ___/___.

Eyes and Ears Script I am testing cranial nerve II using the Snellen chart. Please stand 20 feet from the chart. Please keep both eyes open and cover one eye with the occluder. Please read me the smallest line you can visualize. Please repeat for the other eye. The vision in the left eye is __/__ and the vision in the right eye is __/__. I am not performing the measurement of vision with the Jaeger screener because the patient is under 40 years old and does not complain of farsightedness. I am testing cranial nerve II, testing the visual fields by confrontation. The peripheral vision is normal. I am testing the corneal light reflex. Please stare straight ahead. The corneal light reflex is symmetrical because the light reflects in the same space on both eyes. I am testing the extraocular muscles and cranial nerves 3, 4 and 6 by using the six cardinal positions of gaze. The eyes were parallel. I am inspecting the external eye structures. The eyebrows, eye lashes, are present and symmetrical. I am inspecting the eyelids. They are free of exudates or inflammation. I am inspecting the lower and upper conjunctiva. They are pink, moist and free of exudates or inflammation. I am inspecting and palpating the lacrimal apparatus. There is no tenderness or exudates among palpation.

I am inspecting the sclera. It is white and uniform. I am inspecting the cornea using a light. It is smooth and free of abrasion. I am inspecting the iris. It is free of cloudiness and is a uniform color. I am assessing the pupil for size (size is ___), shape, and testing direct and consensual response to light with accommodation. Patient is PERRLA (Pupils equal, round, reactive to light with accommodation). I am inspecting the external ear. The position is normal in relation to the cranium and face, The alignment is aligned with the nose. The skin is smooth and pink and free of lesions. The auditory meatus is present and unoccluded. I am palpating the pinna, tragus and mastoid process. There is no tenderness. I am performing an otoscopic exam. I am putting gloves on and preparing the otoscope. I am visualizing the auditory canal. It is free of cerumen. I am visualizing the tympanic membrane. It is pearly gray and intact. I am assessing hearing using the whisper test. Please repeat the words I whisper to you. I am assessing using the Weber test. (Bangs tuning fork) Please tell me if you can hear the tone in both ears. I am assessing using the Rinne test. (bangs fork and holds end to mastoid process) please tell me when you stop hearing the tone. (Bone conduction=___) Moves fork to ear. Please tell me when you stop hearing the tone. (Air conduction=____). Air conduction is greater than bone conduction. I am assessing the blood pressure. It is ___/___.