ROS

1. HEADACHE
2. DIZZNESS
3. EYES PROBLEMS
4. EAR PROBLEMS
5. NASAL CONGESTION
6. SORE THROAT
7. SWELLING GLANDS
8. FEVER/CHILL
9. FATIGUE
10.SOB
11.COUGH
12.CHEST
13.HEART RAICING
14.NAUSEA/VOMITING
15.ABDOMINAL PAIN
16.CONSTIPATION/DIARRHEA
17.CHANGE WEIGHT
18.CHANGE APPETITE/ ANY CHANGE IN DIET/ EXERCISE
19.CHANGE BOWEL MOVEMENT
20.CHANGE URINARY HABBITS
21.CHANGE IN SLEEP HABITS
22.JOINT PAIN( PAIN IN OTHER PART OF YOUR BODY)
23.RECENT INJURY
24.ILLS CONTACT/ RECENT TRAVEL

PHYSICAL EXPLORATION
HEAD
1. Now I am going to exam your head.. Exam de atra pa lante..DECIR : I dont
see any masses or bruises

2. any pain?
3. Now I am going to press your face.. any pain?
4. Now I am going to touch your face: is the same on both sides(tres lugares)
5. Now I am going to exam your eyes can you look up
6. Can you fallow my finger w/o moving your head. mov y conversion
7. Can you look at point in the wall and tell me when you see my finger.
8. Now I am going to shine a light in your eyes
9. Now I am going to turn off the light to look in your eyes
10.Now I am going to exam your ears any pain?
11.Do you hear this? And this?
12.Now I am going to put this instrument on top of your head. Please tell me if
the sound is the same in both ears.. WEBBER
13. Now I am going to put this instrument behind your ear please tell me when
this stop. Do you hear this DOS OREJAS RINNE
14.Now I am going to look into your ears.
15.Vestibularlook to the L to the R .. any dizziness
16.Now I am going to see your nose.. alumbrar con la luz
17.Can you open your mouth.. alumbrar con la luz
18.Can you say ahh
19.Please stick out your tongue.. move to the right, to the left, up, down
20.Can you smile
21.Can you lift your eyebrows
22.
Please close your eyes and dont let me open*******
23.Shrug your shoulder
24.
Xxxxx please do this /strait your arms and hold
25.
Please squis my hand.. thank you
26.
I am going to check your muscle strength. Resist me
27.
I am going to check your pulses
28. I am going to touch your neck
29.Now I will go to your back to touch your neck. I need you to swallow would
you like some water
30.I need to listen on your neck. Please take a deep breath and hold the breath
ausculto y palpo BL
31.I am going to exam your lungs Can you untie your gown.. I can help you.
32.I am going to look on your back
33.I am going to touch your back.. any painparaspinal, spinal
34. I am going to leasing your lungs please every time I touch breath in and out
with your mouth
35.I am going to tap on your back
36.Please every time I touch your back say 99
37.Please take a deep breath =TVF
38.I am going to tap on your back.. ANY PAIN= CVAT
heart
39.Can you lower your gown, Im going to check your heart
40. Im going to touch .. any pain tocas dos veces
41.Im going to listening your heart (A/P/T/M).. mujer en mitral please lift your
breast

42.Can you bent forward (auscultas aurtico)

43.Can you bent a little backward.. can you look to your left=JVD
44.Can you lay down=auscultas
45.Im going to touch your chest can you turn to the left
46.Can you cover your chest
Abd
47.Now Im going to exam your belly can you uncover your belly
48.I am going to look ..rash redness(ISPECCION)
49.I am going to listening your belly (AUSCULTACION)
50.I am going to touch your belly(PALPACION)
51.Now a little deeper
52.Does this cause painRovsing/Rebound
53.I am going to top on your belly(PERCUSION)
54.Murphys.. deap breath
55.You can cover your belly
EXT
56.Now I am going to exam your arms and legs(iNSPECCION)
57.PALPATION any pain.. HOMBRO/CODO MUNECA..
58.ROM: CRUCE POR ARRIBA LAS MANOS EN LA ESPALDA TOCANDOSE
ESCAPULAS Y POR ABAJO IGUAL..
59.Resist me: alante, atras , afuera, adentro codo en Angulo de 90 grados
60.Pulso..radial y brachial
61.Sensation (tres partes sharp and dull) this is sharp and this is dull. Please
close yours eyes .. can you tell me
62.DTR: biceps tricepss
63.Piernas: PALPAS RODILLA/BATATA/ANKLE
64.Strength
65.Pulsos DP..tibial/radial
66.Sensation 3
67.Reflex: rodilla Achilles
68.Cerebellar: can you stand up: Can you walks few steps in straight line..can
you turn back.. call in your heel. With your tip toes
69.Can you put your arms like this and close your eyes
70.Can you touch your nose with the tip of you finger and then my finger
MMSE:
1.
2.
3.
4.
5.
6.
7.
8.

I am going to check your memory

Tell me your full name
Where are you right now?
Im going to tell you three words please repeat after me because I will as you
then later: car, apple table. Thank you
What day is today today?
Who is the president of the US
Please close your eyes, please open
Can you spell the word world backward

9. Can you tell me the three words