EARS, NOSE, MOUTH

• Head is atraumatic, face is non-edematous / edematous, swollen
• Hears and understands verbal questions and commands
• Face is symmetric and expressive / drooping
• No rhinorrhea / thick mucus discharge
• Lips and gums healthy
• Good dentition, good oral hygiene
• No oral lesions

NEUROLOGIC

• Mental status: at baseline
• Recent and remote memory intact
• Coordination
• Cranial nerves:
  • Visual Acuity (II)
  • Extraocular movement (III, IV, VI)
  • Facial sensation & chewing (V)
  • Facial muscles and eyelids closing (VII)
  • Hearing (VIII)
  • Swallowing (X)
  • Shoulder shrug (XI)
  • Tongue movement (XII)

EYES

• Conjunctivae & sclera normal
• No exudates or crusting
• Pupils equal and round
• Extraocular movements full

NECK

• Neck is overall symmetric without gross swelling
• No jugular venous distension while patient seated upright
• Full range of motion without discomfort (degrees of flexion)

PSYCHIATRIC

• Alert & oriented to time, place, person
• Mood & affect: calm / anxious, expressive / flat, crying, laughing
• Behavior: normal, cooperative
• Speech: normal / pressured / slow
• Thought content: normal
• Judgment: normal

RESPIRATORY

• Speaking in full sentences / Speech limited due to SOB
• No significant coughing observed / Cough is frequent and coarse
• No audible wheezes or other abnormal breath sounds
• Normal respiratory rate / Breathing rapidly
• Normal work of breathing, no accessory muscle use

SKIN

• No diaphoresis, cyanosis
• Not pale
• No rashes or lesions on observed skin

CONSTITUTIONAL

• Awake, Alert
• Well / Ill-appearing
• No distress / Distressed
• Well groomed/ Disheveled
• Attentive / Fatigued
• Conversive / Reserved

ABDOMEN

• Non-distended / distended
• Self or caregiver palpation of abdomen was non-tender / refused / painful
• Able to jump up and down without increased discomfort (peritonitis)

MUSCULOSKELETAL

• Normal digits and nails / clubbing, cyanosis, wounds, petechiae, pallor
• Normal bulk / Atrophic extremities
• Normal range of motion / Limited motion due to pain or weakness
• Controlled movements / flaccid, weak, spastic, abnormal movements
• Nonedematous / edema in ankles or hands
• Self-assessment of musculoskeletal injuries (i.e. Ottawa ankle and knee rules)