Center for Epidemiologic Studies Depression Scale ... - myCME.com

Vital Signs BP P T Wt. lb Ht. inEyes V nl conjunctiva & lidsPupils V pupils symmetrical, reactiveFundus V nl discs & pos elementsENT-External V no scars, lesions, massesOtoscopic V nl canals & tympanic membranesHearing V nl to _ ________Intranasal V nl mucosa, septum, turbinateAnt. Oral V nl lips, teeth, gumsOropharynx V nl tongue, palate, pharynxNeck palp. V symmetrical without massesThyroid V no enlargement or tendernessResp. effort V nl without retractionsChest percuss. V no dullness or hyperresonanceChest palp. V no fremitusAuscultation V nl bilateral breath sounds w/o ralesHeart palp. V nl location, sizeCardiac ausc. V no murmur, gallop, or rubCarotids V nl intensity w/o bruitPedal pulses V nl posterior tibial & dorsalis pedisMS Gait V nl gait & stationNails V no clubbing, cyanosisCheck nl, circ abn ROM Strength Tone AbnormalsVVVVSkin V nl to inspection & palpationNeurologic V nl alertness, attentiveCranial nerves V w/o gross deficitCoordination V nl rapid alternating movementDTR’s V symmetrical, __ (scale: 0-4+)Sensation V nl touch, proprioceptionMMSEPsych Orient’n V nl to day, mo, yr, time, location _ /10Registration V register 3 items _ _/3Attn/Calc V serial subtraction, world bckwd _ _/5Recall V recall 3 items _ _/3Language V nl nam’g, repit’n,compr’n, read’g, rit’g _ _/8Visuospatial V copy design, clock _ _/1Knowledge V current/past presidents totals _ /30Mood V nl GDS GDS Score _ _/15Breasts V nl inspection & palpation GDS (circle positives)Abdomen V no masses or tendernessSatisfied Afraid WonderfulL/S V no liver/spleenDropped Happy WorthlessHernia V no hernia identifiedEmpty Helpless EnergyAnus/rectal V no abnormality or massesBored Stay home HopelessSpirits Memory Others betterGU male V nl to inspection & palpationProstate V nl size w/o nodularityBetter off dead?Considered harming yourself?GU female V external genitalia nl w/o lesionsInt. inspection V nl bladder, urethra, & vaginaSpeech V nl rate, volumeCervix V nl appearance w/o dischargeThought cont. V logical, coherentUterus V nl size, position, w/o tendernessPsychosis V no hallucinations, delusionsAdnexa V no masses or tendernessJudgement V nlLymphatic V nl neck & axillaeBehavior V cooperative, appropriateLymph other VAdditional Description of positive findings:2 Tools May be copied without permission