Appearance (1/3 point)
No visible abnormal findings
Rash
Striae
Distension
Visible masses (warts, cysts, or tumors)
Freckles, birthmark, or discoloration
Excessive hair growth
Scarring
Laceration, lesion, or wound
Bruising
Redness
Jaundice
Prominent veins
Inspected for edema in lower extremities 1 of 1 point
Right: Edema (1/4 point) Right: Severity Of Edema (1/4 point)
No edema No edema
Pitting 1+ Slight pitting
Non-pitting 2+ Deeper pit, disappears in 10 to 15 seconds
3+ Noticeably deep pit that lasts more than a minute
4+ Very deep pit that lasts 2 to 5 minutes
Left: Edema (1/4 point) Left: Severity Of Edema (1/4 point)
No edema No edema
Pitting 1+ Slight pitting
Non-pitting 2+ Deeper pit, disappears in 10 to 15 seconds
3+ Noticeably deep pit that lasts more than a minute
4+ Very deep pit that lasts 2 to 5 minutes
Auscultated heart sounds 1 of 1 point
Heart Sounds (1/2 point) Extra Heart Sounds (1/2 point)
S1 and S2 audible No extra sounds
S1, S2, and S3 audible Gallops
S1, S2, and S4 audible Murmur
S1, S2, S3, and S4 audible Friction rub
Valve clicks
Auscultated breath sounds 1 of 1 point
Breath Sounds (1/3 point) Adventitious Sounds (1/3 point)
Present in all areas No adventitious sounds
Diminished in some areas Wheezing
Absent in some areas Fine crackles
Stridor
Rhonchi
Rales
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