Copy of Script - 3440 Head to Toe (1).docx - Introduction Knock introduce self Head to toe assessment today Orientation name DOB where are you who am I

Copy of Script - 3440 Head to Toe (1).docx - Introduction...

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Introduction: Knock, introduce self, Head to toe assessment today Orientation - name, DOB, where are you, who am I, what are we doing (person, place, time, situation): Pt is oriented x4 Sitting posture: Pt is sitting with an erect and upright posture Inspect skin on arms and face: Pt’s skin is smooth, even colored appropriate for ethnicity; No redness, no masses, no lesions. Skin is warm and dry to the touch. Compare arms: Arms are symmetrical bilaterally; No edema, no varicose veins. Look at skul: Skull is round and proportional to body size Look at scalp using fingers: no lesions or scaliness on the scalp; Hair is clean and dry and evenly distributed, no sign of balding Palpate skull, say “tell me if you have any pain or tenderness”: Skull has no masses, no lumps, no tenderness Palpate ears: Auricles are symmetrical bilaterally; No lesions or nodules Palpate lymph nodes: Lymph nodes non-palpable, no tenderness; occipital, pre- auricular, post-auricular, tonsillar, submandibular, submental, post cervical, superficial cervical, deep cervical and supraclavicular Inspect Neck: Neck is symmetrical, color is even and smooth, no lesions, no masses, no tenderness; Palpate neck: Trachea is midline, no deviation, no tenderness, no masses. Palpate thyroid from behind: Thyroid is non-palpable, no masses, no tenderness. Pt swallows: thyroid cartilage rises smoothly and evenly with swallowing Neck range of motion (left, right, up, down): Pt has full range of motion of neck. Shrug shoulders against resistance: CN 11, spinal accessory, is intact Palpate TMJ, do range of motion of TMJ: Pt has strength in temporalis and masseter muscles, even bilaterally; No clicking or crepitus felt, no tenderness; Pt has full range of motion at TMJ have pt bite down: CN 5 Trigeminal motor is intact. Pt sticks out tongue: Tongue is symmetrical and midline, no twitching or abnormal movements, no swelling, no lesions Have pt push tongue to cheek against resistance: Hypoglossal, Cranial Nerve 12 is intact. Inspect lips: Lips are pink and moist; no lesions, no ulcers, no swelling Inspect mouth: Buccal mucosa is pink and moist; no lesions, no ulcers, no swelling; No swelling, redness, or exudate on soft or hard palate. Lift tongue: no lesions, no ulcers, no swelling under the tongue; Pt says “ahhh”: soft palate and uvula rise symmetrically; No swelling or redness of tonsils; tonsils are 2+ in size Gag: Gag reflex is intact; glossopharyngeal nerve (CN IX) and vagus nerve (CN X) intact Have pt breathe through each nostril, one at a time: Pt is able to breathe through each nostril with ease Shine light in nostrils: No septal deviation, nasal mucosa is pink and free from lesions, discharge, masses, polyps, or exudate
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