Rinne test evaluates by testing air conduction to bone conduction. A tuning fork is placed against the patient’s mastoid bone, and the patient is instructed to signal when the sound is no longer heard. Then, the tuning fork is placed near the auditory canal and the patient is instructed to do the same. Nose External nose Intact with no abnormalities. Smell intact, can identify the small of coffee with eyes closed. Patency of nostrils Bilateral patent nostrils, no abnormal drainage. Describe the purpose of the speculum evaluate nasal mucosa, septum, and turbinates Using a speculum allows for better examination of the internal nose including nasals mucosa, septum and turbinate because it widens the passage. Mouth and Throat Lips and buccal mucosa Lips pink, full, intact. Some dry skin noted, buccal mucosa pink, moist, intact. Teeth and gums Teeth normal, no broken or missing teeth, gums intact, moist, pink. Braces noted. 7
Tongue, hard palate, and soft palate Tongue has good movement, able to move on command. Hard and soft palate intact. Tonsils Tonsils pink and equal with no signs of swelling or irritation Uvula (cranial nerves IX, X) Cranial nerves IX and X intact. Able to swallow without difficultly, Uvula pink, moist, intact. Moves with patient said, “Ahhhh” Tongue (cranial nerve XII) Tongue pink, moist, intact. Cranial nerve XII intact. Able to protrude tongue and move side to side without issues. Neck Symmetry, lumps, and pulsations Symmetric. No lumps or pulsations. Cervical lymph nodes Cervical lymph nodes present and normal Carotid pulse (bruits if indicated) Carotid pulses present, equal and normal bilateral Trachea Midline placement, cartilage rings intact regular breathing. ROM (cranial nerve XI) Cranial nerve XI intact. Able to raise and drop shoulders symmetrically and without difficulty. Thyroid gland Present, moves appropriately. Chest and Lungs: Posterior and Lateral Thoracic cage configuration Skin characteristics Symmetric expansion Tactile fremitus Lumps or tenderness Skin posterior and laterally of thoracic cage intact, color normal for ethnicity and without lesions. Patient states no tenderness. No lumps noted in area. Chest expansion symmetric. Tactile fremitus present. All ribs noted to be present upon visualization and palpation. Spinous process All palpable spinous processes present, non tender. Percussion over lung fields Low-pitched hollow resonance throughout lung fields when percussed. CVA tenderness No CVA tenderness Breath sounds All lobes clear bilaterally upon auscultation Adventitious sounds No adventitious sounds auscultated Chest and Lungs: Anterior Respirations and skin Regular depth, Skin with no abnormalities, skin 8
characteristics dry, intact, normal, color appropriate. No retractions. Tactile fremitus, lumps, and Tenderness Tactile fremitus present. No lumps or tenderness noted.
You've reached the end of your free preview.
Want to read all 11 pages?
- Fall '18