Rinne test evaluates by testing air conduction to

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.