Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement Patient able to walk, run, jump, move all joints, and has absent tremors. Facial expression Patient appears with smile and appropriate facial expression. Mood and affect Patient presents with slightly flat affect, but overall pleasant. Speech: articulation, pattern, content and appropriate, native language Speech clear, appropriate articulation, pattern, content. English Hearing Patient is able to hear clearly, and repeats words/ communicates without difficulty. Personal hygiene Appears clean and well-manicured. Measurements and Vital Signs Weight 145 Height 6’0’’ BMI 19.7 Radial pulse: rate rhythm Regular strong, 64 bpm Respirations: rate depth 16 Normal/ average depth Blood pressure (indicate if sitting or lying) 120/80 Sitting 5
Temperature (if indicated) 98.6 Pain assessment Denies pain Skin Hands and nails Clean, dry, intact. All fingers present. No abnormalities. Some minor abrasions noticed. Color and pigmentation Normal for ethnicity. Temperature Warm Moisture No excessive moisture noted Texture Soft Turgor No tenting. Brisk tugar Presence of lesions? None Head and Face Scalp Hair Cranium Scalp intact, no signs of lesions/ trauma. Hair is light brown and shoulder length. Face (cranial nerve VII) Intact, able to make symmetrical facial movements including frowning, smiling, pursed lips, raising and lowering eye brows. Temporal artery and temporomandibular joint Temporal arteries equal bilateral and normal. Maxillary sinuses and frontal sinuses Present, denies pain, swelling, or infection. Eyes Visual fields (cranial nerve II) Visual acuity 20/20 on each eye per Snellen chart. Able to differentiate colors with each eye. Able to visualize throughout all visual fields. Extraocular muscles, corneal light reflex, and cardinal positions of gaze (cranial nerves III, IV, VI) Cranial nerves III, IV, VI intact. Able to move both eyes throughout the 6 cardinal positions of gaze. Able to open and close eyes, able to hold head still with following the H shape. Bilateral eyes pos corneal light reflex, no nystagmus noted External structures Eyelids present/ intact. Eye lashes present. Tear ducts present and functioning. 6
Conjunctivae, sclerae, and corneas No apparent abnormality to conjuctivas, sclera, or corneas of eye bilaterally. No cataracts noted. No redness or excessive tearing noted. Pupils Equal and reactive Describe the purpose of an Opthalmascope for assessing the eyes Allows for a view the inside of the eye which provides examination of the retina and fundus. Ears External ear External ear intact, no abnormalities bilateral. Any tenderness? None Purpose of the otoscope Visualized middle ear canal and ear drum Test hearing (cranial nerve VIII) and conduct the voice test Cranial nerve VIII intact. Repeats words whispered in each ear individually. Balance intact Explain the Weber and Rinne tests Weber test uses tuning forks placed away from the head and the patient is asked to identify loudness and location, often used to test for conductive hearing loss.
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- Fall '18