Ears External ear Elastic no drainage or redness noted Any tenderness No

Ears external ear elastic no drainage or redness

This preview shows page 7 - 10 out of 11 pages.

Ears External ear Elastic, no drainage or redness noted Any tenderness? No tenderness Purpose of the otoscope The otoscope looks into the ears with a light. It shows a view of the ear canal and tympanic membrane. Test hearing (cranial nerve VIII) and conduct the voice test Patient able to correctly hear both whispered statements in each ear. Explain the Weber and Rinne tests The Weber test uses a tuning fork to detect hearing loss. It checks unilateral, middle or inner ear hearing loss. The Rinne test evaluates hearing loss in one ear. Compares sound in air vs bone. Nose External nose External nose intact, no sores noted Patency of nostrils Both nostrils patent Describe the purpose of the speculum evaluate nasal mucosa, septum, and turbinates The speculum is used to evaluate nasal anatomy. It shows the color of the mucosa, amount of drainage, looks at the turbinates and if there are any polyps present. Mouth and Throat 7
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Lips and buccal mucosa Lips and mucosa well hydrated, no sores noted Teeth and gums Teeth and gums intact, pink and moist Tongue, hard palate, and soft palate Tongue midline and symmetrical. Hard and soft palate moist and pink, no sores noted. Tonsils Tonsils pink, no redness or sores noted Uvula (cranial nerves IX, X) Gag reflex intact, uvula moved upward Tongue (cranial nerve XII) Tongue midline, pink, no sores noted Neck Symmetry, lumps, and pulsations Neck symmetrical, no lumps, tenderness or pulsations noted Cervical lymph nodes Cervical lymph nodes intact, no tenderness or swelling noted Carotid pulse (bruits if indicated) Carotid pulse present, not bounding, no bruits present Trachea Trachea intact, no deformities noted ROM (cranial nerve XI) ROM appropriate, intact, symmetrical. Patient able to do ROM against resistance Thyroid gland Thyroid gland intact, no swelling or deformities noted. Thyroid gland did upward movement during swallow evaluation Chest and Lungs: Posterior and Lateral Thoracic cage configuration Skin characteristics Symmetric expansion Tactile fremitus Lumps or tenderness Skin pink/warm/dry, appropriate for ethnicity. Symmetrical expansion noted, tactile fremitus equal, no lumps/bumps noted, patient denied tenderness or pain Spinous process No deformities or step-offs noted Percussion over lung fields Resonance heard and equal CVA tenderness No CVA tenderness Breath sounds Clear 8
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Adventitious sounds None noted Chest and Lungs: Anterior Respirations and skin characteristics Respirations equal and non-labored, skin intact, no bruises or sores noted Tactile fremitus, lumps, and Tenderness Tactile fremitus equal over all areas, no lumps or tenderness noted Percuss lung fields Resonance heard and equal Breath sounds Clear and equal Upper Extremities ROM and muscle strength ROM and muscle strength equal and intact Epitrochlear nodes No tenderness or masses noted Discuss the process for assessing breasts and axilla Assessment of axilla lymph nodes is done by palpating and rolling the fingers around the skin in the axilla. Assessment of the breasts is done using pads of the fingers are moving in a clockwise direction over breast tissue.
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