Patency of nostrils nostrils patent bilateral no

Patency of nostrils Nostrils patent bilateral. 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 nasal mucosa, septum and
turbinates because it widens the passages.
Mouth and Throat
Lips and buccal mucosa Lips pink, full and intact. No dry skin. Buccal mucosa
pink, moist and intact.
Teeth and gums Teeth normal, no broken or missing teeth. Gums intact,
moist and pink.
Tongue, hard palate, and
soft palate
Tongue has good movement, able to protrude. Hard
and soft palate intact upon visual assessment.
Tonsils Tonsils pink and equal. No signs of swelling or
irritation.
Uvula (cranial nerves IX,
X)
Cranial nerves IX and X intact. Able to swallow without
difficulty. Uvula pink, moist and intact. Moves forward
when patient says “ahhhhhh”
Tongue (cranial nerve XII) Tongue is pink, moist, full and intact. Cranial nerve XII
intact. Able to protrude tongue and move side to side
without difficulty.
Neck
Symmetry, lumps, and
pulsations
Symmetric. No sign of lumps or pulsations.
Cervical lymph nodes Cervical lymph nodes present and normal; No swelling
Carotid pulse (bruits if
indicated)
Carotid pulses present, equal and normal bilateral
Trachea Trachea at midline, cartilage rings intact. Patient
exhibits regular breathing.
ROM (cranial nerve XI) Cranial nerve XI intact. Able to raise and drop (shrug)
shoulders symmetrically and without difficulty
Thyroid gland Present, moves appropriately during swallow.
Chest and Lungs: Posterior and Lateral
Thoracic cage configuration
 Skin characteristics
 Symmetric expansion
 Tactile fremitus
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
8

 Lumps or tenderness 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 noted.
Breath sounds All lobes clear bilaterally upon auscultation
Adventitious sounds No adventitious sounds auscultated.
Chest and Lungs: Anterior
Respirations and skin
characteristics
Eupnea. Regular depth. Skin of anterior
chest/thoracic area clean, dry, intact and normal
color for ethnicity. No retractions noted.
Tactile fremitus, lumps, and
tenderness
Tactile fremitus present. No lumps or tenderness
noted.
Percuss lung fields Resonance present upon percussion throughout
lung fields.
Breath sounds All lobes clear bilaterally upon auscultation
Upper Extremities
ROM and muscle strength Normal active ROM. Moderate and equal strength.