Patency of nostrils Nostrils patent bilateral No abnormal drainage Describe the

Patency of nostrils nostrils patent bilateral no

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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
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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.
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