Conjunctivae, sclerae, and corneas Conjunctivae moist and pink. Sclera observed to be white. Cornea smooth and intact. No abnormalities observed. Pupils PERRLA Describe the purpose of an Opthalmascope for assessing the eyes An instrument for assessing the eye and structures within the eye. Ears External ear No drainage, or redness noted. Structures intact. Any tenderness? None Purpose of the otoscope An instrument used to visualize the internal structures of the ear. Test hearing (cranial nerve VIII) and conduct the voice test Whisper test utilized to assess hearing. Patient was able to repeat back. Explain the Weber and Rinne tests The Weber test assesses cranial nerve VIII for hearing. A vibrating fork is used by placing on a patient’s head or forehead. A normal conclusion would be that the patient can hear the vibration equally. The Rinne test is conducted by placing the fork behind the ear. Nose External nose Septum intact. Nares symmetrical. Patency of nostrils Patent bilaterally. Describe the purpose of the speculum evaluate nasal mucosa, septum, and turbinates To visualize the inside of the nares, assess mucosa, drainage, patency of nares, turbinates and septum. 7
Mouth and Throat Lips and buccal mucosa Pink and moist. No lesions noted. Teeth and gums Good dentition. Teeth intact. No bleeding or ulcers observed. Tongue, hard palate, and soft palate Tongue and palates pink, moist, and intact. Able to move tongue in all directions. No lesions or mass observed. Tonsils Tonsils present and intact. No lesions or swelling observed. Uvula (cranial nerves IX, X) Uvula pink, midline, and intact. No lesions or masses. Tongue (cranial nerve XII) Able to move tongue freely. Neck Symmetry, lumps, and pulsations Symmetrical. No obvious masses or pulsations. Cervical lymph nodes Palpated, non-tender, and moves easily. Carotid pulse (bruits if indicated) Palpable, no bruit. Trachea Midline ROM (cranial nerve XI) Moves easily without pain or tenderness. Good strength and ROM. Thyroid gland Non-palpable. No goiter, or nodules. Chest and Lungs: Posterior and Lateral Thoracic cage configuration Skin characteristics Symmetric expansion Tactile fremitus Lumps or tenderness Breathing/expansion symmetrical. No masses, fremitus, or tenderness upon palpation. Spinous process Intact and symmetrical. Percussion over lung fields Resonance equal bilaterally. CVA tenderness None present. Breath sounds Clear to auscultation bilaterally. Adventitious sounds None present. 8
Chest and Lungs: Anterior Respirations and skin characteristics Equal and unlabored bilaterally. No lesions observed. Tactile fremitus, lumps, and Tenderness Breathing/expansion symmetrical. No masses, fremitus or tenderness upon palpation. Percuss lung fields Resonance equal bilaterally. Breath sounds Clear to auscultation bilaterally. Upper Extremities ROM and muscle strength Full ROM observed in upper extremities. Equal strength noted with push, pull, and grasp. No pain noted. Epitrochlear nodes Nonpalpable Discuss the process for assessing breasts and axilla Arms at sides: Assess appearance of skin. -color -Thickening, and unusual pores -Size and symmetry -Contour -Nipple characteristics, size, shape, direction, rashes, ulcerations, and discharge.
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- Spring '16
- Shelley Ashby