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palpable popping or grinding notedMaxillary sinuses and frontal sinusesNo swelling or discomfort noted to sinusesEyesVisual fields (cranial nerve II)6 cardinal movements all intact, 20/20 vision observed with Snellen chart with patient’s corrective eye wear in place, cranial nerve II intactExtraocular muscles, corneal light reflex, and cardinal positions of gaze (cranial nerves III, IV, VI)Cranial nerves III, IV, VI all intact, no abnormalities noted with extraocular muscles, normal light reflex noted, 6 cardinal movements all intactExternal structuresNo abnormalities noted with even hair distribution to eyebrows and eyelashesConjunctivae, sclerae, and corneasConjunctivae is pink and moistSclerae is whiteCorneas are smooth with regular contourPupilsPERRLADescribe the purpose of an Opthalmascope for assessing the eyesOphthalmoscope is an instrument with a light and small lenses that is used to examine the inner eyeEarsExternal earNo abnormal structure notedAny tenderness?No tenderness notedPurpose of the otoscopeThe otoscope is a medical device that is used to look into the ears to screen for any illness that affect the inner ear.Test hearing (cranial nerve VIII) and conduct the voice testCranial nerve VIII intact, testing concluded no hearing difficultiesExplain the Weber and Rinne testsThese tests are exams that test for hearing loss using a tuning fork. They help determine conductive or sensorineural hearing loss. 7
NoseExternal noseNo abnormal structure to external nose notedPatency of nostrilsPatency x2 notedDescribe the purpose of the speculum evaluate nasal mucosa, septum, and turbinatesThis is an instrument used to widen the opening of the nostril to have a better view.Patients nasal mucosa/turbinates are pink, moist. Septum is midlineNo inflammation or drainage notedMouth and ThroatLips and buccal mucosaLips are moist, no lesions noted. Buccal Mucosa is pink and moistTeeth and gumsGums appear pink and healthyNo cracked teeth or dental carries noted.Patient appears to have good dental hygiene Tongue, hard palate, andsoft palateTongue is midline and hard/soft palates moist, no abnormalities notedTonsilsTonsils are symmetrical, no swelling notedUvula (cranial nerves IX, X)Uvula is midlineCranial nerves IX, X intactTongue (cranial nerve XII)Tongue midline, cranial nerve XII intactNeckSymmetry, lumps, and pulsationsNeck is symmetric, no lumps or abnormal pulsations noted, no discomfort noted upon palpationCervical lymph nodesNo pain or discomfort noted with palpation, no node enlargements notedCarotid pulse (bruits if indicated)Carotid pulse 72, no bruits notedTracheaTrachea is midline, symmetrical ROM (cranial nerve XI)Patient with full ROM to neck, cranial nerve XI intactThyroid glandThyroid gland normal in size, no enlargement or nodules noted8
Chest and Lungs: Posterior and LateralThoracic cage configurationSkin characteristicsSymmetric expansionTactile fremitusLumps or tendernessSkin to chest area dry, warm to touch.