palpable popping or grinding noted Maxillary sinuses and frontal sinuses No

Palpable popping or grinding noted maxillary sinuses

This preview shows page 7 - 10 out of 12 pages.

palpable popping or grinding noted Maxillary sinuses and frontal sinuses No swelling or discomfort noted to sinuses Eyes Visual 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 intact Extraocular 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 intact External structures No abnormalities noted with even hair distribution to eyebrows and eyelashes Conjunctivae, sclerae, and corneas Conjunctivae is pink and moist Sclerae is white Corneas are smooth with regular contour Pupils PERRLA Describe the purpose of an Opthalmascope for assessing the eyes Ophthalmoscope is an instrument with a light and small lenses that is used to examine the inner eye Ears External ear No abnormal structure noted Any tenderness? No tenderness noted Purpose of the otoscope The 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 test Cranial nerve VIII intact, testing concluded no hearing difficulties Explain the Weber and Rinne tests These tests are exams that test for hearing loss using a tuning fork. They help determine conductive or sensorineural hearing loss. 7
Image of page 7
Nose External nose No abnormal structure to external nose noted Patency of nostrils Patency x2 noted Describe the purpose of the speculum evaluate nasal mucosa, septum, and turbinates This is an instrument used to widen the opening of the nostril to have a better view. Patients nasal mucosa/ t urbinates are pink, moist. Septum is midline No inflammation or drainage noted Mouth and Throat Lips and buccal mucosa Lips are moist, no lesions noted. Buccal Mucosa is pink and moist Teeth and gums Gums appear pink and healthy No cracked teeth or dental carries noted. Patient appears to have good dental hygiene Tongue, hard palate, and soft palate Tongue is midline and hard/soft palates moist, no abnormalities noted Tonsils Tonsils are symmetrical, no swelling noted Uvula (cranial nerves IX, X) Uvula is midline Cranial nerves IX, X intact Tongue (cranial nerve XII) Tongue midline, cranial nerve XII intact Neck Symmetry, lumps, and pulsations Neck is symmetric, no lumps or abnormal pulsations noted, no discomfort noted upon palpation Cervical lymph nodes No pain or discomfort noted with palpation, no node enlargements noted Carotid pulse (bruits if indicated) Carotid pulse 72, no bruits noted Trachea Trachea is midline, symmetrical ROM (cranial nerve XI) Patient with full ROM to neck, cranial nerve XI intact Thyroid gland Thyroid gland normal in size, no enlargement or nodules noted 8
Image of page 8
Chest and Lungs: Posterior and Lateral Thoracic cage configuration Skin characteristics Symmetric expansion Tactile fremitus Lumps or tenderness Skin to chest area dry, warm to touch.
Image of page 9
Image of page 10

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture