- The first thing you do when you come into the room?
Hello My name is Ben Wade I am a nursing student in the Nurse Practitioner program. Would it be alright if I do a head to toe assessment on you?
Greet the patient and wash your hands
Midline and erect
Eyebrows, eyelids, nasolabial folds and mouth are?
- HAIR is?
smooth, color is _____, no lesions or lumps, hair is evenly distributed
- SKULL is?
Normocephalic, scalp is intact.
- TEMPORAL ARTERY:
I’m gonna feel for your temporal arteries. Any pain or tenderness? I’m gonna listen for any bruits bilaterally.
I do not hear any bruits.
I am gonna have you take off your glasses are you okay with that?
I’m gonna have you open your mouth for me? I will then place my hands on the TMJ. Okay go ahead and close. Any pain or tenderness? No.
No pain or tenderness noted. No crepitus or popping.
Okay again tightly close your mouth.
Trigeminal nerve intact. That is the motor part of the trigeminal nerve.
Im gonna feel for your sinuses.
Any pain or tenderness?
No, pain or tenderness noted at the frontal and maxillary sinuses.
- FACE EXPRESSIONS:
I’m gonna have you do a series of facial expressions. If you will raise your eyebrows, wrinkle your forehead, smile for me. Okay, smile for me without showing your teeth. If you would poof out our cheeks. Purse your lips and blow. Tightly close your eyes.
Facial nerve grossly intact. Facial expression is plesent.
- COTTON BALL:
I’m gonna pace something soft and hard on your face. And for the sake of time I will do only one side, but it will be done bilaterally.
Trigeminal nerve and sensory intact bilaterally.
Okay, I’m gonna have your bring your arms straight out. You’re gonna be touching your nose but closing your eyes.
No ataxia. Smooth coordinated movements.
Now I’m gonna go toward your neck (looking at neck and symmetry).
Visual inspection of neck is symmetrical. Trachea of the neck is midline.
I’m gonna feel for your carotids. Any tenderness? No.
I’m gonna listen again (with bell).
No tenderness at the carotid arteries. No bruits noted.
- LYMPH NODES:
I’m gonna feel for your lymph nodes. I’m starting at the occipital, postauricular, preauricular, retropharyngeal, submandibular, submental, supraclavicular, anterior cervical chain and posterior cervical chain. Any tenderness there? No.
No tenderness and lymph nodes are non palpable.
I’m gonna have you do range of motion. I’m gonna have you look up to the top of the ceiling (thats hyperextension). Bring your head down for forward flexion. I’m gonna have you look the right and the left (thats rotation). Bring your ear to your shoulder on the left and the right (thats lateral bending).
I’m gonna have you push agains my hand with your head. Can you shrug your shoulders?
Full resistance to opposition. Spinal accessory nerve intact.
I’m gonna feel for your thyroid? Go ahead and swallow for me.
Thyroid is pliable and soft. No nodules. No lumps or masses. Thyroid moves during swallowing.
I’m gonna test your eyes. I’m gonna hold onto your chin and for the sake of time were gonna only do one side, but this would be done bilaterally. (Trail finger at an upward diagonal angle, horizontal angle and lower diagonal angle.)
Extraocular eye movements are intact in all six cardinal fields of vision. Smooth coordinated movements.
Next thing is confrontation test. I’m gonna have you look at my ear. When you see my fingers come into your peripheral vision let me know. I will patient and myself cover the same eye. Thats about 90 degrees.
Confrontation intact. Visual fields full by confrontation.
The next thing is accommodation. I’m gonna have you follow my finger. Trail finger in toward patient’s nose (both eyes should follow inward). Perfect now look behind me.
Pupillary accommodation intact. Eyes constrict and converge when looking at a close object and dilates when looking at a far object.
With the light I’m going to look at your pupils. If you can look at my ear. Look though ophthalmoscope at patient’s eyes.
Light shines in both eyes symmetrically and bilaterally.
For the sake of time I’m gonna pretend that I turned off the lights for this test. Look at my ear again and I’m gonna shine this in your eye.
Pupils are equal round and reactive to light and eyes have accommodation and constricted to light direct and consensual.
- RED REFLEX:
I’m gonna look in you eye and consider this bilaterally. (when looking in patient’s right eye look through ophthalmoscope with right eye)
I see red reflection. Arterial venous ration of three to five. The macula is yellow. I see a cream colored disc. No exudate on the eye.
I’m gonna go to inspection of the nose? I’m gonna feel your nose.
General inspection of the nose is smooth. The nares are equally positioned. There is a nice stable structure to the nose. The nose is the same color as the facial skin wich is a lite pink to peach.
I’m gonna look in you nose and this will be bilaterally. I do see turbinates middle and inferior.
The turbinates are glistening, pink and moist. The septum is fairly strait and midline.
Now I’m gonna look at your ears. I’m gonna look in your ears. I’m gonna feel your ears.
Visual inspection of the ears is symmetrical. The top of the auricle is horizontal with the canthus of the eye. The lateral position is equal and less than ten degrees. No drainage seen or odor. There is a firm stable structure with the cartilage. It recoils from folded position. The color of the ears is the same as the facial skin which is lite pink.
- EAR CANAL:
I’m gonna look in your ears this will be considered bilaterally. I’m gonna pull up and back. Any tenderness to the ear canal? No. Your ear looks really good. If you were a child I would assess if the child could have and ear exam now or at the end based on if it would be traumatic. When I do an ear exam on a child it will be down and back to visualize the tympanic membrane. If the child is crying I would realize the tympanic membrane will have a reddish color.
Theres a pink canal. No tenderness. I see the tympanic membrane is a pearly gray and translucent. I do see a bony structure and the light reflected and a little bit of cerumen with varing shades of yellow, but not bad. Okay that was bilaterally.
The gag reflex.
Visual inspection of the mouth.
Okay can you open your mouth for me?
Bite down with your teeth.
I’m gonna look at the top of your mouth.
Looking at the uvula can you say “ah”.
I’ll have you stick your tongue out for me.
Can you lift up your tongue?
Bring you tongue toward your nose, chin and side to side
I also wanted to look at your tonsils. Say “ah” again.
Visual inspection of the mouth is symmetrical vertically and horizontally with movement and without movement. The lips are well defined from the rest of the skin.
The lips are lite, dark pink in color.
The buccal mucosa is pink and glistening.
The gingiva is lite pink, firm and moist.
Teeth are firmly anchored and the color is a pearly white with yellow stains which is very normal. 32 teeth are visible. The top teeth fit nicely with the grooves of the bottom teeth.
The hard palate is dome shaped. Protuberance of the hard palate is midline continuous with the soft palate. Soft palate is a nice pink color and the same as the hard palate.
Uvula is midline. The uvula is midline. The soft palate rises when saying “ah” and uvula stays midline.
Tongue is pinkish in color. Anterior surface is smooth but slightly rough. Posterior surface is smooth but slightly raised. Theres blood vessels on both sides for the frenulum. No leukoplakia, lessions or masses.
Hypoglossal nerve intact.
Tonsils are symmetrical, pinkish in color, no exudate with size of plus one.
Back of throat is moist and glistening.
Visualization of the chest
The AP diameter to transverse diameter of the chest is a 2 to 1 ratio. Front of chest is symmetrical. Chest expansion is even with breathing. Respirations are between 12 and 20 breaths per minute. There is no labored breathing, use of accessory muscles and it is a regular rhythm.
I’m gonna check your breath sounds
Clear breath sounds no adventitious breath sounds.
I’m gonna check your kidneys (palm flat and pat with other hand). Any tenderness? No.
No costovertebral tenderness.
Going toward the heart now. I’m gonna listen with the diaphragm first. Right side two intercostal spaces down I have the aortic valve, across to pulmonic, erb’s (tricuspid), mitral. And with the bell I listen to aortic, pulmonic, tricuspid and mitral.
No murmurs, regular rhythm (60 to 90 beats per minute).
If I was listening to S1 is would be at the apex of the heart. S2 would be at the base of the heart.
I’m gonna feel for pulses bilaterally, but for time I will feel on one side. The radial pulse, brachial pulse, femoral pulse, popliteal artery, posterior tibial artery, dorsalis pedis.
Pulses are strong at 2+ bilaterally.
I’m going to inspect the legs.
Visual inspection there is even distribution of hair on both the arms and legs. Patient is cool to warm to touch. No edema, deformities, masses or skin lesion noted.
- CAPILLARY REFILL
Capillary refill on feet and fingers.
Capillary refill is less than 2 seconds on all extremities.
I’m going to look at your nails while I have you here.
Nails have varying pink opacities. The ends of the nails are smooth. The shape of the fingernails is convexed. There is longitudinal beeding of the nails.
Can you lay back for me (supine). I’m going to look at your abdomen.
Visual inspection of the abdomen is no scars, striations. Abdomen rises evenly with breathing. Shape of the abdomen is slightly rounded. Maximum point of convesity is at the umbilicus. The color of the abdomen is the same as the rest of the skin.
- AUSCULTATION OF ABDOMEN (DIAPHRAGM)
I’m gonna listen to your abdomen in all four quadrants.
Clicks and gurgles heard in abdomen at 5 to 30 per minute.
- AUSCULTATION (BELL)
While I have you here I’m going to listen to the arteries tin the abdomen. The aortic artery, renal arteries, iliac arteries.
No bruits, friction rubs or venous hums.
Now I’m gonna percuss on your abdomen.
I’m gonna palpate the abdomen now let me know if you have pain or tenderness this is light palpation. Any pain? No pain.
I hear tympany and dullness over the organs.
Stomach remain soft, no tenderness or masses.
- PALPATE ORGANS
Now I’m gonna palpate for the liver.
Now I’m gonna palpate the kidney and spleen.
Now I’m gonna palpate the aorta.
Right side of patient take left hand an place under back and us right hand on top. You go under the ribs.
The kidney is palpated on the paient’s left above the spleen. The spleen is palpated on the patient’s left just below the left kidney. Left hand of the practitioner reaches across to patient’s back. Right hand palpates on top.
- HIP MOVMENT
Next I’m gonna assess your hip movement. I’m gonna move your hip outward this is abducting. Bringing the hip back into alignment with the other is adducting. I’m gonna bring you knee in and turn it outward this is external rotation. I will bring your bent knee inward and this is internal rotation.
I’m gonna have you sit up
I’m gonna have you bring you knee out for hyperextension and back down for flexion.
We’re gonna do those same movements but I will provide resistance with my hand.
Full resistance with opposition using quadriceps and hamstrings muscles
Bring your foot down for plantar flexion and toes up for dorsiflexion. Now with resistance from me.
Point the soles of your feet together for inversion and point sole of foot outward is eversion.
Full resistance with opposition to feet bilaterally.
Can you bend at the wrist for me that is flexion.
Bring the wrist upward that is hyperextension of the wrist.
Bring your fingers down only that is metacarpal flexion.
Bring your fingers up toward the sealing that is metacarpal hyperextension.
Touch each finger to pinky. Now make a fist.
No limitations to thumb opposition.
Can you bring your fingers out for abduction.
Can you bring your fingers in for adduction.
Can you bring your wrist in for inversion of the radial.
Can you bring your wrist out for eversion of the ulnar
Can you grip my fingers?
Firm sustained grip
- RAPID MOVEMENT
Can you rotate hand on knees palm and back of hands.
No limitations to rapidly alternating movements.
Biceps reflex present with fluid motion. Tricep reflex present fluid motion. Patellar reflex present with fluid motion. Achilles reflex present with fluid motion. Plantar flexion present with babinski.
Bring your arms in like lifting a barbell. Flexion and extend your arms (extension). Now with resistance to arms.
Full resistance to opposition using biceps and triceps.
Turn hand in for inversion and out for eversion.
Now turn your palms up for supination and palms down for pronation
- Stand up
I’m gonna get you to stand up and just follow my movements.
Raise arms to roof for flexion and arms back for hyperextension.
Fingers inner locked behind your neck for external rotation
Palms together behind your back for internal rotation
Do abduction of palms
I’m gonna feel your hips.
Anterior and posterior iliac crest and greater trochanter symmetrical.
Appearance of spine:
I’m gonna look at your spine. Any pain or tenderness? No.
No pain or tenderness. Spine is straight and erect.
Touch your toes with your fingers for flexion.
Lean back with hands on hips for hyperextension.
Lateral movement of spine left and right.
Rotation of hips (left and right)
Walk strait line and come back
Gait is steady, even stride with rhythmic motion.
Have your feet together and close your eyes.
Slight swing no risk of falling. Romberg test is negative.