lOMoARcPSD|67691079
Introduction:
Give name and who you are
Wash hands
State/show supplies location, room, and ID
What you are doing, and do you mind being recorded?
General:
Ask name and DOB
Where are you at today?
Day of the week? Today’s date?
Describe mood
Answers questions appropriately?
Well-dressed for occasion, well groomed, describes mood as … which matches her affect,
and she is alert and oriented to person, place, and time
Skin:
Inspection—overall look at your body, lean forward to look at back, legs, arms, abdomen
o Skin is fair/dark complexion consistent with ethnicity
Describe signs of lacerations, excoriations, ecchymosis, or abrasions
Describe erythema or abscesses, masses noted
Skin temperature—patient is warm and dry to the touch
Skin turgor—instant recoil
Edema—none noted to body
Nails—place fingers out—nails well-groomed and no signs of cyanosis, smooth, no signs of
ridges
Nail bed angle—place thumbs like this and do this with all your fingers—nail bed angles
approximately 160 degrees and no signs of clubbing
Capillary refill < 2 seconds to upper extremity and < 2 seconds to lower extremity
Hair—evenly distributed, no signs of loss
o Note length and color—appears smooth w/ no signs of infestation
Palpate scalp for tenderness and masses or nodules
Facial features are symmetrical
Eyebrows are symmetrical
Eyelashes evenly distributed
Eyes:
Inspect—sclera is white, irises are brown, pupils 4mm bilaterally, conjunctiva is pink, no
signs of drainage or pus from eyes
Palpate—close eyes to assess for any tenderness—eyes are firm and fixed—No tenderness
to palpation of the eyeballs or eyelids, lacrimal apparatus is soft
PERRLA (Pupils equal, round, reactive to light and accommodates)
Direct and consensual light reflex—shine light in each eye to watch for constriction
Corneal light reflex—shine light up to nose to see if light reflects in both eyes same spot
Accommodation—follow penlight in and out
Nystagmus or Drifting—cover/uncover test to both eyes
Six Cardinal Fields of Gaze—follow penlight in 6 directions
Snellen Chart—test for far vision— we would have a sign on the wall that has different
letters, have you stand at 20 ft, read the smallest line you could with both eyes, and then
each eye covered one at a time messages.pdf_cover_qr_code_label
messages.downloaded_by
, lOMoARcPSD|67691079
Rosenberg Chart—test for near vision—we would have a sign about 14 inches from your
face, have you read the smallest line you could with both eyes, then have you cover each
eye one at a time and read the smallest line you could
Ophthalmoscope exam—going to shine a light in your eye by holding it in my dominant
hand my right eye will looking into right eye looking for what we call a red light reflex and
then come close to face while bracing to the back of your head—right eye have red light
reflex visualized, the optic disc is round, margins are well defined, no signs of
hemorrhaging of the vessels—repeat with other eye
Nose and Sinuses:
Inspection—nose is midline, no signs of open sores or deviation
Cranial Nerve 1 (Olfactory)—differentiation of odors
Palpation—nose for tenderness
Inspect with light looking up—nares for pink and moist, no signs of foreign body or
congestion, septum is midline
Plug one nostril and breath—repeat on other side for patency
Palpate sinuses—frontal, maxillary—if pressure or congestion would do transillumination
Mouth:
Inspect—pink and moist
Tongue Blade—lift tongue, moist tongue, midline tongue and frenulum, no signs of open
sores in mouth, no erythema, count teeth (32), pearly white, no signs of dental caries
Inspect uvula (does not retract on phonation), tonsils 1+ bilaterally, say ahhh, check gag
reflex intact
Cranial Nerve 9 (Glossopharyngeal) and Cranial Nerve 10 (Vagas) intact evidenced
by uvula retracting on phonation and gag reflex intact and differentiation between bitter
and sour
Cranial Nerve 12 (Hypoglossal)—stick your tongue out try to touch your chin you try to
touch your nose side to side, push against my fingers, push against my fingers
Ears:
Inspection--pinna in alignment with ithis bilaterally, no signs of erythema to the ears, no
drainage
Palpate ears—no tenderness of pinna and ears bilaterally, mastoid no tenderness
Otoscope exam— pull the pinna down and back--ear canal clear, no signs of cerumen, no
excoriation or erythema, no ear drainage, no signs of foreign body—the TM was visualized
in the left ear it was pearly gray bony landmarks were seen there were no signs of
perforation or retraction, bulging, no erythema to the eardrum, the light reflex was seen at
the 7 o’clock position
Cranial Nerve Eight ( now so I'm going have you do is might me sit back in the bed this
is our acoustic nerve it's a sensory nerve and what this what we will do is we will do what
we call the whisper test I'm going to have you plug your left here I'm going to stand two
feet over here and I'm going to whisper two words and I want you to repeat them back to
me okay one two three okay and we're going
Neck:
Palpate lymph nodes for tenderness—occipital, postular, oric, tonsillar, submandibular,
submental, posterior cervical, anterior cervical. lean forward for super clavicular, axillary,
epitrochiary
Cranial Nerve 11 (Spinal Accessory nerve)—push against my hands, push against my
hand, push against my hand messages.pdf_cover_qr_code_label
messages.downloaded_by
Introduction:
Give name and who you are
Wash hands
State/show supplies location, room, and ID
What you are doing, and do you mind being recorded?
General:
Ask name and DOB
Where are you at today?
Day of the week? Today’s date?
Describe mood
Answers questions appropriately?
Well-dressed for occasion, well groomed, describes mood as … which matches her affect,
and she is alert and oriented to person, place, and time
Skin:
Inspection—overall look at your body, lean forward to look at back, legs, arms, abdomen
o Skin is fair/dark complexion consistent with ethnicity
Describe signs of lacerations, excoriations, ecchymosis, or abrasions
Describe erythema or abscesses, masses noted
Skin temperature—patient is warm and dry to the touch
Skin turgor—instant recoil
Edema—none noted to body
Nails—place fingers out—nails well-groomed and no signs of cyanosis, smooth, no signs of
ridges
Nail bed angle—place thumbs like this and do this with all your fingers—nail bed angles
approximately 160 degrees and no signs of clubbing
Capillary refill < 2 seconds to upper extremity and < 2 seconds to lower extremity
Hair—evenly distributed, no signs of loss
o Note length and color—appears smooth w/ no signs of infestation
Palpate scalp for tenderness and masses or nodules
Facial features are symmetrical
Eyebrows are symmetrical
Eyelashes evenly distributed
Eyes:
Inspect—sclera is white, irises are brown, pupils 4mm bilaterally, conjunctiva is pink, no
signs of drainage or pus from eyes
Palpate—close eyes to assess for any tenderness—eyes are firm and fixed—No tenderness
to palpation of the eyeballs or eyelids, lacrimal apparatus is soft
PERRLA (Pupils equal, round, reactive to light and accommodates)
Direct and consensual light reflex—shine light in each eye to watch for constriction
Corneal light reflex—shine light up to nose to see if light reflects in both eyes same spot
Accommodation—follow penlight in and out
Nystagmus or Drifting—cover/uncover test to both eyes
Six Cardinal Fields of Gaze—follow penlight in 6 directions
Snellen Chart—test for far vision— we would have a sign on the wall that has different
letters, have you stand at 20 ft, read the smallest line you could with both eyes, and then
each eye covered one at a time messages.pdf_cover_qr_code_label
messages.downloaded_by
, lOMoARcPSD|67691079
Rosenberg Chart—test for near vision—we would have a sign about 14 inches from your
face, have you read the smallest line you could with both eyes, then have you cover each
eye one at a time and read the smallest line you could
Ophthalmoscope exam—going to shine a light in your eye by holding it in my dominant
hand my right eye will looking into right eye looking for what we call a red light reflex and
then come close to face while bracing to the back of your head—right eye have red light
reflex visualized, the optic disc is round, margins are well defined, no signs of
hemorrhaging of the vessels—repeat with other eye
Nose and Sinuses:
Inspection—nose is midline, no signs of open sores or deviation
Cranial Nerve 1 (Olfactory)—differentiation of odors
Palpation—nose for tenderness
Inspect with light looking up—nares for pink and moist, no signs of foreign body or
congestion, septum is midline
Plug one nostril and breath—repeat on other side for patency
Palpate sinuses—frontal, maxillary—if pressure or congestion would do transillumination
Mouth:
Inspect—pink and moist
Tongue Blade—lift tongue, moist tongue, midline tongue and frenulum, no signs of open
sores in mouth, no erythema, count teeth (32), pearly white, no signs of dental caries
Inspect uvula (does not retract on phonation), tonsils 1+ bilaterally, say ahhh, check gag
reflex intact
Cranial Nerve 9 (Glossopharyngeal) and Cranial Nerve 10 (Vagas) intact evidenced
by uvula retracting on phonation and gag reflex intact and differentiation between bitter
and sour
Cranial Nerve 12 (Hypoglossal)—stick your tongue out try to touch your chin you try to
touch your nose side to side, push against my fingers, push against my fingers
Ears:
Inspection--pinna in alignment with ithis bilaterally, no signs of erythema to the ears, no
drainage
Palpate ears—no tenderness of pinna and ears bilaterally, mastoid no tenderness
Otoscope exam— pull the pinna down and back--ear canal clear, no signs of cerumen, no
excoriation or erythema, no ear drainage, no signs of foreign body—the TM was visualized
in the left ear it was pearly gray bony landmarks were seen there were no signs of
perforation or retraction, bulging, no erythema to the eardrum, the light reflex was seen at
the 7 o’clock position
Cranial Nerve Eight ( now so I'm going have you do is might me sit back in the bed this
is our acoustic nerve it's a sensory nerve and what this what we will do is we will do what
we call the whisper test I'm going to have you plug your left here I'm going to stand two
feet over here and I'm going to whisper two words and I want you to repeat them back to
me okay one two three okay and we're going
Neck:
Palpate lymph nodes for tenderness—occipital, postular, oric, tonsillar, submandibular,
submental, posterior cervical, anterior cervical. lean forward for super clavicular, axillary,
epitrochiary
Cranial Nerve 11 (Spinal Accessory nerve)—push against my hands, push against my
hand, push against my hand messages.pdf_cover_qr_code_label
messages.downloaded_by
