MSN 610 Head to Toe Assessment
Introduction - Answer-- scan room/show ID
- introduction/ask permission to record exam on video
- sanitize hands/"let me know if you have any questions throughout the exam"
- your vitals were:
BP: 118/78; HR 76; RR 16; O2 99%; 97.4
- "when I walked in, I noticed you had a steady gait, you maintain good posture, you look well-nourished
and well-groomed.
inspection of skin and face - Answer-- color is appropriate to ethnicity and no visible abnormal findings
bilaterally
- facial features are symmetric bilaterally and no abnormalities are noted on external ears, eyes, nose,
mouth/lips
- no involuntary facial movements or crusting of the eyebrows or eyelashes noted
Touching/palpating skin and face - Answer-- Skin turgor is less than 2 seconds
- please let me know if you feel any pain or discomfort when I palpate your face and skin
inspecting head/skull for shape/contour, hair distribution; palpating head/skull for lumps/abnormalities
- Answer-- head is normocephalic and atraumatic
- skull is symmetric
- scalp has no lumps/bumps/masses
, - hair texture is fine with normal and even hair distribution (no signs of hair loss or brittleness); quantity
is thick
- do you feel any pain or tenderness anywhere when I palpate?
temporal mandibular joint - Answer-- is there any pain or tenderness when I press here?
- open and close your mouth please
- no clicking noted and no palpable abnormalities bilaterally
eye exam using ophthalmoscope examining back of eyes - Answer-- please look straight ahead
- finding red reflex, which yours is intact
- following the red reflex in to examine the lens, retinal surface, the blood vessels, following them to the
optic disc, cup, and retina vessels
- bilateral exam
- no abnormalities noted in either eye
ear exam using otoscope - Answer-- tug test: any pain or discomfort?
- using largest speculum that would fit in ear
- pull pinna up and back to straighten canal
- auditory canal is pink and clear, no abnormalities.
- tympanic membrane, which is intact and pearly gray with no abnormalitie
- specific structures identified are the bony prominences of the malleus, handle of the malleus, and the
light reflex. R cone of light = 5:00. L cone of light = 7:00
- bilateral exam
nasal exam using otoscope - Answer-- flex neck slightly back so I can take a look inside your nose
- mucosa tissue glistens and is deep pink, no visual abnormalities
- scant watery clear mucous
Introduction - Answer-- scan room/show ID
- introduction/ask permission to record exam on video
- sanitize hands/"let me know if you have any questions throughout the exam"
- your vitals were:
BP: 118/78; HR 76; RR 16; O2 99%; 97.4
- "when I walked in, I noticed you had a steady gait, you maintain good posture, you look well-nourished
and well-groomed.
inspection of skin and face - Answer-- color is appropriate to ethnicity and no visible abnormal findings
bilaterally
- facial features are symmetric bilaterally and no abnormalities are noted on external ears, eyes, nose,
mouth/lips
- no involuntary facial movements or crusting of the eyebrows or eyelashes noted
Touching/palpating skin and face - Answer-- Skin turgor is less than 2 seconds
- please let me know if you feel any pain or discomfort when I palpate your face and skin
inspecting head/skull for shape/contour, hair distribution; palpating head/skull for lumps/abnormalities
- Answer-- head is normocephalic and atraumatic
- skull is symmetric
- scalp has no lumps/bumps/masses
, - hair texture is fine with normal and even hair distribution (no signs of hair loss or brittleness); quantity
is thick
- do you feel any pain or tenderness anywhere when I palpate?
temporal mandibular joint - Answer-- is there any pain or tenderness when I press here?
- open and close your mouth please
- no clicking noted and no palpable abnormalities bilaterally
eye exam using ophthalmoscope examining back of eyes - Answer-- please look straight ahead
- finding red reflex, which yours is intact
- following the red reflex in to examine the lens, retinal surface, the blood vessels, following them to the
optic disc, cup, and retina vessels
- bilateral exam
- no abnormalities noted in either eye
ear exam using otoscope - Answer-- tug test: any pain or discomfort?
- using largest speculum that would fit in ear
- pull pinna up and back to straighten canal
- auditory canal is pink and clear, no abnormalities.
- tympanic membrane, which is intact and pearly gray with no abnormalitie
- specific structures identified are the bony prominences of the malleus, handle of the malleus, and the
light reflex. R cone of light = 5:00. L cone of light = 7:00
- bilateral exam
nasal exam using otoscope - Answer-- flex neck slightly back so I can take a look inside your nose
- mucosa tissue glistens and is deep pink, no visual abnormalities
- scant watery clear mucous
