MSN 610 Head to Toe Assessment || All Correct.
Introduction correct answers - 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 correct answers - 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 correct answers - 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 correct answers - 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 correct answers - 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 correct answers - 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 correct answers - 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 correct answers - 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
- septum has no septal deviation, is midline and straight, no abnormalities noted
patency of nostrils correct answers - occlude nostril and breathe in and out with your mouth
closed
- nostrils are patent bilaterally with noiseless and easy nasal breathing
- bilateral exam
sinus regions palpation (frontal, sphenoid, ethmoid, and maxillary) correct answers - feeling for
pressure, pain, etc.: do you feel any pain or tenderness when I palpate any of the sinuses?
- no pressure or pain noted in any of the four nasal sinuses
Cranial nerve 1 correct answers - olfactory nerve, or your sense of smell
- have you noticed any changes in your smell lately?
- cranial nerve I intact
Cranial nerve 2 correct answers - optic nerve
- Tested with your visual acuity using the Snellen chart.
- Your visual acuity is 20/20 bilaterally, which is perfect vision
- cranial nerve II is intact.
Cranial nerve 3 correct answers - the oculomotor nerve
- we will be testing your pupil reactivity
- Please look directly into the light
- Pupils are equal, round, and reactive to both direct light and consensual light
- Check accommodation: please look at an object in the distance, now look at the tip of my finger
- accommodation intact
Cranial nerve 3
Cranial nerve 4
Cranial nerve 6 correct answers - Cranial nerve III = the oculomotor nerve
- Cranial nerve IV = the trochlear nerve
- Cranial nerve VI = the abducens nerve)
- tested with the six cardinal views test
- convergence: please follow my pen light as I bring it towards the bridge of your nose
- You have convergence, and your pupils constrict
- Any double vision?
- No nystagmus noted
- Cranial nerves III, IV, and VI are intact.
Cranial nerve 5 correct answers - the trigeminal nerve
Introduction correct answers - 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 correct answers - 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 correct answers - 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 correct answers - 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 correct answers - 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 correct answers - 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 correct answers - 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 correct answers - 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
- septum has no septal deviation, is midline and straight, no abnormalities noted
patency of nostrils correct answers - occlude nostril and breathe in and out with your mouth
closed
- nostrils are patent bilaterally with noiseless and easy nasal breathing
- bilateral exam
sinus regions palpation (frontal, sphenoid, ethmoid, and maxillary) correct answers - feeling for
pressure, pain, etc.: do you feel any pain or tenderness when I palpate any of the sinuses?
- no pressure or pain noted in any of the four nasal sinuses
Cranial nerve 1 correct answers - olfactory nerve, or your sense of smell
- have you noticed any changes in your smell lately?
- cranial nerve I intact
Cranial nerve 2 correct answers - optic nerve
- Tested with your visual acuity using the Snellen chart.
- Your visual acuity is 20/20 bilaterally, which is perfect vision
- cranial nerve II is intact.
Cranial nerve 3 correct answers - the oculomotor nerve
- we will be testing your pupil reactivity
- Please look directly into the light
- Pupils are equal, round, and reactive to both direct light and consensual light
- Check accommodation: please look at an object in the distance, now look at the tip of my finger
- accommodation intact
Cranial nerve 3
Cranial nerve 4
Cranial nerve 6 correct answers - Cranial nerve III = the oculomotor nerve
- Cranial nerve IV = the trochlear nerve
- Cranial nerve VI = the abducens nerve)
- tested with the six cardinal views test
- convergence: please follow my pen light as I bring it towards the bridge of your nose
- You have convergence, and your pupils constrict
- Any double vision?
- No nystagmus noted
- Cranial nerves III, IV, and VI are intact.
Cranial nerve 5 correct answers - the trigeminal nerve
