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Eyes
- Abnormalities: Glaucoma/Strabismus (crossed Eye)
- Test
- Acuity Confrontation: Peripheral Vision intact
- Cardinal (6 points) bilateral eye movement CNS 3, 4, and 6 intact
- Cover and uncover: steady fixed gaze bilaterally
- Corneal Light Reflex: symmetrical light reflex
- PERRLA: Pupils equal, round, reactive to light and accommodation
- Red Reflex (Ophthalmoscope) Positive red reflex observed bilaterally
- Inspect
- Relaxed Facial Expression
- External
- Upper eyelids: approximate completely when closed
- Orbits: symmetric bilaterally, no peripheral edema noted
- Lacrimal Glands and Ducts: No swelling, redness or excessive tearing palpate in the inner eye next to nose
- Eyelashes: evenly distributed bilaterally
- Eyeballs: aligned bilaterally
- Conjunctiva: clear, pink over lower lids, white over sclera bilaterally (look up and pull down lower lids)
- Sclera: white
- Internal
- Cornea: smooth and clear Shine a light
- Iris : round, regular shape with even coloration bilaterally
- Pupil: size 2mm bilaterally
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Head and Face
- Inspect skin characteristics
- Inspect symmetry and external characteristics of eyes and ears
- Inspect and palpate scalp and hair for texture, distribution and quantity
- Palpate sinus region
- Palpate temporomandibular joint
- Ask client to clench teeth, squeeze eyes tightly shut, wrinkle forehead, smile, stick out tongue puff out cheeks (CN VII)
- Test light sensation of forehead, cheeks, chin (CN V)
-
Ears
Abnormalities: Acute Otitis Media (AOM)/Hearing Loss (DEAF)
- Inspect external structures of the ear, alignment, configuration, and abnormalities:Ears equal size bilaterally with no swelling or thickening noted. Skin intact. Darwin's tubercle present bilaterally. External auditory meatus without swelling, redness, or discharge bilaterally.
- Inspect and describe each ear canal, note abnormalities: External canal without redness, swelling lesions, foreign bodies, or discharge. Cerumen present bilaterally.
- Inspect and describe tympanic membrane: Tympanic membrane shiny and translucent with a pearly-gray color bilaterally. Light reflex prominent in the anterior inferior quadrant bilaterally. Appears flat; slightly pulled at center.
- Perform whisper test and describe findings (CN VIII): repeat at least 3 out of a possible 6 numbers/letters whispered bilaterally.
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Nose
Abnormalities: sinusitis/fractured nose/seasonal allergies
- Inspect skin characteristic, midline:Nares symmetric; nose midline and in proportion to other facial features. No inflammation, deformity or skin lesions noted.
- Determine patency of each nostril: Nares patent bilaterally
- Inspect mucosa, septum, turbinates:Nasal mucosa red, smooth, moist surface; no discharge or foreign body noted. No septal deviation, perforation or bleeding noted. Turbinates gray and gobby due to allergies with small polyp left are, and no growths noted.
- Assess olfactory function, test sense of smell (CN I):CN I intact web patient's ability to identify appropriately an aroma bilaterally
-
Mouth and Pharynx
- Inspect condition of lips, gums, teeth
- Inspect condition of buccal mucosa, tongue, hard and soft palates, floor of mouth, ducts
- Inspect oropharynx, grade tonsils
- Inspect tongue, symmetry, movement (CN XII)
- Assess TMJ and range of motion of jaw
- Note if uvula elevates in midline when patient
- Says “ahh” and test gag reflex (CN IX, X)
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Neck
- Inspect for symmetry of neck structures/muscles
- Inspect for jugular vein distention
- Inspect range of motion
- Test shoulder shrug & head resistance against Examiner’s hand (CN XI)
- Palpate tracheal position
- Palpate thyroid
- Palpate lymph nodes:
- * pre
- * post auricular
- * occipital
- * jugulodigastic
- * submandibular
- * submental
- * superficial,
- * deep
- * posterior, cervical chain
- * supraclavicular
- Auscultate carotid arteries: No Bruit noted
-
Chest/Lung Examination
- Inspect for symmetry, contour (AP/transverse ratio) note deformities
- Assess breathing rate, pattern, depth, effort
- Palpate for symmetry of chest expansion (posterior only)
- Percuss posterior lung fields only, note predominant sound and symmetry
- Auscultate anterior/posterior/lateral lung fields, note findings
- In terms of breath sounds heard, presence or absence adventitious sounds
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Cardiovascular System: FETCO
- Force (pulses: radial, posterior tibial, dorsalis pedis
- Edema (no edema in the upper and lower extremities)
- Temperature (warm equal bilaterally upper and lower extremities
- COlor even and consistent with genetic background
-
Abdomen
- INSPECT:
- Contour: Flat, Rounded, Scaphoid (undernutrition), Distended
- Aortic pulsation (light from side) *visible 1 cm above umbilicusSymmetry
- Smooth Skin
- Abnormalities: no lesions, scars, striae (abnormalities)
- AUSCULTATENormoactive Bowel Sounds present in all 4 quadrants
- PERCUSSTympany predominates abdomen
- Liver: measure span (6-12 cm)
- PALPATION
- No swelling, enlargement, or tenderness
- Unable to palpate: SPLENE, LIVER, KIDNEYS
- CVA tenderness
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Neuromuscular
- UPPER EXTREMITIES:
- Strength
- Grip
- Resistance
- Range of motion
- Nose to Fingers (Close Eyes)
- BOTH EXTREMITIES
-
LIGHT vs SHARP (Eyes close) - REFLEXES: Biceps, Triceps, Patellar, Achilles
- LOWER EXTREMITIES:
Plantar (Positive) vs Babinski (only for BABY – Negative) - Heel to Tibia
- Spine:
- Inspection: Bend over
- Range of Motion:
- Hyperextension
- Lateral bend
- Rotation
- GAIT:
- Romberg’s Test
- Heel to Toe (Tandem walking)
- Gait
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