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NR 509 Immersion Physical Exam Summary Advanced Physical Assessment

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Head and Face:

  1. Inspect Facial Skin: No discolorations or lesions observed.
  2. Inspect Head: Head is midline and symmetrical.
  3. Palpate Lymph Nodes: Palpated preauricular, postauricular, occipital, tonsillar, submandibular, submental, anterior cervical, posterior cervical, and supraclavicular lymph nodes. No enlargement felt; equal bilaterally.
  4. Cranial Nerve 5 (Trigeminal):
    • Motor: Palpated masseter muscle during jaw clenching; no distortions, good strength.
    • Sensory: Patient identified light touch on forehead, cheeks, chin, and nose.
  5. Cranial Nerve 7 (Facial):
    • Patient performed smile, frown, raised eyebrows, puffed cheeks, and puckered lips. Symmetrical movements noted.

Ear:

  1. Inspect Outer Ear: No nodules or skin lesions, symmetrical.
  2. Inspect Auditory Canal and Tympanic Membrane: Clear canals, no swelling, redness, or drainage. Tympanic membranes are pearly gray with no effusion.
  3. Palpate Pinnae and Tragus: No nodules or tenderness.
  4. Cranial Nerve 8 (Acoustic):
    • Whisper test conducted; hearing intact bilaterally.

Eye:

  1. Inspect Sclera and Conjunctiva: Conjunctiva pink and clear, sclera white and clear.
  2. Cranial Nerve 2 (Optic):
    • Assessed visual acuity with Snellen chart; 20/20 vision in both eyes.
    • Checked pupillary response to light; pupils constrict equally.
  3. Cranial Nerves 3, 4, 6 (Oculomotor, Trochlear, Abducens):
    • Tested conjugate gaze with EOM; intact.

Nose:

  1. Inspect Nose: Midline, no obstructions or noticeable fractures.
  2. Assess Nasal Turbinates and Septum: Pink and moist turbinates, septum straight.
  3. Palpate Sinuses: No tenderness in frontal or maxillary sinuses.

Throat and Mouth:

  1. Inspect Lips, Teeth, Gums, Buccal Mucosa, Palate, Tongue, Floor of Mouth, Posterior Pharynx, and Tonsils: Pink, moist, healthy structures; no lesions, nodules, or drainage.
  2. Cranial Nerves 9 and 10 (Glossopharyngeal, Vagus):
    • Uvula rises symmetrically with phonation.
  3. Cranial Nerve 12 (Hypoglossal):
    • Tongue moves left to right symmetrically.
  4. Palpate TMJ: No subluxations, tenderness, or crepitus.

Neck:

  1. Inspect for Deformities and Symmetry: Symmetrical.
  2. Palpate Trachea: Midline.
  3. Palpate Thyroid Gland: No abnormalities or nodules.
  4. Palpate Carotid Artery: Pulsations normal, no bruits.
  5. Auscultate Carotid Arteries: No bruits detected.
  6. Assess Active ROM: Flexion, extension, lateral flexion, rotation intact.
  7. Cranial Nerve 11 (Spinal Accessory):
    • Shoulder shrug against resistance intact.

Heart:

  1. Auscultate in All 5 Areas: Aortic, pulmonic, Erb’s point, tricuspid, and mitral areas clear with diaphragm and bell.

Anterior Chest:

  1. Inspect for Deformities and Symmetry: No deformities.
  2. Auscultate Lung Sounds: Clear in anterior lung fields.

Posterior Chest (Back):

  1. Auscultate Lung Fields: Clear in posterior lung fields and lateral lung fields including right middle lobe.

Upper Extremities:

  1. Inspect Joints: No redness, swelling, or deformities.
  2. Palpate for Capillary Refill: Normal, less than 3 seconds bilaterally.
  3. Assess Radial Pulses: Equal bilaterally.
  4. Assess Hand Grips: 5/5 strength bilaterally.
  5. Assess Passive ROM of Elbows and Shoulders: Flexion, extension, internal/external rotation, abduction, and adduction intact.
  6. Assess Strength of Biceps and Triceps: 5/5 strength bilaterally.
  7. Assess Cerebellar Coordination: Rapid alternating movements intact.

Abdomen:

  1. Inspect Abdominal Contours and Symmetry: No distortions.
  2. Auscultate for Bowel Sounds and Bruits: Bowel sounds present in all quadrants; no bruits.
  3. Percuss for Tympany, Dullness, Flatness: Normal.
  4. Palpate for Tenderness and Masses: None felt.
  5. Palpate Liver and Spleen: Normal.
  6. Perform Blumberg’s Sign: No rebound tenderness.

Lower Extremities:

  1. Inspect Skin Integrity and Edema: No lesions or edema.
  2. Assess Passive ROM of Hips and Knees: Flexion, abduction, adduction, internal/external rotation intact.
  3. Assess Strength of Knees: 5/5 strength bilaterally.
  4. Assess Passive ROM of Ankles: Dorsiflexion, plantar flexion, rotation intact.
  5. Assess Strength of Ankles: 5/5 strength bilaterally.
  6. Assess Dorsalis Pedis Pulse: 2+ and equal bilaterally.

Spine:

  1. Inspect and Palpate Spine: Normal curvatures, alignment, no tenderness.
  2. Assess Active ROM of Spine: Flexion, extension, lateral flexion, rotation intact.
  3. Assess Romberg: Negative.
  4. Assess Gait: Normal.