ICM - General Assessment, Vitals, Skin, HEENT

Question 1

General Assessment: General state of health, signs of distress, facial expression, stature, build, posture, grooming/ hygiene, speech, mobility, mental alertness, etc.

Answer 1

“I am inspecting for general state of health, signs of distress, etc….” “Patient is well developed, well nourished, alert and appropriate and in no acute distress….”

Question 2

Height, Weight, Temperature

Answer 2

“I have noted your height, weight, and temperature documented on your chart. “

Question 3

Blood pressure

Answer 3

“Now I will take your vital signs. Do you know what your last blood pressure was…?” “Blood pressure is __/__”

Question 4

Respirations

Answer 4

“Respirations are __ per minute and unlabored. No retractions are noted.”

Question 5

Pulse

Answer 5

“Pulse is regular and strong.”

Question 6

Inspect: skin color and lesions for location, distribution, grouping, and color

Answer 6

“I am checking exposed skin for color, lesions for location, size…..”

Question 7

Palpate: Turgor, Texture, Temperature

Answer 7

“Skin turgor and texture are normal (as you palpate skin); skin is warm & dry….”

Question 8

Inspect: facial features • Make note of any asymmetry Inspect: hair, scalp, and skull

Answer 8

“The head is normocephalic and atraumatic, face is symmetrical, without lesions…..”

Question 9

Palpate: hair, scalp, skull

Answer 9

“Symmetrical hair distribution, hair is coarse, curly with male pattern baldness.” (if appropriate)

Question 10

Test facial muscle function: (CN VII)

Answer 10

“Squeeze eyes shut, wrinkle forehead, smile, puff out cheeks…..”

Question 11

Light touch: forehead, cheeks, chin (CN V, sensory)

Answer 11

“Close your eyes. Say ‘now’ each time you feel me touch your face.”

Question 12

Palpate: facial bones & sinuses

Answer 12

“Do you have any sinus tenderness?”

Question 13

Palpate TMJ & test TMJ ROM

Answer 13

“Open your mouth, move jaw from side to side”

Question 14

Palpate masseter muscles: (CN V, motor)

Answer 14

“Clench teeth”

Question 15

Inspect: external eyes: conjunctiva, sclera, iris, cornea, lids

Answer 15

“I am inspecting the eyes for symmetry, exophthalmos, ptosis, edema, icterus, lesions…”

Question 16

Visual acuity (CN II) - Snellen or hand-held (Rosenbaum)

Answer 16

“I would normally test vision using Snellen or hand held eye chart….”

Question 17

Corneal reflex (CN V – sensory and CN VII – motor)

Answer 17

“I would normally check the corneal reflex, lightly touching the cornea, which when tested would cause the patient to blink.”

Question 18

Direct pupillary light reflex (CN III)

Answer 18

“Pupils equal, round, and reactive to light.”

Question 19

Consensual pupillary light reflex (CN III)

Answer 19

Evaluate in six cardinal positions, using H pattern. “Extraocular movements are intact bilaterally, without nystagmus.”

Question 20

Accommodation (CN III)

Answer 20

“Eyes converge and pupils accommodate to near vision.”

Question 21

Perform: Ophthalmoscopic examination bilaterally - Obtain red reflex - Inspect cornea and lens

Answer 21

“Red reflex is present.”

Question 22

Funduscopic exam: inspect disc, cup margins, vessels, retina and macula/fovea

Answer 22

“Disc margins are sharp” “AV ratio is 2:3 without nicking or spasms.” “There are no hemorrhages or exudates.”

Question 23

Check hearing:(CN VIII)

Answer 23

Whisper or rub fingers close to patient’s ears. “Tell me when you hear my fingers rubbing together”

Question 24

Inspect: auricle and surrounding tissue for deformity, masses, lesions

Answer 24

“I am inspecting the ears for masses or lesions…”

Question 25

Palpate: auricle, tragus, mastoid

Answer 25

“There is no discoloration of the mastoid, no edema, no ecchymosis.”

Question 26

Otoscopic examination: Inspect canals, Inspect TM for landmarks, light reflex, deformities, inflammation,

Answer 26

“External auditory canals are clear” OR “Canals are occluded with cerumen” “TM is pearly gray and translucent, light reflex present, landmarks are present.” “There is no evidence of fluid in the middle ear.”

Question 27

Inspect: Nose external appearance

Answer 27

“Nose is midline without lesions…”

Question 28

Palpate: external nose

Answer 28

“No bony deformities are palpated”

Question 29

Test: nasal patency

Answer 29

“Occlude one nostril with your index finger, and sniff”

Question 30

Speculum exam: septum, turbinates and nasal mucosa

Answer 30

“Mucosa is pink and moist without lesions…” OR “Scant clear rhinorrhea is present…” OR other appropriate description

Question 31

1. Inspect • Lips • Teeth, gums, mouth odor • Buccal mucosa, posterior oropharynx, tonsils and pillars

Answer 31

“Lips are red, without lesions…” “Teeth are in good repair, non tender, good oral hygiene…” “Breath odor is non offensive.” (eg. fruity, alcoholic) “I am inspecting the buccal (pronounced “buckle”) mucosa, posterior pharynx, pillars, and tonsils for size and color

Question 32

Soft palate and uvula: 1. Say “Ah” (CN IX, X) 2. Note vocal quality

Answer 32

Ask patient to open mouth and say “Ah”.

Question 33

Protrude tongue, move side-to-side (CN XII)

Answer 33

“Tongue is midline without deviation

Question 34

Palpate: oral cavity (bimanual, gloved technique

Answer 34

“I would normally conduct a bimanual exam of the oral cavity.”