Immersion Checklist

Question 1

General Survey

Answer 1

1. Mental status A and Ox3.
2. General appearance/presence of discomfort or distress.
3. Dress, grooming, hygiene.

Question 2

Skin

Answer 2

1. Pigmentation, texture, moisture, temperature.
2. Lesions: Presence, absence. If present, describe characteristics, distribution.
3. Nails: Cap refill, hygiene, shape, lesions.

Question 3

Head

Answer 3

1. Scalp: Presence, absence of lesions, nodules.

2. Hair: Texture, distribution.

Question 4

Eye

Answer 4

1. Inspection
   a. Lids: Direction of lashes, lesions, ptosis, edema, erythema.
   b. Conjunctiva: Bulbar and palpebral. Pale, injected (pull lids up and down to see).
   c. Sclera: Color, lesions.
   d. Cornea: Clear, scarred, lesions, arcus (walk to side and shine pen light from angle).
   e. Iris: Uniform color.
2. Pupils: Size, shape, regularity, equality.
3. Pupillary response
   a. Direct and consensual reaction to light (Shine light in eyes x 2. Second time block light with hand and look at opposite eye.). CN3 Oculomotor.
   b. Accommodation (Look from finger to wall. Constricts on finger. Dilates on wall.).
4. EOMs: Present, nystagmus present, absent (Follow finger in H pattern). CN 3/4/6 Oculomotor, Trochlear, Abducens.
5. Visual fields (Cover R eye and NP cover L eye and wiggle fingers in peripheral vision). CN2 Optic.
6. Visual acuity: Snellen chart. CN2 Optic.

Question 5

Ears

Answer 5

1. Auricles: Inspect anterior and posterior.
2. Palpate external ear and mastoid process for tenderness.
3. External canal: Inspect for lesions, drainage, cerumen.
4. Tympanic membrane: Inspect, comment on landmarks, cone of light.
5. Hearing: Test with whispered voice or watch tick. CN 8 Acoustic.

Question 6

Nose and Sinuses

Answer 6

1. External structure: Skeleton
2. Internal structures: a. Septum: Inspect for deviation, perforation, lesions. b. Mucosa, turbinates: Inspect for color, lesions, edema, discharge.
3. Sinuses: Frontal, maxillary. Palpate for tenderness.

Question 7

Mouth and Pharynx

Answer 7

1. Lips: Inspect for lesions, dryness.
2. Buccal mucosa: Lesions.
3. Teeth, gums: Inspect for lesions, caries, repairs, absent teeth, edema, erythema, bleeding of gums.
4. Tongue: Inspect for coating, papillation, lesions, tongue protrude midline. CN 12 Hypoglossal motor.
5. Sublingual area: Inspect for lesions, saliva.
6. Hard palate, uvula, soft palate: Inspect for lesions.
7. Tonsils: Inspect for presence/absence, size, erythema, swelling, exudate.
8. Posterior pharynx: Inspect for erythema, exudate, lesions.

Question 8

Nodes

Answer 8

1. Cervical: Pre-auricular, post-auricular, tonsillar, submandibular, submental, anterior cervical, superficial cervical, deep cervical, posterior cervical, occipital.
2. Supraclavicular, infraclavicular.
3. Epitrochlear.
4. Inguinal (horizontal and vertical).

Question 9

Neck

Answer 9

1. Trachea: Midline.
2. Thyroid: Inspect for enlargement, palpate for enlargement, nodules, tenderness.
3. Carotids: Palpate for presence/absence, quality of pulsation, auscultate for bruits.

Question 10

Thorax and Lungs

Answer 10

1. Inspection: AP to lateral diameter ratio, Respiratory effort (Use of accessory muscles, retraction of interspaces), Respiratory rate.
2. Percuss posterior lung fields and location of diaphragm.
3. Auscultate: breath sounds anterior, posterior and describe findings, adventitious sounds.
4. Voice sounds (egophony or bronchophony).

Question 11

Breasts

Answer 11

1. Inspection: Breast size, symmetry, contour, skin lesions/texture, nipples.
2. Positions: Sitting with hands on hips and arms raised overhead, stand and lean forward.
3. Palpate 4 quadrants each breast for tenderness, masses; palpate areola/ nipples for tenderness, masses.
4. Axillary nodes (central, lateral, pectoral, subscapular).

Question 12

Heart

Answer 12

1. Neck veins: Observe and measure at 30°. Observe with HOB over 30°.
2. Precordium: a. Inspect precordium: heaves, lifts. b. Palpate precordium: pulsations, thrills.
3. Apical impulse: location, amplitude, identify rate and rhythm at apical impulse.
4. Ascultation (use bell and diaphragm): a. Identify landmarks and auscultate using diaphragm. Aortic area, identify S1, S2. Pulmonic area, identify S1, S2. Tricuspid area, identify S1, S2. Mitral area, identify S1, S2. b. Listen to all areas with bell. c. Have pt turn to left side: listen at mitral area with bell for mitral murmur. d. Have pt sit up, lean forward, diaphragm in aortic area for aortic murmur.

Question 13

Peripheral Vascular

Answer 13

1. Palpate and comment presence/absence, symmetry:
   a. Temporal
   b. Radial
   c. Femoral
   d. Popliteal
   e. Posterior tibial
   f. Dorsalis pedis
2. Inspect LE for signs of arterial insufficiency.
3. Inspect LE for varicosities.
4. Inspect/palpate LE for edema.

Question 14

Abdomen

Answer 14

1. Inspect: contour, masses, scars, skin.
2. Auscultate: bowel sounds in 4 quadrants.
3. Auscultate: aorta, renal arteries for bruits.
4. Percuss abdomen.
5. Light and deep palpation to all 4 quadrants and flanks: tenderness, masses.
6. Special Maneuvers:
   a. Percuss liver span.
   b. Palpate liver edge.
   c. Percuss for enlarged spleen along left costal margin.
   d. Palpate for enlarged spleen.
   e. Rebound tenderness.
   f. Psoas sign/Obturator sign.
   g. CVA tenderness.
   h. Aortic span

Question 15

MSK

Answer 15

Inspect, palpate, and ROM.

1. TM joints
2. Neck. Landmarks: Cervical vertebrae, paravertebral muscles. ROM: Flexion, extension, lateral bending, rotation.
3. Spine. Landmarks: vertebrae, paravertebral muscles, sciatic notch. ROM: flexion, extension, lateral bending, rotation.
4. Shoulder. Landmarks: AC joint, bicipital groove, glenohumeral joint. ROM: abduction, adduction, internal & external rotation, flexion, extension.
5. Elbow. Landmarks: olecranon process, humeral epicondyles. ROM: flexion, extension, supination, pronation.
6. Wrist. Landmarks: radial and ulnar styloids, carpal bones. ROM: flexion, extension, radial deviation, ulnar deviation.
7. Hand. Landmarks: metacarpals, phalanges, MCP’s, PIP’s, DIP’s. ROM: flexion, extension, abduction, adduction of fingers.
8. Knee. Landmarks: femoral condyles, tibial condyles, medial and lateral joint spaces, tibial tuberosities. ROM: flexion, extension.
9. Ankle. Landmarks: medial and lateral malleoli. ROM: flexion, extension, inversion, eversion.
10. Toes. Landmarks: tarsals, MTP’s, PIP’s, DIP’s. ROM: flexion, extension, abduction, adduction of toes.
11. Hips. Landmarks: greater trochanters. ROM: abduction, adduction, internal & external rotation, flexion, extension.

Question 16

Neurological

Answer 16

1. Mental Status. Cognitive function (WORLD backwards). Higher intellectual function (Don’t count your chickens before they’re hatched).
2. Cranial Nerves: 2 Optic: visual acuity, visual fields.
   3 Oculomotor: pupil response, upper lid movement.
   4 Trochlear: look for EOM with cardinal fields of gaze.
   6 Abducens: observe lateral eye movement with cardinal field of gaze.
   5 Trigeminal sensory: light touch, pain to 3 facial dermatomes. Trigeminal motor: strength of temporal and masseter muscles.
   7 Facial motor: frown, smile & show teeth, wrinkle forehead.
   8 Acoustic: whispered voice (with head and neck exam).
   9&10 Glossopharyngeal & vagus motor: symmetrical rising of palate, uvula: hoarseness (with head and neck exam). Sensory: gag reflex, taste not required.
   11 Spinal accessory motor: turn head, shrug against resistance.
   12 Hypoglossal motor: tongue protrudes in midline.
3. Motor:
   a. Inspection: muscle bulk, tone. Unusual movements, tremors, fasiculations.
   b. Test muscle strength against resistance in major muscle groups. Grade muscle strength 0-5: Upper extremities, lower extremities, Shoulder girdle: pronator drift: arms extended, palms up.
4. Sensory: Major dermatomes of extremities. Test for light touch and pain separately.
   a. Light touch (cotton).
   b. Pain (broken tongue blade, paper clip.
   c. Vibratory sense with 128 Hz tuning fork.
   d. Position sense great toe and index finger bilaterally.
5. Reflexes: Triceps, biceps, brachioradialis, knee (Patellar), ankle (Achilles), plantar response (Babinski).
6. Cerebellar Function: Equilibrium & Gait
   a. Gait.
   b. Heel to toe (tandem) walking.
   c. Romberg: feet together, eyes closed, arms at side for 20-30 seconds.
7. Test coordination: Demonstrate either rapid alternating movements or point-to-point with upper extremities and lower extremities.