Practical #2

Question 1

First thing you do when you walk in the room

Answer 1

Introduce yourself
Verify Patient Identity
State your purpose and if it is okay

Question 2

1 of 11

Answer 2

Vital signs: BP, HR, and RR
HR is 80 2+ and regular, RR is 14 unlabored and regular
General: patient is 31 yo female A&O x3, in NAD, WD, WN

Question 3

2 of 11

Answer 3

HEAD
Patient is normocephalic, Head is atraumatic, symetrical, and smooth without deformity. Scalp is mobile not fixed. Hair is smooth, not brittle
Face is symmetrical without drooping or facies. Skin is without sores, rashes, or lesions

Question 4

3 of 11

Answer 4

Frontal and maxillary sinuses are non-tender to palpation and percussion

Question 5

4 of 11

Answer 5

Nose is symmetric and patent bilaterally
Nasal mucosa is shiny, pink, and moist
Turbinates are non-boggy
Septum is midline, intact, and without perforation

Question 6

5 of 11

Answer 6

Auricle are without masses or lesions
No mastoid or pre-auricular tenderness
Auditory canals are clear, without lesions, and not dry
TMs are pearly gray, cone of light intact, and bony landmarks are visualized
Hearing is symmetric bilaterally. Weber does not lateralize. Rinne test AC>BC

Question 7

6 of 11

Answer 7

Lips are symmetric, without sores or cracks, pink and moist. Vermillion border is sharp.
Oral mucosa is pink and moist w/o lesions. Gums are pink w/o pallor. Stenson’s ducts are visualized and unremarkable.
Sublingual area is unremarkable.
Pharynx and tonsils are without erythema or exudate
Dentition is good.
Examine mouth: no masses, no gingival tenderness.
Tongue is symmetric, w/o lesions or ulcerations
Uvula rises midline and gag reflex is intact
Tongue projects midline w/o deviation strenght is intact bilaterally

Question 8

7 of 11

Answer 8

Neck is supple without masses or tenderness
Trachea is midline and mobile
Thyroid is smooth w/o masses or nodules

Question 9

8 of 11

Answer 9

Lymphnodes are palpated w/o tenderness or enlargement

No lymphadenopathy

Question 10

9 of 11

Answer 10

Chest, back, extremities, face and neck are w/o sores, rashes or lesions.
No suspicious moles
W/o color changes like jaundice, cyanosis, pallor, or edema

Question 11

10 of 11 - exam

Answer 11

Visual acuity is 20/20
Eyes are symmetric w/o edema. Eyelids are symmetric and even in appearance.
Sclera are white, bulbar and palpebral conjunctiva are pink and moist w/o injection
Globes are nontender and w/o resistance
No palpable masses or tenderness of lacrimal ducts or eye lids

Question 12

10 of 11 - tests

Answer 12

Light reflex is intact symmetrically and bilaterally
Pupils are 4 mm and round
Direct and consensual pupil reaction are intact bilat. and sym.
Accommodation is intact bilaterally.
No strabismus with cover-uncover.
Eyes converge and constrict symmetrically.
EOMs are intact
No nystagmus

Question 13

10 of 11 - ophthalmascope

Answer 13

Tangential light w/o shadows - ant. chamber clear of debris, deformity, or clouding
Red reflex intact
Retinal vessels are distinct and optic disc is round with sharp margins

Question 14

11 of 11!

Answer 14

CN 1 - not tested
CN 2 - visual acuity
CN 3, 4, 6 - EOM good
CN 5 - facial sensation and muscles of mastication
CN 7 - facial expression - dont let me open your eyes
CN 8 - hearing, weber, rinne, and nystagmus
CN 9 - gag reflex
CN 10 - gag reflex and uvula rise midline
CN 11 - shrug shoulder and turn face
CN 12 - tongue projects midline and strength

Question 15

Order

Answer 15

VS/General, Head, Sinuses, Nose, Ears, Mouth, Neck, Lymphnodes, Skin, Eyes, CNs