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NR 509 Physical Examination Grading RubricGrades are awarded as follows:2 = Demonstrated thoroughly with correct technique1 = Demonstrated Partially0 = Did not demonstrate*A head to toe (cephalo-caudal), and anterior-posterior approach should be used when conducting the exam. No deductions given for exam steps out of order. Students should verbalize each exam step and must identify all cranial nerves by name and number. Exam should be completed within 30 minutes. Introduce yourself to the patient. Have patient sit upHEAD AND FACEInspects facial skin – note abnormal lesions None noted210Inspect head for size, symmetry, midline position Head symmetrical, of normal size, and midline.210Palpates lymph nodes of the head and neck: Preauricular (in front ears), postauricular (behind ears), occipital (back of head), tonsillar (edge of jaw), submandibular (under jaw), submental (chin), anterior cervical (front neck), posterior cervical (back neck), supraclavicular (above clavicle) (verbalize these) No enlargements and they are equal bilaterally210CN 5 (Trigeminal)Motor – palpate over the masseter muscle as patient clenches jaw-(No Distortions and has great strength)Sensory – light touch sensation to forehead, cheeks, chin, nose (patient closes eyes and identifies where they are being touched) -CN 5 intact210CN 7 (Facial)Inspect for facial symmetry with smile, frown, raise eyebrows, puff cheeks, Those are equal bilaterally. pucker lips (Normal and tight)210EARInspect outer ear for skin lesions and symmetry. No lesions and symmetrical bilaterally210Inspect auditory canal and TM (using otoscope) To both earsPull up and back. External auditory canal is clear. No swelling, redness, drainage, or cerumen. Tympanic membrane is pearly gray and there is no effusion. 210Palpate pinnae and tragus (in front of ear) for nodules and tenderness. Any tenderness? No nodules or tenderness.210CN 8 (Acoustic) (Hearing)Whisper Test (whisper 3 words out of patient’s sight, and patient repeats words back) Test one ear at a time. Hearing is intact bilaterally.210EYEInspects sclera and conjunctiva. Sclera is white and clear, and conjunctiva is pink and clear.210CN 2 (Optic)Assess gross visual acuity and peripheral/central vision First Snellen standing 6 feet away. Have pt cover 1 eye at a time and read smallest line possible. Then read both eyes together. (LTFPH) Pt has normal 20/20 vision.Still CN 2 Peripheral vision- stand at same eye level and bring hands from beside patient until they see them. Let me know when you see my hands. Do directly beside, above, and below. Peripheral vision is normal.210CN 2 (Optic) Check pupillary response to light [PERRL] Using ophthalmoscope with light have patient stare at my nose and come from side with light source. Pupils are about 2-3mm and they respond to light.210CN 3 (Oculomotor), 4 (Trochlear), 6 (Abducens)Test for conjugate gaze with EOM. Using an H pattern have patient follow with only eyes. All EOM’s are intact equally.210NOSEInspect nose midline and straight210Assess nasal turbinates and septum (using light source) Lift tip of noseAll turbinates are pink and moist. Septum is midline. Angling anteriorly, I see the septum is straight with no deviation. 210Palpates frontal and maxillary sinuses Any Tenderness? No tenderness noted. 210THROAT AND MOUTH Inspect lips, teeth, gums, buccal mucosa, palate, tongue, the floor of the mouth (under the tongue), posterior pharynx, and tonsils (grade tonsils, if present)Lips-pink and moist. Open mouth. Teeth-no signs of decay or cracks. Gums- no redness or swelling and moist and pink. Buccal Mucosa-moist and pink bilaterallyUpper Soft and Hard Palates-pink and moistTongue-smooth and pinkLift tongueFloor of mouth is pink with no nodules or drainage and is moist. Posterior pharynx- no drainage and is moist and pink. Grade Tonsils if present1+ visible, 2+ halfway between pillars & uvula, 3+ touching uvula, 4+ touch each other. 210 PAGE SUBTOTAL: /34CN 9 (glossopharyngeal) and 10 (Vagus). Say “Ahh” and soft palate and uvula rise symmetrically with phonation (CN 10)* Gag reflex not tested for this exam (CN 9). Must only state name and numberUvula rises symmetrically with phonation, so CN 10 is intact. 210CN 12 (Hypoglossal)Stick out tongue and move it left to right. Intact210Palpate TMJ or temporomandibular joint for any subluxation, tenderness, or crepitus. Palpate both sides while pt opens and closes mouth. None noted.210NECKInspect for obvious deformities and symmetry None noted and is symmetrical.210Palpates trachea – midline It is midline.210Palpates thyroid gland Find cricoid process and suprasternal notch. Place hand on side of neck and ask pt to swallow while retracting a bit. I’m feeling for nodules and size. I feel no nodules.210Palpates carotid artery pulsation One at a time at side of trachea. Normal and bounding.210Auscultate over the carotid arteries for bruits using the bell of stethoscope Have pt hold breath. No bruits noted210Assess active ROM – flexion (chin to chest), extension (look at ceiling), lateral flexion (ear to shoulder), Rotation (look over shoulders) All intact equally210CN 11 (Spinal Accessory)Shrug shoulders against resistance Equal and intact210HEARTAuscultate in all 5 areas with the diaphragm and bell with the patient sitting (if stethoscope does not have a bell, then verbalize you would also auscultate with the bell)Verbalize Areas: Aortic (2nd intercostal space on R sternal border)Pulmonic (2nd intercostal space on L sternal border)Erb’s Point (3rd intercostal space on L sternal border)Tricuspid (4th intercostal space on L sternal border)Mitral (5th intercostal space in midclavicular line)410ANTERIOR CHESTInspect for obvious deformities and symmetry I do not see any210Auscultate lung sounds in anterior lung fields Beginning in intercostal spaces. Breath sounds are nice and clear throughout.210POSTERIOR CHEST (BACK)Auscultate posterior lung fields: Start above scapula alternating side-to-side in intercostal spaces. Go down into bases of lungs. Assess lateral lung fields (get right middle lobe) 8 areas All clear bilaterally410UPPER EXTREMITIES *All ROM & DTR examination only needs to be performed unilaterally for purposes of the immersion evaluation. Strength testing should be performed bilaterally.Inspect the joints of the hands – redness, swelling,Deformities Extend hands please. I do not see any.210Palpate for capillary refill. Testing one finger on each hand until it turns white. They turn pink in < 3 seconds. Normal capillary refill bilaterally. 210Assess radial pulses. Face palms in. They are equal, 2+, bilaterally. 210Assess hand grips (bilateral) – 5/5 strength Squeeze tight. Strength 5/5 bilaterally.210Assess passive unilateral ROM of the elbows (flexion (Bend), extension (straight))210Assess strength of biceps, triceps (bilateral) – flex/extend elbow againstresistance – 5/5 strength Flex up elbows and pull and then push. Strength is 5/5.210Assess passive unilateral ROM of the shoulders (flexion, extension, internal rotation, external rotation, abduction, adduction)Flexion-Arm straight up, Extension-Arm bend and back like upper cutInternal rotation- arm bent and hand across chest.External Rotation-Arm bent and out to sideAbduction-straight arm out to sideAdduction-bend arm up and in front of chest like getting ready to karate chop. ? 210 PAGE SUBTOTAL: /46Assess cerebellar coordination with rapid alternating movement: Serial finger opposition (thumb to fingers), hand flip-flop (hands on knees and alternate getting faster) Those are both normal and well coordinated.210Assess unilateral DTRs. Biceps, patellar, achillesBiceps-Support pt arm on arm and place my thumb on medial aspect of antecubital fossa. Then I’ll strike my thumb with the pointy end of the hammer. Contracted well. Patellar-Will use the flat end. Good contraction.Achilles-pt relax foot while I dorsiflex foot and tap with flat end. Pt has pronation. 210Have patient lie downABDOMENInspect abdominal contours and symmetry No distortions.210Auscultate for bowel sounds in all 4 quadrants. Present in all 4 quadrants. 410Auscultate for bruits (verbalize) – aorta, renal arteries, iliac arteries. Must use the bell of stethoscope (if no bell on stethoscope, then state bell would normally be used)Aortic- midline right below xyphoid process.L Renal-Above and lateral to the L of umbilicus.R Renal-Above and lateral to the R of umbilicus.L Iliac-below and L of the umbilicus.R Iliac-below and R of the umbilicus.No bruits noted. 410Percuss in all 4 quadrants for tympany, dullness, flatness. Normal 210Palpate in all 4 quadrants for tenderness and masses. Any tenderness? Feels normal with no masses.210Palpate liver and spleen (verbalize). Liver-Place L hand underneath pt. Look at midclavicular line on R side. I’m placing palm upward right at edge of costovertebral angle. When pt takes a deep breath, I’ll push down and up and may feel the lower edge of the liver. Spleen-Have pt come toward me laterally with knees bent. Place L hand underneath. Again at costovertebral angle I’ll push down and up as the pt takes a deep breath. I don’t feel the spleen, which is normal.210Perform Blumberg’s sign (verbalize). I’ll press straight into abdomen at 90 degrees. If pt feels pain when release it would be a positive Blumberg. Any rebound pain? No Then it’s Negative.210LOWER EXTREMITIESInspect the skin integrity of lower extremities and assess for edema or lesions. None noted. 210Assess passive unilateral ROM of hips (flexion, abduction, adduction, internal rotation, external rotation) *extension not tested for this examFlexion-bend knee upAbduction- straight leg awayAdduction- straight leg acrossInternal Rotation-bent knee in and foot outExternal Rotation-bent knee out and foot in210Assess passive unilateral ROM of the knees (flexion (bend), extension (straight))210Assess strength at the knees (bilateral) – flex/extend against resistance – 5/5 strength. Bend knees up and place feet on table. Push up and pull in against resistance. Strength 5/5 and equal bilaterally. 210Assess passive unilateral ROM of the ankles (dorsiflexion (toes towards body), plantar flexion (toes toward ground), rotation (roll)) 210Assess strength at ankles (bilateral) – dorsi/plantar flex against resistance – 5/5 strength. Push feet down/Plantar flex against my hands and pull feet up/dorsiflex. Strength 5/5 and equal bilaterally. 210Assess dorsalis pedis pulse (top of foot) 2+ and equal bilaterally. 210Have patient stand upInspect and palpate both sides of the spine – expected curvatures, alignment, tenderness. No abnormalities.210Assess active ROM of the spine (flexion (touch toes), extension (bend back), lateral flexion (lean to sides), and rotation(twist to sides)). Good active ROM210Assess Romberg. I’m going to have you close your eyes. We’ll do this for 20 seconds and look for swaying. You can open your eyes. None seen which equals Negative Romberg.210Assess gait (just several steps) I’ll have you walk away for a couple steps and then turn around and walk back. 210 PAGE SUBTOTAL: /44(Minimum score of 104 required to pass) EXAM TOTAL: /124 ................
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