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NR 509 Physical Examination Grading RubricA head to toe (cephalo-caudal), and anterior-posterior approach should be used when conducting the exam. Students should verbalize each exam step and also identify cranial nerves by name. *Exam should be completed in 30 minutes or less. *No deductions given for exam steps out of order.Introduce yourself to the patient. Have patient sit upHEAD AND FACEInspects facial skin – note abnormal lesionsInspect head for size, symmetry, midline positionPalpates lymph nodes of the head and neck: preauricular, postauricular, occipital, tonsillar, submandibular, submental, anterior cervical, posterior cervical, supraclavicular (verbalize these)CN 5 (Trigeminal)Motor – palpate over the masseter muscle as patient clenches jaw Sensory – light touch sensation to forehead, cheeks, chin, nose (patient closes eyes and identifies where they are being touched)CN 7 (Facial)Inspect for facial symmetry with smile, frown, raise eyebrows, puff cheeks, pucker lipsEARInspect outer ear for shape and positionInspect auditory canal and TM (using otoscope)Palpate pinnae and tragus for masses and tendernessCN 8 (Acoustic)Whisper Test (whisper words out of patient’s sight, and patient repeats words back) Test one ear at a time. EYEInspects sclera and conjunctivaCN 2 (Optic)Assess gross visual acuity and peripheral/central vision CN 2 (Optic)Check pupillary response to light [PERRL]CN 3, 4, 6 (Oculomotor, Trochlear, Abducens)Test for conjugate gaze with EOM NOSEInspect nose midline and straightAssess nasal turbinates and septum (using light source)Palpates frontal and maxillary sinusesTHROAT AND MOUTHInspect lips, teeth, gums, buccal mucosa, palate, tongue, the floor of the mouth (under the tongue), posterior pharynx, and tonsils (grade tonsils, if present)CN 9 and 10 (Glossopharyngeal, Vagus)Say “Ahh” and soft palate and uvula rise symmetrically with phonation (CN 10)* Gag reflex not tested for this exam (CN 9)CN 12 (Hypoglossal)Stick out tongue and move it left to rightPalpate TMJ for any subluxation, tenderness, or crepitusNECKInspect for obvious deformities and symmetryPalpates trachea – midlinePalpates thyroid glandPalpates carotid artery pulsationAuscultate over the carotid for bruitsTest ROM – flexion, extension, lateral flexion,rotationCN 11 (Spinal Accessory)Shrug shoulders against resistanceHEARTAuscultate in all 5 areas with the bell and diaphragm with the patient sitting (if stethoscope does not have a bell then verbalize you would use the bell)Verbalize Areas:Aortic Pulmonic Erb’s pointTricuspid MitralANTERIOR CHESTInspect for obvious deformities and symmetryAuscultate lung sounds in anterior lung fieldsPOSTERIOR 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)UPPER EXTREMITIESInspect the joints of the hands – redness, swelling,deformitiesPalpate for capillary refillAssess radial pulsesAssess hand grips – 5/5 strengthAssess ROM of the elbows (flexion, extension)Assess strength of biceps, triceps – flex/extend elbow againstresistance – 5/5 strengthAssess ROM of the shoulders (flexion, extension, internal rotation, external rotation, abduction, adduction)Assess cerebellar coordination with rapid alternating movement:Serial finger opposition, hand flip-flopAssess DTRs: Biceps, patellar, achillesHave patient lie downABDOMENInspect abdominal contours and symmetry Auscultate for bowel sounds in all 4 quadrants Auscultate for bruits (verbalize) – aorta, renal arteries, iliac arteriesPercuss in all 4 quadrants for tympany, dullness, flatness Palpate in all 4 quadrants for tenderness and massesPalpate liver and spleen (verbalize)Perform Blumberg’s sign (verbalize)LOWER EXTREMITIESInspect the skin integrity of lower extremities and assess for edema.Assess ROM of hips (flexion, abduction, adduction, internal rotation, external rotation) *extension not tested for this examAssess ROM of the knees (flexion, extension)Assess strength at the knees – flex/extend against resistance – 5/5 strengthAssess ROM of the ankles (dorsiflexion, plantar flexion, rotation)Assess strength at ankles – dorsi/plantar flex against resistance – 5/5 strengthAssess dorsalis pedis pulseHave patient stand upInspect and palpate the spine – expected curvatures, alignment, tendernessAssess ROM of the spine (flexion, extension, lateral flexion, and rotation)Assess RombergAssess gait (just several steps) ................
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