Health Assessment

Make sure to have pen light, gloves, and tool to check reflex
Walk up introduce and state what you are doing

General survey
1.31 y/o female level of con is awake and alert skin color is normal for ethnicity
facial featured are symmetrical
Body stature she is 5 foot nutrition is well nourished her body is overall
symmetrical her posture is sitting erect on the side of the bed
2.check gait have patient stand up and walk. Her gait appears smooth not using
an assisted devices.
Her facial expression is calm her mood and affect is cooperative her speech is
clear her dress is well kept and personal hygiene is well kept and clean.

Cranial Nerves
Now we are going to start cranial nerves
1. Olfactory sensory- have patient close eyes and smell alcohol wipe. Cranial
nerve 1 olfactory is intact
2. Optic sensory – im going to check your visual acuity as stated earlier Snellen
chart her vision is 20/20 corrected with eye glasses ( if your partner wears
glasses or contact!!!!!!) Visual fields im going to perform the confrontation
test. If you could look at me cover your right eye and tell me when you see
my fingers start coming in to your peripheral. Then do the other eye.
Confrontation test is intact so that’s cranial nerve 2
3. Oculomotor- im going to assess perrla which is pupils equal round and
reactive to light accommodation. Her pupil size is about a 4mm shape is
round response to light im going to shine a bright light in your eye. Pupils
react to light both direct and consensual. For accommodation I am going
 to ask you to look at the tip of my pen and then look back at that door and
then back to my pen. When checking for accommodation her pupils will
constrict when looking at my pen and dilate with looking at the door. That’s
intact. Next im going to assess her extraocular movements so this is cranial
nerve 4 trochlear and cranial nerve 6 abducen along with cranial nerve
number 3. That is when we have our patient follow our pen in the up down
side and diagonal with their eyes. Cranial nerve 3 ,4, 6 are intact

5. Trigeminal- this is sensory and motor the sensory is sensation of the face. Use
something hard and soft to touch to their face. Have the patient state if its hard
or soft and where it is on their face ( eyebrow cheek and chin) sensory is intact
now im going to assess her motor movement while also palpating her temporal
and masseter muscles. Have them open their jaw and move it side to side. Ask if
there was any pain while doing that. State you didn’t feel any clicking. Cranial
nerve 5 is intact
7.Facial – sensory “ were you able to eat this morning?” “ Did you taste” the taste
on the anterior 2/3 of the tongue is intact the motor component is movement of
the face. Can you raise your eyebrows smile show your teeth puff your cheeks out
and close eyes tightly. The motor component is intact. Cranial nerve number 7 in
intact
8.Acoustic-which is the hearing test. Perform the whisper test. Cranial nerve * is
in intact
9 and 10 Glossopharyngeal and vagus – sensory I stated earlier the posterior 1/3
of the tongue patient can already taste and sensations were also intact of her
throat and her tongue. The motor component is swallowing and phonation. Have
partner open mouth stick out tongue and say ah uvula rises and falls
symmetrically and also her gag reflex is intact. Cranial nerve 9 and 10 are intact
11.Spinal Accessory im going to check your shoulders for movement. Shrug for me
and now try to shrug with some resistance. Check her head muscles against
resistance. look to your left look to your right she is able to push against
resistance. Cranial nerve 11 in intact.
12.Hypoglossal which is motor. This is tongue movement im going to ask you to
stick your tongue and push it inside each cheek. Cranial nerve number 12 is intact.

Head and Face

Look at hair, it is intact and no balding is noticed the scalp and skull is also intact
no trauma and symmetrical. Her face is also symmetrical . im also going to palpate
her temporal artery plus 2 regular
Eyes
inspect external eyes. looking at eyebrows are intact there is no infestation or
balding their symmetrical, eyelids are symmetrical there is no drooping eyelashes
are also symmetrical they are outward turning with no infestation or balding
noticed. The conjunctiva is pink there is no redness and the sclera are white there
is no redness or yellowing color
Ears
External ear inspect and palpate they look symmetrical with no trauma. As I feel
the auricle, tragus and mastoid process is there any pain or tenderness when I
pressing. There is no trauma they are symmetrical no lesions or swelling.
Earlier I performed the otoscopic exam the external auditoyr canal was pink no
serum or edema the tympanic membrane was a pearly grey color translucent
there was no building or redness noted.

Nose
The external is symmetrical at Midline there is no curving to the right or left.
Mucosa im going to use my penlight have the patient look up. Mucosa is moist no
discharge or abnormal color. No blood swelling or lesions.
Palpate the sinuses frontal (above eyebrows) and maxillary below cheekbones.
Ask if there was any pain or pressure.
 Mouth ( make sure to wear gloves!!!!!)
Im going to inspect the mouth starting with the lips and then looking around. The
lip as symmetrical there is no breakage it is moist. Looking at the buccal mucosa it
is pink no bleeding.
Gums are pink no redness or swelling. Teeth are intact they are white no carries
noted. Floor of the mouth have patient lift up tongue state is pink no bleeding or
swelling. The palate both hard and soft are pink there is no redness. The tongue
has capilly on it, it is pink there is no white or black discoloration noted. Tonsils
are symmetrical no swelling noted the oropharynx is also pink no redness noted.
Neck
Looking at the neck it does appear symmetrical I do not see any tracheal
deviation or goiter noted.next palpate the thyroids. Go behind your patient to
perform. Have them look down and to the right and swallow and then down to
the left and swallow.ask if that hurt or was at all painful. State you didn’t feel any
abnormalities or swelling.
 Now the lymph nodes.

All were less than 1 cm mobile and soft. Abnormal would be greater than 2 cm
hard and dense

Posterior chest
Inspect while looking at the back I notice her spine is straight and there is
symmetry. Her thorax is symmetrical scapula symmetrical. Downward slopping
ribs no skeletal deformities such as scoliosis or barrel chest . skin is intact normal
for ethnicity no lesions or scar. Push on back have them state if there any pain or
not when pushing. No masses were noted now move onto auscultating. Im going
to do this at 7 points bilaterally. Tell the patient everytime I put my stethoscope
down breath in and out.
 ANTEROIR CHEST
Anterior chest is symmetrical there is no retraction or bulging noted. Ribs are
downward slopping costal angle 90 degrees there is no retraction or signs of
struggling to breath. Skin is intact no lesions scars or nevis noted. She is relaxed.
Breathing pattern is normal there is tachypnea or brady noted her respiratory rate
as noted earlier is 15 breaths per minute and it was non labored.palpate the chest
and ask if there is any tenderness . no masses were felt. Next auscultate 6 points

symmetrically.
Normal breath sounds are going to be bronchial which is heard of the trachea
area. Bronchovesicular which is the 1st and 2nd intercostal space and vesicular is
heard over the lung field
 Cardiovascular
Auscultate the carotid arteries

Make sure to have your patient hold their breath. Once you listen to one spot
have them breath and the hold their breath again for each spot. State No bruits
were noted.
Next palpate one side at a time. State +2 and regular
Next are the 5 precordial points
Aortic- second intercoastal space, right sternal
boarder

Pulmonic- second intercoastal space,left sternal

boarder

Erb’s point- third intercoastal space left sternal

boarder

Tricuspid- fourth intercoastal space, left sternal

boarder

Mitral- fifth intercoastal space, left sternal

boarder
 Normal heart sounds are s1 an s2. S1 is best heard over the apex which is the
mitral area and s2 is best heard over the base which is the aortic area.
Next assess arteries for pulses bilaterally and provide a grade
Radial femoral popliteal posterior tibialis and dorsalis pedis state they are +2 and
regular
 Next im going to look at the extremities for peripheral edema ,in the lower
extremities im going to pull up her clothes ( pant leg) and push along her legs no
edema was noted bilaterally in the lower extremities.
Next im going to check skin temperature which is warm upper and lower
extremities texture is smooth moisture is dry and color is normal for ethnicity
upper and lower extremities next is skin tugor check hand for this. It was brisk less
than 3 seconds. Nails capillary refill im going to push on the nail that was also
brisk less than 3 seconds on upper and lower extremities.

Abdomen
Have patient lay down, inspect her abdomen, contour is flat color is normal for
ethnicity there is no lesion scars nevi or dilated veins,
Next identify 4 quadrants of abdomen
RUQ LUQ RLQ LLQ
After identifying, listen to bowel sounds in each quadrants. * state* Im listening
for 5 to 30 sounds per minute which would be normal active anything else above
would be hyperactive and anything below would be hypoactive.
After listening palpate lightly starting with the RLQ -RUQ-LUQ-LLQ. Have the
patient state if there is any pain while pushing on all 4 quadrants.

Musculoskeletal system
inspect and palpate joints-shoulders, elbows, wrists, fingers, hips, knees, ankles,
toes. Ask if there was any pain or tenderness. I did not feel any deformities or
swelling, the color is pink no redness noted.
Next complete ROM
Neck- flex neck extend neck and rotate to the right , rotate to the left, laterally
bend the left and then laterally bend the right
 elbow – flex your elbox extend your elbow
wrist- flex your wrist extend your wrist
fingers-flex and extend your fingers then show show abduction and adduction in
the fingers

Hips- flex extend abduction adduction internal rotation external rotation

 Knees- flex extend

Ankles- plantar flexion point down, dorsiflexion point up. Inversion and eversion

Next im going to test your muscle strength in your upper and lower extremities.
Upper push out, push in, push towards me pull away and squeeze my fingers.
With your legs push out push in push towards me push back now push up with
your foot.
I would say the muscle strength is a +5 normal complete range of motion against
gravity and full resistance.
 Neurological system
I previously checked your gait so now we are going to do rapid alternating
movements. Do this as quickly as possible. With hand to thigh have patient put
hands downward on thighs and flip up rapidly. Next finger to thumb touch all
fingers to thumb as quickly as possible.
Finger to nose have your finger out and the patient take their finger and go from
your finger to their nose rapidly. Next heel to shin have their patient take their
heel and drag down each shin.
Deep tendon reflex
Tricep

I did see movement on her fingers

 Patellar

I did see reflex which it kicked for me so tricep and patellar deep tendon reflexes
are intact.
Thank You very much