lab midterm

set up / intro

• Announced that I performed hand hygiene at a sink and knock before entering the room

“Hello, my name is Kayla Mejia, and I am a student nurse at UMass Amherst. Can you please tell me your name and date of birth? Is it okay if I perform a partial head to toe physical exam to collect data and assess your overall health, it should only take 25 minutes? Thank you! Before starting the exam I want to let you know that I will need to touch you during some parts, is that okay? Perfect let me know if you want me to stop at any point of this exam.

general survey

Starting with the general survey the patient appears to be her stated age and looks healthy and well developed. She looks presentable and her hair/skin/nails are well-groomed and visible. Her facial expression is neutral which is appropriate for the current situation. I can assume that her gait, mobility, and hearing are within normal limits because I don’t see any assistive or mobility devices, or auditory aides. I will note that the patient is wearing glasses.

Can you please tell me where you are right now? Do you know what day it is? Can you tell me your name? Do you have any allergies to food, environment, or medications? The patient’s level of consciousness is alert and responsive. She is also oriented to time, person, and place. The patient also reports no allergies.

HEENT

Next ,I will inspect the patient’s head. During this part of the exam I will need to touch your head, is that okay? The cranium is normocephalic because of its appropriate shape and size. The hairline is well-defined and even. She has wavy brown hair. I will now put on gloves to palpate the scalp. Do you have scalp concerns before I begin? Let me know if you feel any tenderness when I palpate. When removing hair to look directly at the scalp I don’t see any redness, lesions, lumps, bumps, or infestations. Hair growth is consistent and covers her whole head. I will now throw away my gloves and sanitize. 

Now inspecting the face. Her face is symmetrical with an even skin tone that is consistent with my perception of her ethnicity. No facial drooping. I don’t notice any lesions, but I do notice piercings on her ears. 

Now, I will palpate the temporal artery bilaterally. The arteries are palpable with +2 grade bilaterally. Now, I will palpate the temporomandibular joint. I am going to place my hands on the sides of your jaw and ask you to open. Can you open it? Okay now you can close your mouth. Did you feel any when I was palpating? The patient states no pain. I did not hear or feel any crepitus or popping, so everything seems to be within normal limits.

Eyes

Next I will assess her eyes. When inspecting I can see that her eyes and eyebrows are symmetrical and intact. There is no ptosis, erythema, lesions, or edema, and the sclera is white with no jaundice. The cornea is clear, not cloudy. Iris is intact. Can you pull down on your lower eyelid? Now can you tilt your head back and pull up on your upper eyelid? Can you press on the lacrimal gland to feel for any bumps or tenderness. The conjunctiva is pink and moist with no drainage and the lacrimal gland seems to have no edema or drainage.

Now I am going to test your 6 cardinal fields of vision. I am going to have you follow my penlight with your eyes only. She was able to follow all 6 directions, nystagmus or strabismus were absent. Now I will test for PERRLA. I will have you close your eyes and then when you open I will shine a bright light into your eyes. The pupils are equal, round, reactive to light. Now to test for accommodation I will have you look at my penlight as I move it towards your eye. Both eyes constricted as I brought the pen forward and accommodated. Finally I will test the consensual light reflex, so I will put the penlight towards the side of your eye and move it to the front on both sides. Can you please position your hand like this in the middle of your face? Both pupils had a direct response to light and there was a consensual response to light on both eyes.

Ears

Moving on to the ears. When inspecting I notice that the helix is Inline with the medial canthus of the eyes. The ears are an appropriate size and shape. I don’t notice any rashes or lesions on the skin of the ears. The external auditory meatus is free from excess cerumen and foreign bodies. Now I will palpate your ears. Please let me know if you feel pain or tenderness as I palpate. Now I will push on the tragus, again let me know if you feel tenderness. When palating I didn’t feel anything abnormal or tenderness. Now, I will perform an otoscope exam. I am going to guard now. I will rest my hand on your cheek and I will lift your pinna to gain access into your ear. The tympanic membrane is intact and pearly gray with the cone of light pointing towards the jaw at roughly 5 o’clock. Now I will check your left ear. I am guarding now. The tympanic membrane is intact and pearly gray with the cone of light pointing towards the jaw at roughly 7 o’clock.

Nose

Now inspecting the nose. The nose is midline and symmetrical to the rest of the face. There's no drainage or edema. Now I will palpate and percuss the maxillary and frontal sinuses. Did you feel pain when I did that? Now I will test patency. Can you cover one nostril at a time and inhale? There was no labored breathing and the nostrils are clear with no blockages on either side. Now I will inspect the inside of your nose with my penlight. Can you tilt your head back? The mucosa is intact, turbinates are pink, no obstructions and septum does not appear deviated. 

Mouth / throat

Now I will inspect the mouth. Can you flip your bottom lip down, can you flip your top lip up. The lips are moist and pink. There is no cracking, ptosis, or lesions. Now I will inspect the inside of the mouth. Can you open your mouth? The tongue is midline. The buccal mucosa is pink and moist, the teeth are intact with no signs of decay or caries, the back of the throat is pink. Both soft and hard palate are present with no abnormalities. There is no inflammation or swelling on the gums and they are intact and pink. Can you lift your tongue to the roof of your mouth? The floor of the mouth is pink and moist with no sores or lesions. Now I will assess your tonsils and uvula. I am going to have you stick out your tongue say ahhh while I use a depressor to gain a better view of your tonsils. Can you stick out your tongue? Can you say ahhh? The tonsils are +1 grade, there is no sign of inflammation or white marking on the tonsils. The uvula is midline and rose symmetrically as the patient said ahh.

neck

Now I will move down to the neck. When inspecting the neck, it is symmetrical with no lumps or pulsations. Next, I will test your range of motion. Can you touch your right ear to your right shoulder? Can you touch your left ear to your left shoulder? Can you touch your chin to your chest? Can you tilt your head back as far as you can? Did you feel pain at any point? Now I will test your muscle strength. I will have you push into my hand as I apply resistance. The patient has full range of motion and didn’t exhibit signs of strain. Her muscle strength is strong against resistance. Next I will palpate the lymph nodes. Here is the preauricular, post auricular, occipital, tonsillar, submandibular, submental, superficial cervical, deep cervical, posterior cervical, and supraclavicular. The lymph nodes are absent and not palpable which is normal. Now I will inspect and palpate trachea. The trachea is midline and there are no lesions or enlargements. Now I will palpate. The trachea is moveable, but still intact. Now I will palpate the thyroid gland. When palpating one at a time there are no modules or enlargements. Can I have you take a sip of water? The thyroid felt symmetrical on both sides when swallowing.

heart and vessels

Next I will move onto the  heart and vessels. I am going to have you lie down at about a 45 degree angle to inspect your chest. Using tangential light I will look for her jugular vein distention, On her it is absent which is normal. I do see her carotid pulsation bilaterally. Now I will inspect the precordium. I am not seeing any pulses, heaves or thrills. Now I will palpate the carotid artery one at a time. The carotid artery is palpable with a +2 grade bilaterally. The pulse has a normal rhythm and rate. Now I will palpate the precordium. I don’t feel any lumps bumps or see any lesions. Her breathing does not appear to be labored. I will now feel for your apical pulse. There are no thrills and the apical pulse is palpable with a regular rhythm and rate. 

Next I will auscultate using my diaphragm. Starting at the 

• aortic location which is at the 2nd intercostal space right sternal border. Here S2 is louder than S1

• moving down to pulmonic at the 2nd intercostal space left sternal border. Here S2 is louder than S1

• then to Erb’s point at the 3rd intercostal space left sternal border. Here S1 and S2 are equal

• then to tricuspid at the 4th intercostal space left sternal border. Here S1 is louder than S2

• finally to the mitral at the left 5th intercostal space midclavicular line. Here S1 is louder than S2

Next I will listen to the same spots using the bell. I am listening for murmurs with the bell because it picks up low-pitched sounds better than the diaphragm. I don’t hear any murmurs.

throax and lungs

You can go ahead and sit up. I will now inspect your thorax and lungs. The chest rises symmetrically. Her breathing does not appear to have labored breathing, doesn’t use accessory muscles and the patient is sitting upright and not in a tripoding position. Looking at the back of the patient the transverse to anterior posterior ratio is 2:1 which is normal. Now I will palpate your thorax, shoulders, and scapula. Are you feeling any tenderness? I don’t feel any tenderness, masses, or crepitus. Now I will test her thoracic expansion. Take a big deep breath in. My thumbs moved apart 3 cm when the thoracic cavity expanded and they expanded in an equal distance. both sides rose symmetrically. Before I begin auscultating I will identify the posterior lung borders. From T1-T3 are the upper lobes of the lungs. From T3 to T10 are the lower lobes of the lungs. Now I will auscultate anteriorly first and then posteriorly. I will listen to four spots. Can you take a deep breath. The lung sounds are clear on both sides with no adventitious sounds (like wheezing). Now I will listen to your posterior lung sounds. I will listen to 6 spots from left to right. The lung sounds are clear on both sides with no adventitious sounds (like wheezing). Now I am going to listen to your right middle lobe which is at the 4th intercostal space right sternal border, 5th intercostal space right mid axillary line and 6th intercostal space right midclavicular line. I heard clear breaths with no adventitious sounds.

end

All right! This concludes our exam. Thank you so much for your participation. Do you have any last questions for me before I leave?