1
Q
Professionalism
A
- Washes hands
- Introduces self to patient
- confirms patients name
2
Q
Vitals signs
A
- STATING BP 120/70
- Radial pulse 70
- Respirations 18
3
Q
Head
A
- STATING I inspected and then palpated scalp head & hair
4
Q
Eyes
A
- STATING I inspected the eyes and retracted the eyelids
- Evaluate extraocular muscle function in 6 directions
- Check for convergence
- Observes pupillary response to light B/L
- Check for near reflex (accommodation)
- Test visual fields by confrontation 4 quadrants for each eye
- Assess visual acuity with snellen chart
5
Q
Eyes part 2 (opthalmoscopic exam)
A
- STATING “I dimmed the light before exam & asked the patient to focus straight ahead. I examined the right eye with my right eye and the left eye with my left eye. I asked the patient to look directly at light and observed the macular bilaterally”
6
Q
Ears
A
- STATING “I examined your ears B/L with the otoscope
2. STATING “I tested the patients auditory acuity and performed the whisper test B/L”
7
Q
Nose
A
- STATING “Nasal patency tested bilaterally”
- STATING “Nasal vaults inspected w/ nasal speculum on otoscope”
- STATING “palpated & percussed front & maxillary sinuses for tenderness”
8
Q
Mouth
A
- STATING“I inspected pt’s lips, teeth, gums, and tongue
- STATING “Floor of mouth and base of tongue inspected while the pt’s mouth was open, patient lifted the tongue to the roof of their mouth”
- STATING “Posterior pharynx inspected”
- STATING “Observed elevation of palate as pt said ahh”
9
Q
Neck
A
- STATING “The following lymph nodes were palpated:
around ears, anterior cervical chain, posterior cervival chain, supraclavicular & axillary”
2.STATING “thyroid palpated” - STATING“Carotids individually palpated bilaterally”
- STATING “carotids auscultated bilaterally while the pt held their breath”
10
Q
Back
A
- inspects spine for curvature
- palpates vertabrae
- performs fist percussion for CVA tenderness
11
Q
Thorax
A
- Palpate lung fields B/L & symmetrically on skin – Anteriorly & Posteriorly
- Percusses lung fields B/L & symmetrically on skin –
Anteriorly & Posteriorly - Instruct patient to take deep breaths through open mouth and then auscultate lung fields B/L & symmetrically on skin– Anteriorly & Posteriorly
12
Q
Heart <3
A
- Palpates PMI
2. Auscultate all 4 areas: aortic, pulmonic, mitral, & triscuspid
13
Q
Abdomen
A
- **AUSCULTATES BEFORE MANIPULATION**
- Percusses x4 quads
- palpates x4 quads lightly then deeply
- feel midline for aorta
- ausculate midline for bruit
- percusses liver span
- palpates liver
- palpates spleen
14
Q
Arms
A
- Inspects & palpates both arms including joints, hands, & fingers
- tests strength- flexion & extension against resistance in: shoulders, elbows, wrists
- tests hand muscles: grip strength, finger spread, break rings
- palpates radial pulse B/L
15
Q
Legs
A
- Palpate both legs including joints & feet
- Tests strength- flexion & extension against resistance in thighs, knees, & ankles
- palpates lower extremity pulses- dorsalis pedis & plantar?
- Checks for leg edema (presses finger on pretibial)
16
Q
Cranial Nerves
A
- CN5: STATING “I palpated the pts clenched masseter muscles & tested upper/middle/lower facial sensation bilaterally”
- CN7: Instruct pt to raise eyebrows & puff out cheeks
- CN9: Test shoulder shrug against resistance
- STATING “Observed pt’s midline protrusion of tongue”
17
Q
Reflexes
A
TEST BILATERALLY
- biceps
- triceps
- brachioradialis
- patellar
- achilles
- plantar/babinski
18
Q
Cerebellar
A
- STATING tested finger to nose bilaterally
- tests rapid alternating hand movement
- Tests heel to shin
- performs romberg test
- observes gait
- observes tandem gait
19
Q
Sensory
A
- explain what is sharp and what is dull
- test in hands, test in feet b/l
- tests position sense in feet b/l
20
Q
Encounter closure
A
- summarized info to pt
- asked if there were any final questions or concerns
- maintained appropriate hand hygiene
HNG515
flashcards
Decks in class (5)
# Cards
