Assessment

Intro, General inspection, Head and face, cranial nerves, eyes, ears, nose,mouth, and throat, neck, upper extremities, hands

Post. chest, Anterior chest, Abdomen, lower extremities, neuro

Do you know where you are and why your here?, Patient is clean well kept does not appear dsicheveled, Patient is displaying an upright posture, does not appear to be straining or in pain., Patient is engage in conversation, alert and relaxed, content.

Inspect- patients skull appears round and symmetrical, hair is evenly distributed., Inspect- facial features are symmetrical, Palpate the scalp- no bogyness, no lumps or deformities, the scalp is dry and smooth., Palpate- face there’s no tenderness, the bones structures are intact, no lesions or deformities., Palpate- sinuses are non tender

clench your teeth, wrinkle your forehead, clench eyes tightly, smile, stick your tongue out, Puff out your cheeks, Cranial nerves 3,5,7,12, Patients sensitivity to light touch is intact

Inspect- eyebrow hair distribution is even, underlying skin is intact, and they’re symmetrical. Eyelids and eyelashes are symmetrical the eyelid skin is intact., Inspect- Can you pull your eyelids down please? The conjunctiva is pink, the sclera is white with some vascularity throughout., Inspect- iris is in even in color and shape, Six cardinal fields of gaze are intact., Peripheral vision is intact, The pupils react to light, look at my pen while i move it closer. Pupils accommodate and are consensually reactive.

Ears are aligned with eyes theyre symmetrical, intact and even in skin color., There’s no discharge coming from the auditory canal, Skin over the superficial lymph nodes is intact, no erythema’s, no red streaks., no masses or tenderness, Tell me when you hear my fingers rubbing together. Gross hearing is intact

His septum is slightly deviated from previous injury, this is his normal, the nose is symmetrical otherwise., finger on each nostril, the nose patent, the nasal turbinates are pink, there is no discharge, the lips are pink the gums are pink and smooth, the hard and soft palates are intact and pink in color, The patients teeth are white and all appear to be intact and fairly straight, The posterior pillars, uvula and tonsils are all present, symmetrical, pink and intact., The tongue is symmetrical pink with some papules which are just his taste buds, and he is able to move it side to side, No TMJ pain

The neck is symmetrical the trache appears midline, the thyroid does not appear enlarged, there’s no venous pulsations., Neck has full ROM, Push head, and shoulder against my hand strength +5, Palpate- trachea is midline, Palpate- Pre. Auricular, post auricular, submandibular, submental, and anterior cervical chain lymph noses all non palpable and non tender., The carotid pulses are intact +2

arms are symmetrical there does not appear to and sore deformities, lesions, or bruising., even temp, no tenderness or deformities upon palpation of the arms, both brachial and radial pulses present +2, Epitrochlear lymph nodes are non palpable and non tender, Test, biceps, triceps, and hand grips for strength +5, Brachioradialis DTR+2