Physical Exam
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Chamberlain College of Nursing *
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Course
509
Subject
Biology
Date
Feb 20, 2024
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9
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NR 509 Immersion Physical Exam.docx.pdf version 1
Advanced Physical Assessment (Chamberlain University)
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NR 509 Immersion Physical Exam.docx.pdf version 1
Advanced Physical Assessment (Chamberlain University)
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NR 509 Physical Examination Grading Rubric
Hello, my name is Chamberlain Student and I will be demonstrating a physical examination for the NR509
advanced physical assessment course.
Can you first tell me your full name and date of birth is and please let me know if you consent to this
physical exam and video?
HEAD AND FACE
Inspects facial skin- note abnormal lesions-
I will begin with inspecting your face. I don't see any discolorations or any lesions.
Inspect head for size, symmetry, midline position-
Next, I will note that her head is midline and it is symmetrical.
Palpates lymph nodes of the head and neck: preauricular, postauricular, occipital,
tonsillar, submandibular, submental, anterior cervical, posterior cervical, supraclavicular
(verbalize these)
Next, I will proceed into palpating the lymph nodes, and I will begin normally with the
preauricular lymph nodes, right in front of the ear, and postauricular, right behind the ear. Then
I will palpate her occipital lymph nodes in the back of the head. And then I'm going to move
forward and palpate the tonsillar lymph nodes. Come under the jawline, the submandibular
lymph nodes, and the submental. Now I will go to the anterior cervical lymph nodes, and the
posterior cervical lymph nodes. And I will end with the supraclavicular lymph nodes right about
the clavicles. I do not feel any enlargement, and they are equal bilaterally.
CN 5 (Trigeminal)
Motor – palpate over the masseter muscle as patient clenches jaw
Next, I will test the trigeminal nerve, which is cranial nerve number five. It has a motor
component, and I will palpate over the masseter muscle as she clenches her jaw. And I don't feel
any distortions, and she has great strength. Next, I will test the sensory portion of the trigeminal
nerve
Sensory – light touch sensation to forehead, cheeks, chin, nose (patient closes eyes and identifies where they are
being touched)
And I'll ask Sarah to close her eyes, and let me know where she feels my touch. Forehead, right
cheek, left cheek, chin, nose.
CN 7 (Facial)
Inspect for facial symmetry with smile, frown, raise eyebrows, puff cheeks, pucker lips
Next, I will test her facial nerve, which is cranial nerve number seven. And I'm going to ask her to
do some facial expressions. And I'll ask for her to begin with a smile, and I know that is
symmetrical.
Next, frown for me. OK. Now raise your eyebrows and go ahead and puff up your cheeks, and you
notice they're equal bilaterally. And now I want you to pucker your lips, very tight pucker. So that
looks good. Thank you.
EAR
Inspect outer ear for skin lesions and symmetry
Now, I'm going to inspect Sarah's ears, and I'm looking for any nodules or any skin lesions. Let's
look at your other ear, Sarah, and they look nice and are symmetrical.
Inspect auditory canal and TM (using otoscope)
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Now I’m going to look inside her ear canal with the otoscope. I'm going to pull her ear up and
back, and as I look in, I see that the external auditory canal is clear, there's no swelling or
redness or drainage or cerumen.
The tympanic membrane is pearly gray, and there is no effusion in the middle ear. I will do the
same for her left ear, pull the ear up and back, looking into the external auditory canal. I see
there is no cerumen, there's no swelling or redness, there is no drainage.
Palpate pinnae and tragus for nodules and tenderness
Her tympanic membrane is pearly grey, and there's no fluid in the external auditory canal. So
you have very normal eardrums and ears. Now I'm going to palpate Sarah's pinna,
[BLANK_AUDIO] For any nodules or tenderness, any tenderness, Sarah? No. And now her tragus,
in front of the ear, any tenderness? No. Thank you
CN 8 (Acoustic)
Whisper Test (whisper words out of patient’s sight, and patient repeats words back) Test one ear at a time.
Next I will be testing her acoustic nerve, which is cranial nerve number eight, and that is her
hearing. So I will be performing a whisper test, so I'm going to ask Sarah to cover one of her ears.
And then I will stand behind her, cover my mouth, and whisper three words.
One, two, three. One, two, three. And let's do the other side. Four, five, six. Four, five, six. And her
hearing is intact bilaterally
EYE
Inspects sclera and conjunctiva
Now I'm going to assess Sarah's eyes, and first I'm going to look at her conjuctiva. I notice that
they're pink and clear, no drainage or lesions. And I'll also note that her sclera is white and clear
CN 2 (Optic)
Assess gross visual acuity and peripheral/central vision
Now I'm going to test Sarah's cranial nerve number two, the optic nerve, and this covers central
vision. And I will use this Snellen eye pocket chart. And I'll stand six feet away and ask Sarah to
cover one eye.
And now read the lowest line possible. LTFPH. Repeat with the other eye. LTFPH. And now with
both eyes. LTFPH. And Sarah has normal vision, 20/20 in her left eye, right eye, and with both
eyes.
CN 2 (Optic)
Check pupillary response to light [PERRL]
And now I will continue checking cranial nerve number two, the optic nerve again, covers
peripheral vision.
So I would like Sarah to stand up so we will be at the same eye level. And I'm going to ask her to
look straight ahead and not move her head, and first of all, do you see my hands now? No. Let me
know when you do. Yes. And then I'm going to cover above, do you see them now?
No. Let me know when you do. Yes. Now come from below, do you see them now? No. Let me
know when you do. Yes. OK, thank you, and you can have a seat. Her peripheral vision is normal.
Now I'm going to continue and check cranial nerve number two again, the optic nerve, for her
pupil response to light.
And I'm using the ophthalmoscope head and turning on my light. And I'm going to ask Sarah to
just stare at my nose. Now I'm going to come from the side with my light source, and I notice that
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3
the pupil constricts, and then I will check the right eye as well. And her pupils are about two to
three millimeters, and they respond to light equally.
CN 3, 4, 6 (Oculomotor, Trochlear, Abducens)
Test for conjugate gaze with EOM
Now I'm gonna be checking cranial nerves number three, which is the ocular motor, cranial
nerve number four, which is the trochlear, and cranial nerve number six, which is the abducens.
And in doing so, I will choose a star or an H pattern, and this is checking the extraocular muscles
of the eye.
So if you will follow my finger, Sarah, with your eyes only. Thank you, and all EOMs are intact
equally.
NOSE
Inspect nose midline and straight
Now I'm going to be checking Sarah's nose, and first I'm going to inspect her nose, and I do see
that it is midline. I don't see any obstruction or any noticeable fracture or swelling
Assess nasal turbinates and septum (using light source)
And now I will insert my speculum of the otoscope inside her nose. And I'm gonna tip her nose
up with the thumb. And I'll look inside her left turbinates, and I do see some pink and moist
turbinates in her septum midline. You should angle anteriorly, and I do see that her septum is
straight, there's no deviation.
Let me cover her right side, once again, looking at the septum anteriorly, or medially, and I do
see that she does have a straight septum, and her turbinates on the lateral aspect are nice and
pink, and healthy, there's no swelling or bogginess.
Palpates frontal and maxillary sinuses
And now, we'll palpate Sarah's sinuses beginning with the frontal sinuses.
Let me know if you feel any tenderness there, Sarah. No. And her maxillary sinuses, any
tenderness? No. Thank you
THROAT AND MOUTH
Inspect lips, teeth, gums, buccal mucosa, palate, tongue, the floor of the mouth (under
t
he tongue), posterior pharynx,
and tonsils (
grade tonsils, if present
)
Now, I'm going to inspect Sarah's throat and mouth, and I'll begin with inspecting her lips, which
are pink, and moist. And now, she will open her mouth, and I am inspecting her teeth.
I do not see any signs of decay or any cracks. Next, I will be looking at the gums, I do not see any
redness or swelling. They look nice, pink, and healthy. And next the buccal mucosa on both sides,
is moist and pink. Next, I will be checking her palate, and looking up at her upper hard and soft
palates.
They look intact and a healthy pink and moist. And next I will be looking at her tongue. And I
noticed that it is smooth, and a healthy pink as well, and moist. And if you will lift your tongue
up, and I'm looking at the floor of the mouth, and once again I do not see any nodules, or
drainage, and it's a healthy pink as well, and moist.
And now I will look at her posterior pharynx towards the back, and it's healthy pink, I do not see
any post nasal drainage. And if she had any tonsils, I would grade them, but she does not
PAGE SUBTOTAL: /34
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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)
Next, I will be checking her cranial nerves number nine and number ten.
And number nine is the glossopharyngeal, which is the gag reflex, and we will not be testing for
that. To check the vagus, which is cranial nerve number ten, I will have her go ahead and open
her mouth again. I'm going to use my light source, and have her say ah.
Ah. And I note that the uvula does rise symmetrically with phonation. Thank you
CN 12 (Hypoglossal)
Stick out tongue and move it left to right
Next would be the cranial nerve number 12, which is the hypoglossal. And I'm going have Sarah
stick her tongue out, and just move it side to side. Thank you.
Palpate TMJ for any subluxation, tenderness, or crepitus
And we will conclude with palpating her TMJ, which is her temporomandibular joint. And I'm
palpating on both sides for any subluxations, tenderness, or crepitus. Go ahead and open your
mouth, and close. Thank you. I do not feel any crepitus, or clicking, or tenderness
NECK
Inspect for obvious deformities and symmetry
Now I'm going to assess Sarah's neck, and I'm going to inspect for any obvious deformities, and
check it for symmetry. And it looks very symmetrical
Palpates trachea – midline
and now I'm going to palpate her trachea. And you find the trachea. It should be midline, and it
is. So that doesn't show any abnormalities there
Palpates thyroid gland
Now, I will palpate her thyroid gland, by finding the cricoid process. With one hand in the
suprasternal notch, right here, with the other hand.
And I will put my fingers on either side, between those two points, landmarks, and I'm actually
going to retract a little bit on one side and ask her to swallow. And I'm feeling the thyroid as it
rises for size in any nodules. And now, when we retract on the opposite side, and ask her to
swallow. And that would be the thyroid gland palpation
Palpates carotid artery pulsation
Next, I will palpate her carotid arteries one at a time, and that's on either side of the trachea.
And they are normal and bounding.
Auscultate over the carotid for bruits
Now, I'm going to auscultate Sarah's carotid arteries, and I'm checking for any bruits bilaterally.
The technique involves asking her to hold her breath, and I'm auscultating the carotid arteries,
so her breath sounds don't distort, or interfere with the auscultation of the carotid arteries.
So Sarah, go ahead and take a breath in and hold it. And breathe. And take a breath in. Hold it.
And breathe.
Assess active ROM – flexion, extension, lateral flexion,
Rotation
Now, I will check her range of motion of the neck, and I'm going to ask Sarah to go ahead and flex
your neck, which means, go ahead and take your chin down to your chest.
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Now straighten your neck, and look up to the ceiling, and extension and now look forward. And I
want you to look over your right shoulder. And that would be rotation, and now your left
shoulder rotation. And now once again, I want you to do a flexion to the side, like ear to your
shoulder.
That's lateral flexion. And the other side, lateral flexion. Thank you, and those are all intact
equally
CN 11 (Spinal Accessory)
Shrug shoulders against resistance
Now, I will test the cranial nerve number 11, which is the spinal accessory nerve. And I'm going put
resistance on her shoulders, and ask her to shrug her shoulders. And that's nice and equal, and intact.
HEART
Auscultate in all 5 areas with the diaphragm
and
bell with the patient sitting (if stethoscope does not have a bell,
then verbalize you would also auscultate with the bell)
Now I'm going to evaluate Sarah's heart sounds. I begin with the auscultation in all five areas,
with the bell and the diaphragm, with the patient sitting
.
Verbalize Areas:
Aortic
Pulmonic
Erb’s point
Tricuspid
Mitral
I will begin with the aortic valve which, is the second intercostal space on the right sternal
border. [BLANK_AUDIO] Next will be the pulmonic valve, which is going to be the second
intercostal space to her left sternal border.
Moving down to the Erb's point, which is the third intercostal space, left sternal border. And
further down would be the tricuspid, which is the fourth intercostal space, left sternal border.
And finish with the mitral area, which is the midclavicular line, fifth intercostal space.
ANTERIOR CHEST
Inspect for obvious deformities and symmetry
Now, I am going to inspect Sarah's anterior chest, for any obvious deformities in symmetry, and I
do not see any.
Auscultate lung sounds in anterior lung fields
Now, I will auscultate her lung sounds in the anterior lung fields, beginning at the intercostal
spaces. Sarah, if you will take some normal breaths in and out through your mouth. And your
breath sounds are nice and clear.
POSTERIOR 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)
Now, I'm going to proceed to the posterior chest. And listen to her lungs.
And Sarah, if you will, for our purposes here, turn around. Actually, there you go. Now I'm going
to auscultate eight areas, beginning above the scapulas. Take some normal breaths, in and out
through your mouth. And I'm going to get the lateral. Middle right, middle low. OK, thank you
UPPER EXTREMITIES
*All ROM & DTR examination only needs to be performed unilaterally for purposes of the immersion
evaluation. Strength testing should be performed bilaterally.
Inspect the joints of the hands – redness, swelling, deformities
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You can sit down. Now I'm going to check Sarah's upper extremities. I'm going to begin with
inspecting the joints of her hands. If you'll extend your hands out. And I'm noting any redness or
swelling or any deformities of her finger joints. Thank you
Palpate for capillary refill
And next I am going to palpate for capillary refill. So I will do that one finger on each hand. I'm
going to press on a finger nail until it turns white and then I'll release, and I see that it turns
pink, a healthy pink, within less than 3 seconds. Let me do the left side, pressing on the nail until
it turns white, release, and it turns a healthy pink in less than 3 seconds. And that would be a
normal capillary refill.
Assess radial pulses
Now I will check her radial pulses bilaterally, and if you will just face your palms in-- inward and
I'm going to palpate the radial pulses. And they are equal, about 2+ bilaterally.
Assess hand grips (bilateral) – 5/5 strength
Next, I'm going to assess her hand grips. So if you'll grip my hands together tight, tight, tight.
Very good, so her strength in her hands are five out of five
Assess passive unilateral ROM of the
elbows
(flexion, extension)
Now I'm going to assess Sarah's range of motion. Range of motion should normally be examined
bilaterally. However, for purposes of this examination, in the emergent evaluation, it is only
necessary to perform a range of motion unilaterally.
And the same will apply when you perform deep tendon reflexes. Now I'm going to assess range
of motion, passive range of motion of the elbow. Flexion and extension. And I would do so on the
other side. And now, I would like to check her strength of her biceps and triceps.
So if you will, flex your elbows and push against my hands. And now, pull back towards you,
thank you. And her biceps and triceps strength was five out of five.
Assess strength of biceps, triceps (bilateral) – flex/extend elbow against
resistance – 5/5 strength
Now I'm going to assess Sarah's range of motion. Range of motion should normally be examined
bilaterally. However, for purposes of this examination, in the emergent evaluation, it is only
necessary to perform a range of motion unilaterally.
And the same will apply when you perform deep tendon reflexes. Now I'm going to assess range
of motion, passive range of motion of the elbow. Flexion and extension. And I would do so on the
other side. And now, I would like to check her strength of her biceps and triceps.
So if you will, flex your elbows and push against my hands. And now, pull back towards you,
thank you. And her biceps and triceps strength was five out of five.
Assess passive unilateral ROM of the
shoulders
(flexion, extension, internal rotation, external rotation, abduction,
adduction)
Now I'm going to assess the passive range of motion of the shoulder. Flexion, extension, internal
rotation, external rotation. Then you have abduction and adduction.
PAGE SUBTOTAL: /46
Assess cerebellar coordination with rapid alternating movement:
Serial finger opposition, hand flip-flop
Now I'm going to assess cerebellar coordination with rapid alternating movements. And Sarah, if
you will take your thumb and touch your index finger, middle finger, and fourth finger, fifth
finger. And just repeat that. She does that very well, and is well coordinated. Next I will do the
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rapid movements of her hands. So palms down on your thighs, and then up, and then down, and
alternate, and increase the speed. Very good, nice and normal and coordinated.
Assess unilateral DTRs:
Biceps, patellar, Achilles
Now I will assess her deep tendon reflexes, only on one side for demonstration purposes. And I
will start with the bicep tendon. So I will support her arm on my arm, and then I'm placing my
thumb on the medial aspect of the antecubital fossa, and I will strike my thumbnail with the
pointy end of the hammer. And as you can see, she contracted her bicep tendon very well. Now
I'm checking her patellar reflex with the flat end of the hammer. And she had a good response.
And I'll come around and do her Achilles. I'll ask her to relax her foot, then I'll dorsiflex the foot
a little bit, and tap with the flat end. And you notice she had a little bit of pronation there
Have patient lie down
ABDOMEN
Inspect abdominal contours and symmetry
Now I'll have the patient lie down for the abdominal exam. I will expose her abdomen. And I am
observing the abdomen for its contours and symmetry, and there is no distortions
Auscultate for bowel sounds in all 4 quadrants
Now I will auscultate her bowel sounds in all four quadrants. Bowel sounds are present in all
four quadrants
Auscultate for bruits (verbalize) – aorta, renal arteries, iliac arteries
Now I will auscultate for any bruits. I will begin with the aortic area, which is right below the
xiphoid process. Midline. Next I will do the left renal, which is above and lateral to the left, the
umbilicus. The right renal is to the right and above the umbilicus.
The iliac, to the left and below the umbilicus. And the right iliac, which is to the right and below
the umbilicus. And I do not hear any bruits
Percuss in all 4 quadrants for tympany, dullness, flatness
Now I'm going to percuss in all four quadrants. I'm percussing for any tympany, dullness, or flatness.
And it’s normal
Palpate in all 4 quadrants for tenderness and masses
Next I'm going to palpate in all four quadrants for tenderness and any masses. And that feels
normal, I do not feel any masses.
Palpate liver and spleen (verbalize)
Now I'm going to palpate the liver and the spleen. Beginning with the liver. I'm going to place my
left hand underneath and I'm looking at the midclavicular line on the right. And I'm placing my
palm upward right at the edge of the costovertebral angle, and I'm asking her to take a deep
breath in. And as she does so, I'm pressing deeper and upward, and I might feel the lower edge of
the liver.
Now for her spleen I'd like her to adjust herself and come over towards me laterally. And I'm
going to put my left hand back here. And right below the costovertebral angle I'm going to put
my right hand. And as she breathes in, once again pushing upward and downward. And I do not
feel the edge of the spleen which is actually normal
Perform Blumberg’s sign (verbalize)
Now I'm going to assess the Blumberg sign. I will take my hand vertically 90 degrees and I will
press down into the abdomen. And when I release, if she feels any pain on the rebound, that
would be a positive Blumberg sign. Any pain?
LOWER EXTREMITIES
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Inspect the skin integrity of lower extremities and assess for edema.
Now I'm going to assess the lower extremities. First I will inspect the skin for any lesions or any
edema. I do not see any.
Assess passive unilateral ROM of
hips
(flexion, abduction, adduction, internal rotation, external rotation) * extension
not tested for this exam
Next I'm going to do range of motion of her hip and I'm going to go ahead and flex her knee. And,
in turn, flex her hip. And then I'm going to go into abduction, taking the leg away. And adduction,
crossing the midline. Next will be internal rotation. And then external rotation. And go ahead
and rest the leg. For purposes of this exam we will not be testing extension.
Assess passive unilateral ROM of the
knees
(flexion, extension)
Assess strength at the knees (bilateral) – flex/extend against resistance – 5/5 strength
Now I'm going to assess range and motion of the knee, flexion and extension. Now I'm going to
assess the strength of her knees. Go ahead and flex your knees. And I'm going to place my hands
on top, and ask her to push up towards them. Now push back. Very good, and her strength is five
out of five and equal
Assess passive unilateral ROM of the
ankles
(dorsiflexion, plantar flexion, rotation)
Go ahead and extend your legs. Now I'm going to do the range of motion of her ankle. Supporting
the ankle, dorsiflexion, plantar flexion, and rotation
Assess strength at ankles (bilateral) – dorsi/plantar flex against resistance – 5/5 strength
Now I will assess the strength of her ankles. And she will dorsiflex with resistance. Plantar
flexion with resistance. And that was five out of five and equal as well
Assess dorsalis pedis pulse
Now I will assess her dorsalis pedis pulses. And they are 2+ and equal.
Have patient stand up
Inspect and palpate the
spine
– expected curvatures, alignment, tenderness
Now I will have Sarah stand up. For the spine examination, I'm going to inspect and palpate
along both sides of the spine for any expected curvatures, alignment, and tenderness
Assess active ROM of the spine (flexion, extension, lateral flexion, and rotation)
Next, I'm going to do range of motion of the spine. And so, I'm going to ask Sarah to go ahead and
bend over and touch her toes. Now straighten back up, and extend backwards. Now straighten
back up and do a lateral flexion to one side and then the other
Assess Romberg
Close her eyes for about 20 seconds, and I'm looking for any swaying. And there is none. You can
open your eyes. So that would be a negative Romberg
Assess gait (just several steps)
Now I will assess her gait, and ask her to take a few steps forward. Turn around and a few steps
more. Her gait is normal
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