Neurological Case Study

0d8ee0e4b7813e436206f0a9484f897d.rtf

Home >Nursing homework help >Neurological Case Study

Seidel : Mosby’s Guide to Physical Examination, 7 th Edition

Checklists - Physical Exam

Physical Examination—Objective Data

VS

TPR, BP, Ht, Wt

G eneral A ppearance

Age, race, gender, posture and gait

M ental S tatus

Consciousness, cognitive ability, memory, emotional stability, thought content, speech quality

S kin

Color, integrity, hygiene, turgor, hydration, edema, lesions, hair distribution and texture, nail texture, nail base angle

H ead

Scalp, temporal arteries, deformities

N eck

Trachea (position, tug), range of motion (ROM), carotid bruit, jugular venous distention (JVD), thyroid, lymph (head and neck)

E yes

Pupils (PERRLA), eyelids, conjunctivae, sclerae, EOMs (CN III, IV, VI), light reflex, visual fields, funduscopy (CN II), acuity (CN II), nystagmus

E ars

Deformities, lesions, discharge, otoscopy (canal, TM), hearing (Rinne, Weber, CN VIII)

N ose

Mucosa, septum, turbinates, discharge, sinus area swelling or tenderness

M outh and T hroat

Lips/teeth/gums, tongue (CN XII), mucosa, palates, tonsils, exudate, uvula, gag reflex (CN IX, X)

C hest/ L ungs

Shape, movement, respirations (rate, rhythm), expansion, accessory muscles, tactile fremitus, crepitus, percussion tone, excursion, auscultation (clear, wheeze, crackles, rhonchi, rubs)

B reasts

Contour, symmetry, nipples, areolae, discharge, lumps/masses, lymph (axillary, supraclavicular, and infraclavicular)

H eart

PMI, lifts, thrills, rate, rhythm, S1, S2, splitting, gallops, rubs, murmurs, snaps

B lood V essels

Cyanosis, clubbing, edema, peripheral pulses, skin, nails

A bdomen

Contour, symmetry, skin, bowel sounds, bruits, hum, liver span, liver border, tenderness, masses, spleen, kidneys, aortic pulsation, reflexes, percussion tone, costovertebral angle (CVA) tenderness, femoral pulses, lymph (inguinal)

M ale G enitalia

Pubic hair, glans, penis, testis, scrotum, epididymis, urethral discharge, hernias

F emale G enitalia

External lesions or discharge, Bartholin and Skene glands, urethra, vaginal walls, cervix (position, lesions, cervical motion tenderness), uterus, adnexa

R ectum/ P rostate

Sacrococcygeal and perineal areas, anus, sphincter tone, rectal walls, masses, fecal occult blood test (FOBT)

Male: Prostate

Female: Rectovaginal septum, uterus

M usculoskeletal

Posture, alignment, symmetry, joint heat/swelling/color, muscle tone, ROM, strength

N eurologic

CN II-XII, rapid alternating movements, finger-to-nose, sensation, vibration, stereognosis, motor system, gait, Romberg, deep tendon reflexes (DTRs), superficial reflexes

Cranial Nerves

I : Smell

II : Visual acuity, visual fields, funduscopy

III, IV, VI : Eyelid opening EOMs: IV up and out, VI lateral, III all others

V : Corneal reflex, facial sensation (3 areas), jaw opening, bite strength

VII : Eyebrow raise, eyelid close, smile, taste

VIII : Rinne, Weber

IX, X : Gag reflex, palate elevation, phonation

XI : Lateral head rotation, neck flexion, shoulder shrug

XII : Tongue protrusion, lateral deviation strength