NR 509 Physical Examination Grading Rubric

Introduction:Hello, my name is [Chamberlain Student], and today I will be conducting a physical examination as part of the NR509 advanced physical assessment course. Could you please tell me your full name and date of birth? Do you consent to this physical exam and video recording?

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Head and Face:

• Inspection:
  • Facial Skin: I will inspect your face for any discolorations or lesions. Your facial skin appears clear without any abnormalities.
  • Head Size and Symmetry: I will check the size and symmetry of your head. Your head is symmetrical and midline.
• Palpation:
  • Lymph Nodes: I will palpate the lymph nodes of your head and neck, including the preauricular, postauricular, occipital, tonsillar, submandibular, submental, anterior cervical, posterior cervical, and supraclavicular nodes. All lymph nodes are non-enlarged and equal bilaterally.
• Cranial Nerves:
  • CN 5 (Trigeminal): I will test the motor component by palpating over the masseter muscle as you clench your jaw. No distortions, with strong muscle strength noted.
  • Sensory Component: I will lightly touch your forehead, cheeks, chin, and nose with your eyes closed. You correctly identify all touch points.
  • CN 7 (Facial): Please perform facial expressions including smiling, frowning, raising eyebrows, puffing cheeks, and puckering lips. Your facial symmetry is intact.

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Ear:

• Inspection:
  • Outer Ear: I will inspect the outer ear for skin lesions and symmetry. Both ears are normal.
• Otoscopy:
  • I will inspect the auditory canal and tympanic membrane using an otoscope. The external auditory canal is clear and the tympanic membrane is pearly gray without effusion.
• Palpation:
  • Pinnae and Tragus: I will palpate the pinnae and tragus for nodules and tenderness. No tenderness or nodules are noted.
• CN 8 (Acoustic):
  • Whisper Test: I will whisper words out of your sight, and you will repeat them. Your hearing is intact bilaterally.

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Eye:

• Inspection:
  • Sclera and Conjunctiva: Your conjunctiva is pink and clear, and the sclera is white without lesions.
• Cranial Nerves:
  • CN 2 (Optic): I will assess your visual acuity using a Snellen eye chart. Your vision is 20/20 in both eyes. Peripheral vision and pupillary response to light are normal.
  • CN 3, 4, 6 (Oculomotor, Trochlear, Abducens): I will test your extraocular movements with an EOM test. All EOMs are intact.

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Nose:

• Inspection:
  • Midline and Straight: Your nose is midline and symmetrical.
  • Nasal Turbinates and Septum: Using a light source, I will inspect your nasal turbinates and septum. Both are pink and healthy.
• Palpation:
  • Sinuses: I will palpate your frontal and maxillary sinuses. No tenderness is noted.

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Throat and Mouth:

• Inspection:
  • Lips, Teeth, Gums, Buccal Mucosa, Palate, Tongue, Floor of Mouth, Posterior Pharynx, and Tonsils: All areas appear healthy, pink, and moist without signs of decay, lesions, or swelling.
• Cranial Nerves:
  • CN 9 and 10 (Glossopharyngeal, Vagus): Say “Ahh,” and I will observe the rise of the soft palate and uvula. Both rise symmetrically.
  • CN 12 (Hypoglossal): Stick out your tongue and move it left to right. Movements are normal.
• Palpation:
  • TMJ: I will palpate the temporomandibular joint for any subluxation, tenderness, or crepitus. No abnormalities are noted.

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Neck:

• Inspection:
  • Your neck is symmetrical without deformities.
• Palpation:
  • Trachea: The trachea is midline.
  • Thyroid Gland: I will palpate your thyroid gland for size and nodules. The gland is normal.
  • Carotid Artery Pulsation: Carotid pulses are normal and bounding.
• Auscultation:
  • Carotid for Bruits: No bruits are detected.
• Range of Motion:
  • Active ROM: Your neck’s flexion, extension, lateral flexion, and rotation are normal.
• Cranial Nerves:
  • CN 11 (Spinal Accessory): Shrug your shoulders against resistance. Strength is normal.

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Heart:

• Auscultation:
  • I will auscultate all five areas (aortic, pulmonic, Erb’s point, tricuspid, mitral) with both the diaphragm and bell. Heart sounds are normal.

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Anterior Chest:

• Inspection:
  • No deformities or asymmetry are noted.
• Auscultation:
  • Breath sounds are clear in the anterior lung fields.

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Posterior Chest (Back):

• Auscultation:
  • I will auscultate the posterior lung fields, including the lateral fields. Breath sounds are clear.

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Upper Extremities:

• Inspection:
  • No redness, swelling, or deformities in the hand joints.
• Palpation:
  • Capillary Refill: Capillary refill is normal.
  • Radial Pulses: Radial pulses are 2+ and equal bilaterally.
• Strength and Range of Motion:
  • Hand Grips: Strength is 5/5 bilaterally.
  • Elbow: Passive ROM (flexion, extension) is normal.
  • Shoulder: Passive ROM (flexion, extension, internal/external rotation, abduction, adduction) is normal.
• Cerebellar Coordination:
  • Rapid Alternating Movements: Coordination is normal.

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Deep Tendon Reflexes:

• Unilateral DTRs: Biceps, patellar, and Achilles reflexes are normal.

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Abdomen:

• Inspection:
  • The abdomen is symmetrical without distortion.
• Auscultation:
  • Bowel sounds are present in all four quadrants.
  • No bruits are detected in the aorta, renal, and iliac arteries.
• Percussion:
  • Normal tympany, dullness, and flatness.
• Palpation:
  • No tenderness or masses. The liver and spleen are normal.
  • Blumberg’s Sign: Negative for rebound tenderness.

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Lower Extremities:

• Inspection:
  • Skin is healthy without edema.
• Range of Motion:
  • Hip: Passive ROM (flexion, abduction, adduction, internal/external rotation) is normal.
  • Knee: Passive ROM (flexion, extension) is normal. Strength is 5/5.
  • Ankle: Passive ROM (dorsiflexion, plantar flexion, rotation) is normal. Strength is 5/5.
• Palpation:
  • Dorsalis Pedis Pulse: Pulses are 2+ and equal bilaterally.

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Spine:

• Inspection and Palpation:
  • Spine curvature, alignment, and tenderness are normal.
• Range of Motion:
  • Active ROM: Flexion, extension, lateral flexion, and rotation are normal.
• Romberg Test:
  • No swaying noted, indicating a negative Romberg test.
• Gait:
  • Gait is normal.