Head to Toe Assessment on a Female Patient | 93 | Unintentional ASMR

Hinzugefügt: 2026-06-01

[00:00:03]All right, I'm going to be performing my head-to-toe assessment. I have Travis go ahead and the camera here. I have a completed health history from Alyssa.

[00:00:08]Alyssa is my patient. Travis is going to time my brain dump, and I'm going to start now.

[00:01:16]Hello, my name is Hannah. I'll be your student nurse today. Shut the door for privacy. Can you state your name and date of birth for me, please?

[00:01:21]>> Alyssa Turner, 28 2004.

[00:01:23]>> All right, I'm just going to verify that on your wristband here. Do you have any allergies I should be aware of?

[00:01:27]Penicillin.

[00:01:28]Okay, and then just taking a look at your provider order, it looks like your provider asked me to come in today to perform a head-to-toe assessment. Would that be okay for today? Yes. Perfect.

[00:01:35]And then while I'm cleansing my equipment here, I'm just going to ask you a couple questions. So, as I looked over your health history, I see that you are currently on the on one medication.

[00:01:43]Is that still going well for you? Yes.

[00:01:45]And then I saw you also had a previous surgery of getting your wisdom teeth removed. Were there any complications with that? No. And then have you had any recent abnormal weight gain or weight loss?

[00:01:54]>> No.

[00:01:55]All right. Do you have any needs? Do you need to use the restroom? Do you have glasses I don't need or do you need hearing aids?

[00:02:00]>> No. Okay. And then, are you in a comfortable position? Yes. All right. I have the patient in a gown for this assessment.

[00:02:06]Um I will apply PPE further throughout the assessment when needed. Do you have any concerns before we begin?

[00:02:10]>> No. All right. So, I'm going to start with general survey going into temperature.

[00:02:30]All right. 98.5.

[00:02:33]And then, I'm also going to get patient's blood pressure.

[00:03:04]All right. So, I stopped feeling it at 120, so I will be adding 30 mm of mercury here in about 1 to 2 minutes. So, while we wait, I'm going to check the patient's overall appearance and hygiene. The patient looks well kept.

[00:03:17]Her hygiene looks clean. Um in regards to speech, she has been answering questions appropriately. I'm not seeing any slur in her speech. Um level of consciousness, you've already stated your name and date of birth. Can you tell me where you're at today? St. Elizabeth Hospital. Can you tell me why you're here? I had a stroke. And do you know what year it is? 2024. Okay.

[00:03:33]Perfect. And then, do you have any pain or discomfort today? No. On a scale of 0 to 10, your pain would be >> 0. 0. And then, just if she were to have any pain, I would go through the old carts mnemonic, which is O is onset, L is location, D is duration, C is characteristics, A is aggravating, R is relieving, T is time or treatment, and S is severity. and then also looking at the patient's overall skin, looking at color, it is appropriate to patient's ethnicity, and they're not seeing any lesions, any bruising, any rashes, any edema. Have you had any history of edema? No. Going through the edema scale, um starting with traces minimal, one plus is 2 mm with a rapid return, two plus is 4 mm with 10 to 15 second return, three plus is 6 mm with 1 to 2 minute return, and four plus is 8 mm with 2 to 3 minutes return and is considered grossly edematous. Looking at the ABCDE mnemonic for skin lesions, A is asymmetrical, B is border, C is color, D is diameter, and E is evolving.

[00:04:27]You don't appear to have any of that today, so that's good. Um and then spend about a minute, so I'm going to retake this with my stethoscope here.

[00:05:12]All right, I got 112 over 62 which is normal and uh blood pressure scale.

[00:05:21]Okay, so I'm going to put this here and I'm going to leave that there for now. And then >> [clears throat] >> I am also going to check or palpate your skin for temperature, texture, turgor.

[00:05:39]Patient's um didn't have any tenting, so the patient is well hydrated. The skin is warm to the touch. It is moist, moisture looks good, and then there is no edema. So, I'm also going to take at your bilateral extremities here, starting with your nail beds, looking at the size, shape, contour, and color. Um patient does have nail polish on the toenails, but not the fingernails, so I'm going to start with capillary refill on the hands here, and there's a less than 2 second return. And then, since patient does have nail polish on, I'm going to go on the sides here. And there's also a less than 2 second return, so that is good. And then, I'm going to go into the cranial nerves. So, I'm going to start with cranial nerve one, which is olfactory. I'm going to have you close your eyes for me, and I'm going to place um something underneath your nose. Can you close one nostril for me, and then tell me what you smell?

[00:06:28]Okay.

[00:06:30]Okay.

[00:06:31]Okay.

[00:06:32]And then, going into cranial nerve two, which is optic, I'm going to stand um far away from you here, and I'm going to have you close one eye, and then read the lowest line down. O F T P H And then, do it on the other side.

[00:06:45]O T F P H >> And then, do it with both eyes. L T F P H Perfect.

[00:06:49]And then, I'm going to have you read up close what is on this here. sterile applicator Okay.

[00:06:57]And then, I'm also going to check your peripheral fields here, so tell me when you can see my finger.

[00:07:02]one one one one Perfect.

[00:07:09]Then, going into cranial nerves three, four, and six, which is ocular motor, trochlear, and abducens, I'm going to start with my penlight here. I'm going to check your pupil size on each side here.

[00:07:19]Patient's pupils they seem to be at a three on both sides, and then I'm going to have Travis hit the lights, and I'm going to check your PERRLA, making sure that your pupils are reactive and equal.

[00:07:32]They're accommodating appropriately.

[00:07:34]Perfect. And then, I'm also going to check movement, so I'm going to take this penlight here, and I'm going I'm going follow in the six cardinal [clears throat] positions.

[00:07:47]And then also checking lateral movements so I'm going from side to side. And then I'm going to bring this close to you and just focus in on it. Okay, checking the nystagmus and convergence all looks good. And then going into cranial nerve five which is trigeminal so I'm going to have you clench down and go from side to side.

[00:08:04]Not feeling any crepitus, good. And then I'm going to have you close your eyes for me. I'm going to have a soft and dull object and I'm going to place it on different parts of your face. Can you tell me where it's located and what if it's dull or soft?

[00:08:16]Um left forehead, dull.

[00:08:19]Right forehead, sharp.

[00:08:22]Right left chin, sharp.

[00:08:25]Left chin, sharp.

[00:08:26]Right left cheek, dull.

[00:08:30]Right cheek, dull. Perfect.

[00:08:31]Now I'm going into cranial nerve seven which is facial.

[00:08:35]Um I'm going to have you smile for me.

[00:08:37]Can you frown? Puff your cheeks out and whistle?

[00:08:41]Perfect. And then I'm going into cranial nerve eight which is acoustic. I'm going to come around the bed here. We're going to do the whisper test. So I'm going to have you close one ear and I'm going to say three letters or numbers and can you repeat them back to me? 176 176 FDH FDH Okay, and then I'm going to have you stand up for me and we're going to perform the Romberg test. So have your arms at your side and just close your eyes for me.

[00:09:25]Okay, you can go ahead and sit back down for me.

[00:09:27]And then cranial nerve nine which is glossopharyngeal.

[00:09:31]Um we would check the anterior part of the tongue for taste. Um and then doing with my penlight here, I'm going to check the back of your throat looking at your uvula. Can you say "Ah" for me?

[00:09:44]>> Ah. Okay, the uvula was moving, so that's what we like to see. And then cracking checking cranial nerve 10, which is vagus. Um, I'm going to check the pharynx, larynx, and esophagus.

[00:09:57]We're not going to be performing this today, but I would use the tongue depressor and I would um check the gag reflex. And then cranial nerve 11, which is accessory. I'm going to come behind the patient here and I'm going to have you shrug your shoulders for me.

[00:10:11]Okay, do it again. Perfect. Then cranial nerve 12, which is hypoglossal. We're just going to check your tongue movements, I'm just going to have you say "Lights, tights, dynamite." Lights, tights, dynamite. Perfect. So, then we're going to go into the head. So, looking at the facial features, um, they are symmetrical and your expression is neutral, which is appropriate for the assessment. And then looking at the head, inspecting the size, shape, and position. The position is midline and the size and shape is appropriate to body patient's body size. And then going into the hair, inspecting the hair. The color is like a dirty blonde, like brown and then blonde. Um, looking at the distribution, it is appropriate and there is no infestations. And then I'm going to palpate the head, so feeling for any masses and is there any tenderness with this? No. Okay, perfect.

[00:10:56]So, then we're going to go into the eyes. So, starting with eye alignment, they are symmetrical. And then looking at the iris, the shape is appropriate and the color is brown. Looking at the eyelids, there's no edema, there's no lid lag, there's no lesions. Looking at the eyelashes, they're um appropriately distributed and they are symmetrical.

[00:11:17]Can you have I'm going to have you pull your eyes down for me looking at your conjunctiva. They are pink and moist.

[00:11:23]And then also checking your sclera with my penlight here, making sure there's no lesions on either side and the color is white, which is what we like to see.

[00:11:33]And then, um now that I've checked your eyes, I'm going to go into the ears. So, checking the outer structure, the size and shape is appropriate on both sides. The color is appropriate to ethnicity. There's no drainage. There's no discharge. There's no She Patient does have earrings, but there's no other foreign bodies. Um the condition of the skin looks good.

[00:12:02]There's no lesions.

[00:12:03]Um and then, um I'm going to start with palpating. So, I would pull the pinna forward.

[00:12:11]And then, pull up push on the tragus, and then push on the mastoid process.

[00:12:14]Was there any tenderness with any of that?

[00:12:16]>> Nope. Okay. So, then I'm going to take my otoscope here.

[00:12:20]I'm going to be looking in the ear.

[00:12:25]Okay. So, for an adult, we pull up and back. And for a child, we pull down and back. So, I'm going to pull up and back, and then going in the ear. Um and then, just checking for any redness, any tenderness of the canal.

[00:12:41]Um the color is pearly gray on the tympanic membrane. The It is flat, not bulging. There's no retractions.

[00:12:48]Um Trying to think what else.

[00:12:53]Um there's no discharge.

[00:12:57]The cerumen on the outer ear structure and the inner ear looks appropriate.

[00:13:02]Um and then, we're going to go into your nose. So, looking at the nose, um the size, shape I'm not seeing any is appropriate. I'm not seeing any discharge from the nose.

[00:13:16]Um the position is midline.

[00:13:19]The color is appropriate to ethnicity.

[00:13:22]And then, I'm going to go up the nasal cavity here. So, the color is pink.

[00:13:27]There's no polyps, there's no deviations, there's no drainage, there's no bleeding, there's no discharge.

[00:13:34]Um and then I'm going to palpate. So, I'm going to grab some gloves here.

[00:13:40]And I'm actually going to start with palpating the eyes because I didn't do that. So, we're going to start with that.

[00:13:47]Going around the outer eye structure.

[00:13:49]And then globes and ducts. Is there any tenderness with any of that?

[00:13:53]>> No. Okay, perfect. And then I'm also going to palpate the outer structure of the nose. Any tenderness with that?

[00:13:59]>> No. And then also your maxillary and frontal sinuses. Is there any tenderness with that?

[00:14:03]>> No. Okay, perfect.

[00:14:05]So, check your sinuses, your outer structure, perfect. Then we're going to go into the mouth and I'm looking at the mouth for >> [snorts] >> the color is pink, there's no lesions.

[00:14:17]Looking at the lips, the color is pink, there's no cracking, there's no lesions, there's no bleeding. And then I'm going to take my penlight here and I'm going to look inside the mouth. So, looking at the Can you open your mouth for me, please?

[00:14:29]Um looking at the bucco buccal mucosa, it is pink and moist. Um looked at the teeth, the condition looked good. Um do you have your wisdom teeth? No. Right.

[00:14:40]So, you have 28 of them. And um they're white, they look good. Um and also I'm going to take a look at your hard and soft palate, they are intact. I'm going to also take a look at your tonsils, they look to be about a two, there's no exudate. And your tongue, the surface looks smooth, the position is midline, the color is pink and it looks moist. Going to take a look under the tongue here at the sublingual region, it is pink and moist, there's no lesions. I'm going to have you pull down your lip for me, I'll take a look at your gums, they are pink, moist, there's no edema, there's no retractions, there's no bleeding.

[00:15:14]Um just verbalizing that for a adult, when we palpate, we would just feel with the hard and soft palate to make sure it's intact. For a neonate, we would have them suck on our finger. Um yours are intact.

[00:15:29]Um and then, in regards to palpating the tongue, I would take a 4x4 gauze and I would place it on the tongue and move the tongue around to see if there's any abnormalities.

[00:15:38]But we're not going to be doing that for today. So then, I'm going to go into your neck. So starting with range of motion, I'm just going to have you go up and down, side to side for me. Just checking your range of motion, it looks good. And I'm also going to have you swallow for me. And the skin around your neck looks good. And then, I'm going to be going into the lymph nodes. So starting with preauricular, postauricular, occipital, tonsillar, submandibular, submental, superficial anterior cervical, posterior cervical. Then I'm going to have you turn your head, and this is considered deep cervical. And then, along the clavicle here is supraclavicular.

[00:16:19]And then, I'm going to have you lay down for me.

[00:16:25]And we're going to check your JVD. So making sure the head is flat here.

[00:16:36]Perfect. Going to take my penlight here, and we're just checking your JVD for any pulsations.

[00:16:42]And I'm not seeing any. Perfect. And then, I'm also going to have you feel one at a time your carotid.

[00:16:52]Okay. And then, I'm also going to take my stethoscope here, and I'm going to use the [snorts] bell side, and we're going to listen for any bruit. So I'm going to have you hold your breath for me, please.

[00:17:06]Okay. Perfect.

[00:17:08]And then, I'm going to place this back underneath your head here, and we'll check your carotid. Oh, well.

[00:17:14]So for JVD, I would have her lay flat, which I just did, and I would check for pulsations, like I just did. And then for the carotid, I would place the pillow underneath her head here, and then I would feel one at a time, like I just did.

[00:17:30]And then I would also take, like I just did with the bell, listening for any breweries. So, I'm going to start with respiratory.

[00:17:38]So, I'm actually going to have you sit back up for me.

[00:17:42]And I'm looking at the anterior posterior lateral ratio. The patient is at a 1 to 2 ratio lateral, and then anterior posterior is 2, so 1 to 2. And then I'm also going to be checking your respirations here. So, I'm going to sit here and wait for a minute.

[00:18:55]Okay, perfect. Done 1 minute. So, looking the rate and rhythm were regular.

[00:19:01]The effort looked good. There was no use of accessory muscles, no retractions.

[00:19:07]Um and the depth looks good. You weren't using that excessively. So then I'm going to go into um chest excursion and tactile fremitus.

[00:19:19]So, going on the posterior here, I'm just going to have you take a big deep breath in and out for me.

[00:19:26]So, making sure that those thumbs come apart, which is it did, so we're good.

[00:19:30]And then I'm also going to have you say 99 three times. 99 99 99 Okay, perfect. And then I'm also going to auscultate, so starting with 10 on the front.

[00:19:46]I'm just going to have you take um deep breaths in and out for me.

[00:20:22]Okay. And then I'm going to go to the posterior here.

[00:20:25]I'm going to do 12 on the back.

[00:21:06]>> [clears throat] >> Okay.

[00:21:08]And then checking lateral.

[00:21:30]Okay. All breath sounds sound good.

[00:21:33]You have about 20 minutes left. 20 minutes. Okay.

[00:21:36]So, then I'm going to have you lay back down for me. We're going to start with cardiovascular here. So, I'm going to be inspecting the precordium for pulsations.

[00:21:47]Not seeing any. Then I'm also going to palpate the precordium here, starting at the apex, going down the left sternal border, and then the base, and then I'm also going to be auscultating.

[00:22:03]So, starting with aortic, using the diaphragm here.

[00:22:09]Going over to pulmonic.

[00:22:14]Going Erb's point.

[00:22:17]Tricuspid.

[00:22:21]And then mitral. And this is where I'm going to be doing the apical pulse.

[00:22:26]Right now.

[00:23:28]>> All right, are you sure you want to do that?

[00:23:34]Okay, so then um S1 is heard best in mitral, S2 is heard best in pulmonic. Um check your apical pulse. So now I'm just going to palpate your bilateral extremities here for color, warmth, movement, and sensation.

[00:23:51]Did you feel everywhere I touched? Um the warmth was appropriate. Um movement was good and sensation or color, warmth, movement, sensation. Got it. Okay.

[00:24:02]So then I'm also going to be checking your peripheral pulses. So starting with temporal.

[00:24:08]We've already done carotid, so I'm going to go down to brachial.

[00:24:14]And then radial.

[00:24:20]And then verbalizing femoral.

[00:24:23]Popliteal.

[00:24:28]Dorsalis pedis.

[00:24:33]And posterior tibialis.

[00:24:37]Perfect. And then I'm going to place this under your knees here.

[00:24:42]We're going to be doing the abdomen, so I'm inspect first, so looking at size, shape, color, contour. It Your stomach is flat. Um looking for any scars, any lesions. I'm not seeing any, I'm not seeing any striae, um hair distribution you don't appear to have any which is appropriate for your gender. And then movement um and pulsations, I'm not seeing any of that.

[00:25:11]Um so then I'm going to auscultate starting in the right lower quadrant with my diaphragm here.

[00:25:36]All right, bowel sounds are active and I'm also going to now use the bell side to listen to the vascular sounds. So, starting with aortic, can I be sucking for me?

[00:25:47]Thank you.

[00:25:48]Aortic.

[00:25:50]And then renal.

[00:25:54]And then iliac.

[00:25:58]Okay.

[00:25:59]And then I'm going to palpate starting in the right lower quadrant feeling for any tenderness, any muscular resistance, or any bladder distension. Is there any pain with that? Okay.

[00:26:10]So, then I'm going to go into musculoskeletal. So, I'm going to have you sit up for me.

[00:26:21]And we're going to start with your gait.

[00:26:23]So, I'm going to have you stand up and I'm going to have you walk 10 to 20 ft forward. I'm going to watch your turn and return looking for any swing phase and stance. All appears well. And then I'm also going to have you walk heel to toe forward and backwards just a couple feet there. Perfect. And then I'm looking at your anterior posture and also your posterior posture looking for any lordosis, scoliosis, or kyphosis.

[00:26:47]Kyphosis is up here in the thoracic and I'm not seeing any of that. Scoliosis is the S curvature in the spine, which I'm not seeing any of that, and lordosis you do not have any have any of that.

[00:26:57]So, then we're going to go into some coordination. So, starting with thumb to finger, can you just do this with all of your digits? And then I'm also going to have you do supination and pronation.

[00:27:07]And then can you run your heel up your shin on both sides?

[00:27:10]Perfect. So, then we're going to go into muscle strength. So, I think I'm going to have you stay standing for this. So, I'm just going to verbalize the scale.

[00:27:22]Um five is normal, four is slightly weak, three is weak, two is poor range of motion, one is severely weak, and zero is paralysis. So, for Alyssa here, I'm going to be checking the size, shape, symmetry, and strength for all muscles, and I'm going to be inspecting and palpating. So, starting with the sternocleidomastoid, I'm just going to have you look left and right, and then I'm going to palpate while you do that.

[00:27:45]Perfect. And then we're going to go into the trapezius. So, I'm just going to have you shrug your shoulders for me.

[00:27:52]I'm going to inspect while you do that.

[00:27:54]Perfect. And then we're going to check your deltoids. I'm going to have you go up and down for abduction and adduction.

[00:27:59]Perfect. And then I'm going to after the shoulders Nope, that's not right. Deltoid, sorry.

[00:28:08]We're going to go into hand grip. So, I'm going to have you grab my hands here and squeeze. Perfect.

[00:28:17]And then um I'm going to have you sit down for me, please.

[00:28:25]And um I'm going to have you Okay. So, sternocleidomastoid, trapezius, deltoid, hand grip, bilateral hand grip we just did. So, now I'm going to go into the hips. So, I'm going to have you um push out for abduction and then in for adduction.

[00:28:48]Go out and in, sorry.

[00:28:50]And then I'm just going to put resistance while you do that. Great.

[00:28:54]Great. And then um for Shoot, I'm messing this up. Deltoid, bilateral hand grip, biceps, triceps.

[00:29:07]So, I'm going to have you push and pull against me.

[00:29:10]For bis and tris? Yes, I got it. Okay, perfect. So, after bis and tris, it's quadriceps and hamstrings. So, I'm going to have you push up on my hands, please, for quadriceps and then I'm going to have you pull back for hamstrings.

[00:29:22]Awesome, great. So, all of your muscles I would rate a five, they are normal, um which is what we would expect. And then going into inspecting range of motion and palpating the synovial joints. So, starting with your temporal mandibular joint, I'm going to have you open your mouth for extension and then close your mouth for flexion and then I'm going to feel while you do that. Perfect, no crepitus. And then I'm going to go into cervical spine here. So, I'm going to have you put your head down for flexion, up for extension.

[00:29:56]I'm going to feel while you do that.

[00:29:58]And then I'm going to have you do lateral, so go ear to shoulder on both sides. So, I'm going to have you feel while you do that and then I'm going to have you rotate your head from left to right.

[00:30:06]Perfect. And then we're going to go into shoulders. So, I'm going to have you do flexion and extension.

[00:30:16]And then I'm [laughter] going to have you feel while you do that.

[00:30:19]I'm going to have you stand up, that would be way easier, right? So, um flexion and extension, perfect. And then I'm going to have you do internal and external for rotation and then I'm just going to feel while you do that. Perfect.

[00:30:33]And then elbow. So, I'm going to have you do flexion and extension.

[00:30:40]Flexion and extension. And then I'm going to have you do a supination and pronation.

[00:30:45]Perfect. And then for the hands, I'm just going to have you make a fist for flexion. And then I'm going to have you do wrist flexion, extension, and then rotation.

[00:30:56]And then Um I'm going to inspect you while you do that. Flexion, extension, rotation. And then for fingers, I'm going to have you do abduction and adduction. Flexion, extension, perfect. Okay. And then um Your knees. So, I'm going to have you bring both knees close to your body.

[00:31:17]I'm going to feel one while you do that.

[00:31:19]Perfect. And then for your hips, I'm going to have you go abduction and adduction in. So, ab ad, perfect. And then um your ankles. So, I'm going to have you sit for me.

[00:31:36]And we're going to do um dorsiflexion, so put your feet up and then plantar flexion, put your feet down. So, I'm going to palpate while you do that. And then do inversion and eversion, and then rotation.

[00:31:50]And then spine. So, I'm going to have you stand up one more time for me. And we're going to do flexion, extension backwards. Okay, do that again for me, please.

[00:32:00]And then I'm going to have you rotate from side to side. Do that again for me.

[00:32:05]And then we're just going to bend from side to side. Can you do that one more time? Perfect. So, then I'm going to have you sit for me. That was a lot of moving.

[00:32:13]>> [laughter] >> And then um all of your range of motion looks good. Your synovial joints felt good. There was no crepitus. Um And then we're going to go into neurological. So, I'm going to ask you an immediate, a recent, and remote question. So, immediate, you have already stated your name and date of birth for me.

[00:32:31]Recent, can you tell me what assessment we just performed? Head to toe.

[00:32:35]And then for remote, can you tell me who the black president of the United States was? Barack Obama. Okay. And then, um I've already completed my cranial nerves, so I'm just going to choose a reflex, and I'm going to choose your knee here, so I'm going to have you uncross. And then, I'm just going Nice.

[00:32:55]Okay.

[00:32:56]Um so, then I'm going to cleanse my equipment here. So, I'm going to grab one of these. [snorts] And I'm going to cleanse my equipment while I go over a few things here. So, um I'm going to physically clean up all of my equipment here.

[00:33:18]And then, let's see. Let me get my I'm going to actually get a look at that for a hot second.

[00:33:27]Um can you tell me how much time I have?

[00:33:32]8 minutes.

[00:33:33]>> Okay. So, I'm probably just going to go through everything here while I cleanse my equipment.

[00:33:40]Perfect. And then, I'm also going to perform hand hygiene.

[00:33:45]And then, uh I am going to document in OneNote.

[00:33:49]There was no abnormalities with this patient, um but I would document if there were any deviations.

[00:33:55]Um so, I'm probably just going to go through this again here real quick. So, um stated that your blood pressure was normal on the scale of blood pressure.

[00:34:09]We took your temperature.

[00:34:11]I did your respirations. So, in regards to respirations, I said rate and rhythm were regular and equal.

[00:34:17]Effort, use of accessory muscles, retractions, and depth. Um I did your peripheral pulses. We did CWMS.

[00:34:30]Um we did your lymph nodes. So, looking back at I said the edema scale, I said the ABCDE mnemonic.

[00:34:42]Um eyes, I palpated your outer eye structure, globes, ducts for tenderness.

[00:34:49]I said alignment, iris, eyelid, lashes, conjunctiva, sclera. We did your four fields.

[00:35:01]Um palpated. So, then the ear. So, outer ear structure.

[00:35:10]So, size, shape was appropriate for patient.

[00:35:17]The color's appropriate to her ethnicity. No excess cerumen.

[00:35:22]No drainage, no foreign bodies besides the earrings. The condition of skin looks good.

[00:35:29]I don't know if I said lesions.

[00:35:31]No lesions on either ear here.

[00:35:34]Um And then within the ear, I pulled your pinna down, pushed on the tragus, mastoid process.

[00:35:41]Um I don't know if I stated within the ear the tympanic membrane was flat, not bulging. The position was at a seven.

[00:35:49]The light was reflecting on a seven on the left and a five on the right. The color was pearly gray.

[00:35:57]There was no redness or tenderness of the canal, cerumen, discharge, foreign bodies, bleeding.

[00:36:09]The color looked good.

[00:36:12]Um Ears.

[00:36:18]I don't even have to write that.

[00:36:22]I think I hit everything in there.

[00:36:24]Um neck, we did range of motion, swallowing, skin looked good.

[00:36:29]Did your lymph nodes, checked your JVD and carotid.

[00:36:36]I don't know if I stated in the vascular sounds for abdominal um we check with the bell for brew as well.

[00:36:46]Um there was a slight bend in the knee for the abdomen assessment.

[00:36:51]Um skin as I said color was appropriate checking the skin, no rashes, no bruising, no lesions, no edema.

[00:37:01]Um and then respiratory we did chest excursion, tactile fremitus, anterior posterior lateral ratio.

[00:37:14]Um did the 10 12 three sounds.

[00:37:19]Cardiovascular inspected your precordium, palpated apex, left sternal border, base for heaves, lifts, and pulsations.

[00:37:30]And then um also heaves, lifts, pulsations.

[00:37:35]And then also with cardiovascular um bronchial, bronchial vesicular, and then vesicular regions and then also um Yeah, I don't know if I said times but I just said that heaves, lifts, pulsations for the apex, left sternal border, and base. And then I checked I auscultated all of them, did your apical pulse.

[00:38:09]The The rate and rhythm for apical pulse was regular and equal.

[00:38:14]Um Let's see here.

[00:38:18]Two minutes. Two minutes, okay.

[00:38:21]So, let's see.

[00:38:26]Grab and then we did musculoskeletal.

[00:38:31]mouth Forgot to palpate the lips, so we're going to do that here. Oh my god.

[00:38:44]I did I palpated your outer eye structure, your nose. Okay, so then your lips we didn't do.

[00:38:50]So, oops Okay.

[00:38:57]So, feeling the lips for any masses, tenderness, or deviations. Is there any tenderness with that? No? Okay.

[00:39:07]Um and then musculoskeletal. So, I'm just going to have you hydrate like Um so, turn your head to the left side.

[00:39:17]trapezius, deltoids biceps, triceps, bilateral hand grips quadriceps, hamstrings Did all of that. Temporomandibular joint.

[00:39:31]cervical spine shoulders, elbows, wrists hands, fingers knees hips ankles Okay.

[00:39:49]About 1 minute. Okay.

[00:39:53]Um Okay.

[00:40:01]Um so, I'm going to end with thanking you for being my client. Do you have any questions on here? I have the time. No?

[00:40:07]All right, so I make sure the call light is locked or the call light is within reach, the bed is locked and lowered, the side rails are secure, the table is within your reach, the pathway is clear of any obstructions.

[00:40:18]I've already cleaned up my equipment here and I've cleaned my equipment.

[00:40:22]And then I hand sanitize one more time.

[00:40:26]Um I have everything at the end.

[00:40:37]Yeah.