534 - Unintentional ASMR - Assessment / Exam / Head to Toe

Ajouté : 2026-05-11

[00:00:01]Come in.

[00:00:04]>> Hi, my name is Gina. I'm the student nurse that's going to be helping you out today. Can I get your name and date?

[00:00:11]>> Larson, 12449.

[00:00:14]And do you have any allergies? No.

[00:00:16]>> No. No. And any um medical conditions that I should be aware of?

[00:00:21]>> No.

[00:00:21]>> No. Okay. I'm just going to check that with your chart and check your band.

[00:00:29]Okay.

[00:00:30]Uh before we get started, I'm just going to be asking you a couple of funny questions, so just bear with me. Um can you give me your name one more time?

[00:00:38]>> M Larson.

[00:00:39]>> Andy, do you know where you are right now? King Cardio University.

[00:00:42]>> Concordia Hospital.

[00:00:43]>> Okay. And do you know what day it is?

[00:00:45]>> Thursday.

[00:00:46]>> Thursday.

[00:00:48]Um and do you know who the president of the United States is?

[00:00:50]>> Joe Biden.

[00:00:51]>> Okay. Patient is oriented times four. No signs of slurred speech or uh involuntary movements.

[00:00:59]Okay. So, what brings you in today?

[00:01:02]>> I was gardening yesterday and I tripped and rolled my ankle.

[00:01:06]>> Okay. Um and are you in pain?

[00:01:09]>> Um I would say it's out of three out of 10.

[00:01:11]>> Okay. So, on a scale of 1 to 10, it's a three.

[00:01:14]>> Yes.

[00:01:14]>> Okay. Um and have you found anything helps or exacerbates the pain?

[00:01:18]>> When I walk, it's about a five.

[00:01:20]>> Okay. So, walking makes it hurt a little bit more. Have you been taking any medic? Does he make it better? No. Okay.

[00:01:25]And is that pain that you're at right now, is that tolerable for you or you have a pain goal?

[00:01:29]>> I would like to be like around around a one.

[00:01:32]>> Okay, that makes sense. So, we'll figure out what we can do um with your visit today to get that pain down. Um but while we have you here, we're just we want to do a headto toe assessment to get to know you a little better. Is that okay?

[00:01:43]>> Yes.

[00:01:43]>> Okay. So, we're literally just going to work head to toe and assess your whole body. So, I'm going to start up here with your head.

[00:01:55]Okay. So, I see no signs of alopecia or dandruff.

[00:02:00]Head looks symmetrical. While I'm here, I'm going to check the skin on your coxix. I don't see any signs of skin breakdown and um skin color looks irregular for ethnicity.

[00:02:14]Okay. Since I'm over here, I'm just going to look inside your ear. Okay.

[00:02:29]Okay. No, excess serum or skin breakdown um for both ears.

[00:02:35]Okay. We'll move on to assess your eyes.

[00:02:37]I'm just going to shine a light. Okay.

[00:02:43]Okay. Um and then I'm just going to um pull down a little bit to check down here. So, scara is white, no signs of jaundice, and conjunctiva um is pink and moist. Um and then I'm just going to have you follow your eyes. Try not to move your neck. Okay.

[00:03:12]Okay. Patient's eyes are pear. um pupils equal around reactive to light and accommodating. Um now I'm just gonna move on to your nose. Okay. If I could have you just tilt your head back a little bit.

[00:03:25]Okay. I don't see any polyps or excess drainage in the nose. Um and now we'll move on to your mouth. So if I could have you smile.

[00:03:33]Okay. And then open your mouth wide.

[00:03:36]>> Stick your tongue out.

[00:03:40]>> Okay. And Millie, do you wear any dentures?

[00:03:42]>> No.

[00:03:43]>> No. Okay. about any glasses?

[00:03:45]>> No.

[00:03:46]>> No. Okay. So, the mucos membranes in the mouth looked moist. Um, no ulcerations.

[00:03:54]Um, okay. So, we're going to move on.

[00:03:56]I'm going to um just check your swallow reflex. Okay.

[00:04:00]So, if I could just have you swallow.

[00:04:03]And do you ever have any difficulty swallowing?

[00:04:06]>> No.

[00:04:06]>> No. Okay. No signs of dysphasia or tracheal um deviation. And then I'm just going to take your pulses corateed pulses are two plus equal bilaterally and then I'm going to take your temporal as well okay temporal pulses are two plus equal bilaterally bilaterally as well okay um and then we're just going to move on um to the lower extremities. So, just let me know if you feel this.

[00:04:48]Okay. Sensation is intact in the upper extremities. And I'm going to take your brachial pulses. Okay.

[00:04:58]Okay. Brachial pulses 2 plus equal bilaterally.

[00:05:06]And radial pulses 2 plus equal bilaterally. And then we're going to assess for range for range of motion.

[00:05:11]So, if I could just have you here. Do you like the YMCA?

[00:05:16]Okay, thank you. Um, range of motion, upper extremities is active and I don't see any signs of skin breakdown on the elbows.

[00:05:28]Okay. Um, now we're going to move on to assessing your um chest area. Okay. So, first I'm going to listen to your heart sounds and then I'll move on to your lung sounds. Okay.

[00:05:51]So this is your aorticonic herbs point tricuspid and mitro. And I'm just going to hang out here for a little over a minute.

[00:06:17]Okay. So, we can get your apical pulse, which um is located in the fifth inner costal space.

[00:07:59]Okay. So, while I was listening to your heart sounds, I found that your heart rate was 80 beats per minute. And I also listened to your I got your respiratory rate as well. Um, and that was 14 breaths per minute. Um, and there were no adventitious heart sounds and and S2 were present. Um, and then now we will move on to listening to your lung sound.

[00:08:23]So, I'm going to have you um inhale and exhale at every point. I listen um on the front and on the back. And then if at any point you feel faint or dizzy, just let me know. Okay.

[00:08:34]>> So, we'll do six points um in the front and eight in the back. Okay.

[00:09:11]Are you doing okay? Yes.

[00:09:26]Okay. There were no adventicious lung sounds. Um, can I have you take a deep breath in and out?

[00:09:36]In and out. Okay. Chest was will rise and fall. So, no signs of flail chest.

[00:09:47]Oh, I'm I'm going to assess your skin t.

[00:09:49]Okay. I'm just going to give you a teeny pinch.

[00:09:53]Okay. So, no signs of tenting. The skin looks hydrated. Um and then let's um assess the strength in your upper extremities. Okay. So, um put your hand to mine. press and then um can you pull?

[00:10:12]Okay. So strength in the upper extremities is a five. Um and then let's um oh also I'm going to check your capillary refill. Okay.

[00:10:34]Okay. cap refills less than two seconds in all 10 fingers. Okay. Um, we're going to move on to assessing your abdomen.

[00:10:42]But before we go ahead and do this, I'm just going to ask you a few more questions. What does your diet normally look like? So, I typically like to eat this a day. In the morning, I like to have like oatmeal with some fruit. For lunch, maybe I have like a salad or sandwich. And then for dinner, I'll probably have some like chicken, rice, and some vegetables.

[00:11:02]>> Okay, that sounds good. And are you drinking fluids?

[00:11:05]>> I drink about two cups of water a day.

[00:11:07]>> Okay. Do you maybe not like the taste of water?

[00:11:10]>> Yeah, I just find it like not very exciting.

[00:11:13]>> Yeah, I get that. I normally like add lemon to mine just to make it like a little bit more like enjoyable. So, I get that. But we do want to have your fluid level um ideally at like eight cups per day.

[00:11:25]>> Okay. Okay. Um and then also, when was your last bowel movement?

[00:11:29]>> My last bowel movement was yesterday night. Okay. Um, and what did it look like?

[00:11:34]>> It was brown.

[00:11:36]>> Brown. Okay. Um, and how often do you have a bowel movement?

[00:11:40]>> About once a day.

[00:11:41]>> Okay. Um, also, what about with urination? How often are you urinating every day?

[00:11:47]>> Like four to six times a day.

[00:11:48]>> Okay, got it. Um, do you have any like pain, any burning when you're urinating?

[00:11:54]>> No.

[00:11:54]>> No. And what about do you notice any odor ever?

[00:11:57]>> No.

[00:11:57]>> No. Okay. Okay. So, I'm just going to have you lie down so we can That's your out.

[00:12:12]>> Okay. Is it okay if I um just pull you up a little bit?

[00:12:21]>> And Millie, um do you have to urinate right now before um I'm going to eventually palpate the bladder?

[00:12:26]>> No, I'm okay.

[00:12:27]>> Okay. Okay. Upon um inspection, I see no signs of bulges or masses, and the abdomen is non-extended.

[00:12:35]Um I'm going to listen to your bowel sounds. Okay.

[00:13:01]Okay, bow sounds are normal, hypoactive, um, in all four quadrants. Um, now I'm going to be palpating. Do you have any tenderness in the abdomen? No. No. Okay.

[00:13:13]So, I'm going to start light. Just let me know if you feel any tenderness in any of these areas. Okay.

[00:13:19]>> No. Okay. Now, I'm going to go a little bit deeper.

[00:13:27]Okay. I don't feel any masses or bulges and um patient reports no signs of tenderness.

[00:13:35]Um and then I am going to palpate the bladder. Okay.

[00:13:42]Bladder is also nonextended. I'm going to pull this back down.

[00:13:53]Thank you.

[00:14:07]Okay. And then we'll move on to assessing your lower extremities. Okay.

[00:14:12]Let me know if you can feel this. Yes.

[00:14:15]Okay. So, sensation is intact in the lower extremities. And then I'm going to feel for your pop with pulse.

[00:14:26]Okay. It's a little bit weak, but that's normal. You could just relax. Um, >> you could just relax. No. Um, actually, I'm going to assess your strength before we move on to working with your feet just for sanitary reasons. Okay. So, first, um, I'm going to have you just try to press up on my hand. Okay, perfect.

[00:14:48]Um, and then we'll move on to your feet.

[00:14:51]Okay. Press down like it's a gas pedal and then try to press up. Okay. Um, so strength is a five.

[00:15:00]And now I'm going to feel for actually the pulses on your feet. Okay.

[00:15:10]>> Okay. Post hip pulses are two plus equal bilaterally and dorsal do this two plus equal bilaterally and then I'm just going to check the cap refill on your feet. Okay.

[00:15:34]Okay. Cap refill in the feet um is less than 2 seconds in all 10 digits.

[00:15:43]Okay. Um and do you ever like need any assisted devices or do you feel like you can move around? I feel like I can move around. Okay, I'm just gonna help you up for safety.

[00:15:55]Step down. Um, and then if you want to just hold on right here for safety, we're just going to look um at the range of motion in your lower extremity. So, let's just kick out.

[00:16:08]Perfect. And then left side and you can kick back and kick back.

[00:16:16]Okay. patient has full um active range of motion in the lower extremities. Um and now we're just going to be assessing like your balance and your gate. So I just am going to have you walk for me just a few steps.

[00:16:35]Okay. Gate does look steady. Um just a little bit of weakness um in the ankle that's injured, but that's okay. We expected that.

[00:16:50]So, just like a little overview of like everything we went over. So, the CNA um I know came and did take your vitals and your temperature was 98.8. Um BP 146 over 84 and then the O2 stat was 97.

[00:17:05]Um let's see what else you came in for the pain. Um doctor did prescribe 400 milligrams of ibuprofen every six hours as needed. Okay. Um, we're going to have you rest and just elevate that ankle and then you can also apply ice like every 20 minutes few times a day. Um, and we would like you to come back in in two weeks and just do a followup with us.

[00:17:31]>> Okay. Sounds good.

[00:17:33]>> Okay.

[00:17:35]>> Do you have any other questions for me?

[00:17:37]>> No. Thank you so much.

[00:17:39]>> Okay. Thank you. It was really nice to meet you.

[00:17:41]>> You, too.