Head to Toe Assessment on a Female Patient | 71 | Unintentional ASMR

Añadido: 2026-05-19

[00:00:02]Hi, Hannah. I'm Emma. I'm gonna be doing an assessment on you today. Let me just finish cleaning my hands real quick.

[00:00:09]>> Is it okay if we go ahead and get started?

[00:00:11]>> Yeah.

[00:00:12]>> Okay. So, the first thing I'm going to be doing is inspecting your head, um your scalp, and your face. Um so, first I'm just going to be looking at it. And you're going to feel me um kind of going through your hair, and I'm just going to go through and make sure that there's nothing abnormal such as lumps, bumps, or lesions.

[00:00:35]And your scalp is a normal color. Your hair is nice and thick.

[00:00:42]I don't see anything um any foreign substances in there at all. I'm going to look at the other side.

[00:00:59]Okay, that looks great.

[00:01:02]Now, I'm just going to palpate your head, which means I'm going to feel it, and I just want to make sure there's no um lumps or bumps. And let me know if you feel any tenderness at all.

[00:01:14]Does that feel okay?

[00:01:16]Okay, perfect. Now, I'm just going to um look at your face and make sure that the bony configuration is symmetrical, that there's no abnormal colors or any abnormal lesions, lumps, or bumps, and there isn't. So, that's great.

[00:01:30]I'm just going to feel. Does this hurt at all? Nope. Okay, great.

[00:01:39]Um, next I'm going to feel your jaw.

[00:01:42]Just going to go right in the um joint right here. Does that hurt at all? Okay.

[00:01:47]Can you open your jaw for me? Okay.

[00:01:50]There's no um clicking or grinding, which is great. Um cranial nerve five is intact. I am just going to have you open your jaw against my hand. Good job.

[00:02:01]Okay. Next, I'm going to assess your lymph nodes, and there's quite a few of them.

[00:02:08]All right. First, I'm going to feel the um occipital lymph nodes. And if you feel any tenderness at all while I'm doing this, just let me know cuz you should not be feeling any pain.

[00:02:20]The post ericular, the pre-uricular I'm going to feel the submandibular, the submental in your tonsular.

[00:02:47]Okay. Now I'm going to feel the um anterior cervical, the superficial and the deep.

[00:02:56]Okay. Now the posterior cervical superficial and deep.

[00:03:02]Now I'm going to feel the um superclavicular.

[00:03:08]Great. Did any of that hurt at all? No.

[00:03:11]Okay, great.

[00:03:13]Next, I'm just going to look at your trachea and make sure that it looks midline, that there's no deviation at all.

[00:03:20]And I can feel that it's midline.

[00:03:24]Okay. Next, I'm going to assess your thyroid. First, I'm just going to look at it and inspect it and make sure that it's not bulging out, doesn't look enlarged. Um, and it does not. You do not have a goer.

[00:03:37]Um, I'm going to assess it from behind.

[00:03:40]So, I'm going to grab some water and I'm going to have you um put this water in your mouth and then swallow it when I tell you to. Okay.

[00:03:50]So, first I'm just going to feel it without the water and then kind of push it from side to side a little bit here. Make sure there's no um grittiness or lumps or bumps. And I do not feel any. Now, I'm going to have you put the water in your mouth.

[00:04:07]Okay. And go ahead and swallow.

[00:04:10]Okay. Great. And again, it doesn't feel like there's any lumps or bumps. It's very smooth. And that's awesome.

[00:04:19]Okay. Next, I'm going to be um looking at your eyes.

[00:04:25]Um the first thing I'm going to do is use something called a smelling chart.

[00:04:32]So, I'm going to take this from you, okay? And I'm gonna have you hold this chart out in front of you with your arms straight.

[00:04:42]Okay? And I want you to cover um that left eye first.

[00:04:46]Okay? And tell me the smallest row that you can read.

[00:04:52]37 428.

[00:04:54]Great. That's 20 30 vision in that eye.

[00:04:56]Now, I'm going to have you switch to the other eye.

[00:05:06]374 28.

[00:05:09]Okay, great. That's 2030 again. And um that means that cranial nerve 2 is intact.

[00:05:21]Just grabbing some supplies over here.

[00:05:28]Okay. Next, I'm just going to look at your eyes and make sure that um your eyebrows are symmetrical, your eyes aren't drooping at all, that there's no swelling or redness or irritation, and they look symmetrical and they look equal, which is great. Um next, I'm just going to look at the structures inside your eye. Um first without a light, and then again, um with a light.

[00:05:54]So, I'm just going to pull in some gloves for this since I'm going to be touching her eye.

[00:06:09]All right. So, first I'm just going to look at the scara and make sure it's um a nice shiny white and is clear without a lot of redness or blood vessels. Then I'm just going to push down on your eyelid a little bit and look at um the conjunctiva of both eyes and then also the lacrimal ducts.

[00:06:27]Um the conjunctiva looks good. It's not red. Um it's there's no excessive tearing. There's no extra date. There's no jaundice. It looks great.

[00:06:46]Okay. Next, I'm going to um dim the lights and look at your pupils.

[00:07:00]Okay, first I'm just going to um visualize the cornea and make sure that it looks nice and clear with no um vessels or lipid deposits. And they look good. They both look the same. Now, with the lights dimmed, I'm going to um check your pupils. And first, I'm going to shine the light in your left eye.

[00:07:22]Now, your right eye.

[00:07:24]Okay. And they are both equal um and round and reactive to light. They're about a size three, which is normal.

[00:07:36]Next, I'm going to actually look at the internal structures of your eye.

[00:07:43]with the lights down.

[00:07:52]Start with your right eye.

[00:07:56]I'm just going to look for something called the red reflex as I shine the light in your cornea.

[00:08:02]And then I'm going to um zoom in and look at the other internal structures.

[00:08:11]I'm going to do the same thing with your other eye.

[00:08:16]And I see a red reflex. I see all the internal structures. And um there's no lesions at all in either eye.

[00:08:25]That's great.

[00:08:32]Okay. Next, I'm going to do something um called assessing your extraocular eye movements.

[00:08:41]Um, so what I want you to do is look at the wall behind me.

[00:08:48]Um, and now look at my pen.

[00:08:51]That's something called accommodation.

[00:08:53]And you had good accommodation. Both eyes went in equally. Now I'm going to do um those extracular eye movements that I just mentioned. So what I want you to do is to follow this um with just your eyes and not move your head at all.

[00:09:05]Okay?

[00:09:22]Now I want you to look all the way up and look all the way down.

[00:09:26]Great. And there was no stigma switch that with that which is normal which would be your eyes twitching from side to side. Um so that assess your um cranial nerve 3, four and six. And that intact and that's great. Now I want you to close your eyes really tight for me and open them and then raise your eyebrows. Okay, great. Cranial nerve seven is intact. And then we also assessed um cranial nerve 2 again when we did that red light in your eyes. Um so again that's intact.

[00:10:00]Okay. Next I'm going to move on to your ears.

[00:10:07]So, first I'm just going to look at the ears. I'm going to move your hair to the side.

[00:10:16]And I just want to make sure that that oracle um looks like it's the same color as the rest of your face. And make sure they're symmetrical. And I'm going to make sure they're in the correct position in regards to the inner canthus of your eye. So, I'm just going to draw a line visually there.

[00:10:34]and make sure that, you know, they're not down too low or up too high. And they look great. I'm also going to just look at um the external auditory canal and make sure there's not a lot of discharge or an odor.

[00:10:55]Okay, it looks great. There's no discharge. There's no odor.

[00:10:59]And then I'm just going to feel and make sure there's no lumps or bumps.

[00:11:06]Is there any tenderness at all? No. Now, I'm going to feel behind the ear on this bone here. Do you feel any tenderness at all?

[00:11:15]Same thing over here. Any tenderness at all? No.

[00:11:19]>> Okay, great. Um, next I'm going to actually look into your ear and look at all of the internal structures.

[00:11:38]Okay. And I see the internal auditory canal, which does have some hairs, which is normal. It's nice and pink. There's not a lot of discharge. There's no bleeding. Um there's no abrasions or um lesions. And I'm going to look in a little further and I see your tempanic membrane is gray. And um it's intact and it's a pearly appearance which is normal.

[00:12:10]Now the other side.

[00:12:15]I'm just going to pull your ear back a little cuz that makes it easier.

[00:12:20]Okay. Same thing. I see the external or the internal auditory canal.

[00:12:25]Um it's pink. It's intact. There's no lesions. And I see the tempanic membrane is a pearly gray. Um, and I see the three other internal ear structures are all intact. And it was the same way on the other side. So that's great.

[00:12:59]Okay. Next, I'm going to assess your hearing.

[00:13:06]So, first, what we're going to do is something called the whisper test. So, what I want you to do is um stick your finger in your right ear, and you're going to be wiggling it while I say three letters or three numbers into your other ear. And then I would like you to repeat back to me what I said.

[00:13:25]325. Great. Now we're going to do the same thing on the other side.

[00:13:30]T I TV. Great. And you heard those equally on both sides. That's great. Um, cranial nerve 8 is intact.

[00:13:40]Um, now I'm going to do something called the Weber and Ryan test, which will assess your hearing um with air conduction and bone conduction.

[00:13:52]So, the first thing I'm going to do is place this tuning fork on the top of your head. And I want you to tell me if you hear the sound equally in both ears or if you just hear it in one more than the other.

[00:14:07]Equally low. Great.

[00:14:10]Okay. Now, I'm going to assess each ear individually. So, I'm going to shake this and place it on that bone behind your ear. And I want you to tell me when you stop hearing the noise. Then I'm gonna move it to just a couple centimeters outside your ear. And I want you to tell me again when you stop hearing it.

[00:14:36]Okay.

[00:14:52]Okay. Same thing on the other side.

[00:15:11]Okay. Good. And you heard um the air conduction twice as long as the bone conduction which is expected and that's what we want. So that's great.

[00:15:29]Okay.

[00:15:31]Um next I'm going to um look at the arteries of your face. So, first I'm going to um feel your temporal arteries and make sure that they feel equal and that they're not bounding and that there's no thrill.

[00:15:47]And they're a two plus. They're equal.

[00:15:50]That's great. I'm also going to feel your corateed arteries and then I'm going to listen to both of them. Okay.

[00:15:55]I'm going to do one at a time. Okay, that's a two plus. It's not bounding.

[00:16:00]There's no throw.

[00:16:04]two plus not bounding no thrill. Okay, now I'm going to listen to those Okay, I'm just feeling a little bit of a different spot to get a better feel.

[00:16:54]Again, two plus not pounding.

[00:16:58]Okay, let me just listen there again.

[00:17:18]Great. I do not hear.

[00:17:23]Um, can you please smile for me, frown for me, and puff out your cheeks?

[00:17:36]And then um cranial nerve seven is intact with that. Um next I'm going to assess your nose. I'm just going to look at your nose and make sure that there's no obvious lump bumps or lesions, no abnormal coloring like some cyanosis. Um and make sure it just looks symmetrical, which it does. Um now I'm just going to feel down your nose here.

[00:17:59]Make sure it feels symmetrical. And then I'm going to your sinuses. While I'm at it, let me know if there's any tenderness of this.

[00:18:10]Does that feel okay?

[00:18:11]>> Yep. Okay. Next, I'm going to look inside your nose.

[00:18:17]And I switched out um my cover here.

[00:18:22]I'm just going to have you look up.

[00:18:25]Okay. Just looking like this. I see that um the septum is midline. It's open.

[00:18:31]There's no deviations.

[00:18:34]I'm just going to look a little deeper here.

[00:18:38]And it's nice and pink with no redness.

[00:18:40]Um, it looks moist. It's not too dry.

[00:18:47]There's no bleeding or crusting.

[00:18:50]Great.

[00:19:01]Okay. Next, I'm going to um assess your mouth. So, I'm just going to look and make sure it looks symmetrical, that there's no drooping on one side or the other. Um your lips look nice and pink and moist, which is good. They're not dry. Um and now I'm going to have you smile for me and open up so I can see your teeth. Okay. And there are um no loose or missing teeth and the gums are nice and pink and moist. And I'm just going to look in a little further.

[00:19:31]I'm going to look at the bugal mucosa.

[00:19:34]There's no um lesions, lumps, bumps, bleeding. There's no tears. It looks nice and pink and moist. I'm going to have you look up a little bit and I'm going to look at the hard and soft palette. It's intact. Um again, no lesions or bleeding.

[00:19:52]And then um I'm going to have you stick out your tongue.

[00:19:59]And your tongue is intact. There's no um coating on it, which is great. It's nice and moist.

[00:20:07]I'm going to look at your tonsils and your uvula. Can you say a for me?

[00:20:13]>> Okay, great. Your tonsils are a two plus which is normal with no exudate um no bleeding and your u is midline and um it does elevate when you say that. So that means that cranial nerve 9 is intact.

[00:20:34]Um can you stick out your tongue again?

[00:20:37]Are you able to move your tongue from left to right and up and down?

[00:20:43]Okay, great. Cranon nerve 12 is intact.

[00:20:46]Now, if you could just um stick your tongue to the side again, and I'm going to look at your tongue and make sure that the sides of it look um good like the rest of it. And now other side.

[00:20:57]Okay. Again, there's no um lesions, nothing concerning. Um can you put your tongue on the roof of your mouth? And I'm just going to look at the bottom of your tongue. Okay. I see two veins, which is normal. That's great. Again, the color um looks great and it's intact.

[00:21:18]Um now I'm going to assess a few more cranial nerves. First I'm going to assess cranial nerve five um which is facial sensation.

[00:21:32]So first I'm going to assess um dull sensation. So, I'm gonna swipe this cotton swab over each side of your face, and I want you to tell me if you feel it more on one side than the other, or you don't feel it at all. Okay?

[00:21:48]>> Is that the same?

[00:21:53]The same.

[00:21:56]>> Is it the same? Yep.

[00:21:58]>> Okay. Now, the same thing with sharp.

[00:22:02]Same. Great.

[00:22:08]Great.

[00:22:16]Um, now I'm going to assess cranial nerve 11. Can you please shrug your shoulders for me? Okay. Now move your head against my hand.

[00:22:25]Okay. On the other side. Great. That's nice and strong. Um, sranal nerve 11 is intact. I also want to assess your cervical spine range of motion. So, if you could just tilt your head to the left and right and then back and forward. Is there any pain with that at all?

[00:22:41]>> Nope.

[00:22:41]>> Okay, great. Cervical spine um is intact and mobile. Um so, next we're going to move to assessing your lungs. So, the first thing I'm going to do is just um look at your chest.

[00:22:56]So, I'm going to um have you just put your gown down if that's okay so I can see everything.

[00:23:02]Um, so first I'm just going to look and make sure that your breathing is symmetrical and that you have an easy work of breathing. I'm also going to look and make sure your respiratory rate isn't too low or too high.

[00:23:34]Okay. And your respiratory rate is 12, which is normal. We want that to be 12 to 20.

[00:23:40]Um, now I'm going to do the same thing on the back.

[00:23:45]I'm just going to watch your breathing.

[00:23:49]You take a nice big deep breath for me.

[00:23:53]Okay. And the breathing is symmetrical.

[00:23:56]Now, I'm going to place my hands on your back and have you take a deep breath again.

[00:24:02]Okay, that's great. And my hands moved apart with the breath, which is great because that means it's symmetrical.

[00:24:09]Now, I'm going to do that same thing in the front here.

[00:24:15]Great. And again, it's symmetrical.

[00:24:18]Okay. Now, I'm just going to feel with my hands and make sure that I don't feel any abnormalities at all at all. So, I'm just feeling for any um which would be air under the skin or any um lump bumps, anything like that.

[00:24:43]And I don't feel any of that. I'm also going to feel on the back here.

[00:24:50]And same thing, I just want to make sure that I don't feel anything abnormal.

[00:25:01]Okay. Now, I'm gonna um test something called tactile fematus. So, when every time I place my hands on your back, if you could just say the word um 99 and I'm going to feel that the vibrations are equal on both sides.

[00:25:17]>> 99 99 Okay, now I'm just going to do the lateral aspect. Same thing. 99 99 Great. And it did feel equal. Felt exactly how it should. Now we're going to do the front. Same thing. 99 99.

[00:25:42]>> Great.

[00:25:44]Okay. Now I'm going to do something called percussion.

[00:25:48]Um, this is where I will be tapping my finger and just making sure I hear resonance over the lungs. We don't want to hear anything dull.

[00:25:57]So, I'm going to begin percussing.

[00:26:21]Okay, I'm just going to have you put your arms up in front of you so I can get to the sides here.

[00:26:28]We're going to do the same thing on the side here.

[00:26:41]Now, the other side.

[00:26:44]Sorry, I'm just going to move the bra here to the side a little bit. I apologize.

[00:26:58]Now I'm going to do that same thing on the back.

[00:27:01]Hold your hair over for me.

[00:27:31]Okay, great. And I did hear um resonance over those areas, which means your lungs are nice and clear with no consolidation. I'm also going to um check for CVA tenderness while I'm back here. So, you're going to feel me um press and I Just want you to let me know if this hurts at all.

[00:27:54]>> That hurt at all?

[00:27:54]>> No.

[00:27:55]>> Okay, great. Um, now I'm going to oscultate, which means I'm going to listen to your lungs and make sure they're nice and clear and equal.

[00:28:15]Take some nice deep breaths for me when you feel my stethoscope.

[00:28:55]Okay, great. The lung sounds in the back are equal and clear. Now I'm going to listen again in the front.

[00:29:30]Okay, now I'm going to listen laterally.

[00:29:32]If you could put your arms up again.

[00:30:05]Okay. And that also sounded um clear and equal laterally. Um I'm going to look at something called AP diameter. I'm just going to look at um the transverse diameter here and then compare it to that side view. And it is 2:1 which is normal. No barrel chest.

[00:30:30]Um, next I'm going to move on to assessing your heart. Um, so the first thing I'm going to do is have you lean forward a little bit.

[00:30:40]And I'm actually I'm just going to palpate for the point of maximum impulse and make sure I can feel it. Excuse my reach here.

[00:30:52]Okay. And I do feel it. And also just looking at your chest. Um I'm just going to make sure there's no obvious abnormalities. Um make sure I don't see that point of maximum impulse bounding out of your chest. And it's not.

[00:31:06]Um and now I'm going to listen in this position and then we'll have you lay down and I'll um assess a few more things. Okay? And I'm going to listen to um five places on your chest and I'm going to listen with the diaphragm and the bell. So, it's going to take me a little a little while.

[00:31:27]First, I'm listening to the oric area and now the pulmonic, the tricuspid and the bicuspit.

[00:31:52]Now I'm going to listen to that apex at the point of maximum impulse.

[00:32:06]I hear normal heart sounds normal um S1 and S2. I do not hear any murmurss, clicks, gallops, any extra sounds. Um I also don't hear any breweries brewies which would mean turbulent blood flow.

[00:32:17]So that is great.

[00:32:19]Um, now I'm going to have you lay back and then if you could lift your chin up.

[00:32:26]I'm going to look at your neck veins and your arteries.

[00:32:31]And I'm just looking to make sure that your pulse isn't, you know, extremely bounding, which would mean there's some turbulent blood flow. And I can see your neck veins. And um, there's no juggler vein distension, which is great.

[00:32:48]Okay. Again, I'm just inspecting the preordium to make sure it looks normal, that I don't see any bounding pulses.

[00:32:58]And I'm going to um listen to your heart again.

[00:33:13]Again, the aortic, the triricuspit, the bicuspit and the PMI.

[00:33:51]I'm going to do the same thing with the bow.

[00:34:33]Okay. And I'd like to um listen in one more position. So, what I'm going to have you do is lay on your left side and you can put this arm up here for me.

[00:34:44]That's perfect.

[00:36:11]Okay, great. And I didn't hear any abnormal heart sounds in any position.

[00:36:16]Um, and I do want to assess those sounds one more time in the sitting position, but a different way. So, we're going to go back and just do that really quick.

[00:36:26]So, I'm going to listen um with that small part of my stethoscope, the bell now in the same position.

[00:37:27]Okay. And I did get your apical pulse just to make sure um it's normal and it was 70 which is great. We want it between 60 and 100. So that's perfect.

[00:37:40]Okay, that concludes the assessment for today. Do you have any questions at all?

[00:37:44]No.

[00:37:44]>> Okay. Everything looks normal. There's nothing I'm concerned with. So, I'll see you back in about a year. Okay.

[00:37:49]>> Okay.