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

Added: 2026-05-31

[00:00:02]Hello, come in.

[00:00:03]>> Hello, my name is Molly and I'm going to be your student nurse today. Um, can you confirm your name and date of birth for me?

[00:00:09]>> Riley, 7/28/03.

[00:00:10]>> Okay.

[00:00:11]Um So, how are you today?

[00:00:14]>> Good.

[00:00:15]>> Um, are you in any pain today?

[00:00:17]>> No.

[00:00:18]>> Um, I'm going to be doing a neurological test on you today. Um, I'm going to be shining a light I'll walk with you.

[00:00:25]Um, are you okay with that?

[00:00:26]>> Yeah.

[00:00:27]>> Um, any history of like stroke or um traumatic brain injury?

[00:00:33]>> No.

[00:00:34]>> Okay.

[00:00:36]Um Okay.

[00:00:38]Um, so patient is alert, a medium pain, rosy colored, um, dressed well, um, well hygiene. Okay.

[00:00:49]Um, so I'm going to wash my hands now.

[00:00:53]Um, the first thing I'm going to have you do is take a walk with me. I'm going to walk with you. Just check out your stride.

[00:01:02]Perfect. And then turn around. Perfect.

[00:01:06]Um, you can sit back down. So, stride is good. Arms are swinging opposite directions. Posture is upright.

[00:01:13]Um Patient scores a 15 on the Glasgow Coma Scale.

[00:01:19]Um, can you tell me where you are today?

[00:01:23]>> I'm at my house.

[00:01:24]>> Okay. Um, can you tell me your name?

[00:01:26]>> Riley.

[00:01:27]>> Uh, the day of the week?

[00:01:29]>> Friday.

[00:01:29]>> Okay, perfect. So, patient is conscious and aware. Um So, now I'm going to have you do a couple of tests for me. So, if you could stand up and then um stand with your arms together and your eyes closed for 20 seconds.

[00:01:48]Okay, it's been 20 seconds. Um, now I'm going to have you Oh, negative on the Romberg test. She made tandem posture.

[00:01:55]Um, I'm going to have you hop in place on one foot.

[00:02:00]>> Oh, oh, I'm sorry.

[00:02:01]>> [laughter] >> Um, and then the other if you can. Okay.

[00:02:09]Um, perfect.

[00:02:11]Sit back down.

[00:02:13]Um, so you're good.

[00:02:17]Um, I'm going to test uh sharp and dull stimulus. So, this one's going to be sharp and this one's going to be dull.

[00:02:25]Okay.

[00:02:26]Close your eyes.

[00:02:28]Sharp.

[00:02:31]Dull.

[00:02:33]Dull.

[00:02:35]Dull.

[00:02:36]>> [laughter] >> Sharp.

[00:02:40]Sharp.

[00:02:43]Dull.

[00:02:45]Dull.

[00:02:46]Okay.

[00:02:47]Now we'll do your left arm.

[00:02:50]Sharp.

[00:02:52]Sharp.

[00:02:55]Dull.

[00:02:55]Dull.

[00:02:57]Sharp.

[00:02:57]Okay, it's perfect. So, was able to differentiate between sharp and dull.

[00:03:06]Um, so now I'm going to be testing your cranial nerves. So, um, cranial nerve one. Uh, have you had any changes in smell?

[00:03:13]>> No.

[00:03:14]>> Okay, cranial nerve one is intact cuz she has not had any smell.

[00:03:19]Um, next um, is number two, which is optic. Um, I would have you do a vision test where you stand 20 ft away from a Snellen chart, read the lowest line possible.

[00:03:35]Um, if you were in 20/20, that's perfect. If your vision is 20/30, I would refer you to an optom- optom- ophthalmologist.

[00:03:45]Um, and then also, um, if you could read something on here without moving the paper.

[00:03:53]Um the cranial nerves Perfect.

[00:03:57]Um so, cranial nerves intact. Um next I'll be doing three, four, and six.

[00:04:04]So, um I'm going to shine this light in your eye.

[00:04:10]Okay.

[00:04:12]Okay.

[00:04:16]I like this one. Okay.

[00:04:18]Um so, eyes are construct, direct, and converge.

[00:04:27]Um They're pupils are round and reactive, so um eyes are Now I'm going to be doing EOM, so if you can just follow my penlight with your eyes without moving your head.

[00:04:43]Okay.

[00:04:46]Okay.

[00:04:50]Okay, awesome. And then now can you just follow it in?

[00:04:54]Perfect. So, cranial nerves three, four, and six are intact. Um eyes are perla and she was able to do the EOM.

[00:05:03]Um next we'll be doing um trigeminal, so I'm going to have you clench your jaw.

[00:05:12]Okay, perfect. So, I felt that. And then um I'm going to be um going to do the stimuli and tell me when you feel it.

[00:05:24]Yep.

[00:05:31]Okay, perfect.

[00:05:33]Um So, next we'll do facial, so I'll have you do a couple movements. Can you close your eyes tightly?

[00:05:41]Okay, and then um smile with your teeth, without, frown, and then puff your Perfect. So, cranial nerve um seven is intact.

[00:05:58]Um then we'll do an acoustic one. So, if you could turn to the side for me, I'm going to say a word. If you could cover your right ear.

[00:06:09]Okay. Um Cover your left.

[00:06:13]Okay.

[00:06:14]And your left Your right. Okay, perfect. So, cranial nerve eight is intact.

[00:06:21]Um next we'll do um Oh, um I'm going to feel your traps. If you could just um push up. Okay, perfect. And then also, if you could push against my head.

[00:06:41]Okay, and then again.

[00:06:44]Okay.

[00:06:44]>> [laughter] >> Um okay, perfect. So, cranial nerve 11 was intact.

[00:06:51]Um next, if you could stick your tongue out for me.

[00:06:55]Okay, and then move it to the [laughter] left.

[00:06:58]And right. Okay, cranial nerve 12 is intact. Okay, um oh, yes. Um let me check. Okay, I'm going to be depressing your tongue.

[00:07:08]Um Okay, um can you say ah?

[00:07:12]Okay, so uvula raised, midline, um tonsils, all that.

[00:07:19]Um next, let me uh I'm going to check your feet and your ankles. Okay, so I'll just Okay.

[00:07:29]Um so, we'll just Okay.

[00:07:39]Okay, next.

[00:07:43]Okay.

[00:07:44]Um so um What's that? [laughter] And then now I will be Oh, yes. Um I'm going to do soft [laughter] socks.

[00:07:57]Do you need any assistance?

[00:07:59]Okay.

[00:08:00]Um I'm just going to take this.

[00:08:05]Um let's try that out. Let's see.