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

Added: 2026-05-31

[00:00:01]Okay, I'm going to pan the room.

[00:00:09]And I'm going to have the patient sign consent to be on film for you to film.

[00:00:25]Thank you.

[00:00:26]Um so I'm going to start by washing my hands with warm water or hand sanitizer and antibacterial hand sanitizer. I'm going to close the door and pull the curtains to provide privacy and I'll start the assessment by introducing myself and explaining what we're going to do today.

[00:00:44]So hi, my name is Elena. I'm a student nurse. How are you?

[00:00:47]>> Good, how are you?

[00:00:47]>> I'm good. Can you I'm going to be doing your head to toe assessment today.

[00:00:53]Can you tell me your name and date of birth?

[00:00:55]>> Um Lauren Martin, 4/12/2002.

[00:00:56]>> Okay, and I'm going to test your recent memory. Can you tell me where you are right now?

[00:00:59]>> In my apartment.

[00:01:00]>> Great, and can you tell me what today's date is?

[00:01:03]>> Um November 12th, 2022.

[00:01:05]>> Okay, so the patient is alert, oriented to person, place, and time. Um I'm going to test her remote memory. Do you know who the first president is?

[00:01:14]>> George Washington.

[00:01:15]>> Great, and I'm going to test her recent memory. Can you tell me what you had for breakfast?

[00:01:18]>> A waffle and carrots for breakfast.

[00:01:20]>> So the patient's um recent and remote memory are intact. Looking at my patient, her pigmentation is appropriate for race. The hair is evenly distributed throughout the body. There's no edema, excessive moisture, or bleeding. There is no lesions, rashes, scars, tattoos, and she has both of her ears pierced.

[00:01:40]I'm going to have you flip your hands over.

[00:01:43]I'm going to assess for capillary refill.

[00:01:48]And your feet.

[00:01:58]Okay, so capillary refill is less than 2 seconds in all four extremities. The nails are in good hygiene and intact at 160° with no lesions. And I can show you that.

[00:02:11]Palpate. Sorry.

[00:02:12]>> [laughter] >> So, there is no tenting noted. There's no edema in all four extremities. And the temperature is even and warm throughout. Her head is normocephalic.

[00:02:34]It is symmetric in size and shape with no deformities. And I'll go ahead and scale.

[00:02:44]Okay, so the hair is evenly distributed with no nodules, lesions, or deformities noted. And I'll have you follow a couple of commands. Can you close your eyes?

[00:02:54]Okay, open. And then, can you puff your cheeks? Can you smile? Can you frown?

[00:02:59]And can you show your teeth? And can you raise your eyebrows? Okay.

[00:03:03]So, the face is symmetric and cranial nerve number seven is intact. I'm going to have you step towards the camera.

[00:03:12]I'm going to palpate for tenderness on the back of your head.

[00:03:16]None there?

[00:03:17]>> No.

[00:03:19]>> And then, around here?

[00:03:20]>> Mm-mm.

[00:03:20]>> Okay, so there is no mastoid tenderness and no bony deformities. And I'll have you clench your jaw. Okay. And I felt both sides of her jaw clench. Um and cranial nerve number five is intact. I'm going to go ahead and inspect the lymph nodes. Let me know if you have any tenderness.

[00:03:41]So, pre- Pre- What is it called?

[00:03:46]>> Preauricular.

[00:03:47]>> Thank you.

[00:03:47]>> [laughter] >> Preauricular, postauricular, occipital.

[00:03:53]And then, have superficial cervical, deep cervical, posterior cervical, supraclavicular, tonsillar, submandibular, and submental. So, no tenderness?

[00:04:08]>> No.

[00:04:08]>> Okay, you can have a seat back there.

[00:04:10]Um so, they're lymph nodes were nonpalpable and nontender.

[00:04:16]Um looking at her lips, they are symmetric with no dryness, lesions, or cracking.

[00:04:23]I'm going to have you just open your mouth and lift up your tongue.

[00:04:30]Okay.

[00:04:31]So, the buccal mucosa and sublingual mucosa are pink and moist with no lesions. Let me just actually peek in here.

[00:04:39]We're going to look at the gums.

[00:04:41]So, the gums are pink with no evidence of um swelling. There's no erythema, no evidence of gingivitis.

[00:04:49]There's no dentures and no missing teeth. I'm going to stick out your tongue.

[00:04:55]Okay, so cranial nerve number 12 is intact.

[00:04:59]Cranial nerve number 12 is intact. The tongue is pink, moist, and midline with no fasciculations.

[00:05:06]Um stick out your tongue one more time and say "Ah."

[00:05:08]>> Ah.

[00:05:09]>> Okay.

[00:05:10]So, the hard and soft palate are fused together with no lesions. The uvula rises and falls midline.

[00:05:18]Um the tonsils are present and one plus in size and an appropriate size for the oral cavity with no lesions or exudate.

[00:05:27]And I'm going to verbalize checking for the gag reflex by taking a tongue depressor and um sticking it to the back of her throat, and which the expected finding would be that she would um gag and cranial nerve number nine would be intact. I'm going to just I her nose. So, her nose is symmetric with no deformities.

[00:05:50]I can palpate her swelling.

[00:05:52]Okay.

[00:05:53]>> Mhm.

[00:05:53]>> Okay.

[00:05:54]Um so, there's no tenderness to the nose, and the nares are patent bilaterally.

[00:06:01]Um any pain or tenderness?

[00:06:08]Um so, the maxillary and frontal sinuses are non-tender.

[00:06:14]And using an otoscope, I would look in the internal structures of her nose, and that the coastal should be um pink with no lesions. There should be no signs of edema, erythema, no septum deviation or perforation.

[00:06:34]And so, you can close your eyes.

[00:06:39]And tell me what you smell.

[00:06:41]>> Okay.

[00:06:42]>> Okay, good. So, cranial nerve number one is intact.

[00:06:47]Um her ears are aligned with the corner of her eyes bilaterally. Looking at the outside of the ear, they are intact with no lesions, erythema, um excessive cerumen or earwax, and no drainage. I'm going to have you step a little closer to the camera.

[00:07:13]I'm going to palpate the external ears.

[00:07:15]I'm going to palpate the pinna, the tragus, and the mastoid. Any tenderness?

[00:07:22]>> No.

[00:07:23]>> Okay, you can have a seat.

[00:07:24]So, there is no tenderness or no tenderness to deformities or nodules to the pinna, tragus, and mastoid.

[00:07:34]Um I'm going to verbalize the Rinne test um by striking the tuning fork and holding it on the mastoid process. When she stops hearing that, I'm going to hold it directly in front of her ear.

[00:07:47]And the expected finding for the Rhine test is that air conduction is greater than bone conduction.

[00:07:53]I'm going to verbalize the Weber's test by striking the tuning fork and placing it at the center of her forehead. And the expected finding is that vibration will be heard equally bilaterally.

[00:08:05]And I'm going to check the cranial nerve eight by doing the whisper test. So, I'll just repeat that to me what I whisper to you.

[00:08:12]And just cover one ear.

[00:08:22]>> pancakes >> Yes.

[00:08:23]>> [laughter] >> water >> water So, cranial nerve number eight is intact and there's no decreased hearing.

[00:08:37]So, the eyes are symmetric and evenly spaced. There's no redness, lesions, erythema, or edema to the conjunctiva.

[00:08:49]Um, the sclera is white, the lens is translucent, and the cornea is smooth.

[00:08:54]Um, I'm going to verbalize assessing for cranial nerve number two by having my patient look at a Snellen chart in which the expected finding is that her vision is 20/20.

[00:09:06]Um, her pupils are equal in size, they are round, and they are 3 mm.

[00:09:16]Um, so, I'm going to check for her reaction to light.

[00:09:24]And then one more time for consensual.

[00:09:29]So, the pupils were reactive to light briskly laterally and constricted to 2 mm.

[00:09:38]Um cranial nerve number three was intact. Consensual uh response to light was appropriate and equal bilaterally.

[00:09:48]Um I am going to have you look at my finger and then at my face. So, at my finger, at my face, at my finger, at my face.

[00:10:00]Then I'm going to have you look at my finger and follow it as it goes closer to your face. And away.

[00:10:07]So, accommodation is appropriate, equal bilaterally, and cranial nerve number four is intact. Um the pupils constricted on convergence and dilated on divergence.

[00:10:19]I'm going to have you uh just follow my finger.

[00:10:31]And EOMs are intact.

[00:10:35]Um So, I'm going to inspect her lungs now. So, looking at the chest, there's no obvious deformities. The thorax is symmetric. She's not using any accessory muscles during respiration.

[00:10:53]She's not in a tripod position, and she is not showing any signs of cyanosis.

[00:11:00]I'm going to listen to her anterior lung sounds.

[00:11:06]Take a deep breath each time I move my stethoscope.

[00:11:10]So, listen for bronchial sounds.

[00:11:16]And bronchovesicular.

[00:11:49]>> Um So, the lungs were clear and equal bilaterally with no adventitious sounds.

[00:11:56]Can you have me stand up?

[00:12:00]And I'm going to inspect the posterior lungs. So, take a deep breath in and out.

[00:12:06]So, the hands rise and fall bilaterally, which means chest expansion is symmetric.

[00:12:11]Let me know if you have any tenderness.

[00:12:14]So, there's no tenderness or crepitus noted.

[00:12:19]And then I'll have you sit up to listen to her lung sounds.

[00:12:21]Same as the front.

[00:12:27]So, listening for bronchial sounds.

[00:12:30]It's clear.

[00:12:38]Bronchovesicular.

[00:13:10]Okay.

[00:13:11]So, the lung sounds were clear and equal bilaterally with vesicular sounds noted, and there was no adventitious sounds.

[00:13:19]I'm going to check for CVA tenderness.

[00:13:23]No.

[00:13:27]No.

[00:13:29]So, there is no CVA tenderness bilaterally. You can have a seat back up here.

[00:13:36]So, I'm going to assess her heart.

[00:13:38]Um so, her apical pulse is not visible and not palpable, but it can be found at the fifth intercostal left midclavicular space.

[00:13:51]I'm going to listen to her heart sounds with the diaphragm and then the bell of the stethoscope.

[00:13:59]So, aortic at the second intercostal right sternal border, pulmonic at the second intercostal left sternal border, Erb's point at the third intercostal left sternal border, tricuspid at the fourth intercostal left sternal border, and mitral at the fifth intercostal midclavicular.

[00:14:24]And then again with the bell of the stethoscope.

[00:14:27]So, aortic, pulmonic, Erb's point, tricuspid, and mitral.

[00:14:40]So, S1 and S2 sounds were present with no extra heart sounds and no murmurs. S3 and S4 sounds were absent with no extra heart sounds and no murmurs.

[00:14:51]Um so, looking at her upper and lower extremities, they are symmetric in size and shape with no edema or varicosities.

[00:15:01]Um I'm going to palpate her pulses.

[00:15:04][snorts] Okay, so the carotid pulse is present, two plus strong, equal bilaterally.

[00:15:15]The brachial pulses are present, two plus strong, equal bilaterally.

[00:15:21]The radial pulses are two plus strong, equal bilaterally.

[00:15:27]The posterior tibial pulses are two plus strong, equal bilaterally.

[00:15:34]And the dorsalis pedis are two plus strong, equal bilaterally.

[00:15:41]Um going to have you lay down.

[00:15:52]So, on inspection, the abdomen is flat and symmetric. There is no signs of um inflammation, discoloration, or any scars. And the umbilicus is um extraverted, and there's no signs of masses or any Um I'm going to go ahead and auscultate in all four quadrants.

[00:16:39]So, the patient has normal active bowel sounds in all four quadrants with 5 to 15 gurgles per minute. Do you have any tenderness? Okay, so I'm going to percuss.

[00:17:00]Okay, so tympany was heard throughout the abdomens over the organs. There's no hepatomegaly, splenomegaly, or organomegaly.

[00:17:08]Um and then I'm just going to palpate.

[00:17:12]Going to do a light palpation first.

[00:17:17]Any Now I'm going to do deep palpation.

[00:17:25]Any tenderness?

[00:17:26]Okay. So, there were no tenderness or masses noted during light and deep palpation. You can go ahead and sit back up.

[00:17:44]Okay.

[00:17:48]So, the lower and upper extremities are um symmetric in size and shape with no deformities or contractures bilaterally.

[00:17:59]I'm going to go ahead and palpate.

[00:18:30]Okay. So, there is no tenderness. No tenderness.

[00:18:34]So, there's no tenderness, no crepitus, or edema on palpation.

[00:18:39]Um I'm just going to have you follow some commands.

[00:18:43]So, you're going to flex your head to your chest, then extend towards the sky.

[00:18:48]Okay. Come back to center.

[00:18:50]Ear to shoulder for lateral bending.

[00:18:53]And side to side for rotation.

[00:18:57]Okay. So, the patient has full range of motion in her neck. And actually, let's just shrug your shoulders. And give me some resistance.

[00:19:06]Okay.

[00:19:06]So, the patient has I'm sorry, cranial nerve number 11 is intact. The shoulders shrug equal bilaterally and are symmetric.

[00:19:15]I'm going to have you move your hands away from your body.

[00:19:19]So, we're testing for abduction against resistance, adduction against resistance. So, the patient has five out of five strength in her shoulder girdles.

[00:19:28]I'm going to have you start this way in flexion elbows forward and then back down and then against resistance.

[00:19:35]And then down against resistance.

[00:19:38]Um so, the patient has full range of motion and five out of five strength in her elbows bilaterally. I'm going to have you take your wrist and flex it down and back to center. Okay, back down.

[00:19:49]And down against resistance and up against resistance.

[00:19:53]So, the patient has full range of motion and five out of five strength in her wrist bilaterally. I'm going to have you spread your fingers and close them and squeeze as much as you can.

[00:20:03]So, the patient has full range of motion and five out of five strength bilaterally in her hands.

[00:20:09]And then we're going to do your feet. So, um extend your knees outward and flex them back and then against resistance and back.

[00:20:19]Okay. So, the knees have full range of motion and five out of five strength bilaterally.

[00:20:24]I'm going to have you extend your feet to the ground and flex them up and turn them inward for Yeah, and externally. Okay.

[00:20:34]And then push up and push back down.

[00:20:38]Okay. So, the ankles are have full range of motion and five out of five strength bilaterally.

[00:20:45]And I'm going to have you lay down so we can test your strength there.

[00:20:52]That's my good side.

[00:20:53]>> I know you're fine.

[00:20:54]>> Um so, with a straight leg, come all the way up.

[00:20:58]Okay.

[00:20:59]And out to the side. Okay. And then I'll test your body for adduction.

[00:21:05]Good.

[00:21:06]So, the way up to the sky.

[00:21:08]All right.

[00:21:10]And away from your body, abduction, and across the body for adduction.

[00:21:15]Good. Bend your knee.

[00:21:17]We're going to do internal rotation, external rotation, and then come out against resistance.

[00:21:25]Same thing.

[00:21:29]Same thing on this side.

[00:21:30]External, sorry, internal rotation, external rotation. And against me, and out.

[00:21:39]So, the patient has full range of motion and five out of five strength in her hips bilaterally. So, you can sit back up.

[00:21:50]Um I'm going to have We're going to test for sensory function.

[00:21:57]So, you just close your eyes and tell me if you feel something soft or hard.

[00:22:03]>> Soft.

[00:22:05]Hard.

[00:22:06]Soft.

[00:22:08]Hard.

[00:22:10]Hard.

[00:22:11]Soft.

[00:22:14]Hard.

[00:22:15]Soft.

[00:22:16]>> Okay, so sensory functions are intact.

[00:22:20]I'm going to have you close your eyes again and flip your hand over. And which way did I flip your finger?

[00:22:26]>> Towards me.

[00:22:26]>> Perfect. And then I'm going to Um I'm sorry.

[00:22:33]Proprioception is intact.

[00:22:36]Um just tell me what number I draw on your hand.

[00:22:39]>> Nine.

[00:22:40]>> Okay.

[00:22:40]And What did you What did I give you?

[00:22:46]>> A five.

[00:22:46]>> Okay, so cortical functions um are intact.

[00:22:52]Um I'm going to have you stand up.

[00:22:56]Just move this back some more, too.

[00:23:01]All right.

[00:23:02]So, I'm going to have you walk that way regularly.

[00:23:06]And then you can walk back towards me heel to toe. Sorry.

[00:23:09]>> You're good.

[00:23:11]>> Okay, so the state is erect and steady and the arm swing opposite when walking.

[00:23:17]Going to have you stand feet together, hands by your side, close your eyes.

[00:23:23]And I'm going to verbalize 20-second test passed. There was no obvious swaying and no Romberg's test is negative.

[00:23:33]Um I'm going to have you follow my directions, so finger to nose.

[00:23:39]Okay. And then we're going to do each finger to your thumb.

[00:23:43]And then faster. Okay.

[00:23:46]Um and then we're going to do heel from your knee to your ankle.

[00:23:53]Perfect. So, these movements were controlled, smooth, and coordinated.

[00:23:58]Cerebellar function is intact.

[00:24:00]Um and then I'm going to do this while you're standing up. Going to assess her spine.

[00:24:07]Um so, standing she um the cervical and lumbar spine are concave and the thoracic spine is convex. Going to have you bend forward.

[00:24:21]So, the spine is straight.

[00:24:24]Any tenderness?

[00:24:25]>> No.

[00:24:25]>> Okay. The spine is straight with no tenderness.

[00:24:29]Um and there is no signs of kyphosis or lordosis or scoliosis.

[00:24:35]So, I'm going to have you sit back down here.

[00:24:40]All right.

[00:24:42]And I'm going to verbalize using a reflex hammer to test her reflexes. Go ahead and hold tight.

[00:24:52]Okay, so the reflexes were two plus and present and appropriate.

[00:24:58]And I'm going to just drag this down your foot.

[00:25:06]Okay.

[00:25:07]And the there was no uh reaction to her toes, so the Babinski test is negative.

[00:25:13]And this concludes the head-to-toe assessment.