NR 509 Immersion Exam With Answers

Purple= graded aspect. Always say the cranial nerve number & name! Red = FNPS script. (black in parentheses)= patient script. Sanitize hands. Hello, ______ my name is ____ and I will be assessing you today. I need you sitting up for the exam. HEAD AND FACE Inspects facial skin – note abnormal lesions; Inspect head for size, symmetry, midline position I will begin by inspecting your face, and I don't see any discolorations, or any lesions and your head is midline and symmetrical. Palpates lymph nodes of the head and neck: Preauricular, Postauricular, Occipital, Tonsillar, Submandibular, submental, Anterior Cervical, Posterior Cervical, Supraclavicular (verbalize these) PPOTSS AC PC S I will palpate your lymph nodes. First, I will begin with the preauricular lymph nodes, right in front of the ear, and postauricular, right behind the ear. Then I will palpate your occipital lymph nodes in the back of the head. And then I will move forward and palpate your tonsillar lymph nodes. Come under the jawline, the submandibular lymph nodes, and the submental. Now I will go to the anterior cervical lymph nodes, and the posterior cervical lymph nodes. And I will end with the supraclavicular lymph nodes right about the clavicles. I do not feel any enlargement, and they are equal bilaterally CN 5 (Trigeminal) Motor – palpate over the masseter muscle as patient clenches jaw I will test the trigeminal nerve, which is . It has a motor component, and I will palpate over the masseter muscle as you clench your jaw. And I don't feel any distortions, and you have great strength cranial nerve number five CN 5 (Trigeminal) Sensory – light touch sensation to forehead, cheeks, chin, nose (patient closes eyes) Now I am testing the sensory portion of the Trigeminal nerve, which is cranial nerve 5. Please close your eyes and let me know where you feel me touch. Forehead, right cheek, left cheek, chin, nose. You have correctly identified where you are being touched. CN 7 (Facial) Inspect for facial symmetry with smile, frown, raise eyebrows, puff cheeks, pucker lips cranial nerve number seven. Next, I will test your facial nerve, which is And I will ask you to do some facial expressions. Please begin with a smile, and I see that it is symmetrical. Next, frown for me. OK. Now raise your eyebrows and go ahead and puff up your cheeks, and I notice they’re equal bilaterally. And now I want you to pucker your lips, very tight pucker. All of your expressions are bilaterally symmetrical. EAR Inspect outer ear for skin lesions and symmetry I’m will inspect your ears for any nodules or any skin lesions. I look at both ears and note that they are symmetrical without any nodules or lesions. Now I am going to look inside your ear canal with the otoscope. Inspect auditory canal and TM (using otoscope). Palpate pinnae and tragus for nodules & tenderness. 1 I'm will pull your auricle up and back. Your external auditory canal is clear, there's no swelling, redness, drainage or cerumen. The tympanic membrane is pearly gray, and there is no effusion in the middle ear. I will do the same for your other ear, pull the auricle up and back, looking into the external auditory canal. I see it is clear without cerumen, swelling, redness, or drainage. Your tympanic membrane is pearly grey, and there's no fluid in the external auditory canal. You have normal eardrums and ears. I'm going to palpate your pinna and tragus for any nodules or tenderness. No nodules or tenderness are noted. CN 8 (Acoustic) Whisper Test (whisper words out of sight, and patient repeats words back) Test one ear at a time! cranial nerve number eight I will be testing your acoustic nerve, which is , and that is your hearing. I will be performing a whisper test, so I'm going to ask you to cover one of your ears. Now, I will stand behind you, cover my mouth, and whisper three words. One, two, three. (One, two, three.) And let's do the other side. Four, five, six. (Four, five, six.) Your hearing is intact bilaterally. EYE Inspects sclera and conjunctiva I will examine your eyes and begin with looking at your conjunctiva. I notice that they're pink and clear, no drainage or lesions. And I also note that your sclera is white and clear. CN 2 (Optic ) Assess gross visual acuity and peripheral/central vision cranial nerve number two Now I'm going to test , the optic nerve, and this covers central vision. And I will use this Snellen eye pocket chart. I'll stand six feet away and ask you to cover one eye. Now read the lowest line possible. (LTFPH). Repeat with the other eye. (LTFPH). And with both eyes? (LTFPH). And you have normal vision, 20/20 in the left eye, right eye, and with both eyes. And now I will check cranial nerve number two, the optic nerve again, covers peripheral vision. I would like you to stand up, so we are at the same eye level. Please look straight ahead and keep your head still. First, do you see my hands now? (No.) Let me know when you do. (Yes). Now I'm going to come from above, do you see them now? (No.) Let me know when you do. (Yes). Now come from below, do you see them now? (No.) Let me know when you do. (Yes). OK, thank you, and you can have a seat. Your peripheral vision is normal. CN 2 (Optic) Check pupillary response to light [PERRL] Now I'm going to continue and check cranial nerve number two again, the optic nerve, for your pupil response to light. And I'm using the ophthalmoscope head and turning on my light. And I want you to just stare at my nose. Now I will come from the side with my light source, and I notice that the pupil constricts, and then I will check the other eye as well. And your pupils are about two to three millimeters, and they respond to light equally. CN 3, 4, 6 (Oculomotor, Trochlear, Abducens) Test for conjugate gaze with EOM (Extra Ocular Movement) Now I will be checking cranial nerves number three, which is the ocular motor, cranial nerve number four, which is the trochlear, and cranial nerve number six, which is the abducens. And in doing so, I will choose a star or an H pattern, and this is checking the extraocular muscles of the eye. So if you will follow my finger, with your eyes only. Thank you, and all EOMs are intact equally. NOSE Inspect nose midline & straight. Assess nasal turbinates & septum (using light source). Palpates frontal & maxillary sinuses Inspecting your nose, I see that it is midline without visible obstruction, fracture, or swelling. I will insert my speculum of the otoscope inside your nose. And I will tip your nose up with my thumb. And I'll look inside your left turbinates, and I note pink and moist turbinates without swelling or bogginess and the septum is midline. I will angle anteriorly, and I see that your septum is straight, there's no deviation. Let me inspect the other side. Looking at the septum anteriorly, or medially, and I see a straight septum, and the turbinates are nice and pink, and healthy, there's no swelling or bogginess. 2 I will palpate your sinuses beginning with the frontal sinuses. Let me know if you feel any tenderness there. (No.) And your maxillary sinuses, any tenderness? (No.) THROAT AND MOUTH Now, I'm going to inspect your throat and mouth, and I'll begin with inspecting your lips, which are pink, and moist. And now, please open your mouth, and I am inspecting your teeth. Inspect lips, teeth, gums, buccal mucosa, palate, tongue, the floor of the mouth (under the tongue), posterior pharynx, and tonsils (grade tonsils, if present) I do not see any signs of decay or any cracks. Next, I will be looking at the gums, I do not see any redness or swelling. The gums look pink without redness or swelling. The buccal mucosa on both sides, is moist and pink. The upper hard and soft palates look intact and a healthy pink and moist. I will be looking at your tongue. It is smooth, a healthy pink as well, and moist. Please lift your tongue up, and I'm looking at the floor of the mouth, and I do not see any nodules, or drainage. It's a healthy pink and moist. Now I will look at your posterior pharynx towards the back, and it is healthy pink. There is no post nasal drainage. If you had any tonsils, I would grade them. (1 normal, 2 mid-line, bilateral) CN 9 and 10 (Glossopharyngeal, Vagus) Say the Glossopharyngeal nerve is CN 9. Say “Ahh” -soft palate and uvula rise symmetrically with phonation (CN 10). Now, using my light I will check the vagus nerve, which is , by having you open your and say ahh. (Ahh). I note that the uvula does rise symmetrically with phonation. I am not testing CN 9 the with your gag reflex for this exam. cranial nerve number ten Glossopharyngeal CN 12 (Hypoglossal) Stick out tongue and move it left to right cranial nerve number 12, Next would be the which is the hypoglossal. And I will have you stick out your tongue and move it side to side. Palpate TMJ for any subluxation, tenderness, or crepitus. Then I will palpate your TMJ, which is the temporomandibular joint, on both sides for any subluxations, tenderness, or crepitus. Go ahead and open your mouth, and close. Thank you. I do not feel any crepitus, or clicking, or tenderness. 3 NECK Inspect for obvious deformities and symmetry. Palpates trachea – midline. Now I'm going to assess your neck. It looks symmetrical and without deformities. Now I'm going to palpate your trachea. It should be midline, and it is. Palpates thyroid gland (Posterior & anterior approach shown) Now, I will palpate the thyroid gland, by finding the cricoid process. With one hand in the suprasternal notch, right here, with the other hand. I will put my fingers on either side, between those two landmarks, and I will retract a bit on one side and ask you to swallow. I'm feeling the thyroid as it rises for size in any nodules. Now, I will retract on the opposite side, and ask you to swallow again. I feel no nodules in your thyroid gland palpation. Palpates carotid artery pulsation I will palpate your carotid arteries one at a time, on each side of the trachea. They are normal and bounding. Auscultate over the carotid for bruits using bell of stethoscope I'm going to auscultate your carotid arteries with my stethoscope bell, and I'm checking for any bruits bilaterally. I will ask you to hold your breath as I am auscultating the carotid arteries, to avoid interference with the auscultation of the carotid arteries. Please take a breath in and hold it. And breathe. And take a breath in. Hold it. And breathe. Assess active ROM (in Neck)– flexion, extension, lateral flexion, Rotation Now, I will check the range of motion of the neck. Please flex your neck by touching your chin down to your chest. Now straighten your neck, and extend it by looking up to the ceiling, and now look forward. And I want you to look over your right shoulder. And that would be rotation, and now your left shoulder rotation. Now, please do a lateral flexion to the side with your ear to your shoulder. And the other side, with your ear to your shoulder, lateral flexion. Thank you, and those are all intact equally. CN 11 (Spinal Accessory) Shrug shoulders against resistance cranial nerve number 11 I will test the , which is the spinal accessory nerve. I will put resistance on your shoulders and ask you to shrug your shoulders. They are equal and intact. 4 HEART Auscultate in all 5 areas with the diaphragm and bell with the patient sitting (if stethoscope does not have a bell, then verbalize you would also auscultate with the bell). Verbalize Areas: Aortic, Pulmonic, Erb’s point, Tricuspid, Mitral. (If you do not have a bell, just use the diaphragm, and comment later that you would use the bell as well in all five areas.) Now I'm going to evaluate your heart sounds. I begin with the auscultation in and the diaphragm, with the patient sitting. I begin with the aortic valve which, is the 2nd intercostal space on the right sternal border. Next, the pulmonic valve, is the 2nd intercostal space to your left sternal border. Moving down to Erb's point, which is the 3rd intercostal space, left sternal border. Further down is the tricuspid, which is the 4th intercostal space, left sternal border. Lastly, the mitral area, which is the midclavicular line, 5th intercostal space. Now I will repeat the 5 areas with the bell of my stethoscope. ANTERIOR CHEST Inspect for obvious deformities and symmetry all five areas, with the bell Now, I am going to inspect your anterior chest, for any obvious deformities in symmetry, and I do not see any. Auscultate 8 lung sounds in anterior lung fields Now, I will auscultate your lung sounds in the anterior lung fields, beginning at the intercostal spaces. Please take some normal breaths in and out through your mouth. And your breath sounds are nice and clear. POSTERIOR CHEST (BACK) Auscultate 8 posterior lung fields: Start above scapula alternating side-to-side in intercostal spaces. Go down into bases of lungs. Assess lateral lung fields (get right middle lobe). Now, I will proceed to the posterior chest. And listen to your lungs. Please turn around. I'm going to auscultate eight areas, beginning above the scapula. Take some normal breaths, in and out through your mouth And I'm gonna get the lateral. Middle right, middle low. UPPER EXTREMITIES *All ROM & DTR examination only needs to be performed unilaterally for purposes of the immersion evaluation. Strength testing should be performed bilaterally. Inspect the joints of the hands – redness, swelling, deformities. Palpate for capillary refill. Assess radial pulses. Assess hand grips (bilateral) – 5/5 strength. Assess passive unilateral ROM of the elbows (flexion, extension). Assess strength of biceps, triceps (bilateral) – flex/extend elbow against resistance – 5/5 strength. Now I will check your upper extremities. I will begin with inspecting the hand joints. If you'll extend your hands out. I don’t note any redness or swelling or any deformities of the finger joints. Next, I will palpate for capillary refill on one finger of each hand by pressing on a finger nail until it turns white and releasing. It turns pink in under 3 seconds. I repeat it on the other side; it turns white, release, and it turns pink in less than 3 seconds. That is a normal capillary refill. Now I will check your radial pulses bilaterally, and if you will just face your palms inward and I will palpate the radial pulses. And they are 2 equal bilaterally. Next, I will assess your hand grips. Please grip my hands tightly. Very good; your hand strength is five out of five. Assess passive unilateral ROM of the shoulders (flexion, extension, internal rotation, external rotation, abduction, adduction). I'm going to assess your range of motion. Normally ROM is examined bilaterally. However, for Immersion evaluation, I will only perform a range of motion unilaterally. I'm going to assess your relaxed or passive range of motion of the elbow. Flexion and extension. I would do so on the other side. And now, I would like to check the strength of your biceps and triceps. So if you will, flex your elbows and push against my hands. And now, pull back towards you. Your biceps and triceps strength was five out of five. Now I will assess the passive range of motion of the shoulder. Flexion, extension, internal rotation, external rotation. Then you have abduction and adduction. Assess cerebellar coordination with rapid alternating movement: Now I'm going to assess cerebellar coordination with rapid alternating movements. If you will take your thumb and touch your index finger, middle finger, and fourth finger, fifth finger. And just repeat that. You do that very well and are well coordinated. Next, I will do the rapid movements of your hands. Serial finger opposition, hand flip-flop So, palms down on your thighs, and then up, and then down, and alternate, and increase the speed. Very good, nice and normal and coordinated. Assess unilateral DTRs: Biceps, patellar, Achilles Now I will assess your deep tendon reflexes, only on one side for demonstration purposes. And I will start with the bicep tendon. I will support your arm on my arm, and then I'm placing my thumb on the medial aspect of the antecubital fossa, and I will strike my thumbnail with the pointy end of the hammer. I can see that you contracted your bicep tendon very well. Now I'm checking your patellar reflex with the flat end of the hammer. And you have a good response. And I'll do your Achilles. I'll ask you to relax your foot, then I'll dorsiflex the foot a little bit, and tap with the flat end. And I notice you had a little bit of pronation there. Good! Have patient lie down ABDOMEN Inspect abdominal contours and symmetry. Auscultate for bowel sounds in all 4 quadrants Now I'll have the patient lie down for the abdominal exam. I will expose your abdomen. And I am observing the abdomen for its contours and symmetry, and there are no distortions. Now, I will auscultate your bowel sounds in all four quadrants. Bowel sounds are present in all four quadrants. Auscultate for bruits (verbalize) – aorta, renal arteries, iliac arteries using the bell of the stethoscope. Now, I will auscultate for any bruits using the bell of the stethoscope. I will begin with the aortic area, right below the xiphoid process. Midline. Next, I will do the left renal, which is above and lateral to the left, the umbilicus. The right renal is to the right and above the umbilicus. The iliac, to the left and below the umbilicus. And the right iliac, which is to the right and below the umbilicus. And I do not hear any bruits. Percuss in all 4 quadrants for tympany, dullness, flatness as well as palpate for tenderness and masses Now I'm going to percuss in all four quadrants. I'm percussing for any tympany, dullness, or flatness. And all areas are normal. Next I will palpate all four quadrants for tenderness and any masses. I do not feel any masses. Palpate liver and spleen (verbalize) Now I'm going to palpate the liver and the spleen. Beginning with the liver I will note if I feel the edge of the liver. I will place my left-hand underneath and I'm looking at the midclavicular line on the right. And I'm placing my palm upward right at the edge of the costovertebral angle, and I'm asking you to take a deep breath in. And as you do so, I'm pressing deeper and upward, and I might feel the lower edge of the liver. Now for your spleen I'd like you to adjust yourself and come over towards me laterally. And I will put my left hand back here. And right below the costovertebral angle I'm will put my right hand. And as you breathe in, once again pushing upward and downward. I do not feel the edge of the spleen which is normal. Perform Blumberg’s sign (verbalize) Now I will assess the Blumberg sign. I will take my hand vertically 90 degrees and I will press down into the abdomen. And when I release, if the patient feels any pain on the rebound, that would be a positive Blumberg sign of rebound tenderness indicative of peritonitis. Any pain? (No). LOWER EXTREMITIES Inspect the skin integrity of lower extremities and assess for edema. I will assess the lower extremities. First, I will inspect the skin for any lesions or any edema. I do not see any. Assess passive unilateral ROM of hips (flexion, abduction, adduction, internal rotation, external rotation) *extension not tested for this exam. Assess passive unilateral ROM of the knees (flexion, extension). Assess strength at the knees (bilateral) – flex/extend against resistance – 5/5 strength. Assess passive unilateral ROM of the ankles (dorsiflexion, plantar flexion, rotation). Assess strength at ankles (bilateral) – dorsi/plantar flex against resistance – 5/5 strength. Next, I'm will check range of motion of your hip and I'm going to go ahead and flex your knee. And, in turn, flex your hip. Then, I will go into abduction, taking the leg away. And adduction, crossing the midline. Next will be internal rotation. And then external rotation. And go ahead and rest the leg. For purposes of this exam we will not be testing extension. Now I'm going to assess range and motion of the knee, flexion and extension. Now I'm going to assess the strength of your knees. Go ahead and flex your knees. I'm going to place my hands on top and ask you to push up towards them. Now push back. Very good, and your strength is five out of five and equal. Go ahead and extend your legs. Now I will do the range of motion of your ankle. Supporting the ankle, dorsiflexion, plantar flexion, and rotation. Strength is five out of five and equal. Now I will assess the strength of your ankles. And you will pull up or dorsiflex with resistance. Plantar flexion or push down with resistance. And that was five out of five and equal as well. Assess dorsalis pedis pulse Now I will assess your dorsalis pedis pulses. And they are 2 and equal. Have patient stand up Inspect and palpate the spine – expected curvatures, alignment, tenderness. Assess active ROM of the spine (flexion, extension, lateral flexion, and rotation). For the spine examination, I'm going to inspect and palpate along both sides of the spine for any expected curvatures, alignment, and tenderness. Next, I will do range of motion of the spine. And so, I'm will ask you to go ahead and bend over and touch your toes. Now straighten back up and extend backwards. Now straighten back up and do a lateral flexion to one side and then the other. And now rotation, to the right and to the left. And you have very good, active range of motion. Assess Romberg Next, I will assess for the Romberg and I'll have you just stand with your arms down by your side. Close your eyes for about 20 seconds, and I'm looking for any swaying. And there is none. You can open your eyes. So that would be a negative Romberg. Assess gait (just several steps) Now I will assess your gait and ask you to take a few steps forward. Turn around and a few steps more.