- Hello, my name is William Drabenstadt and I am a nursing student from YSU, I will be

performing a physical examination on you today.

- Can you please state your name and age?
- Where are we located right now?
- What year is it?
- And who is the current president?
- Now why are you here today Mr. Cifra?
- And are you in any pain right now on a scale of zero to ten?
- Okay, you are alert and oriented and I noticed you had a smooth and steady gait on your
way over to the examination table.
- I will now perform a head-to-toe assessment on you starting with your head and working
my way down.
- *Inspect entire body* (Under arms, back, behind legs)
- *Focus on face*
- You appear to have symmetrical facial features and there is no edema present.
- *Focus on eyes*
- Your eyes appear to be equal and symmetrical with no periorbital edema.
- Can you shut your eyelids for me?
- Now can you blink them a couple times?
- You appear to have no lesions on your eyelids and no lid lag.
- Your conjunctiva is clear
- Now with your eyes can you look up for me? I am going to pull down your lower eyelids
to examine your sclera.
- Your sclera is white
- Your pupils are about a size four and are equal and symmetrical
- Okay now I am going to check your pupillary light reflex by taking my penlight and
shining into your eye from each side.
- Can you look at me?
- *Bring penlight in from side, observe and wait for pupils to dilate again and repeat with
the other side*
- Okay, your pupils constricted to about a size three with direct and consensual pupil
reflexes present.
- Now I am going to check for accommodation, can you look at my penlight please?
- Now look at the wall behind me.
- Your pupils are equal, round, reactive to light and accommodation.
- Okay, now I am going to inspect your ears
- *Focus on ears*
- Your ears are equal and symmetrical with no lesions present.
- I am going to palpate your ears now and just let me know if there is any pain or
tenderness present okay?
- *Palpate and name structures of ear* (Pinna, tragus, mastoid process)
- Now I am going to move on to your nose.
- *Focus on nose*
- Your nose is symmetric with no lesions present.
- I am now going to palpate your nose and just let me know if there is any pain or
tenderness present okay?
- *Palpate nose*
- Now I am going to check the inside of your nose, can you tilt your head up for me?
- *Use penlight to inspect inside of nose*
- The inside of your nose is pink and your septum is not deviated with no blood or
discharge.
- Now I am going to check the patency of your nose.
- Can you hold one nostril closed with your finger and breathe in and out through your
nose for me?
- And with the other side?
- Good, now I am going to move on to your mouth.
- Your lips appear to be pink and a little dry but that’s okay considering the recent weather
changes.
- Can you smile for me?
- Your teeth appear to be white and straight.
- Now I am going to inspect the inside of your mouth.
- I am going to pull down your bottom lip to check your gums.
- *With a glove on, pull down bottom lip*
- Your gums and oral mucosa are pink and moist.
- Now I am going to use this tongue blade to check the insides of your cheeks.
- *Use tongue blade to inspect inside of cheek while using your penlight, pull out tongue
blade and repeat with the other cheek*
- Your buccal mucosa is pink and moist.
- Now can you stick your tongue up to the roof of your mouth?
- Your sublingual mucosa is pink and moist and the blue veins are present.
- Can you stick out your tongue for me and say “ahhhh”?
- Your uvula rises and I noticed your tonsils are about a 1+
- *Replace gloves*
- Okay, now I am going to check the temperature of your skin.
- *Use back of hands* (Forehead, cheeks, shoulders, arms, hands, legs, feet)
- Your skin is warm and dry.
- Now I am going to check your turgor.
- *Pull skin above clavicle*
- Your turgor is good which means you are hydrated.
- Now I am going to check your brachial and radial pulses.
- *Check both brachial pulses at the same time*
- *Check both radial pulses at the same time*
- Your brachial and radial pulses were about a 2+ and equal bilaterally.
- Now I am going to examine your nails.
- *Focus on nails*
- Your nail beds are pink and adhere well to your skin.
- *Check capillary refill* (One nail on each hand)
- Your capillary refill is less than 2 seconds and there is no clubbing present.
- I am going to move onto your neck.
- *Focus on neck*
- There are no lesions present.
- Now I am going to check your lymph nodes, let me know if there is any pain or
tenderness while I do this.
- *Palpate and name each lymph node* (Preauricular, postauricular, occipital,
jugulodigastric, submandibular, submental, anterior cervical, posterior cervical, *Instruct
patient to rotate neck* deep cervical, *Instruct patient to shrug shoulders*
supraclavicular)
- I am now going to check your temporal and carotid artery pulses.
- *Palpate both temporal pulses at the same time*
- *Palpate carotid artery pulses separate*
- Okay, your temporal and carotid artery pulses were about a 2+ and equal bilaterally.
- I am now going to check for bruits.
- Can you take in a breath and hold it for me?
- *Auscultate with the bell of the stethoscope on each carotid artery*
- Okay you can breathe.
- There are no bruits present.