Exam (elaborations)
NR509 Physical Assessment Exam template
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NR509 Physical Assessment Exam template
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“My name is Tara Lucero, and this is my physical examination assignment for NR509.” Volunteer statement…Introduction to pt: Hellos, my name is TL and I am a NP student. I am going to do your Physical Exam. Would you please sit up
for me. Thank you
Criteria Exam Technique
Head & Face: Sitting
Inspect facial skin
Inspect and Verbalize: head is normocephalic, midline, and symmetrical. Mild acne lesions to forehead
Palpate: Preauricular, postauricular, occipital, tonsillar, submandibular, submental, anterior cervical,
Palpate lymph nodes of head and posterior cervical, and supraclavicular.
neck Verbalize: No enlargements and equal bilaterally.
CN #5 (Trigeminal Nerve):
Motor: Palpate over the masseter muscle as pt clenches their jaw.
Sensory: Light touch sensation to forehead, cheeks, chin, and nose. Have pt close their eyes
Cranial Nerve (CN) #5 and verbally identify where they are being touched.
(Trigeminal Nerve) Verbalize: No distortion and good muscle strength. Sensory and motor component of CN#5
Motor intact.
Sensory CN #7 (Facial Nerve): for facial symmetry with smile, frown, raised eyebrows, puffed cheeks, and
Peripheral vision puckered lips.
Verbalize: bilateral symmetry noted, CN#7 intact.
CN #7 (Facial Nerve)
Ear: Sitting
Inspect outer ears for skin lesions
Inspect: Outer ears. Verbalize: skin intact, ears are symmetrical, no lesions, nodules or deformities
and symmetry
noted.
Inspect Auditory Canal and TM
Use Otoscope to inspect ears. Verbalize: External auditory canal is clear, no swelling, redness, drainage,
or cerumen noted. Tympanic membrane is pearly grey, no effusion in the middle ear.
Palpate pinnae and tragus Palpate pinnae and tragus. Verbalize: No nodules or tenderness note.
CN #8 (Acoustic Nerve) CN #8 (Acoustic Nerve): Perform Whisper Test, one ear at a time. Verbalize: CN #8 intact bilaterally.
Eye: Sitting
Inspect sclera and conjunctiva
Inspect : note findings for both sclera and conjunctiva. Verbalize: sclera is white & clear. Conjunctiva is
pink, moist, & without drainage or lesions.
CN #2 (Optic Nerve) CN #2 (Optic Nerve):
Gross visual acuity Gross Visual Acuity with SNELLEN chart. Verbalize: Corrected visual acuity 20/20.
Pupillary Response Pupillary response to light (PERRLA). Verbalize: Bilaterally pupils are Equal, Round
Peripheral vision (approx. 2-3 cm), and Reactive to Light with Accommodation.
CN #3, 4, and 6 (Oculomotor, CN #3. 4. &6 (Oculomotor, Trochlear, & Abducens Nerve): Test for conjugate gaze with extraocular
Trochlear, and Abducens Nerve) movements (EOM) in H pattern. Verbalize: Eyes parallel track, EOM intact & without nystagmus. CN
#3, 4, &6 intact.
Nose: Sitting
Inspect nose
Inspect: Nose. Verbalize: Nose is midline and straight
Inspect/Assess nasal turbinates and
With otoscope & Verbalize: septum is midline, turbinates are pink & moist. Patent nasal passages
septum
without swelling or bogginess bilaterally.
Palpate frontal and maxillary
Palpate: press thumbs to bony brows (frontal), then upward on cheekbones (maxillary).
sinuses
Verbalize: No tenderness noted.
Throat & Mouth: Sitting
Inspect throat and mouth
Inspect Mouth & Verbalize: lips, gums, palate, tongue, bilateral buccal mucosa & floor of the mouth &
pink, moist without drainage or nodules. No decay or cracks to teeth. Posterior pharynx is pink/moist and
CN #9 ( Glossopharyngeal nerve) w/o post-nasal drainage. Tonsils are grade 1.
CN # 9 (glossopharyngeal): Gag reflex will not be assessed on this exam.
CN #10 (Vagus nerve): Say “Ahh” Verbalize: soft palate and uvula rise symmetrically. CN #10 is
CN#10 (Vagus nerve)
intact.
CN #12 (hypoglossal nerve): Have pt stick their tongue out and move it left to right. Verbalize: CN #12
CN #12 (hypoglossal nerve) is intact
Palpate: TMJ, open/close your mouth. Verbalize: No subluxation, tenderness, or crepitus noted.
Palpate TMJ
Neck: Sitting
Inspect neck
Inspect: for abnormalities. Verbalize: Neck is symmetric, no obvious lumps, masses, or deformities. .
Palpate Trachea. Verbalize: Trachea is midline
Palpate trachea Palpate thyroid gland. Gently place fingers on pt’s neck, to that index fingers are just below the cricoid
Palpate thyroid gland cartilage. Ask pt to swallow to feel thyroid isthmus rise under the fingers. Then displace the trachea to the
right with the left hand; with the right-hand fingers palpate the right lobe. Then palpate the left side.
Auscultate with diaphragm of stethoscope: both carotid arteries, ONE at a time! Have pt hold breath
Auscultate carotid arteries
while listening. Verbalize: No bruits noted to bilateral carotid arteries.
Palpate: both carotid arteries, ONE at a time! Verbalize: pulse, normal, brisk & regular bilaterally.
Palpate Carotid artery pulsation Active neck ROM: flexion (chin to chest), extension (look to ceiling),R+L lateral flexion (head to
Assess active neck ROM shoulder), R+L rotation (look over shoulder). Verbalize: full ROM, and equal bilaterally.
CN #11 (Spinal Accessory Nerve) CN #11 (Spinal Accessory nerve): Place your hands on pt’s shoulders, apply pressure. Have pt shrug
their shoulders against your resistance. Verbalize: Strength 5/5 and intact bilaterally
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