Alyssa ONeill

Patient: C.J.

Date/Time of Assessment: 30 November 2016; 1600.

General Appearance: 30-year-old Caucasian female. Alert and oriented x 3. Appears

stated age. Appropriate eye contact. Engaged in conversation and cooperative. Dressed
appropriately for exam, folded clothes appear appropriate for weather. Appropriate
body hygiene. Healthy in appearance.

Hands: Skin pink, even in tone. No cyanosis. Brisk capillary refill to all nail beds. No
clubbing. Nails clean and short. No lumps, lesions or tenderness. Radial pulse 2+ equal
bilaterally.

Head: Normocephalic configuration. No lumps, lesions or tenderness. Hair normal

texture, evenly distributed, clean, no flaking or hair loss. Skin pink, even in tone.

Eyes: No ptosis noted. Eyes centered in socket and parallel. CN II intact, near vision
WNL. No use of corrective lenses. Peripheral vision intact, equal bilaterally. CN III, IV,
VI; EOM intact and equal. PERRLA. Red reflex bilaterally. Optic disc round, oval,
defined borders. Ocular vessels WNL. White sclera, pink conjunctiva; moist with no
redness or swelling noted. No exudate noted.

Ears: CN VIII intact; equally identified finger rub bilaterally. Rinne; AC > BC bilaterally.
Weber test positive bilaterally midline. No lumps, lesions or tenderness of auricles. No
drainage or excess cerumen. Tympanic membranes intact, pearly-gray bilaterally. Cone
of light visualized at 5 oclock R TM, 7 oclock L TM.

Nose and sinuses: No tenderness in maxillary or frontal sinuses. CN I intact; able to

correctly identify scents bilaterally. Nasal septum midline. No nasal flaring noted. Nares
symmetric. Turbinates pink, free of swelling or lesions. Nasal mucosa moist, mild
drainage; no bleeding, perforations or lesions noted.

Face, throat, and mouth: CN VII, IX, X, XI, XII intact. No swelling or tenderness in
TMJ. TMJ ROM WNL. CN V, facial sensation intact and distinguishable. Lips pink and
moist. No dental implants noted. Teeth white and in good condition. Mucosa and gums
pink and moist. Tongue red and midline. Uvula midline. No tonsils present. No lumps,
lesions or tenderness of face, throat or mouth.

Neck: Trachea visible, midline, symmetrical, mobile. No lumps, lesions or tenderness.

Thyroid nonpalpable. CN 11 intact; shoulder shrug equal in strength bilaterally with
resistance; 5/5, turns head against resistance equally bilaterally. ROM WNL. Lymph
nodes nonpalpable.

Thorax and lung: Normal shape and configuration. Sternum midline and symmetrical.
Skin pink, even in tone. No use of accessory muscles noted. Equal bilateral excursion.
Positive for tactile fremitus, equal bilaterally. Resonance percussed over the lungs. Full
 Alyssa ONeill

lung expansion. CTA. No adventitious sounds noted. Rate, rhythm, and depth WNL. A-P
ratio WNL.

Heart: Carotid arteries smooth, 2+ equal bilaterally. No bruit auscultated over carotids.
S1 and S2 RRR. No S3 or S4 noted. No murmurs noted. PMI palpable at 5th ICS
midclavicular line; not visible. No lifts or heaves.

Abdomen: Skin is even in tone, slightly rounded and symmetrical. Surgical scars on
umbilicus and on LLQ. Umbilicus midline. No masses, pulsations or hernias noted.
Bowel sounds normal x 4 quadrants. No bruit of aortic and renal arteries. Tympany over
upper gastric region. Dullness over liver and URQ. Spleen, liver, kidneys nonpalpable.
No lumps, lesions or tenderness noted with light or deep palpation. No organomegaly.

Back: 3 tattoos. Skin pink and even in tone. Scapulae even, symmetrical, nonprotruding.
Scapulae and shoulders equal height and horizontally even. C7 present and
distinguishable. Spine straight and midline. Spinal processes aligned with shoulders,
scapulae and hips. Posture erect. Cervical and lumbar concave. Thoracic convex. No
spinal tenderness. No costovertebral angle tenderness.

Lower Extremities: Skin pink. No cyanosis. Brisk capillary refill to all nail beds. No
edema noted on legs. PT 2+ equal bilaterally. DP 2+ equal bilaterally. No lumps, lesions
or tenderness. No knee crepitus noted bilaterally. ROM WNL. Warm in temperature,
equal bilaterally.

Upper Extremities: Skin pink. No lumps, lesions or tenderness. 2 scar anterior R wrist.
1 scar posterior L wrist. 2 tattoos R wrist, extending into forearm. ROM WNL. Warm in
temperature, equal bilaterally.

Cranial Nerves: CN I-XII intact.

Motor Exam: Muscle tone WNL in all extremities; 5/5 strength and tone. Shoulder
abduction and adduction ROM WNL; 5/5. Hand grip not assessed. Biceps equal in
strength bilaterally in extension and flexion; 5/5. Knees equal in strength bilaterally in
extension and flexion; 5/5. Foot dorsiflexion equal in strength bilaterally; 5/5. Plantar
flexion equal in strength bilaterally; 5/5. No atrophy noted. Full ROM of all extremities.

Sensory Exam: CN V intact and distinguishable. Sharp and dull sensations intact and
distinguishable on arms, hands, legs and feet. Vibratory sense intact and distinguishable
in feet bilaterally. Proprioception of hands intact bilaterally. Negative Romberg; 0.

Reflexes: Patellar reflex 2+ equal bilaterally. Achilles reflex 1+ equal bilaterally. Negative
Babinski reflex bilaterally; 0.

Coordination and Cerebellar Function: Gait smooth, coordinated. Able to walk heel to
toe, walk on tip toes, touch toes, and squat. Able to stand and balance on one leg and on
tip toes. RAM intact with fingers to thumb.
 Alyssa ONeill

Reflections: During the head-to-toe assessment, I forgot to assess the hand grips
bilaterally. This test was listed on my note card, however, my mind was clouded from
multiple practices prior to the assessment. I could have improved by working on my
flow with a greater frequency over time and not as greatly immediately prior to the
assessment. Additionally, it would have been beneficial to practice on a wider diversity
of patients. I am pleased with the flow I established for my head-to-toe; I believe it
minimized movement of myself and the patient and was done in a comprehensible
manner. I also believe I did well at communicating the process to the patient without
using terminology the patient may not understand. I believe I could have worked more
quickly through better familiarization with the appropriate medical equipment as
opposed to improvisations.