22 Physical Exam
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o Next, I am going to move on to the mouth and throat. I am inspecting the
lips, teeth, gums, and tongue which are all pink, and normal in appearance.
Buccal mucosa also appears normal. Can I have you open wide and say
AHHH. Soft and hard palate are visualized. Anterior and posterior pillars
are intact.
o Next, I am going to inspect and grade tonsils. Can you say "AHHHHH".
Tonsils are not visualized (0) or grade them appropriately.
o Next, I am going to access CN IX Glossopharyngeal and cranial nerve X,
the Vagus...Can you say AHHHH? Cranial nerves intact. Next, I'll assess
cranial nerve XII Hypoglossal. Can you stick out your tongue and move it
side to side? That cranial nerve is also intact.
o Moving on to the neck. The neck is symmetrical with no enlargements
visualized.
o Next, I am going to palpate and name the lymph nodes. We will start with
, the pre-auricular, posterior auricular, occipital, tonsillar, submandibular,
submental, (Can you turn your head to the side) anterior cervical
superficial, anterior cervical deep and posterior cervical chain. No lymph
nodes were palpated which is a normal finding.
o Now I am going to inspect and palpate the trachea for deviation. There is
no deviation noted.
o Next, I am going to examine the thyroid. (Feel thyroid and ask patient to
swallow).Do you have any tenderness? No nodules or tenderness present.
o Now I am going to assess cranial nerve XI Accessory Function. Can you
shrug your shoulders? Cranial nerve XI is intact
o Now I am going to observe for JVD. Can you lay back 30 degrees? Can
you turn your head to the right? No JVD Noted. Can you turn your head to
the left? No JVD noted.
6 Past Medical Hx
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o Do you have any infectious illnesses? NO.
o Do you have any allergies to medications, food, environmental, or other
substances?
o Have you ever had any surgeries? If you did, I would want to know what
type, if there were any complications, or any difficulty with anesthesia?
o Have you had any injuries or previous hospitalizations?
o Are you up to date on your immunizations?
25 Physcial Exam
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, o Now I am going to assess for chest expansion. Expansion is symmetrical.
(Make W with hands on front of chest.
o Palpate for tactile fremitus (ninety-nine)
o Percuss the anterior and lateral chest. The chest is resonate throughout.
o Auscultate the anterior chest. (Minimum of 8 areas) Lungs fields clear to
auscultation bilaterally.
o Now I am inspecting for heaves and lifts. None are noted.
o Now I am going to palpate for heaves and thrills. None noted.
o Now I am going to palpate the apical impulse
o Now I am going to assess the carotid arteries through auscultation and
palpation. Pulses are even.
20 Physical Exam
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o Next, I am going to move on to the mouth and throat. I am inspecting the
lips, teeth, gums, and tongue which are all pink, and normal in appearance.
Buccal mucosa also appears normal. Can I have you open wide and say
AHHH. Soft and hard palate are visualized. Anterior and posterior pillars
are intact.
o Next, I am going to inspect and grade tonsils. Can you say "AHHHHH".
Tonsils are not visualized (0) or grade them appropriately.
o Next, I am going to access CN IX Glossopharyngeal and cranial nerve X,
the Vagus...Can you say AHHHH? Cranial nerves intact. Next, I'll assess
cranial nerve XII Hypoglossal. Can you stick out your tongue and move it
side to side? That cranial nerve is also intact.
o Moving on to the neck. The neck is symmetrical with no enlargements
visualized.
o Next, I am going to palpate and name the lymph nodes. We will start with
, the pre-auricular, posterior auricular, occipital, tonsillar, submandibular,
submental, (Can you turn your head to the side) anterior cervical
superficial, anterior cervical deep and posterior cervical chain. No lymph
nodes were palpated which is a normal finding.
o Now I am going to inspect and palpate the trachea for deviation. There is
no deviation noted.
o Next, I am going to examine the thyroid. (Feel thyroid and ask patient to
swallow).Do you have any tenderness? No nodules or tenderness present.
o Now I am going to assess cranial nerve XI Accessory Function. Can you
shrug your shoulders? Cranial nerve XI is intact
o Now I am going to observe for JVD. Can you lay back 30 degrees? Can
you turn your head to the right? No JVD Noted. Can you turn your head to
the left? No JVD noted.
6 Past Medical Hx
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o Do you have any infectious illnesses? NO.
o Do you have any allergies to medications, food, environmental, or other
substances?
o Have you ever had any surgeries? If you did, I would want to know what
type, if there were any complications, or any difficulty with anesthesia?
o Have you had any injuries or previous hospitalizations?
o Are you up to date on your immunizations?
25 Physcial Exam
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, o Now I am going to assess for chest expansion. Expansion is symmetrical.
(Make W with hands on front of chest.
o Palpate for tactile fremitus (ninety-nine)
o Percuss the anterior and lateral chest. The chest is resonate throughout.
o Auscultate the anterior chest. (Minimum of 8 areas) Lungs fields clear to
auscultation bilaterally.
o Now I am inspecting for heaves and lifts. None are noted.
o Now I am going to palpate for heaves and thrills. None noted.
o Now I am going to palpate the apical impulse
o Now I am going to assess the carotid arteries through auscultation and
palpation. Pulses are even.
20 Physical Exam
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