Chamberlain College of Nursing NR509 Advanced Physical Assessment

Student Name: ________________________________________

EPISODIC ASSESSMENT/ NON-SPECIFIC HEADACHE

INTRODUCTION

_____1. Introduces self as NP student (1)

_____2. Acknowledges purpose of exam (complete H&P or episodic visit) (1)

_____3. Asks open-ended questions then narrows down to closed ended questions (1)

_____4. Asks questions in an appropriate, professional, manner (1)

CC / HPI

_____1. Includes the following:

ð Onset (2)

ð Location (2)

ð Duration/Timing (2)

ð Characteristics/Quality/Severity (2)

ð Aggravating factors/Associated Symptoms (2)

ð Relieving factors (2)

ð Treatment/Medications/Remedies (2)

_____2. Summarizes HPI at end of information gathering (1)

PMH

_____1. Major childhood illnesses (1) _____5. Immunizations (1)

_____2. Major adult illnesses (1) _____6. Allergies to medications, foods and environment (2)

_____3. Surgeries (1) _____7. Medications (including RX, OTC, herbal) (2)

_____4. Hospitalizations (1)

FAMILY HISTORY

_____1. Asks about both parents (1)

_____2. Siblings (1)

SOCIAL HISTORY

_____1. Living Situation (1)

_____2. Children (1)

_____3. Employment (1)

HABITS

_____1. Tobacco (1)

_____2. ETOH/Illegal Drug Use (1)

ROS

_____1. Constitutional (1) _____4. Cardiovascular/Lungs (1)

_____2. HEENT (1) _____5. Neurologic (1)

_____3. Neck/Lymphatic (1)

Sub-total History Points: ______/40

EPISODIC PHYSICAL EXAMINATION

GENERAL [1]

_____1. Overall assessment of Mental Status (1)

HEENT [6]

_____1. Inspect the face: note swelling, facial symmetry (1)

_____2. Inspect the eyes (1)

_____3. Inspect the ears (1)

_____4. Inspect the nostrils (1)

_____5. Inspect the mouth (1)

_____6. Palpate for sinus tenderness (1)

NECK/LYMPHATIC [6]

_____1. Inspect the neck (2)

_____2. Palpate neck for lymph nodes (2)

_____3. Auscultate bilateral carotid pulse (2)

CARDIOVASCULAR/LUNGS [4]

____1. Auscultates lungs all anterior and posterior fields (2)

____2. Auscultates heart (2)

BASIC NEUROLOGICAL EXAM:

1. Assess Cranial Nerves I- XII [24 total points]:

_____Cranial Nerve I (Olfactory): Have patient occlude one nostril and close their eyes and ask

patient to identify smell (alcohol); repeat with other nostril. (2)

_____Cranial Nerve II (Optic): Check central vision with Snellen Chart (assess each eye

separately) and peripheral vision with Visual Fields Test. Check pupillary response to

light and accommodation (Convergence Test) [PERRLA]. (2)

_____Cranial Nerve III (Oculomotor), Cranial Nerve IV (Trochlear) & Cranial Nerve VI

(Abducens): Extra Ocular Movements (Six Cardinal Fields of Gaze Test: “Star” or “H”

formation) - Checks lateral eye movement (CN VI), downward and towards nose and

internal rotation eye movement (CN IV) and all other eye movements, ability to raise eye

lids and mediate pupillary constriction (CN III). (6)

_____Cranial Nerve V (Trigeminal): Test both Sensory - Patient closes eyes when checking

light touch to face of the forehead, cheek and jaw bilaterally and Motor portions – Ask

patient to clench teeth and move jaw side-to-side. [Not testing Corneal Reflex which is

CN V (sensory) and CN VII (motor)]. (2)

_____Cranial Nerve VII (Facial): Testing Motor only – Ask patient to smile, frown, raise

eyebrows/wrinkle forehead, close and open eyes and puff out cheeks. (2)

_____Cranial Nerve VIII (Acoustic): Whisper Test (Whisper and patient repeats words back or

rub fingers together and ask patient if heard them). Test one ear at a time. (2)

_____Cranial Nerve XII (Hypoglossal), Cranial Nerve X (Vagus) & Cranial Nerve IX

(Glossopharyngeal): Ask patient to stick out tongue and move it right and left (CN XII),

then to open mouth and say “Ahh,” (check if uvula is midline and palate rises

symmetrically) and also note patient’s ability to speak and swallow (CN X). [Not testing

Gag Reflex (CN IX and X)]. (6)

_____Cranial Nerve XI (Spinal Accessary): Ask patient to turn head to the left into your right

hand (assesses right sternocleidomastoid) and then turn head to right into your left

hand (assesses left sternocleidomastoid) and shrug their shoulders into your hands

(assesses trapezius muscle). (2)

____2. Motor Assessment [6]

Upper extremity strength (shoulder/bicep/tricep/flexors/extensors) (2)

Grip or Interosseous Strength test (2)

Lower extremity strength (hip/quadracepts/hamstrings/dorsiflexion/plantarflexion) (2)

____3. Extremity Sensory Assessment [2]

Sensation (light touch to upper and lower extremities) (2)

____4. Cerebellum and Gait Assessment [6]

Gait – normal walking + heel to toe walking (2)

Romberg Maneuver and Pronator drift test (2)

Heel down opposite shin of each leg (2)

____5. Reflexes [5]

Deep Tendon Reflexes (Bicep, Patellar and Achilles) (3)

Babinski Reflex (2)

Sub-total Physical Exam Points: ______/60

Grand Total Points: ______/100

Score of 84% or greater is required to pass

Faculty Comments:

Faculty Signature: ___________________________________________ Date: __________

10/15