Knock knock. Hi. Hi. My name's Lisa.
I'm going to be your nurse today. Hello. Can you tell me your name and your date of birth?
Elizabeth Nosek, 3-11-94. Great. And what brings you in today? Just for a general checkup. General checkup.
Okay. Okay. And do you know what month it is?
It is August. Okay. And do you know where we are right now?
We're at the doctor's office. Perfect. So just by that I can tell that my patient is alert and orientated times four.
Do you have any allergies I should know about? No. No. And say on a scale of 0 to 10, 10 being the worst, are you in any pain? No.
No. Okay, great. So just right now, I would go ahead and do my vital signs on my patient, which would be the temperature, heart rate, respirations, blood pressure, and O2 saturation, which are all within normal limits.
So just by looking at my patient, she appears her stated age. Her skin color is even and appropriate for her ethnicity. Her facial features are symmetric and she doesn't have any she doesn't show any signs of distress No acute distress. Her body posture is upright It's symmetrical and no obvious signs of any deformities. Her height and weight is appropriate with her body stature Her hair looks clean She articulates clearly Well hygiene and she is dressed appropriate for the weather So I am going to go ahead and just do a full head to toe assessment before the doctor comes in.
So we're literally going to start with your head and work all the way down. Perfect. Sound good?
Okay. We'll put on some gloves. We're going to come over here to your head. Feel around. So hair looks good.
No lumps, lesions, or infestations. Shape is normal cephalic. And then I see that you do wear glasses.
Is that for near? I can't see far. You can't see far.
Okay, sounds good. So I'm going to have you go ahead and take those off really quick. So just by looking at my patient, I can tell that her pupils are equal and round. So I am going to flash a light in your eyes.
So just look at my nose here. And they both react to light. I'm going to have you follow this to your nose.
And they accommodate bilaterally. So next I'm just going to kind of pull down your eyelid. So her conjunctiva is pink and her sclera is white. Next foot the ears, do you have any hearing aids? No.
Nothing like that? Okay, great. And no environmental factors like at work, any loud noises or at home? No.
Okay, so I'm gonna take a look inside. No redness, drainage, anything like that. Patient does have some ear piercings on both sides here. Any pain with any of that?
No. No, okay. And then I did look, she does not have any skin breakdowns behind her ear due to the glasses or anything like that. So for your nose, I'm, oh yeah, you can put your glasses on. I am going to have you tilt your head up and we're going to take a look in some...
No drainage, no redness, no signs of deviated septums. Have you had any trauma ever to the nose? No. Any surgeries? No, okay.
So I'm gonna have you plug one nostril and breathe. Same with the other side. Great. And her nares are patent bilaterally, so she has a good airway. Next, we're gonna look inside your mouth.
So, have you open up and say, ah. Ah. Great.
So her mucous membranes are pink and moist. Her teeth are intact and her uvula rises and falls midline. Lips are pink, moist, and don't look dry at all.
So next with your neck, we're going to test your range of motion. So I'm going to have you look up and down and to the side and other side. So patient does have full range of motion with her cervical spine.
Next, we're going to assess her carotid arteries right here, her carotid pulses. Good. She has plus two bilaterally. Next we're going to auscultate to see if you have any Barui and no Barui is noted on auscultation.
So next we're going to work down to your chest area so this is going to be your lungs and your heart sounds. So just by looking at my patient she doesn't doesn't have any labored breathing. She's not using any of her accessory muscles.
So we're going to go ahead and listen to your front side and your back side, okay? Okay. So I am going to put my stethoscope six different places each time.
If I could just have you take a deep breath in and out. Okay, okay, great. We're gonna do the same thing back here. Okay, deep breath.
Great. So lung sounds bilaterally are clear on her anterior and posterior chest. No adventitious sounds were noted.
So next we're going to go ahead and listen to your heart sounds, okay? And you can breathe. Thank you.
Great. Next we're going to check for any heart murmurs with the bell. So same thing.
Thank you. Great. So S1 and S2 were regular. no extra heart sounds, no murmurs were noted on exam.
So next I'm going to just go ahead and assess your skin since I have you up like this. So skin is warm with pink undertones, no tenting is present, and then no lumps, lesions, scars, no tattoos, anything like that. Radial pulse is plus two bilaterally.
And capillary refill lasts them three seconds. Which is great. And then just looking at her nails, they are short, round, clean.
And then I'm going to have you go like this. No signs of clubbing or anything like that, so that looks good. Next we're going to go ahead and listen to your apical pulse for one full minute.
So I will have you go ahead and lay back. Bring this up for your feet. There we go.
Perfect. Are you comfortable like this? Yes.
Yeah, okay. So like I said, I'm just gonna listen for one full minute, okay? Okay. Give it time to take a little nap or something. Okay, begin.
Perfect. So patient's ethical heart rate was 86 and regular. So since I have you laying down, we'll just go ahead and inspect your abdomen next.
Okay. So just, I would lift the patient's shirt, but for this, we'll just keep it down. So looking at my patient, I can tell that her contour is flat to rounded. Her umbilicus is midline.
Her skin is consistent throughout the whole. Lumps, lesions, no pulsations, and no hernia. ...is present.
We are going to go ahead really quick and auscultate to see if you got a wheeze. Now I'm going to go ahead and auscultate all four quadrants just to make sure we do have some vowel sounds there. And patient does have active bowel sounds in all four quadrants. So next I'm going to go ahead and just push around in a couple different areas on your stomach so you let me know if you do have any pain with that, okay? Any pain with that?
No. Okay, so patient reports no pain or tenderness on palpation. Patient wasn't grimacing or guarding or anything like that.
While I have you laying down, I will check your pedal pulse here. Plus two bilaterally. And then posterior tibial pulse.
Plus two bilaterally. I'll go ahead and have you lift up your knees. No, you're fine.
Check if there's any edema at all. No edema present. Bilaterally on lower extremities. Okay, perfect.
So I'll have you go ahead and sit up here. So I'm gonna have you raise your arms like this. Perfect.
So I'm gonna have you push out, in, towards you, and towards me. Same with down here. So out, in, towards you, and out towards me. Great. So patient has five out of five muscle strength on upper and lower extremities.
Alright, so we're complete with our head-to-toe assessment. Do you have any other questions before the doctor comes in? No.
Okay, so I'm going to leave you here with your call light in case you need anything before I'm back or the doctor comes in. I make sure my patient's bed is low, locked, and she has her call light. Okay, thank you.
Thank you so much.