Neuro
CN II (how to test)
Snellen and color eye chart
Below jawline/chin
Tonsillar
Verbal assessments of muskuloskeletal
Pain level, history of injury
CN I (how to test)
Smell test with eyes closed
Aware of person, place, time, and self
Oriented x4
CN X
Gag reflex, equal rise of uvula
In front of/behind ears
Pre-post auricular
How to perform Romberg sign
Have patient stand at bedside, close eyes, monitor for swaying
PERRLA (Which cranial nerve assessing?)
Erect, midline, no slouching
Posture
CN VII
Puff out cheeks, smile
Above collar bone
Supraclavicular
Name and describe the 3 spinal deformities
Lordosis- concave curvature of spine
Scoliosis- S curvature of spine
Kyphosis- convex curvature of spine
Describe normal oral cavity
Pink, moist mucus membranes. Teeth and gums are intact.
Disheveled
Hygiene
Which CN are you testing with cardinal fields of gaze?
CN III, IV, VI
Submental
Identify and describe how to assess CN XI (11)
Shrug shoulders/turn head
Identify and discuss how to assess CN V?
Trigeminal nerve, superficial touch of face
MoCA
Montreal Cognitive Assessment
Grade of a normal reflex
2+
Describe a normal assessment of lymph nodes
No palpable or tender lymph nodes noted
Expected findings of musculoskeletal assessment (WNL)
Gait
ROM
Strength
Pain
Alignment
Coordinated smooth gait, complete ROM against gravity with full resistance in all joints (5/5), without pain, shoulders aligned, vertebral column straight with no signs of lordosis, kyphosis, or scoliosis noted.
Expected findings of HEENT assessment
Head
Eyes
Ears
Nose
Throat
Head symmetric and proportionate, face and jaw symmetric, no visual impairments noted, conjunctiva white, moist, no redness or drainage noted, Ears aligned, no drainage noted, no tenderness to palpation. Nasal passages patent, mucuous membranes moist, septum midline, Lips symmetric, moist, tongue symmetric. Uvula midline. All 12 cranial nerves intact,
Have you ever wished you would go to sleep and never wake up?
Have you ever made a plan to harm yourself?
Suicide risk assessment
CSSR