Objective Data Collection, Assessment Example

Skin/Hair/Nails – Patient was examined and appeared to be resting comfortably with normal skin complexion and hygiene. On further inspection of the skin, no lesions or scars were noted. On palpation, skin demonstrated normal turgor, mobility, temperature, moisture and texture. Inspection of the hair revealed normal color, distribution and quantity, while palpation was unremarkable without being overly fine or coarse. Inspection of the nails demonstrated no change in pigment, length, symmetry and an absence of pitting, clubbing or splinter hemorrhages. Capillary refill at the second finger in both hand was within normal limits.

Head/Neck – On gross inspection, the head appeared to be position correctly with no angle or difficulty in maintaining position. The skull and scalp appeared to be of regular size and shape with no lesions. Similarly, the facial features were symmetrical and absence of any tics. On palpation, the skull was symmetrical without any tenderness (pressure and trans-illumination as especially focused on the frontal and maxillary sinuses). The temporal region was palpated and demonstrated normal hardness and a lack of tenderness and on auscultation was unremarkable. The angle of the jaw was examined and the temporo-mandibular joint appears to function without pain. The salivary glands and tonsils were inspected and palpated and found to be of normal color, size and tenderness. The neck was inspected and found to be symmetrical, devoid of masses and without lymph node enlargement, jugular vein disttensionn or carotid artery prominence. On palpation of the neck, the thyroid was of normal shape and consistency without nodules and on auscultation found to be devoid of bruits. Lastly, the range of motion of the neck was assessed and found to be within normal limits.

Eyes – External examination of the eye was performed. Inspection revealed no change in the color of the conjunctiva, sclera, iris or pupil. Palpation of the orbital rim did not present with any discomfort. Visual acuity was found to be grossly intact without any self-reported issues. Pupil response was assessed with a pen light and found to be normal. Ocular mobility and accommodation was assessed and normal range of motion was found for all ocular muscles.

Ears – Inspection of the outer ear including the pinna, tragus and lobe was unremarkable with no change in color or lesions. Inspection of the tympanic membrane showed it to be intact and non-inflamed. The ear canal was unremarkable without accumulation of excessive cemun. Lastly a Weber and Rinne Test were performed with appropriate localization of sound to suggest an absence of any neurologic or conductive hearing issue. For the Weber test, the tuning fork was placed in the center of the forehead directly on top of the head equally far from both ears. The test was interpreted as normal as the patient count not distinguish which ear was louder. The Rinne test was done by placing the tuning fork directly upon the mastoid process. Once the sound dissipated the fork was then moved infront of each ear to determine if the sound was greater through the air or bone. The bone conduction was found to be greater.

Mouth – On inspection the patient’s mouth was unremarkable with no unusual color or lesions. Tongue had no growths or thrush present. Uvula was midline. Dental hygiene was unremarkable.

Reference

Swaminatha V. Mahadevan; Gus. M. Garmel (5 July 2005). An introduction to clinical emergency medicine. Cambridge University Press.