D222 Health Assessment Script: Video Submission Guide

D222 Health Assessment Script: Video Submission Guide

Student Name

Western Governors University

D222 Comprehensive Health Assessment

Prof. Name:

Date

Introduction

Hi, my name is ________. This document presents my comprehensive health assessment video submission. In this assessment, I will demonstrate a systematic physical examination on my volunteer patient.

Introduction to the Volunteer
This is my volunteer patient. Could you please state your full name and date of birth for verification purposes? Thank you. Do I have your permission to record and perform a full physical health assessment on you today? Excellent. Let us begin.

Part 1: Measurements and Vital Signs

Initial Assessment (Sitting Position)

During this stage, I will ask a few general health questions, collect vital signs, and record measurement data.

Health Interview Questions:

Vital Signs Assessment:

1. Radial Pulse: The radial pulse was assessed for rate, rhythm, and strength by palpation for 30 seconds, multiplied by two for accuracy. The pulse was strong, +2, and regular.

2. Respirations: Respiratory effort was counted for 30 seconds and multiplied by two. Respirations were even, unlabored, and non-labored with no accessory muscle use.

3. Blood Pressure: Measured with the patient seated, legs uncrossed, and feet flat on the ground. The recorded blood pressure was within normal limits (WNL).

Skin Assessment

I am now assessing the patient’s skin for overall health and appearance.

The skin was observed for color consistency, pigmentation, pallor, erythema, cyanosis, jaundice, or lesions. Temperature, texture, and moisture were evaluated through palpation. The skin felt warm, dry, and even with no abnormalities noted.

Hands and Nails:
The patient’s hands were examined for swelling, moisture, or dryness. No edema or tenting was present, and turgor was normal. The nails were assessed for ridges, clubbing, yellowing, and thickness—all within normal limits.

Head and Face Assessment

The patient’s head and face were inspected and palpated for lesions, lumps, tenderness, or trauma. Hair and scalp were free from scaling and scarring. The patient reported no pain or tenderness.

Cranial Nerve VII (Facial Nerve) Examination:
The patient performed several facial movements including raising eyebrows, closing eyes tightly, smiling, frowning, and puffing cheeks. Facial symmetry and muscle strength were intact with no involuntary movements observed. Cranial Nerve VII is intact.

Eyes

Eye structure was examined for symmetry and swelling. The eyelids were within normal limits, with no ptosis, discharge, or crusting. Eyelashes and eyebrows demonstrated even distribution and symmetry. The sclera was white, and conjunctivae were moist and pink.

Pupillary Response:
Pupils were equal, round, and reactive to light and accommodation (PERRLA). At rest, pupil size measured 3 mm bilaterally, dilating 2 mm with light stimulus. Corneas were clear with no redness or haziness.

Cranial Nerve II and Peripheral Vision Test:
Using the confrontation test, the patient identified numbers in all four visual quadrants with both eyes tested separately. Cranial Nerve II is intact.

Extraocular Muscles and Cranial Nerves III, IV, VI:
The patient followed finger movements across six cardinal fields of gaze without nystagmus or strabismus. Pupils constricted appropriately with near focus. Cranial nerves III, IV, and VI are intact.

Corneal Light Reflex:
A symmetric light reflection was observed in both eyes, confirming ocular alignment.

Ears

External ears were assessed for lesions, drainage, and symmetry. The patient denied pain, tenderness, ringing, or dizziness. Hearing appeared intact, and there was no use of hearing aids reported.

Nose

The nasal structure appeared symmetrical, without discharge or redness. Both nostrils were patent upon inspection. The patient denied a history of nosebleeds.

Mouth and Throat

Oral Health Questions:

• When was your last dental visit? The patient reported a recent dental check-up.

• How often do you brush and floss your teeth? Twice daily brushing and regular flossing reported.

Oral Examination:
Lips and buccal mucosa were moist, pink, and lesion-free. The gums and tongue were pink and moist with good dentition. The patient denied gum bleeding.

Cranial Nerves IX and X (Glossopharyngeal and Vagus):
The uvula rose midline upon saying “ah,” and the gag reflex was present, indicating intact function of cranial nerves IX and X.

Neck

The neck was inspected for lumps, lesions, and symmetry. The trachea was midline. Carotid pulses were palpable, strong, and without bruits. Cranial nerve XI (Accessory Nerve) was assessed by testing shoulder shrug and head resistance; range of motion and strength were normal bilaterally.

Part 3: Chest and Lungs

Posterior Thoracic Assessment:
The thoracic cage was symmetrical with equal chest expansion. No tenderness, lumps, or crepitus were noted. Tactile fremitus was normal, and the patient denied any chest pain. Lung sounds were clear bilaterally on auscultation.

Anterior Thoracic Assessment:
The anterior chest showed symmetrical movement and no use of accessory muscles. No abnormalities were observed during tactile fremitus or auscultation. Lung fields were clear throughout.

Heart

The apical pulse was located at the fifth intercostal space, midclavicular line, and auscultated for 60 seconds. Heart rate was regular. S1 and S2 sounds were distinct with no murmurs. All five cardiac auscultation sites (aortic, pulmonic, Erb’s point, tricuspid, and mitral) were assessed with normal findings.

Upper Extremities

Full range of motion was observed in both upper extremities. Strength was equal bilaterally, and no pain or abnormalities were reported. Radial and brachial pulses were +2 and symmetrical. Capillary refill time was under two seconds bilaterally.

Part 4: Jugular Vein and Abdomen

Jugular Vein: No jugular vein distention was observed.

Abdominal Inspection:
The abdomen was slightly rounded, symmetrical, and free from bulges. The umbilicus was midline and inverted.

Auscultation:
Bowel sounds were normoactive in all four quadrants.

Palpation and Percussion:
The abdomen was soft, non-tender, and without masses. Percussion revealed tympany throughout with no dullness.

Lower Extremities

Both lower extremities were symmetrical with no edema, redness, or ulcers. Skin temperature was warm and dry, and hair distribution was even. Capillary refill in toes was less than two seconds. Pulses (femoral, popliteal, posterior tibial, and dorsalis pedis) were 2+ bilaterally. Full range of motion was observed in hips, knees, and ankles, with no pain or crepitation.

Part 5: Neuromuscular System

Deep Tendon Reflexes:
Reflexes were assessed bilaterally at the biceps, triceps, brachioradialis, patellar, and Achilles tendons. All reflexes were present and strong, indicating intact neurological function.

Sensation Test:
Soft and sharp touch sensations were tested on the face, arms, hands, legs, and feet. The patient correctly identified all sensations, confirming intact peripheral sensation.

Coordination and Spine Assessment:
The spine was midline with no scoliosis or kyphosis. Range of motion was complete. The patient demonstrated proper coordination during heel-to-toe walking, tiptoe walking, and walking on heels.

Patient Education and Recommendations

Based on assessment findings, two key health education topics were discussed:

1. Sleep Hygiene:
   Since the patient reported only six hours of sleep per night, the importance of maintaining 7–8 hours of quality sleep was emphasized. Adequate sleep supports cardiovascular health, emotional balance, cognitive performance, and immune function (Centers for Disease Control and Prevention [CDC], 2023).

2. Physical Activity:
   The patient was encouraged to engage in regular physical exercise, aiming for at least 150 minutes of moderate-intensity aerobic activity weekly along with two days of strength training (World Health Organization [WHO], 2023). Activities such as brisk walking, cycling, and water aerobics were recommended to improve cardiovascular and musculoskeletal health.

The patient was advised to follow up with their primary care provider as needed and to seek medical attention if any new symptoms arise.

Conclusion:
Thank you for participating in this physical assessment. This concludes the examination.

References

Centers for Disease Control and Prevention. (2023). How much sleep do I need? https://www.cdc.gov/sleep/about_sleep/how_much_sleep.html

D222 Health Assessment Script: Video Submission Guide

World Health Organization. (2023). Physical activity fact sheet. https://www.who.int/news-room/fact-sheets/detail/physical-activity