Page 431 - 2021 IDMT Digital

Exam Behavior Skill Comment
Introduction and General Assessment
1. Indicate wash hands and dons Verbalize step
PPE as indicated prior to exams
2. Introduces self as IDMT student “Good morning, I am Sgt/Airman ___, I
am an IDMT student performing a
physical exam for you today”
Head, Face, and Scalp
3. Inspect head/hair/scalp “normocephalic with even hair
distribution; no masses or swelling”
4. Palpate head/hair/scalp “hair texture is normal without
infestations; scalp has no scaling or
lesions”
“mastoid is nontender and without
discoloration”
5. Inspect, palpate and perform “TMJ not tender and without swelling;
ROM of TMJ no pain, popping or locking with ROM”
(Open, close, side to side, forward, back)
6. CN V “CN V intact”
(Clench teeth-temporalis/masseter)
7. CN VII “CN VII intact”
(Raise eyebrows, frown, close eyes and
attempt to open with resistance, show
teeth, smile and puff out cheeks)
Eyes
8. Verbalize visual acuity “Visual acuity checked”
9. Inspect eyes, brows, lashes and “no exophthalmos, ptosis, periorbital
lids discoloration, edema, or skin lesions”
10. Inspect conjunctiva and sclera “no injection, icterus, lesions, edema or
foreign bodies”
11. Inspect and palpate lacrimal duct “no swelling and no regurgitation”
12. Evaluate visual fields by “visual fields are full and equal to
confrontation examiner”
13. Check extraocular movement and “EOMIs equal without nystagmus, no lid
lid lag lag”
14. Assess for pupillary reaction to “eyes converge equally and pupils
convergence and accommodation constrict with near focus”
(near/far)
15. Evaluate position and alignment “no strabismus observed”
of eyes (cover/uncover and Hirschberg)
16. Inspect iris and pupillary reaction “pupils are equal, round, and reactive to
to light (direct and consensual) light and accommodation bilaterally”
17. Anterior chamber depth “No crescent shadow”
18. Inspect for red reflex “red reflex present”
19. Inspect clarity of cornea, anterior “cornea, anterior chamber, lens, and
chamber, lens, and vitreous vitreous are clear without opacities,
haze or encroachments”
20. Inspect optic disc “disc color is ______, margins are sharp,
and cup-to-disc ratio is 1:2”
21. Inspect retinal vessels “AV ratio is 2:3 without nicking or
spasms”
22. Inspect fundus “there are no hemorrhages or
exudates”
23. Inspect macula (have pt look into “no lesions on macula”
light)
24. Ophthalmoscopic exam technique
Ears
25. Inspect auricles and tragus “no lesions or discoloration”

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