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Health Assessment

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Health Assessment
Physical Assessment Documentation Form
Date: __3/1/16________

Patient Information
Patient Initials
BR
Age
30
Sex
Female

General Survey

Does patient appear to be their stated age?
Yes
Level of consciousness

Alert and Oriented to person, place and time.
Skin color

Pinkish tan
Nutritional status

Well nourished
Posture and position

Good posture, sitting upright
Obvious physical deformities

None noted
Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement
Steady gait, no assistive devices, no involuntary movement
Facial expression

Symmetrical
Mood and affect

appears to be in good mood
Speech: articulation, pattern, content and appropriate, native language

Speech appropriate clear, English
Hearing

No difficulty hearing
Personal hygiene

Clean, Good hygiene

Measurements and Vital Signs
Height

5’7”
Weight

144
BMI

22.6
Radial pulse: • Rate • Rhythm

62 bpm, Regular rhythm
Respirations:
• Rate • Depth

12 breaths per min, regular
Blood pressure (indicate if sitting or lying)

118/76
Pain assessment

0/10

Physical Assessment
Skin
Hands and nails

no clubbing biting or discolorations
Color and pigmentation

Uniformly pinkish tan in color. Warm, dry, intact, good turgor. No lesions, birthmarks, edema. Moles noted, al round shape and circular borders.
Presence of lesions? none Temperature

warm
Moisture

dry
Texture

smooth, firm
Turgor

good

Head and Face
Scalp
Hair
Cranium
Normal distribution and texture, no pests or inhabitants. Normocephalic. No lumps, lesions, scaling, parasites, or tenderness.
Face (cranial nerve VII)

Symmetrical. No weakness, no involuntary movements.

Temporal artery and temporomandibular joint
No slipping or crepitation.
Maxillary sinuses and frontal sinuses

No sinus tenderness

Eyes
External structures
Eyelids, eye lashes, eyebrows

No ptosis, lid lag, discharge or crusting. Eyelashes, eyebrows equal bilaterally.
Conjunctivae, sclerae cornea, and iris
Clear. Sclerae white, no lesion or redness.
Pupil – size, shape, and light reflex

3mm resting, 2 mm constricted and bilaterally. PERRLA
Visual fields (cranial nerve II)

Full by confrontation
Convergence and Accommodation

Extraocular muscles (cranial nerves III, IV, VI)

Intact; no nystagmus
Corneal light reflex

Symmetric; no strabismus
Describe the purpose of an ophthalmoscope for assessing the eyes
Purpose is to inspect ocular fundus and media by enlarging your view of the eye.

Ears
External ear

No mass, lesions, scaling, discharge or tenderness to palpation.
Any tenderness?

No tederness
Whispered voice test

Whispered words heard bilaterally
Describe the purpose of the otoscope

Purpose is to visualize the ear drum (tympanic membrane)
Explain the Weber and Rinne tests

Weber and Rinne test usually performed together with results of each combined to determine location and nature of hearing loss. Weber test- a tuning fork is placed on the forehead, above upper lip, under nose over teeth or on top of head equally spaced from ears. Patient asked to repeat which ear sound is louder. Normal = sound heard equally in both ears. Ring test- vibrating tuning fork placed on mastoid process behind ear until sound heard. Normal or positive when sound heard outside ear is louder than initial sound heard from tuning fork placed against chin and mastoid process behind the ear.

Nose
External nose

No deformities or tenderness to palpation. Mucisa pink, no lesions, septum midline , no perforation.
Patency of nostrils

Nares patent bilaterally
Describe the purpose of the nasal speculum exam

To view each nasal cavity and inspect nasal mucosa

Mouth and Throat
Lips and buccal mucosa

Mucosa and gingival pink, no lesions or bleeding.
Teeth and gums

No missing teeth, gums pink
Tongue, hard palate, and soft palate
Tongue symmetric, protrudes midline, no tremor, pharynx pink, no exudate. Hard palate white with transverse reggae. Soft palate pink and smooth.
Tonsils

Tonsils not present
Uvula (cranial nerves IX, X)
Uvula rises midline on phonation
Tongue (cranial nerve XII)
Symmetric, protrudes midline

Neck
Symmetry, lumps, and pulsations
Symmetric, no masses, tenderness.
Cervical lymph nodes

Soft, non-tender.
Carotid pulse (bruits if indicated)

2+ and equal bilaterally. No bruits.
Trachea

Midline
ROM

Full ROM
Thyroid gland

non-palpable, non-tender.

Chest and Lungs: Posterior and Lateral
Thoracic cage configuration • Skin characteristics • Symmetric expansion • Tactile fremitus • Lumps or tenderness

Pinkish Tan, warm
AP<transverse diameter
Symmetrical
Equal bilaterally
None, No tenderness
Spinous process

Normal spinal profile, no scoliosis
Percussion over lung fields

Lung fields resonant
CVA tenderness

No tenderness
Breath sounds

Clear, equal bilaterally
Adventitious sounds

none

Chest and Lungs: Anterior
Respirations and skin characteristics

Normal, Pinkish tan warm, no lesions.
Tactile fremitus, lumps, and tenderness Equal bilaterally, no lumps tenderness
Percuss lung fields

Lung fields resonant
Breath sounds

Clear in all lobes bilaterally

Heart
Precordium: pulsations and heave

No abnormal pulsation, no heaves
Apical impulse (PMI)

Apical pulse at 5th ICS in left MCL
Precordium and thrills

no thrills
Apical rate and rhythm

62 bpm , regular rhythm
Heart sounds

S1- S2 are not diminished or accentuated, no S3 or S4

Upper Extremities
ROM and muscle strength

Full ROM, symmetric, able to maintain flexion against resistance and without tenderness
Epitrochlear nodes

Not palpable
Discuss the process for assessing breasts and axilla

Inspect breasts, general appearance size shape, skin color, characteristics (bulging, dimpling) Observe axillary and supraclavicular regions. Nipples symmetry, on same plane of breast, characteristics (protrude, flat, inverted) Screen for retraction by having lift arms above head, breast should move up symmetrically. Insect and palpate axillae. Inspect skin for rash or infection. Lift arms and palpate axillae. Palpate breast by having patient in supine position with arms over head. Use pads of first 3 fingers and gentle rotary motion of breast. Using the vertical strip pattern: Start high in axillae and palpate down to midaxillary line just lateral to breast down to braille. Proceed medially until every square inch of breast examined. Then palpate nipple. Note any induration or subareolar mass. Then with forefinger and thumb depress nipple tissue well behind areola. Tissue should move inward easily. Ask about nay nipple discharge. If lump reported be sure to examine unaffected breast first to get baseline for breast tissue. Teach patient how to perform self breast exams. (Jarvis , p.397)

Neck Vessels
Jugular venous pulsation

+2 equal bilaterally
Presence of jugular venous distension

Flat at 45 degree angle

Abdomen
Contour, symmetry, skin characteristics, umbilicus, and pulsations
Flat symmetric. Skin smooth with no lesions, scars or striae
Bowel sounds
Present, normative x all quadrants
Vascular sounds
No bruits
Percussion
Tymphany predominates in all quadrants
Liver span in right MCL
7 cm in Right MCL
Palpate Liver and Spleen

Light and deep palpation
Abdomen soft, no organmegaly. No masses or tenderness
Inguinal Area
Femoral pulse

2+ equal bilaterally
Inguinal nodes

No inguinal lymphadenopathy

Lower Extremities
Symmetry, skin characteristics, and hair distribution

Symmetrical, tan pink, no hair present
Temperature and pretibial edema

Warm, dry
Pulses:
• Popliteal • Posterior tibial • Dorsalis pedis

2+ equal bilaterally
2+ equal bilaterally
2+ equal bilaterally
Toes
• capillary refill

brisk <2 secs.

ROM and Muscle Strength
Ankles and feet

Full Rom, skin smooth even coloring, no lesions
Hip – ROM

Full ROM, steady gait
Sensation:
• Face • Arms • Hands • Legs • Feet

Intact to dull and sharp sensation
Position sense

Intact, normal response
Stereognosis

Able to identify key
Cerebellar function (heel to shin)

Heel moves in a straight line down shin
Cerebellar function (finger to nose)

Accurate and smooth movement
Deep tendon reflexes: • Biceps • Triceps • Brachioradialis • Patellar • Achilles

2+; brisk response normal bilaterally
2+; brisk response normal bilaterally
2+; brisk response normal bilaterally
2+; brisk response normal bilaterally
2+; brisk response normal bilaterally
Babinski reflex

Negative (flexion of toes downward occurs)
Romberg sign
Negative- posture and balance maintained
Touch toes

90 degree flexion, smooth symmetrical movement
ROM of spine

Full ROM
Shallow knee bend

Normal position sense, muscle strength, cerebellar function

Walk across room heel to toe

Straight and balanced
Walk on tiptoes, then walk on heels

Straight and balanced

Analysis of findings:

Source:
Jarvis, C. (2015). Physical examination & health assessment (7th ed.). St. Louis: Elsevier, Saunders. ISBN: 9781455728107

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