Holistic Health Assessment: SOAP Paper

Roxie Butterfield

University of Texas at Arlington

Assessment of BB

BB appears to be a healthy 63 year old male. He is neatly groomed and dressed. He is

5”10 and weighs 220 lbs. His BMI is 29.04.

Subjective Data

Skin, hair, and nails:

BB states he has no skin rashes or lesions. He does, however, state that he has very dry skin. Patient states that he has no bruising, swelling, or pigmentation problems. His main concern today is a large raised mole on his shoulder.

C: light brown dry raised mole. “I think about 1/2” in length.”

O: “It has been there for a long time.”

L: “It is on my right shoulder, you can't miss it. I don't have anything like it on my body.”

D: “It doesn't go away and I haven't noticed that it has changed in size or color.”

S: “It doesn't really bother me but I have heard I should have it check out.”

P: “There isn't anything that makes it feel better or worse, because it doesn't hurt at all.”

A: “I am afraid that I might scrape it when I am putting my shirt on and off. It bothers my wife more than it does me.”

BB denies having any other moles that he is concerned with. BB states that he hasn't had any other skin issues such as itching, pain, tingling or redness. BB does think that his skin is somewhat dry. BB states that he has had no skin problems other than a sunburn once in a while. He doesn't know of any allergies or skin reactions other than the normal skin reactions such as poison ivy. BB states that he doesn't notice any significant hair loss. He has not noticed any changes in his nails or nail beds. BB denies any issues with body odor.

Past History:

BB states that he has never had neck or head injuries. He has never had surgery on his head or neck. He doesn't take any medication for his head or neck other than an occasional ibuprofen or aspirin.

Family History:

BB does not recall any family member of his having skin cancer or skin problems in general. He also does not know of any of his siblings having skin cancer or skin problems.

Lifestyle and Health Practices:

BB states he has been a tennis player most of his life and has spent many hours out in the sun. He does state that he puts on sunscreen and usually wears a hat. He does not have a regular skin care regiment. He washes his skin with soap and water and his hair with shampoo. He clips his nails regularly. He states he tries to follow a healthy diet eating lots of fruits and vegetables. He does try to get some form of exercise daily.

Head and neck:

Current Symptoms:

BB denies having any lumps on his head or neck. BB states that he occasionally has trouble moving his neck but that is just because he slept wrong on it the night before. He denies having any trouble moving his head. He rarely has a headache and doesn't know what a real bad headache would feel like. He has no facial or neck pain. He states he has never lost consciousness. He does recall times when he feels like the room is spinning but it usually doesn't last long. He has no dizziness or lightheadedness.

Past History:

BB states that he has never had neck or head injuries. He has never had surgery on his head or neck. He doesn't take any medication for his head or neck other than an occasional ibuprofen or aspirin.

Family History:

He is not aware of any family history that involves head an neck problems. His does not recollect his mother, father or grandparents having migraines. He does have a sister that does have migraines but that was mostly in her younger years.

Lifestyle and Health Practices:

BB does not smoke or use tobacco and has not been subjected to secondhand smoke. He hasn't ridden a bike since he was very young and has never worn a hard hat. He does wear a baseball cap when he is outside. He states that he tries very hard to sit upright when relaxing and takes breaks often when working on the computer. He normally sleeps with one fairly firm pillow. For recreation BB plays tennis. He does do a light weight work out along with walking. He states that he is satisfied with his appearance.

Eye:

Current Symptoms:

BB states that he has noticed in the last year he has noticed a change in his eyesight. He has no floaters or spots in his eyes. He denies having blind spots or anything out of the ordinary. He does, however, noticed trouble seeing at night but contributes that to his age. He does not have any eye pain and has never had double vision. The only time that he has redness and watery eyes is during hay fever season. He denies any swelling.

Past History:

He has never had eye surgery or vision problems. He just recently got a pair of glasses to wear during night driving. He also states that he does wear reading glasses but just started doing that a few years ago. He states that he is very grateful for having good eyesight.

Family History:

He does not recall either of his parents having vision problems. They did both wear glasses but that was in their older years. He is not aware of his grandparents having any vision problems either.

Lifestyle and Health Practices:

BB has not been exposed to harmful chemicals, smoke, fumes, etc. He states that he does wear safety glasses when it is in his best interest to do so. He just recently started to wear sunglasses. He does not take any medication. The recent change in his vision has not stopped him from taking care of himself or his family. His last eye exam he thinks was about 1 year ago. He states that his insurance pays for an eye exam once and year and he gets a reminder in the mail that it is time for his next exam.

Ear:

Current Symptoms:

BB states that he has not noticed any hearing loss. He denies having any discharge from his ears. He states that he has had an occasional ear pain mostly due to a cold or sinus pressure. He does not having any ringing or cracking in his ears.

Past History:

He has no notable ear problems other than a few ear infections when he was younger. He has never had a ruptured eardrum or surgery to his ears. He knows of no medication that he would have taken that would have done any damage to his ears.

Family History:

BB states that his mother did have hearing loss in both her ears. He states that she got an ear infection when she was very small and that was the cause of her hearing loss. His dad did not have any hearing loss. He does not recall either set of his grandparents having any hearing loss.

Lifestyle and Health Practices:

He has not had any exposure to loud noises throughout his life. He does not wear earphones and does not wear ear plugs when he is in the water. He denies having any hearing loss.

Mouth, throat, nose and sinus:

Current Symptoms:

BB states that he does not have any sores or lesions in his mouth. His mouth is not sore or red. His gums are pain free and he has not noticed any bleeding. He has an occasional cold which will affect his sinus but he has no chronic sinus problems. He states that he is able to breathe without difficulty out of both nostrils and is able to smell and taste. He cannot recall the last time he has a nose bleed.

Past History:

BB states he has not had any mouth surgery other than a couple of wisdom teeth pulled. He has not had throat, sinus, or nose surgery or any other problems. He denies using nasal sprays. He does not wake up in the morning with sore jaws. He is not a teeth grinder nor does he clinch his jaw. He visits the dentist at least 2 times a year and he has all his original teeth.

Family History:

He does not recall any family history of mouth, nasal or throat problems. He states that his mother had dentures at a very young age but his father had his original teeth.

Lifestyle and Health Practices:

BB states that he practices good oral hygiene bushes his teeth at least twice daily and flossing on a regular basis. He has healthy eating habits and tries to stay away from eating too much sugar. BB states that within the last 24 hours he has consumed a bowl of cereal with milk, an orange, a ham and cheese sandwich with some potato chips, 2 glasses of water, a piece of baked chicken, green beans, baked potato and a piece of bread. He is not a smoker and does not consume alcohol and only drinks soda on rare occasions.

Thoracic and lung:

Current Symptoms:

BB denies any difficulty breathing. He does state that when he plays tennis he sometimes gets winded but recovers quickly once he stops the activity. He denies experiencing any chest pain and has not had a cold recently. He has not had a cough any time recently.

Past History:

BB states that he does not have a history of any respiratory problems. He has not had thoracic surgery or any trauma to the thoracic region. Patient does state that he has hay fever in the fall time of the year. He has a very runny nose and watery eyes during this time of year. He has not taken medication for it. He has not had a chest x-ray or had the flu vaccine. He has recently had a TB skin test that was negative.

Family History:

He states he knows of no one in his family that has had any kind of lung disease. His parents as well as maternal and paternal grandparents did not have any respiratory problems. He states his siblings do not have any respiratory problems.

Lifestyle and Health Practices:

BB states he had never used tobacco or cigarettes. He has not been exposed to second hand smoke and any harmful chemicals. He does not have any problems doing daily activities. He considers his lifestyle to be stress free. He has not ever had and medications prescribed for breathing.

Heart and neck vessel and peripheral vascular:

Current Symptoms:

BB denies any chest pain. He states he does not have palpitations or any dizziness. He has not noticed swelling ankles. BB is concerned that when he drives for extended about of time he has noticed that his ankles have swollen.

C: “ I have noticed when I drive for several hours I get swollen ankles.”

O: “I noticed this the last time I was on a trip and drove for 11 hours.”

L: “ It is in both my ankles.”

D: “It usually is gone in a day or so.”

S: “There is no pain associated with it.”

P: “It gets better in a day and it helps to elevate my feet.”

A: “ I don't really have any other symptoms. It worries me a little because I don't know if

there is something wrong or not.”

Past History:

BB states he has not had any heart problems and has never been told he has a heart murmur or heart defect. He has never had a diagnosis of hypertension. He denies having rheumatic fever and does not have diabetes or an elevated cholesterol. He has never had heart surgery.

Family History:

BB states his mother had a diagnosis of angina. She suffered an MI had CAD and a malfunctioning heart valve. She had a coronary artery bypass as well a a valve replacement. She also had type II diabetes. His father had CAD and suffered two MI's. He was not aware of either of his parents having elevated cholesterol but thinks that most likely they did. BB states that his maternal grandparents did not have any heart problems that he was aware of. Neither of them had diabetes or hypertension. BB states that his paternal grandfather did not have any heart problems, hypertension, CAD, or diabetes. His paternal grandmother had diabetes and had one MI. He states she most likely had CAD. His siblings do not have any heart problems, diabetes, CAD or hypertension that he is aware of.

Lifestyle and Health Practices:

BB states that he has never smoked cigarettes and has tried to live a stress free lifestyle. He states he tries to eat healthy and he exercises daily at least 30 minutes or longer. He does not and has not ever consumed alcohol. He sleeps approximately 7-8 hours a night using one pillow and gets up usually one time a night to urinate. He does not take medication for his heart. He does not monitor his blood pressure or heart rate on his own but has a physical at least yearly. He states that he does not have coronary heart disease.

Current Symptoms:

BB states he has not noticed any changes in his skin color or temperature. He does, however, state that he has a little dry skin but nothing that is concerning. He denies having leg pain or leg aches of any kind. He does not have bulging veins in his legs. He doesn't have any open sores or wounds of any kind on his legs. He denies swelling in his legs and stated above about the swelling he has noticed in his ankles after driving for a long time. He states that he hasn't noticed any changes in his sexual activity. He denies having any swollen glands or nodules.

Past History:

BB states that he has not had any problems with his circulation in his upper and lower extremities. He has not ever had a blot clot or noticed any kind of numbness. He has not ever had any sores that don't heal. He has not ever noticed any kind of hair loss. He has not ever had any heart or blood vessel surgery. In fact he has not ever had any surgery.

Family History:

BB's mother had type II diabetes as well as CAD. His father had varicose veins and hypertension and CAD he believes. He is not sure if either of his parents has elevated cholesterol or triglyceride levels but thinks they most likely did. He states that his maternal grandparents did not have CAD, hypertension or diabetes. He is not aware of them having elevated cholesterol or triglycerides. As far as his paternal grandparents go he states that his grandmother had diabetes but he is not sure if she had hypertension or CAD. His grandfather did not have diabetes, hypertension, CAD. Again, he is not sure if either of his paternal grandparents had elevated cholesterol and triglyceride levels. BB states that he is not aware that his siblings have any circulatory problems.

Lifestyle and Health Practices:

BB states that he has never smoked or used tobacco. He tries to exercise on a daily basis and lives a relatively low stress lifestyle. He does not have any peripheral problems that prevent him from taking care of himself and his family. He does not take any medications.

Abdomen:

Current Symptoms:

BB denies abdominal pain at present time. He has not had any diarrhea, nausea or vomiting. He has not had any changes in his appetite. He denies any weight loss or gain.

Past History:

BB states that he has never had any abdominal surgery, injuries, trauma or medications. He denies ever being treated for abdominal pain. BB states that he has never had any lab work up or gastrointestinal studies performed.

Family History:

BB states that his father did not have cancer of any type. His dad did have appendicitis and hemorrhoids. He did not have colitis or abdominal pain. His mother also did not have cancer of any type. She did have appendicitis, gallbladder removed, and hemorrhoids. She did not have any GI bleeding or abdominal pain or colitis. BB states that his paternal grandfather did not have any type of cancer. He also did not have appendicitis, colitis, GI bleeding or hemorrhoids. His paternal grandmother did not have cancer of any type. She did have appendicitis. She did not have colitis, GI bleeding, abdominal pain or hemorrhoids. BB states that his maternal grandfather did not have cancer of any type. He did not have appendicitis, colitis, hemorrhoids or GI bleeding. His maternal grandmother did not have any cancer of any type. She did have appendicitis and hemorrhoids. She did not have colitis, abdominal pain, or GI bleeding. His siblings do not have cancer of the stomach, colon or liver. He does have one sister that had appendicitis. BB states that his mother was responsible for the nutrition of the family.

Lifestyle and Health Practices:

BB denies smoking and he does not drink alcohol. BB has had a bowl of cereal, a piece of salmon, corn, a green salad with a little piece of chicken, 5 cookies and a glass of milk. He states that he rarely uses an antacid. He does not take medication. He estimates that he has had approximately 1 quart of liquid to drink. He states that he took a 5 mile walk today and tries to exercise daily. He states that he lives a fairly stress free life. He did state that when he is stressed he thinks he may eat a little more. He has not had any abdominal pain or problems.

Musculoskeletal:

BB denies any recent weight gain or difficulty swallowing. He does not have any joint or bone throbbing. He does state that he has some muscle aches in his back.

C: “Intermittent pain and it is very uncomfortable. It hurts to the point that I can't do

certain things.”

O: “It began several years ago.”

L: “Lower back in the lumbar region.”

D: “It usually will hurt for 3 weeks or so and then it somehow seems to heal.”

S: “It is disabling and stops me from doing almost everything.”

P: “I have to be careful on posture. If I sit too long it hurts. It helps to lay down flat or stand.”

A: “There is swelling in the lower part of my back. I have to fight depression when it

happens.”

Past History:

BB states that he has had tennis elbow, strained wrist, frozen shoulder, dislocated shoulder, a ruptured rectus femoris, a ruptured gastrocnemius and numbness in his right thigh. He states he has not had any surgery or taken any medications. He has no had physical therapy. He has just rested the muscle until the pain subsides and then gradually started using it again. BB states that he has had tetanus and polio immunizations. He has never had a diagnosis of diabetes, sickle cell or lupus.

Family History:

BB states that neither his father or mother had rheumatoid arthritis, gout, osteoporosis, infectious tuberculosis or psoriasis. He states his paternal grandfather did not have rheumatoid arthritis, gout, osteoporosis or infectious tuberculosis. His paternal grandmother did have osteoporosis and gout. She did not have rheumatoid arthritis, psoriasis or infectious tuberculosis. He states that his maternal grandparents did not have rheumatoid arthritis, gout, osteoporosis, psoriasis or infectious tuberculosis. He states that his siblings do not have any of the above conditions.

Lifestyle and Health Practices:

BB states that he lifts light weights 3 to 4 times a week. He states that the home remedies his uses for musculoskeletal problems is rest, ice, massage and elevating sore muscle. He uses no assistive devices. He states that he does not smoke, drink caffeine or alcohol. He tries to drink milk but does not take any calcium supplements. He is retired. He plays a fair amount of tennis and enjoys working outdoors so he estimates that his time in the sun might be 2 hours per day in the summer. He tries to do some form of exercise daily. He states that he does not have any difficulty performing daily living activities. He tries to always have a good posture. He states that he does have any interference with his sexual activity. He states that he has a positive body image and is able to socialize and interact with people without difficulty. He tries to live a stress free life.

Neurological:

Present History (with COLDSPA):

His states that his biggest health concern today is he has some abdominal pain.

C: burning in abdominal area

O: two weeks ago

L: Abdominal area, after eating, does not radiate

D: Pain comes and goes lasting 10-15 minutes at a time

S: rates the pain 8/10 on 0-10 pain scale, “Pain is very intense and hurts a lot”

P: occurs usually after eating

A: other symptoms include intermittent constipation along bouts of diarrhea. BB denies seeing any dark stools. BB states he is reluctant to eat because of the burning and uncomfortable feeling he gets afterward.

BB states that he is also concerned with his blood pressure and his inability to lose weight.

Past Health History:

BB denies that he has had any head injuries, meningitis, encephalitis, or a stroke. He has not had any surgeries or any past medical diagnosis. He states he has never been to counseling. He denies having headaches. He did serve in the military but not active duty just reserves. He states he has never had any difficulty breathing. He denies have any heart palpitations. He has not been exposed to any harmful environmental toxins.

Family History:

BB states that his mother or father did not have any mental health problems. His paternal grandparents did not have any mental health problems nor did his maternal grandparents have any mental health problems. BB states that neither his mother or father had any psychiatric disorders, dementia, or brain tumors. He states that neither set of grandparents had any psychiatric disorders, dementia, or brain tumors. He did have a brother who recently committed suicide. He was not aware that his brother had any mental health issues.

Lifestyle and Health Practices:

BB states that his typical day consists of exercising about 1 hour a day. He does chores around the house, reads and cooks. He states that he has plenty of energy. He tries to eat a balanced diet. He does not drink any alcohol or take any medications. He states that he tires to get at least 7 to 8 hours of sleep per night. He states that he usually has one bowel movement a day. He exercises daily. He does not use over the counter medications. He is involved in his religion. He is a father to 4 grown children and 2 grandchildren. He is friendly with neighbors. He states that he has a good self image. He looks to his future with hope and happiness. He states that he feels he has accomplished his biggest goal and that is raising 4 children who are healthy and happy.

What is your definition of health?

BB states that his definition of health is that is can be relative or absolute. When one speaks of losing their health it is used in an absolute sense. He states that otherwise one can speak of good health and of bad health. He states that here the definition is relative.

What is your definition of illness?

BB states that his definition of illness is a condition that could be permanent, chronic, or temporary, physical or mental. He states it is something that distracts from a healthy mind or body. It could be caused by substances that one breathes in. It could be something that one ingests. It can be caused by trauma. It can be caused by something malfunctioning in one’s body. It can be multiple symptoms and multiple systems. It is basically anything that prevents one from enjoying everyday activities.

When you are ill, what do you think causes the problem?

BB states that he believes illness, which comes in many forms, prevents the body from working properly. This stops the body from doing what it is designed to do, which is stay well. The actual cause of illness can be a multitude of different things, but it is something that throws the body out of equilibrium. It may be permanent or temporary. The body responds with symptoms as it tries to recover.

Why do you think you get ill when you do?

BB thinks that he gets ill when his body does not have the right mechanism in place to resist the cause of illness. He states that he may not have the ability to resist a new virus for instance. Obviously if your body cannot fight off an invasion of germs or viruses, sickness will be the result, he states.

What does your sickness do to you?

BB states that when he is sick he does not feel “normal.” He states that it weakens him and he feels pain and discomfort. He states that it prevents him from enjoying life when he is sick.

How severe is your illness when you have one?

BB states that when he is sick it varies from an annoying symptom to a systemic problem that is highly involved. He states that he very rarely has a severe illness.

What results do you expect from health care workers when you get ill?

He states that he only seeks medical attention if it is potentially very serious or fatal. He states that those times have been few and far between. He states that he realizes that health care can only do so much and most of the time his illness is something that just has to run its course.

What are the chief problems your illness cause you?

He states that his mind doesn't work as well and he may have soreness in the head and eyes, aches, sore throat, lack of energy and general malaise. They prevent him from doing everyday activities and enjoying life to its fullest. He states that he has not had much illness in his life.

. Who is the healer in your culture?

BB states that in his culture he believes the healer is the body designed by God. Knowledgeable doctors and priesthood holders are also healers. He states that in his church he may choose to get a priesthood blessing and it is through his faith and the blessing and the will of God that he may be healed.

What is the sick role in your culture?

BB states that the sick role in his culture is take it easy for a few days and let nature do its part to get the body back to normal. He states that he believes his culture is like that of most people. If you are sick you stay home and away from other people until you feel better.
.

Who is your God and how do you define your God in illness?

BB states that his belief is that his God is his Spirit Father who has a resurrected body and understands his body.

What is your God relationship to health?

BB states that his God can heal based on faith of the sick person or those performing prayers for him. He states that all things are done according to his purposes and with his wisdom.

Genogram:
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Ecomap:

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Objective Data

General appearance, height, weight, BMI:

BB is a 63 year old male who is neatly groomed and dressed. He has a mesomorphic frame and appears to be in good physical health. The distance between the top of patient's head to pubis appears to be equal to the distance between the pubis and the bottom of BB's feet. Circumference of patient's head is proportionate to patient's build. Arm span also appears to be equal and proportionate to patient's physique. Patient's sexual development appears to be in line with the patient's age. BB looks younger than his current age of 63. BB is a fair skinned individual. BB's skin is pink in color with no apparent discoloration. Patient's posture is erect with no apparent abnormal curvature of the spine. BB has slightly slumped shoulders. Patient's gait is even and unlabored with arms slightly swinging by his side as he walks.

BB has a mesomorph frame. He has good muscle tone in his upper and lower extremities bilaterally. He does have some subcutaneous fat around his abdominal area BB's height was measured after removing his shoes and standing upright. BB's height is recorded as 70 inches or 5'10”. BB's was weighed without shoes and wearing light weight clothing. BB's weight is recorded at 202lbs or 91.81 kg. BB's IBW was calculated and is 121.7%. BB's IBW is over the recommended percentage of 10%. BB's BMI was calculated and is 29.04 which is above the recommendation of the National Institute of Health. BB's is at risk for health problems if his current weight is not decreased.

BB's temperature was taken orally. The patient was instructed to keep the thermometer under his tongue until a beeping noise is heard. BB's temperature was 98.3 F. Patient's radial pulse is palpated bilaterally and is strong (3+) with a rate of 77 beats per minute. Apical pulse is auscultated and strong rate heart is heard with a rate of 77 beats per minute. Pulses are found to be regular with equal intervals and pulsation is equal bilaterally. Upon palpation BB's arteries are spongy and are straight with no rigidity noted. Observing BB's respirations for 30 seconds the chest rose and fell 7 times for respirations of 14 per minute. The rhythm of respirations appears to be regular and chest expansion is equal bilaterally. Blood pressure is taken with BB in a sitting position with his left (dominate) arm relaxed. Brachial pulse is palpated before cuff is positioned on patient. Appropriate size cuff is selected and positioned on patient's arm in a correct manner. Brachial pulse is palpated and stethoscope is placed lightly over brachial pulse. Blood pressure cuff is gradually inflated to 170 mmHg and the cuff is gradually deflated. Patient's systolic pressure is 130 mmHg and diastolic pressure is 87 mmHg. Using the same method blood pressure in patient's right arm is taken with a systolic pressure of 126 mmHg and a diastolic pressure of 83 mmHg.

Skin, hair and nails:

BB's skin tone is fair with no apparent discoloration. There is no sign of cyanosis or pallor. Patient does not have any odor to his skin. Patient does not have any freckles or white patches. Patient nipples are darker in color along with his lips and genital area. Patient does have some solar lentigines bilaterally on his hands and forearms. There is no skin break down and boney prominences are intact. There is no redness noted. Patient's skin has no lesions and is smooth in texture. Patient does have moles on his upper shoulder area and abdominal area. Patient does have a 10mm seborrheic keratosis on his right shoulder. There are no stretch marks, birth marks or scars. Patient's skin feels smooth and even. There is some patches of dryness on forearms bilaterally. Patient has callouses on his right and left feet along with his left hand. Patient's skin is dry with moisture under arms. The temperature of BB's skin is warm to the touch. Skin turgor is elastic and resilient. There is no edema noted on patient.

Patient has short gray hair and is not chemically colored. Patient's scalp is clean with a small amount of dandruff noted. Hair is coarse. Patient's hair on head is distributed equally, no bald areas are noted. Patient has small amount of chest hair that is white in color. Hair is present bilaterally in axillary area and distributed evenly.

BB's nails are pink with longitudinal ridges noted. Nails have a 160-degree curvature with no clubbing or concaveness noted. Upon palpation nails are hard and are not movable. Toe nails are thick have a slightly yellow cast to them. Nails are attached firmly and are smooth and firm. Capillary refill test is performed on all ten nails pink tone is returned immediately once the pressure is released.

Head and neck:

Upon inspection patient's head is proportional to patient's body. “Head is symmetrical, round, erect and in midline” (Weber, 2010, p. 217). There are no lesions or abrasions noted. Patient holds his head still and upright during inspection, no shakiness or involuntary movement is noted. Head is hard with no soft spots detected. Patient's face is round in appearance and symmetrical. There are fine wrinkles noted around both right and left eyes. There is no drooping noted. The temporal artery is palpated bilaterally and non tender and elasticity is noted. The pulse is strong bilaterally. The temporomandibular joint is palpated bilaterally by placing a finger over the front of BB's ear. BB was asked to open and close his mouth. There was no tenderness or swelling bilaterally. There was no noise heard while opening and closing of his mouth. Patient does not have trouble opening and closing his jaw. BB's neck is inspected. There is no swelling or bulges noted. Patient's neck is symmetrical and his head is centered. BB is asked to swallow as the thyroid is inspected. The thyroid cartilage, cricoid cartilage and thyroid gland move upward symmetrically as BB swallows (Weber, 2010, p. 218). Inspection of the cervical vertebrae is visible and palpable. There is no swelling or fat noted. BB is able to move his head from right to left without difficulty and in a controlled, smooth manner. There is no decrease in flexion noted. The trachea is palpated and found to be midline. The thyroid gland is palpated hyoid bone, thyroid cartilage, and cricoid cartilage are all positioned midline. There are no swelling or growths noted. Patient's thyroid is palpated the lobes are smooth and firm with the right lobe being slightly larger than the left lobe. There are no nodules noted as BB swallows. There are no masses detected bilaterally and no bruits heard upon auscultation bilaterally. The preauricular nodes are palpated bilaterally with no swelling, tenderness or enlargement noted. The postauricular nodes and the occipital nodes are palpated bilaterally and there is no enlargement, swelling or tenderness noted. The tonsillar nodes are palpated bilaterally with no swelling, tenderness or hardness noted. The submandibular nodes are palpated bilaterally with no tenderness or enlargement noted. The submental nodes, superficial cervical nodes, posterior cervical nodes are all palpated bilaterally with no enlargement or tenderness noted. The deep cervical chain nodes as well as the supraclavicular nodes are palpated bilaterally with no enlargement or tenderness present. Eye:

BB has 20/20 vision as the Snellen test was performed. The test for visual field and gross peripheral vision was performed. BB was able to see my finger at the same time I saw my finger. This test was performed both on the right and left eye. With a pen light the corneal light reflex test is performed. “The reflection of the light on the corneas is in the exact same spot on each eye” (Weber, 2010, p. 238). Patient was asked to cover his right eye and then his left eye the uncovered eye remained fixed. The uncovered eye was observed after uncovering it and no deviation was noted in either eye. Patient was given the positions test and patient's eyes moved smoothly and symmetrical in all six directions. Inspection of the eyelids and eyelashes is performed next. The eyelids and eyelashes are inspected next. There is no drooping of either the right or left eyelids. There is no white sclera noted above or below the patient's iris. The lids close easily and completely. There is no upward or inward or outward turning of either the right or left lower eyelid. Patient has well proportionate eyelashes. There is no swelling, discharge, lesions or redness noted in either the right of left eye. The position of the eyeballs are symmetrical and there is no protruding or sinking noted in either the right or left eye. The bublar conjunctiva and sclera are clear, smooth and moist. There is no pinguecula noted. Inspection of the palpebral conjuctiva is performed the “lower and upper palpebral conjunctivae are clear and free of swelling or lesions” (Weber, 2010, p. 240). Both in the right and left eye. There is no swelling or indication of trauma or foreign material in either palpebral conjunctiva. The lacrimal apparatus is inspected next there is no redness or swelling noted over the lacrima gland. The puncta is located and there is no swelling or redness noted either in the right or left eye. No drainage is noted from the puncta upon palpation bilaterally. With a light the cornea is inspected and is found to be transparent and free from opacities bilaterally. The surface is smooth and the lenses are free of opacities. The iris and pupil are inspected for abnormalities. The iris is round and the color is equal bilaterally. The pupils are round and with regular borders and is centered in the middle of the iris bilaterally. The pupils are equal and reactive to light bilaterally. Consensual response is assessed is constrictive upon light being shown in eyes bilaterally. Accommodation of the pupils is assessed and pupils restrict and eyes converge bilaterally. The internal eye is inspected with an ophthalmoscope there is a red reflex noted that appears round with regular borders bilaterally. The optic disc is inspected next and is round and borders are sharp and defined well. There is no enlargement of the physiologic cup in either the right or left eye. The retinal vessels are inspected. The arterioles are bright red in color and the narrow as the move away from the optic disc. This is bilaterally. The venules are darker red in color and they appear to be larger than the arterioles and they also narrow as they move away from the optic disc. This is also bilaterally. There are no nicks or tapering of the arterioles to suggest hypertension. This is also the case in the right and left eye. The retinal background appears to be consistent in texture bilaterally. The fovea and macula are inspected and there is no clumped pigment noted bilaterally. The anterior chamber is transparent in both the right and left eye.

Ear:

BB's auricle, tragus and lobule are inspected bilaterally. The ears are the same in diameter and shape bilaterally. “The auricle aligns with the corner of each eye” (Weber, 2010, p. 269). This is the same with both the right and left ear. The earlobes are attached bilaterally. The skin on both the right and left ear is smooth. There is no redness, nodules or lumps detected on either the right or left ear. There is no tenderness to the auricle, tragus and mastoid process upon palpation. Using the otoscope the external auditory canal is inspected. A small amount of light yellow cerumen is seen in both the right and left ear. The canal walls appear to be pink and free of nodules bilaterally. The tympanic membrane is gray and shiny and no bulging is seen in either ear. “The short process and handle of the malleus and the umbo are clearly visible” (Weber, 2010, p. 271). This is the case in both the right and left ear. The Weber's test is performed using a tuning fork. BB hears vibrations equally in both ears. The Rinne test is performed. 14 for AC 22 for BC in both the right and left ear. The Romberg test is given to check patient's equilibrium. BB was able to stand for 20 seconds without detecting any swaying movement.

Mouth, throat, nose and sinus:

BB's lips are moist, pink and smooth. There are no lesions or swelling on his lips. BB's teeth are white and stain free. He does have a fair amount of dental filling on the top and bottom molars. BB has 28 teeth as he had his wisdom teeth extracted. The gums are pink, moist with no swelling detected. There are no lesions or masses noted. Inspection of the buccal mucosa is pink and smooth bilaterally. There is no swelling or lesions bilaterally. Patient's tongue is pink in color and moist. The size of the tongue is proportional to patient's mouth and papillae is present. There are no lesions or discoloration noted. The ventral side of patient's tongue is smooth, lesion free and is pink in color. Veins are visible. The patient's frenulum is midline. “Wharton's ducts are visible with salivary flow” (Weber, 2010, p. 288). There is no swelling, pain or redness noted. The sides of patient's tongue are free from lesions, redness, ulcers and nodules. Patient has strong resistance in his tongue and BB can detect sweet and salty. A penlight is used to inspect the hard and soft palates as well as his uvula. The hard palate is pale pink in color. It is hard and transverse rugae are present. There is no odor detected as patient opens mouth. The uvula is inspected by depressing the tongue. The uvula is midline and hangs freely in the back of patient's throat. There is no redness noted. Tonsils are present and pink and symmetrical bilaterally and are 1+. There is no swelling or redness noted. The posterior pharyngeal wall is pink and free from lesions and exudate.

The color of BB's nose is consistent with the rest of his face. It is smooth to the touch and symmetrical. There is no tenderness upon palpation. BB is able to breathe through each nostril without difficulty. The nasal mucosa is moist and pink in color. Patient's nasal septum is intact and free from sores and lesions. Patient's sinuses are palpated both the frontal and maxillary sinuses are non tender to the touch and there is no crepitus noted. Sinuses are percussed and are non-tender bilaterally.

Thoracic and lung:

BB does not have any nasal flaring. He does not breath with pursed lips. His diaphragm expands equally has his chest rises and falls. BB has pink colored lips along with his face and chest. He has no discoloration noted. Upon inspection of his 10 nailbeds they are all pink and there is no clubbing seen. Inspection of BB's scapulae they are found to be symmetrical with no protruding noted. His spinous process does not deviate. His thorax is symmetrical with his ribs. There is no curvature of the thoracic spine. BB does not use his accessory muscles as he breaths. He is able to breath easily while sitting. BB reports no pain or tenderness upon palpation of his posterior thorax. His skin temperature is warm and dry bilaterally. There is no crepitus noted and his skin is free of any lesions or masses. Palpation for fremitus was completed and found to be symmetrical as BB said, “ninety-nine.” Chest expansion is equal and symmetrical. Percussion of the posterior thorax is performed bilaterally. There is no dullness or hyperresoance is noted. Excursion of the posterior thorax is equal bilaterally. Excursion measurement is 5 cm. With BB sitting in an upright position auscultation of breath sounds is performed. Patient is asked to take a deep breath in. BB's bronchial sounds are high pitched and loud with a ratio of inspiration/expiration ratio of 1:2. Patient's broncho-vesicular as auscultated next and the pitch is medium and is of moderate sound. His inspiration/expiration ratio is 1:1. Patient's vesicular breath sounds are auscultated next. A low pitch sound that is soft is heard with an inspiration/expiration ratio of 2:1. There are no crackles or wheezes noted upon auscultation of BB's lung field bilaterally. BB's is asked to say, “ninety-nine”, to check bronchophony, the words are soft and muffled. Egophony is checked next by having BB say, “E” . A soft and muffled sound is heard but it is understood. The whispered-pectoriloquy test is performed next by having BB whisper, “one-two-three”. The sound heard is very faint and muffled.

BB's anteroposterior diameter is less than the transverse diameter (Weber, 2010, p.319). The ratio is 1:2. His sternum is midline and straight with no deviation noted. There are no sternal retractions noted. Inspection of the ribs are symmetrical and slope downward. BB's breaths are equal and non-labored. BB respiration rate is 17 per minute. There is no bulging of the intercostal space noted. He does not use accessory muscles as he breaths. Palpation findings are there is no pain or tenderness noted while he is breathing. Palpation over the costochondral junctions shows no tenderness, crepitus or lesions. Fremitus is symmetrical. Chest expansion is symmetrical. Resonance is heard while percussion over lung fields bilaterally. There are no crackles or wheezes heard while auscultation of BB's anterior thorax is performed.

Heart and neck vessels and peripheral vascular:

BB's jugular veins are not visible upon inspection. Upon light inspection pulsations are noted bilaterally. There is no distention noted of the jugular vein bilaterally. Auscultation of the carotid artery is performed there is no swishing or blowing sounds noted and pulses are equal and strong bilaterally. Arteries are elastic with no thrills noted bilaterally. Palpation of the carotid arteries show no thrills and an elastic feeling is felt bilaterally. BB's apical pulse is not visible upon inspection. Palpation of the apical pulse is felt. There are no pulsations or vibrations palpated in the apex area (Weber, 2010, p. 366). Auscultation of the heart is performed on BB at this time. BB's heart rate is 70 beats per minutes with a regular rhythm noted. Identification of S1 and S2 are located at the apex of the heart. S1 corresponds with each carotid pulsation (Weber, 2010, p. 367). Listening to the aortic area by placing the stethoscope in the second intercostal space to the right of the sternal border (Weber, 2010, p. 358). The S2 is greater than the S1. The pulmonic area is found by placing the stethoscope over the third intercostal space to the left of the sternal border (Weber, 2010, p. 258). The S2 is great than the S1. Erb's point is found by placing the stethoscope over the 4th intercostal space to the left of the sternal border (Weber, 2010, p. 358). S1 and S2 are the same. Tricuspid area is found by placing the stethoscope over the fifth intercostal space to the left of the lower sternal border (Weber, 2010, p. 358). S1 is heard greater than S2. The mitral area is found by placing the stethoscope in the fifth intercostal space near the left midclavicular line (Weber, 2010, p. 358). S1 and S2 are heard. There are no extra heart sounds or murmurs are detected. BB's is asked to sit in other positions as S1 and S2 are auscultated they are heard normally.

Inspection of BB's arms find that they are symmetrical bilaterally with no difference in size and shape noted. There is no edema, venous patterning or discoloration noted bilaterally. BB's skin temperature in his hands, fingers, and arms is warm and dry bilaterally. Capillary refill is assessment is done on all 10 fingers and capillary refill is noted to be less than 2 seconds. BB's radial pulses are palpated bilaterally and are equally strong 3+ with a rate of 39 beats minute. They are resilient bilaterally. Ulnar pulses are palpated but could not be palpated. Brachial pulses are palpated bilaterally and are found to be 3+ with a rate of 38 beats per minute bilaterally. Epitrochlear lymph nodes are not palpable. The Allen test is performed on both hands. BB's color returned to his palms in 4 seconds once the pressure on the ulnar artery is released, this was the finding bilaterally. BB's color returned to his palms in 4 seconds once the pressure of the radial artery was released, this was the finding bilaterally. BB's legs are pink in color with no discoloration bilaterally. There is hair equally distributed on both legs and legs have no lesions noted. Legs are equal in size and shape with no swelling noted bilaterally. Upon palpation there is also no edema noted bilaterally. The temperature of BB's legs, toes, and feet are warm and dry bilaterally. BB's inguinal lymph nodes are non tender and movable bilaterally. Patients femoral pulses are palpated and are equal and strong 3+ bilaterally with a rate of 39 beats per minute. Auscultation of the femoral pulses is performed with no sounds noted bilaterally. BB's popliteal pulses were not found bilaterally. BB's doralis pedis pulses are palpated bilaterally and are equally strong 3+ bilaterally with a rate of 37 beats per minute. Palpation of BB's posterior tibial pulses are found to be strong 3+ bilaterally with a rate of 38 bilaterally. BB has not varicosities noted on either leg. BB has negative Homan's sign bilaterally. BB had no weak pulses in either leg thus no more testing needed to be performed.

Abdomen:

BB has slightly lighter skin on his abdomen than the skin on the rest of his body. No unusual color is noted. BB has a few fine veins that are visible on his abdomen. BB does not have any stretch marks or white striae or scaring on his abdomen. His abdomen does not have any lesions or rashes. The skin tone on BB's umbilicus is light in color like the rest of his abdomen. His umbilicus is midline and not deviated it is also recessed. BB's abdomen is slightly rounded and symmetrical. As BB raises his head his abdomen does not bulge. As BB breathes his abdomen rises and falls. There was not pulsation of the abdominal aorta noted or peristaltic waves. Active bowel sounds are heard in all four quadrants. There are no bruits heard over the abdominal aorta or renal, iliac, or femoral arteries (Weber, 2010, p. 428). There is no venous hum when listening with the bell of the stethoscope over the epigastric and umbilical area. Upon listening over the liver there is no friction rub noted. Percussion of BB's four quadrants is performed next and a tympany sound is noted with a dullness heard over his liver and spleen area. The scratch test is performed to in order to find the liver span. At the midclavicular line BB's liver span is 8cm. At the midsternal line BB's liver span is 5 cm. Percussion of BB's spleen is performed next there is no enlargement of the spleen detected. There is no tenderness noted upon blunt percussion on the liver and the kidneys. There is not tenderness noted in BB's abdomen upon light palpation. Deep palpation is performed on all four quadrants there is slight tenderness noted over the xiphoid, aorta, and sigmoid colon. There are no masses noted. There is no swelling, bulges or masses noted around the umbilicus. BB has a strong aorta pulse. Palpation of the liver indicates there is no hardness noted. The spleen is soft and non-tender. BB's right and left kidneys are palpated are and the right is slightly tender. BB does not have ascites, The Rovsing's test is performed next. BB did not have any rebound tenderness. Deep palpation of BB's left lower quadrant is done and released quickly with no rebound pain noted. Assessment of Psoas sign is done with no abdominal pain noted. No abdominal pain is noted when BB flex's his leg and knee and the leg is slightly rotated internally and externally. The hypersensitivity test is performed next with BB feeling no pain. There is not tenderness noted in BB's right upper quadrant to indicate cholecystitis.

Musculoskeletal:

BB's weight is evenly distributed as he walks. BB is able to stand on his heels and his toes. He feet point forward and his posture is erect. He swings his arms in opposition and his walk is rhythmic. BB does not fall backward has he stands (Weber, 2010, p.537). Upon inspection and palpation of BB's temporomandibular joint he moves it laterally with some clicking noted bilaterally. His mouth open without difficulty and his jaw protrudes and retracts without difficulty. BB has full ROM against resistance. He has no pain or spasms. Inspection and palpation of BB's sternoclavicular joint bilaterally there is no bony overgrowth or swelling, or redness, his joint is nontender (Weber, 2010, p. 538). BB's cervical and lumbar spines are concave while the thoracic spine is convex. His spine is straight when looked at from behind (Weber, 2010, p. 538). BB does not complain of any tenderness upon palpation of his spinous processes. They are firm and smooth. BB has flexion of his cervical spine of 45 degrees and extension of his cervical spine is also 45 degree. He complained of no pain or soreness. BB can bend his head/neck 40 degrees to the right and left without difficulty. He is able to rotate his head approximately 70 degrees. BB has full range of motion against resistance. BB has flexion of approximately 80 degrees in his thoracic and lumbar spine. His movement is smooth as his spinal processes are in alignment. BB is able to bend laterally approximately 35 degrees. Hyperextension is approximately 30 degrees while rotation is around 30 degrees. These movements are all performed without any pain to patient. BB did not have any pain upon performing the Lasegue's test. BB's legs are equal in length.

Inspection and palpation of BB's shoulders, arms and elbows are performed next. His shoulders are round and symmetrical. There is no redness, swelling noted. His clavicles and scapulae are even and symmetrical without any soreness noted upon palpation. ROM is tested next. BB is able to forward extent 180 degrees bilaterally and hyperextend 50 degrees bilaterally and adduction, 50 degrees, and abduction 180 degrees bilaterally and without difficulty. His external and internal rotation is about 80 degrees bilaterally. BB can flex, extend, adduct, abduct, rotate, and shrug shoulders against resistance without difficulty and pain (Weber, 2010, p. 544). BB's elbows are symmetrical bilaterally with no redness or swelling noted bilaterally. He has no tenderness and there are no nodules noted bilaterally. Flexion is approximately 160 degrees bilaterally while extension is approximately 180 degrees bilaterally. There is approximately 90 degrees of pronation and 90 degrees of supination bilaterally. BB has full ROM against resistance bilaterally (Weber, 2010, p. 545). BB's wrists are symmetrical and there is no redness or swelling noted bilaterally. There is no tenderness or nodules noted bilaterally. There is no tenderness noted upon palpation of BB's anatomic snuffbox bilaterally. BB has full ROM in wrists bilaterally. 90 degrees flexion, 70 degrees hyperextension, 55 degrees ulnar deviation and 20 degreesst radial deviation bilaterally. BB has full ROM against resistance in both wrists (Weber, 2010, p. 546). The Phalen's test is administered next with no tingling, numbness, or pain bilaterally noted.

BB's hands and fingers are symmetrical bilaterally. There is no tenderness noted and no nodules bilaterally. His fingers are in a straight line with no swelling, redness or deformities noted on any of his fingers. BB's ROM is approximately 30 degrees of abduction, full adduction of fingers, 90 degrees of flexion and 30 degrees of hyperextension. He can easily move his thumb away from his other fingers and he has approximately 50 degrees of thumb flexion. BB has full ROM against resistance bilaterally (Weber, 2010, p. 549).

BB has equally sized buttocks and his iliac crests are symmetrical in height. His hips are stable, non-tender, and without crepitus. BB has approximately 90 degrees of hip flexion with knees straight and 120 degrees of hip flexion with the knee bent and the other leg remaining straight bilaterally. He has approximately 45 degrees of abduction and approximately 25 degrees of abduction bilaterally. With BB's knee bend his leg was turned inward and then outward. He has approximately 40 degrees internal hip rotations and 45 degrees external hip rotations bilaterally. With BB lying prone he is asked to raise his leg up in the air. He has approximately a 15 degree hip hyperextension bilaterally. BB has full ROM against resistance (Walker, 2010, p. 550-551).

Inspection and palpation of BB's knees is performed next. His knees are symmetrical with hollows present on both sides of the patella with no swelling or deformities noted bilaterally. His lower leg is in alignment with his upper leg bilaterally. There is no tenderness noted upon palpation of both knees. His knee muscles are firm there is no warmth noted and no nodules bilaterally. BB has no bulging on the medial side of his knees bilaterally. The ballottement test is performed next there is no movement of the patella noted bilaterally. His patella rests firmly over his femur bilaterally. Upon palpation of the tibiofemoral space there is no pain or tenderness noted bilaterally. BB has normal ROM in his knees bilaterally. Approximately 120 degrees of flexion and 0 degree of extension and approximately 15 degrees of hyperextension bilaterally. BB has full ROM against resistance bilaterally. BB did not complain of either of his knees “locking up” (Weber, 2010, p. 551-553).

Inspection of BB's feet his toes point forward and they both lie flat. His toes and feet are in alignment with his lower leg bilaterally. He has smooth and rounded medial malleolar prominences with prominent heels and metatarsophalangeal joints bilaterally. He does have calluses on both of his feet on the tip of his toes and the balls of his feet bilaterally. During palpation of patient's ankles and feet there is no tenderness, swelling, warmth or nodules noted bilaterally. ROM is checked next. Patient has dorsiflexion of approximately 20 degrees of his ankle and foot bilaterally. He has approximately 45 degrees of plantar flexion of his ankle and foot bilaterally. Patient has eversion of approximately 20 degree and approximately 30 degrees of inversion bilaterally. BB has abduction of approximately 10 degree and approximately 20 degrees of abduction bilaterally. BB is asked to turn his toes under his foot which is flexion. He has approximately 40 degree of flexion and approximately 20 degrees of extension bilaterally. BB has full ROM against resistance bilaterally (Weber, 2010, p. 554-555).

Neurological:

Testing of CN I, olfactory, was performed on BB. He was able to correctly identify the smell of vanilla with is left nare occulted and lime with his right nare occulted. Testing of CN II, optic, was performed next. BB has 20/20 vision. BB is able to read a newspaper at 10 inches without difficulty. BB's round and red reflex is present, his optic disc is approximately 1.5 mm, it is round with well defined margins bilaterally. Testing of CN III, oculomotor, IV, trochlear, and VI, abducens, is performed next. BB's eyelid covers approximately 2 mm of his iris bilaterally. His eyes move in a smooth and coordinated motion in all six fields without difficulty bilaterally. BB's pupils constrict simultaneously bilaterally. Testing of CN V, trigeminal, is performed. Patient's temporal and masseter muscles contract bilaterally without difficulty. BB is able to identify sharp and dull stimuli as well as light touch to his forehead, cheeks and chin without difficulty. BB blinks his eyelids bilaterally. Testing of CN VII, facial, is performed next. BB can smile, frown, wrinkle his forehead, shows his teeth, puffs out his cheeks, purses lips, raises eyebrows, and closes eyes against resistance and without difficulty. BB's movements are symmetrical. Patient is able to correctly identify the taste of sugar on his tongue. Testing of CN VIII, acoustic/vestibulocochlear, is performed next. BB is able to hear a whisper from 2 feet away. Vibration is heard equally well in both his ears. The Rinne test is performed with results of 15 AC and 22 BC in both ears. CN IX, glossopharyngeal, and X, vagus, is tested. BB's uvula and soft palate rise bilaterally and symmetrical on phonation. BB's gag reflex is intact and BB is able to swallow without difficulty. He has no hoarseness noted. CN XI, spinal accessory, is performed. There is symmetrical, strong contraction of BB's trapezius muscles bilaterally. He also has a strong contraction of his sternocleidomastoid muscle on side opposite his turned face bilaterally. CN XIII, hypoglossal, is performed by asking BB to stick out his tongue, move it from side to side against resistance. This was performed without difficulty (Weber, 2010, p.576-581).

BB's muscles are fully developed and symmetrical bilaterally. His relaxed muscles contract voluntarily and have mild, smooth resistance to passive movements. His muscle groups are all equally strong against resistance and without flaccidity, spasticity, or rigidity. There is no fasciulations, tics or tremors noted on patient. BB's gait is steady and he swings his arms as he walks. BB is able to maintain balance with tandem walking. He walks on his heels and toes without any difficulty. BB is able to stand with arms at side and feet together with no swaying with his eyes open and closed. Patient is able to bend knee while standing on one foot bilaterally. He can hop on each foot without losing his balance. BB is able to touch his finger to his nose and his movement is smooth. BB is able to touch each finger rapidly, turns palms up and down rapidly. BB is able to run his heel smoothly down each shin without difficulty (Weber, 2010, p. 581-584).

BB is able to identify a light touch, a dull and sharp sensation along with hot and cold temperatures on various parts of his body. BB is able to identify vibration correctly. BB is able to identify directions of movements. A quarter was put in BB's right hand with eyes closed and he was able to identify it correctly. In his left hand a key was put while his eyes were closed. He was able to identify it correctly. BB is touched in various parts of his body and he is able to identify the areas touched. He is able to identify number written in the palm of his hand without difficulty. BB is able to identify two points on his fingertips, forearm, dorsal hands, back, and thighs without difficulty. BB is able to identify simultaneously touch without difficulty (Weber, 2010, p. 585-587).

BB's reflexes are tested next. BB's biceps reflexes are found to be 2+ bilaterally. His brachioradialis reflex is found to be 2+ bilaterally. His triceps are tested next and the findings are 2+ bilaterally. BB's patellar reflex is 2+ bilaterally. BB's achilles reflex is 1+ bilaterally and his ankle clonus has no rapid contractions noted bilaterally. BB's plantar reflex is within normal limits. Flexion of the toes occurred when the end of the reflex hammer stroked the lateral aspect of the sole from the heel bilaterally. BB's abdomen muscles contract when stroked above the abdomen on each side. His umbilicus deviated toward the side being stroked. There were no findings that indicated addition testing for meningeal irritation (Weber, 2010, p. 587-591).

References

Weber, J. & Kelly, J. (2010). Lab manual to accompany health assessment in nursing (4th ed.)

Philadelphia, PA: Lippincott Williams & Wilkins

Weber, J. & Kelly, J. (2010) Health assessment in nursing (4th ed.) Philadelphia PA: Lippincott

Williams & Wilkins