Health Assessment
Physical Assessment Documentation Form
Date: __3/3/16

Patient Information Patient Initials | LD | Age | 30 | Sex | Female |

General Survey

Does patient appear to be their stated age? | Yes | Level of consciousness | Alert and Oriented x3 | Skin color | Caucasain | Nutritional status | No malnurishment noted, pt she eats three meals a day | Posture and position | Patient maintains good posture and position | Obvious physical deformities | No physical deformities noted | Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement | no problems with mobility noted, patient ambulates w/o assistance, ROM of joints intact, patient pt able to rotate feet, ankles, and arms, no Involuntary twitches or movements noted | Facial expression | No abnormal facial expressions noted, pt has nice smile | Mood and affect | patient appears to be in good spirits, patient has smile on face, pt cooperative and answers questions when prompted | Speech: articulation, pattern, content and appropriate, native language | patient speaks English appropriately, patient articulates and enunciates well, all content related to pt’s health | Hearing | patient denies hearing problems, patient able to hear and follow commands when directed | Personal hygiene | patient appears clean, no dirty skin visible, no foul smells noted | | | | | Measurements and Vital Signs Height | 5 foot, 4 inches | Weight | 130 lbs | BMI | 24% | Radial pulse: * Rate * Rhythm | 87 Normal Rhythm noted | Respirations: * Rate * Depth | 14 Normal depth noted, no distress noted, pt denies SOB | Blood pressure (indicate if sitting or lying) | Sitting 120/62 | Pain assessment | patient denies all pain | Physical Assessment Skin Hands and nails | patient has clean , well groomed hands and finger nails, no dirt or broken nails noted, no lesions noted on hands | Color and pigmentation | Slight pink, warm skin, no lesions noted | Presence of lesions? | No lesion noted anywhere on body, all skin intact | Temperature | 98.2 | Moisture | Dry | Texture | Smooth | Turgor | No tinting noted | | | Head and Face Scalp Hair Cranium | No lesions or rashes or balding noted in hair or scalp, cranium intact | Face (cranial nerve VII) | Asymmetry noted of facial expressions during conversation, patient smiles, and open and closes mouth well, able to see pt’s teeth when smiling | Temporal artery and temporomandibular joint | Patient able to move temporomandibular area with open mouth and moving jaw, temporal artery Thrill present, pulse present | Maxillary sinuses and frontal sinuses | no problems noted with sinuses, no drainage noted | | | Eyes External structures Eyelids, eye lashes, eyebrows | Eye lids intact, able to open and close, no lesions noted, eyebrows present, no problems noted with eyebrows, lashes present and full, pt denies c/o | Conjunctivae, sclerae cornea, and iris | Pupil of eye intact, sclearae is white and intact, conjunctivae intact, eye color green, iris intact | Pupil – size, shape, and light reflex | Light reflex noted in pupil, size and shape of pupil noted, no problems or abnormalities noted | Visual fields (cranial nerve II) | All visual fields intact | Convergence and Accommodation | eyes accommodate well, no problems noted | Extraocular muscles (cranial nerves III, IV, VI) | no problems noted, eyes able to open and shut, pt blinks involuntarily, pt able to squint eyes | Corneal light reflex | no problems noted, light reflex noted in corneal | Describe the purpose of an ophthalmoscope for assessing the eyes | To check reactivity of eyes, constriction of pupil | Ears External ear | Ears intact, no problems noted, no drainage noted, no lesions noted, pt denies c/o regarding ears, lobe intact | Any tenderness? | NO | Whispered voice test | helps detect hearing impairment, The patient was able to hear herself whispering. | Describe the purpose of the otoscope | checking ears for buildup and injuries, drainage, etc | Explain the Weber and Rinne tests | Rinne test involves tuning fork to be placed on the mastoid bone, and ask when patient no longer hears the vibration,and checks for air conduction and bone conduction Weber test involves stricking the tunning fork in placing in middle of head and ask what ear the sound is coming from, hearing sound in both ears could be a sign of hearing loss (Stubblefield, 2014) | Nose External nose | External nose skin intact, no lesion noted, smooth skin noted, small pores pt denies c/o, no problems noted | Patency of nostrils | Patency noted in nostrils, no drainage noted | Describe the purpose of the nasal speculum exam | Nasal speculum is used to widen the nasal passage for inspection | Mouth and Throat Lips and buccal mucosa | mucosa moist no problems noted | Teeth and gums | teeth and gums intact | Tongue, hard palate, and soft palate | all moist, intact, no problems noted | Tonsils | Tonsils in place, no redness, or patches noted | Uvula (cranial nerves IX, X) | Uvula intact, no redness or patches noted, no lesion noted | Tongue (cranial nerve XII) | Tongue pink and intact, no white patches or yeast noted | Neck Symmetry, lumps, and pulsations | Symmetry noted in neck, no lumps noted, pulsations present in veins | Cervical lymph nodes | No swelling noted in cervical lymph nodes | Carotid pulse (bruits if indicated) | Carotid pulse present and bounding | Trachea | Trachea straight, curvature or protrusions noted | ROM | patient able to fully rotate neck, shake head yes and twist head no | Thyroid gland | No swelling noted in thyroid gland, thyroid gland present | Chest and Lungs: Posterior and Lateral Thoracic cage configuration * Skin characteristics * Symmetric expansion * Tactile fremitus * Lumps or tenderness | no lumps or tenderness noted, skin intact, no lesions noted, thoracic cage with symmetry noted, vibration palpable on chest wall when patient is talking | Spinous process | Spinous process noted, no curvature noted | Percussion over lung fields | no dullness noted | CVA tenderness | patient denies tenderness | Breath sounds | Lungs clear upon auscultation | Adventitious sounds | None noted, lungs sounds clear | Chest and Lungs: Anterior Respirations and skin characteristics | no problems noted with skin, pt denies c/o, lungs sounds clear, 14 respirations noted per minute | Tactile fremitus, lumps, and tenderness | Vibration of chest noted when saying “Blue”, no problems noted, no tenderness noted, pt denies c/o | Percuss lung fields | no problems noted, lung fields resonant, except over area of heart on left side of chest | Breath sounds | no problems noted, no abnormal breath sounds noted | Heart Precordium: pulsations and heave | no problems noted, pulsations noted, no heave noted | Apical impulse (PMI) | 82 wnl | Precordium and thrills | + for thrill and Bruit over region of heart and lower thorax | Apical rate and rhythm | 82, normal rhythm noted | Heart sounds | no abnormal sounds noted | Upper Extremities ROM and muscle strength | muscle strength noted, pt able to grip well, ROM noted | Epitrochlear nodes | no problems noted, no swelling noted, able to palpate nodes | Discuss the process for assessing breasts and axilla | Would have pt lay flat , and raise left arm over head and exam breast by pressing counter clock wise from outer breast to inner breast including axilla | Neck Vessels Jugular venous pulsation | Jugular Venous pulsation present, no problems noted, no distention noted | Presence of jugular venous distension | No presence of jugular venous distension noted | Abdomen Contour, symmetry, skin characteristics, umbilicus, and pulsations | Symmetry noted in abdomen, small amount of contouring noted, no lesion noted in skin, umbilicus intact, pt belly button is tucked in, no bounding pulsations noted | Bowel sounds | Bowel sounds present in all four quadrants | Vascular sounds | Vascular sounds present in abdomen | Percussion | No pain or rebound tenderness noted, pt denies pain upon percussion, no dullness noted, liver span noted | Liver span in right MCL | liver span noted upon percussion no pain or swelling noted upon percussion, pt denies pain | Palpate Liver and Spleen | No pain noted upon palpation per pt, pt denies pain, no tenderness or swelling noted | Light and deep palpation | No rebound tenderness noted, pt denies pain upon palpation | Inguinal Area Femoral pulse | no problems noted, pulse present | Inguinal nodes | Nodes present, no swelling noted, no problems noted | Lower Extremities Symmetry, skin characteristics, and hair distribution | no problems noted, no lesions noted, hair distributed evenly, skin warm to touch, dry and intact | Temperature and pretibial edema | no problems noted, no edema noted, skin warm to touch | Pulses: * Popliteal * Posterior tibial * Dorsalis pedis | all pulses present | Toes * capillary refill | <3 seconds | ROM and Muscle Strength Ankles and feet | no problems noted, pt able to fully twist and move ankles and feet | Hip – ROM | no problems noted, ROM present, pt able to fully rotate hips | Sensation: * Face * Arms * Hands * Legs * Feet | sensation felt in all areas | Position sense | no problems noted, pt able to sense postion with eyes closed | Stereognosis | patient able to perceive object in hand with eyes closes, pt identified glove and pen in hands | Cerebellar function (heel to shin) | no problems noted, patient able to place heel to shin w/o problems. | Cerebellar function (finger to nose) | no problems noted, pt able to place finger to nose. | Deep tendon reflexes: * Biceps * Triceps * Brachioradialis * Patellar * Achilles | all reflexes noted. | Babinski reflex | reflex not present | Romberg sign | no problems noted | Touch toes | no problems noted, pt able to touch toes | ROM of spine | ROM present in spine, pt able to bend forward and backwards and twist at hips | Shallow knee bend | no problems noted, pt able to bend knee | Walk across room heel to toe | no problems noted, pt able to perform w/o problems, pt walked across the room heel to toe w/o problems or c/o | Walk on tiptoes, then walk on heels | no problems noted, pt able to perform w/o problems, pt able to walk on tiptoes, and walk on heels w/o problems or c/o |

Analysis of findings: 1-2 paragraph summary of your assessment findings – See item D. in Task directions and also task rubric Laci Dodson is a 30 year old white female who volunteered today for a physical assessment. She is alert and oriented x3. Her respirations are even and unlabored. She shows no sign of distress. No compliant of pain or discomfort. Her BMI is at 24%, which places her in the normal weight range for her height and age. Her current weight is 130lbs and height is 5 feet 4 inches. Laci should start a low impact exercise program with cardio and light weight lifting if desired. Laci is also encouraged to perform monthly breast examinations every month. Laci informed that monthly examinations of breast and axillary area are important for early detection of lumps in breast or axillary area. Laci is also recommended to obtain a healthier diet intake. Laci was informed that a healthier diet could help increase energy. A balanced diet is very important to obtain and maintain a healthy nutritional status. It is recommend that Laci follow-up with her Primary Care Physician before starting any lifestyle changes.

Source: List any references for completing documentation form. See item E in Task directions and rubric.

Stubblefield, H. (2014, January 22). Rinne and Webber Test. Retrieved December 2, 2016, from Health Line: http://www.healthline.com/health/rinne-and-weber-tests#Overview1