Health Assessment Physical Assessment Documentation Form Date:July 26, 2015 Patient Information Patient Initials Age 25 Sex General Survey General Observations Does patient appear to be their stated age? No, patient stated a false age for student learning purposes. Level of consciousness Patient is Alert and oriented to person, place, and time. Skin color Skin color is appropriate for patient race.
Nutritional status Well nourished Posture and position Appropriate position and posture for age Obvious physical deformities None noted Mobility: gait, use of assisted devices, ROOM of joints, no involuntary oven t Appropriate gait No use Of assisted devices ROOM appropriate for BEE & BLEW No involuntary movement noted Facial expression Smiles, and uses appropriate gestures Mood and affect Pleasant and appropriate Speech: articulation, pattern, content and appropriate, native language Articulate speech, pattern, and content.
Patient speaks native language of English Hearing Bilateral ears intact, hearing function normal Personal hygiene Appears clean, hygiene appropriate Measurements and Vital Signs Weight 195 lbs Height Not assessed, patient states 5′ 1 1″ IBM 27. , overweight Radial pulse: rate rhythm 0 rate regular Respirations: depth 16 breaths per minute regular, no SOB, or tachyon noted Blood pressure (indicate if sitting or lying) Sitting 117/72 Temperature (if indicated) Not assessed Pain assessment Not assessed (although no tenderness throughout) Physical Assessment Skin Hands and nails Appropriate color, equal size/shape, cap refill less than 3 seconds Color and pigmentation Appropriate color for patient race Temperature Warm Moisture dry Texture smooth Tu rigor Skin tutor appropriate for age, non-tenting Presence of lesions? O lesions noted Head and Face Scalp Hair Cranium Scalp dry and intact Beginning of thin inning hair Cranium symmetrical Face (cranial nerve VII) Cranial nerve 7 intact, during smiling and puffing cheeks Temporal artery and temporariness’s joint Intact, no pain when assessing temporariness’s joint (opening mouth, wiggling jaw) Maxillary sinuses and frontal sinuses No sensitivity when pressure applied to sinuses Eyes Visual fields (cranial nerve II) Snell already finished with 20/20 vision noted, patient able to see peripherally when fingers were “wiggling” by RAN.
Cranial never II intact Extravehicular muscles, corneal light reflex, and cardinal positions of gaze (cranial nerves Ill, IV, VI) PEARL performed, corneal light reflex, patient able to track finger in “H” pattern by RAN. Cranial nerves Ill, IV, VI intact. External Structures Eye lids intact, appropriate hair on eye lashes, no redness noted. Conjunctivas, sclera, and corneas Conjunctivas pink and normal in color. Pupils pupils round a restrictive to light Describe the purpose of an Ophthalmologic for assessing the eyes A lighted instrument that is used to examine the inside of the eye, including the retina and the optic nerve.
Ears External ear Clean, dry, intact Any tenderness? No tenderness stated by patient Purpose of the outscore To observe internal structures of the outer and inner ear. Test hearing and conduct the voice test Cranial nerve VIII intact, patient able to hear fingers rubbing an arms length from ears. Explain the Weber and Urine tests Assessing if a patient has conductive or censoriously hearing loss using a GHz tuning fork. Weber: top of head Urine: on mastoid bone Nose External nose Normal in color and appearance, symmetrical. Potency of nostrils Bilateral nostrils patent.
Describe the purpose of the speculum evaluate nasal mucosa, septum, and turbinated To assess normal color mucosa, septum, and visualizing inside the turbinated tit light. Mouth and Throat Lips and abacas mucosa Lips equal, no drooping of mouth, pink. Pink abacas mucosa. Teeth and gums Teeth clean, no caries noted. Gums pink and intact. No bleeding. Tongue, hard palate, and soft palate Tongue even, normal color and papillae. Hard and soft palate light pink in color. Tonsils Tonsils intact, no inflammation. Uvula (cranial nerves IX, X) Uvula intact, cranial nerves IX, X.
Patient able to say “Ah” and swallow. Tongue (cranial nerve XII) Cranial nerve XII intact, patient able to stick tongue out. Neck Symmetry, lumps, and pulsations Neck symmetrical, no lumps or pulsations. Cervical lymph nodes No signs of enlarged cervical lymph nodes or tenderness Carotid pulse (bruits if indicated) No bruits heard on carotids. Trachea Trachea even and midlines. No deviation. ROOM ROOM normal for patient and age. Full ROOM. Thyroid gland Patient able to swallow water while assessing thyroid. Intact, moves when swallowing.
No tenderness. Chest and Lungs: Posterior and Lateral Thoracic cage configuration Skin characteristics Symmetric expansion Tactile premises Lumps or tenderness Thoracic cage symmetrical. Skin intact, normal color throughout. Symmetric expansion when performing deep breaths. Patient able to state “99” when assessing tactile premises. Tactile vibrations felt. No lumps or tenderness when assessing chest. Copious process Copious process normal. No enlarged bony prominences noted. Percussion over lung fields Resonance noted while percussion lung fields.
C.V. tenderness Patient states no tenderness over C.V.. Breath sounds Bilateral clear airways. Slight diminished to bilateral lower lobes. Clear upper airway. Adventitious sounds Chest and Lungs: Anterior Respirations and skin characteristics Skin normal for patient race. Warm. Respirations even, non-labored. Tactile reemits, lumps, and Tenderness Tactile premises felt upon palpation. No lumps or tenderness noted. Apercus lung fields Resonance to lung fields. Even clear breath sounds. Upper Extremities ROOM and muscle strength Patient has full ROOM to BIKE.
Muscle strength strong against resistance. Petrodollar nodes No enlargement of nodes. Discuss the process for assessing breasts and axial use the pads of middle 3 fingers of one hand, press downward using a circular motion while patients hand/arm is behind their head. Apply steady pressure, busing down to level of chest wall. Palpate 3 levels of depth. Palpate the nipple and areola regions. Neck Vessels Jugular venous pulse Palpated. Not visual. Presence of jugular venous distension JIVED not detected.
Heart Presidium: pulsations and heave Pulsations felt, no heave noted. Apical impulse and PM Apical pulse coincided with carotid pulse. Rate of 70 BPML. Presidium and thrills No thrills noted. Apical rate and rhythm Apical rate of 70, regular rhythm. Heart sounds SSL & SO noted. No sounds of any murmurs. Abdomen Contour, symmetry, skin characteristics, umbilicus, and pulsations Contour of abdomen is even, symmetrical, even colored skin, umbilicus normal for attention, and pulsations noted. Bowel sounds Patient has active bowel sounds in all 4 quadrants.
Vascular sounds Calculated aorta, renal arteries, iliac arteries, and femoral arteries. Unable to be heard with stethoscope. Percussion Tympanis over abdomen, and dull over liver. Liver span in right MAC ever assessed and below ribcage using the hook technique. Spleen Unable to palpate, but assessed. Light and deep palpation Light and deep palpation performed on patient. Liver normal size. Palpation of liver, spleen, kidneys, and aorta Palpation of liver, spleen, kidneys, and aorta. Patient tolerated palpation of internal organs.
Inguinal Area Femoral pulse +2 pulses femoral pulse Inguinal nodes No inguinal lymph nodes noted Lower Extremities Symmetry, skin characteristics, and hair distribution BLEW symmetrical and even, normal hair growth and distribution, skin warm, appropriate for ethnicity. Pulses: Politely posterior tibiae dorsal piped Politely, posterior tibiae, dorsal piped: +2 pulses , even, regular Temperature and pretrial edema Temperature even, patient BLEW warm, no pretrial edema noted. Toes Toes intact, cap refill less than 3 seconds, fingernails clean. No clubbing. ROOM and Muscle Strength
Ankles and feet Full ROOM in ankles and feet, strong in muscle strength against resistance. Neurological patient neurologically intact. Coax. Sensation: face arms hands legs feet Patient able to detect dull and sharp sensations on face, arms, hands, legs, and feet. Sensation intact. Position sense Patient able to detect when finger/toes are lifted up or down. Stereoscopes Intact. Patient able to detect foreign object placed in hand without vision. Cerebella function (finger to nose) Patient able to place finger to nose while eyes were shut with both arms. Cerebella function (heel to shin)
Patient able to stand without losing balance during heel to shin assessment. Deep tendon reflexes: biceps triceps aphrodisiac’s patellar Achilles +2 brisk response to all deep tendon reflexes. Banking reflex Patients toes curled in resulting in negative Banking reflex. Musculoskeletal Walk across room heel to toe Patient able to walk across room heel to toe with no issues in losing balance. Walk on tiptoes, then walk on heels Patient able to walk across room on tiptoes and heels without losing balance. Remember sign Patient able to close eyes and stand without losing balance during Remember est..