Head to Toe Write up PDF

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Head to toe physical exam write up...

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NUR 245 Complete Physical Examination Date: 06/20/18 Student: Samuel Kollmorgen Patient Initials: H.K. Age: 25 Occupation: Student

Gender: Male

General Survey of Patient 1. Appears stated age: Pt seems appropriate for stated age. 2. Level of consciousness: Pt is alert and oriented x3 3. Skin color: PWD, appropriate appearance for stated age and ethnicity 4. Nutritional status: Stated dietary intake is adequate, pt seems well nourished. 5. Posture and position: Upright, erect posture. No abnormalities detected. 6. Obvious physical deformities: No obvious physical deformities seen. 7. Mobility: Normal gait and posture, pt is mobile w/o assistive device. 8. Facial expression: No signs of distress, pain, or anxiety. Face symmetrical. 9. Mood and affect: Pt is content and displays a normal affect. 10. Speech: Pt’s speech is appropriate and understandable. 11. Hearing: Pt does not state to have any issues hearing. 12. Personal hygiene: Pt is well groomed and appropriately dressed. Measurements and Vital Signs 1. Weight: 178 lbs 2. Height: 70 in. 3. Body mass index: 25.5 4. Vision using Snellen eye chart: 20/20 bilaterally with corrective lenses. 5. Radial pulse, rate, and rhythm: 78, 2+ radial pulses RRR 6. Respirations, rate, depth: 16, Normal work of breathing 7. Blood pressure: 136/72 right arm, sitting. 8. Temperature (if indicated): N/A 9. Pain assessment: 0/10 Skin 1. Hand and nails: No clubbing or deformities, cap refill < 2 sec, skin PWD, nail beds pink. Color and pigmentation: Color tan-pink, even pigmentation, no lesions noted. Temperature: Warm Moisture: Dry Texture: Smooth Turgor: Good turgor, no signs of tenting. Any lesions: No notable lesions. Head and Face

1. Scalp, hair, cranium: Normocephalic, normal hair distribution, no lesions or deformities. Skin PWD. 2. Face (cranial nerve VII): Pt facial expressions symmetrical, no deficit noted. 3. Temporal artery, temporomandibular joint: Temporal pulse present bilaterally, TMJ shows no signs of crepitus, smooth movement of joint. 4. Maxillary sinuses, frontal sinuses: Nontender, no signs of erythema or swelling. Eyes 1. Visual fields (cranial nerve II): Visual field in-tact, 20/20 vision bilaterally w/ corrective lenses 2. corneal light reflex: symmetrical light reflection bilaterally 3. Cardinal positions of gaze (cranial nerves III, IV, VI): Smooth tracking, no nystagmus, extraocular movement intact. 4. Pupillary light reflex: PERRLA 5. External structures: Lacrimal apparatus non-tender. Normal hair distribution. 6. Conjunctiva: Clear, No discharge or redness. 7. Sclerae: White, no abnormalities. 8. Corneas: Red reflex present bilaterally, vessels present in all four quadrants. 9. Iris: Intact 10. Pupils: 6mm, equal bilaterally. Ears 1. External ear: Normal alignment and placement, skin PWD, no lesions or discharge noted. 2. Any tenderness: Tragus and Auditory meatus nontender. 3. Otoscope, ear canal: Clear ear canal. TM opaque and intact bilaterally, light reflects appropriately. No signs of infection. 4. Test hearing (cranial nerve VIII), voice test: pt able to hear all words. Nose 1. External nose: Symmetrical, skin PWD, no deformities, tenderness lesions, discharge or redness. 2. Patency of nostrils: Both nares are patent. 3. Nasal mucosa: Pink, no polyps or lesions. 4. Septum: No deviation or perforation 5. Turbinates: Pink, no abnormalities detected. Mouth and Throat 1. Lips and buccal mucosa: Mucosa pink, no lesions or exudate. 2. Teeth and gums: can clench teeth together, normal dentition. Gingivae pink. 3. Tongue: Smooth, pink, no lesions. 4. Hard/soft palate: Pink, no lesions or masses. 5. Tonsils: 1+, no exudate or signs of infection. 6. Uvula (cranial nerves IX, X): able to say “ah”, Uvula rises symmetrically, gag reflex present.

7. Tongue (cranial nerve XII): Protrudes midline, no tremor. Neck 1. Symmetry, lumps, pulsations: Symmetrical, no abnormal lumps, no goiter present, no abnormal pulsations. 2. Cervical lymph nodes: All lymph nodes nontender and nonpalpable. 3. Carotid pulse (bruits if indicated): 2+ bilaterally 4. Trachea: Midline 5. ROM and muscle strength (cranial nerve XI): Full ROM and 5/5 strength. no pain Chest and Lungs, Posterior and Lateral 1. Thoracic cage configuration: Normal configuration, AP < transverse diameter 2. Skin characteristics: PWD, no lesions or abnormalities. 3. Symmetry: Symmetrical bone and muscle placement, normal posture. 4. Symmetric expansion: Symmetric chest expansion bilaterally. 5. Tactile fremitus: Equal bilaterally 6. Lumps and tenderness: no tenderness or lumps 7. Spinous processes: No step-offs or deformities. Non-tender. 8. Percussion over lung fields: Resonant to percussion over all lung fields. 9. CVA tenderness: Non-tender 10. Breath sounds: Normal Breath sounds 11. Adventitious sounds: No adventitious lung sounds. Chest and Lungs, Anterior 1. Respirations and skin characteristics: Normal WOB, no accessory muscle use. Skin PWD, no lesions or lumps. 2. Tactile fremitus, lumps, tenderness: Tactile fremitus equal bilaterally, no lumps or tenderness. 3. Percuss lung fields: Resonant to percussion over all lung fields. 4. Breath sounds: Normal Breath sounds Upper Extremities 1. ROM and muscle strength: Full ROM, muscle strength 5/5. no pain 2. Epitrochlear nodes: Nonpalpable 3. Pulse: a. Brachial: 2+, equal bilaterally b. Radial: 2+, equal bilaterally c. Ulnar: 1+, equal bilaterally 4. Capillary Refill: < 2 seconds

Breasts- Document Normal Findings as per breast/manikin model 1. Symmetry, mobility, dimpling: Symmetric, no dimpling or retractions. 2. Supraclavicular and infraclavicular areas: Skin PWD, smooth, no masses or lesions.

3. Breast palpation: Contour and consistency firm and homogenous, no masses or tenderness. 4. Nipple: No redness or discharge. 5. Axillae and regional nodes: No swelling, erythema, or lymphedema. Lymph nodes nontender and nonpalpable. 6. Teach breast self-examination: One a month, 4-7 days after the start of your menses, check for symmetry in the mirror while raising hand above head, placing on hips, and pushing hands together. Palpate the breasts in the shower in an up and down motion, pay attention to the upper outer quadrant. Call the doctor if any suspicious masses are palpated. Neck Vessels 1. Jugular venous pulse: Present, No JVD, normal pulsation. Heart 1. Precordium: No Pulsations or heaves. Skin PWD, no lesions or masses. Hair distribution is normal. 2. Apical impulse: Can be seen at left second interspace. 3. Precordium, thrills: No thrills 4. Apical rate and rhythm: RRR 5. Heart sounds: S1/S2 normal, no S3, S4 sounds or murmurs. Abdomen 1. Contour, symmetry: Straight contour, symmetrical. 2. Skin characteristics: PWD, no masses or lesions noted 3. Umbilicus and pulsations: Abdominal aortic pulsation present. 4. Bowel sounds: Normal bowel sounds, present in all four quadrants. 5. Vascular sounds: Normal Aortic, Renal, Iliac, and Femoral vascular sounds. No bruits. 6. Percussion: Tympany through all four quadrants, dullness at border of liver. 7. Spleen: Nonpalpable, no swelling or tenderness. 8. Light palpation: No rigidity, guarding or tenderness. Negative fluid wave. 9. Palpation of liver, spleen, kidneys, aorta: Palpable liver and kidneys, nontender and no abnormalities detected. Spleen and aorta nonpalpable. Lower Extremities 1. Symmetry: Symmetric 2. Skin characteristics, hair distribution: Skin PWD, color uniform, no masses, lesions or signs of trauma. Hair distribution is normal. 3. Pulse, popliteal: Nonpalpable 4. Posterior tibial: 2+ RRR, equal bilaterally 5. Dorsalis pedis: 1+ RRR, equal bilaterally 6. Temperature, pretibial edema: No edema or erythema, skin warm and dry. 7. Toes: Nail beds pink, cap refill < 2 seconds, sensation normal, no masses or lesions. 8. ROM and muscle strength, hips: Full ROM, 5/5 strength

9. Knees: Full ROM, 5/5 strength 10. Ankles and feet: Full ROM, 5/5 strength, no pain Neurologic 1. Sensation, face: Pinprick, light touch intact. 2. Arms and hands: Pinprick, light touch intact. 3. Legs and feet: Pinprick, light touch intact. 4. Position sense: N/A 5. Stereognosis: Able to identify coin. 6. Cerebellar function, finger-to-nose: Smoothly intact 7. Cerebellar function, heel-to-shin: Smoothly intact 8. Deep tendon reflexes a. Biceps: 2+ b. Triceps: 1+ c. Brachioradialis: 1+ d. Patellar: 2+ e. Achilles: 2+ f. Plantar reflex: 2+, no Babinski sign Musculoskeletal 1. Walk across room: Movement smooth, normal gait 2. Walk, heel to toe: Movement smooth 3. Walk on tiptoes, then walk on heels: Movement smooth 4. Romberg sign: Negative 5. Shallow knee bend: Pt able to perform knee bend bilaterally 6. Touch toes: N/A 7. ROM of spine: Full ROM, no pain Male Genitalia 1. Teach testicular self-examination: Once a month, while taking a warm shower, cup your testicle in one hand and with the other hand lightly palpate both testicles. Pay attention for any abnormal lumps, and if found see your doctor....