Complete Physical Assessment

ABDOMEN: The lung basis appeared unremarkable. The liver, spleen, gallbladder, adrenals, kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seen constant with acute appendicitis. Osseous structures of the abdomen appeared unremarkable. No free air was seen.

Peripheral pulses posterior tibial and dorsalis pedis 2+ bilaterally. No edema on legs. Apical pulse regular rate and rhythm; s1, s2 noted. No murmurs, rubs or gallop rhythms. Denies dizziness, and fainting. Resp RR between 36-40 SpO2 85% per oximetry on 2 liters oxygen by n/c. Difficulty breathing and complaints of chest tightness. Patient unable to lay flat. Lung sound bilateral wheezes and crackles in right lower lobe. All other lobes clear A&P. Cough with yellow sputum. Tachypnea. Head of bed 45 degree. GI Last bowel movement 2 days ago, hard, long brown stool. Complains of constipation related to medication. Bowel sound are WNL in all 4 quadrants. Abdomen is soft, with no palpable masses. Poor appetite. Like sweet foods. Does not like vegetable or fruits. Like sodas, beer, scotch. Little water intake. GU Urinates every 2-3 hours. Yellow. No odor of urine. No history of UTI. One vaginal infection 2 years ago. No abnormal periods, last menstrual period 3 weeks ago. No pain or discharge. Skin Hair poorly groomed, dirty and oily. Nail are dirty and appear to be bitten. Skin clammy and moist with flushed color. IV IV of D5W at 125 mL in left forearm with 18

Abdomen: The lipases appeared unremarkable. The liver, spleen, gallbladder adrenals, kidneys, pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seemed consistent with acute appendicitis. All the structures of the abdomen appeared unremarkable. No free air was seen.

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

The patient complained of right lower quadrant pain and of feeling faint. Dr. O'Donnel documented a chief complaint, a brief history of present illness, and a systemic review of the gastrointestinal system and respiratory system. Dr. O'Donnel also documented a complete examination of all body systems, which included all required elements. Medical decision making was of moderate complexity.

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appeared her stated age and appeared in good health. She was in no acute distress. She was alert, satisfactorily groomed, and casually dressed. She was cooperative and appropriate in the meeting. She had normal motor activity, with no unusual gestures or mannerisms. She made eye contact appropriately. her affect was appropriate. Client ambulates with a cane. She was oriented to person, place, time and situation. She denied suicidal or homicidal ideation.

HEENT: No thyroid enlargement, masses or adenopathy, JVP was 5 cm above sternal Angle, carotid pulse was strong and regular

Patient Presentation: Benjamin Fowler arrived 15 minutes late for his appointment today. He was accompanied by his sister, Paula Fowler. She joined us in the interview to assist Benjamin and to answer some questions concerning Benjamin's behavior. Benjamin is a 27-year-olds African American male. He wore a t-shirt with dress pants and tennis shoes to his interview. Benjamin looked like he had not showered recently. Benjamin had issues focusing on the questions during the interview. He also was distracted by objects in the office during the interview. Benjamin also spoke in a quick manner. Benjamin was not able to tell me what day it was or where he was.

Cardiovascular Assessment: No visible pulsations, no heaves or lifts. Apical pulse present in the fifth intercostal space at the left midclavicular line. Auscultation of apical rate 62 beats per minute, normal rhythm regular S1 - S2 heart sounds present. Pulsations present when supine and disappear at a 45 degree angle position. Extremities are brown color without redness, cyanosis, lesions or varicosities bilaterally. Temperature warm bilaterally, Allen test was negative. Homan’s sign negative. Carotids: +2 and present bilaterally. Right Radial +2, left radial +1 , Right Brachial: +2

The patient is a 45 year old man who had GI surgery 4 days ago.  He is NPO, has a nasogastric tube, and IV fluids of D51/2saline at 100 mL/hr.  The nursing physical assessment includes the following:  alert and oriented; fine crackles; capillary refill within normal limits; moving all extremities, complaining of abdominal pain, muscle aches, and "cottony" mouth; dry mucous membranes, bowel sounds hypoactive, last BM four days ago; skin turgor is poor; 200 mL of dark green substance has drained from NG tube in last 3 hours.  Voiding dark amber urine without difficulty.  Intake for last 24 hours is 2500mL.  Output is 2000mL including urine and NG drainage.  Febrile and diaphoretic; BP 130/80; pulse 88; urine specific gravity 1.035; serum

| The liver is located in the right upper quadrant and would elicit a dull percussion note.

Head and Neck: Patient skull is of normocephalic, atraumatic and without masses. The patient 's facial expression and facial contours are normal. The parotid glands are normal. The sinuses are non-tender. Palpation of the temporal and masseter muscles reveals normal strength of muscle contraction. There is symmetry of the nasolabial folds. There is no facial droop noted. Trachea midline. Thyroid is smooth, no goiter or

Josephine has come in today because she is having issues with her weight and currently struggling with an eating disorder. Conducting a physical and nutritional assessment would be the best way to determine where she is experiencing deficiencies and what might be causing these problems. The first assessment would be the anthropometrics phase. These are measurements of the body such as weight, circumference, skin fold thickness and body max index (BMI). BMI tests are a common measurement technique many practitioners use mainly because it is easy to perform and inexpensive. Josephine has a BMI of 21.4, which is considered a normal and healthy BMI for her height and weight.

* Prior to performing A.’s physical assessment, I gathered information over her diagnosis tonsillectomy, adenoidectomy, and vitiligo and any passed medical problems to be aware of. I then introduced myself to A. and her family and asked her if she wanted her grandparents to stay in the room during her physical assessment. I then explained the process of starting at her head and working downward to her feet by providing privacy throughout the whole assessment. First I started, by observing her appearance and behavior and how well A. communicated with me, A.’s behavior was calm, cooperative and appropriate for her age. I assessed PERRLA in both eyes, her pupils were a 3, equal, round, reactive to light and accommodated. I assessed her mucus membranes which were pink and moist along with assessing her throat by looking at the back of throat and checking for bleeding , whitish area, and odor. I then asked her if she had any frequent swallowing and trickling of blood in her throat. A. stated she did not have any frequent swallowing or blood in her throat just some soreness and discomfort in her throat. A.’s throat had white areas on both sides where the tonsils were removed with no bleeding. I auscultated her heart and lungs, and heard S1S2 and her