Health Assessment

1302 Words Mar 26th, 2016 6 Pages
Health Assessment
Physical Assessment Documentation Form
Date: __3/1/16________

Patient Information
Patient Initials
BR
Age
30
Sex
Female

General Survey

Does patient appear to be their stated age?
Yes
Level of consciousness

Alert and Oriented to person, place and time.
Skin color

Pinkish tan
Nutritional status

Well nourished
Posture and position

Good posture, sitting upright
Obvious physical deformities

None noted
Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement
Steady gait, no assistive devices, no involuntary movement
Facial expression

Symmetrical
Mood and affect

appears to be in good mood
Speech: articulation, pattern, content and appropriate, native
…show more content…
Soft palate pink and smooth.
Tonsils

Tonsils not present
Uvula (cranial nerves IX, X)
Uvula rises midline on phonation
Tongue (cranial nerve XII)
Symmetric, protrudes midline

Neck
Symmetry, lumps, and pulsations
Symmetric, no masses, tenderness.
Cervical lymph nodes

Soft, non-tender.
Carotid pulse (bruits if indicated)

2+ and equal bilaterally. No bruits.
Trachea

Midline
ROM

Full ROM
Thyroid gland

non-palpable, non-tender.

Chest and Lungs: Posterior and Lateral
Thoracic cage configuration • Skin characteristics • Symmetric expansion • Tactile fremitus • Lumps or tenderness

Pinkish Tan, warm
AP<transverse diameter
Symmetrical
Equal bilaterally
None, No tenderness
Spinous process

Normal spinal profile, no scoliosis
Percussion over lung fields

Lung fields resonant
CVA tenderness

No tenderness
Breath sounds

Clear, equal bilaterally
Adventitious sounds

none

Chest and Lungs: Anterior
Respirations and skin characteristics

Normal, Pinkish tan warm, no lesions.
Tactile fremitus, lumps, and tenderness Equal bilaterally, no lumps tenderness
Percuss lung fields

Lung fields resonant
Breath sounds

Clear in all lobes bilaterally

Heart
Precordium: pulsations and heave

No abnormal pulsation, no heaves
Apical impulse (PMI)

Apical pulse at 5th ICS in left MCL
Precordium and thrills

no thrills
Apical rate and rhythm

62 bpm , regular rhythm
Heart sounds

S1- S2

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