Health Assessment

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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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