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Health Assessment Physical Assessment Documentation Form Date: __3/3/16 Patient Information Patient Initials | LD | Age | 30 | Sex | Female | General Survey Does patient appear to be their stated age? | Yes | Level of consciousness | Alert and Oriented x3 | Skin color | Caucasain | Nutritional status | No malnurishment noted, pt she eats three meals a day | Posture and position | Patient maintains good posture and position | Obvious physical deformities | No physical deformities noted | Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement | no problems with mobility noted, patient ambulates w/o assistance, ROM of joints intact, patient pt able to rotate feet,…show more content…
| Describe the purpose of the otoscope | checking ears for buildup and injuries, drainage, etc | Explain the Weber and Rinne tests | Rinne test involves tuning fork to be placed on the mastoid bone, and ask when patient no longer hears the vibration,and checks for air conduction and bone conduction Weber test involves stricking the tunning fork in placing in middle of head and ask what ear the sound is coming from, hearing sound in both ears could be a sign of hearing loss (Stubblefield, 2014) | Nose External nose | External nose skin intact, no lesion noted, smooth skin noted, small pores pt denies c/o, no problems noted | Patency of nostrils | Patency noted in nostrils, no drainage noted | Describe the purpose of the nasal speculum exam | Nasal speculum is used to widen the nasal passage for inspection | Mouth and Throat Lips and buccal mucosa | mucosa moist no problems noted | Teeth and gums | teeth and gums intact | Tongue, hard palate, and soft palate | all moist, intact, no problems noted | Tonsils | Tonsils in place, no redness, or patches noted | Uvula (cranial nerves IX, X) | Uvula intact, no redness or patches noted, no lesion noted | Tongue (cranial nerve XII) | Tongue pink and intact, no white patches or yeast noted | Neck Symmetry, lumps, and pulsations | Symmetry noted in neck, no lumps noted, pulsations present in veins |

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