Physical Exam Paper

1951 Words8 Pages
Running head: PHYSICAL EXAMINATION (PE) WRITTEN DOCUMENTATION Nursing 200: Complete Physical Examination (PE) Written Documentation Indiana State University College of Nursing, Health, and Human Services Nursing 200: Complete Physical Examination (PE) Written Documentation The format for this paper is based on : Jarvis (2008). Examiner: , SN ISU Date: 4/12/09 Patient: S.C. Age: 20 Occupation: Full-time nursing student taking 14 hours Language spoken: English Gender: Marital Status Race: Caucasian Ethnic affiliation / association: American Measurements (2 points): • Weight (in lbs & kgs) 125 lbs 56.8kgs • Height (in in & cm) 60 inches 15.2 cm • Waist-to-hip ratio .82 • BMI 21.2…show more content…
Heart & Peripheral Vascular (2 points): Carotid arteries 2+ bilat, external jugular visible in supine position, not visible when elevated. No visible chest wall pulsations, no heave, lift, apical pulse in 5th intercostals space at midclavicular line, pulse 61, regular rate, rhythm. Aortic, pulmonic valves, S2>S1. Erb’s point, S2=S1. Tricuspid, mitral valves, S1>S2. No gallops, murmurs, extra heart sounds. All pulses present 2+ bilat, no lymphadenopathy. Legs absent of varicosities, tenderness, edema, atrophy, warm bil. Epitrochlear lymph nodes not palpable, no Homan’s signs. Thorax & Lungs (2 points): AP less than transverse diameter; respiratory rate and pattern relaxed, even; chest expansion symmetrical; tactile fremitus equal bilat; no tenderness, lumps, lesions; resonant to percussion over lung fields; vesicular breath sounds clear over lung fields; no adventitious sounds. Bronchial sounds, inspiration < expiration over trachea and larynx. Bronchovesicular, inspiration=expiration
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