Screening Physical Assessment

The physician performs a problem focused history and physical examination with straightforward decision making 99201

Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include the relevant data for your client.

REMEMBER: Make notes of the physical examination findings, ensuring that you have addressed all of the components listed on the Return Demonstration Checklist. Students are also encouraged to take notes about their experiences while conducting the physical examination for reference when creating the assignment, particularly the reflection section.

Trauma one Pediatric Emergency Department! Trauma one Pediatric Emergency Department responding over! Rescue Unit 29 transporting a 12 year-old boy, named Mike, hit by a car while riding his bicycle. This is a hit and run accident, but other motorists called a rescue unit. The child was not wearing a helmet. Facial bleeding is under control, but he suffered facial and head trauma. There appeared to be no facture of the extremities. Presently he is awake and semi-alert. Vitals signs: BP 120/56, Pulse 120, Oxygen

The job that I have selected is a courier position with FedEx. The job requires lifting and transporting boxes either assisted (with a hand truck) or unassisted. Physical stamina is also required, as some shifts run in excess of ten hours per day doing this kind of work.

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

SEIDAL, H, M., BALL, J, W., DAINS, J, E., BENEDICT, G, W. (2006) Mosby’s Guide to Physical Examination. 6th edn. Philadelphia: Elsevier.

aggravated by physical exercise. A fitness instructor can then assess and prescribe the correct fitness plan for the individual. Screening takes place in the form of a questionnaire and physiological measurements.

Friday, December 1st Mr. Franco has gracefully allowed us to perform a Vision Screening Assessment to the MLK 27 students that participate in the Migrant Program. Our staff will be there from 9:00 to 10:00 AM to administer the test. We will need to have access to a room with a phone so we can administer the test and call the students to their class.

Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems

This assessment was challenging at first but It gets easier as I go along. It was challenging because EM is not very cooperative at times and have to wait for him to finish his morning nap. EM has multiple medical diagnoses and at his age I was impressed that he didn’t need assistance when ambulating. He can turn and change position with no problems and able to hear my requests with ease. Doing the head to toe focused assessment was my favorite part.

A head to toe assessment is the visual and manual inspection of each body part starting at the head and scalp and continuing downward to the feet and toes. These four techniques will be used: Inspection=what can be seen, Palpation=what can be felt, Percussion=what can be heard and Auscultation=what can be heard using a stethoscope. It is very important to perform a complete head to toe assessment on all patients at the beginning of the shift as this information will help determine if the patient is getting worse or starts having any unforeseen problems.

There can be multiple benefits to performing a physical examination. You can find any lumps or bruises the patient didn't notice. Telling the patient the benefits about a physical exam is important. Explain to the patient the benefits by telling them what could be caught if they perform basic physicals, catch something that could be concern to the patients care or well being. A complete physical is when the person examines the entire body and check every part. Focus physical is when a certain part of the body is the main focus of the

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.

1. Discuss the age specific physical assessment/s properly completed this week. State techniques you used in completing the physical assessment of your patient. Often these techniques will differ from an examination of an adult.