Comprehensive Health Case Study
NU333 Complete Physical Assessment
Jarvis: Physical Examination and Health Assessment, 6th Edition Complete Physical Examination Form
COMPLETE PHYSICAL EXAMINATION
Date __8/31/2013______________
Patient __Jane Doe_________________________ Age __33_ Sex _F__
Occupation Healthcare worker Client Representative/Interpreter: __none__
Examiner _Emanuel Singleton RN________
General Survey of Patient 1. Appears stated age: Yes_____________________________________ 2. Level of consciousness: Alert and oriented x 3 (person, place and time) 3. Skin color: Brown 4. Nutritional status: Appears well nourished 5. Posture and position: Upright, WNL 6. Obvious physical deformities: None noted 7. Mobility:
gait, use of assistive devices, ROM of joints, no involuntary movement: WNL 8. Facial expression: WNL 9. Mood and affect: WNL 10. Speech: articulation, pattern, content appropriate, native language: Speaks English, WNL 11. Hearing: WNL 12. Personal hygiene: well groomed, WNL
Measurement and Vital Signs 1. Weight: 82.2 kg 2. Height 62 inches 3. Skinfold thickness, if indicated: Not assessed 4. Vision using Snellen eye chart: OD 20/20_OS 20/20_Correction? Not applicable 5. Radial pulse, rate, and rhythm 88, Normal 6. Respirations, rate, depth 20, equal and unlabored 7. Blood pressure Right arm 112/62 sitting _____________(sitting or lying?) Left arm _114/64 sitting______________(sitting or lying?) 8. Temperature (if indicated) 37.0 C, oral 9. Pain assessment Denies all pain and distress
STAND IN FRONT OF PATIENT, PATIENT IS SITTING
Skin
1. Hands and nails 2. (For rest of exam, examine skin with corresponding region) Color and pigmentation Temperature Moisture Texture Turgor Any lesions
Head and Face 1. Scalp, hair, cranium 2. Face (cranial nerve VII) 3. Temporal artery, temporomandibular joint 4. Maxillary sinuses, frontal sinuses
Eyes
1. Visual fields (cranial nerve II) 2. Extraocular muscles, corneal light reflex Cardinal positions of gaze (cranial nerves III, IV, VI) 3. External structures 4. Conjunctivae Sclerae Corneas Irides 5. Pupils 6. Ophthalmoscope, red reflex Disc Vessels Retinal background
Ears
1. External ear 2. Any tenderness 3. Otoscope, ear canal Tympanic membrane 4. Test hearing (cranial nerve VIII), voice test Weber test Rinne test
Nose
1. External nose 2. Patency of nostrils 3. Speculum, nasal mucosa Septum Turbinates
Mouth and Throat 1. Lips and buccal mucosa Teeth and gums Tongue Hard/soft palate 2. Tonsils 3. Uvula (cranial nerves IX, X) 4. Tongue (cranial nerve XII)
Neck
1. Symmetry, lumps, pulsations 2. Cervical lymph nodes 3. Carotid pulse (bruits if indicated) 4. Trachea 5. ROM and muscle strength (cranial nerve XI)
MOVE TO BACK OF PATIENT, PATIENT SITTING 6. Thyroid gland
Chest and Lungs, Posterior and Lateral 1. Thoracic cage configuration Skin characteristics Symmetry 2. Symmetric expansion Tactile fremitus Lumps or tenderness 3. Spinous processes 4. Percussion over lung fields Diaphragmatic excursion 5. CVA tenderness 6. Breath sounds 7. Adventitious sounds
MOVE TO FRONT OF PATIENT
Chest and Lungs, Anterior 1. Respirations and skin characteristics 2. Tactile fremitus, lumps, tenderness 3. Percuss lung fields 4. Breath sounds
Upper Extremities 1. ROM and muscle strength 2. Epitrochlear nodes
Breasts
1. Symmetry, mobility, dimpling 2. Supraclavicular and infraclavicular areas
PATIENT SUPINE, STAND AT PATIENT’S RIGHT 3. Breast palpation 4. Nipple 5. Axillae and regional nodes 6. Teach breast self-examination
Neck Vessels 1. Jugular venous pulse 2. Jugular venous pressure, if indicated
Heart
1. Precordium: pulsations and heave 2. Apical impulse 3. Precordium, thrills 4. Apical rate and rhythm 5. Heart sounds
Abdomen
1. Contour, symmetry Skin characteristics Umbilicus and pulsations 2. Bowel sounds 3. Vascular sounds 4. Percussion 5. Liver span in right MCL 6. Spleen 7. Light and deep palpation 8. Palpation of liver, spleen, kidneys, aorta 9. Abdominal reflexes, if indicated
Inguinal Area 1. Femoral pulse 2. Inguinal nodes
Lower Extremities 1. Symmetry Skin characteristics, hair distribution 2. Pulses, popliteal Posterior tibial Dorsalis pedis 3. Temperature, pretibial edema 4. Toes
PATIENT SITS UP 5. ROM and muscle strength, hips Knees Ankles and feet
Neurologic
1. Sensation, face Arms and hands Legs and feet 2. Position sense 3. Stereognosis 4. Cerebellar function, finger-to-nose 5. Cerebellar function, heel-to-shin 6. Deep tendon reflexes Biceps ______________________________ Triceps Brachioradialis __________________________ Patellar Achilles 7. Babinski reflex
PATIENT STANDS UP
Musculoskeletal
1. Walk across room Walk, heel to toe 2. Walk on tiptoes, then walk on heels 3. Romberg sign 4. Shallow knee bend 5. Touch toes 6. ROM of spine
Male Genitalia 1. Penis and scrotum 2. Testes and spermatic cord 3. Inguinal hernia 4. Teach testicular self-examination
Male Rectum 1. Perianal area 2. Rectal walls and prostate gland 3. Stool for occult blood
FEMALE PATIENT IN LITHOTOMY POSITION
Female Genitalia and Rectum 1. Perineal and perianal areas 2. Vaginal speculum: cervix and vaginal walls 3. Procure specimens 4. Bimanual: cervix, uterus, and adnexa 5. Rectovaginal 6. Stool for occult blood
HELP PATIENT SIT UP
THANK PATIENT FOR TIME, DEPART FROM PATIENT
Jarvis: Physical Examination and Health Assessment, 6th Edition Complete Physical Examination Form
COMPLETE PHYSICAL EXAMINATION
Date __8/31/2013______________
Patient __Jane Doe_________________________ Age __33_ Sex _F__
Occupation Healthcare worker Client Representative/Interpreter: __none__
Examiner _Emanuel Singleton RN________
General Survey of Patient 1. Appears stated age: Yes_____________________________________ 2. Level of consciousness: Alert and oriented x 3 (person, place and time) 3. Skin color: Brown 4. Nutritional status: Appears well nourished 5. Posture and position: Upright, WNL 6. Obvious physical deformities: None noted 7. Mobility:
gait, use of assistive devices, ROM of joints, no involuntary movement: WNL 8. Facial expression: WNL 9. Mood and affect: WNL 10. Speech: articulation, pattern, content appropriate, native language: Speaks English, WNL 11. Hearing: WNL 12. Personal hygiene: well groomed, WNL
Measurement and Vital Signs 1. Weight: 82.2 kg 2. Height 62 inches 3. Skinfold thickness, if indicated: Not assessed 4. Vision using Snellen eye chart: OD 20/20_OS 20/20_Correction? Not applicable 5. Radial pulse, rate, and rhythm 88, Normal 6. Respirations, rate, depth 20, equal and unlabored 7. Blood pressure Right arm 112/62 sitting _____________(sitting or lying?) Left arm _114/64 sitting______________(sitting or lying?) 8. Temperature (if indicated) 37.0 C, oral 9. Pain assessment Denies all pain and distress
STAND IN FRONT OF PATIENT, PATIENT IS SITTING
Skin
1. Hands and nails 2. (For rest of exam, examine skin with corresponding region) Color and pigmentation Temperature Moisture Texture Turgor Any lesions
Head and Face 1. Scalp, hair, cranium 2. Face (cranial nerve VII) 3. Temporal artery, temporomandibular joint 4. Maxillary sinuses, frontal sinuses
Eyes
1. Visual fields (cranial nerve II) 2. Extraocular muscles, corneal light reflex Cardinal positions of gaze (cranial nerves III, IV, VI) 3. External structures 4. Conjunctivae Sclerae Corneas Irides 5. Pupils 6. Ophthalmoscope, red reflex Disc Vessels Retinal background
Ears
1. External ear 2. Any tenderness 3. Otoscope, ear canal Tympanic membrane 4. Test hearing (cranial nerve VIII), voice test Weber test Rinne test
Nose
1. External nose 2. Patency of nostrils 3. Speculum, nasal mucosa Septum Turbinates
Mouth and Throat 1. Lips and buccal mucosa Teeth and gums Tongue Hard/soft palate 2. Tonsils 3. Uvula (cranial nerves IX, X) 4. Tongue (cranial nerve XII)
Neck
1. Symmetry, lumps, pulsations 2. Cervical lymph nodes 3. Carotid pulse (bruits if indicated) 4. Trachea 5. ROM and muscle strength (cranial nerve XI)
MOVE TO BACK OF PATIENT, PATIENT SITTING 6. Thyroid gland
Chest and Lungs, Posterior and Lateral 1. Thoracic cage configuration Skin characteristics Symmetry 2. Symmetric expansion Tactile fremitus Lumps or tenderness 3. Spinous processes 4. Percussion over lung fields Diaphragmatic excursion 5. CVA tenderness 6. Breath sounds 7. Adventitious sounds
MOVE TO FRONT OF PATIENT
Chest and Lungs, Anterior 1. Respirations and skin characteristics 2. Tactile fremitus, lumps, tenderness 3. Percuss lung fields 4. Breath sounds
Upper Extremities 1. ROM and muscle strength 2. Epitrochlear nodes
Breasts
1. Symmetry, mobility, dimpling 2. Supraclavicular and infraclavicular areas
PATIENT SUPINE, STAND AT PATIENT’S RIGHT 3. Breast palpation 4. Nipple 5. Axillae and regional nodes 6. Teach breast self-examination
Neck Vessels 1. Jugular venous pulse 2. Jugular venous pressure, if indicated
Heart
1. Precordium: pulsations and heave 2. Apical impulse 3. Precordium, thrills 4. Apical rate and rhythm 5. Heart sounds
Abdomen
1. Contour, symmetry Skin characteristics Umbilicus and pulsations 2. Bowel sounds 3. Vascular sounds 4. Percussion 5. Liver span in right MCL 6. Spleen 7. Light and deep palpation 8. Palpation of liver, spleen, kidneys, aorta 9. Abdominal reflexes, if indicated
Inguinal Area 1. Femoral pulse 2. Inguinal nodes
Lower Extremities 1. Symmetry Skin characteristics, hair distribution 2. Pulses, popliteal Posterior tibial Dorsalis pedis 3. Temperature, pretibial edema 4. Toes
PATIENT SITS UP 5. ROM and muscle strength, hips Knees Ankles and feet
Neurologic
1. Sensation, face Arms and hands Legs and feet 2. Position sense 3. Stereognosis 4. Cerebellar function, finger-to-nose 5. Cerebellar function, heel-to-shin 6. Deep tendon reflexes Biceps ______________________________ Triceps Brachioradialis __________________________ Patellar Achilles 7. Babinski reflex
PATIENT STANDS UP
Musculoskeletal
1. Walk across room Walk, heel to toe 2. Walk on tiptoes, then walk on heels 3. Romberg sign 4. Shallow knee bend 5. Touch toes 6. ROM of spine
Male Genitalia 1. Penis and scrotum 2. Testes and spermatic cord 3. Inguinal hernia 4. Teach testicular self-examination
Male Rectum 1. Perianal area 2. Rectal walls and prostate gland 3. Stool for occult blood
FEMALE PATIENT IN LITHOTOMY POSITION
Female Genitalia and Rectum 1. Perineal and perianal areas 2. Vaginal speculum: cervix and vaginal walls 3. Procure specimens 4. Bimanual: cervix, uterus, and adnexa 5. Rectovaginal 6. Stool for occult blood
HELP PATIENT SIT UP
THANK PATIENT FOR TIME, DEPART FROM PATIENT