CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT

CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT

SKIN, HAIR AND NAILS
Skin pink, warm, dry and elastic.  No lesions or excoriations noted.  Old appendectomy scar right lower abdomen 4 inches long, thin, and white.  Sprinkling of freckles noted across cheeks and nose.  Hair brown, shoulder length, clean, shiny.  Normal distribution of hair on scalp and perineum.  Hair has been removed form legs, axillae.  Nails form 160 degree angle at base, are hard, smooth, and immobile.  Nailbeds pink without clubbing.  Cuticles smooth, no detachment of nailplate.  Hands well-manicured with clear enamel.                                                           

HEAD AND NECK
Head symmetrically round, hard, and smooth without lesions or bumps.  Face oval, smooth, and symmetrical.  Temporal artery elastic and nontender.  Temporomandibular joint palpated with full range of motion without tenderness.  Neck symmetric with centered head position and no bulging masses.  C7 is visible and palpable with neck flexion.  Has smooth, controlled, full range of motion of neck.  Thyroid gland nonvisible but palpable when swallowing.  Trachea in midline.  Lymph nodes nonpalpable.

EYE AND EAR
Acuity by Snellen chart O.D. 20/20, O.S. 20/20.  Visual fields full by confrontation.  Extraocular movements smooth and symmetric with no nystagmus.  Evelids in normal position with no abnormal widening or ptosis.  No redness, discharge, or crusting noted on lid margins.  Conjunctiva and sclera appear moist and smooth.  Sclera white with no lesions or redness.  No swelling or redness over lacrimal gland.  Cornea is transparent, smooth, and moist with no opacities, lens is free of opacities.  Irises are round, flat, and evenly colored.  Pupils are equal in size and reactive to light and accommodation.  Pupils converge evenly. 
Ears are equal in size bilaterally.  Auricles are aligned with the corner of each eye.  Skin smooth, no lumps, lesions, nodules.  No discharge.  Nontender on palpation.  Small amount of moist yellow cerumen in external canal.  Whisper test : patient repeats 2 syllable word.

MOUTH, THROAT, NOSE, AND SINUS
Lips pink, smooth, and moist without lesions.  Buccal mucosa pink, moist, and without exudates.  Stensen/s ducts visible with no redness or swelling.  32 white to yellowish teeth present.  Gums pink without redness or swelling.  Protrudes geographic tongue in midline with no tremors.  Equal bilateral strength in tongue.  Ventral surface of tongue smooth and shiny pink with small visible veins present.  Frenulum in midline.  Soft palate smooth and pink.  Tonsillar pillars pink and symmetric.  
Nose somewhat large but smooth and symmetric.  Able to sniff through each nostril. Nasal septum slightly deviated to the left, but does not obstruct airflow.  Inferior and middle turbinates dark pink, moist, and free of lesions.  No purulent drainage noted.  Frontal and maxillary sinuses  are nontender to palpation and percussion.

THORAX AND LUNG
Respirations 18/minute, relaxed and even.  Anteroposterior less than transverse diameter.
Chest expansion symmetric.  No retraction or bulging of interspaces.  No pain or tenderness on palpation.  Tactile fremitus symmetric.  Percussion tones resonant over all lung fields.  Vesicular breath sounds auscultated over lung fields.  No adventitious sounds present.

BREASTS AND LYMPHACIC
Bilateral breasts moderate in size, pendulant, and symmetric.  Breast skin pale, pink with light brown areola.  Nipples everted bilaterally.  Free movement of breasts with position changes of arms and hands.  No dimpling, retraction, lesions, or inflammation noted.  Axillae free of rashes or inflammation.
No masses or tenderness noted on palpation.  Bilateral mammary ridge present.  No discharge noted from nipples.  Axillary ( central, posterior, or anterior) and lateral arm lymph nodes nonpalpable.  Demonstrates appropriate technique for BSE.

HEART AND NECK VESSELS
Carotid pulse equal bilaterally, 2+, elastic.  No bruits auscultated over carotids.  Jugular venous pulsation disappears when upright.  Apical  impulse palpated in the fifth ICS at the left MCL.  Apical pulse- 70 beats/minute, regular rhythm, S1 heard best at the apex, S2 heard best at the base. 

ABDOMEN
Skin of abdomen is free of striae, scars, lesions, or rashes.  Umbilicus is midline and recessed with no bulging.  Abdomen is flat and symmetric with no bulges or lumps.  No bulges noted when patient raises head.  No peristaltic movements seen.  Soft clicks and gurgles heard at a rate of 15 per minute.   Percussion reveals generalized tympany over all four quadrants.  No tenderness or guarding                                 in any quadrant with light palpation.  Umbilicus and surrounding area free of masses, swelling, and bulges.

MALE GENITALIA
pubic hair growth pattern is normal for adult male: pubic hair and base of penis are free of excoriation and infestation.  Circumcised penis is free of rashes, lesions, and lumps and is soft, flaccid and nontender on palpation.  Glans is rounded, and free of lesions; urinary meatus is centrally located on glans; no discharge is palpated from urinary meatus.  No masses or swelling noted in scrotum and left side hangs slightly lower than right side.  Skin is free of lesions and appears rugated and darkly pigmented.  Two descended testicles palpated.  No swelling, tenderness,or masses palpated along the testicle.  No bulges or masses palpated in inguinal or femoral canal. 

FEMALE GENITALIA
Normal hair distribution, no lesions, masses, or swelling.  Labia majora pink, smooth, and free of lesions, excoriation, and swelling.  Lania minora dark pink, moist, and free of lesions, excoriation, swelling or discharge.  No discharge from urethral opening.  No malodorous discharge noted from vagina. 

ANUS AND  RECTUM
The anal opening is hairless, moist, and closed tightly.  Perinanal area is free of redness, lumps, ulcers, lesions, and rashes.  No bulging of lesions appear when the patient performs the Valsalva maneuver.  Patient can close external sphincter around gloved finger.  Anus is smooth, nontender, and free of nodules and hardness. 

PERIPHERAL VASCULAR
arms are equal in size, no swelling, pinkish skin tone, no clubbing of finger tips, warm bilaterally.  Capillary refill time less than 2 seconds, radial and brachial pulses strong bilaterally.  No epitroclear lymph nodes  palpated.  Legs are pink in color from toes bilaterally, normal distribution of hair, no ulcers or edema.  Legs are warm bilaterally.  Femoral, popliteal, dorsalis pedis, and  posterior tibial pulses strongly palpated bilaterally.  No apparent varicosities or superficial thrombophlebitis noted.

MUSCULOSKELETAL
Gait smooth, with equal stride and good base of support.  Full ROM of TMJ with no pain, tenderness, clicking or crepitus.  Sternoclavicular joint midline with swelling or redness.  Normal curves of cervical, thoracic, and lumbar spine.  Paravertebrals nontender.  Full smooth ROM of cervical and lumbar spine.  Upper and lower extremities symmetric  without lesions,nodules, deformities,or swelling.  Full smooth ROM against gravity and resistance.

NEUROLOGICAL
Cranial Nerves:
1. Identifies correct scents
2. Vision 20/20 OS, 20/20 OD, full visual fields
     intact.
3,4,6 No ptosis, full extraocular movements (EOM)
    pupils equally round, react to light and   
    accommodation (PERRLA)
5. Temporal and masseter muscles contract                  

                   Bilaterally.  Able to identify light, sharp, dull
            touch to forehead, cheek, and chin.  Corneal
            reflex present.
        7. Able to smile, frown, wrinkle forehead, show
            teeth, puff out cheeks, purse lips, raise eye-
            brows, and close eyes against resistance.
        8. Wispered 2 syllable words heard bilaterally.
        9 and 10.  Uvula and soft palate rise symmetrically
           on phonation.  Gag reflex present.  Swallows
           without difficulty. 
        11. Equal shoulder shrug against resistance;
               turns head in both directions against
               resistance.
         12. Protrudes tongue in midline with no tremors,
               able to push tongue blade to right and left with
               no difficulty.

Motor and Cerebellar System

No atrophy, tremors, weakness, full ROM of all extremities.  No fasciculations, tics, or tremors.  Gait and tandem walk normal and steady.  Negative Romberg test.  Performs repetitive alternating movements, finger to nose at smooth, good pace. Runs each heel down each shin with no deviation.

Sensory System

Identifies light touch, dull and sharp sensations to trunk and extremities.  Vibratory sensation, stereognosis, graphesthesia, two-point descrimination intact.

Reflexes

Reflexes 2+ bilaterally, except Achilles 1+.  No Babinski
present.

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About Heather Swift

Heather “Swifty” Swift has been Kicking mAss since 1998. At 28 she was diagnosed with ovarian cancer as a recently single mom with two small babies on her hip. After completing treatment with the thought that cancer was in her rear view mirror she worked, locally, as a volunteer for Ithaca Breast Cancer Alliance doing community outreach to be certain that no one faced cancer alone. In 2005, she had a secondary diagnosis of breast cancer and tested positive for the BRCA2 mutation, which only amped up her commitment to creating positive change and to becoming a strong and effective advocate for the young adult cancer community. Now, at age 42, Swifty, her partner, Brian, and her two teenage children work together locally, nationally and internationally to advocate for change. Swifty regularly meets with legislators to work towards tangible change in health care, legislation that addresses the needs of cancer patients, care-partners, and families. She works directly with clinicians, medical/nursing students, youth & college students, cancer support organizations and others to educate them about the special needs of young adults living with a cancer diagnosis. Swifty is passionate about providing support by connecting people living with cancer to resources, to other cancer survivors, and to mobilizing and training individuals and groups to find their inner advocate. Swifty currently works with a number of amazing, hand-selected organizations, which provide her with opportunities to educate, to advocate, and to change the conversation about cancer and to work to bring an end to the disease. A few include: LiveSTRONG, mAss Kickers, Imerman Angels, National Breast Cancer Coalition, Cancer Resource Center of the Finger Lakes, Dusty Showers & The Second Basemen, and Stupid Cancer. Swifty is an oncology nursing student in upstate New York, loves time with her family, paddling sports, and peanut butter. She is a Virgo, but not the really anal-retentive type. Her strange fascination with superheroes makes her popular in geek circles, but it can be endearing. Swifty will be riding a llama across Oregon in July of 2012 and really does believe we can achieve and end to cancer and in world peace. Motto: Never Give Up! Favorite quote: “Our own life has to be our message.” ― Thich Nhat Hanh

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