Physical_Assessment_Documentation_Form-2 - evaluation. Health Assessment Physical Assessment Documentation Form Date Patient Information Patient

Physical_Assessment_Documentation_Form-2 - evaluation....

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This form must be included in submission with video or it will be returned without  evaluation.  Includes Analysis of Findings paragraph and Source- page 8. Health Assessment Physical Assessment Documentation Form Date: 9/8/2016 Patient Information Patient Initials MT Age 49 Sex Male General Survey- complete with descriptive medical terminology and not “WNL”. Every blank needs to be filled in. If you did not complete an assessment on your video recording, please type, “not assessed.” Does patient appear to be their stated age? 49 y/o male that is alert and oriented to person, place, and time. Appears healthy and looks stated age. Level of consciousness Alert and oriented to person, place and time. Skin color Pink. Uniform in color. Appropriate for race. Nutritional status Appears to have no nutritional deficiency. Posture and position Normal posture and position. No abnormalities noted. Obvious physical deformities No physical deformities observed. Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement Full range of motion exhibited in all extremities, hips, joints. No assistive devices needed. No involuntary movement. Facial expression Symmetrical Mood and affect Calm, cooperative, and appropriate Speech: articulation, pattern, content and appropriate, native language Normal, clear speech articulation. Hearing Normal hearing. No deficits. Personal hygiene Clean. Groomed. No odor or visible dirt. Measurements and Vital Signs Height 5’5 Weight 165 lbs
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BMI 27.5 Radial pulse:  Rate Rhythm Radial pulse 76 bpm Regular rhythm Respirations: Rate Depth 14 bpm Regular Chest expansion symmetrical Blood pressure (indicate if sitting or lying) 128 systolic 82 diastolic Sitting left arm Pain assessment 0/10 Physical Assessment Skin Hands and nails No clubbing or cyanosis of the hands and nails. Nails beds pink. Color and pigmentation Pink with regular pigmentation Presence of lesions? No lesions present Temperature Warm Moisture Dry Texture Smooth Turgor Non tenting Head and Face Scalp Hair Cranium Scalp- 0 lesions, tenderness Hair - Normal texture. Some gray. Cranium - no tenderness Face (cranial nerve VII) Performed various facial expression without any difficulty. Expressions were symmetrical. Temporal artery and temporomandibular joint No clicks when opening jaw. Symmetrical movement. Maxillary sinuses and frontal sinuses No tenderness noted. Eyes External structures Eyelids, eye lashes, eyebrows Skin intact with no discharge and no discoloration. Lids close symmetrically. Conjunctivae, sclerae cornea, and iris Sclera-white
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Conjuntivae-Pink Pupil – size, shape, and light reflex Equal in size with consensual and direct reaction. Equally round and reactive to light and accommodation.
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  • Fall '15
  • pulse, tenderness, buccal mucosa, tactile fremitus, Mr. Thrasher

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