denies any history of mental health problems . Objective Data HEENT Ms. Jones head is normocephalic, hair is evenly distributed. The scalp is clean and free of lesions. She has acne on her face. Facial hair is seen on her upper lip area. Darkeing of skin is noted on her neck. Ms. Jones eyebrows are symmetrical, eyelids are free of lesions. No ptosis
Patient Analysis and Health Promotion Teach Tool Proposal 10 or edema. Her conjunctiva is pink and sclera is white. Bilateral pupils are round, equal and reactive to light. Extra ocular movements are intact. 20/20 vision. Ears are symmetrical, no lesions. Otoscopic exam discovered clear ear canals bilaterally. Bilateral tympanic membranes are intact and pearly gray with positive light reflex. Whispered words exam discovered bilateral equal hearing. Her nose is midline. Nares are patent. Membranes are moist and pink, no lesions. Frontal and maxillary sinuses are nontender upon palpation. Oral mucosa is pink, no lesions. The uvula and soft palate rise with “ah.” The pharynx, uvula and tonsils are pink, moist, no lesions. Teeth are clean, white and intact. The tongue is mobile, no lesions. Gag reflex is intact. No caries noted. Temporomandibular joint is symmetrical. The thyroid is nonpalpable. No goiter present. Lymph nodes of the neck are nonpalpable. Respiratory Ms. Jones’ chest is symmetric with respirations. Her lung sounds are clear to auscultation bilaterally in all lobes. No adventitious sounds are heard. Resonance throughout with percussion of the chest. Her spirometry reading is FVC 3.91 L and FEV1 3.15. Cardiovascular Upon cardiac assessment regular heart rate. S1, S2 is auscultated without murmurs, gallops or rubs. Bilateral carotids are regular with no bruits. The upper extremities are warm and skin color is normal. No lesions or edema noted. Fingernails are clear and pink. Capillary refill is less than three seconds bilaterally. Brachial and radial pulses are regular rhythm, +2 and equal bilaterally. Lower extremities are warm. Skin color is normal. Wound on right foot plantar surface, pus exudates.. Edema 1+ pitting on right foot. No varicosities. Toenails are clear and pink. Capillary refill is less than 3 seconds bilaterally. Femoral, tibial and dorsalis tibialis pulses are +2(left), regular and equal bilaterally(except for right tibialis pulse). Right foot pulses: dorsalis pedis 1+ diminished. No bruits. PMI is at the midclavicular line, 5 th intercostal space. No heaves or lifts. Abdomen
Patient Analysis and Health Promotion Teach Tool Proposal 11 Ms. Jones’ abdomen is large and symmetrical. The umbilicus is midline. Abdominal skin color is normal and with striae. Coarse hair is noted from the pubis to fundus. No bulges or ascites are observed. The abdomen is soft. Ms. Jones is not guarded and does not complain of tenderness with palpation. Bowel sounds are normoactive in all four quadrants. No bruits are auscultated. Sounds are tympanic throughout to percussion. Liver span is 7 cm on MCL. The bladder and spleen are nonpalpable. No CVA tenderness.
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- Fall '17