Bowel sounds x 4 Quadrants Normoactive Hyperactive Hypoactive Absent RUQ RUQ

Bowel sounds x 4 quadrants normoactive hyperactive

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Bowel sounds (x 4 Quadrants Normoactive Hyperactive Hypoactive Absent RUQ RUQ RUQ RUQ RLQ RLQ RLQ RLQ LUQ LUQ LUQ LUQ LLQ LLQ LLQ LLQ Pt is without abnormal findings. Light and deep palpation of 4 quadrants Light RLQ RUQ LUQ Sof No mass No tenderness Pt is without abnormal findings. Rev: 113017
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PADF pg. 8 LLQ Deep RLQ RUQ LUQ LLQ Sof No mass No tenderness Percussion x 4 quadrants RLQ RUQ LUQ LLQ Tympany Dullness Pt is without abnormal findings. Lower extremities (4) Symmetry, skin characteristics, hair distribution Symmetrical Non-symmetrical Pallor Erythema Cyanosis Ulcers Lesions Varicosities Hair evenly distributed Pt is without abnormal findings. Toes a. Capillary refill Clubbing Capillary refill: (L) (R) Pt is without abnormal findings. Temperature, pretibial edema Cool Warm Lef Lef Right Right Pretibial Edema (L): Pretibial Edema (R): Pt is without abnormal findings. Pulses a. Femoral b. Popliteal c. Posterior tibial d. Dorsalis pedis (0)Absent, (1+)Weak, (2+)Normal, (3+) Increased, full, bounding (L) Femoral (R) Femoral (L) Popliteal (R) Popliteal (L) Posterior tibial (R) Posterior tibial (L) Dorsalis pedis (R) Dorsalis pedis Pt is without abnormal findings. Rev: 113017
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PADF pg. 9 Musculoskeletal /neurologic (2) Hip – ROM Pain Tenderness Crepitation Pt is without abnormal findings. Flexion Abduction Internal Rotation External Rotation 120 approximate degrees 50 approximate degrees 40 approximate degrees 60 approximate degrees Ankles and feet a. ROM b. Strength ☐ Swelling ☐ Pain ☐ Tenderness ☐ Ulcers ☐ Redness ☐ Edema Pt is without abnormal findings. Plantar Flexion Dorsiflexion Eversion (L) (R) (L) (R) (L) (R) Musculoskeletal /neurologic (2) Return to sitting position Bilateral deep tendon reflexes a. Biceps b. Triceps c. Brachioradialis d. Patellar e. Achilles 0 No response, 1+ Diminished, low normal 2+ Average, normal 3+ Brisker than average 4+ Very brisk, hyperactive with clonus Pt is without abnormal findings. a. Biceps b. Triceps c. Brachioradialis d. Patellar e. Achilles Sensation – light touch sensation a. face b. arms c. hands d. legs e. feet Face Arms Hands Legs Feet Present Click or tap here to enter text. Spine/neurologi c (5) Touch toes Full ROM Limited ROM Pain with ROM Pt is without abnormal findings. Rev: 113017
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PADF pg. 10 Have patient stand ROM of spine Full ROM Limited ROM Pain with ROM Pt is without abnormal findings. Shallow knee bend Full ROM Limited ROM Pain with ROM Pt is without abnormal findings. Walk across room (heel to toe) Appropriate coordination Poor coordination Pt is without abnormal findings.
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  • Spring '17
  • Jodi, damper-moore
  • pulse, Abnormal Findings, Fremitus

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