Heart precordium pulsations and heave not present

Heart
Precordium: pulsations and
heave
Not present.
Apical impulse and PMI Unable to palpate the patient’s apical impulse or
point of maximum impulse
Precordium and thrills Not present.
Apical rate and rhythm 78 and regular.
Heart sounds Regular rhythm. S1 and S2 heart. No clicks,
murmurs, gallops or rubs.
Abdomen
Contour, symmetry, skin
characteristics, umbilicus,
and pulsations
Soft, round and symmetric, no distention noted.
Skin is absent of abnormalities, and race
appropriate. No visible pulsations noted. Umbilicus
midline, and inverted.
Bowel sounds Present in all four quadrants. No reports of diarrhea
or constipation.
Vascular sounds No bruits present. Able to auscultate aorta, renal
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artery and iliac artery.
Percussion Dull and tympanitic sounds in all four quadrants. No
pain or tenderness.
Liver span in right MCL No pain or tenderness. Liver palpated, no
enlargement noted.
Spleen No pain or tenderness. Spleen palpated, no
enlargement noted.
Light and deep palpation No pain or tenderness noted. No masses felt.
Palpation of liver, spleen,
kidneys, and aorta
No signs of enlargement of liver or spleen. Aorta is
midline, no bruit or visible pulsation noted. Kidney’s
palpated.
Inguinal Area
Femoral pulse Pulses palpable bilaterally. No pain or tenderness.
Inguinal nodes No enlargement noted.
Lower Extremities
Symmetry, skin
characteristics, and hair
distribution
Equal ROM bilaterally. No abnormalities noted. No
tenderness or pain. Strength is 5/5. Even hair
distribution.
Pulses:
 Popliteal
 posterior tibial
 dorsalis pedis
Popliteal, posterior tibial, and dorsalis pedis pulses
all palpable bilaterally, easily felt, and regular beats.
Temperature and pretibial
edema
Warm, dry and intact. Race appropriate. No edema
noted.
Toes Toes are clean and intact. Patient is able to move all
toes with ease, no pain or tenderness. No
abnormalities noted.
ROM and Muscle Strength
Ankles and feet Ankles and feet are clean and intact. Patient is
able to move ankles and feet bilaterally with ease,
no pain or tenderness. No abnormalities noted.
Neurologic Patient is alerts and oriented to person, place,
time and situation. Memory is intact. Patient is
calm, cooperative and pleasant.
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Sensation:
 face
 arms
 hands
 legs
 feet
Sensation intact in face, arms, hands, legs and
feet. No presence of numbness, tingling or
decreased feeling.
Position sense Patient is able to identify which direction the RN is
moving big toe on both feet. Patient is also able to
identify which direction the RN is moving the
patient’s finger on both hands.
Stereognosis Patient is able to identify the object that has been
placed in hand. Patient is able to identify the
number that was written in palm of hand.
Cerebellar function (finger to
nose)
Patient is able to bring finger to RN’s finger and
back to nose rapidly.
Cerebellar function (heel to
shin)
Patient is able to slide his heel down both shins
without difficulty.
Deep tendon reflexes:
 biceps
 triceps
 brachioradialis
 patellar
 achilles
Bicep, tricep, brachioradialis, patellar and Achilles
deep tendon reflexes are intact and +2 bilaterally.