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 10
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. 11
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.
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- Spring '16
- Shelley Ashby