Epitrochlear nodes No nodes palpated. No pain or tenderness Discuss the process for assessing breasts and axilla Inspect breast for symmetry- nipples, areola, axillae- review skin conditions, size, shape, color. Note hair distribution. While using 3 fingers and strip or circle method, note any abnormal lumps or masses Neck Vessels Jugular venous pulse Not assessed Presence of jugular venous distension Not assessed Heart Precordium: pulsations and No abnormal pulsations or vibrations noted 8
heave Apical impulse and PMI No abnormal pulsations or vibrations at 5 th intercostal space Precordium and thrills No thrills or heaves Apical rate and rhythm 80, regular and even Heart sounds S1, S2 heard. No S3, S4. No murmurs. Abdomen Contour, symmetry, skin characteristics, umbilicus, and pulsations Abdomen flat with no lumps or bulges. Umbilicus is midline and inverted. Aortic impulses not visible. Bowel sounds Present x 4 Vascular sounds Present. No bruits Percussion Dull sounds. No pain or tenderness Liver span in right MCL No enlargement. No pain or tenderness. Spleen No pain or tenderness Light and deep palpation No pain or tenderness upon palpation Palpation of liver, spleen, kidneys, and aorta No pain or tenderness upon palpation Inguinal Area Femoral pulse Present, strong and even Inguinal nodes No nodes palpated. No pain or tenderness Lower Extremities Symmetry, skin characteristics, and hair distribution Skin is even, smooth, pain, warm, dry and intact bilaterally. Hair distribution is even bilaterally Pulses: Popliteal posterior tibial dorsalis pedis All pulses present. Even and equal bilaterally. 9
Temperature and pretibial edema Warm. No edema present Toes No issues. Capillary refill <3 secs bilaterally ROM and Muscle Strength Ankles and feet No edema. Full ROM noted. Neurologic Sensation of soft/sharp touch assessed bilaterally Sensation: face arms hands legs feet Sensation of soft/sharp touch intact bilaterally to feet, legs, hands, arms and face. Position sense Finger to nose test preformed bilaterally and adequately. Stereognosis Able to identify pen with eyes closed. Cerebellar function (finger to nose) Able to follow directions and perform finger to nose assessment without deficits. Cerebellar function (heel to shin) Able to place heel to skin, somewhat unstable bilaterally Deep tendon reflexes: biceps triceps brachioradialis patellar achilles All Reflexes present and symmetrical bilaterally Babinski reflex Negative Musculoskeletal Walk across room heel to toe Smooth and rhythmic gait. Coordinated. Walk on tiptoes, then walk on heels Able to walk on tiptoes and heels without problems. Romberg sign Negative 10
Shallow knee bend Not preformed ROM of spine No issues noted D. Analyze Findings A 19 year old female presents to the clinic in order to establish patient care. Upon discussion, she denies current any concerns, issues or problems.
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