The skin is pink without lesions or excoriations noted. There are no lumps, tenderness, or tactile fremitus. Spinous process The spinous process was without lumps or lesions. Percussion over lung fields The patient did not have a percussion over lung fields because the patient reported a negative cough and had clear lung sounds. CVA tenderness The patient reports negative to costovertebral angle tenderness. Breath sounds The patient had clear lungs sounds bilaterally. Adventitious sounds There are no adventitious sounds noted. 9
Chest and Lungs: Anterior Respirations and skin characteristics The respirations are even and nonlabored. The skin is pink, moist, and elastic. Tactile fremitus, lumps, and Tenderness There are negative tactile fremitus, lumps, and tenderness noted. Percuss lung fields Percussion tones resonant over all lung fields. Breath sounds The patient had clear lung sounds bilaterally. Upper Extremities ROM and muscle strength The patient had full range of motion and reported no deficits in muscle strength noted. Epitrochlear nodes The epitrochlear nodes are without tenderness or pain noted. Discuss the process for assessing breasts and axilla Have the patient in a sitting position with arms at the patient’s side, disrobed and visually inspect the axilla and bilateral breasts. Take note of the color, redness, inflammation, thickening of skin, dimpling, and/or excoriations. Take note of the patient’s size and symmetry of the breasts. Take note of the patient’s nipples and areola, the shape, color, and whether outward or retraced. The patient can place one arm over their head as the side of the breast are inspected and the axilla of that side. The process is repeated on the other side of the patient’s body. Neck Vessels Jugular venous pulse A healthy patient has a jugular venous pulse noted. Presence of jugular venous distension The patient has a negative presence of jugular venous distension. Heart Precordium: pulsations and heave The patient’s precordium was without any visible scars, prominent veins, or bulges. The patient had a palpable heart sounds without parasternal heave. Apical impulse and PMI Apical impulse palpated in the fifth ICS at the left MCL. The apical pulse had a regular rhythm. Precordium and thrills The patient had a negative thrill or pericardial friction rubs. 10
Apical rate and rhythm The apical rate had a regular, consistent rhythm. Heart sounds The heart sounds at S1 and S2 were without adventitious sounds. S1 was heard best at the apex and S2 heard best at the base. Abdomen Contour, symmetry, skin characteristics, umbilicus, and pulsations The patient has normal pink skin color. The patient’s abdomen was symmetrical, with no obvious pulsations, lumps, or lesions noted. Bowel sounds The bowel sounds were active in all quadrants. Vascular sounds The vascular sounds were active and audible. Percussion Percussion was performed with generalized tympany in all quadrants. Liver span in right MCL This was palpated to the right side of the patient through deep palpation without tenderness.
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- Spring '16
- Shelley Ashby