Check nipples for any sores, peeling or change in direction or discharge.Think of the breast like a clock. Start at the 12 o’clock and move toward 1 o’clock. In a small circular motion with your fingers flat move around the breast. When you get to the 1 o’clock move in 1 inch towards the nipple until you have felt the entire breast. Making sure to feel the upper outer areas that extend to the armpits.7
Neck VesselsJugular venous pulseDisappears when uprightPresence of jugular venousdistensionNo distension notedHeartPrecordium: pulsations andheaveNo heave or palpable heart sounds Apical impulse and PMIPalpated in the fifth ICS at the left MCL. Precordium and thrillsNo thrillsApical rate and rhythmApical pulse 64 beat/minute with a regular rhythmHeart soundsS1 and S2 sounds heardAbdomenContour, symmetry, skin characteristics, umbilicus, and pulsationsFree of striae, scars, lesions or rashes. Umbilicus ismidline and recessed without budges. Abdomen isflat and symmetric with no bulges or lumps. No pulsations notedBowel soundsActive in all 4 quadrantsVascular soundsNo rubs or bruitsPercussionTympanic soundsLiver span in right MCLNontenderSpleenNontenderLight and deep palpationNo tenderness or guarding in any quadrantsPalpation of liver, spleen, kidneys, and aortaNontender, no CVA tendernessInguinal AreaFemoral pulseAble to feel, non-boundingInguinal nodesNo swelling and nontenderLower ExtremitiesSymmetry, skin characteristics, and hair distributionAtraumatic in appearance without tenderness or deformity. No swelling or erythema. Full ROM. Strong muscle strength. Equal hair destitution.Pulses: Poplitealposterior tibialdorsalis pedisPalpable, non-boundingPalpable, non-boundingPalpable, non-boundingTemperature and pretibial edemaWarm bilaterally and no edema8
ToesNo sores or webbing. Capillary refill under 3 seconds.ROM and Muscle StrengthAnkles and feetNormal dorsiflexion, plantarflexion, eversion and inversionNeurologicNo deficitsSensation: facearmshandslegsfeetAble to feel sharp and soft in all areas. No numbness or tingling.Position senseAble to feel in all areas without differences between left and right sideStereognosisAble to tell that a key was placed in her handCerebellar function (finger to nose)No abnormality (No dysmetria)Cerebellar function (heel to shin)No abnormality. Able to keep foot on shinDeep tendon reflexes:bicepstricepsbrachioradialispatellarAchilles2+ brisk response, normal2+ brisk response, normal2+ brisk response, normal2+ brisk response, normal2+ brisk response, normalBabinski reflexNegativeMusculoskeletalWalk across room heel to toeNo problems. Steady gaitWalk on tiptoes, then walk on heelsNo problems. Steady gaitRomberg signNo swaying or falling. Negative. Shallow knee bendAble to perform without painROM of spineAble to move in all directions with out pain 9
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- Spring '16
- Shelley Ashby
- pulse, factor V Leiden