Symmetric expansion on inhaling and exhaling Tactile fremitus present No lumps

Symmetric expansion on inhaling and exhaling tactile

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Symmetric expansion on inhaling and exhaling. Tactile fremitus present. No lumps, no tenderness, no swelling Spinous process In alignment, no deformities Percussion over lung fields Resonant sounds noted CVA tenderness No CVA tenderness Breath sounds Vesicular breath sounds noted over all lung fields Adventitious sounds Absence of wheezing, ronchi, crackles, no adventitious breath sounds noted. Chest and Lungs: Anterior Respirations and skin characteristics Even, unlabored, equal chest expansion on inhaling and exhaling. Skin intact, no lesions, no swelling, no deformities. Tactile fremitus, lumps, and Tenderness Tactile fremitus present. No lumps, no tenderness Percuss lung fields Resonant sounds noted. Breath sounds Vesicular breath sounds noted over all lung fields. No crackles, no ronchi, no wheezing. Upper Extremities ROM and muscle strength Full ROM, strength is strong, 5+. Internal and external rotation appropriate. No deformities noted. Epitrochlear nodes Non-palpable Discuss the process for assessing breasts and axilla Palpate breasts with both the flat of your hand and fingers. Follow systematically in a circular pattern around the nipple or along the radial lines (simulate a clock) or vertical segments and feel 9
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the entire breast, including the tail near the axilla. Palpate the areola and nipple with fingers. Palpate the axilla with the pads of fingers [ CITATION Nat19 \l 1033 ]. Neck Vessels Jugular venous pulse Regular rate and rhythm. 2+, HR 60 Presence of jugular venous distension No presence of JVD Heart Precordium: pulsations and heave No pulsations, no heaves, no lifts noted on inspection Apical impulse and PMI Not palpable Precordium and thrills No thrills, no heaves, no ventricular dilatation on palpation Apical rate and rhythm Apical rate – 60, regular rhythm Heart sounds S1-S2 noted, no S3-S4, no murmur, no gallops, sinus rhythm. Abdomen Contour, symmetry, skin characteristics, umbilicus, and pulsations Abdomen is round, protuberant, symmetrical. Skin intact - no lesions, no lumps, no swelling. Umbilicus inverted. No hernias, no pulsations, no masses, no wounds. Bowel sounds Present, active Vascular sounds No bruit noted Percussion Tympanic sounds noted, no dullness Liver span in right MCL 6cm Spleen Tympanic sound on percussion Light and deep palpation Abdomen is soft, no guarding, no rigidity, no lumps, no masses. 10
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Palpation of liver, spleen, kidneys, and aorta Liver, spleen, kidneys, aorta not palpable Inguinal Area Femoral pulse Rate is 60, regular, 2+, equal Inguinal nodes 1-2cm, no enlargement noted Lower Extremities Symmetry, skin characteristics, and hair distribution Symmetrical, skin intact, no lesions, no swelling, no redness, no lumps, no deformities. Color appropriate for ethnicity. Hair evenly distributed. Pulses: Popliteal posterior tibial dorsalis pedis Pulses 2+, equal, regular rhythm bilaterally in popliteal, PT and DP Temperature and pretibial edema Warm, dry, no edema present Toes All digits present, no deformities, nails pink, cap refill < 3 seconds.
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