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Symmetric expansion on inhaling and exhaling.Tactile fremitus present.No lumps, no tenderness, no swellingSpinous processIn alignment, no deformitiesPercussion over lung fieldsResonant sounds notedCVA tendernessNo CVA tendernessBreath soundsVesicular breath sounds noted over all lung fieldsAdventitious soundsAbsence of wheezing, ronchi, crackles, no adventitious breath sounds noted.Chest and Lungs: AnteriorRespirations and skin characteristicsEven, unlabored, equal chest expansion on inhaling and exhaling.Skin intact, no lesions, no swelling, no deformities.Tactile fremitus, lumps, andTendernessTactile fremitus present.No lumps, no tendernessPercuss lung fieldsResonant sounds noted.Breath soundsVesicular breath sounds noted over all lung fields. No crackles, no ronchi, no wheezing.Upper ExtremitiesROM and muscle strengthFull ROM, strength is strong, 5+.Internal and external rotation appropriate. No deformities noted.Epitrochlear nodesNon-palpableDiscuss the process for assessing breasts and axillaPalpate breasts with both the flat of your hand andfingers. Follow systematically in a circular pattern around the nipple or along the radial lines (simulate a clock) or vertical segments and feel 9
the entire breast, including the tail near the axilla. Palpate the areola and nipple with fingers. Palpatethe axilla with the pads of fingers [ CITATION Nat19\l 1033 ].Neck VesselsJugular venous pulseRegular rate and rhythm. 2+, HR 60Presence of jugular venousdistensionNo presence of JVDHeartPrecordium: pulsations andheaveNo pulsations, no heaves, no lifts noted on inspectionApical impulse and PMINot palpablePrecordium and thrillsNo thrills, no heaves, no ventricular dilatation on palpationApical rate and rhythmApical rate – 60, regular rhythmHeart soundsS1-S2 noted, no S3-S4, no murmur, no gallops, sinus rhythm.AbdomenContour, symmetry, skin characteristics, umbilicus, and pulsationsAbdomen is round, protuberant, symmetrical.Skin intact - no lesions, no lumps, no swelling. Umbilicus inverted. No hernias, no pulsations, no masses, no wounds.Bowel soundsPresent, activeVascular soundsNo bruit notedPercussionTympanic sounds noted, no dullnessLiver span in right MCL6cmSpleenTympanic sound on percussionLight and deep palpationAbdomen is soft, no guarding, no rigidity, no lumps, no masses.10
Palpation of liver, spleen, kidneys, and aortaLiver, spleen, kidneys, aorta not palpableInguinal AreaFemoral pulseRate is 60, regular, 2+, equalInguinal nodes1-2cm, no enlargement notedLower ExtremitiesSymmetry, skin characteristics, and hair distributionSymmetrical, skin intact, no lesions, no swelling, no redness, no lumps, no deformities. Color appropriate for ethnicity. Hair evenly distributed.Pulses: Poplitealposterior tibialdorsalis pedisPulses 2+, equal, regular rhythm bilaterally in popliteal, PT and DPTemperature and pretibial edemaWarm, dry, no edema presentToesAll digits present, no deformities, nails pink, cap refill < 3 seconds.