CLINPHARM: MIKEE

FINDINGS

PATIENT NAME: Ma. Mikhaela M. Ayson

AGE: 19

GENDER: F

HPI History of past illness

Ovarian cyst 2016

Hydron.....nitis 2019

FH Family History

SH Social Hostorn

Occasional alcoholic drinks

Meds

Neozep

Para

Clindamycin

All

Allergy: Sea food

From the conducted assessment there was no found abnormal foundings that would prognose or
diagnose a disease. Starting from the vital signs the all of the results were found normal

The Other Side of the Stethoscope

CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT

Heather Swif

6 years ago

CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT

SKIN, HAIR AND NAILS

Skin pink, warm, dry and elastic. No lesions or excoriations noted. Old appendectomy scar right lower
abdomen 4 inches long, thin, and white. Sprinkling of freckles noted across cheeks and nose. Hair
brown, shoulder length, clean, shiny. Normal distribution of hair on scalp and perineum. Hair has been
removed form legs, axillae. Nails form 160 degree angle at base, are hard, smooth, and immobile.
Nailbeds pink without clubbing. Cuticles smooth, no detachment of nailplate. Hands well-manicured
with clear enamel.

HEAD AND NECK

Head symmetrically round, hard, and smooth without lesions or bumps. Face oval, smooth, and
symmetrical. Temporal artery elastic and nontender. Temporomandibular joint palpated with full range
of motion without tenderness. Neck symmetric with centered head position and no bulging masses. C7
is visible and palpable with neck flexion. Has smooth, controlled, full range of motion of neck. Thyroid
gland nonvisible but palpable when swallowing. Trachea in midline. Lymph nodes nonpalpable.

EYE AND EAR

Acuity by Snellen chart O.D. 20/20, O.S. 20/20. Visual fields full by confrontation. Extraocular
movements smooth and symmetric with no nystagmus. Evelids in normal position with no abnormal
widening or ptosis. No redness, discharge, or crusting noted on lid margins. Conjunctiva and sclera
appear moist and smooth. Sclera white with no lesions or redness. No swelling or redness over lacrimal
gland. Cornea is transparent, smooth, and moist with no opacities, lens is free of opacities. Irises are
round, flat, and evenly colored. Pupils are equal in size and reactive to light and accommodation. Pupils
converge evenly.

Ears are equal in size bilaterally. Auricles are aligned with the corner of each eye. Skin smooth, no
lumps, lesions, nodules. No discharge. Nontender on palpation. Small amount of moist yellow cerumen
in external canal. Whisper test : patient repeats 2 syllable word.

MOUTH, THROAT, NOSE, AND SINUS

Lips pink, smooth, and moist without lesions. Buccal mucosa pink, moist, and without exudates.
Stensen/s ducts visible with no redness or swelling. 32 white to yellowish teeth present. Gums pink
without redness or swelling. Protrudes geographic tongue in midline with no tremors. Equal bilateral
strength in tongue. Ventral surface of tongue smooth and shiny pink with small visible veins present.
Frenulum in midline. Sof palate smooth and pink. Tonsillar pillars pink and symmetric.

Nose somewhat large but smooth and symmetric. Able to sniff through each nostril. Nasal septum
slightly deviated to the lef, but does not obstruct airflow. Inferior and middle turbinates dark pink,
moist, and free of lesions. No purulent drainage noted. Frontal and maxillary sinuses are nontender to
palpation and percussion.

THORAX AND LUNG

Respirations 18/minute, relaxed and even. Anteroposterior less than transverse diameter.

Chest expansion symmetric. No retraction or bulging of interspaces. No pain or tenderness on

palpation. Tactile fremitus symmetric. Percussion tones resonant over all lung fields. Vesicular breath
sounds auscultated over lung fields. No adventitious sounds present.

BREASTS AND LYMPHACIC

Bilateral breasts moderate in size, pendulant, and symmetric. Breast skin pale, pink with light brown
areola. Nipples everted bilaterally. Free movement of breasts with position changes of arms and hands.
No dimpling, retraction, lesions, or inflammation noted. Axillae free of rashes or inflammation.

No masses or tenderness noted on palpation. Bilateral mammary ridge present. No discharge noted
from nipples. Axillary ( central, posterior, or anterior) and lateral arm lymph nodes nonpalpable.
Demonstrates appropriate technique for BSE.

HEART AND NECK VESSELS

Carotid pulse equal bilaterally, 2+, elastic. No bruits auscultated over carotids. Jugular venous pulsation
disappears when upright. Apical impulse palpated in the fifh ICS at the lef MCL. Apical pulse- 70
beats/minute, regular rhythm, S1 heard best at the apex, S2 heard best at the base.

ABDOMEN

Skin of abdomen is free of striae, scars, lesions, or rashes. Umbilicus is midline and recessed with no
bulging. Abdomen is flat and symmetric with no bulges or lumps. No bulges noted when patient raises
head. No peristaltic movements seen. Sof clicks and gurgles heard at a rate of 15 per minute.
Percussion reveals generalized tympany over all four quadrants. No tenderness or guarding
in any quadrant with light palpation. Umbilicus and surrounding area free of masses, swelling, and
bulges.

MALE GENITALIA

pubic hair growth pattern is normal for adult male: pubic hair and base of penis are free of excoriation
and infestation. Circumcised penis is free of rashes, lesions, and lumps and is sof, flaccid and nontender
on palpation. Glans is rounded, and free of lesions; urinary meatus is centrally located on glans; no
discharge is palpated from urinary meatus. No masses or swelling noted in scrotum and lef side hangs
slightly lower than right side. Skin is free of lesions and appears rugated and darkly pigmented. Two
descended testicles palpated. No swelling, tenderness,or masses palpated along the testicle. No bulges
or masses palpated in inguinal or femoral canal.

FEMALE GENITALIA

Normal hair distribution, no lesions, masses, or swelling. Labia majora pink, smooth, and free of lesions,
excoriation, and swelling. Lania minora dark pink, moist, and free of lesions, excoriation, swelling or
discharge. No discharge from urethral opening. No malodorous discharge noted from vagina.

ANUS AND RECTUM

The anal opening is hairless, moist, and closed tightly. Perinanal area is free of redness, lumps, ulcers,
lesions, and rashes. No bulging of lesions appear when the patient performs the Valsalva maneuver.
Patient can close external sphincter around gloved finger. Anus is smooth, nontender, and free of
nodules and hardness.

PERIPHERAL VASCULAR
arms are equal in size, no swelling, pinkish skin tone, no clubbing of finger tips, warm bilaterally.
Capillary refill time less than 2 seconds, radial and brachial pulses strong bilaterally. No epitroclear
lymph nodes palpated. Legs are pink in color from toes bilaterally, normal distribution of hair, no ulcers
or edema. Legs are warm bilaterally. Femoral, popliteal, dorsalis pedis, and posterior tibial pulses
strongly palpated bilaterally. No apparent varicosities or superficial thrombophlebitis noted.

MUSCULOSKELETAL

Gait smooth, with equal stride and good base of support. Full ROM of TMJ with no pain, tenderness,
clicking or crepitus. Sternoclavicular joint midline with swelling or redness. Normal curves of cervical,
thoracic, and lumbar spine. Paravertebrals nontender. Full smooth ROM of cervical and lumbar spine.
Upper and lower extremities symmetric without lesions,nodules, deformities,or swelling. Full smooth
ROM against gravity and resistance.

NEUROLOGICAL

Cranial Nerves:

1. Identifies correct scents

2. Vision 20/20 OS, 20/20 OD, full visual fields

intact.

3,4,6 No ptosis, full extraocular movements (EOM)

pupils equally round, react to light and

accommodation (PERRLA)

5. Temporal and masseter muscles contract

Bilaterally. Able to identify light, sharp, dull

touch to forehead, cheek, and chin. Corneal

reflex present.

7. Able to smile, frown, wrinkle forehead, show

teeth, puff out cheeks, purse lips, raise eye-

brows, and close eyes against resistance.

 8. Wispered 2 syllable words heard bilaterally.

9 and 10. Uvula and sof palate rise symmetrically

on phonation. Gag reflex present. Swallows

without difficulty.

11. Equal shoulder shrug against resistance;

turns head in both directions against

resistance.

12. Protrudes tongue in midline with no tremors,

able to push tongue blade to right and lef with

no difficulty.

Motor and Cerebellar System

No atrophy, tremors, weakness, full ROM of all extremities. No fasciculations, tics, or tremors. Gait and
tandem walk normal and steady. Negative Romberg test. Performs repetitive alternating movements,
finger to nose at smooth, good pace. Runs each heel down each shin with no deviation.

Sensory System

Identifies light touch, dull and sharp sensations to trunk and extremities. Vibratory sensation,
stereognosis, graphesthesia, two-point descrimination intact.

Reflexes

Reflexes 2+ bilaterally, except Achilles 1+. No Babinski

present.
Categories: Uncategorized

Tags: Charting Examples, Documentation, Narrative, Nursing Note, Physical Assessment, Student Nurse

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