Charting Examples For Physical

CHARTING EXAMPLES FOR PHYSICALASSESSMENT 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.& Soft 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 left, 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 LYMPHATIC 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 fifth ICS at the left 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.& Soft 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 soft, 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 left 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 soft palate rise symmetrically &&&&&&&&&& on phonation.& Gag reflex present.& Swallows &&&&&&&&&& without difÏculty.& &&&&&&& 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 left with &&&&&&&&&&&&&& no difÏculty. 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.