Health Assessment Physical Exam Discussion Paper

Posted: December 23rd, 2022

Health Assessment Physical Exam Discussion Paper

Upon assessment, Ms. Jones’ vital signs are height: 170 cm, weight: 84 kg, BMI: 29.0, blood glucose: 100, RR: 15, HR: 78, BP: 128 / 82, SpO2: 99%, and temperature: 99.0 F.

Ms. Jones’ head is uniformly shaped, her hair is well-placed, and her scalp is clean and devoid of abnormalities. Her brows are perfectly symmetrical. There was no indication of edema or ptosis. Her pupils are circular, brisk, and equal in size, and they respond to light. She has white sclera and pink conjunctiva. Her current corrective glasses have improved her vision to 20/20. Her face is covered with acne. Her top lip is also covered with facial hair. This patient’s nose is symmetrical and is midline, and her nostrils are pink, moist, and patent. There are no lesions visible. Upon palpitation, non-tender maxillary sinuses were noted. Her tympanic membranes are bilateral and intact with pearly gray color and a positive light reflex. The examination of whispered words shows equal hearing bilaterally. The oral mucosa appears pink and free of abnormalities. The tonsils, uvula, and pharynx are moist and pink, and there are no lesions apparent. Her teeth are intact, white, and clean. There were no caries observed. The tongue is movable, and it is free of any lesions. The gag reflex is intact.  The temporomandibular joint (TMJ) is symmetric and smooth. She has a non-palpable thyroid. There was no indication of a goiter. Neck lymph nodes were non-palpable Health Assessment Physical Exam Discussion Paper.

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Ms. Jones’s chest is symmetrical, according to the assessment. Auscultation of her lungs reveals that she has bilateral clear lung sounds in all lobes. There were no adventitious sounds noted. With chest percussion, there is a resonant sound throughout. Her spirometry results show that her FVC is 3.91 L, and her FEV1 is 3.15 L. Her FEV1/FVC ratio is 80.56 percent.

The patient’s cardiovascular exam shows that her heart rate is regular. S1 and S2 are auscultated without the presence of rubs, gallops, or murmurs. The carotid arteries are regular and free of bruits bilaterally. Her skin on the upper extremities is warm, and the color is normal. There were no edema or lesions detected. The color of my fingernails is pink and clear. Bilateral capillary refill takes less than three seconds. The radial and brachial pulses are equal bilaterally, +2, and have a regular rhythm. It is warm in the lower extremities, with normal skin color. There were no lesions observed. No varicosities or edema were seen. She has Pink and clear toenails. The bilateral femoral, tibial, and dorsalis tibialis pulses are all equal, positive, and regular. There is no lymphadenopathy or bruits noted. The PMI is located in the midclavicular line, 5th intercostal space. No lifts or heaves Health Assessment Physical Exam Discussion Paper.

Ms. Jones’ abdomen appears to be large and symmetric on examination, with the umbilicus located in the midline. The color of the skin on the abdomen is normal and free of lesions. From the pubis to the fundus, coarse hair is visible. There are no ascites or bulges noted. The abdomen has a soft feel to it. No tenderness or guarding when her abdomen is palpated. Positive bowel sounds may be heard in all four quadrants. There are no bruits heard during the auscultation. There are tympanic sounds upon percussion. On MCL, the liver span is 7 cm. Both the spleen and bladder are not palpable organs. There is no indication of CVA tenderness.

There are no tumors, lesions, edema, or abnormalities noted. The shoulders and clavicle are identical in size on both sides. Both the lower and upper extremities have a full bilateral range of motion and 5/5 muscular strength. There is no discomfort with movements. Non-tender joints are noted. The spine is located in the midline and has a full range of motion Health Assessment Physical Exam Discussion Paper.

Ms. Jones’ neurologic system was examined, and the results revealed normal cerebellar function tests, graphesthesia, stereognosis, and rapid alternating motions bilaterally. She has equal and positive deep tendon reflexes in her bilateral upper and lower extremities. On her bilateral plantar surfaces, she exhibits reduced sensitivity to monofilament.

Submit a typed write-up of your physical assessment of Tina Jones (Shadow Health) based on the comprehensive assessment module. – Make sure to follow the proper sequencing order in your physical assessment write up and use correct terminology Health Assessment Physical Exam Discussion Paper