7/31/2019 Physical Card

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General:Obtain urine sample (amt., color, clarity, complaints of ), Observegait-Heal to toe, Romberg, WT, HT, BMI= wt/ht^2x703 Normal is 18.5-24.9. Race,

Gender, Age, VS w/apical

Head: LOC, Signs of distress (rate pain) Mental status, Behavior,

Appearance(grooming), Speech k ch, congruence of verbal and non-verbal,

observe skin(color, temp, moisture, lesions, scars) TURGOR, Cap refill, Head(hair),

PERRLA, 6 fields of gaze, sclera, conjunctiva, Consensual response, Corneal light

reflex(should be the same on both eyesred eye), Corneal Reflex (cotton),Vision(close 12-14 in.) (Snellen distance 20 ft.), Ear-symmetry, lobe, whisper test, weber,

rinne Mucosa, lips, teeth, gums, Carotid(bruits), Lymph nodes

Go to Back: Inspect symmetry, check spine, SYMMETRICAL

EXPANSION(VV), tactile fremitus(99), thorax(Note shape & contour), AP

Diameter(2:1), Listen to breathe sounds(1-10 Normal vs. Adventitious-crackle,

wheeze), Palpate for tenderness, lumps & bumps, Percuss 1-10

Resonance-hollow, low pitch

Tympani-Air drum

Dull-thud fluid, increased sound over an organ

Flat-increased over bone

Costovertebral Angle Tenderness-hand flat hit w/fistFlank pain?

Go to front: Inspect shape, symmetry, Respiration pattern(16-20), breathesounds 1-7 *front starts above clavicle side 1-7, 7th on right side-3rd lobe Percuss,

Palpate HR 60-100 Auscultate Heart Sounds-valves closing

Aortic-semi lunar, S2, 2nd intercostal on right sternal border

Pulmonic- semi lunar, 2nd intercostal on left sternal border

ERBS-3rd intercostal space on left sternal border, S1=S2

Tricuspid-S1, A/V, 4th intercostal space left sternal border

Mitral-A/V, mid clavicle, PMI, Apical

***Use bell to listen for bruits***

Abnormal Heart Sounds

S3-lub-dub-E (FVE) S4-ta-lub-dub(damage) Murmur-whoosh Pericardial Friction Rub Prosthetic Heart Sounds Any splitting, clicking, or murmurs?

Abdomen: Lay BackJVD, 1stInspect- contour (Note colormasses, lesions, scars, venous pattern) Auscultate -BS x 4 QuTangeal Light- look for visible waves

Bruits: use bell Aorta Renal

Iliac Femoral

Percuss-x 4 Quad Palpate (lightly Liver-right side, spleen-lef

Rebound Tenderness-pain with withdrawalGeneral: Bladder Distention, Measure Abdominal Girth, Last

Normal patternSit Up: Check pulses-Brachial, Radial, Ulnar & Femoral Insp(+1-+4), ROM-(ELBOW) Flexion/Extension, sup-, pro- (size,

color, contour, deformity?)Crepitation-tenderness, painHand grasps, Arm Resistance, Plantar/Dorsiflex-Resistance

Pulses: Popliteal pulse Dorsalis pedis pulse

posterior tibial pulse