Physical assessment

Objective

Thirty four year old African American male present to clinic for a complete head to toe

assessment. Bp (140/80), HR (60) R (18) T (98.3) W (200). Speech appropriate. Alert and

oriented to person, place, time. Upon observation, client skin tone appropriate with ethnicity.

Skin is warm, dry, intact; turgor good. No lesions, birthmarks, edema or open sores. Head: full

head of hair, no bald spots, lice, lesions, or lumps. Eyes. Sclera is white, no lesion or redness,

visual fields full by confrontation, no discharge, or crusting, Pupils constricts and dilates

bilaterally. Face symmetrical, no weakness or involuntary movement. Patient can feel me rub his

cheeks bilaterally. Patient can puff his cheeks, smile and move his forehead up and down. Nose

is in the middle of face, nose is pink, septum midline. No drainage. Patient can blow though one

nostril while holding the other one down for patency. There is no clicking or grating

temporomandibular joint. Patient roof of mouth is negative of white spots, Trachea is in the

middle of throat, no swelling noted. No swelling or redness of tonsils. Patient can say ahh and

stick his tongue out gag reflex intact. Patient can look up and at celling and shrug her shoulders.

Patient pinna is free of mass, lesions, scaling, discharge, or tenderness to palpation. Canals clear.

Tympanic membrane pearly gray, whispered words heard bilaterally. Patient can move neck side

to side and lift head up and down. No masses, tenderness, trachea midline. Thyroid nonpalpable,

not tender. Jugular veins flat. Carotid arteries 2+ bilaterally no bruits. Chest expansion

symmetric. Tactile fremitus equal bilaterally. Breath sounds diminished bilaterally. No wheeze

or rhonchi in posterior chest bilateral bases cleared. No cough or use of accessory muscles.

Negative for bronchophony repeating of (9…99…99…) and egophony (eeeeee). No abnormal

pulsations, no heaves. Apical impulse at 5th intercostal space. S1–S2 heard at the apex no

murmur, loudest at left lower sternal border. Breasts is symmetric. No discharge, or lesions. No

masses or tenderness. Abdomen flat, soft symmetric. Skin smooth with no lesions or scars.

Bowel sounds present in all four quadrants. No bruits. Patient extremities all peripheral pulses

present, 2+ and bilaterally with regular rhythm symmetrical. Patient upper body, skin appears

clean and appropriate for ethnicity. Skin is warm, no pallor, swelling or cyanosis and no legion.

Nails bed are pink with capillaries refill return of less than 2second bilaterally. Fingers profile

are less than 60degrees symmetrical. Patient lower body, hair distribution are even on legs, skin

is warm no swelling/pitting edema and cyanosis. No varicose or spider veins or ulcer. Negative

for pain in his thighs, right calf or legs. Positive for blister on right leg. No drainage but positive

for redness. Toes nail bed are pink with capillaries refill less than two seconds bilaterally. No

deformity or curvature; full extension, lateral bending, rotation. Arms symmetric, legs measure

as symmetric, extremities have full range of motion, no pain or crepitation. Muscle strength: able

to maintain flexion against resistance and without tenderness. Able to tandem walk with shoes

on. Negative Romberg sign. Patient has express he rather not have his genitals examine.

Risk factor

Patient is an overweight African America male. This puts his at risk for heart disease obesity,

hypertension and other disease.

Patient has a blister on his right leg that is red and swollen around it. Patient is at risk for an open

wound or infection if the blister opens up or become infected.

3

Peripheral vascular system

Thelma H. Walker

Rasmussen College

COURSE#: NUR2180 Physical Assessment

Professor Casey Kelly

December 1, 2020

Subjective

Mr. Ortiz, an 88-year-old Mexican American man woman

Admitted diagnosis: Peripheral arterial disease

Medications: Rosuvastatin and clopidogrel simvastatin

Allergies: NKDA

Substance use: cigarette use (1 pack day for the last 50 years )

Status: Mr. Ortiz lives in along care facility. When asking the Patient about the circulation in his legs, he states that it is not very good. The Patient states he is experiencing an increase in pain, particularly when he is walking and occasionally when he is trying to sleep at night.

Pain: 6 /10 bilateral legs & feet.

Associated symptoms: Sensation in legs/feet and recent falls.

Past medical history: myocardial infarction 15 years ago, hypertension, hypercholesteremia, chronic renal failure(CRF0, and peripheral arterial disease (PAD)

Objective Information

Upon examination: vital sign: oral temp 36.8 C, HR 90 BPM, RR 18 and BP 140/92 mm Hg,

Upon an inspection, Thin, shiny, taut skin. Hair growth absent in bilateral lower extremities. Toenails are hard and thickened. Rubor on bilateral lower legs noted when limbs are dependent. Bilateral feet pale when elevated;

Upon palpation: 1+ dorsalis Pedi and posterior tibial pulses bilaterally. Feet cool. Capillary refill 7 seconds on bilateral lower extremities. Unable to differentiate between sharp versus dull sensation on bilateral feet and lower legs (below knee)

Risk Factors

References