NR304 Chamberlain College Health History And Physical Examination Case Paper

Attached you can find the guideline of the assignment and the rubric of how is going to be graded. Below I did a breakdown of the systems review of what needs to be touched. You can make up anything about this patient she is 21 Y.O, initials are A.W, African American, the other details or family history you can make it up. Please follow the guidelines and rubric.

Thank you!

o HEENT (head, eyes, ears, nose, and throat)

head – Inspect and palpate scalp, hair and skull (normocephalic, no lesions, or infestation) c Inspect the face (assess expression, symmetry, facial structures, skin, tattoos, and piercings) c Palpate lymph nodes (verbalize location {preauricular, posteriorauricular, occipital, submental, submandibular, jugulodigastric} assess for lymphadenopathy

eyes – Inspect external ocular structures (assess symmetry, lesions, discharge, and infestation of: eyebrows, eyelids, and eyelashes) c Inspect Conjunctiva and Sclera (assess color change, swelling, or lesions; conjunctiva: pink and sclera: white) c Test PERRLA (Pupils Equal, Round, Reactive to Light, and Accommodation)

ears- Inspect external ear (assess symmetry, position, alignment, lesions, and piercings) c Inspect external auditory meatus (no swelling, redness, or discharge) c Assess for hearing loss, hearing aid use, any exposure to environmental noise, and method of cleaning c Assess for skin breakdown behind the ear (assess tenderness) c Palpate Tragus (assess tenderness)

nose- inspect external structure (assess symmetry, midline position, proportional to other facial features, and lesions) c Inspect internal structures (assess for foreign bodies and deviated septum) c Assess bilateral patency c Assess for drainage

mouth and throat- Inspect the lips, teeth and gums (assess color, moisture, cracking, lesions, and alignment) c Inspect the oral mucosa (tongue, buccal mucosa, palate: assess odor, color, moisture, and lesions) c Inspect posterior pharyngeal and uvula

o Neck (including thyroid and lymph chains)

c Inspect the neck (inspect symmetry, ROM, head position midline, pulsations, and masses) c Palpate cervical lymph nodes (verbalize location {superficial, posterior, deep} assess for lymphadenopathy) c Palpate supraclavicular lymph nodes (assess for lymphadenopathy)

o Respiratory system

c Inspect the anterior chest (respirations and accessory muscle use) c Palpate anterior chest (masses and tenderness) c Auscultate anterior lung fields (6-8 positions, verbalizes lobe at each location and sounds heard at each location)

o Cardiovascular system

Inspect Jugular Venous pulse c Inspect Carotid pulse c Palpate each carotid pulse (may verbalize to first auscultate for bruit if older than middle age or signs and symptoms of cardiovascular disease) c Inspect the anterior chest (symmetry and apical impulse if visible) c Auscultate apical impulse (verbalize location: fourth or fifth intercostal space, left midclavicular line) c Auscultate 5 cardiac areas with diaphragm and bell (verbalize areas and location) c Palpate radial pulse (verbalize findings)

o Neurological system

Assess mental status

o Gastrointestinal system

c Inspect abdomen (color, contour, symmetry, skin, and pulsations) c Assess abdominal aorta, listen for bruits c Auscultate bowel sounds in all 4 quadrants c Light palpation of all quadrants (assess for muscle guarding, rigidity, large masses, tenderness)

o Musculoskeletalsystem o peripheral vascular system

c Test Range of Motion (ROM) c Insect size and contour c Inspect skin color and characteristics c Palpate c Test muscle strength of upper and lower extremities c Palpate dorsalis pedis pulses (verbalize finding)

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