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TINA JONES COMPREHENSIVE PHYSICAL ASSESSMENT

TINA JONES COMPREHENSIVE PHYSICAL ASSESSMENT

Inspected head and neck, Scattered pustules on face and facial hair on upper lip(Found)
Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems.

Head is normocephalic, atraumatic
Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patient’s head can identify any indications of trauma.
Normal scalp hair distribution (Found)

It’s important to inspect your patient’s hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems.
Acanthosis nigricans noted on neck (Available)

Skin changes are common in patients with uncontrolled diabetes. A thorough inspection should be conducted of your patient’s skin, especially in folds around the neck, axilla, and groin.
Inspected eyebrows and orbital area
Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema (Found)
Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.
Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema (Found)
Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.
Palpated scalp, No masses (Found)
Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses.
No frontal sinus tenderness (Found)

Palpating the frontal sinuses checks for sinusitis.
Palpating the maxillary sinuses checks for sinusitis.
No clicks, full ROM (Found)
Palpating the jaw checks for crepitus can identify TMJ or injury.
Palpated lymph nodes, No axillary lymphadenopathy (Found)

Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.
No supraclavicular lymphadenopathy (Found)
Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.
Palpated thyroid
Thyroid smooth without nodules, no goiter (Found)
Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder.
Inspected eyelids and conjunctiva
Upper eyelids: conjunctiva pink, no lesions, white sclera (Found)
Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.
Lower eyelids: conjunctiva pink, no lesions, white sclera (Found)
Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.
Tested PERRL with penlight
Right pupil: equal, round, reactive to light (Found)

When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.
Left pupil: equal, round, reactive to light (Available)
When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.
Tested eye movements
Normal convergence (Found)
This test accommodation assesses the eye’s ability to focus on close objects.
EOMs intact bilaterally, no nystagmus( Found)
For this examination, the patient should look in the six cardinal fields without moving her head. Lag, nystagmus, and deviations may indicate neurologic conditions.
Tested peripheral vision
Peripheral vision intact in both eyes, all fields(Found)
Inspected interior eyes with ophthalmoscope
Mild retinopathic changes on right (Available)

Description

TINA JONES COMPREHENSIVE PHYSICAL ASSESSMENT

Inspected head and neck, Scattered pustules on face and facial hair on upper lip(Found)
Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems.

Head is normocephalic, atraumatic
Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patient’s head can identify any indications of trauma.
Normal scalp hair distribution (Found)

It’s important to inspect your patient’s hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems.
Acanthosis nigricans noted on neck (Available)

Skin changes are common in patients with uncontrolled diabetes. A thorough inspection should be conducted of your patient’s skin, especially in folds around the neck, axilla, and groin.
Inspected eyebrows and orbital area
Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema (Found)
Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.
Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema (Found)
Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.
Palpated scalp, No masses (Found)
Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses.
No frontal sinus tenderness (Found)

Palpating the frontal sinuses checks for sinusitis.
Palpating the maxillary sinuses checks for sinusitis.
No clicks, full ROM (Found)
Palpating the jaw checks for crepitus can identify TMJ or injury.
Palpated lymph nodes, No axillary lymphadenopathy (Found)

Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.
No supraclavicular lymphadenopathy (Found)
Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.
Palpated thyroid
Thyroid smooth without nodules, no goiter (Found)
Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder.
Inspected eyelids and conjunctiva
Upper eyelids: conjunctiva pink, no lesions, white sclera (Found)
Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.
Lower eyelids: conjunctiva pink, no lesions, white sclera (Found)
Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.
Tested PERRL with penlight
Right pupil: equal, round, reactive to light (Found)

When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.
Left pupil: equal, round, reactive to light (Available)
When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.
Tested eye movements
Normal convergence (Found)
This test accommodation assesses the eye’s ability to focus on close objects.
EOMs intact bilaterally, no nystagmus( Found)
For this examination, the patient should look in the six cardinal fields without moving her head. Lag, nystagmus, and deviations may indicate neurologic conditions.
Tested peripheral vision
Peripheral vision intact in both eyes, all fields(Found)
Inspected interior eyes with ophthalmoscope
Mild retinopathic changes on right (Available)

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TINA JONES COMPREHENSIVE PHYSICAL ASSESSMENT

Inspected head and neck, Scattered pustules on face and facial hair on upper lip(Found)
Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems.

Head is normocephalic, atraumatic
Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patient’s head can identify any indications of trauma.
Normal scalp hair distribution (Found)

It’s important to inspect your patient’s hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems.
Acanthosis nigricans noted on neck (Available)

Skin changes are common in patients with uncontrolled diabetes. A thorough inspection should be conducted of your patient’s skin, especially in folds around the neck, axilla, and groin.
Inspected eyebrows and orbital area
Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema (Found)
Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.
Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema (Found)
Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.
Palpated scalp, No masses (Found)
Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses.
No frontal sinus tenderness (Found)

Palpating the frontal sinuses checks for sinusitis.
Palpating the maxillary sinuses checks for sinusitis.
No clicks, full ROM (Found)
Palpating the jaw checks for crepitus can identify TMJ or injury.
Palpated lymph nodes, No axillary lymphadenopathy (Found)

Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.
No supraclavicular lymphadenopathy (Found)
Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.
Palpated thyroid
Thyroid smooth without nodules, no goiter (Found)
Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder.
Inspected eyelids and conjunctiva
Upper eyelids: conjunctiva pink, no lesions, white sclera (Found)
Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.
Lower eyelids: conjunctiva pink, no lesions, white sclera (Found)
Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.
Tested PERRL with penlight
Right pupil: equal, round, reactive to light (Found)

When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.
Left pupil: equal, round, reactive to light (Available)
When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.
Tested eye movements
Normal convergence (Found)
This test accommodation assesses the eye’s ability to focus on close objects.
EOMs intact bilaterally, no nystagmus( Found)
For this examination, the patient should look in the six cardinal fields without moving her head. Lag, nystagmus, and deviations may indicate neurologic conditions.
Tested peripheral vision
Peripheral vision intact in both eyes, all fields(Found)
Inspected interior eyes with ophthalmoscope
Mild retinopathic changes on right (Available)