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Comprehensive Health
Assessment: Objective Findings
Objective Data Collection
HEENT
Inspected head and neck: Scattered pustules on face and facial hair on upper lip Head is normocephalic, atraumatic Normal scalp hair distribution Acanthosis nigricans noted on neck Inspected eyebrows and orbital area: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema Palpated scalp: No masses Palpated sinuses: No frontal sinus tenderness No maxillary sinus tenderness Palpated jaw: No clicks, full ROM Palpated lymph nodes: No axillary lymphadenopathy No supraclavicular lymphadenopathy Palpated thyroid: Thyroid smooth without nodules, no goiter Inspected eyelids and conjunctiva: Upper eyelids: conjunctiva pink, no lesions, white sclera Lower eyelids: conjunctiva pink, no lesions, white sclera Tested PERRL with penlight: Right pupil: equal, round, reactive to light Left pupil: equal, round, reactive to light Tested eye movements: Normal convergence, EOMs intact bilaterally, no nystagmus Tested peripheral vision: Peripheral vision intact in both eyes, all fields Inspected interior eyes with ophthalmoscope: Mild retinopathic changes on right Left fundus with sharp disc margins, no hemorrhages Tested visual acuity: Vision 20/20 right eye with corrective lenses Vision 20/20 left eye with corrective lenses Examined nasal cavities with otoscope: Nasal mucosa moist and pink, septum midline on right Nasal mucosa moist and pink, septum midline on left Examined ear cavities with otoscope: Right TM intact and pearly gray, positive light reflex Left TM intact and pearly gray, positive light reflex Practiced whisper test:
Whispered words heard on right Whispered words heard on left Inspected mouth and throat with tongue blade: Oral mucosa moist without ulcerations or lesions, uvula midline Gag reflex intact
Respiratory
Tested pulse oximetry: Oxygen saturation 99% Tested lung capacity: FVC is 3.91 L and FEV1/FVC ratio is 80.56% Inspected chest wall: Anterior chest wall symmetric, no deformity or lesions Posterior chest wall symmetric, no deformity or lesions Palpated thoracic expansion: Thoracic expansion symmetric Palpated tactile fremitus: Anterior upper chest wall: normal fremitus Anterior lower chest wall: normal fremitus Posterior upper chest wall: normal fremitus Posterior middle chest wall: normal fremitus Posterior lower chest wall: normal fremitus Percussed anterior chest wall: Right upper chest: resonant Left upper chest: resonant Left middle chest: resonant Right middle chest: resonant Right lower chest: resonant Left lower chest: resonant Percussed posterior chest wall: Left upper chest: resonant Right upper chest: resonant Right middle chest: resonant Left middle chest: resonant Left lower chest: resonant Right lower chest: resonant Auscultated breath sounds of anterior chest wall: Right upper lungs: no adventitious sounds Left upper lungs: no adventitious sounds Left middle lungs: no adventitious sounds Right middle lungs: no adventitious sounds Right lower lungs: no adventitious sounds Left lower lungs: no adventitious sounds Auscultated breath sounds of posterior chest wall: Left upper lungs: no adventitious sounds Right upper lungs: no adventitious sounds Right middle lungs: no adventitious sounds Left middle lungs: no adventitious sounds Left lower lungs: no adventitious sounds Right lower lungs: no adventitious sounds Auscultated anterior lungs for bronchophony: Right upper lungs: muffled voice sounds Left upper lungs: muffled voice sounds Left middle lungs: muffled voice sounds
Left femoral artery: no bruit Performed Capillary Refill: Capillary Refill < 3 sec Inspected for edema: Left leg: no edema Right leg: no edema
Gastrointestinal
Inspected abdomen: Abdomen protuberant, symmetric, no visible masses or lesions, coarse hair from pubis to umbilicus Auscultated bowel sounds: Right upper quadrant: normoactive Right lower quadrant: normoactive Left upper quadrant: normoactive Left lower quadrant: normoactive Auscultated arterial sounds: Aortic artery: no bruit Percussed CVA tenderness: Right flank: none reported Left flank: none reported Percussed organs: Spleen percussion: no dullness Liver span: 7 cm MCL on percussion Percussed abdomen: Right upper quadrant: tympanic Right lower quadrant: tympanic Left lower quadrant: tympanic Left upper quadrant: tympanic Palpated abdomen - light: Right upper quadrant: soft, no tenderness or masses Right lower quadrant: soft, no tenderness or masses Left lower quadrant: soft, no tenderness or masses Left upper quadrant: soft, no tenderness or masses Palpated abdomen - deep: Right upper quadrant: no masses, guarding or rebound Right lower quadrant: no masses, guarding or rebound Left upper quadrant: no masses, guarding or rebound Left lower quadrant: no masses, guarding or rebound Palpated organs: Liver: palpable 1 cm below right costal margin Spleen: not palpable Right kidney: not palpable, no masses Left kidney: not palpable, no masses
Musculoskeletal
Inspected neck: Neck without swelling, masses, or deformity Inspected upper extremities: Right shoulder without swelling, masses, or deformity Right arm without swelling, masses, or deformity Right elbow without swelling, masses, or deformity Right wrist and hand without swelling, masses, or deformity
Left shoulder without swelling, masses, or deformity Left arm without swelling, masses, or deformity Left elbow without swelling, masses, or deformity Left wrist and hand without swelling, masses, or deformity Fingernails: no ridges or abnormalities in nails, pink nailbeds Inspected hips: Hips without swelling, masses, or deformity Inspected lower extremities: Right leg without swelling, masses, or deformity Right knee without swelling, masses, or deformity Right ankle without swelling, masses, deformity, or discoloration Right foot without swelling, masses, or deformity Left leg without swelling, masses, or deformity Left knee without swelling, masses, or deformity Left ankle without swelling, masses, or deformity Left foot without swelling, masses, or deformity Toenails: no ridges or abnormalities in nails, pink nailbeds Tested ROM for upper extremities: Right and left shoulders: full ROM Right and left elbows: full ROM Right and left wrists: full ROM Tested ROM for spine: Rotate left: full ROM Rotate right: full ROM Extension: full ROM Flexion: full ROM Tested ROM for hips: Right and left hips: full ROM Tested ROM for lower extremities: Right and left knees: full ROM Right and left ankles: full ROM Tested strength for neck: Right and left side neck strength: 5/ Tested strength for upper extremities: Right and left shoulder strength: 5/ Right and left elbow strength: 5/ Right and left wrist strength: 5/ Right and left hand strength: 5/ Tested strength for hips: Right and left hip strength: 5/ Tested strength for lower extremities: Right and left knee strength: 5/ Right and left ankle strength: 5/
Neurological
Tested graphesthesia: Identified the number '8' drawn on right hand Identified the letter 'A' drawn on left hand Tested sensation in feet with monofilament: Decreased sensation in right foot Decreased sensation in left foot Tested ability to sense light touch of upper extremities: Right arm proximal light touch sensation intact Right arm distal light touch sensation intact Left arm proximal light touch sensation intact
Left foot straight line down shin, smooth and accurate Tested rapid alternating hand movements: Rapid alternating hand movements: smooth
