Nursing 200: Complete Physical Examination (PE) Written Documentation
Indiana State University
College of Nursing, Health, and Human Services
Nursing 200: Complete Physical Examination (PE) Written Documentation The format for this paper is based on : Jarvis (2008).
Examiner: , SN ISU Date: 4/12/09
Patient: S.C. Age: 20 Occupation: Full-time nursing student taking 14 hours Language spoken: English Gender: Marital Status Race: Caucasian
Ethnic affiliation / association: American
Measurements (2 points):
• Weight (in lbs & kgs) 125 lbs 56.8kgs
• Height (in in & cm) 60 inches 15.2 cm
• Waist-to-hip ratio .82
• BMI 21.2 Category normal
Vital signs (2 points):
• Radial pulse rate 61 /min; Rhythm regular-regular
• Respiratory rate 16 /min; Ease of respirations: easy • Temperature (if indicated) 98.2 degrees ; Route
• Blood pressure
Right arm 120 / 80 mmHg; Pt position:
Left arm 120 / 82 mmHg; Pt position:
General Survey/Mental Status (2 points): well-nourished, well- hydrated; erect, relaxed posture; voluntary, coordinated movements; appears stated age, dress appropriate for age and gender; well-groomed; A/O x3; relaxed expressions, speech clear, articulate, word choice clear, understandable; affect matches stated mood; attentive; college level reading and writing, logical judgment, thought process consistent and realistic; denies suicidal ideation.
Skin, Hair, & Nails (3 points): Skin pinkish tan, light pigmentation, warm and dry; texture smooth and firm, uniform, mobile, immediate recoil when pinched; no vascularity, bruising, lesions; Hair brown; texture thick, curly; evenly distributed, fully covers scalp; clean with no lesions,bruising. Nails clean, edges smooth and rounded; uniform thickness, smooth, regular, no clubbing, no sponginess; even distribution; nail pink, capillary refill less than 3 seconds bil.
Head, neck & lymphatics (4 points): Skull normocephalic; no present deformities, lumps, tenderness; temporal artery smooth, easily palpable; temporomandibular joint smooth movement bil; facial structures symmetrical; no involuntary movements, edema, masses, lesions; neck centered, symmetrical; full range of motion; cervical muscles strong bilat; no abnormal pulsations; no enlargement of thyroid, lymph, salivary glands; lymph nodes are preauricula, postauricular, occipital, jugulodigastric,submandibular, superficial cervical,deep cervical, posterior cervical, submental, and supraclavicular; all not palpable; no tenderness bil.
Eyes (2 points): OU 20/20 with glasses on Snellen chart; OU 20/25 with glasses on pocket vision screener; fields intact bilat. on confrontation test; corneal light reflex shows light reflects bilat; steady fixed gaze on cover test; diagnostic positions test shows parallel tracking bilat; general eye structure shows relaxed expression, accompanies adequate vision; eyebrows present bilat; eyelids and eyelashes evenly distributed and present bilat; eyeballs aligned normally with no protrusions or sunken appearance bil; conjunctiva and sclera clear and china white; lacrimal gland and puncta shows no redness or swelling; cornea smooth and clear; pupil round, regular, bil; pupils constrict bilat to direct and consensual light reflex; accommodation pupilary constriction and convergence bilat; red reflex present bil.
Ears (2 points): Ear size and shape equal bilat; no swelling, thickening; skin intact, color consistent with rest of body, no lumps, lesions; firm, no tenderness, pain bil; external auditory meatus no swelling, redness, discharge bil; external canal has no swelling, lesions, foreign bodies, discharge bil; tympanic membrane shiny, translucent, pearly gray; eardrum position flat, slightly pulled at center; integrity of membrane intact bil; repeats words in whispered voice test; weber test both...