https://nku.instructure.com/courses/65752/files/8680800?wrap=1 https://nku.instructure.com/courses/65752/files/8680784?wrap=1
Pneumothorax
Tachycardia
Cyanosis
Respiratory distress
Bulging intercostal spaces
Respiratory lag on affected side
Contralateral tracheal deviation with tension pneumothorax
Diminished to absent fremitus
Cardiac apical impulse, trachea, and mediastinum shifted contralaterally
Diminished to absent tactile fremitus
Tachycardia
Hyperresonance
Diminished to absent breath sounds
Succussion splash audible if air and fluid mix
Sternal and precordial clicks and crackling (Hamman sign) from pneumomediastinum
Diminished to absent whispered voice sounds
Northern Kentucky University
MSN 610: Diagnostic Reasoning and Advanced Physical Assessment
Comprehensive History & Physical Exam
DEMOGRAPHICS
Providers Name: ___________________________________ Patient’s Initials: (Data Source)____________________
Date of Exam: _____________________________________ Patient’s DOB/AGE: _______________
Chief Complaint: ____________________________________ Gender/Sexual Orientation: ____________________
History of Present Illness:
Past Medical History:
Active Problems:
Resolved Problems:
Previous Hospitalizations:
Surgical History:
Allergies:
Current Medications:
Social History:
Living Arrangements:
Occupation:
Environmental Safety:
Smoking:
Alcohol:
Drugs:
Diet:
Other Non-Prescribed Drugs:
Family History:
Relationship Living or Deceased Age Illnesses
Preventative Health/ Anticipatory Guidance: (Age Appropriate)
1. Safety Issues:
2. Screenings:
3. Immunizations:
Reproductive health:
Review of Systems:
General:
Skin, Hair, Nails:
HEENT:
Neck:
Cardiovascular:
Pulmonary:
Abd/GI:
Genitourinary/ Gynecology/ Breast:
Musculoskeletal:
Neuro:
Endo/Lymphatic:
Hematology:
Psych:
Physical Exam
Vital Signs: Temp: __________ Pulse: _______ BP: _________/________ Resp: ______ O2 sat: _________
General:
Head:
Ears:
Eyes:
Nose:
Throat:
Neck:
Assessment Statement:
Problem List (As many or as few as needed)
Include ICD – 10 CODE
1.
2.
3.
Plan:
1.
2.
3.
4.
Submitted by: __________________________________________________
Date: __________________________________________
PLACE THIS ORDER OR A SIMILAR ORDER WITH RESEARCH MOLE TODAY AND GET AN AMAZING DISCOUNT
