Purdue University Unit 8 journal Advance health

Unit 8/Module 4 Journal NU552

Date                   Student Name:

Complete patient information below.

Part I

Complete the physical assessment documentation per the sports physical requirements. Part I is not performed in the video submission but for your learning practice on sports physical documentation.

Place N in the Normal Column. Place AB in the Abnormal column with a comment if you choose. There does not need to be abnormal findings. If so you must comment.

You must add comments in the heart and genitalia sections (as if for a male). 

This is for your learning.

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The patient History is completed by the parent first, then an ROS; which are not a part of this journal exercise.

SYSTEM

Patient Name       Sex M

HT 5/10    WT 190

T- 98 P-70 R-15 B/P110/7 

N

AB

COMMENTS

HEAD

Hair, scalp, masses, injuries

N

EYES

Proptosis, conjunctivae, sclera, EOMI,

pupillary size, reaction to light,

peripheral vision, 

N

EARS

Gross hearing/ TMs/ Discharge

N

NOSE

Septum, mucosa, sinuses

N

THROAT/MOUTH

Teeth condition, tongue, tonsils, lesions

N

NECK

Thyroid, vessels, range of motion, adenopathy, masses, voice abnormalities

N

THORAX/LUNGS

Shape, expansion, deformities, rhonchi, wheezes, rales

N

HEART

PMI, sounds, thrills, murmurs, gallops, 

N

Normal heart sounds, no murmurs, gallops, or thrills noted.

LYMPHATICS

Cervical, axillary

ABDOMEN

Organ enlargement (liver, spleen, etc.), masses, tenderness, hernias, scars

N

GENITALIA

Scrotum, testicles, lesions, discharge, hernias

(female deferred)

N

Normal findings; no hernias, lesions, or discharge noted. 

UPPER EXTREMITIES

Range of motion, joint stability, muscle strength, limitations, effusion, ecchymoses, atrophy, deformities, edema, clubbing, pulses, veins, injuries

N

LOWER EXTREMITIES

Range of motion, joint stability, muscle strength, limitations, effusion, ecchymoses, atrophy, deformities, edema, clubbing, pulses, veins, injuries

N

BACK

Flexion, extension, scoliosis, kyphosis, excessive lordosis, injuries

N

NEUROLOGICAL

Cranial nerves, reflexes, motor, gait, balance, sensory

N

SKIN

Texture, striae, rash, acne

N

MENTAL STATUS

Affect, hostility, agitation

N

OBJECTIVE 

Part II Complete the MS and Peripheral Vascular exam documentation as in a physical exam for this component of a sport physical exam with detail and specifics as would be appropriate for this specialty exam. This should be more than Normal or Abnormal for this journal exercise. Sign the form by typing your name or using the draw feature.

Musculoskeletal

Joint stability, muscle strength, and range of motion in both the upper and lower limbs are all carefully checked. All of the joints can move normally, with no pain or restrictions. There were no signs of inflammation, degeneration, fluid, or abnormalities.

Peripheral Vascular

The peripheral beats are whole and even. There were no signs of venous disease, like varicose veins or blood clots. All four limbs have capillary refill times of less than 2 seconds, which means that blood flow is good to the rest of the body.

Approved Y/ N Provider Signature ____________________________________________

How might diagnostic reasoning and clinical judgment be used to move toward a diagnosis during this assessment? Include 2-3 evidence based resources about sports physical exam considerations; at least one of which is a clinical guideline for a condition that may be a differential if any abnormalities were found. Use an example. Word count 75-100

Diagnostic thinking and clinical opinion are used during the sports physical exam to come up with possible explanations by putting together the patient's background, physical results, and symptoms. For instance, if an athlete comes in with knee pain, stiffness, and weakness, other possible explanations could be an ACL tear, a meniscus injury, or a dislocated patellar tendon. Putting together the results with professional standards from groups like the American Academy of Pediatrics or the American College of Sports Medicine can help with more tests and treatment.