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Trisquel.ink/Nursing
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Adult Health Assesment
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Chapter 19: Thorax and Lungs
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Thorax & Lungs – Physical Assessment Report (Normal Findings)
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Thorax & Lungs – Physical Assessment Report (Normal Findings)

Physical Assessment Report (Longer Format)
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📝 Respiratory System – Key Questions

📌 Current Symptoms

  • Do you ever feel shortness of breath (SOB)?
  • Do you have chest pain when breathing?
  • Do you have a cough? If yes:
    • How long have you had it (acute, chronic)?
    • Is it dry or productive?
    • If productive → what is the color, consistency, and quantity of sputum? (clear, white, yellow, green, bloody, frothy)
  • Do you wake up short of breath or need to use extra pillows to breathe comfortably at night (orthopnea)? How many pillows?

👨‍👩‍👧 Past Medical History

  • Have you ever been diagnosed with:
    • Asthma
    • Bronchitis
    • Emphysema/COPD
    • Pneumonia or frequent respiratory infections (URI)
    • Tuberculosis (TB)
  • Any history of allergies (environmental, seasonal)?

💊 Lifestyle / Risk Factors

  • Do you smoke cigarettes, vape, or use other tobacco products?
    • If yes: How many packs/day and for how many years? (Pack-year history)
  • Are you exposed to dust, chemicals, or fumes at work or home?
  • Do you live with anyone who smokes?

👀 General Appearance / Posture

  • Patient positioned upright, appears relaxed, and in no acute distress.
  • No signs of discomfort or anxiety observed
  • Respirations even, symmetrical, within normal rate. Quiet, unlabored,.
  • No nasal flaring or use of accessory muscle.

🫁 Thorax Inspection

  • Thorax symmetric bilaterally with normal Anterior-Posterior to transverse ratio ≈ 1:2
  • Anatomical landmarks identified: suprasternal notch, sternum, manubrium, angle of Louis, 2nd rib, 2nd intercostal spaces, C7 and T1 spinous process
  • Vertical reference lines visualized: mid-sternal, mid-clavicular, anterior/mid/posterior axillary lines, and mid-scapular lines, mid-spinal
  • Trachea midline; no deviation.
  • Skin color consistent with ethnicity, with good hygiene.
  • No masses, lumps, or abnormal lesion distribution patterns.
  • No deformities (no barrel chest, scoliosis, kyphosis, or pectus abnormalities).
  • No lesions, scars, rashes, edema, or abnormal pigmentation.

💅 Nails & 🧴 Skin

  • Skin: skin is smooth, intact, warm, and dry.
  • Normal mobility and turgor. No lesions, masses.
  • Nails: clean, smooth, and firmly attached
  • Nail beds pink, with normal shape.
  • No clubbing, cyanosis, deformities, or lesions.
  • Capillary refill < 3 seconds bilaterally.

✋ Palpation

  • Symmetrical chest wall expansion, anterior and posterior.
  • Tactile fremitus: vibrations are equal bilaterally (apices → bases, anterior, posterior, lateral).
  • No tenderness, crepitus, palpable masses or subcutaneous emphysema.
  • Spine midline, no abnormal curvature detected.

🔨 Percussion

  • Patient correctly positioned.
  • No dullness or hyperresonance detected on anterior, posterior, or lateral lung fields.

🎧 Auscultation

  • Breath sounds normal, clear and vesicular bilaterall in all lung lobes.
  • No adventitious sounds.
  • Normal bronchial, bronchovesicular, and vesicular sounds heard in appropriate locations.