Chapters 19 &20-Regional Write Up-Thorax and Lungs & Heart
Name:___________________________________________Date:_________________________
Patient Initials:______________________________Age:____________Gender:_____________
I Health History-Subjective Data (yes no answers-all yes answers explain)
Thorax and Lungs & Heart
1. Do you have a cough?__________________________________________________________
2. Any shortness of breath?________________________________________________________
3. Any chest pain with breathing?___________________________________________________
4. Any chest pain or tightness?_____________________________________________________
5. Do you seem to tire easily?______________________________________________________
6. Do you sleep with more than one pillow?__________________________________________
7. Does your skin ever turn blue or ashen?___________________________________________
8. Do you have any swelling of the feet or legs?_______________________________________
9. Do you awaken at night to urinate?_______________________________________________
10. Ever smoke cigarettes? How many/per day? Alcohol use? Number of Drinks a Day?_______
______________________________________________________________________________
11. Any living or work conditions that affect your breathing?_____________________________
12. Last TB skin test, chest x-ray, flu vaccine?________________________________________
13. Any past history of heart or lung disease?_________________________________________
14. Assess personal and familial cardiac risk factors: diabetes, hypertension, smoking, high
cholesterol, obesity, sedentary lifestyle,
age?__________________________________________________________
______________________________________________________________________________
II Physical Exam-Objective Data-Thorax and Lungs & Heart
A. Inspection
1. Thorax cage_________________________________________________________________
2. Respiratory rate and pattern_____________________________________________________
3. Overall skin and nail color______________________________________________________
4. Patientàposition______________________________________________________________
5. Facial expression_____________________________________________________________
6. Level of consciousness_________________________________________________________
B. Palpation
1. Confirm symmetric chest expansion_______________________________________________
2. Tactile fremitus_______________________________________________________________
3. Detect any lumps, masses or tenderness____________________________________________
4. Trachea_____________________________________________________________________
C. Auscultation
1. Listen to anterior, posterior and lateral lung sounds__________________________________
2. Note any adventitious lung sounds?______________________________________________
D. Carotid Arteries
1. Palpate and grade R____________________________L______________________________
(0=absent, 1+=weak, 2+=normal, 3+=increased,4+=bounding)
2. Auscultate the carotid arteries for Bruits___________________________________________
Health Assessment-Regional Write Up-2022
E. Precordium
1. Skin color and condition________________________________________________________
2. Chest wall pulsations__________________________________________________________
3. Heave or lift_________________________________________________________________
E. Precordium continued
4. Note Location: Palpate the apical impulse in the ________ or _________intercostal space at
the __________________________________________line.
F. Auscultation
1. Rate and rhythm______________________________________________________________
2. Note any murmurs_____________________________________________________________
(Auscultate heart sounds in the aortic, pulmonic, erbàpoint, tricuspid and mitral area)
Summary Thorax and Lungs & Heart
Write a paragraph reporting all of your subjective and objective findings:
Health Assessment-Regional Write Up-2022

Purchase answer to see full
attachment