Lung and Thorax write-up
Dear Writter this are the intructions for the assigment: • It’s a writte up for a Lung and Thorax video.
☆All findings are normal.
This type of objective data only is required for the following videos: • Exam Video, Lung/ Thorax •
☆Patient : TS is a Male 25 yoa, Caucasian,
The student should use the Body System Exam rubric as a guide and only document their physical exam findings. (All findings are normal)
• The student should use medical terminology when documenting the examination findings in the objective section and be specific in documenting each rubric item assessed on video.
☆This is not a long narrative transcript of the video.
• Please use headers and bullet points for organization.
• The student should follow APA format with a title page. No references are used in a write-up as this is the student’s own physical examination University Rubric for referance.
☆Thorax and Lung Examination Video Documentation/ Check list Inspection · Assess for chest wall deformity – notes A/Transverse ratio while patient seated or standing (compares ant/posterior to profile) ·
Respiratory effort and movement, e.g. retraction, accessory muscles diaphragmatic breathing, respiratory rate (posterior and anterior) ·
Inspects nails for clubbing, lips/fingers, and overall color for cyanosis. ·
Respiratory excursion – extent, symmetry (ant/posterior)
Palpation · Respiratory excursion – extent, symmetry (ant/posterior) ·
Tactile fremitus (anterior and posterior)-99 repeat no vibration. ·
Costal chondral tenderness (anterior) · Patient instruction Percussion · Procedure (side to side comparison) use non dominant hand middle finger tab ·
Percussion technique ·
Percussion in all lung fields: anterior · Percussion in all lung fields: posterior · Diaphragmatic excursion (bilaterally or performs one side and verbalizes they would do both sides)= Amount diaphragm moves during inspiration/expiration normally between 3-6 cm in someone well condition, lungs in good health.
Patient instruction
Auscultation ·
Procedure- side to side comparison (ladder fashion) ·
Auscultation in all lung fields: anterior -Breath in and out ·
Auscultation in all lung fields:
posterior · Auscultation in all lung fields: lateral R ·Auscultation in all lung fields: lateral L to check right middle lobes · Auscultation in all lung fields: apices · Perform one of the following tests if you feel the patient has pneumonia or consolidation or coughing, : and explain what it demonstrates (what a positive finding would be): Bronchophony.
