sample physical assessment
Post on 11-Mar-2015
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Physical Assessment
Vital Signs
Axillary T= 36 C, PR= 73 bpm, RR= 22, , BP= 90/60 mmHg.
General survey
Height=, weight= kilos, head circumference= cm, abdominal
circumference= inches. Mesomorph. No signs of distress noted upon
assessment, able to smile, cooperate well, responsive to questions, conscious
and alert, conversant. Well oriented. Show calmness during the examination.
The patient has IVF infused, and was asleep at initial assessment.
Skin
Skin is brown in color, rough, dry and warm. has good skin turgor.
Brownish discolorations that resemble freckles are observed on arms and face.
Head
Skull is round in shape, symmetrical (normocephalic). No masses
noted. Facial movement is symmetrical. Hair is dry in texture; its color is black
with mimimal streaks of gray. Scalp is clear from dandruff and lice. No scars
and wounds noted.
Eyes
Has symmetrical eyebrows movement, shape and hair distribution.
Eyebrows have same color with hair. Eyelashes are evenly distributed and
curled outward. Eyelids have no discharges and bilaterally blink. Upper lid
covers the small portion of the iris and cornea. Lacrimal duct openings (puncta)
are evident at nasal ends of upper and lower lid with no tenderness noted.
Palpebral conjunctiva are pinkish in color while the pupils constricted to light
(2mm), round in shape, isocoric, shows uniform convergence. he is able to
rotate eyes and has coordinated eye movements.
Ears
Auricle has same color with the skin, has symmetrical shape and
located a little bit higher than the eye. Pinnas are symmetrical, mobile, and able
to recoil, with no lesions noted. he has wet cerumen noted on both ears when
pulled down and back for better visualization. he is able to hear on both ears..
Nose
Nose has uniform color and symmetrical in shape. Nasal hairs are
very evident when light is flashed through the nasal passageways; its color is
black. No nasal flaring observed upon respiration. Both nares are patent, air
moves freely as client breathes through the nares. Nasal septum is straight and
in midline. Nasal mucosa is pinkish in color, has no discharges and no lesions.
No tenderness of sinuses noted.
Mouth
Lips are a little brownish in color, dry and has cracks. Tongue is in
midline, pinkish in color with thin whitish coating on top. Able to move tongue
freely (up & down, side to side). Soft palate is light pink in color while hard
palate is lighter in color. Gums are pinkish in color. Her first and second right
molars of the lower teeth, and her first left molar of the upper teeth are missing.
Her teeth are a little yellow in color with few plaques usually found on her
remaining molars.
Pharynx
Uvula is found well placed in midline of soft palate. Mucosa is
pinkish in color. Tonsils are not inflamed.
Neck
Trachea is in midline. No tenderness of thyroid noted. No
enlargement of the neck noted. She is able to flex and extend neck and move it
laterally (L and R).
Chest and Lungs
Breathing pattern is regular (eupnea). Anteroposterior diameter to
transverse diameter is in 1:2. Respiratory excursion is symmetrical (thumb
separates to 2-3cm). Vocal tactile fremitus is bilaterally equal. She refused to
have her breasts examined. Slight wheezing heard on the left upper lung field.
Heart and Central Vessels
Heart sounds are regular. Pulsation of heart is heard in 4 anatomical
areas but more audible in apical area upon auscultation.
Back and Extremities
Peripheral pulses are symmetrical and regular. Nails are long and
untrimmed, pinkish in color, and have a capillary refill time of 2 sec. after
blanching; and no clubbing of fingernails were noted. Calluses were observed at
the tip of her fingers and toes. His hands are a little rough. Muscle strength is
equal on both sides of the upper and lower extremities. Spine is a little deviated
to the left as seen when client was asked to bend over. he is able to stand and
walk on both feet independently, and his movements are well coordinated. Toes
point straight ahead. And he is able to sit up straight.
Abdomen
His abdomen’s color is same with the rest of the part of the body.
Her umbilicus is coated with blackish dirt. has globular abdomen and dullness
was noted upon percussion.
Neurologic Assessment
CN 1 Olfactory: Client was able to identify smell of alcohol with eyes closed.
CN 2 Optic: She was able to see objects but not clearly as evidenced by pulling
a piece of paper near her eyes when reading. Her pupils are reactive to light
and accommodation. The patient’s pupils constrict when assessor’s finger was
moved near her nose.
CN 3 Oculomotor: Her pupils constricted when light stimulation was applied. Her
eyes were able to move laterally, medially and superiorly. Her eyelids also
elevated very well.
CN 4 Trochlear: She can look downward.
CN 5 Trigeminal: As observed, the client was able to chew while eating. And
she can move her jaw laterally against the assessor’s hand.
CN 6 Abducens: The patient can move her eyes from side to side.
CN 7 Facial: The patient can smile, frown, puff her cheeks and raise her
eyebrows. She can also determine the taste of the food she was eating as
evidenced by.”
CN 8 Vestibulocochlear: She was able to hear questions and answered them
appropriately such as:
She can walk independently without tripping off or falling down.
CN 9 Glossopharyngeal: The client was able to swallow her food and water.
CN 10 Vagus: Her voice was soft. Together with CN 9, gag reflex was not
tested with the use of sterile padded tongue depressor but with the client’s
ability to swallow food and the absence of aspiration during eating.
CN 11 Spinal Accessory: The client can turn her head from side to side and can
resist the force applied on her shoulders (sternocleidomastoid and trapezius
muscles). She is able to shrug her shoulders with equal strength.
CN 12 Hypoglossal: She can move her tongue laterally and protrude it. She can
converse well.
She has an RLS of 1 as evidenced by being alert and awake during
assessment. She had her eyes open and directly looking at the examiner. She
could respond to questions appropriately.
She has a GCS of 15 as evidenced by:
- (4) Opening of her eyes spontaneously. She directly looked at the
one who opens the curtain of her room or cubicle.
- (5) Oriented. She gave appropriate answers to questions.
- (6) Obeys commands. When asked to raise her arms for vital signs
assessment (blood pressure; BP cuff) she hurriedly and willingly
obeyed.
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