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.