V.

Physical Assessment

Area Assessed

Technique

Normal Findings

Findings

Analysis

A. Skin Color Inspection Light brown, tanned skin (may vary according to race) Moisture Inspection/ Palpation Temperature Texture Turgor Palpation Palpation Palpation Normally warm Smooth and soft Skin snaps back immediately B. Skin Appendages Nails Inspection Transparent, smooth and convex Nail beds Inspection Pinkish Transparent, smooth and convex Pinkish Normal Normal Normally warm Smooth and soft Skin snaps back immediately Normal Normal Normal Skin normally dry Skin normally dry Normal Light brown skin Normal

Nail base Hair distribution Color

Inspection Inspection Inspection

Firm Evenly distributed Black to light brown

Firm Evenly distributed Light brown

Normal Normal Normal

C. Upper Extremities Arms Palms and dorsal surface Warm to touch and tenderness Pinkish and slightly rough Warm to touch, no lesions Pinkish, slightly rough Normal Normal

Shoulders

Perform w/o any difficulty

Can move without difficulty and have a tattoo of his wife on left shoulder Can bend without difficulty

Normal

Elbows

Inspection Inspection

Perform without any difficulty

Normal

skull

Generally round

Round

Normal

D. Eyes Inspection Eyes Non protruding Visual acuity : Normal

20/20 Eyebrows Inspection Symmetrical in size, extension, hair texture and movement Inspection Eyelashes Evenly distributed Evenly distributed Normal Symmetrical in size, extension, hair texture and movement Normal

Inspection Eyelids Same colour as skin Inspection Conjunctiva Transparent with light pink color Transparent with light pink color Normal Same colour as skin Normal

Sclera

Inspection Inspection

Color white

Color white

Normal

E. Ears

Free of Lesions, discharge of inflammation

Free of Lesions, discharge of inflammation

Normal

Hearing acuity

Inspection

Client normally

Client normally

hears words when whispered. F. Nose Inspection Nose in the midline; no discharges; no bone or cartilage deviation noted. Inspection G. Neck No visible mass or lumps; symmetrical; no jugular venous distension.

hears words when whispered. No tenderness noted; no signs of any discharges Normal

No mass or lumps; symmetrical

Normal

Inspection lymph nodes May not be palpable; nontender IF PALPABLE; less than 1cm in size. Inspection thyroid Normally nonNo nodules Normal Firm; non-tender and less than 1cm in size Normal

palpable; no nodules palpable

present

H. Thorax Auscultation Lungs Illustrate voluntary sound Voluntary sounds present Normal

Pulsation I. Cardiovascular Pulse visible; no lift or heaves. apical pulsations is present Normal

Inspection J. Abdomen Skin color is uniform, no lesions; some may have presence of striae or scars Inspection K. Lower extremities Equal in size; no Equal in size; no Normal No venous engorgement; no tenderness noted; no muscles guarding Normal

edema; no crepitus

edema

I.

Personal Data My patients name is XX She lives in Manila. She is 61 years old and was born on April 25, 1951. She is a Catholic. Her attending Physician is Dr. Julius Ceasar Dalupang M.D Medical Diagnosis is Arthroscopic Meniscectomy her Chief Complaint wasRight knee pain. Medical History: A. History of present illness 2 weeks prior to admission patient was going down a bus when she overstepped. She felt heavy feeling, popping sensation on her right knee. She felt pain on her right knee. Patient went to Emergency Room. B. Past Medical History The patient said that in her childhood she never experienced any major illness and was never hospitalized before. He also said that he only experienced those common illnesses like fever, cough and colds, flu and takes Paracetamol and Neozep when illness occurs. The patient has complete vaccines. The patient has no allergies both on food and medicines. C. Family Medical History The patients parents have Hypertension and Diabetes Mellitus on both sides. D. Social History The patient drinks occasionally. She was a previous smoker; she had stopped 10 years ago. 1pack/day x 31 years

II.