V.

Physical Assessment
Date: March 6, 2013 Time: 10:00 am A. General Appearance: Patient is lying flat on bed wearing surgical gown afebrile with anxious appearance. Cooperative and oriented with ongoing 5% Dextrose in Lactated Ringer Solution 1L at 700 ml inserted at the right cephalic vein regulated at 31 to 32 drops per minute infusing well. Weight: 59.5 kg Height: 159 cm BMI = 23.52 normal weight B. Vital signs: T: 36.5 c P: 100 bpm R: 20 cpm BP: 130/80 mmHg
BODY PART Skin TECHNIQUES Inspection NORMAL FINDINGS Uniform in color no presence of dry skin. ACTUAL FINDINGS -brown skin color with presence of dry skin. -Free from lesions/rashes equal bilaterally, warm to touch No presence of tenderness Smooth, a certain amount of roughness can be normal. It returns to INTERPRETATION Abnormal

-Free from lesions/rashes Palpation equal bilaterally, warm to touch No presence of tenderness Smooth, a certain amount of roughness can be normal. It should return

Normal

Normal

Normal

Normal

Normal

Nails

Inspection

to its original contour immediately. Pink cast in lightskinned individuals, and brown in darkskinned individuals. Smooth and slightly rounded or flat. Nail thickness should be uniform throughout Prompt return of pink or usual color should be 1-2 sec

original contour immediately Pinkish in color Normal

Palpation

Rough, slightly rounded and thick

Abnormal

Capillary refill time of 4 seconds

Abnormal

Head Size Symmetry Inspection -Round, proportional to the size of the body -No areas of tenderness -Clean, free from masses, lumps, lice, nits, dandruff and lesions Inspection -Round, proportional to the size of the body -no areas of tenderness -Clean, free from masses, lumps, lice, nits, lesions but positive from dandruff Normal

Palpation

Normal

Normal

Hair Color

Black, thick and evenly distributed

Black but some are grey in color, thick and evenly distributed

Normal

Scalp

Palpation

Smooth texture, no oiliness, no areas of

Smooth scalp, no Normal oiliness, no areas of tenderness

tenderness

Face Skin color Facial movement Inspection Light to dark brown Symmetric facial features & no involuntary movement -lids open and close symmetrically and has frequently blinking reflex up to 20 times per minute Symmetrical in size, extension, hair texture and movement Distributed evenly and curved upward Dark brown Normal

Inspection

Eyes

Inspection

Symmetric facial features & no involuntary movement -lids open and close symmetrically and has frequently blinking reflex up to 17 times per minute Symmetrical in size, extension, hair texture and movement Distributed evenly and curved upward

Normal

Normal

Eyebrows

Inspection

Normal

Eyelashes

Inspection

Normal

Eyelids Conjunctiva

Inspection

Same color as the skin Pinkish palpebral and bulbar conjunctiva Symmetrical no lesion or discharges present Smooth, symmetric and same color as the face

Same color as the skin Pale palpebral and bulbar conjunctiva Symmetrical no lesion or discharges present Smooth, symmetric and same color as the face

Normal

Inspection

Abnormal

Ears

Inspection

Normal

Nose

Inspection

Normal

Mouth Lips Buccal mucosa Gums Inspection Pink, moist symmetric Pink, soft, moist Dark, dry, symmetric Dark brown, soft, moist Dark Brown, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface 30 adult teeth Brown and black discoloration of the enamel Proportional to the size of the body and head No palpable lumps or areas of tenderness Presence of 3cm scars on left midscapular line Chest symmetric, spine vertically aligned. Full and symmetric expansion. Percussion notes resonate except over the scapula. Excursion is 35cm bilaterally. Abnormal

Inspection

Abnormal

Inspection

Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface 32 adult teeth Firmly set, white and shiny

Abnormal

Tongue

Inspection

Normal

Teeth

Inspection

Abnormal

Neck

Inspection

Proportional to the size of the body and head No palpable lumps or areas of tenderness Free from lesions and scars

Normal

Palpation

Normal

Posterior Thorax

Inspection

Abnormal

Palpation

Chest symmetric, spine vertically aligned. Full and symmetric expansion. Percussion notes resonate except over the scapula. Excursion is 35cm bilaterally.

Normal

Percussion

Normal

Auscultation

Normal

Normal

Anterior Thorax

Inspection

Vesicular and bronchovesicular breathe sounds. Free from lesions and scars

Vesicular and Normal bronchovesicular breathe sounds. Presence of 2 cm Abnormal scar on midsternal line Symmetrical chest movement Respiratory rate of 20 cpm Normal

Symmetrical chest movement Auscultation Respiratory rate within normal range [16 20 cpm] Trachea is bronchial and tubular in sound Abdomen Inspection Skin color same as the body, symmetric movement Clicks or gurgling sounds occur irregularly and range from 5-20 per minute Tympany over stomach and gas-filled bowels; dullness over the liver and spleen or full bladder No tenderness, relaxed abdomen Liver may not be palpable, no tenderness, boarders feels

Normal

Trachea is bronchial and tubular in sound Skin color same as the body, symmetric movement Gurgling sounds occurred irregularly 16 times per minute There is tympany over stomach and gas-filled bowels

Normal

Normal

Bowel sounds

Auscultation

Normal

Normal Percussion

Palpation (Light)

No tenderness, relaxed abdomen Palpable liver, no tenderness, boarders feels smooth

Normal

Normal

Palpation (Deep)

smooth Tenderness may be present near xiphoid process or sigmoid colon Bladder not palpable

Presence of tenderness near xiphoid process

Normal

Not palpable

Normal

Genitals

Pubic hair Inspection Triangular distribution Hairless (shaved) Normal

Penis Inspection Penile skin intact slightly wrinkled and same color as the body skin Smooth and semifirm Penile skin intact slightly wrinkled and same color as the body skin Smooth and semifirm Normal

Palpation

Normal

Scrotum Inspection Scrotal skin is loose and darker in color. Scrotal skin is loose and darker in color

Normal

Scrotum appears asymmetric

Marked asymmetry in size of right scrotum (right scrotum is larger) Presence of hardened testicles

Abnormal

Palpation

Testicles are rubbery and smooth.

Abnormal

Testes is about 2 x 4 cm

Right testes is 4 x 6 cm

Abnormal

Inguinal Area Inspection No swelling or bulges Presence of bulges while client is bearing down Presence of tenderness in the right inguinal area Abnormal

Palpation

No tenderness

Abnormal

Upper Extremities

Inspection

-skin color same as the whole body, free from lesions and scars -free from masses, warm to touch

-skin color same as the whole body, free from lesions and scars -free from masses, warm to touch

Normal

Palpation

Normal

Lower Inspection Extremities/ Feet

Uniform in color no presence of dry skin.

-brown skin color with presence of dry skin. -free from masses, warm to touch

Abnormal

Palpation

Free from masses, warm to touch

Normal