A. Physical Assessment Date: May 6, 2013 V/S: BP- 130/90 mmHg, PR: 63 bpm, RR: 22 cpm, T-36.

6.3 C LOC: Oriented

AREA ASSESSED A. SKULL 1. Size, shape and symmetry of the skull

TECHNIQUE Inspection Palpation

NORMAL FINDINGS Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour Smooth, uniform consistence; absence of nodules or masses

ACTUAL FINDINGS Rounded(normocephalic); smooth skull contour

ANALYSIS and INTERPRETATION Normal

2. Presence of nodules, masses, and depressions 3. Facial Features

Palpation Inspection Inspection Palpation Inspection

Has no tenderness; no masses nor nodules

Normal Normal

Symmetric or slightly asymmetric Symmetrical and palpebral facial features; palpebral fissure fissure equal in size, nasolabial equal in size; symmetric nasolabial folds are symmetrical No edema and hollowness No edema and hollowness

4. Presence of edema and hollowness in the eye. C. HAIR 1. Evenness of growth, thickness, or thinness of hair

Normal

Inspection Palpation

Evenly distributed and covers the whole scalp; Maybe thick or thin

Thinning of hair is noted

Normal may possibly be related to aging process. Androgentic Alopecia(Hormones play the dominant role when talking about Androgenetic Alopecia)

2. Texture and oiliness over the scalp 3. Presence of infection and infestation D. FACE Facial features, symmetry of facial movements

Inspection Palpation Inspection Palpation

Silky; resilient hair No infection and infestation

Smooth and resilient hair Infestation and infections are not present

Normal Normal

Inspection

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

Freckles and moles are noted in different areas around the face. Skin is wrinkled and somewhat dry. No abnormal facial movements noted

Wrinkling and drying is caused by aging since the client is already 70 years. Freckles and moles might be caused by UV rays when client was exposed under the sunlight for too long.

IV. EYES A. EYEBROWS Hair distribution, alignment, skin quality and movement B. EYELASHES Evenness of distribution and direction of curl C. EYELIDS Surface characteristics and position (in relation to the cornea, ability to blink, and frequency of Inspection Upper eyelids cover the small Able to close the eyes and has Normal portion of the iris, cornea, and the ability to blink. Wrinkling is sclera when eyes are open; eyelids noted as well meet completely when the eyes are Inspection Palpation Evenly distributed; turned outward Turned outward eyelashes; hair equally distributed Normal Inspection Symmetrical and in line with each other; maybe black, brown or blond depending on race; evenly distributed Symmetrical and aligned with each other; black; evenly distributed. Movements are symmetrical. Normal

blinking) D. CONJUNCTIVA 1. Color, texture, and the presence of lesions in the bulbar conjunctiva 2. Color, texture, and the presence of lesions in the palpebral conjunctiva E. SCLERA Color and clarity Inspection Inspection Palpation Inspection Palpation

closed; symmetrical

Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers

Pinkish color is noted in the conjunctiva. No foreign lesions are observed. Pinkish as well and no lesions and ulcers noted.

Normal

Normal

White in color; clear; no yellowish discoloration; some capillaries maybe visible

White sclera with some visible capillaries, anicteric sclera.

Normal

F. CORNEA Clarity and texture Inspection No irregularities on the surface; looks smooth; clear or transparent There is whitish scarring noted on both eyes caused by different operation that the client had undergone This is a deviation from normal because corneal structure should be free from scarring

G. IRIS Shape and color Inspection Anterior chamber is transparent; no noted visible materials; color depends on the persons race Dark brown in color; transparent anterior chamber Normal

H. PUPILS 1. Color, shape, and Inspection Color depends on the persons race Equal in size and rounded and are equal in size; equally Normal

symmetry of size 2. Light reaction and accommodation Inspection

round Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual Dilates when looking at far objects and constricts when looking at near objects. Constricts when there is light. Normal

I. VISUAL ACUITY 1. Near vision Inspection Able to read written words on the notebook. Unable to understand written words when reading This is a deviation from normal because normally the client should be seeing clearly but since he is affected by cataract and past eye problems, his visual acuity had suffered. Normal

J. LACRIMAL GLAND Palpability and tenderness of the lacrimal gland Palpation No edema or tenderness over lacrimal gland No tenderness and edema noted.

K. EXTRAOCULAR MUSCLES Eye alignment and coordination L. VISUAL FIELDS Peripheral visual fields Inspection When looking straight ahead, client can see objects in the periphery Can see objects in the periphery but is somewhat cloudy Another deviation caused by the cataract. The cataract not only affects visual acuity but the clients periphery as well Inspection Both eyes coordinated, move in unison, with parallel alignment Moves in Unison Normal

V. EARS

A. AURICLES 1. Color, symmetry of size, and position Inspection Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees from vertical Same color as the facial skin; tip of auricle aligned at the outer canthus of the eye. Normal

2. Texture, elasticity and areas of tenderness C. HEARING ACUITY TESTS 1. Clients response to normal tones (Ticking watch test) VI. NOSE 1.Any deviations in shape, size, or color and flaring or discharge from the nares 2. Nasal septum (between the nasal chambers) 3. Patency of both nasal cavities 4. Tenderness, masses, and displacements of bone and cartilage

Palpation

Mobile, firm, and not tender; pinna Smooth in texture, flexible and recoils after it is folded elastic pinna; no tenderness

Normal

Inspection

Client normally hears the ticking in the watch ( Ticking watch test)

Client did not heard the ticking

Hearing is impaired due to aging and smoking.

Inspection

Symmetric and straight; no discharge or flaring; Uniform color Nasal septum intact and in midline Air moves freely as the client breathes through the nares Not tender; no lesions

Symmetric and straight; Uniform in color

Normal

Inspection Palpation Inspection Palpation

Nasal septum intact and in midline Both nares are patent and the client is breathing clearly. Nor tenderness nor lesions.

Normal Normal Normal

VII. SINUSES Identification of the sinuses and for tenderness VIII. MOUTH A. LIPS Symmetry of contour, color and texture B. BUCCAL MUCOSA Color, moisture, texture, and the presence of lesions C. TEETH Color, number and condition and presence of dentures D. GUMS Color and condition E. TONGUE/FLOOR OF THE MOUTH Inspection Pink gums; no retraction Pink gums; has no visible retractions Normal Inspection 32 adult teeth; smooth, white, shiny tooth enamel; smooth, intact dentures The client is using dentures. Due to aging, client chose to wear dentures to avoid having dental problems. Can be observed as normal Inspection Uniform pink color; moist, smooth, soft, glistening, and elastic texture Pink color and dry. Abnormal, May suggests dehydration Inspection Palpation Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse lips Pink in color, dry lips Abnormal, May suggest cellular dehydration. Inspection Not tender Not painful when palpated Normal

1. Color and texture of the mouth floor and frenulum. 2. Position, color and texture, movement and base of the tongue 3. Any nodules, lumps, or excoriated areas F. PALATES and UVULA 1. Color, shape, texture and the presence of bony prominences 2. Position of the uvula and mobility (while examining the palates) G. OROPHARYNX and TONSILS 1. Color and texture 2. Size, color, and discharge of the tonsils 3. Gag reflex X. THORAX

Inspection

pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness Central position; pink color; smooth tongue base with prominent veins Smooth with no palpable nodules, lumps, or excoriated areas

Pink and moist. Tongue moves Normal freely and no pain felt. Located and positioned in the center. No tenderness nor masses Normal

Inspection

Palpation Inspection

Normal

Inspection Palpation Inspection

Light pink, smooth, soft palate; lighter pink hard palate , more irregular texture

The hard palate has a lighter color than the soft palate; has quite rough texture

Normal

Positioned in midline of soft palate Positioned at the center of the oropharynx

Normal

Inspection Inspection Inspection

Pink and smooth posterior wall Pink and smooth; no discharge; of normal size Present

Moist, pinkish in color. Has no discharge; pinkish Present

Normal Normal Normal

A. ANTERIOR THORAX 1. Breathing patterns 2. Temperature, tenderness, masses Inspection Palpation Quiet, rhythmic, and effortless respirations Quiet, rhythmic, and effortless respirations is noted Normal Normal

Skin intact; uniform temperature; Has an intact skin; has equal chest wall intact; no tenderness; no warmth on both sides. No masses masses.

3. Anterior thorax auscultation B. POSTERIOR THORAX 1. Shape, symmetry, and comparison of anteroposterior thorax to transverse diameter 2. Spinal alignment 3. Temperature, tenderness, and masses 7. Posterior thorax auscultation XI. CARDIOVASCULAR

Auscultation

Bronchovesicular and vesicular breath sounds

No crackles heard during auscultation

Normal

Inspection Palpation

Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric Spine vertically aligned

Has a anteroposterior to transverse diameter ratio of 1:2, elliptical in shape and symmetrical chest Has a vertical alignment

Normal

Inspection Palpation

Normal Normal

Skin intact; uniform temperature; No masses nor tenderness; has chest wall intact; no tenderness; no equal warmth on each side masses Vesicular and bronchovesicular breath sounds No crackles heard during auscultation

Auscultation

Normal

A. AORTIC and PULMONIC AREAS B. TRICUSPID AREA C. APICAL AREA

Auscultation Auscultation Auscultation

No pulsations No pulsations; no lift or heave Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL Aortic pulsations S1: Usually heard at all sites Usually louder at the apical area S2: Usually heard at all sites Usually louder at the base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate (60 to 90 beats/min) Diastole: silent interval; slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults

No pulsations felt No pulsations of lifts Has full pulsation

Normal Normal Normal

D. EPIGASTRIC AREA E. CARDIOVASCULAR AREAS AUSCULTATION

Auscultation Auscultation

Has pulsation Has full pulsation. 63 beats per minute. Sounds on the aortic and pulmonic areas; has a lub sound on the apex and dub sounds on the tricuspid area. Blood pressure is 130/90 mm Hg.

Normal Normal

Normal

Normal

XII. CAROTID ARTERIES

1. Carotid artery palpation

Palpation

Symmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from sitting to supine position; elastic arterial wall

Has weak pulsation. Symmetrical pulse.

Abnormal, decreased amount of blood volume passing the artery

XIV. AXILLAE 1. Axillary, subclavicular, and supraclavicular lymph nodes XV. ABDOMEN 1. Skin integrity 2. Abdominal contour 3. Enlargement of liver or spleen 4.Symmetry of contour 5. Abdominal movements associated with respirations, peristalsis or aortic pulsations 6. Vascular pattern Inspection Inspection Inspection Inspection Inspection Unblemished skin; uniform color Flat, rounded(convex), or scaphoid(concave) No evidence of enlargement of liver or spleen Symmetric contour Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin persons at epigastric area No visible vascular pattern Uniform color and has no blemishes Has a concave abdomen. No enlargement of the spleen and liver seen Has a symmetrical abdominal contour Abdominal movements noted when inhaling. Normal Normal Normal Normal Normal Inspection No tenderness, masses, or nodules Have no masses and nodules. Normal

Inspection

Has no blood vessels visible

Normal

XVI. MUSCULOSKELETAL SYSTEM

A. MUSCLES 1. Muscle size and comparison on the other side 2. Fasciculation and tremors in the muscles 3. Muscle tonicity 4. Muscle strength Inspection Proportionate to the body; even in both sides No fasciculation and tremors Even and firm muscle tone Has equal muscular strength on both sides Proportionate to the body; even in both sides Has no fasciculation and tremors Decreased muscle tone noted Decreased muscle strength noted Normal

Inspection Palpation Palpation

Normal Abnormal, possibly related to aging and amount of activities done by the client. Abnormal, possibly related to aging and amount of activities done by the client.

C. JOINTS 1. Joint swelling Inspection No swelling, no warmth, no redness, no pain, no crepitus No swelling, no warmth, no redness, no pain. No swelling, no warmth, no redness, no pain, no crepitus Edema is not noted Normal

EXTREMETIES

Inspection, Palpation

Normal

PHYSICAL ASSESSMENT SUMMARY

GENERAL: The client is mainly bothered by his decreased vision because it affects his activities. Oriented and alert VITAL SIGNS: Temperature: 36.3C, PR: 63 bpm, RR: 22 cpm, BP: 130/90 mmHg HEENT: Scarring on both eyes caused by different surgical procedures done to the client NECK: Supple. No carotid bruits. No lymphadenopathy or thyromegaly. LUNGS: Crackles heard on the anterior and middle part of right and left lungs. HEART: Regular rate and rhythm without murmur, but weak in pulsation. ABDOMEN: Soft, not tender, and not distended. No Hepatosplenomegaly. SKIN: Skin is dry and wrinkly may be due to aging.