Scribd Logo
Upload

Welcome to Scribd!

  • C

    Uploaded by

    Kengkai Mii
    27 views6 pages
    C. PHYSICAL EXAMINATION SYSYTEM PHYSICAL EXAMINATION A. General Survey Body Built - Proportionate, thin Posture and Gait - Pt is bed ridden Hygiene and Grooming - Clean and neat Body Odor - No odor Signs of Distress - Grimacing Affect or Mood - Cooperative Speech - Understandable B. Vital Signs Temperature - 38.1 degree Celsius, axillary Pulse Rate - 97 bpm, regular Respiratory Rate - 22 cpm, regular Blood Pressure - 110/80 mmHg, lying C. Anthropometric Measurements Height - 162.56 cm (64 inches) Weight - 50 kg (110 lbs) BMI = 18.12 (Underweight) D. Skin Color - Light Symmetry of Color - Uniform Edema - No edema Skin lesions - Surgical incision Moisture - Moist Temperature - Uniform, warm to touch Skin Turgor - Good   E. Hair and Scalp Distribution of Hair - Evenly distributed Thickness - Thick Texture and Oiliness - Silky, resilient Body Hair - Sparse leg hair F. Nails Curvature and Angle - Convex 160° Texture - Smooth Nail bed Color - Pinkish Surrounding Tissue - Intact Capillary Refill - Less than 4 seconds G. Skull and Face Size and Shape - Normocephalic Contour - Smooth Facial Features - Symmetrical Facial Movements - Symmetric   H. Eye Structures and Visual Acuity Eyebrows - Evenly distributed Eyelashes - Equally distributed, curled outward Eyelids - Intact skin, close symmetrically, 15-20 involuntary blinks, bilateral blinking Conjunctiva - Transparent, pinkish, shiny, smooth Cornea - Transparent, smooth Pupils - Black, equal in size, PERRLA Peripheral Vision - Intact Extraocular Movement - Coordinated Visual Acuity - Difficulty I. Ears and Hearing Pinna - Uniform color with skin, symmetrical, aligned, mobile, firm Ear Canal - Grayish tan, dry ceremen Tympanic Membrane - Pearly gray Hearing acuity - Intact J. Nose and Sinuses External Nose - Symmetric, uniform color, (-) discharge Nasal Cavity - Patent, septum in midline   K. Mouth and Oropharynx Lips - Pinkish, soft, moist, smooth, symmetrical, movable Teeth - Missing, shiny white Gums - Pinkish, moist, firm Tongue - Midline, pinkish, smooth, movable Palate - Light pink, smooth Uvula - In midline Oropharynx - Pink, smooth Tonsils - Pink, smooth Gag reflex - Intact L. Neck Muscles - Equal in size Movement - Coordinated Range of Motion - Limited Muscle strength - Equal Lymph nodes - Not palpable Trachea - In midline Thyroid gland - Not visible Carotid Pulse - Symmetric pulse Jugular veins - Not visible   M. Thorax and Lungs Breathing Pattern - Quiet, regular, effortless Coastal Angle - Less than 90° Shape and Symmetry - Symmetrical Spinal Alignment - Not assessed, pt is bed ridden Skin - Smooth Respiratory Excursion - Full, symmetric Fremitus - Bilateral Percussion sounds - Resonant Breath Sounds - Clear N. Heart Heart Sounds - S1 louder at S2 at base - S2 louder at S1 at apex O. Abdomen Skin Integrity - Presence of stitches due to surgical incision Contour - Flat Symmetry - Symmetrical Bowel Sounds - Normoactive (8 bowel sounds per min.) Percussion - Pt refused to assess Palpation - Pt refused to assess   P. Genitals Pubic Hair - Pubic Skin - Penile Shaft and Glans - Scrotum - Q. Anus and Rectum R. Upper and Lower Extremities Muscle size - Equal Muscle Tone - Muscle Strength - Bones - Joints - Range of Motion - Limited

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    C. PHYSICAL EXAMINATION SYSYTEM PHYSICAL EXAMINATION A. General Survey Body Built - Proportionate, thin Posture and Gait - Pt is bed ridden Hygiene and Grooming - Clean and neat Body Odor - No odor Signs of Distress - Grimacing Affect or Mood - Cooperative Speech - Understandable B. Vital Signs Temperature - 38.1 degree Celsius, axillary Pulse Rate - 97 bpm, regular Respiratory Rate - 22 cpm, regular Blood Pressure - 110/80 mmHg, lying C. Anthropometric Measurements Height - 162.56 cm (64 inches) Weight - 50 kg (110 lbs) BMI = 18.12 (Underweight) D. Skin Color - Light Symmetry of Color - Uniform Edema - No edema Skin lesions - Surgical incision Moisture - Moist Temperature - Uniform, warm to touch Skin Turgor - Good   E. Hair and Scalp Distribution of Hair - Evenly distributed Thickness - Thick Texture and Oiliness - Silky, resilient Body Hair - Sparse leg hair F. Nails Curvature and Angle - Convex 160° Texture - Smooth Nail bed Color - Pinkish Surrounding Tissue - Intact Capillary Refill - Less than 4 seconds G. Skull and Face Size and Shape - Normocephalic Contour - Smooth Facial Features - Symmetrical Facial Movements - Symmetric   H. Eye Structures and Visual Acuity Eyebrows - Evenly distributed Eyelashes - Equally distributed, curled outward Eyelids - Intact skin, close symmetrically, 15-20 involuntary blinks, bilateral blinking Conjunctiva - Transparent, pinkish, shiny, smooth Cornea - Transparent, smooth Pupils - Black, equal in size, PERRLA Peripheral Vision - Intact Extraocular Movement - Coordinated Visual Acuity - Difficulty I. Ears and Hearing Pinna - Uniform color with skin, symmetrical, aligned, mobile, firm Ear Canal - Grayish tan, dry ceremen Tympanic Membrane - Pearly gray Hearing acuity - Intact J. Nose and Sinuses External Nose - Symmetric, uniform color, (-) discharge Nasal Cavity - Patent, septum in midline   K. Mouth and Oropharynx Lips - Pinkish, soft, moist, smooth, symmetrical, movable Teeth - Missing, shiny white Gums - Pinkish, moist, firm Tongue - Midline, pinkish, smooth, movable Palate - Light pink, smooth Uvula - In midline Oropharynx - Pink, smooth Tonsils - Pink, smooth Gag reflex - Intact L. Neck Muscles - Equal in size Movement - Coordinated Range of Motion - Limited Muscle strength - Equal Lymph nodes - Not palpable Trachea - In midline Thyroid gland - Not visible Carotid Pulse - Symmetric pulse Jugular veins - Not visible   M. Thorax and Lungs Breathing Pattern - Quiet, regular, effortless Coastal Angle - Less than 90° Shape and Symmetry - Symmetrical Spinal Alignment - Not assessed, pt is bed ridden Skin - Smooth Respiratory Excursion - Full, symmetric Fremitus - Bilateral Percussion sounds - Resonant Breath Sounds - Clear N. Heart Heart Sounds - S1 louder at S2 at base - S2 louder at S1 at apex O. Abdomen Skin Integrity - Presence of stitches due to surgical incision Contour - Flat Symmetry - Symmetrical Bowel Sounds - Normoactive (8 bowel sounds per min.) Percussion - Pt refused to assess Palpation - Pt refused to assess   P. Genitals Pubic Hair - Pubic Skin - Penile Shaft and Glans - Scrotum - Q. Anus and Rectum R. Upper and Lower Extremities Muscle size - Equal Muscle Tone - Muscle Strength - Bones - Joints - Range of Motion - Limited

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    27 views6 pages

    C

    Uploaded by

    Kengkai Mii
    C. PHYSICAL EXAMINATION SYSYTEM PHYSICAL EXAMINATION A. General Survey Body Built - Proportionate, thin Posture and Gait - Pt is bed ridden Hygiene and Grooming - Clean and neat Body Odor - No odor Signs of Distress - Grimacing Affect or Mood - Cooperative Speech - Understandable B. Vital Signs Temperature - 38.1 degree Celsius, axillary Pulse Rate - 97 bpm, regular Respiratory Rate - 22 cpm, regular Blood Pressure - 110/80 mmHg, lying C. Anthropometric Measurements Height - 162.56 cm (64 inches) Weight - 50 kg (110 lbs) BMI = 18.12 (Underweight) D. Skin Color - Light Symmetry of Color - Uniform Edema - No edema Skin lesions - Surgical incision Moisture - Moist Temperature - Uniform, warm to touch Skin Turgor - Good   E. Hair and Scalp Distribution of Hair - Evenly distributed Thickness - Thick Texture and Oiliness - Silky, resilient Body Hair - Sparse leg hair F. Nails Curvature and Angle - Convex 160° Texture - Smooth Nail bed Color - Pinkish Surrounding Tissue - Intact Capillary Refill - Less than 4 seconds G. Skull and Face Size and Shape - Normocephalic Contour - Smooth Facial Features - Symmetrical Facial Movements - Symmetric   H. Eye Structures and Visual Acuity Eyebrows - Evenly distributed Eyelashes - Equally distributed, curled outward Eyelids - Intact skin, close symmetrically, 15-20 involuntary blinks, bilateral blinking Conjunctiva - Transparent, pinkish, shiny, smooth Cornea - Transparent, smooth Pupils - Black, equal in size, PERRLA Peripheral Vision - Intact Extraocular Movement - Coordinated Visual Acuity - Difficulty I. Ears and Hearing Pinna - Uniform color with skin, symmetrical, aligned, mobile, firm Ear Canal - Grayish tan, dry ceremen Tympanic Membrane - Pearly gray Hearing acuity - Intact J. Nose and Sinuses External Nose - Symmetric, uniform color, (-) discharge Nasal Cavity - Patent, septum in midline   K. Mouth and Oropharynx Lips - Pinkish, soft, moist, smooth, symmetrical, movable Teeth - Missing, shiny white Gums - Pinkish, moist, firm Tongue - Midline, pinkish, smooth, movable Palate - Light pink, smooth Uvula - In midline Oropharynx - Pink, smooth Tonsils - Pink, smooth Gag reflex - Intact L. Neck Muscles - Equal in size Movement - Coordinated Range of Motion - Limited Muscle strength - Equal Lymph nodes - Not palpable Trachea - In midline Thyroid gland - Not visible Carotid Pulse - Symmetric pulse Jugular veins - Not visible   M. Thorax and Lungs Breathing Pattern - Quiet, regular, effortless Coastal Angle - Less than 90° Shape and Symmetry - Symmetrical Spinal Alignment - Not assessed, pt is bed ridden Skin - Smooth Respiratory Excursion - Full, symmetric Fremitus - Bilateral Percussion sounds - Resonant Breath Sounds - Clear N. Heart Heart Sounds - S1 louder at S2 at base - S2 louder at S1 at apex O. Abdomen Skin Integrity - Presence of stitches due to surgical incision Contour - Flat Symmetry - Symmetrical Bowel Sounds - Normoactive (8 bowel sounds per min.) Percussion - Pt refused to assess Palpation - Pt refused to assess   P. Genitals Pubic Hair - Pubic Skin - Penile Shaft and Glans - Scrotum - Q. Anus and Rectum R. Upper and Lower Extremities Muscle size - Equal Muscle Tone - Muscle Strength - Bones - Joints - Range of Motion - Limited

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 6

    C. PHYSICAL EXAMINATION SYSYTEM A.

    General Survey PHYSICAL EXAMINATION Body Built - Proportionate, thin Posture and Gait - Pt is bed ridden Hygiene and Grooming - Clean and neat Body Odor - No odor Signs of Distress - Grimacing Affect or Mood - Cooperative Speech - Understandable Temperature - 38.1 degree Celsius, axillary Pulse Rate - 97 bpm, regular Respiratory Rate - 22 cpm, regular Blood Pressure - 110/80 mmHg, lying Height - 162.56 cm (64 inches) Weight - 50 kg (110 lbs) BMI = 18.12 (Underweight) Color - Light Symmetry of Color - Uniform Edema - No edema Skin lesions - Surgical incision Moisture - Moist Temperature - Uniform, warm to touch Skin Turgor - Good

    B. Vital Signs

    C. Anthropometric Measurements

    D. Skin

    E. Hair and Scalp

    F. Nails

    G. Skull and Face

    Distribution of Hair - Evenly distributed Thickness - Thick Texture and Oiliness - Silky, resilient Body Hair - Sparse leg hair Curvature and Angle - Convex 160 Texture - Smooth Nail bed Color - Pinkish Surrounding Tissue - Intact Capillary Refill - Less than 4 seconds Size and Shape - Normocephalic Contour - Smooth Facial Features - Symmetrical Facial Movements - Symmetric

    H. Eye Structures and Visual Acuity

    I. Ears and Hearing

    J. Nose and Sinuses

    Eyebrows - Evenly distributed Eyelashes - Equally distributed, curled outward Eyelids - Intact skin, close symmetrically, 15-20 involuntary blinks, bilateral blinking Conjunctiva - Transparent, pinkish, shiny, smooth Cornea - Transparent, smooth Pupils - Black, equal in size, PERRLA Peripheral Vision - Intact Extraocular Movement - Coordinated Visual Acuity - Difficulty Pinna - Uniform color with skin, symmetrical, aligned, mobile, firm Ear Canal - Grayish tan, dry ceremen Tympanic Membrane - Pearly gray Hearing acuity - Intact External Nose - Symmetric, uniform color, (-) discharge Nasal Cavity - Patent, septum in midline

    K. Mouth and Oropharynx

    Lips - Pinkish, soft, moist, smooth, symmetrical, movable Teeth - Missing, shiny white Gums - Pinkish, moist, firm Tongue - Midline, pinkish, smooth, movable Palate - Light pink, smooth Uvula - In midline Oropharynx - Pink, smooth Tonsils - Pink, smooth Gag reflex - Intact Muscles - Equal in size Movement - Coordinated Range of Motion - Limited Muscle strength - Equal Lymph nodes - Not palpable Trachea - In midline Thyroid gland - Not visible Carotid Pulse - Symmetric pulse Jugular veins - Not visible

    L. Neck

    M. Thorax and Lungs

    N. Heart

    O. Abdomen

    Breathing Pattern - Quiet, regular, effortless Coastal Angle - Less than 90 Shape and Symmetry - Symmetrical Spinal Alignment - Not assessed, pt is bed ridden Skin - Smooth Respiratory Excursion - Full, symmetric Fremitus - Bilateral Percussion sounds - Resonant Breath Sounds - Clear Heart Sounds - S1 louder at S2 at base - S2 louder at S1 at apex Skin Integrity - Presence of stitches due to surgical incision Contour - Flat Symmetry - Symmetrical Bowel Sounds - Normoactive (8 bowel sounds per min.) Percussion - Pt refused to assess Palpation - Pt refused to assess

    P. Genitals

    Pubic Hair Pubic Skin Penile Shaft and Glans Scrotum Muscle size - Equal Muscle Tone Muscle Strength Bones Joints Range of Motion - Limited

    Q. Anus and Rectum R. Upper and Lower Extremities

    You might also like