PHYSICAL ASSESSMENT General Survey On September 5, 2013 in Lorma Medical Center , medical female ward at 4:35 pm Mrs.

s. GGD was assessed cepalaucally. The general survey was physically strong enough to supplement. Activities of Daily Living. Mrs. GGD was conversant, cooperative and afebrile. On general status, her vital signs were as follows: Temperature= 36C , BP= 110/80, Respiratory Rate= 17, Heart Rate= 68 Skin, Hair, Nails A. Skin The clients skin is of normal racial tone which is light brown. Generally uniform except for areas exposed to sun. It is dry and smooth. She doesnt have any edema, no lesion, no abrasions but there are some freckles. B. Hair Her hair is evenly distributed and the strands are thin and brittle. The color of her hair is grayish. C. Nail The clients nail shape is convex curvature and has an angle of nail plate about 160 degrees, the nail is untrimmed and dirty and the nail bed is pink. The capillary refill is within 3 seconds. Head and Face The clients skull is proportionate to the body size. There was no tenderness in the scalp. There were no presence of nodules, and infestation. Her head is round and symmetrical its consistency is hard. A. Eyes The condition of her eyes is straight normal; the eye brows are evenly distributed, skin intact, eyebrows symmetrically aligned, equal movement. Eyelids have effectively closure and no discharge. Lids close symmetrically; approximately 15 to 20 involuntary blinks per minute. When lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered. The blink response is bilateral, eye balls are symmetrical, bulbar conjunctiva is clear, the palpebral conjunctiva is pink and the sclera is white. The palpebral slant is aligning with the tip of the pinna. The corneal sensitivity reflex is present cornea is transparent, the color of her eyes are brown, the shape are equal, it is uniform in color. Pupils are equal in size. Pupils are equally round and reactive to light and accommodation. She can execute the occular movements. The lacrimal apparatus are moist.

B. Ear The color of the ear is of normal racial tone which is brown, it is symmetrical. The alignment of the pinna is symmetrical. The pinnas are elastic and recoil when folded. The mastoid process is tender. The auditory canal contains some cerumen, the color is brown and there is an absent of discharges. C. Nose The color of the clients nose is of racial tone which is brown. Her septum is in the midline. The mucosa is pink, nostrils are both patent, nasal flaring is absent. Landmarks are visible. Sinuses are non-tender. D. Mouth and Oropharynx The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is pink, the gum is pink, the tongue is in the midline, the color is pink and it is smooth. The tongue movements are not that smooth. Its texture is rough. The color of the hard and soft palate is pink. And it is intact. Uvula is in the midline, gag reflex is absent. Neck The neck has involuntary movement and with resistance, the muscle strength 3/5. The trachea is in the midline, thyroid is in the midline and it is smooth. Maxillary lymph nodes are palpable. Chest and Lungs The color of the chest is of normal racial tone which is brown, the shape is AP to lateral ratio 1:2. There is absence of intercoastal retraction, costal angle is 45 chest wall are symmetrical, and the chest expansion is symmetrical. Respiratory rhythm is regular. The respiratory depth is shallow. Respiratory pattern is normal. When palpated he doesnt feet any tenderness. The vocal fremitus is normal, tactile fremitus is symmetrical. The lung expansion is normal. When percussed the sound is resonance. When auscultated brondual is absent. No adrentition sound. Respiratory rate is 24 breaths per minute. A. Heart The rhythm is regular. PMI(point of maximal impulse) is located in the apical pulse. Heart rate is 68 beats per minute. B. Breast The breasts are symmetrical. Shape is flat, the skin surface is smooth. Lympnodes are not palpable. The areola is color brown, shape is round and the nipple is everted, there are no discharges and there are no Lympnodes and no tenderness.

 Abdomen Skin is of normal racial tone which is brown, the contour is flat. Peristalsis is non-visible. The bowel sound is normal active and no bruits. When percussed the sound is tympany. When palpated he doesnt have any tenderness and when light palpation is done muscle guarding is absent. The liver is not palpable. Genitorectal Area: Pt. refuse to the assessment Musculoskeletal A. Upper extremities The client cannot resist force when asked to resist. Muscle strength is 3/5. The peripheral pulses are equal. Lympnodes are not palpable. The IV site is in his left arm. B. Lower extremities The client cannot resist force when asked to resist. Muscle strength is 2/5. He doesnt have any deformity. The peripheral pulses are equal. Lympnodes are non-palpable. Neurological/Mental Status Patient has a GCS of 15/15, conscious and coherent, oriented to time, place, and event.