PhysicaI Assessment

General appearance
Client has medium frame body built, appropriately dressed and has no body and breath
odor. He has an upright posture and smooth rhythmic gait. There are no obvious
physical deformities.
VS: Bp= 100/70 temp=36.9 PR= 64 RR=24
Mental status
Client is conscious and coherent. Oriented to time, place and person. He is cooperative.
She uses simple words in communicating. He is slightly dizzy and experienced pain in
the nape.

Skin
Skin is in normal racial tone. t is warm and dry. t is rough and has poor skin turgor.
There are no lesions noted and hair is evenly distributed.

Nails
Nail plate shape is convex 160. t is rough and nail bed is slightly pale. Capillary refills
within 3 seconds.

Head and Face
Skull is proportionate to body size, scalp is white no tenderness and no lesions . hair is
thin and white it is evenly distributed. Face symmetry and facial movement is
symmetrical. Shows facial grimace due to pain.

Eyes
Eyes are straight normal. Eyebrows are thin. Eyelids have an effective closure, no fallen
lashes. Blink response is bilateral. Eyeballs are symmetrical. Bulbar conjunctiva is pale
and palpebral conjucticva is pale Sclera is red. Pupil's size are equal.


Ears
Auricles' color is in normal racial tone, it is symmetrical elastic and non tender. Pinna
recoils when folded, there are some serumen at the external canal. Patient responds to
normal voice but can't respond to whispered voice because she has difficulty in hearing.
Nose
Nose is symmetrical, color is in normal racial tone. Septum is in midline. With nasal
flaring noted. nternal mucosa is pink in color.

Mouth and Oropharynx
Mouth is symmetrical, lips are slightly dry and pale. Gum is pink. No mouth sores.
Tongue is in midline, the color is pink, rough and movable. Tonsils are not inflamed.
Teeth are not complete.


Neck
Neck is symmetrical, and proportionate to body size. Thyroid is in midline. No palpable
lymphnodes. Pain in the nape pain scale of 5/10.

Breast
Not assessed

Chest and Lungs
Shape is AP to lateral ratio is 1:2.lung expansion is symmetrical both anterior and
posterior. Tactile fremitus is symmetrical. Breathing pattern is irregular. Breathe sound
are vesicular and bronchovesicular.
Abdomen
Skin integrity is in normal racial tone. No lesions or scar. Contour is rounded. Movement
is asymmetrical. hypoactive bowel sounds of 2/min There is abdo,imal distention and
tenderness upon palpation. Bladder is not distended. Liver is not palpable.


&pper and Lower extremities
No obvious physical deformity.

&pper Extremities
Motor strength is 5/5. Neither lesions nor deformities. Peripheral pulses are normal.
Lymph nodes are not palpable.
Lower Extremities
Motor strength is 5/5. Neither lesions nor deformities. Peripheral pulses are normal.
Lymph nodes are not palpable. No presence of varicosities

Genitalia and Rectum
Not assessed.