5 Physical-assessment.docx

PHYSICAL ASSESSMENT 1. General Inspection Patient lying in bed in supine position. Dressed in hospital gown. Patient is awake and lethargic. She is responsive and cooperate in her treatment. Weak in appearance. Cannot perform ADL’s alone with Braiden scale: 13. Facial grimace can be seen with pain scale: 7/10. Patient has increased tension and restless. 2. Skin Smooth and intact; with good skin turgor. Temperature above normal level, 38.0°C. No lesions or excoriations noted. Old TAHBSO and Cholecystectomy scar in her abdomen. 3. Nails Blanch test is 2 sec, appears in a convex shape. Nails form 160 degree angle at base, are hard, smooth, and immobile. Nail beds pink without clubbing. Cuticles smooth, no detachment of nail plate. 4. Head & Face Head is symmetrically round, hard, and smooth without lesions or bumps. Face oval, smooth, and symmetrically. Hair black, shoulder length, clean and shiny. 5. Eyes Evenly placed and in line with each other. None protruding. Equal palpebral fissure. PERRLA. Extra ocular movements smooth and symmetric with no nystagmus. Eyelids in normal position with no abnormal widening or ptosis. No redness, discharge, or crusting noted on lid margins. Conjunctiva and sclera appear moist and smooth. Sclera white with no lesions or redness. No swelling or redness over lacrimal gland. Cornea is transparent, smooth, and moist with no opacities, lens is free of opacities. Irises are round, flat, and evenly colored. Pupils are equal in size and reactive to light and accommodation. Pupils converge evenly. Patient has sunken eyes. 6. Ears Ears are equal in size bilaterally in size bilaterally. Auricles are aligned with the corner of each eye. Skin smooth, no lumps, lesions, nodules. No discharge. Non tender in palpation. Small amount of moist yellow cerumen in external canal. Whisper test: patient repeats 2 syllable word.

7. Nose & Sinuses Nose is small and smooth and symmetric. Able to sniff through each nostril. Nasal septum slightly deviated to the left, but does not obstruct airflow. Inferior and middle turbinates dark pink, moist, and free of lesions no purulent drainage noted. Frontal and maxillary sinuses are nontender to palpation and percussion. 8. Mouth & Pharynx Lips pink, smooth, and moist without lesions. Buccal mucosa pink, moist, and without exudates. Stensen/s duct visible with no redness or swelling. 30 white to yellowish teeth present. Gums pink without redness or swelling. Protrudes geographic tongue in midline with no tremors. Equal bilateral strength in tongue. Ventral surface of tongue smooth and shiny pink with small visible veins present. Frenulum in midline. Soft palate smooth and pink. Tonsillar pillars pink and symmetric. 9. Neck Neck symmetric with centered head position and no bulging masses. C7 is visible and palpable with neck flexion. Has smooth, controlled, altered range of motion of neck. Trachea in midline. Lymph nodes nonpalpable. 10. Thorax & Lungs Respirations 20 beats per minute, relaxed and even. Anteroposterior less than transverse diameter. Chest expansion symmetric. No retraction or bulging interspaces. No pain or tenderness on palpation. Tactile fremitus symmetric. Percussion tones resonant over all lung fields. Vesicular breath sounds auscultated over lung fields. No adventitious sounds presents. 11. Heart Normal cardiac sound and rhythm. 12. Breasts Bilateral breast in moderate size, pendulant, and symmetric. Breast skin pale, pink with light brown areola. Nipples everted bilaterally. Free movement of breast with position changes of arms and hands. No dimpling, retraction, lesions, or inflammation noted. No masses or tenderness noted on palpation. No discharge noted from nipples. 13. Abdomen

Skin in abdomen has a scar due to operation of TAHBSO and Cholecystectomy to her. Abdomen is a little bit bulge with no lumps. No peristaltic movement seen. Percussion reveals generalized tympany over all four quadrants. No tenderness or guarding in any quadrant with light palpation. Umbilicus and surrounding area free of masses, swelling, and bulges. 14. Upper and lower Extremities IV attached on the right side. No signs of edema. Slow passive range of movement and decrease muscle strength. Temperature is warm and even with uneven skin color. Cannot perform ADL’s by self. With limited ROM and Muscle strength weakness. With limitations in movements. 16. Spine Spine in midline position without deviation to either side. Patient experience pain in her back. Pain scale 7/10. 17. Neurological Level of consciousness is lethargic. GCS score is 15. Patient is oriented and speech is fluent. She can answer correctly in question and can participate in her treatment.