Physical-assesment.docx

SYSTEM

PHYSICAL ASSESMENT

INTEGUMENTARY

Pt.’s skin was warm to touch with poor skin turgor. Pallor was not noted. Pt. was able to feel sensation.

HEAD AND FACE

EYES

EARS

NOSE

MOUTH

NECK

Head is symmetrical upon inspection. Head is proportionate to her body with normal facial feautures. Pt.’s hair is evenly distributed. Dryness of the hair not noted. No lesions and tenderness noted. Pt. has no history of accidental head injury. Pt.was able to smile and frown. Pt.was able to blown out cheeks. Pt.was able to raise her eyebrows. Pt.was able to feel sensation upon touching her forehead, cheeks and chin. No abrasions and lesions on her face was noted. Eyes are symmetrical upon inspection. Pt. has black eyes. Eyelashes and eyebrows are equally but finely distributed on both sides of the face. Pupils are equal, round, reactive to light. both left and right. No unusual discharges from the lacrimal ducts noted upon palpation. Pt. can able to recognize size, shape and colors correctly. Ears are symmetrical upon inspection with upper attachment at level of the eyes corner (lateral canthus). Pinna and external canals are intact upon inspection. Pt.reported she has no history of ear pain, ringing in the ear, or ear infections. Nose is symmetrical with good septal deviation noted upon inspection. No lesions or scars noted. Nasal mucosa is red with adequate nasal hair and accumulated mucos secretions upon inspection. Client is able to smell pleasant and foul odors suggesting good olfaction. Pt.’s lips has no presence of lesion upon inspection. Palor is noted. Pt. was able to close mouth. No inflammation of tonsils noted. Tongue is normal in color with moisture. No lesions noted upon inspection. Neck muscles are symmetrical upon inspection. Skin on the neck is intact with poor integrity. Neck lymph nodes are not swollen upon palpation. Carotid pulse is palpable. Trachea is at the center and immovable upon palpation. No masses and lesions noted.

RESPIRATORY SYSTEM

RR of 21 cycles per minute, regular in rhythm, with noted exertion and use of accessory muscle upon inspection. Frequent coughing accompanied by expectoration of thick-yellowish phlegm in moderate amount noted upon entire duration assessment. Crackles heard upon percussion of the anterior and posterior of the chest. O2 is attached

CARDIOVASCULAR SYSTEM

No heart murmurs heard during auscultation. Regular rhythm with a pulse rate of ranging from 65-76 bpm. Pt.’s blood pressure was normal in range.

BREAST

Pt. stated her breasts are equally symmetrical. No tenderness noted upon palpation. No unusual discharges reported. Lymph nodes on the axilla are not swollen upon palpation. She has no family history of breast carcinomas on both paternal and maternal sides.

MUSCULOSKELETAL SYSTEM

GASTROINTESTINAL SYSTEM

URINARY SYSTEM

NEUROLOGICAL SYSTEM

Pt. has report of muscle weakness as evidenced by limited movement. Pt. needs assistance when turning side to side. Pt. can slightly raise and move her upper and lower extremities. Pt. has no complaints of nausea and vomiting. Abdomen is globular upon inspection. Skin integrity in the abdomen in intact with no lesions noted. Pt. was wearing adult diaper upon assessment. Pt. was able to void with 500ml of urine after weighing the diaper. No reports of UTI. No complaints of unusual discharges. Pt. stated she can able to pass flatus and defecate. Upon assessment, Pt. was weak when laying down with head of bed elevated. Speech was clear. Pt. was oriented to time, place, and person. But admitted she can no longer remember some events in her life. Pt. was cooperative during assessment. She responded appropriately to my questions.