I.

PHYSICAL ASSESMENT Normal Actual Findings 35.1 C 83 16 130/80 mmHg 147.32 cm 48 kg

Desirable body weight: 39 - 47 kg BMI: 22.11 kg/m2

Vital Signs Analysis Normal Normal Normal Normal

Temperature Pulse Rate Respiratory Rate Blood Pressure Weight Height BMI

36.5C - 37.5C 60-100 bpm 12-20 bpm 90-120 mmHg/ 6080mmHg

Normal

Physical Assessment

Body Parts

Normal Findings

Actual Findings

Interpretation

Skin color, uniformity of color

Presence of edema Presence of lesions according to location, distribution, size, shape, type or structure. Skin moisture Skin temperature Skin turgor

Integumentary Skin Varies from light to deep brown; from rudy pink to light pink; from yellow The client has dark overtones to olive complexion and his skin color is deep brown. Generally uniform except on areas exposed to the sun. No edema There was no noted edema in the clients skin. Freckles, some birthmarks, some flat and raised nevi; The client has no noted no abrasions or other freckles, abrasions or any lesions. types of lesions. Moisture in skin folds and the axillae Uniform; within normal range When pinched, skin The clients skin is moist. The client has uniform temperature. The clients skin springs

Normal

Normal

Normal

Normal Normal Normal

springs back to previous state Nails Fingernail plate shape Fingernail and toenail texture Fingernail and toenail bed color Convex curvature; angle of nail plate about 160 Smooth texture Highly vascular and pink in light-skinned clients; darkskinned clients may have brown or black pigmentation in longitudinal streaks Intact epidermis

back to previous state.. The clients nail formed convex curvature. The client has smooth texture. The clients nail beds are brown and has a dead fingernail on his left thumb Normal Normal

Normal

Tissues surrounding nails Blanch test of capillary refill

Size, shape or symmetry Presence of nodules, masses and depressions Color and appearance Areas of tenderness Evenness of growth; thickness or thinness Texture and oiliness over the scalp Face Facial features, symmetry of facial movements

The issues surrounding the clients nails are that intact and not sloughing off. Prompt return of pink or The color of the clients usual color (generally less nail took 2 seconds to than 4 seconds) return to the normal state. Head Skull Rounded The client is (normocephalic); smooth normocephalic. skull contour Smooth, uniform There is absence of consistency; absence of nodules or any masses in nodules or masses the clients skull Scalp Light brown; no dandruff The clients scalp is light brown and has no danruff No tenderness There was no noted tenderness in the scalp of the client Hair Hair growth is The clients hair proportionately proportionately distributed distributed but there are areas with thin and dry hair Smooth texture The clients hair has dry texture Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

Normal

Normal

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Normal

Abnormal

The clients nasolabial folds are symmetric; facial features palpebral.

Normal

Lacrimal gland Lacrimal sac and nasolacrimal duct Hair distribution and direction of curl Surface characteristics, position in relation to the cornea, ability to blink and frequency of blinking Bulbar conjunctiva for color, texture, and presence of lesions Palpebral conjunctiva for color, texture, and presence of lesions Inspect the color and clarity Clarity and texture; corneal reflex; shape and color

Eyes Lacrimal gland, lacrimal sac, and nasolacrimal duct No edema or tenderness No noted tenderness in clients lacrimal gland No edema or tearing No noted edema in clients nasolacrimal gland Eyebrows and Eyelashes Hair of eyebrows equally The clients Hair of distributed; eyelashes eyebrows equally equally distributed and distributed. curved slightly outward Eyelids Skin is intact; no discharge; no discoloration Lids close symmetrically The clients eyelids skin is Approximately 15 to 20 intact, no discoloration blinks per minute; and lids are symmetrical. bilateral blinking Conjunctiva Transparent; capillaries sometimes evident sclera The clients bulbar appears white conjunctiva is transparent; sclera appears white. Shinny, smooth and pink or red The clients palbebral conjunctiva is pink to pale in color.

Normal Normal

Normal

Normal

Normal

Shape, color, and symmetrical size Color, shape, and symmetry of size

Sclera The clients sclera is white in color with visible blood vessels. Cornea Transparent, shinny and The client has transparent, smooth shiny and smooth cornea. Client blinks when the He blinks when the cornea cornea is touched, is touched, indicating that indicating that the the trigeminal nerve is trigeminal nerve is intact. intact. Iris Round in shape, flat and The borders of his iris are evenly colored. colored white and clear. Pupils Black in color; equal in The clients pupil is black size; normally 3 to 7 mm in color White and shinny

Normal

Normal

Alignment and coordination

Color Symmetry and position, texture,elasticity, and areas for tenderness

Cerumen, skin lesions, pus and blood

Deviations in shape, size, or color and flaring or discharge from nares Tenderness, masses, displacements of bone and cartilage Patency of both nasal cavities Presence of redness, swelling, growths, and discharge Inspect the nasal Septum between the nasal chambers Symmetry of contour, color

in diameter; round, smooth border Extraocular Muscles Both eyes coordinated, The clients eyes move in move in unison, with unison, with parallel parallel alignment alignment EARS Auricle The color is skin toned, symmetrical, Auricle aligned with the outer The clients color is skin canthus of eye, no toned and symmetrical. tenderness, no recoils No tenderness. after it is folded, mobile, firm External Ear Canal Distal third contains hair follicles and glands The client has dry Dry cerumen, grayish cerumen. The cerumen is tan color, or sticky, wet tan in color. cerumen in various shades of brown NOSE Symmetric and straight The clients nose is No discharge of flaring symmetric and straight Uniform color No discharge of flaring No tenderness, no lesions, no masses, no displacement of bone cartilage Air moves freely as the client breathes through the nares Mucosa pink Clear, watery discharge No lesions Nasal Septum intact and in midline

Normal

Normal

Normal

Normal

The client has no noted tenderness, no lesions, no masses The air moves freely from the clients nares. The clients mucosa is pink, And there no lesions noted. The clients nasal septum is intact and in midline.

Normal

Normal

Normal

Normal

MOUTH Lips Uniform pink color The clients lips is soft. Dry Soft, moist, smooth texture and is

Abnormal

and texture

Color moisture, texture and presence of lesions Color, number and condition and presence of dentures

Color and texture of the mouth floor and frenulum

Tenderness, movement and base of the tongue Nodules, lumps or excoriated areas Color and texture size of tonsils color and discharge Lymph nodes and for tenderness Placement

texture uniform pink in color. Symmetry of contour Protruded Ability to purse lips Buccal Mucosa Uniform pink color The clients buccal Moist, smooth, soft, mucosa is uniform pink glistening and elastic color and has texture glistening texture. Teeth 32 adult teeth Smooth, white, shiny, The client has 19 adult tooth enamel teeth and with dark Pink gums brown gums. Yellowish Moist, firm texture to in color with some gums decays. No retraction of gums Tongue/Floor of the mouth Central Position Pink Color; moist; slightly The clients tongue is pink rough; thin whitish in color, moist, slightly coating rough and with thin Smooth, lateral margins; whitish coating. no lesions Raised papillae No tenderness; no lesions There was no lesions noted in the clients tongue. There was no nodules and lumps noted in the clients tongue. Oropharynx and tonsils Pink and smooth posterior There was no discharge wall noted in the clients No discharge tonsils. NECK AND LYMPH NODES Lymph nodes Not palpable The lymph nodes are not palpable. Trachea Central placement in The trachea is centrally middle of neck; spaces placed. are equal on both sides Thyroid Gland Not visible on inspection The thyroid gland is not visible upon inspection. Thorax No nodules, lumps or excoriated areas

Normal

Abnormal

Normal

Normal

Normal

Normal

Normal

Normal

Symmetry and visible masses,

Normal

Size, shape, symmetry, diameter of the anteroposterior thorax and transverse diameter. Spinal alignment Temperature, tenderness and masses Auscultation of posterior thorax

Posterior Thorax Anteroposterior to transverse diameter in The clients ratio of AP ratio of 1:2 diameter to transverse diameter is 1:2. His chest Chest symmetric has symmetric movement. The clients spine is vertically aligned. uniform temperature, no The clients temperature is tenderness, no masses uniform. There were no tenderness and masses noted in the clients posterior thorax. Vesicular and Upon auscultation, bronchovesicular breath vesicular and sounds bronchovesicular sounds were heard in the upper posterior thorax. Anterior Thorax Quiet, rhythmic,and The clients breaths effortless respirations quietly, effortless and with rhythm. uniform temperature, no The clients temperature is tenderness, no masses uniform. There were no tenderness and masses noted in the clients anterior thorax. Full and symmetric chest The client can fully and expansion symmetrically expands his chest. Same as posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas of the heart and the liver, and tympanic over the underlying stomach Bronchial and tubular breath sounds The clients vocal fremitus decreases over heart and breast but has the same posterior vocal fremitus. The client has resonate sound at the level of the diaphragm but flat over muscular areas and bone, dull sounds are heard on areas of heart and liver, tympanic sounds on stomach. Bronchial and tubular sounds present upon auscultation of the Spine vertically aligned

Normal

Normal

Normal

Normal

Breathing patterns Temperature, tenderness and masses Respiratory excursion Vocal fremitus

Normal

Normal

Normal

Normal

Percussion of anterior thorax

Normal

Auscultation of the trachea

Normal

Auscultation of the anterior thorax Aortic and pulmonic areas Tricuspid areas Apical area Auscultation of the aortic, pulmonic, tricuspid and apical valves

trachea. Bronchovesicular and Bronchovesicular and vesicular breath sounds vesicular sounds were noted upon auscultation of the anterior thorax. Cardiovascular No pulsations Theres no pulsations noted. No pulsations, lift or Theres no pulsations, lift heave or heave noted. Pulsations visible in 50% Theres no lift or heave adults; no lift or heave noted. S1: usually heard at all times and usually louder at apical area S2: usually heard at all sites and usually louder at the base of the heart S3 in children and young adults S4 in many older adults Carotid arteries S1 and s2 sounds present at the sites where they are usually heard louder.

Normal

Normal Normal Normal

Normal

Palpation of carotid artery Auscultation of carotid artery Skin integrity Symmetry of contour Auscultation of the abdomen for bowel sounds, vascular sounds, and peritoneal friction rub Percussion of the four quadrants

Carotid arteries are palpable. They have symmetric pulse volumes and thrushing quality. No sound heard on There was no sound heard auscultation in the carotid artery during auscultation. Abdomen Unblemished skin; The clients abdominal uniform color; silver white skin is uniform in color. striae Symmetric contour The clients abdomen has symmetric contour. Audible bowel sounds Absence of arterial bruits There were no audible Absence of friction rub bowel sounds, no bruits and friction rubs heard upon auscultation. Tympany over the stomach and gas filled bowels; dullness Tympany over the stomach and dullness on liver and spleen are heard

Symmetric pulse volumes; full pulsations, thrusting quality

Normal

Normal

Normal Normal

Normal

Normal

Palpation of the four quadrants

Muscles size Inspection of the muscle and tendons for contractures Fasciculations and tremors Muscle tonicity Bones Inspection of skeleton for structure Palpation of bones to locate any areas of edema or tenderness Joints Swelling Tenderness, smoothness of movement, swelling, crepitation, ad presence of nodule. Range of motion

especially over the liver during percussion of the and spleen or a full abdomen. bladder No tenderness; relaxed No tenderness noted. abdomen with smooth, Relaxed consistent tension Musculoskeletal system Muscles Equal size on both sides The clients body is equal of the body on both sides. No contractures There were no contractures noted upon inspection. No tremors Normally firm No deformities No tenderness or swelling There were fine tremors noted upon inspection. The clients muscle tonicity was firm. There were no deformities noted in the clients skeleton structure. There were no tenderness and swelling noted upon palpation of the patients bone.

Normal

Normal Normal Abnormal Normal

Normal

Normal

Normal No tenderness, swelling, crepitation, or nodules Joints move smoothly

There were no tenderness, crepitations and swelling noted upon movement of the patients joints. But there were presence of 3 masses on his left arm (2x4cm) and on his (9x7cm.)

Abnormal

Posture, Gait, Standing, Sitting, Walking Overall Hygiene and Grooming Body and Breath

Varies to some degree in accordance with persons The client can perform genetic makeup and some range of motions. degree of physical activity. General Appearance Relaxed, erect posture, The client has coordinated coordinated movement movement. His movements are relax. Clean and Neat No body odor or minor The client looks untidy. The client has no body

Abnormal

Normal

Abnormal Normal

Odor Signs of Distress Obvious signs of Health or Illness Attitude Affect / Mood Quantity / Quality of Speech

body relative to work or exercise; no breath odor. No distress noted Healthy appearance Cooperative, able to follow instructions Appropriate to situation Understandable, moderate pace; clear tone and inflection; exhibits thought association Logical sequence; makes sense, has sense of reality

odor. Theres no sign of distress noted in the patient. The client is not healthylooking The client is cooperative and able to follow instructions. The clients mood is appropriate to situation. The clients speech is slow but can be understood, with clear thought and association. The client thoughts are clear and has a sense of reality. Normal Abnormal Normal Normal Normal

Reverence and Organization of Thought

Normal