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PHYSICAL ASSESSMENT
A. General Appearance
HEENT
Essentially normal
CHEST/LUNGS
Essentially normal
HEART
Essentially normal
ABDOMEN
Essentially normal
EXTREMITIES
Essentially normal
Skin
FINDINGS
NORMAL FINDINGS
Skull is proportionate to
body, no tenderness, hair
evenly distributed. Face
is symmetrical with
symmetrical facial
movement.
Pale
Capillary refill >3 secs.
Not normal
Normal
Nails
Eyes
Nose
Normal
Symmetrical, tongue is
in midline, lips pinkish
and symmetrical
Normal
Musculoskeletal System
ROM grading of 2.
Cannot resist strength
due to the pain she felt.
No deformities
No lesions
No deformities
No lesions
Mouth
Neck
Abdomen
At the moment, patient perceives his health as poor. Before hospitalization, he has a
sedentary lifestyle and is not concerned about his diet. He was not eating properly
and frequently starves himself. He also was not able to attend his needs in times he
felt sick or ill, unless it becomes severe.
Nutritional/Metabolic Pattern
Patients intake is 3-4 meals per day and 5-8 glasses of fluid intake per day. She
also has a sedentary lifestyle and shows no concern on gaining weight. Does not
have food restrictions or allergies and likes to eat meat, fish, and poultry rather than
fruits and vegetables.
Elimination Pattern
Patient frequently experiences fatigue and weakness and practices poor methods to
provide self care. Uses only one pillow when sleeping and doesnt have occupation
at the moment. Leisure time is watching television and taking care of her kids.
Sleeps for 6-8 hrs a day without any difficulty in sleeping or insomnia. Methods to
promote sleep include watching television. Occasionally awakens at night.
Present pain experienced on her flank or lower back with a punching quality, usually
with a severity of 8/10. Patients decision-making is fair, with knowledge level of quite
fair as well.
The patient is married. She is happy with his family and friends.
Patient is sexually active and does not have any problems in sexual life. She is not
using any contraceptives. Patient has 3 children.
Seems satisfied with the way of her life. She is hoping and praying that her condition
would be better. She had much faith in God and goes to church every Sunday with
her family.