Physical Assessment Vital Signs Axillary T= 36 C, PR= 73 bpm, RR= 22, , BP= 90/60 mmHg.

General survey Height=, weight= kilos, head circumference= cm, abdominal circumference= inches. Mesomorph. No signs of distress noted upon assessment, able to smile, cooperate well, responsive to questions, conscious and alert, conversant. Well oriented. Show calmness during the examination. The patient has IVF infused, and was asleep at initial assessment. Skin Skin is brown in color, rough, dry and warm. has good skin turgor. Brownish discolorations that resemble freckles are observed on arms and face. Head Skull is round in shape, symmetrical (normocephalic). No masses noted. Facial movement is symmetrical. Hair is dry in texture; its color is black with mimimal streaks of gray. Scalp is clear from dandruff and lice. No scars and wounds noted. Eyes Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows have same color with hair. Eyelashes are evenly distributed and curled outward. Eyelids have no discharges and bilaterally blink. Upper lid covers the small portion of the iris and cornea. Lacrimal duct openings (puncta) are evident at nasal ends of upper and lower lid with no tenderness noted. Palpebral conjunctiva are pinkish in color while the pupils constricted to light (2mm), round in shape, isocoric, shows uniform convergence. he is able to rotate eyes and has coordinated eye movements. Ears Auricle has same color with the skin, has symmetrical shape and located a little bit higher than the eye. Pinnas are symmetrical, mobile, and able to recoil,

with no lesions noted. he has wet cerumen noted on both he is able to hear on both ears.. Nose Nose has uniform color and symmetrical in

Heart sounds are regular. Pulsation of heart is area upon auscultation. Back and Extremities Peripheral pulses are symmetrical and regular.

ears when pulled down and back for better visualization. heard in 4 anatomical areas but more audible in apical

shape. Nasal hairs are very evident when light is flashed Nails are long and untrimmed, pinkish in color, and have through the nasal passageways; its color is black. No a capillary refill time of 2 sec. after blanching; and no nasal flaring observed upon respiration. Both nares are clubbing of fingernails were noted. Calluses were patent, air moves freely as client breathes through the observed at the tip of her fingers and toes. His hands are nares. Nasal septum is straight and in midline. Nasal a little rough. Muscle strength is equal on both sides of mucosa is pinkish in color, has no discharges and no the upper and lower extremities. Spine is a little deviated lesions. No tenderness of sinuses noted. Mouth to the left as seen when client was asked to bend over. he is able to stand and walk on both feet independently, Lips are a little brownish in color, dry and has and his movements are well coordinated. Toes point cracks. Tongue is in midline, pinkish in color with thin straight ahead. And he is able to sit up straight. whitish coating on top. Able to move tongue freely (up & Abdomen down, side to side). Soft palate is light pink in color while His abdomens color is same with the rest of the hard palate is lighter in color. Gums are pinkish in color. part of the body. Her umbilicus is coated with blackish Her first and second right molars of the lower teeth, and dirt. has globular abdomen and dullness was noted upon her first left molar of the upper teeth are missing. Her percussion. teeth are a little yellow in color with few plaques usually Neurologic Assessment found on her remaining molars. Pharynx CN 1 Olfactory: Client was able to identify smell of alcohol with eyes closed.

Uvula is found well placed in midline of soft CN 2 Optic: She was able to see objects but not clearly as palate. Mucosa is pinkish in color. Tonsils are not evidenced by pulling a piece of paper near her eyes when inflamed. Neck reading. Her pupils are reactive to light and accommodation. The patients pupils constrict when Trachea is in midline. No tenderness of thyroid assessors finger was moved near her nose. noted. No enlargement of the neck noted. She is able to CN 3 Oculomotor: Her pupils constricted when light flex and extend neck and move it laterally (L and R). Chest and Lungs Breathing pattern is regular stimulation was applied. Her eyes were able to move laterally, medially and superiorly. Her eyelids also

(eupnea). elevated very well.

Anteroposterior diameter to transverse diameter is in 1:2. CN 4 Trochlear: She can look downward. Respiratory excursion is symmetrical (thumb separates CN 5 Trigeminal: As observed, the client was able to to 2-3cm). Vocal tactile fremitus is bilaterally equal. She chew while eating. And she can move her jaw laterally refused to have her breasts examined. Slight wheezing against the assessors hand. heard on the left upper lung field. Heart and Central Vessels CN 6 Abducens: The patient can move her eyes from side to side.

CN 7 Facial: The patient can smile, frown, puff her cheeks and raise her eyebrows. She can also determine the taste of the food she was eating as evidenced by. CN 8 Vestibulocochlear: She was able to hear questions and answered them appropriately such as: She can walk independently without tripping off or falling down. CN 9 Glossopharyngeal: The client was able to swallow her food and water. CN 10 Vagus: Her voice was soft. Together with CN 9, gag reflex was not tested with the use of sterile padded tongue depressor but with the clients ability to swallow food and the absence of aspiration during eating. CN 11 Spinal Accessory: The client can turn her head from side to side and can resist the force applied on her shoulders (sternocleidomastoid and trapezius muscles). She is able to shrug her shoulders with equal strength. CN 12 Hypoglossal: She can move her tongue laterally and protrude it. She can converse well. She has an RLS of 1 as evidenced by being alert and awake during assessment. She had her eyes open and directly looking at the examiner. She could respond to questions appropriately. She has a GCS of 15 as evidenced by: (4) Opening of her eyes spontaneously. She directly looked at the one who opens the curtain of her room or cubicle. (5) Oriented. She gave appropriate answers to questions. (6) Obeys commands. When asked to raise her arms for vital signs assessment (blood pressure; BP cuff) she hurriedly and willingly obeyed.