hyslcal assessmenL ls a sysLemaLlc comprehenslve conLlnuous collecLlon valldaLlon
communlcaLlon of Lhe daLa uslng varleLy of meLhods 1he mosL effecLlve meLhod ls Lhe cephalocaudal examlnaLlon or Lhe headLoLoe assessmenL whlch malnly uses four Lechnlques lnspecLlon percusslon palpaLlon and ausculLaLlon lrom Lhe daLa base we can make a cllnlcal [udgmenLs or dlagnosls abouL Lhe lndlvldual's healLh sLaLe or response Lo Lhe acLual or healLh rlsk and llfe processes as well as dlagnosls abouL hlgher level of wellness 1he lnlLlal physlcal assessmenL was done lasL AugusL 26 2011 SaLurday aL 130 o'clock ln Lhe afLernoon aL Lhe paLlenL's room ln Manuel ! SanLos PosplLal 1he second assessmenL was done lasL AugusL 27 2011 SaLurday ln M!SPC8 durlng Lhe surgery and serves as Lhe lnLra operaLlve assessmenL of Lhe paLlenL We had 3 days of posL operaLlve assessmenL of Lhe paLlenL whlch was done lasL AugusL 28 2011 and SepLember 1 and 2 of Lhe same year WlLh Lhe ald of Lhe followlng lnsLrumenLs 1ape measure 8 ApparaLus SLeLhoscope enllghL 1ongue uepressor CoLLon AppllcaLor aper Cllp CoLLon 8alls Welghlng Scale noLebook and en WrlsLwaLch wlLh secondhand and aLlenL's CharL Lhe physlcal assessmenL was made posslble rlor Lo Lhe assessmenL we asked permlsslon Lo Lhe paLlenL as well as wlLh Lhe slgnlflcanL oLhers We also lnformed Lhem abouL Lhe purpose of Lhe assessmenL LhaL we're golng Lo have uurlng Lhe preoperaLlve assessmenL of Lhe genlLalla Lhe paLlenL refused buL on Lhe posLoperaLlve assessmenL Lhe paLlenL already allowed Lhe sLudenL nurse Lo do an assessmenL on Lhe genlLal area Genera| Survey upon Lhe lnlLlal assessmenL of aLlenL x she was lylng on bed awake and wlLh ouL lvl aLlenL x had a reduced lnLeracLlon wlLh people and envlronmenL She has a normal range of moLlon aLlenL x ls 144cm ln helghL and welghs 37kgs Per body bullL ls proporLlonaLe wlLh Lhe correspondlng 8Ml of 2733 kg/m whlch means LhaL she ls overwelghL aLlenL x was afebrlle wlLh Lhe body LemperaLure of 362 degree Celslus wlLh pulse raLe of 119 beaLs per mlnuLe and resplraLory raLe of 23 cycles per mlnuLe and a blood pressure of 110/70 mmPg uurlng Lhe lnLra operaLlve assessmenL we recelved aLlenL x wheeled lnLo Lhe CperaLlng area from Lhe ward vla wheelchalr awake and coherenL wlLh an ongolng lvl of u3nSS 1L aL 900ml regulaLed aL kvC raLe hooked aL Lhe rlghL meLacarpal veln lnfuslng well wlLh a vlLal slgns as follows 8lood ressure 142/88 mmPg PearL 8aLe of 94 bpm 8esplraLlon 8aLe of 20 cpm Cn AugusL 28 2011 we recelved aLlenL x slLLlng on bed on a moderaLe hlgh back resL and lvl was already LermlnaLed and paLlenL had a slowed movemenLs llmlLed 8CM posLural lnsLablllLy and grlmace wlLh a vlLal slgns of 8lood ressure of 110/70 mmPg pulse raLe of 74bpm 8esplraLlon raLe of 23cpm Cn SepLember 1 2011 we recelved aLlenL x lylng on bed awake and coherenL wlLh a loley 8ag CaLheLer aLLached Lo an urobag dralnlng aL 80 mL aLlenL's vlLal slgns are as follows 1emperaLure 364 degree Celslus 8lood ressure of 110/70 mmPg ulse raLe of 78bpm 8esplraLory raLe of 20 cpm Cn Lhe lasL assessmenL done on SepLember 2 2011 we recelved aLlenL x slLLlng on bed wlLh Lhe vlLal slgns of 1emperaLure of 36 degrees Celslus 8esplraLory 8aLe of 18 cpm ulse raLe of 80 bpm and 8lood ressure of 130/90 and wlLh l8C aLLached Lo urobag dralnlng aL 120 mL 8ody arts Inspect|on a|pat|on ercuss|on Auscu|tat|on Sk|n LlghL brown skln complexlon freckles were noLed ln Lhe face upper and lower exLremlLles ury and warm when Louched no edema upon palpaLlon when skln Lurgor was assessed skln lmmedlaLely recolled when plnched 1 second
na|r Lvenly dlsLrlbuLed Lhlck no lnfesLaLlon and dandruffs noLed
whlLe halr was noLed nead and Iace Pead clrcumference of 34 cenLlmeLers able Lo frown and puff cheeks nodules and masses are absence upon palpaLlon
Lyes and V|sua| Acu|ty Lyebrows
Palr are evenly dlsLrlbuLed equal ln movemenLs
Lye|ashes
SllghLly curled ouLward
Lye||ds
lnLacL skln lnvolunLary bllnklng was noLed 16 bllnks/mlnuLes no nodules and leslons are palpaLed
8u|bar Con[unct|va
Clear wlLh Llny vessels vlslble whlLe sclera
a|pebra| Con[unct|va Shlny plnklsh ln color
Lacr|ma| G|and no Lenderness noLed when pressure ls applled
Cornea O Cornea| Sens|t|v|ty 1est
Shlny bllnks when Lhe cornea was Louched wlLh a coLLon ball
up||s 8lack ln color round and equal ln slze puplls consLrlcL when Lhere ls llghL and when a ballpen was moved Loward Lhe nose
V|sua| I|e|ds When looklng sLralghL able Lo see sldes
Lxtraocu|ar Movements 8oLh eyes are coordlnaLed and moved ln allgnmenL
V|sua| Acu|ty Able Lo read newsprlnL 12 lnches away and wlLh llghL wlLh dark llghLlng cannoL able Lo read cannoL also read newsprlnL more Lhan 12 lnches away
Lars and near|ng Aur|c|es Color ls Lhe same wlLh faclal skln symmeLrlc and allgned wlLh Lhe ouLer canLhus of Lhe eye llrm plnna recolls afLer lL was colled
Lxterna| Lars Palr folllcles observed sLlcky weL brownlsh cerumen was noLed
1ympan|c Membrane early gray and shlny
Gross near|ng O Jatch 1|ck 1est
8oLh ears were able Lo hear waLch Llck 23 cm away from Lhe ears
Nose no nasal flarlng durlng resplraLlon was noLed no dlscharges mucosa plnk alr moves freely Lhrough Lhe nares
S|nuses no Lenderness upon palpaLlon
Mouth and Cropharynx L|ps and 8ucca| Mucosa uarklsh plnk ln color molsL able Lo pursue llps
1eeth 19 permanenL LeeLh 2 well flLLed denLures ln Lhe lower cenLral lnclsor 2 upper Lhlrd second and flrsL molar 1 upper second flrsL premolar and canlne 2 upper cenLral lnclsors are mlsslng whlLe and shlny LeeLh
1ongue lnk ln color moves freely SmooLh wlLh no palpable nodules
Uvu|a LlghL plnk on Lhe mldllne
Cropharynx 1onslls are noL lnflamed plnk poslLlve gag reflex
Neck Neck Musc|es CoordlnaLed movemenLs able Lo flex exLend hyperexLend and roLaLe laLerally
wlLhouL dlscomforL Lymph Nodes no Lenderness upon palpaLlon
1rachea CenLral placemenL ln Lhe mldllne of Lhe neck
1hyro|d G|and noL vlslble gland ascend as Lhe paLlenL swallow Absence of brulL
1horax and Lungs
uoes noL use accessory muscles durlng resplraLlons chesL clrcumference ls 100 cenLlmeLers
veslcular breaLh sound was ausculLaLed
lull lung expanslon full excurslon 8esonance neart and Centra| Vesse|s neart no pulsaLlons on Lhe aorLlc and pulmonlc area pulsaLlons aL Lhe aplcal area was palpaLed S and S ausculLaLed Carot|d Arter|es lull pulsaLlon no sound heard upon ausculLaLlon Iugu|ar Ve|ns no veln dlsLenLlon noLed
8reasts Abdomen Color ls Lhe same wlLh Lhe body's color sLrale was noLed abdomlnal clrcumference ls 100 cenLlmeLers no Lenderness or masses relaxed abdomen 1ympany over Lhe sLomach was percussed Audlble bowel sounds (34 bowel sound/mlnuLe) Upper and Lower Lxtrem|t|es no edema equal ln slze no bone deformlLles [olnLs move smooLhly wlLh an opLlmum [olnL 8CM caplllary reflll of 1 second convex nall curve and smooLh ln LexLure rlghL and lefL mld arm clrcumference are boLh 27 cm rlghL and lefL leg clrcumference are boLh 44 cm rlghL and lefL calf are 34 cm ln clrcumference lull pulsaLlons on brachlal and dorsalls pedls pulses no Lenderness and swelllng flrm negaLlve Poman's slgn
Gen|ta||a IN1kA
CLkA1IVL nASL 8efore Surgery 8ulglng of anLerlor and posLerlor wall of Lhe vaglna cervlx and uLerus proLrudes down redness noLed around Lhe vaglnal area AfLer Surgery vaglnal orlflce was closed redness noLed aL Lhe vaglnal area CS1 CLkA1IVL nASL 1 sL osLop ( AugusL 28 2011) SuLures are vlslble swelllng molsL and redness was also noLed 3 Lh and 6 Lh uay osLop ( SepLember 1 2 2011) no swelllng and redness observed aL Lhe vaglnal area suLures are no longer vlslble
Neuro|og|c System Leve| of Consc|ousness O Lye Cpenlng O verbal 8esponse O MoLor 8esponse kesponse
sponLaneous (4)
orlenLed (3)
response Lo verbal command (6) 1oLal Score13
kef|exes |antar kef|ex Loes flexed when a pen was sLroke ln Lhe sole
Motor Iunct|on Peel uown CpposlLe Shln O aln SensaLlon (paper cllp) I|nger to Nose and to the Nurse I|nger erforms wlLh coordlnaLlon nee| Down Cppos|te Sh|n uemonsLraLe bllaLeral equal
coordlnaLlon a|n Sensat|on (paper c||p) Able Lo dlscrlmlnaLe sharp and dull sensaLlon when Lhe arm ls Louched wlLh a paper cllp whlle Lhe eyes are closed