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hys|ca| Assessment

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

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