Physical Assessment

INTEGUMENTARY

The skin is pail in color with no scars and free from lesions noted. Skin is moist to touch, texture is smooth and firm with the capillary refill time of 2 seconds.

HEAD AND NECK

Skull and face are symmetrical in shape. The patient can rotate head from midline to sides, up and down. Neck is within centered head position and no bulging masses noted. Neck has smooth, controlled and full range of motion as observed. Hair is black, long, thick, oily and evenly distributed.

EYES
The color of the eyes is black and the eyelids is pink , no redness and discharges noted . Conjunctiva and sclera appears moist and smooth. No drainage on nasolacrimal duct when palpated. Irises are round and pupils are equal in size and reactive to light.

EARS
Ears are equal in size bilaterally; auricles are aligned with the corner on each eye and color same as the facial skin. No discharges and free of lesions upon assessment. During interview normal voice tone not audible.

NOSE AND SINUSES

Uniform in color and nasal structure is symmetric and straight. No tenderness and discharges upon assessment.

MOUTH AND OROPHARYNX

Patients lip color is pale and symmetrical; 32 teeth are present, smooth, white and yellowish. Tongue is smooth and move freely.

THORAX AND LUNGS

Thorax is normal and elliptical in shape, full and symmetric chest expansion when client takes a deep breath. Lungs are normal and no adventitious sounds during interview.

ABDOMEN
Abdomen has presence of surgical wound. Umbilicus is in midline and recessed with no bulging. Skin is free of lesions and scars noted. Abdomen rises with inspirations and falls with expiration.

MUSCULOSKELETAL
Client is feet and inches tall and weighs 90 kg. Patient is able to walk without gait but has shortness of breath noted. Head, shoulders, arms and legs can move freely and no swelling noted.