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PHYSICAL EXAMINATION AND REVIEW OF SYSTEM

SYSTEM
GENERAL ASSESSMENT

PHYSICAL EXAM
Upon Admission:
BP: 120/80 mmHg
HR: 69 bpm
RR: 16 cpm
T: 36 C
HEIGHT: 157.5 CM
WEIGHT: 72 kg
BMI: 29.02 - overweight
Upon assessment:
BP: 110/70 mmHg
HR: 70 bpm
RR: 16 cpm
T: 36.6 C
HEIGHT: 157.5
WEIGHT: 57 kg
BMI: 25.8 - overweight

MENTAL STATUS
EXAMINATION
SKIN, HAIR, NAILS

Patient was cooperative


and didnt have any
difficulty in talking and
hearing but has difficulty in
seeing due to blurry vision.
INSPECTION:
Oriented to what is
happening at the time of
the interview and physical
assessment.
Alert to person, place, day
and time and can interact
well at the same time,
conversant.
SKIN INSPECTION:
Skin color is from light to
dark brown. Moles are
found in some areas of the

REVIEW OF SYSTEM

Patient has Acute Angle


Closure Glucoma.

skin. Skin temperature is


C.
. No reddened areas and
foul odor. There is Senile
Lentigines at the forearms
and dorsa of the hands.
PALPATION:
Skin is not that warm or
cold to touch. Turgor is
decreased and skin
recedes slowly.
HAIR INSPECTION:
There is thin and with white
hair. Scalp is free from
lesions. Amount of hair in
the axillae is decreased
NAILS INSPECTION:
Nail surface is slightly
curved smooth and is
clean. Have brown-black
pigmented areas along the
nail edges. Toenails are
thick.
PALPATION:
Nails are hard and
basically immobile. Nail
plate is firmly attached to
nail bed. When nails are
pressed between the
fingers (Capillary Refill),
the nails return to usual
color in 3 seconds.

HEAD AND NECK

INSPECTION:
HEAD Normocephalic and
symmetrical. There is a
scar with stiches at the
back of his head that was
caused by fall.

PALPATION:
There are no nodules or
masses and depressions
when palpated.
NECK INSPECTION:
Head is positioned in the
center. Accessory neck
muscles are symmetrical.
Motion is soft and
controlled when turn to
sides and extending the
head backward.
PALPATION:
Trachea is located at
midline. Lymph nodes are
not palpable. There are no
swelling, enlargement and
tenderness in the lymph
nodes. Thyroid tissue
moves up when
swallowing.
INSPECTION:
EYES The upper lid margin is
between the upper margin
of the iris and the upper
margin of the pupil. The
lower lid margin rests on
the lower boarder of the
iris.
The upper and lower lids
close easily and meet
completely when closed.
The lower eyelid is upright
with no inward or outward
turning. Eyelashes are
evenly distributed and
curve outward along the lid
margins. There is redness
around the iris and pupils
are dilated. Cornea looks

Patient has Acute Angle


Closure Glaucoma,
Increased Intraocular
Pressure, decrease in
peripheral vision.
RIGHT EYE:
Opthalmoscopic
examination was
performed and
showed cupping and
pallor of the Optic
Nerve. There was
NO RED REFLEX
NOTED.
Pupil is now nonreactive.
Laser Iridotomy was
performed last

steamy and the anterior


chamber is shallow. There
is clouding of vision,
sudden eye pain, and
halos around lights.
Eyeballs are symmetrically
aligned and no protrusion
or sinking noted.
There is no swelling or
redness appearing over the
area of the lacrimal gland.
No drainage noted over the
puncta when palpating the
nasolacrimal duct.
Wears eyeglasses.

February 5, 2016 at
OD.
Ocular Movement
was performed in
front of the patient
and observed the
right eye using a
penlight, Iris cannot
constrict
immediately when
directed by light.
Visual Acuity result
was 20/400
Visual field shows
that patient cannot
see the 4 corners of
the eye except the
central vision.
LEFT EYE:
Opthalmoscopic
examination was
performed and
showed cupping and
pallor of the Optic
Nerve. There was
NO RED REFLEX
NOTED.
Pupil is now nonreactive.
Laser Iridotomy was
performed last April
4, 2016 at OS.
Ocular Movement
was performed in
front of the patient
and observed the
right eye using a
penlight, Iris are
dilated with or
without light.
Visual Acuity result
was 20/600.
Visual field shows
that patient cannot

see the 4 corners of


the eye except the
central vision.
EARS INSPECTION:
Ears are equal in size
bilaterally. The auricle
aligns with the corner of
each eye. Skin color is
consistent with the
persons facial skin color.
No difficulty of hearing.
MOUTH, THROAT, NOSE,
SINUSES

MOUTH INSPECTION:
Lips are smooth without
lesions or swelling.
Can talk clearly without
complains of difficulty,
Uvula is positioned in the
midline of the soft palate.
Patient is not using
dentures. Have complete
teeth and are aligned.
NOSE INSPECTION AND
PALPATION:
The nose appeared
symmetric, straight and
uniform in color. There was
no presence of discharge.
There were no tenderness
and lesions palpated.
SINUSES PALPATION:
Frontal and maxillary
sinuses are non-tender
when palpated.
PERCUSSION:
Sinuses are non-tender
when percussed.

BREAST

INSPECTION:
Areola is dark brown and

round. No edema.
AXILLA:
Presence of hair in the
axillary area.
THORAX AND LUNGS

GENERAL INSPECTION:
Client has evenly colored
skin tone without unusual
or prominent discoloration.
THORAX INSPECTION:
Scapulae are symmetric
and non-protruding,
shoulders and scapulae at
equal horizontal positions.
Do not experience any
cough.
PALPATION:
No tenderness, pain or
unusual sensation, skin
and subcutaneous tissue
and free of lesions and
masses.
PERCUSSION:
Resonance in the chest
area, cardiac dullness, liver
dullness, stomach tympany
was noted upon
percussion.
AUSCULTATE:
Normal breath sound upon
auscultation.
RR

HEART AND NECK


VESSELS

NECK
PALPATION:
The apical impulse is
palpated in the mitral area.
No pulsation or vibration is

palpated in the area, apex,


left sternal border or base.
AUSCULTATION:
Heart rate of 78 bpm.
No blowing, swishing
sound when carotid artery
was auscultated.
ARMS
PERIPHERAL VASCULAR INSPECTION:
Arms are bilaterally
symmetric with minimal
variation in size and shape.
No edema but prominent
venous patterning noted.
Color is from light to dark
brown.
PALPATION:
Skin is not hot or cold to
touch. Capillary beds refill
is 3 seconds.
Radial pulses are
bilaterally normal. There
was no pain felt upon
palpation.
BP
LEGS
INSPECTION:
Hair covers the skin on the
legs and appears on the
dorsal surface of the toes.
PALPATION:
Veins are not prominent
and unseen on the surface
of the skin.
ABDOMEN
INSPECTION:
Abdominal skin is lighter
than the rest of the body.
With some hair in the

abdomen. Abdomen is flat,


symmetric and does not
bulge. Peristaltic wave not
seen. A scar is present at
the left lower quadrant.

AUSCULTATE:
Bowel sounds gurgling
are present.
PERCUSSION:
Tympany is predominant in
all four quadrants. Dullness
is present upon percussing
the spleen area. Umbilicus
and surrounding area are
free of swelling bulges or
masses. Abdomen is nontender and soft.
PALPATION:
No palpable mass and no
abdominal pain present.
GENITOURINARY
Patients menstruation
started when she was 14
years old and menopaused
at 45 years old.
MUSCULOSKELETAL
GAIT
INSPECTION:
Evenly distributed weight.
Client can stand up and
walk without feeling pain.

SHOULDERS AND ARMS


INSPECTION AND
PALPATION:
Shoulders are
symmetrically round, no
redness, swelling or heat.
Muscles are fully

developed.
CERVICAL, THORACIC
AND LUMBAR SPINE
INSPECTION AND
PALPATION
Non tender paravertebral
muscles.
ELBOWS
INSPECTION AND
PALPATION
Even and symmetrical, no
tenderness reported. Fill
ROM. Can flex, extend,
abduct, rotate, and shrug
shoulders against
resistance.

WRIST
INSPECTION AND
PALPATION
Wrists are symmetric
without redness or
swelling. Full ROM of wrist.

HANDS AND FINGERS


INSPECTION AND
PALPATION
Symmetric, non-tender and
without nodules. No
swelling or deformities. Full
ROM OF hands and
fingers.
KNEES
INSPECTION AND
PALPATION
Knees symmetric, there is
no swelling on knees.
Lower leg in alignment with
upper leg. Muscle is firm.
There is no difficulty in

walking and standing.

ANKLES AND FEET


INSPECTION
Toes point forward and lie
flat.
ANUS/RECTUM
INSPECTION:
Can eliminate once a day
with brownish-yellowish
stool once or twice a day.