PHYSICAL ASSESSMENT General survey: Physical examination was done last August 23, 2011.

Patient was received awake while lying on his hospital bed. He was coherent, oriented to time and place, but appeared drowsy, made spontaneous movements, easily aroused by gentle shaking and saying patients name, and was able to follow verbal commands. Patient appeared weak looking. There was a foot lesion that was noted on his right, distal and anterior foot at the base.

BODY PARTS SKIN Color

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS & INTERPRETATION No visible abnormalities

INSPECTION

Light to deep Patients skin is brown uniform in brown in color. color except the areas exposed to the sun. . (Bates Guide to Physical Examination 10th edition p. 168). Moisture; smooth in texture. No edema. (Bates Guide to Physical Examination 10th edition p. 169). When pinched skin springs back to previous state (Fundamentals of Nursing 8th edition by Kozier, pg. 579580) Skin is warm, temperature is equal bilaterally (physical examination & health assessment Dry, wrinkled texture.

Moisture

PALPATION

No visible abnormalities

Turgor

PALPATION

When pinched, skin springs back to previous state within 1-2 seconds

No visible abnormalities

Temperature

PALPATION

Skin is warm temperature is equal bilaterally in the upper extremities. There is an unequal

Abnormal findings as a result of inflammation process of the patient right foot lesion. (Taylor et al Fundamentals in
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by Carolyn SaruisPg 233)

temperature on lower extremities right foot is warmer than the left upon palpation. Nail is long. The convex curvature is 180 degrees.

Nursing 6th edition p. 612)

NAILS Appearance, shape & angle INSPECTION Clean, convex curvature: angle of nail plate is 160 degrees This is due to vasodilation with increased blood flow to the distal portion of the digits and changes of connective tissue. (Bates Guide to Physical Examination 10th edition p. 192). No visible abnormalities.

Texture

PALPATION

Smooth in texture, not brittle or splitting

Nail is smooth, not brittle.

Color

INSPECTION

Nail plate is translucent, pinkish nail bed

Nail plate is cyanotic

No visible abnormalities.

Capillary Refill

PALPATION

Color return is instant or at least within a few seconds. (Bates Guide to Physical Examination 10th edition p. 192).

Color return within No visible 1-2 seconds abnormalities.

HEAD Skull Size, shape, symmetry INSPECTION Normocephalic and symmetric with frontal, parietal, temporal & occipital prominences. Rounded No visible normocephalic and abnormalities. symmetric with frontal, parietal, temporal & occipital
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Smooth skull contour Nodules, muscles and depression. Scalp Color and appearance Lesions/rashes INSPECTION PALPATION/ INSPECTION Lighter than complexion No lesions, lies, dandruff, bruises or lumps found (Manual of Nursing 7th edition by Lippincott pg. 54) Evenly distributed. Thick Evenly color PALPATION Absence of nodules or masses (Fundamentals of Nursing 8th edition by Kozier pg. 585)

prominences and smooth skull contour No nodules and masses No visible abnormalities.

Scalp is lighter than complexion. No lesions, lies, dandruff, bruises or lumps found

No visible abnormalities. No visible abnormalities

Hair Evenness of growth and thickness Color INSPECTION Evenly distributed hair Some hair are color white No visible abnormalities. Changes concurrent with age. This is due to decrease melanin production on the hair which affects the discoloration of the hair as the person ages. (Marieb, Essentials of Human Anatomy and Physiology 8th Ed p. 119) No visible abnormalities.

INSPECTION

Texture & oiliness Face Facial features

PALPATION

Silky & resilient (Fundamentals of Nursing 7th edition by Kozier pg. 582) Symmetric or slightly asymmetric

Silky and resilient.

INSPECTION

The facials features are

Moles are not that uncommon. No threat

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facial features

symmetric. Moles and warts are visible The facial movements are symmetric

to health. (Bates Guide to Physical Examination 10th edition p. 197). No visible abnormalities.

Symmetry of facial movements

INSPECTION

Symmetric facial movement (Fundamentals of Nursing 8th edition by Kozier pg. 585) Equal sensation of the face and neck.

Facial sensation

INSPECTION

The patient cannot identify light touch sensation to the left side of his forehead and face. There is a right side sensation prominence.

Abnormal finding include inability to identify to identify location of touch. There is an abnormality in patient CN V (Taylor et al Fundamentals in Nursing 6th edition p. 648)

Eyes Eyebrows Distribution Alignment, skin, quality & movement INSPECTION INSPECTION Hair is evenly distributed Skin intact, eyebrows symmetrically aligned, equal movement (Fundamentals of Nursing 8th edition by Kozier pg. 588) Equally distributed and curled slightly outward (Fundamentals of Nursing 8th edition by Kozier pg. 544) The hair is distributed Alignment is symmetrical, skin is intact, & equal movement No visible abnormalities. No visible abnormalities.

Eyelashes Evenness of distribution and direction of curl INSPECTION Equally distributed and curled slightly outwards No visible abnormalities.

Eyelids
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Surface INSPECTION characteristics, positions in relation to the cornea, able to blink: frequency of blinking

Skin is intact, no discharges & no discoloration Lids close symmetrically When lids open, no visible sclera above corneas, upper and lower borders of cornea are slightly covered (Fundamentals of Nursing 8th edition by Kozier pg. 588) Normally aligned, with no protrusion or sunken appearance

Skin is intact, no discharges & no discoloration Lids close symmetrically There is no visible sclera above corneas when lids open. Upper and lower borders of cornea are slightly covered Patients eyeball is Normally aligned, with no protrusion or sunken appearance Looks moist and glossy, with small blood vessels, clear, pale over lower lids

No visible abnormalities. No visible abnormalities.

Eyeballs

INSPECTION

No visible abnormalities

Conjunctiva Appearance INSPECTION Looks moist and glossy, small blood vessels, clear, pink over lower lids Pale conjunctiva is due decrease concentration of hemoglobin thus an inadequate oxygenation of blood. (Bates Guide to Physical Examination 10th edition p. 214). No visible abnormalities No visible abnormalities

Sclera Color and clarity Cornea Color, texture and shape INSPECTION White in color Patients sclera is white It has transparent, shiny and smooth. Details of sclera are visible. And dome-shaped.

INSPECTION

Transparent, shiny & smooth details in the iris are visible, and dome-shaped. (Fundamentals of Nursing 8th edition by Kozier pg. 590)

Iris
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Shape and color

INSPECTION

Flat and round (Fundamentals of Nursing 8th edition by Kozier pg. 590) Black in color, 3-7 mm in diameter, round, smooth border Constriction when direct light Far vision- pupils dilate, near visionpupils constrict Pupil Equally Round Reacted to Light & Accommodation

Color is brown and No visible it is rounded abnormalities

Pupils Color, shape and size INSPECTION Black in color, 3-4 mm in diameter, round, smooth border Patients pupil constricts about 3 mm when direct to light Patient is near sighted Pupil Equally Round Reacted to Light & Accommodation No visible abnormalities

Pupillary light reflex Accommodatio n

INSPECTION

No visible abnormalities No visible abnormalities No visible abnormalities

INSPECTION

Extraocular muscles Alignment: coordination INSPECTION Both eyes coordinated. Move in unison and parallel alignment Patients both eyes No visible moved in unison abnormalities. with parallel alignment and both coordinated Patients has an equal size bilaterally, no swelling or thickening of her ears Color of the patients auricle is same as the facial skin. Symmetrically in size. Aligned with No visible abnormalities.

Ears Size & shape INSPECTION Equal size bilaterally, no swelling or thickening

Color, symmetry position

INSPECTION

Color same as facial skin, symmetrical, auricle aligned with outer cantus of eye, about 10 degrees

No visible abnormalities.

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from vertical Texture, elasticity and tenderness PALPATION

outer cantus of the eye Texture is smooth, elastic and tenderness. It is firm and mobile pinna recoils after folded Patient has no swelling or redness, no discharge The patients nose is symmetric and straight. The color ranges from medium to light brown. Uniform to the color of the face. Not deviated nasal septum. Mucosa is pink, no watery discharge; and no lesions No visible abnormalities.

Mobile film and tender: pinna recoils after it is folded (Fundamentals of Nursing 8th edition by Kozier pg. 596) No swelling or redness, no discharge

External auditory meatus Nose Shape, size. Color, flaring/discharg e from nares

PALPATION

No visible abnormalities.

INSPECTION

Symmetric and straight; no discharge or flaring. Uniform in color. Nasal septum is not deviated.

No visible abnormalities

Nasal cavities, redness, swelling, growths, and discharge. Tenderness, masses and displacement of bone and cartilage

INSPECTION

Pink mucosa, clear watery discharge; no lesions

No visible Abnormalities

PALPATION

No tenderness, no lesions

No tenderness, no lesion

No visible abnormalities

Mouth
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Lips Symmetry of contour, color texture INSPECTION PINKISH: symmetrical with lips margin. Smooth and moist (Fundamentals of Nursing 8th edition by Kozier pg. 602) Patient has moist lips. Symmetrical with lips margin. No visible abnormalities.

Tongue/mouth floor Tongue INSPECTION Smooth, and moist. Smooth, moist with white buds present. Color of tongue is pale to pink Center in position, freely movable. Frenulum centrally located. No visible abnormalities. No visible abnormalities No visible abnormalities.

Color

INSPECTION

Pink color

Position & movement

INSPECTION

Center in position, freely movable (Fundamentals of Nursing 8th edition by Kozier pg. 603604) Patient can identify taste with various agents. Color white to yellowish, straight and evenly spaced, clean, free from decay

Sense of taste. Teeth Color, position

INSPECTION

INSPECTION

No dentures. Teeth No visible are complete. 32 abnormalities permanent teeth present. Yellowish in color.

Neck Neck muscles Neck muscles for abnormal swellings or masses Head INSPECTION Muscle equal in size: head centered Head and muscles are equal in size No visible abnormalities.

INSPECTION

Coordinated.

The client can

No visible
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movements Lymph nodes PALPATION

Smooth movements with no discomfort No swollen, no enlargement No visible lifts or heaves, no JVD. (Bates Guide to Physical Examination 10th edition p. 323-325). No presence of heart murmurs. (Taylor et al. Fundamentals in Nursing 6th edition p. 631) Symmetric, elliptical in shape, about 45 degrees relative to spine (Physical Examination & Health Assessment 4th edition by Carolyn Jarvis pg. 449) Diameter should be < transverse diameter 1:2

move his head Patient show no swollen and enlargement of her lymph nodes No visible lifts or heaves. Jugular nein not distended.

abnormalities. No visible abnormalities No visible abnormalities No visible abnormalities

Heart

Inspection

Auscultation

No heart murmur noted.

No visible abnormalities.

Thoracic & Lungs Thoracic cage Symmetry & shape

INSPECTION

Patient thoracic is Symmetric, elliptical in shape, about 45 degrees relative to spine

No visible abnormalities

Anteroposterior

INSPECTION

Patient anteroposterior diameter is < transverse diameter 1:2

No visible abnormalities

Lungs Posterior Chest Lung Field Breath Sounds PALPATION Vibration should feel the same on each side Resonance for Vibration on both sides Patient has a dull No visible abnormalities This indicates that he
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PERCUSSION

healthy lung tissue

sound over left lower lobe.

has pneumonia. (Bates Guide to Physical Examination 10th edition p. 301). Crackles sounds due to air bubbles flowing through secretions or lightly closed airways during respiration. (Bates Guide to Physical Examination 10th edition p. 319). No visible abnormalities No visible abnormalities

Anterior Chest

AUSCULTAT ION

Normal breath sound

Crackles are audible upon auscultation on his left lower lobe.

Shape & configuration

INSPECTION

Symmetric, costal angle within 90 degrees Symmetric expansion (Bates Guide to Physical Examination 10th edition p. 298-321).

It is symmetric, costal angle within 90 degrees Patient anterior chest is symmetric in expansion

Chest expansion PALPATION

Breast and axillae Breast Areola Shape, color, masses or lesions INSPECTION Bilaterally the same: color varies widely from light pink to dark brown. No lumps, masses or areas of tenderness Round: everted/inverted: equal in size: similar in color. Equal and generally symmetric The skin is uniform in color No visible abnormalities.

Nipples

PALPATION

Round everted and equal in size. Similar in color, texture is smooth and soft.

No visible abnormalities.

Size, shape color, position

Soft and smooth: no No discharges and discharge, masses lesions and masses

No visible abnormalities.
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discharge and lesions

or lesions. No lumps and masses (Fundamentals of Nursing 8th edition by Kozier pg. 628630)

Abdomen Abdomen skin Abdomen for contour INSPECTION Uniform color. Flat, The color is light rounded, symmetric to medium brown contour and it is uniform. Unblemished skin. Symmetric bilaterally. No bulging, asymmetric or visible mass Rounded and symmetric contour Symmetric bilaterally. No bulging, asymmetric or visible mass Sounds of high pitched, gurgling, cascading sounds occurring 24 times per minutes. No visible abnormalities.

Symmetry

INSPECTION

No visible abnormalities No visible abnormalities

Bowel sounds

AUSCULTAT ION

Sounds of high pitched, gurgling, cascading sounds occurring irregularly anywhere from 530 minutes. Stomach growling borborygmus No sound present Tympanitic Dull sound

Abnormal bowel sound often heard on patient with diarrhea or in early bowel obstruction. (Taylor et al Fundamentals in Nursing 6th edition p. 638) N/A N/A N/A

Vascular sounds PERCUSSION General tempany Liver span

Spleen

Dull sound not wider 7mm

The ff. assessment has not been done due abdominal pain complained by the patient on his RUQ during palpation. Patient refuses to do any further palpation on his abdomen. -unable to assess-

N/A

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Liver Spleen Kidneys

PALPATION

Not palpable, nothing firm Not palpable, nothing firm Round, smooth mass (Bates Guide to Physical Examination 10thedition p. 434451).

Assessment refused Assessment refused Assessment refused

N/A N/A N/A

Musculoskelet al Size INSPECTION Muscle is equal in both size Coordinated body movements Muscles are equal on both sides of the body Patient has body weakness No visible abnormalities. Due to underlying condition patient demonstrate uncooperative and body weakness. (Taylor et al Fundamentals in Nursing 6th edition p. 643) No visible abnormalities. Abnormal findings due to inflammation process on the patient right foot lesion. (Taylor et al Fundamentals in Nursing 6th edition p. 611) No visible abnormalities.

Movements

Deformities Tenderness

No deformities No tenderness or swelling on bones and joints

No deformities Tenderness noted due to right foot lesion.

Joint movements Inspection,

Joints movement smoothly (Bates Guide to

Joint move it smoothly

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Palpation

Physical Examination 10th edition p. 571-589). No swelling, no warmth, no redness, no pain and equal in sensation both left/right and upper/lower extremities. No lesions. Bilaterally equal in in temperature. Non edematous. Free from swelling/inflammati ons. Left arm weak in sensation. And slightly weak on his right arm. Right and left foot is good and reactive to stimuli. Right foot is warmer than the left. There was a lesion that was noted on his right, distal, anterior foot at the base. Lesion shows signs of inflammation. Discharge is yellowish in color. Glasgow coma scale of the patient was scored as 14: wherein eye response has the score of 3, 5 for verbal response and 5 for motor response. The patient was able to perform all of the said reflexes such as biceps and triceps reflex, brachioradialis, patellar and Achilles reflex. Abnormal findings may indicate a musculoskeletal disease, infection, trauma, or a neurologic disease. (Taylor et al Fundamentals in Nursing 6th edition p. 643)

EXTREMETI ES

Inspection, Palpation

Neurologic System

Inspection

Glasgow coma scale is 15 Positive reflexes such as biceps reflex, triceps reflex, brachioradialis, patellar reflex and Achilles reflex

Patients eye opening is 3 patient respond to verbal command. For motor 5 (localizes to pain) is due to body weakness that he cannot obeys command. (Taylor et al Fundamentals in Nursing 6th edition p. 647)

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