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PHYSICAL ASSESSMENT Date of Physical Assessment: January 2, 2012 6:00pm Height: 55 Weight: 70kgs Vital Signs: BP: 120/70

Temperature: 39.7C Pulse rate: 94bpm Respiratory rate: 29cpm Pain scale: 7/10 General survey: The client is a 32 years old and appears to be oriented and alert and he attends to question appropriately. Facial features are symmetric with movements. Maintain eye contact; expressions are appropriate to the situation. The skin color is brown. The body parts are equal bilaterally and are relative proportion to each other. Clothes are appropriate to the climate and age, fit the body but not well groomed and not properly kept clean. Body Parts Skin Method of Assessment Inspection Normal Findings Varies from light to deep brown, generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nailbeds) Freckles, some birth marks, no abrasions ( Kozier and Erbs. techniques in clinical nursing. Physical health examination. P.58) No presence of edema Temperature is uniform When pinched, skin springs back to previous state. Resilient, evenly Actual findings Brown color, moist and flushed skin. (+) erythematous maculopapular rash all over the body Analysis and Interpretation A maculopapular rash is a type of rash characterized by a flat, red area on the skin that is covered with small confluent bumps.

Palpation

No presence of edema Skin is warm to touch due to fever With good skin turgor

Fever is present due to an infectious agent which causes an alteration in thermoregulatory set point Client manifests normal

Hair

Inspection

Hair is evenly

Nails

Inspection

distributed and neither dry nor oily. Found all over the body except for the palms and sole of the feet. No presence of infestation of lice or sores. Convex curvature, angle of nail plate is about 160. Highly vascularized pink in light skinned color. Prompt return of pink or usual color generally less than 4 seconds.

distributed, it is oily. Hair is found all over the body except for the palms and sole of the feet. There is no presence of infestation of lice or sores seen by the patient. The curvature of the nails of the patient is convex, and its angle is about 160. The nails are highly vascularized and are pink in color. The blanch test was done, nails returned to pink generally less than 4 seconds.

findings

Client manifests normal findings

Palpation

Smooth, firm and nontender Capillary refill within three to four seconds

Eyes

Inspection

Ears

Inspection

When palpated, the nails are smooth, firm and non-tender and its capillary refill is three seconds. Positioned symmetrical The eyes of the patient to each other are positioned symmetrically to each The eyebrows have other, his eyebrows are equal distribution in equal distribution, and his eyelashes are The eyelashes curl curl outwardly. No outward pigmentations, cloudiness or any There are no presence of abnormal pigmentations, discharges are seen in cloudiness or any the patients eyes. presence of abnormal Pupils are equally discharges in the eyes rounded and are in normal sizes. Pupils equally rounded Pupillary activity and appear normal in appears normal and is size reactive to light. The pupils are equally Pupillary activity rounded reactive to appears normal light and accommodation. The external surface of The external surfaces the ears should be of the ears are smooth smooth and the size and and the size and shape shape of the ears is of the ears is symmetric and symmetrical and proportional to the head proportional to the The ears are in normal head. positioning. They are in The ears are in normal

Client manifests normal findings

Client manifests normal findings

Client manifests normal findings

line with the outer canthus of the eyes

Head and Face

Inspection

Palpation Nose Inspection

Palpation

Mouth, Throat, Neck

Inspection

positioning. They are in line with the outer canthus of the eyes. No There is no evidence of evidence of lesions, lesions, discharges, discharges, odor, odor, bleeding, pain bleeding, pain and pus. and pus Ears are neither bulging nor perforated. The ears are neither The client has no bulging nor perforated hearing aid and can hear normal voice tones The parts of the head The parts of the head Client manifests normal and face is proportion and face are proportion findings to each other and to each other and are symmetric symmetrical. The shape is gently curved with Shape is gently curved prominences at the with prominences at the frontal and parietal frontal and parietal bones. The patient has bones symmetric facial movements. Symmetric facial movements Smooth uniform Smooth uniform Client manifests normal consistency; absence of consistency; absence of findings nodules or masses nodules or masses The nose is at the The nose of the patient Client manifests normal midline with no is at the midline, there findings presence of abnormal are no presence of discharges and drainage abnormal discharges and drainage. The nose Nose is symmetric and is symmetrical and straight, no presence of straight, there is no discharges, no presence presence of discharges, of lesions and uniform no lesion was seen and in color is uniform in color. No swelling or redness The patient has no of the nose. Nasal swelling or redness in septum is not the nose and his nasal perforated. septum is not perforated. Frontal and maxillary When sinuses are Client manifests normal sinuses not tender palpated, there no findings tenderness reported on the maxillary and frontal area. The lips are pink, The patients lips Koplik's spots moist, smooth and are appear dark, moist, and characterized as in normal symmetry smooth and are in clustered, white lesions normal symmetry, on the buccal mucosa The gums are pink and gums are dark in color are pathognomonic (dia smooth and smooth. The gnostic) for measles tongue is pink in color The tongue does not and is smooth;Tonsils possess negative are not distended, the thrushes and lesions uvula is at midline.

Tongue is smooth and is pink in color There is no presence of odor Tonsils are not distended The uvula is at midline The mouth is generally reddish/pinkish in color There is no significant or palpable mass at the thyroid area JVD is not present The lymph nodes are not distended The trachea is palpable at the midline of the neck. No venous patterns, varicosities, rashes and ulcers

(+) Aptha ulcer in buccal mucosa

Palpation

No significant or palpable mass was reported at the thyroid area. Jugular vein is not distended. Lymph nodes are not palpable.The trachea is palpable at the midline of the neck. No venous patterns, varicosities, rashes and ulcers IV seen on left hand peripheral line

Client manifests normal findings

Upper extremities

Inspection

Client manifests normal findings

Thorax and Lungs

Inspection

Chest is symmetric and skin is intact Quiet, rhythmic, and effortless respirations Temperature is uniform Chest wall is intact; no tenderness; no masses

Palpation

Chest is symmetric and skin is intact, the respiratory rate of the patient is 29 cpm. Quiet, rhythmic, and effortless respirations Temperature is uniform Chest wall is intact; no tenderness and masses upon palpation. Have clear breath sounds No visible lifts or heaves

Tachypnea is commonly seen in patients who are experiencing severe pain. Client manifests normal findings

Auscultation Heart Inspection

No adventitious breath sounds No visible lifts or heaves Peripheral veins in dependent position, distention and nodular bulges at calves are present

Client manifests normal findings Client manifests normal findings

Palpation

Full Pulsation

Has Full Pulsation

Client manifests normal findings

Breast

Inspection

Breasts even with the chest wall and there are presence of pigmentation Areola and nipples are rounded and dark brown No tenderness, masses, or nodules Flat and there are presence of pigmentation No lesions. Not visible peristaltic movements Audible bowel sounds Not low-pitched and murmur sounds For bowel sounds, it is high pitched sound occur 5 to 30 times per minute

Breasts even with the chest wall and uniformed in color Areola and nipples are rounded and dark brown No tenderness, masses, or nodules Flat and there are presence of pigmentation No lesions. Not visible peristaltic movements Audible bowel sounds; intermittent gurgling high pitched sound was heard. When auscultated, 27 were number of bowel sounds heard in one full minute (+) Tympanitic upon percussion of the abdomen

Client manifests normal findings

Palpation Abdomen Inspection

Client manifests normal findings Client manifests normal findings

Auscultation

Client manifests normal findings

Percussion

Palpation

Tympany over the stomach and gas- filled bowels; dullness especially over the liver and spleen, or a full bladder No tenderness, relaxed abdomen with smooth, consistent tension Bladder and Liver is not palpable Muscles has equal size on both sides of the body, no contractures, no fasciculation, or tremors Bones has no deformities Joints has no swelling Muscles are firm, has smooth coordinated movements

Client manifests normal findings

There is pain/tenderness noted in the epigastric area with a pain scale of 7/10 Muscles has equal size on both sides of the body, no contractures, no fasciculation, or tremors Bones has no deformities Joints has no swelling Muscles are firm, has smooth coordinated movements

Epigastric pain may occur with conditions that cause inflammation of the digestive organs or caused by infectious agent Client manifests normal findings

Musculoskeletal Inspection

Palpation

Client manifests normal findings

Bones has no Bones has no tenderness and swelling tenderness and swelling Joints have no tenderness and swelling, crepitation or nodules. Joints moves smoothly Joints have no tenderness and swelling, crepitation or nodules. Joints moves smoothly

Lower Extremities Neurologic System

Inspection Inspection

No venous pattern, varicosities, rashes, ulcers Glasgow coma scale is 15 Positive reflexes such as biceps reflex, triceps reflex, brachioradialis, patellar reflex and Achilles reflex

No venous pattern, varicosities Glasgow coma scale of the patient was scored as 15 wherein eye response has the score of 4, 5 for verbal response and 6 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. Not performed

Client manifests normal findings Client manifests normal findings

Genitourinary

Inspection

Penile skin intact, wrinkled and brown, Circumcised Urethral meatus is pinkish and slight like in appearance. Position at the tip of the penis Scrotal skin is darker in color than the rest of the body and is loose

Kidneys

Urine color is straw, amber or transparent; urine consistency clear liquid; urine glucose not present. BUN 8-20 mg/dL Creatinine 0.61.2mg/dL Inspection

Urine is slightly yellowish in color.

Rectum and Anus

Intact perineal skin; Not performed usually slightly more pigmented than the skin of the buttocks. anal skin is normally more pigmented, coarser and moister than perianal skin and is usually hairless Anal sphincter has good tone Rectal wall is smooth and not tender Stool color is brown; consistency of the stool Stool color is brown; watery in consistency One of the clinical manifestations of amoebiasis is having diarrhea, watery and ful smelling stool often containing bloodstreaked mucus.

Palpation

is formed semisolid and moist Stool odor is aromatic. No presence of blood

and aromatic