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  • Physical Assessment

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    Edmar Dalmacio
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    The patient received a physical assessment where the following was noted: 1) Vital signs were within normal limits and the patient was cooperative. 2) Skin, hair, nails, head, eyes, ears, nose, mouth, neck, chest, lungs, abdomen and extremities were examined and found to be largely unremarkable except for a tattoo on the left leg and a scar on the epigastric area of the abdomen. 3) Tenderness was noted in the lower left quadrant of the abdomen.

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    The patient received a physical assessment where the following was noted: 1) Vital signs were within normal limits and the patient was cooperative. 2) Skin, hair, nails, head, eyes, ears, nose, mouth, neck, chest, lungs, abdomen and extremities were examined and found to be largely unremarkable except for a tattoo on the left leg and a scar on the epigastric area of the abdomen. 3) Tenderness was noted in the lower left quadrant of the abdomen.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Scarica in formato DOCX, PDF, TXT o leggi online su Scribd
    Segnala contenuti inappropriati
    152 visualizzazioni2 pagine

    Physical Assessment

    Caricato da

    Edmar Dalmacio
    The patient received a physical assessment where the following was noted: 1) Vital signs were within normal limits and the patient was cooperative. 2) Skin, hair, nails, head, eyes, ears, nose, mouth, neck, chest, lungs, abdomen and extremities were examined and found to be largely unremarkable except for a tattoo on the left leg and a scar on the epigastric area of the abdomen. 3) Tenderness was noted in the lower left quadrant of the abdomen.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Scarica in formato DOCX, PDF, TXT o leggi online su Scribd
    Segnala contenuti inappropriati
    di 2

    PHYSICAL ASSESSMENT

    General survey
    • Received lying on bed, conscious, coherent and awake; with ongoing IVF # 3
    D5LR 1 L at 20 gtts/min, infusing well
    • Afebrile
    • Good posture and coordinated body movement
    • No body odor
    • Cooperative and able to follow instructions
    • Vital signs:
    T: 36 ℃ R: 19 cpm
    P: 78 bpm BP: 110/80 mmHg

    Skin
    • Uniform in skin color
    • No edema noted
    • No skin lesions noted
    • Has a tattoo on his L leg
    • Uniform skin temperature
    • Good skin turgor
    • Skins spring back to previous state

    Hair and nails


    • Hair is evenly distributed
    • Thick hair
    • No infection and infestation noted
    • Convex nail curvature
    • Pinkish nail bed

    Head
    • Rounded and smooth skull contour
    • Absence of nodules and masses
    • Symmetric facial features
    • Symmetric facial movements

    Eyes
    • Eyebrows hair are evenly distributed
    • Eyebrows symmetrically aligned and equal in movement
    • Lid close symmetrically
    • No edema or tenderness over lacrimal gland
    • Pupil equally round ad react to light accommodation

    Ears and nose


    • Auricle aligned with outer canthus of eye
    • Auricle are mobile firm and not tender
    • Pinna recoils after it is folded
    • Able to hear ticking sounds in both ears
    • Nose located midline of face
    • No discharge or flaring and no lesion in the external nose

    Mouth
    • Dry lips
    • Lips are symmetric in contour
    • Uniform pink in color in inner lips
    • Pink gums
    • Moist, firm texture of gums
    • Smooth intact dentures
    • Tongue moves freely

    Neck
    • Neck muscle equal in size
    • Coordinated and smooth head movements with no discomfort
    • Lymph nodes not palpable
    • Thyroid gland not visible upon inspection
    • Thyroid gland ascends during swallowing

    Thorax and lungs


    • Chest symmetric
    • Spine vertically aligned
    • Chest wall intact; no tenderness and no masses noted
    • Symmetric chest expansion
    • Vesicular breath sounds
    • Symmetric lung expansion

    Abdomen
    • Unblemished skin
    • Incision scar noted at the epigastric area upon inspection
    • Flat abdominal contour
    • No evidence of enlargement of liver and spleen
    • Symmetric abdominal contour
    • Symmetric abdominal movement during respiration
    • Tenderness noted at LLQ

    Extremities
    • Muscles equal in size on both sides of the body
    • No muscle contractures and tremors noted
    • Smooth coordinated muscle movements
    • No bone deformities and not tender
    • No joint tenderness
    • Joint moves smoothly and freely

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