PHYSICAL ASSESSMENT

On August 19, 2010, at 5:30 pm a comprehensive physical assessment was conducted to our client N.A., a 45 year old male, who was admitted last August 16, 2010 9:05 PM in St. Luke ward with the chief complaint of weakness.

I. General Survey During our assessment, we received our patient lying on his bed. He was awake, coherent, and responsive to stimuli and was oriented to the time, person and place. He has a mesomorphic body built. He has a body weight of 52.5 kg and a height of 161cm. (1.6 m) these yielded to a body mass index of (20.25 kg/m) Upon assessment, the patient appears to be relaxed and cooperative. He has O2 inhalation at 1-2 LPM. He has an IVF of PNSS 1 L at 50 cc/ infusing well at his left metacarpal vein. Overall, the patient is looking well and he is not on any form of respiratory distress.

II. Vital Signs Upon the assessment, the patients vital signs are as follows:

Vital Signs

Actual

Normal Values

Clinical Significance

Temperature(axillary) Cardiac Rate Pulse Rate Respiratory Rate Blood Pressure

35.6C 65 bpm 62bpm 22cycles 120/60

35.5-37.5 C 70-80 bpm 70-80 bpm 16- 24 cycles 110/70-130/90

Normal Normal Normal Normal Normal

III. Skin General skin color is brown. Skin is generally uniform in color except in areas exposed to sun and areas with lighter pigmentation such as the lips. Pallor noted on his palms and nails. Jaundice also noted on his stomach. His skin is smooth in texture, warm and dry to touch. Good skin turgor is observed characterized with skin springing back to previous state less than 2 seconds. No lesions, edema and ulceration noted upon assessing the patient. Scars noted on his both lower extremities.

IV. Head Head is normocephalic. Fontanels are closed. Upon palpation there are no signs of enlargement or any mass noted. Through inspection, scalp is clean and free from dandruff. Lice, wounds, scars and lesions are not noted. His hair is short, black in color and straight, fine and evenly distributed. The facial movements are all coordinated. Muscle strength of jaw is normal.

V. Eyes His eyebrows are aligned. Eyelashes are evenly distributed and both are fine and black in color and curled outward. Eyelids have equal movement; without any discharges noted and closes symmetrically. His eyebrows are symmetrically aligned with equal movement. Upon inspection his conjunctiva is pallor. Skins of the eyelids were intact; discharges, discolorations and lesions are not observed. Edema, tenderness and excessive tearing are not noted over lacrimal gland, lacrimal sac and nasolacrimal duct upon palpation. He has an icteric sclera. Pupils are equally round and briskly reactive to light and accommodation with pupil constriction of 2mm on both eyes. Movements of the eyes are coordinated and uniform. He can see objects in periphery and can read a text in 3 feet away with a font size of 14.

VI. Ears The upper of the pinna are normoset, symmetrical and in line with the outer canthus of eyes. Auricles have the same color as the facial skin, symmetrical in position, firm and not tender. The pinna recoiled after it was folded.

No presence of lesions, swelling or odorous discharges noted on both ears. Minimal cerumen is noted in the external canal. He can clearly hear spoken words. Patients gross hearing is symmetrical on both ears. He could hear normal voice tones and could hear whispered voices within 2 feet.

VII. Nose Nasolabial fold is symmetrical. Nasal septum is at the midline. Presence of tenderness and lesions, are not noted. Nostrils are symmetrical in shape and size. External nares are both patent and there are no discharges noted. External nares are symmetrical to each other. Frontal and maxillary sinuses are not tender.

VIII. Mouth and teeth Lips are symmetrical and pale to brown in color. There are no lesions, discharges, and ulcerations noted. Teeth are yellowish in color. At present he has 27 teeth with dental carries noted. He was using 4 teeth denture as replacement for mastication at upper teeth. Gums are pale in color and firm. The tongue is located midline. Palates are pale and normally concave with no lesions. Uvula is in the midline with a pallor mucosa. Tonsils are not inflamed. Gag reflex was noted. His speech is spontaneous.

IX. Neck The neck is symmetrical without any deformities, lesions or tenderness noted. The patient is able to move his neck from side to side then up and down without any pain or discomfort while flexing. The trachea is in midline. Lymph nodes are not palpable upon palpation. Upon swallowing the thyroid gland is not palpable. The carotid artery on the neck area has full pulsation with moderate force. Jugular veins are not distended.

X. Chest and Lungs Patient has full and symmetric chest expansion. Upon palpation, there are no lesions, masses, deformities, and tenderness noted. There are no bulges or retraction on the intercostals upon respiration. When vocal (tactile) fremitus was assessed, the result indicated symmetrical sensation on both hands. There are clear breath sounds on both lung fields upon auscultation with respiratory rate of 22 cycles per minute. No tenderness, masses, and retractions on the chest were noted.

XI. Breast and Axillae Upon inspection of the breast, there were no unusualties noted such as tenderness or presence of lesions. His areola is brown in color .Upon assessment on his axillae, presence of hair is evident. There are no palpable lymph nodes noted.

XII. Heart Upon assessment there is no bulging or thrusting of the pericardium. The point of maximum impulse could be heard on the 5th intercostal space with regular heart beats and strong pulsations. Extra sounds such as S3 and S4 are not heard upon auscultation. Apical pulse is regular with the heart rate is 65 beats per minute. There are no masses noted.

XIII. Abdomen Jaundice noted on his abdomen. Bowel sounds is normoactive with 11 sounds per minute. Upon palpation, there is minimal tenderness noted. Umbilicus is centrally located, clean without any discharges and signs of inflammation noted. There are no masses or any other forms of unusualities noted. Upon percussion a tympanic sound was elicited. Bladder is not palpable. Ascites also was not noted.

XIV. Genito-Urinary As verbalized by the client, pubic hair is evenly distributed with dark color. There are no lesions, parasitic infection, enlargement and tenderness noted. Scrotum is symmetrical. Hernia and other unusualities are not noted.

XV. Back and Extremities Skin color is darker than the skin in the chest. Spine is vertically aligned without any deformities. Both upper and lower extremities are symmetrical. It is warm to touch without any lesions. Upper and lower extremities have good range of motion. Toenails and fingernails are convex in shape, short and well trimmed with capillary refill time of greater than 2 seconds. Nail beds are pale in color. There was no edema noted on both upper and lower extremities. Scars noted on both lower extremities. There is no tenderness and swelling noted in the back and in the extremities. Radial pulse and posterior tibial pulse are equal.

XVII. Cranial Nerve Assessment CRANIAL NERVE I. Olfactory ASSESSMENT The patient is asked to sniff different kinds of aromas and asked to identify it. RESULT The client is able to identify aromatic substances such as alcohol, mango and orange. II. Optic This is done by testing the vision and visual fields with an eye chart or by having the patient read a few statements from an article or by testing the point at which the subject first sees an object moving into the visual field. III. Oculomotor Assess the six ocular movement, movement of the sphincter of pupil, movement of ciliary muscles of lens and pupil reaction. The patient is able to move his eye on six different directions. His pupil is reactive to light and the pupils are brisk; The client is able to read a text with the font of 14 and with a distance of 3 feet. Also, he is able to see a moving object at a distance of 5 meters away.

with pupil size of 2mm. IV. Trochlear Tested in similarity with cranial nerve III, in this test patient is tested to move his eyeball downward and laterally. V. Trigeminal This is done by testing the sensations of pain, touch, pressure and temperature. Motor branch is tested by asking the client to open mouth against resistance and move jaw from side to side. The patient is able to distinguish if it is dull or sharp by the use of the cap of the ballpen and the feeling of coldness of an ice cold mineral water bottle. Corneal sensation and blinking are present. Also, he is able to open his mouth evenly against resistance. VI. Abducens Tested in similarity with cranial nerve III for the ability to move each eye laterally. Assess direction of gaze. VII. Facial Client is asked to close eyes, smile, purse lips and frown. He is able to close his eyes and demonstrate many facial expressions such as smiling, frowning and pursing of lips. VIII. Vestibulocochlear Whispering words to the client and asking him to follow saying the word after you.. The client can reiterate the words that were whispered to his ears. Patient can move his eyes laterally. He is able to move his eyes downward and laterally, by following the finger.

The words Wednesday and Kadayawan were uttered by the patient after asked to repeat what was heard. IX. Glossopharyngeal Gag and swallowing reflexes are checked by asking the client to speak and cough. Gag reflex is present. A tongue depressor was placed on the posterior portion of the tongue and he started to act like he wants to vomit. X. Vagus It is tested in similarity with cranial nerve IX, since they both serve as muscles of the throat. XI. Accessory Sternocleidomastoid and trapezius muscles are checked for strength by asking him to turn his head side to side and shrug shoulders against resistance. XII. Hypoglossal He is able to turn his head side to side without any difficulty. He can shrug his shoulders against resistance without any pain felt. Gag reflex is present and he is able to swallow food without difficulty.

Patient was asked to stick out He is able to stick his his tongue and move his tongue in different directions tongue out and he is able to move it in different directions.