I.

Physical Examination

Height: Actual Weight:

Vital Signs:
Temperature: 36.5ºC Respiratory Rate: 25 cpm
Pulse Rate: 92 bpm Blood Pressure: 140/90 mmHg

Date and Time of Examination: 08/17/10 – 9:30 am

Regional Examination:

General Appearance:
 Client has a proportional body build & slouched bent posture. Client has
coordinated body movements, clean and neat, with no body odor. Facial grimace
is noted when the client experiences pain and guarding behavior is also present.
Client is weak looking with slow movements, is fully cooperative and able to
follow simple instruction. Client can concentrate but drowsy most of the time.
Client use slow pace, soft toned voice.

A. Skin:
I:  Skin is pale
 Fair skin color
 No edema noted
 Large amount of loose skin particularly on the neck and arms
 Presence of wrinkles and lentigo senilis
 No abrasions and lesions noted
P: Afebrile but cold to touch on the lower extremities
 Skin is moist
Skin turgor about 2 seconds assessed at sternum.
 Thickened and rough skin on both sole of the feet

B. Nails:
I:  Fingernails convex curvature; normal angle of curvature about 160˚
Light pink in color on fingers and nail beds on toes
 Fingernails and toe nails are cut clean and surrounding tissues are intact
No clubbing of nails noted
P:  Smooth finger and toe nails
 Brisk capillary refill of finger and toe nails about 3 seconds

C. Head and Face:

I:  Normocephalic
Symmetric facial features
Symmetric facial movements
 With visible brown spots, freckles on right maxillary bone about 2 cm
P:  No nodules and masses noted

D. Eyes:
I: Eyebrows symmetrically aligned and moves equally
Lids close symmetrically
Skin surrounding the eyes intact and no discoloration
No eye discharge
Has the ability to bilaterally blink: 16 blinks per minute
Brown iris
Arcus senilis present on both eyes
Pupils equal in size
Pupils equally round and react to light and accommodation
Coordinated movements of both eyes
Able to read medicine labels
Unable to see far objects clearly
P:Corneal reflex present
No edema on lacrimal gland and nasolacrimal duct noted

E. Ears:
I:  Same color with facial skin
Symmetrical in size
 Aligned to the outer canthus of the eye
Able to hear normal voice tone
P: Auricles are mobile, firm and no tenderness noted
Pinna recoils after folded
No tenderness palpated
 Pinna recoils after being folded
Negative Weber
Positive Rinne

F. Nose:
I: External nose symmetric
Nasal septum intact and along midline
Patent airway
No inflammation noted
No nasal flaring noted
With Oxygen support via nasal cannula maintained at 2LPM

P:
No tenderness and masses noted
G. Mouth and Oropharynx:

I:Uniform pink color of outer lips

Soft, moist, smooth texture of outer lips
Ability to purse lips
Inner lips and buccal mucosa pink in color
No sores in buccal mucosa noted
Upper and lower dentures noted
Tongue at the midline and moves freely

P:  Gag reflex present

H. Neck:
I: Head centered
 Coordinated movements
P: No enlargement of lymph nodes noted
 Decreased muscle strength
Trachea in midline of the neck
 Thyroid gland is not enlarged.

I. Spine:
I:  No swelling noted
Spine vertically aligned
P:No tenderness noted
 No slipped disc or swelling palpated

J. Thorax and Lungs:

I:  Symmetric anterior chest
Spontaneous, non labored respirations
 With Oxygen administration via nasal cannula maintained at 2LPM
PalSkin of anterior and posterior thorax chest wall is intact
No tenderness noted
No masses noted
Per:  Resonance over lungs
 Flat over bones
Aus:  Crackles on the both base of the lung

K. Cardiovascular/Heart:
I:  No lifts or heaves noted
  No distention of jugular veins noted
No vein engorgement noted
Pa: Symmetrical, weak pulsations
 Symmetric pulse volume at the carotid artery
Aus:  With gallops (S3) heard over the apex of the heart
 No bruit noted

L. Breast:
I:Saggy skin
Round and bilaterally the same areola
No discharge noted

Pa: No mass or tenderness noted

M. Abdomen:
I:  No discolorations present; uniform in color; with silver white striae
 Round, globular abdomen
Umbilicus in the midline without discharge
 Peristalsis is not visible.
Distended abdomen with abdominal girth of 101 cm
Aus:  20 borborygmi/minute
Pa: Pain upon palpation
 Tenderness on epigastric area noted
 Liver is not palpable and not enlarged
Per:  Client refused due to pain

N. Extremities:

Upper:

I: Symmetrical and weak pulses

No peripheral cyanosis and swelling noted
With IVF at left metacarpal vein, intact and patent, no swelling noted
Hematoma noted at the right arm
No lesions and abrasions noted

P: No edema and tenderness noted

No contractures or tremors noted
Able to perform ROM exercises
Symmetrical muscle contour
 Lower:

I: Symmetrical and weak pulses

No peripheral cyanosis and swelling noted
Symmetrical muscle contour

P: Unable to perform active ROM exercises

Able to perform passive ROM
Symmetrical muscle strength

O. Genitals:
I: pubic hair is distributed in the shape of inverse triangle
pubic skin intact , no lesion grayish in color
labia round, full and relatively symmetric
no swelling, inflammation or discharge
P:no enlargement or tenderness of inguinal lymph nodes

P. Rectum and Anus:

I: intact perianal skin; more pigmented than the skin of the buttocks
erythematous sacral area noted

Q. Neurologic Exam:
• Conscious
• Coherent upon interaction
• Oriented to person and place but she doesn’t know the date and time
• Able to answer questions appropriately
• Speech in slow pace, soft tone voice
• Client can recall immediate, recent and remote memory
• Able to discriminate sharp and dull sensation
• Able to discriminate temperature sensation
• Able to name the objects that are pointed
• Able to understand verbal instruction
• Stereognosis: recognizes objects by touching them
• Extinction phenomenon: both points of stimulus are felt
• GCS = 15 (E4 V5 M6)