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UNIVERSITY OF SAN JOSE-RECOLETOS

Magallanes St., Cebu City
COLLEGE OF NURSING

PHYSICAL EXAMINATION

I. PATIENT’S DATA Name: BB Date: 11-25-09

Sex: Female Marital status: Single Date of Birth: April 4, 1977
Address: Maguikay Mandaue City, Cebu
Occupation: None Employer: None
Chief Complaint: Attacks of seizures
Physician’s Diagnosis: Bipolar 1, with manic episodes
Date of Admission:
Vital Signs: T:37°C; PR:76 bpm; RR:18 cpm; BP: 120/80 mmHg
Height: 5’3’’ Weight: 155 kg
Gross deformities: None

III. PHYSICAL EXAMINATION

A. Symptom Overview:
General   Sinus infection   Urgency to urinate
  Allergies   Sore throat
  Depression   Tonsillitis Cardiovascular
  Dizziness   Vision problems   High blood pressure
  Fainting   Low blood pressure
  Fatigue Gastrointestinal   Hardening of the arteries
  Fever   Abdominal pain   Irregular pulse
  Headaches   Bloody or tarry stool   Pain over heart
  Loss of sleep   Colitis / Crohn’s   Palpitation
  Mental illness   Colon trouble   Poor circulation
  Nervousness   Constipation   Rapid heart beat
  Tremors   Diarrhea   Slow heart beat
  Weight loss / gain  Indigestion   Swelling of ankles
  Diverticulosis
  Colic Respiratory
Muscle / Joint   Arthritis /   Polyphagia   Chest pain
rheumatism   Gallbladder trouble   Chronic cough
  Bursitis   Hernia   Difficulty breathing
  Foot trouble   Hemorrhoids   Hay fever
  Muscle weakness   Intestinal worms   Shortness of breath
  Low back pain   Jaundice   Spitting up phlegm / blood
  Neck pain   Liver trouble   Wheezing
  Mid back pain   Nausea
  Joint pain   Painful defecation Check any of the
  Pain over stomach conditions
Skin   Poor appetite you have or have had:
  Boils   Vomiting   Alcoholism
  Bruise easily   Vomiting of blood   Anemia
  Dryness   Appendicitis
  Hives or allergies Genitourinary   Arteriosclerosis
  Itching   Bed-wetting   Asthma
  Rash   Bladder infection   Bronchitis
  Varicose veins   Blood in urine   Cancer
Cyanosis   Kidney infection   Chicken pox
  Kidney stones   Cold sores
Eye, Ear, Nose & Throat   Prostate trouble   Diabetes
  Colds   Pyuria   Eczema
  Deafness   Stress incontinence   Edema
  Ear ache   Emphysema
  Eye pain Urination   Epilepsy
  Gum trouble   Overnight more than twice   Goiter
  Hoarseness   Polyuria: More than 8x in   Gout
  Nasal obstruction 24hrs   Heart burn
  Epistaxis   Decreased flow/force   Heart disease
  Tinnitus   Dysuria   Hepatitis
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  Herpes   Multiple sclerosis   Rheumatic fever

  High cholesterol   Mumps   Stroke
  HIV/AIDS   Numbness/tingling   Thyroid disease
  Influenza   Pace maker   Tuberculosis
  Malaria   Osteoporosis   Ulcers
  Measles   Pneumonia
  Miscarriage   Polio

Women only
  Congested breasts
  Hot flashes
  Lumps in breast
  Menopause
  Vaginal discharge

Please list any medication you are currently taking and why:
Patient is currently taking carbamazepine

B. CEPHALO-CAUDAL ASSESSMENT
1. Skin
 Scars / Marks / Moles/ pigmentation: scars are present at her right foot, moles are also
present in face
 Texture: texture of her skin are smooth
 Temperature: warm on palm of hands and feet
 Color: client is fair-skinned (brown).
 Ulcers/lesions (describe location and appearance): their are lesions in the lower
right extremity
Skin Turgor: (+) skin turgor: skin is not that elastic anymore it will take seconds to go back due
ageing process
2. Head
 Hair: well distributed, white in color
 Shape: normocephalic
 Masses: none
 Tenderness: none

3. Eye:
External inspection
 Size, shape symmetry: symmetrically rounded
 Lids, lashes: evenly distributed lashes; skin intact
 Conjunctiva: shiny, smooth and pink
 Sclera: appears white
Examination
 Ocular movements: both eyes coordinated; moved in unison
 Visual fields: when looking straight ahead client can see objects in the periphery

 PERRLA:: pupil constricts when looking at near objects; pupils dilate when looking at far object
 Corneal reflex: client blinks when the cornea is touched :

4. Ear:
External inspection
 Size, shape symmetry: size and shape are proportion and symmetrical
 Position & alignment of head: auricle aligned with outer canthus of eye

 Skin condition (color, lumps, lesions): skin condition is fine the color of the skin is brown but in
the right arm burns are noted

5. Nose:
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External inspection
 Size, shape symmetry: symmetrical and straight
 Patency: client breaths easily with the nares and no signs of dyspnea
 Skin condition : even color; no sensitivity: but there are keloids due to burns

6. Mouth and Throat:

 Size, shape symmetry: proportion in shape
 Lips: lenient; smooth texture; even pink color
 Mucosa: Buccal/Labial undeviating pink in color; moist;
 Teeth and Gingiva: smooth, white, pink gums, no renunciation of gums
 Swallowing ability: patient has no difficulty in swallowing solid foods, patient is able to swallow;

7. Neck
 Skin generally even in color; no lesions or masses
 Thyroid not visible on inspection

 Resisted ROM the same strength; smooth movements with no distress

8. Heart-Lungs:
Inspection
 Shape & symmetry, bony markings chest symmetric; spine vertically aligned

 Spinal shape & curvature (kyphosis, lordosis, scoliosis) spine is vertically aligned

 Extremities: (-)Digital clubbing Capillary Refill test: less than 3 seconds

9. Upper and lower extremities

 Strength: Leg raise against resistance: equal strength

Cerebellar Function Tests: R L

 Finger-to-Nose Test: can constantly touches the nose
 Rapid pro/supination: can interchangeably supinate & pronate hands rapidly
 Gait/heel-toe walk keeps heel-toe walking along straight line

Sensory:
 Stereognosis: Identifies common objects (coin)
 Extinction: both spur are felt at the patient’s back
 Sharp/Dull: capable to identify and differentiate “shrill” and “dull” sensations
 Hot/Cold: able to identify and differentiate “hot” and “cold” sensations

10. Mental Status:

 Behavior (Alert, lethargic, confusion, speech): alert; speech is sometimes slurry
 Orientation (Time, person, place & situation) oriented to time, person, place and situation

11. Cranial Nerves:

I - Olfactory R L
 Scent: able to identify common scents correctly (perfume)

II- Optic: can see things at the edge when looking straight ahead

III, IV, VI - Oculomotor, trochlear, abducens

 ‘H’ pattern both eyes are able to follow pattern
 Ocular Movements:(+) cardinal signs; eyes move in accord
 Corneal touch reflex: (+) blink reflex; eyes blink when touched with cotton wisp

VII - Facial R L
 Facial expressions: intelligible to what she feels
 Facial expression #2: patient has no trouble in smiling, levitation her brows, and puffing out
cheeks when asked to

VIII – Vestibulocochlear: patient can hear whispered words and can repeat words clearly given by
the nurse
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IX- Glossopharyngeal: patient can move tongue from side to side, up and down

X- Vagus: patient speaks softly and clearly, but sometimes slurry

XI - Spinal accessory: client can turn head side to side against resistance

XII – Hypoglossal
 Stick out tongue: tongue at midline; can move both from side to side