The document provides a physical assessment of a 72-year-old female patient over four dates in February 2017. It records vital signs and describes the clinical examination findings for general appearance and various body systems, which were found to be normal. The assessment found the patient's skin, hair, nails, head, eyes, ears, nose, mouth, lungs, heart, and breasts showed no abnormalities.
The document provides a physical assessment of a 72-year-old female patient over four dates in February 2017. It records vital signs and describes the clinical examination findings for general appearance and various body systems, which were found to be normal. The assessment found the patient's skin, hair, nails, head, eyes, ears, nose, mouth, lungs, heart, and breasts showed no abnormalities.
The document provides a physical assessment of a 72-year-old female patient over four dates in February 2017. It records vital signs and describes the clinical examination findings for general appearance and various body systems, which were found to be normal. The assessment found the patient's skin, hair, nails, head, eyes, ears, nose, mouth, lungs, heart, and breasts showed no abnormalities.
The document provides a physical assessment of a 72-year-old female patient over four dates in February 2017. It records vital signs and describes the clinical examination findings for general appearance and various body systems, which were found to be normal. The assessment found the patient's skin, hair, nails, head, eyes, ears, nose, mouth, lungs, heart, and breasts showed no abnormalities.
Appears neat & clean GENERAL Conscious, alert and APPEARANCE responds to questions Facial expression is appropriate for the situation
Skin: The clients skin is
uniform in color, SKIN, unblemished and no HAIR presence of any foul odor. & He has a good skin turgor
1 NAILS and skins temperature is within normal limit (36.5- 37.5c, hydrated skin. Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. There are also no signs of infection and infestation observed. Can be black, brown or burgundy depending on the race. No evidences of Alopecia Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 3 seconds.
Neck: The neck muscles are
HEAD equal in size. The client & showed coordinated, smooth NECK head movement with no discomfort. The lymph nodes of the client are not palpable. The trachea is placed in the midline of the neck. The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible. Eyebrows: Hair is evenly distributed. The clients eyebrows are symmetrically aligned and showed equal No swelling Does not have enlarged thyroid glands. No presence of lymph nodes. Head: The head of the client is round; normocephalic and symmetrical.
2 Skull: There are no nodules or masses and depressions when palpated. Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.
Color of the eyes depends
EYES on the race Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward. Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks approximately 15-20 times per minute. Eyes o The Bulbar conjunctiva appeared transparent with few capillaries evident. o The sclera appeared white. o The palpebral conjunctiva appeared shiny, smooth and pink. o There is no edema or tearing of the lacrimal gland. o Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was touched. o The pupils of the eyes are black and equal in size. The iris is flat and round.
3 PERRLA (pupils equally round respond to light accommodation), illuminated and non- illuminated pupils constricts. Pupils constrict when looking at near object and dilate at far object. Pupils converge when object is moved towards the nose. o When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead. Ears: The Auricles are EARS symmetrical and has the same color with his facial skin. The auricles are aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile, firm and not tender. The pinna recoils when folded. During the assessment of hearing such as whispering to the other ear and then the other one to see if the client was able to hear properly, she pass the test and was able to hear the word
4 The nose appeared symmetric, straight and NOSE uniform in color. There was no presence of discharge or flaring. When lightly palpated, there were no tenderness and lesions
Mouth: MOUTH The lips of the client are uniformly pink; moist, symmetric and have a smooth texture. The client was able to purse his lips when asked to whistle. Teeth and Gums: There are no discoloration of the enamels, no retraction of gums, pinkish in color of gums The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and with elastic texture. The tongue of the client is centrally positioned. It is pink in color, moist and slightly rough. There is a presence of thin whitish coating. The smooth palates are light pink and smooth while the hard palate has a more irregular texture. The uvula of the client is positioned in the midline of
5 the soft palate.
THORAX, Regular breathing pattern
LUNGS In a normal air-filled lung, & vesicular sounds are heard CARDIOVASCULAR over most of the lung fields, bronchovesicular sounds are heard between the 1st and 2nd interspaces on the anterior chest, bronchial sounds are heard over the body of the sternum, and tracheal sounds are heard over the trachea No cough RR should be 16-20 cpm PR should be 60-100 BP should be 90/60-120/80 Lungs / Chest: The chest wall is intact with no tenderness and masses. Theres a full and symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when assessing for the respiratory excursion. The client manifested quiet, rhythmic and effortless respirations. The spine is vertically aligned. The right and left shoulders and hips are of the same height. Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence of heaves or lifts.
BREAST Breast should be even.
May or may not be completely symmetrical at rest. The areola is round or oval, with same color, (Color varies form light pink to
6 dark brown depending on race). Nipples are round, everted, same size and equal in color. No orange peel skin is noted which is present in edema. The veins maybe visible but not engorge and prominent. No obvious mass noted. Not fixated and moves bilaterally when hands are abducted over the head, or is learning forward. No retractions or dimpling. No lumps or masses are palpable. No tenderness upon palpation. No discharges from the nipples.
ABDOMEN Abdomen: The abdomen of
the client should have an unblemished skin and is uniform in color. The abdomen has a symmetric contour. There were symmetric movements caused associated with clients respiration. The jugular veins are not visible.
7 EXTREMITIES Skin color is normal Fingers in both hands is complete Toes in both feet is complete Voluntary movement Flexible Edema is normal for pregnant woman. It is caused by increased pressure from their growing baby The extremities are symmetrical in size and length. Muscles: The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth, coordinated movements. Bones: There were no presence of bone deformities, tenderness and swelling. Joints: There were no swelling, tenderness and joints move smoothly.
GENITALIA Pubic hair is present
No lesions, pubic lice and warts present
8 ANUS No lesions, tear and scars, & No bleeding RECTUM
