PHYSICAL ASSESSMENT DONE ON: JULY 06, 2011/6:55pm General Observations: The patient was conscious, coherent, oriented

to time, person, and place. He has thrombo embolic stockings on his both lower extremities and was undergo surgery (June 30, 2011) on his thoracic thus completely limited in mobilization. Hemovac at the back was noted. Complaining for back pain. BODY PARTS SKIN METHODS OF ASSESSMENT Inspect NORMAL ACTUAL FINDINGS The overall appearance of patients skin is light brown. Has a good skin turgor and has generally dry skin. However some elevated circumscribed fluid-filled less than 1cm in diameter was noted at the back. ANALYZATION The blood supply particularly at the back area decreased (due to prolong lying in bed). thus insufficient amount of oxygen cause skin lesions.

Skin can be fair, black or brown depending on race

HEAD Skull Inspect Palpation Generally round, with prominences in the frontal and occipital area Lighter in color than the complexion. Can be moist or oily. No scars The head is normocephalic in shape without the presence of mumps or disorientation The scalp is moisten during inspection showing good for a

Normocephalic

Scalp

Inspect

The scalp is moist during inspection

Hair

Inspect

FACE EYEBROWS, EYELASHES EYES,

Inspect

Inspect

EARS

Inspect

noted normal scalp Can be black, brown or The hair are evenly burgundy depending on distributed without the Thin hair, evenly race. Evenly presence of lies or distributed. light brown distributed; covers dandruff in color. No presence of whole scalp. May be lice thick, thin or coarse or smooth. Symmetrical. No Intact cranial nerve V Face is symmetrical involuntary muscle and VII movement Eyebrows are The eyebrows and symmetrical and in line eyelashes are evenly with each other. It may distributed which is Eyebrows are same in be black, brown or black in color. color with hair, dark blonde depending on brown, evenly race. distributed and Eyes are evenly placed symmetrical. and in line with each Black eyelashes evenly other. distributed and turned Eyelashes color outward. dependent on race. Evenly distributed and turned outward. Earlobes are bean The ears dont have any Earlobes are bean shaped, parallel to the discharge and no shaped, parallel and eye and symmetrical. lesions. It has a normal symmetrical. Skin is No lesions seen. No shaped like a bean and same color as presence of earwax can parallel to the outer complexion. No lesions. be notice cantus of the eyes

NOSE

Inspect Symmetrical. No discharges. Symmetrical. No discharge noted Pink colored gums. Moist buccal mucosa Symmetrical without any visible mass or lumps

MOUTH

Inspect

Uniform pink color of the gums,moist and smooth in texture Neck is straight without any visible mass or lumps. Symmetrical Smooth and usually long enough to extend over the fingertips; should be colored pink, convex in shape and with 160 angle between the nail and the nail beds.

No presence of discharge like mucous secretion coming out from the nose. The mouth has no deviation noted. The neck has enough strength to carry and support its head in moving. No presence of mass noted The patient receive enough oxygen to the body.

NECK

Inspect Palpation

NAILS

Inspect

Good capillary refill. Light pink in color, convex in shape.

CHEST/THORAX

Inspect Palpation Auscultation Chest is symmetrical, rhythmic and breathing pattern is effortless.

Symmetrical expansion of the chest was observed during inhalation with no accessory muscles. Thoracostomy tube and surgical staples on the left side as well as orthopaedic hardware at the thoracic spine remain in place.

Deviation in the spinal cord

ABDOMEN

Inspection Palpation

Flat abdomen and normo active bowel sound

LEGS EXTREMITIES

AND

Inspect Bilateral symmetry without any presence of deformities, edema and discoloration. Intact.

Rounded contour Negative bowel movement for one week(June 30-July 06) Dull percussion note was heard over the liver and tympanic note over the rest of the abdomen. Kidneys,liver, and spleen were notpalpable and tender. Hands are steady and no tremor noted. However muscle weakness and numbness with hyperflexion, and positive from joint pains were noted .

Indicates poor muscle tone or excessive fat deposits.

Manifestation for Potts disease were presented.