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Patient's Name: Jeneth Sulayman Religion: Roman Catholic

Age/Gender: 28 years old Room/Bed #: Main Station FW3

Physical Assessment

General Survey:

Vital signs are: body temperature of 35.7 C; pulse rate 82 beats per minute with
regular rhythm upon palpatation; respiratory rate of 27 cycles per minute with regular
rhytm; with equal expansion of the chest; blood pressure of systolic 130 and diastolic of
90 mmHg noted upon auscultation.
Patient is awake , conscious and coherent. Speech is adequate and converses
are well oriented. Client is responsive to questions both verbally and physically.

Skin:

Patient has brown skin complexion upon inspection. Hypertrophic scar


secondary to caesarian section approximately 4.5 inches long noted on the lower
abdomen. Stretch marks noted, white in color and approximately 3 to 4 inches
long noted. Discoloration of the lateral grooves of the thumb nails noted. Skin on
the right arm is punctured due to intravenous fluid infusion but with no noted
swelling, reddening, heat and pain. Body hair is fine and thinly distributed. Skin is
warm to touch, with good skin turgor, and with adequate moisture upon palpation.

Head:

Head is symmetrical upon inspection. Long, fine, black, wavy hair noted in thin
distribution. Nodular lesions with brown color and equally distributed noted on the face
upon inspection. No masses noted upon palpatation. The client doesn’t complain of
dizziness, vertigo and headache upon the interview. She has no family history of mental
disorders noted upon assessment of her/his family background.

EARS:
EARS ARE SYMMETRICAL UPON INSPECTION. TOPS OF EARS ARE ALIGNED WITH THE OUTER CANTHI
OF THE EYES NOTED SUGGESTING NO SIGN OF DOWN’S SYNDROME. PINNA AND EXTERNAL AUDITORY CANALS

ARE INTACT UPON INSPECTION. IMPACTED CERUMEN NOTED IN BOTH EARS SUGGESTING POOR HYGIENE. HE/SHE
REPORTED NO HISTORY OF EAR PAIN, RINGING IN THE EAR, OR EAR INFECTIONS. SHE/HE USES NO HEARING

AIDS TO FACILITATE HEARING.

Eyes:

Eyes are symmetrical upon inspection. Client has brownish black eyes.
Eyelashes and eyebrows are equally but finely distributed on both sides of the
face. Pupils are equal, round, reactive to light. No unusual discharges from the
lacrimal ducts noted upon palpatation. She/he is able to recognize size, shape,
and colors correctly. She reported use of correctional eyeglasses of 175 visual
grades on the left side and none on the right side.

Nose:

Nose is symmetrical with good septal deviation noted upon inspection. No


lesions and scars noted. Nasal mucosa is red with adequate nasal hair and
accumulated mucus secretions noted upon inspection. Client is able to breath
without difficulties when one nostril is occluded suggesting nares on both side of
the nose are patent. Client is able to smell pleasant and foul odors suggesting
good olfaction.

Neck:

Neck muscles are symmetrical upon inspection. Skin on the neck is intact with
good integrity. Neck lymph nodes are not swollen upon palpation. Carotid pulse is
palpable. Trachea is at the center and immovable upon palpation. No masses and
lesions noted. Voice is clear and well modulated. Client is able to perform active range
of motion exercises in the neck without mobility restrictions and pain upon assessment.

BREAST AND AXILLA:

SYMMETRICAL BREAST WITH ROUND, BROWN AND REVERTED NIPPLES NOTED UPON INSPECTION.
AXILLARY HAIR NOTED WITH ADEQUATE DISTRIBUTION. NO UNUSUAL DISCHARGES UPON PALPATION OF THE
NIPPLES. LYMPH NODES ON THE AXILLAE ARE NOT SWOLLEN UPON PALPATION. SHE HAS NO FAMILY HISTORY OF

BREAST CARCINOMAS ON BOTH FATHER AND MOTHER SIDES.


Chest and Lungs:

Respiratory rate of 27 cycles per minute, regular in rhythm, with noted exertion
and use of accessory muscle upon inspection. Frequent coughing accompanied by
expectoration of whitish to yellowish phlegm in moderate amount noted upon entire
duration of assessment. Resonant sounds heard upon percussion of the anterior and
posterior chest.

HEART:

Abdomen:

Abdomen is globular upon inspection. Skin integrity in the abdomen is intact with
hypertrophic scar approximately 4.5 inches long secondary to caesarian section note on
the lower abdomen. Stretch marks noted, white in color and approximately 3 to 4 inches
long noted upon inspection of the lower abdomen.

Genito- Urinary:

Client is able to void urine with yellow color, clear in character, and in
moderate amounts upon inspection. Pubic hair noted. She reported having
history of urinary tract infections during her last pregnancy. No unusual
discharges and lesions noted.

Extremities:

Upper Extremities:

Lower Extremities: