Patient's Name: Paz Balboa Religion: Roman Catholic

Age/Gender: 59 years old Room/Bed #: Main Station FW1

Physical Assessment

General Survey:

Vital signs are: body temperature of 36.5 C; pulse rate 82 beats per minute with
regular rhythm upon palpatation; respiratory rate of 28 cycles per minute with regular
rhytm; blood pressure of systolic 120 and diastolic of 80 mmHg noted upon
auscultation.
Patient is lying on bed 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. 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 hair noted in thin
distribution. 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 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 NOT NOTED IN BOTH EARS. SHE REPORTED NO HISTORY OF

EAR PAIN OR EAR INFECTIONS. SHE 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.

Nose:

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

lesions and scars noted. Nasal mucosa is red with adequate nasal hair. Client is
able to breath without difficulties. Nasolabial folds have normal opening, is neither
shaloow nor flaring. The septum is located at the midline. 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.

Chest and Lungs:

Chest expansion during respiration were equal.Respiratory rate of 28 cycles per

minute, regular in rhythm. Upon auscultation crackles were not heard.

HEART:

Upon auscultation, the point of maximal impulse is located at the fifth intercostals
space, left midclavicular line, apical pulse can also be heard. He has cardiac rate of 82
beats per minute and has regular heart sounds.
Abdomen:

Abdomen is globular upon inspection. Skin integrity in the abdomen is intact with
waist line of 35 inches. No presence of lesions and scars noted upon inspection.

Genito- Urinary:

Client is able to void urine with yellow color, clear in character, and in
moderate amounts upon inspection. No pain felt during voiding. She reported no
history of urinary tract infections. No unusual discharges and lesions noted.

Extremities:

Upper &Lower Extremities:

The patient peripheral pulses were symmetrically palpated. He had a decrease

range of motion with body weakness noted. No deformities in his upper and lower
extremities.