V.

Physical Assessment Date and Time Performed: April 25,2011 1:10PM Vital Signs: Pulse Rate: 107 bpm Respiration Rate: 27cpm Blood Pressure: 167/109 mmHg BODY PARTS General Appearance TECHNIQUE USED (IPPA) Inspection FINDINGS Body built: proportionate Hygiene and Grooming: Clean and Neat Body odor: no odor Signs of distress: grimace Affect or mood: cooperative Skin Inspection and Palpation Color: Light Brown Symmetry of color: Uniform Edema: no edema Skin Lesions: no lesions Moisture: moist Temperature: uniform and within the normal range Skin Turgor: Good ANALYSIS Normal Normal

Normal Deviation from normal due to anxiety Normal Normal Normal Normal Normal Normal Normal

Normal

Nails

Inspection and palpation

Nail Curvature: Convex 160 Texture: smooth Nail Bed Color: Pallor Surrounding tissue: intact

Normal Normal Deviation from normal due to cold environment Normal

Capillary refill: less than 4 seconds Head Inspection and Palpation Distribution: Evenly distributed Thickness: thick Texture and oiliness: silky Size and Shape: normocephalic Contour: Smooth Facial Feature: symmetrical Facial Movements: symmetrical Eyes Inspection and Palpation Eyebrows: evenly Distributed Eyelashes: Equally Distributed Eyelids: Intact, Close symmetrically and has 15-20 involuntary blinks per minute Conjunctiva: Transparent, Pinkish, shiny and smooth Lacrimal Gland: no presence of edema, tenderness nor swelling Cornea: Transparent and smooth Pupils: Black, equal in size, PERRLA Extraocular Movement: coordinated

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Normal

Normal

Normal

Normal Normal

Ears

Inspection and Palpation

Pinna: Uniform color Normal with skin, symmetrical, aligned to the outer canthus of the eye 10 from vertical, mobile and firm Hearing Acuity: Intact Normal Normal

Nose

Inspection and Palpation

External Nose: Symmetrical and uniform color No discharges

Normal

Nasal Cavity: Patent Septum in the midline Sinus Tenderness: no tenderness Pharynx Inspection and Palpation Uvula: in Midline Oropharynx: Pink and smooth Tonsils: Pink, smooth and grade 1(behind the tonsillar pillars) Gag Reflex: Intact

Normal Normal Normal Normal Normal Normal

Normal

Mouth

Inspection and Palpation

Lips: Pinkish, Soft, moist and smooth Teeth: Wears dentures (but removed during the operation) Gums: Pinkish, moist and firm

Normal Due to increasing age

Normal

Tongue: at the midline, pinkish, smooth and movable Palate: Light pink and smooth Neck Inspection and Palpation Movement: coordinated Range of motion: Full Lymph nodes: not palpable Trachea: in midline Thyroid Gland : not visible Carotid pulse: symmetric pulse Chest and Lungs Inspection and Auscultation Breathing pattern: quiet and regular Coastal Angle: less than 90 Shape and symmetry: anterior to tranverse ratio is 1:2 Skin: smooth Abdomen Inspection and auscultation Inspection Skin integrity: unblemished Muscle tone: firm Muscle strength: equal Range of motion: full Absence of lesions

Normal

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Normal Normal

Back and extremities

Normal Normal Normal Normal