PHYSICAL ASSESSMENT General Survey: The patient was conscious and coherent lying on bed with following contraptions

IV on the right metacarpal infusing well at 18 gtts/sec. She looks according to age. She is well nourished and practices good hygiene. Patient shows irritability, feel distress when had a chest pain. Initial vital signs: Vital Signs Normal Range Actual Findings Interpretation Analysis

Temperature

Middle Adult: 36.1 37.6 C

36.7 C

Normal

Pulse Rate

Middle Adult: 60 100 bpm Middle Adult: 12 20 cpm

104 bpm

Normal

Respiration

18 cpm

Normal

Blood Pressure

Middle Adult: Systolic: 110-120 mmHg Diastolic: 70-80 mmHg

Systolic: 120 mmHg Diastolic: 70 mmHg

Normal

Anthropometric Measurements: Height: 511 Weight: 180 lbs BMI=wt in kg/ht in cm x (2) 81.64/180.34 x 2=

C. Cephalocaudal Approach 1. Skin Body Parts Skin Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection Palpation

Intact condition. Appropriate distribution of pigmentation. Slow, progressive decrease in skin turgor due to decrease in collagen production and sebaceous glands. Warm to touch.

His skin was dry.

Dry skin and skin turgor back in normal at 2 seconds

Dry skin is more prominent over the extremities.

2. Head Body Parts Skull Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection Palpation

Proportional to the size of the body/ round/ with prominence on the frontal area and the occipital are posterior, symmetrical in all planes, gently curved

Proportional to the size of the body/ round/ with prominence on the frontal area and the occipital are posterior, symmetrical in all planes, gently curved

Normal

Hair

Inspection

Evenly distributed hair Silky, resilient hair

Patches of hair loss Dry hair

They may be loss of scalp

Scalp

Inspection Palpation

White, clean, free from masses, lumps scars, lice, nits, dandruff, and lesions, no area of tenderness. Oval/oblong/square/round/ heart-shaped. Symmetrical. With wrinkles and no involuntary movements

White, free from masses, Normal lumps, scars, lice, nits, and lesions. No area of tenderness. Round. Symmetrical and no involuntary movements. Color of face is even. Wrinkles present. Normal construction of the face. Wrinkles present due to the aging process. The skin loses its elasticity and wrinkles. Wrinkles first appear on face and neck, which are abundant in collagen and elastic fiber.

Face

Inspection

3. Eyes Body Parts Eyes Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection

Parallel evenly placed, symmetrical, nonprotruding, with scant secretion. No presence of eye bags.

Parallel evenly placed, symmetrical, nonprotruding, with scant secretion on both eyes.

Normal

Eyebrow

Inspection

Graying. Symmetrical. Evenly distributed and parallel with each other.

Small amount of gray hair present. Symmetrical. Evenly

Normal

distributed and parallel with each other.

Eyelashes Inspection

Black, evenly distributed and turned outward

Lashes are black, evenly distributed and turned outward

Normal

Eyelids

Inspection

Upper lids cover the small portion of the iris cornea and sclera when they are open.

Upper lids cover the small portion of the iris cornea and sclera when they are open.

Normal

4. Ears Body Parts Ears Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection

Parallel, symmetrical and proportional to the size of the head bean-shape and helix is in line with the outer cantus of the eyes and skin is the same color as the surrounding area and clean

Parallel, symmetrical and proportional to the size of the head bean-shape and helix is in line with the outer cantus of the eyes and skin is the same color as the surrounding area and clean

Normal

Ear canal

Inspection

Pinkish, clean with scant amount of cerumen and a

Pinkish and with scant cilin and minimum

Normal

few cillin

scattered cerumen is present

Hearing Acuity

Inspection

Able to hear the tickling of a watch on both ears

Able to hear the tickling of a watch on both ears

Normal

5. Nose Body Parts Nose Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection Palpation

In the midline, symmetrical and patent.

In the midline, symmetrical and patent. With nasal cannula regulated at 5LPM

Normal

6. Mouth Body Parts Lips Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection

Pinkish, symmetrical with margin well-defined, smooth and moist.

Pinkish, symmetrical with margin welldefined, smooth and moist.

Normal

Gums

Inspection

Smooth, moist, and has no discharge.

Smooth, moist, and has no discharge.

Normal

Teeth

Inspection

32 permanent teeth well aligned, free from caries, no filling.

18 teeth present with Not well aligned and yellowish in color, with tartar. Missing teeth and ill-fit dentures, Calcular deposit because of smoking and irregular dental check up and irregular prophylaxis.

Poor oral hygiene

The teeth may show signs of staining, erosion, chipping and abrasions due to loss of dentin. Tooth loss occurs as a result of dental disease but is preventable with good oral hygiene.

Tongue

Inspection

Large or medium red or pink slightly rough on top smooth along the lateral margin moist shiny and freely movable.

Large. Light pink and freely movable. No lesions.

Normal

Frenulum

Inspection

Midline, straight and thin

Midline, straight and thin

Normal

Buccal mucosa

Inspection

Pinkish, smooth and moist

Pinkish, smooth and moist

Normal

Soft palate

Inspection

Pinkish, smooth and moist.

Light pink, smooth and moist.

Normal

Hard palate

Inspection

Pinkish, smooth and moist.

Light pink, smooth and moist.

Normal

Uvula

Inspection

At the center, freely movable, and symmetrical

At the center, freely movable, and symmetrical Pinkish, not inflamed

Normal

Tonsils

Inspection

Pinkish, not inflamed.

Normal

Voice

Inspection

No hoarseness and well modulated

No hoarseness and well modulated

Normal

7. Neck Body Parts Neck Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection

Proportional to the size of Muscles equal in size; the head, symmetrical head centered. and straight. . Freely movable without difficulty. No palpable lumps or tenderness No palpable lumps or tenderness. Normal

Palpation

8. Thorax Body Parts Anterior and Posterior Thorax Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection

Chest symmetric. Spinal column is straight. Skin intact. Full and symmetric chest expansion. Bilateral symmetry of tactile fremitus. No tenderness. No adventitious breath sounds. Color of the skin is even. Uniform in movement. Umbilicus is the center. Bowel sounds present (5-20 sounds per minute).

Chest symmetric. Spinal column is straight. Skin intact. Full and symmetric chest expansion. Bilateral symmetry of tactile fremitus. No tenderness. No adventitious breath sounds. Color of the skin is even. Uniform in movement. Umbilicus is the center.

Normal

Palpation Auscultation

Normal Normal

Abdomen

Inspection

Normal

Auscultation

Bowel sounds present. 6 bowel sounds in a minute on the lower right quadrant. Liver is not palpable. No tenderness.

Normal

Palpation

Liver is not palpable. No tenderness.

Normal

9. Breast Body Parts Breast Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection Palpation

No masses and lumps No tenderness

No gynecomastia. No masses and lumps. No tenderness

Normal

Areola

Inspection Palpation

Dark in color in contrast to surrounding skin. No masses, lumps, and lesions. No tenderness and the lymph nodes are not palpable Size is proportional. No discharge or secretions.

Dark brown. No masses, lumps, and lesions. No tenderness and the lymph nodes are not palpable

Normal

Nipples

Inspection

Size is proportional. No discharge or secretions.

Normal

10. Cardiovascular and Peripheral Vascular System Body Parts Techniques Heart Auscultation Normal Findings Actual Findings Interpretation Analysis

No presence of Murmurs are present. murmurs. Point of Maximal Pulse on the 5th ICS at MCL. S1 and S2 heart sounds heard clearly at all four anatomic sites: aortic, pulmonic, tricuspid, and apical.

Central Vessels

Palpation

No jugular vein distention. Carotid arteries pulsate fully with thrusting quality. No presence of bruits on the carotid arteries.

Not visible and fully with thrusting quality.

No bruits on the carotid arteries

Peripheral Perfusion

Inspection

Skin color is pink.

cyanotic

Palpation

Skin temperature not excessively warm or cold.

Skin cool

Peripheral Pulses

Palpation

Symmetric pulse volumes Full pulsations

Decreased, weak, thread pulsations(indicate impaired cardiac output)

Poor blood oxygen supply and possible arterial occlusion.

11. Upper Extremities Body Parts Arms Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection

Palpation

Able to tolerate wide range of motion. No difficulty upon bending and stretching. Warm, dry and smooth. Skin turgor is elastic and mobile. Able to tolerate wide range of motion. No difficulty upon bending and stretching

Able to tolerate wide range of motion. No difficulty upon bending and stretching. Warm, dry and smooth. Skin turgor is elastic and mobile. Able to tolerate wide range of motion. No difficulty upon bending and stretching.

Normal

Shoulders

Inspection

Normal

Elbows

Inspection

Able to tolerate wide range of motion. No difficulty upon bending and stretching.

Able to tolerate wide range of motion. No difficulty upon bending and stretching.

Normal

Wrist

Inspection

Able to tolerate wide range of motion. No

Able to tolerate wide range of motion. No

Normal

difficulty upon bending and stretching.

difficulty upon bending and stretching.

Hands and Inspection fingers

Able to tolerate wide range of motion. No difficulty upon bending and stretching. Convex, angle of nail plate about 160, smooth texture and intact epidermis. Color returns within 3 seconds.

No edema and no difficulty upon bending and stretching.

Normal

Nails

Inspection Capillary refill test

Convex, angle of nail plate about 160, smooth texture and intact epidermis.

Normal

Color returns within 2 seconds.

12. Lower Extremities Body Parts Hip Techniques Normal Findings Actual Findings Interpretation Analysis

Inspection

Able to perform wide range of motion

Able to perform wide range of motion

Normal

Leg

Inspection

Able to perform wide range of motion

Able to perform wide range of motion.

Normal

Knee

Inspection

Able to perform wide

Able to perform wide

Normal

range of motion Foot and toes Inspection Able to perform wide range of motion

range of motion. Able to perform wide range of motion Normal

Nails

Inspection

Convex, angle of nail plate about 160, smooth texture and intact epidermis.

Convex, angle of nail plate about 160, smooth texture and intact epidermis.

Normal

13. Musculoskeletal Body Parts Muscular Strength Techniques Normal Findings Muscle Strength Test: Score of 5 Actual Findings Interpretation Analysis

Inspection Palpation

Right arm: Deltoid = 3 Biceps = 2 Triceps = 2 Forearm and hand = 5 Left arm: Deltoid = 3 Biceps = 2 Triceps = 2 Forearm and hand = 5 Right Leg: Quadriceps = 3 Anterior Tibial = 1 Gastrocnemius =1

Normal

Muscle Strength Test: 0 = total paralysis 1 = visible or palpable contraction but no movement 2 = Full muscle

Normal

movement with force of gravity eliminated 3 = Full muscle movement against gravity but no movement against resistance 4 = Full muscle movement against gravity, partial movement against resistance 5 = Full muscle movement against gravity, full movement against resistance Muscular Tone Inspection Symmetrical in size of structure and muscular strength.

Extensor digitorum longus =3 Left Leg: Quadriceps = 3 Anterior Tibial = 1 Gastrocnemius =1 Extensor digitorum longus =3

Symmetrical in size of structure and muscular strength.

Normal

Bones

Inspection

No deformities, tenderness or swelling.

No deformities, tenderness or swelling.

Normal

Joints

Inspection

Wide with a slight decrease in range of joint movements.

Wide with a slight decrease in Normal range of joint movements.