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Physical Assessment

Physical Assessment

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Published by: Ronnel Alvin Antonio Adriano on Sep 06, 2010
Copyright:Attribution Non-commercial


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PHYSICAL ASSESSMENTGeneral AppearanceMy client has a small frame body built, upright in posture with smooth rhythmicgait. He is appropriately dressed and he has no bad odor.Mental StatusMy client is conscious enough to time, place, and person oriented. He is usingsimple words as way of communication and language and he is very cooperative.SkinMy client has normal skin color with a warm body temperature. He has drymoisture, smooth in texture, and with evenly hair distribution. He has a skinturgor of elastic and mobile and doesn’t have any lesions.NailsHe has an convex 160-nail plate shape and his nail condition is smooth and hehas pink nail bed color. His capillary refills within 3 seconds.Head and FaceMy client has a proportionate skull to his body size and he has fine and evenlydistributed hair with a tender scalp and his face is symmetrical and his facialmovement is symmetrical and easy movement.EyesMy clients eye condition is straight normal and he has thin eyebrows in hair distribution and his eyelids were effectively closure and his blink response isbilateral frequent and his eyeballs are symmetric. His conjuctiva has clear bulbar and pink palpebral and his sclera is white and his pupils are equal in size and hehas brisk reaction to light and accommodation between his right and left eye. Hisvisual acuity is able to recognize objects. His lacrimal apparatus is moist.EarsMy clients auricle is symmetrical and the color is normal racial tone and histexture and elasticity is tender and elastic. His pinna recoils when folded and hisexternal canal have some cerumen on it. His hearing acuity responds to normalvoice and he also respond to whispered voice within 2ft. away.
NoseMy clients nose color is normal racial tone and his septum is on the midline andhis mucosa is pink and the patency is both patent. His nasal cavity is moist andhis sinuses are not tender.MouthMy clients lips is symmetrical and pink in color. His mucosa is pink and histongue is on the midline and it is smooth in texture and the color is pink. Histongues movement is movable. His teeth are not complete and his gums are inpink in color and no mouth sores.PharynxMy clients uvula is on the midline and his mucosa is pink in color. His tonsils arenot inflamed and his posterior pharynx is congested and his gag reflex is present.NeckMy clients neck muscle is equal in size and his lymph nodes are not palpable andhis trachea is on the midline and his thyroid gland is not palpable.Chest and LungsMy clients chest shape is AP to lateral ratio of 1:2 and her lung expansion in theanterior side is symmetrical and on the posterior side is symmetrical. His fremitusis symmetrical and her breathing pattern is regular and bronchovesicular insound. The sound of the percussion is resonant and her costal angle is on 45degrees.HeartMy client has a peripheral pulses at both sides of the body have equal strength.Breast and AxillaMy client refused to have breast examination so we don’t have the chance toassess his breast and axilla.AbdomenMy clients skin integrity is normal racial tone and unblemished. His contour andsymmetry is flat and his movement is symmetrical and his bowel sounds arenormal. His abdomens palpation is tender and his liver is palpable.

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