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Physical assessment

Physical assessment

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Published by majamorena

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Published by: majamorena on Oct 28, 2010
Copyright:Attribution Non-commercial


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Patient: TTCc: body weaknessImp: musculoskeletal spasmsHistory of Present IllnessOn the day of admission, the client was scheduled for routine check up with Dr. M.D. The clientcomplained that she was unable to get up from bed by herself. Her doctor requested that shebe brought to the E.R. for admission.Maintenance medications of the client includes: etoricoxib, clopidogrel and lacidipine.Past Medical History(+) HPN(-) DM(-) CA3 episodes of mild strokePhysical AssessmentI . General Survey:Received this 76 year old, female, widow, Roman Catholic, on low fowlers position,accompanied by her private nurse. The client is conscious, alert, readily aroused, fully aware of external and internal stimuli and responds appropriately to questions. Approximately 5 feet inheight, is slightly emaciated, with pale sagging skin. Her skin texture is wrinkled and cool totouch. She is moderately groomed and is wearing a flower pattern blouse and loose slacks. Vitalsigns: Temperature: 36.5 C; Pulse: 80; Respiration: 16; BP: 140/90mmHg.
. HeadA.
Hair, scalp, cranium and faceHair is evenly distributed and is cut short. There is an abundance of brittle and drygreying hair. The head is round with smooth skull contour. There is facial asymmetrydue to the sagging and wrinkling of the cheeks.B. Eyes and vision- With diminished visual acuity; has trouble seeing large letters at 3 ft distance, botheyes move parallel to each other; non sunken eyeball notes; with thinning eyebrows;lids are wrinkled and of the same color of the face; lesions are not noted; blinksinvoluntarily and bilaterally; with anicteric sclerae; pupils equally round, reactive to lightand accommodation; pupil size is 3mm in diameter; pupil reaction is slightly sluggish.C. Ears and hearingEars are symmetrical. The auricles are aligned with the outer cantus of the eye. They aremobile, firm and not tender. The pinna recoils after it is folded. The client is unable tohear whispered words on both ears.D. Nose and sinusesThe nose is symmetric and straight. There is no discharge or flaring. No tendernessdetected in the sinuses.E. Mouth and oropharynxThe lips are uniform pale pink in color and are soft and smooth. The teeth are slightlyyellowed and the incisors show cracks. The tongue is smooth and at the midline. Theclient has the ability to move the tongue in all directions when asked. The buccalmucosa is thin and shiny. There are no lesions in the buccal mucosa nor are the tonsilsinflamed. Gag reflex is present.F. Cranial nerves
Olfactory- Can identify the smell of alcoholII.
Optic- Impaired visual acuityIII.
Oculomotor IV Trochlear and VI Abduscens  Presence of cardinal positions of gazeV. Trigeminal Good chewing movementVII. Facial- AsymmetricVIII. Acoustic- Unable to hear whispered words in both earsIX Glossopharyngeal and X Vagus - Normal pharyngeal movement, uvula at midlineXI Spinal Accessory Slight atrophyXII Hypoglossal- The tongue is midline upon thrusting3. Neck- With limited range of motion. Lymph nodes are not palpable. The trachea is at themidline of the neck and spaces are equal on both sides.4. Upper ExtremitiesNails on both hands are dry, brittle and are of convex curvature. There is muscle atrophyon both shoulders. The left arm is slightly weaker than the right arm.5. Chest, back and lungsThere is an increase in the anteroposterior diameter of the chest. The spine is slightlykyphotic. Bony prominences are palpable. The skin is intact and uniform totemperature. The chest wall shows no tenderness but there are some depressions.Chest expansion is decreased although it is symmetric. The client takes 16 breaths perminute.

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