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P. 1
Physical Assessment

Physical Assessment

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Published by api-3717941

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Published by: api-3717941 on Oct 14, 2008
Copyright:Attribution Non-commercial

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03/18/2014

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PHYSICAL ASSESSMENT
A. Skin\u2022
Skin color is deep brown, evenly distributed; light colors of the skin are
found in palms and nails.
\u2022
Skin is relatively dry through the body with minimal amount of
perspiration on axilla and scalp.
\u2022
Skin texture is rough.
\u2022
Poor skin turgor, skin slowly returns to its original shape after squeezed.
\u2022
Skin temperature is relatively warm through out the body.
\u2022

Skin lesions noted on face and on feet. 6 moles noted on face, dark brown in color, size vary from small to large, distribution is discrete, individual moles are separate and distinct. Callus noted on right and left ankle of the feet. Edema noted on left arm.

B. Hair\u2022
Hair in the body is evenly distributed, texture is fine and short and black in
color. Hair in axilla is curly, about 1 inch in length, and thick.
\u2022
Hair in head is short about 2 inch long, thin, unevenly distributed, patchy
hair loss noted, black with grey in color, shiny and smooth.
\u2022
Small like perspiration noted.
C. Scalp
\u2022
No dandruff noted
\u2022
No lesions noted
\u2022
Moist and oily
D. Head
\u2022
Head is normocephalic and symmetrical
\u2022
Head is positioned to midline and has an oral contour
\u2022
No masses noted
\u2022
Temporal pulse rate is 103 b/m, amplitude of pulse is normal, pulse
rhythm is regular
E. Face\u2022
Color is brown
\u2022
Presence of wrinkles especially on forehead
\u2022

Capable of facial movements like elevation of eyebrows, lowering of eyebrows, closing of eyes, able to smile grin and frown, facial movements symmetrical.

\u2022
Mustache noted; length is about 1 cm, color is black with grey and is
thick.
\u2022

Lesions noted on face and on feet. 6 moles noted on face, dark brown in color, size vary from small to large, distribution is discrete, individual moles are separate and distinct.

F. Eyes
\u2022
Hair in eyebrow are thick evenly distributed; eyebrow are symmetrical and
of equal movements
\u2022
Eyelashes are equally distributed and are straight
\u2022
Eyelids closes symmetrically, drooping upper eyelid
\u2022
Sclera is yellowish in color
\u2022
Iris is round, cloudy and slightly bluish in color
\u2022
No redness noted, no edema noted, no inflammation, no lesion noted
\u2022
Good visual acuity
G. Nose
\u2022
Nasal septum positioned in midline
\u2022
Nose is symmetrical
\u2022
Color of nose is brown
\u2022
No deformity noted
\u2022
No tenderness noted upon palpation
\u2022
Evenly distributed ciliary hairs
\u2022
Discharges noted; thick, whitish
\u2022
Flaring noted
\u2022
Air movement in and out is obstructed
H. Mouth and Pharynx
\u2022
Lips is dark pink in color
\u2022
Dry lips
\u2022
Ability to purse lips
\u2022
Mouth is symmetrical aligned to pharynx
\u2022
Lips is symmetric
\u2022
Tongue moves freely
\u2022
Tongue in midline
\u2022
Teeth color is dirty white
\u2022
Soft and hard palate is pink
\u2022
Poor gag reflex
\u2022
Plague and tartar is present
\u2022
Incomplete dentilation
\u2022
Smooth and soft, no nodules, no lesions
I. Neck
\u2022
Carotid vein is visible
\u2022
Wrinkles noted
\u2022
Difficulty to flex
\u2022
No enlargement of thyroid glands
\u2022
Trachea in midline
\u2022
No masses and nodules noted
J. Ears\u2022
Dark brown in color
\u2022
Tenderness and masses not noted
\u2022
Symmetrical

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