Physical Assessment

Feb. 25, 2009

2:00pm

Body Parts I. Skin

Technique Inspection

Findings Fair complexion Poor skin turgor Prominent facial features Evenly Distributed White hair No lesion, No scaling Eyebrows are symmetrically aligned Sclera is slightly aligned Conjunctiva is pale in color

Interpretation Normal Normal Normal

Significance Due to aging

II. Head

Due to aging

-Hair Inspection -Scalp Inspection -Eyes Inspection

Normal

Normal

Normal

Inspection

Normal

Due to aging

Normal

Due to aging

-Ears Pinna

No lesion, Symmetrical Firm and not tender Symmetrical contour Dry lips Inspection & Palpation Inspection

Normal

Normal

Inspection - Nose Palpation -Mouth

Normal

Abnormal due to DHN Normal Due to aging

Tongue is pale in color Absence of teeth

Abnormal

Due to smoking (accumulation of nicotine in the teeth)

III. Neck Inspection Palpation -Shoulder Inspection IV. Chest V. Thorax Inspection

Head is centered No palpable Lymph node Symmetrical

Normal Normal

Normal

Symmetrical Crackles Noted

Normal Abnormal

Due to presence of sputum or Increase mucus secretion Due to narrowing & inflammation of the airway

Auscultation

Wheezing noted

Abnormal

VI. Axilla

Inspection

Slightly white in color No Mass Palpated No lesions

Normal

Palpation VII. Abdomen Inspection VIII. Upper Extremities Inspection -Palms & Hands IX. Lower Extremities Inspection -Right Leg X. Genitals

Normal Normal Normal

Uniformly Colored

Slightly pale palms

Abnormal

Due to aging

Dry Skin

Normal

Due to aging

REFUSED