Professional Documents
Culture Documents
Physical Assessment
Physical Assessment
palpation
proportional to the size of the body, round, with prominences in the frontal area anteriorly & the occipital area posteriorly, symmetrical in all planes, gently curved scalp is white, clean, free from masses, lumps, nits, dandruff & lesions, with no areas of tenderness upon palpation; hair is black, evenly distributed & covers the whole scalp, thick & shiny oblong shaped, symmetrical, smooth & no involuntary muscle movements eyes are parallel & evenly placed, symmetrical, nonprotruding, with scant amount of secretions, both eyes black & clear; sclera is white & clear; eyebrows are black, symmetrical, thick, can raise both symmetrically & without difficulty, evenly distributed & parallel with each other; eyelashes are evenly
Normal
Scalp/ Hair
inspection palpation
Normal
Face
inspection
Normal
Eyes/ Vision
inspection palpation
Normal
distributed & turned outward; upper eyelids cover a small portion of the iris, cornea & the sclera when the eyes are open, when the eyes are closed the lids meet completely, symmetrical & the color is the same as the surrounding skin; lid margins are clear, without scaling or secretions; lower palpebral conjunctiva are shiny, moist, transparent & salmon pink in color; iris are proportional to the size of the eye, round & symmetrical; pupils are from pinpoint to almost the size of the iris, round, symmetrical, constricts with increasing light & accommodation; able to move eyes in full range of direction
Ears/ Hearing
inspection palpation
ears are parallel, symmetrical, proportional to the size of the head, bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area & clean; ear canal is pinkish, clean, with scant amount of cerumen & a few cilia; able to hear
Normal
whisper spoken 2 feet away; 2 piercing are found in left ear and 1 piercing in right ear Nose inspection palpation nose is in midline, symmetrical, patent; internal nares are clean, dark pink with few cilia lips are pinkish, symmetrical, lip margin is welldefined, smooth & moist; gums are pinkish, smooth, moist, no swelling, no retraction, no discharge; 32 teeth are present, aligned, with no dental caries; tongue is pinkish, slightly rough on top, smooth along the lateral margins, moist, shiny & freely movable; cheeks are pinkish, moist & smooth; frenulum is in midline, straight & thin; soft palate is pinkish, smooth & moist; hard palate is slightly pinkish; uvula is at the center, symmetrical & freely movable proportional to the size of the body & head, symmetrical & straight, no palpable lumps, masses or areas of tenderness chest contour is symmetrical, spine is straight, no lumps, Normal
Mouth/ Lips
inspection palpation
Normal
NECK
inspection palpation
Normal
Normal
auscultation
no masses, no tender areas, with clear breath sounds no abnormal pulsations, pulsations are palpable & visible in apical area symmetrical, pinkish nipples, no cracks & discharges, uniform in skin color, smooth & intact, no lumps, masses & tenderness abdominal skin is unblemished, no scars, color is uniform with the body color, abdomen is rounded with symmetric movements caused by respiration; umbilicus is concave symmetrical, with visible veins, fine hair evenly distributed, warm, dry & elastic upon palpation, with area of tenderness on the left arm; palms are pinkish, warm, soft & elastic; nails are transparent, smooth & convex with light pink nail beds & white translucent tips; 5 fingers in each hand; both shoulders, arms, elbows, hands & wrists can be moved in different range of motion with Normal
HEART
BREAST
inspection palpation
Normal
ABDOMEN
Normal
UPPER EXTREMITIES
inspection palpation
Normal
relative ease; c marks of petechial rashes LOWER EXTREMITIES inspection palpation skin is smooth, fine hair is evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical, 5 toes in each foot, sole & dorsal surface is smooth with pink nail beds & white translucent tips; both legs, knees, ankles, & toes can be moved in different range of motion with relative ease; scar on both patellar; c non pitting bipedal edema Normal