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Physical Assesment

Physical Assesment

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Published by deborah malnegro

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Published by: deborah malnegro on Oct 09, 2008
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Date: September 17, 2008 Time: 4:00 p.m.


Patient is a 60 year-old male and was received on moderate high back rest with O2 inhalation via nasal prongs at 3-4 LPM, awake, responsive, coherent and oriented to time and place. He looks according to his age with endomorphic body built. Appears weak with limited range of motion but cooperative with mood suitable to situation. Communicates thoroughly in a moderate pace with thoughts intact and associated. Upon survey, patient was in pain as evidenced by grimaced, guarding behavior and verbalization of pain. Untidy clothes with breath and body odor noted. Vital Signs BP = 140/90 mmHg HR = 80 bpm RR = 18 cpm PR = 78 bpm T = 36.8 ºC Height and Weight Height = 5 ft. 7 in. Weight = 152 kgs

Skin Deep brown skin complexion noted except in areas exposed in sun, with areas of lighter pigmentation in palms and nailbeds. It is slightly cool to touch with uremic frost noted on upper

extremities and poor skin turgor. Hyperhidrosis and body odor are both noted upon assessment. Edema noted on scrotum noted upon examination with decubitus ulcers about the size of a one peso coin. Gangrenous tissues are noted on patient's right foot with three toes already amputated. Nails Nail plates on both fingernails and toenails are colorless and with convex curvatures about 160º, smooth in texture upon inspection. Nailbeds are slightly pale in color with intact epidermis. Good capillary refill of less than 2 seconds observed upon blanche testing.

Head Head is normocephalic and symmetrical with frontal, parietal, and occipital prominences observed. Gray hair is minimal, unevenly distributed with no infection or infestations noted. Smooth skull contour with uniform consistency without nodules and masses noted upon palpation. Symmetric facial features, palpebral fissures with symmetric facial movements noted. Eyes and Vision Eyebrow hairs are evenly distributed, skin is intact, symmetrically aligned with equal movement upon raising and lowering. Eyelashes equally distributed and curled slightly outward. Skin of both eyelids is intact, closes symmetrically with no discharge and no discoloration. Cornea in both eyes is cloudy with slow blinking reflex. Pupils are black in color, flat, equally round but with sluggish reaction to light accommodation. Both eyes are coordinated with each other with 100/20 vision. Ears Auricles have same color as facial skin with symmetry, aligned with outer canthus of eyes, mobile, firm and not tender. Pinnae recoil after it is folded. Distal third contains hair follicles without redness noted. Normal voice tones are slightly not audible to the patient. Both ears are not able to hear the ticking of a watch. Nose Symmetric, straight, uniform in color without discharges and flaring noted externally. Not tender and no lesions are noted upon palpation. Air moves freely as the client breathes through the nares. Internally, the mucosa is pink, no discharges, and no lesions with nasal septum intact and in

midline. Sinuses are not tender upon palpation. Mouth Outer part of the lips are symmetrical, purplish in color, dry, cracked and are able to purse. Inner lips are purplish in color, dry, with slightly freckled brown pigments . There are 32 smooth, yellowish teeth. Purplish and firm gums without retraction noted. Tongue is in central position, purplish brown pigmentation on tongue borders, dry, slightly rough with thin whitish coating without lesions assessed. Tongue moves freely without tenderness, without palpable nodules noted with uvula in the midline. Gag reflex present. Neck Neck muscles are equal in size, head is centered with coordinated smooth movements without any discomfort felt. Head flexes about 45º, hyperextends about 60º, laterally flexes and rotates with equal strength on both sternoclaidomastoid and trapezius muscles. Lymph nodes are not palpable with trachea in the midline of neck and spaces are equal on both sides. Thyroid gland is not visible upon inspection without bruit sounds heard upon auscultation.

THORAX AND LUNGS Heart Point of maximum impulse is heard over left midclavicular line and near 5th left intercostals space which is slightly below the nipple with a rate of 80 beats per minute, with S1 and S2 sounds heard upon auscultation. Carotid arteries have full, thrusting pulsations with quality remaining the same when client breathes, turns head or changes position. With no bruit sounds noted. Jugular veins are not visible or distended. Pulses have full pulsations with a rate of 78 beats per minute. Breast and Axillae Breasts are rounded and are slightly unequal in size with skin uniform in color, smooth and intact. Areolas are both round and bilaterally the same and brownish in color with irregular placement of sebaceous glands. Nipples are round, everted and equal in size with similar pinkish to brownish color, soft and smooth with both nipples pointing in same direction. No discharges noted. Both axillae have minimal hairs and are slightly darker in color than the rest of the body. Breasts and axillae do not

have tenderness, masses or nodules.

ABDOMEN Unblemished skin is noted in the abdominal are that is uniform color. It is flabby, distended and round in contour. No evidence of enlargement of liver and spleen. With asymmetric contour when standing and with symmetric movements caused by respiration upon assessment. Audible borborygmi sounds heard upon auscultation about 11 bowel sounds per minute.

EXTREMITIES AND MUSCULOSKELETAL FUNCTION Upper Extremities Both sides are symmetrical in shape and in size. Arms with fatty deposits are equal on both sides of the body with no contractures, no fasciculation, nor tremors noted. Arms are moving coordinately but with limited range of motion. No deformities, tenderness or swelling of bones with joints moving smoothly without swelling, crepitations, tenderness nor nodules noted. Lower Extremities Symmetrical on both sides of the body with no contractures, without fasciculation nor tremors noted. Muscles are firm with smooth coordinated movements and with equal strength on each side of the body. Bones have no deformities, no tenderness, or swelling with joints moving smoothly and coordinated without any swelling, tenderness, nodules nor crepitations noted. Scar is noted on the anterior lower half of the left extremity about 2 inches in diameter.

GENITALIA Pubic hair is kinky and evenly distributed. Pubic skin is intact, with no lesions, lice, nor excoriation noted. Enlargement and tenderness noted on the patient's scrotum upon inspection.

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