PHYSICAL EXAMINATION

June 28, 2011

BMI: 24.75 Interpretation: Normal Weight: 65 kg Height: 1.62

BODY PARTS

METHODS
Inspection

NORMAL FINDINGS
Evenly distributed hair Thick, silky, resilient hair No infection or infestation Absence of lesions Absence of nodules or masses Skull; rounded smooth contour Smooth, uniform consistency; absence of nodules or masses Symmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds Symmetric facial movements Eyebrows hair are evenly distributed; ski intact Eyebrows symmetrically aligned; equal movement

ACTUAL FINDINGS
Hair is evenly distributed Hair is thick, silky and resilient No infection Absence of lesions Absence of dandruff Absence of nodules or masses Skull; rounded smooth contour

INTERPRETATION OR ANALYSIS
The clients hair is

normal

Hair

Inspection Scalp

The clients scalp is normal

Inspection Skull Palpation

The clients skull is normal

Inspection Face

Symmetric facial movements

The clients face is normal

Inspection Eyes and Vision

Eyebrows are symmetrically aligned Eyebrows evenly distributed both with equal movement

Eyebrows are

normal

 Inspection and palpation Pupils direct and consensual reaction to light test
Pupils

reaction to accommodat

Eyelashes are equally distributed; curled slightly forward Eyelids skin are intact; no discharge; no discoloration Lids are symmetrically close Approximately 15 to 20 involuntary blinks per minute; bilateral blinking The bulbar conjunctiva are transparent; capillaries sometimes evident; sclera appears white The palpebral conjunctiva are shiny; smooth and pink or red Pupils are black in color; equal in size; normally 3 to 7mm in diameter; round, smooth border, iris flat and round No edema or tenderness over lacrimal gland, lacrimal sac and nasolacrimal duct Illuminated pupil constricts (direct response); Nonilluminated pupil constricts (consensual response) Pupils constrict when looking at near object; pupils

Eyelash is evenly distributed both equal movement Eyelids skin are intact; no discharge; no discoloration Lids are symmetrically close 17 involuntary blinks per minute; bilateral blinking
Bulbar conjunctiva

Eyelashes are normal Eyelids are normal

are transparent; sclera appears yellow

Conjunctiva are normal Jaundiced sclera indicates liver disease

Palpebral conjunctiva are shiny; smooth and red Pupils are black in color; equal in size

Pupils are normal

No edema or tenderness over lacrimal gland; no tearing

Illuminated pupil

Lacrimal gland are normal

constricts and nonilluminated pupil constricts

Pupils constrict when looking at near object; pupils

ion test

Corneal Sensitivity Test Eye movement test Cover test Near Vision test Inspection

dilate when looking at far object; pupils converge when near object is moved toward nose The client blinks when the cornea is touched, indicating that the trigeminal nerve is intact Both eyes coordinated, move in unison, with parallel alignment Uncovered eye does not move Able to read newsprint
Auricles are

dilate when looking at far object; pupils converge when near object is moved toward nose The client blinks when the cornea is touched Both eyes coordinated, move in unison, with parallel alignment Uncovered eye does not move Able to read newsprint Ears are symmetrical

Corneas are normal

Eye movements are normal Able to focus on object

Ears Palpation

Gross hearing acuity tests Inspection

symmetrical; color same as facial skin; aligned with outer canthus of eye, about 10 degrees from vertical Auricles are mobile, firm and not tender; pinna recoils after it is folded Normal voice tones audible Nose is symmetric and straight No discharge Uniform in color Nasal septum intact and in midline Not tender; no lesions Maxillary and

The clients ears are normal

Recoils after being folded

Normal voice tones audible Nose is symmetric and straight No discharge Uniform in color Nasal septum intact and in midline Not tender; no lesions Maxillary and The clients nose is normal

Nose Palpation

 Inspection

frontal sinuses for tenderness Outer lips are uniform pink color Soft, moist, smooth texture Symmetry of contour Ability to purse lips Inner lips are uniform in color Moist smooth, soft, glistening and elastic texture Teeth are smooth, white, shiny tooth enamel Pink gums Tongue is in central position; moves freely; no tenderness; pink color; no lesions; raised papillae

frontal sinuses for tenderness Outer lips are uniform pink color Presence of crusts Symmetry of contour Ability to purse lips Inner lips are uniform in color Excessive dryness Teeth are smooth, white, shiny tooth enamel Pink gums Tongue is in central position; moves freely; no tenderness; color; no lesions; raised papillae Presence of white coating Smooth with no palpable nodules Muscles equal in size; head centered Head is coordinated, smooth movements with no discomfort Trachea is in central placement in midline of neck; spaces are equal on both sides

Presence of crusts can be an indication of thrust

Mouth

Excessive dryness due to decreased salivation

Palpation
Inspection

Neck Palpation

Smooth with no palpable nodules Muscles equal in size; head centered Head is coordinated, smooth movements with no discomfort Trachea is in central placement in midline of neck; spaces are equal on both sides

Presence of white coating indicates oral yeast infection The clients neck is normal

UPPER EXTREMITIES

BODY PARTS

METHODS
Inspection

NORMAL FINDINGS
Skin color varies

ACTUAL FINDINGS
Yellow in color which is uniform with the rest of the body Generally uniform except in areas exposed to sun No edema No presence of swelling and inflammation No abrasions or lesions The skin is warm to touch When pinched, skin slight back to its previous state Clubbing (above 180 )

INTERPRETATION OR ANALYSIS
Jaundiced color of skin indicates liver disease

from light to deep brown

Generally uniform except in areas exposed to sun No edema Skin Birthmarks; no abrasions or other lesions Moisture in skin folds and the axillae When pinched, skin springs back to previous state Convex nails; angle of nail about plate about 160 Smooth texture of nails Toenail bed; highly vascular and pink or brown in pigmentation Intact epidermis

Palpation Skin turgor test

Inspection

Clubbing indicates lack of oxygen

Nails

Highly vascular and yellow skinned color The epidermis tissue that surrounds the nails is intact After doing the blanch test, his nails, return to his previous nail color in 5secs.

Highly vascular and yellow skinned color indicates presence of liver disease

Blanch Test

Prompt return of pink or usual color

 Inspection

Skin temperature

Peripheral Vascular Palpation Capillary Refill Test Inspection

is not excessively warm or cold No edema Skin texture resilient and moist Symmetric pulse volumes. Full pulsations Immediate return of color

Skin

temperature is excessively warm No edema Skin texture resilient and moist Symmetric pulse volumes. Full pulsations Delayed return of color

Delayed return of usual color which may indicates circulatory impairment Hyperthermia

Muscle Strength

Palpation

Muscle Strength Test Inspection Joint

Equal on both sides of the body No contractures, tremors Normally firm Smooth coordinated movements Equal strength on both sides No swelling, Joint moves smoothly No tenderness, crepitation or nodules Unblemished skin Uniform color
Silver-white striae

Equal on both sides of the body No contractures, tremors Normally firm Flaccidity Muscle strength is 25% of normal strength Swollen joints Had difficulty in moving joints smoothly Presence of tenderness Absence of rash or other lesions Tense, glistening skin Silver-white striae

Delayed return of color indicates arterial insufficiency Flaccidity indicates body weakness 25% of normal strength; full muscle movement against gravity; with support

Findings indicates pain and difficulty in moving joints

Palpation Inspection Abdomen

Tense, glistening skin

indicates ascites

 Auscultation

Percussion of abdomen

Abdomen contour and symmetry is flat, rounded, scaphoid No evidence of enlargement of liver or spleen Symmetric contour No visible vascular pattern Audible bowel sounds Absence of arterial bruits Absence of friction rub Tympany over the stomach and gasfilled bowels; dullness, especially over the liver and spleen, or a full bladder Size is 6 to 12 cm in the midclavicular line; 4 to 8 cm at midsternal line No tenderness; relaxed abdomen with smooth, consistent tension May not be palpable Border feels smooth Not palpable AC 28 to 32 inches; may vary depending on body built

Abdomen is distended Evidence of enlargement of liver or spleen Symmetric contour Visible venous pattern Audible bowel sounds Absence of arterial bruits Absence of friction rub Tympany over the stomach and gas-filled bowels; dullness; especially over the liver and spleen, or a full bladder 18 cm in the midclavicular line; 14 cm at the midsternal line No tenderness; relaxed abdomen with smooth, consistent tension Enlarged liver Smooth but hard Not palpable AC is 38 inches

Distended abdomen indicates presence of mass Enlargement of liver associated with liver disease Visible venous pattern is associated with liver disease, ascites

Percussion of the liver

Enlarged size

associated with liver disease

Palpation of the liver Palpation of the bladder Measuring AC

Enlarged size of the liver indicates liver disease

Enlargement in size of the abdomen

CHEST AND BACK BODY PARTS METHODS

Inspection of

NORMAL FINDINGS
Anteroposterior to transverse diameter in ratio of 1:2 Spine is vertically aligned Spinal column is straight, right and left shoulders and hips are at the same height Skin intact; uniform temperature Chest wall intact; no tenderness; no masses Full and symmetric chest expansion Bilateral symmetry Fremitus is heard most clearly at the apex of the lungs Low-pitched voice Diaphragm is usually slightly higher on the right side Vesicular and bronchovesicular breath sounds Quiet, rhythmic and effortless respirations

ACTUAL FINDINGS
Anteroposterior to transverse diameter in ratio of 1:2 Spine is vertically aligned Spinal column is straight, right and left shoulders and hips are at the same height Skin intact; uniform temperature Chest wall intact; no tenderness; no masses Decreased chest expansion Bilateral symmetry Increased fremitus Low-pitched voice Restricted excursion Adventitious breath sounds

INTERPRETATION OR ANALYSIS

posterior thorax

Palpation of posterior thorax

Chest, Thorax and Lungs Palpation of chest for tactile fremitus

Decreased chest expansion indicates presence of respiratory illness Increased fremitus associated with consolidated lung tissue like pneumonia Restricted excursion associated with lung disorder Adventitious breath sounds indicates difficulty in breathing Hyperventilation indicates oerexpansion of lungs characterized by rapid and deep breaths

Percussion of diaphragmati c excursion Auscultation of chest Inspection of breathing patterns Palpation of

Hyperventilation 35 bpm

anterior chest for respiration excursion Inspection and Palpation of the aortic and pulmonary area Inspection and Palpation of the tricuspid area Inspection and Palpation of the apical area Auscultation of the heart in all four anatomic sites

Full symmetric excursion; thumbs normally separates 3 to 5cm No pulsations

Decreased respiratory excursion; separates 2 to 3 cm No pulsations

Decreased chest expansion indicates presence of respiratory illness The clients heart and central veins are normal

No pulsations

No pulsations

Pulsation visible

Pulsation visible

Heart and Central Vessels

Palpation of carotid artery Auscultation of the carotid artery Inspection of the jugular veins Inspection

S1: usually heard at all sites; usually louder at apical sites S2: usually heard at all sites; usually louder at base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate Diastole: silent interval; slightly longer duration than systole at normal heart rates Symmetric pulse volumes Full pulsations, thrusting quality No sound heard Veins not visible Breast even with

S1: usually heard at all sites; usually louder at apical sites S2: usually heard at all sites; usually louder at base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate Diastole: silent interval; slightly longer duration than systole at normal heart rates Symmetric pulse volumes Full pulsations, thrusting quality No sound heard Veins not visible Skin uniform in The breast and axillae

Breast and Axillae

Palpation of the axilliary, subclavicular and supraclavicul ar lymph nodes Palpation of breasts Palpation of areola and the nipples

the chest wall Skin uniform in color Skin smooth and intact Areola area are round, or oval and bilaterally the same Areola is round or oval, color varies Nipples are round, everted, both nipples point in the same direction No tenderness, masses or nodules and discharge

color, smooth and intact No tenderness, masses or nodules and discharge

are in normal condition

No tenderness, masses, nodules or nipple discharge No tenderness, masses or nipple discharge

LOWER EXTREMITIES BODY PARTS METHODS

Skin Generally uniform except Inspection

NORMAL FINDINGS
Skin color varies from light to deep brown

ACTUAL FINDINGS
Yellow in color which is uniform with the rest of the body Generally

INTERPRETATION OR ANALYSIS
Jaundiced color of skin indicates liver disease

in areas exposed to sun No edema

Palpation Skin turgor test

Birthmarks; no abrasions or other lesions Moisture in skin folds and the axillae When pinched, skin springs back to previous state Convex nails; angle of toenails about plate about 160 Smooth texture of toenails Toenail bed; highly vascular and pink or brown in pigmentation Intact epidermis

uniform except in areas exposed to sun No edema No presence of swelling and inflammation No abrasions or lesions The skin is warm to touch

Inspection

Toenails

When pinched, skin slight back to its previous state Nail plates have convex curvature with approximately 160 in angle on the nail texture Highly vascular and yellow skinned color The epidermis tissue that surrounds the nails is intact After doing the blanch test, his nails, return to his previous nail color in 2 seconds Not performed Equal on both sides of the body No contractures, tremors Normally firm

The clients toenails are normal

Blanch Test

Prompt return of pink or usual color

Genitals

Not performed Inspection

Not performed Equal on both sides of the body No contractures, tremors Normally firm Smooth

Not performed Flaccidity indicates body weakness 25% of normal strength; full muscle movement against gravity; with support

Muscle Strength

Palpation

Muscle Strength Test

coordinated movements Equal strength on both sides

Flaccidity Muscle strength is 25% of normal strength Swollen joints Had difficulty in moving joints smoothly Presence of tenderness

Inspection Joint

No swelling, Joint moves smoothly No tenderness, crepitation or nodules

Findings indicates pain and difficulty in moving joints