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IV.

PHYSICAL ASSESSMENT DATE: FEBRUARY 22, 2013 Area Integument  Skin Method Inspection/ palpation Findings Color: Skin becomes pallor, dry and pale lips, and palmar surface pale nailbeds; capillary refill test= 2 sec Inspection Pinch up skin returns immediately Black color; well distributed in the scalp and in the overall skin. Normal Interpretation

Nails

Hair

Normal

Head  Skull and face

Inspection

Symmetrical skull and is appropriate in size; symmetrical facial features and no involuntary movement.

Normal

Palpation

No lumps or bumps on the scalp

Normal

Eyes and vision

Inspection

Uniform in color; round and equal; PERRLA. Symmetrical ears and equal in size align in the outer cantus of the eye. No discharge seen; Pinna recoils

Normal

Ears and hearing

Inspection Palpation

Normal

Normal

smooth and no lesions. Normal Normal Palpation No presence of bumps and tenderness.immediately. bleeding or lesions. moist. tongue is pinkish. no pain reported. no infection occurring. with gag reflex Normal Neck  Neck muscles Inspection Symmetrical with head in central position.  Nose and sinuses Inspection Nose is midline of the face without swelling. No presence of discharge No deformities seen. movement through full range of motion without complaint of discomfort. symmetrical movement of neck muscles. Sinuses are not tender Normal Normal  Mouth and oropharynx Inspection Palate is moist and intact. Lymph nodes are non palpable Trachea is in midline position Normal   Lymph nodes Inspection Normal Trachea Inspection Normal . Patient can breathe with both nostrils.

irregular gurgles 535 times /min. no rashes and lesions High pitched. present equally in all four quadrants Normal Auscultation Normal . shape and size. Air filled lungs with resonant sounds RR: 22 bpm Normal Thyroid gland Palpation Normal  Thorax and lungs Inspection Normal Percussion Normal Auscultation Cardiovascular system  Heart sounds Auscultation Normal CR: 92 beats per minute. no extra heart sounds and no murmurs heard. symmetrical. Symmetrical chest. non palpable lobes not enlarged and rises as patient swallows.Auscultation  Bronchial breath sounds heard over the trachea In midline position. Normal Breast and axillae  Breast size and symmetry Inspection Breasts are equal Normal Abdomen  Abdominal symmetry Inspection Uniform in color same as skin. thorax rises and fall with inspiration and expiration.

Urinary system Inspection . it goes to the urine.Palpation Pain in the hypogastric region Urine: dark tea colored urine The glomerular is damage therefore it cannot filtrate the blood.