G.

The patient is conscious, well-oriented of his present condition and showed interest with the
interview by answering every question instantaneously.

• The patient’s Vital Signs are normal with a temperature of 37.4 centigrade, pulse rate of 89
beats per minute, respiration rate of 21 breaths per minute and blood pressure of 130/90 mmHg

• The patient showed no sign or potential signs of distress.

HEAD

• HEAD AND FACE

The client’s scalp is lighter than the color of her skin and there was no scar noted, no tenderness was felt
when palpated. The hair is black in color and is evenly distributed and thick. White hair strands are
noted also. The client’s face is oval in shape and facial complexion is light with freckles noted on both
cheeks. The client has symmetric facial movements.

EYES

The patient’s eyebrows have evenly distributed hair, has intact skin, symmetrically aligned, and has
equal movement. The conjunctiva is transparent, capillaries are evident, and sclera appears white and
clear. The cornea is transparent, shiny and smooth, details of iris are visible. The iris is brown, flat and
round. The patient’s visual acuity is normal.

NOSE

. The nose is in the midline, has no discharges, no nasal flaring, both nares are patent, and no bone and
cartilage deviation noted on palpation.

EARS

The client’s external ear canal is dry, has presence of hair follicles, no pus or blood. Normal voice tones
are audible to patient. Sound is heard on both or localized at the center of the head. The client’s ear has
no masses.

MOUTH AND THROAT

The patient’s mouth is pink in color, moist, smooth, soft, glistening and elastic in texture, and has no
lesions. Teeth are white to yellowish in color, gums are pink, moist, firm and there is no bleeding noted.
Tongue is pink, has thin whitish color. Uvula is positioned in the midline of soft palate. The tonsils are
pink in color, and have no discharges. The client has chlorine smelling breath.

SINUSES

The patient has no tenderness on sinuses when palpated. No bulging was noted and light passes through
the sinuses when flashed with penlight.
OTHER OBSERVATIONS

The client has no repetitive behaviour and sits in proper posture during the assessment. The client is
interested throughout the assessment.

TRACHEA

The trachea is on central placement in the midline of the neck, spaces are equal on both sides.

THYROID GLANDS

The thyroid gland is not visible in inspection, gland ascends during swallowing, no masses palpated.

GREAT VESSELS

Inspection showed no sign of jugular vein distention and carotid artery is not bulging. When palpated,
the client felt slight tenderness. Auscultation result reveals no bruit sounds on both vessels.

LYMPH NODES

There was no palpable lymph nodes anywhere on the neck and axillary area. The client has no signs of
infection or nodular enlargement.

CLAVICLE RIBS INTERCOSTAL SPACE

The client’s clavicle is equal in length and has no lesions when palpated. The client did not allow
assessment of the ribs and intercostal spaces.

HEART

The client was instructed to put the stethoscope on the apex with proper guidance. The heart has
audible sound and there is no presence of cardiac murmur during the assessment, heaves are also not
observed.

BREAST

The client refused to be assessed in her breast

Other observations

The client’s chest size is appropriate for her body structure. There is too much fat deposit on the
anterior chest and the client’s abdomen is protruding and big.

SCAPULA

The scapula is hard to palpate due to the fat deposits on the back of the client.

SPINE

The spine alignment is good but not palpable. The client’s posture is normal and there is no presence of
scar on the client’s back
LUNGS

Breathing pattern is quiet, rhythmic and effortless. Chest is symmetric upon expansion and recoil.

FLANKS

The client refused to be assessed on her flanks.

OTHER OBSERVATION

The client snores very loud and sleeps on the wrong position.

INTERNAL ORGANS

The client’s abdomen is uniformed in color, round and protruding. Notable stretch marks are observed
around the abdomen and there is a pfannenstiel incision below the navel. Palpation and percussion was
not performed because the client refused.

BOWEL SOUNDS

Bowel sounds are heard seven times every minute.

OTHER OBSERVATION

The client defecates once or twice a day.

UPPER EXTREMITY

POWER

The client has adequate muscle power in the upper extremity, she has no contractures and tremors and
muscle tension is normal. The bones are uniform in structure, no deformities, tenderness or edema.
Joints are not tender, has smooth movement and no nodules.

RESISTANCE

The client was able to resist the force that was inserted in both of her palms. The client’s hand was able
to resist the downward pressure that was introduced during the test.

LOWER EXTREMITIES

POWER

The client’s power on lower extremity is normal. She was able to lift 1 liter of water in a container for 5
seconds. The lower extremities has no contractures and tremors, muscle tension is normal. The bones
on the lower limb are hard, uniformed in structure and no tenderness was observed when palpated.

RESISTANCE

The client was able to resist the downward pressure that was introduced during the assessment when
the client is sitting, the client can do range of motion all by herself.
BALANCE

Balance test was not conducted due to the size of the client, elevated blood pressure and type of setting
where the assessment is conducted.

OTHER OBSERVATIONS

The client’s lower extremities have scars and no varicosities are noted. It has equal fat deposits and the
bones produce flat sounds when percussed.

ANTERIOR REPRO ORGAN

The client refused to be assessed in her reproductive organ.

POSTERIOR

The client refused to be assessed in the posterior area of her reproductive organ.