COURSE CODE: INP

COURSE/YEAR/SECTION: BSN-IV
CONCEPT: ENT
RLE GROUP AND CLUSTER: GROUP 2 subgroup I
DATE: MAY 25, 2021

PHYSICAL ASSESSMENT
GENERAL APPEARANCE
A 35-year-old female patient, awake and conscious. Her look is congruent to her actual
age. She is attentive and cooperative and with good grooming. She is ectomorph body type. Her
overall skin complexion is pale, and it appeared smooth, warm, and moist. The patient appeared
anxious. Overall health state was weak.
Vital Signs:

 Pulse Rate: 92 beats per minute

 Blood Pressure: 130/60 mmHg

HEAD TO TOE ASSESSMENT

SKIN
Upon inspection, the color of her skin is brown. She has a smooth, warm, and moist skin
upon palpation. She has good skin turgor.
HEENT
HEAD
The head of the patient is round, symmetrical and it is proportionate. There are no
nodules or masses and depressions when palpated. The face of the patient appeared
smooth and has uniform consistency and with no presence of nodules or masses. The hair
of the adult is soft and straight with no lice noted upon inspection.
EYES
 Eyebrows- Hair is evenly distributed. The patient’s eyebrows are symmetrically
aligned and showed equal movement when asked to raise and lower eyebrows.
 Eyelashes- Eyelashes appeared to be equally distributed and curled slightly
outward and black in color.
 Eyelids- Upon inspection her eyes were not prominent, there is protruding or
bulging in the eye. Also discharges and redness noted.

EARS
 The auricles are symmetrical and has the same color with her facial skin. The
auricles are aligned with the outer canthus of eye. When palpating for the texture, the
auricles are mobile, firm and not tender. The pinna recoils when folded.

NOSE
The nose of the patient appeared symmetric, straight and same in color with the
face. There was no presence of discharge or flaring noted. There were no tenderness and
lesions upon palpation.

THROAT AND MOUTH

The lips of the patient are pink in color, moist, symmetric and have a smooth
texture. Teeth are yellowish in color and gums is pinkish in color. The buccal mucosa of
the patient appeared pink, moist, and with elastic texture. Tongue is pink in color and
uvula position in the midline of the soft palate.
NECK
Upon inspection of the neck of the patient, the trachea is in midline. During palpation there is
enlarged and palpable mass on anterior portion of the neck. Nodules being of firm consistency
and there was no lymphadenopathy. The pulse site is palpable. The patient was able to flex and
extend neck and move it laterally (L and R).
CHEST (Anterior/Posterior)
The color of her chest is lighter than her skin color on his face, upper and lower
extremities. With no lesions noted and her nipples are round upon inspection. With normal
posterior thorax and the posterior thorax of the patient is symmetrical with no muscle retraction
when breathing. With a bounding cardiac apical impulse and pulmonic flow murmur was heard
upon auscultation.
ABDOMEN
The abdomen’s color is same with the rest of the part of the body. No pain and tenderness
upon palpation and with active bowel sound upon auscultation.

UPPER AND LOWER EXTREMITIES

Upon testing and inspecting, the patient has a fine tremor at both upper extremities, and she
couldn't rise from a deep knee bend without aid. Peripheral pulses are symmetrical and regular
upon palpation. Nails are short and trimmed, pinkish in color, and have a capillary refill time of 2
sec. after blanching. There is no clubbing of fingernails was noted. Calluses were observed at the
tip of her fingers and toes. Her muscle strength is equal on both sides of the upper and lower
extremities.