PHYSICAL ASSESSMENT

FIRST PHYSICAL ASSESSMENT

Name: Danica C. Sagut
PN1-2A
Patient Name: Jesusa C Razon
Age: 58 yrs old
AREA TECHNIQUE ACTUAL FINDINGS NORMAL ANALYSIS
FEATURE FINDINGS
TO
ASSESS
SKIN INSPECTION UPON INSPECTION THE SKIN IS NO SIGNS OF EDEMA NORMAL
PALPATION LIGHT BROWN IN COLOR. THERE IS AND NO SIGNS
NO SKIN DRYNESS, WOUNDS, OR LESSIONS
ANY RASHES. UPON PALPATION
THE TEMP. OF THE SKIN IS WARM
TO TOUCH, THE TEXTURE OF THE
SKIN IS FIRM AND SOFT NO
LESSIONS NO MASSES NOTED
HEAD INSPECTION UPON INSPECTION OF THE HEAD THE HEAD IS ABNORMAL
PALPATION ITS ROUND AND SYMETRICAL. THE SYMMETRICAL NO PRESENCE OF
SCALP IS NORMAL NO DANDRUFF TENDERNESS CIRCULAR BALD ON
THAT CAN BE SEEN.PRESENCE OF NO MASSES THE TOP OF CENTER
LARGE CIRCULAR BALD ON THE OF THE HEAD
TOP OF CENTER OF THE HEAD.
UPON PALPATION PLACING MY
HAND IN THE FRONTAL AREA
CONTINUING OVER PARIETAL,
TEMPORAL AND OCCIPTAL AREA
NO MASSES NO LESSION NO
TENDERNESS
FACE INSPECTION UPON INSPECTION HER FACIAL FACIAL FEATURES ARE NORMAL
PALPATION FEATURES ARE SYMETRICAL. SYMETRIC NO SIGNS
THERE ARE NO MASS NOTED THE OF EDEMA AND
TEMPORAL MANDIBULAR JAW IS TENDERNESS
SYMETRICAL NO TENDERNESS NO
SWELLING. UPON INSPECTION
HER SMILE, FROWN HER FACIAL
MOVEMENT ARE SYMETRICAL.
UPOM PALPATION I TEST THE
SENSATION FOR HEAD CHEEKS
AND CHIN SHES ABLE TO FEEL
 TOUCH THE SENSATION. UPON
PALPATION OF TEMPORAL
ARTERIES FOR ELASTICITY AND
TENDERNESS NO SIGNS OF
SWELLING AND TENDERNESS
EYES INSPECTION UPON INSPECTION THE EXTERNAL PRESENCE OF ABNORMAL
EYES ARE EQUALLY AND BULGING EYES AND
SYMETRICALLY ALLIGN, THE DRY EYES
EYELIDS HAVE NO DISCHARGE BUT
SWELLING IN THE UPPER TISSUE
OF EYELIDS THE EYES ARE DRY.
UPON INSPECTION THE BOTH
CORNEA OF THE EYES APPEARS
TRANSPARENT SHINY AND
SMOOTH PUPIL IS BLACK IN
COLOR EQUAL IN SIZE AND
ROUND. UPON INSPECTION OF
PERIPHERAL VISION TEST FROM
RIGHT TO LEFT BOTH EYES ARE
MOVING IN NORMAL RANGE
EAR INSPECTION UPON INSPECTION USING THE NO PRESENCE OF NORMAL
PALPATION PEN LIGHT NO SKIN CHANGES, NO LESSIONS NO EDEMA
DISCHARGE NO LESSIONS BOTH
OF THE EXTERNAL EAR CANAL,THE
HAIR FOLICLES AND GLANDS ARE
DRY. WHISPERED VOICE TEST
CORRECTLY RESPONDED
NOSE INSPECTION UPON INSPECTION OF EXTERNAL AIRFLOW THROUGH NORMAL
PALPATION NOSE THE SHAPE AND COLOR IS NOSTRILS AIR ARE
UNIFORM NO FRACTURE NO BOTH NORMAL NO
DEFORMITIES SYMETRIC AND SIGNS OF DISCHARGE
STRAIGHT UPON PALPATION OF
EXTERNAL NOSE NO TENDERNESS
NO LESSIONS NOTED
UPON PALPATION OF LEFT AND
RIGHT NOSTRIL THE AIRFLOW
THROUGH NOSTRILS ARE BOTH
NORMAL, HER SMELL IS ACTIVE
SHES ABLE TO SMELL CORRECTLY.
USING A NOSECOPE INSPECT THE
INTERNAL NOSE NASAL VESTIBULE
NASAL SEPTUM INFERIOR
TURBINATES APPEARS IN THE
MIDLINE NO WATER DISCHARGE
NO LESSIONS APPEARS PINK IN
COLOR.
MOUTH AND INSPECTION UPON INSPECTION THE LIPS IS NORMAL NO NORMAL
THROAT PALPATION PINK IN COLOR SOFT MOIST AND LESSIONS NO
SMOOTH SYMETRICAL NOTED OF SWELLING
FALSE TEETH BOTH UP AND
DOWN UPON OPENING HER
MOUTH THE UVULA IS IN
POSITION IN MIDLINE OF THE
SOFT PALLET PINK GUMS FIRM IN
TEXTURE NO REFRACTIONS OF
GUMS UPON INSPECTION OF THE
TONSILS NORMAL SIZE NO
DISCHARGE PINK IN COLOR
MOIST. THE TONGUE IS MOVABLE
FUNCTIONING IN TASTING
CENTRAL IN POSITION. THERE IS
NO LESSION ON THE TONGUE
MOUTH AND INSPECTION UPON INSPECTION SHE CLOSE THERE IS NO LESSIONS NORMAL
THROAT PALPATION HER EYES FOR HER TASTE
SENSATIONS SHE’S ABLE TO IT
TASTE CORRECTLY

NECK INSPECTION UPON INPSECTION OF THE NECK ASYMMETRICAL ABNORMAL

PALPATION SHE’S FACING AT ME THE MUSCLE ENLARGEMENT OF
AUSCULTATIO OF THE NECK ARE ASYMMETRICAL THYROID GLAND
N WITH THE HEAD IN CENTRAL
POSITION. SHE’S ABLE TO MOVE
THE HEAD THROUGH FULL RANGE
OF MOTION WITHOUT
DISCOMFORT. UPON DRINGKING
A SIP OF WATER AND SWALLOW
TWICE A MASS OR ENLARGEMENT
OF THE THYROID GLAND THAT
CAN BE SEEN. UPON
AUSCULTATION REVEALS THE
PRESENCE OF A BRUIT OVER AND
ENLARGE THYROID GLAND.
ARMS HAND INSPECTION UPON INSPECTION THE UPPER VISIBLE INFLAMATION ABNORMAL
AND FINGERS PALPATION EXTREMITIES BOTH ARMS ARE OF THE HANDS AND
SYMETRICAL. UPON PALPATION CARPAL AREAS
OF THE SKIN ELASTICTY THE SKIN
ABILITY TO RETURN TO NORMAL.
THE SKIN IS SOFT AND MOIST.THE
RADIAL ARTERY BOTH ARE
NORMAL. THE WRIST IS INFLAME
THERES IS INFLAMATION OF META
CARPAL AND CARPAL AREAS.
THERE’S ALSO DIFFICULTY OF
MOVEMENT OF THE RIGHT UPPER
 ARM. LIMITED RANGE OF MOTION
OF THE UPPER RIGHT
EXTREMITIES
POSTERIOR INSPECTION UPON INSPECTION NO ANY SCARS NORMAL NO NORMAL
CHEST PALPATION OR OHER SKIN ABNORMALITIES TENDERNESS NO
AUSCULTATIO NO MASSES NO RETRACTIONS NO MASSES NO LESSIONS
N TENDERNESS OR PAIN. UPON
PALPATION I USE THE FINGERTIPS
AND FLAT OF THE HAND IN ORDER
TO PALPATE THE THORAX THE
LOWER AND UPPER IGHT AND
LEFT QUADRANT IT IS FIRM AND
GENTLE PRESSURE AND THE
BREATH SOUNDS IS NORMAL.
NOTED THE ACCESORY MUSCLE
BREATHING SHE DOES NOT USE
ACCESORY MUSCLE TO BREATH.
UPON PALPATION THE CHEST
THERE IS NO INFLAMATION
TENDERNESS AND LESSIONS
HEART UPON PALPATION THERE IS A HEART RATE RESULTS ABNORMAL
PALPATION VERY LIGHT PUMPING SENSATION ABNORMAL. THE
AUSCULTATIO AND ITS AVERAGE PER MINUTE. NORMAL HEART BEAT
N ABNORMAL PRESENCE OF IS 60 TO 100 PER
TACHYCARDIA. UPON MINUTE
AUCULTATION IRREGULAR HEART
RHYTHM. HER HEART BEAT PER
MINUTE IS MORE THAN 100
BEATS

ABDOMEN INSPECTION UPON INSPECTION THE SHAPE NO SIGNS OF EDEMA NORMAL

PALPATION AND CONTUR IS NORMAL NO NO TENDERNESS NO
AUSCULTATIO INFLAMATION NO MASS .UPPER LESSIONS
N AND LOWER QUADRANT LEFT
PERCUSSION AND RIGHT SYMETRICAL. UPON
PALPATION FOR THE SOFTNESS OF
THE UPPER AND LOWER
ABDOMEN NO TENDERNESS NO
MASSES NO LESSIONS. UPON
AUSCULTATION OF THE BOWEL
SOUNDS ARE IN HIGH PITCH AND
 IT HAS NORMAL BOWEL SOUNDS
LOWER INSPECTION UPON INSPECTION THE LOWER NO SIGNS OF NORMAL
EXTREMITIES AUSCULTATIO EXTREMITIES THE COLOR IS STILL LESSIONS
LEGS, FEET, N SAME SKIN COLOR NO INFLAMATIONS AND
TOES PERCUSSION DISCOLORATIION IT WAS FIRM ITS SYMETRICAL
AND MOIST NO SWELLING. THE
RANGE MOTIONS OF THE KNEES
AND ANKLES IT CAN MOVE
WITHOUT DIFFICULTY. I TEST THE
SENSATION POSITION AND
VIBRATORY SHES ABLE TO
RECOGNIZE THE SENSATION THE
MUSCLE AND OF THE LEG AND
FEET ARE SYMETRIC IN SIZE UPON
PALPATION FOR EDEMA
SKINTEMP. MUSCLE SIZE AND TOE
THE MUSCLE ARE SYMETRICAL NO
SIGNS OF EDEMA. UPON
AUSCULATION OF THE KNEES NO
CRACKLING SOUNDS THAT CAN BE
HEARD. AND ITS SYMETRICAL
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