G.

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

• The client’s Vital Signs are normal with a temperature of 36.9 centigrade, pulse rate of 78 beats
per minute, respiration rate of 19 breaths per minute and blood pressure of 100/75 mmHg

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

HEAD

• HEAD AND FACE

The client’s scalp is lighter in color and there was no scar noted, no tenderness was felt when palpated.
The hair is black in color and is evenly distributed and thick. The client’s face is oval in shape and facial
complexion is light, no skin lesions, freckles and scars were noted. The client has symmetric facial
movements.

EYES

The client’s eyebrows have evenly distributed hair, has intact skin, symmetrically aligned, and has equal
movement. The conjunctiva is transparent, capillaries are not visible, and sclera appears white and clear.
The cornea is transparent, shiny and smooth, details of iris are visible. The iris is light 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 moist, has presence of few 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 in color, gums are pink, moist, firm and there is no bleeding noted. Tongue is
pink and has visible taste buds. Uvula is positioned in the midline of soft palate. The tonsils are pink in
color, and have no discharges. The client has minty smelling breath.

SINUSES

The patient has no tenderness on sinuses when palpated. No bulging was noted and light passes from
the sinuses to the mouth when illuminated with penlight.
OTHER OBSERVATIONS

The client has no repetitive behaviour and sits in proper posture during the assessment. The client
displays interest and cooperation 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. No tenderness
noted during palpation. 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 refused to be
assessed on the chest and ribs.

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, there is no presence
of heaves.

BREAST

The client refused to be assessed in her breast

Other observations

The client’s chest size is small. There is no fatty layer of skin present in the anterior chest and the
client’s abdomen is flat.

SCAPULA

The scapula is intact and the skin that covers it has no noted lesions. It produces flat sound when
percussed.

SPINE

The spine alignment is good and palpable. The client’s posture is normal and there is no presence of scar
on the client’s back. No nodules are palpated on the client’s back.
LUNGS

Breathing pattern is quiet, rhythmic and effortless. Chest is symmetric during inhalation and expiration.

FLANKS

The client refused to be assessed on her flanks.

OTHER OBSERVATION

None

INTERNAL ORGANS

Palpation and percussion was not performed because the client refused.

BOWEL SOUNDS

Bowel sounds are heard four times every minute.

OTHER OBSERVATION

The client defecates four times a week.

UPPER EXTREMITY

POWER

The client has average muscle power in the upper extremity, she elicits slight tremors on her hands. The
bones are uniform in structure and produces flat sound when palpated, no deformities, tenderness or
edema. Joints are not tender, has smooth movement and no nodules.

RESISTANCE

The client’s was able to resist the downward pressure that was introduced during the test.

LOWER EXTREMITIES

POWER

The client’s power on lower extremity is average. The lower extremities has no contractures and
tremors. The bones on the lower limb are hard, produces flat sound when palpated and 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

The client was able to maintain balance on her chair during the entire duration of the assessment. She
was also able to stand still for 15 seconds with her one leg raised.

OTHER OBSERVATIONS

The client’s lower extremities have no scars and hairy. Client’s nails look clean and not polished.

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.