This document summarizes a head-to-toe assessment of a patient conducted on August 29, 2021. The assessment found the patient was alert and oriented, with normal vital signs. A physical examination identified no abnormalities except for a scar on the right leg. The patient reported sharp pain in the right lower extremity when walking that was relieved by rest.
This document summarizes a head-to-toe assessment of a patient conducted on August 29, 2021. The assessment found the patient was alert and oriented, with normal vital signs. A physical examination identified no abnormalities except for a scar on the right leg. The patient reported sharp pain in the right lower extremity when walking that was relieved by rest.
This document summarizes a head-to-toe assessment of a patient conducted on August 29, 2021. The assessment found the patient was alert and oriented, with normal vital signs. A physical examination identified no abnormalities except for a scar on the right leg. The patient reported sharp pain in the right lower extremity when walking that was relieved by rest.
Assessment conducted by: Bagus Kurnia Hariyadi Time:11.00 Am
LOC □ Alert □Drowsy □Lethargic Temp vs. trunk (warm / cool) □Stuporous □Coma Grip equal and strong Yes Orientation Capillary refill <3 sec Yes Person Perfect Orientation Vein filling rapid Place Perfect Orientation Time Perfect Orientation Situation Perfect Orientation Vitals Temp 36.6 o C □ R 24x / m Neck BP 112/88 MmHg □ Pulse Ox 100% Lower Extremities Head Hair present thin and black Hair Black, Thick, and distributed well Edema Edema not found in both extremities PERLA Symetris, Right and Left 2,5mm Foot strength Nose Symetris, without any Alteration Homain's (+ / -) Claudication (+ / -) Ears Symetris, without any Alteration Temp vs. Trunk (warm / cool) Mouth Moist texture, soft with normal color Nails □ Yellowed □ Thickened □ Ingrown o Midline tongue Perfect positioned Pedal pulse R(palp / doppler) L(palp / doppler) o Moist ROM / Strength Good Moisture Upper R Normal □ Upper R Normal o Lesions Upper L Normal □ Upper L Normal No lesions o Dentition Lower R Normal □ Lower R Normal Full, without any discoloration and cavity Lower L Normal □ Lower L Normal Sensation Carotid pulse 98 tpm □ JVD + □Trachea midline Chest General Assessment Apical Pulse 98 tpm □Muffled □Arrhythmia Weight/Height 59kg / 160cm Breath Sounds - Anterior BM 23,3 Kg/m Posterior Vesicular Lateral Vesicular Pain Assessment Chest Symmetry Chest Position perfect without Acute/Chronic □ Intensity (0-10) 2 alteration Location Right Lower Extremity Skin Turgor (clavicle) Turgor Normal Duration 1-2 minutes Abdomen Characteristics Sharp pain Inspection No Lesions found Precipitation Punctured by nails Auscultation Frequency when walking o LUQ (active / hyper / absent) Non-verbals Patient walking by one leg o RUQ (active / hyper / absent) Relief factors take a rest o LLQ (active / hyper / absent) Sleep patient can sleep well o RLQ (active / hyper / absent) Skin Assessment Palpation Description: Not found any enlargement in size of liver, spleen, Patient skin free from lesion, scar found on the right kidneys and gallbladder leg and skin turgor normal.