PHYSICAL ASSESSMENT

Patient’s name: x

Age: 23 year old Gender: male

Diagnosis: T/C Blunt chest and abdominal trauma secondary to MVA

 PHYSICAL ASSESSMENT
Patient’s name: x

Age: 23 year old Gender: male

Diagnosis: T/C Blunt chest and abdominal trauma secondary to MVA

 PHYSICAL ASSESSMENT III. INTEGUMENTARY SYSTEM
 SKIN
Inspection
Patient’s name: x
 Generally dark brown skin color
Age: 23 year old
Gender: male  Skin appears dry
Diagnosis: T/C Blunt chest and abdominal trauma secondary to MVA  Two scrapes in circular shape noted on the right side of the head
 Several abrasions noted on the right leg
I. GENERAL APPEARANCE  Sutures noted around the periorbital area of the left eye
 Received patient lying on bed in semi fowler position, awake and responsive,  Left face is swelling and redness noted
with ongoing bottle of PLR 975 mL left infusing well at right metacarpal vein  Left knee has bandage noted
regulated at 30 gtts/min with no signs of inflammation and infiltration  Left leg has several abrasions noted
 Responsive but not so active  No discharges in the wounds noted
 Wore comfortable clothing  Skin is intact in other body parts
 No body odor
Palpation
 Patient appears slightly unfresh because has not yet taken a bed bath
 Skin is warm to touch
 Skin is dry when touched
II. VITAL SIGNS
VITAL SIGNS 8:00  No pain noted upon palpating except on the affected areas where there
(December 13, 2021) AM are abrasions
TEMPERATURE 35.5 OC  Tenderness palpated on the right cheek
PULSE RATE 96 bpm  No edema or masses upon palpation on other body parts
RESPIRATION RATE 25 cpm  Normal skin turgor (returned to normal state in less 2 seconds)
BP 110/80
O2 98 %  HAIR
Inspection
 Black in color and well distributed.
 Hair is straight and short
 Hair is thin in texture
  Hair is silky, not dry  Skull has no masses and depression upon palpation
 Presence of minimal dandruff upon inspection
 No presence of lice and nits upon inspection
 Cranial Nerve Assessment (Facial)
Inspection
 NAILS  Rounded facial features
Inspection  Able to open and close eyes
 Short fingernails in both hands but slightly soiled  Nasolabial folds are symmetrical
 Nails in toes slightly long and soiled  Eye brows are symmetrical as well as eyelids
 Nail bed pinkish in color  No presence of scars on the face noted
 No clubbing of fingers
 Nail plate firmly attached to nail bed. Palpation
 No pain noted upon palpation
Palpation  No masses, lumps.
• Blanch test normal. Capillary refill returns back immediately
 EYES
Inspection
IV. HEAD AND NECK
 Each pupil constricts when looking or reflected by a light
 HEAD
 Eyeballs are aligned normally in the sockets
Inspection
 Eyelids and eyebrows are asymmetrical
 Symmetrical to facial features
 Eyelids and eyebrows are symmetrical, no deviations noted  Eyes are not aligned to each other and left sclera is red
 Neck is symmetric, with head centered & without bulging masses  Right palpebral conjunctiva slightly pale
 Can move neck sidewards, up and downwards freely without experiencing
pain.
Palpation
Palpation  No edema, tenderness, masses and lesions noted
 No tenderness, lumps upon palpation  No unusual discharges.
 No lesions nodules and masses on face noted upon palpation  Tenderness on the left periorbital area
 EARS
Inspection  MOUTH
 Auricles are clean and same in color with the skin of the face Inspection
 Auricles are with no lesion lumps or nodules  Lips are symmetric, dry and slightly pale in color
 Canal walls are smooth without nodules  Scrape in the left lower lip noted
 Symmetrical, aligned at the outer canthus of the eye  Buccal mucosa is pinkish, with no lesions and nodules
 Tympanic membrane pearly gray with no bulging  There are 6 teeth on upper portion; 6 teeth on lower portion
 Few yellow cerumen noted in both left and right ear 
 Tongue is in midline of the mouth, uniform in color & moves freely
Palpation  Uvula rises on the midline
 Elastic and smooth to touch  No retraction of gums
 No lesions and masses noted upon palpation  Frenulum on proper position
 No tenderness noted  No bleeding, no offensive odor noted
 Pinna recoils after it is folded
Palpation
 NOSES AND SINUSES  No edema, tenderness and lesions and pain noted upon palpation
Inspection
 External nose is symmetric and straight  NECK
 Color is the same as the facial skin Inspection
 Nasal septum positioned at the center  Can move neck side wards (rotation), up and downwards (flexion) freely
 No nasal flaring without experiencing pain.
 Neck is symmetric, with head centered and without bulging masses
 No discharges
 No swelling, enlargement, or tenderness of the lymph nodes
 Mucus membrane is dry
Palpation
Palpation  No swelling, enlargement, or tenderness of the lymph nodes
 Smooth to touch  No bulging masses
 No lesions, masses, tenderness, pain and bone displacements upon
palpation
 V. THORAX AND LUNGS  No deformities noted in both left and right breast
Inspection  No swelling, nodules, ulcerations
 Chest is symmetrical, with no deformities noted
 Skin is uniform in color Palpation
 No retraction of the intercostal spaces  No skin lesions, edema and masses noted

Palpation VIII. ABDOMEN

 Symmetric chest expansion Inspection
 Uniform in skin color all over the area
Auscultation  No lesions, masses, striae
• No adventitious sounds heard  Abdomen is rounded
• respiratory rate: 25 cpm  Umbilicus is positioned at the midline, inverted
 No enlarged organs and masses noted upon inspection
VI. HEART
Inspection Auscultation
 No visible pulsation noted upon inspection  No vascular sound heard upon auscultation
 No thrills and vibration  No muscular resistance noted
 Heard 10 bowel sound/min.
Auscultation
 S1 and S2 heard upon auscultating the apical pulse Percussion
 HR: 96 bpm  Without tenderness noted upon percussion
 No murmurs heard
Palpation
VII. BREAST  No evidence of enlarge organ
Inspection  No rebound tenderness noted upon palpation
 Color is same as the face
 Equal in size and generally symmetric
 Both nipple point forward and no discharges noted
 Smooth in texture
IX. MUSCULOSKELETAL SYSTEM
Inspection
 Lies on bed, with minimal movements
 Is not able to raise, extend, and flex the left leg because pain is felt when
moving
 Able to move, raise, extend, flex arms with minimal pain and discomfort
 No contractures, tremors, or bony enlargement noted

X. NEUROLOGICAL SYSTEM
Inspection
 Pupils constrict with light
 Able to respond with sound and visual objects ( e.g., video). Grabs the
hand of the assessor and points out birds in the outside
 Able to feel sensations. Removes the stethoscope when touched to his
skin.
XI. GENITOURINARY SYSTEM
Inspection
 Foley catheter noted
 Urine output: 300 ml not yet drained
 stool: has not yet defecated for 1 day