Physical Assessment

Past Health History

-She was diagnosed with hypertension and hypercholesterolemia approximately 15 years ago and has
been seeing her former primary physician every 6 months for checkups. Mrs. Maria also has
osteoarthritis of the right knee with occasional pain. She had her mammogram annually. Her last Pap
smear was 2 years ago. She had a tonsillectomy at age 7, cholecystectomy at age 41, and colonoscopy at
age 55.

Integumentary system

-The client has fair and dry skin. She has evenly distributed, black and shiny hair. Her nails are smooth
with intact epidermis and has good capillary refill time.

Head

-Her head is normocephalic and symmetrical. There are no nodules or masses found upon palpation. The
face of the client appeared smooth and has uniform consistency and with no presence of nodules or
masses.

Neck

-The neck muscles are all of the same size. The client demonstrated synchronized, fluid head movement.
The client's lymph nodes are not palpable. The trachea is located near the neck's midline. The thyroid
gland is not visible on inspection, and the glands ascend but are not visible after swallowing.

Eyes and Vision

-The pupils of the eyes are all the same size and color. The iris is round and flat. Illuminated and non-
illuminated pupils constrict, PERRLA (pupils equally round react to light accommodation). When staring
at a close item, the pupils constrict, and when looking at a remote object, the pupils widen. When an
item is moved towards the nose, the pupils converge.

Ears and Hearing

-There is no drainage, erythema, or swelling in the external ear canals and her tympanic membrane is
intact.

Mouth

-Symmetrical, pale lips, brown gums and able to purse lips. Client is wearing dentures. The tongue is in
central position, pink but with whitish coating which is normal, with veins prominent in the floor of the
mouth. The client’s tongue is able to move without difficulty.

Nose and Sinus

-Symmetric and straight, there is no evidence flaring, uniform in color, air moves freely as the clients
breathes through the nares. The client’s mucosa is pink, there are no lesions and nasal septum intact
and in middle with no tenderness.

Thorax, Lungs, and Abdomen

-There are no tenderness or lumps on the thorax. When examining for the respiratory excursion, there is
a complete and symmetric expansion, and the thumbs split 2-3 cm after deep inhalation. The client's
breathing was calm, regular, and effortless. The skin on the client's abdomen is smooth and
homogeneous in color. The abdomen is symmetrical in shape. As a result of the client's breathing, there
were symmetrical motions. Client has experienced dyspnea without chest pain.

Heart

-Cardiac examination reveals S1, S2 with no murmurs, gallops, or clicks. Client has reported that she was
diagnosed with hypertension and hypercholesterolemia 15 years ago.

Extremities

-The size and length of the extremities are symmetrical. The muscles do not exhibit tremors.
They're solid and move in a smooth, coordinated manner. There were no abnormalities, soreness, or
swelling in the bones. Despite the absence of swelling, discomfort, or edema, the client complains
occasional knee pain. Her extremities show no signs of cyanosis, clubbing, or edema.

Neurologic

-Speech or sign language has been used to express oneself. Able identify certain person, location, date,
or period. As seen by properly answering the questions, the client is able to focus. A total of 15 points
indicates the client is fully oriented and aware. Maintains balance while keeping an erect posture and a
steady walk with an unassisted opposing arm movement. For at least five (5) seconds, the client is able
to maintain position. Maintains a straight line when walking from heel to toe. Capable of taking many
steps on toes or heels. Can rapidly alternately supinate and pronate hands. The client was able to
perform with a high level of coordination and speed.  With each hand, the client is able to quickly taps
each finger to the thumb. When contacted with a needle or cotton, she is able to distinguish between
acute and dull sensations.

Lifestyle and health practices

-Client stated that she is independent in all activities of daily living and instrumental activities of daily
living. She drives her own automobile.

Medication

-Currently taking hydrochlorothiazide 12.5mg daily; atorvastatin, 20mg daily; and Tylenol Arthritis, 2
tablets as needed for knee pain.