PHYSICAL FINDINGS

ASSESSMENT
GENERAL SURVEY
Patient R. is conscious and non-ambulatory. She was rushed to
OPD in a wheelchair. As I observe the patient, she holds her
abdominal area and exclaims in pain. When asked about the pain,
she explains it as a burning pain in her stomach, on the pain scale
of 1-10 she expresses that the pain is an 8. The patient expresses
her feelings of pain through verbal speech and using facial
expressions by grimacing. The Glasgow Coma Scale of the patient
is 4 points for Eye Opening Response, 5 points for Verbal
Response, and 6 points for Motor Response, with a total score of 15
points.

SKIN, HAIR AND Inspection:

NAILS
Skin manifests skin pallor. It is uniform in color, consistent with the
patient’s genetic background and unblemished. There are no visible
lesions, abrasions, rashes and foul odor, and no erythema.

The patient’s hair is thick, silky, smooth and intact, coarse, even
distribution of hair, and has no signs of infection and infestation
observed.

The nails are observed to be yellowish in color with Beau’s lines

evident on the nails, convex curve shape, firm, and epidermis is dry
and pale. No clubbing manifestation.

Palpitation:

Skin is dry and warm to touch (temperature = 38.8 °C), is mobile but
skin turgor remains elevated after being pulled up and released,
calluses noted on palms and soles, no edema noted when feet is
palpated.

Nails are smooth and firm; nail plates are firmly attached to the nail
bed, with a capillary refill less than 2 seconds.

HEAD, NECK, AND Inspection:

CERVICAL LYMPH
NODES Patient R.’s head appears to be rounded, normocephalic and
symmetrical.

Neck muscles are equal in size, showing coordinated, and smooth

head movement with no discomfort.

Trachea of the patient is placed in the midline of the neck.

The thyroid gland is not visible during inspection, and glands

ascend during swallowing but are not visible.
 Palpitation:

There are no nodules or masses and depressions when palpated.

Lymph Nodes are not palpable.

No nodule or abnormally during palpation.

EYES Inspection:

Patient R.’s eyes look tired and dull. The patient’s bulbar
conjunctiva appeared transparent with few capillaries evident, sclera
is white, and palpebral conjunctiva appears shiny, smooth and pink.

No secretions and edema or tearing of the lacrimal gland. The

cornea of the eye is transparent, smooth and shiny. Iris is visible;
flat and round, there is blinking when the cornea is touched.

Pupils of the eyes are black and equal in size; constrict when
looking at a near object and dilate at far object; converge when the
object is moved towards the nose.

PERRLA, illuminated and non-illuminated pupils constrict. Can see

objects in the periphery when looking straight ahead, and both eyes
coordinately moved in unison with parallel alignment. 

EAR Inspection:

Patient R.’s auricles are symmetrical and have the same color as
her facial skin; aligned with the outer canthus of the eye.

Palpitation:
Mobile, firm and not tender. Pinna recoils when folded, and Patient
R can hear ticking in both ears (Watch tick test).

MOUTH Inspection:

Patient R.’s lips appear to have discoloration and

hyperpigmentation, symmetric and have apparent lines due to
cracked and dry lips, there is a yellow tinge of discoloration of the
gums and enamels, no retraction of gums.

Buccal mucosa appeared pale with minimal discoloration; the

buccal mucosa dry due to cotton mouth or dry mouth.

Tongue is centrally positioned; cracked with minimal yellow

discoloration, dry and slightly rough; presence of yellowish coating.
Smooth palates are pale and dry while the hard palate has a more
irregular texture, uvula is positioned in the midline of the soft palate
and has foul odor.
NOSE AND SINUSES Inspection:

Patient R.’s nose appeared symmetric, straight and there is a

yellowish tinge in color. There is a presence of mucus discharge. No
flaring, tenderness and lesions observed.

THORAX AND Inspection:

LUNGS  Patient R has difficulty breathing in a supine position, there is
irregular, shallow, breathing through mouth and uses accessory
muscle for breathing and has audible breath sounds.

Auscultation:

Bilateral coarse crackles and wheezing sounds on lower lobes

heard upon auscultation with decreased breath sounds at posterior
area.  

BREASTS Inspection:

The breasts are symmetrical, non-tender and have no suspicious

masses and no secretions.

HEART Inspection:

The JVP (Jugular Venous Pressure) is 3cm above sternal angle and
the apex beat is palpated in the 5th intercostal space, midclavicular
line, no palpable thrills over valve areas and precordial heaves.

The external chest is normal in appearance without lifts, heaves, or

thrills.

Palpitation:

PMI (Point of Maximal Impulse) is not visible and is palpated in the

5th intercostal space at the midclavicular line.

The radial pulse is above normal and symmetrical. Carotid pulse is

above normal, and the pulse rate is 110bpm.

Auscultation:

There is no S3/S4 (S3 is the 3rd heart sound also known as

“ventricular gallop. It is a low-pitched sound that doctors can hear
when blood rushes rapidly from the heart's atrium into the ventricle.)

(S4 is the 4th heart sound, it is a low-pitched sound coincident with

late diastolic filling of the ventricle due to atrial contraction.)
detected, no murmurs, gallops, or rubs are auscultated.
 The patient heart rate is 110 bpm and the BP is 150/100 mmHg.

ABDOMEN Inspection:

The skin is unblemished and uniform in color.

There are no visible lesions and scars. The aorta is midline without
bruit or visible pulsation. The contour is symmetrical and soft. And
movements are asymmetrical.

Palpitation:

It is tender with distention. The patient expresses pain in her

abdomen, pointing to the upper right quadrant. When asked about
the pain, she explains it as a burning pain in her stomach, on the
pain scale of 1-10 she expresses that the pain is an 8.

FEMALE GENETALIA Inspection:

There is skin over mons pubis with minimal to no pubic hair.

Palpitation:

Upon palpation, there are no bumps, lesions or any significant

deviations noted.

LABIA MINORA AND Inspection:

MAJORA
The Labia minora and majora are symmetrical and smooth to
somewhat wrinkled, and slightly pigmented with pinkish skin tone.

There are no signs of ecchymosis, no signs of abrasion, no nodules,

no signs of swelling, no signs of rash, and no lesions.

SKENE’S GLANDS Inspection:

AND BARTHOLIN’S
GLANDS The Skene’s Glands and Bartholin's Glands are not normally seen
by the naked eye; it has no skin lesions, no unusual pigmentations,
or other skin changes noted.

With no unusual size or changes of the clitoris or hood and no signs

of inflammation, no edema, or no other lesions of the periurethral
tissue are being noted.

There is no bleeding, no discharge, no STD lesions, no foreign

bodies, no abnormal vascular pattern, no petechiae, or other lesions
on the walls of the vagina and cervix noted.

ANUS AND RECTUM Inspection:

 Patient R. has no fresh or healed lesions, dried secretions,
ecchymosiss, rashes, STD lesions, handprints or fingerprints noted.

There is no inflammation noted, anal tone is within normal limits.

The anus is patent.

There is melena which presents that the stool is black, due to that
there is blood present.
MUSCULOSKELETAL Inspection:

Patient R. Verbalized pain and discomfort during mobilization. The

strength of the patient’s handgrip are affected and it causes the
patient to have a lesser capability to balance herself.

Patient R. can't do lateral bending except when she feels the pain in
her abdomen on the upper right quadrant.

There is no presence of masses or swelling on the sternoclavicular

joint and there's a presence of two forward curves in the neck and
lower back.
NEUROLOGIC
Patient R. is alert and oriented. She has spontaneous eye opening,
has a good speech pattern, and obeys commands correctly. The
patient scored 15 in the Glasgow Coma Scale. Mist. H. has equal
motor strength and sensation. 
 
DEVELOPMENTAL
Patient R. speaks clearly and can count 1 to 10 or more objects.
She correctly names at least 4 colors and 3 shapes and can
recognize some letters and is able to write them. Understands the
concept of time and the order of daily activities. Have a greater
attention span. She follows 2 to 3-part commands and recognizes
familiar words. She can’t stand on one foot for more than 9 seconds
due to the pain she feels in her abdomen. She also cannot walk up
and down the stairs without assistance, she has difficulty walking
forward and backward easily due to the pain.