B.

PHYSICAL ASSESSMENT

General Appearance
Physical Development, Budy build & Body is proportional. Bilateral muscles are firm and well developed. There is
Fat Distribution equal distribution of fat with some subcutaneous fat. Body parts are intact
and appear equal without obvious deformities.
Posture & Gait Altered
Apparent Age as Compared to Well developed for age
Reported Age
Skin Condition & Color Color is even without obvious lesions; The client have brown complexion
Dress & Hygiene Appropriately dresses for the season
Skin
General Skin Coloration Evenly colored skin tones without unusual or prominent discoloration
Color Variations Suntanned areas in face and upper extremities
Skin Integrity Skin is intact
Texture Smooth and even
Moisture Moist
Temperature Warm
Mobility and turgor Skin is mobile, with elasticity and returns to original shape quickly
Edema Skin rebounds and does not remail indented when pressure is released
Head
Size, Shape & Configuration Head is symmetric, round, erect, and in midline and appropriately related to
body size. No lesions are visible.
Movement No involuntary movements, can be held still and upright
Consistency Hard and smooth without lesions
Face Symmetric with oval appearance. No abnormal movements noted
Temporal Artery Elastic and non-tender
Temporomandibular Joint (TMJ) No swelling, tenderness, or crepitation with movement. Mouth open and
closes fully and jaw moves laterally in each direction.
Eyes
Eyelids & Eye lashes The upper and lower lids close easily and meet completely when closed.
Without redness, swelling and lesions. Eyelashes are evenly distributed.
Eyeballs Symmetrically aligned in sockets without protruding or sinking.
Bulbar Conjunctiva and Sclera Bulbar conjunctiva is clear, moist, and smooth. Sclera is white.
Palpebral Conjunctiva Clear and free of swelling and lesions
Lacrimal Apparatus No swelling or redness
Cornea and Lens Cornea is transparent, with no opacities. Oblique view shows a smooth and
overall moist surface; the lens is free of opacities
Iris and Pupil Iris is round, flat, and evenly colored. The pupils are round, centered to iris
and equal in size bilaterally.

Ears

Auricle, Tragus and Lobule Ears are equal in size bilaterally. The auricle aligns with the corner of each
eye. Earlobes are free and tightly attached to adjacent skin. Skin is smooth,
with no lesions, lumps, or nodules. Color is consistent with facial color. No
discharge present. Non-tender.
Nose
Appearance Symmetrical and no lesions present
Nasal Sinuses No tenderness palpable
Patency of airflow Client is able to sniff through each nostril while other is occluded
 Mouth
Lips Slightly pale, smooth, and dry without lesions or swelling
Tongue In center, moist
Neck
Appearance Neck is symmetric, with head centered without bulging masses.

Movement Thyroid cartilage and cricoid cartilage move upward symmetrically as the
client swallows
Range of motion Neck movements are smooth and controlled.
Trachea Trachea is in midline.
Thyroid gland Landmarks are positioned midline. No presence of edema and masses.

Musculoskeletal (Upper Extremities)

Shoulders & Arms Shoulders are symmetrically round; no redness, swelling or deformities.
Muscles are fully developed. Clavicles and scapulae are even and symmetric.
Elbows Elbows are symmetric, without deformities, redness, or swelling. Nontender;
without nodules.
Wrists Wrists are symmetric, without redness, or swelling. They are nontender and
free of nodules.
Hands & Fingers Hands and fingers are symmetric, nontender, and without nodules. Fingers
lie in straight line. No swelling or deformities.
Thorax and Lungs
Posterior Thorax Scapulae are symmetric and non-protruding. Shoulders and scapulae are at
equal horizontal positions. No palpable crepitus. Skin is free of lesions and
masses. Fremitus is symmetric. Normal chest expansion. The client does not
use accessory muscles to assist breathing.
Anterior Thorax Sternum is positioned midline and straight. Retractions not observed. Ribs
slope downward with symmetric intercoastal spaces. Respirations are
relaxed, effortless, regular, and quiet. No retractions or bulging in intercoastal
spaces. Use of accessory muscles is not seen with normal respiratory effort.